T exas Medicaid Bulletin

Transcription

1 T exas Medicaid Bulletin Bimonthly update to the Texas Medicaid Provider Procedures Manual July/August 2009 No. 224 Mammography Certification Issued by DSHS On September 1, 2008, the Department of State Health Services (DSHS) began to issue mammography certification to providers who render mammography services. Providers can submit this certification to the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Department in lieu of certification issued by the Food and Drug Administration (FDA) because certification issued by DSHS is recognized by the FDA. TMHP will also continue to accept mammography certification issued by the FDA. Providers are reminded to check the expiration date of their mammography certification and submit an updated mammography certification prior to the expiration date. Mail or fax certifications to: Texas Medicaid & Healthcare Partnership Provider Enrollment PO Box Austin, TX Fax: Coming This Summer to Radio TMHP: The CPW Program Coming this summer, TMHP will air an episode on Radio TMHP at that will provide information about the Texas Medicaid Case Management for Children and Pregnant Women (CPW) program. Providers will be notified of the date the episode will air in a future notification. CONTENTS All Providers 1 Mammography Certification Issued by DSHS Coming This Summer to Radio TMHP: The CPW Program Out-of-State Providers Who Perform Services to Migrant Farm Workers Rate Change for Clinical Laboratory Panel Bekesy Audiometry is No Longer a Benefit of Texas Medicaid Evaluation of Oral and Pharyngeal Swallowing Function First Quarter 2009 HCPCS Updates Available Second Quarter HCPCS Updates Available July 1, Filing Claims for Uninsured Evacuees of Hurricane Dolly and Hurricane Ike Initial Reimbursement Rates Implemented for Mobility Aids PACT Transitioning to HHSC RHC Claims Filing and Family Planning Changes Initial Reimbursement Rate for Toilet Seat Lift Mechanism Implemented Online Fee Schedule Look-up Functionality Available Claims Billed with Manufacturer s Suggested Retail Price (MSRP) Product Classification List Change Texas Medicaid Claims Reprocessing Medicaid Integrity Group of the Centers for Medicare & Medicaid Services Conducting Audits of Some Providers.. 11 Personal Care Services Prior Authorization FAQs DME Reimbursement Rate Changes Reminder about Claims for IMD Services and Associated Professional Services Nonclinical Laboratory Reimbursement Rates Changed for Texas Medicaid Cytogenetics Testing Procedure Code Limitation Changes Molecular Laboratory Services Benefits Change Federal Stimulus Package Increases FMAP Rate For Federal Fiscal Year 2009 Quarters One and Two Removal of Cerumen Criteria Established Revised Texas Medicaid Fee Schedules Available Scheduled System Maintenance Continued on page 2 Copyright Acknowledgments Use of the American Medical Association s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2008 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/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use. 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 2008 American Dental Association. All Rights Reserved. Applicable FARS/DFARS restrictions apply.

2 CONTENTS Continued from page 1 Drugs That Require NDC for Texas Medicaid and CSHCN Services Program Reimbursement Issue with Duplicate Medicare Payments Updates to Previously Published Information Family Planning Providers 42 Use of Modifier FP to Change for Family Planning Services. 42 Home Health Providers 44 Mandatory Order Form for Home Health Services (Title XIX) DME/Medical Supplies Managed Care Providers 44 Primary Care Providers and THSteps Services Inpatient Stay Following Scheduled Day Surgery Anesthesia, Consultation, and Medical Procedure Codes Claims Reprocessing THSteps Dental Providers 45 New Dental Diagnostic Services are THSteps Benefits Update Corrections to Texas Medicaid Provider Procedures Manual THSteps Medical Providers 46 THSteps Medical Checkups in FQHC and RHC Facilities Update to THSteps Medical Checkups in 2009 Texas Medicaid Provider Procedures Manual Women s Health Program Providers 46 Occlusive Sterilization System Elective Abortions May Not Be Performed or Promoted Changes to Women s Health Program and Family Planning Benefits and Claims Filing Criteria Excluded Providers 53 Forms 59 Provider Information Change Form Electronic Funds Transfer (EFT) Authorization Agreement. 62 Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Types 31 and Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Type Certification of Compliance Contact Information Out-of-State Providers Who Perform Services to Migrant Farm Workers For additional information about Texas Medicaid, call the TMHP Contact Center at Effective for dates of service on or after July 1, 2009, out-of-state providers that render services to Primary Care Case Management (PCCM) clients who are migrant farm workers do not need a referral from the client s primary care provider. To be considered for reimbursement, providers must include modifier UC for each billed procedure code. Although these claims will initially be denied, the denied claims will be reprocessed and adjusted on the third week of every month starting July 22, No further action on the part of the provider is necessary. Claims that are denied for reasons other than a missing primary care provider referral are the responsibility of the provider and must be appealed. FQHC Out-of-State Providers Who Perform Services to Migrant Farm Workers Effective for dates of service on or after April 1, 2009, out-of-state federally qualified health center (FQHC) providers that render services to PCCM clients who are migrant farm workers do not need a referral from the client s primary care provider. To be considered for reimbursement, providers must include modifier UC for each billed procedure code. Claims submitted before May 7, 2009, without modifier UC will be reprocessed. Providers will not need to resubmit these claims. Although claims will initially be denied, the denied claims will be reprocessed and adjusted on the third week of every month starting May 4, No further action on the part of the provider is necessary. Claims that are denied for reasons other than a missing primary care provider referral are the responsibility of the provider and must be appealed. For additional information about Primary Care Case Management (PCCM) articles in this bulletin, call the PCCM Provider Helpline at For additional information about articles pertaining to the Children with Special Health Care Needs (CSHCN) Services Program, call the TMHP CSHCN Contact Center at Texas Medicaid Bulletin, No July/August 2009

3 Evaluation of Oral and Pharyngeal Swallowing Function Effective for dates of service on or after April 1, 2009, Comprehensive Care Program (CCP) speech language pathologist, provider type 50 (CCP Provider) and specialty A0 (Speech Therapy), may be reimbursed in the outpatient hospital setting for procedure code Rate Change for Clinical Laboratory Panel Effective March 27, 2009, procedure code (clinical laboratory panel) is reimbursed at the appropriate automated test panel (ATP) pricing in accordance with the Centers for Medicare & Medicaid Services (CMS) clinical laboratory fee schedule, which is available on the CMS website at /ClinicalLabFeeSched/01_overview.asp#TopOfPage. Additionally, procedure codes , , 5-G0306, and 5-G0307 will be reimbursed at a flat-fee rate and not at an ATP rate. The reimbursement rates for clinical laboratory procedure codes are available on the TMHP website at Providers may also refer to the 2009 Texas Medicaid Provider Procedures Manual section , Organ or Disease Panels, on page 26-6, section , Waiver Certificate, on page 26-2, and section , Hospital Laboratory Services, on page 25-32, for more information about clinical laboratory panels. Bekesy Audiometry is No Longer a Benefit of Texas Medicaid Effective May 15, 2009, procedure code 5/I is no longer a benefit of Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program. First Quarter 2009 HCPCS Updates Available On April 1, 2009, TMHP implemented the first quarter 2009 Healthcare Common Procedure Coding System (HCPCS) additions, changes, and deletions that are effective for dates of service on or after April 1, Deleted procedure codes are no longer benefits of Texas Medicaid, Medicaid Managed Care, or the CSHCN Services Program HCPCS Procedure Code Additions The following is a list of new procedure codes that do not replace existing procedure codes: Procedure Code 1-C K K S S S3870 Discontinued Procedure Codes Procedure code J-S8190 has been discontinued by CMS. Other Changes Procedure code 9-E1340 is no longer covered by Medicare, but it continues to be a benefit of Texas Medicaid and the CSHCN Services Program. Second Quarter HCPCS Updates Available July 1, 2009 On July 1, 2009, TMHP will implement second quarter 2009 HCPCS additions, changes, and deletions effective for dates of service on or after July 1, Deleted procedure codes will no longer be benefits of Texas Medicaid fee-forservice, Medicaid Managed Care, and the CSHCN Services Program. Details of these changes are available on the TMHP website at and will also be included in the September/October 2009 Texas Medicaid Bulletin, No. 225 and the November 2009 CSHCN Services Program Provider Bulletin, No. 72. July/August Texas Medicaid Bulletin, No. 224

4 Filing Claims for Uninsured Evacuees of Hurricane Dolly and Hurricane Ike The State of Texas has received a special Social Services Block Grant from the U.S. Department of Health and Human Services that can be used, in part, to process claims related to 2008 s Hurricane Ike and Hurricane Dolly for uninsured evacuees. A Medicaid provider may be reimbursed for services rendered to a hurricane evacuee who is uninsured and is not eligible for Medicaid. Hurricane Ike and Hurricane Dolly claims are exempt from prior authorization and 95-day filing deadline requirements. Funds for uninsured evacuees of Hurricane Dolly and Hurricane Ike are limited, and claims will be paid only until the funds are exhausted. Providers are encouraged to file claims as soon as possible. Claims will be accepted in three stages: 1) Hurricane Dolly Claims (dates of service from July 22, 2008, through September 19, 2008) Hurricane Ike Claims (with FEMA number) (dates of service from September 7, 2008, through November 7, 2008) Claim submission dates: May 1, 2009, through June 30, ) Hurricane Ike Claims (without FEMA number) - (dates of service from September 7, 2008, through October 5, 2008) Claim submission dates: July 1, 2009, through July 31, ) Hurricane Ike Claims (without FEMA number) (dates of service from October 6, 2008, through November 7, 2008) Claim submission dates: August 1, 2009, through August 31, The following Hurricane Ike/Hurricane Dolly claims will be denied: Claims that are filed with incomplete client information. Claims for which TMHP is unable to validate the information. A claim that is denied for either reason will include the explanation of benefits (EOB) message 00182, Client number invalid. Please resubmit with accurate client information. The provider must submit a claim that is denied with this EOB message as a new day claim with the complete, accurate client information. New day claims will be considered for reimbursement for: Medicaid enrolled providers. Medicaid covered services. Services to clients without other insurance coverage. Services delivered to U.S. citizens or legal permanent residents. Do not resubmit a denied claim as an appeal. All claims must be filed as new day claims and within the timeframes specified below. Providers will be required to complete an attestation indicating the following: Services were delivered to a disaster evacuee or related to the disaster. No other health insurance was available. Services were delivered to either a U.S. citizen or legal permanent resident. The attestation form is available on page 69 of this bulletin, and the TMHP website at The form must be submitted to the following address: Texas Medicaid & Healthcare Partnership Claims PO Box Austin, TX Hurricane Dolly dates of service from July 22, 2008, through September 19, 2008 To be considered for reimbursement for services rendered to uninsured evacuees of Hurricane Dolly, a claim must meet the following criteria: The provider must submit the claims during the period that begins May 1, 2009, and ends June 30, A claim for an inpatient hospital stay must have an admission date during the period that begins July 22, 2008, and ends September 19, The person to whom the services were provided: - - Must be an evacuee of Hurricane Dolly; and Must, as determined from the person s ZIP Code, have resided in the identified evacuation area for Hurricane Dolly. (Refer to the TMHP website for a list of affected counties and ZIP Codes). Texas Medicaid Bulletin, No July/August 2009

5 Funds for uninsured evacuees of Hurricane Dolly and Hurricane Ike are limited, and claims will be paid only until the funds are exhausted. The client s patient control number (PCN) must be FEMA information is not required for Hurricane Dolly claims. TexMedConnect submitters: The client s ID number must not be entered on the initial claim screen Claims Submission Step 1. The provider must leave the Client # field blank and advance to the next screen where the provider can manually enter the client s number and client information. Hurricane Ike (with FEMA number) dates of service from September 7, 2008, through November 7, 2008 To be considered for reimbursement for services rendered to uninsured evacuees of Hurricane Ike, a claim must satisfy the following criteria: The provider must submit the claims during the period that begins May 1, 2009, and ends June 30, A claim for an inpatient hospital stay must have an admission date during the period that begins September 7, 2008, and ends November 7, The person to whom the services were provided: - - Must be an evacuee of Hurricane Ike; and Must, as determined by the person s ZIP Code, have resided in the identified evacuation area for Hurricane Ike. (Refer to the TMHP website for a list of affected counties and ZIP Codes). The client s PCN must be TexMedConnect submitters: The client s ID number must not be entered on the initial claim screen Claims Submission Step 1. Providers must leave the Client # field blank and advance to the next screen where they can manually enter the client s number and client information. The claim must contain the 13-digit FEMA information number consisting of the 9-digit FEMA household number and the 4-digit disaster number (1791 for Hurricane Ike), and the word FEMA in claim fields as follows: Paper Claims CMS-1500 Field digit FEMA number (no dashes or special characters) and Field 11c the word FEMA UB-04 CMS-1450 Field digit FEMA number (no dashes or special characters) and Field 61 the word FEMA 2006 ADA Field 8 13-digit FEMA number (no dashes or special characters) and Field 5 the word FEMA Electronic Claims Electronic submitters must indicate the FEMA information in the corresponding other insurance electronic fields. TexMedConnect submitters: Refer to the TMHP website at File Library /TexMedConnect Requirements.pdf for information about other insurance fields and requirements. EDI submitters: Refer to the TMHP website at File Library /EDI Requirements.pdf for information about other insurance fields and requirements. Hurricane Ike (without FEMA number) dates of service from September 7, 2008, through October 5, 2008 A provider who did not obtain the FEMA number from the client can submit claims without the FEMA number as follows: The provider must submit the claims during the period that begins July 1, 2009, and ends July 31, A claim for an inpatient hospital stay must have an admission date during the period that begins September 7, 2008, and ends October 5, The person to whom the services were provided: - - Must be an evacuee of Hurricane Ike; and Must, as determined by the person s ZIP Code, have resided in the identified evacuation area for Hurricane Ike. (Refer to the TMHP website for a list of affected counties and ZIP Codes). The client s PCN must be TexMedConnect submitters: The client s ID number must not be entered on the initial claim July/August Texas Medicaid Bulletin, No. 224

6 screen Claims Submission Step 1. Providers must leave the Client # field blank and advance to the next screen where they can manually enter the client s number and client information. These claims will be placed on hold for review until the submission period ends (up to 30 days). HHSC will determine available funds, which may result in payments being reduced, and will direct TMHP to process claims accordingly. By accepting assignment, a provider specifically agrees that such payment is payment in full for these claims Important: By accepting assignment, a provider specifically agrees that such payment is payment in full for these claims, and the provider is prohibited from billing or seeking payment from a Hurricane Dolly and Hurricane Ike evacuee. Hurricane Ike (without FEMA number) dates of service from October 6, 2008, through November 7, 2008 The provider must submit the claims during the period that begins August 1, 2009, and ends August 31, A claim for an inpatient hospital stay must have an admission date during the period that begins October 6, 2008, and ends November 7, The person to whom the services were provided: - - Must be an evacuee of Hurricane Ike; and Must, as determined by the person s ZIP Code, have resided in the identified evacuation area for Hurricane Ike. (Refer to the TMHP website for a list of affected counties and ZIP Codes). The client s PCN must be TexMedConnect submitters: The client s ID number must not be entered on the initial claim screen Claims Submission Step 1. Providers must leave the Client # field blank and advance to the next screen where they can manually enter the client s number and client information. These claims will be placed on hold for review until the submission period ends (up to 30 days). HHSC will determine available funds, which may result in payments being reduced, and will direct TMHP to process claims accordingly. Important: By accepting assignment, a provider specifically agrees that such payment is payment in full for these claims, and the provider is prohibited from billing or seeking payment from a Hurricane Dolly and Hurricane Ike evacuee. Initial Reimbursement Rates Implemented for Mobility Aids Effective for dates of services on or after April 1, 2009, Texas Medicaid implemented initial reimbursement rates for some mobility aids procedure codes. Initial reimbursement rates for procedure codes are as follows: TOS Procedure Code Reimbursement Rate J E0628 $ J E0629 $ J E1010 $1, J E2300 $2, PACT Transitioning to HHSC Effective September 1, 2009, the Program for Amplification for Children of Texas (PACT) will transition from DSHS to the Health and Human Services Commission (HHSC). The new program will be called Hearing Services for Children (HSC) and will be administered by TMHP. Beginning May 2009, TMHP began reaching out to providers currently contracted with DSHS to provide PACT services to Texas Medicaid clients with information about how the program will be administered, how to enroll with Texas Medicaid and the CSHCN Services Program, and how to obtain reimbursement under the administration of the HSC program. A special HSC webpage has been created to give updates as the transition from DSHS to HHSC occurs. Providers can access this page by clicking on the Providers tab on the TMHP website at Texas Medicaid Bulletin, No July/August 2009

