reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 1 - MEDICAID PROCEDURES FOR PROVIDERS › Section 354.1005 - Unauthorized Charges

Current through Reg. 49, No. 28; July 12, 2024
(a) An eligible
					 provider must certify that no charges beyond reimbursement paid under the Texas
					 Medicaid Program for a covered service or any function incidental to the
					 provision of a covered service, have been, or will be, billed to an eligible
					 recipient.
(b) Within the
					 provisions cited in §
											RSA
					 354.1131 of this chapter (relating to
					 Payments to Eligible Providers), an eligible provider may not bill or take
					 other recourse against an eligible recipient for claims denied as a result of
					 an error attributed to the provider.
(c) For purposes of subsection (a) of this
					 section, functions incidental to the provision of a covered service include:
(1) signing, completing, or providing a copy
					 of a health assessment form, such as a physical examination form required for
					 the eligible recipient's enrollment in school or participation in school or
					 other activities;
(2) providing a
					 copy of a medical record requested:
(A) by or
					 on behalf of any health care practitioner for purposes of medical care or
					 treatment of the eligible recipient;
(B) under Texas Health and Safety Code §
													RSA
					 161.202;
(C) as a supplement to a form described in
					 paragraph (1) of this subsection; or
(D) by an eligible recipient, for any reason,
					 for the first time in a one-year period; and
(3) providing a copy of any subsequent
					 amendment, supplement, or correction to a medical record under paragraph (2) of
					 this subsection.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 2 - MEDICAID VISION CARE PROGRAM › Section 354.1017 - Specifications for Eyewear

Current through Reg. 49, No. 28; July 12, 2024
The provider must ensure that eyewear meets the following
						specifications.
(1) Lenses must meet
					 federal and state specifications and all standards of the American standard
					 prescription requirements for first quality lenses and dress eyewear.
(2) Standard frame sizes are dispensed at no
					 cost to the eligible recipient.
(3)
					 An eyeglass supplier must show each eligible recipient a minimum selection of
					 frame styles and colors as required by the Texas Health and Human Services
					 Commission policy.
(4) Frames are
					 only those manufactured in the United States of America, unless foreign-made
					 frames are comparable in quality to and less expensive than American
					 made-frames. Lenses are only those manufactured in the United States of
					 America, unless foreign-made lenses are comparable in quality to and less
					 expensive than American-made lenses.
(5) Frames are serviceable and meet
					 prescription quality standards.
(6)
					 Lenses and frame materials are new.
(7) Supplies are at least equivalent in
					 quality to program eyewear provided under this division at no cost to the
					 eligible recipients.
(8) All repair
					 materials billed to Texas Medicaid must be new and at least equivalent to the
					 original item and meet the specifications for prosthetic eyewear cited in these
					 provisions.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 2 - MEDICAID VISION CARE PROGRAM › Section 354.1021 - Additional Claims Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
Providers must meet the claim criteria established in the
						provisions of this division for optometric services and the provisions for
						participation in the Medicaid program established under Division 1, Medicaid
						Procedures for Providers, and Division 11, General Administration, of this
						subchapter. In addition to the claims information requirements established in
						§
											RSA
						354.1001 of this subchapter (relating to
						Claim Information Requirements), the following information is required for
						claims for vision care services:
(1)
					 name, address, and Medicaid provider identification number of the ordering
					 provider, as appropriate;
(2)
					 description of lenses and frames provided;
(3) provider's signature on the claim form,
					 including degrees or credentials, verifying the diopter or axis changes
					 required for the dispensing of replacement eyewear;
(4) claims for eyewear with special features
					 must be accompanied by a signed form by the recipient that acknowledges his
					 selection of eyewear that is beyond the specifications for eyewear in
					 §354.1017 of this division (relating to Specifications for Eyewear). A
					 signed patient certification satisfies this requirement for claims that are
					 electronically submitted;
(5) if
					 the claim is for replacement of prosthetic eyewear that was lost, stolen, or
					 damaged beyond repair, the recipient must sign the claim form or, in the case
					 of providers who electronically bill, a patient certification; and
(6) if the claim is for vision care services
					 provided to a Medicaid recipient residing in a skilled nursing facility or an
					 intermediate care facility, the claim must indicate the name of the physician
					 who ordered the services and the name of the facility where the recipient
					 resides as the place of service.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 2 - MEDICAID VISION CARE PROGRAM › Section 354.1023 - Optometric Services Provider

