Medicaid Title 19 Form PDF Details

In the landscape of healthcare services provided through Medicaid, the complexities of accessing and billing for home health services are navigated with the assistance of the Medicaid Title 19 form. This document serves as a comprehensive guide for service providers, ranging from enrolment protocols for home health and Home and Community Support Services Agencies (HCSSA) through the intricate processes of agency certification and Medicaid managed care enrollment. It outlines reimbursement methodologies, emphasizing eligibility criteria, retroactive eligibility, and prior authorization processes essential for service delivery and compensation. Furthermore, it meticulously details the specific services covered, including skilled nursing visits, home health aide services, and physician supervision requirements, alongside a broad spectrum of durable medical equipment (DME), medical supplies, and therapy services. These provisions are sculpted within a framework that advocates for thorough documentation, adherence to medical necessity, and compliance with both state and federal regulations. Health providers must navigate these procedural waters, ensuring they meet the stringent requirements for Medicaid billing, including changes in address or telephone numbers, pending agency certifications, and the often complex terrain of managed care enrollment. The form's depth encompasses service authorization requirements, including specifics on client evaluations, plan of care stipulations, benefits eligibility, and mandatory provider responsibilities. Each segment from enrollment to claims submission and compliance with the Clinical Laboratory Improvement Amendments (CLIA) is structured to support service delivery adhering to approved medical standards while safeguarding the entitlement of Medicaid beneficiaries.

QuestionAnswer
Form NameMedicaid Title 19 Form
Form Length74 pages
Fillable?No
Fillable fields0
Avg. time to fill out18 min 30 sec
Other namestitle 19 dme form texas, title xix form, what is title 19, medicaid title 19 form

Form Preview Example

2 4 Texas M edicaid (Title XIX) Home Health Services

2 4 .1 Enro llme nt

. 2

4 -4

2 4

.1 .1 Change o f Addre s s / Te le pho ne Numbe r

. 2

4 -4

2 4

.1 .2 Pe nding Age nc y Ce rtific atio n

. 2

4 -4

2 4 .2 Me dic aid Manage d Care Enro llme nt

. 2

4 -5

2 4 .3 Re imburs e me nt

. 2

4 -5

2 4

.3 .1 Eligibility

. 2

4 -5

 

2 4

.3 .1 .1 Re tro ac tive Eligibility

. 2

4 -6

 

2 4

.3 .1 .2 Autho rizatio n o f Re tro ac tive Eligibility

. 2

4 -6

2 4

.3 .2 Prio r Autho rizatio n

. 2

4 -6

2 4 .4 Ho me He alth Se rvic e s

. 2

4 -7

2 4

.4 .1 Clie nt Evaluatio n

. 2

4 -7

2 4

.4 .2 Phys ic ian Supe rvis io n— Plan o f Care

. 2

4 -7

 

2 4

.4 .2 .1 Writte n Plan o f Care

. 2

4 -7

2 4 .5 Be ne fits

. 2

4 -8

2 4

.5 .1 Ho me He alth Skille d Nurs ing Se rvic e s

. 2

4 -9

 

2 4

.5 .1 .1 Skille d Nurs ing Vis its

. 2

4 -9

2 4

.5 .2 Ho me He alth Aide Se rvic e s

2 4

-1 1

 

2 4

.5 .2 .1 Ho me He alth Aide Vis its

2 4

-1 1

 

2 4

.5 .2 .2 S upe rvis io n o f Ho me He alth Aide s

2 4

-1 1

2 4

.5 .3 Ho me He alth Skille d Nurs ing and Ho me He alth Aide s Se rvic e s

 

 

 

Pro vide r Re s po ns ibilitie s

2 4

-1 2

2 4

.5 .4 Ho me He alth Skille d Nurs ing and Ho me He alth Aide Se rvic e s

 

 

 

Prio r Autho rizatio n Re quire me nts

2 4

-1 2

 

2 4

.5 .4 .1 Canc e ling an Autho rizatio n

2 4

-1 3

 

2 4

.5 .4 .2 Ho me He alth Skille d Nurs ing Se rvic e s and Ho me He alth

 

 

 

 

AIDE Se rvic e s that will no t be Prio r Autho rize d

2 4

-1 3

2 4

.5 .5 Ho me He alth Skille d Nurs ing and Ho me He alth Aide Se rvic e s

 

 

 

