TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Reimbursement

24.3.1 Eligibility

To verify client Medicaid eligibility and retroactive eligibility, the home health agency or DMEH/medical supplier should contact the Automated Inquiry System (AIS) at 1-800-925-9126 or the TMHP Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638.

Home health clients do not need to be homebound to qualify for services. Providers who have received previous denials based on homebound criteria need to appeal their claims with appropriate documentation to include a copy of the claim, R&S report, and authorization requests.

The Medicaid client must be eligible on the date(s) of services (DOS) and must meet all the following requirements to qualify for Home Health Services:

•Have a medical need for home health professional services, DME, or supplies that are considered a benefit under Home Health Services and as documented in the client's plan of care (POC).

•Receive services that meet the client's existing medical needs and can be safely provided in the client's home.

•Receive prior authorization from TMHP for all home health professional services, DME, or supplies.

Certain DME/supplies may be obtained without prior authorization although providers must retain a Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form reviewed and signed by the treating physician for these clients.

Refer to: "Automated Inquiry System (AIS)" on page vii.

Note: Medicaid beneficiaries who are under 21 years of age are entitled to all medically necessary private duty nursing (PDN) services and/or home health SN services. Nursing services are medically necessary when the requested services are nursing services as defined in the Texas Nursing Practice Act and its implementing regulations; the requested services correct or ameliorate the beneficiary's disability or physical or mental illness or condition; and there is no third-party resource that is financially responsible for the services. Requests for nursing services must be submitted on the required Medicaid forms and must include supporting documentation. The supporting documentation must clearly and consistently describe the beneficiary's current diagnosis, functional status and condition; consistently describe the treatment throughout the documentation; and provide a sufficient explanation of how the requested nursing services correct or ameliorate the beneficiary's disability or physical or mental illness or condition. Medically necessary nursing services will be authorized either as PDN services or as Home Health SN services, depending on whether the beneficiary's nursing needs can be met on a per visit basis.