Healthy Texas Women Program Handbook

1 ​General Information

The information in this handbook is intended for Healthy Texas Women (HTW) program providers. The handbook provides information about Texas Medicaid’s HTW benefits, policies, and procedures that are applicable to these service providers.

​Important:All providers are required to read and comply with Section 1: Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid clients, including HTW clients, in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver healthcare items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

​Refer to: The Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about providing services to Texas Medicaid and Texas Health Steps (THSteps) clients.

“Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

“Texas Medicaid Administration” in the Preliminary Information (Vol. 1, General Information).

The Healthy Texas Women website at www.healthytexaswomen.org for information about family planning and the locations of clinics receiving family planning funding from HHSC.

The Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for information about Texas Medicaid fee-for service and Title XIX family planning benefits for gynecological and reproductive health services.

The Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information about services provided in a Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

2 ​Healthy Texas Women (HTW) Program Overview

The goal of HTW is to expand access to women’s health and family planning services to reduce unintended pregnancies, positively affect the outcome of future pregnancies, and positively impact the health and wellbeing of women and their families in the eligible population.

HTW is established to achieve the following objectives:

•​Implement the state policy to favor childbirth and family planning services that do not include elective abortions or the promotion of elective abortions.

•​Ensure the efficient and effective use of state funds in support of these objectives and to avoid the direct or indirect use of state funds to promote or support elective abortions.

•​Reduce the overall cost of publicly-funded healthcare (including federally-funded healthcare) by providing low-income Texans access to safe, effective services that are consistent with these objectives.

•​Enforce Human Resources Code §32.024(c-1).

​Refer to: Subsection 1.1, “Family Planning Overview” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for an overview of family planning funding sources.

The HTW page of the TMHP website at www.tmhp.com for more information about provider certification.

Healthy Texas Women Plus (HTW Plus) is a set of additional physical health, mental health, and substance use disorder benefits that are available to HTW clients during the first 12 months of their eligibility following a pregnancy in addition to all standard HTW benefits. These outpatient services target major health conditions that contribute to maternal mortality and severe morbidity in the extended postpartum period and provide continuity of care for chronic conditions treated during the pregnancy period.

Health-care providers who want to provide HTW Plus services must be enrolled as Texas Medicaid providers and have completed the HTW provider certification process. There are no additional requirements for HTW providers to provide HTW Plus benefits within their scope of education and training, because HTW Plus is not a separate program from HTW.

2.1​Guidelines for HTW Providers

HTW provides family planning services, related preventive health services that are beneficial to reproductive health, and other preventive health services that positively affect maternal health and future pregnancies for women who:

•​Are 15 through 44 years of age.

​Note:Women who are 15 through 17 years of age must have a parent or legal guardian apply on their behalf.

•​Are a United States citizen or eligible immigrant.

•​Are a resident of Texas.

•​Do not currently receive benefits through another Medicaid program (including Medicaid for Pregnant Women), Children’s Health Insurance Program (CHIP), or Medicare Part A or B.

•​Have a household income at or below 204.2 percent of the federal poverty level.

•​Are not pregnant.

•​Do not have other insurance that covers the services that HTW provides.

​Exception:A client who has other private health insurance may be eligible to receive HTW services if a spouse, parent, or other person would cause physical, emotional, or other harm to the client because the client filed a claim on the health insurance.

HTW medical services are provided by a physician or by another qualified health-care professional operating under physician direction. A physician provides direction for family planning services through written standing delegation orders and medical protocols. The physician is not required to be on the premises for the provision of family planning services by an RN, PA, NP, or CNS. HTW participants may receive services from any provider that participates in HTW.

HTW clients must be allowed freedom of choice in the selection of contraceptive methods as medically appropriate. They must also be allowed the freedom to accept or reject services without coercion. All HTW-covered methods of contraception must be made available to the client, either directly or by referral to another provider of contraceptive services. Services must be provided without regard to age, marital status, race, ethnicity, parenthood, disability, religion, national origin, or contraceptive preference.

Client eligibility can be verified by:

•​Using TexMedConnect.