Current through Reg. 49, No. 28; July 12, 2024
(a) In
					 addition to those services described in §
											RSA
					 354.1015 and §
											RSA
					 363.502 of this title (both relating to
					 Benefits and Limitations), and subject to the specifications, conditions,
					 limitations, and requirements established by the Texas Health and Human
					 Services Commission (HHSC) or its designee, diagnostic and treatment services
					 performed by a provider qualified to provide optometric services under Texas
					 Medicaid are covered by the Texas Medicaid Program.
(b) To be covered, the evaluation,
					 diagnostic, and treatment services must be:
(1) within the provider's scope of practice,
					 as defined by state law;
(2)
					 reasonable and medically necessary as determined by HHSC; and
(3) provided to an eligible recipient by a
					 qualified provider enrolled in the Texas Medicaid Program at the time the
					 service(s) are provided.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 2 - MEDICAID VISION CARE PROGRAM › Section 354.1025 - Competitive Procurement of Vision Care Services

Current through Reg. 49, No. 28; July 12, 2024
The Texas Health and Human Services Commission (HHSC) may
						establish a process for procuring eyewear that encourages competition and
						results in savings to the state.
(1)
					 HHSC will determine what categories or individual types of eyewear may be
					 procured through a competitive process using the following criteria:
(A) the cost effectiveness of competitively
					 procuring a particular category or type of eyewear; and
(B) providing quality vision care services
					 for recipients.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1031 - General

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. The purpose of this division is
					 to establish rules for the Title XIX (Medicaid) home health services
					 benefit.
(b) Definitions. The
					 following words and terms when used in this division have the following
					 meanings, unless the context clearly indicates otherwise.
(1) Allowed practitioner--An individual:
(A) that maintains a valid and registered
					 prescriptive authority agreement in accordance with Texas Occupations Code,
					 Chapter 157, Subchapter B; and
(B)
					 is licensed as:
(i) a physician assistant
					 under Texas Occupations Code, Chapter 204; or
(ii) an advanced practice registered nurse
					 licensed by the Texas Board of Nursing as a:
(I) certified nurse practitioner;
					 or
(II) clinical nurse
					 specialist.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1035 - Recipient Qualifications for Home Health Services

Current through Reg. 49, No. 28; July 12, 2024
(a) An eligible Medicaid recipient must meet
					 the following requirements to qualify for Medicaid home health services.
(1) An eligible recipient must be under the
					 continuing care and medical supervision of a physician or an allowed
					 practitioner who has established a plan of care or submitted a request form for
					 the recipient in accordance with §354.1037 or §354.1039 of this
					 division (relating to Written Plan of Care and Benefits and Limitations of Home
					 Health Services). A recipient must be seen by the recipient's physician or
					 allowed practitioner within 30 days prior to the start of home health services.
					 This visit may be waived when a diagnosis has already been established by the
					 physician or allowed practitioner and the recipient is under the continuing
					 care and medical supervision of the physician or allowed practitioner. Any
					 waiver must be based on the physician's or allowed practitioner's statement
					 that an additional evaluation visit is not medically necessary.
(2) An eligible recipient must have a medical
					 need for covered home health services as documented in the recipient's plan of
					 care or request form for the recipient in accordance with §354.1037 or
					 §354.1039 of this division.
(3) An eligible recipient must receive
					 services that meet the recipient's existing medical needs, subject to
					 §354.1039 of this division and that can be safely provided in the
					 recipient's home.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1037 - Written Plan of Care

Current through Reg. 49, No. 28; July 12, 2024
(a) A plan of care
					 must be recommended, signed and dated by the recipient's physician or allowed
					 practitioner.
(b) The plan of care
					 must contain the following information:
(1)
					 all pertinent diagnoses;
(2) mental
					 status;
(3) types of services,
					 including amount, duration and frequency;
(4) equipment required;
(5) prognosis;
(6) rehabilitation potential;
(7) functional limitations;
(8) activities permitted;
(9) nutritional requirements;
(10) medications;
(11) treatments, including amount and
					 frequency;
(12) safety measures to
					 protect against injury;
(13)
					 instructions for timely discharge or referral; and
(14) date the recipient was last seen by the
					 physician or allowed practitioner.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1039 - Benefits and Limitations of Home Health Services

