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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 4. Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC) : 4.4 Claims Filing and Reimbursement

Providers must bill Medicare before Medicaid when clients are eligible for services under both programs. Medicaid’s responsibility for the coinsurance or deductible is determined in accordance with Medicaid benefits and limitations. Providers must check the client’s Medicare card for Part B coverage before billing Medicaid. When Medicare is primary, it is inappropriate to bill Medicaid without first billing Medicare. Medicaid is responsible for the coinsurance and deductible of Medicare-allowed services on a crossover basis only.
Refer to:
Subsection 2.6.2, “Part B” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).
Subsection 4.11.2, “Medicare Part B Crossovers” in Section 4, “Client Eligibility” (Vol. 1, General Information).
LCSW, LMFT, and LPC services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
Subsection 6.1, “Claims Information” in Section 6, “Claims Filing” (Vol. 1, General Information) for general information about claims filing.
Subsection 6.5, “CMS‑1500 Paper Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.
According to 1 TAC §355.8091, the Texas Medicaid rate for LCSWs, LMFTs, and LPCs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at Under 1 TAC §355.8261, an FQHC is reimbursed according to its specific prospective payment system (PPS) rate per visit for LCSW services.
Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.
Additional information about rate changes is available on the TMHP website at
Refer to:
Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.
Subsection 6.3, “The 12-Hour System Limitation” in this handbook for details about the 12‑hours-per-day behavioral health services limitation.

Texas Medicaid & Healthcare Partnership
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