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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) : 3.4 Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services : 3.4.4 Freestanding and State Psychiatric Facilities : Reimbursement for Services Rendered in an IMD
The following services will not be reimbursed during an inpatient stay when they are rendered to clients who are admitted as inpatients to an IMD:
IMD providers may be reimbursed only for services that are rendered to clients who are 20 years of age and younger or 65 years of age and older. IMD services and services rendered at an IMD to clients who are 21 years of age through 64 years of age are not eligible for reimbursement.
Services that are rendered in an IMD facility must be identified in the client’s plan of care. Services that are not included in the client’s plan of care are subject to recoupment.
If the client has not been discharged from the IMD, the IMD provider is responsible for acute care services that are rendered to the client in an acute care facility, and claims that are submitted for these services will be denied as a duplicate service that has been paid to another provider.
Services that are rendered on the date of admission to the IMD and the date of discharge from the IMD may be reimbursed.
Claims for professional services rendered during an inpatient stay in an Institution for Mental Disease (IMD) must include the IMD facility’s ten-digit National Provider Identifier (NPI). Claims that do not include the IMD Facility’s NPI will be denied.
Freestanding psychiatric hospitals that are enrolled in Medicare may also receive Medicaid payment for the Medicare coinsurance or deductible according to current Medicaid guidelines.
Exception: IMD services for clients who are 21 through 64 years of age are not benefits of Texas Medicaid. Medicaid will not reimburse coinsurance and deductible payments for psychiatric services that are rendered to these clients in an IMD.
Refer to:
Subsection 2.7, “Medicare Crossover Claim Reimbursement,” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for additional information about Medicaid guidelines for Medicare coinsurance and deductible payments.

Texas Medicaid & Healthcare Partnership
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