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC determines authorization
					 requirements and limitations for covered home health services. The home health
					 agency is responsible for obtaining prior authorization where specified for the
					 home health service, supply, or item of durable medical equipment (DME). Home
					 health services include the following:
(1)
					 Skilled nursing. Nursing services provided by a registered nurse (RN) or
					 licensed vocational nurse (LVN) licensed by the Texas Board of Nursing provided
					 on a part-time or intermittent basis and furnished through an enrolled home
					 health agency are covered home health services. Billable nursing visits may
					 include:
(A) nursing visits required to teach
					 the recipient, the primary caregiver, a family member, or a neighbor how to
					 administer or assist in a service or activity that is necessary to the care and
					 treatment of the recipient in a home setting; and
(B) RN visits for skilled nursing
					 observation, assessment, and evaluation, provided:
(i) a physician or an allowed practitioner
					 specifically requests that an RN visits the recipient for this purpose;
					 and
(ii) the request reflects the
					 need for the assessment visit.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1040 - Requirements for Wheeled Mobility Systems

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. This section details the
					 requirements for receiving reimbursement for the provision of, or the
					 performance of a major modification to, a wheeled mobility system. This section
					 implements Texas Human Resources Code §
											RSA
					 32.0425.
(b) Definitions. The following words and
					 terms when used in this section have the following meanings, unless the context
					 clearly indicates otherwise.
(1) Occupational
					 therapist (OT)--A person licensed by the Texas Board of Occupational Therapy
					 Examiners to practice occupational therapy, as defined in Texas Occupations
					 Code §
												RSA
					 454.002(4) (relating to
					 Definitions).
(2) Physical
					 therapist (PT)--A person licensed by the Texas Board of Physical Therapy
					 Examiners to practice physical therapy, as defined in §
												RSA 354.1121 of this
					 subchapter (relating to Definitions).
(3) Qualified rehabilitation professional
					 (QRP)--A person who holds one or more of the following certifications:
(A) a certification as an assistive
					 technology professional or a rehabilitation engineering technologist issued by,
					 and in good standing with, the Rehabilitation Engineering and Assistive
					 Technology Society of North America (RESNA);
(B) a certification as a seating and mobility
					 specialist issued by, and in good standing with, RESNA; or
(C) a certification as a certified
					 rehabilitation technology supplier issued by, and in good standing with, the
					 National Registry of Rehabilitation Technology Suppliers (NRRTS).
(4) Wheeled Mobility System--An
					 item of durable medical equipment (DME) that is a customized powered or manual
					 mobility device or a feature or component of the device, including:
(A) seated positioning components;
(B) powered or manual seating
					 options;
(C) specialty driving
					 controls;
(D) multiple adjustment
					 frame;
(E) nonstandard performance
					 options; and
(F) other complex or
					 specialized components.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1041 - Benefits for Medicare/Medicaid Recipients

Current through Reg. 49, No. 28; July 12, 2024
For recipients who are eligible for both Medicare and
						Medicaid (dual eligible), Medicare is the primary payor.
(1) Medicaid will pay the Medicare deductible
					 and coinsurance subject to the limitations described in §
											RSA
					 354.1143 of this subchapter (relating to
					 Coordination of Medicaid with Medicare Parts A, B, and C) for qualified
					 recipients of home health services.
(2) Eligible recipients who have exhausted
					 their home health benefits under Medicare are not entitled to receive all home
					 health services under the Medicaid program. Home health aide services, DME,
					 supplies, or appliances may be a covered service if:
(A) an eligible Medicaid recipient enrolled
					 in Medicare does not qualify for home health services under Medicare because
					 skilled nursing care, physical therapy, speech therapy or occupational therapy
					 is not an essential element of the recipient's treatment plan; and/or
(B) the medical supplies, equipment, or
					 appliances for use in the eligible recipient's place of residence are not
					 otherwise available as a Medicare Part B benefit.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1042 - Supplies Provided by a Pharmacy

