TMPPM 2008 > Provider Information > Texas Medicaid Reimbursement > Medicaid Service Provided Outside Texas

2.5 Medicaid Service Provided Outside Texas

Any eligible provider in a state other than Texas who provides services to Texans eligible for Medicaid is entitled to bill the Texas Medicaid Program. The provider must contact TMHP Provider Enrollment to obtain the appropriate forms, requirements, and guidelines for claims filing; complete the forms; and return them to TMHP.

The Texas Medicaid Program covers medical assistance services provided to eligible Texas recipients 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 provider 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: Providers enrolled for this criteria 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 recipient's health is endangered if he is required to travel to Texas.

Note: Providers enrolled for this criteria will be enrolled for a period of 90 days from the enrollment date.

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

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

•The department 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.

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

Note: Providers enrolled for this criteria will be enrolled for a period of 90 days from the enrollment date.

Providers located in a state other than Texas but within 200 miles of the Texas border are not considered out-of-state providers and therefore do not need to meet one of the six TAC criteria. Enrollment applications for these providers will be processed as an in-state Medicaid provider.

Payments to out-of-state providers enrolled in the Texas Medicaid Program are made according to the usual, customary, and reasonable charges or the stipulated fee for services as appropriate for the provided care. Payment of practitioners, providers, or suppliers who are reimbursed on a reasonable charge basis may not exceed the lesser of:

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

•When mutually agreed on by the contractor and state agency, 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: "Procedure Codes Requiring Prior Authorization" .