Healthy Texas Women Program
Handbook

 

1 General Information

The information in this handbook is intended for Healthy Texas Women (HTW) program providers. The handbook provides information about Texas Medicaid’s HTW benefits, policies, and procedures that are applicable to these service providers.

Important:All providers are required to read and comply with Section 1: Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid clients, including HTW clients, in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver healthcare items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

Refer to:  The Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about providing services to Texas Medicaid and Texas Health Steps (THSteps) clients.

“Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

“Texas Medicaid Administration” in the Preliminary Information (Vol. 1, General Information).

The Healthy Texas Women website at www.healthytexaswomen.org for information about family planning and the locations of clinics receiving family planning funding from HHSC.

The Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for information about Texas Medicaid fee-for service and Title XIX family planning benefits for gynecological and reproductive health services.

The Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information about services provided in a Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

2 Healthy Texas Women (HTW) Program Overview

The goal of HTW is to expand access to women’s health and family planning services to reduce unintended pregnancies, positively affect the outcome of future pregnancies, and positively impact the health and wellbeing of women and their families in the eligible population.

HTW is established to achieve the following objectives:

Implement the state policy to favor childbirth and family planning services that do not include elective abortions or the promotion of elective abortions.

Ensure the efficient and effective use of state funds in support of these objectives and to avoid the direct or indirect use of state funds to promote or support elective abortions.

Reduce the overall cost of publicly-funded healthcare (including federally-funded healthcare) by providing low-income Texans access to safe, effective services that are consistent with these objectives.

Enforce Human Resources Code §32.024(c-1).

Refer to:  Subsection 1.1, “Family Planning Overview” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for an overview of family planning funding sources.

The HTW page of the TMHP website at www.tmhp.com for more information about provider certification.

Healthy Texas Women Plus (HTW Plus) is a set of additional physical health, mental health, and substance use disorder benefits that are available to HTW clients during the first 12 months of their eligi­bility following a pregnancy. These outpatient services target major health conditions that contribute to maternal mortality and severe morbidity in the extended postpartum period and provide continuity of care for chronic conditions treated during the pregnancy period.

Health-care providers who want to provide HTW Plus services must be enrolled as Texas Medicaid providers and have completed the HTW provider certification process. There are no additional require­ments for HTW providers to provide HTW Plus benefits within their scope of education and training, because HTW Plus is not a separate program from HTW.

2.1Guidelines for HTW Providers

HTW provides family planning services, related preventive health services that are beneficial to repro­ductive health, and other preventive health services that positively affect maternal health and future pregnancies for women who:

Are 15 through 44 years of age.

Note:Women who are 15 through 17 years of age must have a parent or legal guardian apply on their behalf.

Are a United States citizen or eligible immigrant.

Are a resident of Texas.

Do not currently receive benefits through another Medicaid program (including Medicaid for Pregnant Women), Children’s Health Insurance Program (CHIP), or Medicare Part A or B.

Have a household income at or below 204.2 percent of the federal poverty level.

Are not pregnant.

Do not have other insurance that covers the services that HTW provides.

Exception:A client who has other private health insurance may be eligible to receive HTW services if a spouse, parent, or other person would cause physical, emotional, or other harm to the client because the client filed a claim on the health insurance.

HTW medical services are provided by a physician or by another qualified health-care professional operating under physician direction. A physician provides direction for family planning services through written standing delegation orders and medical protocols. The physician is not required to be on the premises for the provision of family planning services by an RN, PA, NP, or CNS. HTW partici­pants may receive services from any provider that participates in HTW.

HTW clients must be allowed freedom of choice in the selection of contraceptive methods as medically appropriate. They must also be allowed the freedom to accept or reject services without coercion. All HTW-covered methods of contraception must be made available to the client, either directly or by referral to another provider of contraceptive services. Services must be provided without regard to age, marital status, race, ethnicity, parenthood, disability, religion, national origin, or contraceptive preference.

Client eligibility can be verified by:

Using TexMedConnect.

Accessing the Medicaid Client Portal for Providers.

Checking an electronic or printed copy of Your Texas Benefits Healthy Texas Women card.

Calling the Automated Inquiry System at 1-800-925-9126.

