Table of Contents i Introduction Program History About the Provider Manual Feedback TMHP-CSHCN Services Program Contact Center Copyright Acknowledgments 1 TMHP and DSHS Contact Information TMHP-CSHCN Services Program Contact Information CSHCN Services Program Telephone and Fax Communication Written Communication with CSHCN Services Program TMHP-CSHCN Services Program Contact Center TMHP-CSHCN Services Program Automated Inquiry System (AIS) TMHP Regional Representatives TMHP Website Information Publications Search Capabilities for the CSHCN Services Program Provider Manual CSHCN Services Program Central and Regional Offices Central Office Regional Offices Region 1 Region 2 Region 3 Region 4 Region 5 North Regions 5 South and 6 Region 7 Region 8 Regions 9 and 10 Region 11 DSHS Health Service Regions Map 2 Provider Enrollment and Responsibilities Provider Enrollment Affordable Care Act of 2010 (ACA) Enrollment Requirements Medical Foods and Hospice Providers Enrollment for Ordering and Referring-Only Providers Changes in Enrollment Claim Filing Provider Identifiers Terminated After 24 Months of No Claim Activity Provider Enrollment Determinations Provider Enrollment Application Types of Providers Provider Information Form (PIF‑1), Principal Information Form (PIF‑2), and Disclosure of Ownership Form Provider Agreement Request for Taxpayer Identification Number and Certification Clinical Laboratory Improvement Amendments (CLIA) of 1988 Provider’s License Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) Transplant Specialty Centers Out-of-State Providers Substitute Physician Providers of Family Support Services Provider Complaints Process Provider Responsibilities Information Change Requests Required Updates General Medical Record Documentation Requirements Retention of Records Utilization Review: General Provisions Release of Confidential Information Waste, Abuse, and Fraud Provider Certification/Assignment Billing Clients Texas Family Code Compliance Child Support Abuse and Neglect Reporting Requirements TMHP-CSHCN Services Program Contact Center 3 Client Benefits and Eligibility Client Benefits Prescription Drug Benefits Medical Transportation Program (MTP) Benefits Services Provided Outside of Texas CSHCN Services Program Services and Supplies Limitations and Exclusions Client Eligibility CSHCN Services Program Application Criteria Eligibility Criteria Financial Eligibility Criteria Medical Eligibility Criteria and the Physician/Dentist Assessment Form (PAF) Medical Certification Definition Primary and Secondary Diagnoses Important Considerations When Completing the PAF CSHCN Services Program Eligibility Form Eligibility Restrictions CSHCN Services Program Eligibility Form Sample Clients Eligible for Medicaid and CSHCN Services Program Benefits Clients Eligible for CHIP and CSHCN Services Program Benefits Clients Eligible for Medicaid and Comprehensive Care Program (CCP) Benefits Medically Needy Program (MNP) MNP Spend Down Processing Provider Assistance to Clients with Spend Down Claims Filing Involving a Medicaid Spend Down Waiting List Information TMHP-CSHCN Contact Center 4 Prior Authorizations and Authorizations General Information Limitations Signature Requirements Requests for Procedures That Are Pending a Rate Hearing Authorizations Services that Require Authorization How To Submit an Authorization Request Prior Authorizations Services that Require Prior Authorization Prior Authorization for Inpatient Admission After Business Hours Retroactive Prior Authorizations How to Submit a Prior Authorization Request Extension of Filing Deadlines for Holidays Specialty Team or Center Services Authorization and Prior Authorization Denials Denied Authorization and Prior Authorization Requests Resubmission Administrative Review for Authorization and Prior Authorization Denials Fair Hearing TMHP-CSHCN Contact Center Authorization and Filing Deadline Calendar for 2012 Authorization and Filing Deadline Calendar for 2013 5 Claims Filing, Third-Party Resources, and Reimbursement TMHP Claims Information Claims Processed by TMHP Claims Processed by the CSHCN Services Program TMHP Processing Procedures Claims Processed by Date of Service Inactive Provider Termination Claims Filing Deadlines Exception to Claim Filing Deadline Fiscal Agent Payment Deadline Third-Party Resource (TPR) Health Maintenance Organization (HMO) CSHCN Services Program Eligibility Form Claims Filing Involving a TPR Verbal Denials by a TPR Filing Deadlines Involving a TPR Blue Cross Blue Shield (BCBS) Nonparticipating Physicians Refunds Refunds to TMHP Resulting