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Claims Processing Issue for STAR Kids and STAR+PLUS Dual Eligible Medicare and Medicaid Clients

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The Texas Medicaid & Healthcare Partnership (TMHP) has identified an issue affecting claims submitted for clients who are STAR Kids and STAR+PLUS Dual Eligible Medicare and Medicaid only. Some claims may have been forwarded incorrectly to managed care organizations (MCOs) instead of being processed as Acute Care fee-for-service (FFS).

Claims Reprocessing

TMHP will reprocess affected FFS claims submitted from June 9, 2025, through December 27, 2025, that were denied with only the following explanations of benefits (EOBs):

  • “00081 CLAIM BILLED TO TMHP IN ERROR. BILL HMO OR DMO. IF CLIENT IS A STAR+PLUS MQMB FILE APPEAL TO TMHP. IF CLAIM IS FOR AN EVV SERVICE WITH DATE OF SERVICE ON OR AFTER 9/1/2019, FILE ELECTRONICALLY TO TMHP.”
  • “00079 REFERRING PROVIDER WAS NOT THE PCP ON THE DATE OF SERVICE. STAR CLAIM DID NOT INCLUDE A VALID NPI/API OF THE MEMBER'S PCP.”

When the claims are reprocessed, providers may receive additional payment, which will be reflected on future Remittance and Status (R&S) Reports.

Affected claims that were forwarded incorrectly to the MCOs during this timeframe should be submitted to TMHP by February 28, 2026. TMHP will waive the timely filing deadline requirement for claims that fall within this timeframe.

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