Third Party Liability Reminder – Medicaid Managed Care Provider Requirements

Date: November 27, 2024

Attention: All Providers

Background information: The Texas Health and Human Services Commission (HHSC), Office of Inspector General-Third Party Recoveries division (OIG-TPR) has recently seen a high number of escalations due to a Medicaid provider refusing to see a Medicaid Member because the Medicaid Member has other health insurance.

Providers who participate in Texas Medicaid may not refuse services to eligible Medicaid Members due to potential other health insurance coverage. Additionally, providers are reminded that 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 Texas Children’s Health Plan (TCHP) for any additional allowable reimbursement.

TCHP would like to remind providers that they cannot refuse services to an eligible Medicaid Member because the Medicaid Member may have other health insurance coverage, and the Medicaid Member cannot be held responsible for charges exceeding a TPL payment for services covered by Texas Medicaid.

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

For access to all provider alerts, log into: www.texaschildrenshealthplan.org/provideralerts