From Other Insurance Accident-Related Claims Accident Resources and Refunds Involving Claims for Accidents Third-Party Liability for Claims Involving Accidents Multipage Claim Forms Tips on Expediting Paper Claims General requirements Data Fields Attachments Correction and Resubmission (Appeal) Time Limits Claims with Incomplete Information Other Insurance Appeals Resubmission of TMHP EDI Rejections TMHP EDI Batch Numbers, Julian Dates Authorization and Filing Deadline Calendar for 2012 Authorization and Filing Deadline Calendar for 2013 Coding Diagnosis Coding Procedure Coding Healthcare Common Procedure Coding System (HCPCS) National Correct Coding Initiative (NCCI) Guidelines Level I Level II Determining Reimbursement Rates for New HCPCS Procedure Codes National Drug Codes (NDC) Modifiers Type of Services (TOS) Place of Service (POS) Coding Benefit Code Claims Filing Instructions Claim Details Provider Types and Selection of Claim Forms Providers and Services Billable on CMS-1500 CMS-1500 Claim Form Provider Definitions CMS-1500 Electronic Billing CMS‑1500 Paper Claim Form Instructions CMS‑1500 Paper Claim Form Example UB-04 CMS-1450 Paper Claim Form Instructions UB-04 CMS-1450 Electronic Billing Instructions for Completing the UB-04 CMS-1450 Paper Claim Form Client Status (for block 17) Occurrence Codes (for blocks 31 through 34) POA Indicators (for blocks 67 and 72) UB-04 CMS-1450 Paper Claim Form Example Dental Claim Filing 2006 ADA Dental Claim Electronic Billing Instructions for Completing the Paper ADA Dental Claim Form Electronic Claims Submission Taxonomy Codes Dates on Claims Span Dates Hospital Billing Group Billing Supervising Physician Provider Number Required on Some Claims Ordering/Referring Provider NPI Reimbursement Electronic Funds Transfer (EFT) Advantages of EFT Enrollment Procedures One-day Payment Window Reimbursement Guidelines Texas Medicaid Reimbursement Methodology (TMRM) Maximum Allowable Fee Schedule Manual Pricing Physician Services in Hospital Outpatient Setting Fees Provider-Specific Rates for Procedure Codes with Modifiers and Age-Range Criteria CSHCN Services Program Reimbursement Information for Clients CSHCN Services Program Accounts Receivables (Using Medicaid Funds to Satisfy the AR) TMHP-CSHCN Services Program Contact Center 6 Remittance and Status (R&S) Reports R&S Report Information Electronic Remittance and Status (ER&S) Reports Banner Pages Explanation of R&S Report Row Headings Explanation of R&S Report Section Headings Claims—Paid or Denied Adjustments to Claims Financial Transactions Financial Transactions/Void and Stop—“Stale-Dated Checks” Claims Payment Summary Claims In Process EOB and EOPS Codes Section R&S Report Examples Physician R&S Report Example: Banner Page Physician R&S Report Example: Blank Page Physician R&S Report Example: Claims – Paid or Denied Physician R&S Report Example: Blank Page Physician R&S Report Example: Payment Summary Page Physician R&S Report Example: Explanation of Benefits (EOB) Page Ambulatory Surgical Center (ASC) R&S Report Example: Banner Page ASC R&S Report Example: Adjustments R&S Report ASC R&S Report Example: Blank Page ASC R&S Report Example: Adjustments R&S Report ASC R&S Report Example: Adjustments R&S Report ASC R&S Report Example: Adjustments R&S Report ASC R&S Report Example: Blank Page ASC R&S Report Example: Claims in Process R&S Report ASC R&S Report Example: Claims in Process R&S Report ASC R&S Report Example: Payment Summary Page ASC R&S Report Example: Explanation of Benefits (EOB) Page TMHP-CSHCN Services Program Contact Center 7 Appeals and Administrative Review Appeals Authorization and Prior Authorization Denials Administrative Review for Authorization or Prior Authorization Denials Fair Hearing Requests for Authorizations or Prior Authorizations Claim Appeals Electronic Appeal Submission Advantages of Electronic Appeal Submission Disallowed Electronic Appeals Electronic Rejections AIS Claim Correction and Resubmission (Appeals) Paper Appeals Total Billed Amount Changes Appeals Submitted Incorrectly Administrative Review for Claims Administrative Review Requirements Fair Hearing for Claims National Correct Coding Initiative (NCCI) Claims Appeals Provider Enrollment Appeals TMHP-CSHCN Services Program Contact Center Authorization and Filing Deadline Calendar for 2012 Authorization and Filing Deadline Calendar for 2013 8 Advanced Practice Registered Nurse (APRN [NP/CNS]) Enrollment Benefits, Limitations, and Authorization Requirements Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 9 Ambulance Enrollment General