Skip to main content

You must have JavaScript enabled in order to access this part of the site. Please enable JavaScript and then reload this page in order to continue.

Non-emergent Emergency Room Visits for Rural Hospitals Pricing Percentage Rate Reduced, Effective September 1, 2021

Last updated on

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 September 1, 2021, the pricing percentage rate for nonemergency emergency room visits at rural hospitals will change from 65 percent to 55 percent. The reduction does not include services that are reimbursed by a flat fee (i.e., clinical diagnostic laboratory, diagnostic radiology, and hospital ambulatory surgical centers).

The rate reduction is per Texas Administrative Code (TAC) rule §355.8061, “Outpatient Hospital Reimbursement.”

Affected claims submitted with dates of service from September 1, 2021 through November 5, 2021, will be reprocessed, and payments may be deducted from future payments (i.e., recouped). Any deductions will be reflected on future Remittance and Status (R&S) reports.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.