Approved Banner Messages For Total Messages (260) Banner Messages for Copyright Acknowledgements

Transcription

1 Banner Messages for 2006 This file contains abbreviated messages meant to provide timely notifications that affect all provider groups (physicians, dentists, and so forth). Additional current and historic information affecting the Medicaid, Medicaid Managed Care, and Children with Special Health Care Needs (CSHCN) provider community may be found in the earlier postings of these files in the TMHP banner library at as well as in the bi-monthly editions of the Texas Medicaid Bulletin and the quarterly CSHCN Bulletin, which update the Texas Medicaid Provider Procedures Manual and CSHCN Provider Manual, respectively. Copyright Acknowledgements 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 2005 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: CDT4/2004 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/ DFARS) restrictions apply. Microsoft Corporation requires the following notice in publications containing trademarked productnames: Microsoft and Windows are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries. Approved Banner Messages For 2006 Total Messages (260) 1 (12/22/06 through 1/12/07) *****Attention All Medicaid Providers***** The following is an update to a banner message that first appeared on the December 15, 2006, Remittance and Status (R&S) report about the STAR+PLUS expansion to the Bexar, Harris/Harris Expansion, Nueces, and Travis service areas. The expansion will not be implemented on January 1, 2007, and has been postponed to a future date. A future banner message will notify providers when the expansion implementation date is available. Following is the latest information regarding the STAR+PLUS expansion. The Health and Human Services Commission (HHSC) is delaying the expansion of the STAR+PLUS program due to a delay in federal approval of the waiver. The current STAR+PLUS program operating in Harris county will continue until federal approval is received. Clients who have already made their STAR+PLUS health plan selections will continue to receive Medicaid services as they do today and will be enrolled in their selected health plan when the program becomes 1 of 81

2 operational. If the federal government approves the waiver in a timely fashion, the program will be operational on February 1, Enrollment will resume the last week of December for those clients who have not yet made a STAR+PLUS selection. The state will be sending a letter to clients who have already made their health plan selection notifying them of the delay. Please visit the STAR+PLUS website at for the most recent information available. 2 (12/22/06 through 01/12/07) *****Attention All Medicaid Providers***** The following is a clarification of reimbursement for associated durable medical equipment (DME) charges for mobility aids provided by home health providers. The Texas Medicaid Program does not reimburse separately for associated DME charges, including, but not limited to, battery disposal fees or state taxes. Reimbursement for associated charges is included in the reimbursement for the specific piece of equipment. 3 (12/15/06 through 01/26/07) *****Attention All Medicaid Providers***** The following is a correction to a banner message that first appeared on the December 1, 2006, Remittance and Status (R&S) report regarding the reprocessing of claims from home health agencies. The original message included a reprocessing date of January, Following is the complete corrected banner message. TMHP has identified an issue impacting claims that include the October 1, 2005, implementation of statewide visit rates for home health agencies that bill professional skilled nursing, home health aide, physical therapy (PT), occupational therapy (OT), and speech-language therapy (ST) visits. Paid claims for dates of service on or after November 1, 2002, through October 1, 2005, that have not been paid in accordance with the statewide visit rate methodology will be reprocessed at a future date. No action on the part of the provider is necessary. Monitor future Remittance and Status (R&S) Reports for claim activity. Providers Affected: Home health agencies that provide home health skilled nursing (SN), PT, OT, and Comprehensive Care Program (CCP), PT, OT, and ST visits. A letter containing the approximate number of claims impacted will be mailed to individual providers. Details about the rate implementation are available in the September/October 2005 Texas Medicaid Bulletin, No. 190 and on the TMHP website at 4 (12/15/06 through 1/5/07) *****Attention All Medicaid Providers***** Effective January 1, 2007, STAR+PLUS is expanding to the Bexar, Harris/Harris Expansion, Nueces, and Travis service areas. Inpatient hospital services will be carved-out for this expansion. The STAR+PLUS health maintenance organizations (HMOs) will authorize inpatient hospital stays, but all inpatient hospital claims will be processed and paid as fee-for-service claims by TMHP. TMHP will be responsible for the processing of all acute care inpatient hospital claims, except for inpatient behavioral health claims in the Harris and Harris expansion service areas (Brazoria, Fort Bend, Galveston, Harris, Montgomery, and Waller counties). A behavioral health claim is a claim submitted with a behavioral health diagnosis as the primary diagnosis. The Texas Health and Human Services Commission (HHSC) will be hosting a web-based training for all hospital providers in the STAR+PLUS areas on Tuesday, December 12, 2006, from 2 p.m. to 4 p.m. For instructions on how to participate in the training, visit the 2 of 81

