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Reminder: Acute Care Providers Can Submit MAP Crossover Claims Electronically

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

This is a reminder that Texas Medicaid acute care providers can submit Medicare Advantage Plan (MAP) crossover claims and the corresponding attachment electronically. To do this, providers must submit both of the following at the same time:

  • The electronic data interchange (EDI) claims transaction, EDI X12 837
  • The EDI X12 275 transaction that contains the Medicare explanation of benefits (EOB)

Complete details are available in the updated 837I and 837P Acute Care Companion Guides and the new 275 Acute Care Guide.

Electronic Claims

Providers that are currently submitting EDI claims and are planning to switch to MAP electronic submissions must:

Note: TMHP only accepts EDI X12 275 attachment transactions for MAP claims and will reject attachments for all other claim types.

Providers that are new to electronic claim submission can refer to the “Get Started” section on TMHP’s EDI web page.

For questions about EDI testing or submission, call the TMHP EDI Help Desk at 888-863-3638.

Paper Claims

There are no changes to how providers submit MAP crossover claims on paper.

Note: TMHP does not accept electronic appeals and adjustments for Medicare crossover claims. For more information, refer to the Texas Medicaid Provider Procedures Manual, Vol. 1 Appeals:

  • Subsection 7.1.1.2, “Disallowed Electronic Appeals”
  • Subsection 7.1.5, “Paper Appeals”

For more information, call the TMHP Contact Center at 800-925-9126.