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

Attention:  All Providers
Reminder: Texas Children’s Health Plan Claim Editing System Update

Texas Children’s Health Plan (TCHP) previously sent a Provider Alert notifying providers that an intended transition to a new Claims Editing System (CES) by Optum was to occur in December 2018. Please be advised that this transition will now be occurring May 31, 2019.  Any claims submitted May 31, 2019 and after, including corrected and adjusted claims, will be processed with the Optum CES edits.

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.  Please note the transition on May 31^st is Phase 1, which includes edits that are applied by the current claims editing system.  Phase 2 will include additional edits specific to Texas and National Medicaid.  We will send notice of Phase 2 implementation once we have a specific timeframe.

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.

Providers are required to bill following the guidance of the CMS and 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

If you have any questions regarding our new system, please contact our Texas Children’s Health Plan Customer Service department at 832-828-1004 or toll-free at 1-877-213-5508.

Provider Network Management
Texas Children’s Health Plan