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Benefit Criteria to Change for Inpatient and Outpatient Mental Health Services for Texas Medicaid

Last updated on 4/17/2020

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 January 1, 2019, benefit criteria will change for psychological, neurobehavioral, and neuropsychological testing for inpatient behavioral health and outpatient mental health services for Texas Medicaid.

Inpatient Behavioral Health

Procedure codes with an asterisk indicate an add-on procedure code and must be billed with appropriate primary procedure code.

Psychological testing evaluations (procedure codes 96130 and 96131*) or neuropsychological testing evaluations (procedure codes 96132 and 96133*) may be reimbursed on the same date of service as psychological or neuropsychological testing administration and scoring (procedure codes 96136 and 96137*).

Affected claims for dates of service between January 1, 2019, and March 31, 2020, will be reprocessed, and providers may receive additional reimbursement, which will be reflected on future Remittance and Status Reports.

Outpatient Mental Health Services

Neurobehavioral testing procedure codes 96116 and 96121* will not be paid for the same date of service to the same provider as psychological testing or neurobehavioral procedure codes:

Procedure Codes
96130 96131* 96132 96133* 96136 96137*

For more information, call the TMHP Contact Center at 800-925-9126.