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1.2.7 Provider Certification/Assignment
Texas Medicaid service providers are required to certify compliance with or agree to various provisions of state and federal laws and regulations. After submitting a signed claim to TMHP, the provider certifies the following:
• Services were personally rendered by the billing provider or under the personal supervision of the billing provider, if allowed for that provider type, or under the substitute physician arrangement.
•The information on the claim form is true, accurate, and complete.
•All services, supplies, or items billed were medically necessary for the client's diagnosis or treatment. Exception is allowed for special preventive and screening programs (for example, family planning and Texas Health Steps [THSteps]).
•Medical records document all services billed and the medical necessity of those services.
•All billed charges are usual and customary for the services provided. The charges must not be higher than the fees charged to private-pay patients.
•The provider will not bill the Texas Medicaid Program for services that are provided or offered to non-Medicaid patients, without charge, discounted or reduced in any fashion including, but not limited to, sliding scales or advertised specials. Any reduced, discounted, free, or special fee advertised to the public must also be offered to Texas Medicaid Program clients.
•Services were provided without regard to race, color, sex, national origin, age, or handicap.
•The provider of medical care and services files a claim with the Texas Medicaid Program agreeing to accept the Medicaid reimbursement as payment in full for those services covered under the Texas Medicaid Program. The client with Medicaid coverage, or others on their behalf, must not be billed for the amount above that which is paid on allowed services or for services denied or reduced as a result of errors made in claims filing, claims preparation, missed filing deadlines, or failure to follow the appropriate appeal process. However, the client may be billed for noncovered services for which the Texas Medicaid Program does not make any payment. Before providing services, providers should always inform clients of their liability for services that are not a benefit of the Texas Medicaid Program, including use of the Client Acknowledgment Statement.
•The provider understands that endorsing or depositing a Texas Medicaid Program check is accepting money from federal and state funds and that any falsification or concealment of material fact related to payment may be grounds for prosecution under federal and state laws.
Providers must not bill for, and agree not to bill for, any service provided for which the client bears no liability to pay (i.e. free services). The only exceptions to this ban on billing for services that are free to the user are:
•Services offered by or through the Title V agency when the service is a benefit of the Texas Medicaid Program and rendered to an eligible client.
•Services included in the Texas Medicaid client's individualized education plan (IEP) or individualized family service plan (IFSP) if the services are covered under the Title XIX state plan, even though they are free to the users of the services.
Refer to: "Supervision" .
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