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December 2013 Texas Medicaid Provider Procedures Manual

Table of Contents

Volume 1, General Information
Preliminary Information
Welcome: Texas Medicaid Provider Procedures Manual
Copyright Acknowledgments
Contents
Volume 1 - General Information
Volume 2 - Provider Handbooks
Introduction
Medicaid Program Administration
TMHP Website
TMHP Telephone and Address Guide
* TMHP Telephone and Fax Communication
Written Communication With TMHP
Other TMHP Information
TMHP Contact Center
Automated Inquiry System (AIS)
TMHP Provider Relations
TMHP Electronic Data Interchange (EDI) Help Desk
Section 1: Provider Enrollment and Responsibilities
1.1 Provider Enrollment
1.1.1 National Provider Identifier (NPI) and Taxonomy Codes
1.1.2 Online Enrollment
1.1.3 Paper Application Enrollment
1.1.4 Provider Enrollment Identification
1.1.4.1 Ordering- or Referring-Only Providers
1.1.5 Affordable Care Act of 2010 (ACA) Enrollment Requirements
1.1.5.1 Provider Screening Requirement
1.1.5.2 Provider Re-enrollment
1.1.5.3 Application Fee
1.1.5.4 Ordering- or Referring-Only Providers Search on the Online Provider Lookup (OPL)
1.1.6 Surety Bond Enrollment Requirement
1.1.7 Provider Enrollment Application Determinations
1.1.8 Enrollment in Medicaid Managed Care Programs
1.1.9 Required Enrollment Forms
1.1.9.1 HHSC Medicaid Provider Agreement
1.1.9.2 Provider Information Form (PIF-1)
1.1.9.3 Principal Information Form (PIF-2)
1.1.9.4 Disclosure of Ownership and Control Interest Statement
1.1.9.5 Internal Revenue Service (IRS) W‑9 Form
1.1.9.6 Medicaid Audit Information Form
1.1.9.7 Corporate Board of Directors Resolution
1.1.9.8 Franchise Tax Account Status Page
1.1.9.9 Certificate of Formation or Certificate of Filing/Certificate of Incorporation
1.1.9.10 Certificate of Filing
1.1.9.11 Copy of License, Temporary License, or Certification
1.1.9.12 Licensure Renewal
1.1.9.13 Medicare Participation
1.1.9.14 Group Information Changes
1.2 Payment Information
1.2.1 Using EFT
1.2.2 Advantages of EFT
1.2.3 EFT Enrollment Procedures
1.2.4 Stale-Dated Checks
1.3 Provider Deactivation/Disenrollment
1.3.1 Excluded Entities and Providers
1.4 Provider Reenrollment
1.4.1 Medicare Number
1.4.2 Provider Status (Individual, Group, Performing Provider, or Facility)
1.4.3 Physical Address
1.4.4 Change in Principal Information
1.5 Change of Ownership Requirements
1.6 Provider Responsibilities
1.6.1 Compliance with Texas Family Code
1.6.1.1 Child Support
1.6.1.2 Reporting Child Abuse or Neglect
1.6.1.3 Procedures for Reporting Abuse or Neglect
1.6.1.4 Procedures for Reporting Suspected Sexual Abuse
1.6.1.5 Training
1.6.1.6 Reporting Abuse and Neglect of the Elderly or Disabled
1.6.1.7 Procedures for Reporting Abuse or Neglect of the Elderly or Disabled
1.6.2 Maintenance of Provider Information
1.6.2.1 NPI Verification
1.6.2.2 Online Provider Lookup (OPL)
1.6.2.3 Updating NPI and Taxonomy Codes
1.6.2.4 Updating Provider Specialty
1.6.3 Retention of Records and Access to Records and Premises
1.6.3.1 Payment Error Rate Measurement (PERM) Process
1.6.4 Release of Confidential Information
1.6.5 Compliance with Federal Legislation
1.6.6 Tamper-Resistant Prescription Pads
1.6.7 Utilization Control — General Provisions
1.6.8 Provider Certification/Assignment
1.6.8.1 Delegation of Signature Authority
1.6.9 Billing Clients
1.6.9.1 Client Acknowledgment Statement
1.6.10 General Medical Record Documentation Requirements
1.6.11 Informing Pregnant Clients About CHIP Benefits
1.7 Electronic Health Records (EHR) Incentive Program
1.7.1 * Attesting to Meaningful Use: Required Documentation for Texas Medicaid EHR Incentive Program
1.7.2 * EHR Notification and Appeal Process
1.8 Enrollment Criteria for Out-of-State Providers
1.9 Medicaid Waste, Abuse, and Fraud Policy
1.9.1 Reporting Waste, Abuse, and Fraud
1.9.2 Suspected Cases of Provider Waste, Abuse, and Fraud
1.9.3 Employee Education on False Claims Recovery
1.9.4 Managed Care Organization (MCO) Special Investigative Unit (SIU)
1.10 Texas Medicaid Limitations and Exclusions
1.11 Forms
Section 2: Texas Medicaid Fee-for-Service Reimbursement
2.1 Payment Information
2.2 Fee-for-Service Reimbursement Methodology
2.2.1 Online Fee Lookup (OFL) and Static Fee Schedules
2.2.1.1 Non-emergent and Non-urgent Evaluation and Management (E/M) Emergency Department Visits
2.2.1.2 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2.2.1.3 Drugs and Biologicals
2.2.2 Cost Reimbursement
2.2.3 Reasonable Cost and Interim Rates
2.2.4 Hospitals
2.2.5 Provider-Specific Visit Rates
2.2.6 Manual Pricing
2.3 Reimbursement Reductions
2.4 Using Payouts to Satisfy Accounts Receivables Across Programs and Alternate Provider Identifiers
2.4.1 HHSC Recoupment of Accounts Receivables from Alternate Provider Identifiers
2.4.2 Medicaid Funds May Be Used to Satisfy Children with Special Health Care Needs (CSHCN) Services Program Accounts Receivables
2.5 Additional Payments to High-Volume Providers
2.6 Out-of-State Medicaid Providers
2.7 Medicare Crossover Claim Reimbursement
2.7.1 Part A
2.7.2 Part B
2.7.3 Part C: Medicare Advantage Plans (MAPs)
2.7.3.1 Contracted MAPs
2.7.3.2 Noncontracted MAPs
2.7.4 Exceptions
2.7.4.1 Full Amount of Part B and Part C Coinsurance and Deductible Reimbursed
2.7.4.2 Nephrology (Hemodialysis, Renal Dialysis) and Renal Dialysis Facility Providers
2.8 Federal Medical Assistance Percentage (FMAP)
Section 3: TMHP Electronic Data Interchange (EDI)
3.1 TMHP EDI Overview
3.1.1 Advantages of Electronic Services
3.1.2 Electronic Services Available
3.1.3 Paper Remittance and Status (R&S) Reports No Longer Available
3.2 Electronic Billing
3.2.1 TexMedConnect
3.2.2 Vendor Software
3.2.3 Third Party Billing Agents
3.3 Gaining Access
3.4 Training
3.5 Electronic Transmission Reports
3.6 Provider Check Amounts Available Online
3.7 Third Party Vendor Implementation
3.7.1 Automated Maintenance Process for All Electronic Submitters
3.7.2 Supported File Types
3.8 Forms
Section 4: Client Eligibility
4.1 General Medicaid Eligibility
4.1.1 Your Texas Benefits Medicaid Card
4.1.2 Retroactive Eligibility
4.1.3 Expedited Eligibility (Applies to Medicaid-eligible Pregnant Women Throughout the State)
4.1.4 Medicaid Buy-In Program for Employed Individuals with Disabilities
4.1.5 Newborn Eligibility
4.1.6 Potential Supplemental Security Income (SSI)/Medicaid Eligibility for Premature Infants
4.1.7 Foster Care
4.1.8 Medicaid Managed Care Eligibility
4.2 Eligibility Verification
4.2.1 Advantages of Electronic Eligibility Transactions
4.2.2 Contract with Outside Parties
4.3 Medicaid Identification and Verification
4.4 Restricted Medicaid Coverage
4.4.1 Emergency Only
4.4.2 Client Lock-in Program
4.4.2.1 Lock-in Medicaid Identification
4.4.2.2 Exceptions to Lock-in Status
4.4.2.3 Selection of Designated Provider and Pharmacy
4.4.2.4 Pharmacy services
4.4.2.5 Duration of Lock-in Status
4.4.2.6 Referral to Other Providers
4.4.2.7 Hospital Services
4.4.2.8 Lock-in Status Claims Payment
4.4.3 Hospice Program
4.4.3.1 Hospice Medicaid Identification
4.4.3.2 Physician Oversight Services
4.4.3.3 Medicaid Services Unrelated to the Terminal Illness
4.4.4 Presumptive Eligibility (PE)
4.4.4.1 PE Medicaid Identification
4.4.4.2 Services
4.4.4.3 Qualified Provider Enrollment
4.4.4.4 Process
4.5 CHIP Perinatal Program
4.5.1 Program Benefits
4.5.2 Claims
4.5.3 Client Eligibility Verification
4.5.3.1 Confirming Receipt of Form H3038
4.5.3.2 Eligibility Verification for Clients Without a Medicaid ID
4.5.3.3 Mother’s eligibility
4.5.3.4 Newborn’s eligibility
4.5.4 Submission of Birth Information to Texas Vital Statistics Unit
4.6 Medicaid Healthy Moms and Babies Services
4.7 Neonatal Care Management Program (NCMP)
4.8 Medically Needy Program (MNP)
4.8.1 Spend Down Processing
4.8.2 Closing an MNP Case
4.9 Medicaid Buy-in for Children (MBIC) Program
4.10 Texas Medicaid Wellness Program
4.11 Texas Women’s Health Program (TWHP)
4.12 Medicaid for Breast and Cervical Cancer (MBCC)
4.12.1 Initial MBCC Program Enrollment
4.12.2 MBCC Program Eligibility
4.12.3 Continued MBCC Program Eligibility
4.13 Medicare and Medicaid Dual Eligibility
4.13.1 QMB/MQMB Identification
4.13.2 Medicare Part B Crossovers
4.13.3 Clients Without QMB or MQMB Status
4.13.4 Medicare Part C
4.14 Third Party Liability (TPL)
4.14.1 Your Texas Benefits Medicaid Card
4.14.2 Workers’ Compensation
4.14.3 Adoption Cases
4.14.4 THSteps TPR Requirements
4.14.5 Accident-Related Claims
4.14.5.1 Accident Resources, Refunds
4.14.6 Third Party Liability - Tort
4.14.6.1 Providers Filing Liens for Third Party Reimbursement
4.14.6.2 Informational Claims
4.14.6.3 Submission of Informational Claims
4.14.6.4 Informational Claim Converting to Claims for Payment
4.15 Health Insurance Premium Payment (HIPP) Program
4.16 Long-Term Care Providers
4.17 State Supported Living Centers
4.18 Forms
Section 5: Fee-for-Service Prior Authorizations
5.1 General Information About Prior Authorization
5.1.1 Prior Authorization Requests for Clients with Retroactive Eligibility
5.1.2 Prior Authorization Requests for Newly Enrolled Providers
5.1.3 Prior Authorization for Services Rendered Out-of-State
5.1.4 Prior Authorization Requests for Clients with Private Insurance
5.1.5 Prior Authorization Requests for Clients with Medicare/Medicaid
5.1.6 Prior Authorizations for Personal Care Services (PCS)
5.1.6.1 Authorizations for Multiple PCS Clients Within the Same Household
5.1.6.2 Verifying the Texas Provider Identifier (TPI) on PCS Authorizations
5.1.7 Prior Authorization for Outpatient Self-Administered Prescription Drugs
5.1.8 Prior Authorization for Nonemergency Ambulance Transport
5.1.8.1 Prior Authorization Types, Definitions
5.1.8.2 Nonemergency Prior Authorization Process
5.1.8.3 Nonemergency Ambulance Exception Request
5.1.8.4 Documentation of Medical Necessity and Run Sheets
5.1.8.5 Nonemergency Prior Authorization and Retroactive Eligibility
5.1.9 Nonemergency Transport Authorization for Medicare and Medicaid Clients
5.2 Authorization Requirements for Unlisted Procedure Codes
5.3 Benefit Code
5.4 Submitting Prior Authorization Forms
5.5 Prior Authorization Submission Methods
5.5.1 Prior Authorization Requests Through the TMHP Website
5.5.1.1 Document Requirements and Retention
5.5.2 Prior Authorization Requests to TMHP by Fax, Telephone, or Mail
5.5.2.1 TMHP Prior Authorization Requests by Fax
5.5.2.2 * TMHP Prior Authorization Requests by Telephone
5.5.2.3 TMHP Prior Authorization Requests by Mail
5.5.3 * Home Health Services Prior Authorizations
5.5.4 Radiology Prior Authorizations Through MedSolutions
5.5.4.1 Online Prior Authorizations Through MedSolutions
5.5.4.2 Prior Authorizations to MedSolutions by Fax, Telephone, or Mail
5.5.4.3 Retroactive Authorization Requests
5.6 Verifying Prior Authorization Status
5.7 Prior Authorization Notifications
5.8 Prior Authorization Denials Appeals Process
5.9 Closing a Prior Authorization
5.10 Submitting Claims for Services That Require Prior Authorization
5.11 Guidelines for Procedures Awaiting Rate Hearing
Section 6: Claims Filing
6.1 Claims Information
6.1.1 TMHP Processing Procedures
6.1.1.1 Fiscal Agent
6.1.1.2 Payment Error Rate Measurement (PERM)
6.1.2 Claims Filing Instructions
6.1.2.1 Wrong Surgery Notification
6.1.2.2 Maximum Number of Units allowed per Claim Detail
6.1.2.3 Tips on Expediting Paper Claims
6.1.3 TMHP Paper Claims Submission
6.1.4 Claims Filing Deadlines
6.1.4.1 Claims for Clients with Retroactive Eligibility
6.1.4.2 Claims for Newly Enrolled Providers
6.1.4.3 Exceptions to the 95‑Day Filing Deadline
6.1.4.4 Appeal Time Limits
6.1.4.5 Claims with Incomplete Information and Zero Paid Claims
6.1.4.6 Claims Filing Reminders
6.1.5 HHSC Payment Deadline
6.1.5.1 Filing Deadline Calendar for 2012
6.1.5.2 Filing Deadline Calendar for 2013
6.2 TMHP Electronic Claims Submission
6.2.1 Benefit and Taxonomy Codes
6.2.2 Electronic Claim Acceptance
6.2.3 Electronic Rejections
6.2.3.1 Newborn Claim Hints
6.2.4 TMHP EDI Batch Numbers, Julian Dates
6.2.5 Modifier Requirements for TOS Assignment
6.2.5.1 Assistant Surgery
6.2.5.2 Anesthesia
6.2.5.3 Interpretations
6.2.5.4 Technical Components
