Private HMO copayment-outpatient
Private PPO copayment-outpatient
Important: Providers must submit a new claim when filing for procedure codes CP001 and CP002. No explanation of benefits (EOB) or any other accompanying documentation is required to be attached to the claim form when filing for these services.
8.8.2.3 PPO Discounts
PPO discounts are not considered a part of other insurance payments. Electronic submitters must supply the PPO discount amount when submitting other insurance information; however, this information is not included in the total other insurance payment during claims processing. Paper submitters are not required to add the PPO discount to the other insurance payment.
8.8.2.4 Verbal Denial
Providers may call the other insurance resource and receive a verbal denial. The other insurance record can either be updated when the provider files the claim or calls the TPL/Tort Customer Service line at 1-800-846-7307. When calling the TPL/Tort Customer Service line and when filing claims to TMHP, the provider must have the following information before any updates are made.
Verbal denial requirements:
• Date of the telephone call to the other insurance resource
• Insurance company’s name and telephone number
• Name of the individual contacted at the insurance company
• Policyholder and group information for the client
• Specific reason for the denial, including the client’s type of coverage to enhance the accuracy of future claims processing (for example, a policy that covers inpatient services or physician services only)
Providers that update a client’s insurance records through the TMHP TPL/Tort Customer Service line must follow the current appeal process once the other insurance information has been updated on the client’s file.
8.8.2.5 110-Day Rule
When a service is billed to a third party and no response has been received, Medicaid providers must allow 110 days to elapse before submitting a claim to TMHP. If a TPR has not responded or delays payment or denial of a provider’s claim for more than 110 days after the date the claim was billed, Medicaid considers the claim for reimbursement. However, the 365-day federal filing deadline requirement must still be met. The following information is required:
• Name and address of the TPR
• Date the TPR was billed
• Statement signed and dated by the provider that no disposition has been received from the TPR within 110 days of the date the claim was billed
When TMHP denies a claim because of the client’s other coverage, information that identifies the other insurance appears on the provider’s Remittance and Status (R&S) Report. The claim is not to be refiled with TMHP until disposition from the TPR has been received or until 110 days have lapsed since the billing of the claim with no disposition from the TPR. A statement from the client or family member which indicates that they no longer have this resource is not sufficient documentation to reprocess the claim.
When a provider is advised by a TPR that benefits have been paid to the client, the information must be included on the claim with the date and amount of payment made to the client if available. If a denial was sent to the client, refer to the verbal denial guidelines above for required information. This enables TMHP to consider the claim for reimbursement.
8.8.2.6 Filing Deadlines
In accordance with federal regulations, all claims must initially be filed with TMHP within 365 days of the date of service (DOS). Claims that involve filing to a TPR have the following deadlines:
• Claims with a valid disposition (payment or denial) must be received by TMHP within 95 days of the date of disposition by the TPR and within 365 days of the DOS. Appealed claims that were originally denied with EOB 00260, which indicates that the provider files with a TPR, must be received within 95 days of the date of disposition by the TPR or within 120 days of the date on which TMHP denied the claim.
• The provider must appeal the claim to TMHP with complete other insurance information, which includes all EOBs and disposition dates. The disposition date is the date on which the other insurance company processed the payment or denial.
• If a provider submits other insurance EOBs without disposition dates, the appeal will be denied. If the other insurance disposition date appears only on the first page of an EOB that has multiple pages and the claim that is being submitted to TMHP is on a subsequent page or pages, the provider must submit the first page that shows the disposition date and all of the pages that show the claim that is being submitted to TMHP.
• If more than 110 days have passed from the date a claim was filed to the TPR without a response, the claim is submitted to TMHP for consideration of payment.
Refer to: Subsection 6.12.2.5, “Filing Deadlines” in “Section 6: Claims Filing” ( Vol. 1, General Information ) for information about filing deadlines for clients with other insurance.
8.9 Other Insurance Appeals
To appeal a claim denial due to other insurance coverage, the provider must submit complete other insurance information including the disposition date. The disposition date indicates when the other insurance company processed the payment or denial. An appeal submitted without this information will be denied.
If submitting a paper appeal the provider must submit EOBs containing disposition dates. If the disposition date appears only on the first page of an EOB that has multiple pages and the claim that is being appealed is on a subsequent page, the provider must also include the first page of the EOB that shows the disposition date.
Note: Claims denied for TPL/other insurance cannot be appealed through the TMHP Automated Inquiry System (AIS).
8.10 Refunds Resulting from Other Insurance Payments
The TMHP Cash Reimbursement Unit is responsible for processing financial adjustments when overlapping payments by Medicaid and a TPR occur.
Providers can use the Texas Medicaid Refund Information Form to:
• Refund the overpayment by issuing a check to TMHP. Providers must submit the refund check to TMHP along with the Texas Medicaid Refund Information Form and all required information requested on the form.
• Request that the claim be reprocessed and the money recouped. The overpayment will be reduced from next weekly payment made after claims are processed.
Refer to: The Texas Medicaid Refund Information Form , which is available in the Forms section of the TMHP website at www.tmhp.com .
If the amount paid by the other insurance carrier is less than Medicaid’s allowed amount, providers may bill TMHP for the difference. All claims must meet all timely filing deadlines.
Providers are prohibited from receiving payment from Medicaid and billing a TPR without refunding the Medicaid payment.
If within 12 months of the date of service a provider identifies that the client has other insurance and wants to submit a claim for payment to the other insurance company, the provider must refund any amounts previously paid by TMHP before submitting the claim to the other insurance.
If other insurance paid for the services submitted on the claim, the provider must submit the following to TMHP:
• The exact amount paid.
• The insurance company’s name and address.
• The client’s policy number and group number.
Providers are limited to the Medicaid allowed amount for the services. Providers are required to accept the TMHP paid amount as payment in full. If the provider fails to refund a payment to TMHP before submitting a claim to the other insurance, TMHP will recoup the entire other insurance payment.
In accordance with 1 TAC §§354.2321 [g] and 354.2322 [i], providers that do not follow TPR rules “may be referred for investigation and prosecution for violations of state or federal Medicaid or false claims laws.” Providers should refer to the full text of these rules for a full description of payment requirements.
8.11 Contact Information
TPL/Tort Telephone and Fax Communication
General Inquiry Telephone number