As s e s s me nts and Re as s e s s me nts

2 4

-1 3

2 4

.5 .6 Supplie s Submitte d with a Plan o f Care

2 4

-1 4

2 4

.5 .7 Me dic atio n Adminis tratio n Limitatio ns

2 4

-1 4

2 4

.5 .8 Phys ic al The rapy (PT) Se rvic e s

2 4

-1 4

 

2 4

.5 .8 .1 Phys ic al The rapy Prio r Autho rizatio n Pro c e dure s

2 4

-1 5

 

2 4

.5 .8 .2 Limitatio ns

2 4

-1 5

2 4

.5 .9 Phys ic al The rapy/ Oc c upatio nal The rapy Pro c e dure Co de s

2 4

-1 5

2 4

.5 .1 0 Oc c upatio nal The rapy (OT) Se rvic e s

2 4

-1 6

 

2 4

.5 .1 0 .1 Oc c upatio nal The rapy Prio r Autho rizatio n Pro c e dure s

2 4

-1 6

 

2 4

.5 .1 0 .2 Limitatio ns

2 4

-1 6

2 4

.5 .1 1 Me dic al Supplie s

2 4

-1 6

 

2 4

.5 .1 1 .1 Supply Pro c e dure Co de s

2 4

-1 8

 

2 4

.5 .1 1 .2 Canc e ling an Autho rizatio n

2 4

-1 8

2 4

.5 .1 2 Diabe tic Supplie s / Equipme nt

2 4

-1 8

 

2 4

.5 .1 2 .1 Blo o d Te s ting Supplie s

2 4

-1 9

 

2 4

.5 .1 2 .2 Blo o d Gluc o s e Mo nito rs

2 4

-1 9

 

2 4

.5 .1 2 .3 Ins ulin and Ins ulin Syringe s

2 4

-2 0

S e c t i o n

24

CPT o nly c o pyright 2 0 0 7 Ame ric an Me dic al As s o c iatio n. All rights re s e rve d.

Se c tio n 2 4

 

2 4

.5

.1 2

.4

Ins ulin Pump

2 4 -2 0

2 4

.5 .1 3 Inc o ntine nc e Supplie s and Equipme nt

2 4 -2 1

 

2 4

.5

.1 3

.1

Inc o ntine nc e Supplie s

2 4 -2 1

 

2 4

.5

.1 3

.2

Inc o ntine nc e Equipme nt

2 4 -2 2

 

2 4

.5

.1 3

.3

Inc o ntine nc e Pro c e dure Co de s With Limitatio ns

2 4 -2 3

 

2 4

.5

.1 3

.4

Mo difie rs

2 4 -2 5

2 4

.5 .1 4 Wo und Care Supplie s and/ o r Sys te ms

2 4 -2 5

 

2 4

.5

.1 4

.1

Wo und Care Supplie s

2 4 -2 5

 

2 4

.5

.1 4

.2

Wo und Care Sys te m

2 4 -2 6

 

2 4

.5

.1 4

.3

The rmal Wo und Care Sys te m

2 4 -2 6

 

2 4

.5

.1 4

.4

Se ale d Suc tio n Wo und Care Sys te m

2 4 -2 6

 

2 4

.5

.1 4

.5

Puls atile Je t Irrigatio n Wo und Care Sys te m

2 4 -2 7

 

2 4

.5

.1 4

.6

Wo und Care Sys te m Crite ria

2 4 -2 7

 

2 4

.5

.1 4

.7

Prio r Autho rizatio n

2 4 -2 7

 

2 4

.5

.1 4

.8

Wo und Care Pro c e dure s and Limitatio ns

2 4 -2 8

2 4

.5 .1 5 Durable Me dic al Equipme nt (DME) and S upplie s

2 4 -2 9

2 4

.5 .1 6 Augme ntative Co mmunic atio n De vic e (ACD) Sys te m

2 4 -3 2

 

2 4

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.1

ACD Sys te ms

2 4 -3 2

 

2 4

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.2

Prio r Autho rizatio n and Re quire d Do c ume ntatio n

2 4 -3 2

 

2 4

.5

.1 6

.3

Pro c e dure Co de s fo r ACD Sys te ms and Ac c e s s o rie s

2 4 -3 3

 

2 4

.5

.1 6

.4

ACD Sys te m Ac c e s s o rie s

2 4 -3 4

 

2 4

.5

.1 6

.5

No nc o ve re d ACD Sys te m Ite ms

2 4 -3 4

 

