Member Eligibility Verification Methods and Information on Medicaid Billing!

Date: June 14, 2023

Attention: All Providers

Member eligibility information: Texas Children’s Health Plan (TCHP) would like to remind providers that the Medicaid and/or CHIP coverage rules changed, beginning April 1, 2023. This means that some of our members will need to go through the process to determine their eligibility for coverage. Our members will be required to renew their Medicaid and/or CHIP coverage or risk losing their plan and access to healthcare. TCHP has actively communicated with members about this change to their coverage so that they are informed of the process and understand the requirements to renew. Click here to access our prior provider alert for more information on how you can assist your patients with their Medicaid and/or CHIP eligibility.

As a result of this change, members may not have their current Member ID cards available to present at the time of their appointment. We ask that you do not turn members away if they cannot present an ID card and instead utilize one of the following ways to verify their enrollment.
Alternatives to validate member eligibility:

• Texas Children’s^® Link provider portal
• TCHP Provider Hotline
  • 832-828-1004, option 3 for benefits & eligibility
• www.TMHP.com then login to TexMedConnect
• TMHP Automated Inquiry System (AIS) at 1-800-925-9126, option 1
  

Medicaid billing

As a reminder, TCHP follows the guidance found in the Texas Medicaid Provider Procedure Manual (TMPPM) section 1.7.11 Provider Enrollment and Responsibilities on billing clients. As stated in the TMPPM, providers should never bill a Medicaid recipient for Medicaid covered services and they should accept the reimbursement paid by Texas Medicaid for the services rendered.  Additionally, providers should not charge their patients or TMHP for filing Medicaid claims. Additional guidance includes the following:

• Providers cannot require a down payment before providing Medicaid-allowable services to eligible patients
• Providers cannot take action against Medicaid eligible patients for denied or reduced claim reimbursement for services that are within the amount, duration, and scope of benefits of Texas Medicaid, if the action is a result of a provider attributed error.
  • Examples of these include failure to submit claims within the deadline, filing incorrect claims, claims missing prior authorization information when services rendered have this requirement, or claims missing required documentation.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.