7 RHC Claims Filing and Family Planning Changes This is a clarification about claim billing requirements for rural health clinics (RHCs). RHCs are reimbursed for general medical services (procedure code T1015) and copayments (procedure codes CP001, CP002, CP005, and CP006) using their RHC national provider identifier (NPI). Providers performing services in the RHC setting are reimbursed for Texas Health Steps (THSteps) medical services and family planning services for Women s Health Program (WHP) clients and Titles V, XIX, and XX clients using the appropriate provider identifier, benefit code, and place of service 72. Note: Providers may refer to the National Provider Identifier Special Bulletin, No. 217, for more information about benefit codes. RHC Claim Filing Requirements Clarification The following information updates the 2009 Texas Medicaid Provider Procedures Manual section 41.4, Benefits and Limitations, on page Update The services listed in the table below may be reimbursed to RHC providers using the RHC s NPI: General Medical Services T1015 General medical services must be billed using one of the following appropriate modifiers: AJ, AH, AM, SA, TD, TE, TH, or U7. Copayments CP001 CP002 CP005 CP006 The following THSteps medical checkups must be billed using the appropriate provider identifier and benefit code EP1 and place of service 72: THSteps Medical Services THSteps medical services must be billed using modifier EP and one of the following modifiers AM, SA, or U7. Family Planning Claim Filing Changes The following information updates the 2009 Texas Medicaid Provider Procedures Manual section 41.4, Benefits and Limitations, on page 41-2, and section O.4.2.3, Family Planning Billing Procedures by FQHCs and RHCs, on page O-3. Effective Dates WHP changes are effective for dates of service on or after April 1, Exception: Modifier FP changes will not be effective until July 1, Providers must use modifier FP as usual on claims billed with dates of service on or after April 1, 2009, through June 30, Title V, XIX, and XX family planning changes are effective for dates of service on or after July 1, Modifier FP changes are effective for dates of service on or after July 1, 2009, and not for the July 1, 2009, implementation date regardless of date of service as previously indicated. For example: For an evaluation and management (E/M) family planning service performed on June 29, 2009, and submitted July 13, 2009, modifier FP must be billed with the procedure code. For a service performed July 2, 2009, and submitted July 13, 2009, modifier FP must be billed only with an annual family planning examination. Update The following family planning services (including implantable contraceptive capsules provision, insertion, or removal) must be billed using the appropriate provider identifier and benefit code and place of service 72: Family Planning Services* ** 99204** ** 99214** J7300** J7302** * Family planning services performed in the RHC setting must be billed with the appropriate modifier: AJ, AM, SA, or U7. ** For Title V and XX clients, only procedure codes 99203, 99204, 99213, 99214, J7300, and J7302 may be billed for family planning services. Family planning services must be billed with the most appropriate E/M procedure code and one of the following family planning diagnosis codes: Diagnosis Codes* V2501 V2502 V2504 V2509 V251 V252 V2540 V2541 V2542 V2543 V2549 V255 V258 V259 V2651 V2652** * One of the diagnosis codes in this table must be included in Block 24 E of the CMS-1500 claim form referencing the appropriate procedure code. **Diagnosis code V2652 is not covered by the WHP. July/August Texas Medicaid Bulletin, No. 224

8 The annual family planning examination must be billed with the most appropriate E/M procedure code, the most appropriate family planning diagnosis code, and modifier FP. Modifier FP must not be billed with any other family planning visit. Claims filed incorrectly may be denied. Reminder: One new patient E/M procedure code is allowed only when three years have elapsed since the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group. For example, if a new patient medical E/M service has been reimbursed, any E/M visit, whether medical or family planning, provided during the subsequent three-year period by the same provider must be billed as an established patient visit. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual section 41.4, Benefits and Limitations, on page 41-2; section O.4.2.3, Family Planning Billing Procedures by FQHCs and RHCs, on page O-3; section , Freestanding Rural health Clinic Services, on page 41-3; and section , Hospital-Based Rural Health Clinic Services, on page 41-4, for more information about RHC claims filing and reimbursement. Product Classification List Change Since August 18, 2008, the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) product classification list, which was previously published by Palmetto Government Benefits Administrator (GBA), has been published by Noridian Administrative Services LLC, as the Pricing, Data Analysis, and Coding (PDAC) product classification list. Providers can visit the Noridian website at for additional information. Initial Reimbursement Rate for Toilet Seat Lift Mechanism Implemented Effective for dates of services on or after April 1, 2009, procedure code J-E0172 is a benefit of Texas Medicaid. The initial reimbursement rate for procedure code J-E0172 is $1,963.90, which was adopted following a public rate hearing on February 17, Online Fee Schedule Look-up Functionality Available Effective June 26, 2009, TMHP implemented online fee schedule lookup functionality on the TMHP website at for Texas Medicaid and the CSHCN Services Program. Providers will be able to do the following: Retrieve fee schedule information in real time. Search for procedure code reimbursement rates individually, in a list or in a range. Search and review their contracted rates. Retrieve up to 24 months of history for a procedure code by searching for specific dates of service within that 2-year period. Search for benefits and limitations for dental and DME procedure codes. A computer based training (CBT) will be available for providers to use beginning in July More details of these fee schedule enhancements will be made available in a future provider notification and on the TMHP website. Claims Billed with Manufacturer s Suggested Retail Price (MSRP) Ordinarily, claims submitted to TMHP must reflect the provider s usual and customary fee for the services provided. The billed charges must not be higher than the fee charged to other carriers or private pay patients. This process is different when billing for durable medical equipment (DME), expendable supplies, and nutritional products that have no established fee. DME and expendable supplies, other than nutritional products, that have no established fee are subject to manual pricing at the documented MSRP less 18 percent or at the provider s documented invoice cost. Nutritional products that have no established fee are subject to manual pricing at the documented average wholesale price (AWP) less 10.5 percent or at the provider s documented invoice cost. These items require prior authorization. The dollar amount billed must match the amount that was prior authorized. Texas Medicaid Bulletin, No July/August 2009

9 Texas Medicaid Claims Reprocessing The following claims issues have been identified. All affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Ambulatory Surgical Centers Claims TMHP has identified an issue that impacts ambulatory surgical center claims with dates of service on or after August 1, 2005, and procedure codes ranging from F through F Claims may have been denied in error with the explanation of benefits message These services are not in accordance with Medical Policy. Following is the complete list of the procedure codes that may have denied in error: Procedure Codes July/August Procedure Codes Attendance at Delivery Claims Reprocessing TMHP has identified an issue that impacts claims submitted before March 5, 2009, with dates of service on or after January 1, 2009, and procedure code Claims may have been denied in error with an EOB message that indicated that the services are not in line with medical policy. Procedure code may be reimbursed in line with medical policy and does not require medical review. Hearing Aid Devices Claims TMHP has identified issues that affect claims billed with dates of service from December 2, 2008, through March 24, 2009, and some hearing devices and services procedure codes. Effective for dates of service on or after December 2, 2008, hearing aid devices are limited to one device per ear every five rolling years. The following monaural procedure codes must be billed with modifier LT or RT: Procedure Codes R-V5030 R-V5040 R-V5170 R-V5180 R-V5244 R-V5245 R-V5246 R-V5247 R-V5254 R-V5255 R-V5256 R-V5257 For dates of service before December 2, 2008, modifier LT or RT was not required for monaural hearing aid device procedure codes. As a result, some claims for second hearing aid devices with dates of service on or after December 2, 2008, through March 24, 2009, may have been paid inappropriately. Effective March 24, 2009, when submitting hearing aid claims for clients who have received another monaural hearing aid through Texas Medicaid within the last five years, providers must include documentation that indicates for which ear the previous hearing aid was reimbursed. This additional documentation is not necessary if modifier LT or RT was included on the claim for the first device. Texas Medicaid Bulletin, No. 224

10 If it is unclear for which ear the first device was reimbursed (i.e., modifier LT or RT is not on the claim for the first device), for claims submitted with dates of service from December 2, 2008, through March 24, 2009, the claim for the second device may be reprocessed and denied with EOB code indicating, This service exceeds benefit limitations but may be paid with medical necessity documentation. Please appeal with appropriate documentation. If it is unclear for which ear the first hearing aid device was reimbursed (i.e., modifier LT or RT is not on the claim for the first device), for claims submitted with dates of service on or after March 25, 2009, and there is no documentation submitted with the claim for the second device indicating for which ear the first device was reimbursed, the claim for the second device will be denied with EOB code indicating, This service exceeds benefit limitations but may be paid with medical necessity documentation. Please appeal with appropriate documentation. If the claim for a hearing aid procedure code is denied because a monaural hearing aid procedure code without a modifier was reimbursed in the last five years, providers must submit documentation with the claim for the second monaural hearing aid procedure code that shows the ear for which the first device was purchased. Necessary documentation may include, but is not limited to, a note in the client s medical record that indicates the ear for which the first hearing aid was purchased and fitted. Additionally, the following issues concerning hearing aid devices have been corrected: Claims billed with procedure code R-V5014 may have been denied in error with an EOB message that indicates prior authorization is required. Procedure code R-V5014 for repair or modification of the hearing aid device may be reimbursed once per year after the 12-month manufacturer s warranty period has expired. Prior authorization is only required for additional repairs beyond one per year and is considered with documentation supporting the need for the additional repair. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Procedure code R-V5110, R-V5160, and R-V5240 may have been denied in error when they were billed with a hearing aid device procedure code. One dispensing fee is allowed per hearing aid device procedure code. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Providers may refer to the website article published November 14, 2008, titled, Benefits to Change for Hearing Devices and Related Services for Texas Medicaid, for more information about hearing devices benefits that were effective for dates of service on or after December 2, Family Planning Claims Reprocessing for Clients with Retroactive Title XIX Eligibility TMHP has identified an issue that impacts claims that were reimbursed under the Family Planning Titles V or XX program with dates of service from May 11, 2007, through August 28, Claims for clients who received retroactive Title XIX eligibility for that period of time will be recouped and will be reimbursed under the Title XIX program. The provider s Titles V or XX Remittance and Status (R&S) Report will show that the Title V or XX claim was adjusted, an accounts receivable was set up, and the adjusted claim will appear as paid on the provider s Title XIX R&S Report. Individual providers will be contacted by DSHS regarding any necessary recoupment of outstanding fiscal year 2007 and fiscal year 2008 Title V or Title XX accounts receivables. Intrauterine Contraceptive System Claims Submitted by FQHCs TMHP has identified an issue that impacts claims submitted by Federally Qualified Health Centers (FQHCs) with dates of service on or after September 1, 2008, and procedure code 1-J7302. These claims may have been denied in error with the EOB message This procedure not covered for this provider type. Newborn Resuscitation for Texas Medicaid and the CSHCN Services Program Effective June 1, 2009, for dates of service on or after January 1, 2009, newborn resuscitation (procedure code ) will be denied if billed on the same date of service by the same provider as neonatal critical care (procedure code ) or initial hospital care (procedure code ). Reimbursement of these services is limited by National Correct Coding Initiative (NCCI) guidelines. Urinary Catheters Services Claims TMHP has identified an issue that affects claims with dates of service from April 1, 2007, through February 19, 2009, and procedure code 9-A4351 or 9-A4352. These claims may have been denied in error with the EOB message, This procedure is part of another procedure/service billed on the same day. Providers can bill procedure code 9-A4351 and 9-A4352 on the same day for the same client when needed. Texas Medicaid Bulletin, No July/August 2009

11 Medicaid Integrity Group of the Centers for Medicare & Medicaid Services Conducting Audits of Some Providers Texas Medicaid is being audited by the Centers for Medicare & Medicaid Services Medicaid Integrity Group (CMS-MIG). CMS-MIG will assess claims for payment for items or services submitted by Texas Medicaid providers. A Medicaid Integrity Contractor (MIC), Health Management Systems (HMS), may ask Medicaid providers for medical records documentation and other information as part of the audit. Section 6034 of the Deficit Reduction Act (DRA) of 2005 (Public Law ) requires the Centers for Medicare & Medicaid Services (CMS) to review the actions of persons or entities that furnish services or items under a state s Medicaid program. The CMS-MIG will assess Texas Medicaid. HMS, will audit claims payments for items or services submitted by some Texas Medicaid providers. The audit is designed to identify instances of fraud, abuse, or waste, to include overpayments to individuals or entities for services or items. HMS may ask selected Medicaid providers for medical records documentation and other information as part of the audit. The audit is intended to determine whether Medicaid provider payments were: For services provided and properly documented. For services billed properly using the appropriate procedure codes. For covered services. Reimbursed appropriately according to State policies, rules, or regulations. CMS-MIG has contracted with the following MICs to perform these audits: As the Audit MIC, HMS will conduct post-payment audits of Medicaid providers, perform a combination of field audits and desk reviews, identify overpayments, and initiate fraud referrals. As the Review MIC, AdvanceMed will review providers to identify potential inappropriate or unnecessary Medicaid expenditure of funds and potential fraud, waste, and abuse through data analysis, and perform risk assessments of Medicaid data including, but not limited to, claims for payment under Title XIX Medicaid. CMS-MIG plans to select an Education MIC to educate providers, beneficiaries, and others about payment integrity and quality of care issues. HMS will notify providers who are selected for audit and will request medical records and supporting documentation. The provider must furnish medical records and other appropriate information within the requested timeframe. Failure to do so may result in payment recoupment from the provider. Section 1902(a)(27) of the Social Security Act requires a Medicaid provider to retain records necessary to fully disclose the extent of services provided to a Medicaid client and to furnish CMS with information about any claims for payment for services rendered. The release of patient medical records to HMS is allowed by federal law and Texas Medicaid policy. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law ) and federal regulations that implement HIPAA (45 C.F.R. parts 160 and 164) authorize the collection and review of protected health information contained in individual-level medical records for payment review purposes. Providers may also refer to Release of Confidential Information on page 1-13 of the Texas Medicaid Provider Procedures Manual. To ensure the HMS request for documentation can be properly delivered, all providers should verify that their contact information is up-to-date in the online provider lookup on the TMHP website at If the information is incorrect, it can be updated online. Keeping contact information current is a contract requirement for Medicaid providers. Providers selected for audit will have an opportunity to review and comment on HMS preliminary findings prior to a final report being issued to HHSC and CMS- MIG. A provider may be required to refund any amounts HMS determines were incorrectly paid. Providers selected for audit will be given specific instructions on how any refunds are to be paid or recouped, and how audit determinations may be appealed. July/August Texas Medicaid Bulletin, No. 224

12 Personal Care Services Prior Authorization FAQs The TMHP Personal Care Services (PCS) Prior Authorization Frequently Asked Questions (FAQs) are available below and on the Alberto N. Related Information page of the TMHP website at TMHP PCS Prior Authorization FAQs Does a provider need prior authorization to provide PCS? Yes, a PCS prior authorization number (PAN) is required to provide and bill for PCS. Providers who have been approved to perform PCS will receive a provider notification letter. The provider notification letter will include the PAN, the number of hours of PCS that a client is authorized to receive, and the beginning and ending dates of the period for which the authorization is valid. A provider must have a current, unexpired PAN to provide PCS. Prior authorization is a condition of reimbursement, but is not a guarantee of payment. How does a provider receive client contact information when the provider has received a PCS prior authorization for a client transferring from another provider? DSHS will fax to providers a Communication Tool that includes the client s name, address, telephone number, and the types of PCS tasks with which the client needs assistance. What should providers do if they do not receive a Communication Tool from DSHS? If providers do not receive a Communication Tool from the DSHS case manager, they should call their DSHS Regional Office and ask to have a copy of the Communication Tool faxed to them. What number of PCS hours should the provider give when a provider receives a provider notification letter with more than one time period? When the provider notification letter includes two time periods, each of which has a beginning and ending date of service, the provider notification letter will specify the number of PCS hours to be delivered during each time period. It is the provider s responsibility to ensure that the authorized hours are provided during the specified time period. TMHP will not send separate letters for each time period. If providers have questions about the provider notification letter, they should call the TMHP PCS Prior Authorization Inquiry Line at to verify the PCS authorization or obtain a copy of the provider notification letter. Does a provider need a new prior authorization if a client s condition or needs have changed during the six-month PCS authorization period? Yes, if a client s condition or needs have changed, the client, parent, guardian, or PCS provider should notify the client s DSHS Regional Office. A DSHS case manager will perform a new assessment and, if necessary, update the quantity of PCS on the prior authorization request. If any changes to the original authorization are required, TMHP will issue an updated PAN and notify the client, parent, or guardian and the PCS provider. If the authorization is modified during the current authorization period, the updated prior authorization for the modified services will start a new six-month authorization period. What if a client needs PCS for more than a six-month authorization period? A DSHS case manager will reassess the client before the end of the current six-month authorization. If the client still needs PCS, the DSHS case manager will request an updated six-month authorization. TMHP will send notification letters to the client, parent, or guardian and the PCS provider after the authorization has been processed. Texas Medicaid Bulletin, No July/August 2009

13 Who can providers call for PCS authorization questions? Providers can call the toll-free TMHP PCS Prior Authorization Inquiry line at The PCS Prior Authorization Inquiry Line will help providers: Verify a PCS authorization. Check the status of a PCS authorization. Obtain a copy of a PCS provider notification letter. Update their Texas Provider Identifiers (TPIs) on PCS authorizations. What should providers do if the authorization period is about to expire and they have not received a provider notification letter for another six-month authorization? If providers realize that the authorization period is about to expire and they have not yet received an updated provider notification letter from TMHP, they can: Call the TMHP PCS Prior Authorization Inquiry Line at and check to see if an authorization is in process. Call the TMHP PCS Client Line at , Option 2, and ask for a referral to DSHS to have a reassessment conducted. Call the DSHS Regional Office and let the DSHS case manager know that a new authorization has not been received. What should providers do if the authorization period has already expired? A provider must have an authorization to deliver PCS. Providers that continue to provide services after an authorization has expired will not be paid for those services. If the authorization has already expired, providers must obtain a new authorization before providing PCS services. To obtain a new PCS authorization, providers should call the: TMHP PCS Client Line at , Option 2, and ask for a referral to DSHS to have a reassessment conducted. DSHS Regional Office and let the DSHS case manager know that a new authorization has not been received. How can a provider within an unrelated organization update an incorrect TPI on a PCS authorization? If a provider receives a provider notification letter with the TPI of a provider that is not a related organization, the provider should call the toll-free TMHP PCS Prior Authorization Inquiry Line at TMHP will work with DSHS to update the PCS authorization with the correct TPI and send out a new provider notification letter to the provider. How can a provider within a related organization update an incorrect TPI on a PCS authorization? If a provider receives a provider notification letter with the TPI of a provider that is in a related organization, the provider should call the toll-free TMHP PCS Prior Authorization Inquiry Line at TMHP will update the PCS authorization with the correct TPI and send out a new provider notification letter to the provider. Is there an FAQ for PCS billing questions? Yes, PCS billing questions are answered in the Billing FAQ, which can be found by clicking on the Alberto N. Related Information link on the TMHP website at July/August Texas Medicaid Bulletin, No. 224