6.2.6 Preferred Provider Organization (PPO)
6.3 Coding
6.3.1 Diagnosis Coding
6.3.1.1 Place of Service (POS) Coding
6.3.2 Type of Service (TOS)
6.3.2.1 TOS Table
6.3.3 Procedure Coding
6.3.3.1 Level I
6.3.3.2 Level II
6.3.3.3 Rate Hearings
6.3.4 National Drug Code (NDC)
6.3.5 Modifiers
6.3.6 Benefit Code
6.4 Claims Filing Instructions
6.4.1 National Correct Coding Initiative (NCCI) Guidelines
6.4.1.1 NCCI Processing Categories
6.4.1.2 CPT and HCPCS Claims Auditing Guidelines
6.4.2 Claim Form Requirements
6.4.2.1 Provider Signature on Claims
6.4.2.2 Group Providers
6.4.2.3 Supervising Physician Provider Number Required on Some Claims
6.4.2.4 Ordering or Referring Provider NPI
6.4.2.5 Prior Authorization Numbers on Claims
6.4.2.6 Newborn Clients Without Medicaid Numbers
6.4.2.7 Multipage Claim Forms
6.4.2.8 Attachments to Claims
6.4.2.9 Clients with a Designated or Primary Care Provider
6.5 CMS‑1500 Paper Claim Filing Instructions
6.5.1 CMS‑1500 Electronic Billing
6.5.2 CMS‑1500 Claim Form (Paper) Billing
6.5.3 CMS‑1500 Blank Paper Claim Form
6.5.4 CMS- 1500 Provider Definitions
6.5.5 * CMS‑1500 Instruction Table
6.6 UB-04 CMS-1450 Paper Claim Filing Instructions
6.6.1 UB-04 CMS-1450 Electronic Billing
6.6.2 UB-04 CMS-1450 Claim Form (Paper) Billing
6.6.3 UB-04 CMS-1450 Blank Paper Claim Form
6.6.4 UB-04 CMS-1450 Instruction Table
6.6.5 Occurrence Codes
6.6.6 Patient Discharge Status Codes
6.6.7 Filing Tips for Outpatient Claims
6.7 2006 American Dental Association (ADA) Dental Claim Filing Instructions
6.7.1 2006 ADA Dental Claim Electronic Billing
6.7.2 ADA Dental Claim Form (Paper) Billing
6.7.3 2006 ADA Dental Claim Form
6.7.4 2006 ADA Dental Claim Form Instruction Table
6.8 Family Planning Claim Filing Instructions
6.8.1 Family Planning Electronic Billing
6.9 Family Planning Claim Form (Paper Billing)
6.9.1 Family Planning 2017 Claim Form
6.9.2 Family Planning 2017 Claim Form Instructions
6.10 Vision Claim Form
6.11 Remittance and Status (R&S) Report
6.11.1 R&S Report Delivery Options
6.11.2 Banner Pages
6.11.3 R&S Report Field Explanation
6.11.4 R&S Report Section Explanation
6.11.4.1 Claims – Paid or Denied
6.11.4.2 Adjustments to Claims
6.11.4.3 Financial Transactions
6.11.4.4 Claims Payment Summary
6.11.4.5 The Following Claims are Being Processed
6.11.4.6 Explanation of Benefit Codes Messages
6.11.4.7 Explanation of Pending Status Codes Appendix
6.11.5 R&S Report Examples
6.11.5.1 Banner Page R&S Report
6.11.5.2 Paid or Denied Claims (Hospital) R&S Report
6.11.5.3 Paid or Denied Claims (Physician) R&S Report
6.11.5.4 Adjustments R&S Report
6.11.5.5 Claims in Process R&S Report
6.11.5.6 System Payouts R&S Report
6.11.5.7 Manual Payouts R&S Report
6.11.5.8 Accounts Receivables R&S Report
6.11.5.9 Void and Stop Pay R&S Report
6.11.5.10 Refunds for Medicaid R&S Report
6.11.5.11 Refunds for Managed Care R&S Report
6.11.5.12 IRS Levy R&S Report
6.11.5.13 Backup Withholding Penalty Information R&S Report
6.11.5.14 Reissues R&S Report
6.11.5.15 Sub-Owner Recoupments R&S Report
6.11.5.16 Summary R&S Report
6.11.5.17 Appendix R&S Report
6.11.6 Provider Inquiries—Status of Claims
6.12 Other Insurance Claims Filing
6.12.1 Unbundled Services That Are Prior Authorized and Manually Priced Procedure Codes
6.12.2 Other Insurance Credits
6.12.2.1 Deductibles
6.12.2.2 Health Maintenance Organization (HMO) Copayments
6.12.2.3 Verbal Denial
6.12.2.4 110‑Day Rule
6.12.2.5 Filing Deadlines
6.12.3 Claims Forwarded to Other Insurance Carriers
6.13 Filing Medicare Primary Claims
6.13.1 Electronic Crossover Claims
6.13.1.1 Medicare Copayments
6.13.1.2 Requirement for Group Billing Providers – Professional Claims
6.13.2 Paper Crossovers Claims
6.13.2.1 TMHP Standardized Medicare and MAP Remittance Advice Notice Form
6.13.2.2 Crossover Paper Claims Filing Deadlines
6.13.3 Filing Medicare-Adjusted Claims
6.13.4 Crossover Claim Type 30 TMHP Standardized MRAN Form
6.13.5 Crossover Claim Type 30 Instructions
6.13.6 Crossover Claim Type 31
6.13.7 Crossover Claim Type 31 Instructions
6.13.8 Crossover Claim Type 50
6.13.9 Crossover Claim Type 50 Instructions
6.14 Medically Needy Claims Filing
6.15 Claims Filing for Consumer-Directed Services (CDS)
6.16 Claims for Medicaid Hospice Clients Not Related to the Terminal Illness
6.16.1 Medical Services When Client is Discharged From Hospice
6.16.2 Claims Address for Medicaid Hospice Clients Not Related to the Terminal Illness
6.16.3 Lab and X-Ray
6.17 Claims for Texas Medicaid and CSHCN Services Program Eligible Clients
6.17.1 New Claim Submissions
6.17.2 CSHCN Services Program Claims Reprocessing for Retroactive Texas Medicaid Eligibility
6.18 Claims for State Supported Living Center Residents (SSLC)
6.19 Children’s Health Insurance Program (CHIP) Perinatal Claims
6.19.1 CHIP Perinatal Newborn Transfer Hospital Claims
6.20 Forms
Section 7: Appeals
7.1 Appeal Methods
7.1.1 Electronic Appeal Submission
7.1.1.1 Advantages of Electronic Appeal Submission
7.1.1.2 Disallowed Electronic Appeals
7.1.2 Resubmission of TMHP Electronic Data Interchange (EDI) Rejections
7.1.3 Automated Inquiry System (AIS) Appeals
7.1.4 Automated Inquiry System Automated Appeals Guide
7.1.5 Paper Appeals
7.1.5.1 Texas Medicaid Fee-for-Service DRG Adjustment Appeal
7.1.5.2 Medical Necessity Denial Appeals
7.1.5.3 Other Insurance Appeals
7.1.6 Appeals Submitted Incorrectly
7.2 Refunds to TMHP
7.2.1 Refunds Resulting from Other Insurance Payments
7.3 Appeals to HHSC Texas Medicaid Fee-for-Service
7.3.1 Administrative Claim Appeals
7.3.1.1 Requirements for Exception Requests
7.3.1.2 Exceptions to the 95‑Day Filing Deadline
7.3.1.3 Exceptions to the 120‑day Appeal Deadline
7.3.1.4 Exceptions to the 24‑Month Payment Deadline
7.3.2 Medical Necessity Appeals
7.3.3 Utilization Review Appeals
7.3.3.1 Admission Denials, Continued Stay Denials for TEFRA Hospitals, DRG Revisions, and Cost/Day Outlier Denials
7.3.3.2 Final Technical Denials
7.3.4 Provider Complaints
7.3.4.1 Provider Complaint Policy
7.3.4.2 Provider Complaint Process
7.3.4.3 Complaints to HHSC—Texas Medicaid Fee-for-Service
7.4 Cost Report Settlement Appeal Process
7.4.1 Appeals to TMHP Medicaid Audit
7.5 Forms
Appendix A: State and Federal Offices Communication Guide
A.1 Texas Health and Human Services Commission (HHSC) and Texas Department of State Health Services (DSHS) Office Addresses
A.2 HHSC Regional Offices of Eligibility Services (OES)
A.2.1 Telephone Communication with HHSC and DSHS
A.3 Client Telephone Communication with HHSC
A.4 Federal and State Telephone Numbers
A.5 DSHS Health Service Regions Map
A.6 DSHS Health Service Region Contacts
A.7 State Participating Local Health Departments and Public Health Districts
A.8 Department of Assistive and Rehabilitative Services (DARS), Blind Services
Appendix B: Vendor Drug Program
B.1 Vendor Drug Program
B.1.1 VDP Benefits for Medicaid Fee-for-Service (FFS) Clients
B.1.2 VDP Formulary Information
B.1.3 Obtaining Outpatient Prescribed Drug Prior Authorization for FFS Clients
B.1.4 Dispensing Life of Prescriptions
B.1.5 National Drug Code (NDC)
B.1.6 VDP Contact Information
7.5.1 72-Hour Emergency Supply
B.1.7 Cost Avoidance Coordination of Benefits
B.1.8 Tamper-Resistant Prescription Pads
B.1.9 Schedule II Controlled Substances (CII) through Schedule V Controlled Substances (CV)
B.1.10 Free Delivery of Medicaid Prescriptions for FFS Clients
B.1.11 Delivery of Medicaid Prescriptions for MCO Clients
B.1.12 Pharmacies Can Dispense Limited Home Health Supplies (LHSS) to Medicaid Clients
B.1.13 Some Vitamin and Mineral Products to Be Available Through VDP Pharmacies
B.2 Medicaid Children’s Services Comprehensive Care Program (CCP) Available for Children and Adolescents
B.3 Palivizumab (Synagis) Available Through the VDP
B.3.1 Participating Palivizumab Distribution Pharmacies
Appendix C: HIV/AIDS
C.1 CDC Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings
C.1.1 Routine HIV Testing Procedure Codes
C.2 Model Workplace Guidelines for Businesses, State Agencies, and State Contractors
C.2.1 Purpose
C.2.2 Authority
C.2.3 Who Must Use Workplace Guidelines
C.2.3.1 State Agencies
C.2.3.2 State Contractors
C.2.4 Why Have Guidelines
C.2.5 Development of Workplace Policy Content
C.2.6 Where to Go for Help
C.2.7 State Agencies Listed Under Health and Safety Code (HSC) §85.113
Appendix D: Acronym Dictionary
Volume 2, Provider Handbooks
Ambulance Services Handbook
1. General Information
2. Ambulance Services
2.1 Enrollment
2.1.1 Subscription Plans
2.2 Services, Benefits, Limitations, and Prior Authorization
2.2.1 Emergency Ambulance Transport Services
2.2.1.1 Prior Authorization for Emergency Out-of-State Transport
2.2.2 Nonemergency Ambulance Transport Services
2.2.3 Levels of Service
2.2.4 Oxygen
2.2.5 Types of Transport
2.2.5.1 Multiple Client Transports
2.2.5.2 Air or Specialized Vehicle Transports
2.2.5.3 Specialty Care Transport (SCT)
2.2.5.4 Transports for Pregnancies
2.2.5.5 Transports to or from State Institutions
2.2.5.6 Not Medically Necessary Transports
2.2.5.7 Transports for Nursing Facility Residents
2.2.5.8 Emergency Transports Involving a Hospital
2.2.5.9 No Transport
2.3 Documentation Requirements
2.3.1 Medicaid Surety Bond Requirements
2.3.1.1 Proof of Continuation
2.4 Claims Filing and Reimbursement
2.4.1 Claims Information
2.4.2 Reimbursement
2.4.2.1 Ambulance Disposable Supplies
2.4.2.2 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2.4.3 Medicare and Medicaid Coverage
2.4.3.1 Medicare Services Paid
2.4.3.2 Medicare Services Denied
2.4.4 Ambulance Claims Coding
2.4.4.1 Place of Service Codes
2.4.4.2 Origin and Destination Codes
2.4.4.3 Transports Billed Without Mileage
2.4.5 Air or Specialized Vehicle Transports
2.4.6 Emergency Transport Billing
2.4.7 Nonemergency Transport Billing
2.4.8 Extra Attendant
2.4.8.1 Emergency Transports
2.4.8.2 Nonemergency Transports
2.4.9 Night Call
2.4.10 Waiting Time
2.4.11 Appeals
2.4.12 Relation of Service to Time of Death
2.5 Claims Resources
2.6 Contact TMHP
3. Forms
4. Claim Form Examples
Behavioral Health, Rehabilitation, and Case Management Services Handbook
1. General Information
1.1 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Blind Children’s Vocational Discovery and Development Program (BCVDDP)
2.1 Overview
2.2 Enrollment
2.3 Services, Benefits, Limitations, and Prior Authorization
2.3.1 Prior Authorization
2.4 Documentation Requirements
2.5 Claims Filing and Reimbursement
3. Case Management for Children and Pregnant Women
3.1 Overview
3.1.1 Eligibility
3.1.2 Referral Process
3.2 Enrollment
3.3 Services, Benefits, Limitations, and Prior Authorization
3.3.1 Prior Authorization
3.4 Technical Assistance
3.4.1 Assistance with Program Concerns
3.5 Documentation Requirements
3.6 Claims Filing and Reimbursement
3.6.1 Claims Information
3.6.2 Managed Care Clients
4. Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC)
4.1 Enrollment
4.1.1 LCSW
4.1.2 LMFT
4.1.3 LPC
4.2 Services, Benefits, Limitations, and Prior Authorization
4.2.1 Prior Authorization
4.2.1.1 Initial Prior Authorization Request for Encounters or Visits Beyond the 30 Encounter or Visit Limit
4.2.1.2 Subsequent Prior Authorization Request for Encounters or Visits after the Initial Prior Authorized Encounters
4.2.1.3 Prior Authorization for Court-Ordered and Department of Family and Protective Services (DFPS)-Directed Services
4.3 Documentation Requirements
4.4 Claims Filing and Reimbursement
5. Mental Health Rehabilitation, Mental Health Case Management, and Intellectual Disability Service Coordination
5.1 Enrollment
5.1.1 Local Authority (LA) Providers
5.2 Services, Benefits, Limitations, and Prior Authorization
5.2.1 Service Coordination
5.2.2 Case Management
5.2.3 MH Rehabilitative Services
5.2.3.1 Day Program
5.2.3.2 Medication Training and Support
5.2.3.3 Crisis Intervention
5.2.3.4 * Skills Training and Development
5.2.3.5 Psychosocial Rehabilitative Services
5.2.3.6 Rehabilitative Services Limitations
5.2.3.7 Billing Units
5.2.4 Prior Authorization
5.3 Documentation Requirements
5.4 Claims Filing and Reimbursement
5.4.1 Managed Care Clients
5.4.2 Reimbursement Reductions
6. Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers
6.1 Enrollment
6.1.1 Physicians
6.1.2 Psychologists