•​Accessing the Medicaid Client Portal for Providers.

•​Checking an electronic or printed copy of Your Texas Benefits Healthy Texas Women card.

•​Calling the Automated Inquiry System at 1-800-925-9126.

​Refer to: Subsection 4.4.3, “Client Eligibility Verification” in “Section 4: Client Eligibility” (Vol. 1, General Information).

HTW clients will have the following identifiers on the feedback received from the stated source:

•​Medicaid Coverage: W - MA - HTW

•​Program Type:

•​68 - MEDICAL ASSISTANCE - HEALTHY TEXAS WOMEN (HTW)

•​69 - MEDICAL ASSISTANCE - HEALTHY TEXAS WOMEN PLUS (HTW PLUS)

•​Program: 100 - MEDICAID

•​Benefit Plan: 100 - Traditional Medicaid

HTW clients will receive 12 months of continuous eligibility unless:

•​The client dies.

•​The client voluntarily withdraws from HTW.

•​The client no longer satisfies the HTW eligibility criteria.

•​The client is certified for another Medicaid program, such as Medicaid for Pregnant Women, or CHIP.

•​State law no longer allows the woman to be covered.

•​HHSC or its designee determines the client provided information affecting her eligibility that was false at the time of application.

If a provider suspects that a HTW client has committed fraud on the application, the provider should report the client to the HHSC Office of Inspector General (OIG) at 1-800-436-6184.

2.1.1​Referrals

If a provider identifies a health problem that is not within their scope of practice, the provider must refer the HTW client to another provider or clinic that can treat her. As mandated by Texas Human Resources Code §32.024(c-1), HTW does not reimburse office visits during which clients are referred for elective abortions.

A provider must refer and provide information about the HHSC Primary Health Care Services Program. Additionally, the toll-free Information and Referral hotline 2-1-1 can assist clients and providers with locating low-cost health services for clients in need.

2.1.2​Referrals for Clients Diagnosed with Breast or Cervical Cancer

Medicaid for Breast and Cervical Cancer (MBCC) provides access to cancer treatment through full Medicaid benefits for qualified women diagnosed with breast or cervical cancer. Health facilities that contract with the Breast and Cervical Cancer Screening (BCCS) program are responsible for helping women with the MBCC application.

To find a BCCS provider, call 2-1-1. For questions about the BCCS program, contact the state office at 512-458-7796, or visit www.healthytexaswomen.org/bccs-program.

2.1.3​Abortions

Elective and non-elective abortions are not covered by HTW.

Texas Human Resources Code Section 32.024(c-1) and Title 1 Texas Administrative Code, §382.17 prohibit the participation of a provider that performs or promotes elective abortions or affiliates with an entity that performs or promotes elective abortions.

A provider that performs elective abortions (through either surgical or medical methods) or that is affiliated with an entity that performs or promotes elective abortions for any patient is ineligible to serve HTW clients and cannot be reimbursed for any services rendered to a HTW client. This prohibition only applies to providers delivering services to HTW clients.

“Elective abortion” means the intentional termination of a pregnancy by an attending physician who knows that the female is pregnant, using any means that is reasonably likely to cause the death of the fetus. The term does not include the use of any such means: (A) to terminate a pregnancy that resulted from an act of rape or incest; (B) in a case in which a woman suffers from a physical disorder, physical disability, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy, that would, as certified by a physician, place the woman in danger of death or risk of substantial impairment of a major bodily function unless an abortion is performed; or (C) in a case in which a fetus has a life-threatening physical condition that, in reasonable medical judgment, regardless of the provision of life-saving treatment, is incompatible with life outside the womb.

Certain providers that want to participate in HTW must certify that they do not perform or promote elective abortions and do not affiliate with any entity that does, as directed by HHSC.

​Refer to: Subsection 2.2, “HTW Provider Enrollment” in this handbook for more information about certification regarding elective abortions.

