MedicaidAdministrativeMedium impact
Issue Identified for Managed Care Carve-Out Services Claims
Texas Medicaid·TX · Family Medicine, Internal Medicine, General Practice·General
We identified it
Jan 30, 2026
Summary
TMHP identified an error causing incorrect denials of managed care carve-out claims due to missing primary care provider information in eligibility records. TMHP will automatically reprocess affected fee-for-service claims submitted on or after June 9, 2025, that were denied with specific EOB codes 00088 or 00091, potentially resulting in additional payments.
Action Required
No immediate action required from billing team. TMHP will automatically reprocess affected claims that were denied with EOB codes 00088 (consults not approved by PCP) or 00091 (adult physical exams must be performed by PCP). Monitor future Remittance and Status Reports for additional payments from reprocessed claims. Contact TMHP at 800-925-9126 for questions about specific claims.