6.1.3 Licensed Psychological Associate (LPA)
6.1.4 Provisionally Licensed Psychologist (PLP)
6.2 Services, Benefits, Limitations, and Prior Authorization
6.2.1 Physicians
6.2.2 Psychologists, LPAs, and PLPs
6.3 The 12-Hour System Limitation
6.3.1 Retrospective Review of Behavioral Health Services Billed in Excess of 12 Hours per Day
6.3.2 Procedure Codes Included in the 12-Hour System Limitation
6.3.3 Formula Applied
6.4 Outpatient Behavioral Health Services
6.4.1 Annual Encounter or Visit Limitations
6.4.2 Prior Authorization Requirements After the Annual Encounter or Visit Limitations Have Been Met
6.5 Court-Ordered and DFPS-Directed Services
6.5.1 Prior Authorization
6.5.2 Documentation Requirements
6.6 Electroconvulsive Therapy (ECT)
6.7 Family Therapy or Counseling Services
6.7.1 Prior Authorization
6.7.2 Documentation Requirements
6.7.3 Reimbursement
6.8 Pharmacological Regimen Oversight
6.8.1 Indications for Pharmacological Regimen Oversight
6.8.2 Prior Authorization
6.8.3 Documentation Requirements
6.8.4 Reimbursement
6.9 Psychiatric Diagnostic Evaluations
6.9.1 Psychiatric Diagnostic Evaluation Without Medical Services
6.9.2 Psychiatric Diagnostic Evaluation With Medical Services
6.9.3 Prior Authorization
6.9.4 Documentation Requirements
6.9.5 Domains of a Clinical Evaluation
6.10 Psychological and Neuropsychological Testing
6.10.1 Prior Authorization
6.10.2 Documentation Requirements
6.10.3 Reimbursement
6.11 Psychotherapy or Counseling
6.11.1 Prior Authorization
6.11.2 Documentation Requirements
6.11.3 Initial Outpatient Psychotherapy or Counseling for an Individual, Group, or Family
6.11.4 Subsequent Outpatient Psychotherapy or Counseling for an Individual, Group or Family
6.11.4.1 Active Treatment Plan Requirements
6.11.4.2 Discharge Plan Requirements
6.11.5 Reimbursement
6.12 Treatment for Alzheimer’s Disease and Dementia
6.13 Narcosynthesis
6.14 Noncovered Services
6.15 Psychiatric Services for Hospitals
6.15.1 Prior Authorization Requirements
6.15.2 Documentation Requirements
6.15.3 Psychological and Neuropsychological Testing Services
6.15.4 Inpatient Hospital Discharge
6.16 Claims Filing and Reimbursement
6.16.1 NCCI and MUE Guidelines
7. Screening, Brief Intervention, and Referral to Treatment (SBIRT)
7.1 Screening
7.2 Brief Intervention
7.3 Brief Treatment
7.4 Referral to Treatment
7.5 Reimbursement and Limitations
7.6 Documentation Requirements
7.7 Claims Filing and Reimbursement
8. Substance Use Disorder (SUD) Services (Abuse and Dependence)
8.1 Overview
8.2 Enrollment
8.2.1 CDTFs
8.3 Assessment
8.4 Detoxification Services
8.4.1 Ambulatory (Outpatient) Detoxification Services
8.4.2 Residential Detoxification Services
8.5 Treatment Services
8.5.1 Residential Treatment Services
8.5.2 Ambulatory (Outpatient) Treatment Services
8.5.3 Physician Services
8.6 Medication Assisted Therapy (MAT)
8.7 Prior Authorization
8.7.1 Prior Authorization for Fee-for-Service Clients
8.7.2 Prior Authorization for Ambulatory (Outpatient) Detoxification Treatment Services
8.7.2.1 Admission Criteria for Ambulatory (Outpatient) Detoxification Treatment Services
8.7.2.2 Continued Stay Criteria for Ambulatory (Outpatient) Detoxification Treatment Services
8.7.3 Prior Authorization for Residential Detoxification Treatment Services
8.7.3.1 Admission Criteria for Residential Detoxification Treatment Services
8.7.3.2 Continued Stay Criteria for Residential Detoxification Treatment Services
8.7.4 Prior Authorization for Residential Treatment Services
8.7.4.1 Admission Criteria for Residential Treatment Services
8.7.4.2 Residential Treatment Services for Adolescents
8.7.4.3 Continued Stay Criteria for Residential Treatment Services
8.7.5 Prior Authorization for Ambulatory (Outpatient) Treatment Services for Clients Who Are 20 Years of Age and Younger
8.8 Documentation Requirements
8.9 Reimbursement and Limitations
8.9.1 Detoxification Services
8.9.2 Treatment Services
8.9.3 MAT Services
8.10 Noncovered Services
8.11 Claims Filing
9. Claims Resources
10. Contact TMHP
11. Forms
12. Claim Form Examples
Children’s Services Handbook
1. General Information
1.1 Medical Transportation Program
1.2 Rates Reduction
1.3 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Medicaid Children’s Services Comprehensive Care Program (CCP)
2.1 CCP Overview
2.1.1 Client Eligibility
2.1.2 Enrollment
2.1.3 Services, Benefits, and Limitations
2.1.4 Prior Authorization and Documentation Requirements
2.1.4.1 Diagnosis Coding
2.1.4.2 Drug and Medical Device Approval
2.1.4.3 Physician Signature
2.2 Certified Respiratory Care Practitioner Services (CCP)
2.2.1 Services, Benefits, and Limitations
2.2.2 Prior Authorization and Documentation Requirements
2.3 Clinician-Directed Care Coordination Services (CCP)
2.3.1 * Services, Benefits, and Limitations
2.3.1.1 Non-Face-to-Face Services
2.3.1.2 Face-to-Face Services
2.3.2 Prior Authorization and Documentation Requirements
2.3.2.1 Documentation Requirements for the Medical Home Clinician for a Telephone Consult with a Specialist
2.3.2.2 Documentation Requirements for the Specialist or Subspecialist for a Telephone Consult with the Medical Home Clinician
2.3.3 Claims Information
2.3.4 Reimbursement
2.4 Comprehensive Outpatient Rehabilitation Facilities (CORFs)and Outpatient Rehabilitation Facilities (ORFs)
2.4.1 Enrollment
2.4.2 Services, Benefits, and Limitations
2.4.3 Occupational Therapy
2.4.3.1 Services, Benefits, and Limitations
2.4.3.2 Prior Authorization and Documentation Requirements
2.4.4 Physical Therapy
2.4.4.1 Services, Benefits, and Limitations
2.4.4.2 Prior Authorization and Documentation Requirements
2.4.5 Speech Therapy (ST)
2.4.5.1 Services, Benefits, and Limitations
2.4.5.2 Prior Authorization and Documentation Requirements
2.4.6 Claims Information
2.4.7 Reimbursement
2.5 Durable Medical Equipment (DME) Supplier (CCP)
2.5.1 Enrollment
2.5.1.1 Pharmacies (CCP)
2.5.2 Services, Benefits, and Limitations
2.5.2.1 Purchase Versus Equipment Rental
2.5.3 Prior Authorization and Documentation Requirements
2.5.3.1 Equipment Accessories
2.5.3.2 Equipment Modifications
2.5.3.3 Equipment Adjustments
2.5.3.4 Equipment Repairs
2.5.3.5 DME Certification and Receipt Form
2.5.3.6 Documentation of Supply Delivery
2.5.3.7 Specific CCP Policies
2.5.4 Blood Pressure Devices
2.5.4.1 Services, Benefits, and Limitations
2.5.4.2 Prior Authorization and Documentation Requirements
2.5.5 Cardiorespiratory (Apnea) Monitor
2.5.5.1 Services, Benefits, and Limitations
2.5.5.2 Prior Authorization and Documentation Requirements
2.5.6 Pulse Oximeter
2.5.6.1 Services, Benefits, and Limitations
2.5.6.2 Prior Authorization and Documentation Requirements
2.5.7 Diabetic Equipment and Supplies
2.5.7.1 Services, Benefits, and Limitations
2.5.7.2 Prior Authorization and Documentation Requirements
2.5.8 Donor Human Milk
2.5.8.1 Services, Benefits, and Limitations
2.5.8.2 Prior Authorization and Documentation Requirements
2.5.9 Incontinence Supplies
2.5.9.1 Services, Benefits, and Limitations
2.5.9.2 Prior Authorization and Documentation Requirements
2.5.10 Mobility Aids
2.5.10.1 Services, Benefits, and Limitations
2.5.10.2 Prior Authorization and Documentation Requirements
2.5.11 Nutritional Products
2.5.11.1 Services, Benefits, and Limitations
2.5.11.2 Women, Infants, and Children Program (WIC)
2.5.11.3 Noncovered Services
2.5.11.4 Prior Authorization and Documentation Requirements
2.5.11.5 Managed Care Clients
2.5.12 Hospital Beds, Cribs, and Equipment
2.5.12.1 Services, Benefits, and Limitations
2.5.12.2 Prior Authorization and Documentation Requirements
2.5.13 Phototherapy Devices
2.5.13.1 Services, Benefits, and Limitations
2.5.13.2 Prior Authorization and Documentation Requirements
2.5.14 Special Needs Car Seats and Travel Restraints
2.5.14.1 Services, Benefits, and Limitations
2.5.14.2 Prior Authorization and Documentation Requirements
2.5.15 Total Parenteral Nutrition (TPN)
2.5.15.1 Services, Benefits, and Limitations
2.5.15.2 Prior Authorization and Documentation Requirements
2.5.16 Vitamin and Mineral Products
2.5.16.1 Services, Benefits, and Limitations
2.5.16.2 Prior Authorization and Documentation Requirements
2.5.17 Claims Information
2.5.18 Reimbursement
2.6 Early Childhood Intervention (ECI) Services
2.6.1 Enrollment
2.6.2 Services, Benefits, Limitations, and Prior Authorization
2.6.2.1 Therapy
2.6.2.2 Specialized Skills Training (SST)
2.6.2.3 Targeted Case Management (TCM)
2.6.3 Documentation Requirements
2.6.4 Claims Filing and Reimbursement
2.6.4.1 Claims Information
2.6.4.2 Reimbursement
2.7 Medical Nutrition Counseling Services (CCP)
2.7.1 Enrollment
2.7.2 Services, Benefits, and Limitations
2.7.3 Prior Authorization and Documentation Requirements
2.7.4 Claims Information
2.7.5 Reimbursement
2.8 Orthotic and Prosthetic Services (CCP)
2.8.1 Enrollment
2.8.2 Orthotics Services
2.8.2.1 Services, Benefits, and Limitations
2.8.2.2 Prior Authorization and Documentation Requirements
2.8.3 Cranial Molding Orthosis
2.8.3.1 Services, Benefits, and Limitations
2.8.3.2 Noncovered Services
2.8.3.3 Prior Authorization and Documentation Requirements
2.8.4 Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers, Standing Frames, Braces, and Parapodiums)
2.8.4.1 Services, Benefits, and Limitations
2.8.4.2 Prior Authorization and Documentation Requirements
2.8.5 Prosthetic Services
2.8.5.1 Services, Benefits, and Limitations
2.8.5.2 Prior Authorization and Documentation Requirements
2.8.6 Claims Information
2.8.7 Reimbursement
2.9 Personal Care Services (PCS) (CCP)
2.9.1 Enrollment
2.9.2 Services, Benefits, and Limitations
2.9.2.1 Place of Services
2.9.2.2 Client Eligibility
2.9.2.3 PCS Provided in Group Settings
2.9.3 Prior Authorization and Documentation Requirements
2.9.3.1 PCS Provider Responsibilities
2.9.3.2 Documentation of Services Provided and Retrospective Review
2.9.4 Claims Information
2.9.4.1 Managed Care Clients
2.9.4.2 PCS for STAR Health Clients
2.9.5 Reimbursement
2.10 Private Duty Nursing (PDN)(CCP)
2.10.1 Enrollment
2.10.2 Services, Benefits, and Limitations
2.10.2.1 PDN Provided During a Skill Nursing Visit for TPN Administration Education
2.10.2.2 Criteria
2.10.3 Prior Authorization and Documentation Requirements
2.10.3.1 Retroactive Client Eligibility
2.10.3.2 Start of Care (SOC)
2.10.3.3 Prior Authorization of Initial Requests
2.10.3.4 Authorization for Revision of Current Services
2.10.3.5 Recertifications of Authorizations
2.10.3.6 Termination of Authorization
2.10.3.7 Client and Provider Notification
2.10.3.8 Authorization Appeals
2.10.3.9 CCP Prior Authorization Request Form
2.10.3.10 Home Health Plan of Care (POC)
2.10.3.11 Nursing Addendum to Plan of Care (CCP) Form
2.10.3.12 Responsible Adult or Identified Contingency Plan Requirement
2.10.3.13 Special Circumstances
2.10.3.14 Documentation of Services Provided and Retrospective Review
2.10.4 Claims Information
2.10.5 Reimbursement
2.11 Therapy Services (CCP)
2.11.1 Occupational Therapy (OT)
2.11.1.1 Enrollment
2.11.1.2 Services, Benefits, and Limitations
2.11.1.3 Prior Authorization and Documentation Requirements
2.11.1.4 Claims Information
2.11.1.5 Reimbursement
2.11.2 Physical Therapy (PT)
2.11.2.1 Enrollment
2.11.2.2 Services, Benefits, and Limitations
2.11.2.3 Prior Authorization and Documentation Requirements
2.11.2.4 Claims Information
2.11.2.5 Reimbursement
2.11.3 Speech Therapy (ST)
2.11.3.1 Enrollment
2.11.3.2 Services, Benefits, and Limitations
2.11.3.3 Prior Authorization and Documentation Requirements
2.11.3.4 Claims Information
2.11.3.5 Reimbursement
2.12 Inpatient Psychiatric Hospital or Facility (Freestanding) (CCP)
2.13 Inpatient Rehabilitation Facility (Freestanding) (CCP)
2.13.1 Enrollment
2.13.1.1 Continuity of Hospital Eligibility Through Change of Ownership
2.13.2 Services, Benefits, and Limitations
2.13.2.1 Comprehensive Treatment
2.13.3 Prior Authorization and Documentation Requirements
2.13.4 Claims Information
2.13.5 Reimbursement
2.13.5.1 Client Transfers
3. School Health and Related Services (SHARS)
3.1 Overview
3.1.1 Random Moment Time Study (RMTS)
3.1.2 Eligibility Verification
3.2 Enrollment
3.2.1 SHARS Enrollment
3.2.2 Private School Enrollment
3.3 Services, Benefits, Limitations, and Prior Authorization
