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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 7 Screening, Brief Intervention, and Referral to Treatment (SBIRT) : 7.7 Claims Filing and Reimbursement

SBIRT services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 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.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
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).
Texas Medicaid rates for Hospitals are calculated according to 1 TAC §355.8061.
According to 1 TAC §355.8091, the Medicaid rate for LCSWs, LMFTs, and LPCs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085.
The Medicaid rates for psychologists are calculated in accordance with 1 TAC §355.8081 and §355.8085.
Texas Medicaid rates for physicians and certain other practitioners are calculated in accordance with TAC §355.8085.
Texas Medicaid rates for Nurse Practitioners and Clinical Nurse Specialists are calculated in accordance with TAC §355.8281.
According to 1 TAC §355.8093, the Medicaid rate for PAs is 92 percent of the rate paid to a physician (MD or DO) for the same professional service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. Services performed by a PA and billed under a physician’s or RHC’s provider identifier are reimbursed according to the Texas Medicaid Reimbursement Methodology (TMRM) for physician services.
Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.
Additional information about rate changes is available on the TMHP website at
Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

Texas Medicaid & Healthcare Partnership
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