Texas Health and Human Services Commission (HHSC) and Office of Inspector General-Third Party Recoveries division (OIG-TPR) has recently seen a high number of escalations due to Providers refusing to see a Medicaid eligible Member because the Member has other health insurance. Per the Texas Medicaid Provider Procedure Manual (TMPPM) Section 8.3 Third Party Liability (TPL), Providers who participate in Texas Medicaid may not refuse services to eligible Medicaid Members due to potential other health insurance coverage.
Additionally, Medicaid-eligible Members cannot be held responsible for charges exceeding a third-party liability (TPL) payment for services covered by Texas Medicaid. If the TPL pays less than the Medicaid managed care amount, Providers should submit a claim to Community First Health Plans, Inc. for any additional allowable reimbursement.
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6294. You can also contact your Provider Relations Representative directly.
To access all Provider alerts:
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News
- Sign up for the Community First Provider eNewsletter
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