3.3.1 Audiology
3.3.1.1 Audiology Billing Table
3.3.2 Counseling Services
3.3.2.1 Counseling Services Billing Table
3.3.3 Psychological Testing and Services
3.3.3.1 Psychological Testing
3.3.3.2 Psychological Services
3.3.4 Nursing Services
3.3.4.1 Nursing Services Billing Table
3.3.5 Occupational Therapy (OT)
3.3.5.1 Referral
3.3.5.2 Description of Services
3.3.5.3 Occupational Therapy Billing Table
3.3.6 Personal Care Services
3.3.6.1 Personal Care Services Billing Table
3.3.7 Physical Therapy (PT)
3.3.7.1 Referral
3.3.7.2 Description of Services
3.3.7.3 Physical Therapy Billing Table
3.3.8 Physician Services
3.3.8.1 Physician Services Billing Table
3.3.9 Speech Therapy (ST)
3.3.9.1 Referral
3.3.9.2 Description of Services
3.3.9.3 Provider and Supervision Requirements
3.3.9.4 Speech Therapy Billing Table
3.3.10 Transportation Services in a School Setting
3.3.10.1 Transportation Services in a School Setting Billing Table
3.3.11 Prior Authorization
3.4 Documentation Requirements
3.4.1 Record Retention
3.5 Claims Filing and Reimbursement
3.5.1 Claims Information
3.5.1.1 Appealing Denied SHARS Claims
3.5.1.2 Billing Units Based on 15 Minutes
3.5.1.3 Billing Units Based on an Hour
3.5.2 Managed Care Clients
3.5.3 Reimbursement
3.5.3.1 Quarterly Certification of Funds
3.6 Cost Reporting, Cost Reconciliation, and Cost Settlement
3.6.1 Cost Reporting
3.6.2 Cost Reconciliation and Cost Settlement
3.6.3 Informal Review of Cost Reports Settlement
4. Texas Health Steps (THSteps) Dental
4.1 Enrollment
4.1.1 THSteps Dental Eligibility
4.1.2 THSteps Dental and ICF/ID Dental Services
4.1.3 THSteps Dental Checkup and Treatment Facilities
4.1.4 Doctor of Dentistry Practicing as a Limited Physician
4.1.5 Client Rights
4.1.6 Complaints and Resolution
4.2 Services, Benefits, Limitations, and Prior Authorization
4.2.1 THSteps Dental Services
4.2.1.1 Eligibility for THSteps Dental Services
4.2.1.2 Parental Accompaniment
4.2.2 Comprehensive Care Program (CCP)
4.2.3 Children’s Medicaid Dental Plan Choices
4.2.4 Authorization Transfers for Medicaid Managed Care Dental Orthodontic Services
4.2.5 ICF/ID Dental Services
4.2.5.1 THSteps and ICF/ID Provision of Dental Services
4.2.5.2 Children in Foster Care
4.2.6 Written Informed Consent and Standards of Care
4.2.7 First Dental Home
4.2.8 Dental Referrals by THSteps Primary Care Providers
4.2.9 Change of Provider
4.2.9.1 Interrupted or Incomplete Orthodontic Treatment Plans
4.2.10 Periodicity for THSteps Dental Services
4.2.10.1 Exceptions to Periodicity
4.2.11 Tooth Identification (TID) and Surface Identification (SID) Systems
4.2.11.1 Supernumerary Tooth Identification
4.2.12 Medicaid Dental Benefits, Limitations, and Fee Schedule
4.2.13 Diagnostic Services
4.2.14 Preventive Services
4.2.15 Therapeutic Services
4.2.16 Restorative Services
4.2.17 Endodontics Services
4.2.18 Periodontal Services
4.2.19 Prosthodontic (Removable) Services
4.2.20 Implant Services
4.2.21 Prosthodontic (Fixed) Services
4.2.22 Oral and Maxillofacial Surgery Services
4.2.23 Adjunctive General Services
4.2.24 Dental Anesthesia
4.2.25 Dental Therapy Under General Anesthesia
4.2.25.1 Criteria for Dental Therapy Under General Anesthesia
4.2.25.2 Criteria for Dental Therapy Under General Anesthesia, Attachment 1
4.2.26 Hospitalization and ASC/HASC
4.2.27 Orthodontic Services (THSteps)
4.2.27.1 Benefits and Limitations for Orthodontic Services
4.2.27.2 Crossbite Therapy
4.2.27.3 Minor Treatment to Control Harmful Habits
4.2.27.4 Premature Termination of Comprehensive Orthodontic Treatment
4.2.27.5 Other Orthodontic Services
4.2.27.6 Non-covered Services
4.2.27.7 Comprehensive Orthodontic Treatment
4.2.27.8 Orthodontic Procedure Codes and Fee Schedule
4.2.28 Special Orthodontic Appliances
4.2.29 Handicapping Labio-lingual Deviation (HLD) Index
4.2.29.1 HLD Score Sheet
4.2.30 Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger
4.2.31 Emergency Services for Medicaid Clients Who Are 21 Years of Age and Older
4.2.31.1 Long Term Care (LTC) Emergency Dental Services
4.2.31.2 Laboratory Requirements
4.2.32 Mandatory Prior Authorization
4.2.32.1 Cone Beam Imaging
4.2.32.2 General Anesthesia for Dental Treatment
4.2.32.3 Orthodontic Services
4.2.33 THSteps and ICF/ID Dental Prior Authorization
4.3 Documentation Requirements
4.3.1 General Anesthesia
4.3.2 Orthodontic Services
4.4 Utilization Review
4.5 Claims Filing and Reimbursement
4.5.1 Reimbursement
4.5.2 Third Party Resources (TPR)
4.5.3 Claim Submission After Loss of Eligibility
4.5.4 Claims Information
4.5.5 Claim Appeals
4.5.6 Frequently Asked Questions About Dental Claims
5. THSteps Medical
5.1 THSteps Medical and Dental Administrative Information
5.1.1 Overview
5.1.2 Statutory Requirements
5.1.3 Texas Vaccines for Children (TVFC) Program
5.1.4 Vaccine Adverse Event Reporting System (VAERS)
5.1.5 Referrals for Medicaid-Covered Services
5.1.6 THSteps Medical Checkup Facilities
5.1.7 THSteps Dental Services
5.2 Enrollment
5.2.1 THSteps Medical Provider Enrollment
5.2.1.1 Requirements for Registered Nurses Who Provide Medical Checkups
5.3 Services, Benefits, Limitations, and Prior Authorization
5.3.1 Eligibility for THSteps Services and Checkup Due Dates
5.3.2 Prior Authorization
5.3.3 Additional Consent Requirements
5.3.4 Verification of Medical Checkups
5.3.5 Medical Home
5.3.6 THSteps Medical Checkups
5.3.7 Exception-to-Periodicity Checkups
5.3.8 Follow-up Medical Checkup
5.3.9 Newborn Examination
5.3.10 THSteps Medical Checkups Periodicity Schedule
5.3.11 Mandated Components
5.3.11.1 Comprehensive Health and Developmental History
5.3.11.2 Comprehensive Unclothed Physical Examination
5.3.11.3 Immunizations
5.3.11.4 Health Education and Anticipatory Guidance
5.3.11.5 Dental Referral
5.3.11.6 Laboratory Test
5.3.12 Non-mandated Components
5.3.12.1 Oral Evaluation and Fluoride Varnish (OEFV) in the Medical Home
5.4 Documentation Requirements
5.4.1 Separate Identifiable Acute Care Evaluation and Management Visit
5.5 Claims Filing and Reimbursement
5.5.1 Claims Information
5.5.2 Reimbursement
6. Claims Resources
7. Contact TMHP
7.1 Automated Inquiry System (AIS)
7.2 TMHP Website
7.3 Dental Information and Assistance
7.3.1 Dental Inquiry Line
7.4 THSteps Information and Assistance
7.5 Assistance with Program
8. Forms
9. Claim Form Examples
Appendix A: THSteps Forms
A.1 Claim Forms
A.2 THSteps Medical Checkup Forms
A.3 Laboratory Forms
A.4 Guidelines for Tuberculosis Skin Testing
A.5 Tuberculosis Screening and Guidelines
A.6 Texas Vaccines For Children (TVFC)
Appendix B: Immunizations
B.1 Immunizations Overview
B.1.1 Vaccine Adverse Event Reporting System (VAERS)
B.1.2 TVFC Versus Non-TVFC Vaccines/Toxoids
B.1.3 Exemption from Immunization for School and Child-Care Facilities
B.2 Recommended Childhood Immunization Schedule
B.2.1 Recommended Childhood and Adolescent Immunization Schedule, 2013
B.3 General Recommendations
B.3.1 How to Obtain Vaccines at No Cost to the Provider
B.3.2 Administrations and Immunizations
B.3.2.1 Administrations
B.3.2.2 Immunizations (Vaccine/Toxoids)
B.3.3 Requirements for TVFC Providers
B.3.4 How to Report Immunization Records to ImmTrac, the Texas Immunization Registry
B.3.4.1 Direct Internet Entry
B.3.4.2 Electronic Data Transfer (Import)
B.3.4.3 Obtaining Parental Consent for Registry Participation
B.4 Texas Vaccines for Children Program Packet
Appendix C: Lead Screening
C.1 Blood Lead Screening Procedures and Follow-up Testing
C.2 Symptoms of Lead Poisoning
C.3 Measuring Blood Lead Levels
C.4 Environmental Lead Investigation Services
C.4.1 Enrollment
C.4.2 Services, Benefits, Limitations, and Prior Authorization
C.4.2.1 Requesting an Environmental Lead Investigation
C.4.2.2 Prior Authorization
C.4.3 Documentation Requirements
C.4.4 Claims Filing and Reimbursement
C.4.4.1 Claims Filing
C.4.4.2 Managed Care Clients
C.4.4.3 Reimbursement
C.5 Form Pb‑109: Reference for Follow-up Blood Lead Testing and Medical Case Management
C.6 Lead Poisoning Prevention Educational Materials and Forms
Appendix D: Texas Health Steps Statutory State Requirements
D.1 Legislative Requirements
D.2 Texas Health Steps (THSteps) Program
D.3 Communicable Disease Reporting
D.4 Early Childhood Intervention (ECI) Referrals
D.5 Parental Accompaniment
D.6 Newborn Blood Screening
D.7 Abuse and Neglect
D.7.1 Requirements for Reporting Abuse or Neglect
D.7.2 Procedures for Reporting Abuse or Neglect
D.7.2.1 Staff Training on Reporting Abuse and Neglect
Appendix E: Hearing Screening Information
E.1 Newborn Hearing (2 Pages)
E.2 Texas Early Hearing Detection and Intervention (TEHDI) Process
E.2.1 Birth Screen
E.2.2 Outpatient Rescreen
E.2.3 Evaluation using Texas Pediatric Protocol for Audiology
E.2.4 Referral to an ECI Program
E.2.5 Periodic Monitoring by the Physician or Medical Home
E.3 JCIH 2007 Position Statement
Appendix F: THSteps Quick Reference Guide
F.1 Texas Health Steps Quick Reference Guide
Appendix G: THSteps Dental Guidelines
G.1 American Academy of Pediatric Dentistry Periodicity Guidelines (9 Pages)
G.2 American Dental Association Guidelines for Prescribing Dental Radiographs (3 Pages)
Clinics and Other Outpatient Facility Services Handbook
1. General Information
1.1 National Drug Codes (NDC)
1.2 Revenue Codes for UB-04 Submissions
1.3 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Birthing Center
2.1 Provider Enrollment
2.2 Services, Benefits, Limitations, and Prior Authorization
2.2.1 Newborn Hearing Screening
2.2.2 Newborn Eligibility Process
2.2.3 Prior Authorization
2.2.4 Services Rendered in the Birthing Center Setting
2.3 Documentation Requirements
2.4 Claims Filing and Reimbursement
2.4.1 Claims Information
2.4.2 Reimbursement
2.4.2.1 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines
3. Comprehensive Health Center (CHC)
4. Federally Qualified Health Center (FQHC)
4.1 Enrollment
4.1.1 Initial Cost Reporting
4.2 Services, Benefits, Limitations, and Prior Authorization
4.2.1 After-Hours Care
4.2.2 Prior Authorization
4.2.3 Referral Requirements
4.3 Documentation Requirements
4.4 Claims Filing and Reimbursement
4.4.1 Claims Information
4.4.2 Reimbursement
4.4.2.1 Medicare Crossover Claims Pricing
4.4.2.2 NCCI and MUE Guidelines
5. Maternity Service Clinic (MSC)
6. Renal Dialysis Facility
6.1 Enrollment
6.2 Services, Benefits, Limitations, and Prior Authorization
6.2.1 Physician Supervision
6.2.1.1 Unscheduled or Emergency Dialysis in a Non-Certified ESRD Facility
6.2.2 Renal Dialysis Facilities-Method I Composite Rate
6.2.3 Method II Dealing Direct-Support Services
6.2.4 Facility Revenue Codes
6.2.5 Training for Hemodialysis, Intermittent Peritoneal Dialysis (IPD), Continuous Cycle Peritoneal Dialysis (CCPD), and Chronic Ambulatory Peritoneal Dialysis (CAPD)
6.2.6 Maintenance Hemodialysis
6.2.7 Maintenance IPD
6.2.8 Maintenance CAPD and CCPD
6.2.9 Laboratory and Radiology Services
6.2.9.1 In-Facility Dialysis—Routine Laboratory
6.2.9.2 In-Facility Dialysis—Nonroutine Laboratory
6.2.9.3 CAPD Laboratory
6.2.9.4 Hematopoietic Injections
6.2.9.5 Blood Transfusions
6.2.10 Prior Authorization
6.3 Documentation Requirements
6.4 Claims Filing and Reimbursement
6.4.1 Claims Information
6.4.2 Reimbursement
6.4.2.1 NCCI and MUE Guidelines
6.5 Medicare and Medicaid
6.5.1 Facility Providers
6.5.2 Physician Providers
7. Rural Health Clinic
7.1 Enrollment
7.1.1 Initial Cost Reporting
7.2 Services, Benefits, Limitations, and Prior Authorization
7.2.1 Services Rendered by the RHC Facility Provider
7.2.1.1 Encounter Rates
7.2.1.2 Medicaid Fee-for-Service Reimbursement Rates
7.2.1.3 Freestanding Rural Health Clinic Services
7.2.1.4 Family Planning Services
7.2.2 Services Rendered by Non-RHC Providers In An RHC Setting
7.2.3 Hospital-Based Rural Health Clinic Services
7.2.3.1 After-Hours Care
7.3 Prior Authorization
7.4 Documentation Requirements
7.4.1 Record Retention
7.5 Claims Filing and Reimbursement
7.5.1 Claims Information
7.5.2 Reimbursement
7.5.2.1 Medicare Crossover Claims Pricing
7.5.2.2 NCCI and MUE Guidelines
8. Tuberculosis Services
8.1 Enrollment
8.1.1 Managed Care Program Enrollment
8.2 Services, Benefits, Limitations, and Prior Authorization
8.2.1 TB-Related Clinic Services
8.2.2 Ancillary Services
