Section 14000, Medicaid Provider Enrollment

Revision 19-0; Effective July 1, 2019

 

 

HHSC FPP contractors are required to enroll as Medicaid (Title XIX) providers with TMHP. The contractor must complete the required Medicaid provider enrollment application forms and enter into a written provider agreement with HHSC, the single state Medicaid agency. TMHP Provider Enrollment supplies these forms.

Family planning agencies are not required to enroll as a physician group, which includes an application for performing provider number. To enroll as a family planning agency, all that is required is a supervisory practitioner. The supervisory practitioner may be a physician or nurse practitioner and may be the same person for all clinic sites. Changes in supervisory practitioner must be reported in writing to TMHP. An application must be submitted for the new supervisory practitioner.

When enrolling as a Title XIX provider, Clinical Laboratory Improvement Amendments (CLIA) information must be provided. For public health agencies that provide limited numbers of tests, one CLIA certificate is all that is required for all clinics. 

 

14100 Provider Identifiers 

Revision 19-0; Effective July 1, 2019

 

When a contractor’s Medicaid application is approved, TMHP assigns the contractor a nine-digit Texas Provider Identifier (TPI). Contractors must have a unique TPI for each clinical service site.

Contractors must submit claims to TMHP using the billing TPI where clinical services are rendered. Contractors must not provide FPP services at one clinic site and bill those services to TMHP using the TPI of a different clinic site. If an additional TPI clinic site is required, providers must contact TMHP and complete the enrollment process.   

The TPI is used in conjunction with a National Provider Identifier (NPI) to identify the provider for claims processing. An NPI is a 10-digit number assigned randomly by the National Plan and Provider Numeration System (NPPES). Contractors may apply for an NPI at the NPPES website.

When a provider obtains their NPI, they are required to attest to NPI data for each of their current TPI. For more information on NPI and the attestation process, visit the TMHP website.

Texas Medicaid & Healthcare Partnership and Compass 21

HHSC FPP claims are submitted to TMHP. TMHP processes claims using Compass 21, an automated claims processing and reporting system. Claims are subject to the following procedures:

The Texas Medicaid Provider & Procedure Manual (TMPPM) includes information related to HHSC FPP claims submission such as:

In addition, Medicaid bulletins and R&S banner messages provide up-to-date claims filing and payment information. The R&S banner messages and the TMPPM are available on the TMHP website.

 

14200 Reimbursement for Family Planning Services

Revision 19-0; Effective July 1, 2019

 

Family planning contractors may seek reimbursement for project costs using one or two methods.

Contractors may designate up to 50% of their total award on a categorical cost reimbursement basis. The remaining portion of their award will be paid on a fee-for-service basis. Contractors may designate up to 100% of their total award on a fee-for-services basis.

 

14210 Categorical Reimbursement

Revision 19-0; Effective July 1, 2019

 

The categorical portion of the HHSC FPP funding is used to develop and maintain contractor infrastructure for the provision of family planning services. The funding can be used to support clinic facilities, staff salaries, utilities, medical and office supplies, equipment and travel, as well as direct medical services. Costs may be assessed against any of the following categories the contractor identifies during their budget development process:

Up to 50% of the HHSC FPP funds may be disbursed to contractors through a voucher system as expenses are incurred during the contract period. Program income must be expended before categorical funds are requested through the voucher process. Contractors must still submit vouchers monthly, even if program income equals or exceeds program expenses, or if the contract reimbursement limit has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all fees paid by the individuals and HHSC FPP fee-for-service reimbursements. 

To request reimbursement for the categorical contract, the following forms must be submitted by the last business day of the following month in which expenses were incurred or services provided:

The following forms must be submitted within 45 days following the end of the contract term:

 

14220 Fee-for-Service Reimbursement

Revision 19-0; Effective July 1, 2019

 

The fee-for-service component of the HHSC FPP funding pays for direct medical services on a fee-for-services basis. Up to 100% of HHSC FPP funds may be reimbursed on a fee-for-service basis. Each contracting agency is responsible for determining an individual’s eligibility for clinical services. The HHSC FPP reimburses contractors on a fee-for-service basis for services and supplies that have been provided to eligible individuals. HHSC FPP contractors must continue to provide services to established individuals and to submit and appeal claims for individual services even after the contract funding limit has been met.

