Provider Alert! Reminder: Texas Children’s Health Plan Claims Editing System (CES) Update

Attention:  All Providers

Update: Texas Children’s Health Plan Claim Editing System

Texas Children’s Health Plan (TCHP) recently sent a Provider Alert updating our plan to transition to a new Claims Editing System (CES) by Optum on May 31, 2019. Please be advised this transition will now include edits specific to Texas and National Medicaid and the transition will occur in June 2019. This was initially scheduled to be done later in the year as another phase of the project, however we decided it would be less disruptive to complete the transition at the same time.

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

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