Fee Schedules Frequently Asked Questions
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1. Q: What is the difference between static fee schedules and Online Fee Lookup?
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A: Static fee schedules are updated quarterly with the fees that are in effect at
the beginning of the quarter. The Online Fee Lookup provides up-to-date information
and provides historical fee information on procedure codes.
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2. Q: Why aren't all of my provider identifiers available for selection?
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A: When using a provider identifier to display corresponding fee schedules, you can
select from only the provider identifiers that are linked to your TMHP.com account.
If the provider identifier you want is not listed, refer to the TMHP Portal Security
Provider Training Manual for instructions on linking the provider identifier to
your account.
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3. Q: What does a quarterly summary report show me?
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A: A quarterly summary report lists changes to any procedure code since the last
static fee schedule was published. The quarterly summary is in addition to provider
notifications through banner messages, website articles, and bulletins.
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4. Q: Where can I find a previous quarter's static fee schedule?
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A: The bottom of the static fee schedule page includes links to the archived fee
schedules.
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5. Q: What does a blank Fee End Date mean?
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A: If the Fee End Date field is blank, the fee associated with that procedure code
was still in effect when the static fee schedule was generated.
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6. Q: How are rates calculated?
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A: Texas Medicaid reimburses most providers based on published rates, which are uniform
statewide by provider type. Providers are paid the lower of the billed charges or
the Texas Medicaid rate published in the applicable fee schedule. These rates are
calculated in accordance with the referenced reimbursement methodology as published
in the Texas Administrative Code (TAC), Part 1 Administration, Part 15 Texas Health
and Human Services Commission (HHSC), and Chapter 355 Reimbursement Rates. Some
providers have rates established by contract with the state, provider specific based
on state wide, encounter or interim rates. These specific rates can be viewed using
Online Fee Lookup.
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7. Q: Are benefit limitations available on static fee schedules?
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A: No. Benefit limitations are available only on the Online Fee Lookup.
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1. Q: Why aren't all of my provider identifiers available for selection?
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A: When using a provider identifier to display corresponding fee schedules, you can
select from only the provider identifiers that are linked to your TMHP.com account.
If the provider identifier you want is not listed, refer to the TMHP Portal Security
Provider Training Manual for instructions on linking the provider identifier to
your account.
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2. Q: I entered a procedure code and received an error message. What happened?
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A: Users will receive an error message if they enter an invalid procedure code or
if the procedure code is not a benefit to the provider type or NPI selected. Procedure
codes that are not a benefit may still be payable if it is a covered 1905(a) service,
is medically necessary and the client is under 21 years of age
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3. Q: What happens if I do not see a fee for a procedure code with a specific
type of service, e.g., is the interpretation payable:?
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A: Only those procedures that are payable will return results. If a specific type
of service is not displayed, the procedure is currently not set up to pay that component
of the procedure.
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4. Q: Are the fees real time?
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A: Yes, but only if you are searching for 10 procedure codes or fewer. You must search
for the following using a batch search:
- 11 to 50 procedure codes
- A range of procedure codes
- All procedure codes that apply to a provider identifier or provider type and specialty
Batch results are available within 36 hours. You can click on the Batch Search
link on the left side of the page to retrieve batch search results.
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5. Q: Is there a maximum number of transactions I can submit?
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A: No. You can submit an unlimited number of transactions.
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6. Q: Can I see fee changes that were made today?
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A: This function is not available.
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7. Q: What are note codes?
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A: Note codes indicate specific payment explanation or limitations including place
of service limitations. You can click on a note code to view its description.
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8. Q: What is a contracted rate search?
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A: Some provider types have rates that are defined in a contract. You can view your
contracted rates by clicking the Contracted Rate Search link on the Online
Fee Lookup.You must be logged in to the TMHP website at www.tmhp.com to access this
functionality. If you have a CSN or DM3 benefit code, you must select Children with
Special Health Care Needs as your program.You might get incorrect fee results
if you select the incorrect program your provider identifier.
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9. Q: What is a benefit limitation?
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A: Benefit limitations describe any limitations on a procedure code (e.g., how many
times per month the service can be provided). Currently, benefit limitations are
only displayed for durable medical equipment and dental procedure codes.
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10. Q: What is the 24-month history?
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A: Starting June 27, 2009 TMHP will begin to compile a 24-month history of all procedure
codes. The history will include any changes to the type of service, provider type,
modifiers, client age, resource-based fee, total relative value units (RVUs)/base
units, conversion factor, Prospective Payment System (PPS) fee, maximum fee, fee
effective date, or fee end date. By clicking Include 24-Month History, you
will be able to retrieve up to a 24-month history of any changes to this information
going back to June 27, 2009.
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11. Q: What about fees for dates of service before June 27, 2009?
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A: For a date of service before June 27, 2009, you can enter the date of service
in your search on the Online Fee Lookup to view the fee that was in effect for that
date of service.
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1. Q: What is a batch search?
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A: A batch search is used to perform the following searches:
- 11 to 50 procedure codes
- A range of procedure codes
- All procedure codes that apply to a provider identifier or provider type and specialty
Batch results are available within 36 hours.
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2. Q: How long does a batch search stay on the portal?
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A: 120 Days.
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3. Q: Is there a maximum number of transactions I can submit?
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A: No. You can submit an unlimited amount of transactions.
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4. Q: Where do I find my batch number?
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A: When you submit a batch search request, the Online Fee Lookup generates a batch
number. Batch results are ready within 36 hours of submission. To get the results
of your batch search, go back to the Online Fee Lookup, click Batch Search,
and enter the batch number.
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