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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 2: Texas Medicaid Fee-for-Service Reimbursement : 2.2 Fee-for-Service Reimbursement Methodology : 2.2.1 Online Fee Lookup (OFL) and Static Fee Schedules

2.2.1
Texas Medicaid reimburses certain providers based on rates published in the OFL and static fee schedules. These rates are uniform statewide and by provider type. According to this type of reimbursement methodology, the provider is paid the lower of the billed charges or the Medicaid rate published in the applicable static fee schedule or OFL.
Providers can obtain fee information using the OFL functionality on the TMHP website at www.tmhp.com.
The online OFL can be used to:
Providers can obtain the static fee schedules as Microsoft Excel® spreadsheets or portable document format (PDF) files from the TMHP website at www.tmhp.com.
Type of service (TOS) codes payable for each procedure code are available on the OFL and the static fee schedules.
The following provider types are reimbursed based on rates published with the rates calculated in accordance with the referenced reimbursement methodology as published in the Texas Administrative Code (TAC), Part 1 Administration, Part 15 Texas Health and Human Services Commission (HHSC), and Chapter 355 Reimbursement Rates.
Ambulance. The Medicaid rates for ambulance services are calculated in accordance with 1 TAC §355.8600.
Ambulatory Surgical Center (ASC). The Medicaid rates for ASCs are calculated in accordance with 1 TAC §355.8121.
Blind Children’s Vocational Discovery and Development Program. The Medicaid rate for this service is calculated in accordance with 1 TAC §355.8381.
Case Management for Children and Pregnant Women. The Medicaid rates for this service are calculated in accordance with 1 TAC §355.8401.
Targeted Case Management for Early Childhood Intervention (ECI). The Medicaid rate for this service is reimbursed in accordance with 1 TAC §§355.8421.
Specialized Skills Training for ECI. The Medicaid rate for this service is reimbursed in accordance with 1 TAC § 355.8422
Certified Nurse-Midwife (CNM). The Medicaid rates for CNMs are calculated in accordance with 1 TAC §355.8161.
Certified Registered Nurse Anesthetist (CRNA). According to 1 TAC §355.8221, the Medicaid rate for CRNAs is 92 percent of the rate reimbursed to a physician anesthesiologist for the same service.
Certified Respiratory Care Practitioner (CRCP) Services. The Medicaid rate per daily visit for 99503 is calculated in accordance with 1 TAC §355.8089.
Chemical Dependency Treatment Facility (CDTF). The Medicaid rates for CDTF services are calculated in accordance with 1 TAC §355.8241.
Chiropractic Services. The Medicaid rates for chiropractic services are calculated in accordance with 1 TAC §355.8081 and 1 TAC §355.8085.
Dental. The Medicaid rates for dentists are calculated as access-based fees in accordance with 1 TAC §355.8081, 1 TAC §355.8085, 1 TAC §355.8441(11), and 1 TAC §355.455(b).
Durable Medical Equipment (DME). Home health agencies are reimbursed for DME and expendable supplies in accordance with 1 TAC §355.8021 (b). Comprehensive Care Program (CCP) is reimbursed for DME and expendable supplies in accordance with 1 TAC §355.8441 (2)(3).
Family Planning Services. The Medicaid rates for family planning services are calculated in accordance with 1 TAC §355.8584.
Genetic Services. The procedure codes and Medicaid rates for genetic services are listed in the OFL or the Physician - Genetics fee schedule on the TMHP website at www.tmhp.com.
Hearing Aid and Audiometric Evaluations. Newborn hearing screenings are provided at the birthing facility before hospital discharge and, as such, are reimbursed in accordance with the reimbursement methodology for the specific type of birthing facility. Outpatient hearing screening and diagnostic testing services for children are provided by physicians and are reimbursed in accordance with the reimbursement methodology for physician services at 1 TAC §355.8085, 1 TAC §355.8141, and 1 TAC §355.8441.
Texas Medicaid (Title XIX) Home Health Services. The reimbursement methodology for professional services delivered by home health agencies are statewide visit rates calculated in accordance with 1 TAC §355.8021(a).
Independent Laboratory. The Medicaid rates for independent laboratories are calculated in accordance with 1 TAC §355.8081 and §355.8610, and the Deficit Reduction Act (DEFRA) of 1984. By federal law, Medicaid payments for a clinical laboratory service cannot exceed the Medicare payment for that service. Early Periodic Screening, Diagnosis, and Treatment (EPSDT)/Texas Health Steps medical and newborn screening laboratory services provided by the Department of State Health Services (DSHS) Laboratory are reimbursed based on the Medicare payment for that service.
Indian Health Services. The reimbursement methodology for services provided in Indian Health Services Facilities operating under the authority of Public Law 93‑638 is located at 1 TAC §355.8620.
In-Home Total Parenteral Nutrition (TPN) Supplier. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8087.
Licensed Clinical Social Worker (LCSW). According to 1 TAC §355.8091, the Medicaid rate for LCSWs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085.
Licensed Marriage and Family Therapist (LMFT). According to 1 TAC §355.8091, the Medicaid rate for LMFTs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085.
Licensed Professional Counselor (LPC). According to 1 TAC §355.8091, the Medicaid rate for LPCs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085.
Maternity Service Clinic (MSC). The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8081.
Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS). According to Title 1 TAC §355.8281, the Medicaid rate for NPs and CNSs is 92 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same service and 100 percent of the rate paid to physicians for laboratory services, X‑ray services, and injections.
Physical Therapists/Independent Practitioners. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8081 and §355.8085.
Physician. The Medicaid rates for physicians and certain other practitioners are calculated in accordance with 1 TAC §355.8085.
Physician Assistant (PA). According to 1 TAC §355.8093, the Medicaid rate for PAs is 92 percent of the rate paid to a physician (MD or DO) for the same service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections.
Psychologist. The Medicaid rates for psychologists are calculated in accordance with 1 TAC §355.8081 and §355.8085.
Radiological and Physiological Laboratory and Portable X-Ray Supplier. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8081 and §355.8085.
Renal Dialysis Facility. The Medicaid rates for these providers are composite rates based on calculations specified by the Centers for Medicare & Medicaid Services (CMS).
School Health and Related Services (SHARS). The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8443.
THSteps reimburses by provider type in accordance with 1 TAC §355.8441. Approved providers enrolled in Texas Medicaid are reimbursed for THSteps services in the same manner as they are reimbursed for other Medicaid services. THSteps CCP reimburses for DME and expendable supplies in accordance with 1 TAC §355.8441(2)(3).
Tuberculosis (TB) Clinics. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8081.
Vision Care (Optometrists, Opticians). The Medicaid rates for these providers are calculated in accordance with 1 TAC §355. 8001, §355.8081, and §355.8085.

Texas Medicaid & Healthcare Partnership
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