8.2.3 Prior Authorization
8.3 Documentation Requirements
8.4 Provider Responsibilities
8.5 Claims Filing and Reimbursement
8.5.1 Claims Information
8.5.1.1 Managed Care Clients
8.5.2 Reimbursement
8.5.2.1 NCCI and MUE Guidelines
9. Claims Resources
10. Contact TMHP
11. Forms
12. Claim Form Examples
Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook
1. General Information
1.1 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Texas Medicaid (Title XIX) Home Health Services
2.1 Enrollment
2.1.1 Pending Agency Certification
2.1.2 Surety Bond Requirements
2.1.2.1 Proof of Continuation
2.2 Services, Benefits, Limitations and Prior Authorization
2.2.1 Home Health Services
2.2.1.1 Client Eligibility
2.2.1.2 Prior Authorization Requests for Clients with Retroactive Eligibility
2.2.1.3 Prior Authorization
2.2.2 Durable Medical Equipment (DME) and Supplies
2.2.2.1 Modifications, Adjustments, and Repairs
2.2.2.2 Prior Authorization
2.2.3 Medical Supplies
2.2.3.1 Supply Procedure Codes
2.2.3.2 Prior Authorization
2.2.3.3 Cancelling a Prior Authorization
2.2.4 Augmentative Communication Device (ACD) System
2.2.4.1 ACD System Accessories
2.2.4.2 Non-Covered ACD System Items
2.2.4.3 Prior Authorization
2.2.5 Bath and Bathroom Equipment
2.2.5.1 Hand-Held Shower Wand
2.2.5.2 Bath Equipment
2.2.5.3 * Bathroom Equipment
2.2.5.4 * Prior Authorization
2.2.5.5 Documentation Requirements
2.2.6 Blood Pressure Devices
2.2.6.1 Prior Authorization
2.2.7 Bone Growth Stimulators
2.2.7.1 Professional Services
2.2.7.2 Prior Authorization Criteria and Documentation Requirements for Bone Growth Stimulators
2.2.7.3 Claims Reimbursement for Professional Services
2.2.8 * Breast Pumps
2.2.8.1 * Prior Authorization
2.2.9 Cochlear Implants
2.2.10 Continuous Passive Motion (CPM) Device
2.2.10.1 Prior Authorization
2.2.11 Diabetic Equipment and Supplies
2.2.11.1 Obtaining Equipment and Supplies Through a Title XIX Form
2.2.11.2 Obtaining Equipment and Supplies Through a Verbal or Detailed Written Order
2.2.11.3 Glucose Testing Equipment and Other Supplies
2.2.11.4 Blood Glucose Monitors
2.2.11.5 External Insulin Pump and Supplies
2.2.11.6 Insulin and Insulin Syringes
2.2.12 Hospital Beds and Equipment
2.2.12.1 Hospital Beds
2.2.12.2 Prior Authorization
2.2.12.3 Documentation Requirements
2.2.12.4 Mattresses and Support Surfaces
2.2.12.5 Equipment and Other Accessories
2.2.12.6 Decubitus Care Accessories
2.2.12.7 Replacement
2.2.12.8 Non-covered Items
2.2.12.9 Hospital Beds and Equipment Procedure Code Table
2.2.13 Incontinence Supplies
2.2.13.1 Skin Sealants, Protectants, Moisturizers, and Ointments for Incontinence-Associated Dermatitis
2.2.13.2 Diapers, Briefs, Pull-ons, and Liners
2.2.13.3 Diaper Wipes
2.2.13.4 Underpads
2.2.13.5 Ostomy Supplies
2.2.13.6 Indwelling or Intermittent Urine Collection Devices
2.2.13.7 Prior Authorization
2.2.13.8 Documentation Requirements
2.2.13.9 Incontinence Procedure Codes with Limitations
2.2.14 Intravenous (IV) Therapy Equipment and Supplies
2.2.14.1 * Prior Authorization
2.2.14.2 Documentation Requirements
2.2.15 Mobility Aids
2.2.15.1 * Canes, Crutches, and Walkers
2.2.15.2 Wheelchairs
2.2.15.3 Manual Wheelchairs-Standard, Standard Hemi, and Standard Reclining
2.2.15.4 Manual Wheelchairs-Lightweight and High-Strength Lightweight
2.2.15.5 Manual Wheelchairs-Heavy-Duty and Extra Heavy Duty
2.2.15.6 Wheeled Mobility Systems
2.2.15.7 Manual Wheeled Mobility System - Tilt-in-Space
2.2.15.8 Manual Wheeled Mobility System- Pediatric Size
2.2.15.9 Manual Wheeled Mobility System -Custom (Includes Custom Ultra-Lightweight)
2.2.15.10 Seating Assessment for Manual and Power Custom Wheelchairs
2.2.15.11 Fitting of Custom Wheeled Mobility Systems
2.2.15.12 Power Wheeled Mobility Systems- Group 1 through Group 5
2.2.15.13 Wheelchair Ramp-Portable and Threshold
2.2.15.14 Power Elevating Leg Lifts
2.2.15.15 Power Seat Elevation System
2.2.15.16 Seat Lift Mechanisms
2.2.15.17 Batteries and Battery Charger
2.2.15.18 Power Wheeled Mobility Systems- Scooter
2.2.15.19 Client Lift
2.2.15.20 Electric Lift
2.2.15.21 Hydraulic Lift
2.2.15.22 Standers
2.2.15.23 Gait Trainers
2.2.15.24 Accessories, Modifications, Adjustments and Repairs
2.2.15.25 Replacement
2.2.15.26 Procedure Codes and Limitations for Mobility Aids
2.2.16 Nutritional (Enteral) Products, Supplies, and Equipment
2.2.16.1 Enteral Nutritional Products, Feeding Pumps, and Feeding Supplies
2.2.16.2 Prior Authorization Requirements
2.2.16.3 Documentation Requirements
2.2.17 Phototherapy Devices
2.2.18 Prothrombin Time/International Normalized Ratio (PT/INR) Home Testing Monitor
2.2.18.1 Prior Authorization
2.2.19 Respiratory Equipment and Supplies
2.2.19.1 * Prior Authorization
2.2.19.2 Nebulizers
2.2.19.3 Vaporizers
2.2.19.4 Humidification Units
2.2.19.5 Secretion Clearance Devices
2.2.19.6 Electrical Percussor
2.2.19.7 Chest Physiotherapy Devices
2.2.19.8 Positive Airway Pressure System Devices
2.2.19.9 Continuous Positive Airway Pressure (CPAP) System
2.2.19.10 Bi-level Positive Airway Pressure System (BiPAP S) Without Backup
2.2.19.11 Bi-level Positive Airway Pressure System With Backup (BiPAP ST)
2.2.19.12 Home Mechanical Ventilation Equipment
2.2.19.13 Volume Ventilators
2.2.19.14 Negative Pressure Ventilators
2.2.19.15 Ventilator Service Agreement
2.2.19.16 Oxygen Therapy
2.2.19.17 Oxygen Therapy Home Delivery System
2.2.19.18 Prior Authorization
2.2.19.19 Documentation Requirements
2.2.19.20 Tracheostomy Tubes
2.2.19.21 Pulse Oximetry
2.2.19.22 Procedure Codes and Limitations for Respiratory Equipment and Supplies
2.2.20 Special Needs Car Seats and Travel Restraints
2.2.21 Subcutaneous Injection Ports
2.2.21.1 Prior Authorization
2.2.21.2 Documentation Requirements
2.2.22 Total Parenteral Nutrition (TPN) Solutions
2.2.22.1 Prior Authorization
2.2.22.2 Documentation Requirements
2.2.23 Wound Care Supplies or Systems
2.2.23.1 Wound Care Supplies
2.2.23.2 Wound Care System
2.2.23.3 Noncovered Services
2.2.23.4 Prior Authorization
2.2.23.5 Documentation Requirements
2.2.23.6 Wound Care Procedures and Limitations
2.2.24 Limitations, Exclusions
2.2.25 Procedure Codes That Do Not Require Prior Authorization
2.3 Other or Special Provisions
2.3.1 Medicaid Relationship to Medicare
2.3.1.1 Possible Medicare Clients
2.3.1.2 Benefits for Medicare and Medicaid Clients
2.3.1.3 Medicare and Medicaid Prior Authorization
2.4 Claims Filing and Reimbursement
2.4.1 Claims Information
2.4.1.1 Benefit Code
2.4.2 Reimbursement
2.4.3 Prohibition of Medicaid Payment to Home Health Agencies Based on Ownership
3. Claims Resources
4. Contact TMHP
5. Forms
6. Claim Form Examples
Gynecological and Reproductive Health and Family Planning Services Handbook
1. General Information
1.1 Family Planning Overview
1.1.1 Guidelines for Family Planning Providers
1.2 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Medicaid Title XIX family planning services
2.1 Title XIX Provider Enrollment
2.2 Services, Benefits, Limitations, and Prior Authorization
2.2.1 Family Planning Annual Exams
2.2.1.1 FQHC Reimbursement for Family Planning Annual Exams
2.2.2 Other Family Planning Office or Outpatient Visits
2.2.2.1 FQHC Reimbursement for Other Family Planning Office or Outpatient Visits
2.2.3 Laboratory Procedures
2.2.3.1 Clinical Laboratory Improvement Amendments (CLIA) Requirement
2.2.3.2 Medical Record Documentation
2.2.3.3 Lab Specimen Handling and Testing
2.2.3.4 Providing Information to the Reference Laboratory
2.2.4 Radiology Services
2.2.5 Contraceptive Devices and Related Procedures
2.2.5.1 External Contraceptives
2.2.5.2 Intrauterine Device
2.2.5.3 Contraceptive Capsules
2.2.6 Drugs and Supplies
2.2.6.1 Prescriptions and Dispensing Medication
2.2.6.2 Injection Administration
2.2.7 Medical Counseling and Education
2.2.8 Sterilization and Sterilization-Related Procedures
2.2.8.1 Sterilization Consent
2.2.8.2 Anesthesia for Sterilization
2.2.8.3 Occlusive Sterilization Device
2.2.8.4 Tubal Ligation
2.2.8.5 Vasectomy
2.2.8.6 Facility Fees for Sterilization
2.2.9 Prior Authorization
2.2.10 Non-covered Services
2.2.10.1 Family Planning Services for Undocumented Aliens
2.3 Documentation Requirements
2.4 Claims Filing and Reimbursement
2.4.1 Claims Information
2.4.1.1 Family Planning and Third Party Liability
2.4.2 Billing Procedures for Non-Family-Planning Services Provided During a Family Planning Visit (Title XIX Only)
2.4.3 National Drug Code
2.4.4 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines
3. Texas Women’s Health Program
3.1 Texas Women’s Health Program (TWHP) Provider Enrollment
3.2 TWHP Overview
3.2.1 Guidelines for TWHP Family Planning Providers
3.2.2 Referrals
3.2.2.1 Referrals for Breast and Cervical Cancer Screening, Diagnostics, and Treatment
3.2.2.2 Referrals for Clients Diagnosed with Breast or Cervical Cancer
3.2.3 Abortions
3.3 Services, Benefits, Limitations, and Prior Authorization
3.3.1 Family Planning Annual Exams
3.3.1.1 FQHC Reimbursement for Family Planning Annual Exams
3.3.2 Other Family Planning Office or Outpatient Visits
3.3.2.1 FQHC Reimbursement for Other Family Planning Office or Outpatient Visits
3.3.3 Laboratory Procedures
3.3.4 Radiology
3.3.5 Contraceptive Devices and Related Procedures
3.3.6 Drugs and Supplies
3.3.6.1 Prescriptions and Dispensing Medication
3.3.6.2 Injection Administration
3.3.7 Instruction in Natural Family Planning Methods
3.3.8 Sterilization and Sterilization-Related Procedures
3.3.8.1 Sterilization Consent
3.3.8.2 Tubal Ligation
3.3.8.3 Anesthesia for Sterilization
3.3.8.4 Facility Fees for Sterilization
3.3.8.5 Hysteroscopic Sterilization
3.3.8.6 TWHP Services After Sterilization
3.3.9 Treatment for Sexually Transmitted Infections (STIs)
3.3.9.1 Gonorrhea Treatment
3.3.10 TWHP Client Eligibility
3.3.10.1 Clients Who Have Received Sterilization Services
3.3.10.2 Eligibility Verification
3.3.11 Prior Authorization
3.4 Documentation Requirements
3.5 TWHP Claims Filing and Reimbursement
3.5.1 Claims Information
3.5.1.1 TWHP and Third Party Liability
3.5.2 Reimbursement
3.5.3 National Drug Code
3.5.4 NCCI and MUE Guidelines
4. Department of State Health Services (DSHS) Family Planning Program Services
4.1 Provider Enrollment for DSHS Family Planning Program Contractors
4.2 Services, Benefits, Limitations, and Prior Authorization
4.2.1 Family Planning Annual Exams
4.2.1.1 FQHC Reimbursement for Family Planning Annual Exams
4.2.2 Family Planning Office or Outpatient Visits
4.2.2.1 FQHC Reimbursement for Family Planning Office or Outpatient Visits
4.2.3 Laboratory Procedures
4.2.3.1 DSHS Family Planning Program
4.2.4 Radiology
4.2.5 Contraceptive Devices and Related Procedures
4.2.5.1 External Contraceptives
4.2.5.2 IUD
4.2.5.3 Contraceptive Capsules
4.2.5.4 Medroxyprogesterone Acetate/Estradiol Cypionate
4.2.6 Drugs and Supplies
4.2.6.1 Prescriptions and Dispensing Medication
4.2.6.2 Oral Medication Reimbursement
4.2.7 Family Planning Education
4.2.7.1 Medical Nutrition Therapy
4.2.7.2 Instruction in Natural Family Planning Methods
4.2.8 Sterilization and Sterilization-Related Procedures
4.2.8.1 Sterilization Consent
4.2.8.2 Incomplete Sterilizations
4.2.8.3 Tubal Ligation
4.2.8.4 Vasectomy
4.2.9 Prior Authorization
4.3 Documentation Requirements
4.4 Claims Filing and Reimbursement
4.4.1 Claims Information
4.4.1.1 Filing Deadlines
4.4.1.2 Third Party Liability
4.4.2 Reimbursement
4.4.2.1 Funds Gone
4.4.3 NCCI and MUE Guidelines
4.4.4 National Drug Code
5. Gynecological Health Services
5.1 Services, Benefits, Limitations, and Prior Authorization
5.2 Endometrial Cryoablation
5.3 Uterine Suspension
5.4 Salpingostomy
5.4.1 Prior Authorization for Salpingostomy
5.5 Assays for the Diagnosis of Vaginitis
5.6 Diagnostic Hysteroscopy
5.7 Abortions
5.7.1 Services Related to Abortion Procedures
5.8 Examination Under Anesthesia
5.9 Laminaria Insertion
5.10 Hysterectomy Services
5.10.1 Hysterectomy Acknowledgment Form
5.11 Pap Smear (Cytopathology Studies)
5.12 Surgery for Masculinized Females
5.13 Documentation Requirements
5.14 Claims Filing and Reimbursement
5.14.1 NCCI and MUE Guidelines
5.15 National Drug Code
6. Claims Resources
7. Contact TMHP
8. Forms
9. Claim Form Examples
Inpatient and Outpatient Hospital Services Handbook
