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Update to “Claims Processing to Change for Medicaid-Only Services Provided to Dual-Eligible Medicaid Clients Enrolled in MCOs”

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This is an update to the article titled “Claims Processing to Change for Medicaid-Only Services Provided to Dual-Eligible Medicaid Clients Enrolled in MCOs,” which was published on this website on July 18, 2025.

For dates of service (DOSs) on or after September 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) does not adjudicate claims submitted by providers for Medicaid-only services that they provide to dual-eligible clients who are enrolled in a managed care organization (MCO). TMHP forwards the claims to the MCO for processing. Claim responses will show that the claims were forwarded, and TMHP will not generate an Electronic Remittance and Status (ER&S) Report.

Providers can find a list of the procedure codes that were transitioned to MCOs in the Rider 32 Procedure Code List file.

Important: The MCO will adjudicate the claims. Providers must contact the MCO directly for adjudication information about forwarded claims.

Claims for Electronic Visit Verification (EVV) Visits

Providers should refer to the article “Rider 32 Provider EVV Impacts” for information about how to submit claims for Medicaid-only services that require an EVV visit.

Programs that are Exempt from the MCO Transition

The following programs are exempt from the MCO transition and claims will continue to be processed by TMHP:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Home and Community-based Services (HCS)
  • Texas Home Living (TxHmL)

Submitting Claims for Medicaid-Only Services for Dual-Eligible Clients

Providers who submit claims using TexMedConnect or electronic data interchange (EDI) must limit them to a single payer. If a claim is submitted with details that are payable by both the MCO and TMHP, TMHP will reject the claim. Providers must submit a separate claim for each payer.

Providers must continue to ensure all claims contain the appropriate modifiers, as outlined in the Texas Medicaid Provider Procedures Manual.

Continuity of Care

Providers and MCOs must ensure that clients receive continuity of care for services that are being transitioned to the MCO.

Provider Responsibilities and Requirements

Providers must: 

  • Continue providing any prior authorized services to clients.
  • Communicate with the MCO to confirm prior authorization and billing.
  • Submit claims to the MCO in accordance with the MCO’s out-of-network claim submissions process. 

MCO Responsibilities and Requirements

MCOs must:

  • Honor all TMHP-approved prior authorizations for transitioned services, even if the provider of the service is not contracted with the MCO.
  • Continue to provide to clients any transitioned services that did not require a prior authorization in fee-for-service Medicaid, even if the MCO requires a prior authorization.
  • Ensure that clients receive transitioned services in the same amount, duration, and scope as before the transition.
  • Provide the transitioned services for the shortest period of one of the following:
  • Until 90 Days after the services were transitioned to the MCO
  • Until the end of the current TMHP-approved prior authorization period
  • Until the MCO has evaluated and assessed the client and issued or denied a new prior authorization

Reimbursement for Out-of-Network Providers

If a provider submits a claim that is forwarded to an MCO but the provider is not already credentialed with that MCO, they may be reimbursed as out-of-network providers.

Have Questions?

Providers can send questions about continuity of care and out-of-network provider issues to hpm_complaints@hhsc.state.tx.us.

Providers who have questions about electronic claims submissions using TexMedConnect or TMHP EDI can call the TMHP Contact Center at 800-925-9126.

Important: Texas Medicaid 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.