2.2​HTW Provider Enrollment

Providers who have completed the Medicaid enrollment process through TMHP, and have certified that they do not perform elective abortions or affiliate with providers that perform elective abortion are eligible to participate. Teaching hospital, independent laboratory, and radiology facility providers are not required to certify.

​Refer to: “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures.

Certain providers that want to participate in HTW must certify that they do not perform or promote elective abortions and do not affiliate with any entity that does, as directed by HHSC. Providers may complete the Healthy Texas Women Certification and disclose the required information as part of the Medicaid enrollment process, or at any time after completing the Medicaid enrollment process. New providers may use the TMHP website to submit the Healthy Texas Women Certification through the Provider Enrollment and Management System (PEMS). Medicaid-only providers may use the TMHP website to submit the Healthy Texas Women Certification through the PEMS.

The following provider types are not required to certify:

•​Teaching hospitals

•​Independent laboratories

•​Radiology facilities

Information that providers submit through PEMS can be searched by clients who use the Find a Doctor feature on the HTW website at www.healthytexaswomen.org.

2.3​* Services, Benefits, Limitations, and Prior Authorization

This section includes information on women’s health and family planning services funded through HTW. HTW benefits include:

•​Contraceptive services

•​Pregnancy testing and counseling

•​Preconception health screenings (e.g., screening for obesity, hypertension, diabetes, cholesterol, smoking, and mental health)

•​Sexually transmitted infection (STI) services

•​Treatment for the following chronic conditions:

•​Hypertension

•​Diabetes

•​High cholesterol

•​Breast and cervical cancer screening and diagnostic services:

•​Radiological procedures including mammograms

•​Screening and diagnosis of breast cancer

•​Diagnosis and treatment of cervical dysplasia

•​Immunizations

•​Treatment of postpartum depression

​Refer to: Subsection 2.3.11, “HTW Plus Services, Benefits, and Limitations” in this handbook for HTW Plus benefit information.

The following procedure codes are benefits for HTW:

Procedure code G0433 will deny if billed on the same day by the same provider as procedure code 86703.

Procedure codes 96156, 96158, 96159, 96167, and 96168 are a benefit for clients who are 20 years of age and younger.

Procedure code 99473 is limited to one service per year, by any provider. Procedure code 99473 may be considered for reimbursement more than once per year when documentation of medical necessity is submitted with the claim.

Procedure code 99474 is limited to four services per year, by any provider, and it may be reimbursed only if a claim for procedure code 99473 has been submitted within the past 12 rolling months.

Self-measured blood pressure monitoring is a benefit when it is used as a diagnostic tool to help a physician diagnose hypertension in individuals whose blood pressure is either elevated or inconclusive when it is evaluated in the office alone.

​Refer to: Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

2.3.1​Family Planning History Check

HTW clients must receive family planning services annually, but no later than the third visit as an established client. These services must include family planning counseling and education, including natural family planning and abstinence. In order to receive reimbursement, all existing HTW clients must have received family planning services and/or counseling within the past rolling year.

The following HTW clients do not require a family planning history check:

•​New clients

•​Women who are sterilized

•​Women who have a long-acting reversible contraception (LARC)

2.3.2​Family Planning Annual Exams

Family planning providers must bill one of the following E/M visit procedure code based on the complexity of the annual family planning examination provided:

The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for the annual examination:

​Refer to: The Family Planning section of the HHSC website for information about the HHSC Family Planning Program.

2.3.2.1​FQHC Reimbursement for Family Planning Annual Exams

To receive their encounter rate for the annual family planning examination for HTW clients, FQHCs must use the most appropriate E/M procedure code for the complexity of service provided as indicated in the previous tables in Subsection 2.3.2, “Family Planning Annual Exams” in this handbook.

A new patient visit for the annual exam may be reimbursed once every three years following the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group. The annual examination must be billed as an established patient visit if E/M services have been provided to the client within the last three years.

Reimbursement for services payable to an FQHC is based on an all-inclusive rate per visit.

2.3.3​Other Family Planning Office or Outpatient Visits

HTW does not cover office visits during which clients are referred for elective abortions.

