TMPPM 2008 > Texas Medicaid Services > Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) > Benefits and Limitations

34.3 Benefits and Limitations

Services performed by NPs and CNSs are benefits if the services meet the following criteria:

•Are within the scope of practice for APNs, as defined by Texas state law.

•Are consistent with rules and regulations promulgated by the Texas BON or other appropriate state licensing authority.

•Are covered by the Texas Medicaid program when provided by a licensed physician (MD or DO).

•Are reasonable and medically necessary as determined by HHSC or its designee.

NPs and CNSs who are employed or remunerated by a physician, hospital, facility, or other provider must not bill the Texas Medicaid program for their services if the billing results in duplicate payment for the same services.

Benefit limitation information for services can be found in the physician services, THSteps medical (includes newborn exams), and family planning sections of this manual.

Laboratory (including pregnancy tests) and radiology services provided during pregnancy must be billed separately from antepartum care visits and received within 95 days from the date of service.

Note: Payment to physicians for supplies is not a benefit of the Texas Medicaid Program. Costs of supplies are included in the reimbursement for office visits.

Procedures billed by an NP or CNS are reviewed retrospectively for appropriateness. Independently enrolled NPs and CNSs with a valid Medicare provider number are eligible to receive payment of deductible and coinsurance amounts as appropriate on Medicare crossover claims.

Refer to: "Family Planning Services" for more information.

"Physician" for more information.

"THSteps Medical Check Up Facilities" for more information on THSteps services.