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2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 4. Outpatient Hospital (Medical/Surgical Acute Care Outpatient Facility) : 4.5 Claims Filing and Reimbursement : 4.5.2 Outpatient Reimbursement

4.5.2
Outpatient services are reimbursed on a reasonable cost based on a percentage of the hospital’s most recent tentative Medicaid cost report settlement.
Reimbursement for outpatient hospital services for high-volume providers is 76.03 percent of allowable cost. For the remaining providers, reimbursement for outpatient hospital services is 72.27 percent of allowable cost. High-volume providers are eligible for additional payments on Texas Medicaid fee-for-service claims. A high-volume outpatient hospital provider is defined as one that was paid at least $200,000 during calendar year 2004.
All clinical laboratory services are reimbursed at 60 percent of the prevailing charge except for those hospitals identified by Medicare as sole community hospitals. These hospitals are reimbursed at 62 percent of the prevailing charges for services provided to clients in the outpatient setting and 60 percent to clients in the inpatient setting. Clinical pathology consultations continue to be allowed for reimbursement.
Refer to:
Subsection 3.7.4, “Provider Cost and Reporting,” in this handbook for more information about the calculation of the interim rate.
Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA),” in Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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