A provider is allowed to bill clients for services that are not a benefit of HTW.

​Refer to: Subsection 1.7.12.1, “Client Acknowledgment Statement” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for the requirements for billing clients.

2.3.3.1​FQHC Reimbursement for Other Family Planning Office or Outpatient Visits

FQHCs may be reimbursed for three family planning encounters per HTW client, per year. Procedure codes J7296, J7297, J7298, J7300, J7301, and J7307 may be reimbursed in addition to the FQHC encounter payment. When seeking reimbursement for an IUD or implantable contraceptive implant, providers must submit on the same claim the procedure code for the contraceptive device along with the procedure code for the encounter. The contraceptive device is not subject to FQHC limitations. Providers must use modifier U8 when submitting claims for a contraceptive device purchased through the 340B Drug Pricing Program.

Outpatient visits for non-family planning-related encounters that are provided by FQHCs for HTW or HTW Plus covered physical and behavioral health services may be reimbursed when medically necessary.

Reimbursement for services payable to an FQHC is based on an all-inclusive rate per visit.

​Refer to: Section 4, “Federally Qualified Health Center (FQHC)” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for more information about FQHC services.

2.3.4​Laboratory Procedures

The fee for the handling or conveyance of the specimen for transfer from the provider’s office to a laboratory may be reimbursed using procedure code 99000.

More than one lab handling fee may be reimbursed per day if multiple specimens are obtained and sent to different laboratories.

​Note:When a provider who renders HTW laboratory services obtains a specimen but does not perform the laboratory procedure, the provider who obtains the specimen may be reimbursed one lab handling fee per day, per client.

Handling fees are not paid for Pap smears or cultures. When billing for Pap smear interpretations, the claim must indicate that the screening and interpretation were actually performed in the office by using the modifier SU (procedure performed in physician’s office).

If more than one of procedure codes 87480, 87510, 87660, 87661, or 87800 is submitted by the same provider for the same client with the same date of service, all of the procedure codes are denied. Only one procedure code (87480, 87510, 87660, 87661, or 87800) may be submitted for reimbursement, and providers must submit the most appropriate procedure code for the test provided.

​Note:Providers must code to the highest level of specificity with a diagnosis to support medical necessity when submitting procedure code 87797.

​Refer to: Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

Appropriate documentation must be kept in the client’s record.

Claims may be subject to retrospective review if they are submitted with diagnosis codes that do not support medical necessity.

HTW follows the Medicare categorization of tests for CLIA certificate holders.

​Refer to: The CMS website at www.cms.gov/CLIA/10_Categorization_of_Tests.asp for information about procedure code and modifier QW requirements.

For waived tests, providers must use modifier QW as indicated on the CMS website.

2.3.5​Contraceptive Devices

Providers must use modifier U8 when submitting claims for a contraceptive device purchased through the 340B Drug Pricing Program.

An E/M procedure code will not be reimbursed when it is billed with the same date of service as procedure code 58301, unless the E/M visit is a significant, separately identifiable service from the removal of the IUD. If the E/M visit occurs on the same date of service as the removal of the IUD, modifier 25 may be used to indicate that the E/M visit was a significant, separately identifiable service from the procedure.

2.3.6​Drugs and Supplies

2.3.6.1​Prescriptions and Dispensing Medication

Drugs and supplies that are dispensed directly to the client must be billed to HTW. Only providers with an appropriate pharmacy license may be reimbursed for dispensing family planning drugs and supplies. Provider types with an appropriate pharmacy license may be reimbursed for dispensing up to a one-year supply of contraceptives in a 12-month period using procedure code J7294, J7295, J7304, or S4993.

Pharmacies under the Vendor Drug Program are allowed to fill all prescriptions as prescribed. Family planning drugs and supplies are exempt from the three prescriptions-per-month rule for up to a six- month supply.

​Refer to: Subsection 1.1, “About the Vendor Drug Program” in the Outpatient Drug Services Handbook (Vol. 2, Provider Handbooks) for information about this program.