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Certain supplies that are covered benefits of Texas Medicaid may be provided by
					 a pharmacy enrolled in the Medicaid Vendor Drug Program (VDP) as described in
					 this section.
(b) Covered supplies
					 include medical equipment or products typically obtained through a pharmacy
					 with a valid prescription that are designated by the Health and Human Services
					 Commission (HHSC) or its designee. A list of covered supplies can be found on
					 HHSC's website at http://www.txvendordrug.com. The list includes insulin
					 syringes and needles, which are also described in §354.1039 of this
					 division (relating to Home Health Services Benefits and Limitations).
(c) The supplies covered under this section
					 may be reimbursed through the Vendor Drug Program (VDP) if a claim is properly
					 submitted and complies with this section.
(d) The supplies covered under this section
					 require a valid prescription and do not require prior authorization unless
					 otherwise specified in HHSC policy. A prescription for supplies covered under
					 this section is valid for six months.
(e) The supplies covered under this section
					 are subject to the limitations defined in the Texas Medicaid Provider
					 Procedures Manual. Exceptions to these limitations require authorization by
					 HHSC.
(f) Supplies covered under
					 this section must be:
(1) Supported by
					 medical literature or evidence-based practice guidelines indicating the use of
					 the supply in the treatment of a disease or condition;
(2) Billed by the pharmacy using a National
					 Drug Code number; and
(3) Eligible
					 for federal financial participation under the Medicaid program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 3 - MEDICAID HOME HEALTH SERVICES › Section 354.1043 - Competitive Procurement of Durable Medical Equipment (DME) and Supplies