Information Origin and Destination Modifiers Place of Service Diagnosis Coding General Documentation Requirements Emergency Ambulance Transports Emergency Prior Authorization Levels of Service Emergency Medical Conditions Non-Emergency Ambulance Transports Nonemergency Prior Authorizations Types of Transport Multiple Client Transport Specialty Care Transport Air or Water Specialized Medical Services Vehicle Transport Out-of- Locality Transport Extra Attendant Extra Attendant - Emergency Ambulance Transports Extra Attendant - Nonemergency Ambulance Transports Oxygen Ambulance Disposable Supplies Mileage Waiting Time Relation of Service to Time of Death Ambulance Transport Services That Are Not Benefits Claims Filing and Reimbursement Claims Filing Emergency Ambulance Claims Non-emergency Ambulance Claims Billing Mileage with $0.00 National Correct Coding Initiative (NCCI) Guidelines Reimbursement One-day Payment Window Reimbursement Guidelines TMHP-CSHCN Services Program Contact Center 10 Augmentative Communication Devices (ACDs) Enrollment Benefits, Limitations, and Authorization Requirements Purchases or Rentals Prior Authorization Requirements for Purchase or Rental Modifications Prior Authorization Requirements for Modifications Repairs Prior Authorization Requirements for ACD Repairs Replacement Prior Authorization Requirements for Replacement Excluded Items Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 11 Blood Pressure Devices and Supplies Enrollment Benefits, Limitations, and Authorization Requirements Blood Pressure Devices Manual and Automated Blood Pressure Devices Hospital-Grade Blood Pressure Devices Blood Pressure Device Components Repair or Replacement Authorization Requirements Manual and Automated Blood Pressure Devices Hospital-Grade Blood Pressure Devices Blood Pressure Device Components Repair or Replacement Documentation of Receipt Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 12 Certified Registered Nurse Anesthetist (CRNA) Enrollment Benefits, Limitations, and Authorization Requirements Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 13 Certified Respiratory Care Practitioner (CRCP) Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 14 Dental Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements Diagnostic Services Prior Authorization Requirements Clinical Oral Evaluations Cone-Beam Imaging First Dental Home Radiographs or Diagnostic Imaging Tests and Oral Pathology Procedures Orthodontia Services Prior Authorization Requirements Required Documentation Submitting Local Codes for Orthodontic Procedures Preventive Services Authorization Requirements Oral Hygiene Instruction Dental Prophylaxis and Topical Fluoride Treatment Dental Sealants Space Maintainers Noncovered Counseling Services Therapeutic Services Prior Authorization Requirements Interrupted Treatment Plan Restorations Endodontics Periodontics Prosthodontics (Removable) and Maxillofacial Prosthetics Oral and Maxillofacial Surgery Adjunctive General Services Dental Anesthesia Dental Behavior Management Internal Bleaching of Discolored Tooth Noncovered Services Dental Treatment in Hospitals and ASCs Dental Hospital Calls Authorization and Prior Authorization Requirements Dental General Anesthesia Provided in the Inpatient or Outpatient Setting (Medically Necessary Dental Rehabilitation or Restoration Services) Doctor of Dentistry Services as a Limited Physician Authorization Requirements Surgery Cleft/Craniofacial Surgery by a Dentist Physician Evaluation and Management or Consultation Radiology and Laboratory Procedures Anesthesia by Dentist Physician Claims Information Dental Emergency Claims Tooth Identification (TID) and Surface Identification (SID) Systems Supernumerary Tooth Identification Reimbursement TMHP-CSHCN Services Program Contact Center 15 Diabetic Equipment and Supplies Enrollment Benefits, Limitations, and Authorization Requirements Glucose Monitor and Supplies Glucose Monitor Glucose Testing Supplies Glucose Tabs and Gel Prior Authorization Requirements Insulin Pump Prior Authorization Requirements Insulin and Insulin Syringes Documentation of Receipt Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 16 Diagnostic Radiology Services Enrollment Benefits, Limitations, and Authorization Requirements Diagnostic Radiology Services Provided by Hospitals Diagnostic Radiology Services Provided by Physicians, Advanced Practice Registered Nurses (APRNs), Physician Assistants, and Clinics Cardiac Blood Pool Imaging Computed Tomography (CT) Scan Contrast Material Magnetic Resonance Angiography (MRA) MRA Authorization