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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.17 Claims Filing and Reimbursement

6.17
Providers must bill Medicare before billing Medicaid. Medicaid’s responsibility for the coinsurance or deductible is determined in accordance with Medicaid benefits and limitations. Providers must check the client’s Medicare card for Part B coverage before billing Texas Medicaid. When Medicare is primary, it is inappropriate to bill Medicaid without first billing Medicare.
Note:
Claims for behavioral health services must be submitted to TMHP in an approved electronic format or on the CMS-1500 or UB-04 CMS-1450 paper claim forms. Providers may purchase CMS-1500 and UB‑04 CMS-1450 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 or UB-04 CMS-1450 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements. The diagnosis code that supports medical necessity for the billed outpatient behavioral health service must be referenced on the claim.
The Medicaid rates for psychologists are calculated in accordance with 1 TAC §355.8081 and §355.8085. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com. An FQHC is reimbursed for psychological services according to its specific Prospective Payment System (PPS) rate per visit calculated in accordance with 1 TAC §355.8261.
A freestanding psychiatric hospital or facility is reimbursed for psychological services in accordance with 1 TAC §355.8060.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
Section 4, “Federally Qualified Health Center (FQHC)” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for more information.
Subsection 4.11.2, “Medicare Part B Crossovers” in Section 4, “Client Eligibility” (Vol. 1, General Information)
Subsection 6.1, “Claims Information” in Section 6, “Claims Filing” (Vol. 1, General Information) for general information about claims filing.
Subsection 6.5, “CMS‑1500 Paper Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.
Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.
Subsection 2.7.2, “Part B” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for information about how coinsurance and deductibles may be reimbursed by Texas Medicaid.

Texas Medicaid & Healthcare Partnership
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