January 01, 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.

How to bill and avoid claim denials

  1. Bill Medicare first (primary payor)
  2. After receiving your Provider Remittance Advice (PRA), find the patient’s service in the chart below and submit the remaining balance to the appropriate secondary payor
    • For services listed in the left-hand column, please bill the remaining balance directly to the Texas Medicaid & Healthcare Partnership (TMHP) for secondary payment
    • Services listed in the right-hand column meet outpatient exemptions. Please bill the remaining balance to UnitedHealthcare for secondary payment.
Send secondary payment to TMHP Send secondary payment to UnitedHealthcare
  • 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
  • Therapies - physical, occupational and speech
  • Organ and tissue transplantation
  • Vision
  • Inpatient facility services
  • Prescription drugs
  • Long-term services and supports:
    • 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 (CFC))
  • Acute care:
    • Medicaid wrap-around, under a non-risk, cost settlement basis for:
      • Outpatient drugs
      • Biological products
      • Certain limited home health supplies (LHHS)
      • Vitamins and minerals in the STAR Kids Members HHSC drug exception file 

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.

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