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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 5. Mental Health Rehabilitation, Mental Health Case Management, and Intellectual Disability Service Coordination : 5.2 Services, Benefits, Limitations, and Prior Authorization

Texas Medicaid provides the following service coordination and case management services:
Service coordination for people who have an intellectual disability or a related condition (adult or child). Persons who have a related condition are eligible if they are being enrolled into the home and community based waiver (HCS); the Texas Home Living Waiver; or an intermediate care facility for persons who have an intellectual disability (ICF/MR) facility.
Service coordination funded by Medicaid as TCM is reimbursed by encounter.
There are two types of encounters:
Comprehensive encounter (Type A): A face-to-face contact with an individual to provide service coordination. The comprehensive encounter is limited to one billable encounter per individual per calendar month. DADS will not authorize payment for a comprehensive encounter that exceeds the cap of one encounter per individual per calendar month.
Supportive encounter (Type B): A face-to-face, telephone, or telemedicine contact with an individual or with a collateral on the individual’s behalf to provide service coordination.
An LA is allowed up to three Type B encounters per calendar month for each Type A encounter that has occurred within the calendar month.
The Type B encounters are not limited to three per individual. Rather, the allowed Type B encounters may be delivered to any individual who needs a Type B encounter. These Type B encounters are allowable as long as the individual who received the Type B encounter also received a Type A encounter that same month.
For example, Sam and Mary receive a Type A encounter in June. It is allowable for the LA to bill for one Type B encounter for Sam in June and five Type B encounters for Mary in June.
Payment for an individual’s Type B encounter is contingent on that individual having a Type A encounter within the same calendar month.
Within the calendar month, the Type A encounter does not have to occur on a date before any of the Type B encounters occur.
Providers must use the following procedure code and applicable modifiers for MH targeted case management:
Routine mental health targeted case management (adult)
32 units (8 hours) per calendar day for clients who are 18 years of age and older
TF, HA, and HZ
32 units (8 hours) per calendar day for clients who are 17 years of age and younger
TG, HA, and HZ
An MH case management reimbursable contact is the provision of a case management activity by an authorized case manager during a face-to-face meeting with an individual who is authorized to receive that specific type of case management. A billable unit of case management is 15 continuous minutes of contact.
Service coordination and case management services are not reimbursable when they are provided to a client who is eligible for Medicaid and who receives services through the HCS waiver. These services are included in the waiver. Claims submitted to TMHP for people who receive services under the HCS waiver are identified quarterly by DADS and payments are recouped.
Texas Medicaid must not be billed for service coordination except for the purpose of discharge planning or waiver enrollments up to 180 days prior to the discharge for persons in ICF/ID facilities or state supported living centers, or case management services provided to people who are residents or inpatients of:
Nursing facilities (for people not mandated by the Omnibus Budget Reconciliation Act [OBRA] of 1987).
A Texas Medicaid-certified residence not already specified.
Texas Medicaid must not be billed for ID service coordination provided to people enrolled in Community Living Assistance and Support Services (CLASS), Community-Based Alternatives (CBA), Program of All-inclusive Care for the Elderly (PACE), Deaf-Blind Multiple Disabilities (DBMD) or Medically Dependent Children Program (MDCP).
An institution for mental diseases, such as a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing the diagnosis, treatment, or care of people who have mental diseases, including medical attention, nursing care, and related services.
A contact by the service coordinator to assist in the discharge planning of some of the above may be reimbursed, if it is provided within 180 days before discharge. Service coordination services provided to people who are on predischarge furlough to the community from a nursing facility, intermediate care facility, or state-supported living centers may be reimbursed. Service coordination services provided to people who are on trial placement from a state MR facility to the community may be reimbursed if the person remains eligible for Texas Medicaid upon release from the facility and receives regular Texas Medicaid coverage.
Texas Medicaid must not be billed for MH case management services provided before the establishment of a diagnosis of mental illness and the authorization of services.
For more information about billing for MH Case Management, providers should refer to 25 TAC, Part 1, Chapter 412, Subchapter I and the Mental Health Case Management Billing Guidelines available through the DSHS Mental Health and Substance Abuse Program Services Division.

Texas Medicaid & Healthcare Partnership
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