Current through Reg. 49, No. 28; July 12, 2024
HHSC may establish a process for procuring DME and
						supplies that encourages competition and results in savings to HHSC.
(1) The categories or individual types of DME
					 and supplies that HHSC may procure through a competitive process will be
					 determined by HHSC using the following criteria:
(A) the DME or supplies are used by a
					 recipient in sufficient quantities to encourage the competitive process and be
					 cost effective for HHSC;
(B) the
					 DME or supplies can be timely, safely, and effectively dispensed or provided by
					 a prime vendor or contractor with a physician's or an allowed practitioner's
					 prescription or order:
(i) without the
					 necessity of fitting or instruction on its use; or
(ii) fitting and instruction can be provided
					 by the prime vendor or contractor in compliance with HHSC criteria;
(C) dispensing or providing the
					 DME or supplies through a prime vendor or contractor will not limit or impair
					 the accessibility and availability of the DME or supplies to the recipient
					 requiring the DME or supplies;
(D)
					 dispensing or providing the DME or supplies through a prime vendor or
					 contractor will not result in the recipient receiving those DME or supplies in
					 an unusable condition;and
(E)
					 acquiring the DME or supplies through a prime vendor or contractor using a
					 competitive process will result in cost savings to HHSC's.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 4 - MEDICAID CHIROPRACTIC SERVICES › Section 354.1051 - Additional Claim Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
In addition to the general requirements in §
											RSA
						354.1001 of this title (relating to Claim
						Information Requirements), the following information is required on
						chiropractic claims:
(1) The diagnosis
					 of subluxation which specifies the level and condition (acute or
					 chronic).
(2) Location of
					 subluxation. The precise level of the subluxation must be specified to
					 substantiate a claim for manipulation of the spine. This designation is made in
					 relation to the part of the spine in which the subluxation is identified. The
					 level of subluxation may be specified in the following ways:
(A) The exact bones may be listed.
(B) The location may be used if it implies
					 several bones.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 4 - MEDICAID CHIROPRACTIC SERVICES › Section 354.1052 - Authorized Chiropractic Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Chiropractic services include those services provided by a doctor of
					 chiropractic and which are within the scope of practice of his profession as
					 defined by state law. Benefits are limited to services which consist of
					 necessary treatment or correction by means of manual manipulation of the spine,
					 by use of hands only, to correct a subluxation to the same extent that such
					 benefits are provided under Part B of Medicare. Benefits are available under
					 this section only for services which are provided during the first 12 visits to
					 any one eligible recipient by a doctor of chiropractic during any one benefit
					 period. Benefit period for purposes of this section means a 12 consecutive
					 month period which begins with the month of the first treatment.
(b) Coverage does not extend to the
					 diagnostic, therapeutic services, or adjunctive therapies furnished by a
					 chiropractor or by others under his or her orders or direction. This exclusion
					 applies to the x-ray taken for the purpose of determining the existence of a
					 subluxation of the spine. Additionally, braces or supports, even though ordered
					 by an MD or DO and supplied by a chiropractor, are not reimbursable
					 items.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1060 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms shall have the following
						meaning when used in this division unless the context clearly indicates
						otherwise.
(1) Direct supervision--The
					 supervising physician must be in the same office, building, or facility when
					 and where the service is provided and must be immediately available to furnish
					 assistance and direction.
(2)
					 Personal supervision--The supervising physician must be physically present in
					 the room when and where the service is being provided.
(3) Substitute physician--A physician who
					 provides services in place of another physician under either a reciprocal or
					 locum tenens arrangement. These arrangements must comply with Medicaid policy,
					 billing, reporting, and documentation requirements.
(A) Reciprocal arrangements--of a substitute
					 physician covering for the billing physician on an occasional basis when the
					 billing physician is unavailable to provide services, and limited to a
					 continuous period of coverage that is no longer than 14 days. Reciprocal
					 arrangements do not have to be in writing.
(B) Locum tenens arrangements--of a
					 substitute physician assuming the practice of a billing physician for a
					 temporary period of no longer than 90 days when the billing physician is absent
					 for reasons such as illness, pregnancy, vacation, continuing medical education,
					 or active duty in the U.S. Armed Forces. When the reason is due to active duty
					 in the Armed Forces, the temporary period may extend over a longer continuous
					 period during all of which the billing physician has been called or ordered to
					 active duty as a member of a reserve component of the Armed Forces. Locum
					 tenens arrangements must be in writing.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1061 - Additional Claim Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
In addition to the general requirements in §
											RSA
						354.1001 of this title (relating to Claim
						Information Requirements), the following information is required on claims for
						physician services:
(1) the
					 appropriate identification number of each physician providing a specific
					 service (except pathologists or radiologists in group practices);
(2) place of service;
(3) the type of each diagnostic, treatment,
					 or surgical procedure performed;
(4) the number of miles for which a travel
					 charge is made;
(5) the date on
					 which each service was provided;
(6) the individual charge for each
					 service;
(7) diagnosis(es) of the
					 condition(s) for which treatment and services were provided. With respect to
					 diagnostic or other services furnished at the request of another physician,
					 this requirement may be waived by the health insuring agent if the physician
					 providing the service shows that such information is not available to him or
					 her;
(8) the name, address, and
					 appropriate identification number of the ordering physician or doctor if
					 services were provided by another physician or doctor;
(9) all pertinent supplemental information,
					 including clarification of the diagnoses in terms of the degree or extent of
					 involvement necessary to substantiate the need for the services provided or
					 charges made, or both; and
(10) for
					 medically necessary hysterectomies, a patient's acknowledgment statement must
					 be attached or added to each claim form which states that the person who
					 secured authorization to perform the hysterectomy has informed the individual
					 and her representative, if any, orally and in writing, that the hysterectomy
					 will render the individual permanently incapable of reproducing. The individual
					 or her representative, if any, must sign the written acknowledgment of receipt
					 of that information prior to the actual surgery.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1062 - Authorized Physician Services

