Review of Inpatient Claims for Spell-of-Illness Limitation
AI Summary
Texas Medicaid is conducting a utilization review of inpatient claims from February 1, 2024 through December 20, 2025, to identify payments made beyond the 30-day spell-of-illness limitation. Any excess payments found will be recouped from future payments and shown on Remittance and Status Reports.
Action Required
Immediately: Billing team must review all Texas Medicaid inpatient claims with dates of service from February 1, 2024 through December 20, 2025 to identify potential spell-of-illness violations. Monitor future Remittance and Status Reports for recoupment deductions. Consult the Texas Medicaid Provider Procedures Manual, Inpatient and Outpatient Hospital Services Handbook for spell-of-illness limitations and exceptions. Contact TMHP at 800-925-9126 for questions about potential recoupments.
Plan Types
Medicaid
States
TX
Specialties
hospitalist, all-specialties