Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after March 1, 2020, benefit information for medication assisted treatment (MAT) services will be updated for Texas Medicaid.
Claims billed for MAT must include the client’s substance use disorder diagnosis.
MAT administration (procedure code H0020 or H0033) for opioid use disorder must be submitted with the following modifiers:
- When MAT is administered with supervision in a facility, the provider must submit claims using the UA modifier to indicate the facility administered doses.
- When MAT is dispensed without supervision as a take-home dose, the provider must submit claims using the U1 modifier to indicate take-home doses.
MAT administration submitted without a modifier will be denied.
MAT provided in an outpatient setting is limited to once per date of service, by any provider, and is reimbursed at a fixed daily rate.
Physician services may be reimbursed separately using the appropriate evaluation and management procedure codes.
Medication dispensed for unsupervised take-home use should be dispensed in alignment with federal opioid treatment standards, per Title 42 of the Code of Federal Regulations (42 CFR) §8.12.
Providers that allow take-home doses must submit procedure code H0020 with modifier U1, for each date of service for which a take-home dose is dispensed.
Reimbursement for procedure code H0020 with modifier U1 is limited to a quantity of 30 per 30 days.
Providers that allow take-home doses must submit procedure code H0033 with modifier U1, for each date of service for which a take-home dose is dispensed.
Reimbursement for procedure code H0033 with modifier U1 is limited to a quantity of 30 per 30 days.
For more information, call the TMHP Contact Center at 800-925-9126.