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.
On October 1, 2021, TMHP will implement the third quarter 2021 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2021.
Discontinued procedure codes will no longer be considered benefits of Texas Medicaid.
Added procedure codes will not be reimbursed until the codes are reviewed and a rate hearing is held. Providers will be notified of any benefit changes in a future article.
Providers can refer to the Texas Medicaid Provider Procedures Manual for current benefit information.
For clinician-administered drug procedure codes included in a quarterly HCPCS update and approved to be added as Medicaid benefits by the Texas Health and Human Services Commission (HHSC), the rate may be effective as of the Centers for Medicare & Medicaid Services (CMS) effective date.
Claims will be denied until the rate is implemented but affected claims will be reprocessed back to the CMS effective date. The procedure codes will be payable at the published rate until the HHSC rate hearing is held, as required by the Texas Administrative Code §355.201.
For more information, call the TMHP Contact Center at 800-925-9126.