February 22, 2022

Claims process change for Texas STAR Kids (Medicaid) members with Medicare benefits

Effective April 1, 2022, we’re changing the way we process claims for STAR Kids (Medicaid) members with Medicare benefits in Texas.

Please review the claims submission process below to ensure accurate claims processing and prevent future claim denials.  Please note that the process for billing members with commercial coverage as primary is not affected by these changes.

How to bill and avoid claim denials:

  1. Bill Medicare first (primary payor) for Medicare-eligible services
  2. After receiving your Provider Remittance Advice (PRA), for the services listed below, please bill the remaining balance directly to Texas Medicaid & Healthcare Partnership (TMHP) for secondary payment:
    • Ambulance
    • Audiology
    • Behavioral health
    • Birthing center
    • Chiropractic services
    • Dialysis
    • Durable medical equipment and supplies
    • Emergency services
    • Family planning
    • Home health
    • Hospital - outpatient
    • Lab, x-ray and radiology
    • Optometry
    • Podiatry
    • Prenatal care
    • Primary care
    • Specialty physician
    • Acute Therapies - physical, occupational and speech
    • Organ and tissue transplantation
    • Vision
    • Inpatient facility services
    • Prescription drugs
  3. Long-term services and supports listed below meet outpatient exemptions are not Medicare-covered services.  Please bill them to UnitedHealthcare for primary payment.
    • Adaptive aids
    • Emergency response
    • Minor home modifications
    • Private duty nursing
    • Personal care
    • Therapies - physical, occupational and speech (provided under the Comprehensive Care Program (CCP))
    • Transition assistance
    • Respite care/flexible family support
    • Employment assistance/supported employment
    • In-home habilitation (Community First Choice)

When and how to submit an appeal
If you submit a secondary claim to UnitedHealthcare, are denied and believe UnitedHealthcare is the proper secondary payor, you can appeal.

For information about filing an appeal, go to UHCprovider.com/TXcommunityplan > Care Provider Manuals > Texas > UnitedHealthcare Community Plan of Texas STAR Kids Administrative Guide / Care Provider Manual.

Additional resources
Texas Medicaid Provider Procedures Manual: Go to tmhp.com > Medicaid Provider Manual > Texas Medicaid Provider Procedures Manual.

For help submitting claims to TMHP: Go to tmhp.com > Medicaid Provider Manual > Texas Medicaid Provider Procedures Manual > Individual Chapters PDF > Volume 1, Section 6: Claims Filing. You can also call the TMHP Contact Center General Inquiries Line at 800-925- 9126.

Questions?
Please call Customer Service at 888-887-9003, 8 a.m.–6 p.m. CT, Monday– Friday.

PCA-22-00310-C&S-News