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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 4 Outpatient Hospital (Medical and Surgical Acute Care Outpatient Facility) : 4.5 Claims Filing and Reimbursement : 4.5.2 Outpatient Reimbursement

Outpatient services are reimbursed on a reasonable cost based on a percentage of the hospital’s most recent tentative Medicaid cost report settlement.
The reimbursement rate for non-high-volume hospitals is as follows with the application of the hospital specific interim rate:
The reimbursement rate for high-volume hospitals is as follows with the application of the hospital specific interim rate:
High-volume providers are eligible for additional payments on Texas Medicaid fee-for-service claims. A high-volume outpatient hospital provider is defined as one that was paid at least $200,000 during calendar year 2004.
All clinical laboratory services are reimbursed at a percentage of the prevailing charge. Hospitals that are identified by Medicare as sole community hospitals are reimbursed at a higher percentage of the prevailing charges for services that are provided to clients in the outpatient setting.
Clinical pathology consultations are also allowed for reimbursement.
Refer to:
The HHSC Rate Analysis web page at for additional information about hospital reimbursement.
Subsection 3.7.4, “Provider Cost and Reporting,” in this handbook for more information about the calculation of the interim rate.
Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA),” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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