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 9 - AMBULANCE SERVICES › Section 354.1111 - 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) Ambulance
					 provider--A provider of ambulance services who:
(A) is enrolled as an ambulance provider in
					 the Texas Medicaid Program to provide ambulance services for Medicaid
					 recipients;
(B) is licensed with
					 the Department of State Health Services, Emergency Medical Services
					 Division;
(C) is enrolled in
					 Medicare;
(D) agrees to accept
					 assignment on all Medicare/Medicaid claims; and
(E) agrees to provide these services
					 according to state and local laws, regulations, and guidelines governing
					 ambulance services.
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 9 - AMBULANCE SERVICES › Section 354.1113 - Additional Claim Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) In addition to the general requirements
					 in §
											354.1001 of this subchapter
					 (relating to Claim Information Requirements), the following information is
					 required on claims for ambulance services.
(1)
					 Documentation of medical necessity in accordance with codes representing
					 medical conditions as designated by HHSC:
(A)
					 the transport documentation must substantiate the level of service and mode of
					 transport provided;
(B)
					 reimbursement is recouped when the documentation does not substantiate that the
					 level of service and mode of transport provided accurately matches the level of
					 service and mode of transport claimed; and
(C) the level of service and mode of
					 transport provided must be medically necessary based on the clinical situation
					 and needs of the recipient.
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 9 - AMBULANCE SERVICES › Section 354.1115 - Authorized Ambulance Services

Current through Reg. 49, No. 28; July 12, 2024
In addition to the requirements stated in this section, a
						provider must comply with §
											354.1001 of this subchapter
						(relating to Claim Information Requirements), and §354.1113 of this
						division (relating to Additional Claim Information Requirements).
(1) Emergency ambulance transportation. HHSC
					 will reimburse a Medicaid-enrolled ambulance provider for the emergency
					 transport of a Medicaid recipient with an emergency medical condition in
					 accordance with the following criteria.
(A)
					 Transport must be to an appropriate facility. If the transport is made to a
					 facility other than an appropriate facility, payment is limited to the amount
					 that would be payable to an appropriate facility.
(B) Transport by air or boat ambulance is
					 reimbursable if the time and distance required to reach an appropriate facility
					 make the transport by ground ambulance impractical or would endanger the life
					 or safety of the recipient. If the recipient's medical condition does not meet
					 the emergency air or boat criteria, but does meet the emergency ground
					 transportation criteria, the payment to the provider is limited to the amount
					 that would be payable at the emergency ground transportation rate.
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 10 - DEFINITIONS › Section 354.1121 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
						shall have the following meanings, unless the context clearly indicates
						otherwise.
(1) Advanced practice
					 registered nurse--A registered nurse authorized by the Texas Board of Nursing
					 to practice as an advanced practice registered nurse. The term includes a nurse
					 practitioner, nurse-midwife, nurse anesthetist, and clinical nurse
					 specialist.
(2) Ambulance service
					 supplier--A person, firm, or institution approved for and participating in
					 Medicare as an air, ground, or specialized ambulance service supplier or
					 provider.
(3) Ambulatory surgical
					 center--A distinct health care entity that operates exclusively for the purpose
					 of providing certain surgical services to patients not requiring overnight
					 inpatient hospital services. The center must meet the conditions for
					 participation described in §
											RSA
					 354.1211 of this subchapter (relating to
					 Conditions for Participation) and other applicable state and federal
					 requirements.
(4) Approved
					 laboratory--A laboratory that is independent of a hospital or physician's
					 office and that has been approved for and is participating in Medicare and only
					 for the procedures certified to that laboratory under Medicare.
(5) Billing agent--A business agent as
					 described in
					 RSA
					 447.10(f).
(6) Claim--A request for payment for
					 authorized benefits on the applicable approved form meeting the established
					 itemization requirements.
(7)
					 Day--With respect to inpatient hospital services, the time period of a day is
					 counted for:
(A) hospital bed occupancy each
					 midnight while under registration in a hospital as an inpatient;
(B) each hospital bed occupancy where
					 admission and discharge occur on the same calendar day while under registration
					 in a hospital as an inpatient.
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 11 - GENERAL ADMINISTRATION › Section 354.1131 - Payments to Eligible Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 Health and Human Services Commission or its designee (HHSC) pays an eligible
					 provider on behalf of an eligible recipient for a service that is a benefit of
					 the Texas Medicaid Program when the service is medically necessary for
					 diagnosis or treatment, or both, of illness or injury, or when the service is
					 appropriately authorized for prevention of the occurrence of a medical
					 condition, and is prescribed by a physician or other qualified practitioner, as
					 appropriate to the particular benefit, in accordance with federal or state law
					 or policy and the utilization review provisions of this chapter.
(b) Subject to the qualifications,
					 limitations, and exclusions set forth in this chapter, Medicaid payment for a
					 covered service is made only to an eligible provider of that service. The
					 provider must accept payment of the reasonable charge, reasonable costs, or
					 stipulated fee for service, as appropriate to the eligible provider, as the
					 full and complete payment. The provider may not charge or take other recourse
					 against any eligible recipient for a service for which payment is made or will
					 be made, except as may otherwise be specifically provided. An eligible provider
					 may charge an eligible recipient for a service that is outside the amount,
					 duration, and scope of benefits of the Texas Medicaid Program. Payment for a
					 covered service is not made to any eligible recipient.
(c) An eligible provider may not bill or take
					 other recourse against an eligible recipient for a denied or reduced claim for
					 a service that is within the amount, duration, and scope of benefits of the
					 Texas Medicaid Program if the denial or payment reduction results from any of
					 the following, as determined by HHSC:
(1) the
					 provider's failure to submit a claim, including claims that are not received by
					 HHSC;
(2) the provider's failure to
					 submit a claim within the claims filing period established by HHSC;
(3) the filing of an unsigned or otherwise
					 incomplete claim, including but not limited to, failure to submit a valid
					 hysterectomy acknowledgment statement or sterilization consent form when these
					 forms are required for the applicable procedures;
(4) the filing of an incorrect
					 claim;
(5) the provider's failure
					 to resubmit a claim within the resubmittal period established by
					 HHSC;
(6) the provider's failure to
					 appeal a claim within the appeal filing period(s) established by
					 HHSC;
(7) errors made in the claims
					 preparation, submission, or appeal processes that are attributable to the
					 provider as discerned by HHSC.
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 11 - GENERAL ADMINISTRATION › Section 354.1133 - Parental Accompaniment Requirement

