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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities : 1.6 Enrollment Criteria for Out-of-State Providers

1.6 Enrollment Criteria for Out-of-State Providers
Texas Medicaid covers medical assistance services provided to eligible Texas Medicaid clients while in a state other than Texas, as long as the client does 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 service meets one or more of the following requirements of 1 TAC §354.1442:
Note:
Note:
An out-of-state provider seeking enrollment under this criterion must include with the enrollment application a copy of the claim that contains the diagnosis that indicates emergency care or medical record documentation. The documentation must demonstrate that emergency care was provided to a Texas Medicaid client. Providers enrolled under this criterion will be enrolled for a limited period of time.
The services are medically necessary to a recipient who is located outside of the state, and in the expert opinion of the recipient’s attending physician or other provider, the recipient’s health would be or would have been endangered if the recipient were required to travel to Texas.
Note:
An out-of-state provider seeking enrollment under this criterion must include with the enrollment application an explanation of the circumstances and demonstrate why the Texas Medicaid client’s health would have been endangered if the client had been required to travel to Texas. Providers enrolled under this criterion will be enrolled for a limited period of time.
Note:
HHSC determines whether this criterion applies on a case-by-case basis. An out-of-state provider that seeks enrollment under this criterion must include with the enrollment application documentation for why this criterion applies, and must provide any additional information requested by HHSC or its designee. Providers that are enrolled under this criterion may be enrolled for a limited period of time.
The services are medically necessary services and it is the customary or general practice of recipients in a particular locality within Texas to obtain services from the out-of-state provider, as demonstrated by the provider being located in the United States and within 50 miles driving distance from the Texas state border.
Note:
HHSC determines whether this criterion applies on a case-by-case basis. An out-of-state provider that is located more than 50 miles from Texas and seeks enrollment under this criterion must include with the enrollment application documentation for why this criterion applies, and must provide any additional information requested by HHSC or its designee. Such providers, if approved for enrollment, may be enrolled for a limited period of time.
The services are medically necessary to a recipient who is eligible on the basis of participation in an adoption assistance or foster care program that is administered by the Texas Department of Family and Protective Services under Title IV-E of the Social Security Act.
Note:
HHSC determines whether this criterion applies on a case-by-case basis. An out-of-state provider that seeks enrollment under this criterion must include with the enrollment application documentation that explains why this criterion applies, and must provide any additional information requested by HHSC or its designee. An out-of-state provider does not meet this criterion merely on the basis of having established business relationships with one or more providers that participate in the Texas Medicaid program, because the criterion in that paragraph applies only to the customary or general practice of recipients in regard to a recipient’s choice of provider. Such providers, if approved for enrollment, may be enrolled for a limited period of time.
Note:
Providers that seek enrollment under this criterion are encouraged to contact TMHP to request approval before filing an enrollment application. TMHP will coordinate the request with HHSC. HHSC determines whether this criterion applies on a case-by-case basis. The provider must provide any additional information requested by HHSC or its designee. Such providers, if approved for enrollment, may be enrolled for a limited period of time.

Texas Medicaid does not cover transplant services rendered out-of-state that are also available in Texas. The provider must submit a copy of the transplant evaluation performed by a Texas facility to support the need for an out-of-state pre-transplant evaluation, when requesting an out-of-state prior authorization for a pre-transplant evaluation.
Providers that are located out-of-state and seek reimbursement under one or more of the above criteria must submit an enrollment application and be approved for enrollment.
An out-of-state provider that meets none of the above criteria but is eligible to receive reimbursement for Medicare crossover claims involving Texas Medicaid dual eligible clients, may seek enrollment in order to receive such reimbursement. Such providers, if approved for enrollment, will be restricted to receiving reimbursement only for Medicare crossover claims.
Refer to:
Payments to out-of-state providers enrolled in Texas Medicaid are made according to the usual, customary, and reasonable charges or the stipulated fee for services as appropriate for the provided care. Reimbursement may not exceed the lesser of:
The Medicaid reasonable charge or fee determined for the same services in Texas; or
If agreed to by HHSC, 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:
Subsection 9.2.1, “Prior Authorization” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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