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 October 6, 2020, COVID-19 testing procedure code 87637 will require the modifier QW when billed. Affected claims submitted with dates of service on or after October 6, 2020, may be reprocessed. When the claims are reprocessed, providers may receive additional payment, which will be reflected on Remittance and Status Reports.
Note: Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.
For more information about procedure code 87637, providers can refer to the articles, “COVID-19 Testing Procedure Codes 87636, 87637, and 87811 Are Now Benefits,” and “COVID-19 Testing Procedure Codes 87636, 87637, and 87811 Are Now Benefits of the CSHCN Services Program,” which were published on the TMHP website.
Reminder: Providers must have the required Clinical Laboratory Improvement Amendments (CLIA) certification on file, and they must use the QW modifier when it is required, per the Centers for Medicare & Medicaid Services. Claims will be denied if the QW modifier is not present on applicable CLIA-waived tests. Providers must refer to the CMS CLIA website for information about CLIA-waived tests, provider certifications, and billing requirements.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.