3 HHSC website at Additional information related to this expansion and available training can be found on the TMHP website at 5 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers***** Effective for dates of service on or after February 1, 2007, phototherapy device rental is a benefit of Texas Medicaid (Title XIX) Home Health Services for infants in the home setting when submitted with one of the following diagnosis codes: 7740, 7741, 7742, 77430, 77431, 77439, 7744, 7745, 7746, or Home phototherapy devices require prior authorization and are provided only for the days that are medically necessary. Prior authorization requirements are based on the current American Academy of Pediatrics guidelines. Home phototherapy services include parent/guardian education and obtaining laboratory specimens. Prior authorization is a condition for reimbursement; it is not a guarantee of payment. To request prior authorization, providers must complete a Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form, attach the necessary supporting documentation, and fax the request to or mail the request to TMHP PO Box Austin, TX Details of these changes are available on the TMHP website at 6 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers**** Effective for dates of service on or after February 1, 2007, the benefit criteria for cytogenetic testing has changed for the Texas Medicaid Program. Details of these changes are available on the TMHP website at 7 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers**** Effective on or after February 1, 2007, procedure code may be considered for reimbursement when submitted for the same date of service as a tonsillectomy, adenoidectomy, or nasal surgery. If procedure code is submitted for the same date of service as a tonsillectomy, adenoidectomy, or nasal surgery, the reimbursement for procedure code is half of the Medicaid-allowable fee. 8 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers**** Effective for dates of service on or after February 1, 2007, treatment for deformities of the foot and lower extremity that includes flat foot as a component of the deformity will be a benefit of the Texas Medicaid Program. The client must present significant pain in the foot, leg, or knee resulting in a decrease in or loss of function, along with a secondary condition such as valgus deformity or plantar fasciitis. Treatment of flat foot (flexible pes planus) that is solely cosmetic in nature is not a benefit of the Texas Medicaid Program. 3 of 81

4 9 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers**** TMHP has identified an issue impacting claims that include procedure code , , , or submitted for dates of service on or after January 1, These claims are pending review after encountering a system processing error. Claims submitted for dates of service on or after January 1, 2006, will be processed. No action on the part of the provider is necessary. 10 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers***** TMHP has identified an issue impacting prenatal visit claims that include procedure codes , , , , or , with modifier TH, submitted for dates of service November 4, 2005, through November 30, These claims received an inappropriate payment reduction. Claims submitted for dates of service November 4, 2005, through November 30, 2006, that include these procedure codes will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 11 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers***** Effective for dates of service on or after February 1, 2007, the age and diagnosis restrictions have been removed from procedure codes , , and Reimbursement will be considered for, but is not limited to, the following clinical indications: persistent pulmonary hypertension, meconium aspiration syndrome, respiratory distress syndrome, adult respiratory distress syndrome, congenital diaphragmatic hernia, sepsis, pneumonia, pre- and post-operative congenital heart disease or heart transplantation, reversible causes of cardiac failure, cardiomyopathy, myocarditis, aspiration pneumonia, pulmonary contusion, and pulmonary embolism. Payment may be recouped if services were provided in the presence of certain contraindicated conditions. Additionally, procedure codes , , and will no longer be a benefit of the Texas Medicaid Program for advance practice nurses and registered nurse/nurse-midwives. For more information please call the TMHP Contact Center at (12/15/06 through 01/05/07) *****Attention All Medicaid Providers***** Effective for dates of service on or after February, 1, 2007, ambulatory electroencelphalograms procedure codes 5/I/T-95950, 5/I/T-95951, 5/I/T-95953, and 5/I/T may be considered for reimbursement for the following diagnosis codes: (Pick s disease), (Other frontotemporal dementia), (Dementia with Lewy bodies), (Concussion; with brief loss of consciousness of 30 minutes or less), and (Concussion; with brief loss of consciousness of 31 to 59 minutes or less). Ambulatory electroencepholograms are no longer a benefit of the Texas Medicaid Program for diagnosis code (Febrile convulsions). Additionally, the time unit for monitoring is 24 hours. Benefits are limited to three units of 24 hours for each physician for the same patient in a six-month period when medically necessary. 4 of 81

5 13 (12/15/06 through 01/05/06) *****Attention All Medicaid Providers***** The following is a correction to an article published on the TMHP website at entitled The Women s Health Program, on November 10, The article incorrectly listed diagnosis code V2503 as a payable diagnosis code. Details and the complete corrected article are available on the TMHP website at 14 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers***** Effective December 1, 2006 for dates of service on or after November 1, 1994, diagnosis code (Vitiligo) is payable for procedure codes , , , , , and Effective December 1, 2006 for dates of service on or after December 1, 2003, diagnosis code (Vitiligo) is payable for procedure codes , , and Claims submitted for dates of service on or after December 1, 2003 that include procedure codes , , , , , , , , and with diagnosis will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 15 (12/15/06 through 01/05/07) *****Attention All Medicaid Providers***** Effective for dates of service on or after February 1, 2007, benefits for aerosol and pentamidine treatments have changed for the Texas Medicaid Program. Details of these changes are available on the TMHP website at and will also be available in the March/April 2007 Texas Medicaid Bulletin. 16 (12/08/06 through 12/29/06) *****Attention All Medicaid Providers***** TMHP has identified an issue impacting claims that included procedure code L-E0935 submitted for dates of service on or after March 1, 2006, for the Texas Medicaid Program. Some claims were incorrectly denied for exceeding a four-per-lifetime limitation. Procedure code L-E0935 is a benefit on a daily basis and is limited to once per day. Reimbursement includes delivery, set-up, and all supplies. Effective November 30, 2006, claims submitted with procedure code L-E0935 for dates of service on or after March 1, 2006, that were denied for exceeding a four-per-lifetime limitation will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 17 (12/08/06 through 12/29/06) *****Attention All Medicaid Providers***** Effective November 30, 2006, for dates of service on or after January 1, 2006, procedure codes and are limited to one service per client in a six month period. Claims submitted for dates of service on or after January 1, 2006, that include these procedure codes will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 5 of 81

