Review of Inpatient Claims for Spell-of-Illness Limitation

Date: June 18, 2026 

Attention: Providers

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that Texas Medicaid is conducting a utilization review of inpatient claims with dates of service from May 23, 2024, through April 21, 2026, to determine whether the claims were paid outside the spell-of-illness limitation, which is 30 days of inpatient hospital care.

How this impacts providers: When Texas Medicaid has reprocessed the claims and finds that any excess payments should be recouped, they may deduct it from future payments. Deductions will appear on future Remittance and Status (R&S) Reports.

For information about the spell-of-illness limitation and exceptions to it, providers can refer to the Texas Medicaid Provider Procedures Manual (TMPPM), Inpatient and Outpatient Hospital Services Handbook.

Next step for Providers: Providers should share this information with their staff. Texas Medicaid managed care organizations (MCOs) like Texas Children’s Health Plan (TCHP) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO/TCHP. Administrative procedures, such as prior authorization, precertification, referrals, claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should reference a member’s specific MCO/TCHP for information on these items. For TCHP, this information can be found on the provider page available at https://www.texaschildrenshealthplan.org/providers.

If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org. 

For access to all provider alerts www.texaschildrenshealthplan.org/provideralerts.