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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.3 Coding : 6.3.3 Procedure Coding : 6.3.3.3 Rate Hearings

6.3.3.3
Rate Hearings
All of the new procedure codes are adopted in accordance with CMS effective dates. Added procedure codes that are not directly replacing a discontinued procedure code must go through the rate hearing process. Health and Human Services Commission (HHSC) conducts public rate hearings to provide an opportunity for the provider community to comment on the Medicaid proposed payment rate.
Services provided before the rates are adopted through the rate hearing process are denied as pending a rate hearing (EOB 02008) until the applicable reimbursement rate is adopted. The client cannot be billed for these services. Providers are responsible for meeting the initial 95-day filing deadline. Once the reimbursement rates are established in the rate hearing and applied, TMHP will reprocess claims, and no further action on the part of the provider is necessary.
Providers must submit the procedure codes that are most appropriate for the services provided, even if the procedure codes have not yet completed the rate hearing process and are denied by Texas Medicaid as pending a rate hearing.
Authorization guidelines for procedure codes awaiting a rate hearing are available in subsection 5.11, “Guidelines for Procedures Awaiting Rate Hearing” in Section 5, “Prior Authorization” (Vol. 1, General Information).

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