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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.14 Claims Filing for Consumer-Directed Services (CDS)

6.14
Clients who participate in the CDS option for both PCS and a waiver program, through DADS are required to choose one Financial Management Services Agency (FMSA) to provide services through both programs. FMSAs are permitted to file only the financial management services (FMS) fee, also known as the monthly administrative fee, through one program. The FMSA should file the FMS claim through the program with the highest reimbursement rate. Currently, the waiver programs have a higher reimbursement rate for the FMS fee than the Texas Medicaid PCS benefit, so a FMSA should file claims for the monthly FMS fee through the waiver programs.
The U8 modifier, which is used when submitting claims for the monthly PCS administrative fee, must be prior authorized. The DSHS case managers have two options when sending a prior authorization request for PCS to TMHP:
If a client is only using the CDS option for Texas Medicaid PCS, a case manager will submit a prior authorization request to TMHP that approves the U8 modifier and either the U7 or UB modifier. In this case, the provider authorization notification letter will include the U8 modifier and the U7 or UB modifier.
If a client is using the CDS option for both Texas Medicaid PCS and a waiver program, a case manager will submit a prior authorization request to TMHP that approves either the U7 or UB modifier. The U8 modifier will not be prior authorized in this situation.
When a provider authorization notification letter is received by a FMSA, the provider should verify that the correct modifiers have been prior authorized for each PCS client. Providers who think that the approved modifiers are incorrect should contact the DSHS case manager and ask for the correct modifiers to be submitted to TMHP for prior authorization.

Texas Medicaid & Healthcare Partnership
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