Provider Alert! Texas Children’s Health Plan Claim Editing System Update

Attention:  All Providers
Subject: Texas Children’s Health Plan Claim Editing System Update
Effective: 12/27/2018

Texas Children’s Health Plan intends to transition to a new Claims Editing System (CES) by Optum on 12/27/2018. Please be aware that claims submitted prior to 12/27/2018 will continue to be processed by our current vendor, McKesson Claim Check.

TCHP is required by Texas Health and Human Services to ensure all required claims edits are consistently applied. Migrating to Optum CES will enable TCHP to efficiently apply all required coding edits and to increase the accuracy and timeliness of claims payment resulting in a net reduction in claims resubmissions.

This transition will be seamless with no action required to be taken by network providers.

How does this change impact you as a Texas Children’s Health Plan network provider?

• Increased accuracy and consistency regarding claims processing according to Centers for Medicare and Medicaid (CMS) and Texas Health and Human Services guidelines.
• Efficient claims payment
• Reduction in claim resubmissions

Providers are required to bill following the guidance of the Center for Medicare and Medicaid Services as well as Texas Health and Human Services guidelines. TCHP will ensure compliance with these guidelines by utilizing the Optum CES coding compliance system.  All providers should stay current with these guidelines by visiting http://www.tmhp.com/Pages/Medicaid/Medicaid_home.aspx which includes all applicable compliance guidelines.

Medicaid National Correct Coding Initiative (NCCI) edits may be found at: https://www.medicaid.gov/medicaid/program-integrity/ncci/edit-files/index.html

Any changes to the timing of the transition will be announced. If you have any questions regarding our new system, please contact our Texas Children’s Health Plan Customer Service department at 832-828-1008 or toll-free at 1-877-213-5508.

Provider Network Management
Texas Children’s Health Plan