14 DME Reimbursement Rate Changes Effective for dates of services on or after April 1, 2009, Texas Medicaid reimbursement rates changed for the following DME procedure codes: TOS Procedure Code Reimbursement Rate J E0130 $59.07 J E0135 $75.88 J E0141 $96.08 L E0141 $17.20 J E0143 $ L E0143 $16.61 J E0147 $ J E0148 $ L E0148 $11.51 J E0149 $ L E0149 $20.20 J E0154 $63.81 J E0159 $16.17 J E0161 $23.41 J E0162 $ L E0162 $13.64 J E0165 $ J E0168 w/tg Modifier $1, J E0181 $ L E0181 $27.36 J E0187 $ L E0187 $24.37 L E0193 $ J E0196 $ J E0199 $32.77 J E0218 $ L E0225 $40.23 J E0235 $ L E0235 $18.12 J E0246 $45.10 J E0255 $1, L E0255 $ J E0260 $1, L E0260 $ J E0265 $1, TOS = Type of Service, J = New DME, L = Leased or Rental, 9 = Other DME TOS Procedure Code Reimbursement Rate L E0265 $ J E0275 $16.08 J E0276 $13.97 L E0277 $ L E0304 $ L E0325 $ E0352 $10.00 J E0371 $4, L E0371 $ J E0372 $4, L E0372 $ J E0373 $5, L E0373 $ J E0459 $ L E0464 $1, L E0470 $ L E0483 $1, L E0580 $13.40 J E0600 $ J E0601 $ L E0601 $93.02 J E0603 $ J E0610 $ J E0630 $1, J E0651 $ L E0651 $96.44 L E0655 $11.31 L E0660 $17.07 L E0665 $14.49 J E0667 $ L E0667 $38.39 J E0710 $34.57 L E0710 $3.46 J E0791 $3, L E0791 $ J E0910 $ L E0910 $18.10 J E0911 $ TOS = Type of Service, J = New DME, L = Leased or Rental, 9 = Other DME Texas Medicaid Bulletin, No July/August 2009

15 TOS Procedure Code Reimbursement Rate L E0911 $45.11 J E0912 $1, L E0912 $ J E0920 $ J E0930 $ L E0935 $23.87 L E0936 $76.80 J E0941 $ L E0941 $45.58 J E0969 $ J E1015 $ J E1017 $ J E1035 $3, J E1092 $1, J E1093 $1, J E1100 $1, J E1110 $1, L E1110 $ J E1170 $ J E1171 $ J E1300 $1, L E1300 $ J E1355 $22.40 L E1390 $ J E1520 $ L E1520 $39.31 L E1530 $56.56 J E1550 $ L E1550 $29.79 L E1575 $0.16 TOS = Type of Service, J = New DME, L = Leased or Rental, 9 = Other DME TOS Procedure Code Reimbursement Rate J E1594 $5, L E1594 $ L E1600 $ L E1636 $1, J E1637 $2.50 L E1700 $30.18 J E1800 $1, J E1801 $1, J E1805 $1, J E1806 $1, J E1810 $1, J E1811 $1, J E1812 $ J E1815 $1, J E1816 $1, J E1818 $1, J E1821 $ J E1825 $1, J E1830 $1, J E1840 $3, L E1841 $4, J E2321 w/kc Modifier $2, J E2343 $ J E2373 w/kc Modifier $1, J E2502 $1, L E2502 $ J E2511 $ L E2512 $89.90 J E2621 $ TOS = Type of Service, J = New DME, L = Leased or Rental, 9 = Other DME Reminder about Claims for IMD Services and Associated Professional Services Institute for mental diseases (IMD) services and any associated professional services provided to clients who are 21 years of age through 64 years of age and who reside in an IMD facility are not a benefit of Texas Medicaid. All claims for IMD services and associated professional services rendered to these clients that have been paid in error by Texas Medicaid will be recouped, and payments will be adjusted accordingly. July/August Texas Medicaid Bulletin, No. 224

16 To make a referral to CPW, call THSTEPS or obtain a Physician Referral Form at dshs.state.tx.us/caseman/forms.shtm. Texas Medicaid Bulletin, No July/August 2009

17 Nonclinical Laboratory Reimbursement Rates Changed for Texas Medicaid Effective for dates of services on or after April 1, 2009, some nonclinical laboratory reimbursement rates changed for Texas Medicaid. The reimbursement rates were adopted following a public rate hearing that was held on February 17, 2009, and apply to clients of all ages. Additional provider specialties or provider types were added for some of the procedure codes listed in the following table. The notes section in the table lists the additional provider types or provider specialties that are payable for a procedure code. If a procedure code has no note, the payable provider types and provider specialties for the procedure code have not changed. The notes key is as follows: 1) 2) These reimbursement rate changes also apply to independent labs/privately owned labs (no physician involvement), independent labs/privately owned labs (physician involvement), radiological labs, portable X-ray suppliers, radiological labs, and physiological labs. These reimbursement rate changes also apply to independent labs/privately owned labs (no physician involvement), independent labs/privately owned labs (physician involvement), nephrology (hemodialysis, renal dialysis), radiological labs, portable X-ray suppliers, radiological labs, and physiological labs. 3) These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. 4) Payable also to pathologists. 5) Payable also to nurse/midwife. 6) Payable also to pathologists and radiologists. The following reimbursement rates are effective April 1, 2009, for nonclinical laboratory services: TOS Procedure Code Reimbursement Rate Notes $23.48 (0.82 Relative Value Unit [RVU], $ $ $ $50.98 (1.78 RVUs, $ $16.91 (1.24 RVUs, $ /I $68.16 (2.38 RVUs, $ $14.46 (0.53 RVU, $ /I $38.66 (1.35 RVUs, $ $39.24 (1.37 RVUs, $ I $39.24 (1.37 RVUs, $ $39.52 (1.38 RVUs, $ I $39.52 (1.38 RVUs, $ $4.30 5/I $5.18 (0.19 RVU, $ /I $5.18 (0.19 RVU, $ $ $16.99 I $ $29.71 I $ July/August Texas Medicaid Bulletin, No. 224

18 TOS Procedure Code Reimbursement Rate Notes $16.98 I $ $14.06 I $ $16.00 I $ $34.02 I $ $ /I $ $ $50.07 I $ T $ $59.86 (2.09 RVUs, $ I $21.77 (0.76 RVU, $ T $38.09 (1.33 RVUs, $ $76.63 I $ T $ $59.66 I $ T $ $88.37 I $47.73 T $ $42.46 I $ T $ $47.42 I $ T $ $74.26 I $ T $ $51.94 I $ T $ $ (3.65 RVUs, $ I $54.13 (1.89 RVUs, $ T $50.41 (1.76 RVUs, $ $ I $ Texas Medicaid Bulletin, No July/August 2009

19 TOS Procedure Code Reimbursement Rate Notes T $65.64 I $50.98 (10.47 RVUs, $ I $62.72 (2.19 RVUs, $ I $79.91 (2.79 RVUs, $ $21.55 (0.79 RVU, $ $23.08 I $ $48.33 I $6.49 (10.47 RVUs, $ $61.31 I $ $ I $ $ I $ $ (8.66 RVUs, $ I $ (3.77 RVUs, $ $16.05 I $ $77.61 (2.71 RVUs, $ I $20.91 (0.73 RVU, $ $65.37 I $ $87.28 I $ $77.90 (2.72 RVUs, $ I $16.32 (0.57 RVU, $ $ I $ $70.45 (2.46 RVUs, $ I $47.26 (1.65 RVUs, $ $31.50 (1.10 RVUs, $ I $23.20 (0.81 RVU, $ $77.90 (2.72 RVUs, $ I $32.65 (1.14 RVUs, $ $78.19 (2.73 RVUs, $ I $33.22 (1.16 RVUs, $ $61.86 (2.16 RVUs, $ I $31.79 (1.11 RVUs, $ $ I $ $ I $ July/August Texas Medicaid Bulletin, No. 224

20 TOS Procedure Code Reimbursement Rate Notes $ I $ $ I $ $ $ I $ $ (4.17 RVUs, $ $ I $ $ I $ $ I $ $ $ (14.36 RVUs, $ $ (18.39 RVUs, $ $ (6.53 RVUs, $ /I $ (6.62 RVUs, $ /I $ (6.80 RVUs, $ /I $ (5.76 RVUs, $ /I $ (6.56 RVUs, $ /I $ (7.84 RVUs, $ /I $ (5.56 RVUs, $ /I $ (6.51 RVUs, $ /I $ (6.73 RVUs, $ $11.18 (0.41 RVU, $ $ $ I $ $ I $ $ I $7.27 5/I $ /I $ $22.63 (0.79 RVU, $ I $22.63 (0.79 RVU, $ $12.60 (0.44 RVU, $ I $12.60 (0.44 RVU, $ $19.48 (0.68 RVU, $ I $19.48 (0.68 RVU, $ Texas Medicaid Bulletin, No July/August 2009

21 TOS Procedure Code Reimbursement Rate Notes 5/I $39.52 I $ $ I $22.63 I $ $16.04 (0.56 RVU, $ I $16.04 (0.56 RVU, $ I $15.47 (0.54 RVU, $ $ I $ /I $ $14.32 (0.50 RVU, $ I $14.32 (0.50 RVU, $ /I $ /I $12.27 (0.45 RVU, $ /I $12.82 (0.47 RVU, $ /I $25.91 (0.95 RVU, $ $16.90 I $16.61 (0.58 RVU, $ /I $ $34.65 (0.79 RVU, $ /I $ $ I $ $ I $19.37 (0.71 RVU, $ T $55.92 (2.05 RVUs, $ $48.97 (1.71 RVUs, $ $ T $ $ I $18.03 T $ $15.82 (0.58 RVU, $ T $9.00 (0.33 RVU, $ I $6.82 (0.25 RVU, $ $ (5.05 RVUs, $ $75.83 (2.78 RVUs, $ $ (5.91 RVUs, $ $10.09 (0.37 RVU, $ $90.28 (3.31 RVUs, $ $92.47 (3.39 RVUs, $ July/August Texas Medicaid Bulletin, No. 224

22 TOS Procedure Code Reimbursement Rate Notes $ $ (3.39 RVUs, $ $16.37 (3.39 RVUs, $ $ (3.39 RVUs, $ $30.82 (1.13 RVUs, $ I $9.82 (0.36 RVU, $ T $21.00 (0.77 RVU, $ $35.43 I $18.00 (0.66 RVU, $ T $ $16.56 I $5.73 (0.21 RVU, $ T $ $25.64 (0.94 RVU, $ $34.91 (1.28 RVUs, $ I $6.27 (0.23 RVU, $ $ (9.28 RVUs, $ I $ (7.41 RVUs, $ T $51.01 (1.87 RVUs, $ I $35.19 (1.29 RVUs, $ T $35.19 (1.29 RVUs, $ I/T $58.37 (2.14 RVUs, $ /I/T $31.91 (1.17 RVUs, $ I/T $30.00 (1.10 RVUs, $ I/T $48.01 (1.76 RVUs, $ I/T $30.82 (1.13 RVUs, $ $7.36 (0.27 RVU, $ I $6.00 (0.22 RVU, $ T $1.36 (0.05 RVU, $ $6.55 (0.24 RVU, $ I $6.00 (0.22 RVU, $ T $0.55 (0.02 RVU, $ $49.37 (1.81 RVUs, $ $22.37 (0.82 RVU, $ $12.55 (0.46 RVU, $ $14.46 (0.53 RVU, $ $24.82 (0.91 RVU, $ I $6.27 (0.23 RVU, $ T $18.55 (0.88 RVU, $ $36.55 (1.34 RVUs, $ $17.73 (0.65 RVU, $ $18.82 (0.69 RVU, $ Texas Medicaid Bulletin, No July/August 2009

23 TOS Procedure Code Reimbursement Rate Notes $57.71 I $14.43 T $ $45.55 (1.67 RVU, $ I $21.55 (0.79 RVU, $ T $24.00 (0.88 RVU, $ $16.91 (0.62 RVU, $ I $3.00 (0.11RVU, $ T $13.91 (0.51 RVU, $ $16.91 (0.62 RVU, $ I $4.09 (0.15 RVU, $ T $12.82 (0.47 RVU, $ $38.95 I $ $18.27 (0.67 RVU, $ I $4.09 (0.15 RVU, $ T $14.18 (0.52 RVU, $ $23.73 (0.87 RVU, $ I $4.64 (0.17 RVU, $ T $19.09 (0.70 RVU, $ $26.18 (0.96 RVU, $ I $9.27 (0.34 RVU, $ T $16.91 (0.62 RVU, $ $32.73 (1.20 RVUs, $ I $9.27 (0.34 RVU, $ T $23.46 (0.86 RVU, $ $25.09 (0.92 RVU, $ I $9.27 (0.34 RVU, $ T $15.82 (0.58 RVU, $ $27.82 (1.02 RVUs, $ I $10.91 (0.40 RVU, $ T $16.91 (0.62 RVU, $ $39.82 (1.46 RVUs, $ I $14.73 (0.54 RVU, $ T $25.09 (0.92 RVU, $ $37.91 (1.39 RVUs, $ I $14.18 (0.52 RVU, $ T $23.73 (0.87 RVU, $ $54.28 (1.99 RVUs, $ I $23.18 (0.85 RVU, $ T $31.09 (1.14 RVUs, $ $ (4.46 RVUs, $ July/August Texas Medicaid Bulletin, No. 224

24 TOS Procedure Code Reimbursement Rate Notes I $53.19 (1.95 RVUs, $ T $68.46 (2.51 RVUs, $ $43.37 (1.59 RVUs, $ I $9.27 (0.34 RVU, $ T $34.10 (1.25 RVUs, $ $47.46 (1.74 RVUs, $ I $7.09 (0.26 RVU, $ T $40.37 (1.48 RVUs, $ $37.91 (1.39 RVUs, $ I $2.73 (0.10 RVU, $ T $35.19 (1.29RVUs, $ $38.73 (1.42 RVUs, $ I $9.27 (0.34 RVU, $ T $29.46 (1.08 RVUs, $ $50.46 (1.85 RVUs, $ I $9.27 (0.34 RVU, $ T $41.19 (1.51 RVUs, $ $53.19 (1.95 RVUs, $ I $8.18 (0.30 RVU, $ T $45.01 (1.65 RVUs, $ $2.18 (0.08 RVU, $ $4.36 (0.16 RVU, $ $27.55 (1.01 RVUs, $ I $5.46 (0.20 RVU, $ T $22.09 (0.81 RVU, $ $ I $59.48 T $ $ (11.69 RVUs, $ I $69.01 (2.53 RVUs, $ T $ (9.16 RVUs, $ $ (17.89 RVUs, $ I $97.10 (3.56 RVUs, $ T $ (14.33 RVUs, $ $ (21.28 RVUs, $ I $ (4.69 RVUs, $ T $ (16.59 RVUs, $ $ (23.44 RVUs, $ I $ (5.04 RVUs, $ T $ (18.40 RVUs, $ $ (6.52 RVUs, $ I $40.64 (1.49 RVUs, $ Texas Medicaid Bulletin, No July/August 2009

25 TOS Procedure Code Reimbursement Rate Notes T $ (5.03 RVUs, $ $ (7.99 RVUs, $ I $64.64 (2.37 RVUs, $ T $ (5.62 RVUs, $ $ (5.98 RVUs, $ I $40.64 (1.49 RVUs, $ T $ (4.49 RVUs, $ $ (6.42 RVUs, $ I $40.64 (1.49 RVUs, $ T $ (4.93 RVUs, $ $ (6.40 RVUs, $ I $40.64 (1.49 RVUs, $ T $ (4.91 RVUs, $ $ I $27.82 (1.02 RVUs, $ T $ $ (10.33 RVUs, $ I $40.10 (1.47 RVUs, $ T $ (1.23 RVUs, $ $ (33.20 RVUs, $ I $ (8.69 RVUs, $ T $ (24.51 RVUs, $ /I $19.09 (0.70 RVU, $ /I $18.00 (0.66 RVU, $ /I $26.46 (0.97 RVU, $ /I $31.37 (1.15 RVUs, $ /I $12.27 (0.45 RVU, $ /I $9.55 (0.35 RVU, $ /I $30.82 (1.13 RVUs, $ $60.83 (2.23 RVUs, $ I $37.10 (1.36 RVUs, $ T $23.73 (0.87 RVU, $ $88.37 (3.24 RVUs, $ I $59.19 (2.17 RVUs, $ T $29.19 (1.07 RVUs, $ $ (3.86 RVUs, $ I $70.92 (2.60 RVUs, $ T $34.37 (1.26 RVUs, $ $ (4.44 RVUs, $ I $75.83 (2.78 RVUs, $ T $45.28 (1.66 RVUs, $ $84.56 (3.10 RVUs, $ July/August Texas Medicaid Bulletin, No. 224

