An official State of Texas website.
Revision 20-4; Effective December 1, 2020
There are two methods of Third-Party Recovery (TPR):
- cost avoidance, in which available third-party benefits are applied before Medicaid payment is made. This is the method of Third-Party Recovery required by the Centers for Medicare and Medicaid Services (CMS); and
- post-payment recovery, where Medicaid pays the medical costs before seeking reimbursement. This method is typically used when Medicaid is unaware of the TPR at the time of billing or the TPR is not eligible for use at the time of billing (e.g., a trust or annuity).
HHSC uses the cost avoidance method of TPR for Medicaid payments to nursing facilities (NF), hospice providers, and non-state intermediate care facilities for persons with intellectual disabilities (ICF/IID). The cost avoidance method requires providers to bill the recipient’s long-term care insurance (if applicable) before billing Medicaid. This ensures that Medicaid is the payer of last resort.
A Medicaid recipient must reimburse HHSC as soon as they receive a third-party payment for medical services already paid by Medicaid.
A provider who receives a third-party payment for medical services already paid by Medicaid must process an adjustment claim and report the third-party payment amount on the claim. The Medicaid paid claim is reduced by the amount of the other insurance payment reported on the adjustment claim.
Providers can contact Texas Medicaid and Healthcare Partnership (TMHP) for assistance with adjustment claims at 800-626-4117, option 3.
Providers may contact TMHP at 800-626-4117, option 6 to report other insurance coverage for a Medicaid recipient.
D–7410 Cost Avoidance
Revision 18-1; Effective March 1, 2018
Inform the person to:
- use health insurance as a resource;
- tell medical providers that the person has insurance coverage; and
- show providers any insurance identification card the person may have.
| If the person, the employer or other sources indicate that ... | then complete ... |
|---|---|
| Medicaid-eligible household members have private health insurance coverage, | information about the private health insurance on:
|
| health insurance coverage is available for Medicaid-eligible household members, but the members are not enrolled in the health insurance plan, | information about the available health insurance on:
|
To contact the TPR Unit with questions or problems concerning TPR:
- HHSC staff may email MCD_Third_Party@hhsc.state.tx.us.
- Medicaid recipients and providers may call the Medicaid TPR Hotline at 800-846-7307, option 2.
HIPP Program Notes: Individuals approved for the HIPP Program receive reimbursement for the employee’s portion of an employer-sponsored health insurance premium payment. For eligibility and co-payment calculations, HIPP reimbursement checks are not considered income. For co-payment calculations, the reimbursed health insurance premium payment is not considered an incurred medical expense.
TMHP will take action to deny all benefits to a recipient who voluntarily drops his or her health insurance coverage or fails to provide TMHP with the information needed to determine cost effectiveness.
A recipient cannot appeal decisions made by TMHP. To obtain assistance in resolving problems or issues concerning HIPP, contact the TPR HIPP Unit at 800-440-0493.
For more information about the HIPP program, see HHS' HIPP website: https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program.
Recipients may also call 800-440-0493 for more information.
D–7420 Post-Payment Recovery
Revision 18-1; Effective March 1, 2018
Major sources for post-payment recovery are liability or casualty insurance and court settlements resulting from accidental injuries. If a recipient reports an injury that requires medical treatment for which liability or casualty insurance may provide payment, ask the recipient to provide the date of the accident.
Report the recipient’s name, Medicaid number, and date of the accident to the HHSC TPR Unit and Provider Recoupment and Holds.
Third Party Recovery
HHSC OIG/TPR Unit
Mail Code 1354
4900 North Lamar Blvd.
Austin, TX 78751
Information can be sent via email to:
MCD_Third_Party@hhsc.state.tx.us; and
Provider Recoupments and Holds
Texas Health and Human Services Commission
Mail Code W-406
P.O. Box 149030
Austin, TX 78714-9030
701 W. 51st Street
Austin, TX 78751
When the TPR Unit at HHSC becomes aware of accidental injuries, it will seek cost recovery from recipients who receive a health insurance or settlement payment for medical services already paid by Medicaid.
Use Form H1210, Subrogation (Trusts/Annuities/Court Settlements), to report to Provider Claims any potential subrogation funds available from trusts, annuities and court settlements.
When a recipient reimburses HHSC for medical expenses, the reimbursement should be in the form of a personal check, cashier's check or money order. If reimbursement is received from a recipient, follow these steps:
| Step | Procedure |
|---|---|
| 1 | Give the recipient Form H4100, Money Receipt. |
| 2 | Enter the types and dates of the medical services in the "For" section of Form H4100. |
| 3 | If unsure about which medical services are involved, attach a memorandum giving as much information as possible about the reimbursement. |
| 4 | Attach a copy of any other information identifying the nature of the payment, such as a statement from the insurance company. |
| 5 | Send the reimbursement, a copy of Form H4100, and other information, if any, to HHSC Accounts Receivable, P.O. Box 149055, Mail Code 1470, Austin, TX 78714-9055. |
State office verifies the actual claims paid by Medicaid and refunds any overpayment.