Medical Billing Forum

General Category => New! => Topic started by: rajesh_sh on May 03, 2012, 10:23:20 AM

Title: Texas Medicaid HMO
Post by: rajesh_sh on May 03, 2012, 10:23:20 AM
Kindly clarify the following.

In our process we have some of claims were denied by Texas medicaid HMO (Molina,Superior & community Health plan) when these insurance are actiing as secondary to Medicare as they will cover only Long term care benefits alone.

When we checked with this HMO they said all other services will be covered only by the direct Texas Medicaid. 

Please confirm this and also provide us the Policy document link to know more details about this.
Title: Re: Texas Medicaid HMO
Post by: PMRNC on May 03, 2012, 11:44:49 AM
Is the provider Par with this HMO?
Title: Re: Texas Medicaid HMO
Post by: macbook on May 03, 2012, 12:21:23 PM
Molina, Superior and CHC(Community Health Choice) are all managed care plans for Texas Medicaid. Now, if these managed care plans will only cover long term care benefits for this patient, and reverts you to TMHP(Traditional Medicaid) then that's what I would do. To check on eligibility status and more info, go to and if you have TMHP user account for your provider then you can log on and find more information there.

If you do not have a TMHP User Account, choose one of the following options:

    To create a TMHP User Account and begin the enrollment process to be a new provider in Texas Medicaid or the CSHCN Services Program, click New Username and Enroll.
    To create a TMHP User Account and activate an existing Texas Medicaid or CSHCN Services Program provider/vendor account for online use, click New Username and Activate Existing Provider.

Hope this helps.

Also, I agree with Linda, your provider needs to also be a participting provider with the Managed care plans.
Title: Re: Texas Medicaid HMO
Post by: ltjen on May 03, 2012, 04:27:57 PM
In my experience, (billing DME) when a client has an HMO with Medicare primary, Medicare makes the payment then they forward the 20% to TMHP. This is what I see with all equipment when they have Medicare/Medicaid-HMO. I'm sorry but I cannot find the link to verify that info. :-\
Title: Re: Texas Medicaid HMO
Post by: rajesh_sh on May 04, 2012, 05:59:06 AM
Yes Linda,

These providers are par with HMO as well.
Title: Re: Texas Medicaid HMO
Post by: macbook on May 04, 2012, 04:42:08 PM

 I was able to come across that as well with Medicare. Although in my case, it did a cross over  directly to TMHP traditional even if my patient stated secondary as a managed care plan or if the TMHP web portal stated it as well.

Now, the best thing for this is to verify benefits from the get go.  With most IVR's they would state that the pt has Managed Care Plan. In this light, you will have to bill Traditional TMHP.

LTC is a benefit (like Star Plus LTC) that is chosen by the patient if they chose to include it under the MCO's plan benefit. With the new rule of TMHP since Jan 2012 not covering for the amount greater than the allowable amount of Medicaid, it will have a denial code of 00238 or the like. For a more detailed explanation, please go to their website for bulletin updates. Or call the MCO's or TMHP directly for clarification.

Hope this helps.