26 TOS Procedure Code Reimbursement Rate Notes I $61.10 (2.24 RVUs, $ T $23.46 (0.86 RVU, $ $69.28 (2.54 RVUs, $ I $48.55 (1.78 RVUs, $ T $20.73 (0.76 RVU, $ $52.92 (1.94 RVUs, $ I $30.00 (1.10 RVUs, $ T $22.91 (0.84 RVU, $ $72.55 (2.66 RVUs, $ I $44.73 (1.64 RVUs, $ T $27.82 (1.02 RVUs, $ $33.82 (1.24 RVUs, $ I $14.18 (0.52 RVU, $ T $19.64 (0.72 RVU, $ $33.00 (1.21 RVUs, $ I $14.18 (0.52 RVU, $ T $18.82 (0.69 RVU, $ $ (4.55 RVUs, $ I $ (3.81 RVUs, $ T $20.18 (0.74 RVU, $ $69.55 (2.55 RVUs, $ I $41.46 (1.52 RVUs, $ T $28.09 (1.03 RVUs, $ $39.55 (1.45 RVUs, $ I $16.09 (0.59 RVU, $ T $23.46 (0.86 RVU, $ $46.37 (1.70 RVUs, $ I $22.64 (0.83 RVU, $ T $23.73 (0.87 RVU, $ $34.91 (1.28 RVUs, $ I $13.09 (0.48 RVU, $ T $21.82 (0.80 RVU, $ $ (4.16 RVUs, $ I $81.28 (2.98 RVUs, $ T $32.19 (1.18 RVUs, $ $54.82 (2.01 RVUs, $ I $33.55 (1.23 RVUs, $ T $21.28 (0.78 RVU, $ $65.74 (2.41 RVUs, $ I $36.00 (1.32 RVUs, $ T $29.73 (1.09 RVUs, $ $86.19 (3.16 RVUs, $ Texas Medicaid Bulletin, No July/August 2009

27 TOS Procedure Code Reimbursement Rate Notes I $34.10 (1.25 RVUs, $ T $52.10 (1.91 RVUs, $ $87.83 (3.22 RVUs, $ I $20.73 (076 RVU, $ T $67.10 (2.46 RVUs, $ $86.19 (3.16 RVUs, $ I $20.46 (0.75 RVU, $ T $65.74 (2.41 RVUs, $ $88.37 (3.24 RVUs, $ I $21.00 (0.77 RVU, $ T $67.37 (2.47 RVUs, $ $ (5.13 RVUs, $ I $55.92 (2.05 RVUs, $ T $84.01 (3.08 RVUs, $ $ (5.41 RVUs, $ I $56.19 (2.06 RVUs, $ T $91.37 (3.35 RVUs, $ $77.46 (2.84 RVUs, $ I $13.37 (0.49 RVU, $ T $64.10 (2.35 RVUs, $ $48.01 (1.76 RVUs, $ I $22.64 (0.83 RVU, $ T $25.37 (0.93 RVU, $ $35.73 (1.31 RVUs, $ I $19.37 (0.71 RVU, $ T $16.37 (0.60 RVU, $ $31.64 (1.16 RVUs, $ I $21.00 (0.77 RVU, $ T $10.64 (0.39 RVU, $ $42.82 (1.57 RVUs, $ I $25.91 (0.95 RVU, $ T $16.91 (0.62 RVU, $ $ (6.58 RVUs, $ I $56.73 (2.08 RVUs, $ T $ (4.50 RVUs, $ $1, I $ (8.27 RVUs, $ T $1, $ (11.06 RVUs, $ I $ (4.52 RVUs, $ T $ (6.54 RVUs, $ $ (6.75 RVUs, $ July/August Texas Medicaid Bulletin, No. 224

28 TOS Procedure Code Reimbursement Rate Notes I $85.65 (3.14 RVUs, $ T $98.47 (3.61 RVUs, $ $ (3.79 RVUs, $ I $37.37 (1.37 RVUs, $ T $66.01 (2.42 RVUs, $ $ (19.42 RVUs, $ I $ (4.25 RVUs, $ T $ (15.17 RVUs, $ $ (10.47 RVUs, $ I $ (5.85 RVUs, $ T $ (4.62 RVUs, $ $37.10 (1.36 RVUs, $ $42.82 (1.57 RVUs, $ $76.37 (2.80 RVUs, $ $41.73 (1.53 RVUs, $ $ (4.68 RVUs, $ $70.92 (2.60 RVUs, $ $ (5.56 RVUs, $ $67.92 (2.49 RVUs, $ $ /I P9012 $ S3820 $3, S3822 $ S3823 $ S3828 $ S3829 $ S3830 $1, S3831 $ S3833 $1, S3834 $ S3840 $ S3841 $ S3842 $ S3843 $ S3844 $ S3845 $ S3846 $ S3847 $ S3848 $ S3849 $ S3850 $ S3851 $ S3853 $ Texas Medicaid Bulletin, No July/August 2009

29 Cytogenetics Testing Procedure Code Limitation Changes Effective for dates of service on or after May 1, 2009, limitations have changed for cytogenetic testing procedure codes for Texas Medicaid and the CSHCN Services Program. Effective for dates of service on or after May 1, 2009, cytogenetics testing procedure codes are no longer limited to 6 services per year and are no longer limited to one procedure code per table per day. Cytogenetics testing are now limited as follows when billed with an appropriate diagnosis code: Tissue Culture Procedure Codes and Limitations Procedure Code Quantity Allowed per day any provider per day any provider per day any provider per day any provider per day any provider Chromosome Analysis Procedure Codes and Limitations Procedure Code Quantity Allowed per day any provider per day any provider per day any provider per day any provider Procedure Code Quantity Allowed per day any provider per day any provider per day any provider per day any provider per day any provider per day any provider per day any provider Molecular Cytogenetics Procedure Codes and Limitations Procedure Code Quantity Allowed per provider per day per provider per day per provider per day per provider per day per provider per day This information updates the 2009 Texas Medicaid Provider Procedures Manual section , Cytogenetics Testing, on page 36-64, and the 2008 CSHCN Services Program Provider Manual section , Cytogenetics Testing, on page Providers may also refer to these sections for the complete list of appropriate diagnosis codes that may be billed with cytogenetics testing procedure codes. July/August Texas Medicaid Bulletin, No. 224

30 Molecular Laboratory Services Benefits Change Effective for dates of service on or after May 1, 2009, benefits have changed for molecular laboratory services. The following procedure codes may be reimbursed to Texas Medicaid and CSHCN Services Program providers (unless otherwise indicated): Procedure Codes 1 per day when billed by any provider S3840 Note: For the CSHCN Services Program, procedure codes , , and will be limited to one per day, any provider. 1 per day when billed by the same provider per day when billed by the same provider per day when billed by the same provider Procedure Codes 50 per day when billed by the same provider per pregnancy any provider ** * ** ** * * Procedure codes and are not benefits of the CSHCN Services Program. ** This limitation is for Texas Medicaid only. For the CSHCN Services Program, procedure codes , , and will be limited to one per day, any provider. 1 per lifetime any provider** 5-S3820* 5-S3822* 5-S3823* 5-S3828* 5-S3829* 5-S3830* 5-S3831* 5-S3833* 5-S3834* 5-S S S S S S S S S S S S3853 * Retroactive authorization may be submitted. ** These S series procedure codes are not benefits of the CSHCN Services Program. Federal Stimulus Package Increases FMAP Rate For Federal Fiscal Year 2009 Quarters One and Two Effective for dates of service from October 1, 2008, through December 21, 2010, the Federal Medical Assistance Percentage (FMAP) has increased from percent to percent as part of the federal stimulus package recently passed by Congress. Affected claims for the first and second quarters of the federal fiscal year 2009 will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. FMAP is the federal government s contribution to states for Medicaid expenditures and is used for Medicaid fee-for-service and managed care. The FMAP change affects only providers that certify expenses and are reimbursed for only the federal share of their claims. The Enhanced Federal Medical Assistance Percentage (EFMAP) rate will not change. The EFMAP percentage remains at percent. Texas Medicaid Bulletin, No July/August 2009

31 Removal of Cerumen Criteria Established The Office of Inspector General (OIG) has identified an issue that affects claims for removal of cerumen (procedure code ) on the same date of service by the same provider or provider group as an E/M service. The American Academy of Otolaryngology- Head and Neck Surgery (AAOHNS) cites the following CMS information regarding billing for the removal of impacted cerumen (procedure code ). Routine removal of cerumen is defined as the use of softening drops, cotton swabs, and/or cerumen spoon. Routine removal of cerumen is considered incidental and a part of the office visit when billed on the same date of service by the same provider or provider group as an E/M service and is not reimbursed separately. Note: Claims billed inappropriately for routine removal of cerumen are subject to recoupment. Cerumen is considered to be impacted when it is copious, obstructive, and cannot be removed without magnification and multiple instrumentations that require physician skills and when any of the following conditions apply: The cerumen impairs examination of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear. The cerumen is extremely hard, dry, and irritative, and causes symptoms such as pain, itching, hearing loss, etc. There is foul odor, infection, or dermatitis. Reimbursement for removal of cerumen will be considered only when all of the following criteria are met: Removal of cerumen is the sole reason for the patient encounter. The procedure is performed by a physician (MD or DO), nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Note: NPs, CNSs, and PAs are provider type 10. The service is provided to a client who is symptomatic. Reimbursement for an E/M visit and removal of cerumen on the same date of service by the same provider or provider group will be considered only when all of the following criteria are met: The E/M visit is for anything other than removal of cerumen. The physician, NP, CNS, or PA observes impacted cerumen, or the patient lodges a specific complaint about his or her ear(s) during the encounter. Otoscopic examination of the tympanic membrane is not possible due to impaction. Removal of the impacted cerumen requires the expertise of an MD or DO, APN, or PA and is personally performed by them. Documentation must be maintained in the client s medical record that indicates a significant time and effort was spent performing the service and includes the equipment required to provide the service. Revised Texas Medicaid Fee Schedules Available Beginning April 6, 2009, Texas Medicaid Fee Schedules have been revised and are available on the TMHP website at Providers can request a free paper copy of a fee schedule by calling the TMHP Contact Center at Scheduled System Maintenance System maintenance to the TMHP claims processing system is scheduled for: Sunday, July 12, 2009, 6:00 p.m. to 11:59 p.m. Sunday, August 9, 2009, 6:00 p.m. to 11:59 p.m. During system maintenance, some of the applications related to the claims engine will be unavailable. Specific details about the affected applications are posted on the TMHP website at July/August Texas Medicaid Bulletin, No. 224

32 Additional Annual 2009 HCPCS Procedure Codes On April 20, 2009, Texas Medicaid reimbursement rates were adopted for additional 2009 Healthcare Common Procedure Coding System (HCPCS) procedure codes, which became effective for dates of services on or after January 1, On May 23, 2009, the CSHCN Services Program adopted the same rates and effective date as Texas Medicaid with the exception of procedure code 1-J1786 which is manually priced for the CSHCN Services Program. All of the rates in the following table apply to both Texas Medicaid and the CSHCN Services Program with the exception of procedure code 1-J7186, which lists a reimbursement rate only for Texas Medicaid. Procedure code 1-J1786 is manually priced for the CSHCN Services Program. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. The following reimbursement rates are effective for all ages unless specified, and are effective for dates of service on or after January 1, 2009: TOS Procedure Code Client Age Range Reimbursement Rate Ambulatory Surgical Center (Facility) F (Group 5) F (Group 5) F (Group 3) F (Group 6) F (Group 6) F (Group 6) F (Group 6) F (Group 6) F (Group 6) F (Group 1) F (Group 1) F (Group 1) F (Group 1) F (Group 8) Anesthesia Birth through 20 years of age years of age or older RVU= Relative Value Unit $ (base unit 10 RVU) $ (base unit 10 RVU) TOS Procedure Code Client Age Range Anesthesia Birth through 20 years of age years of age or older Reimbursement Rate $ (base unit 18 RVU) $ (base unit 18 RVU) Clinical Laboratory $ $11.95 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEOPS) 9 A6545 $ A9284 $ L0113 $ L8604 $99.25 Laboratory, Professional and Technical Components $20.33 (0.71 RVU, $ $44.39 (1.55 RVUs, $ $52.41 (1.83 RVUs, $ $61.29 (2.14 RVUs, $ $56.71 (1.98 RVUs, $ $69.02 (2.41 RVUs, $ $80.76 (2.82 RVUs, $ $38.38 (1.34 RVUs, $ RVU= Relative Value Unit Texas Medicaid Bulletin, No July/August 2009

33 TOS Procedure Code Client Age Range Reimbursement Rate Laboratory, Professional and Technical Components $21.77 (0.76 RVU, $ $28.64 (1.00 RVUs, $ $34.37 (1.20 RVUs, $ $52.70 (1.84 RVUs, $ $32.94 (1.15 RVUs, $ $29.79 (1.04 RVUs, $ $47.54 (1.66 RVUs, $ $29.21 (1.02 RVUs, $ $52.70 (1.84 RVUs, $ $28.93 (1.01 RVUs, $ $23.48 (0.82 RVU, $ $43.82 (1.53 RVUs, $ $ (7.42 RVUs, $ I $56.99 (1.99 RVUs, $ RVU= Relative Value Unit TOS Procedure Code Client Age Range Reimbursement Rate Medical Services Excluding Drugs T $ (5.43 RVUs, $ $ (7.68 RVUs, $ Birth through 1 year of age Birth through 1 year of age Birth through 1 year of age through 11 years of age through 11 years of age through 11 years of age through 19 years of age through 19 years of age through 19 years of age years of age or older years of age or older years of age or older RVU= Relative Value Unit $ (26.67 RVUs, $ $ $ $ (21.85 RVUs, $ $ (12.39 RVUs, $ $ (8.39 RVUs, $ $ (17.55 RVUs, $ $ (11.85 RVUs, $ $ (7.77 RVUs, $ $ (7.81 RVUs, $ $ (6.30 RVUs, $ $ (4.55 RVUs, $ July/August Texas Medicaid Bulletin, No. 224

34 TOS Procedure Code Client Age Range Reimbursement Rate Medical Services Excluding Drugs Birth through 1 year of age through 11 years of age through 19 years of age years of age or older Birth through 1 year of age through 11 years of age through 19 years of age years of age or older years of age or older through 5 years of age through 5 years of $ (15.06 RVUs, $ $ (12.55 RVUs, $ $ (11.93 RVUs, $ $ (6.23 RVUs, $ $15.47 (0.54 RVUs, $ $12.03 (0.42 RVUs, $ $11.74 (0.41 RVUs, $ $6.30 (0.22 RVU, $ $32.36 (1.13 RVUs, $ $ (14.87 RVUs, $ $ (8.83 RVUs, $ age Radiation Therapy, Professional, and Technical Components $ (5.16 RVUs, $ I $56.71 (1.98 RVUs, $ T $91.08 (3.18 RVUs, $ RVU= Relative Value Unit TOS Procedure Code Client Age Range Reimbursement Rate Radiation Therapy, Professional, and Technical Components $ (15.47 RVUs, $ I $ (4.47 RVUs, $ T $ (11.01 RVUs, $ Surgery and Assistant Surgery $ (28.14 RVUs, $ $ (4.50 RVUs, $ $ (33.09 RVUs, $ $ (5.29 RVUs, $ $ (22.36 RVUs, $ $ (24.61 RVUs, $ $1, (56.81 RVUs, $ $ (9.09 RVUs, $ $1, (43.86 RVUs, $ $ (7.02 RVUs, $ $1, (53.94 RVUs, $ RVU= Relative Value Unit Texas Medicaid Bulletin, No July/August 2009

35 TOS Procedure Code Client Age Range Reimbursement Rate Surgery and Assistant Surgery $ (8.63 RVUs, $ $1, (58.25 RVUs, $ $ (9.32 RVUs, $ $1, (52.79 RVUs, $ $ (8.45 RVUs, $ $99.67 (3.48 RVUs, $ $ (32.69 RVUs, $ $ (5.23 RVUs, $ $ (19.87 RVUs, $ $91.08 (3.18 RVUs, $ $ (24.80 RVUs, $ $ (3.97 RVUs, $ $ (22.80 RVUs, $ $ (3.65 RVUs, $ RVU= Relative Value Unit TOS Procedure Code Client Age Range Reimbursement Rate Surgery and Assistant Surgery $ (27.45 RVUs, $ $ (4.39 RVUs, $ $ (22.89 RVUs, $ $ (3.66 RVUs, $ $ (33.05 RVUs, $ $ (5.29 RVUs, $ $ (10.93 RVUs, $ $ (20.28 RVUs, $ $ (5.54 RVUs, $ $ (20.28 RVUs, $ $ (7.66 RVUs, $ $ (3.93 RVUs, $ $ (6.61 RVUs, $ $ (20.28 RVUs, $ $ (6.37 RVUs, $ RVU= Relative Value Unit July/August Texas Medicaid Bulletin, No. 224

36 TOS Procedure Code Client Age Range Reimbursement Rate Surgery and Assistant Surgery $38.95 (1.36 RVUs, $ $63.01 (2.20 RVUs, $ $ (27.48 RVUs, $ $ (4.40 RVUs, $ $ Vaccines and Drugs 1/S $ /S $ C9245 $ J0641 $ J1267 $ J1453 $1.57 RVU= Relative Value Unit TOS Procedure Code Client Age Range Reimbursement Rate Vaccines and Drugs 1 J1459 $ J1750 $ J2785 $ J3101 $ J3300 $ J7186* $ J9033 $ Q4100 Manually Priced 1 Q4102 $ Q4103 $ Q4104 $ Q4105 $ Q4106 $ Q4107 $ Q4111 $ Q4112 $ Q4113 $ Q4114 $ * Manually priced for the CSHCN Services Program RVU= Relative Value Unit Drugs That Require NDC for Texas Medicaid and CSHCN Services Program Reimbursement Texas Medicaid and the CSHCN Services Program are expanding the list of procedure codes that will be denied if submitted without an 11-digit National Drug Code (NDC). Effective June 1, 2009, claims for the following additional procedure codes must be submitted with an 11-digit NDC: Procedure Codes J1170 J1626 J2405 J3370 J9062 J9178 J9190 J9206 J9293 If these procedure codes are submitted without NDC information, they will be denied, even if they have been prior authorized. The new list, called Drugs Requiring NDC for Texas Medicaid and CSHCN Services Program Reimbursement, is available in the following table, and on the TMHP website at The NDC number submitted to Medicaid or the CSHCN Services Program must be the NDC number on the package or container from which the medication was administered. Drugs Requiring NDC for Texas Medicaid and CSHCN Services Program Reimbursement Procedure Codes J0640 J0696 J1100 J1170 J1260 J1626 J1631 J1885 J2405 J2430 J2550 J3010 J3370 J7190 J7192 J9000 J9040 J9045 J9060 J9062 J9178 J9190 J9206 J9217 J9265 J9293 J9390 Texas Medicaid Bulletin, No July/August 2009