Requirements Magnetic Resonance Imaging (MRI) MRI Authorization Requirements MRI Benefits and Limitations Mammography Certification Positron Emission Tomography (PET) X-ray and Ultrasound Procedures Diagnostic Imaging Interventional Radiological Procedures Abdominal Flat Plates (AFPs) and Kidney, Ureter, and Bladder (KUB) Reimbursement Information X-ray and Ultrasound Prior Authorization Requirements Noncovered Services Claims Information Reimbursement One-day Payment Window Reimbursement Guidelines TMHP-CSHCN Services Program Contact Center 17 Durable Medical Equipment (DME) Enrollment Custom DME Requirements Program Overview and Guidelines Custom DME Standard DME Program Guidelines Benefits, Limitations, and Authorization Requirements Adaptive Strollers Authorization Requirements Ambulation Aids Crutches, Walkers, Gait and Ambulation Belts, and Canes Breast Prosthesis Breast Prosthesis Prior Authorization Requirements Burn Care Garments Cochlear Implant Device Continuous Passive Motion (CPM) Device Enuresis Alarms Prior Authorization Requirements Gait Trainers (Supported or Sling Walkers) Authorization Requirements Hospital Beds (Manual and Electric) Authorization and Prior Authorization Requirements Pressure Reducing Pads Hospital Cribs and Enclosed Beds Hygiene Equipment Authorization Requirements Adaptive Feeder Seats Commode Chair Commode Chair with Integrated Seat Lifts Commode Seat Lift Mechanism Infusion Pumps Portable Paraffin Units Seat Lift Mechanism Special Needs Car Seats and Travel Restraints Car Seats Travel Restraints Standers, Prone or Supine Authorization Requirements TENS Units Transfer Boards Travel Chairs Prior Authorization Requirements Wheelchairs Wheelchair Authorization Requirements Manual Wheelchairs Custom Manual Wheelchairs Power Wheelchairs Approval Criteria for Power Wheelchairs Wheelchair Battery Wheelchair Positioning Equipment Wheelchair Power Elevating Leg Lifts Wheelchair Power Seat Elevation System Portable Wheelchair Ramps Noncovered Rehabilitative and Therapeutic DME Repairs and Modifications Documentation of Receipt Rental of Equipment Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 18 Expendable Medical Supplies Enrollment Benefits, Limitations, and Authorization Requirements Examples of Covered Supplies Diapers, Briefs, Pull-ups, and Liners Gastrostomy Devices Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 19 Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) Enrollment Benefits, Limitations and Authorization Requirements General Medical Services Preventive Care Medical Checkups Behavioral Health Services Dental Services Vision Services Claims Filing Reimbursement TMHP-CSHCN Services Program Contact Center 20 Hearing Services Enrollment Non-Implantable Hearing Aid Devices and Services Implantable Hearing Aid Devices and Services Benefits, Limitations, and Authorization Requirements – Non-Implantable Devices and Services Hearing Screening Abnormal Hearing Screens Hearing Testing, Examination, and Evaluation Services Audiometric Testing Otological Examination Vestibular Evaluations Authorization/Documentation Requirements Limitations Hearing Aid Devices and Accessories Documentation Requirements Prior Authorization Requirements Limitations Hearing Aid Services Documentation Requirements Prior Authorization Requirements Limitations Benefits, Limitations, and Authorization Requirements – Implantable Devices and Services Bone-Anchored Hearing Aid (BAHA) Prior Authorization Requirements Limitations Cochlear Implants Device, Implantation and Supplies Auditory Rehabilitation Frequency Modulation (FM) Systems Authorization Requirements Limitations Sound Processor Replacement Guidelines Claims Information Claims Filing for Non-Implantable Hearing Devices and Services Claims Filing for Implantable Hearing Devices and Services Reimbursement Reimbursement for Hearing Tests Reimbursement for Non-Implantable Hearing Devices and Services Reimbursement for Implantable Hearing Devices and Services TMHP-CSHCN Services Program Contact Center 21 Home Health Services Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements for Home Health Services Home Health Aide (HHA) Visits Supervision of Home Health Aides Prior Authorization for Home Health Aide (HHA) Visits Skilled Nursing Services Limitations for Skilled Nursing Services Prior Authorization for Skilled Nursing Services Occupational Therapy (OT) and Physical Therapy (PT) Limitations for Occupational Therapy (OT) and Physical Therapy (PT) Prior Authorization for Occupational Therapy (OT) and Physical Therapy (PT) Speech-Language