Fillable Texas Medicaid Refund Information Form printable pdf download

Texas Medicaid Refund Information Form

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Texas Medicaid Refund Information Form

To refund a Texas Medicaid payment to TMHP, complete this form and attach the refund check. Make the refund check

payable to TMHP, and include a copy of the corresponding Texas Medicaid Remittance and Status (R&S) report that

shows the remitted payment. Mail the completed form, the refund check, and the R&S report to the TMHP-Financial

Department at the following address:

Texas Medicaid & Healthcare Partnership Financial Department

12357-B Riata Trace Parkway Suite 100

Austin, TX 78727

A. Provider Information

Provider Name (please print):

TPI:

NPI:

Taxonomy:

Contact Name (please print):

Telephone Number with Extension:

E-mail Address:

B. Claim Information

Apply refund to claim ICN number (from Texas Medicaid R&S report):

Patient’s Name:

Patient’s Medicaid Number (PCN):

Date(s) of Service (DOS):

C. Reason for the Refund (Choose One)

F TMHP audit identified overpayment

F Other Insurance paid $ _________ on this claim.

Instructions: If the submitted refund is because

F Duplicate Medicaid payment

of another insurance payment, attach the other

F Claim paid on wrong provider’s Medicaid TPI/NPI/API

insurance Explanation of Benefits [EOB] document

that shows the payment. If no EOB is available,

F Billing error

complete the following:

F Late credit for blood or pharmacy

F Patient’ Medicare eligibility

• Insurance Co. Name:

F Credit balance refund

• Address:

F Claim paid on wrong patient’s Medicaid ID number

• Telephone Number:

F Above named person is not our patient

• Policy Number:

F Service was not rendered as billed

• Group Number:

F Other refund reason (describe in detail):

Provider Signature (stamped signatures not accepted)

Date

Revised: 06/19/2015 | Effective: 08/01/2014

F00079

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Texas Medicaid Refund Information Form

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