6 18 (12/01/06 through 12/22/06) *****Attention All Medicaid Providers***** The following is a correction to the article published on the TMHP website at on October 9, 2006, entitled Therapeutic Dental Procedures Changing for Texas Medicaid Providers. The article incorrectly stated that the following procedure codes were a benefit of the Texas Medicaid Program: D9970, D2336, D2337, D2380, D2381, D2382, D2385, D2386, D2387, D2388, D2712, and D2799. Additionally, some benefit information was not included in the original article. The complete, corrected article is available on the TMHP website at 19 (12/01/06 through 12/22/06) *****Attention All Medicaid Providers***** The following is a correction to an article published in the November/December 2006 Texas Medicaid Bulletin, No. 199, entitled Therapeutic Phlebotomy, located on page 20. Diagnosis code 2384 was inadvertently repeated with the incorrect description. Diagnosis code 2750 was omitted as a payable diagnosis for procedure code Details and the corrected article are available on the TMHP website at and will be available in the March/April 2007 Texas Medicaid Bulletin. 20 (12/01/06 through 01/05/07) *****Attention All Medicaid Providers***** Reminder: Providers must maintain compliance with the Texas Family Code. The Texas Family Code places certain restrictions on child support obligors. Family Code (d) requires a person who applies for, bids on, or contracts for state funds to submit a statement that the person is not delinquent in paying child support. This law applies to an individual whose business is a sole proprietorship, partnership, or corporation in which the individual has an ownership interest of at least 25 percent of the business entity. This law does not apply to contracts/agreements with governmental entities or nonprofit corporations. The required statement has been incorporated into the Texas Medicaid Provider Agreement. The law also requires that payments be stopped when notified that the contractor/provider is more than 30 days delinquent in paying child support. Medicaid payments are placed on hold when it is discovered that a currently enrolled provider is delinquent in paying child support. A provider application may also be denied or a provider agreement terminated when the provider is delinquent in paying child support. 21 (11/24/06 through 12/15/06) *****Attention All Medicaid Providers***** TMHP has identified an issue impacting crossover files submitted by TrailBlazer (a Medicare intermediary). A TrailBlazer Part B file was not received on August 3, Additionally, a TrailBlazer Part A and a TrailBlazer Part B file from August 14, 2006, were not processed. TMHP began to process these files on November 15, Providers are encouraged to compare their weekly Remittance and Status (R&S) reports against their Medicare Remittance Advice Notices to ensure that all crossover claims are received and processed accordingly. 22 (11/24/06 through 12/15/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after January 1, 2006, the encounter rate for outpatient services provided in Indian Health Services (IHS) facilities operating under the authority of Public Law increased to 6 of 81

7 $ for the Texas Medicaid Program. This rate increase only applies to IHS facilities operating under the authority of Public Law The IHS facility must be a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act. The reimbursement methodology for outpatient services provided in IHS facilities operating under the authority of Public Law is located at Title 1 Texas Administrative Code (TAC), The previous encounter rate for outpatient IHS facilities was $ Claims paid at the previous encounter rate of $ for dates of service on or after January 1, 2006, will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 23 (11/17/06 through 12/08/06) *****Attention All Medicaid Providers***** The following is a correction to a banner message that first appeared on the October 13, 2006, Remittance and Status (R&S) report about changes to immunizations (vaccines/toxoids) reimbursement. The complete article titled Changes to Immunizations (Vaccines/Toxoids) Reimbursement appeared on the TMHP website at on October 13, The banner message and website article incorrectly included immunization procedure codes that are not a benefit of the Texas Medicaid Program. Additionally, clarification is provided for those immunization procedure codes that are eligible for reimbursement and those that are submitted as informational-only provided for Texas Medicaid Program clients birth through 20 years of age. Providers should refer to the TMHP website for the complete article. 24 (11/17/06 through 12/08/06) *****Attention All Medicaid Providers***** The following is a correction to a banner message that first appeared on the October 20, 2006, Remittance and Status (R&S) report about the Women s Health Program (WHP). The banner message did not include the reference to Title XIX in the first sentence, the phrase or eligible immigrants in the second sentence, and a referral to the TMHP website. The following is the complete, corrected article: Effective January 1, 2007, the Health and Human Services Commission (HHSC) will implement the Women s Health Program (WHP), a new type of client assistance. These services will be covered by the Texas Medicaid Program (Title XIX) and provided on a fee-for-service basis, even in areas with managed care. This new type of assistance is available to women 18 to 44 years of age who are United States citizens or eligible immigrants and Texas residents with a net family income at or below 185 percent of the federal poverty level (FPL). Details of these changes are available on the TMHP website at and will be in the January/ February 2007 Texas Medicaid Bulletin, No (11/10/06 through 12/1/06) *****Attention All Medicaid Providers***** The banner message regarding the Women s Health Program that first appeared on October 20, 2006, Remittance and Status (R&S) report and the TMHP website is under review. A complete, revised banner message and website article will be published in a future R&S report and will be posted to the TMHP website at 7 of 81

