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TMPPM Update for Initial Hospital Care Visit

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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.

Beginning June 1, 2022, Texas Medicaid & Healthcare Partnership (TMHP) will update reimbursement language for an initial hospital care visit in the Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, section 9.2.58.5.1 “Hospital Admissions, Initial Visits, and Subsequent Visits”.

The “same diagnosis” language will be removed from the following statement:

Only one initial hospital care visit may be reimbursed to the same provider within a 30-day period for the same diagnosis. Additional initial hospital visits with the same diagnosis within a 30-day period will be denied.

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