Clinics and Other Outpatient Facility Services Handbook - TMHP
Clinics and Other Outpatient Facility Services Handbook - TMHP
Clinics and Other Outpatient Facility Services Handbook - TMHP
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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013<br />
When filing for a client who has Medicare <strong>and</strong> Medicaid coverage, providers must file on the same claim<br />
form that was filed with Medicare.<br />
<strong>Services</strong> provided by a health-care professional require one of the following modifiers with procedure<br />
code T1015, to designate the health-care professional providing the services: AH, AJ, AM, SA, TD, TE,<br />
or U7.<br />
• If more than one health-care professional is seen during the encounter, the modifier must indicate<br />
the primary contact. The primary contact is defined as the health-care professional who spends the<br />
greatest amount of time with the client during that encounter.<br />
• If the encounter is for antepartum care or postpartum care, the modifier TH must be indicated on<br />
the claim in addition to any other appropriate modifier.<br />
• If the antepartum or postpartum care is provided by a CNM, the modifier SA must be indicated on<br />
the claim in addition to any other appropriate modifiers.<br />
Use modifier TD or TE for home health services provided in areas with a shortage of home health<br />
agencies.<br />
Refer to:<br />
Section 3: <strong>TMHP</strong> Electronic Data Interchange (EDI) (Vol. 1, General Information) for<br />
information on electronic claims submissions.<br />
Section 6: Claims Filing (Vol. 1, General Information) for general information about claims<br />
filing.<br />
Section 12, “Claim Form Examples,” in this h<strong>and</strong>book.<br />
The Gynecological <strong>and</strong> Reproductive Health <strong>and</strong> Family Planning <strong>Services</strong> H<strong>and</strong>book<br />
(Vol. 2, Provider H<strong>and</strong>books).<br />
4.4.2 Reimbursement<br />
FQHCs are reimbursed provider-specific prospective payment system encounter rates in accordance<br />
with 1 TAC §355.8261.<br />
FQHCs are exempt from the m<strong>and</strong>ated rate reductions except for family planning services.<br />
Texas Medicaid implemented m<strong>and</strong>ated rate reductions for certain services. Additional information<br />
about rate changes is available on the <strong>TMHP</strong> website at www.tmhp.com/pages/topics/rates.aspx.<br />
Refer to: Subsection 2.2, “Fee-for-Service Reimbursement Methodology” <strong>and</strong> subsection 2.3,<br />
“Reimbursement Reductions” in Section 2, “Texas Medicaid Fee-for-Service<br />
Reimbursement” (Vol. 1, General Information) for more information about<br />
reimbursement.<br />
4.4.2.1 Medicare-Medicaid Crossover Claims Pricing<br />
For FQHC Medicare-Medicaid crossover claims, Texas Medicaid will reimburse the lesser of the<br />
following:<br />
• The coinsurance <strong>and</strong> deductible payment<br />
• The amount remaining after the Medicare payment amount is subtracted from the allowed<br />
Medicaid fee or encounter rate for the service<br />
If the Medicare payment is equal to, or exceeds the Medicaid allowed amount or encounter payment for<br />
the service, Texas Medicaid will not make a payment for coinsurance <strong>and</strong> deductible.<br />
The client has no liability for any balance or Medicare coinsurance <strong>and</strong> deductible related to Medicaidcovered<br />
services.<br />
OP-18<br />
CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.