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December 2016 Texas Medicaid Provider Procedures Manual

Section 2: Texas Medicaid Fee‑for‑Service Reimbursement

Section 2: Texas Medicaid Fee‑for‑Service Reimbursement
Table of Contents
2.1 Payment Information 3
2.2 Fee-for-Service Reimbursement Methodology 3
2.2.1 Online Fee Lookup (OFL) and Static Fee Schedules 3
2.2.1.1 Non-emergent and Non-urgent Evaluation and Management (E/M) Emergency Department Visits 6
2.2.1.2 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 7
2.2.1.3 Drugs and Biologicals 7
2.2.2 Cost Reimbursement 7
2.2.3 Reasonable Cost and Interim Rates 8
2.2.4 Hospitals 8
2.2.5 Provider-Specific Visit Rates 8
2.2.6 Manual Pricing 8
2.3 Reimbursement Reductions 8
2.4 Using Payouts to Satisfy Accounts Receivables Across Programs and Alternate Provider Identifiers 9
2.4.1 HHSC Recoupment of Accounts Receivables from Alternate Provider Identifiers 9
2.4.2 Medicaid Funds May Be Used to Satisfy Children with Special Health Care Needs (CSHCN) Services Program Accounts Receivables 10
2.5 Additional Payments to High-Volume Providers 10
2.6 Out-of-State Medicaid Providers 11
2.7 Medicare Crossover Claim Reimbursement 11
2.7.1 Part A 11
2.7.2 Part B 11
2.7.3 Part C: Medicare Advantage Plans (MAPs) 12
2.7.3.1 Contracted MAPs 12
2.7.3.2 Noncontracted MAPs 12
2.7.4 Exceptions 12
2.7.4.1 Full Amount of Part B and Part C Coinsurance and Deductible Reimbursed 12
2.7.4.2 Nephrology (Hemodialysis, Renal Dialysis) and Renal Dialysis Facility Providers 12
2.8 Home Health Agency Reimbursement 13
2.8.1 Pending Agency Certification 13
2.8.2 Prohibition of Medicaid Payment to Home Health Agencies Based on Ownership 13
2.9 Federal Medical Assistance Percentage (FMAP) 14
 

Texas Medicaid & Healthcare Partnership
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