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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.2 Services, Benefits, Limitations, and Prior Authorization - Acute Care : 3.2.2 Hysterectomy Services

Hysterectomy services are considered for reimbursement when the claim is filed with a signed Hysterectomy Acknowledgment Form or submitted documentation indicates that the Hysterectomy Acknowledgment Form could not be obtained.
Claims for services related to the hysterectomy cannot be reimbursed unless the signed Hysterectomy Acknowledgement Form is on file; consequently, to avoid claim denials, each individual provider is encouraged to submit a copy of the valid Hysterectomy Acknowledgement Form and not rely on another provider to do so.
Refer to:
Subsection 5.14.1, “Hysterectomy Acknowledgment,” in Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks) for additional information.
Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information on the TMHP website at

Texas Medicaid & Healthcare Partnership
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