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December 2016 Texas Medicaid Provider Procedures Manual

Section 2: Texas Medicaid Fee‑for‑Service Reimbursement : 2.8 Home Health Agency Reimbursement : 2.8.2 Prohibition of Medicaid Payment to Home Health Agencies Based on Ownership

2.8.2
Medicaid denies Home Health Services claims when TMHP records indicate that the physician ordering treatment has a significant ownership interest in, or a significant financial or contractual relationship with, the nongovernmental home health agency billing for the services. Federal regulation Title 42 CFR §424.22 (d) states that “a physician who has a significant financial or contractual relationship with, or a significant ownership in a nongovernmental home health agency may not certify or recertify the need for Home Health Services care services and may not establish or review a plan of treatment.”
A physician is considered to have a significant ownership interest in a home health agency if either of the following conditions apply:
The physician has an ownership of five percent or more of any mortgage, deed of trust, or other obligation that is secured by the agency, if that interest equals five percent or more of the agency’s assets.
A physician is considered to have a significant financial or contractual relationship with a home health agency if any of the following conditions apply:
The physician has indirect business transactions, such as contracts, agreements, purchase orders, or leases to obtain services, medical supplies, DME, space, and salaried employment with the home health agency.
The physician has direct or indirect business transactions with the home health agency that, in any fiscal year, amount to more than $25,000 or five percent of the agency’s total operating expenses, whichever is less.
Providers must submit claims for CCP services and general home health services on two separate UB‑04 CMS-1450 paper claim forms with the appropriate prior authorization number. Claims that are denied because of an ownership conflict will continue to be denied until the home health agency submits documentation that indicates that the ordering physician no longer has a significant ownership interest in, or a significant financial or contractual relationship with, the home health agency that is providing the services. Providers should send documentation to TMHP Provider Enrollment at the address indicated in the “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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