2 4

.5

.1 6

.6

Prio r Autho rizatio n

2 4 -3 4

 

2 4

.5

.1 6

.7

Trial Pe rio d/ Re ntal/ Purc has e

2 4 -3 5

 

2 4

.5

.1 6

.8

DME Ce rtific atio n

2 4 -3 5

 

2 4

.5

.1 6

.9

Re imburs e me nt

2 4 -3 5

 

2 4

.5

.1 6

.1 0 No nwarranty Re pairs

2 4 -3 5

 

2 4

.5

.1 6

.1 1 Re plac e me nt

2 4 -3 5

 

2 4

.5

.1 6

.1 2 ACD Pro c e dure Co de s and Limitatio ns

2 4 -3 6

2 4

.5 .1 7 Bath and Bathro o m Equipme nt

2 4 -3 6

2 4

.5 .1 8 Blo o d Pre s s ure De vic e s

2 4 -3 9

2 4

.5 .1 9 Bre as t Pumps

2 4 -3 9

2 4

.5 .2 0 Co ntinuo us Pas s ive Mo tio n (CPM) De vic e

2 4 -3 9

2 4

.5 .2 1 Intrave no us (IV) The rapy Equipme nt and Supplie s

2 4 -3 9

2 4

.5 .2 2 Pho to the rapy De vic e s

2 4 -4 2

2 4

.5 .2 3 Ho s pital Be ds and Equipme nt

2 4 -4 3

 

2 4

.5

.2 3

.1

Crite ria fo r Gro uping Le ve ls

2 4 -4 4

 

2 4

.5

.2 3

.2

De c ubitus Care Ac c e s s o rie s

2 4 -4 7

 

2 4

.5

.2 3

.3

Ho s pital Be ds and Equipme nt Pro c e dure Co de Table

2 4 -4 7

2 4

.5 .2 4 Re flux Slings and We dge s

2 4 -4 8

2 4

.5 .2 5 Spe c ial Ne e ds Car Se ats and Trave l Re s traints

2 4 -4 8

2 4

.5 .2 6 Mo bility Aids

2 4 -4 8

 

2 4

.5

.2 6

.1

Cane s , Crutc he s , and Walke rs

2 4 -4 8

 

2 4

.5

.2 6

.2

Fe e de r Se ats , Flo o r Sitte rs , Co rne r Chairs , and Trave l Chairs

2 4 -4 8

 

2 4

.5

.2 6

.3

Whe e lc hairs

2 4 -4 8

 

2 4

.5

.2 6

.4

Se ating As s e s s me nt fo r Manual and Po we r Cus to m Whe e lc hairs . . . .

2 4 -4 9

 

2 4

.5

.2 6

.5

Manual Whe e lc hairs — Cus to m

2 4 -4 9

 

2 4

.5

.2 6

.6

Le ve ls fo r Cus to m Manual and Po we re d Whe e lc hairs

2 4 -4 9

 

2 4

.5

.2 6

.7

Po we r Whe e lc hairs — Standard

2 4 -4 9

 

2 4

.5

.2 6

.8

Po we r Whe e lc hairs — Cus to m

2 4 -5 0

 

2 4 .5 .2 6 .9 Sc o o te rs

2 4 -5 0

 

2 4

.5 .2 6

.1 0 Clie nt Lift

2 4 -5 0

2 4 –2

CPT o nly c o pyright 2 0 0 7 Ame ric an Me dic al As s o c iatio n. All rights re s e rve d.

Te xas Me dic aid (Title XIX) Ho me He alth S e rvic e s

2 4

.

5

.2 6

.1 1

Hydraulic Lift

2 4 -5 1

2 4

.

5

.2 6

.1 2

Ele c tric Lift

2 4 -5 1

2 4

.

5

.2 6

.1 3

Stande rs

2 4 -5 1

2 4

.

5

.2 6

.1 4

Gait Traine rs

2 4 -5 1

2 4

.

5

.2 6

.1 5

Batte rie s and Batte ry Charge r

2 4 -5 1

2 4

.5 .2 6

.1 6

Ac c e s s o rie s

2 4 -5 1

2 4

.5 .2 6

.1 7

Mo dific atio ns

2 4 -5 1

2 4

.5 .2 6

.1 8

Adjus tme nts

2 4 -5 2

2 4

.5 .2 6

.1 9

Re pairs

2 4 -5 2

2 4

.

