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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 3. Certified Nurse Midwife (CNM) : 3.2 Services, Benefits, Limitations, and Prior Authorization : 3.2.7 Claims Filing and Reimbursement

3.2.7
CNMs must bill maternity services in one of two ways: itemizing each service individually on one claim form and filing at the time of delivery (the filing deadline is applied to the date of delivery) or itemizing each service individually and submitting claims as the services are rendered (the filing deadline is applied to each individual date of service).
CNM services must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms.
When completing a CMS-1500 claim form all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.
According to 1 TAC §355.8161, the Medicaid rate for CNMs is 92 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. The 92 percent fee is not reflected within the fee schedule and is applied before the payment is processed.
Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.
Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.
Refer to:
Subsection 4.1, “General Medicaid Eligibility,” in Section 4, Client Eligibility (Vol. 1, General Information) for information about crossover payments.
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
Subsection 6.1, “Claims Information,” in Section 6, “Claims Filing” (Vol. 1, General Information) for general information about claims filing.
Subsection 6.5, “CMS‑1500 Paper Claim Filing Instructions,” in Section 6, “Claims Filing” (Vol. 1, General Information).
Subsection 2.2, “Fee-for-Service Reimbursement Methodology,” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.

Texas Medicaid & Healthcare Partnership
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