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December 2016 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook

Clinics and Other Outpatient Facility Services Handbook
Table of Contents
1 General Information 5
1.1 National Drug Codes (NDC) 5
1.2 Revenue Codes for UB-04 Submissions 5
1.3 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 5
2 Birthing Center 6
2.1 Provider Enrollment 6
2.2 Services, Benefits, Limitations, and Prior Authorization 6
2.2.1 Newborn Hearing Screening 7
2.2.2 Newborn Eligibility Process 7
2.2.3 Prior Authorization 7
2.2.4 Services Rendered in the Birthing Center Setting 8
2.3 Documentation Requirements 8
2.4 Claims Filing and Reimbursement 8
2.4.1 Claims Information 8
2.4.2 Reimbursement 8
2.4.2.1 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines 8
3 Comprehensive Health Center (CHC) 9
4 Federally Qualified Health Center (FQHC) 9
4.1 Enrollment 9
4.1.1 Initial Cost Reporting 10
4.2 Services, Benefits, Limitations, and Prior Authorization 10
4.2.1 After-Hours Care 14
4.2.2 Prior Authorization 14
4.2.3 Referral Requirements 14
4.3 Documentation Requirements 14
4.4 Claims Filing and Reimbursement 14
4.4.1 Claims Information 14
4.4.2 Reimbursement 16
4.4.2.1 Medicare Crossover Claims Pricing 16
4.4.2.2 NCCI and MUE Guidelines 17
5 Maternity Service Clinic (MSC) 17
6 Renal Dialysis Facility 17
6.1 Enrollment 17
6.2 Services, Benefits, Limitations, and Prior Authorization 17
6.2.1 Physician Supervision 18
6.2.1.1 Unscheduled or Emergency Dialysis in a Non-Certified ESRD Facility 20
6.2.2 Renal Dialysis Facilities-Method I Composite Rate 21
6.2.3 Method II Dealing Direct-Support Services 23
6.2.4 Facility Revenue Codes 24
6.2.5 Training for Hemodialysis, Intermittent Peritoneal Dialysis (IPD), Continuous Cycle Peritoneal Dialysis (CCPD), and Chronic Ambulatory Peritoneal Dialysis (CAPD) 25
6.2.6 Maintenance Hemodialysis 25
6.2.7 Maintenance IPD 25
6.2.8 Maintenance CAPD and CCPD 25
6.2.9 Laboratory and Radiology Services 25
6.2.9.1 In-Facility Dialysis—Routine Laboratory 25
6.2.9.2 In-Facility Dialysis—Nonroutine Laboratory 26
6.2.9.3 CAPD Laboratory 27
6.2.9.4 Hematopoietic Injections 27
6.2.9.5 Blood Transfusions 28
6.2.10 Prior Authorization 28
6.3 Documentation Requirements 28
6.4 Claims Filing and Reimbursement 28
6.4.1 Claims Information 28
6.4.2 Reimbursement 28
6.4.2.1 NCCI and MUE Guidelines 29
6.5 Medicare and Medicaid 29
6.5.1 Facility Providers 29
6.5.2 Physician Providers 29
7 Rural Health Clinic 29
7.1 Enrollment 29
7.1.1 Initial Cost Reporting 30
7.2 Services, Benefits, Limitations, and Prior Authorization 30
7.2.1 Services Rendered by the RHC Facility Provider 30
7.2.1.1 Encounter Rates 31
7.2.1.2 Medicaid Fee-for-Service Reimbursement Rates 31
7.2.1.3 Freestanding Rural Health Clinic Services 31
7.2.1.4 * Family Planning Services 32
7.2.2 Services Rendered by Non-RHC Providers In An RHC Setting 33
7.2.3 Hospital-Based Rural Health Clinic Services 33
7.2.3.1 After-Hours Care 34
7.3 Prior Authorization 34
7.4 Documentation Requirements 34
7.4.1 Record Retention 34
7.5 Claims Filing and Reimbursement 34
7.5.1 Claims Information 34
7.5.2 Reimbursement 34
7.5.2.1 Medicare Crossover Claims Pricing 35
7.5.2.2 NCCI and MUE Guidelines 35
8 Tuberculosis Services 35
8.1 Enrollment 35
8.1.1 Managed Care Program Enrollment 36
8.2 Services, Benefits, Limitations, and Prior Authorization 36
8.2.1 TB-Related Clinic Services 36
8.2.2 Ancillary Services 38
8.2.3 Prior Authorization 38
8.3 Documentation Requirements 38
8.4 Provider Responsibilities 38
8.5 Claims Filing and Reimbursement 39
8.5.1 Claims Information 39
8.5.1.1 Managed Care Clients 40
8.5.2 Reimbursement 40
8.5.2.1 NCCI and MUE Guidelines 40
9 Claims Resources 40
10 Contact TMHP 40
11 Forms 41
12 Claim Form Examples 41
 

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