Current through Reg. 49, No. 28; July 12, 2024
(a) Scope. This section applies to a service
					 provided or furnished pursuant to 25 TAC Chapter 33 (relating to Early and
					 Periodic Screening, Diagnosis, and Treatment) or Chapter 380 of this title
					 (relating to Medical Transportation Program).
(b) Definitions. For the purposes of this
					 section, the following terms have the following meanings.
(1) Affiliate--Except for an individual
					 listed in §32.001(a)(1) - (3) of the Family Code, a person who is employed
					 by, contracts with, or volunteers with:
(A) a
					 provider or an entity contracted with a provider;
(B) an organization established by a provider
					 or group of providers; or
(C) an
					 entity that is associated with or related to a provider and that receives at
					 least 25 percent of its financial support from:
(i) a provider;
(ii) a group of providers; or
(iii) an organization related to a provider
					 or a group of providers.
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 11 - GENERAL ADMINISTRATION › Section 354.1135 - Claims Procedures

Current through Reg. 49, No. 28; July 12, 2024
The health insuring agent:
(1) rejects all claims not payable under this
					 chapter;
(2) suspends payments to
					 any eligible provider in accordance with procedures approved by the department
					 or after notification from the department to suspend such payments and promptly
					 provides the department appropriate information pertaining to any such
					 suspension;
(3) notifies any
					 provider submitting the claims of their reduction or rejection and the reason
					 therefor;
(4) collects any payments
					 made in error, as set forth in this chapter, effects a current record credit to
					 the department, and provides the department with required data relating to such
					 error corrections;
(5) within a
					 period not to exceed 30 days of receipt and determination of proper evidence
					 establishing the validity of claims, invoices, and statements, prepares checks
					 or drafts to providers, except for cases in which the department agrees that a
					 basis exists for further review, suspension, or other irregularity;
(6) with respect to eligible providers who
					 have furnished eligible recipient's benefits, payment for which is to be made
					 on a reasonable cost basis, the health insuring agent makes provisions for
					 payments:
(A) on an interim basis, not less
					 often than once each calendar month, in amount which will approximate the
					 reasonable cost of such services; and
(B) on a final audited annual basis for the
					 reasonable cost of such services;
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 11 - GENERAL ADMINISTRATION › Section 354.1137 - Review of Questionable Claims

