Medicaid & Medicaid HMO Insurance

Traditional Medicaid
You get traditional Medicaid if you are not in the PCCM, STAR, or STAR+PLUS plans.

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Primary Care Case Management (PCCM)

Texas Medicaid and Healthcare Partnership (TMHP)

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STAR

Aetna Medicaid

AMERIGROUP Community Care

Community First Health Plans

Community Health Choice

Cook Children’s Health Plan

Driscoll Children’s Health Plan

El Paso First Premier

FirstCare Health Plans

Molina Healthcare of Texas

Parkland Healthfirst 

Superior HealthPlan

Texas Children’s Health Plan

Unicare Health Plans

UnitedHealthcare
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STAR+PLUS


AMERIGROUP Community Care

Evercare

Molina Healthcare of Texas 

Superior HealthPlan

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Children’s Health Insurance Program Health Plans

Children in the Children’s Health Insurance Program (CHIP) get their health and medical services through a health plan in their area. Some CHIP health plans also offer services to mothers who are pregnant. This is called CHIP perinatal coverage. 
You can find the CHIP health plans in your area by using the CHIP Health Plan Search tool.
CHIP Health Plans
Aetna Medicaid


AMERIGROUP Community Care

CHIP Member Handbooks:

Community First Health Plans

Community Health Choice

Cook’s Children’s Health Plan

Delta Dental

Driscoll Children’s Health Plan

El Paso First Premier

FirstCare Health Plans

Mercy Health Plans

CHIP Perinatal Coverage Handbooks: 

Molina Healthcare of Texas

Parkland Healthfirst 

Seton Healthplan

Texas Children’s Health Plan
  
Unicare Health Plans

United Healthcare Texas

Birth day Rule

For your children's coverage, the primary carrier is generally determined by the birthday rule: coverage of the parent whose birthday (month and day, not year) comes first in the year is considered to be your children's primary coverage. The birthday rule may be superseded by a divorce agreement or other court ruling.

Important Denial Codes:

1 – Deductible amount

2 – Coins's amount

3 – Copay amount

4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.
5 - The procedure code/bill type is inconsistent with the place of service.
6 - The procedure/revenue code is inconsistent with the patient's age.
7 - The procedure/revenue code is inconsistent with the patient's gender.
8 - The procedure code is inconsistent with the provider type/specialty (taxonomy).
9 - The diagnosis is inconsistent with the patient's age.
10 - The diagnosis is inconsistent with the patient's gender.
11 - The diagnosis is inconsistent with the procedure.
12 - The diagnosis is inconsistent with the provider type.

15 - authorization number is missing, invalid, or does not apply to the billed services or provider

16 – Service lack information

18 – Duplicate

19-  Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

23 - Payment adjusted because charges have been paid by another payer

26- Expenses incurred prior to coverage.
27- Expenses incurred after coverage terminated.
29 - The time limit for filing has expired.

35 - Lifetime benefit maximum has been reached.

39 - Services denied at the time authorization/pre-certification was requested.

45 - Charges exceed your contracted/ legislated fee arrangement.

47 - This (these) diagnosis(es) is (are) not covered, missing, or are invalid

49 - These are non-covered services because this is a routine exam or screening procedure done in          conjunction with a routine exam.
50 - These are non-covered services because this is not deemed a `medical necessity' by the payer.
51 - These are non-covered services because this is a pre-existing condition

96 – Non-Covered charges

97 – Benefit Included for another service

109- Claim not covered by this payer

119 - Benefit maximum for this time period or occurrence has been reached

226 – Information requested for Billing/Rendering provider

234- Procedure is not paid separately