Home Health (Skilled Nursing) Care
To enroll in the CSHCN Services Program, home health agencies providing skilled nursing services must be actively enrolled in Texas Medicaid, have a valid provider agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, be a licensed and certified home and community services support agency (HCSSA), and comply with all applicable state laws and requirements. Out-of-state home health skilled nursing providers must meet all these conditions, be located in the United States, within 50 miles of the Texas state border, and be approved by the Department of State Health Services (DSHS).
Important:CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid.
By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 26 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371.
CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1659 for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 26 TAC §351.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid.
Refer to: Section 2.1, “Provider Enrollment” in Chapter 2, “Provider Enrollment and Responsibilities” for more detailed information about CSHCN Services Program provider enrollment procedures.
22.2Benefits, Limitations, and Authorization Requirements
The CSHCN Services Program may cover up to 200 hours per client, per year of part-time, intermittent skilled nursing services (procedure codes S9123 and S9124). These services must be provided in the home by an HCSSA-registered nurse (RN) or licensed vocational nurse (LVN) enrolled in the CSHCN Services Program.
The admission visit performed by the agency RN may be reimbursed at the same rate as the home visit and counts toward the 200 hours per year. RN visits to perform assessments that are required to complete the plan of care may be reimbursed at the same rate as the home visit and will count toward the 200 hours per year limit.
Skilled nursing services must meet the following conditions for reimbursement by the CSHCN Services Program:
•Prescribed by a physician
•Medically necessary and appropriate
•Provided according to an established plan of care which is reviewed, at a minimum, by the prescribing physician every 60 days
•Authorized
Skilled nursing can include, but is not limited to:
•Periodic nursing assessment of a client.
•Visits for administering medications, including intravenous (IV) medications and chemotherapy.
•Visits for acute illness, postsurgical, and sterile wound care.
•Education of the primary caregiver and client about the illness process and the skills required to care for the client’s medical needs.
•Medical treatments that require the skills of a licensed nurse.
•Transition from an inpatient to a community-based home setting.
The CSHCN Services Program covers other services, therapies, supplies, and equipment that may be provided in the home. Refer to Chapter 21, “Home Health Services” for guidelines.
Skilled nursing services do not include respite care. Families should be referred to the DSHS regional office in their area for respite care services.
Refer to: Chapter 1, “TMHP and HHSC Contact Information” for a list of DSHS regional offices.
Nursing services are not reimbursed if provided in conjunction with the administration of total parenteral nutrition (TPN). The reimbursement for TPN is an all-inclusive fee.
Refer to: Section 26.6, “Total Parenteral Nutrition (TPN)” in Chapter 26, “Medical Nutrition Services” for more detailed information.
Skilled nursing for in-home administration of blood or blood products is not a benefit.
22.2.1Authorization Requirements
Skilled nursing services must be authorized. The number of skilled nursing hours that may be authorized or reimbursed is limited to 200 hours per calendar year per client.
Requests for skilled nursing hours must be submitted in writing to TMHP within 95 days of the date of service using the CSHCN Services Program Home Health Skilled Nursing Request and Plan of Care Form.
Note:Fax transmittal confirmations are not accepted as proof of timely authorization submissions.
An additional 200 hours of service per client, per calendar year may be prior authorized with documented justification of medical necessity.
Refer to: Chapter 4, “Prior Authorizations and Authorizations” for additional information about authorization and prior authorization requirements.
Home health services claims must be submitted to TMHP in an approved electronic format or on a UB-04 CMS-1450 paper claim form. Providers may purchase UB-04 CMS-1450 paper claim forms from the vendor of their choice. TMHP does not supply the forms.
When completing a UB-04 CMS-1450 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills or itemized statements, are not accepted as claim supplements.
The Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the Centers for Medicare & Medicaid Services (CMS) NCCI web page for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails.
Refer to: Chapter 41, “TMHP Electronic Data Interchange (EDI)” for information about electronic claims submissions.
Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for general information about claims filing.
Section 5.7.2.7, “Instructions for Completing the UB-04 CMS-1450 Paper Claim Form” in Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.
Services and supplies that exceed the 28-items-per-page limitation must be submitted on separate UB-04 CMS-1450 paper claim forms.
Skilled nursing care may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.
For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com.
The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled “Adjusted Fee” to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/resources/rate-and-code-updates/rate-changes.
Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.
22.5TMHP-CSHCN Services Program Contact Center
The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community.