Pathology (SLP) Prior Authorization for Speech-Language Pathology (SLP) Medical Nutritional Counseling Services Prior Authorization for Medical Nutritional Counseling Services Social Work Services Prior Authorization for Social Work Services Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 22 Home Health (Skilled Nursing) Care Enrollment Benefits, Limitations, and Authorization Requirements Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 23 Hospice Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 24 Hospital Enrollment Continuity of Hospital Eligibility Through Change of Ownership Specialty Team or Center Inpatient/Outpatient Benefits, Limitations, and Authorization Requirements Blood Factor Products Chemotherapy Cochlear Implants Electrodiagnostic Testing (Electromyography and Nerve Conduction Studies) Fluocinolone Acetonide Intravitreal Implant (Retisert) Laboratory Services_ Inpatient Services Benefits, Limitations, and Authorization Requirements Inpatient Behavioral Health Inpatient Rehabilitation Services Renal (Kidney) Transplants Stem Cell Transplants Reimbursement Information One-day Payment Window Reimbursement Guidelines Outpatient Services Benefits, Limitations, and Authorization Requirements Hospital-Based Outpatient Behavioral Health Services Hospital-Based Emergency Services Department Outpatient Observation Sleep Studies Hyperbaric Oxygen Therapy (HBOT) Reimbursement Information Hospital-Based Emergency Services Department One-day Payment Window Reimbursement Guidelines Ambulatory Surgical Centers Benefits, Limitations, and Authorization Requirements Freestanding Surgical Centers Reimbursement Information Claims Information Inpatient Claims Outpatient Claims Revenue Code and Procedure Code Requirements for All Outpatient Services HASC Claims Inpatient Stays Following Scheduled Day Surgeries Inpatient Stays Following Unscheduled (Emergency) Day Surgeries TMHP-CSHCN Services Program Contact Center 25 Laboratory Services Enrollment Clinical Laboratory Improvement Amendments (CLIA) of 1988 Waiver and Physician-Performed Microscopy Procedure (PPMP) Certificates Benefits, Limitations, and Authorization Requirements Hospital Laboratory Services Independent Laboratory Services Physician-Owned Laboratory Services Other Physician Laboratory-Related Services Clinical Pathology Services Other Laboratory Procedures Cytogenetics Testing Cytopathology of Vaginal, Cervical, and Uterine Sites Cytopathology Studies Other Than Vaginal, Cervical, or Uterine Helicobacter pylori (H. pylori) Laboratory Panel Tests Organ or Disease Panels Complete Blood Count (CBC) Ferritin and Iron Studies Urinalysis Other Laboratory Services Repeated Procedures Modifier 91 Receiving Labs and Lab Handling Fees Claims Information Modifiers To Use When Billing Laboratory Procedures Reimbursement Clinical Laboratory Fee Schedule One-day Payment Window Reimbursement Guidelines TMHP-CSHCN Services Program Contact Center 26 Medical Nutrition Services Enrollment Vitamins and Minerals Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements Claims Information Reimbursement Medical Foods Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements Claims Information Reimbursement Medical Nutritional Counseling Services Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements Claims Information Reimbursement Medical Nutritional Products Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Requirements Claims Information Reimbursement Total Parenteral Nutrition (TPN) Enrollment Benefits, Limitations, and Authorization Requirements Prior Authorization Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 27 Neurostimulator Devices and Supplies Enrollment Benefits, Limitations, and Authorization Requirements Dorsal Column Neurostimulation (DCN) Intracranial Neurostimulation (ICN) Neuromuscular Electrical Stimulation (NMES) NMES for Muscle Atrophy NMES for Walking in Clients with Spinal Cord Injury (SCI) Percutaneous Electrical Nerve Stimulation (PENS) Sacral Nerve Stimulation (SNS) Transcutaneous Electrical Nerve Stimulation (TENS) TENS Rental TENS Purchase Vagal Nerve Stimulation (VNS) Electronic Analysis for Implantable Neurostimulators (DCN, ICN, SNS, or VNS) Revision or Removal of Implantable Neurostimulators (DCN, ICN, SNS, or VNS) Neurostimulator Supplies NMES and TENS Garments NMES and TENS Supplies Noncovered Services Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 28 Orthotic and Prosthetic Devices Enrollment Benefits, Limitations, and Authorization Requirements General Authorization Requirements Orthoses and Prostheses (Not