Current through Reg. 49, No. 28; July 12, 2024
The health insuring agent has physicians, or other
						professional consultants, or both, as appropriate, review all questionable
						claims for:
(1) interpretation of
					 benefit coverage with respect to illness or mental disease;
(2) determinations on questions regarding
					 overutilization or other misutilization of services by eligible recipients or
					 eligible providers;
(3)
					 determinations on questions regarding excessive charges by eligible
					 providers;
(4) determination of the
					 reasonable amount to be paid when a claim is made for a procedure or service
					 for which a reasonable charge determination has not been established by the
					 health insuring agent. Such determination is made in comparison with
					 established reasonable charges for other procedures requiring similar degrees
					 of skill, training, or experience, and considering the locale in which the
					 service was provided and the characteristics of the patient;
(5) quality of care provided and unethical
					 practices of eligible providers. Cases where quality of service or ethical
					 practices of the eligible provider are in question are identified and not paid
					 until further review.
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 11 - GENERAL ADMINISTRATION › Section 354.1139 - Verification of Cost Data

Current through Reg. 49, No. 28; July 12, 2024
The health insuring agent is responsible for verification
						of all eligible provider cost data where applicable under the Medical
						Assistance Program for services provided under this chapter.
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 11 - GENERAL ADMINISTRATION › Section 354.1141 - Notification to Eligible Providers

Current through Reg. 49, No. 28; July 12, 2024
The health insuring agent develops and implements
						procedures to advise eligible providers that they must report and utilize other
						sources of payment available to eligible recipients to the maximum extent
						permitted. Payment is reduced to the extent that part of any specified benefits
						are covered by any health, accident, or other insurance policy or contract. In
						determining coverage, no exclusion of the insurance policy or benefit system
						with respect to benefits otherwise payable is taken into
						account.
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 11 - GENERAL ADMINISTRATION › Section 354.1143 - Coordination of Medicaid with Medicare Parts A, B, and C

Current through Reg. 49, No. 28; July 12, 2024
(a) If a Medicaid recipient is eligible for
					 Medicare coverage (a dual eligible), the Health and Human Services Commission
					 (HHSC) or its designee pays the recipient's Medicare deductible and coinsurance
					 as specified in this section. Payment of deductible and coinsurance is subject
					 to the reimbursement limitations of the Texas Medical Assistance Program
					 (Medicaid).
(1) For qualified Medicare
					 beneficiaries as defined in the Social Security Act, §1905(p), HHSC or its
					 designee pays on valid Medicare claims the recipient's Part A and Part B
					 deductible and coinsurance as specified in this section. Payments for benefits
					 for individuals eligible for Medicaid only as qualified Medicare beneficiaries
					 are limited to payments for Medicare deductible and coinsurance as described in
					 subsection (b) of this section. Physicians must accept Medicare assignment for
					 Medicaid payment of Part B deductible and coinsurance.
(2) For Medicaid recipients who are not
					 qualified Medicare beneficiaries, but for whom HHSC otherwise has Part A and
					 Part B deductible or coinsurance liabilities, HHSC or its designee pays the
					 recipient's Part B deductible on valid, assigned Medicare claims. Payment of
					 the recipient's Part B coinsurance and Part A deductible and coinsurance on
					 valid, assigned Medicare claims is limited to claims for services that:
(A) are within the amount, duration, and
					 scope of Medicaid; and
(B) would be
					 covered by Medicaid, when the services are provided, if Medicare did not
					 exist.
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 11 - GENERAL ADMINISTRATION › Section 354.1145 - Nonliability

Current through Reg. 49, No. 28; July 12, 2024
Neither the department nor the health insuring agent is
						liable for any act or omission by any eligible provider, their agents, or
						employees in caring for a person receiving services for which benefits are
						provided under this chapter.
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 11 - GENERAL ADMINISTRATION › Section 354.1147 - Medicaid Fee Schedule

