Header:
TEXAS ADMINISTRATIVE CODE
TITLE 25. HEALTH SERVICES
PART 1. DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 38. CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM
SUBCHAPTER A. BOARD MEMBERS AND MEETINGS--DUTIES
Date:
08/31/2009
Document:
§ 38.10. Payment of Services
The program reimburses providers for covered services for clients. Payment may be made only after the delivery of the service, with the exception of meals, transportation, lodging, and insurance premium payments. Excluding allowable insurance or health maintenance organization co-payments, the client or client's family must not be billed for the service or be required to make a preadmission or pretreatment payment or deposit. Providers may not request or accept payment from the client or the client's family for completing any program forms. Providers must agree to accept established fees as payment in full. The program may negotiate reimbursement alternatives to reduce costs through requests for proposals, contract purchases, or incentive programs.
(1) Payment or denial of claims. All payments made on behalf of a client will be for claims received by the program or its payment contractor within 95 days of the date of service, within 95 days from the date of discharge from inpatient hospital and inpatient rehabilitation facilities, within 95 days from the date the client's eligibility is added to program automation systems, or within the submission deadlines listed in paragraphs (1)(B)(ii) and (2) of this section, whichever is later. If the 95th day for receipt of a claim falls on a weekend or holiday, the deadline shall be extended to the next business day following the weekend or holiday. Claims will either be paid or denied within 30 days of receipt. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) may waive the filing deadlines according to the conditions and circumstances specified in paragraphs (3) - (5) of this section. A claim must be processed and paid within 24 months of the date of service. Claims received by the program or its payment contractor after this time frame will not be considered for payment by the program.
(A) Claims will be paid if submitted on claim forms approved by the program (including electronic claims submission systems) and if the required documentation is received with the claim.
(B) Denied claims are claims which are incomplete, submitted on the wrong form, lack necessary documentation, contain inaccurate information, fail to meet the filing deadline, are for ineligible persons, services, or providers, or are for clients who do not qualify for the health care benefit claimed. (i) Corrected claims must be submitted on claim forms approved by the program along with required documentation within the filing deadline established in clause (ii) of this subparagraph. (ii) Denied claims may be corrected and resubmitted for reconsideration if received within 120 days of the last denial or adjustment to the original claim. If the results of the reconsideration process are unsatisfactory, denied claims may be appealed according to § 38.13 of this title (relating to Right of Appeal).
(2) Claims involving health insurance coverage, CHIP, or Medicaid. Any health insurance that provides coverage to the client must be utilized before the program can pay for services. Providers must file a claim with health insurance, CHIP, or Medicaid prior to submitting any claim to the program for payment. Claims with health insurance must be received by the program within 95 days of the date of disposition by the other third party resource, and no later than 365 days from the date of service. The program will consider claims received for the first time after the 365-day deadline if a third party resource recoups a payment made in error; however, the claim must be received by the program within 95 days from the third party's disposition. The program may pay for covered health care benefits during CHIP or other health insurance enrollment waiting periods. During these periods, providers may file claims directly with the program without evidence of denial by the other insurer.
(A) Health insurance denial or nonresponse. If a claim is denied by health insurance, the provider may bill the program if the letter of denial also is submitted with the claim form. If the denial letter is not available, the provider must include on the claim form the date the claim was filed with the insurance company, the reason for the denial, name and telephone number of the insurance company, the policy number, the name of the policy holder and identification numbers for each policy covering the client, the name of the insurance company employee who provided the information on the denial of benefits, and the date of the contact. If more than 110 days have elapsed from the date a claim was filed with the third party resource and no response has been received, the claim may be submitted to the program for consideration of payment. Claims must be submitted with documentation indicating the third party resource has not responded.
(B) Explanation of benefits (EOB). The health insurance EOB must accompany any claim sent to the program for payment if available. If the EOB is unavailable, the provider must include on the claim form the name and telephone number of the insurance company, the amount paid, the policy number, and name of the insured for each policy covering the client.
(C) Late filing. Claims denied by health insurance on the basis of late filing will not be considered for payment by the program.
(D) Deductibles and coinsurance. If the client has other third party coverage, the program may pay a deductible or coinsurance for the client as long as the total amount paid to the provider does not exceed the allowable amount for the covered service and conforms with current program policies regarding third party resources, deductible, and coinsurance.