37 Issue with Duplicate Medicare Payments TMHP has identified an issue that impacts professional claims that are duplicates of professional claims filed to Medicare, (i.e., crossover claims). Professional claims with dates of service on or after January 1, 2004, that are duplicates of professional crossover claims may have been paid in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. As a reminder, public health programs available to clients with Medicaid such as Medicare and Tricare are considered a third-party resource (TPR) as indicated in the Texas Medicaid Provider Procedures Manual, section 4.10 Third- Party Resources (TPR) and Title 1 Texas Administrative Code (TAC) As indicated in Title 1 TAC and the 2009 Texas Medicaid Provider Procedures Manual, section 6.2 titled Refunds to TMHP Resulting from Other Insurance Payment on page 6-4, a provider can submit a claim to a third-party health insurer for payment that has been paid by TMHP only after the provider refunds any amounts paid by TMHP. The TMHP Cash Reimbursement Unit is responsible for processing financial adjustments when any of the following occur: Overpayment Duplicate payment Payment to incorrect providers Overlapping payments by Medicaid and a TPR In accordance with Title 1 TAC [g] and [i], providers that do not follow TPR rules may be referred for investigation and prosecution for violations of state and/or federal Medicaid or false claims laws. Providers should refer to the full text of these rules for a full description of payment requirements. Providers can refer to the 2009 Texas Medicaid Provider Procedures Manual, section B.66 titled Texas Medicaid Refund Information Form on page B-107, for information on how to refund a payment to Texas Medicaid by sending funds directly to TMHP. Updates to Previously Published Information The following are updates and corrections to articles that were published in previous bulletins or on the TMHP wbsite at as either banner messages or web articles. Update to 2009 HCPCS Immunization Procedure Codes and Components This is an update to an article that was published in the 2009 HCPCS Special Bulletin, No. 221, on page 16, subtitled Immunizations (Vaccine/Toxoids). The articles listed procedure codes and as new immunizations but did not indicate the components that are associated with each procedure code. Procedure code has one component and procedure code has two components. Corrections to the 2009 Texas Medicaid Provider Procedures Manual Federally Qualified Health Center (FQHC) Section 21 This is a correction to the 2009 Texas Medicaid Provider Procedures Manual, section 21.3 titled Benefits and Limitations on page The manual includes an incorrect place of service (POS) and omits some valid modifiers for procedure code T1015. The correct statement is as follows: Services provided by a health-care professional require one of the following modifiers with procedure code T1015, to indicate the health-care professional providing the services: AH, AJ, AM, SA, TD, TE, TH, or U7. Services billed with modifier TD or TE must be billed with POS 2. Texas Medicaid (Title XIX) Home Health Services Section 24 This is a correction to the 2009 Texas Medicaid Provider Procedures Manual, section , Pediatric CPAP Criteria, on page The section incorrectly indicates that polysomnography documentation of an Apnea/ Hypopnea Index (AHI) less than 1 may be used as a saturation level for clients 18 years of age or younger. The correct information is as follows: One of the following AHI and/or oxygen saturation levels may be used for clients 18 years of age or younger: Polysomnography documentation AHI greater than 1. An oxygen saturation less than 92 percent, taken upon exertion breathing room air. Refer to the 2009 Texas Medicaid Provider Procedures Manual, section , Continuous Positive Airway July/August Texas Medicaid Bulletin, No. 224

38 Pressure (CPAP) System, on page for additional information on CPAP systems. Physician Section 36 (Radiation Therapy) This is an update to the 2009 Texas Medicaid Provider Procedures Manual, section , Radiation Therapy, on page Effective for dates of service on or after July 1, 2009, established office visits (procedure codes 99211, 99212, 99213, 99214, and 99215) and outpatient visits (procedure codes 99281, 99282, 99283, 99284, and 99285) may be reimbursed when provided within the 90-day period after radiation treatment by the same provider. Radiological and Physiological Laboratory and Portable X-Ray Supplier Section 39 This is an update to the 2009 Texas Medicaid Provider Procedures Manual, section , Contrast Materials/ Radiopharmaceuticals, on page This section states that contrast materials when used for diagnostic purposes in radiopharmaceutical studies are not benefits. Following is the updated information: Some diagnostic radiopharmaceuticals are benefits of Texas Medicaid. Providers may refer to the fee schedules available on the TMHP website at for the diagnostic radiopharmaceuticals reimbursed by Texas Medicaid. Texas Health Steps (THSteps) Section 43 (Licensed Dietitians) This is a correction to the 2009 Texas Medicaid Provider Procedures Manual section titled Benefits and Limitations for licensed dietitians on page The manual incorrectly states that procedure code S9470 is not a benefit in the home setting and is limited to eight 30-minute units per rolling year. The correct procedure code should be The correct statement is as follows: Procedure code is not a benefit in the home setting and is limited to eight units per rolling year. One unit is equivalent to 30 minutes. Administration Procedure Codes Submitted for Adults This is an update to an article that was published in the November/December 2008 Texas Medicaid Bulletin No. 219 titled, Vaccine/Toxoids Reimbursement Changes. The article states procedure code , , , or may be used to bill for vaccine/toxoid administration for clients who are 21 years of age or older. Procedure codes and are restricted to clients who are birth through 20 years of age, and these procedure codes may not be used when billing for clients who are 21 years of age or older. Claims submitted for clients who are 21 years of age or older with dates of service from August 1, 2008, through April 30, 2009, and procedure code , , , or , may have denied in error as not a benefit. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Claims that were submitted with procedure code or will be denied again because the procedure code is inappropriate for the client s age. Providers must not bill clients for claims that are denied because they were billed inappropriately. Clarification to New Process for MAPs Claims for 2005 through 2007 Dates of Service Article This is an update to an article posted on the TMHP website at on March 6, 2009, titled New Process for Medicare Advantage Plans (MAP) Claims for 2005 through 2007 Dates of Service. The previous article and the MAP Submission Forms and Instructions direct providers to submit the original claim on form HCFA 1500 or HCFA 1450/UB-92. These were the forms in use during the dates of service affected by the new process. In 2007, the CMS-1500 and CMS-1450-UB/04 forms replaced the HCFA forms. Providers should submit the new claim forms; however, if a provider is unable to submit claims with the new claim form, TMHP will accept the HCFA forms. Effective May 1, 2009, TMHP allows providers to submit claims for clients enrolled in a MAP on one of two new MAP submission forms with a completed claim form. The new submission forms apply only to claims with dates of service from January 1, 2005, through December 31, Claims submitted for dates of service outside of these dates are denied. Note: Institutional inpatient claims are processed by admission date and may have a discharge date beyond December 31, TMHP will process all MAP claims described above that are received between May 1, 2009, and October 31, Claims that are received outside of this submission period will not be processed and will be returned to the provider as an invalid Medicare Remittance Advice Notice (MRAN). Texas Medicaid Bulletin, No July/August 2009

39 The field entries on the MAP Submission Form must be typed or computer-generated. Handwritten forms are not accepted and are returned to the provider. All fields (excluding Medicaid information fields) must be completed using the information from the MAP Remittance Advice or Remittance Notice. Providers must follow the paper appeal guidelines as described in the 2009 Texas Medicaid Provider Procedures Manual, section 6.1.4, Paper Appeals on page 6-3. Appeals received with MAP submission forms will be accepted. Revised MAP submission forms and instructions are available on page 65 of this bulletin, and in the file library on the TMHP website at Update to Medicaid Reimbursement Rates for Patient Lifts Article This is an update to an article that was published on the TMHP website at on December 5, 2008, titled Texas Medicaid Reimbursement Rates Change for Patient Lifts. The reimbursement rate for procedure code J-E0635 without the TG modifier was not included. The reimbursement rate for procedure code J-E0635 without the TG modifier is $1, Procedure code J-E0635 when submitted with modifier TG is reimbursable only to DME suppliers. The following table indicates the corrected reimbursement rates for procedure code J-E0635, which includes procedure code J-E0635 with and without modifier TG and procedure code L-E0635. These rates are effective for dates of service on or after December 1, 2008: TOS Procedure Code Modifier Reimbursement Rate J E0635 $1, *J E0635 TG Manually Reviewed L E0635 $ * J-E0635 with TG modifier is reimbursable only to DME suppliers Reimbursement Rates Changed for some DME This is a correction to an article that was published on the TMHP website at on March 27, 2009, titled Texas Medicaid Reimbursement Rates Will Change for Some Durable Medical Equipment Procedure Codes. The article incorrectly included procedure codes J-E0164 and J-E0166 as reimbursable procedure codes for Texas Medicaid. Procedure codes J-E0164 and J-E0166 are no longer reimbursable procedure codes for Texas Medicaid. The correct article appears on page 14 of this bulletin. Update to Texas Medicaid Reimbursement Rates Change for Some Medical Services, Surgical, Interpretation, and Total Component Effective for dates of services on or after April 1, 2009, some medical services, surgical, interpretation, and total component procedure codes reimbursement rates have changed for Texas Medicaid. The reimbursement rates were adopted following a public rate hearing that was held on February 17, The following reimbursement rates are for all client ages, and are effective April 1, 2009: Type of Service Procedure Code Reimbursement Rate Interpretations I $75.65 I $14.32 (0.50 RVU, $ I $16.04 (0.56 RVU, $ I $13.17 (0.46 RVU, $ I $5.41 I $10.31 (0.36 RVU, $ I $9.16 (0.32 RVU, $ I $11.46 (0.40 RVU, $ I $79.05 (2.76 RVUs, $ I $63.87 (2.23 RVUs, $ I $ I $ (6.81 RVUs, $ I $ (6.54 RVUs, $ I $ I $ (8.00 RVUs, $ I $ (11.01 RVUs, $ * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. July/August Texas Medicaid Bulletin, No. 224

40 Type of Service Procedure Code Reimbursement Rate Interpretations I $ (11.03 RVUs, $ I $ I $ I $ (13.68 RVUs, $ I $ (7.63 RVUs, $ I $ I $ I $ I $ (10.16 RVUs, $ I $78.76 (2.75 RVUs, $ I $61.86 (2.16 RVUs, $ I $ I $ I $ I $ I $ I $ I $ I $40.67 (1.42 RVUs, $ I $69.61 I $ I $ I $ I $ I $ I $ (4.46 RVUs, $ I $ I $ I $ I $ I $ I $ I $62.03 * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. Type of Service Procedure Code Reimbursement Rate Medical Services $33.51 (1.17 relative value units [RVUs], $ * $45.25 (1.58 RVUs, $ * $46.97 (1.17 RVUs, $ * $ * $37.80 (1.32 RVUs, $ * $35.51 (1.24 RVUs, $ * $63.58 (2.22 RVUs, $ Surgical Services $ (3.61 RVUs, $ $ $ $ $ $ (20.70 RVUs, $ $ (29.41 RVUs, $ $1, $1, $1, $1, $1, $2, $2, $1, $ $2, $1, $1, $ $ $ $ * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. Texas Medicaid Bulletin, No July/August 2009

41 Type of Service Procedure Code Reimbursement Rate Surgical Services $ $ $ $ $ $ $ $ $ $1, $ $ $1, $ $ $ $ $ $ Total Component T $27.74 T $40.89 T $19.19 (0.67 RVU, $ T $29.21 (1.02 RVUs, $ T $33.80 (1.18 RVUs, $ T $22.00 T $27.49 (0.96 RVU, $ T $26.35 (0.92 RVU, $ T $52.12 (1.82 RVUs, $ T $ T $63.87 T $ T $ (13.89 RVUs, $ * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. Type of Service Procedure Code Reimbursement Rate Total Component T $ (22.87 RVUs, $ T $1, T $1, T $ T $1, T $1, T $1, T $1, T $1, T $ T $1, T $1, T $1, T $ T $88.65 T $81.94 T $44.87 T $70.11 T $ T $56.99 T $67.47 T $ T $10.10 T $28.33 T $ T $ T $ T $ T $ T $1, T $63.39 T $6.22 T $ T $ T $ T $67.44 * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. July/August Texas Medicaid Bulletin, No. 224

42 Family Planning Providers Family Planning Providers Use of Modifier FP to Change for Family Planning Services Reminder: Effective for dates of service on or after July 1, 2009, the Women s Health Program (WHP) and Titles V, XIX, and XX family planning will be changing the way modifier FP is used on claims for family planning services. After July 1, modifier FP should be used only when billing the annual family planning examination. All other family planning services (e.g., evaluation and management [E/M] services, laboratory services, and anesthesia services) must omit modifier FP. Claims filed incorrectly may be denied. The change in the way modifier FP is used impacts the 2009 Texas Medicaid Provider Procedures Manual in the following ways: Revisions to Chapter 5, Claims Filing The following information updates the tables in section 5.3.5, Modifiers, beginning on page 5-21: Modifier Special Instructions/ Notes (if applicable) Visits FP+ Use to indicate that the service was an annual family planning examination. +Modifier is required for accurate claims processing Anesthesia Note: Modifier FP must be omitted when billing anesthesia for a sterilization procedure. Refer to the appropriate section in the provider manual for instructions for billing family planning services. Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHCs) FP Use to indicate that the service was an annual family planning examination. Certified Registered Nurse Anesthetist (CRNA) Note: Modifier FP must be omitted when billing anesthesia for a sterilization procedure. Refer to the appropriate section in the provider manual for instructions for billing family planning services. Laboratory/Radiology Note: Modifier FP must be omitted with procedure code for lab handling services related to family planning. Refer to the appropriate section in the provider manual for instructions for billing family planning services. Revisions to Chapter 20, Family Planning Services Laboratory Procedures The following information updates section , Laboratory Procedures Title XlX Only, on page 20-9: If a provider does not perform the laboratory procedure, the provider may be reimbursed one lab handling fee a day, per client, unless multiple specimens are obtained and sent to different laboratories. Procedure code with a family planning diagnosis code may be reimbursed for handling and/or conveyance of the specimen for transfer from the provider s office to a laboratory. Modifier FP should be omitted. Refer to: Section 20.6, Diagnosis Codes, on page 20-7, for the complete list of family planning diagnosis codes. Drugs and Supplies The following information updates section , Drugs and Supplies, on page 20-10, and section , Dispensing Medication, on page 20-11: Procedure code A9150 is a benefit for Title V and XX clients only and is reimbursed at a fee of $ Procedure code A9150 may be billed when a nonprescription medication to treat a monilia infection is provided to the client. Modifier FP should be omitted. Note: For Title XIX, clients are provided a prescription to be filled through the Vendor Drug Program. Injection Administration The following information updates section , Injection Administration Title XIX Only, on page 20-11: If billed without procedure code J1055, procedure code must be billed with a family planning diagnosis code and a description of the medication in the Remarks field of the claim. Modifier FP must be omitted. Refer to: Section 20.6, Diagnosis Codes, on page 20-7, for the complete list of family planning diagnosis codes. Family Planning Hospital/Auspice The following information updates section , Introduction to Family Planning in Hospital Setting/ Auspices Title V and XX Only, on page 20-11: Procedure code S9445 must be billed with a family planning diagnosis code and consists of an overview of family planning benefits to encourage pregnant or postpartum women to use family planning services following delivery. Modifier FP must be omitted. Texas Medicaid Bulletin, No July/August 2009

43 Family Planning Providers Refer to: Section 20.6, Diagnosis Codes, on page 20-7, for the complete list of family planning diagnosis codes. Education/Counseling The following information updates section , Method-Specific Education/Counseling Title V and XX Only, on page 20-11: Procedure code provides information about the contraceptive method chosen for use by the client, including its proper use, the possible side effects and complications, its reliability, and its reversibility. Modifier FP should be omitted when billing this service. Initial Patient Education The following information updates section , Initial Patient Education - Title V and XX Only, on page 20-12: Procedure code is provided to facilitate selection of an effective contraceptive method. Modifier FP must be omitted when billing this service. Anesthesia for Sterilization Title XIX Only The following information updates section , Anesthesia for Sterilization, on page 20-13: Procedure codes 00851, 00921, and may be reimbursed for anesthesia for sterilization services for Title XIX family planning clients only. Procedure code requires a family planning diagnosis code. Procedure codes 00840, 00920, 00922, 00940, and may no longer be used to bill anesthesia for sterilization. Revisions to Chapter 26 Independent Laboratory The following information updates section , Reference Labs and Lab Handling Fees, on page 26-4: Family planning agencies must use procedure code with a family planning diagnosis code to bill their laboratory handling charges for laboratory specimens sent out. Modifier FP should be omitted. As with the procedure code 99000, only one handling fee may be charged for each laboratory to the agency that sends specimens, regardless of the number of specimens taken. Refer to: Section 20.6, Diagnosis Codes, on page 20-7, for the complete list of family planning diagnosis codes. Revisions to Chapter 36 Physician Anesthesia for Sterilization The following information updates section , Anesthesia for Sterilization, on page 36-13: Procedure codes 00851, 00921, and may be reimbursed for anesthesia for sterilization services. Procedure code requires a family planning diagnosis code. Refer to: Section 20.6, Diagnosis Codes, on page 20-7, for the complete list of family planning diagnosis codes. Procedure codes 00840, 00920, 00922, 00940, and may no longer be used to bill anesthesia for sterilization. Family Planning The following information updates section , Family Planning, on page 36-38: Physicians, PAs, nurse practitioners (NPs), and CNSs are encouraged to provide family planning services to Texas Medicaid clients, especially pregnant and postpartum clients. No separate enrollment is required. Providers are reimbursed for family planning services through Texas Medicaid (Title XIX) and not through the Family Planning Program (Titles V, X, and XX). Refer to: Section 20, Family Planning, on page 20-1, for more information about the Family Planning Program. Family planning services are preventive health, medical, counseling, and educational services that help an individual to control fertility and achieve optimal reproductive and general health. Family planning services should be billed with a family planning diagnosis code. Refer to: Section 20.6, Diagnosis Codes, on page 20-7, for the complete list of family planning diagnosis codes. The federal contribution to Texas is enhanced by the use of a family planning diagnosis code, which increases the total amount of funds available for reimbursement. Revisions to Appendix O Women s Health Program Laboratory Services The following information updates section O.4.2.4, Laboratory Services, on page O-4: Procedure code billed with a WHP family planning diagnosis code may be reimbursed for handling and/or conveyance of the specimen for transfer from the physician s office to a laboratory. Modifier FP must be omitted to bill this service. Refer to: Section O.4.1, Diagnosis Codes, on page O-3, for the complete list of WHP family planning diagnosis codes. Anesthesia for Sterilization The following information updates section O.4.3, Sterilization and Sterilization-Related Procedures, on page O-5: Procedure code is used to report anesthesia services for a sterilization procedure. Modifier FP should be omitted. July/August Texas Medicaid Bulletin, No. 224

