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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 : 2.4 Claims Filing and Reimbursement : 2.4.4 Prohibition of Medicaid Payment to Home Health Agencies Based on Ownership

2.4.4
Medicaid denies home health services claims when TMHP records indicate that the physician ordering treatment has a significant ownership interest in, or a significant financial or contractual relationship with, the nongovernmental home health agency billing for the services. Federal regulation Title 42 CFR §424.22 (d) states that “a physician who has a significant financial or contractual relationship with, or a significant ownership in a nongovernmental home health agency may not certify or recertify the need for home health services care services and may not establish or review a plan of treatment.”
A physician is considered to have a significant ownership interest in a home health agency if either of the following conditions apply:
The physician has an ownership of five percent or more of any mortgage, deed of trust, or other obligation that is secured by the agency, if that interest equals five percent or more of the agency’s assets.
A physician is considered to have a significant financial or contractual relationship with a home health agency if any of the following conditions apply:
The physician has indirect business transactions, such as contracts, agreements, purchase orders, or leases to obtain services, supplies, equipment, space, and salaried employment with the home health agency.
The physician has direct or indirect business transactions with the home health agency that, in any fiscal year, amount to more than $25,000 or 5 percent of the agency’s total operating expenses, whichever is less.
When providing CCP services and general home health services, the provider must file these on two separate UB‑04 CMS-1450 paper claim forms with the appropriate prior authorization number, and must send them to the appropriate address.
Claims denied because of an ownership conflict will continue to be denied unless the home health agency submits documentation indicating that the ordering physician no longer has a significant ownership interest in, or a significant financial or contractual relationship with, the home health agency providing services. Documentation must be sent to TMHP Provider Enrollment at the address indicated in “Written Communication With TMHP” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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