Texas Medicaid: Clean claims and other claim reminders

UnitedHealthcare Community Plan abides by Texas Medicaid Healthcare Partnership’s (TMHP) claims adjudication requirements for clean claims. All submitted claims should adhere to the clean claims best practices and requirements.

Submitting clean claims
While there are many required pieces of information for a claim to be considered clean, these are some key items:

• You must be in good standing for the dates of service billed (i.e., not on vendor payment hold for any reason).
• The member must be Medicaid-eligible for the dates of service billed.
• Medical necessity determination (prior authorization as applicable) must be in place for the dates of service billed.
• All claims must meet National Correct Coding Initiative (NCCI) guidelines.
• Professional and institutional claims need to include the taxonomy code, National Provider Identifier (NPI) and address exactly as enrolled or attested in Texas Medicaid, whether through TMHP or the Texas Health and Human Services Commission. This applies to attending, rendering and billing care providers, as well as electronic or paper claims. For example, if attested as your business address at 100 Main Street, submitting claims with “100 Main St.” will result in denials.
• Institutional claims need both the attending and the rendering provider information. If the information is the same for both, only the attending provider information should be included.
• Professional claims need to add qualifiers to the taxonomy code.

In order to be considered clean, professional and institutional claims also require that some information be included on the claim and exactly match the information attested with TMHP. Examples include:

• Member’s name, Medicaid ID and date of birth
• Rendering, billing, and attending provider taxonomy codes
• Rendering, billing, and attending provider NPIs
• Billing provider address

Additional claims and billing reminders
Billing and coding issues should be discussed directly with your provider advocate or UnitedHealthcare Customer Service. You should not discuss these issues directly with members.

Do not balance bill members if:

• The charge amount and the UnitedHealthcare Community Plan fee schedule differ
• Your claim is denied for late submission, unauthorized service or as not medically necessary
• UnitedHealthcare Community Plan is reviewing a claim

The following members may never be billed, nor payment sought from them, for any balance amount of a charge for delivery of a service that is a covered health care benefit: STAR, STAR+PLUS, STAR Kids, CHIP Perinate, CHIP Perinate Newborn members and CHIP members who are Native American or Alaskan Natives.

• Additionally, for CHIP members there is no cost-sharing on benefits for well-baby and well-child services, preventive services or pregnancy-related assistance
• You are able to balance bill the member for non-covered services only if:
  • A specific service or item is provided at the member’s request
  • You have obtained and keep a written Member Acknowledgment Statement signed by the member, or member representative under informed consent

Our benefits contracts are subject to subrogation and coordination of benefits (COB) rules:

• Subrogation: We may recover benefits paid for a member’s treatment when a third party causes the injury or illness.
• COB: We coordinate benefits based on the member’s benefit contract and applicable regulations.

UnitedHealthcare Community Plan is the payer of last resort. Other coverage should be billed as the primary carrier. When billing UnitedHealthcare Community Plan, submit the primary payer’s explanation of benefits or remittance advice with the claim.

Learn more
For more information on filing claims, go to UHCprovider.com/TXcommunityplan > Care Provider Manuals > Texas.

For information on TMHP’s requirements, including definitions for attending and rendering providers, go to tmhp.com > Medicaid Provider Manual > Vol. 1 Claims Filing.

Questions?
Contact your Provider Advocate directly or call Customer Service at 888-887-9003, 8 a.m.–6 p.m., Monday–Friday, if you have questions.

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