Refer to:  Subsection 4.4.3, “Client Eligibility Verification” in “Section 4: Client Eligibility” (Vol. 1, General Information).

HTW clients will have the following identifiers on the feedback received from the stated source:

Medicaid Coverage: W - MA - HTW

Program Type:

68 - MEDICAL ASSISTANCE - HEALTHY TEXAS WOMEN (HTW)

69 - MEDICAL ASSISTANCE - HEALTHY TEXAS WOMEN PLUS (HTW PLUS)

Program: 100 - MEDICAID

Benefit Plan: 100 - Traditional Medicaid

HTW clients will receive 12 months of continuous eligibility unless:

The client dies.

The client voluntarily withdraws from HTW.

The client no longer satisfies the HTW eligibility criteria.

The client is certified for another Medicaid program, such as Medicaid for Pregnant Women, or CHIP.

State law no longer allows the woman to be covered.

HHSC or its designee determines the client provided information affecting her eligibility that was false at the time of application.

If a provider suspects that a HTW client has committed fraud on the application, the provider should report the client to the HHSC Office of Inspector General (OIG) at 1-800-436-6184.

2.1.1Referrals

If a provider identifies a health problem that is not within their scope of practice, the provider must refer the HTW client to another provider or clinic that can treat her. As mandated by Texas Human Resources Code §32.024(c-1), HTW does not reimburse office visits during which clients are referred for elective abortions.

HHSC prefers that clients be referred to local indigent care services. However, the toll-free Information and Referral hotline 2-1-1, can assist clients and providers with locating low-cost health services for clients in need.

2.1.2Referrals for Clients Diagnosed with Breast or Cervical Cancer

Medicaid for Breast and Cervical Cancer (MBCC) provides access to cancer treatment through full Medicaid benefits for qualified women diagnosed with breast or cervical cancer. Health facilities that contract with the Breast and Cervical Cancer Screening (BCCS) program are responsible for helping women with the MBCC application.

To find a BCCS provider, call 2-1-1. For questions about the BCCS program, contact the state office at 512-458-7796, or visit www.healthytexaswomen.org/bccs-program.

2.1.3Abortions

Elective and non-elective abortions are not covered by HTW.

Texas Human Resources Code Section 32.024(c-1) and Title 1 Texas Administrative Code, §382.17 prohibit the participation of a provider that performs or promotes elective abortions or affiliates with an entity that performs or promotes elective abortions.

A provider that performs elective abortions (through either surgical or medical methods) or that is affil­iated with an entity that performs or promotes elective abortions for any patient is ineligible to serve HTW clients and cannot be reimbursed for any services rendered to a HTW client. This prohibition only applies to providers delivering services to HTW clients.

“Elective abortion” means the intentional termination of a pregnancy by an attending physician who knows that the female is pregnant, using any means that is reasonably likely to cause the death of the fetus. The term does not include the use of any such means: (A) to terminate a pregnancy that resulted from an act of rape or incest; (B) in a case in which a woman suffers from a physical disorder, physical disability, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy, that would, as certified by a physician, place the woman in danger of death or risk of substantial impairment of a major bodily function unless an abortion is performed; or (C) in a case in which a fetus has a life-threatening physical condition that, in reasonable medical judgment, regardless of the provision of life-saving treatment, is incompatible with life outside the womb.

Certain providers that want to participate in HTW must certify that they do not perform or promote elective abortions and do not affiliate with any entity that does, as directed by HHSC.

Refer to:  Subsection 2.2, “HTW Provider Enrollment” in this handbook for more information about certification regarding elective abortions.

2.2HTW Provider Enrollment

Providers who have completed the Medicaid enrollment process through TMHP, and have certified that they do not perform elective abortions or affiliate with providers that perform elective abortion are eligible to participate. Teaching hospital, independent laboratory, and radiology facility providers are not required to certify.

Refer to:  “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures.

Certain providers that want to participate in HTW must certify that they do not perform or promote elective abortions and do not affiliate with any entity that does, as directed by HHSC. Providers may complete the Healthy Texas Women Certification and disclose the required information as part of the Medicaid enrollment process, or at any time after completing the Medicaid enrollment process. New providers may use the TMHP website to submit the Healthy Texas Women Certification through the Provider Enrollment Portal (PEP). Medicaid-only providers may use the TMHP website to submit the Healthy Texas Women Certification through the Provider Information Management System (PIMS).

