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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Texas Medicaid Patient Verification

Verify electronically through TMHP EDI. Providers may inquire about a patient’s eligibility by electronically submitting one of the following for each patient:

    • Medicaid or Children with Special Health Care Needs (CSHCN) Services Program identification number.
    • One of the following combinations: Social Security number and last name; Social Security number and date of birth; or last name, first name, and date of birth. Providers can narrow the search by entering the patient’s county code or sex.
    • Submit electronic verifications in batches limited to 5,000 inquiries per transmission.
    • Verify the patient’s Medicaid eligibility using the Medicaid Eligibility Verification (Form H1027) or by accessing the Your Texas Benefits Medicaid website at www.yourtexasbenefitscard.com.
    • Contact the TMHP Contact Center or AIS at 1-800-925-9126 or 1-512-335-5986.
    • Submit a hard-copy list of patients to TMHP. This service is only used for patients with eligibility that is difficult to verify. A charge of $15 per hour plus $0.20 per page, payable to TMHP, applies to this eligibility verification. The list includes names, gender, and dates of birth if the Social Security and Medicaid ID numbers are unavailable. TMHP can check the patient’s eligibility manually, verify eligibility, and provide the Medicaid ID numbers. Mail the lists to the following address:

Texas Medicaid & Healthcare Partnership Contact Center

12357-A Riata Trace Parkway

Suite 100 Austin, TX 78727

Managed Care

Providers can obtain patient eligibility information for a patient who is enrolled in a Medicaid managed care organization (MCO) from the MCO’s web page. Providers can also check the MCO’s web page for submission of electronic claims, prior authorization requests, claim appeals and reconsiderations, exchange of clinical data, and other documentation necessary for prior authorization and claim processing.

Advantages of Electronic Eligibility Transactions

Eligibility transactions through TexMedConnect or EDI have the following advantages:

  • Submissions are available 24-hours a day 7 days a week.
  • Submission of EDI batches of 5000 per transmission.
  • Submission of patient group lists through TexMedConnect. Providers can create lists of patients to verify eligibility. 
  • Each patient group can contain up to 250 patients, providers can create up to 100 groups for each National Provider Identifier (NPI). Electronic eligibility responses contain:
    • Restrictions applicable to the patient’s eligibility such as lock-in, emergency, or womens health.
    • Medicare eligibility and effective dates, including Part A, B, and C.
    • Complete other insurance information, including name and address, and effective dates. EDI transactions also indicate the patient relationship to policy holder.
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