All contractors are required to submit claims for all HHSC FPP services to TMHP, using the 2017 Claim form found on the TMHP website. The Texas Medicaid Provider Procedures Manual (TMPPM) provides detailed instructions of how to complete the form, including required and optional fields.

Effective May 1, 2017, FPP providers can submit professional claims electronically using a modified CMS-1500 electronic claim form.

HHSC FPP claims or appeals must be filed within certain time frames:

HHSC FPP contractors may contact the TMHP Contact Center from 7 a.m. to 7 p.m. (CST), Monday through Friday at 800-925-9126 for questions about claims and payment status.

 

14300 HHSC FPP Reimbursable Codes

Revision 19-0; Effective July 1, 2019

 

HHSC FPP reimbursement is limited to a prescribed set of procedure codes approved by HHSC. For a complete list of valid HHSC FPP procedures, see Appendix I, Reimbursable Codes.

HHSC FPP contractors may submit claims for individuals’ office visits that reflect different levels of service for new and established individuals. A new individual is defined as one who has not received clinical services at the contractor’s clinic(s) during the previous three years. The level of services, which determines the procedure code to be billed for that individual visit, is indicated by a combination of factors such as the complexity of the problem addressed, and the time spent with the individual by clinic providers. The American Medical Association (AMA) publishes materials related to Current Procedural Terminology (CPT) coding that includes guidance on office visit codes [Evaluation and Management Services (E/M)].

 

14310 Medroxyprogesterone Acetate Injection

Revision 19-0; Effective July 1, 2019

 

Providers may not bill a lower complexity office visit code (99211/99212) when the primary purpose is for the individual to receive an injection of Medroxyprogesterone acetate (Depo-Provera/DMPA/depo) injection. Rather, contractors should bill the injection fee (96372) with the Depo-Provera contraceptive method (J1050).

 

14400 Electronic Claims Submission

Revision 19-0; Effective July 1, 2019

 

All HHSC FPP contractors are strongly encouraged to submit claims electronically. TMHP offers specifications for electronic claims formats. These specifications are available from the TMHP Provider Portal and relate the paper claim instruction to the electronic format. Contractors may use their own claims filing system, vendor software or TexMedConnect (a free web-based claims submission tool available through the TMHP website) for submission of electronic claims. For more information concerning electronic claims submission, contractors may contact the TMHP Electronic Data Interchange (EDI) Help Desk at 512-514-4150 or 888-863-3638. Additional information may be found on the TMHP website.

 

14410 HTW Claims Pending Eligibility Determination

Revision 19-0; Effective July 1, 2019

 

To verify an applicant’s Healthy Texas Women (HTW) eligibility:

Contractors must hold claims up to 45 calendar days for individuals who have applied to HTW. If an individual’s HTW eligibility has not been determined after 45 calendar days, the contractor may bill the service to the HHSC FPP if the individual has a current HHSC FPP eligibility form on file. The contractor can file an HHSC FPP claim before the 45-day waiting period if a copy of the HTW program denial letter is in the individual’s record before filing the claim. 

 

14500 Sterilization Billing and Reporting

Revision 19-0; Effective July 1, 2019

 

HHSC FPP contractors can receive reimbursement for vasectomy or tubal ligation/occlusion sterilization procedures as part of their family planning services. The individual may not be billed for any cost above the reimbursement rates. Individual co-pays for sterilizations must follow the contractor’s established co-pay policy and may not exceed the allowable amount.

Contractors shall expend no more than 15% of their combined HHSC fee-for-service and HHSC categorical contract amounts on female sterilizations. An exemption may be granted to this policy on a case-by-case basis. Contact famplan@hhsc.state.tx.us for more information.

Allowable sterilization codes and descriptions are presented in Appendix I, Reimbursable Codes.

Conditions for Sterilization Procedures

Individuals receiving a vasectomy or tubal ligation/occlusion sterilization procedure must:

Waiting Period

The consent for sterilization is valid for 180 days from the date of the individual’s signature. 

 

14510 Sterilization Consent Form                                                         

Revision 19-0; Effective July 1, 2019

 

The Texas Medicaid Provider Procedures Manual (TMPPM) provides both an English and Spanish version of the Sterilization Consent form to be used by HHSC FPP contractors. The form may be copied for use and contractors are encouraged to frequently re-copy the original form to ensure legible copies and to expedite consent validation. The TMPPM also includes detailed instructions for the completion of the Sterilization Consent form. It is important that contractors use the most recent Sterilization Consent form available. Additionally, it is the contractor’s responsibility to ensure that the form is complete and accurate prior to submission to TMHP. For more information regarding the Sterilization Consent form and instructions, see Section 11210, Sterilization Procedures and Consent Form.

