The Children with Special Health Care Needs (CSHCN) Services Program enrolls hospice organizations and home health agencies licensed to provide hospice services. These agencies are not required to be actively enrolled in Texas Medicaid. However, they must be licensed by the Texas Health and Human Commission (HHSC), have a valid provider agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state hospice providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border.
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/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.
23.2Benefits, Limitations, and Authorization Requirements
Hospice services are benefits of the CSHCN Services Program. Hospice care includes palliative care for clients with a prognosis of 6 months or less.
Services must be related to palliative care for the terminal diagnosis and may include any or all of the following services: direct care, respite, durable medical equipment (DME), supplies, and medications prescribed for the terminal illness.
Direct care services may include:
•Skilled nursing services.
•Social work services.
•Home health aide services.
•Pastoral care services.
•Medical supervision by the hospice medical director.
•Physical therapy and occupational therapy.
•Speech therapy.
•Dietitian services.
The hospice benefit does not cover curative care for the terminal diagnosis.
Coverage for conditions unrelated to the terminal illness is unaffected.
If nutritional supplements are the client’s sole source of nutrition, the supplements are included in the per diem rate.
Total parenteral nutrition (TPN) provided to a client on hospice services may be reimbursed separately.
Refer to: Section 26.6.2, “Benefits, Limitations, and Authorization Requirements” in Chapter 26, “Medical Nutrition Services” for TPN benefits, limitations, and authorization requirements.
Hospice and home health services may not be reimbursed on the same date of service, with the exception of the initial date of service when the client is being discharged from home health service and admitted to hospice service.
23.2.1Prior Authorization Requirements
Prior authorization is required for hospice services. The TMHP-CSHCN Services Program medical review staff review requests for hospice services. Hospice services may be prior authorized up to a maximum of 6 months per request.
Providers must submit the CSHCN Services Program Prior Authorization Request for Hospice Services Form or the provider’s plan of care (POC) if it includes the same information as the CSHCN Services Program Prior Authorization Request for Hospice Services Form and the provider and physician signatures. All of the fields on the prior authorization form must be completed. A copy of the POC, signed and dated by a physician, must be maintained by the physician and hospice provider in the client’s medical record.
The CSHCN Services Program Prior Authorization Request for Hospice Services Form must include the client’s demographic information, the requested services, and required provider information and signature as follows:
23.2.1.1The client’s demographic information
•First and last name
•CSHCN Services Program number/client identifier
•Date of birth
•Hospice diagnosis codes
•Address
23.2.1.2The requested services
•Start of care and end of care dates
•Type of hospice care to be delivered (i.e., routine home care, continuous home care, inpatient hospice care, or respite care)
•The criteria used to assess appropriateness of hospice for this client
•A specific description of all direct care to be provided, durable medical equipment, supplies, and medications anticipated for the care of the client
23.2.1.3Required provider information and signature
•Provider name
•CSHCN Services Program National Provider Identifier (NPI)
•Taxonomy and benefit codes
•Telephone and fax numbers
•Address
•Dated signature
If the client requires hospice care beyond the initial 6-month period, authorization for additional 6-month periods may be considered with a new request that includes the following documentation:
•An updated CSHCN Services Program Prior Authorization Request for Hospice Services Form or a POC that includes the same information as the CSHCN Services Program Prior Authorization Request for Hospice Services Form.
•A current date with the hospice provider and the attending physician.
•An updated description of all direct care, DME, supplies, and medications anticipated for the client’s care.
Refer to: Section 4.4, “Prior Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about prior authorization requirements.
Claims for hospice services must be billed using the following revenue codes:
Revenue Code | Description |
|---|---|
651 | Hospice services—home care |
652 | Hospice services—continuous home care - ½ (at least 8 but less than 16 hrs care) |
655 | Hospice services—inpatient respite care |
656 | Hospice services—general inpatient care/non-respite |
Hospice services must be submitted to TMHP in an approved electronic format or on the
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 TMHP does not key any information from claim 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.
Hospice services are limited to one of any hospice procedure per day, by any provider. Hospice services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid up to the maximum allowed per diem rate. The per diem rate does not cover care for conditions or illnesses unrelated to the terminal diagnosis.
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.
23.5TMHP-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.