The following provider types are not required to certify:

Teaching hospitals

Independent laboratories

Radiology facilities

Information that providers submit through PIMS can be searched by clients who use the Find a Doctor feature on the HTW website at www.healthytexaswomen.org.

2.3Services, Benefits, Limitations, and Prior Authorization

This section includes information on women’s health and family planning services funded through HTW. HTW benefits include:

Contraceptive services

Pregnancy testing and counseling

Preconception health screenings (e.g., screening for obesity, hypertension, diabetes, cholesterol, smoking, and mental health)

Sexually transmitted infection (STI) services

Treatment for the following chronic conditions:

Hypertension

Diabetes

High cholesterol

Breast and cervical cancer screening and diagnostic services:

Radiological procedures including mammograms

Screening and diagnosis of breast cancer

Diagnosis and treatment of cervical dysplasia

Immunizations

Treatment of postpartum depression

Refer to:  Subsection 2.3.10, “HTW Plus Services, Benefits, and Limitations” in this handbook for HTW Plus benefit information.

The following procedure codes are benefits for HTW:

Procedure Codes

Contraceptive and STI Services

00851

11976

11981

11982

11983

57170

58300

58301

58340

58562

58600

58611

58615

58670

58671

73060

74740

76830

76856

76857

76881

76882

80061^

81000

81001

81002*

81003^

81005

81015

81025*

81513

81514

82947^

82948

84443^

84702

84703^

85013*

85014^

85018^

85025^

85027

86318^

86580

86592

86689

86695

86696

86701^

86702

86703

86762

86803^

86900

86901

87070

87086

87088

87102

87110

87205

87210^

87220

87252

87389^

87480

87490

87491

87510

87535

87563

87590

87591

87624

87625

87660

87797

87800

87801^

87810

87850

88150

88164

88175

90460

90471

90651

96372

G0433

Behavioral Health Services

90791

90792

96156

96158

96159

96167

96168

97802

97803

97804

99000

99078

99406

99407

Supplies and Services

A4261

A4266

A4267

A4268

A4269

A9150

H1010

J0696

J0699

J1050

J3490

J7294

J7295

J7296

J7297

J7298

J7300

J7301

J7304

J7307

S4993

Evaluation and Management

99202

99203

99204

99205

99211

99212

99213

99214

99215

99241

99242

99243

99244

99384

99385

99386

99394

99395

99396

99417

99473

99474

G0466

G0467

G0468

G0469

G0470

T1015

Breast Cancer Screening

00400

19000

19081

19082

19083

19084

19100

19101

19120

19125

19126

19281

19282

19283

19284

19285

19286

71045

71046

74018

74019

76098

76641

76642

76942

77046

77047

77048

77049

77053

77063

77065

77066

77067

80048^

80053^

85730

88305

88307

93000

G0279

Cervical Cancer Screening

00940

57452

57454

57455

57456

57460

57461

57500

57505

57520

57522

58110

71045

71046

74018

74019

80048^

80053^

85730

88141

88142

88143

88173

88174

88305

88307

93000

Problem-Focused Gynecological Services

56405

56420

56501

56515

56605

56606

56820

57023

57061

57100

57421

57511

58100

Immunizations and Vaccinations

90460

90471

90472

90632

90633

90636

90654

90656

90660

90670

90673

90686

90688

90707

90710

90714

90715

90716

90732

90733

90734

90736

90743

90744

90746

Other Preventative Services

76700

76705

76770

80050

80051^

80053^

80069^

80074

80076

82270*

82681

82465^

82950^

82951^

83020

83021

83036^

84450^

84460^

84478^

84479

85007

85610^

85660

85730

86631

86677

86704

86706

86780^

86885

87270

87512

87529

87530

87661

88155

88160

88161

88165

88167

88172

94760

J0558

J0561

J0690

J2010

* CLIA waived test

^ QW Modifier

Procedure code G0433 will deny if billed on the same day by the same provider as procedure code 86703.

Procedure codes 96156, 96158, 96159, 96167, and 96168 are a benefit for clients who are 20 years of age and younger.