5

.2 6

.2 0

Re plac e me nt

2 4 -5 2

2 4

.5 .2 6

.2 1

Whe e lc hair Ramp— Po rtable and Thre s ho ld

2 4 -5 2

2 4

.5 .2 6

.2 2

Pro c e dure Co de s and Limitatio ns fo r Mo bility Aids

2 4 -5 2

2 4 .5 .2 7 Re s pirato ry Equipme nt and Supplie s

2 4 -5 7

2 4

.5 .2 7

.1 Ne bulize rs

2 4 -5 8

2 4

.5 .2 7

.2 Vapo rize rs

2 4 -5 8

2 4

.5 .2 7

.3 Humidific atio n Units

2 4 -5 8

2 4

.5 .2 7

.4 Se c re tio n Cle aranc e De vic e s

2 4 -5 8

2 4

.5 .2 7

.5 Ele c tric al Pe rc us s o r

2 4 -5 9

2 4

.5 .2 7

.6 Che s t Phys io the rapy De vic e s

2 4 -5 9

2 4

.5 .2 7

.7 Po s itive Airway Pre s s ure Sys te m De vic e s

2 4 -6 1

2 4

.5 .2 7

.8 Co ntinuo us Po s itive Airway Pre s s ure (CPAP) Sys te m

2 4 -6 1

2 4

.5 .2 7

.9 Pe diatric CPAP Change s

2 4 -6 1

2 4

.5 .2 7

.1 0

CPAP Prio r Autho rizatio n Re ne wal

2 4 -6 1

2 4

.5 .2 7

.1 1

Bi-le ve l Po s itive Airway Pre s s ure S ys te m (BiPAP S ) Witho ut Bac kup .

2 4 -6 2

2 4

.5 .2 7

.1 2

Bi-le ve l Po s itive Airway Pre s s ure Sys te m With Bac kup (BiPAP ST) . .

2 4 -6 2

2 4

.5 .2 7

.1 3

Vo lume Ve ntilato rs

2 4 -6 3

2 4

.5 .2 7

.1 4

Ne gative Pre s s ure Ve ntilato rs

2 4 -6 3

2 4

.5 .2 7

.1 5

Ve ntilato r Se rvic e Agre e me nt

2 4 -6 3

2 4

.5 .2 7

.1 6

Oxyge n The rapy

2 4 -6 4

2 4

.5 .2 7

.1 7

Initial Oxyge n The rapy Me dic al Ne c e s s ity Ce rtific atio n

2 4 -6 4

2 4

.5 .2 7

.1 8

Oxyge n The rapy Re c e rtific atio n

2 4 -6 5

2 4

.5 .2 7

.1 9

Oxyge n The rapy Ho me De live ry S ys te m Type s

2 4 -6 5

2 4

.5 .2 7

.2 0

Trac he o s to my Tube s

2 4 -6 5

2 4

.5 .2 7

.2 1

Puls e Oxime try

2 4 -6 5

2 4

.5 .2 7

.2 2

Pro c e dure Co de s and Limitatio ns fo r Re s pirato ry

 

 

 

 

 

Equipme nt and Supplie s

2 4 -6 5

2 4 .5 .2 8 Pro c e dure Co de s That Do No t Re quire Prio r Autho rizatio n

2 4 -6 7

2 4 .5 .2 9 Nutritio nal (Ente ral) Pro duc ts , Supplie s , and Equipme nt

2 4 -6 7

2 4

.5 .2 9

.1 Nutritio nal Pro duc ts and Supplie s

2 4 -6 7

2 4

.5 .2 9

.2 Ente ral Nutritio nal Pro duc ts

2 4 -6 8

2 4

.5 .2 9

.3 Ente ral Fe e ding Pumps

2 4 -6 9

2 4 .5 .3 0 Limitatio ns , Exc lus io ns

2 4 -6 9

2 4 .6 Me dic aid Re latio ns hip to Me dic are

2 4 -7 0

2 4 .6 .1 Po s s ible Me dic are Clie nts

2 4 -7 0

2 4 .6 .2 Be ne fits fo r Me dic are / Me dic aid Clie nts

2 4 -7 1

2 4 .6 .3 Me dic are / Me dic aid Autho rizatio n

2 4 -7 1

2 4 .6 .4 Me dic are / Me dic aid Autho rizatio n and Re imburs e me nt

2 4 -7 1

2 4 .7 Pro hibitio n o f Me dic aid Payme nt to Ho me He alth Age nc ie s Bas e d o n Owne rs hip . . .

2 4 -7 2

2 4 .8 Claims Info rmatio n

2 4 -7 2

2 4 .9 Claim Filing Re s o urc e s

2 4 -7 3

2 4

CPT o nly c o pyright 2 0 0 7 Ame ric an Me dic al As s o c iatio n. All rights re s e rve d.

2 4 –3

Se c tio n 2 4

2 4 .1 Enrollment

To e nro ll in the Ho me He alth Se rvic e s Pro gram, ho me he alth s e rvic e s and Ho me and Co mmunity Suppo rt Se rvic e s (HCS SA) pro vide rs mus t c o mple te the Te xas

Me dic aid Pro vide r Enro llme nt Applic atio n. Me dic are c e rti- fic atio n is re quire d fo r pro vide rs that are lic e ns e d as a Lic e ns e d and Ce rtifie d Ho me He alth Age nc y. Pro vide rs that are lic e ns e d as a Lic e ns e d Ho me He alth Age nc y are no t re quire d to e nro ll in Me dic are as a pre re quis ite to

e nro llme nt with the Te xas Me dic aid Pro gram.

Lic e ns e d and c e rtifie d ho me he alth age nc ie s that are

e nro lle d as Me dic aid pro vide rs c an pro vide pe rs o nal c are s e rvic e s (PCS) us ing the ir e xis ting pro vide r ide ntifie r.

PCS fo r c lie nts yo unge r than 2 1 ye ars o f age will be pro vide d by the Te xas He alth and Human Se rvic e s Co mmis s io n (HHSC) unde r the PCS be ne fit.

Refer to: " Pe rs o nal Care Se rvic e s (THSte ps -CCP Only)" o n page 4 3 -6 5 .

To pro vide Te xas He alth Ste ps (THSte ps )-Co mpre he ns ive Care Pro gram (CCP) s e rvic e s , HCSSA pro vide rs mus t

fo llo w the e nro llme nt pro c e dure s in Se c tio n 4 3 .4 , “ THSte ps -Co mpre he ns ive Care Pro gram (CCP).”

Enro lle d pro vide rs o f durable me dic al e quipme nt (DME) and/ o r e xpe ndable me dic al s upplie s will be is s ue d a DME-Ho me He alth Se rvic e s Pro vide r Ide ntifie r that is

s pe c ific to ho me he alth pro vide rs . All DME pro vide rs mus t be Me dic are -c e rtifie d be fo re applying fo r e nro llme nt in the Te xas Me dic aid Pro gram.

Pro vide rs may o btain the applic atio n by writing to the fo llo wing addre s s :

Te xas Me dic aid & He althc are Partne rs hip

Pro vide r Enro llme nt PO Bo x 2 0 0 7 9 5

Aus tin, TX 7 8 7 2 0 -0 7 9 5

1 -8 0 0 -9 2 5 -9 1 2 6

Fax: 1 -5 1 2 -5 1 4 -4 2 1 4

Fo r prio r autho rizatio n re que s ts o n the Ho me He alth Se rvic e s c o ntac t:

Te xas Me dic aid & He althc are Partne rs hip

Ho me He alth S e rvic e s

PO Bo x 2 0 2 9 7 7

Aus tin, TX 7 8 7 2 0 -2 9 7 7

1 -8 0 0 -9 2 5 -8 9 5 7

Fax: 1 -5 1 2 -5 1 4 -4 2 0 9

Fo r ge ne ral que s tio ns , s uc h as c laims his to ry info rmatio n, prio r autho rizatio n his to ry, pro c e dure c o de s , pro c e dural matte rs , o r to ve rify if prio r autho rizatio n has alre ady be e n is s ue d, c all the TMHP Co mpre he ns ive Care Pro gram (CCP)-Ho me He alth Pro vide r Line at 1 -8 0 0 -8 4 6 -7 4 7 0 .

Import ant : All pro vide rs are re quire d to re ad and c o mply with Se c tio n 1 , Pro vide r Enro llme nt and Re s po ns ibilitie s . In additio n to re quire d c o mplianc e with all re quire me nts s pe c ific to the Te xas Me dic aid Pro gram, it is a vio latio n o f Te xas Me dic aid Pro gram rule s whe n a pro vide r fails to pro vide he alth-c are s e rvic e s o r ite ms to Me dic aid c lie nts in ac c o rdanc e with ac c e pte d me dic al c o mmunity

s tandards and s tandards that go ve rn o c c upatio ns , as

e xplaine d in Title 1 Te xas Adminis trative Co de (TAC) § 3 7 1 .1 6 1 7 (a)(6 )(A). Ac c o rdingly, in additio n to be ing

s ubje c t to s anc tio ns fo r failure to c o mply with the re quire - me nts that are s pe c ific to the Te xas Me dic aid Pro gram, pro vide rs c an als o be s ubje c t to Te xas Me dic aid Pro gram s anc tio ns fo r failure , at all time s , to de live r he alth-c are ite ms and s e rvic e s to Me dic aid c lie nts in full ac c o rdanc e with all applic able lic e ns ure and c e rtific atio n re quire me nts inc luding, witho ut limitatio n, tho s e re late d to do c ume n- tatio n and re c o rd mainte nanc e .

Refer to: " Pro vide r Enro llme nt" o n page 1 -2 fo r info r- matio n abo ut e nro llme nt pro c e dure s .

2 4 .1 .1 Change of Address/ Telephone Number

A c urre nt phys ic al and mailing addre s s and te le pho ne numbe r mus t be o n file fo r the age nc y/ c o mpany to re c e ive Re mittanc e & S tatus (R&S ) re po rts , re imburs e me nt

c he c ks , Me dic aid pro vide r pro c e dure s manuals , the Te xas Me dic aid Bulle tin (bimo nthly update to the Te xas Me dic aid Pro vide r Pro c e dure s Manual), and all o the r TMHP c o rre - s po nde nc e . Pro mptly s e nd all addre s s and te le pho ne numbe r c hange s to TMHP Pro vide r Enro llme nt at the addre s s lis te d abo ve in " Enro llme nt" o n page 2 4 -4 .

2 4 .1 .2 Pending Agency Certification

Ho me he alth age nc ie s and DME-Ho me He alth Se rvic e s (DMEH) s upplie rs s ubmitting c laims be fo re the e nro llme nt pro c e s s is c o mple te o r witho ut autho rizatio n fo r s e rvic e s is s ue d by TMHP Ho me He alth Se rvic e s Autho rizatio n

De partme nt will no t be re imburs e d. The e ffe c tive date o f e nro llme nt is whe n all Me dic aid pro vide r e nro llme nt fo rms are re c e ive d and appro ve d by TMHP.

Upo n the re c e ipt o f no tic e o f Me dic aid e nro llme nt, the age nc y/ s upplie r mus t c o ntac t TMHP’ s Ho me He alth Se rvic e s Autho rizatio n De partme nt be fo re s e rving a Me dic aid c lie nt fo r s e rvic e s that re quire a prio r autho ri- zatio n numbe r. Prio r autho rizatio n c anno t be is s ue d be fo re Me dic aid e nro llme nt is c o mple te . Re gular prio r autho rizatio n pro c e dure s are fo llo we d at that time .

Ho me he alth age nc ie s that pro vide labo rato ry s e rvic e s mus t c o mply with the rule s and re gulatio ns o f the Clinic al Labo rato ry Impro ve me nt Ame ndme nts (CLIA). Pro vide rs who do no t c o mply with CLIA will no t be re imburs e d fo r labo rato ry s e rvic e s .

Do no t s ubmit Ho me He alth S e rvic e s c laims fo r payme nt until Me dic aid c e rtific atio n is re c e ive d and a prio r autho ri- zatio n numbe r is as s igne d.

Refer to: " Clinic al Labo rato ry Impro ve me nt Ame ndme nts (CLIA)" o n page 2 6 -2 .

2 4 –4

CPT o nly c o pyright 2 0 0 7 Ame ric an Me dic al As s o c iatio n. All rights re s e rve d.

Te xas Me dic aid (Title XIX) Ho me He alth S e rvic e s

2 4 .2 M edicaid M anaged Care Enrollment

Ce rtain pro vide rs may be re quire d to e nro ll with a Me dic aid Manage d Care plan to be re imburs e d fo r

s e rvic e s pro vide d to Me dic aid Manage d Care c lie nts . Co ntac t the individual he alth plan fo r e nro llme nt info rmatio n.

Refer to: " Me dic aid Manage d Care " o n page 7 -4 .

2 4 .3 Reimbursement

The re imburs e me nt me tho do lo gy fo r pro fe s s io nal s e rvic e s de live re d by ho me he alth age nc ie s are s tate wide vis it rate s c alc ulate d in ac c o rdanc e with 1 TAC § 3 5 5 .8 0 2 1 (a).

Fe e s c he dule s fo r all s e rvic e s in this c hapte r are available o n the TMHP we bs ite at www.tmhp.c o m/ file %2 0 library

/ file %2 0 library/ fe e %2 0 s c he dule s .

A s kille d nurs e (S N) and/ o r ho me he alth aide (HHA) vis it may be pro vide d up to a maximum o f 2 .5 ho urs pe r vis it. A c o mbine d to tal o f thre e SN and/ o r HHA vis its may be re imburs e d pe r day.

Whe n s e rvic e s are pro vide d to mo re than o ne c lie nt in the s ame s e tting, o nly the units dire c tly pro vide d to e ac h

c lie nt at dis tinc t, s e parate time pe rio ds will be

re imburs e d. Pro vide r do c ume ntatio n mus t s uppo rt the

s e rvic e s we re de live re d at dis tinc t, s e parate time pe rio ds . To tal ho me he alth s e rvic e s bille d fo r all c lie nts c anno t

e xc e e d the individual pro vide r’ s to tal numbe r o f ho urs s pe nt at the plac e o f s e rvic e (POS).

One as ne e de d (PRN) SN vis it may be re imburs e d e ve ry 3 0 days o uts ide o f the prio r autho rize d vis its whe n SN vis its have be e n autho rize d fo r the partic ular c lie nt.

Fo r re imburs e me nt purpo s e s , Ho me He alth SN and/ o r HHA s e rvic e s are always bille d as POS 2 (ho me )

re gardle s s o f the s e tting in whic h the s e rvic e s are ac tually pro vide d. SN and/ o r HHA s e rvic e s pro vide d in the day

c are o r s c ho o l s e tting will no t be re imburs e d.

All unique pro c e dure c o de s mus t be bille d ac c o rding to the de s c riptio n o f the pro c e dure c o de . The quantity bille d mus t be ide ntifie d and e ac h pro c e dure c o de mus t be

lis te d as s e parate line ite ms o n the c laim. SN, HHA, phys ic al the rapy (PT), and o c c upatio nal the rapy (OT) vis its mus t be bille d in 1 5 minute inc re me nts .

Pro c e dural mo difie rs are re quire d whe n billing SN, HHA, PT, and OT vis its .

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S N o r ho me he alth aide s e c o nd vis it pe r day

 

 

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SN o r ho me he alth aide third vis it pe r day

 

 

GP

PT

 

 

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OT

 

 

Ho me he alth age nc ie s are re imburs e d fo r DME and e xpe ndable s upplie s in ac c o rdanc e with

1TAC § 3 5 5 .8 0 2 1 . The c urre nt DME fe e s c he dule is available o n the TMHP we bs ite at www.tmhp.c o m.

Pro vide rs may als o re que s t a hard c o py o f the fe e

s c he dule by c o ntac ting the TMHP Co ntac t Ce nte r at 1 -8 0 0 -9 2 5 -9 1 2 6 .

TMHP manually pric e s DME and e xpe ndable s upplie s that have no e s tablis he d fe e , o the r than nutritio nal pro duc ts , bas e d o n the manufac ture r’ s s ugge s te d re tail pric e (MSRP) le s s 1 8 pe rc e nt, with do c ume ntatio n o f the MSRP s ubmitte d by the pro vide r. If the re is no MSRP available , re imburs e me nt is at an e s tablis he d pe rc e ntage o f the pro vide r’ s invo ic e c o s t. Nutritio nal pro duc ts that re quire manual pric ing are pric e d at 8 9 .5 pe rc e nt o f the ave rage who le s ale pric e (AWP). The Te xas Me dic aid Pro gram do e s no t re imburs e s e parate ly fo r as s o c iate d DME c harge s , inc luding but no t limite d to , batte ry dis po s al fe e s o r s tate taxe s . Re imburs e me nt fo r any as s o c iate d c harge s is

inc lude d in the re imburs e me nt fo r a s pe c ific pie c e o f e quipme nt.

Refer to: " Te xas Me dic aid Re imburs e me nt" o n page 2 -1 fo r mo re info rmatio n abo ut re imburs e me nt.