8 26 (11/10/06 through 12/01/06) *****Attention All Medicaid Providers***** TMHP has identified an issue impacting claims that included procedure code J/L-E0135 submitted for dates of service on or after October 16, 2003, for the Texas Medicaid Program. Authorization is required for claims submitted with procedure code J/L-E0135. Claims submitted for dates of service on or after October 16, 2003, that include this procedure code will be reprocessed and payments adjusted accordingly. No action on the part of the provider is required. 27 (11/10/06 through 12/01/06) *****Attention All Medicaid Providers**** Effective September 1, 2005, hospitals are allowed to release a patient s protected health information (PHI) to a transporting emergency medical services provider for treatment, payment, and health care operations according to Senate Bill 1113, which amended the Texas Health and Safety Code, Providers are required to release a patient s PHI to agents of HHSC or its designee, TMHP, upon request and without charge. Providers are encouraged to release PHI to transporting emergency services providers upon request and without charge to avoid the need for TMHP intervention. 28 (10/27/06 through 11/17/ 06) *****Attention All Medicaid Providers***** The following is a correction to a banner message that first appeared on the October 13, 2006, Remittance and Status (R&S) report about Texas Health Steps (THSteps) benefit changes for Rotavirus and the combined tetanus, diphtheria, and pertussis (Tdap) vaccines. The complete article appeared on the TMHP website at on October 6, The banner message and website article incorrectly included information about the Tdap vaccine that is not applicable for THSteps providers. Providers should refer to the TMHP website for the complete article. Following is the corrected banner message. Effective December 1, 2006, for dates of service on or after February 21, 2006, the Rotavirus vaccine is a benefit of the Texas Medicaid Program, including Texas Health Steps (THSteps), when administered according to the Advisory Committee on Immunization Practices (ACIP) recommendations. 29 (10/27/06 through 11/17/06) *****Attention All Medicaid Providers***** The following is a correction to a banner message that first appeared on the September 30, 2005, through October 28, 2005, Remittance and Status (R&S) report. The banner message incorrectly listed procedure codes and as payable for the Texas Medicaid Program. Additionally, the banner message incorrectly stated that procedure codes and could be billed as type of service (TOS) T (technical component). Procedure codes and are a benefit for TOS I (professional component) only. The following is the complete, corrected banner message. Effective for dates of service on or after November 1, 2005, the following procedure codes are a benefit of the Texas Medicaid Program when performed in the office setting: 2/F-22520, 2/F-22521, 2/F-22522, 2/F-35476, 2/F-36145, 2/F-36555, 2/F-36556, 2/F-36557, 2/F-36558, 2/F-36560, 2/F-36561, 2/F-36563, 2/F-36565, 2/F-36566, 2/F-36568, 2/F-36569, 2/F-36570, 2/F-36571, 2/F-36575, 2/F-36576, 2/F-36578, 2/F-36580, 2/F-36581, 2/F-36582, 2/F-36583, 2/F-36584, 2/F-36585, 2/F-36589, 2/F-36590, 2/F-36595, 2/F-36596, 2/F-36597, 2/F-36870, 4/I/T-75790, 4/I/T-75901, 4/I/T-75902, 4/I/T-75978, I-76012, and I of 81