Current through Reg. 49, No. 28; July 12, 2024
The health insuring agent provides to any requesting
						eligible provider a copy of the Texas Medicaid fee schedule in accordance with
						applicable laws and regulations. Cost of the fee schedule is borne by the
						requesting eligible provider.
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 11 - GENERAL ADMINISTRATION › Section 354.1149 - Exclusions and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Notwithstanding any other provision of this subchapter, Medicaid services or
					 supplies that are not medically necessary will not be considered for Medicaid
					 reimbursement. The following benefit exclusions and limitations are applicable
					 under the Medicaid program for services provided under this subchapter. They do
					 not apply to Medicaid services provided through the Texas Health Steps
					 Comprehensive Care Program. Additional exclusions and limitations are listed in
					 the Texas Medicaid Provider Procedures Manual. The following benefits are not
					 included in the Texas Medicaid Program:
(1)
					 services provided to any individual who is an inmate in a public institution
					 (except as a patient in a medical institution approved for participation in the
					 Medicaid program), or is a patient in:
(A)
					 the hospital or nursing sections of facilities for persons with intellectual
					 and developmental disabilities; or
(B) an institution for mental disease if the
					 patient is between the ages of 22 and 64;
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 11 - GENERAL ADMINISTRATION › Section 354.1151 - Freedom of Choice

Current through Reg. 49, No. 28; July 12, 2024
Eligible recipients have the freedom of choice of an
						eligible provider. The provider also has the right of choice of serving an
						eligible recipient; however, in making a determination of whether to serve a
						recipient, the requirements of the Civil Rights Act of 1964 must be observed.
						See § 29.2 of this title (relating to Compliance with Civil Rights
						Act).
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 11 - GENERAL ADMINISTRATION › Section 354.1153 - Subrogation

Current through Reg. 49, No. 28; July 12, 2024
(a) The health insuring agent will be
					 subrogated to any individual's right of recovery against third parties for
					 personal injury or to any other right to payment under any insurance coverage
					 to the extent of the allowable claims paid under this chapter for services
					 caused by illness or injury.
(b)
					 The health insuring agent and the department, through mutual agreement,
					 establish procedures, controls, and guidelines so as to ensure that all such
					 appropriate cases are discovered, that necessary action is taken, and that all
					 facts necessary are acquired and evaluated to determine if any right of
					 recovery exists.
(c) The health
					 insuring agent and the department mutually agree on guidelines for action to be
					 taken on subrogation claims by the health insuring agent to effectuate recovery
					 of amounts paid under the health insuring contract for services caused by
					 illness or injury. The health insuring agent has authority to commence legal
					 action, compromise, and settle such claims in accordance with the procedures
					 and guidelines so established, and to execute appropriate releases.
(d) The health insuring agent exerts all
					 reasonable efforts to acquire and evaluate all appropriate facts to determine
					 if subrogation rights exist. When a case is reviewed by the health insuring
					 agent, if it appears the facts are such that there are valid rights of
					 recovery, the case is reported by the health insuring agent to the department
					 in accordance with procedures as mutually agreed.
(e) Any sums recovered under subrogation by
					 the health insuring agent, less court costs, attorney's fees, and other costs
					 of litigation, if any, are applied back against the claims involved in
					 accordance with procedures and documentation as approved by the department. Any
					 sums recovered by the department on subrogation claims which the health
					 insuring agent notifies the department of its election not to pursue are
					 retained by the department.
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 11 - GENERAL ADMINISTRATION › Section 354.1155 - Confidentiality of Information

Current through Reg. 49, No. 28; July 12, 2024
The health insuring agent and all subcontractors must
						treat all information which is obtained through performance under the health
						insuring contract as confidential information to the extent that confidential
						treatment is provided under law and regulations, and may not use any
						information so obtained in any manner except as necessary to the proper
						discharge of obligations and securing of rights as defined in this
						chapter.
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 11 - GENERAL ADMINISTRATION › Section 354.1159 - Utilization Review