All-Inclusive) Repairs, Replacements, and Modifications to Orthoses and Prostheses Orthoses and Prostheses Training Orthoses and Related Services Prior Authorization and Documentation Requirements Orthotic and Orthopedic Devices Procedure Codes Noncovered Orthotic and Prosthetic Services Spinal Orthoses Thoracic-Hip-Knee-Ankle (THKA) Orthoses Lower-Limb Orthoses Ankle-Foot Orthoses (AFO) Reciprocating Gait Orthoses (RGO) Foot Orthoses Foot Inserts Prescription Shoes Noncovered Shoes or Shoe Inserts Wedges and Lifts Upper-Limb Orthoses Other Orthopedic Devices Protective Helmets Cranial Molding Orthosis Dynamic Splints Prostheses and Related Services Prior Authorization and Documentation Requirements Prostheses Procedure Codes Preparatory or Temporary Prostheses Upper-Limb Prostheses Myoelectric Prostheses Lower-Limb Prostheses Microprocessor-Controlled Lower-Limb Prostheses Foot Prostheses Knee Prosthesis Ankle Prosthesis Sockets Accessories Repairs, Replacements, and Modifications to Orthoses and Prostheses Other Artificial Devices CSHCN Services Program Documentation of Receipt Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 29 Outpatient Behavioral Health Enrollment Benefits, Limitations, and Authorization Requirements Authorization Requirements Documentation Requirements Pharmacological Management Services Documentation Pharmacological Regimen Oversight Documentation Reimbursement—The 12-Hour System Limitation Procedure Codes Included in the 12-Hour System Limitation Psychological and Neuropsychological Testing Psychotherapy and Counseling Pharmacological Regimen Oversight and Pharmacological Management Noncovered Services National Correct Coding Initiative (NCCI) Guidelines Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 30 Physical Medicine and Rehabilitation Enrollment Benefits, Limitations, and Authorization Requirements Osteopathic Manipulative Treatment (OMT) Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT) Authorization Requirements Coordination with the Public School System Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 31 Physician Enrollment Group Practices Changes in Provider Enrollment Substitute Physician Benefits, Limitations, and Authorization Requirements Authorization and Prior Authorization Requirements Aerosol Treatments/Inhalation Therapy Allergy Services Collagen Skin Tests Prior Authorization Requirements for Unlisted Procedure Codes Anesthesia Services Medical Direction Monitored Anesthesia Care Anesthesia Modifiers Dental General Anesthesia Reimbursement Conversion Factor Time-Based Fees Audiometry/Hearing Services Augmentative Communication Devices (ACDs) Biofeedback Services Medical Record Documentation Provider Certification Authorization Requirements Noncovered Services Blood Factor Products Bone Growth Stimulators Internal Electromagnetic Bone Growth Stimulator Electrical Stimulation (Noninvasive) External Low-Intensity Ultrasound Stimulation Prior Authorization Requirements for Bone Growth Stimulators Casting Chemotherapy Clinician-Directed Care Coordination Services Face-to-Face Clinician-Directed Care Coordination Services Non-Face-to-Face Clinician-Directed Care Coordination Services Cochlear Implants Colorectal Cancer Screening Critical Care Services Pediatric Critical Care Neonatal Critical Care Intensive Care (Noncritical) Services Newborn Resuscitation Echoencephalography Intraoperative Echography Ambulatory Electroencephalogram Electrodiagnostic Testing Authorization and Prior Authorization Requirements Limitations Evaluation and Management (E/M) Services New or Established Patient Visits Inpatient Professional Services Emergency Services Consultations Services Outside of Business Hours Prolonged Physician Services Observation Room Services Preventive Care Services Preventive Care Medical Checkups and Developmental Testing Preventive Care Medical Checkup Components Teaching Physicians Extracorporeal Shock Wave Lithotripsy (ESWL) Gastrostomy Devices Genetics Family History Genetic Tests Laboratory Practices Genetic Counselors Hyperbaric Oxygen Therapy (HBOT) Prior Authorization Requirements Immunizations (Vaccines and Toxoids) Texas Vaccines for Children (TVFC) Program Reporting Assessment Vaccine Information Statement Authorization Requirements Immunizations During an Office Visit Administration Fee Administration Fee Billing Examples Vaccine and Toxoid Procedure Codes Reimbursement for Vaccines and Toxoids Bacille Calmette-Guerin (BCG) Vaccine Rabies Postexposure Prophylaxis Respiratory Synctial Virus (RSV) Prophylaxis Injections and Oral Medications Injection