9 Procedure codes and may be billed as a professional component (TOS I). These procedure codes are not payable as a technical component (TOS T) or a total component (TOS 4). Procedure codes I and I are a benefit when performed in an outpatient hospital in addition to the office setting. 30 (10/27/06 through 11/17/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after December 1, 2006, procedure codes and will be reimbursed by the Texas Medicaid Program at access-based maximum fee rate instead of a relative value unit (RVU) calculation; however, these codes will keep the same maximum fee amounts for anesthesiologists of $ for procedure code and $ for procedure code Effective for dates of service on or after December 1, 2006, providers will no longer report actual face-to-face minutes with the client for procedure codes and Providers will continue to report time in minutes; however the time reported will represent minutes between the start time and stop time for these procedures. Providers billing these codes should refer to the Current Procedural Terminology (CPT) Manual definition of time. The published definition of time in the CPT Manual, entitled Time Reporting, located on page 33 is Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance; that is, when the patient may be safely placed under the postoperative supervision. The flat fees for anesthesiologists are $ for procedure code and $ for procedure code The maximum fees for certified registered nurse anesthetists (CRNAs) are 92 percent of the maximum fees paid to anesthesiologists. 31 (10/27/06 through 11/17/06) *******Attention All Medicaid Providers******* Effective for dates of service on or after October 31, 2006, benefit criteria, including documentation requirements, for psychiatric diagnostic interviews, and pharmacological management will change for the Texas Medicaid Program. Details of these changes are available on the TMHP website at 32 (10/27/06 through 11/17/06) *****Attention All Medicaid Providers***** Effective on or after December 2, 2006, providers of Mental Health Case Management and Rehabilitative Services will submit all claims directly to TMHP. The Resiliency and Disease Management (RDM) translator will cease to process claims on December 1, Claims submitted to the translator after 12:00 p.m. on December 2, 2006, will not be processed. Additional information will be provided via broadcast message from the Department of State Health Services (DSHS). Details of these changes are available on the TMHP website at 33 (10/20/06 through 11/10/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after January 1, 2007, Pap smear procedure codes: I-88141, , , , , , , , , , , , , 9 of 81

10 , and will not be reimbursed separately to either the physician or a laboratory when billed on the same day as a Texas Health Steps (THSteps) medical checkup visit (procedure codes S-99381, S-99382, S-99383, S-99384, S-99385, S-99391, S-99392, S-99393, S-99394, and S-99395). 34 (10/20/06 through 11/10/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after December 1, 2006, the following benefit changes for injections of chelating agents will be implemented for the Texas Medicaid Program: Podiatrists, registered nurse/nurse midwife, medical suppliers (durable medical equipment [DME]), radiation treatment centers, podiatry groups, and dentistry groups will no longer be reimbursed for chelation therapy procedure codes 1-J0470, 1-J0600, 1-J0895, and 1-J3520. Procedure code 1-J3520 is a benefit when billed with diagnosis codes and Procedure code 1-J3520 is no longer a benefit when billed with diagnosis codes 4271, 42741, and Procedure code 1-J0600 is no longer a benefit when billed with diagnosis codes 9850, 9851, 9852, 9853, 9854, 9855, 9856, and Procedure code 1-J0895 is a benefit when billed with diagnosis codes 9640, 9730, 9858, and Procedure code 1-J0895 is no longer a benefit when billed with diagnosis codes 28522, 28529, and Procedure code 1-J0470 is a benefit when billed with diagnosis codes 9840, 9841, 9848, 9849, 9850, 9851, 9858, and (10/20/06 through 11/10/06) *****Attention All Medicaid Providers***** Effective January 1, 2007, a new type of client assistance, the Women s Health Program (WHP), will be implemented by the Health and Human Services Commission (HHSC). WHP is available to women 18 to 44 years of age who are United States citizens and Texas residents and who have a net family income at or below 185 percent of the Federal Poverty Level (FPL). WHP clients will receive limited family-planning benefits covered by Medicaid. Details of these changes are available on the TMHP website at and will also be available in the January/February 2007 Texas Medicaid Bulletin. 36 (10/13/06 through 11/03/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after November 1, 2006, benefits for immunizations (vaccines/toxoids) will change for the Texas Medicaid program. Providers may be reimbursed for the administration of any vaccine/toxoid that has been recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Health and Human Services Commission. This administration fee reimbursement also applies to vaccines/toxoids not distributed through the Texas Vaccines For Children (TVFC) program. Providers are expected to follow the ACIP recommendations for administration. The specific diagnosis necessitating the vaccine/toxoid is required when billing with the administration fee (procedure codes 1/S-90465, 1/S-90466, 1/S-90467, 1/S-90468, 1/S-90471, 1/S-90472, 1/S-90473, and 1/S-90474) in combination with the appropriate vaccine procedure code. Vaccine/toxoid administration fees for clients younger than 21 years of age will be reimbursed based on the number of state-defined components administered per injection. The following billing criteria are required: 10 of 81

