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 for dates of service on or after March 1, 2021, reimbursement rate changes and updates for procedure codes that were presented at a public rate hearing on November 13, 2020, will be implemented.
Providers are required to seek Medicare reimbursement for dual eligible clients, including for telemonitoring procedure code 99091.
The following topics were covered at the public rate hearing:
Effective for dates of services on or after March 1, 2021
- Calendar Fee Review for:
- Ambulatory Surgical Center (ASC)/hospital-based ASC (HASC)
- Birthing Centers
- Clinical Laboratory Services
- Clinical Laboratory Services Gapfill
- G Codes
- General and Integumentary System Surgery
- Nervous System Surgery
- Orthotic Procedures and Devices
- Physician Administered Drugs - Non-Oncology
- Physician Administered Drugs – Oncology
- Physician Administered Drugs – Vaccines
- NDCX List
- Healthcare Common Procedure Coding System (HCPCS) for:
- Medical Policy Review for:
- Colorectal Cancer Screening Policy
- Digital Breast Tomosynthesis (DBT)
- Digital Breast Tomosynthesis (DBT) Hospitals
- Nutritional (Enteral) Products, Supplies, and Equipment - Home Health & CCP: Immobilized Lipase Cartridge
- Stereotactic Radiosurgery
- Wound Care
- Wound Care ASC/HASC
- Wound Care Q Codes
For more information:
- Refer to the Health and Human Services (HHS) Rate Analysis web page at rad.hhs.texas.gov/rate-packets.
- Call the TMHP Contact Center at 800-925-9126.