General Category > General Questions

Facility Medicaid Billing

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Michele:
Is there a provider rep that can help you?  It sounds like there is an issue on their end.

PMRNC:

--- Quote ---How do you handle two ER visits within 24 hours? We have a payer that will pay one claim and the other they global our charges. The TMHP manual states "If a client visits the
Emergency Room more than once in one day, the times must be given for each visit.". We've informed the payer that we do this and they still global our claims.
--- End quote ---

In one of your posts you mentioned it was a TX Medicaid HMO.. if that's the case I don't think the TMHP would be particularly useful since the HMO plan (PATIENT CHOOSES) will have their own policies and plan provisions.

mariorodriguez36:
Most of our HMOs follow TMHP guidelines. The specific plan we are having issues with is kind of tricky. Some instances they say to refer to the TMHP provider manual but for anything else they inform us they have their own guidelines. We are kind of skeptical of referring to this specific plans provider manual as most of the information is incorrect. For instance last week we found out that our CRNA 1500 claims were needing to be billed with an authorization. We were unaware of this, we called this specific plan and 3 different reps informed us no auth was required. We looked at the manual (which was updated in 2016) and it states auth is required. We called today 01/23/2018 and a rep from this plan informed us that all reps received a memo stating CRNA claims do require auth but to inform providers that no auth is required due to them also barley finding this info out.

Michele:
This doesn't seem right.  Have you contacted the state?  Even though it's a Medicaid HMO it is funded by the state and they might want to know about the issues you are having. 

mariorodriguez36:
We haven't contacted the state at this point. We were working with our provider rep from this plan to try and sort everything out but we have been working with her for almost a year already and nothing has changed. We haven't had to contact the state on a compliant like this before so are unaware of where to call.

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