1. General Information
1.1 National Drug Codes (NDC)
1.2 Medicaid Managed Care Services
2. Enrollment
2.1 Hospital Eligibility Through Change of Ownership
2.1.1 Hospital-based Ambulatory Surgical Center (HASC) Enrollment
2.2 Hospital-based Rural Health Clinic Enrollment
3. Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility)
3.1 General Information
3.1.1 Reimbursement Limitations
3.1.2 Spell of Illness
3.1.3 Take-Home Drugs, Self-Administered Drug, or Personal Comfort Items
3.1.4 Services Included in the Inpatient Stay
3.2 Services, Benefits, Limitations, and Prior Authorization - Acute Care
3.2.1 Bed and Board
3.2.2 Hysterectomy Services
3.2.3 Maternity Care
3.2.3.1 Emergency Coverage
3.2.3.2 Mother and Newborn Hospital Stay
3.2.3.3 Children’s Health Insurance Program (CHIP) Perinatal Coverage
3.2.4 Newborn Care
3.2.4.1 Newborn Eligibility
3.2.5 Organ and Tissue Transplant Services
3.2.5.1 Transplant Facilities
3.2.5.2 Transplant Benefits and Limitations
3.2.5.3 Prior Authorization for Organ and Transplant Services
3.2.5.4 Transplants for Medicare-Eligible Clients
3.2.5.5 Experimental or Investigational Services
3.2.5.6 Reimbursement for Transplant Services
3.2.5.7 Nonsolid Organ Transplants
3.3 Services, Benefits, Limitations, and Prior Authorization - Inpatient Rehabilitation Services
3.4 Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services
3.4.1 Enrollment
3.4.2 General Information
3.4.2.1 Professional Services Rendered in the Inpatient Setting
3.4.2.2 Documentation Requirements
3.4.2.3 Noncovered Services
3.4.2.4 CLIA Certification for Laboratory Services
3.4.3 Acute Care Hospital Psychiatric Services
3.4.3.1 Prior Authorization Requirements
3.4.4 Freestanding and State Psychiatric Facilities
3.4.4.1 CCIP Services
3.4.4.2 Psychiatric Services for Clients 65 Years of Age and Older
3.4.4.3 Reimbursement for Services Rendered in an IMD
3.4.4.4 Providing IMD Client Information to TMHP
3.4.5 Medicaid Clinical Criteria for Inpatient Psychiatric Care for Clients
3.4.6 Continued Stays
3.4.7 Court-Ordered Services
3.4.8 Denials
3.5 Inpatient Utilization Review
3.5.1 Utilization Review Process
3.5.1.1 Admission Review
3.5.1.2 Readmission Review
3.5.1.3 Hospital-Based Ambulatory (HASC) Surgical Procedures
3.5.1.4 Quality Review
3.5.1.5 Diagnosis-Related Group Validation
3.5.2 Recommendations to Enhance Compliance with Texas Medicaid Fee-for-Service Hospital Claims Submission
3.5.3 Hospitals Reimbursed Under Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982
3.5.4 Technical Denials (DRG Prospective Payment and TEFRA)
3.5.4.1 On-Site Reviews
3.5.4.2 Mail-In Reviews
3.5.5 Acknowledgment of Penalty Notice
3.5.6 Sanctions
3.5.7 Utilization Review Appeals
3.6 Claims Filing and Reimbursement
3.6.1 Medicaid Relationship to Medicare
3.6.2 * Inpatient Claims Information
3.6.3 Inpatient Reimbursement
3.6.3.1 Prospective Payment Methodology
3.6.3.2 Client Transfers
3.6.3.3 Observation Status to Inpatient Admission
3.6.3.4 Outliers
3.6.3.5 Children’s Hospitals
3.6.3.6 Potentially Preventable Complications (PPC) and Potentially Preventable Readmissions (PPR)
3.6.3.7 State-owned Teaching Hospitals
3.6.3.8 * Payment Window Reimbursement Guidelines
3.6.3.9 Potentially Preventable Readmissions (PPR)
3.6.4 Provider Cost and Reporting
3.6.5 Third Party Liability
4. Outpatient Hospital (Medical and Surgical Acute Care Outpatient Facility)
4.1 General Information
4.1.1 Drugs and Supplies
4.1.1.1 Self-Administered Drugs
4.1.1.2 Take-Home Drugs and Supplies
4.1.2 Outpatient Services Provided Without Charge
4.1.3 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
4.2 Services, Benefits, Limitations, and Prior Authorization
4.2.1 Prior Authorization Requirements
4.2.2 Emergency Department Services
4.2.2.1 Emergency Department Payment Reductions
4.2.3 Day Surgery
4.2.3.1 Inpatient Admissions for Day Surgeries
4.2.3.2 Complications Following Elective or Scheduled Day Surgeries
4.2.3.3 Inpatient Admissions After Day Surgery
4.2.3.4 Emergency or Unscheduled Day Surgeries
4.2.3.5 Complications Following Emergency or Unscheduled Day Surgery
4.2.3.6 Incomplete Day Surgeries
4.2.4 Outpatient Observation Room Services
4.2.4.1 Direct Outpatient Observation Admission
4.2.4.2 Observation Following Emergency Room
4.2.4.3 Observation Following Outpatient Day Surgery
4.2.4.4 Observation Following Outpatient Diagnostic Testing or Therapeutic Services
4.2.4.5 Documentation Requirements for Outpatient Observation
4.2.4.6 Reporting Hours of Observation
4.2.4.7 Client Status Change
4.2.4.8 Observation Services that are not a benefit
4.2.5 Hospital-Based Rural Health Clinic Services
4.2.6 Cardiac Rehabilitation
4.2.7 Chemotherapy Administration
4.2.8 Colorectal Cancer Screening
4.2.9 Computed Tomography and Magnetic Resonance Imaging
4.2.10 Electrodiagnostic (EDX) Testing
4.2.11 Fluocinolone Acetonide
4.2.11.1 Prior Authorization for Fluocinolone Acetonide
4.2.12 Fetal Nonstress Testing and Contraction Stress Test
4.2.13 Hyperbaric Oxygen Therapy (HBOT)
4.2.14 Laboratory Services
4.2.14.1 Clinical Laboratory Improvement Amendments (CLIA)
4.2.15 Lung Volume Reduction Surgery (LVRS)
4.2.16 Neurostimulators
4.2.16.1 Prior Authorization for Neurostimulators
4.2.17 Occupational and Physical Therapy Services
4.2.18 Radiation Therapy Services
4.2.18.1 Radiopharmaceuticals
4.2.19 Respiratory Services
4.2.19.1 Aerosol Treatment
4.2.19.2 Pentamidine Aerosol
4.2.19.3 Diagnostic Testing
4.2.19.4 Pulmonary Function Studies
4.2.20 Screening, Brief Intervention, and Referral to Treatment (SBIRT)
4.3 Documentation Requirements
4.4 Outpatient Utilization Review
4.5 Claims Filing and Reimbursement
4.5.1 Outpatient Claims Information
4.5.2 Outpatient Reimbursement
4.5.3 Provider Cost and Reporting
4.5.4 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines
4.5.5 Outpatient Hospital Revenue Codes
4.5.6 Third Party Liability
5. Ambulatory Surgical Center and Hospital Ambulatory Surgical Center
5.1 Enrollment
5.2 Services, Benefits, Limitations, and Prior Authorization
5.2.1 Drugs and Supplies
5.2.2 Incomplete Surgical Procedures
5.2.3 Complications Following Day Surgery Requiring Outpatient Observation or Inpatient Admission
5.2.4 Planned Admission for Day Surgery
5.2.7 Dental Therapy Under General Anesthesia
5.2.8 Fluocinolone Acetonide
5.2.9 Implantable Infusion Pumps
5.2.9.1 Prior Authorization for Implantable Infusion Pump
5.2.10 Stereotactic Radiosurgery
5.2.11 Brachytherapy
5.2.12 Neurostimulators
5.2.13 Prior Authorization
5.3 Documentation Requirements
5.4 Claims Filing and Reimbursement
5.4.1 Claims Information
5.4.2 Reimbursement
5.4.2.1 ASC and HASC Global Services
5.4.2.2 NCCI and MUE Guidelines
6. Military Hospitals
6.1 Military Hospital Enrollment
6.2 Services, Benefits, Limitations and Prior Authorization
6.2.1 Military Hospital Inpatient Services
6.2.2 Military Hospital Outpatient and Physician Services
6.2.3 Prior Authorization
6.3 Documentation Requirements
6.3.1 Documentation for Nursing Facility Admissions
6.4 Claims Filing and Reimbursement
6.4.1 Military Hospital Claims Information
6.4.2 Military Hospital Reimbursement
7. Claims Resources
8. Contact TMHP
9. Forms
10. Claim Form Examples
Medicaid Managed Care Handbook
1. General Information
2. Overview of Medicaid Managed Care
2.1 Managed Care Services
2.1.1 Medical Services
2.1.2 Prescription Drug/Pharmacy Services
2.1.2.1 Prescription Drug Prior Authorizations
2.2 Provider Enrollment and Responsibilities
2.2.1 Enrollment, Contracting, and Credentialing
2.2.2 Online Provider Lookup (OPL)
2.2.3 Terminated Enrollment
2.2.4 Excluded Entities and Providers
2.2.5 Accounts Receivable
2.2.6 Educating Clients about Managed Care
2.3 General Information About Client Enrollment in Managed Care
2.3.1 Managed Care Enrollment Broker
2.3.2 Eligibility Verification Resources
2.3.3 Client Rights
2.3.3.1 Advance Directives
2.3.3.2 PCP/Main Dentist and Health/Dental Plan Changes
2.3.4 Client Responsibilities
2.4 PCP/Main Dentist Guidelines for Medicaid Managed Care Clients
2.4.1 Enrolling as a PCP or Main Dentist
2.4.2 PCP Requirements for THSteps Medical Services
2.4.3 PCP and Main Dentist Changes
2.4.4 Continuous Access
2.4.4.1 After-Hours Guidelines
2.4.4.2 Unacceptable Telephone Arrangements
2.5 Cultural Competency and Sensitivity
2.5.1 Limited English Proficiency
2.6 Reimbursement
2.6.1 Coinsurance and Deductible Payments for Dual-Eligible Clients
2.6.2 Third Party Liability (TPL)
2.6.2.1 TPL Overview and Provider Responsibilities for Medicaid Managed Care Clients
2.6.3 Health Insurance Premium Payment Program
2.6.4 Providers With Unsatisfied Medicaid Accounts Receivables
2.7 Managed Care Plan Changes
2.7.1 Client-Initiated Plan Changes
2.7.2 Plan Administrator-Initiated Changes
2.8 Authorizations for Managed Care Services
2.9 Claims Filing for Managed Care Services
2.9.1 Newborn Claims Filing for MCO Services
2.9.2 Filing Deadlines
2.9.3 System Requirements for MCO and Dental Plan Claim Submissions Through TMHP
2.10 MCO/Dental Plan Appeals, Complaints, and Fair Hearings
2.10.1 Medicaid Managed Care Complaints and Fair Hearings
3. STAR Program
3.1 STAR Program Clients
3.2 STAR Client Enrollment
3.2.1 Expedited Enrollment of Pregnant Women (Program Type 40)
3.2.2 Enrollment of Newborns
3.2.3 Timely Notification and Assignment of Medicaid ID for Newborns
3.3 STAR Program Benefits
3.3.1 Spell of Illness
3.3.2 Prescriptions
3.3.3 National Drug Code
4. STAR+PLUS Program
4.1 STAR+PLUS Program Clients
4.1.1 STAR+PLUS Program Dual-Eligible Clients
4.1.2 Clients Who Are Ineligible For The STAR+PLUS Program
4.2 STAR+PLUS Client Enrollment
4.2.1 Enrollment of Newborns
4.3 STAR+PLUS Program Benefits
4.3.1 Prescriptions
4.3.2 Spell of Illness
4.3.3 Service Coordination and Care Management
5. NorthSTAR Program
5.1 NorthSTAR Program Clients
5.2 NorthSTAR Client Enrollment
5.3 NorthSTAR Program Benefits
5.3.1 Hospital Billing
5.3.2 Behavioral Health Billing
5.3.3 Prior Authorization Requirements
5.4 Complaints and Appeals
6. STAR Health Program
6.1 STAR Health Program Clients
6.2 STAR Health Client Enrollment
6.3 STAR Health Program Benefits
6.3.1 STAR Health Mental Health Rehabilitation Mental Health Claims Submissions
7. Children’s Medicaid Dental Services
7.1 Overview
7.2 Children’s Medicaid Dental Services Model
7.3 Client Eligibility
7.4 Client Enrollment
7.5 Children’s Medicaid Dental Plan Choices
7.6 Authorizations for Children’s Medicaid Managed Care Dental Services (Non-orthodontia Services)
7.7 Children’s Medicaid Dental Orthodontia Services
8. Carve-Out Services
8.1 Family Planning Carve-Out Services
8.1.1 Professional and Outpatient Claims
8.1.1.1 Claim Forms for Submission to TMHP
8.1.2 Inpatient Claims
8.1.3 Provider Working With Clients Enrolled in the Christus Health Plan
9. PCCM and Managed Care Claims Processed by TMHP Before March 1, 2012
9.1 PCCM Appeals
9.2 PCCM Cost and Reporting
9.2.1 PCCM Outpatient Services Cost Reporting
10. Other State Health-Care Programs
11. Contact Information
Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
1. General Information
1.1 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Chiropractic Manipulative Treatment (CMT)
2.1 Enrollment
2.2 Services, Benefits, Limitations, and Prior Authorization
2.2.1 Prior Authorization
2.3 Documentation Requirements
2.4 Claims Filing and Reimbursement
2.4.1 Claims Information
2.4.2 Reimbursement
3. Certified Nurse Midwife (CNM)
3.1 Provider Enrollment
3.1.1 Enrollment in Texas Health Steps (THSteps)
3.2 Services, Benefits, Limitations, and Prior Authorization
3.2.1 Deliveries
3.2.2 Newborn Services
3.2.3 Prenatal and Postpartum Services
3.2.4 Laboratory and Radiology Services
3.2.5 Prior Authorization
3.2.6 Documentation Requirements
3.2.7 Claims Filing and Reimbursement
4. Certified Registered Nurse Anesthetist (CRNA)
4.1 Enrollment
4.2 Services, Benefits, Limitations, and Prior Authorization
4.2.1 Prior Authorization
4.3 Documentation Requirements
4.4 Claims Filing and Reimbursement
4.4.1 Claims Information
4.4.1.1 Interpreting the R&S Report
4.4.2 Reimbursement
5. Geneticists
5.1 Enrollment
5.1.1 Geneticists
5.2 Services, Benefits, Limitations, and Prior Authorization
