Tag: Medicaid
Avoid Medicaid Disenrollment
Physicians Must Validate Email to Avoid Medicaid Disenrollment, Payment Delays
By Emma Freer
Texas Physicians who care for Medicaid patients should confirm their email address is valid in the Texas Medicaid and Healthcare Partnership’s (TMHP’s) Provider Enrollment Management System (PEMS) to ensure effective communication and timely payments from the state Medicaid administrator.
Without a valid email address on file in PEMS, clinicians will not receive online correspondence from TMHP, including reminders regarding their upcoming revalidation due dates, or be able to start a revalidation request, among other consequences.
Clinicians who fail to complete their respective revalidations by their given due dates will be disenrolled from Medicaid.
For step-by-step instructions on how to add and verify your email address in PEMS, check out TMHP’s handout.
TMHP also encourages clinicians to add the “TMHP.com” domain to their safe senders list in their email system and to avoid unsubscribing from TMHP emails.
For more information, reach out to TMHP via email or by calling (800) 925-9126.
Superior Prior Auth Changes Eff. 1/1/2024
For some services, utilization review is necessary to determine the medical necessity and appropriateness of a covered health care service for Superior HealthPlan’s managed care members. For those services, utilization review is performed BEFORE (prior authorization), during (concurrent review) or after (retrospective review) the service is delivered.
Medicaid and CHIP Program Revalidation
IMPORTANT:
During the Public Health Emergency (PHE), Provider
Revalidation was waived by HHSC.
The PHE ended May 11, 2023
Beginning May 12, 2023, Provider Revalidation Requirements were resumed.
Providers must ensure Medicaid and/or CHIP enrollment revalidation is completed on or before the provider’s scheduled revalidation date.
Providers that do not complete the revalidation process by their deadline are DISENROLLED from all Texas state healthcare programs, including Medicaid and/or CHIP managed care programs.
Visit the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment webpage to view and confirm your upcoming Medicaid and /or CHIP program revalidation date, verify current enrollment is active and verify all information in the PEMS system is accurate.
10,000 Members Lost Medicaid Coverage
HHSC Notice: Erroneous Termination of Superior Member Coverage
A recent notice from the Texas Health and Human Services Commission (HHSC) indicated that approximately 10,000 Superior HealthPlan members incorrectly lost their Medicaid coverage after April 1, 2023. This error is currently being addressed by HHSC, and we anticipate the reinstatement of benefits for these members soon.
Requested Action for Providers
Member Reimbursements
- Should members approach you with a request for refunds due to out-of-pocket expenses made during their period of interrupted coverage, they are entitled to full reimbursement.
- It is essential that you promptly process these refunds.
- As indicated by HHSC, these members will continue to have coverage until their cases have been reviewed. Any services for these members provided during this period can be billed to Superior HealthPlan.
Prompt Claim Submission
- After processing member refunds, please submit the relevant claims to Superior immediately. This swift action is crucial to avoid denials due to timely filing.
Prompt Claim Re-Submission
- If a claim was rejected as a result of member ineligibility, please resubmit the claim for processing.
- If a denial was received and is within 95 Days of the denial date, please submit a new claim.
- If more than 95 Days have elapsed since the denial, please follow the process for submitting a reconsideration, outlined in the Claims Reconsiderations section of the Superior HealthPlan STAR, CHIP, STAR+PLUS, STAR Health and STAR Kids Provider Manual. In the reconsideration request, please indicate: Member’s eligibility retroactively reinstated.
Handling Timely Filing Denials
- If you face a denial for timely filing, please follow the process for submitting a reconsideration, outlined in the Claims Reconsiderations section of the Superior HealthPlan STAR, CHIP, STAR+PLUS, STAR Health and STAR Kids Provider Manual. In the reconsideration request, please indicate: Member’s eligibility retroactively reinstated. Please also include the following when submitting a reconsideration:
- Explanation of payment.
- Documentation showing the reimbursement provided to the member for the affected dates of service.
For additional support, queries or clarifications regarding this situation, please contact your local Account Manager.
It Has to End Sometime. Doesn’t It?
What Will the End of the PHE Mean for Coverage?
The PHE has been extended 8 times since January 31st. We all have I fingers crossed that this is the last time. But there is a lot of uneasiness regarding the “WHAT IFs” of when it does.
To get some great insight check out this article from TMA.ED
PHE Extended Through 7/15/2022
Will the End of the PHE Impact Physicians Practices and Patient Coverage?
You Bet Your Rain Boots it Will!
UHC Policy Updates for March 2022
Just click the button to check out the latest from UHC.
Md and CHIP Patients Required to Verify!
Medicaid and CHIP patients are required to verify their eligibility EVERY YEAR or risk losing it.
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