TMHP Shifts Medicaid-Only Service Claims for Dual-Eligible Clients to MCOs

The Texas Medicaid and Healthcare Partnership (TMHP) has announced the adjustments to the processing of the claims for services delivered under Medicaid only by the dual-eligible clients when they are subscribers to managed care organizations (MCOs).

TMHP will not adjudicate these claims after September 1, 2025, when the date of service (DOS) falls or later. Instead, they will be passed on to the MCO of the client of TMHP and adjudicated. Response to claims will have this forwarding ,but TMHP will not produce an Electronic Remittance and Status (ER&S) Report. Adjudication information has to be obtained by the providers themselves from the MCO.

In the Rider 32 Procedure Code List, a list of procedure codes transitioned is provided. The providers are also advised to consult the corresponding article “Rider 32 Provider EVV Impacts” regarding how to make claims regarding services that need Electronic Visit Verification (EVV).

Exempt Programs

The existing programs will not be exempt from the MCO transition and will still be handled under TMHP:

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

Claim Submission Guidance

The healthcare providers who have been utilizing TexMedConnect or electronic data interchange (EDI) have to submit claims to one payer. The claims that include information that will be paid by both TMHP and an MCO will be refused and should be submitted separately. The modifiers used in all claims should be right, as in the Texas Medicaid Provider Procedures Manual.

Provider/ MCO Responsibilities

The providers are required to continue providing authorized services, to review the previous authorizations with the MCO, and to make claims based on the out-of-network process of each MCO.

MCOs are required to:

• Approved prior authorizations of transitioned services by Honor TMHP.
• 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.
• Provide continuity by ensuring that the amount of services, duration of services, and scope of services remain the same.
• Offer transitioned services until the latest of 90 days after transition, the expiration of a TMHP-approved authorization, or the completion of a client examination by an MCO.

Assistance

• Questions on continuity of care and out-of-network issues: hpm_complaints@hhsc.state.tx.us
• Questions on electronic claims submission: TMHP Contact Center at 800-925-9126