Tag: Texas Health and Human Services Commission (HHSC)
Superior HealthPlan Billing Changes
Important Provider Update
Effective September 1, 2025
The Texas Health and Human Services Commission (HHSC) will transition Medicaid-only services for dually eligible clients (eligible for both Medicare and Medicaid) from Fee-for-Service (FFS) to a Managed Care service delivery system.
Superior HealthPlan will be responsible for adjudicating these claims.
Provider Responsibilities
Submit claims for Medicaid-only services for dual eligible clients directly to the Managed Care Organization (MCO).
If a Claim is Sent to TMHP in Error:
TMHP will forward the claim to the correct MCO.
The TMHP response will only confirm forwarding – no ER&S report will be issued.
Claims with dates of service on or after Sept. 1, 2025 will not be adjudicated by TMHP.
Provider Action Steps
✅ Submit Medicaid-only service claims directly to the MCO.
✅ Contact the MCO for claim status and adjudication questions.
✅ Review the Rider 32 Procedure Code List (PDF) for impacted services.
✅ Reach out to your Provider Representative via the Find My Provider Representative webpage.
Need Help?
Contact your dedicated Provider Representative
HEADS UP! Rider 32 Transition
Effective September 1, 2025
Texas Health and Human Services Commission will implement Rider 32, which will transition Medicaid only services for dually eligible members from a fee-for-service model to a managed care delivery system.
This change affects services provided to members who are eligible for both Medicaid and Medicare. It applies only to those Medicaid services not covered by Medicare.
Providers will bill the MCO for Medicaid wrap-around services provided to dually eligible members.
Wrap-around services include all Medicaid services not covered by Medicare. They are limited to those already covered under managed care for Medicaid-only members.
HHSC Extends Medicaid PEMS Revalidation
~Phil West, TMA
Health and Human Services Commission (HHSC) has provided an extension for physicians due for revalidation between Dec. 13 and May 31 through Texas Medicaid & Health Partnership’s (TMHP’s) Provider Enrollment and Management System (PEMS).
While the extension grants an additional 180 days to physicians due for revalidation between those dates, TMA advises physicians who are due for revalidation over the next six months to file online with HHSC as soon as possible.
Information for Medicaid Providers
Upcoming Changes to STAR+PLUS
Effective September 1, HHSC is transitioning contracts for the STAR+PLUS program. Below are a few resources that may help.
If you need help with….
Try…
Managed Organization Complaints.
Knowing how this transition will impact my billing.
Please reach out to the MCO to understand their billing process.
Helping your clients through the transition.
See the HHSC Star+Plus webpage for transition resources.
For any STAR+PLUS transition related issues, please contact the STAR+PLUS Go Live Inbox.
And as always, contact POET if you have any concerns.
HHSC Extends Postpartum Coverage.
Effective March 12, 2024, women enrolled in Medicaid or CHIP who are pregnant or become pregnant will be automatically enrolled for 12 months of postpartum coverage (formerly only 2 months).
Medicaid or CHIP coverage will be automatically extended to women while pregnant and still within their 12-month postpartum period if they are still residents of Texas. Coverage will be reinstated for the remainder of the 12-month postpartum period.
HHSC: Star+Plus Webinars
HHSC is transitioning contracts for the STAR+PLUS program effective September 1, 2024.
They will be conducting webinars to assist with the STAR+PLUS transition as this change will affect both members and providers.
ONLY TWO SESSIONS LEFT
Saturday June 22nd, 9:00-10:00 AM
Monday June 24th, 1:00-2:00 PM
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.
Upcoming Texas Incentives for Physicians and Professional Services (TIPPS)
REPORTING PERIOD
October 10 – November 6, 2022
Below please find information on the upcoming Texas Incentives for Physicians and Professional Services (TIPPS) reporting period (October 10 – November 6, 2022) for state fiscal year (SFY) 2023 (year [Y] 2.
- HHSC will hold a reporting webinar to provide instruction on the reporting process and template. The Y2 Round 1 reporting webinar will be held on October 13, 2022 at 2:00 PM. Please register using the link below.
- HHSC will notify participating providers when the reporting companion (instructions for using and submitting the template) and reporting template are posted to the reporting portal Bulletin Board by October 10, 2022. HHSC will post a link to the recorded Y2 reporting webinar on the bulletin Board by October 14, 2022.
- Participating providers must report data using the data measurement period of January 1, 2022 – June 30, 2022 (i.e., the first six months of calendar year 2022). All of the calendar year 2022 will be reported during Y2 Round 2 in April/May 2023
A few other links of interest:
Contact the HHSC CPP Quality Team: [email protected]
Contact the Provider Finance Department (PFD): [email protected]
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
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