Revision 12-2; Effective June 1, 2012

Form H3086, Explanation of Benefits (EOB), is mailed each month to a random sample of Medicaid recipients. The EOB is a statement of all Medicaid services that were billed and paid on the recipient's behalf in the preceding month.

The EOB is mailed with a return envelope. If a recipient has a question about reported Medicaid services, the recipient circles the service in question, enters a contact telephone number and returns the EOB to state office. The recipient can call 1-800-252-8263 if questions arise about the EOB information.

If a recipient contacts HHSC about a questionable EOB, explain the purpose of the EOB. If a question still exists, instruct the recipient to mail the EOB to:

Office of Inspector General/Medicaid Provider Integrity
Mail Code 1361
P.O. Box 82500
Austin, TX 78708-9920

If the EOB is readily available, record on the EOB the recipient statement about the discrepancy. (Example: "Client states she has never seen a Dr. Jones.")

After an EOB is returned to state office, the EOB analyst checks the service in question for possible billing errors. If a billing error is found, appropriate action is taken to correct the files. The EOB analyst notifies the recipient that correction has been made. If no billing error can be found, the EOB is referred to the appropriate local office for a contact with the recipient.

When an EOB from state office is received, attempt to contact the recipient and discuss the reason for returning the EOB. The contact may be by telephone, office visit or home visit. Do not contact the provider of service under any circumstance.

If the recipient did not understand the purpose of the EOB, or if the problem can be resolved by talking to him/her, check the appropriate box on the EOB-Form Letter (FL) 1 and return the EOB-FL 1 and EOB to state office.

If the recipient alleges that the service in question was not received, reports an additional charge or reports other problems in relation to the service questions, check the appropriate box, record the recipient's statement in the space provided on the EOB-FL 1 and return the EOB-FL 1 and EOB to state office. (A cover memorandum is not necessary.) After the EOB is returned to state office, the EOB is referred to the Texas Medicaid and Healthcare Partnership (TMHP) for further investigation, and no further action on the part of the eligibility specialist is required.

If a provider of services has questions about an EOB, explain the purpose of the EOB. If additional information is requested, or a service listed is in question, ask the provider to telephone TMHP using the provider contact information below:

• Automated Inquiry System (AIS) – 1-800-925-9126
• TMHP Contact Center – 1-800-925-9126

Reminder: Only services billed and paid appear on the monthly EOB.