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Reimbursement Rate Updates for Drug Procedure Codes C9151, J1961, and Q5127 Effective July 1, 2023

Last updated on 9/29/2023

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after July 1, 2023, reimbursement rate updates for second quarter 2023 Healthcare Common Procedure Coding System (HCPCS) procedure codes C9151, J1961, and Q5127 will be implemented for Texas Medicaid.

Effective for dates of service on or after July 1, 2023, the Children with Special Health Care Needs (CSHCN) Services Program will follow Medicaid and implement procedure code C9151 with a reimbursement rate of $156.80 for individuals 18 years of age or older.

The Texas Medicaid & Healthcare Partnership (TMHP) will reprocess any affected claims that are identified. Providers are not required to appeal the claims unless the claims are denied for additional reasons after reprocessing is completed.

Updates are available at Drugs.

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