Current through Reg. 49, No. 28; July 12, 2024
The health insuring agent performs the following
						utilization review functions:
(1)
					 studies conducted by the professional and paraprofessional staff to develop,
					 test, revise, implement, and monitor prepayment and postpayment screens
					 relating to medical necessity, appropriateness of care, setting in which
					 service was delivered, and potential fraud;
(2) consultation with professional
					 associations in defining criteria;
(3) publication and distribution of
					 prepayment criteria to appropriate providers;
(4) review of suspended claims to determine
					 medical necessity; review and resolution of claims suspended by the system for
					 professional or paraprofessional determination of medical necessity;
(5) provider communications:
(A) seminars and workshops to the extent that
					 such meetings relate to utilization review;
(B) visits to individual physicians, doctors,
					 hospitals, etc., to discuss patterns of practice, billing practices as they
					 directly relate to utilization and recovery of any funds.
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 11 - GENERAL ADMINISTRATION › Section 354.1161 - Provider Re-Enrollment or Provider Contract or Agreement Modification

Current through Reg. 49, No. 28; July 12, 2024
(a) No later than the date specified in Title
					 1 §371.1000 (Provider Re-enrollment or Provider Contract Modification), a
					 provider who is enrolled in the Medicaid program who wants to continue to
					 participate in the program must, in accordance with instructions from an agency
					 operating part of the Medicaid program, either re-enroll in the Medicaid
					 program under a new contract or agreement approved by the Health and Human
					 Services Commission or modify the provider's existing contract or agreement
					 using language approved by the Health and Human Services Commission.
(b) A provider enrolled in the Medicaid
					 program who does not re-enroll in the program under the new contract or
					 agreement or modify the existing provider contract or agreement in accordance
					 with the instructions of an agency operating part of the Medicaid program by
					 the date specified in Title 1 §371.1000 (Provider Re-enrollment or
					 Provider Contract Modification), does not retain eligibility to participate in
					 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 11 - GENERAL ADMINISTRATION › Section 354.1163 - Fair Hearings

Current through Reg. 49, No. 28; July 12, 2024
As determined by the department, the health insuring
						agent participates in all fair hearings requested by applicants, eligible
						recipients, or eligible providers where issues involve the health insuring
						agent. Such hearings are arranged by the department and are conducted in
						accordance with guidelines, rules, and regulations promulgated by the
						department for such hearings.
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 11 - GENERAL ADMINISTRATION › Section 354.1165 - Free Services for Recipients

Current through Reg. 49, No. 28; July 12, 2024
Benefits available free of charge to recipients from
						other sources are to be considered as a resource in determining what benefits,
						if any, are available under the Texas Medical Assistance
						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 11 - GENERAL ADMINISTRATION › Section 354.1167 - Reimbursement for Abortions

Current through Reg. 49, No. 28; July 12, 2024
Reimbursement for an abortion is available when a
						physician has found and so certified in writing to the Texas Department of
						Health (department) or its designee that, on the basis of his or her
						professional judgment, the life of the mother would be endangered if the fetus
						were carried to term, or that the pregnancy was the result of rape or incest.
						In cases which do not clearly satisfy the criteria for reimbursement under the
						Medicaid program, as established by the department or its designee, a second
						medical opinion may be required.
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 11 - GENERAL ADMINISTRATION › Section 354.1169 - Ectopic Pregnancy

Current through Reg. 49, No. 28; July 12, 2024
Medical procedures necessary for the termination of an
						ectopic pregnancy are not considered to be abortion procedures and will be paid
						for by 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 11 - GENERAL ADMINISTRATION › Section 354.1171 - Use of Drugs or Devices to Prevent Implantation of the Fertilized Ovum

Current through Reg. 49, No. 28; July 12, 2024
The use of drugs or devices to prevent implantation of
						the fertilized ovum is not considered an abortion procedure and will be paid
						for by the Medicaid Program as long as treatment occurs before the fact of
						pregnancy is established, including the prompt treatment of rape or incest
						victims.
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 11 - GENERAL ADMINISTRATION › Section 354.1175 - Organ Transplants

