Member Eligibility Verification Methods and Information on Medicaid Billing

Date: November 5, 2024

Attention: All Providers

Member eligibility information: Texas Children’s Health Plan (TCHP) would like to remind providers when a member is unable to provide their health records or Member ID, there are other ways to verify eligibility for Medicaid services. By going through other options on verifying eligibility, we can ensure the member receives required health services on schedule while improving workflow and efficiency. 

If members do 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. 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 800-925-9126, option 1 
• YourTexasBenefitsCards.com Provider Portal

For more information, here is a short case study on Verifying Medicaid Eligibility provided by Texas Health Steps regarding different options in verifying member’s eligibility.

Please note, TCHP has actively communicates with members on the importance of bringing their Member ID cards with them to appointments, however there may be extenuating circumstances where a member may not have their ID card when they go for their scheduled service.

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 instead 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: https://www.texaschildrenshealthplan.org/provideralerts