44 Home Health Providers/Managed Care Providers Home Health Providers Mandatory Order Form for Home Health Services (Title XIX) DME/Medical Supplies Effective June 1, 2009, for all dates of service, TMHP will accept only the revised Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form (effective date Oct. 21, 2008). This updates the information previously published that indicated that the old forms were going to be returned beginning April 1, Effective June 1, 2009, if an old order form is submitted, it is returned to the provider with instructions to submit the revised form. The revised form was published in the 2009 March/April Texas Medicaid Bulletin, No. 222, and is available on the TMHP website at Managed Care Providers Primary Care Providers and THSteps Services Primary care providers are encouraged to complete the Texas Health Steps (THSteps) medical checkup as part of the medical home for their clients who are enrolled in Primary Care Case Management (PCCM). Providers that refer these clients to a THSteps provider for a THSteps medical checkup must document that THSteps medical checkup in their clients records. If a client selfrefers to a THSteps provider for a THSteps medical checkup, the provider who performs THSteps medical checkup services must work in collaboration with the client s primary care provider and provide the THSteps medical checkup results to the primary care provider to ensure continuity of care. Primary care providers that want to become THSteps providers can enroll online through the TMHP website at or by downloading the Texas Medicaid Provider Enrollment Application from the TMHP website and submitting it by mail. Anesthesia, Consultation, and Medical Procedure Codes Claims Reprocessing TMHP has identified an issue that affects claims for dates of service on or after September 1, 2007, billed with the following anesthesia and consultation procedure codes: , , , and for PCCM. These claims may have been reimbursed at an incorrect rate. In addition, TMHP has identified an issue that affects claims for dates of service on or after September 1, 2007, billed with medical procedure code 1-J1885 for PCCM. These claims may have been reimbursed at an incorrect rate. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Providers should refer to the fee schedule for pricing. Inpatient Stay Following Scheduled Day Surgery Reminder: Notification for an inpatient stay is required when a prior-authorized, scheduled outpatient day surgery for a client enrolled in PCCM becomes an inpatient stay due to complications. The prior authorization for the day surgery is not valid as authorization for the inpatient stay. Refer to the 2009 Texas Medicaid Provider Procedures Manual, section , PCCM Inpatient Authorization Process, section , Urgent and Emergent Admission, and section 7.7.2, Inpatient/ Outpatient Prior Authorization Line for Contact Center telephone and fax numbers. Texas Medicaid Bulletin, No July/August 2009

45 THSteps Providers THSteps Dental Providers New Dental Diagnostic Services are THSteps Benefits Update Effective for dates of service on or after April 1, 2009, Texas Health Steps (THSteps) diagnostic dental services procedure codes D0360, D0362, and D0363 are benefits of Texas Medicaid. The reimbursement rates were adopted following a public rate hearing that was held on February 17, These procedure codes require prior authorization. To obtain prior authorization, providers must submit a THSteps Dental Mandatory Prior Authorization Request Form with documentation that supports medical necessity and appropriateness. Required documentation includes, but is not limited to, the following: Presenting conditions Medical necessity Status of the client s treatment Procedure codes D0360, D0362, and D0363 are limited to clients who are birth through 20 years of age, with a combined maximum of three services per year, any provider. Additional services may be considered with documentation of medical necessity. The following diagnostic dental services reimbursement rates are effective April 1, 2009: Diagnosis Code Reimbursement Rate D0360 $ D0362 $ D0363 $ Corrections to Texas Medicaid Provider Procedures Manual Dental Therapy Under General Anesthesia This is a correction to the 2009 Texas Medicaid Provider Procedures Manual section titled Dental Therapy Under General Anesthesia on page Procedure code with EP modifier is referenced in this section. The correct procedure code is with EP modifier. The complete corrected paragraph is below: Surgical services related to THSteps dental services must be coded as follows: Anesthesia services for dental rehabilitation/restoration, with EP modifier. ASC/HASC dental rehabilitation/ restoration, with EP modifier. Physical examinations prior to dental restorations under anesthesia using the appropriate Current Procedural Terminology (CPT) procedure code when provided in the office, inpatient hospital, or outpatient settings. Orthodontic Procedure Codes and Fee Schedule This is a correction to the 2009 Texas Medicaid Provider Procedures Manual section titled Orthodontic Procedure Codes and Fee Schedule on page Procedure code D8692 was omitted from this section but should have been included as a nonpayable code. Although procedure code D8692 is not a benefit of Texas Medicaid, providers can use procedure code D8680 to bill for retainer(s). Providers should include local code Z2014 or Z2015 on the claim form to indicate upper or lower, as appropriate. July/August Texas Medicaid Bulletin, No. 224

46 THSteps Providers/Women's Health Program Providers THSteps Medical Providers THSteps Medical Checkups in FQHC and RHC Facilities In a federally qualified health center (FQHC) or rural health clinic (RHC) facility, Texas Health Steps (THSteps) medical checkups must be performed by a physician (MD or DO), advanced practice nurse (APN), or physician assistant (PA). Registered nurses (RN) may assist in the completion of some components of a medical checkup, but the unclothed physical examination must be completed by a physician, APN, or PA. An RN cannot be the sole provider for a THSteps medical checkup for FQHC and RHC providers. RNs that provide visiting nurse services for FQHCs and RHCs are limited to homebound clients in areas that have been determined to have a shortage of home health agencies. Update to THSteps Medical Checkups in 2009 Texas Medicaid Provider Procedures Manual This is an update to the 2009 Texas Medicaid Provider Procedures Manual section titled Medical Checkups on page The following two paragraphs should be added to section : If the provider that performs the medical checkup provides treatment for an identified condition on the same day, the provider may submit a separate claim for an established-client office visit. The separate claim must include the established-client procedure code that is appropriate for the diagnosis and treatment of the identified problem. Treatment of minor illnesses or conditions (e.g., follow-up of a mild upper respiratory infection) during the THSteps medical checkup may not warrant additional billing. For more information about conducting a THSteps checkup, providers can refer to the THSteps online educational modules at Women s Health Program Providers Occlusive Sterilization System Procedure code 9-E1399 is reimbursed for the occlusive sterilization system (micro-insert) and must be submitted with modifier UD and the most appropriate WHP diagnosis code. Procedure code 9-E1399 with modifier UD may be reimbursed separately from the surgery (procedure code 2/F-58565) to place the device. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, section , Hysteroscopic Sterilization, on page 36-40, and section , Contraceptive Devices and Related Procedures, on page 20-10, for more information. The complete list of WHP diagnosis codes is found in the 2009 Texas Medicaid Provider Procedures Manual, section O.4.1, Diagnosis Codes, on page O-3. Providers may also refer to the article, Family Planning Diagnosis Codes Expanded for the Annual Examination on the TMHP website at for more information about family planning changes. Elective Abortions May Not Be Performed or Promoted Section , Human Resources Code, prohibits payment of WHP funds to a provider that performs or promotes elective abortions. A provider that has performed or promoted elective abortions (through either surgical or medical methods) for any patient is ineligible to serve WHP clients and cannot be reimbursed for those services. This prohibition has been in effect since September 1, The Health and Human Services Commission (HHSC) will recoup WHP funds that it determines were paid to providers that have performed or promoted elective abortions. Texas Medicaid Bulletin, No July/August 2009

47 Women's Health Program Providers Changes to Women s Health Program and Family Planning Benefits and Claims Filing Criteria Some family planning claims filing criteria and benefits have changed for Texas Medicaid Title XIX Family Planning, the Women s Health Program (WHP), and Family Planning Titles V and XX. WHP claims filing criteria and benefit changes are effective for dates of service on or after April 1, Family Planning Titles V, XIX, and XX claims filing criteria and benefit changes are effective for dates of service on or after July 1, Overview of Changes The following family planning claims filing and benefit criteria have changed: Modifier FP is used only when billing the annual family planning examination. All other services must be submitted without modifier FP. All family planning evaluation and management (E/M) visits are billed with the most appropriate E/M procedure code ( ) and the most appropriate family planning diagnosis code for both general family planning visits and the annual family planning examination. Additional procedure code changes are effective for WHP and for Title XIX family planning services. Effective Dates Dates of Service On or After April 1, 2009 WHP benefit changes are effective for dates of service on or after April 1, Exception: Modifier FP changes are not effective until July 1, Providers must use modifier FP as usual on claims with dates of service on or after April 1, 2009, through June 30, Dates of Service On or After July 1, 2009 Family Planning Title V, XIX, and XX benefit changes are effective for dates of service on or after July 1, Modifier FP changes are effective for dates of service on or after July 1, 2009, and not for the July 1 implementation date regardless of date of service as previously indicated. For example an E/M family planning service performed on June 29, 2009, and submitted July 13, 2009, must bill using modifier FP with the procedure code. For a service performed July 2, 2009, and submitted July 13, 2009, modifier FP must be billed only with an annual family planning examination. The details are included in the specific sections that follow: WHP includes an overview of the changes, claims filing requirements, and federally qualified health center (FQHC) and rural health clinic (RHC) claims filing requirements. Title XIX Family Planning including an overview of the changes, claims filing requirements, and FQHC and RHC claims filing requirements. Title V and XX Family Planning claims filing requirements. Note: These changes do not affect Title X family planning. Change to how modifier FP is used. Women s Health Program Effective April 1, 2009 Important: TMHP will not implement the following changes until July 1, 2009; however, WHP providers must begin to bill claims for dates of service on or after April 1, 2009, using the new claims filing criteria and the new benefits. Claims billed before the implementation date of July 1, 2009, will be denied as not a benefit. TMHP will automatically reprocess affected WHP claims after the implementation on July 1, The client cannot be billed for these services. Providers must not wait until July 1, 2009, to bill claims for dates of service on or after April 1, Providers are responsible for meeting the initial 95-day filing deadline; claims denied for late filing will not be reprocessed or reimbursed. Effective for dates of service on or after April 1, 2009, the annual family planning examination and general family planning visits must be billed using the most appropriate E/M visit procedure code from the following table that corresponds to the complexity of the family planning examination provided. New Patient Visit Procedure Codes Established Patient Visit Procedure Codes July/August Texas Medicaid Bulletin, No. 224

48 Women's Health Program Providers Note: Effective for dates of service on or after July 1, 2009, only the annual family planning examination requires modifier FP. All other family planning office visits must not include modifier FP. One annual family planning examination is allowed per state fiscal year. Claims filed incorrectly may be denied. The most appropriate E/M procedure code must be billed with one of the following WHP diagnosis codes allowed for family planning visits: Diagnosis Codes V2501 V2502 V2504 V2509 V251 V252 V2540 V2541 V2542 V2543 V2549 V255 V258 V259 V2651 Reminder: One new patient E/M procedure code is allowed every three years following the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group. For example, if a new patient medical E/M service has been reimbursed, the next E/M visit, whether medical or family planning, provided during the subsequent three-year period by the same provider must be billed as an established patient visit. A new patient E/M visit will be allowed only after three years have elapsed since the last service provided to the client by that provider or a provider of the same specialty in the same group. In addition to the expanded E/M procedure codes and revised billing procedures listed previously, the following services are benefits of the WHP with the diagnosis codes indicated: Procedure Code Diagnosis Codes 2/F V2501, V2502, V2504, V2509, V251, V252, V2540, V2541, V2542, V2543, V2549, V255, V258, V259, V615 2/F V2543 2/F V2501, V2502, V2509, V251, V252, V2540, V2541, V2542, V2543, V2549, V255, V258, V259, V V2501, V2502, V2504, V2509, V251, V252, V2540, V2541, V2542, V2543, V2549, V255, V258, V259, V2651 2/F V252, V615 Claims Filing Requirements for the WHP The following table shows how modifier FP should be used on WHP claims submitted with dates of service on or after July 1, For WHP claims submitted with dates of service before July 1, 2009, providers should continue to use modifier FP as usual. Service Billing Criteria Frequency New patient: general family planning visit New patient: annual family planning examination Established patient: general family planning visit Established patient: annual family planning examination Most appropriate E/M procedure code ( ) with a family planning diagnosis code* Note: For dates of service between April 1 and June 30, modifier FP must be billed. Most appropriate E/M procedure code ( ) with modifier FP and a family planning diagnosis code Most appropriate E/M procedure code ( ) with a family planning diagnosis code* Note: Between April 1 and June 30, modifier FP must be billed. Most appropriate E/M procedure code ( ) with modifier FP and a family planning diagnosis code One new patient code every three years following the last E/M visit provided the client by that provider or a provider in the same group As needed Once per state fiscal year Note: The established patient procedure code will be denied if a new patient procedure code has been billed for the annual examination in the same year. * Family planning services provided during a WHP visit in which only family planning services were provided must be submitted with these procedure codes and the most appropriate informational procedure codes for services that were rendered. Texas Medicaid Bulletin, No July/August 2009

49 Women's Health Program Providers The following services are benefits of the WHP with a WHP diagnosis code: Procedure Codes /I/T /I/T /I/T /I/T E J7307 WHP Diagnosis Codes V2501 V2502 V2504 V2509 V251 V252 V2540 V2541 V2542 V2543 V2549 V255 V258 V259 V2651 Procedure code 1-H1010 is a benefit of the WHP and is limited to one service per day when billed by any provider. Procedure codes and are no longer benefits of the WHP. FQHC and RHC Claims Filing Requirements for the WHP For WHP family planning services to receive their encounter rate for a general family planning visit and for the annual family planning examination, FQHCs may use the most appropriate E/M procedure code for the complexity of service provided. The following table summarizes the billing criteria and frequency for procedure codes used for FQHC encounters, and shows how modifier FP should be used on WHP claims submitted with dates of service on or after July 1, For WHP claims submitted with dates of service before July 1, 2009, providers should continue to use modifier FP as usual. Service Billing Criteria Frequency New patient: general family planning encounter Established patient: general family planning encounter New patient: annual family planning examination Established patient: annual family planning examination Most appropriate E/M or IUD procedure code ( , 1-J7300 or 1-J7302) with a family diagnosis code* Note: For dates of service between April 1 and June 30, modifier FP must be billed. Most appropriate E/M or IUD procedure code ( , 1-J7300 or 1-J7302) with a family planning diagnosis code* Note: For dates of service between April 1 and June 30, modifier FP must be billed. Most appropriate E/M procedure code ( ) with modifier FP and a family diagnosis code Most appropriate E/M procedure code ( ) with modifier FP and a family planning diagnosis code Three family planning encounters may be reimbursed per year Note: One new patient E/M code is allowed every three years following the last E/M visit provided the client by the FQHC. * Family planning services provided during a WHP visit in which only family planning services were provided must be submitted with these procedure codes and the most appropriate informational procedure codes for services that were rendered. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, Appendix O, Women s Health Program, on page O-1, for more information. For services performed in the RHC setting, the provider performing the service must bill the most appropriate E/M procedure code with a WHP family planning diagnosis code (and modifier FP if the annual examination was performed). Family planning services (including implantable contraceptive capsules provision, insertion, or removal) must be billed using the appropriate provider identifier and benefit code. These services must also be billed with place of service code 72 if performed in an RHC setting. Reminder: The new patient procedure codes are limited to one new patient E/M procedure code three years following the last E/M visit provided the client by that provider or a provider of the same specialty in the same group. A new patient visit may no longer be billed once a year for the annual family planning examination. The annual examination must be billed as an established patient visit if E/M services have been provided the client within the last three years. July/August Texas Medicaid Bulletin, No. 224

