MedicaidAdministrativeMedium impact
Review of Inpatient Claims for Spell-of-Illness Limitation
Texas Medicaid·TX·General
We identified it
Jun 13, 2026
Summary
Texas Medicaid is conducting a utilization review of inpatient claims from May 23, 2024, through April 21, 2026, to identify claims paid outside the 30-day spell-of-illness limitation. Excess payments may be recouped through deductions from future payments, which will appear on Remittance and Status (R&S) Reports.
Action Required
Immediately: Billing team should review all Texas Medicaid inpatient claims from May 23, 2024, forward to ensure compliance with the 30-day spell-of-illness limitation. Monitor future R&S Reports for potential payment deductions. Reference the Texas Medicaid Provider Procedures Manual (TMPPM), Inpatient and Outpatient Hospital Services Handbook for spell-of-illness limitations and exceptions. Contact TMHP Contact Center at 800-925-9126 for questions.