«Volumes 1 & 2 The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health ...»
Volumes 1 & 2
The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid
under contract with the Texas Health and Human Services Commission.
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 DECEMBER 2015
PRELIMINARY INFORMATIONTable of Contents Welcome: Texas Medicaid Provider Procedures Manual....................................... iii Copyright Acknowledgments........................................................... iv Contents.................................................................................. iv Volume 1 - General Information......................................................... iv Volume 2 - Provider Handbooks.......................................................... v Introduction................................................................................ v Medicaid Program Administration....................................................... v II
CPT ONLY - COPYRIGHT 2014 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
PRELIMINARY INFORMATION DECEMBER 2015Welcome: Texas Medicaid Provider Procedures Manual This manual is a comprehensive guide for Texas Medicaid providers. It contains information about Texas Medicaid fee-for-service benefits, policies, and procedures including medical, dental, and children’s services benefits.
Refer to: The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for information about the Medicaid Managed Care, which is administered by Texas Health and Human Services Commission (HHSC)-contracted managed care organizations (MCOs), dental managed care organizations, and behavioral health organizations (BHOs) across the state.
The Texas Medicaid Provider Procedures Manual is updated monthly on the TMHP website at www.tmhp.com to include revisions to policies and procedures that went into effect in the prior month.
The manual is available in portable document format (PDF) as a complete book and as individual sections and handbooks. A hypertext markup language (HTML) version is also be available.
The current version of the manual always appears prominently on the Texas Medicaid Provider Procedures Manual web page. All previously published annual editions of the Texas Medicaid Provider Procedures Manual have been archived. Users can access the archives through links on the Texas Medicaid Provider Procedures Manual web page.
Providers can determine what has changed each month by following the Release Notes link on the Texas Medicaid Provider Procedures Manual web page. The release notes include the sections and handbooks that have changed for the current month and the nature of the changes. Most changes have been previously announced in news articles on the TMHP website, and, where appropriate, the release notes link to prior website articles.
Publishing the manual monthly has eliminated the need for the Texas Medicaid Bulletin, which was discontinued following the publication of the September/October 2012 Texas Medicaid Bulletin, No.
243. Special bulletins, such as the annual Healthcare Common Procedure Coding System (HCPCS) bulletin, which is published in January of each year, will continue to be published on an as-needed basis.
The Texas Medicaid Provider Procedures Manual is divided into two volumes as follows:
• Volume I: General Information Volume 1 applies to all health-care providers who are enrolled in Texas Medicaid and provide services to Texas Medicaid fee-for-service clients. The sections in Volume 1 include general information for enrolling in the program, receiving appropriate reimbursement, prior authorizations, claim submissions and appeals for services rendered.
• Volume 2: Provider Handbooks Each handbook in Volume 2 covers Medicaid policies, procedures, and claims filing requirements
for specific products or services. Volume 2 includes the following handbooks:
• Ambulance Services Handbook
• Behavioral Health, Rehabilitation, and Case Management Services Handbook
• Children’s Services Handbook
• Clinics and Other Outpatient Facility Services Handbook
• Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook
• Expanded Primary Healthcare Program Handbook
• Gynecological and Reproductive Health and Family Planning Services Handbook
• Inpatient and Outpatient Hospital Services Handbook
• Medicaid Managed Care Handbook
Use of the AMA’s copyrighted CPT® is allowed in this publication with the following disclosure:
“Current Procedural Terminology (CPT) is copyright © 2014 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply.” The American Dental Association requires the following copyright notice in all publications containing
Current Dental Terminology (CDT) codes:
“Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2013 American Dental Association.
All rights reserved. Applicable FARS/DFARS apply.” Microsoft Corporation requires the following notice in publications containing trademarked product
“Microsoft® and Windows® are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries.”
Volume 2 - Provider Handbooks Ambulance Services Handbook Behavioral Health, Rehabilitation, and Case Management Services Handbook Children’s Services Handbook Clinics and Other Outpatient Facility Services Handbook Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook Gynecological and Reproductive Health and Family Planning Services Handbook Inpatient and Outpatient Hospital Services Handbook Medicaid Managed Care Handbook Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook Medical Transportation Program Handbook Nursing and Therapy Services Handbook Radiology and Laboratory Services Handbook Telecommunication Services Handbook Vision and Hearing Services Handbook
IntroductionMedicaid Program Administration The Texas Medical Assistance (Medicaid) Program was implemented on September 1, 1967, under the provisions of Title XIX of the federal Social Security Act and Chapter 32 of the Texas Human Resources Code.
The state of Texas and the federal government share the cost of funding Texas Medicaid. The Health and Human Services Commission (HHSC), the single state Medicaid agency, is responsible for the Title XIX Program. The administration of the program is accomplished through contracts and agreements with
• Medical providers
• Texas Medicaid & Healthcare Partnership (TMHP), the fee-for-service claims administrator
• MAXIMUS, the enrollment broker
• Various managed care organizations (MCOs) and dental managed care organization (dental plans), that administer Medicaid Managed Care benefits.
