Claims Submission: Starting September 1, 2019, Medicaid providers currently required to use electronic visit verification (EVV) must submit all claims for EVV-relevant services, with a date of service on or after September 1, 2019, to the Texas Medicaid Healthcare Partnership (TMHP) via TexMedConnect or Electronic Data Interchange (EDI) for the new EVV claims matching process to be performed.
Providers enrolled with Medicaid through TMHP, but who do not currently submit claims to TMHP, must establish a Compass 21 (C21) Submitter ID. Provider who wish to submit through EDI must also establish a Receiver ID.
Long-Term Services and Supports (LTSS) providers enrolled through HHSC must establish both a C21 Submitter ID and Receiver ID to submit claims to TMHP through EDI starting September 1, 2019. LTSS providers may not submit claims through TexMedConnect.
Providers who submit claims for dates of service on or after September 1, 2019 to their managed care organization (MCO) will have their claims denied or rejected and the MCO will inform the providers to submit their claims to TMHP.
Claims Matching Process: Upon receipt of a claim with EVV-relevant services, TMHP will perform the claims match by comparing the claim data to the EVV visit data that was previously sent to the EVV Aggregator at TMHP. The EVV Aggregator is a centralized database that collects, validates, and stores statewide EVV visit data transmitted by an HHSC-approved EVV system. Once the EVV claims matching process has been performed, all claims will be forwarded to the appropriate MCO for final processing.
If the following data elements do not match, the MCO must deny the claim:
• National Provider Identifier or Atypical Provider Identifier
• Date of Service
• Medicaid Identifier of the individual
• Service Identifier as Healthcare Common Procedure Coding System and any associated Modifier(s)
• Units of service delivered
Only pre-payment claims matching will be conducted and payers will no longer pay any unmatched claims. If you are using a third-party submitter, please notify them to prepare for this change.
For questions regarding TexMedConnect or EDI contact TMHP.
To obtain a C21 Submitter ID and/or a Receiver ID contact the TMHP EDI Helpdesk at 1-888-863-3638.
Visit the TMHP EDI Homepage for additional information.