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Reimbursement Rate Updates for Procedure Code Q5115 Effective April 1, 2020

Last updated on 7/31/2020

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 July 21, 2020, for dates of service on or after April 1, 2020, the reimbursement rate for procedure code Q5115 has been updated.

The following table shows the updates.

Drugs Table:

TOS*

Procedure Code

Age Range

Non-Facility (N)/Facility (F)

 Current Medicaid Fee

Percent Reduction

 Current Adjusted Medicaid Fee

Medicaid Fee Effective 4/1/2020

Percent Reduction

Adjusted Medicaid Fee Effective 4/1/2020

1

Q5115

0-999

N/F

Not a Benefit

0.00%

Not a Benefit

$87.09

0.00%

$87.09

*Type of Service (TOS): 1 = Medical Services

Affected claims with dates of service from April 1, 2020, through July 21, 2020, if any are identified, will be reprocessed. Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is completed.

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