2.3.6.1.1​Long-Acting Reversible Contraception Products

Certain LARC products are available as a pharmacy benefit of HTW and are available through a limited number of specialty pharmacies that work with LARC manufacturers. Providers can refer to the Texas Medicaid/CHIP Vendor Drug Program website at www.txvendordrug.com/about/manuals/pharmacy-provider-procedure-manual/p-9-formulary-coverage/long-acting-reversible-contraception-products for additional information, including a list of covered products and participating specialty pharmacies.

2.3.7​Sterilization and Sterilization-Related Procedures

Sterilizations are considered to be permanent, once per lifetime procedures. Denied claims may be appealed with documentation that supports the medical necessity for a repeat sterilization.

The sterilization services that are available to HTW clients include surgical or nonsurgical sterilization, follow-up office visits related to confirming the sterilization, and any necessary short-term contraception.

HTW covers sterilization as a form of birth control. To be eligible for a sterilization procedure through HTW, the client must be 21 years of age or older and must complete and sign a Sterilization Consent Form within at least 30 days of the date of the surgery but no more than 180 days. In the case of an emergency, there must be at least 72 hours between the date on which the consent form is signed and the date of the surgery. Operative reports that detail the need for emergency surgery are required.

2.3.7.1​Sterilization Consent

Per federal regulation 42 Code of Federal Regulations (CFR) 50, Subpart B, all sterilization procedures require an approved Sterilization Consent Form.

​Note:The Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information form is not sterilization consent.

​Refer to: Sterilization Consent Form (English) on the TMHP website at www.tmhp.com.

Sterilization Consent Form (Spanish) on the TMHP website at www.tmhp.com.

Sterilization Consent Form Instructions on the TMHP website at www.tmhp.com.

2.3.8​Treatment for Sexually Transmitted Infections (STIs)

HTW covers treatment for the following conditions:

•​Gardnerella

•​Trichomoniasis

•​Candida

•​Chlamydia

•​Gonorrhea

•​Herpes

•​Syphilis

2.3.9​Immunizations and Vaccinations

HTW covers the following immunizations and vaccinations:

•​HPV

•​Hep A

•​Hep B

•​Chicken pox

•​MMR

•​Tdap

•​Flu

2.3.10​Telemedicine and Telehealth Services

Certain telemedicine and telehealth services may be provided for HTW clients if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interactions, such as an in-person visit, as well as the use of synchronous audio-visual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. The following HTW services are authorized for telemedicine delivery using synchronous audiovisual and synchronous telephone (audio-only), when noted, technologies:

The following HTW services are authorized for telemedicine and telehealth delivery using synchronous telephone (audio-only) technologies:

2.3.10.1​Synchronous Audiovisual Technology

New patient and established client services provided by synchronous audiovisual technology must be billed using modifier 95. The following procedure codes are for new and established client services:

2.3.10.2​Synchronous Telephone (Audio-Only) Technology

Established client services for behavioral health or substance use conditions provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. Established patient services for non-behavioral health conditions provided by synchronous telephone (audio-only) technology must be billed using modifier 93.

The following procedure codes are for established client services:

Established client service (procedure code 99211) is only during certain public health emergencies. Procedure codes that indicate remote (telemedicine medical and telehealth services) delivery in the description do not need to be billed with the 95 modifier.

FQHCs and RHCs that provide telemedicine and telehealth services using synchronous audiovisual and synchronous telephone (audio-only) technology may be reimbursed for the following HTW services:

Behavioral health services delivered using synchronous telephone (audio-only) technologies must be billed using the FQ modifier. Non-behavioral health services delivered using synchronous telephone (audio-only) technologies must be billed using the 93 modifier.

FQHCs and RHCs may be reimbursed for telemedicine and telehealth in the following manner:

•​The distant site provider fee is reimbursable as a prospective payment system (PPS), alternative prospective payment system (APPS), or AIR (All Inclusive Rate) PPS.

