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3.1.4.2 More Than Fifty Miles From the Texas State Border
Requests for medical services provided by an out-of-state provider must be submitted to the CSHCN Services Program for consideration.
The CSHCN Services Program may approve coverage of services that are within the scope of the CSHCN Services Program, provided by health-care providers located within the United States, and more than 50 miles from the Texas border. The CSHCN Services Program participating physician, client, parent or guardian, and CSHCN Services Program medical director may agree in unique circumstances that:
• An out-of-state provider is the provider of choice for quality care.
•The same treatment or another treatment of equal benefit or cost is not available from Texas CSHCN Services Program providers.
•The out-of-state treatment should result in a decrease in the total projected CSHCN Services Program cost of the client's treatment.
•Medical literature indicates that the out-of-state treatment is accepted medical practice and is expected to improve the client's quality of life.
The limitations listed above do not apply to coverage for or payment to CSHCN Services Program providers of selected products or devices such as medical foods or hearing amplification devices, which are always less costly or are only available from out-of-state sources.
Inpatient and outpatient reimbursement rates for providers located more than 50 miles from the Texas state border are negotiated. Physicians may be reimbursed according to the Texas Medicaid Reimbursement Methodology (TMRM), unless the procedure is normally priced by another methodology. The CSHCN Services Program may cover the costs of transportation and associated meals and lodging for a client and, if necessary, a responsible adult for travel to and from the location of out-of-state services that meet program approval. Travel costs are negotiated, and the approval of specific travel options is based on overall cost-effectiveness.
The provider must enroll in the CSHCN Services Program to be reimbursed. Specialty team or center requirements do not apply. Filing deadlines apply, but routine authorization requirements and procedures do not apply, as special, advance approval must be given by the CSHCN Services Program.
Enrollment applies only to the services approved for an individual client. After the approved claims are processed for the out-of-state services, the provider's enrollment and identifying numbers are discontinued. No additional services are paid.
For more information, contact the CSHCN Services Program by telephone at 1-800-252-8023 or by mail at:
CSHCN Services Program
Purchased Health Services Unit, MC-1938
Texas Department of State Health Services
PO Box 149347
Austin, TX 78714-9347
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