11 The provider must bill an administration fee without a modifier when a vaccine/toxoid with one state-defined component is administered. A vaccine/toxoid billed without a modifier will be reimbursed at $5.00. The provider must bill an administration fee with state-defined modifier U2 when a vaccine/toxoid with two state-defined components is administered. A vaccine/toxoid billed with modifier U2 will be reimbursed at $7.50. The provider must bill an administration fee with state-defined modifier U3 when a vaccine/toxoid with three state-defined components is administered. A vaccine/toxoid billed with modifier U3 will be reimbursed at $ For clients younger than 21 years of age, diagnosis code V202 (Routine infant or routine child health check) may be used. 37 (10/13/06 through 11/03/06) *****Attention All Medicaid Providers***** Effective December 1, 2006, for dates of service on or after February 21, 2006, the Rotavirus vaccine is a benefit of Texas Health Steps (THSteps) Program when administered according to the Advisory Committee on Immunization Practices (ACIP) recommendations. Effective December 1, 2006, for dates of service on or after June 20, 2006, the combined tetanus, diphtheria and pertussis (Tdap) vaccine is a benefit of Texas Health Steps (THSteps) Program when administered according to the Advisory Committee on Immunization Practices (ACIP) recommendations. For more information, refer to the complete article at 38 (09/29/06 through 10/20/06) *****Attention All Medicaid Providers***** Effective September 15, 2006, for dates of service on or after February 21, 2006, procedure code will process as informational-only for family nurse practitioner, pediatric nurse practitioner, physician and physician group, physician assistants, registered nurse/nurse mid-wife, hospital, and independent rural health clinic providers. These providers are eligible for a $5 administration fee for services performed in the office, home, outpatient hospital, or nursing home setting. Claims submitted for dates of service on or after February 21, 2006, that include this procedure code will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 39 (09/29/06 through 10/20/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after January 1, 2005, the encounter rate for outpatient services provided in Indian Health Services (IHS) facilities operating under the authority of Public Law increased to $ for the Texas Medicaid Program. This rate increase only applies to Indian Health Services facilities operating under the authority of Public Law The IHS facility must be a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act. The reimbursement methodology for outpatient services provided in IHS facilities operating under the authority of Public Law is located at Title 1 Texas Administrative Code (TAC), The previous encounter rate for outpatient Indian Health Services was $ Claims paid at the previous encounter rate of $ for dates of service on or after January 1, 2005, will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 11 of 81

12 40 (09/29/06 through 10/20/06) *****Attention All Medicaid Providers***** On April 28, 2006, the Centers for Medicare and Medicaid Services awarded Texas a $5.3 million grant to reimburse providers that incurred uncompensated care costs during the period from Sept. 23, 2005, through Jan. 31, 2006, for medically necessary services for Rita evacuees who did not have other health insurance coverage. The grant is for the sole purpose of reimbursing providers for Hurricane Rita related uncompensated care services provided to evacuees, not for uncompensated care services that providers incur as part of their normal business. Evacuee refers to an individual who is a resident of the emergency area affected by a national disaster as declared by the President of the United States, and has been displaced from his or her home, and is not a nonqualified alien. The Health and Human Services Commission has modified the original claims filing deadline for Hurricane Rita claims. As a result providers will no longer have 365 days from the date of service to submit a claim. All Hurricane Rita related claims must be submitted to Texas Medicaid & Healthcare Partnership for processing no later than Sept. 30, For claims covered under this provision the following information, at a minimum, is required: client name, Social Security number (if available), date of birth, sex, age and Zip code. The client s Zip code must be in a declared disaster area for the claim to be eligible for payment. The claims submitted also must include services provided and dates of service. Claims may not be submitted for services that a provider has received payment from an individual or organization as part of a public or private hurricane relief effort. Uncompensated care claims paid through this provision cannot be counted as uncompensated care in the hospital-specific disproportionate share hospital limit as defined in section 1923(g)(1)(A) of the Social Security Act. Claims will be retrospectively reviewed. 41 (09/22/06 through 10/13/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after September 1, 2006, HHSC has implemented a process that allows TMHP to consider appeals submitted for psychological evaluation, or testing and therapy performed by a qualified provider at the request of the Department of Family and Protective Services (DFPS) or by a court order. Details of these changes are available on the TMHP website at and will also be available in the January/February 2007 Texas Medicaid Bulletin. 42 (09/22/06 through 10/13/06) *****Attention All Medicaid Providers***** HHSC has modified the original claims filing deadline for Hurricane Rita claims. As a result, providers will no longer have 365 days from the date of service to submit a claim. All Hurricane Rita related claims must be submitted to TMHP for processing no later than September 30, You are eligible for reimbursement only for health care services for Hurricane Rita evacuees. Claims submitted for uncompensated care for individuals that were not a Hurricane Rita evacuee constitutes fraud and abuse. The HHSC OIG office will be conducting retrospective reviews and if fraud and abuse is found, providers will be subject to prosecution. HHSC will update the HHSC and TMHP websites as additional information becomes available. 43 (09/15/06 through 10/06/06) *****Attention All Medicaid Providers***** 12 of 81