5.2.1 Family History
5.2.2 Genetic Tests
5.2.3 Laboratory Practices
5.2.4 Genetic Counselors
5.2.5 Genetic Evaluation and Counseling by a Geneticist
5.2.6 Prior Authorization
5.3 Documentation Requirements
5.4 Claims Filing and Reimbursement
5.4.1 Claims Information
5.4.2 Reimbursement
6. Licensed Midwife (LM)
6.1 Provider Enrollment
6.2 Services, Benefits, Limitations, and Prior Authorization
6.2.1 Deliveries
6.2.2 Newborn Services
6.2.3 Prenatal Services
6.2.4 Prior Authorization
6.2.5 Documentation Requirements
6.2.6 Claims Filing and Reimbursement
7. Maternity Service Clinics (MSC)
7.1 Provider Enrollment
7.1.1 Physician Responsibility
7.1.2 Case Management Services to High-Risk Individuals
7.2 Services, Benefits, Limitations, and Prior Authorization
7.2.1 Initial Prenatal Care Visit Components
7.2.1.1 History
7.2.1.2 Physical Examination
7.2.1.3 Laboratory Tests
7.2.1.4 Assessment
7.2.1.5 Plan
7.2.1.6 Education and Counseling
7.2.2 Subsequent Prenatal Care Visits
7.2.2.1 Physical Examination
7.2.2.2 Laboratory Tests
7.2.3 Postpartum Care Visit
7.2.4 Prior Authorization
7.3 Documentation Requirements
7.4 Claims Filing and Reimbursement
8. Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS)
8.1 Enrollment
8.1.1 Enrollment in Texas Health Steps (THSteps)
8.2 Services, Benefits, Limitations, and Prior Authorization
8.2.1 Prior Authorization
8.3 Documentation Requirements
8.4 Claims Filing and Reimbursement
8.4.1 Claims Information
8.4.2 Reimbursement
9. Physician
9.1 Enrollment
9.1.1 Physicians and Doctors
9.2 Services, Benefits, Limitations, and Prior Authorization
9.2.1 Teaching Physician and Resident Physician
9.2.1.1 Teaching Physician Prerequisites
9.2.2 Substitute Physician
9.2.3 Aerosol Treatment
9.2.3.1 Diagnostic Testing
9.2.4 Allergy Services
9.2.4.1 Allergy Immunotherapy
9.2.4.2 Allergy Testing
9.2.5 Ambulance Transport Services - Nonemergency
9.2.6 Anesthesia
9.2.6.1 Medical Direction by an Anesthesiologist
9.2.6.2 Anesthesia for Sterilization
9.2.6.3 Anesthesia for Labor and Delivery
9.2.6.4 Anesthesia Provided by the Surgeon (Other Than Labor and Delivery)
9.2.6.5 Complicated Anesthesia
9.2.6.6 Multiple Procedures
9.2.6.7 Monitored Anesthesia Care
9.2.6.8 Reimbursement Methodology
9.2.6.9 Anesthesia Modifiers
9.2.6.10 Prior Authorization for Anesthesia
9.2.6.11 Claims Filing
9.2.6.12 Anesthesia (General) for THSteps Dental
9.2.7 Abdominal Aortic Aneurysm Screening
9.2.8 Bariatric Surgery
9.2.8.1 Prior Authorization for Bariatric Surgery
9.2.9 Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer
9.2.10 Behavioral Health Services
9.2.11 Biopsy
9.2.12 Biofeedback Services
9.2.12.1 Biofeedback Certification
9.2.12.2 Prior Authorization for Biofeedback Services
9.2.13 *Blepharoplasty Procedures
9.2.14 Bone Growth Stimulation
9.2.14.1 Invasive Bone Growth Stimulation
9.2.14.2 Non-invasive Bone Growth Stimulation
9.2.14.3 Ultrasound Bone Growth Stimulation
9.2.14.4 Reimbursement
9.2.15 *Cancer Screening and Testing
9.2.15.1 BRCA Testing
9.2.15.2 Colorectal Cancer Screening
9.2.15.3 Genetic Testing for Colorectal Cancer
9.2.15.4 Mammography (Screening and Diagnostic Studies of the Breast)
9.2.15.5 Prognostic Breast and Gynecological Cancer Studies
9.2.16 Capsulotomy
9.2.17 Cardiac Rehabilitation
9.2.17.1 Prior Authorization for Cardiac Rehabilitation
9.2.17.2 Reimbursement
9.2.18 Casting, Splinting, and Strapping
9.2.19 Cardiopulmonary Resuscitation (CPR)
9.2.20 Chemotherapy
9.2.20.1 Chemotherapy Procedure Codes
9.2.21 Circumcisions
9.2.22 Closure of Wounds
9.2.23 Cochlear Implants
9.2.24 Continuous Glucose Monitoring (CGM)
9.2.24.1 Prior Authorization for Continuous Glucose Monitoring
9.2.25 Developmental and Neurological Assessment and Testing
9.2.25.1 Assessment of Aphasia
9.2.25.2 Developmental Screening
9.2.25.3 Developmental Testing
9.2.25.4 Neurobehavioral Testing
9.2.25.5 12-Hour Limitation for Procedure Codes 96110, 96111, and 96116
9.2.26 Diagnostic Tests
9.2.26.1 Ambulatory Blood Pressure Monitoring
9.2.26.2 Ambulatory Electroencephalogram (Ambulatory EEG)
9.2.26.3 Bone Marrow Aspiration, Biopsy
9.2.26.4 Cytopathology Studies—Other Than Gynecological
9.2.26.5 Echoencephalography
9.2.26.6 Electrocardiogram (ECG)
9.2.26.7 Esophageal pH Probe Monitoring
9.2.26.8 Helicobacter Pylori (H. pylori)
9.2.26.9 Myocardial Perfusion Imaging
9.2.26.10 Pediatric Pneumogram
9.2.27 Diagnostic Doppler Sonography
9.2.28 Evoked Response Tests and Neuromuscular Procedures
9.2.28.1 Autonomic Function Tests
9.2.28.2 Electromyography and Nerve Conduction Studies
9.2.28.3 Evoked Potential Testing
9.2.28.4 Motion Analysis Studies
9.2.29 Extracorporeal Membrane Oxygenation (ECMO)
9.2.30 Family Planning
9.2.31 Gynecological Health Services
9.2.32 Hospital Visits
9.2.33 Hyperbaric Oxygen Therapy (HBOT)
9.2.33.1 Prior Authorization for HBOT
9.2.34 Ilizarov Device and Procedure
9.2.35 Immunization Guidelines and Administration
9.2.35.1 Administration Fee
9.2.35.2 Documentation
9.2.35.3 Vaccine Adverse Event Reporting System (VAERS)
9.2.36 Immunizations for Clients Birth through 20 Years of Age
9.2.36.1 Vaccine Coverage Through the TVFC Program
9.2.36.2 Vaccine and Toxoid Procedure Codes
9.2.37 Immunizations for Clients Who Are 21 Years of Age and Older
9.2.38 Postexposure Prophylaxis for Rabies
9.2.38.1 Prior Authorization for Postexposure Rabies Vaccine
9.2.38.2 Limitations for Postexposure Rabies Vaccine
9.2.39 Medications - Injectable
9.2.39.1 Abatacept (Orencia)
9.2.39.2 Alatrofloxacin Mesylate (Trovan)
9.2.39.3 Alglucosidase Alfa (Myozyme)
9.2.39.4 17-Alpha Hydroxyprogesterone Caproate
9.2.39.5 Amifostine
9.2.39.6 Antibiotics and Steroids
9.2.39.7 Antihemophilic Factor
9.2.39.8 Botulinum Toxin Type A and Type B
9.2.39.9 Chelating Agents
9.2.39.10 Clofarabine
9.2.39.11 Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim)
9.2.39.12 Hematopoietic Injections
9.2.39.13 Fluocinolone Acetonide (Retisert)
9.2.39.14 Immune Globulin
9.2.39.15 Medroxyprogesterone Acetate (Depo Provera)
9.2.39.16 Immunosuppressive Drugs
9.2.39.17 Interferon
9.2.39.18 Joint Injections and Trigger Point Injections
9.2.39.19 Leuprolide Acetate (Lupron Depot)
9.2.39.20 Omalizumab
9.2.39.21 Paclitaxel
9.2.39.22 Implantable Infusion Pumps
9.2.39.23 Trastuzumab
9.2.39.24 Vitamin B12 (Cyanocobalamin) Injections
9.2.39.25 Injection Administration
9.2.39.26 Billing for Injectable Medications
9.2.39.27 Unit Calculations for Billing Drugs
9.2.40 Medications - Oral
9.2.40.1 Drug Monitoring Services
9.2.41 Laboratory Services
9.2.41.1 THSteps Laboratory Services
9.2.41.2 Laboratory Handling Charge
9.2.41.3 Blood Counts
9.2.41.4 Clinical Lab Panel Implementation
9.2.41.5 Clinical Pathology Consultations
9.2.41.6 Cytogenetics Testing
9.2.41.7 Maternal Serum Alpha-Fetoprotein (MSAFP)
9.2.42 Lung Volume Reduction Surgery (LVRS)
9.2.42.1 Prior Authorization for Lung Volume Reduction Surgery
9.2.43 Mastectomy and Breast Reconstruction
9.2.43.1 Mastectomies
9.2.43.2 Prophylactic Mastectomies
9.2.43.3 Breast Reconstruction
9.2.43.4 Tattooing to Correct Color Defects of the Skin
9.2.43.5 Treatment for Complications of Breast Reconstruction
9.2.43.6 External Breast Prostheses
9.2.43.7 Prior Authorization Requirements for Mastectomy and Breast Reconstruction
9.2.44 Neurostimulators
9.2.44.1 Prior Authorization for Neurostimulators
9.2.44.2 Neuromuscular Electrical Stimulation (NMES)
9.2.44.3 Transcutaneous Electrical Nerve Stimulation (TENS)
9.2.44.4 NMES and TENS Garments
9.2.44.5 NMES and TENS Supplies
9.2.44.6 Dorsal Column Neurostimulator (DCN)
9.2.44.7 Intracranial Neurostimulators
9.2.44.8 Percutaneous Electrical Nerve Stimulation (PENS)
9.2.44.9 Sacral Nerve Stimulators (SNS)
9.2.44.10 Vagal Nerve Stimulators (VNS)
9.2.44.11 Prior Authorization of Neurostimulator Devices Procedure Codes
9.2.44.12 Supplies for Neurostimulators
9.2.44.13 Electronic Analysis for Neurostimulators
9.2.44.14 Revision or Removal of Neurostimulator Devices
9.2.44.15 Noncovered Neurostimulator Services
9.2.45 Newborn Services
9.2.45.1 Circumcisions for Newborns
9.2.45.2 Hospital Visits and Routine Care
9.2.45.3 Newborn Hearing Screening
9.2.46 Obstetrics and Prenatal Care
9.2.46.1 Amniocentesis, Cordocentesis, and Ultra­sonic Guidance
9.2.46.2 Deliveries
9.2.46.3 External Cephalic Version
9.2.46.4 Fetal Fibronectin
9.2.46.5 Fetal Intrauterine Transfusion (FIUT)
9.2.46.6 Doppler Studies
9.2.46.7 Fetal Echocardiography
9.2.46.8 Obstetric Ultrasound
9.2.46.9 Prenatal Surveillance
9.2.46.10 Tobacco Use Cessation Counseling
9.2.46.11 Transabdominal Amnioinfusion
9.2.46.12 Documentation Requirements for Diagnostic Studies
9.2.46.13 Required Screening of Pregnant Women for Syphilis, HIV, and Hepatitis B
9.2.47 Occupational Therapy (OT) Services
9.2.48 Ophthalmology
9.2.48.1 Corneal Transplants
9.2.48.2 Eye Surgery by Laser
9.2.48.3 Eye Surgery by Incision
9.2.48.4 Intraocular Lens (IOL)
9.2.48.5 Intravitreal Drug Delivery System
9.2.48.6 Other Eye Surgery Limitations
9.2.49 Organ/Tissue Transplants
9.2.49.1 Heart Transplants
9.2.49.2 Intestinal Transplants
9.2.49.3 Kidney Transplants
9.2.49.4 Liver Transplants
9.2.49.5 Lung Transplants
9.2.49.6 Pancreas Transplant and Simultaneous Kidney-Pancreas Transplant
9.2.49.7 Nonsolid Organ Transplants
9.2.49.8 Organ Procurement
9.2.49.9 Prior Authorization for All Transplants
9.2.50 Orthognathic Surgery
9.2.50.1 Prior Authorization for Orthognathic Surgery
9.2.51 Osteopathic Manipulative Treatment (OMT)
9.2.52 Pain Management
9.2.52.1 Epidural and Subarachnoid Infusion (Not Including Labor and Delivery)
9.2.53 Palivizumab Injections
9.2.54 Panniculectomy and Abdominoplasty
9.2.54.1 Panniculectomy
9.2.54.2 Abdominoplasty
9.2.55 Penile and Testicular Prostheses
9.2.56 Pentamidine Aerosol
9.2.57 Percutaneous Transluminal Coronary Interventions
9.2.58 Physical Therapy (PT) Services
9.2.59 Physician Evaluation and Management (E/M) Services
9.2.59.1 Office or Other Outpatient Hospital Services
9.2.59.2 Domiciliary, Rest Home, or Custodial Care Services
9.2.59.3 Physician Services Provided in the Emergency Department
9.2.59.4 Group Clinical Visits
9.2.59.5 Home Services
9.2.59.6 Inpatient Hospital Services
9.2.59.7 Prolonged Physician Services
9.2.59.8 Referrals
9.2.60 Physician Services in a Long Term Care (LTC) Nursing Facility
9.2.61 Podiatry and Related Services
9.2.61.1 Clubfoot Casting
9.2.61.2 Flat Foot Treatment
9.2.61.3 Routine Foot Care
9.2.62 Prostate Surgery
9.2.63 Radiation Therapy
9.2.63.1 Brachytherapy
9.2.63.2 Stereotactic Radiosurgery
9.2.64 Radiology Services
9.2.64.1 Diagnosis Requirements
9.2.64.2 Cardiac Blood Pool Imaging
9.2.64.3 Chest X-Rays
9.2.64.4 Magnetic Resonance Angiography (MRA)
9.2.64.5 Magnetic Resonance Imaging (MRI)
9.2.64.6 Technetium TC 99M
9.2.65 Reduction Mammaplasties
9.2.65.1 Prior Authorization for Reduction Mammaplasty
9.2.66 Renal Disease
9.2.66.1 Dialysis Patients
9.2.66.2 Laboratory Services for Dialysis Patients
9.2.66.3 Self-Dialysis Patients
9.2.67 Sign Language Interpreting Services
9.2.68 Skin Therapy
9.2.69 Sleep Studies
9.2.69.1 Actigraphy
9.2.69.2 Pneumocardiograms
9.2.69.3 Polysomnography
9.2.69.4 Multiple Sleep Latency Test (MSLT)
9.2.69.5 Sleep Facility Restrictions for Polysomnography and Multiple Sleep Latency Testing
9.2.70 Speech Therapy (ST) Services
9.2.71 Surgery Billing Guidelines
9.2.71.1 Primary Surgeon
9.2.71.2 Anesthesia Administered by Surgeon
9.2.71.3 Assistant Surgeon
9.2.71.4 Bilateral Procedures
9.2.71.5 Cosurgery
9.2.71.6 Global Fees
9.2.71.7 Multiple Surgeries
9.2.71.8 Office Procedures
9.2.71.9 Orthopedic Hardware
9.2.71.10 Second Opinions
9.2.71.11 Supplies, Trays, and Drugs
9.2.72 Telemedicine Services
9.2.73 Therapeutic Apheresis
9.2.74 Therapeutic Phlebotomy
9.2.75 Therapeutic Radiopharmaceuticals
9.2.75.1 Prior Authorization for Therapeutic Radiopharmaceuticals
9.2.75.2 Other Limitations on Therapeutic Radiopharmaceuticals
9.2.76 Urethral Dilation
9.2.77 Ventilation Assist and Management for the Inpatient
9.2.78 Wearable Cardiac Defibrillator (WCD)
9.2.78.1 Prior Authorization for WCD
9.2.79 Wound Care Management
9.2.79.1 First-Line Wound Care Therapy
9.2.79.2 Second-Line Wound Care Therapy
9.2.79.3 Documentation Requirements
