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December 2016 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2 Texas Medicaid (Title XIX) Home Health Services : 2.3 Other or Special Provisions : 2.3.1 Medicaid Relationship to Medicare : 2.3.1.3 Medicare and Medicaid Prior Authorization

2.3.1.3
Contact TMHP for prior authorization of Medicaid services (based on medical necessity and benefits of Home Health Services) within 30 days of the date on the MRAN.
Note:
For MQMB clients, do not submit prior authorization requests to TMHP if the Medicare denial reason states “not medically necessary.” Medicaid only will consider prior authorization requests if the Medicare denial states “not a benefit” of Medicare.
Qualified Medicare Beneficiaries (QMB) are not eligible for Medicaid benefits. Texas Medicaid is only responsible for premiums, coinsurance, or deductibles on these clients according to payment guidelines. Providers should not submit prior authorization requests to the TMHP Home Health Services Prior Authorization Department for these clients.
To ensure Medicare benefits are used first in accordance with Texas Medicaid regulations, the following procedures apply when requesting Medicaid prior authorization and payment of home health services for clients.
Contact TMHP for prior authorization of Medicaid services (based on medical necessity and benefits of Home Health Services) within 30 days of the date on the MRAN. Fax a copy of the original Medicare MRAN and the Medicare appeal review letter to the TMHP Home Health Services Prior Authorization Department for prior authorization.
Note:
Claims for STAR+PLUS MQMB clients (those with Medicare and Medicaid) must always be submitted to TMHP as noted on these pages. The STAR+PLUS health plan is not responsible for these services if Medicare denies the service as not a benefit.
When the client is 65 years of age and older or appears otherwise eligible for Medicare such as blind and disabled, but has no Part A or Part B Medicare, the TMHP Home Health Services Prior Authorization Department uses regular prior authorization procedures. In this situation, the claim is held for a midyear status determined by HHSC. The maximum length of time a claim may be held in a “pending status” for Medicare determination is 90 days. After the waiting period, the claim is paid or denied. If denied, the EOB code on the R&S report indicates that Medicare is to be billed.
Refer to:
Section 3, “Home Health Skilled Nursing and Home Health Aide Services” in the Home Health Nursing and Private Duty Nursing Services Handbook (Vol. 2, Provider Handbooks).
Refer to:
Subsection 3.2.3, “Home Health Skilled Nursing Services” in the Nursing and Therapy Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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