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the
					 specifications, conditions, and limitations established by the Health and Human
					 Services Commission (HHSC), organ transplant services are covered as follows:
(1) Coverage is limited to those services, as
					 approved by HHSC or its designee, that are determined to be reasonable,
					 medically necessary, and standard medical procedures.
(2) Coverage includes solid and nonsolid
					 organ procurement (including acquiring/harvesting, processing, preserving,
					 storing, distributing, and tissue typing). If a hospital obtains an organ
					 outside of the hospital, the hospital must obtain it from an organ procurement
					 organization designated by the secretary of the Department of Health and Human
					 Services. Coverage does not include donor expenses.
(3) Coverage of each type of solid organ
					 transplant is limited to an initial transplant and one subsequent retransplant
					 because of rejection as a lifetime 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 11 - GENERAL ADMINISTRATION › Section 354.1181 - Provider Compliance with the Clinical Laboratory Improvement Amendments of 1988

Current through Reg. 49, No. 28; July 12, 2024
Effective September 1, 1992, all providers seeking
						reimbursement from the Texas Medical Assistance Program for covered laboratory
						services, regardless of location, size, or type of laboratory must meet the
						registration and certification requirements as set forth in the Clinical
						Laboratory Improvement Amendments of 1988, Public Law
						100-578.
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 11 - GENERAL ADMINISTRATION › Section 354.1183 - Provider Compliance with the Mammography Quality Standards Act of 1992

Current through Reg. 49, No. 28; July 12, 2024
Providers seeking reimbursement from the Texas Medical
						Assistance (Medicaid) Program for covered mammography screening and diagnostic
						services, must meet the registration and accreditation requirements of the
						department's Bureau of Radiation Control and Compliance, the recognized
						accrediting body for the state under the provisions of the Mammography Quality
						Standards Act of 1992, Public Law
						102-539.
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 11 - GENERAL ADMINISTRATION › Section 354.1185 - Provider Compliance with Durable Medical Equipment (DME) Certification Requirements

Current through Reg. 49, No. 28; July 12, 2024
Providers of DME must sign the Texas Department of Health
						(department) DME Certification and Receipt prior to submitting any claim to the
						department's designee for payment for DME. The DME provider must maintain the
						DME Certification and Receipt in the provider's office and must produce it for
						review upon the request of the department or its designee. The signature of the
						DME provider certifies that the:
(1)
					 recipient has received the equipment as prescribed by the physician;
(2) equipment has been properly fitted to the
					 recipient and/or meets the recipient's needs; and
(3) recipient, the parent or guardian of the
					 recipient, and/or the primary caregiver of the recipient, has received training
					 and instruction regarding the equipment's proper use and maintenance.
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 11 - GENERAL ADMINISTRATION › Section 354.1186 - Requirements for the Health Passport

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 The Health Passport is an electronic medical record used to document healthcare
					 services provided to clients who receive services through the comprehensive
					 foster care healthcare delivery system, mandated by the Texas Family Code
					 §
											RSA
					 266.003 and §
											RSA 266.006, and
					 other Medicaid clients as may be designated by the Health and Human Services
					 Commission (HHSC).
(b) The contents
					 of the Health Passport must include, but are not limited to:
(1) Client's name, birthdate, address of
					 record, and Medicaid ID number;
(2)
					 Name and address of each of the client's physicians and health care
					 providers;
(3) A record of each
					 visit to a physician or other healthcare provider, including routine checkups
					 conducted in accordance with the Texas Health Steps Program;
(4) A record of immunizations;
(5) Identification of the client's known
					 health problems; and
(6)
					 Information on all client prescriptions.
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 11 - GENERAL ADMINISTRATION › Section 354.1187 - Responsibilities of Third-Party Billing Vendors

Current through Reg. 49, No. 28; July 12, 2024
A third-party billing vendor who submits a claim to the
						Health and Human Services Commission, or its designee, for payment on behalf of
						a provider of medical services under the medical assistance program must enter
						into a contract with the commission, or its designee, authorizing that
						activity.
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 11 - GENERAL ADMINISTRATION › Section 354.1189 - Acute Care Medicaid Billing Coordination System