9.3 Doctor of Dentistry Practicing as a Limited Physician
9.3.1 Prior Authorization for General Dental Services Due to Life-Threatening Medical Condition
9.3.1.1 Guidelines for Requesting Mandatory Prior Authorization
9.3.2 Benefits and Limitations
9.3.2.1 Diagnosis Codes
9.3.2.2 Evaluation and Management Procedure Codes
9.3.2.3 Additional Payable Procedure Codes
9.3.2.4 Immune Globulin by a Doctor of Dentistry as a Limited Physician
9.3.2.5 Radiographs by a Doctor of Dentistry Practicing as a Limited Physician
9.3.2.6 Dental Anesthesia by a Doctor of Dentistry Practicing as a Limited Physician
9.4 Documentation Requirements
9.5 Claims Filing and Reimbursement
9.5.1 Claims Information
9.5.2 National Drug Codes (NDC)
9.5.3 Reimbursement
9.5.3.1 Affordable Care Act of 2010 (ACA) Rate Increase for Primary Care Services
10. Physician Assistant
10.1 Enrollment
10.2 Services, Benefits, Limitations, and Prior Authorization
10.2.1 Prior Authorization
10.3 Documentation Requirements
10.4 Claims Filing and Reimbursement
10.4.1 Claims Information
10.4.2 Reimbursement
11. Claims Resources
12. Contact TMHP
13. Forms
14. Claim Form Examples
Medical Transportation Program Handbook
1. General Information
1.1 Contacting MTP
2. Individual Transportation Provider (ITP)
2.1 Enrollment for ITPs
2.2 Prior Authorization for ITPs
2.3 Claims Filing for ITPs
3. Lodging Provider
3.1 Enrollment for Lodging Providers
3.2 Prior Authorization for Lodging Providers
3.3 Claims Filing for Lodging Providers
4. Meals Provider
4.1 Enrollment for Meals Providers
4.2 Prior Authorization for Meals Providers
4.3 Claims Filing for Meals Providers
5. Prior Authorization
5.1 Retention of Prior Authorization Documents
5.2 Definition of Prior Authorization Documents
5.3 Copies of Prior Authorization Documents
5.4 Storage of Prior Authorization Document Storage
6. Claims Filing
6.1 Claims Filing Deadlines
6.2 Auditing of Claims
6.3 Important Codes for All MTP Providers
6.4 Delegation of Signature Authority
6.5 Electronic Claims
6.5.1 TMHP Electronic Data Interchange (EDI)
6.5.2 TexMedConnect
6.5.3 Vendor Software
6.5.4 Third Party Vendor Implementation
6.6 Paper Claims
6.6.1 Tips on Expediting Paper Claims
6.6.1.1 General requirements
6.6.1.2 Data Fields
6.6.1.3 Attachments
6.6.1.4 Attachments to Claims
6.6.2 CMS-1500 Instruction Table
7. Claim Form Examples
Nursing and Therapy Services Handbook
1. General Information
2. Certified Respiratory Care Practitioner (CRCP) Services
2.1 Enrollment
2.2 Services, Benefits, Limitations, and Prior Authorization
2.2.1 Prior Authorization
2.3 Documentation Requirements
2.4 Claims Filing and Reimbursement
2.4.1 Claims Information
2.4.2 Reimbursement
3. Home Health Nursing and Therapy Services
3.1 Enrollment
3.1.1 Change of Address and Telephone Number
3.1.2 Pending Agency Certification
3.1.3 Home Health Skilled Nursing and Home Health Aide (HHA) Services Provider Responsibilities
3.2 Services, Benefits, Limitations, and Prior Authorization
3.2.1 Home Health
3.2.1.1 Client Eligibility
3.2.1.2 Prior Authorization Requests for Clients with Retroactive Eligibility
3.2.1.3 Client Evaluation
3.2.2 Benefits
3.2.3 Home Health Skilled Nursing Services
3.2.3.1 SN Visits
3.2.4 Home Health Aide Services
3.2.4.1 HHA Visits
3.2.4.2 Supervision of HHA
3.2.5 DME and Medical Supplies Submitted with a Plan of Care (POC)
3.2.6 Medication Administration Limitations
3.2.7 Occupational Therapy (OT) Services
3.2.8 Physical Therapy (PT) Services
3.2.9 * Prior Authorization
3.2.9.1 Home Health SN and HHA Services Prior Authorization Requirements
3.2.9.2 Canceling a Prior Authorization
3.2.9.3 Home Health SN and HHA Services That Will Not Be Prior Authorized
3.2.9.4 OT and PT Prior Authorization Requirements
3.2.9.5 Medicare and Medicaid Prior Authorization
3.2.10 Limitations and Exclusions
3.3 Documentation Requirements
3.3.1 Written POC
3.3.1.1 Physician Supervision-POC
3.3.2 Home Health SN and HHA Services Assessments and Reassessments
3.4 Claims Filing and Reimbursement
3.4.1 Claims Information
3.4.2 Reimbursement
3.4.3 Prohibition of Medicaid Payment to Home Health Agencies Based on Ownership
3.4.4 Claims Filing for OT Services
3.4.5 Claims Filing for PT Services
3.4.6 OT Limitations
3.4.7 PT Limitations
3.4.8 OT Procedure Codes
3.4.9 PT Procedure Codes
4. Therapists, Independent Practitioners, and Physicians
4.1 Enrollment
4.2 Services, Benefits, Limitations, and Prior Authorization
4.2.1 OT Services
4.2.2 PT Services
4.2.3 ST Services
4.2.4 Therapy in a Nursing Facility
4.2.5 Prior Authorization
4.2.6 Noncovered Services
4.2.7 Rehabilitative Services
4.3 Documentation Requirements
4.4 Claims Filing and Reimbursement
4.4.1 Claims Information
5. Claims Resources
6. Contact TMHP
7. Forms
8. Claim Form Examples
Radiology and Laboratory Services Handbook
1. General Information
1.1 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Independent Laboratory
2.1 Enrollment
2.1.1 Clinical Laboratory Improvement Amendments (CLIA)
2.1.2 CLIA Requirements
2.2 Services, Benefits, Limitations, and Prior Authorization
2.2.1 CLIA Certificates
2.2.2 Laboratory Handling Fees and Reference Laboratories
2.2.2.1 Independent Laboratory Providers
2.2.2.2 Physician Providers
2.2.2.3 Outpatient Hospital Providers
2.2.2.4 Family Planning Laboratory Tests
2.2.3 Nonclinical Laboratory Procedures
2.2.4 Clinical Laboratory Procedures
2.2.4.1 Repeat Procedures
2.2.5 Automated Laboratory Tests and Laboratory Paneling
2.2.5.1 Fee Calculations for Automated Tests and Laboratory Panels
2.2.6 Complete Blood Count (CBC)
2.2.7 Genetic Testing for Colorectal Cancer
2.2.7.1 Documentation Requirements
2.2.7.2 Authorization Requirements
2.2.8 Human Immunodeficiency Virus (HIV) Drug Resistance Testing
2.2.9 Iron Studies
2.2.10 Urinalysis
2.2.11 Additional Laboratory Services
2.2.11.1 Breast Cancer (BRCA) Testing
2.2.11.2 Colorectal Cancer Screening
2.2.11.3 Cytopathology Studies
2.2.11.4 Helicobacter pylori Testing
2.2.11.5 Laboratory Services for Clients on Dialysis
2.2.11.6 Prognostic Breast and Gynecological Cancer Studies
2.2.11.7 THSteps Outpatient Laboratory Services
2.2.11.8 Authorization Requirements
2.3 Documentation Requirements
2.4 Claims Filing and Reimbursement
2.4.1 Claims Information
2.4.1.1 Electronic Filing for Laboratory Providers
2.4.2 Reimbursement
2.4.2.1 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines
3. Radiological and physiological laboratory services
3.1 Enrollment
3.1.1 Enrollment Criteria for Mammography Providers
3.2 Services, Benefits, Limitations, and Prior Authorization
3.2.1 Cardiac Nuclear Imaging
3.2.1.1 Authorization Requirements
3.2.2 Computed Tomography and Magnetic Resonance Imaging
3.2.2.1 Functional MRI (fMRI)
3.2.2.2 Intraoperative MRI (iMRI)
3.2.2.3 Authorization Requirements and Flexibility
3.2.3 Positron Emission Tomography (PET) Scan Imaging
3.2.3.1 Authorization Requirements
3.2.4 Radiology/Diagnostic Imaging Policy
3.2.4.1 Authorization Requirements
3.2.5 Physician-Performed Radiology Services
3.2.6 Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac Nuclear Imaging Services
3.2.6.1 Retroactive Authorization
3.2.6.2 Request Form and Documentation
3.2.6.3 Methods of Submission
3.2.7 Additional Radiology and Physiological Laboratory Services
3.2.7.1 Ambulatory Electroencephalogram
3.2.7.2 Brachytherapy
3.2.7.3 Diagnostic Doppler Sonography
3.2.7.4 Electrocardiograms
3.2.7.5 Electromyography (EMG and Nerve Conduction Studies (NCS))
3.2.7.6 Esophageal pH Probe Monitoring
3.2.7.7 Mammography Services
3.2.7.8 Nonsurgical Vision Services
3.2.7.9 Obstetric Services
3.2.7.10 Radiation Therapy Services
3.2.7.11 Screening and Diagnostic Studies of the Breast
3.2.7.12 Sleep Studies
3.3 Documentation Requirements
3.4 Claims Filing and Reimbursement
3.4.1 Claims Information
3.4.1.1 Diagnosis Requirements
3.4.1.2 Modifier Requirements for Type of Service Assignment
3.4.2 Reimbursement
3.4.2.1 NCCI and MUE Guidelines
4. Claims Resources
5. Contact TMHP
6. Forms
8. Claim Form Examples
Telecommunication Services Handbook
1. General Information
2. Enrollment
3. Services, Benefits, Limitations, and Prior Authorization
3.1 Telemedicine Services
3.1.1 Distant Site
3.1.2 Patient Site
3.2 Telehealth Services
3.2.1 Distant Site
3.2.2 Patient Site
3.3 Telemonitoring Services
3.3.1 Facility Services
3.4 Prior Authorization
3.4.1 Prior Authorization of Telemonitoring Services
3.5 Documentation Requirements
4. Claims Filing and Reimbursement
4.1 Claims Information
4.2 Reimbursement
5. Claims Resources
6. Contact TMHP
7. Forms
Vision and Hearing Services Handbook
1. General Information
1.1 * Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission
2. Nonimplantable Hearing Aid Devices and Related Services
2.1 Enrollment
2.1.1 School Districts, State Agencies, and Inpatient Facilities
2.2 Services, Benefits, Limitations, and Prior Authorization
2.2.1 Limitations and Required Forms
2.2.2 Hearing Screenings
2.2.2.1 Routine Hearing Screenings
2.2.2.2 Additional Hearing Screenings
2.2.2.3 Abnormal Hearing Screening Results
2.2.3 Audiology and Audiometry Evaluation and Diagnostic Services
2.2.3.1 Otological Examinations
2.2.3.2 Vestibular Evaluations
2.2.3.3 Forms and Documentation
2.2.3.4 Prior Authorization
2.2.3.5 Limitations
2.2.3.6 SHARS Audiology Services
2.2.3.7 Noncovered Services
2.2.4 Hearing Aid Devices and Accessories (Nonimplantable)
2.2.4.1 Forms and Documentation
2.2.4.2 Prior Authorization
2.2.4.3 Limitations
2.2.5 Hearing Aid Services
2.2.5.1 Forms and Documentation
2.2.5.2 Prior Authorization
2.2.5.3 Limitations
2.3 Documentation Requirements
2.4 Claims Filing and Reimbursement
2.4.1 Claims Filing
2.4.1.1 Non-implantable Hearing Aid Devices
2.4.1.2 Third Party Liability
2.4.2 Reimbursement
2.4.2.1 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines
3. Implantable Hearing Devices and Related Services
3.1 Enrollment
3.2 Services, Benefits, Limitations and Prior Authorization
3.2.1 Cochlear Implants
3.2.1.1 Prior Authorization
3.2.1.2 Limitations
3.2.1.3 Auditory Rehabilitation
3.2.2 Auditory Brainstem Implant (ABI)
3.2.2.1 Prior Authorization
3.2.2.2 Limitations
3.2.3 Bone-Anchored Hearing Aid (BAHA)
3.2.3.1 Prior Authorization
3.2.3.2 Limitations
3.2.4 Sound Processor Replacement and Repair
3.2.4.1 Prior Authorization
3.2.4.2 Limitations
3.2.5 Electromagnetic Bone Conduction Hearing Device - Removal Only
3.3 Documentation Requirements
3.4 Claims Filing and Reimbursement
3.4.1 Claims Filing
3.4.1.1 Third Party Liability
3.4.2 Reimbursement
3.4.2.1 NCCI and MUE Guidelines
4. Vision Care Professionals
4.1 Enrollment
4.2 Provider Responsibilities
4.3 Services, Benefits, Limitations, and Prior Authorization
4.3.1 Services Performed in Long-Term Care Facilities
4.3.2 Services Performed in Federally Qualified Healthcare Centers (FQHC)
4.3.3 THSteps Medical Checkup Vision Screening
4.3.3.1 Vision Screening Outside of a THSteps Preventive Care Medical Checkup
4.3.4 Noncovered Services
4.3.5 Vision Testing
4.3.5.1 Routine Vision Testing
4.3.5.2 Medically Necessary Eye Examinations
4.3.5.3 Ophthalmological Examination and Evaluation with General Anesthesia
4.3.5.4 Ophthalmic Ultrasound
4.3.5.5 Corneal Topography
4.3.5.6 Sensorimotor Examination
4.3.5.7 Orthoptic or Pleoptic Training
4.3.5.8 Ophthalmoscopy, Angioscopy or Angiography
4.3.5.9 Other Professional Services
4.3.6 Vision Services for Nonprosthetic Eyewear
4.3.6.1 Eyeglass Lenses and Frames
4.3.6.2 Contact Lens and Corneal Bandage
4.3.6.3 Dispensing Requirements
4.3.6.4 Repair
4.3.6.5 Replacement
4.3.6.6 Medicare Coverage for Nonprosthetic Eyewear
4.3.7 Vision Services for Prosthetic Eyewear
4.3.7.1 Temporary Eyeglasses or Contact Lenses
4.3.7.2 Contact Lens Fitting and Modification
4.3.7.3 Repair
4.3.7.4 Replacement
4.3.7.5 Intraocular Lens (IOL) and Additional Eyewear
4.3.7.6 Artificial Eyes
4.3.7.7 Ultraviolet (U-V) Protection
4.3.8 Surgical Vision Services
4.4 Documentation Requirements
4.5 Claims Filing and Reimbursement
4.5.1 Claims Filing
4.5.2 Reimbursement
4.5.2.1 NCCI and MUE Guidelines
5. Claims Resources
6. Contact TMHP
7. Forms
8. Claim Form Examples
Texas Medicaid & Healthcare Partnership
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