TMPPM 2010 >1.5 Enrollment Criteria for Out-of-State Providers

1.5 Enrollment Criteria for Out-of-State Providers

Texas Medicaid covers medical assistance services provided to eligible Texas clients while absent from Texas, as long as they do not leave Texas to receive out-of-state medical care that can be received in Texas. Services provided outside the state are covered to the same extent medical assistance is furnished and covered in Texas when the service meets one or more of the following requirements of 1 TAC §355.8083:

•The medical services are needed because of a medical emergency documented by the attending physician or other provider.

Note: An out-of-state provider seeking enrollment under this criterion must include with the enrollment application a copy of the claim containing the diagnosis indicating emergency care or medical record documentation. The documentation must demonstrate emergency care was provided to a Texas Medicaid client. Providers enrolled under this criterion will be enrolled for a period of 90 days from the enrollment date.

•The services are medically necessary and, in the opinion of the attending physician or other provider, the clients health may be endangered if he or she were required to travel to Texas.

Note: An out-of-state provider seeking enrollment under this criterion must include with the enrollment application an explanation of the circumstances, demonstrating why the Texas Medicaid client's health would have been endangered if the client had been required to travel to Texas. Providers enrolled under this criterion will be enrolled for a period of 90 days from the enrollment date.

•HHSC or its designee determines that the medically necessary services are more readily available in the state where the client is located.

Note: This criterion may apply when the Texas Medicaid client is already out-of-state and receives services that are not readily available in Texas, or when a Texas Medicaid client must leave Texas in order to receive care that is not readily available in Texas. HHSC makes the determination of whether this criterion applies on a case by case basis. An out-of-state provider seeking enrollment under this criterion must include with the enrollment application documentation for why this criterion applies, and must provide any additional information requested by HHSC or its designee. Providers enrolled under this criterion may be enrolled for a time limited period.

•The customary or general practice for recipients in a particular locality is to use medical resources in the other state.

Note: An out-of-state provider located within 50 miles of the Texas border is automatically considered to meet this criterion. HHSC makes the determination of whether this criterion applies on a case by case basis. An out-of-state provider located more than 50 miles from Texas and seeking enrollment under this criterion must include with the enrollment application documentation for why this criterion applies, and must provide any additional information requested by HHSC or its designee. Such providers, if approved for enrollment, may be enrolled for a time limited period.

•HHSC makes Title IV-E adoption assistance or Title IV-E foster care maintenance payments for a child who is also eligible for Texas medical assistance benefits.

Note: HHSC makes the determination of whether this criterion applies on a case by case basis. An out-of-state provider seeking enrollment under this criterion must include with the enrollment application documentation explaining why this criterion applies, and must provide any additional information requested by HHSC or its designee. Such providers, if approved for enrollment, may be enrolled for a time limited period.

•Other out-of-state medical care may be considered when prior authorized by HHSC or its designee.

Note: Providers seeking enrollment under this criterion are encouraged to contact TMHP to request approval before filing an enrollment application. TMHP will coordinate the request with HHSC. HHSC will make the determination of whether this criterion applies on a case by case basis. The provider must provide any additional information requested by HHSC or its designee. Such providers, if approved for enrollment, may be enrolled for a time limited period.

Providers located out-of-state seeking reimbursement under one or more of the above criteria must submit an enrollment application and be approved for enrollment.

An out-of-state provider that meets none of the above criteria, but that is eligible to receive reimbursement for Medicare crossover claims involving Texas Medicaid dual eligible clients, may seek enrollment in order to receive such reimbursement. Such providers, if approved for enrollment, will be restricted to receiving reimbursement only for Medicare crossover claims.

Refer to: Subsection 2.6, "Medicare Crossover Reimbursement" in this handbook.

Payments to out-of-state providers enrolled in Texas Medicaid are made according to the usual, customary, and reasonable charges or the stipulated fee for services as appropriate for the provided care. Reimbursement may not exceed the lesser of:

• The Medicaid reasonable charge or fee determined for the same services in Texas; or

• If agreed to by HHSC, 100 percent of the Medicare reasonable charge determination for the same service in the state where the service was provided.

Inpatient hospital stays are reimbursed according to the Texas prospective payment methodology (diagnosis-related group [DRG]). Payments made on a reasonable cost basis are mutually determined by the state agency and the contractor.

TMHP must receive claims from out-of-state providers within 365 days from the date of service.

Refer to: Subsection 7.2.1, "Prior Authorization" in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).