TMPPM 2009 > Provider Information > Managed Care > PCCM

7.7.21.9 Claims for Specialist Services

Specialists may bill for health-care services provided to PCCM clients if the patient was referred by the client's primary care provider. Electronic claims submissions by specialists require a referral from the PCCM client's primary care provider. The specialist can submit claims electronically by including the complete, correct name of the referring provider who is also the PCCM client's primary care provider, and the referring provider's NPI number in the NPI required blocks. An NPI only is required for electronic claims submissions. If a TPI is submitted on an electronic claim, the claim will be denied. Paper claims submissions by specialists also require a referral from the PCCM client's primary care provider. To indicate a referral from the client's primary care provider, the primary care provider's name, NPI, and provider identifier must be included in the Referring Physician field (blocks 17 and 17b) on the CMS-1500 claim form. A referral is not required if a specialist is providing a service that does not require a referral from a primary care provider.

Reimbursement for specialists is based on the current Texas Medicaid fee-for-service rates.

Refer to: "Referrals" and "Self-Referred Services" .

PCS are authorized and reimbursed by TMHP for PCCM.

For claims filing purposes, the PCS provider must bill place of service 2 (home) when submitting claims to TMHP. Texas Medicaid will not reimburse providers for PCS that duplicate services that are the legal responsibility of school districts.