50 Women's Health Program Providers Title XIX Family Planning Effective July 1, 2009 Effective for dates of service on or after July 1, 2009, providers must bill the most appropriate E/M visit procedure code from the following table for the complexity of the family planning examination provided. To bill an annual family planning examination, the procedure code must be used with modifier FP and a family planning diagnosis code. To bill a general family planning visit, the procedure code must be used with a family planning diagnosis code only (without modifier FP). New Patient Visits Procedure Codes Established Patient Visits Procedure Codes Note: Each of these procedure codes may be used for any family planning visit, both the general visit and the annual examination. Only the annual family planning examination requires modifier FP. All other family planning office visits must not include modifier FP. One annual family planning examination is allowed per state fiscal year. Claims filed incorrectly may be denied. The following table lists all of the family planning diagnosis codes allowed for Title XIX family planning visits: Diagnosis Codes V2501 V2502 V2504 V2509 V251 V252 V2540 V2541 V2542 V2543 V2549 V255 V258 V259 V2651 V2652 Note: One of the diagnosis codes in this table must be included in Block 24 E of the CMS-1500 claim form referencing the appropriate procedure code. Reminder: One new patient E/M procedure code is allowed every three years following the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group. For example, if a new patient medical E/M service has been reimbursed, the next E/M visit, whether medical or family planning, provided during the subsequent three-year period by the same provider must be billed as an established patient visit. A new patient E/M visit will be allowed only after three years have elapsed since the last service provided to the client by that provider or a provider of the same specialty in the same group. Claims Filing Requirements for Title XIX Family Planning Services The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for each type of visit: Service Billing Criteria Frequency New patient: general family planning visit New patient: annual family planning examination Established patient: general family planning visit Established patient: annual family planning examination Most appropriate E/M procedure code ( ) with a family planning diagnosis code Most appropriate E/M procedure code ( ) with modifier FP and a family planning diagnosis code Most appropriate E/M procedure code ( ) with a family planning diagnosis code Most appropriate E/M procedure code ( ) with modifier FP and a family planning diagnosis code One new patient E/M code every three years following the last E/M visit provided the client by that provider or a provider of the same specialty in the same group As needed Once a state fiscal year Note: The established patient procedure code will be denied if a new patient procedure code has been billed for the annual examination in the same year. Additionally, procedure codes 1-S9445 and 1-H1010 are benefits of Title XIX family planning and are limited to one service per day when billed by any provider. Texas Medicaid Bulletin, No July/August 2009

51 Women's Health Program Providers FQHC and RHC Claims Filing Requirements for Family Planning Title XIX Services For Title XIX family planning services, to receive their encounter rate for a general family planning visit and for the annual family planning examination, FQHCs must use the most appropriate E/M procedure code for the complexity of service provided. The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for each type of family planning encounter: Service Billing Criteria Frequency New patient: general family planning encounter Established patient: general family planning encounter New patient: annual family planning examination Established patient: annual family planning examination Most appropriate E/M or IUD procedure code ( , 1-J7300 or 1-J7302) with a family planning diagnosis code* Most appropriate E/M or IUD procedure code ( , 1-J7300 or 1-J7302) with a family planning diagnosis code* Most appropriate E/M procedure code ( ) with modifier FP and a family planning diagnosis code Most appropriate E/M procedure code ( ) with modifier FP and a family planning diagnosis code Three family planning encounters may be reimbursed per year Note: One new patient E/M code is allowed every three years following the last E/M visit provided to a client by the FQHC. * Family planning services provided during an encounter in which only family planning services were provided must be submitted with these procedure codes and the most appropriate informational procedure codes for services that were rendered. FQHCs must use the appropriate FQHC encounter procedure code for encounters other than family planning. Providers may refer to the article titled, Reminder for FQHC Providers, published on August 8, 2008, on the TMHP website at for more information about procedure codes that are payable to FQHCs. For services performed in the RHC setting, the provider performing the service must bill the most appropriate E/M procedure code with a WHP family planning diagnosis code (and modifier FP if the annual examination was performed). Family planning services (including implantable contraceptive capsules provision, insertion, or removal) must be billed using the appropriate provider identifier and benefit code. These services must also be billed with place of service code 72 if performed in an RHC setting. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, section , Family Planning, on page 36-38, and section , Billing Procedures for Non-Family Planning Services Provided During a Family Planning Visit, on page 20-7, for more information. Titles V and XX Family Planning Effective July 1, 2009 Family planning visits, both general visits and the annual family planning examination, for Titles V and XX family planning clients will continue to be billed using procedure codes , , , or Effective for dates of service on or after July 1, 2009, general family planning visits and the annual family planning examination for Titles V and XX clients must be billed using the requirements on the following page. For appropriate claims processing, providers are encouraged to use one of the following diagnosis codes to bill family planning services for Titles V and XX clients: Diagnosis Codes V2501 V2502 V2504 V2509 V251 V252 V2540 V2541 V2542 V2543 V2549 V255 V258 V259 V2651 V2652 For services performed in the RHC setting, the provider performing the service must bill the most appropriate E/M procedure code with a WHP family planning diagnosis code (and modifier FP if the annual examination was performed). Family planning services (including implantable contraceptive capsules provision, insertion, or removal) must be billed using the appropriate provider identifier and benefit code. These services must also be billed with place of service code 72 if performed in an RHC setting. July/August Texas Medicaid Bulletin, No. 224

52 Women's Health Program Providers Titles V and XX Family Planning Effective July 1, 2009 Family planning visits, both general visits and the annual family planning examination, for Titles V and XX family planning clients will continue to be billed using procedure code , , , or Effective for dates of service on or after July 1, 2009, general family planning visits and the annual family planning examination for Titles V and XX clients must be billed using the following requirements: Service Billing Criteria Frequency New patient: General family planning visit New patient: Annual family planning examination Established patient: General family planning visit Established patient: Annual family planning examination Procedure code or Procedure code or with modifier FP* Procedure code or Procedure code or with modifier FP* One new patient code every three years following the last E/M visit provided the client by that provider or a provider in the same group As needed Once per state fiscal year Note: The established patient procedure code will be denied if a new patient procedure code has been billed for the annual examination in the same year. * Only the annual family planning examination requires modifier FP. All other family planning office visits should not include modifier FP. One annual family planning examination is allowed per state fiscal year. Claims filed incorrectly may be denied. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, section 20.7, Procedure Codes and Reimbursement Amounts, on page 20-7, and section , Billing Procedures for Non-Family Planning Services Provided During a Family Planning Visit, on page 20-7, for more information. Change to FP Modifier Usage Effective July 1, 2009 Effective for dates of service on or after July 1, 2009, TMHP changed the way modifier FP is used on family planning claims. Providers should use modifier FP only to indicate an annual family planning examination. Claims for all other family planning office visits should omit modifier FP. One annual family planning examination is allowed per state fiscal year. Claims filed incorrectly may be denied. Texas Medicaid Bulletin, No July/August 2009

53 Excluded Providers Excluded Providers As required by the Medicare and Medicaid Patient Protection Act of 1987, HHSC identifies providers or employees of providers who have been excluded from state and federal health-care programs. Providers excluded from Texas Medicaid and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries, wages, or benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any client. Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by Texas Medicaid for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of HHSC s exclusion list. The HHSC-Sanctions Department submits updates to the exclusion list periodically and the updates appear on the website weekly. Review the entire Texas Medicaid exclusion list at /Exclusions/Search.aspx. To report Medicaid providers who engage in fraud/abuse, call or , or write to the following address: Provider Brian Klozik, Director HHSC Office of Inspector General, Medicaid Provider Integrity, MC-1361 PO Box Austin TX License Number Start Date Type Provider City State Add Date Aaron, Deborah K Dec-08 RN Houston TX 25-Mar-09 Aaron, Genny L Dec-08 RN Mineral Wells TX 25-Mar-09 Allen, Deanna L Apr-09 RN Kilgore TX 20-Jun-05 Anderson, Irene A Aug-08 LVN Dallas TX 16-Mar-09 Archie, Evelyn F Dec-08 LVN Galveston TX 06-Apr-09 Arias, Ignacio L Sep-08 RN Killeen TX 16-Mar-09 August, Jeremy Sep-08 MD San Antonio TX 13-Mar-09 Avila, Juan E. NA 22-Apr-09 DME Roma TX 20-Jan-09 Baca, Regina B Nov-08 RN New Braunfels TX 23-Mar-09 Baker, Angela L Nov-08 LVN Marshall TX 13-Apr-09 Baptiste, Keeonna W Dec-08 RN Gretna LA 25-Mar-09 Barber, Connie L Apr-09 RN San Antonio TX 16-Jan-09 Bean, Jamie K Dec-08 LVN Milam TX 06-Apr-09 Beckwith, Paige L Nov-08 RN Garland TX 23-Mar-09 Bell, Melisa L May-08 RN Arlington TX 16-Mar-09 Bernauer, Robert D. E Dec-08 MD Lake Charles LA 07-Apr-09 Blaylock, Christy J Oct-08 LVN McLean TX 16-Mar-09 Box, Micheal S Nov-08 LVN Amarillo TX 01-Apr-09 Browder, Renee L Dec-08 RN Brenham TX 25-Mar-09 Brown, Jacqueline A Nov-08 LVN Sarasota FL 13-Apr-09 Brunon, Gloria J Nov-08 LVN Longview TX 30-Mar-09 Bullard, Tawni E Dec-08 RN Shallowater TX 25-Mar-09 July/August Texas Medicaid Bulletin, No. 224

54 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Burns, Sherrilyn R Apr-09 LVN Diana TX 18-Oct-07 Calhoun, Deborah A Nov-08 LVN Bloomburg TX 31-Mar-09 Chetty, Pamela L Dec-08 RN Rowlett TX 25-Mar-09 Clark, Kelly N Jul-08 RN Tyler TX 19-Mar-09 Clary, Janice A Feb-08 RN Cedar Hill TX 24-Mar-09 Cockburn, Jean E Dec-07 RN Flower Mound TX 24-Mar-09 Conner-Jones, Phyllis 19-Jun-08 Owner Houston TX 16-Mar-09 Cosgrove, Zachary K May-08 MD New Braunfels TX 27-Mar-09 Crawford, Cynthia A Dec-08 LVN Hilltop Lakes TX 10-Apr-09 Crawford, Kimberly D Nov-08 LVN Panhandle TX 31-Mar-09 Crochet, Cheryl A Apr-09 RN Houma LA 31-Mar-07 Doster, Desiree D Jun-08 RN Sherman TX 25-Mar-09 Douglas, Garrie E Nov-08 Ph Baytown TX 16-Mar-09 Dowell, Jennifer L Apr-08 LVN Frisco TX 25-Mar-09 Duin, Reda L Jan-08 RN San Antonio TX 24-Mar-09 Dunn, Billie J Nov-08 LVN Colorado City TX 06-Apr-09 Earnshaw, Leonora Sep-08 RN Nolanville TX 17-Mar-09 Edem, Samuel E. 18-Dec-08 DME Sugarland TX 09-Apr-09 Ellington, Natalie G Apr-09 RN Crowley TX 22-Jan-09 Ellis, Denise M Nov-08 LVN New Braunfels TX 01-Apr-09 Ervin, Toni D Oct-08 LVN Gorman TX 16-Mar-09 Eshett, Offonmbuk U. 20-Nov-08 Owner Stafford TX 16-Mar-09 Estrada, Jay A Nov-08 Tech Houston TX 16-Mar-09 Ferguson, Karen L Nov-08 LVN Knox City TX 01-Apr-09 Followell, Sammy K Mar-08 LVN Sherman TX 25-Mar-09 Frith, Babette Jan-08 RN Salado TX 20-Mar-09 Garcia, Javier Apr-09 Dent San Antonio TX 15-Jan-09 Garrett, Dell L Dec-08 RN Lubbock TX 25-Mar-09 Gartrell, Paula J Dec-08 RN Copperas Cove TX 09-Apr-09 Gaston, Janice M May-08 LVN Humble TX 20-Mar-09 Gibson, Jayme Dec-08 LVN Lake Charles LA 16-Mar-09 Glasco, Pamela D Jun-08 LVN Granbury TX 25-Mar-09 Gonzo Medical Billing Specialty 20-Mar-08 Baytown TX 27-Mar-09 Groenig, Frederick K Nov-08 RN Odessa TX 23-Mar-09 Gruhlke, Kenneth B Dec-08 LVN Shady Shores TX 20-Mar-09 Guier, Crystal G Apr-09 PHTEC Texarkana TX 21-Apr-09 Gutierrez, Gerardo S Nov-08 LVN Pecos TX 17-Mar-09 Hall, Jackie L Jun-08 RN Amarillo TX 25-Mar-09 Hanson, Linda Aug-08 RN Katy TX 11-Mar-09 Helt, Jennifer J Oct-08 LVN Lake Dallas TX 16-Mar-09 Hendricks, Sharon K Dec-08 LVN Amarillo TX 10-Apr-09 Texas Medicaid Bulletin, No July/August 2009

55 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Hendricks, Stacy D Apr-08 LVN Waxahachie TX 25-Mar-09 Hettinga, John R Nov-08 LVN Augusta GA 31-Mar-09 Hinze, Canelia W Jan-09 RN League City TX 10-Apr-09 Hollenbaugh, Amanda L Sep-08 LVN Quanah TX 16-Mar-09 Hoyt, Thomas A. G Dec-08 MD Bryan TX 06-Apr-09 Hulick, Angela Oct-08 RN Dallas TX 17-Mar-09 Hurnes, Sherry D Nov-08 LVN Amarillo TX 31-Mar-09 Jackson, Angela M Jun-08 LVN San Antonio TX 27-Mar-09 Jacobs, Terry E Dec-08 MD Kingston GA 16-Mar-09 Johnson, Dolores NA 20-Feb-08 owner Bryan TX 14-Apr-09 Johnson, Jeanette S Apr-08 LVN Harker Heights TX 25-Mar-09 Jones, Ashlee N Jun-08 Tech Burleson TX 17-Mar-09 Jones, Noel W. 18-Sep-08 Owner Cypress TX 17-Mar-09 Jones, Stanford A Jul-08 LVN Copperas Cove TX 16-Mar-09 Kearns Jr, Raphael E Jul-08 RN Frisco TX 25-Mar-09 Kierce, Wayne L Dec-08 RN Kerrville TX 19-Mar-09 Kim, Michael D. F Oct-08 MD Houston TX 17-Mar-09 Kirby, Mitzi Dec-07 RN Dallas TX 27-Mar-09 Koonce, Tiffany D Nov-08 Tech Arlington TX 16-Mar-09 Kornell, Bernard D. F Oct-08 MD Dallas TX 17-Mar-09 Kreder, Patricia A Nov-08 RN West TX 23-Mar-09 Lawrence, Joy J Nov-08 RN Ferndale WA 23-Mar-09 Laws, John 19-Jun-08 Owner Oakdale LA 16-Mar-09 Lewis, Leslie M Dec-08 LVN Mound TX 10-Apr-09 Lines, Gail A May-08 RN Fort Worth TX 24-Mar-09 Loggins, Teresa L Dec-08 LVN Flint TX 07-Apr-09 Martinez, Jose Jul-08 RN Laredo TX 24-Mar-09 Mason, Cheryl Denise Dec-07 LVN Amarillo TX 24-Mar-09 Maxwell, Lisa A Oct-08 RN Rockwall TX 16-Mar-09 McAhon, Catherine D Jul-08 RN Abilene TX 24-Mar-09 McAteer, Malinda J Jun-08 LVN Chandler TX 25-Mar-09 McClure, Carolyn Jan-09 LVN Austin TX 13-Apr-09 McIntyre, Judy B Aug-08 RN Spearman TX 16-Mar-09 McLaughlin, Ellis M Nov-08 RN San Antonio TX 23-Mar-09 McMurtray, Theodora Apr-08 RN Rosharon TX 27-Mar-09 Menefield, Minnie Nov-08 LVN Shamrock TX 30-Mar-09 Mesta, Erin L Dec-07 LVN El Paso TX 27-Mar-09 Miles, Patricia R Nov-08 LVN Channelview TX 07-Apr-09 Miller, Caprice D Aug-08 RN Amarillo TX 16-Mar-09 Miller, Stephen P. G Jun-08 MD Fremont CA 27-Mar-09 Mitchell, Vernon C May-08 LVN Pharr TX 26-Mar-09 July/August Texas Medicaid Bulletin, No. 224

56 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Montalvo, Gabriel Aug-08 Tech Houston TX 16-Mar-09 Montgomery, Lisa D Nov-08 LVN Cleburne TX 07-Apr-09 Moon Gagliardo, Kelli L Sep-08 RN Denton TX 17-Mar-09 Moore, Charles T. E Aug-08 MD Austin TX 17-Mar-09 Myers, Lauren K Dec-08 RN Montgomery TX 23-Mar-09 Myers, Yotessa R May-08 LVN San Antonio TX 27-Mar-09 Nelson, Carlos L. 08-Mar-09 Greenville TX 11-Mar-09 Newton, LaCharolette Nov-08 LVN Waco TX 31-Mar-09 Newton, Rubye J Nov-08 RN Houston TX 20-Mar-09 Noble, Vivian A Dec-08 RN Amarillo TX 23-Mar-09 Nordman, Vicki R Nov-08 LVN Odessa TX 07-Apr-09 Olesen, Carole M Nov-08 RN Belton TX 30-Mar-09 Oquendo, Amaury 20-Nov-08 Owner Pecos TX 16-Mar-09 Padgett, Celeste R Dec-08 RN Arlington TX 10-Apr-09 Palmer, Susan M Dec-08 LVN Longview TX 09-Apr-09 Patel, Jayshree F May-08 MD Sugar Land TX 17-Mar-09 Pearl, Terri S Dec-08 RN Jacksonville AR 10-Apr-09 Pebernat, David H May-08 LVN Spring TX 26-Mar-09 Pena, Rebecca May-08 LVN Round Rock TX 26-Mar-09 Phillips, Rebecca L Aug-08 LVN Cuero TX 16-Mar-09 Porterfield, Mary C Nov-08 LVN Bastrop TX 09-Apr-09 Raburn, Lloyd B Oct-08 LVN Valley Mills TX 06-Apr-09 Ramos, Angela E Jun-08 LVN San Antonio TX 27-Mar-09 Reid, Stephanie L Apr-09 CHIRO Edinburg TX 15-Jan-09 Rice, Alma C Nov-08 RN Dyersburg TN 23-Mar-09 Ritchey, Carol A Jul-08 RN Fort Worth TX 26-Mar-09 Rivas, Sonya M Jun-08 LVN San Antonio TX 27-Mar-09 Roberts, Jerri L Apr-08 LVN Corpus Christi TX 26-Mar-09 Rodgers, Michael L Feb-08 RN Denton TX 26-Mar-09 Ross, Charles Apr-09 CAN Dallas TX 20-Feb-08 Ruesing, Rhonda D Jun-08 LVN Odessa TX 26-Mar-09 Runnels, Dorothy F Apr-09 LVN Tyler TX 20-Jun-00 Saenz, Kimberly C May-08 LVN Pollock TX 10-Apr-09 Salazar, Aron L Oct-08 LVN Midland TX 16-Mar-09 Saleh, Ayoub M Apr-09 RN San Antonio TX 22-Jan-09 Schei, Frederick R May-08 RN Irving TX 17-Mar-09 Shanti, Ihsan K Dec-08 MD Houston TX 07-Apr-09 Sheehan, Valerie A. C Aug-08 MD Dallas TX 11-Mar-09 Shin, James Y. J Dec-08 MD Spring TX 07-Apr-09 Shynglee, Charles O. 30-Apr-09 owner Houston TX 20-Jul-03 Smith, Deanna A Apr-09 PTech Houston TX 09-Apr-09 Texas Medicaid Bulletin, No July/August 2009

