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2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook

Inpatient and Outpatient Hospital Services Handbook
Table of Contents
1. General Information HS-7
1.1 National Drug Codes (NDC) HS-7
1.2 Medicaid Managed Care Services HS-7
2. Enrollment HS-7
2.1 Hospital Eligibility Through Change of Ownership HS-7
2.1.1 Hospital-based Ambulatory Surgical Center (HASC) Enrollment HS-8
2.2 Hospital-based Rural Health Clinic Enrollment HS-8
3. Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) HS-8
3.1 General Information HS-8
3.1.1 Reimbursement Limitations HS-8
3.1.2 Spell of Illness HS-9
3.1.3 Take-Home Drugs, Self-Administered Drug, or Personal Comfort Items HS-9
3.1.4 Services Included in the Inpatient Stay HS-9
3.2 Services, Benefits, Limitations, and Prior Authorization - Acute Care HS-10
3.2.1 Bed and Board HS-10
3.2.2 Hysterectomy Services HS-10
3.2.3 Maternity Care HS-11
3.2.3.1 Emergency Coverage HS-11
3.2.3.2 Mother and Newborn Hospital Stay HS-11
3.2.3.3 Children's Health Insurance Program (CHIP) Perinatal Coverage HS-11
3.2.4 Newborn Care HS-11
3.2.4.1 Newborn Eligibility HS-12
3.2.5 Organ and Tissue Transplant Services HS-12
3.2.5.1 Transplant Facilities HS-12
3.2.5.2 Transplant Benefits and Limitations HS-13
3.2.5.3 Prior Authorization for Organ/Transplant Services HS-14
3.2.5.4 Transplants for Medicare-Eligible Clients HS-14
3.2.5.5 Experimental or Investigational Services HS-14
3.2.5.6 Reimbursement for Transplant Services HS-14
3.3 Services, Benefits, Limitations, and Prior Authorization - Inpatient Rehabilitation
Services HS-14
3.4 Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric
Services (IMD) HS-15
3.5 Documentation Requirements HS-16
3.5.1 Documentation for Nursing Facility Admissions HS-16
3.6 Inpatient Utilization Review HS-16
3.6.1 Utilization Review Process HS-16
3.6.1.1 Admission Review HS-17
3.6.1.2 Readmission Review HS-17
3.6.1.3 Hospital-Based Ambulatory (HASC) Surgical Procedures HS-18
3.6.1.4 Quality Review HS-18
3.6.1.5 Diagnosis-Related Group Validation HS-18
3.6.2 Recommendations to Enhance Compliance with Texas Medicaid Fee-for-Service
Hospital Claims Submission HS-18
3.6.3 Hospitals Reimbursed Under Tax Equity and Fiscal Responsibility Act (TEFRA)
of 1982 HS-19
3.6.4 Technical Denials (DRG Prospective Payment and TEFRA) HS-19
3.6.4.1 On-Site Reviews HS-19
3.6.4.2 Mail-In Reviews HS-20
3.6.5 Acknowledgment of Penalty Notice HS-20
3.6.6 Sanctions HS-20
3.6.7 Utilization Review Appeals HS-20
3.7 Claims Filing and Reimbursement HS-21
3.7.1 Medicaid Relationship to Medicare HS-21
3.7.2 Inpatient Claims Information HS-21
3.7.3 Inpatient Reimbursement HS-27
3.7.3.1 Prospective Payment Methodology HS-27
3.7.3.2 Client Transfers HS-28
3.7.3.3 Observation Status to Inpatient Admission HS-29
3.7.3.4 Outliers HS-29
3.7.3.5 Children’s Hospitals HS-30
3.7.3.6 State-owned Teaching Hospitals HS-30
3.7.4 Provider Cost and Reporting HS-31
3.7.4.1 Primary Care Case Management (PCCM) Outpatient Services Cost
Reporting HS-32
3.7.5 Third Party Liability HS-32
4. Outpatient Hospital (Medical/Surgical Acute Care Outpatient Facility) HS-32
4.1 General Information HS-33
4.1.1 Drugs and Supplies HS-33
4.1.1.1 Self-Administered Drugs HS-33
4.1.1.2 Take-Home Drugs and Supplies HS-33
4.1.2 Outpatient Services Provided Without Charge HS-33
4.2 Services, Benefits, Limitations, and Prior Authorization HS-33
4.2.1 Prior Authorization Requirements HS-33
4.2.2 Emergency Department Services HS-34
4.2.3 Day Surgery HS-35
4.2.3.1 Inpatient Admissions for Day Surgeries HS-35
4.2.3.2 Complications Following Elective/Scheduled Day Surgeries HS-36
4.2.3.3 Inpatient Admissions After Day Surgery HS-36
4.2.3.4 Emergency/Unscheduled Day Surgeries HS-37
4.2.3.5 Complications Following Emergency/Unscheduled Day Surgery HS-37
4.2.3.6 Incomplete Day Surgeries HS-37
4.2.4 Outpatient Observation Room Services HS-38
4.2.4.1 Direct Outpatient Observation Admission HS-39
4.2.4.2 Observation Following Emergency Room HS-39
4.2.4.3 Observation Following Outpatient Day Surgery HS-39