• The Institute for Child Health Policy (ICHP), the quality monitor
• State agencies Texas Medicaid providers are reimbursed for services through contracts with health-insuring contractors, fiscal agents, or direct vendor payments.
By signing an HHSC Medicaid Provider Agreement (through the enrollment process) and submitting Medicaid claims, each enrolled provider agrees to abide by the policies and procedures of Medicaid, published regulations, and the information and instructions in manuals, bulletins, and other instructional material furnished to the provider.
Refer to: “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information) for addresses and telephone numbers of HHSC and Department of State Health Services (DSHS) regional offices.
1.1 Provider Enrollment and Reenrollment
To be eligible for Texas Medicaid reimbursement, a provider of medical services (including an out-ofstate provider) must:
• Meet all applicable eligibility criteria.
• Be approved by the Texas Health and Human Services Commission (HHSC) for enrollment.
• Obtain a National Provider Identifier (NPI) from the National Plan and Provider Enumeration System (NPPES).
Refer to: Subsection 1.1.1, “NPI and Taxonomy Codes” in this section.
• File with the Texas Medicaid & Healthcare Partnership (TMHP) the required Texas Medicaid enrollment application ensuring that the application is correct, complete, and includes all required attachments and additional information.
• Provide any additional information requested by TMHP, HHSC, or the HHSC Office of Inspector General (OIG) in connection with the processing of the application.
• Be approved by HHSC for enrollment and enter into a written provider agreement with HHSC.
Providers can use the online provider enrollment on the portal (PEP) tool to enroll electronically through the TMHP website at www.tmhp.com by clicking “Enroll Today!” at the top of most web pages.
Refer to: Subsection 1.1.2, “Online Enrollment” in this section.
Paper versions of the enrollment applications are also available for download from the Forms section of the TMHP website.
Refer to: Subsection 1.1.3, “Paper Application Enrollment” in this section.
After receipt of all information necessary to process the application, the entire application process can typically take up to 60 days. This may be extended in special circumstances. Requests for exceptions to the enrollment process, risk category, and provider types that require additional state approval may extend the length of the application process.
All providers must be enrolled in Texas Medicaid before enrollment can be approved for any other service or program, including, but not limited to, Medicaid managed care.
Certain provider types are required to enroll in Medicare as a prerequisite for enrolling in Texas Medicaid. During the Texas Medicaid enrollment process, with HHSC approval, the Claims Administrator may waive the mandatory prerequisite for Medicare enrollment for certain providers whose type of practice will never serve Medicare-eligible individuals (e.g., pediatrics, obstetrician/gynecologist [OB/GYN]).
Providers must maintain a valid, current license or certification to be entitled to Texas Medicaid reimbursement. Providers cannot enroll in Texas Medicaid if their license or certification is due to expire within 30 days of application. A current license or certification must be submitted, if applicable.
Refer to: Subsection 126.96.36.199, “Copy of License, Temporary License, or Certification” in this section.
A provider identifier is issued when a determination has been made that a provider qualifies for participation.
Refer to: Subsection 1.9, “Enrollment Criteria for Out-of-State Providers” in this handbook for additional criteria that out-of-state providers must meet to enroll in Texas Medicaid.
CPT ONLY - COPYRIGHT 2014 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
SECTION 1: PROVIDER ENROLLMENT AND RESPONSIBILITIES DECEMBER 20151.1.1 NPI and Taxonomy Codes The NPI final rule, Federal Register 45, Code of Federal Regulations (CFR) Part 162, established the NPI as the standard unique identifier for health-care providers and requires covered health-care providers, clearinghouses, and health plans to use this identifier in Health Insurance Portability and Accountability Act (HIPAA)-covered transactions. An NPI is a 10-digit number assigned randomly by the NPPES. An NPI must be obtained before a provider can enroll as a Texas Medicaid provider.
An NPI is not required for enrollment for certain provider types; however, the provider must submit a signed letter on company letterhead that attests that they are not a health-care provider and are unable to obtain an NPI.
The Health Care Provider Taxonomy Code Set is an external, non-medical collection of alphanumeric codes designed to classify health-care providers by provider type and specialty. Providers may have more than one taxonomy code. (Taxonomy codes can be obtained from the Washington Publishing Company website at www.wpc-edi.com).
During the enrollment process, providers must select a primary and, if applicable, secondary taxonomy code associated with their provider type. Providers will be supplied a list of taxonomy codes to choose from that correspond to the services rendered by the type of provider they wish to enroll as. Only the code will be displayed. Due to copyright laws, TMHP is unable to publish the taxonomy description.
Therefore, providers must verify the taxonomy code associated with their provider type and specialty before beginning the online attestation process.
1.1.2 Online Enrollment
The following provider types can use PEP to enroll and reenroll:
• Texas Medicaid providers
• Home and Community Based Services – Adult Mental Health (HCBS-AMH) providers
• Ordering/referring-only providers
• Children with Special Health Care Needs (CSHCN) Services Program providers
• Texas Health Steps (THSteps) dental services provider, including fee-for-service dental providers and managed care
• THSteps medical checkup providers