Procedure code 99473 is limited to one service per year, by any provider. Procedure code 99473 may be considered for reimbursement more than once per year when documentation of medical necessity is submitted with the claim.

Procedure code 99474 is limited to four services per year, by any provider, and it may be reimbursed only if a claim for procedure code 99473 has been submitted within the past 12 rolling months.

Self-measured blood pressure monitoring is a benefit when it is used as a diagnostic tool to help a physician diagnose hypertension in individuals whose blood pressure is either elevated or inconclusive when it is evaluated in the office alone.

Refer to:  Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

2.3.1Family Planning History Check

HTW clients must receive family planning services annually, but no later than the third visit as an estab­lished client. These services must include family planning counseling and education, including natural family planning and abstinence. In order to receive reimbursement, all existing HTW clients must have received family planning services and/or counseling within the past rolling year.

The following HTW clients do not require a family planning history check:

New clients

Women who are sterilized

Women who have a long-acting reversible contraception (LARC)

2.3.2Family Planning Annual Exams

Family planning providers must bill one of the following E/M visit procedure code based on the complexity of the annual family planning examination provided:

Procedure Codes

99202

99203

99204

99205

99211

99212

99213

99214

99215

99241

99242

99243

99244

99384

99385

99386

99394

99395

99396

G0466

G0467

G0468

G0469

G0470

T1015

The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for the annual examination:

Billing Criteria

Frequency

New patient: Most appropriate E/M procedure code

One new patient E/M code every 3 years following the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group

Refer to:  The Family Planning section of the HHSC website for information about the HHSC Family Planning Program.

2.3.2.1FQHC Reimbursement for Family Planning Annual Exams

To receive their encounter rate for the annual family planning examination for HTW clients, FQHCs must use the most appropriate E/M procedure code for the complexity of service provided as indicated in the previous tables in Subsection 2.3.2, “Family Planning Annual Exams” in this handbook.

A new patient visit for the annual exam may be reimbursed once every three years following the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group. The annual examination must be billed as an established patient visit if E/M services have been provided to the client within the last three years.

Reimbursement for services payable to an FQHC is based on an all-inclusive rate per visit.

2.3.3Other Family Planning Office or Outpatient Visits

HTW does not cover office visits during which clients are referred for elective abortions.

A provider is allowed to bill clients for services that are not a benefit of HTW.

Refer to:  Subsection 1.7.11.1, “Client Acknowledgment Statement” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for the requirements for billing clients.

2.3.3.1FQHC Reimbursement for Other Family Planning Office or Outpatient Visits

FQHCs may be reimbursed for three family planning encounters per HTW client, per year. Procedure codes J7296, J7297, J7298, J7300, J7301, and J7307 may be reimbursed in addition to the FQHC encounter payment. When seeking reimbursement for an IUD or implantable contraceptive implant, providers must submit on the same claim the procedure code for the contraceptive device along with the procedure code for the encounter. The contraceptive device is not subject to FQHC limitations. Providers must use modifier U8 when submitting claims for a contraceptive device purchased through the 340B Drug Pricing Program.

Outpatient visits for non-family planning-related encounters that are provided by FQHCs for HTW or HTW Plus covered physical and behavioral health services may be reimbursed when medically necessary.

Reimbursement for services payable to an FQHC is based on an all-inclusive rate per visit.

Refer to:  Section 4, “Federally Qualified Health Center (FQHC)” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for more information about FQHC services.

2.3.4Laboratory Procedures

The fee for the handling or conveyance of the specimen for transfer from the provider’s office to a laboratory may be reimbursed using procedure code 99000.

More than one lab handling fee may be reimbursed per day if multiple specimens are obtained and sent to different laboratories.

Note:When a provider who renders HTW laboratory services obtains a specimen but does not perform the laboratory procedure, the provider who obtains the specimen may be reimbursed one lab handling fee per day, per client.

Handling fees are not paid for Pap smears or cultures. When billing for Pap smear interpretations, the claim must indicate that the screening and interpretation were actually performed in the office by using the modifier SU (procedure performed in physician’s office).

If more than one of procedure codes 87480, 87510, 87660, 87661, or 87800 is submitted by the same provider for the same client with the same date of service, all of the procedure codes are denied. Only one procedure code (87480, 87510, 87660, 87661, or 87800) may be submitted for reimbursement, and providers must submit the most appropriate procedure code for the test provided.