57 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Smith, Debbie L Nov-08 LVN Paris TX 09-Apr-09 Smith, Morgan R Nov-08 RN Plano TX 20-Mar-09 St. Michaels Health Services 27-Apr-09 Houston TX 20-Nov-08 Standish, Susan K Jan-09 RN Carrollton TX 13-Apr-09 Stoeckel, Mark D. L Jun-08 MD Austin TX 16-Mar-09 Suddith, Bradley R Aug-08 LVN Kerrville TX 16-Mar-09 Taylor, Jodi L Aug-08 LVN Hemphill TX 16-Mar-09 Thomas-Stone, Cynthia A Dec-07 RN San Antonio TX 26-Mar-09 Thompson, Darcy C. VA 28-Apr-09 RN Bassett VA 14-Jan Thurman, Gayla R May-08 Owner Bryan TX 27-Mar-09 TMMI for Geriatrics, Inc. 29-Apr-09 Houston TX 19-Feb-09 Tomlinson, Peggy A Dec-08 RN Darlington SC 25-Mar-09 Turner, Barbara D Apr-08 LVN Fort Worth TX 26-Mar-09 Udebu, Thomas S. 24-Feb-09 Owner Houston TX 17-Mar-09 Utuk, Becalo Apr-09 RN Houston TX 20-Nov-05 Van Wormer, Mark E. H Nov-08 MD Clayton NM 17-Mar-09 Wadley, Rhonda R Sep-08 LVN Amarillo TX 16-Mar-09 Ward, Mark D Dec-08 RN Laconia NH 23-Mar-09 Watson, Shericka C Oct-08 C N A Tyler TX 16-Mar-09 Werner, Peter W. D Oct-08 MD Austin TX 17-Mar-09 West Universal Healthcare Services 27-Apr-09 DME Houston TX 20-Nov-08 Suppl White, Susan D Jul-08 RN Fort Worth TX 26-Mar-09 Williams, Rhonda G May-08 LVN Pearland TX 26-Mar-09 Wilson, Brandi D Dec-08 LVN Hawkins TX 09-Apr-09 Wilson, Ritchie W Oct-08 LVN Edgewood TX 16-Mar-09 Winfield, Johnnie L. 20-Jan-09 Owner Houston TX 06-Apr-09 Wolfe, Teri L Sep-08 PT Kirby TX 11-Mar-09 Wood-DeGraff, Kyla E. 18-Dec-08 LTCA Lewisville TX 20-Mar-09 Woodley, Anna C Apr-09 Tech Rosenburg TX 19-Feb-09 Wren, Donnie G Oct-08 RN Odessa TX 20-Mar-09 July/August Texas Medicaid Bulletin, No. 224

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59 Forms Provider Information Change Form Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page. Check the box to indicate a PCCM Provider Date : / / Nine-Digit Texas Provider Identifier (TPI): Provider Name: National Provider Identifier (NPI): Atypical Provider Identifier (API): Primary Taxonomy Code: Benefit Code: List any additional TPIs that use the same provider information: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: Physical Address The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who change their ZIP Code must submit a copy of the Medicare letter along with this form. Street address City County State Zip Code Telephone: ( ) Fax Number: ( ) Accounting/Mailing Address All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form. Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Secondary Address Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Type of Change (check the appropriate box) Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance) Comments: Tax Information Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS) Tax ID number: Effective Date: Exact name reported to the IRS for this Tax ID: Provider Demographic Information Note: This information can be updated on Languages spoken other than English: Provider office hours by location: Accepting new clients by program (check one): Accepting new clients Current clients only No Patient age range accepted by provider: Additional services offered (check one): HIV High Risk OB Participation in the Woman s Health Program? Yes No Patient gender limitations: Female Male Both Signature and date are required or the form will not be processed. Provider signature: Date: / / Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Fax: Effective Date_ /Revised Date_ July/August Texas Medicaid Bulletin, No. 224

60 Forms Instructions for Completing the Provider Information Change Form Signatures The provider s signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers. Address Performing providers (physicians performing services within a group) may not change accounting information. For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form. For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers. Tax Identification Number (TIN) TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN. Provider Demographic Information An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, please visit the OPL at Please review the existing information and add or modify any specific practice limitations accordingly. This will allow clients more detailed information about your practice. General TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable) in order to process the change. Forms will be returned if this information is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Fax: Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No July/August 2009

61 Forms Electronic Funds Transfer (EFT) Information Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account. The following items are specific to EFT: Pre notification to your bank takes place on the cycle following the application processing. Future deposits are received electronically after pre notification. The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider s account during the weekly cycle. Specific deposits and associated R&S reports are cross referenced by both the provider identifiers (i.e., NPI, TPI, and API) and R&S number. EFT funds are released by TMHP to depository financial institutions each Friday. The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received. TMHP must provide the following notification according to ACH guidelines: Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date. However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer s needs. In all cases, credits received should be posted to the customer s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date. To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return the agreement and either a voided check or a statement from your bank written on the bank s letterhead to the TMHP address indicated on the form. Call the TMHP Contact Center at for assistance. July/August 2009 A STATE MEDICAID CONTRACTOR 61 Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No. 224

62 Forms Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form NOTE: Complete all sections below and attach a voided check or a statement from your bank written on the bank s letterhead. Type of Authorization: NEW CHANGE Provider Name Nine Character Billing TPI National Provider Identifier (NPI)/Atypical Provider Identifier (API): Provider Accounting Address Bank Name Primary Taxonomy Code: Benefit Code: Provider Phone Number ( ) Ext. ABA/Transit Number Bank Phone Number Account Number Bank Address Type Account (check one) Checking Savings I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period. I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations. Authorized Signature Date Title Address (if applicable) Contact Name Phone Return this form to: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box Austin TX DO NOT WRITE IN THIS AREA For Office Use Input By: Input Date: A STATE MEDICAID CONTRACTOR Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No July/August 2009

63 Forms Medicare Advantage Plans (MAPs) Submission Form Instructions For Crossover Claim Types 31 and 50 Providers can bill inpatient and outpatient crossover claims for services rendered to dual eligible clients of MAPs for dates of service from January 1, 2005, through December 31, Dates outside of this period will not be considered by TMHP. These claims will only be accepted from May 1, 2009, to October 31, 2009, and a legible, completed claim must be attached. Claims received after October 31, 2009, will be returned to the provider with a message indicating that they have submitted an incorrect Medicare Remittance Advice Notice (MRAN). All fields (excluding Medicaid information fields) on the form must be completed using the Remittance Advice or Remittance Notice that was received from the MAP. The MAP Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Claim Types 31 and 50 Submission Form: Field Description Medicare Paid Date Provider Name NPI/API/TPI Medicare ID Street Address City State ZIP Bill Type From DOS Through DOS Patient Last Name Patient First Name Medicare HIC Medicare ICN Guidelines Enter the Medicare Paid Date listed on the MAP Remittance Advice/Remittance Notice. Enter the billing provider s name. Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API)/Texas Provider Identifier (TPI) for the billing provider. Note: NPI/TPI or API/TPI. Enter the Medicare Provider ID of the billing provider number listed on the MAP Remittance Advice/Remittance Notice. Enter the billing provider s street address. Enter the billing provider s city. Enter the billing provider s state. Enter the billing provider s ZIP code. Enter the Medicare Bill Type listed on the MAP Remittance Advice/Remittance Notice. Note: The Medicare Bill Type may not match the type of bill (TOB) listed on the claim form. Enter the first date of service (DOS) for all procedures in a MM/DD/YYYY format. Enter the last DOS for all procedures in a MM/DD/YYYY format. Enter the patient s last name listed on the MAP Remittance Advice/Remittance Notice. Enter the patient s first name listed on the MAP Remittance Advice/Remittance Notice. Enter the patient s Medicare Health Insurance Claim (HIC) number (Medicare Identification number) listed on the MAP Remittance Advice/Remittance Notice. Enter the Medicare Internal Control Number (ICN) listed on the MAP Remittance Advice/Remittance Notice. July/August Texas Medicaid Bulletin, No. 224

64 Forms Field Description Total Charges Covered Charges Non Covered Charges/Reason Code DRG Amount Deductible Blood Deductible Coinsurance Medicare Paid Amount DRG Code Guidelines Enter the Medicare total charges (billed amount) listed on the MAP Remittance Advice/Remittance Notice. Enter the covered charges listed on the MAP Remittance Advice/Remittance Notice. Enter the noncovered charges listed on the MAP Remittance Advice/Remittance Notice followed by the reason code listed on the Medicare Remittance Advice/Remittance Notice. Enter the diagnosis-related group (DRG) amount listed on the MAP Remittance Advice/Remittance Notice for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG amount. Enter the Medicare deductible amount listed on the MAP Remittance Advice/Remittance Notice. Enter the blood deductible listed on the MAP Remittance Advice/Remittance Notice for inpatient claims, if applicable. Note: Outpatient claims do not require a blood deductible amount. Enter the Medicare coinsurance amount listed on the MAP Remittance Advice/Remittance Notice. Enter the Medicare paid amount listed on the MAP Remittance Advice/Remittance Notice. Enter the DRG code listed on the MAP Remittance Advice/Remittance Notice for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG code. Texas Medicaid Bulletin, No July/August 2009

65 Forms Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Types 31 and 50 ONLY for use for the submission of services rendered to dual eligible clients of MAPs for services rendered between January 1, 2005, through December 31, Note: Dates outside of this period will not be considered by TMHP. Submissions will only be accepted from May 1, 2009, to October 31, 2009, and a legible, completed claim must be attached. Medicare Paid Date: Provider Name: NPI/API /TPI: Medicare ID: Street Address: City: State: ZIP: Bill Type From DOS Through DOS Patient Last Name Patient First Name Medicare HIC Medicare ICN Total Charges Covered Charges Non Covered Charges/Reason Code DRG Amount Deductible Blood Deductible Coinsurance Medicare Paid Amount DRG Code Save As July/August Texas Medicaid Bulletin, No. 224

66 Forms Medicare Advantage Plan (MAPs) Submission Form Instructions For Crossover Claim Type 30 Instructions Providers can bill professional services claims for services rendered to dual eligible clients of MAPs for services rendered between January 1, 2005, through December 31, Dates outside of this period will not be considered by TMHP. These claims will only be accepted from May 1, 2009, to October 31, 2009, and a legible, completed claim must be attached. Claims received after October 31, 2009, will be returned to the provider with a message indicating that they have submitted an incorrect Medicare Remittance Advice Notice (MRAN). All fields (excluding Medicaid information fields) on the form must be completed using the Remittance Advice or Remittance Notice that was received from the MAP. The MAP Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Claim Type 30 Submission Form: Block No. Field Description Guidelines 1 NPI/API Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API) for the billing provider. 2 Medicare ID Enter the Medicare Provider ID number of the billing provider listed on the MAP Remittance Advice/Remittance Notice. 3 TPI Enter the Medicaid Texas Provider Identifier (TPI) number of the billing provider. 4 Provider Name Enter the billing provider s name. 5 Medicaid Client Number Enter the client s nine-digit Medicaid number from the Medicaid identification form. 6 Client Last Name Enter the client s last name listed on the MAP Remittance Advice/Remittance Notice. 7 Client First Name Enter the client s first name listed on the MAP Remittance Advice/Remittance Notice. 8 Medicare Paid Date Enter the Medicare Paid Date listed on the MAP Remittance Advice/Remittance Notice. 9 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the MAP Remittance Advice/Remittance Notice. 10 Client HIC Number Enter the client s identification number listed on the MAP Remittance Advice/Remittance Notice. 11 From DOS Enter the first date of service (DOS) for each procedure in a MM/DD/YYYY format. 11 To DOS Enter the last DOS for each procedure in a MM/DD/YYYY format. 11 POS Enter the place of service (POS) listed on the MAP Remittance Advice/Remittance Notice. 11 Units Enter the number of units (quantity billed) from the MAP Remittance Advice/Remittance Notice. Texas Medicaid Bulletin, No July/August 2009

67 Forms Block No. Field Description Guidelines 11 CPT Enter the appropriate Current Procedural Terminology (CPT) procedure code for each procedure/service listed on the MAP Remittance Advice/Remittance Notice. Note: The procedure code listed on the MAP Submission Form may not match the procedure code listed on the claim form attached. 11 Mods Enter the modifier (when applicable) listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Charges Enter the Medicare charges (billed amount) listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Allow Enter the Medicare allowed amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Ded Enter the Medicare deductible amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Coins Enter the Medicare coinsurance amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Paid Enter the Medicare paid amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Reason Code Enter Medicare s reason code listed on the MAP Remittance Advice/Remittance Notice for each detail. 12 Total Charges Enter the Medicare total charges (billed amount) listed on the MAP Remittance Advice/Remittance Notice. Note: A provider may attach additional template forms (pages) as necessary. The combined total charges for all pages should be listed on the last page. All other forms must indicate Continue in this block. 12 Total Allow Enter the Medicare total allowed amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Ded Enter the Medicare total deductible amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Coins Enter the Medicare total coinsurance amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Paid Enter the Medicare total paid amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Reason Code Leave this field blank. 13 Medicare Prev Paid Enter the Medicare previous paid amount listed on the MAP Remittance Advice/Remittance Notice. July/August Texas Medicaid Bulletin, No. 224

68 Forms Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Type 30 ONLY for use for the submission of services rendered to dual eligible clients of MAPs for services rendered between January 1, 2005, through December 31, Note: Dates outside of this period will not be considered by TMHP. Submissions will only be accepted from May 1, 2009, to October 31, 2009, and a legible, completed claim must be attached. 1 NPI/API 2 Medicare ID 3 TPI 4 Provider Name 5 Medicaid Client Number 6 Client Last Name 7 Client First Name 8 Medicare Paid Date 9 Medicare ICN 10 Patient HIC Number 11 Detail(s) Information From DOS To DOS POS Units CPT Mods Charges Allow Ded Coins Paid Reason Code 12 Totals Information Charges Allow Ded Coins Paid Reason Code 13 Medicare Prev Paid Save As Texas Medicaid Bulletin, No July/August 2009

69 Forms TEXAS HEALTH AND HUMAN SERVICES COMMISSION Certification of Compliance with Hurricane Dolly and Ike Social Services Block Grant for Uncompensated Care Name TPI Number(s): Whereas, the Administration for Children and Families (ACF) of the U.S. Department of Health and Human Services awarded the State of Texas Social Services Block Grant (SSBG) funds to be used to reimburse providers that served Hurricane Dolly and Ike evacuees who were uninsured and were not eligible for Texas Medicaid or Texas Children s Health Insurance Plan at the time services were rendered. Whereas, under the SSBG funding provisions, the Texas Health and Human Services Commission (HHSC) may reimburse a provider for uncompensated care costs for medically necessary services and supplies provided by the provider in accordance with the Texas Medicaid State Plan in effect during July Such services and supplies must have been provided as indicated below: Dates of Service Hurricane Dolly: July 22, 2008, through September 19, 2008 Hurricane Ike: September 7, 2008 November 7, 2008 Services Services were delivered to a disaster evacuee or related to the disaster. No other health insurance was available. Services were delivered to either a U.S. citizen or legal permanent resident. Certification I certify that the claims filed under the SSBG for uncompensated care comply with the conditions listed above and the conditions prescribed by HHSC in conjunction with its July/August Texas Medicaid Bulletin, No. 224

70 Forms implementation of the terms of the SSBG award. I further certify that I have read and understood the above statement; that the statement is true, correct, and complete; and that I am authorized to bind and certify to the above. The undersigned is aware that the claims submitted are subject to retrospective review, audit, and investigation by federal and state authorities and are subject to recoupment. Signature Date Name (print or type) Title N Texas Medicaid Bulletin, No July/August 2009

71 Notes July/August Texas Medicaid Bulletin, No. 224

72 Texas Medicaid & Healthcare Partnership B Riata Trace Parkway, Ste 150 Austin, TX A STATE MEDICAID CONTR ACTOR PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE July/August 2009 No. 224 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual Look inside for these and other important updates: Page 1 Page 30 Page 31 Page 31 Mammography Certification Issued by DSHS Federal Stimulus Package Increases FMAP Rate for Federal Fiscal Year 2009 Quarters One and Two Removal of Cerumen Criteria Established Revised Texas Medicaid Fee Schedules Available