Skip to main content

Issue Identified for Managed Care Carve-Out Services Claims

Last updated on

The Texas Medicaid & Healthcare Partnership (TMHP) has identified an issue with claims submitted for managed care carve-out services that are administered as fee-for-service benefits. Some claims may have been denied in error due to missing primary care provider identification in eligibility records.

Claims Reprocessing

TMHP will reprocess affected fee-for-service claims submitted on or after June 9, 2025, that have been denied with only the following explanations of benefits (EOBs):

  • “00088 CONSULTS NOT APPROVED BY MEMBER’S PCP.”
  • “00091 ADULT PHYSICAL EXAMS MUST BE PERFORMED BY MEMBER’S PCP.”

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

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