Managed Care Denials
Most Texas Medicaid members receive services through this type of plan instead of fee-for-service.
What is managed care?
A payment notification was received on 03/01/2026, and the payment has not yet been posted. When documenting the claim in Statewise, this is the appropriate claim status to select.
What is Paid in Full – Within Last 30 Days?
This system is required in Texas to electronically confirm PDN visits.
What is EVV (Electronic Visit Verification)?
This is required before PDN services begin, and missing it often results in denial.
What is prior authorization?
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Each MCO may have its own requirements for this submission before approving PDN hours.
What is clinical documentation submission?
A claim review shows it is still processing with no new updates. A note is entered in Statewise stating the claim remains in process. The following month, it appears on your aging report for follow-up. This statement is true or false: The claim should not have appeared on the aging report.
What is False?
A denial may occur if the clock-in and clock-out times do not match these authorized hours.
What are approved service hours?
This occurs when submitted nursing hours exceed what was approved by the payer.
What is exceeding authorized hours?
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What is Jeopardy!?
This process allows providers to challenge a denied claim.
What is an appeal?
A claim has denied for timely filing, all reconsideration and appeal options have been exhausted, and the claim has been determined to be a write-off. This is the correct claim status to select before completing the appropriate next steps.
What is RCM Manager – Pending Write-Off Review?
This common EVV issue happens when the nurse forgets to clock out.
What is a missing clock-out?
This documentation must support medical necessity for PDN services.
What is a physician’s order and plan of care?
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What is The Office?
This must often be submitted within a specific number of days after receiving a denial.
What is a reconsideration or appeal request?
An updated response has been received from a provider representative regarding a previously submitted outstanding project. After revising and resubmitting your responses, this is the correct claim status to document in Statewise.
What is Payer Project?
If EVV location data does not match the member’s approved service address, this may trigger denial.
What is a location mismatch?
Claims may be denied if this required visit verification system data is missing or incomplete.
What is EVV (Electronic Visit Verification)?
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Failure to verify eligibility before billing can result in this type of denial.
What is an eligibility denial?
A claim appears to be short paid, but upon review, you identify a payer rounding rule impacting the reimbursement amount. This is the appropriate claim status to select in Statewise.
What is RCM Manager – Adjustment Review?
Failure to correct EVV exceptions within required timeframes may result in this.
What is a compliance denial?
This happens when services are billed outside the approved authorization date span.
What is billing outside the authorization period?
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