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Texas Medicaid

Provider Procedures Manual

May 2021

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.

PRELIMINARY INFORMATION

Table of Contents

Welcome: Texas Medicaid Provider Procedures Manual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Copyright Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Volume 1 - General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Volume 2 - Provider Handbooks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Texas Medicaid Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

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Welcome: 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.

Referto: 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 Proce- dures 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 previ- ously 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 infor- mation 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

•Certified Respiratory Care Practitioners (CRCP) Services Handbook

•Children’s Services Handbook

•Clinics and Other Outpatient Facility Services Handbook

•Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

•Gynecological, Obstetrics, and Family Planning Title XIX Services

•Health and Human Services Commission Family Planning Program Services Handbook

•Healthy Texas Women Program Handbook

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•Home Health Nursing and Private Duty Nursing 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

•Outpatient Drug Services Handbook

•Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook

•Radiology and Laboratory Services Handbook

•Telecommunications Services Handbook

•Vision and Hearing Services Handbook

Copyright Acknowledgments

Use of the AMA’s copyrighted CPT® is allowed in this publication with the following disclosure:

“Current Procedural Terminology (CPT) is copyright © 2020 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 © 2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.”

Microsoft Corporation requires the following notice in publications containing trademarked product names:

“Microsoft® and Windows® are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries.”

Contents

Volume 1 - General Information

Welcome: Texas Medicaid Provider Procedures Manual

Contents

Introduction

Section 1: Provider Enrollment and Responsibilities

Section 2: Texas Medicaid Fee-for-Service Reimbursement

Section 3: TMHP Electronic Data Interchange (EDI)

Section 4: Client Eligibility

Section 5: Fee-for-Service Prior Authorizations

Section 6: Claims Filing

Section 7: Appeals

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Appendix A: State, Federal, and TMHP Contact Information

Appendix B: HIV/AIDS

Appendix C: Acronym Dictionary

Volume 2 - Provider Handbooks

Ambulance Services Handbook

Behavioral Health and Case Management Services Handbook Certified Respiratory Care Practitioner (CRCP) Services Handbook Children’s Services Handbook

Clinics and Other Outpatient Facility Services Handbook

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook

Health and Human Services Commission Family Planning Program Services Handbook Healthy Texas Women Program Handbook

Home Health Nursing and Private Duty Nursing 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

Outpatient Drug Services Handbook

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook Radiology and Laboratory Services Handbook

Telecommunication Services Handbook

Vision and Hearing Services Handbook

Introduction

Texas Medicaid 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 the following:

•Medical providers

•Texas Medicaid & Healthcare Partnership (TMHP), the fee-for-service claims administrator

•MAXIMUS, the enrollment broker

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•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 instruc- tional material furnished to the provider.

Referto: “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Infor- mation) for addresses and telephone numbers of HHSC and Department of State Health Services (DSHS) regional offices.

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SECTION 1: PROVIDER ENROLLMENT AND

RESPONSIBILITIES

Table of Contents

1.1.5.2Ordering or Referring-Only Providers Participating in Other State

Health-Care Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.1.5.3 Interns and Medical Residents Who Order, Prescribe, or Refer . . . . . . . . . . . . . . 11

1.1.6 Affordable Care Act of 2010 (ACA) Enrollment Requirements. . . . . . . . . . . . . . . . . . . . . . 11

1.1.6.1 Provider Screening Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.1.6.2 Provider Revalidation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.1.6.3 Application Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.1.6.4Ordering- or Referring-Only Providers Search on the Online Provider

Lookup (OPL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.1.7 Surety Bond Enrollment Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.1.7.1 Ambulance Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.1.8 Provider Enrollment Application Determinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.1.9 Enrollment in Medicaid Managed Care Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.1.10 Required Enrollment Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.1.10.1 Application Payment Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.1.10.2 HHSC Medicaid Provider Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.1.10.3 Provider Information Form (PIF-1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.1.10.4 Principal Information Form (PIF-2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.1.10.5 Disclosure of Ownership and Control Interest Statement . . . . . . . . . . . . . . . . . . . 17

1.1.10.6 Internal Revenue Service (IRS) W-9 Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.1.10.7 Medicaid Audit Information Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.1.10.8 Corporate Board of Directors Resolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.1.10.9 Franchise Tax Account Status Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.1.10.10Certificate of Formation or Certificate of Filing/Articles or Certificate of

Incorporation/Certificate of Fact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.1.10.11 Copy of License, Temporary License, or Certification . . . . . . . . . . . . . . . . . . . . . . . 18 1.1.10.12 Federally Qualified Health Center Affiliation Affidavit . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.13 Physician’s Letter of Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.14 Licensure Renewal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.15 Medicare Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.16 Group Information Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.2 Payment Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

1.2.1 Using EFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.2.2 Advantages of EFT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.2.3 EFT Enrollment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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1.2.4 Receiving Paper Checks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.2.5 Stale-Dated Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.7.14.1Home Health Skilled Nursing and Home Health Aide (HHA) Services

Provider Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.7.15 Private Duty Nursing (PDN) Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.7.16 Certified Respiratory Care Practitioner (CRCP) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 1.7.17 Physical, Occupational, and Speech Therapy Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

1.7.17.1 CCP Enrollment for Children’s Services—20 Years of Age and Younger . . . . . 44 1.7.18 Children’s Services Comprehensive Care Program (CCP) . . . . . . . . . . . . . . . . . . . . . . . . . . 45

1.8 Electronic Health Record Incentive/Promoting Interoperability Program . . . . . . . . . . .45

1.8.1Attesting to Meaningful Use-Required Documentation for Texas Medicaid

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