Current through Reg. 49, No. 28; July 12, 2024
An acute care Medicaid billing coordination system is
						mandated by the Government Code §
											RSA
						531.02413. The Health and Human Services
						Commission (HHSC) will develop and implement an acute care Medicaid billing
						coordination system for the fee-for-service delivery model that identifies
						whether another entity has primary payor responsibility.
(1) An entity holding a permit, license, or
					 certificate of authority issued by a state regulatory agency must allow HHSC or
					 its designee to access databases that enable it to carry out the purposes of
					 this section. Entities subject to this section are those entities that are, by
					 statute, contract or agreement, legally responsible for the payment of a claim
					 for a health care item or service.
(2) HHSC shall refer any entity that violates
					 this rule to the regulatory agency issuing the permit, license, or certificate
					 of authority for possible administrative sanction.
(3) After September 1, 2008, no public funds
					 shall be expended on entities not in compliance with this section unless a
					 memorandum of understanding is entered into between the entity and
					 HHSC.
(4) Information obtained
					 under this section must be secure and maintain the confidentiality of the
					 client's health records in compliance with security and privacy rules adopted
					 by the U.S. Department of Health and Human Services under the Health Insurance
					 Portability and Accountability Act of 1996 (HIPAA),
					 RSA 164.302 -
					 RSA
					 164.318 and §§
											RSA 164.500 -
					 RSA
					 164.534.
(5) The administrator of the acute care
					 Medicaid billing coordination system shall be determined by HHSC. The
					 administrator shall be responsible for meeting all requirements of the acute
					 care Medicaid billing coordination system.
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 11 - GENERAL ADMINISTRATION › Section 354.1190 - Medicaid Provider Database

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 Medicaid Provider Database is an electronic, searchable, Internet-based
					 database of all participating providers in the Medicaid program.
(1) Definitions
(A) "Executive commissioner" means the
					 executive commissioner of the Health and Human Services Commission.
(B) "Health care provider" means a person,
					 other than a physician, who:
(i) is licensed
					 or otherwise authorized to provide a health care service in this state
					 including:
(I) a pharmacist, dentist,
					 optometrist, mental health counselor, social worker, advanced practice nurse,
					 physician assistant, or durable medical equipment supplier; or
(II) a pharmacy, hospital, or other
					 institution organization;
(ii) is wholly owned or controlled by:
(I) a health care provider or a group of
					 health care providers described by clause (i) of this subparagraph;
(II) one or more hospitals and physicians,
					 including a physician-hospital organization;
(iii) is a professional association of
					 physicians organized under the Texas Professional Association Law, as described
					 by §
														RSA
					 1.008, Business Organizations Code;
(iv) is an approved nonprofit health
					 corporation certified under Chapter 162, Occupations Code;
(v) is a medical and dental unit, as defined
					 by §
														RSA
					 61.003, Education code, a medical school, as
					 defined by §
														RSA
					 61.501, Education Code, or a health science
					 center described by Subchapter K, Chapter 74, Education Code, that employs or
					 contracts with physicians to teach or provide medical services, or employs
					 physicians and contracts with physicians in a practice plan; or
(vi) is another person wholly owned by
					 physicians.
(C) "Managed
					 care plan" has the meaning assigned by §
													RSA
					 533.001, Government Code.
(D) "Participating provider" means a
					 physician or health care provider who provides Medicaid services, including a
					 physician or health care provider who contracts or otherwise agrees with a
					 managed care organization to provide Medicaid services.
(E) "Physician" means an individual licensed
					 to practice medicine in this state.
(F) "Recipient" means a recipient of medical
					 assistance.
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 12 - RURAL HEALTH CLINICS › Section 354.1201 - Authorized Services by Rural Health Clinics

Current through Reg. 49, No. 28; July 12, 2024
There are two categories of services for which the
						department will reimburse providers in rural health clinic settings:
(1) "Rural health clinic services" include
					 those items and services which:
(A) meet the
					 definition of rural health clinic services as stated in federal regulations at
					 42 Code of Federal Regulations §449.10(b)(2)(ii);
(B) are medically necessary; and
(C) are provided by a certified and approved
					 rural health clinic in accordance with applicable federal, state, and local
					 laws and regulations.
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 12 - RURAL HEALTH CLINICS › Section 354.1202 - Conditions for Payments to Rural Health Clinics

