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TMPPM Updates for Obstetric Services Effective July 1, 2021

Last updated on 5/14/2021

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 1, 2021, TMHP will update the Texas Medicaid Provider Procedures Manual, Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook, section 4.1, “Services, Benefits, Limitations, and Prior Authorization,” and Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, section 9.2.7.3, “Anesthesia for Labor and Delivery.”

4.1 Services, Benefits, Limitations, and Prior Authorization

The following statement will be updated to include neuraxial labor analgesia:

Medicaid may reimburse only one delivery of Cesarean section procedure code per client in a seven-month period; reimbursement includes multiple births. Delivering physicians who perform regional anesthesia or nerve block do not receive additional reimbursement because these charges are included in the reimbursement for the delivery except when it is decided a Cesarean delivery is required following neuraxial labor analgesia. Procedure code 01967 may be reimbursed separately with Cesarean procedure codes 59514, 59515, 59620, and 59622.

9.2.7.3 Anesthesia for Labor and Delivery

The following statement will be updated:

For continuous epidural analgesia procedure codes, Texas Medicaid reimburses providers for the time when the physician is physically present and monitors the continuous epidural. Reimbursable time refers to the period between the catheter insertion and when the delivery commences.

The following statement will be removed:

Texas Medicaid reimburses the epidural anesthesia services and the delivery at full allowance when they are provided by the delivering obstetrician.

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