Note:Providers must code to the highest level of specificity with a diagnosis to support medical necessity when submitting procedure code 87797.

Refer to:  Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

Appropriate documentation must be kept in the client’s record.

Claims may be subject to retrospective review if they are submitted with diagnosis codes that do not support medical necessity.

HTW follows the Medicare categorization of tests for CLIA certificate holders.

Refer to:  The CMS website at www.cms.gov/CLIA/10_Categorization_of_Tests.asp for information about procedure code and modifier QW requirements.

For waived tests, providers must use modifier QW as indicated on the CMS website.

2.3.5Contraceptive Devices

Providers must use modifier U8 when submitting claims for a contraceptive device purchased through the 340B Drug Pricing Program.

An E/M procedure code will not be reimbursed when it is billed with the same date of service as procedure code 58301, unless the E/M visit is a significant, separately identifiable service from the removal of the IUD. If the E/M visit occurs on the same date of service as the removal of the IUD, modifier 25 may be used to indicate that the E/M visit was a significant, separately identifiable service from the procedure.

Note:HTW does not reimburse for counseling for, or provision of, emergency contraception.

2.3.6Drugs and Supplies

2.3.6.1Prescriptions and Dispensing Medication

Drugs and supplies that are dispensed directly to the client must be billed to HTW. Only providers with an appropriate pharmacy license may be reimbursed for dispensing family planning drugs and supplies. Provider types with an appropriate pharmacy license may be reimbursed for dispensing up to a one-year supply of contraceptives in a 12-month period using procedure code J7294, J7295, J7304, or S4993.

Pharmacies under the Vendor Drug Program are allowed to fill all prescriptions as prescribed. Family planning drugs and supplies are exempt from the three prescriptions-per-month rule for up to a six- month supply.

Refer to:  Subsection 1.1, “About the Vendor Drug Program” in the Outpatient Drug Services Handbook (Vol. 2, Provider Handbooks) for information about this program.

2.3.6.1.1Long-Acting Reversible Contraception Products

Certain LARC products are available as a pharmacy benefit of HTW and are available through a limited number of specialty pharmacies that work with LARC manufacturers. Providers can refer to the Texas Medicaid/CHIP Vendor Drug Program website at www.txvendordrug.com/about/manuals/pharmacy-provider-procedure-manual/8-drug-policy/8-7-drug-specific-requirements/8-30 for additional infor­mation, including a list of covered products and participating specialty pharmacies.

2.3.7Sterilization and Sterilization-Related Procedures

Sterilizations are considered to be permanent, once per lifetime procedures. Denied claims may be appealed with documentation that supports the medical necessity for a repeat sterilization.

The sterilization services that are available to HTW clients include surgical or nonsurgical sterilization, follow-up office visits related to confirming the sterilization, and any necessary short-term contraception.

HTW covers sterilization as a form of birth control. To be eligible for a sterilization procedure through HTW, the client must be 21 years of age or older and must complete and sign a Sterilization Consent Form within at least 30 days of the date of the surgery but no more than 180 days. In the case of an emergency, there must be at least 72 hours between the date on which the consent form is signed and the date of the surgery. Operative reports that detail the need for emergency surgery are required.

2.3.7.1Sterilization Consent

Per federal regulation 42 Code of Federal Regulations (CFR) 50, Subpart B, all sterilization procedures require an approved Sterilization Consent Form.

Note:The Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information form is not sterilization consent.

Refer to:  Sterilization Consent Form (English) on the TMHP website at www.tmhp.com.

Sterilization Consent Form (Spanish) on the TMHP website at www.tmhp.com.

Sterilization Consent Form Instructions on the TMHP website at www.tmhp.com.

