TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > THSteps-Comprehensive Care Program (CCP)

43.4.10.7 Claims Information

TMHP processes PCS claims. PCS providers must submit claims for services in an approved electronic claims format or on the appropriate claim form based on their provider type. Providers, other than home health agencies, enrolled as a PAS-only provider, a CDSA, or an SRO provider should file PCS claims using claim form CMS-1500. Home health agencies, including those enrolled as a CDSA, or an SRO provider, should file PCS claims using the UB-04 CMS-1450 claim form. TMHP does not supply the forms.

PCS is considered for reimbursement when providers use procedure code 1-T1019 in conjunction with the appropriate modifier listed in the table below. PCS provided by a home health agency or PAS-only provider, including PCS being provided under the SRO defined in the 40 TAC Part 1, Chapter 41, must be billed in 15-minute increments. PCS provided by a CDSA under the CDS option defined in 40 TAC Part 1, Chapter 41, must submit the attendant fee in 15-minute increments. CDSAs must bill the administration fee once per calendar month per client for any month in which the client receives PCS under the CDS option and regardless of the number of PCS units of service the client receives under the CDS option during the month. PCS claims are considered for reimbursement only when TMHP has issued a valid PAN to a PCS provider.

When PCS is provided in a provider/client ratio other than one-to-one, only the time spent on direct PCS for each client may be billed. Total PCS billed for all clients cannot exceed the individual provider's total number of hours spent at the POS.

Example: If the prior authorized PCS hours for Client A is 4 hours, Client B is 6 hours, and the actual time spent with both clients is 8 hours, the provider must bill for the actual one-on-one time spent with each client, not to exceed the client's prior authorized hours or total hours worked. It would be acceptable to bill 4 hours for Client A and 4 hours for Client B, or 3 hours for Client A and 5 hours for Client B. It would not be acceptable to bill 5 hours for Client A and 3 hours for Client B. It would be acceptable to bill 10 hours if the individual person actually spent 10 hours onsite providing prior authorized PCS split as 4 hours for Client A and 6 hours for Client B. A total of 10 hours cannot be billed if the individual person worked only 8 hours.

Refer to: "TMHP Electronic Data Interchange (EDI)" for information on electronic claims submissions.

"Claims Filing" for general information about claims filing.

"CMS-1500 Claim Filing Instructions" for claims completion instructions. Attach the invoice to the claim for any specialized equipment.

"UB-04 CMS-1450 Instruction Table" for claims completion instructions.