Administration Billed by a Physician Unit Calculations for Billing Drugs Injection Procedure Codes Bevacizumab Botulinum Toxin (Type A and Type B) Erythropoietin Alfa (EPO) and Darbepoetin Growth Hormone Immune Globulins Leuprolide Acetate Injection Omalizumab Intracranial Pressure Monitoring Laboratory Services Physician Laboratory Services Laboratory Handling Fee Claims Filing for Laboratory Tests Clinical Pathology Services and Pathology Consultations Reimbursement Cytopathology Studies (Gynecological, Pap Smears) Cytogenetics Testing Helicobacter pylori (H. pylori) CLIA Requirement Neurostimulator Devices and Supplies Ophthalmological Services Intraocular Lenses (IOL) Vitrasert Ganciclovir Implant Osteopathic Manipulative Treatment (OMT) Physical Medicine and Physical Therapy (PT) Services Podiatry Psychological Testing Sign Language Interpreting Services Skin Therapy Sleep Studies Polysomnography Multiple Sleep Latency Test Pediatric Pneumogram Surgery Anesthesia Administered by Surgeon Primary Surgeons Assistant Surgeons Cosurgery Bilateral Procedures Global Fees Multiple Surgeries Second Opinions Unlisted Surgical Procedure Code Considerations Circumcision Cleft/Craniofacial Procedures Mastectomy and Related Services Other Reconstructive Cosmetic Procedures Rhizotomy Septoplasty Telemedicine Services Distant Site Patient Site Therapeutic Apheresis Transplants Renal (Kidney) Transplant Stem Cell Transplant Wound Care Management First-Line Wound Care Therapy Second-Line Wound Care Therapy Documentation Requirements Claims Information General Medical Record Documentation Requirements Reimbursement Physician Services in Outpatient Hospital Setting Reimbursement Reduction Authorization Requirement TMHP-CSHCN Services Program Contact Center 32 Physician Assistant (PA) Enrollment Benefits, Limitations, and Authorization Requirements Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 33 Radiation Therapy Services Enrollment Benefits, Limitations, and Authorization Requirements Clinical Brachytherapy Clinical Treatment Planning Intensity Modulated Radiation Therapy (IMRT) Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services Procedure Code Limitations Proton-Beam and Neutron-Beam Delivery Prior Authorization Requirements Radiation Treatment Management and Delivery Radioisotope Therapy Stereotactic Radiosurgery Strontium-89 Technetium TC 99M Tetrofosmin Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 34 Renal Dialysis Enrollment Client Eligibility Benefits, Limitations, and Authorization Requirements In-Facility Services and Method I Home Dialysis Services Method II Home Dialysis (Dealing Direct) Maintenance Hemodialysis Dialysis Training Unscheduled or Emergency Dialysis in a Non-Certified ESRD Facility Ultrafiltration Evaluation and Management Prior Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 35 Respiratory Equipment and Supplies Enrollment Benefits, Limitations, and Authorization Requirements General Authorization Requirements Cardiorespiratory (Apnea) Monitors Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) Systems Controlled Dose Inhalation Drug Delivery System Cough Stimulating Devices High Frequency Chest Wall Compression System (HFCWCS) Mucus Clearance Valve Nebulizers Pulse Oximeters Tracheostomy Tubes Other Equipment Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 36 Speech-Language Pathology (SLP) Services Enrollment Benefits, Limitations, and Authorization Requirements Authorization Requirements Rehabilitation Postcochlear Implant Coordination with the Public School System Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 37 Transportation of Deceased Clients Enrollment Benefits, Limitations, and Authorization Requirements Authorization Requirements Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 38 Vision Services Enrollment Benefits, Limitations, and Authorization Requirements Frames, Lenses, and Contact Lenses Frames Eyeglass Lenses Special Eyeglass Lenses Contact Lenses Eye Wear Services Requiring Authorization Services Requiring Prior Authorization Eye Prostheses Eye and Vision Examinations Vision Examinations with Refraction Medical Eye Examinations Services Requiring Authorization Special Vision Services Authorization Requirements Ocular Viewing and Diagnostic Testing Procedures Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center 39 TMHP Electronic Data Interchange (EDI) TMHP EDI Overview Advantages of Electronic Services Getting Help Electronic Services Available Electronic Billing Step 1—Choose How Claims Are Submitted TexMedConnect Vendor Software Third-Party