•​The facility fee (procedure code Q3014) is an add-on procedure code that should not be included in any cost reporting that is used to calculate a FQHC PPS, APPS, or the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

Services delivered using synchronous audiovisual technologies must be billed using modifier 95. Procedure codes that indicate remote (telemedicine medical and telehealth services) delivery in the description do not need to be billed with the 95 modifier.

During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

2.3.11​HTW Plus Services, Benefits, and Limitations

In addition to all HTW services, HTW Plus provides enhanced postpartum services to eligible HTW clients for the following targeted health conditions and services:

•​Behavioral health conditions

•​Individual, family, and group psychotherapy services

•​Peer specialist services

•​Cardiovascular and coronary conditions

•​Cardiovascular evaluation imaging and laboratory studies

•​Blood pressure monitoring equipment

•​Anticoagulant, antiplatelet, and antihypertensive medications

•​Substance use disorders

•​Screening, brief intervention, and referral for treatment

•​Outpatient substance use counseling

•​Smoking cessation services

•​Medication-assisted treatment

•​Peer specialist services

•​Diabetes

•​Laboratory studies

•​Additional injectable insulin options

•​Blood glucose testing supplies

•​Voice-integrated glucometers for women with diabetes who are visually impaired

•​Glucose monitoring supplies

•​Asthma

•​Medications and supplies

The following procedure codes are benefits of HTW Plus:

HTW Plus benefits are subject to the same restrictions and limitations that are applied to Texas Medicaid’s coverage for the same procedure codes.

​Refer to: The relevant handbooks for detailed coverage information of HTW Plus benefits.

2.3.11.1​HTW Plus Telemedicine and Telehealth Services

Certain telemedicine and telehealth services may be provided for HTW Plus clients if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interactions, such as an in-person visit, as well as the use of synchronous audio-visual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. The following HTW Plus services are authorized for delivery using synchronous audiovisual and synchronous telephone (audio-only), when noted, technologies:

​Note:Procedure codes 90833, 90836, and 90838 are add-on codes and must be billed with a primary procedure code in order to be reimbursed.

Behavioral health services delivered using synchronous telephone (audio-only) technologies must be billed using the FQ modifier.

​Refer to: The Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) for information on restrictions for behavioral health services delivered by synchronous audiovisual and synchronous telephone (audio-only) technologies.

Procedure code H0001 is authorized for delivery by synchronous telephone (audio-only) technology only during certain public health emergencies or natural disasters; to the extent allowed by federal law (assessments for withdrawal management services are excluded); and the ‘existing clinical relationship’ requirement is waived.

During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

2.3.12​Prior Authorization

Prior authorization is not required for HTW services.

2.4​Documentation Requirements

All services require documentation to support the medical necessity of the service rendered.

HTW services are subject to retrospective review and recoupment if documentation does not support the service billed.

Documentation requirements for a telemedicine or telehealth service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the means of delivery when provided by telemedicine or telehealth.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on restrictions for services delivered by synchronous audiovisual and synchronous telephone (audio-only) technologies.

Additional documentation requirements apply for certain behavioral health services delivered by synchronous audiovisual technology and synchronous telephone (audio-only) technology.

2.5​HTW Claims Filing and Reimbursement

2.5.1​Claims Information

Providers must use the appropriate claim form to submit HTW claims to TMHP.

​Refer to: Subsection 2.4, “Claims Filing and Reimbursement” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for more information about filing family planning claims.

2.5.1.1​HTW and Third Party Liability

Federal and state regulations mandate that family planning client information be kept confidential.

Because seeking information from third party insurance may jeopardize the client’s confidentiality, third party billing for HTW is not allowed.

2.5.2​Reimbursement

Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

2.5.3​National Drug Code

​Refer to: Subsection 6.3.4, “National Drug Code (NDC)” in “Section 6: Claims Filing” (Vol. 1, General Information).

2.5.4​NCCI and MUE Guidelines

The Health Care Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manual. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

3 ​Claims Resources

4 ​Contact TMHP

The TMHP Contact Center at 1-800-925-9126 is available Monday-Friday from 7 a.m. to 7 p.m., Central Time.

5 ​Forms

The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at www.tmhp.com: