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 .

M odifier

Visit Service Category

 

 

U2

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

 

 

U3

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

 

 

GP

PT

 

 

GO

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

Se c tio n 2 4

c ially re s po ns ible fo r the s e rvic e s . Re que s ts fo r nurs ing s e rvic e s mus t be s ubmitte d o n the re quire d Me dic aid fo rms and mus t inc lude s uppo rting do c ume ntatio n. The s uppo rting do c ume ntatio n mus t c le arly and c o ns is te ntly de s c ribe the be ne fic iary’ s c urre nt diagno s is , func tio nal s tatus and c o nditio n; c o ns is te ntly de s c ribe the tre atme nt thro ugho ut the do c ume ntatio n; and pro vide a s uffic ie nt e xplanatio n o f ho w the re que s te d nurs ing 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. Me dic ally ne c e s s ary nurs ing s e rvic e s will be autho rize d e ithe r as PDN s e rvic e s o r as Ho me He alth SN s e rvic e s , de pe nding o n whe the r the

be ne fic iary’ s nurs ing ne e ds c an be me t o n a pe r vis it bas is .

2 4 .3 .1 .1 Retroactive Eligibility

Whe n a ho me he alth age nc y is pro viding s e rvic e s to a c lie nt who is pe nding Me dic aid c o ve rage , the age nc y is re s po ns ible fo r finding o ut the e ffe c tive date s fo r e ligi- bility, whic h c an be do ne by c o ntac ting AIS at

1 -8 0 0 -9 2 5 -9 1 2 6 o r the TMHP EDI He lp De s k at 1 -8 8 8 -8 6 3 -3 6 3 8 .

TMHP mus t re c e ive all do c ume ntatio n and c laims fo r

c lie nts with re tro ac tive e ligibility within 9 5 days fro m the date e ligibility was adde d to TMHP’ s e ligibility file .

2 4 .3 .1 .2 Authorization of Retroactive Eligibility

Afte r the c lie nt’ s e ligibility is o n TMHP’ s e ligibility file , the age nc y has 9 5 days fro m the add date to o btain autho ri- zatio n fo r s e rvic e s alre ady re nde re d. The age nc y mus t

c o ntac t TMHP Ho me He alth S e rvic e s Autho rizatio n

De partme nt to o btain autho rizatio n fo r c urre nt s e rvic e s within thre e bus ine s s days o f the c lie nt’s e ligibility be ing adde d to TMHP’s e ligibility file . The nurs e who made the initial as s e s s me nt vis it in the c lie nt’ s ho me s ho uld make this c all.

2 4 .3 .2 Prior Authorization

Prio r autho rizatio n o f initial c o ve rage o f ho me he alth

s e rvic e s (SN, HHA, PT, OT) fo r an e ligible c lie nt c an be

o btaine d by c alling the TMHP Co ntac t Ce nte r Ho me He alth Se rvic e s line at 1 -8 0 0 -9 2 5 -8 9 5 7 , by fax to

1 -5 1 2 -5 1 4 -4 2 0 9 o r thro ugh the TMHP we bs ite at www.tmhp.c o m.

The fo llo wing autho rizatio n re que s ts c an be s ubmitte d thro ugh the TMHP we bs ite at www.tmhp.c o m:

•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.

•Me dic aid Ce rtific ate o f Me dic al Ne c e s s ity fo r CPAP/ BiPAP o r Oxyge n The rapy.

•Me dic aid Ce rtific ate o f Ne c e s s ity fo r Che s t Phys io - the rapy De vic e Fo rm— Initial Re que s t.

•Me dic aid Ce rtific ate o f Ne c e s s ity fo r Che s t Phys io - the rapy De vic e Fo rm— Exte nde d Re que s t.

•State me nt fo r Initial Wo und The rapy Sys te m In-Ho me Us e .

•State me nt fo r Re c e rtific atio n o f Wo und The rapy Sys te m In-Ho me Us e .

•Whe e lc hair/ Sc o o te r/ Stro lle r Se ating As s e s s me nt Fo rm (THSte ps -CCP/ Ho me He alth Se rvic e s ) (Attac hme nts will be s e nt s e parate ly due to s ize and de taile d

info rmatio n).

•Ho me He alth Se rvic e s Plan o f Care (POC).

Refer to: " Prio r Autho rizatio n Re que s ts Thro ugh the TMHP We bs ite " o n page 5 -4 fo r mo re info rmatio n, inc luding mandato ry do c ume ntatio n

re quire me nts .

If a c lie nt’ s primary c o ve rage is private ins uranc e , and Me dic aid is s e c o ndary, prio r autho rizatio n is re quire d fo r Me dic aid re imburs e me nt.

If the primary c o ve rage is Me dic are , and Me dic are appro ve s the s e rvic e , and Me dic aid is s e c o ndary, prio r autho rizatio n is no t re quire d. TMHP will o nly pay the

c o ins uranc e .

If Me dic are de nie d the s e rvic e , the n Me dic aid prio r autho - rizatio n is re quire d. Co ntac t Me dic aid within 3 0 days o f re c e ipt o f Me dic are ’ s final de nial le tte r. The final de nial le tte r fro m Me dic are mus t ac c o mpany the autho rizatio n re que s t.

If the s e rvic e is a Me dic aid-o nly s e rvic e , prio r autho rizatio n is re quire d.

The pro vide r is re s po ns ible fo r de te rmining if e ligibility is e ffe c tive by us ing AIS o r an e le c tro nic e ligibility inquiry thro ugh TMHP EDI gate way.

The pro vide r mus t c o ntac t TMHP Ho me He alth S e rvic e s Autho rizatio n De partme nt within thre e bus ine s s days o f the s tart o f c are (SOC) fo r pro fe s s io nal s e rvic e s o r the DOS fo r DME/ me dic al s upplie s to o btain autho rizatio n. Fo llo wing the re gis te re d nurs e ’ s (RN) as s e s s me nt/ e valu- atio n o f the c lie nt in the ho me s e tting, the nurs e who made the initial as s e s s me nt vis it in the c lie nt’ s ho me

s ho uld make this c all to ans we r que s tio ns abo ut the

c lie nt’ s c o nditio n as it re late s to the me dic al ne c e s s ity.

If inade quate o r inc o mple te info rmatio n is pro vide d o r is lac king me dic al ne c e s s ity, the pro vide r will be re que s te d to furnis h additio nal do c ume ntatio n as re quire d to make a de c is io n o n the re que s t. Pro vide rs have two we e ks to s ubmit the re que s te d do c ume ntatio n be c aus e it o fte n mus t be o btaine d fro m the c lie nt’ s phys ic ian. If the additio nal do c ume ntatio n is re c e ive d within the two -we e k pe rio d, autho rizatio n c an be c o ns ide re d fo r the o riginal date o f c o ntac t. If the additio nal do c ume ntatio n is

re c e ive d mo re than two we e ks fro m the re que s t fo r the do c ume ntatio n, autho rizatio n is no t c o ns ide re d be fo re the date the additio nal do c ume ntatio n is re c e ive d. It is the DME/ s upplie r/ ho me he alth age nc y’ s re s po ns ibility to

c o ntac t the phys ic ian to o btain the re que s te d additio nal do c ume ntatio n.

TMHP’ s Ho me He alth Se rvic e s to ll-fre e numbe r is

1 -8 0 0 -9 2 5 -8 9 5 7 . The Ho me He alth Se rvic e s Autho rizatio n Che c klis t is a us e ful re s o urc e fo r ho me he alth age nc y

2 4 –6

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

pro vide rs c o mple ting the autho rizatio n pro c e s s . This

o ptio nal fo rm o ffe rs the nurs e a de taile d ac c o unt o f the c lie nt’ s ne e ds whe n c o mple te d. Co ntac t TMHP In-Ho me Care Co ntac t Ce nte r at 1 -8 0 0 -8 4 6 -7 4 7 0 fo r mo re

info rmatio n.

Refer to: " Durable Me dic al Equipme nt (DME) and Supplie s " o n page 2 4 -2 9 fo r DME/ me dic al s upplie s prio r autho rizatio n and " Me dic aid Re latio ns hip to Me dic are " o n page 2 4 -7 0 .

Clie nt e ligibility fo r Me dic aid is fo r o ne mo nth at a time . Pro vide rs s ho uld ve rify e ligibility e ve ry mo nth. Prio r autho - rizatio n do e s no t guarante e payme nt.

2 4 .4 Home Health Services

The be ne fit pe rio d fo r ho me he alth pro fe s s io nal s e rvic e s is up to 6 0 days with a c urre nt POC. In c hro nic and s table s ituatio ns , DME and s upplie s o rde re d o n a Ho me He alth S e rvic e s (Title XIX) Durable Me dic al Equipme nt

(DME)/ Me dic al Supplie s Phys ic ian Orde r Fo rm may be autho rize d fo r up to s ix mo nths with me dic al ne c e s s ity de te rminatio n. Be c aus e a Me dic aid c lie nt’ s e ligibility pe rio d is fo r o ne mo nth, pro vide rs s ho uld bill fo r a o ne mo nth s upply at a time , e ve n tho ugh prio r autho rizatio n may be grante d fo r up to s ix mo nths . This e xte nde d autho - rizatio n pe rio d be gins o n the date that c lie nts re c e ive the ir firs t autho rize d ho me he alth s e rvic e . The Te xas Me dic aid Pro gram allo ws additio nal vis its , DME, o r s upplie s that have be e n de te rmine d to be me dic ally ne c e s s ary and have be e n autho rize d by TMHP Ho me He alth Se rvic e s Autho rizatio n De partme nt. Pro vide rs mus t re tain all

o rde rs , s igne d and date d Title XIX fo rms , de live ry s lips , and invo ic e s fo r all s upplie s pro vide d to a c lie nt and mus t dis c lo s e the m to the HHSC o r its de s igne e o n re que s t. The s e re c o rds and c laims mus t be re taine d fo r a minimum o f five ye ars fro m the date o f s e rvic e (DOS) o r until audit que s tio ns , appe als , he arings , inve s tigatio ns , o r c o urt

c as e s are re s o lve d. Us e o f the s e s e rvic e s is s ubje c t to re tro s pe c tive re vie w.

2 4 .4 .1 Client Evaluation

Whe n a ho me he alth age nc y re c e ive s a re fe rral to pro vide ho me he alth s e rvic e s , s upplie s , o r DME fo r a Me dic aid- e ligible c lie nt, the age nc y-e mplo ye d RN s ho uld e valuate the c lie nt in the ho me be fo re c alling TMHP fo r prio r autho - rizatio n. Altho ugh re c o mme nde d, a ho me vis it is no t

re quire d if o nly DME o r s upplie s are ne e de d and be ing re que s te d by the phys ic ian o n a Title XIX fo rm. DME o r s upplie s re que s te d o n a Ho me He alth S e rvic e s POC

re quire an RN ho me e valuatio n. It is e xpe c te d that appro - priate re fe rrals will be made be twe e n ho me he alth

age nc ie s and DME s upplie rs fo r c are . It is re c o mme nde d that DME s upplie rs ke e p o pe n c o mmunic atio n with the c lie nt’ s phys ic ian fo r c urre nt re po rting.

This e valuatio n s ho uld inc lude as s e s s me nt o f the fo llo wing:

•Me dic al ne c e s s ity fo r ho me he alth s e rvic e s , s upplie s , o r DME.

•Safe ty.

• Appro priate ne s s o f c are in the ho me s e tting.

•Capable c are give r available if c lie nts are unable to

pe rfo rm the ir o wn c are o r mo nito r the ir o wn me dic al c o nditio n.

Fo llo wing the RN’ s as s e s s me nt/ e valuatio n o f the c lie nt in the ho me s e tting fo r ho me he alth s e rvic e s ne e ds , the age nc y RN who c o mple te d the ho me e valuatio n mus t

c o ntac t TMHP fo r prio r autho rizatio n within thre e bus ine s s days o f the SOC.

2 4 .4 .2 Physician Supervision— Plan of Care

Fo r the Ho me He alth S e rvic e s plan o f c are (POC) to be valid, the tre ating phys ic ian mus t s ign and date it, and indic ate whe n the s e rvic e s will be gin. The ho me he alth age nc y mus t update and maintain the POC at le as t e ve ry 6 0 days o r as ne c e s s itate d by a c hange in c o nditio n.

Me dic are Fo rm 4 8 5 is no t ac c e pte d as a POC. The Ho me He alth Se rvic e s POC is the o nly ac c e ptable fo rm fo r

re imburs e me nt fro m the Te xas Me dic aid Pro gram.

2 4 .4 .2 .1 Written Plan of Care

A Ho me He alth Se rvic e s POC is re quire d fo r SN s e rvic e s , HHA, PT, and OT s e rvic e s . The POC is no t re quire d as an attac hme nt with the c laim, but a s igne d and date d POC mus t be re taine d in the c lie nt’ s me dic al re c o rd with the pro vide r and re que s ting phys ic ian. The c lie nt’ s atte nding phys ic ian mus t re c o mme nd, s ign, and date a POC. The POC do e s no t ne e d to be s igne d by the phys ic ian be fo re c o ntac ting TMHP fo r autho rizatio n whe n o rde rs fo r ho me c are have be e n re c e ive d fro m the phys ic ian. The POC s hall be initiate d by the RN in a c le ar and le gible fo rmat. The POC mus t c o ntain the fo llo wing info rmatio n:

•Ac tivitie s pe rmitte d.

•All pe rtine nt diagno s e s .

•Available c are give r.

•Clie nt Me dic aid numbe r.

• Date the c lie nt was las t s e e n by the phys ic ian. The

c lie nt mus t be s e e n by a phys ic ian within 3 0 days o f the initial S OC and at le as t o nc e e ve ry s ix mo nths the re - afte r unle s s a diagno s is has be e n e s tablis he d by the phys ic ian and the c lie nt is c urre ntly unde rgo ing

phys ic ian c are and tre atme nt. The phys ic ian vis it may be waive d whe n a diagno s is has alre ady be e n e s tab - lis he d by the phys ic ian and the re c ipie nt is unde r the c o ntinuing c are and me dic al s upe rvis io n o f the

phys ic ian. Any waive r mus t be bas e d o n the phys ic ian’ s writte n s tate me nt that an additio nal e valuatio n vis it is no t me dic ally ne c e s s ary. The o riginal mus t be maintaine d by the re que s ting phys ic ian and a c o py mus t be maintaine d in the pro viding pro vide r’ s file s .

•Equipme nt/ s upplie s re quire d.

•Ins truc tio ns fo r time ly dis c harge o r re fe rral.

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 –7
Me dic atio ns inc luding the do s e , ro ute , and fre que nc y.

Se c tio n 2 4

•Lis t all c o mmunity o r s tate age nc y s e rvic e s the c lie nt re c e ive s in the ho me (e .g., primary ho me c are [PHC], PCS , c o mmunity-bas e d alte rnative [CBA], Me dic ally De pe nde nt Childre n’ s Pro gram [MDCP]).

•

•Me ntal s tatus .

•Nutritio nal re quire me nts .

•Phys ic ian lic e ns e numbe r.

•Prio r and c urre nt func tio nal limitatio ns .

•Pro gno s is .

•Pro vide r Me dic aid numbe r.

•Re habilitatio n po te ntial.

•S afe ty me as ure s to pro te c t agains t injury.

•SOC date fo r ho me he alth s e rvic e s .

•Tre atme nts , inc luding amo unt, duratio n, and fre que nc y.

•Type s o f s e rvic e s inc luding amo unt, duratio n, and fre que nc y.

•Wo und c are o rde rs and me as ure me nts .

Phys ic ian o rde rs fo r PT and/ o r OT s e rvic e s mus t inc lude the Inte rnatio nal Clas s ific atio n o f Dis e as e s , Ninth Re vis io n,

Clinic al Mo dific atio n (ICD-9 -CM) diagno s is c o de s fo r an ac ute o r e xac e rbate d e ve nt, if the fo llo wing c o nditio ns apply:

•PT/ OT is be ing re que s te d.

• Spe c ific pro c e dure s and mo dalitie s are to be us e d.

• Amo unt, fre que nc y, and duratio n o f the rapy ne e de d.

•Phys ic al and/ o r o c c upatio nal the rapy and go als .

•Name o f the rapis t who partic ipate d in de ve lo ping the POC is lis te d.

The phys ic ian and ho me he alth age nc y nurs ing, PT, and OT pe rs o nne l mus t re vie w the POC as o fte n as the s e ve rity o f the c lie nt’ s c o nditio n re quire s o r at le as t o nc e e ve ry 6 0 days . This s igne d and date d do c ume ntatio n mus t be maintaine d in the c lie nt’ s me dic al re c o rd with the o rde ring phys ic ian and re que s ting pro vide r. This applie s to all writte n and ve rbal o rde rs , and plans o f c are .

Ve rbal phys ic ian o rde rs may o nly be give n to pe o ple autho - rize d to re c e ive the m unde r s tate and fe de ral law. The y mus t be re duc e d to writing, s igne d, and date d by the RN o r qualifie d the rapis t re s po ns ible fo r furnis hing o r s upe r- vis ing the o rde re d s e rvic e , and plac e d in the c lie nt’ s c hart. The phys ic ian mus t s ign the writte n c o py o f the ve rbal

o rde r within two we e ks o r pe r age nc y po lic y if le s s than two we e ks . A c o py o f the writte n ve rbal o rde r mus t be maintaine d in the c lie nt’ s c hart be fo re and afte r be ing s igne d by the phys ic ian.

The type and fre que nc y o f vis its , s upplie s , o r DME mus t appe ar o n the POC be fo re the phys ic ian s igns the o rde rs , and may no t be adde d afte r the phys ic ian has s igne d the o rde rs . If any c hange in the POC o c c urs during an autho ri- zatio n pe rio d (additio nal vis its , s upplie s , o r DME), the

ho me he alth age nc y mus t c all TMHP Ho me He alth

Se rvic e s Autho rizatio n De partme nt fo r autho rizatio n and maintain a c o mple te d re vis e d re que s t POC s igne d by the phys ic ian.

Co ve rage pe rio ds do no t ne c e s s arily c o inc ide with

c ale ndar we e ks o r mo nths but ins te ad c o ve r a numbe r o f s e rvic e s to be s c he dule d be twe e n a s tart and e nd date that is as s igne d during the prio r autho rizatio n. The age nc y mus t c o ntac t TMHP within thre e bus ine s s days afte r the SOC date fo r prio r autho rizatio n.

Refer to: “ Ho me He alth S e rvic e s Plan o f Care (POC)” o n page B-4 7 .

" Phys ic al The rapy (PT) Se rvic e s " o n page 2 4 -1 4 .

2 4 .5 Benefits

Ho me he alth s e rvic e s inc lude SN s e rvic e s , HHA vis its , PT vis its , OT vis its , DME, and e xpe ndable me dic al s upplie s that are pro vide d to e ligible Me dic aid c lie nts at the ir plac e o f re s ide nc e .

Me dic aid be ne fic iarie s unde r 2 1 ye ars o f age are e ntitle d to all me dic ally ne c e s s ary DME. DME is me dic ally

ne c e s s ary whe n it is re quire d to c o rre c t o r ame lio rate dis abilitie s o r phys ic al o r me ntal illne s s e s o r c o nditio ns . Any nume ric al limit o n the amo unt o f a partic ular ite m o f DME c an be e xc e e de d fo r Me dic aid be ne fic iarie s unde r 2 1 ye ars o f age if me dic ally ne c e s s ary. Like wis e , time pe rio ds fo r re plac e me nt o f DME will no t apply to Me dic aid be ne fic iarie s unde r 2 1 ye ars o f age if the re plac e me nt is me dic ally ne c e s s ary. Whe n prio r autho rizatio n is re quire d, the info rmatio n s ubmitte d with the re que s t mus t be s uffi- c ie nt to do c ume nt the re as o ns why the re que s te d DME ite m o r quantity is me dic ally ne c e s s ary.

Me dic aid be ne fic iarie s unde r 2 1 ye ars o f age are e ntitle d to all me dic ally ne c e s s ary 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 by the Te xas Nurs ing Prac tic e Ac t and its imple me nting re gulatio 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 financ ially re s po ns ible fo r the

s e rvic e s . Re que s ts fo r nurs ing s e rvic e s mus t be

s ubmitte d o n the re quire d Me dic aid fo rms and inc lude

s uppo rting do c ume ntatio n. The s uppo rting do c ume ntatio n mus t: c le arly and c o ns is te ntly de s c ribe the be ne fic iary’ s c urre nt diagno s is , func tio nal s tatus and c o nditio n; c o ns is - te ntly de s c ribe the tre atme nt thro ugho ut the

do c ume ntatio n; and pro vide a s uffic ie nt e xplanatio n as to ho w the re que s te d nurs ing 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. Me dic ally ne c e s s ary nurs ing s e rvic e s will be autho rize d e ithe r as PDN s e rvic e s o r as Ho me He alth S N s e rvic e s , de pe nding o n whe the r the be ne fic iary’ s nurs ing ne e ds c an be me t o n a pe r vis it bas is .

Prio r autho rizatio n mus t be o btaine d fo r all pro fe s s io nal s e rvic e s , s o me s upplie s , and mo s t DME fro m TMHP within thre e bus ine s s days o f SOC. Altho ugh pro vide rs may s upply s o me DME and me dic al s upplie s to a c lie nt witho ut prio r autho rizatio n, the y mus t s till re tain a c o py o f the Ho me

2 4 –8

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

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 that has be e n c o mple te d and s igne d by the c lie nt’ s atte nding phys ic ian.

Fo r re imburs e me nt, pro vide rs s ho uld no te the fo llo wing:

• The c lie nt’ s atte nding phys ic ian mus t re que s t pro fe s -

s io nal and/ o r HHA s e rvic e s thro ugh a ho me he alth age nc y, and s ign and date the POC.

•Claims are appro ve d o r de nie d ac c o rding to the e ligi- bility, prio r autho rizatio n s tatus , and me dic al

appro priate ne s s .

• Claims mus t re pre s e nt a quantity o f 1 mo nth fo r s upplie s bille d.

•Nurs ing, nurs e aide , PT, and OT s e rvic e s mus t be pro vide d thro ugh a Me dic aid-e nro lle d ho me he alth

age nc y. The s e s e rvic e s mus t be bille d us ing the ho me he alth age nc y’ s pro vide r ide ntifie r. File the s e s e rvic e s o n a UB-0 4 CMS -1 4 5 0 c laim fo rm.

•PT, OT, and/ o r s pe e c h the rapy (ST) are always bille d as

POS 2 and may be autho rize d to be pro vide d in the fo llo wing lo c atio ns : ho me o f the c lie nt, ho me o f the c are give r/ guardian, c lie nt’ s day c are fac ility, o r the

c lie nt’ s s c ho o l. Se rvic e s pro vide d to a c lie nt o n s c ho o l pre mis e s are o nly pe rmitte d whe n de live re d be fo re o r afte r s c ho o l ho urs . The o nly THSte ps -CCP the rapy that c an be de live re d in the c lie nt’ s s c ho o l during re gular s c ho o l ho urs are tho s e de live re d by s c ho o l dis tric ts as Sc ho o l He alth and Re late d Se rvic e s (SHARS) in POS 9 .

• DME/ s upplie s mus t be pro vide d by e ithe r a Me dic aid e nro lle d ho me he alth age nc y’ s Me dic aid/ DME s upply pro vide r o r an inde pe nde ntly-e nro lle d Me dic aid/ DME s upply pro vide r. Bo th mus t e nro ll and bill us ing the pro vide r ide ntifie r e nro lle d as a DME s upplie r. File the s e s e rvic e s o n a CMS -1 5 0 0 c laim fo rm.

Note: Me dic al s o c ial s e rvic e s and s pe e c h-language patho lo gy s e rvic e s are available to c lie nts 2 0 ye ars o f age and yo unge r and are no t a be ne fit o f Ho me He alth

Se rvic e s . The s e s e rvic e s may be c o ns ide re d a be ne fit fo r c lie nts who qualify fo r THSte ps -CCP.

Us e the fo llo wing type o f s e rvic e (TOS) c o de s whe n pro viding ho me he alth s e rvic e s :

TOS

Descript ion

 

 

1

Me dic al s e rvic e s (inc luding s o me inje c table

 

drugs )

 

 

9

Me dic al s upplie s

 

 

C

Ho me He alth Pro c e dure

 

 

J

Purc has e (ne w)

 

 

L

Re ntal, mo nthly

 

 

2 4 .5 .1 Home Health Skilled Nursing Services

Ho me he alth S N s e rvic e s are a be ne fit o f the Ho me He alth Se rvic e s whe n a c lie nt re quire s nurs ing s e rvic e s fo r an ac ute c o nditio n o r an ac ute e xac e rbatio n o f a c hro nic

c o nditio n that c an be me t o n an inte rmitte nt o r part-time

bas is and typic ally has an e nd-po int. SN vis its may be pro vide d o n c o ns e c utive days . SN vis its are inte nde d to pro vide SN c are to pro mo te inde pe nde nc e and s uppo rt the c lie nt living at ho me . Ho me He alth S e rvic e s mus t be pro vide d by a lic e ns e d and c e rtifie d ho me he alth age nc y e nro lle d in the Te xas Me dic aid Pro gram.

Note: Nurs ing vis its fo r the primary purpo s e o f as s e s s ing

ac lie nt’ s c are ne e ds to de ve lo p a POC are c o ns ide re d adminis trative and no t billable . The s e vis it c o s ts are

re fle c te d o n the c o s t re po rt.

An ac ute c o nditio n is c o ns ide re d a c o nditio n o r e xac e r- batio n that is antic ipate d to impro ve and re ac h re s o lutio n within 6 0 days . An inte rmitte nt bas is is c o ns ide re d an SN vis it pro vide d fo r le s s than e ight ho urs pe r vis it and le s s fre que ntly than daily. Inte rmitte nt vis its may be de live re d in inte rval vis its up to 2 .5 ho urs pe r vis it, no t to e xc e e d a c o mbine d to tal o f thre e vis its pe r day. A part-time bas is is c o ns ide re d an S N vis it pro vide d le s s than e ight ho urs pe r day fo r any numbe r o f days pe r we e k. Part-time vis its may be c o ntinuo us up to 7 .5 ho urs pe r day (no t to e xc e e d a c o mbine d to tal o f thre e 2 .5 ho ur vis its ).

S N vis its are c o ns ide re d me dic ally ne c e s s ary fo r c lie nts who re quire the fo llo wing:

• Skillful o bs e rvatio ns and judgme nt to impro ve he alth s tatus , s kille d as s e s s me nt, o r s kille d

tre atme nts / pro c e dure s .

• Individualize d, inte rmitte nt, ac ute s kille d c are .

• S kille d inte rve ntio ns to impro ve he alth s tatus , and if s kille d inte rve ntio n is de laye d, it is e xpe c te d to re s ult in the de te rio ratio n o f a c hro nic c o nditio n o r o ne o f the fo llo wing:

•Lo s s o f func tio n.

•Immine nt ris k to he alth s tatus due to me dic al fragility, o r ris k o f de ath.

Whe n do c ume ntatio n do e s no t s uppo rt me dic al ne c e s s ity fo r ho me he alth SN vis its , pro vide rs may be dire c te d to po s s ible alte rnative s e rvic e s bas e d o n the c lie nt’ s age and ne e ds .

2 4 .5 .1 .1 Skilled Nursing Visits

All SN s e rvic e s mus t be prio r autho rize d.

SN vis its are limite d to SN pro c e dure s pe rfo rme d by an RN o r LVN lic e ns e d to pe rfo rm the s e s e rvic e s unde r the Te xas Nurs ing Prac tic e Ac t and inc lude dire c t SN c are , and pare nt o r guardian, c are give r training, and e duc atio n as we ll as SN o bs e rvatio n, as s e s s me nt, and e valuatio n by an RN, pro vide d a phys ic ian s pe c ific ally re que s ts that a nurs e vis it the c lie nt fo r this purpo s e , and the phys ic ian’ s o rde r re fle c ts the me dic al ne c e s s ity fo r the vis it.

Fo r all c lie nts , SN vis its may be pro vide d in the fo llo wing lo c atio ns :

• Ho me o f the c lie nt, pare nt, guardian, o r c are give r.

•Fo s te r ho me s .

•Inde pe nde nt living arrange me nts .

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 –9

Se c tio n 2 4

Skilled Nursing Care

Skille d nurs ing c are c o ns is ts o f tho s e s e rvic e s that mus t, unde r s tate law, be pe rfo rme d by a RN o r LVN, and me e t the c rite ria fo r SN s e rvic e s s pe c ifie d in the Title 4 2 Co de o f Fe de ral Re gulatio ns (CFR) § § 4 0 9 .3 2 , 4 0 9 .3 3 , and

4 0 9 .4 4 ).

In de te rmining whe the r a s e rvic e re quire s the s kill o f a lic e ns e d nurs e , c o ns ide ratio n mus t be give n to the inhe re nt c o mple xity o f the s e rvic e , the c o nditio n o f the

c lie nt, and the ac c e pte d s tandards o f me dic al and nurs ing prac tic e .

The fac t that the S N s e rvic e c an be , o r is , taught to the c lie nt o r to the c lie nt’ s family o r frie nds do e s no t ne gate the s kille d as pe c t o f the s e rvic e whe n the s e rvic e is

pe rfo rme d by a nurs e .

If the s e rvic e c o uld be pe rfo rme d by the ave rage

no nme dic al pe rs o n, the abs e nc e o f a c o mpe te nt pe rs o n to pe rfo rm it do e s no t c aus e it to be an S N s e rvic e .

If the nature o f a s e rvic e is s uc h that it c an s afe ly and e ffe c tive ly be pe rfo rme d by the ave rage no nme dic al

pe rs o n witho ut dire c t s upe rvis io n o f a lic e ns e d nurs e , the s e rvic e c anno t be re garde d as an SN s e rvic e .

So me s e rvic e s are c las s ifie d as SN s e rvic e s o n the bas is o f c o mple xity alo ne (e .g., intrave no us and intramus c ular inje c tio ns o r ins e rtio n o f c athe te rs ), and if re as o nable and ne c e s s ary to the tre atme nt o f the c lie nt’ s illne s s o r injury, wo uld be c o ve re d o n that bas is . Ho we ve r, in s o me c as e s , the c lie nt’ s c o nditio n may c aus e a s e rvic e that wo uld

o rdinarily be c o ns ide re d uns kille d to be c o ns ide re d an SN s e rvic e . This wo uld o c c ur whe n the c lie nt’ s c o nditio n is s uc h that the s e rvic e c an be s afe ly and e ffe c tive ly

pro vide d o nly by a nurs e .

A s e rvic e whic h, by its nature , re quire s the s kills o f a nurs e to be pro vide d s afe ly and e ffe c tive ly c o ntinue s to be a s kille d s e rvic e e ve n if it is taught to the c lie nt, the

c lie nt’ s family, o r o the r c are give rs . Whe re the c lie nt ne e ds the SN c are and the re is no o ne traine d, able and willing to pro vide it, the s e rvic e s o f a nurs e wo uld be re as o nable and ne c e s s ary to the tre atme nt o f the illne s s o r injury.

The S N s e rvic e s mus t be re as o nable and ne c e s s ary to the diagno s is and tre atme nt o f the c lie nt’ s illne s s o r injury within the c o nte xt o f the c lie nt’ s unique me dic al c o nditio n. To be c o ns ide re d re as o nable and ne c e s s ary fo r the diagno s is o r tre atme nt o f the c lie nt’ s illne s s o r injury, the s e rvic e s mus t be c o ns is te nt with the nature and s e ve rity o f the illne s s o r injury, the c lie nt’ s partic ular me dic al

ne e ds , and within ac c e pte d s tandards o f me dic al and nurs ing prac tic e . A c lie nt’ s o ve rall me dic al c o nditio n is a valid fac to r in de c iding whe the r s kille d s e rvic e s are

ne e de d. A c lie nt’ s diagno s is s ho uld ne ve r be the s o le fac to r in de c iding whe the r the s e rvic e the c lie nt ne e ds is e ithe r s kille d o r no t s kille d.

The de te rminatio n o f whe the r the s e rvic e s are re as o nable and ne c e s s ary s ho uld be made in c o ns ide ratio n o f the phys ic ian’ s de te rminatio n that the s e rvic e s o rde re d are re as o nable and ne c e s s ary. The s e rvic e s mus t, the re fo re , be vie we d fro m the pe rs pe c tive o f the c o nditio n o f the

c lie nt whe n the s e rvic e s we re o rde re d, and what was , at

that time , re as o nably e xpe c te d to be appro priate

tre atme nt fo r the illne s s o r injury thro ugho ut the c e rtifi- c atio n pe rio d.

The SN c are mus t be pro vide d o n a part-time o r inte r- mitte nt bas is .

Professional Nursing

Pro fe s s io nal nurs ing pro vide d by an RN, as de fine d in the Te xas Nurs e Prac tic e Ac t, me ans the pe rfo rmanc e o f an ac t that re quire s s ubs tantial s pe c ialize d judgme nt and

s kill, the pro pe r pe rfo rmanc e o f whic h is bas e d o n

kno wle dge and applic atio n o f the princ iple s o f bio lo gic al, phys ic al, and s o c ial s c ie nc e as ac quire d by a c o mple te d c o urs e in an appro ve d s c ho o l o f pro fe s s io nal nurs ing. The te rm do e s no t inc lude ac ts o f me dic al diagno s is o r the pre s c riptio n o f the rape utic o r c o rre c tive me as ure s . Pro fe s - s io nal nurs ing invo lve s :

•

The o bs e rvatio n, as s e s s me nt, inte rve ntio n, e valuatio n,

 

re habilitatio n, c are and c o uns e l, o r he alth te ac hings o f

 

a pe rs o n who is ill, injure d, infirm, o r e xpe rie nc ing a

 

c hange in no rmal he alth pro c e s s e s .

•

The mainte nanc e o f he alth o r pre ve ntio n o f illne s s .

•

The adminis tratio n o f a me dic atio n o r tre atme nt as

 

o rde re d by a phys ic ian, po diatris t, o r de ntis t.

•The s upe rvis io n o f de le gate d nurs ing tas ks o r te ac hing o f nurs ing.

•The adminis tratio n, s upe rvis io n, and e valuatio n o f nurs ing prac tic e s , po lic ie s , and pro c e dure s .

• The pe rfo rmanc e o f an ac t de le gate d by a phys ic ian.

•De ve lo pme nt o f the nurs ing c are plan.

Pro fe s s io nal nurs ing als o invo lve s as s is ting in the e valu- atio n o f an individual’ s re s po ns e to a nurs ing inte rve ntio n and the ide ntific atio n o f an individual’ s ne e ds and

e ngaging in o the r ac ts that re quire e duc atio n and training, as pre s c ribe d by bo ard rule s and po lic ie s , c o mme ns urate with the nurs e ’ s e xpe rie nc e , c o ntinuing e duc atio n, and de mo ns trate d c o mpe te nc y.

Vocational Nursing

Vo c atio nal nurs ing, as de fine d in the Te xas Nurs e Prac tic e Ac t, me ans a dire c te d s c o pe o f nurs ing prac tic e , inc luding the pe rfo rmanc e o f an ac t that re quire s s pe c ialize d judgme nt and s kill, the pro pe r pe rfo rmanc e o f whic h is bas e d o n kno wle dge and applic atio n o f the princ iple s o f bio lo gic al, phys ic al, and s o c ial s c ie nc e as ac quire d by a c o mple te d c o urs e in an appro ve d s c ho o l o f vo c atio nal nurs ing. The te rm do e s no t inc lude ac ts o f me dic al diagno s is o r the pre s c riptio n o f the rape utic o r c o rre c tive me as ure s . Vo c atio nal nurs ing invo lve s :

•Co lle c ting data and pe rfo rming fo c us e d nurs ing as s e s s -

me nts o f the he alth s tatus o f an individual.

• Partic ipating in the planning o f the nurs ing c are ne e ds o f an individual.

•Partic ipating in the de ve lo pme nt and mo dific atio n o f the nurs ing c are plan.

•Partic ipating in he alth te ac hing and c o uns e ling to

pro mo te , attain, and maintain the o ptimum he alth le ve l o f an individual.

2 4 –1 0

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.

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2. Right after filling out this section, head on to the subsequent stage and fill out the essential particulars in these fields - Prio r Autho rizatio n Re quire me, Canc e ling an Autho rizatio, AIDE Se rvic e s that will no t be, Ho me He alth Skille d Nurs, As s e s s me nts and Re as s e s, Supplie s Submitte d with a, Me dic atio n Adminis tratio n, Phys ic al The rapy PT Se rvic, Phys ic al The rapy Prio r, Limitatio ns, Phys ic al The rapy Oc c, Oc c upatio nal The rapy OT, Oc c upatio nal The rapy, Limitatio ns, and Me dic al Supplie s.

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