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23.4 Reimbursement
In compliance with state and federal law, the CSHCN Services Program reimburses laboratories for most services according to maximum fees established by federal law, Medicare, or HHSC. Clinical laboratory services may be reimbursed at the lower of the CMS national fee schedule, the Medicaid fee schedule, or the billed amount. Some services (e.g., anatomical pathology) may be reimbursed according to the Texas Medicaid Reimbursement Methodology (TMRM).
Physicians are reimbursed the lower of either the billed amount or the amount allowed by Texas Medicaid. Laboratories are reimbursed the lower of the national fee schedule amount, the billed amount, or the amount allowed by Texas Medicaid. Outpatient hospitals are reimbursed at 80 percent of the rate equivalent to the hospital's Medicaid interim rate. Advanced practice nurses (APNs) are reimbursed the lower of either the billed amount or 92 percent of the amount allowed by Texas Medicaid for the same service provided by a physician.
As the result of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, independent laboratories are not directly reimbursed by the CSHCN Services Program when providing tests to clients registered as hospital inpatients or hospital outpatients. Reimbursement must be obtained from the hospital. These services cannot be billed to the client.
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