13 Effective for dates of service on or after November 1, 2006, procedure code J9310 will no longer be diagnosis restricted; however, a valid and applicable International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code indicating the client s physical condition is required for reimbursement consideration. 44 (09/15/06 through 10/06/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after November 1, 2006, procedure code is a benefit of the Texas Medicaid Program when billed with the following diagnosis codes: 2384 (Polycythemia vera), 2750 (Disorders of iron metabolism), 2771 (Disorder of porphrin metabolism), 2859 (Anemia, unspecified), 2890 (Polycythemia secondary), 2896 (Familial polycythemia), and 7764 (Polycythemia of newborn). Additionally, procedure code will no longer be payable by the Texas Medicaid Program to the following provider types: inpatient hospital, advanced practice nurse, clinical nurse specialist, physician assistant, and certified nurse midwife. 45 (09/01/06 through 09/22/06) *****Attention All Medicaid Providers***** As outlined in the 2006 Texas Medicaid Provider Procedures Manual, Section 4.2 Medicaid Identification, Verification, located on page 4-4, providers are responsible for requesting and verifying current eligibility information from the client by asking the client to produce either a Medicaid Identification (Form H3087) or Medicaid Verification Letter (Form H1027) issued for the month that services are provided. Providers must accept either of these documents as valid proof of eligibility but should request additional identification when unsure the person presenting the form is the actual person identified on the form. Providers should retain a copy of the form for their records to verify that the client is eligible for Medicaid coverage before providing services. Providers should also check the eligibility date to determine whether the client has possible retroactive coverage for previous bills. The Texas Health and Human Services Commission issues Form H1027-A, B, or C only when Form H3087 is lost or stolen or in the event of temporary emergency Medicaid coverage. Providers should check Form H1027 to confirm there are no limitations that would affect the client s eligibility for an intended service. 46 (09/01/06 through 09/22/06) *****Attention All Medicaid Providers***** The following is a correction to a banner message that first appeared on the August 18, 2006, Remittance and Status (R&S) report about Texas Medicaid Program benefit changes for skin therapy. The banner message incorrectly excluded a comprehensive list of dia nosis codes for leishmaniasis. Following is the complete corrected article. Effective for dates of service on or after September 1, 2006, the Texas Medicaid Program will implement the following benefit changes for skin therapy: Procedure codes , , , and will no longer be payable for diagnosis code Procedure codes , , , and will be payable for diagnosis codes 0780, 0850, 0851, 0852, 0853, 0854, 0855, 0859, and Procedure codes 2/F and 2/F will be payable for the following diagnosis codes: 0780, 0850, 0851, 0852, 0853, 0854, 0855, 0859, and Procedure codes 2/F-96920, 2/F-96921, and 2/F will be payable for the following diagnosis codes: 13 of 81

14 0780, 0850, 0851, 0852, 0853, 0854, 0855, 0859, and (09/01/06 through 09/22/06) *****Attention All Medicaid Providers***** Effective September 1, 2006, providers can no longer bill TMHP for off-campus acute care services provided to Medicaid-eligible state school residents, except for inpatient hospital care for individuals that are eligible for Supplemental Security Income (SSI) Medicaid. Providers can contact the following individuals for assistance or information about billing procedures for state school services: Brenham Region (Includes Brenham, Corpus Christi, Lufkin, Richmond, and San Antonio state school residents): Judy Grote at or ; Abilene Region (Includes Abilene, San Angelo, Lubbock, and El Paso state school residents): Jerolyn Beyer at or ; Mexia Region (Includes Mexia, Denton, and Austin state school residents): Ron Fowler at or (08/25/06 through 09/15/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after September 1, 2006, claims submitted for nonemergency ambulance transport will require prior authorization in accordance with the Human Resource Code (HRC). The HRC requires a physician, nursing facility, health care provider, or other responsible party to obtain prior authorization for nonemergency ambulance transport from the TMHP Ambulance Prior Authorization department. A provider who is denied payment for nonemergency ambulance transport because of failure to obtain prior authorization or because a request for prior authorization was denied can appeal to TMHP. If the review shows that prior authorization was not obtained before transport, the denial of reimbursement will be upheld. If the review shows that prior authorization was obtained before transport or that the request for prior authorization was improperly denied based on the documentation of medical necessity submitted initially, the denial of reimbursement may be overturned. 14 of 81

