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Maternal Level of Care Designation Required for Hospital Providers Rendering Inpatient and Outpatient Services

Last updated on 8/30/2021

Effective September 1, 2021, hospitals enrolled in Texas Medicaid can be reimbursed for inpatient and outpatient maternal services only if the hospitals have received a maternal level of care designation from the Department of State Health Services (DSHS) in accordance with 25 Texas Administrative Code §§133.201-133.210. The maternal level of care designation applies to Texas Medicaid and Texas Medicaid managed care organizations (MCOs).

Hospitals That Do Not Meet Minimum Requirements for Maternal Level of Care Designation

A hospital that does not meet the minimum requirements for any level of care designation for maternal services will not be reimbursed for inpatient and outpatient maternal services rendered to Texas Medicaid and Medicaid MCO clients. Hospitals without a maternal level of care designation may be reimbursed for emergency services provided or reimbursed under state or federal law to stabilize a mother prior to transport to a facility capable of providing the appropriate level of care.

Note: Maternal LOC designation is not required for state-owned providers.

Claims for inpatient and outpatient maternal services submitted by hospitals that do not have a maternal level of care designation on file will be denied. Providers can appeal the claim with documentation of the emergency services required.

If maternal inpatient and outpatient services are rendered by a facility that has applied for (but not yet received) a maternal designation, the facility must still adhere to existing claim filing deadlines (95 days from the date of discharge) and is also responsible for keeping their claim appeals active while awaiting maternal level of care designations to adhere to the 120-day claim appeal deadline.

Requirements to obtain a maternal level of care designation apply only to facilities located in Texas. Entities physically located outside of Texas but enrolled in Texas Medicaid (i.e., out-of-state or border state facilities) are exempt from the requirement to obtain a maternal level of care designation for inpatient and outpatient services rendered to maternal clients.

Note: When submitting paper claims for inpatient and outpatient maternal services rendered at a facility with an address that differs from the provider’s billing address, providers must enter the address of the facility where services were rendered in the remarks field.

Other Requirements

The facility address on the submitted claim must match the physical address of the location that has been issued a maternal level of care designation. If the facility address is not included on the claim, the submitted billing address must match the physical address of the location that was issued a maternal level of care designation.

Important: Claims will be denied if the address on the submitted claim does not match the physical address of the location that was issued a maternal level of care designation. For example, numbers must be spelled out as words or left numeric on the claim to match the address on the maternal level of care designation on file. “Street” or “avenue” must either be spelled out or abbreviated, etc.

Address on Maternal Designation File

Correct

Incorrect (Claim may be denied)

12345 First Street

12345 First Street

12345 1st Street

6 Maine Street

6 Maine Street

Six Maine St.

Providers can refer to the DSHS approval letter for the correct address.

TPI Change Due to Split or Merge

Hospital providers with a Texas Provider Identifier (TPI) change that is due to a split or merge will be responsible for notifying DSHS. Also, hospital providers must notify the DSHS EMS/Trauma Systems Section, Designation Unit of any maintenance required on their maternal level of care designation address due to an address change.

Crossover Claims for Dual-eligible Clients

Maternal level of care designation requirements will also apply for maternal inpatient and outpatient crossover claims rendered to a client who has dual Medicare and Medicaid eligibility on the date of admission.

Resources

Other DSHS website/resource:

Maternal Level of Care Designation Reminder

Reminder: Hospitals must apply for a maternal level of care designation for each physical location. Information about applying for the designation can be found at www.dshs.texas.gov/emstraumasystems/formsresources.shtm.

DSHS will assign one of four maternal level of care designations to each hospital location based on the services and care provided at each hospital location.

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