Current through Reg. 49, No. 28; July 12, 2024
(a) This
					 rule specifies the conditions under which a physician may bill Texas Medicaid
					 for covered services. Such conditions include compliance with this rule as well
					 as compliance with all applicable federal and state laws, rules, regulations
					 and policies relating to covered services.
(b) Physician services. A physician may bill
					 for reasonable and medically necessary services that are within the scope of
					 practice of medicine or osteopathy as defined by state law. Except for services
					 provided under subsections (c), (d), and (e) of this section, eligible
					 physician services include those performed by the physician and those medical
					 acts delegated by the physician to qualified and properly trained persons
					 acting under the physician's supervision. Delegation and supervision of medical
					 services must be consistent with this chapter and the rules and laws of the
					 Texas Medical Board, and supervision of the delegated medical act must be
					 appropriately documented in the patient's chart. A physician shall not bill the
					 Texas Medicaid program for services if that billing would result in duplicate
					 payment for the same services.
(c)
					 Physician supervising other physicians. A physician supervising other
					 physicians may bill when the supervision and services are performed in the
					 context of an accredited graduate medical education program. Facilities and
					 professional practices do not qualify for reimbursement for services provided
					 by resident physicians in an outpatient setting unless the facility or
					 professional practice is owned by, or affiliated with, an accredited graduate
					 medical education program.
(1) For all
					 services billed to the Medicaid program, the supervision must be medically
					 appropriate, as described in this rule, and provided to a resident physician
					 performing a Medicaid-covered service. The supervision must be either personal
					 or direct. To qualify for reimbursement, the medical record must clearly
					 establish:
(A) The nature of the supervisory
					 role of the billing physician in the delivery of the services provided by the
					 resident physician; and
(B) That
					 the supervision complies with the definition of supervision applicable to the
					 covered service, as defined in §
													RSA 354.1060 of this
					 title (relating to Definitions).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1063 - Preventable Adverse Events

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Reimbursement for physician services associated with preventable adverse events
					 that occur in a hospital setting will be denied or reduced.
(b) Preventable adverse events are defined in
					 §
											RSA 354.1070 of this
					 title (relating to Definitions).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1064 - Anesthesiologist Assistant Conditions of Participation

Current through Reg. 49, No. 28; July 12, 2024
To be a provider of Medicaid covered services, an
						anesthesiologist assistant must:
(1)
					 be a graduate of a medical school-based anesthesiologist assistant educational
					 program that:
(A) is accredited by the
					 Commission on Accreditation of Allied Health Education Programs (CAAHEP) or
					 CAAHEP's predecessor organization, the Committee on Allied Health Education and
					 Accreditation (CAHEA); and
(B)
					 includes approximately two years of specialized basic science and clinical
					 education in anesthesia at a level that builds on a premedical undergraduate
					 science background;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1065 - Anesthesiologist Assistant Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the specifications,
					 conditions, requirements, and limitations established by the Health and Human
					 Services Commission or its designee (HHSC), services performed by an
					 anesthesiologist assistant are considered for reimbursement if the services:
(1) are performed under the personal or
					 direct supervision of a licensed anesthesiologist in accordance with state
					 law;
(2) are consistent with rules
					 for physician delegation and supervision promulgated by the Texas Medical
					 Board; and
(3) would be covered by
					 the Texas Medicaid Program if provided by a licensed
					 anesthesiologist.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1066 - Physician Assistant Conditions of Participation

