The following table shows the laboratory procedure codes that are benefits of WHP and must be billed with a WHP-covered family planning diagnosis code:

The following table shows family planning diagnosis codes that are covered by WHP:

To prevent claim denials, laboratories that provide services to WHP clients must submit laboratory procedure codes with the appropriate WHP diagnosis code. The referring provider must include the WHP diagnosis code on the referral slip.

If a laboratory procedure code is denied with the explanation of benefits (EOB) message “Procedure code and/or diagnosis are not part of this benefit plan,” the laboratory provider must be able to show the following if the denied services are to be considered for reimbursement on appeal:

·         The procedure code is an authorized service for WHP clients.

·         The service resulted from a family planning examination.

·         The diagnosis code reflects the family planning examination and not the diagnosis code that is usually used when the laboratory test is performed.

Note: The laboratory provider must contact the referring provider to verify the family planning examination and the WHP-covered diagnosis code if the information is not included on the referral slip.

Providers may appeal only the denied details and must meet all filing deadlines as defined in the 2009 Texas Medicaid Provider Procedures Manual, section O.5.2.1, “Filing Deadlines,” on page O-7.

When a laboratory service is not a benefit of WHP, providers must inform a WHP client that the client will be liable for payment if the tests are performed. The provider may refer the client to community resources that may be able to perform the tests at no cost or at a reduced fee to the client.

If the client requests laboratory services that are not a benefit of WHP, providers may bill the client.

To enable the laboratory to identify the appropriate party to bill for services when the client elects not to seek assistance from a community resource, the referring provider must indicate on the referral slip to the reference laboratory which of the ordered tests is not covered by WHP.

For more information, call the TMHP Contact Center at 1-800-925-9126.