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2012 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook

Clinics and Other Outpatient Facility Services Handbook
Table of Contents
1. General Information OP-7
1.1 National Drug Codes (NDC) OP-7
2. Birthing Center OP-7
2.1 Provider Enrollment OP-7
2.2 Services, Benefits, Limitations, and Prior Authorization OP-8
2.2.1 Newborn Hearing Screening OP-8
2.2.2 Newborn Eligibility Process OP-8
2.2.3 Prior Authorization OP-9
2.2.4 Services Rendered in the Birthing Center Setting OP-9
2.3 Documentation Requirements OP-9
2.4 Claims Filing and Reimbursement OP-9
2.4.1 Claims Information OP-9
2.4.2 Reimbursement OP-10
2.4.2.1 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit
(MUE) Guidelines OP-10
3. Comprehensive Health Center (CHC) OP-10
4. Federally Qualified Health Center (FQHC) OP-10
4.1 Enrollment OP-10
4.1.1 Initial Cost Reporting OP-11
4.2 Services, Benefits, Limitations, and Prior Authorization OP-12
4.2.1 After-Hours Care OP-16
4.2.2 Prior Authorization OP-16
4.2.3 Referral Requirements OP-16
4.3 Documentation Requirements OP-16
4.4 Claims Filing and Reimbursement OP-16
4.4.1 Claims Information OP-16
4.4.2 Reimbursement OP-18
4.4.2.1 Medicare-Medicaid Crossover Claims Pricing OP-18
4.4.2.2 NCCI and MUE Guidelines OP-18
5. Maternity Service Clinic (MSC) OP-18
6. Renal Dialysis Facility OP-18
6.1 Enrollment OP-18
6.2 Services, Benefits, Limitations, and Prior Authorization OP-19
6.2.1 Physician Supervision OP-19
6.2.1.1 Unscheduled or Emergency Dialysis in a Non-Certified ESRD Facility OP-22
6.2.2 Renal Dialysis Facilities-Method I Composite Rate OP-22
6.2.3 Method II Dealing Direct-Support Services OP-24
6.2.4 Facility Revenue Codes OP-25
6.2.5 Training for Hemodialysis, Intermittent Peritoneal Dialysis (IPD), Continuous
Cycle Peritoneal Dialysis (CCPD), and Chronic Ambulatory Peritoneal
Dialysis (CAPD) OP-26
6.2.6 Maintenance Hemodialysis OP-26
6.2.7 Maintenance IPD OP-26
6.2.8 Maintenance CAPD and CCPD OP-26
6.2.9 Laboratory and Radiology Services OP-27
6.2.9.1 In-Facility Dialysis—Routine Laboratory OP-27
6.2.9.2 In-Facility Dialysis—Nonroutine Laboratory OP-28
6.2.9.3 CAPD Laboratory OP-28
6.2.9.4 Hematopoietic Injections OP-29
6.2.9.5 Blood Transfusions OP-29
6.2.10 Prior Authorization OP-29
6.3 Documentation Requirements OP-29
6.4 Claims Filing and Reimbursement OP-29
6.4.1 Claims Information OP-29
6.4.2 Reimbursement OP-30
6.4.2.1 NCCI and MUE Guidelines OP-30
6.5 Medicare and Medicaid OP-30
7. Rural Health Clinic OP-31
7.1 Enrollment OP-31
7.1.1 Initial Cost Reporting OP-31
7.2 Services, Benefits, Limitations, and Prior Authorization OP-31
7.2.1 Freestanding and Hospital-Based RHC Services OP-33
7.2.1.1 Freestanding Rural Health Clinic Services OP-33
7.2.1.2 Hospital-Based Rural Health Clinic Services OP-34
7.2.1.3 After-Hours Care OP-35
7.2.2 Prior Authorization OP-35
7.3 Documentation Requirements OP-35
7.3.1 Record Retention OP-35
7.4 Claims Filing and Reimbursement OP-35
7.4.1 Claims Information OP-35
7.4.2 Reimbursement OP-35
7.4.2.1 NCCI and MUE Guidelines OP-35
7.4.2.2 Cost Report Submission OP-36
8. Tuberculosis Services OP-36
8.1 Enrollment OP-36
8.1.1 Managed Care Program Enrollment OP-37
8.2 Services, Benefits, Limitations, and Prior Authorization OP-37
8.2.1 TB-Related Clinic Services OP-37
8.2.2 Ancillary Services OP-38
8.2.3 Prior Authorization OP-39
8.3 Documentation Requirements OP-39
8.4 Provider Responsibilities OP-39
8.5 Claims Filing and Reimbursement OP-40
8.5.1 Claims Information OP-40
8.5.1.1 Managed Care Clients OP-40
8.5.2 Reimbursement OP-40
8.5.2.1 NCCI and MUE Guidelines OP-41
9. Claims Resources OP-41
10. Contact TMHP OP-41
11. Forms OP-41
OP.1 Community and Migrant Health Center Affiliation Affidavit OP-42
OP.2 Newborn Child or Children (Form 7484) OP-43
12. Claim Form Examples OP-44
OP.3 Birthing Center OP-45
OP.4 Family Planning Claim Form OP-46
OP.5 Family Planning Services for Hospitals, FQHCs OP-47
OP.6 FQHC Encounter (T1015) OP-48
OP.7 FQHC Follow-Up OP-49
OP.8 Renal Dialysis Facility CAPD Training OP-50
OP.9 Renal Dialysis Facility CAPD/CCPD OP-51
OP.10 Renal Dialysis CMS-1500 Example OP-52
OP.11 Rural Health Clinic Freestanding OP-53
OP.12 Rural Health Clinic Freestanding (Immunization) OP-54
OP.13 Rural Health Clinic Hospital-Based OP-55
OP.14 Tuberculosis OP-56
Index OP-57

Texas Medicaid & Healthcare Partnership
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