Current through Reg. 49, No. 28; July 12, 2024
To be a provider of Medicaid covered services, a
						physician assistant must:
(1) be
					 licensed as a physician assistant by the Texas Physician Assistant Board as
					 described in the Occupations Code §
											RSA
					 204.101(2) and
					 (3);
(2) comply with all applicable federal and
					 state laws and regulations governing the service provided;
(3) be enrolled and approved for
					 participation in the Texas Medical Assistance Program;
(4) sign a written provider agreement with
					 the Health and Human Services Commission (HHSC) or its designee;
(5) comply with the terms of the provider
					 agreement and all requirements of the Texas Medical Assistance Program,
					 including federal and state regulations, rules, manuals, standards, and
					 guidelines published by HHSC or its designee; and bill for services covered by
					 the Texas Medical Assistance Program in the manner and format prescribed by
					 HHSC or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1067 - Physician Assistant Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the specifications,
					 conditions, requirements, and limitations established by HHSC or its designee,
					 services performed by a licensed physician assistant are considered for
					 reimbursement if the services:
(1) are within
					 the scope of practice for a physician assistant, as defined by the licensing
					 board and state law;
(2) are
					 consistent with rules and regulations promulgated by the Texas State Medical
					 Board; and
(3) would be covered by
					 the Texas Medical Assistance Program if provided by a licensed physician (MD or
					 DO).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES › Section 354.1069 - Sign Language Interpreter Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. The following words and
					 terms, when used in this chapter, have the following meanings.
(1) Deaf--The term "deaf" is defined in the
					 Human Resources Code, Title 4, Services for the Deaf, Chapter 81, Texas
					 Commission for the Deaf and Hard of Hearing, §81.001,
					 Definitions.
(2) Hard of
					 Hearing--The term "hard of hearing" is defined in the Human Resources Code,
					 Title 4, Services for the Deaf, Chapter 81, Texas Commission for the Deaf and
					 Hard of Hearing, §81.001, Definitions.
(3) Interpreter--An interpreter is an
					 individual who possesses one of the following certification levels (i.e.,
					 levels A - H) issued by either the Department of Assistive and Rehabilitative
					 Services, Office for Deaf and Hard of Hearing Services, Board for Evaluation of
					 Interpreters (BEI) or the National Registry of Interpreters for the Deaf (RID):
(A) Certification Level A:
(i) Level I/Ii; and
(ii) OC:B (Oral Certificate:
					 Basic).
(B)
					 Certification Level B:
(i) BEI Basic;
					 and
(ii) RID NIC (National
					 Interpreter Certificate) Certified.
(C) Certification Level C:
(i) BEI Level II/IIi;
(ii) RID CI (Certificate of
					 Interpretation);
(iii) RID CT
					 (Certificate of Transliteration);
(iv) RID IC, (Interpretation Certificate);
					 and
(v) RID TC (Transliteration
					 Certificate).
(D)
					 Certification Level D:
(i) BEI Level
					 III/IIIi;
(ii) BEI OC: C (Oral
					 Certificate: Comprehensive);
(iii)
					 BEI OC: V (Oral Certificate: Visible);
(iv) RID CSC (Comprehensive Skills
					 Certificate);
(v) RID IC/TC
					 (Interpretation Certificate/Transliteration Certificate);
(vi) RID CI/CT (Certificate of
					 Interpretation/Certificate of Transliteration);
(vii) RID RSC (Reverse Skills Certificate);
					 and
(viii) RID CDI (Certified Deaf
					 Interpreter).
(E)
					 Certification Level E:
(i) BEI Advanced;
					 and
(ii) RID NIC
					 Advanced.
(F)
					 Certification Level F:
(i) BEI
					 IV/IVi;
(ii) RID MCSC (Master
					 Comprehensive Skills Certificate); and
(iii) RID SC: L (Specialist Certificate:
					 Legal).
(G)
					 Certification Level G is BEI V/VI.
(H) Certification Level H:
(i) BEI Master; and
(ii) RID NIC Master.
(4) Interpreting Services--The
					 provision of voice-to-sign, sign-to-voice, gestural-to-sign, sign-to-gestural,
					 voice-to-visual, visual-to-voice, sign-to-visual, or visual-to-sign services
					 for communication access provided by a certified interpreter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 6 - HOSPITAL SERVICES › Section 354.1070 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						subchapter, shall have the following meanings, unless the context clearly
						indicates otherwise.
(1) Present on
					 Admission--Present at the time the order for inpatient admission occurs.
					 Conditions that develop during an outpatient encounter, including emergency
					 department, observation, or outpatient surgery, are considered present on
					 admission.
(2) Preventable Adverse
					 Event--A serious, clearly identifiable and measurable error in medical care
					 that is of concern to both the public and health care professionals and
					 providers. The Health and Human Services Commission (HHSC) will determine
					 Medicaid preventable adverse events, which may include the following:
(A) a health care-associated adverse
					 condition or event for which the Medicare program will not provide additional
					 payment under a policy adopted by the federal Centers for Medicare and Medicaid
					 Services, which may be referred to as a hospital acquired condition, hospital
					 acquired infection, never event, or National Coverage Determination
					 (NCD).
(B) any other preventable
					 adverse event that causes patient death or serious disability in a health care
					 setting, including an event on the list of adverse events identified by the
					 National Quality Forum.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 6 - HOSPITAL SERVICES › Section 354.1073 - Authorized Outpatient Hospital Services