15 In addition, the HRC states a provider denied payment for nonemergency ambulance transport may be entitled to payment from the nursing facility, health care provider, or other responsible party that requested the service if payment under the Medical Assistance Program is denied because of lack of prior authorization and the provider submits a copy of the bill for which payment was denied. 49 (08/25/06 through 09/15/06) *****Attention All Medicaid Providers***** The following is a correction to a banner message that first appeared on the July 21, 2006, Remittance and Status (R&S) report about prior authorization requests for inpatient hospital psychiatric services. The banner message incorrectly included Axis III and Axis IV diagnosis codes and did not specify comprehensive care inpatient psychiatric (CCIP) providers. Following is the complete corrected article: Effective for dates of service on or after September 1, 2006, comprehensive care inpatient psychiatric (CCIP) providers submitting a prior authorization request for inpatient psychiatric services must include all Axis I and Axis II diagnosis codes. Additionally, when requesting prior authorization for inpatient psychiatric services, CCIP providers must use the revised Psychiatric Hospital Inpatient Admission Form and the revised Psychiatric Inpatient (Extended) Request Form. The revised forms are available on the TMHP website at and will also be available in the November/December 2006 Texas Medicaid Bulletin, No (08/18/06 through 09/08/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after September 1, 2006, the Texas Medicaid Program will implement the following benefit changes for skin therapy: Procedure codes , , , and will no longer be payable for diagnosis code Procedure codes , , , and will be payable for the following diagnosis codes: 6953, 7060, 7061, 0780, 0850, and Procedure codes and will be payable for the following diagnosis codes: 6953, 7060, 7061, 0850, 135, and Procedure codes , 2/F-96921, and 2/F will be payable for the following diagnosis codes: 6953, 7060, and (08/18/06 through 09/08/06) *****Attention All Medicaid Providers***** Medicare recently updated 2006 rates for physicians paid under the Medicare Physician Fee Schedule (MPFS). As a result, Medicare contractors have begun to make mass adjustments to claims that were processed under the previous rates for dates of service on or after January 1, This adjustment process, which was completed by Medicare in July 2006, has increased the number of Medicare adjustment claims that will be crossed over to trading partners such as TMHP. As a result of these Medicare adjustment claims, some providers will see adjustments on their Remittance and Status (R&S) reports. Impacted claims will be reprocessed using the corrected rate and the original payment made for the co-insurance and deductible will be adjusted accordingly. Providers are required to monitor their R&S reports to ensure the crossover from Medicare occurs. Refer to the 2006 Texas Medicaid Providers Procedures Manual (TMPPM), Section 4.5 Medicare/Medicaid Clients, on page 4-11, for more detailed information. 15 of 81

16 52 (08/18/06 through 09/08/06) *****Attention All Medicaid Providers***** Effective for dates of admission on or after September 1, 2006, the Texas Health and Human Services Commission Office of Inspector General Utilization Review Unit will use evidence-based guidelines to perform retrospective utilization review of inpatient hospital claims for Medicaid clients. The evidence-based guidelines are Milliman Care Guidelines, which replace the physician-developed and physician-approved Medicaid Hospital Screening Criteria addressed through a rule revision effective August 1, Reviews required by the Texas Medical Review Program (TMRP), Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), and the current LoneSTAR Select II Contracting Program are included. 53 (08/18/06 through 09/08/06) *****Attention All Medicaid Fee-For-Service Providers***** On April 28, 2006, the Centers for Medicare & Medicaid Services (CMS) authorized Texas to cover health care services for hurricane Rita evacuees. The amendment covers health care provided to hurricane Rita evacuees who reside in one of the covered counties or parishes and did not have other health care coverage. Texas Medicaid providers are eligible for reimbursement for services rendered in accordance with Texas Medicaid State plan in place on September 23, 2005, and will be reimbursed at the Texas Medicaid rates. All claims are subject to retrospective review. Benefits include health care, long-term care, prescription medicines, and medical transportation. Services for adults 21 years of age and older that were not part of Texas Medicaid State plan on September 23, 2005, are not eligible for reimbursement, include hearing aids, eyeglasses and contact lenses, and services provided by podiatrists, chiropractors, licensed clinical social workers, licensed marriage and family therapists, licensed psychologists, and licensed professional counselors. Beginning September 2, 2006, providers may submit claims to TMHP using as the nine-digit Texas Medicaid ID Number (PCN). Services must have been provided from September 23, 2005, though January 31, Providers must include the client s name, Social Security number (if available), date of birth, sex, age, and ZIP code on the claim. The client s ZIP code must be in a declared disaster area for the claim to be eligible for payment. 16 of 81

17 Services rendered on these claims do not require prior authorization. Details of these changes are available on the TMHP website at 54 (08/04/06 through 08/25/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after November 1, 2006, procedure code J9264 will no longer be restricted by diagnosis; however, a valid and applicable International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code that indicates the client s physical condition is required for reimbursement consideration. Claims denied for dates of service from January 1, 2006, through October 31, 2006, that include diagnosis codes 1740, 1741, 1742, 1743, 1744, 1745, 1746, 1748, 1749, 1750, or 1759 will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 55 (07/28/06 through 08/18/06) *****Attention All Medicaid Providers***** Effective for claims received on or after September 1, 2006, the Texas Medicaid claims processing system will be updated to accept health-care-professional modifiers for a registered nurse (TD) or a licensed practical nurse/licensed vocational nurse (TE) in places of service (POS) other than home. Previously, procedure codes billed with these modifiers were only allowing claims payment if the POS billed was a home. Providers can submit claims modifiers TD or TE in all places of service (POS). Texas Health Steps (THSteps) and Mental Health and Mental Retardation (MHMR) providers required to designate the practitioner delivering a service should resume submitting claims with the TD or TE modifier whenever appropriate. Federally qualified health care centers (FQHCs) and rural health clinics (RHCs) must continue to use a TD or TE modifier if billing for a visiting nurse services in a client's home or if billing THSteps for a service performed by a nurse. 17 of 81