2 4 .3 .1 Eligibility

To ve rify c lie nt Me dic aid e ligibility and re tro ac tive e ligi- bility, the ho me he alth age nc y o r DMEH/ me dic al s upplie r s ho uld c o ntac t the Auto mate d Inquiry Sys te m (AIS) at

1 -8 0 0 -9 2 5 -9 1 2 6 o r the TMHP Ele c tro nic Data Inte rc hange (EDI) He lp De s k at 1 -8 8 8 -8 6 3 -3 6 3 8 .

Ho me he alth c lie nts do no t ne e d to be ho me bo und to qualify fo r s e rvic e s . Pro vide rs who have re c e ive d pre vio us de nials bas e d o n ho me bo und c rite ria ne e d to appe al the ir c laims with appro priate do c ume ntatio n to inc lude a c o py o f the c laim, R&S re po rt, and autho rizatio n re que s ts .

The Me dic aid c lie nt mus t be e ligible o n the date (s ) o f

s e rvic e s (DOS) and mus t me e t all the fo llo wing re quire - me nts to qualify fo r Ho me He alth Se rvic e s :

• Have a me dic al ne e d fo r ho me he alth pro fe s s io nal s e rvic e s , DME, o r s upplie s that are c o ns ide re d a be ne fit unde r Ho me He alth Se rvic e s and as

do c ume nte d in the c lie nt’ s plan o f c are (POC).

•Re c e ive s e rvic e s that me e t the c lie nt’ s e xis ting me dic al

ne e ds and c an be s afe ly pro vide d in the c lie nt’ s ho me .

•Re c e ive prio r autho rizatio n fro m TMHP fo r all ho me he alth pro fe s s io nal s e rvic e s , DME, o r s upplie s .

Ce rtain DME/s upplie s may be o btaine d witho ut prio r autho - rizatio n altho ugh pro vide rs must re tain a Ho me He alth

Se rvic e s (Title XIX) Durable Me dic al Equipme nt (DME)/Me dic al Supplie s Phys ic ian Orde r Fo rm re vie we d and s igne d by the tre ating phys ic ian fo r the s e c lie nts .

Refer to: “ Auto mate d Inquiry Sys te m (AIS)” o n page xiii.

Note: Me dic aid be ne fic iarie s who are unde r 2 1 ye ars o f age are e ntitle d to all me dic ally ne c e s s ary private duty nurs ing (PDN) s e rvic e s and/o r ho me he alth SN s e rvic e s . Nurs ing s e rvic e s are me dic ally ne c e s s ary whe n the

re que s te d s e rvic e s are nurs ing s e rvic e s as de fine d in the Te xas Nurs ing Prac tic e Ac t and its imple me nting re gula- tio ns ; the re que s te d s e rvic e s c o rre c t o r ame lio rate the be ne fic iary’ s dis ability o r phys ic al o r me ntal illne s s o r

c o nditio n; and the re is no third-party re s o urc e that is finan-

2 4

CPT o nly c o pyright 2 0 0 7 Ame ric an Me dic al As s o c iatio n. All rights re s e rve d.

2 4 –5

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As for AIDE Se rvic e s that will no t be and Me dic atio n Adminis tratio n, make sure that you get them right in this section. Those two are the key ones in the page.

3. In this step, look at Ins ulin Pump, Inc o ntine nc e Supplie s, Inc o ntine nc e Supplie s, Inc o ntine nc e Equipme nt, Inc o ntine nc e Pro c e, Mo difie rs, Wo und Care Supplie s and o r, Wo und Care Supplie s, Wo und Care Sys te m, The rmal Wo und Care Sys te, Se ale d Suc tio n Wo und, Puls atile Je t Irrigatio n, Wo und Care Sys te m Crite, Prio r Autho rizatio n, and Wo und Care Pro c e dure s. Each one of these have to be filled in with utmost attention to detail.

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4. The subsequent part needs your involvement in the subsequent places: ACD Sys te m Ac c e s s o, No nc o ve re d ACD Sys te m, Prio r Autho rizatio n, Trial Pe rio d Re ntal Purc, DME Ce rtific atio n, Re imburs e me nt, No nwarranty Re pairs, Re plac e me nt, ACD Pro c e dure Co de s, Bath and Bathro o m Equipme, Blo o d Pre s s ure De vic e, Bre as t Pumps, Co ntinuo us Pas s ive Mo tio, Intrave no us IV The rapy, and Pho to the rapy De vic e s. Just remember to provide all of the required info to move onward.

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