 

14520 Sterilization Complications

Revision 19-0; Effective July 1, 2019

 

Contractors may request reimbursement for costs associated with patient complications related to sterilization procedures. Contractors may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, contractors should provide the HHSC FPP with the following information:

 

14600 IUD and Contraceptive Implant Complications

Revision 19-0; Effective July 1, 2019

 

Contractors may request reimbursement for costs associated with patient complications related to IUD or contraceptive implant insertions or removals. Contractors may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, contractors should provide the HHSC FPP with the following information:

 

14700 Retroactive Eligibility

Revision 19-0; Effective July 1, 2019

 

Title XIX Retroactive Eligibility

Retroactive eligibility occurs when an individual has applied for Medicaid coverage but has not yet been assigned a Medicaid individual number at the time of service. Individuals who are eligible for Title XIX (Medicaid) medical assistance receive three months prior eligibility to cover any medical expenses incurred during that period. 

HHSC FPP Retroactive Eligibility

Any co-pay collected from an individual found to be eligible retroactively for Medicaid must be refunded to the individual. If a claim has been paid and later the individual receives retroactive Title XIX (Medicaid) eligibility, TMHP recoups/adjusts the funds paid from the HHSC FPP and processes the claim as Title XIX. An HHSC FPP accounts receivable (A/R) is then established for the adjusted claim. 

Note: Contractors are responsible for paying HHSC back the amount of any HHSC FPP A/R balance that may remain at the end of a state fiscal year.

The contractor’s HHSC FPP R&S Report(s) will reflect the retroactive Title XIX adjustment with EOB message “Recoupment is due to Title XIX retro eligibility.”

Assistance on reconciling R&S reports may be provided through the TMHP Contact Center from 7 a.m. to 7 p.m. CST, Monday through Friday at 800-925-9126. A TMHP Provider Relations representative is also available for these specific questions, as a representative can be located by region on the TMHP website.

Performing Provider Number and Retroactive Eligibility

HHSC family planning claims do not require a performing provider number for reimbursement. However, if a Title XIX retroactive eligibility claim does not have a performing provider number in a TPI format, TMHP will deny the services. A common EOB message for this specific denial is “EOB 00118: Service(s) require performing provider name/number for payment.” A request for reconsideration of claim reimbursement may be sent to TMHP through the appeal methods.

Note: The performing provider number requirement applies to all Title XIX submissions.

 

14800 Claims Submitted with Laboratory Services

Revision 19-0; Effective July 1, 2019

 

If a Title XIX retroactive eligibility claim includes laboratory services and the HHSC FPP contractor is not CLIA certified for the date of service on the claim, TMHP will deny the laboratory services. The Title XIX R&S report will reflect EOB 00488 message: “Our records indicate that there is not a CLIA number on file for this provider number or the CLIA is not valid for the dates of services on the claim.” 

When this occurs, the laboratory that performed the procedure(s) is responsible for refiling laboratory charges with TMHP to receive Title XIX reimbursement. For claims past the 95-day filing deadline, the laboratory will be required to follow their Medicaid appeals process. Contractors must make arrangements with their contracted laboratory to recoup any funds paid to the laboratory for lab services for HHSC FPP individuals prior to Title XIX retro eligibility determination.

 

14810 Patient Co-pays

Revision 19-0; Effective July 1, 2019

 

Title XIX does not allow providers to collect co-pays. HHSC FPP contractors must refund any co-pay collected if the individual services were billed to Title XIX.

Also see Section 10400, Client Fees, Co-pays and Guidelines.

Note: Contractors who have expended their awarded funds must continue to serve their existing eligible individuals and submit fee-for-service claims for services provided. It is allowable to obtain other funding to pay for these services, as well as continue to charge co-pay, per policy. This funding should be recorded as program income for the FPP contract. 

 

14900 Donations

Revision 19-0; Effective July 1, 2019

 

Voluntary donations from individuals are permissible. However, individuals must not be pressured to make donations and donations must not be a prerequisite to the provision of services or supplies. Donations are considered program income per specification of contract general provisions. All donations must be documented by source, amount and date they were received by the contractor. Contractors must have a written policy on the collection of donations. Individual donations collected by the contractor must be utilized to support the delivery of family planning services.