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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities : 1.8 Texas Medicaid Limitations and Exclusions

1.8 Texas Medicaid Limitations and Exclusions
Medicaid pays for services on behalf of clients to the provider of service according to Texas Medicaid’s limitations and procedures. TMHP does not make Medicaid payments directly to clients.
The following services, supplies, procedures, and expenses are not benefits of Texas Medicaid. This list is not all inclusive.
Inpatient hospital services to a client in an institution for tuberculosis, mental disease, or a nursing section of public institutions for persons with intellectual disabilities
More than $200,000 per client per benefit year (November 1 through October 31) for any medical and remedial care services provided to a hospital inpatient by the hospital (If the $200,000 amount is exceeded because of an admission for an approved organ transplant, the allowed amount for that claim is excluded from the computation. This limitation does not apply to clients eligible for CCP or clients with an organ transplant.)
More than 30 days of inpatient hospital stay per spell of illness (Each spell of illness must be separated by 60 consecutive days during which the client has not been an inpatient in a hospital.)
CCP provides medically necessary, federally allowable treatment for Medicaid/THSteps clients who are 20 years of age and younger. Some medical services that usually would not be covered under Medicaid may be available to CCP-eligible clients. An additional 30day spell of illness begins with the date of specified covered organ transplant. No spell-of-illness limitation exists for Medicaid THSteps clients who are 20 years of age and younger.
Oral medications, except when claims are submitted by a hospital for services that are provided given in the emergency room or the inpatient setting (Hospital take-home drugs or medications given to the client are not a benefit.)
Outpatient behavioral health services performed by a licensed chemical dependency counselor (LCDC), psychiatric nurse, mental health worker, non-LCSW social worker, or psychological associate (excluding a Masters-level licensed psychological associate [LPA]) regardless of physician or licensed psychologist supervision
Payment to physicians for supplies (All supplies, including anesthetizing agents such as Xylocaine, inhalants, surgical trays, or dressings, are included in the surgical payment.)
Refer to:
Section 4, “Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC)” in Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks).
Section 6, “Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers” in Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks).
Separate fees for completing or filing a Medicaid claim form (The cost of claims filing is to be incorporated in the provider’s usual and customary charges to all clients.)
Services or supplies provided to a client after a finding has been made under utilization review procedures that these services or supplies are not medically necessary
Services or supplies provided to a Texas Medicaid client before the effective date of his or her designation as a client, or after the effective date of his or her denial of eligibility
Sterilizations (including vasectomies) unless the client has given informed consent 30 days before surgery, is mentally competent, and is 21 years of age or older at the time of consent (This policy complies with 42 CFR §441.250, Subpart F.)
Take-home and self-administered drugs except as provided under the Vendor Drug or family planning pharmacy services or for clients being treated for a substance use disorder
Treatment of flatfoot conditions for solely cosmetic purposes, the prescription of supportive devices (including special shoes), and the treatment of subluxations of the foot
Refer to the applicable handbooks in Volume 2 of this manual for additional information.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.