(3) Exceptions to the claim receipt or correction and resubmission deadlines. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) will consider a provider's request for an exception to the claim receipt or correction and resubmission deadlines provided in paragraphs (1) and (2) of this section if the delay in claim receipt or correction and resubmission is due to one of the following reasons:
(A) damage to or destruction of the provider's business office or records by a catastrophic event or natural disaster including, but not limited to fire, flood, hurricane, or earthquake that substantially interferes with normal business operations of the provider;
(B) damage to or destruction of the provider's business office or records caused by the intentional acts of an employee or agent of the provider only if: (i) the employment or agency relationship has been terminated; and (ii) the provider has filed criminal charges against the former employee or agent;
(C) delay, error, or constraint imposed by the program in the eligibility determination of a client or in claims processing, or delay due to erroneous written information from the program or its designee, or another state agency; or
(D) delay due to problems with the provider's electronic claim system or other documented and verifiable problems with claims submission.
(4) Exception requests. Providers requesting an exception under paragraph (3)(A) - (D) of this section must submit an affidavit or statement from a person with personal knowledge of the facts detailing the exception being requested, the cause for the delay, verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's employee or agent, and any additional information requested by the program. All claims for which the provider requests an exception must accompany the request. The program will consider only the claim(s) attached to the request, and the exception request must be received by the program within 18 months from the date of service.
(A) For exception requests under paragraph (3)(A) of this section, the provider must submit: (i) independent evidence of insurable loss; (ii) medical, accident, or death records; or (iii) a police or fire department report substantiating the damage or destruction.
(B) For exception requests under paragraph (3)(B) of this section, the provider must submit a police or fire report substantiating the damage or destruction caused by the former employee or agent's criminal activity.
(C) For exception requests under paragraph (3)(C) of this section, the provider must submit written documentation from the program, its designee, or another state agency containing the erroneous information or explanation of the delay, error, or constraint.
(D) For exception requests under paragraph (3)(D) of this section, the provider must submit the following: (i) a written repair statement or invoice, a computer or modem generated error report indicating attempts to transmit the data failed for reasons outside the control of the provider, or an explanation for the system implementation or other claim submission problems; (ii) a detailed, written statement concerning the relationship of the computer problem to delayed claims submission; and (iii) the reason alternative billing procedures were not initiated after the problem(s) became known.
(5) Other exceptions to claims receipt or correction and resubmission deadlines. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) will consider a provider's request for an exception to claims receipt or correction and resubmission deadlines due to delays caused by entities other than the provider and the program under the following circumstances:
(A) all claims that are to be considered for the same exception must accompany the request;
(B) only the claim(s) that are attached to the request will be considered;
(C) the exception request has been received by the program within 18 months from the date of service; and
(D) the exception request includes an affidavit or statement from a representative of an original payer, a third party payer, or a person who has personal knowledge of the facts, stating the exception being requested, documenting the cause for the delay, and providing verification that the delay was caused by another entity and not the neglect, indifference, or lack of diligence of the provider or the provider's employee(s) or agent(s).
(6) Program fees. Subject to any reductions or limitations authorized by § 38.16(b)(2)(E) of this title (relating to Procedures to Address Program Budget Alignment), the program or its designee shall reimburse claims for covered medical, dental, and other services according to the following:
(A) meals, lodging, and transportation: (i) meals--up to the amount specified in the current State of Texas Travel Allowance Guide as per diem meal expenses; (ii) lodging:
(I) hotel--the amount as contracted with the Texas Medicaid Medical Transportation Program (MTP), not to exceed the amount specified in the current State of Texas Travel Allowance Guide as per diem lodging expenses plus all applicable hotel occupancy taxes; and
(II) Ronald McDonald House--the amount contracted with the MTP; and (iii) transportation:
(I) mileage--the distance and amount per mile as specified in the current State of Texas Travel Allowance Guide;
(II) by contract--the amount as negotiated by the MTP with contractors such as intercity buses, vans, cabs, or urban mass transit authorities;
(III) air fare--the ticket price reflecting the state discount if ordered by MTP or the billed amount if MTP had no opportunity to coordinate transportation in an emergency; and
(IV) cab fare--the billed amount if other transportation is unavailable or the MTP is unable to coordinate transportation;
(B) administrative fee to social service organizations--the percentage of the charge for meals, lodging, and transportation negotiated by the MTP with these entities;
(C) ambulance service--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(D) transportation of remains: (i) first call--$ 150; (ii) embalming--$ 100; (iii) container--$ 150; (iv) mileage billed by funeral home--$ 1.00 per mile; and (v) air freight--the billed amount;
(E) nutritional products--the least of the billed amount, the amount allowed by the Texas Medicaid Program, or the Average Wholesale Price (AWP) per unit according to the prices in the current edition of the Drug Topics Red Book, published by Medical Economics Company, Inc., Montvale, New Jersey 07645-1742, on file with the CSHCN Services Program. For products not listed in the current edition of the Drug Topics Red Book, reimbursement shall be based on the same methodology using the AWP supplied by the manufacturer of the product;