4.2.4.4 Observation Following Outpatient Diagnostic Testing or Therapeutic
Services HS-40
4.2.4.5 Documentation Requirements for Outpatient Observation HS-40
4.2.4.6 Reporting Hours of Operation HS-40
4.2.4.7 Client Status Change HS-41
4.2.4.8 Observation Services that are not a benefit HS-42
4.2.5 Hospital-Based Rural Health Clinic Services HS-42
4.2.6 Cardiac Rehabilitation HS-43
4.2.7 Chemotherapy Administration HS-45
4.2.8 Colorectal Cancer Screening HS-45
4.2.9 Computed Tomography and Magnetic Resonance Imaging HS-46
4.2.10 Electrodiagnostic (EDX) Testing HS-46
4.2.11 Fluocinolone Acetonide HS-46
4.2.11.1 Prior Authorization for Fluocinolone Acetonide HS-47
4.2.12 Fetal Nonstress Testing and Contraction Stress Test HS-47
4.2.13 Hyperbaric Oxygen Therapy (HBOT) HS-47
4.2.14 Laboratory Services HS-47
4.2.14.1 Clinical Laboratory Improvement Amendments (CLIA) HS-48
4.2.15 Lung Volume Reduction Surgery (LVRS) HS-48
4.2.16 Neurostimulators HS-49
4.2.16.1 Prior Authorization for Neurostimulators HS-49
4.2.17 Occupational and Physical Therapy Services HS-49
4.2.18 Radiation Therapy Services HS-49
4.2.18.1 Radiopharmaceuticals HS-49
4.2.19 Respiratory Services HS-50
4.2.19.1 Aerosol Treatment HS-50
4.2.19.2 Pentamidine Aerosol HS-51
4.2.19.3 Pulmonary Function Studies HS-52
4.2.20 Screening, Brief Intervention, and Referral to Treatment (SBIRT) HS-52
4.3 Documentation Requirements HS-53
4.4 Outpatient Utilization Review HS-53
4.5 Claims Filing and Reimbursement HS-54
4.5.1 Outpatient Claims Information HS-54
4.5.2 Outpatient Reimbursement HS-56
4.5.3 Provider Cost and Reporting HS-56
4.5.4 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE)
Guidelines HS-57
4.5.5 Outpatient Hospital Revenue Codes HS-57
4.5.6 Third Party Liability HS-62
5. Ambulatory Surgical Center and Hospital Ambulatory Surgical Center HS-63
5.1 Enrollment HS-63
5.2 Services/Benefits, Limitations, and Prior Authorization HS-63
5.2.1 Drugs and Supplies HS-63
5.2.2 Incomplete Surgical Procedures HS-63
5.2.3 Complications Following Day Surgery Requiring Outpatient Observation or
Inpatient Admission HS-64
5.2.4 Planned Admission for Day Surgery HS-64
5.2.7 Dental Therapy Under General Anesthesia HS-65
5.2.8 Fluocinolone Acetonide HS-65
5.2.9 Implantable Infusion Pumps HS-65
5.2.9.1 Prior Authorization for Implantable Infusion Pump HS-65
5.2.10 Stereotactic Radiosurgery HS-66
5.2.11 Brachytherapy HS-66
5.2.12 Neurostimulators HS-66
5.2.13 Prior Authorization HS-66
5.3 Documentation Requirements HS-67
5.4 Claims Filing and Reimbursement HS-67
5.4.1 Claims Information HS-67
5.4.2 Reimbursement HS-67
5.4.2.1 ASC and HASC Global Services HS-67
5.4.2.2 NCCI and MUE Guidelines HS-68
6. Military Hospitals HS-68
6.1 Military Hospital Enrollment HS-68
6.2 Services, Benefits, Limitations and Prior Authorization HS-68
6.2.1 Military Hospital Inpatient Services HS-68
6.2.2 Military Hospital Outpatient/Physician Services HS-69
6.2.3 Prior Authorization HS-69
6.3 Documentation Requirements HS-69
6.4 Claims Filing and Reimbursement HS-70
6.4.1 Military Hospital Claims Information HS-70
6.4.2 Military Hospital Reimbursement HS-70
7. Claims Resources HS-71
8. Contact TMHP HS-71
9. Forms HS-71
HS.1 Hospital Report (Newborn Child or Children) (Form 7484) HS-72
HS.2 Hysterectomy Acknowledgment Form HS-73
HS.3 Nonemergency Ambulance Prior Authorization Request HS-74
HS.4 Provider Instructions for Nonemergency Ambulance Prior Authorization Request Form HS-75
HS.5 Psychiatric Inpatient Initial Admission Request Form HS-76
HS.6 Psychiatric Inpatient Extended Stay Request Form HS-77
HS.7 Radiology Prior Authorization Request Form HS-78
HS.8 Sterilization Consent Form Instructions (2 Pages) HS-79
HS.9 Sterilization Consent Form (English) HS-81
HS.10 Sterilization Consent Form (Spanish) HS-82
10. Claim Form Examples HS-83
HS.11 Ambulatory Surgical Center HS-84
HS.12 Hospital-Based ASC HS-85
HS.13 Hospital Inpatient HS-86
HS.14 Military Hospital (Emergency Inpatient) HS-87
Index HS-88

Texas Medicaid & Healthcare Partnership
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