TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Medicaid Relationship to Medicare

24.6.4 Medicare/Medicaid Authorization and Reimbursement

To ensure Medicare benefits are used first in accordance with Texas Medicaid Program regulations, the following procedures apply when requesting Medicaid authorization and payment of home health services for clients.

Contact TMHP for authorization of Medicaid services (based on medical necessity and benefits of Home Health Services) within 30 days of the date on the Medicare final denial letter. Fax a copy of the original Medicare final denial letter and the Medicare appeal review letter to the TMHP Home Health Services Prior Authorization Department for prior authorization.

A Medicare denial letter is not required when a client is eligible for Medicare/Medicaid and needs HHA visits only. However, a skilled supervisory nursing visit must be made on the same day as the initial HHA visit and at least every 60 days (on the same day a HHA visit is made) thereafter as long as no skilled need exists. A SN supervisory visit is reimbursable, but an SN visit made for the primary purpose of assessing a client's nursing care is not.

The SOC date will be the date of the first requested Medicare home health services visit as listed on the original Medicare denial letter.

Note: Claims for STAR+PLUS MQMB clients (those with Medicare and Medicaid) should always be submitted to TMHP as noted on these pages. The STAR+PLUS health plan is not responsible for these services if Medicare denies the service as not a benefit.

When the client is older than 65 years of age or appears otherwise eligible for Medicare such as blind and disabled, but has no Part A or Part B Medicare, the TMHP Home Health Services Prior Authorization Department uses regular prior authorization procedures. In this situation, the claim is held for a midyear status determined by HHSC. The maximum length of time a claim may be held in a "pending status" for Medicare determination is 120 days. After the waiting period, the claim is paid or denied. If denied, the EOB code on the R&S report indicates that Medicare is to be billed.

Refer to: "Home Health Skilled Nursing Services" .