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TMHP to Update Place of Service Code 55

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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.

On November 3, 2023, the national place of service (POS) code 55 will be updated to crosswalk to POS code 5 (outpatient hospital). The Texas Medicaid & Healthcare Partnership (TMHP) will reprocess any claims that are identified with dates of service on or after November 1, 2020. Providers will have to appeal claims only if the claims are denied for additional reasons after reprocessing is completed.

This update will be reflected in the POS identification tables in the Texas Medicaid Provider Procedures Manual (TMPPM), Vol. 1. Claims Filing on December 1, 2023, and the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement,” and chapter 9, “Ambulance,” on December 15, 2023.

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