2.3.8Treatment for Sexually Transmitted Infections (STIs)

HTW covers treatment for the following conditions:

Gardnerella

Trichomoniasis

Candida

Chlamydia

Gonorrhea

Herpes

Syphilis

2.3.9Immunizations and Vaccinations

HTW covers the following immunizations and vaccinations:

HPV

Hep A

Hep B

Chicken pox

MMR

Tdap

Flu

2.3.10HTW Plus Services, Benefits, and Limitations

HTW Plus provides enhanced postpartum services to HTW clients for the following targeted health conditions and services:

Behavioral health conditions

Individual, family, and group psychotherapy services

Peer specialist services

Cardiovascular and coronary conditions

Cardiovascular evaluation imaging and laboratory studies

Blood pressure monitoring equipment

Anticoagulant, antiplatelet, and antihypertensive medications

Substance use disorders

Screening, brief intervention, and referral for treatment

Outpatient substance use counseling

Smoking cessation services

Medication-assisted treatment

Peer specialist services

Diabetes

Laboratory studies

Additional injectable insulin options

Blood glucose testing supplies

Voice-integrated glucometers for women with diabetes who are visually impaired

Glucose monitoring supplies

Asthma

Medications and supplies

The following procedure codes are benefits of HTW Plus:

Procedure Codes

Behavioral Health Services

90832

90833

90834

90836

90837

90838

90847

90853

90870

96130

96131

96136

96137

99354

99355

H0038

Cardiovascular and Coronary Services

37187

37211

37212

70498

70547

70548

71275

73706

74174

74175

75571

75574

75635

75716

75736

93005

93010

93015

93016

93017

93018

93041

93042

93224

93225

93226

93227

93241

93242

93243

93244

93245

93246

93247

93248

93306

93307

93308

93312

93319

93320

93321

93325

93350

93351

93660

93893

93923

93970

93971

94619

A4663

A4670

Substance Use Disorder Services

99408

H0001

H0004

H0005

H0020

H0038

H0049

J2310

J2315

Q9991

Q9992

Diabetes Services

83037

A4253

A4258

A4259

E2100

J1610

S5550

S5552

Asthma Services

94150

94617

A4614

A4627

E0570

J1720

J3301

J7611

J7613

J7614

J7620

J7626

J7644

S8101

Laboratory Services

81240

81241

81291

82530

82533

82550

82553

82945

82946

82955

82960

82985

83050

83525

83527

83605

83615

83625

84144

84146

84206

85004

85041

85044

85045

85048

85049

85130

85210

85220

85250

85302

85303

85305

85306

85362

85370

85378

85379

85380

85384

85385

85390

85396

85520

85525

86147

86337

86340

86341

86905

86906

Additional Breast and Gynecological Services

19020

HTW Plus benefits are subject to the same restrictions and limitations that are applied to Texas Medicaid’s coverage for the same procedure codes.

Refer to:  The relevant handbooks for detailed coverage information of HTW Plus benefits.

2.3.11Prior Authorization

Prior authorization is not required for HTW services.

2.4Documentation Requirements

All services require documentation to support the medical necessity of the service rendered.

HTW services are subject to retrospective review and recoupment if documentation does not support the service billed.

2.5HTW Claims Filing and Reimbursement

2.5.1Claims Information

Providers must use the appropriate claim form to submit HTW claims to TMHP.

Refer to:  Subsection 2.4, “Claims Filing and Reimbursement” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for more infor­mation about filing family planning claims.

2.5.1.1HTW and Third Party Liability

Federal and state regulations mandate that family planning client information be kept confidential.

Because seeking information from third party insurance may jeopardize the client’s confidentiality, third party billing for HTW is not allowed.

2.5.2Reimbursement

Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

2.5.3National Drug Code

Refer to:  Subsection 6.3.4, “National Drug Code (NDC)” in “Section 6: Claims Filing” (Vol. 1, General Information).

2.5.4NCCI and MUE Guidelines

The Health Care Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manual. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

3 Claims Resources

Resource

Location

Acronym Dictionary

“Appendix C: Acronym Dictionary” (Vol. 1, General Information)

Automated Inquiry System (AIS)

Subsection A.10, “TMHP Telephone and Fax Communication” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

2017 Claim Form Instructions

Subsection 6.8, “Family Planning Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information)

4 Contact TMHP

The TMHP Contact Center at 1-800-925-9126 is available Monday-Friday from 7 a.m. to 7 p.m., Central Time.

5 Forms

The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at www.tmhp.com:

Forms

Sterilization Consent Form Instructions

Sterilization Consent Form (English)

Sterilization Consent Form (Spanish) 

2017 Claim Form

Healthy Texas Women Certification