Current through Reg. 49, No. 28; July 12, 2024
Outpatient hospital services include diagnostic,
						therapeutic, rehabilitative, or palliative items or services furnished by or
						under the direction of a physician except that no payment is made for:
(1) drugs and biologicals which are
					 self-administered;
(2) occupational
					 therapy that is not medically prescribed treatment designed to improve or
					 restore an individual's ability to perform those tasks required for independent
					 functioning in self-care activities for eating, personal hygiene, dressing, and
					 communication;
(3) outpatient
					 services from a Title XIX hospital which provides these services without charge
					 upon payment of a registration fee. The registration fee is paid instead of any
					 other benefits for services;
(4)
					 parenteral hyperalimentation therapy unless prior authorization is received
					 from the department's health insuring agent. These services must be considered
					 medically necessary in order to sustain life. Coverage does not extend to
					 hyperalimentation administered as a nutritional supplement.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 6 - HOSPITAL SERVICES › Section 354.1075 - Hospitalization (Dental Care Only) for Individuals under Age 21 Years

Current through Reg. 49, No. 28; July 12, 2024
Hospitalization is authorized under the EPSDT program for
						individuals under the age of 21 years for dental care that requires in-hospital
						services. Prior approval must be obtained from the Texas Department of Health
						before admission and treatment. Claims for the hospital and physician are
						processed in the usual manner through the health insuring agent, and claims
						from the dentist will be processed through the Texas Department of
						Health.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 6 - HOSPITAL SERVICES › Section 354.1077 - Provider Participation Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A hospital must comply with each of the
					 following requirements to qualify for participation as a hospital in the Texas
					 Medical Assistance (Medicaid) Program. A hospital must:
(1) be licensed by the Department of State
					 Health Services (department) as a general or special hospital, unless exempt
					 from licensure by the appropriate licensing authority. This requirement does
					 not apply to military hospitals providing inpatient emergency hospital
					 services;
(2) be enrolled and
					 participating in the Medicare Program as a hospital;
(3) sign a written provider agreement with
					 the department or its designee to participate in the Medicaid program. The
					 provider agreement requires the hospital to comply with the terms of the
					 agreement and all requirements of the Medicaid program, including regulations,
					 rules, handbooks, standards, and guidelines published by the department or its
					 designee; and
(4) comply with the
					 utilization review plan approved by the department or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 7 - LABORATORY, X-RAY, AND RADIATION THERAPY › Section 354.1091 - Additional Claim Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
In addition to the general requirements in § 29.1 of
						this title (relating to Claim Information Requirements), the following
						information is required on claims for laboratory and x-ray services and
						radiation therapy; the name, address, and appropriate identification number (if
						known) of ordering physician.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 7 - LABORATORY, X-RAY, AND RADIATION THERAPY › Section 354.1092 - Authorized Services

Current through Reg. 49, No. 28; July 12, 2024
Laboratory and x-ray services and radiation therapy
						include professional and technical laboratory and radiological services ordered
						by a physician and provided to a patient by or under the direction of a
						physician in either:
(1) an office or
					 similar facility other than a hospital outpatient department or a clinic;
					 or
(2) an approved laboratory (but
					 only with respect to those services which the laboratory is certified to
					 provide under Medicare).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 8 - PODIATRY SERVICES › Section 354.1101 - Additional Claim Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
In addition to the general requirements in §
											RSA
						354.1001 of this title (relating to Claim
						Information Requirements), the following information is required on claims for
						podiatry services:
(1) place of
					 service;
(2) the type of each
					 diagnostic, treatment, or surgical procedure;
(3) the number of miles for which a travel
					 charge is made;
(4) the individual
					 charge for each service;
(5)
					 diagnosis(es) of the condition(s) for which treatment and services were
					 provided. With respect to diagnostic or other services furnished at the request
					 of a physician or another podiatrist, this requirement may be waived by the
					 health insuring agent if the podiatrist providing the services shows that such
					 information is not available to him or her;
(6) name, address, and appropriate
					 identification number of the ordering physician or podiatrist if services were
					 provided by a non-ordering podiatrist; and
(7) all supplemental information, including
					 clarification of the diagnoses in terms of the degree or extent of involvement,
					 necessary to substantiate the need for the services provided or changes made,
					 or both.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 8 - PODIATRY SERVICES › Section 354.1102 - Authorized Podiatry Services

Current through Reg. 49, No. 28; July 12, 2024
The term "podiatry services" includes those services
						provided by or under the personal supervision of a doctor of podiatry which are
						within the scope of practice of his profession as defined by state law and for
						which benefits are or would have been provided under Medicare had the recipient
						been eligible for Medicare.