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.
Additional procedure codes for coronavirus testing are a benefit of Texas Medicaid, effective on or after the following dates of service:
|Dates of Service||Procedure Codes|
|March 1, 2020||G2023 and G2024|
|March 13, 2020||87635|
|April 10, 2020||86328 and 86769|
|April 14, 2020||U0003 and U0004|
Note: The new procedure codes will not be reimbursed until expenditures are approved and the rates are adopted by Texas Medicaid. Providers will be notified of any benefit changes in a future article.
Services provided before the expenditures are approved will be denied with an explanation of benefits (EOB) 02008, “This procedure code has been approved as a benefit pending the approval of expenditures. Providers will be notified of the effective dates of service in a future notification if expenditures are approved.”
Once expenditures are approved, TMHP will automatically reprocess the affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.
Modifier Requirement for Procedure Code 87635
Effective for dates of service on or after March 20, 2020, procedure code 87635 must be submitted with modifier QW.
Revised Procedure Code Description
Effective for dates of service on or after April 10, 2020, the description for procedure code 86318 has been revised. Providers must contact the appropriate copyright holder to obtain procedure code descriptions.
For more information, call the TMHP Contact Center at 800-925-9126.