(F) nutritional services--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(G) medical foods--the least of the billed amount, the manufacturer's suggested retail price (MSRP), or the amount allowed by the Texas Medicaid Program;
(H) out-patient medications: (i) medications covered by Medicaid when billed by pharmacies--the same drug costs and dispensing fees allowed by the Texas Medicaid Vendor Drug Program; (ii) medications not covered by Medicaid when billed by pharmacies--the lower of the billed amount or the drug cost available through the database used by the Texas Medicaid Vendor Drug Program plus the same dispensing fees allowed by the Texas Medicaid Vendor Drug Program; (iii) medications covered by Medicaid when billed by hospitals--(the lower of the billed amount or the drug cost available through the database used by the Texas Medicaid Vendor Drug Program plus dispensing fee); and (iv) hemophilia blood factor products--the lower of the billed price or the United States Public Health Service (USPHS) price in effect on the date of service;
(I) expendable medical supplies--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(J) durable medical equipment--provided by enrolled home health agencies and durable medical equipment providers, the lower of the billed amount or the amount allowed by the Texas Medicaid Program. If the Texas Medicaid Program has not established an allowable amount, then reimbursement will be the least of the following: (i) the billed amount; or (ii) the Medicare fee schedule as defined in 1 Texas Administrative Code, § 354.1031(b)(9); or (iii) the Manufacturer's Suggested Retail Price (MSRP) minus a discount as established by the Texas Medicaid Program; or if no MSRP exists, the incurred cost to the dealer plus a percentage as determined by the Texas Medicaid Program;
(K) orthotics and prosthetics--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(L) total parenteral nutrition and hyperalimentation (including equipment, supplies and related services)--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(M) home health nursing services (provided only through participating program home and community support service agencies)--reimbursement for a maximum of 200 hours per client per calendar year, with an additional 200 hours per client per calendar year available if justification of need and cost effectiveness are documented; (i) services provided by a registered nurse--the lower of the billed amount or the amount allowed by the Texas Medicaid Program; (ii) services provided by a licensed vocational nurse--the lower of the billed amount or the amount allowed by the Texas Medicaid Program; and (iii) services provided by a home health aide or home health medication aide (including those legally delegated by a supervising registered nurse)--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(N) outpatient physical therapy, occupational therapy, speech-language pathology, and respiratory therapy (provided by physicians or by therapists other than physicians)--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(O) audiological testing and amplification devices--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(P) insurance premium payment assistance program--the lowest available premium for a plan which covers the client if cost effective;
(Q) hospital (inpatient and outpatient care) and inpatient psychiatric care--reimbursed at 80% of the rate authorized by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) which is equivalent to the hospital's Medicaid interim rate;
(R) inpatient rehabilitation care--reimbursed at 80% of TEFRA rates for a maximum of 90 inpatient days per calendar year;
(S) hospice services--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(T) care for renal disease-- (i) renal dialysis services--the lower of the billed amount or the amount allowed by the Texas Medicaid Program; and (ii) renal transplant services--renal transplants may be covered if the projected cost for the transplant and follow-up care is less than that of continuing renal dialysis. Negotiated coverage and cost are based on prior authorization documentation of cost effectiveness;
(U) freestanding ambulatory surgical centers--the lower of the billed amount or the amount allowed by the Texas Medicaid Program based upon Ambulatory Surgical Code Groupings approved by the Centers for Medicare and Medicaid Services (CMS) and the Department of State Health Services;
(V) hospital ambulatory surgical centers--the lower of the amount billed or the amount allowed by the Texas Medicaid Program based upon Ambulatory Surgical Code Groupings approved by the CMS and the Department of State Health Services;
(W) covered professional services by physicians, podiatrists, advanced practice registered nurses, psychologists, licensed professional counselors, or other providers that are not otherwise specified--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(X) independent laboratory--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(Y) radiology services--the lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(Z) dental services--the lower of the billed amount or the amount allowed by the Texas Medicaid Program; and
(AA) vision services--the lower of the billed amount or the amount allowed by the Texas Medicaid Program, except certain specialized lenses, which are reimbursed at the manufacturer's suggested retail price less 18%.
(7) Required documentation. The program may require documentation of the delivery of goods and services from the provider.
(8) Overpayments.
(A) Overpayments are payments made by the program due to the following: (i) duplicate billings; (ii) services paid by public or private insurance or other resources; (iii) payments made for services not delivered; (iv) services disallowed by the CSHCN Services Program; and (v) subrogation.
(B) Overpayments made to providers must be reimbursed to the department by lump sum payment or, at the department's discretion, offset against current payments due to the provider for services to other clients. The department also shall require reimbursement of overpayments from any person or persons who have a legal obligation to support the client and have received payments from a payer of other benefits. Providers, clients, and person(s) responsible for clients may appeal proposed recoupment of overpayments by the department according to § 38.13 of this title.
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