SECTION 354.2356. Provider Requirements to Bill Third Party Health Coverage

(a) To the extent allowed by federal law, a health care service provider must seek reimbursement from any third party resource that the provider knows about or should know about before billing Medicaid, except for Medicaid programs and services that are required to be paid first prior to billing the third party resource.

(b) Providers cannot bill Medicaid recipients for copayments, deductibles, or coinsurance for Medicaid-covered services. If a recipient's third party resource does not cover a copayment, deductible, or coinsurance, the provider must bill Medicaid for reimbursement of the copayment, deductible, or coinsurance, as follows.

(1) Deductible or coinsurance: Include the explanation of benefits from the third party resource with the claim showing the payment amount was applied directly to the recipient's deductible or coinsurance.

(2) Copayment: Include the copayment code on the claim form in order to be eligible for reimbursement.

Source Note: The provisions of this §354.2356 adopted to be effective March 28, 2004, 29 TexReg 2867; amended to be effective February 22, 2024, 49 TexReg 855