Billing Agents Automated Maintenance Process for All Electronic Submitters Step 2—Gaining Access Step 3—Training Request for Electronic Transmission Reports Provider Check Amounts Available Online Third-Party Vendor Implementation EDI Version 5010 Claims Response and Electronic Remittance & Status (R&S) Files Supported File Types Forms TMHP-CSHCN Services Program Contact Center A Acronyms and Initialisms Dictionary B Forms CSHCN Services Program Prior Authorization Request for Apnea Monitor Form and Instructions CSHCN Services Program Prior Authorization Request for Augmentative Communication Devices (ACDs) Form and Instructions CSHCN Services Program Prior Authorization Request for Chest Physiotherapy Devices Form and Instructions CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services Form and Instructions CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners Form and Instructions CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form and Instructions CSHCN Services Program Prior Authorization Request for External Insulin Pump Form and Instructions CSHCN Services Program Prior Authorization Request for Hospice Services Form and Instructions CSHCN Services Program Prior Authorization Request for Inpatient Psychiatric Care Form and Instructions CSHCN Services Program Prior Authorization Request for Inpatient Hospital Admission—For Use by Facilities Only Form and Instructions CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission Form and Instructions CSHCN Services Program Prior Authorization Request for Medical Foods Form and Instructions CSHCN Services Program Prior Authorization Request for Medical Nutritional Services Form and Instructions Non-emergency Ambulance Prior Authorization Request and Instructions CSHCN Services Program Prior Authorization Request for Omalizumab Form and Instructions CSHCN Services Program Prior Authorization Request for Palivizumab (Synagis) Form and Instructions CSHCN Services Program Prior Authorization Request for Pulse Oximeter Devices Form and Instructions CSHCN Services Program Prior Authorization Request for Renal Dialysis Treatment Form and Instructions CSHCN Services Program Prior Authorization Request for Respiratory Care—Certified Respiratory Care Practitioner (CRCP) Form and Instructions CSHCN Services Program Prior Authorization Request for Stem Cell or Renal Transplant Form and Instructions CSHCN Services Program Prior Authorization Request for Inpatient Surgery—For Surgeons Only Form and Instructions CSHCN Services Program Prior Authorization and Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons Form and Instructions CSHCN Services Program Authorization Request for Hemophilia Blood Factor Products Form and Instructions CSHCN Services Program Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordinated Services Form and Instructions CSHCN Services Program Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordinated Services CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2) Form and Instructions CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1) Form and Instructions CSHCN Services Program Authorization and Prior Authorization Request Form and Instructions CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia CSHCN Services Program Policy About the Criteria for Dental Therapy Under General Anesthesia, Attachment 1 CSHCN Services Program Documentation of Receipt CSHCN Services Program Documentation of Receipt (Spanish) CSHCN Services Program Home Health (Skilled Nursing) Referral and Treatment Plan Form and Instructions CSHCN Services Program Instructions for Physician/Dentist Assessment Form CSHCN Services Program Instructions for Physician/Dentist Assessment Form (Spanish) CSHCN Services Program Physician/Dentist Assessment Form CSHCN Services Program Reimbursement Request for Transportation of the Remains of Deceased Clients CSHCN Services Program Vision Care Eyeglass Client Certification Form CSHCN Services Program Vision Care Eyeglass Client Certification Form (Spanish) CSHCN Services Program Wheelchair Seating Evaluation Form and Instructions Claim Status Inquiry (CSI) Authorization Electronic Funds Transfer (EFT) Notification Electronic Remittance and Status (ER&S) Agreement Instructions for Completing the Provider Information Change Form Provider Information Change Form CSHCN Services Program Refund Information Form Tort Response Form Department of State Health Services Form to Release CSHCN Services Program Claims History Department of State Health Services Form to Release CSHCN Services Program Claims History (Spanish)