Current through Reg. 49, No. 28; July 12, 2024
The department will reimburse rural health clinics for
						services provided to eligible recipients under the following conditions:
(1) To receive payment for rural health
					 clinic services as defined in § 29.1201 of this title (relating to
					 Authorized Services by Rural Health Clinics), the following conditions must be
					 met:
(A) the rural health clinic must
					 contract with the department to become a provider of rural health clinic
					 services;
(B) the rural health
					 clinic must provide reports and other information specified by the department
					 or its authorized representative;
(C) rural health clinic personnel providing
					 primary health care must be licensed in Texas or in the state within the United
					 States in which and at the time and place the service(s) is provided and/or
					 meet all other established qualifications; and
(D) the rural health clinic must be certified
					 and participate under Title XVIII of the Social Security Act.
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 12 - RURAL HEALTH CLINICS › Section 354.1203 - Relationship of Recipient's Treating Physician to Rural Health Clinics

Current through Reg. 49, No. 28; July 12, 2024
(a) Any covered service furnished to an
					 eligible recipient in a long-term care facility must be ordered by the
					 recipient's treating physician. A physician is defined as a MD or DO.
(b) The plan of treatment to be used for
					 visiting nurse services must be developed by the rural health clinic physician
					 and be approved and ordered by the recipient's treating 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 13 - AMBULATORY SURGICAL CENTERS › Section 354.1211 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications and limitations established
						by the department, an ambulatory surgical center (ASC) must meet the following
						conditions for participation in the Texas Medical Assistance (Medicaid)
						Program.
(1) The ambulatory surgical
					 center must meet and comply with:
(A)
					 applicable federal and state laws, regulations, rules, and licensure
					 requirements for ambulatory surgical centers; and
(B) provisions of the state plan under Title
					 XIX of the Social Security Act for medical assistance.
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 13 - AMBULATORY SURGICAL CENTERS › Section 354.1212 - Services and Limitations

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, and
						limitations established by the department, ambulatory surgical center facility
						services are limited to items and services furnished by an ambulatory surgical
						center (ASC) in connection with or directly related to a covered surgical
						procedure, unless otherwise specified by the department. Covered surgical
						procedures are those surgical procedures approved by the Health Care Financing
						Administration and covered by Medicare, when performed in an ASC, unless
						otherwise specified by the department.
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 14 - DENTISTS' SERVICES › Section 354.1221 - Authorized Dentists' Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Dentists' services provided by a doctor of dentistry (DDS, DMD, or DDM), as
					 defined in §
											RSA 354.1121 of this
					 subchapter (relating to Definitions), are covered by the Texas Medicaid Program
					 if the services:
(1) are within the dentist's
					 scope of practice, as defined by state law; and
(2) would be covered by the Texas Medicaid
					 Program when they are 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 15 - HEARING AID SERVICES › Section 354.1231 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Benefits.
					 Reimbursement for hearing aid services available through the Texas Medical
					 Assistance (Medicaid) Program shall be provided in accordance with federal
					 regulations found at 42 CFR Chapter IV, Subchapter C, Medical Assistance
					 Programs, and the provisions and procedures found elsewhere in this chapter.
					 The following hearing aid services shall be reimbursed through the Texas
					 Medicaid Program:
(1) physician, or, under
					 physician delegation, a nurse practitioner, clinical nurse specialist, or
					 physician assistant, examination to determine the medical necessity for a
					 hearing aid;
(2) hearing aid
					 evaluations;
(3) hearing aids
					 (monaural or binaural) and hearing aid repairs;
(4) replacement batteries and related hearing
					 aid supplies;
(5) initial fitting,
					 dispensing, and post-fitting check of the hearing aid(s); and
(6) first and second revisits to assess the
					 recipient's adaptation to the hearing aid(s) and the functioning of the
					 instrument(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 15 - HEARING AID SERVICES › Section 354.1233 - Requirements for Hearing Aid Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Hearing aid services. Providers of hearing aid services must comply with:
(1) all applicable federal and state laws and
					 regulations;
(2) recognized
					 professional standards;
(3) the
					 provisions in Division 1 of this subchapter (relating to Medicaid Procedures
					 for Providers);
(4) the provisions
					 in Division 11 of this subchapter (relating to General
					 Administration);
(5) the
					 conditions, specifications, and limitations established by the Texas Health and
					 Human Services Commission (HHSC); and
(6) applicable requirements of their
					 licensing authority.