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5.6.2.4 Determining Benefits for New HCPCS Procedure Codes
The CSHCN Services Program adopts the new codes that are direct replacements of discontinued codes at the discontinued codes reimbursement rate. The new HCPCS procedure codes that are not directly replacing discontinued codes require a rate hearing to determine an appropriate Texas Medicaid reimbursement rate. The Health and Human Services Commission (HHSC) conducts public rate hearings to provide an opportunity for the provider community to comment on the Medicaid proposed payment rate. After the rate hearings are complete for each procedure code, the CSHCN Services Program makes the determination to adopt the Texas Medicaid rate established through the rate hearing process or to adopt the rate of a similar discontinued code.
Claims for procedure codes that require a rate hearing as indicated in the HCPCS Special Bulletin that is published at the beginning of each year must be submitted within the initial 95-day filing deadline. The most appropriate procedure code for the service provided must be submitted. Services provided are denied as pending a rate hearing (EOB 02008) until the applicable reimbursement rate is adopted.
Once the Medicaid reimbursement rate has been determined through the rate hearing process, the CSHCN Services Program will evaluate the proposed rate to determine whether alignment with the Medicaid rate is fiscally feasible. Once reimbursement rates are established in the rate hearing, evaluated by the CSHCN Services Program, and applied, TMHP will reprocess the claim. No action on the part of the provider is necessary. Providers are notified of the implementation date and reprocessing efforts. The client cannot be billed for these services.
For those procedures requiring authorization or prior authorization, providers must follow the established authorization/prior authorization processes as defined in the current CSHCN Services Program Provider Manual, and must obtain a timely authorization or prior authorization for services provided. Providers must not wait until the procedure codes have completed the rate hearing process to request an authorization or prior authorization.
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