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2012 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 7. Rural Health Clinic : 7.2 Services, Benefits, Limitations, and Prior Authorization

7.2 Services, Benefits, Limitations, and Prior Authorization
The services listed in the table below may be reimbursed to RHC providers.
RHC Freestanding or Hospital Based Facility
General services and copayments are billed using the RHC’s National Provider Identifier (NPI). All other services billed using the RHC’s NPI are processed as informational only. Providers submitting claims for THSteps and Family Planning services must use their NPI and the appropriate benefit code.
Encounter Rates
An encounter rate may be reimbursed to the RHC facility only for the following services:
 
Note:
If the encounter is for antepartum or postpartum care, use modifier TH in addition to the modifier required to clarify the service that was performed.
Medicaid Fee-for-Service Reimbursement Rates
The following copayments may be reimbursed to RHC providers billing under their own NPI, and are reimbursed at the Medicaid fee-for-service rate.
Providers Rendering Services in a RHC Freestanding or Hospital Based Facility
The following services, when rendered in an RHC setting by a non-RHC provider, will process as an encounter and will be reimbursed an encounter rate equivalent to the host facility.
Providers must submit claims using their NPI and the appropriate benefit code.
Non-RHC providers rendering services in an RHC setting must use the appropriate national place of service (72) in order for claims to process as encounters:
Note:
Encounter Rates
An encounter rate may be reimbursed to the provider who renders services in an RHC setting for the following services:
THSteps Medical Services
An encounter rate may be reimbursed to the provider who renders services in an RHC setting for the following services:
Family Planning Services
 
Refer to:
Subsection 6.3.5, “Modifiers” in Section 6, “Claims Filing” (Vol. 1, General Information) for a definition of modifiers.
Section 8, “Physician,” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Section 5, “THSteps Medical,” in Children’s Services Handbook (Vol. 2, Provider Handbooks).
Section 2, “Medicaid Title XIX family planning services,” in Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks).
Subsection 6.12.2.2, “Managed Care Organization (MCO) Copayments” in Section 6, “Claims Filing” (Vol. 1, General Information).
Subsection 8.2.60.1.2, “Preventive Care Visits” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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