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 September 16, 2020, for dates of service on or after September 8, 2020, COVID-19 testing procedure code 86413 will be added in the following programs: Medicaid, the Children with Special Health Care Needs (CSHCN) Services Program, Healthy Texas Women (HTW), and Family Planning Program.
Procedure code 86413 is a benefit for the following providers and places of service listed in this table.
Note: Procedure code 86413 will not be reimbursed until expenditures are approved Texas Medicaid adopts the rates. Providers will be notified of any benefit changes in a future article.
Services provided before the expenditures are approved will receive the following explanation of benefits (EOB) 02008 notification, “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.
For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.