Chapter 6: General Billing Guidelines

6.1 Overview

General billing guidelines are applicable to all services arrays. Some service arrays have additional billing requirements. For additional information, see the chapter that describes the respective service array.

Providers are required to follow all billing guidelines and requirements.

6.2 Service Authorization

Service authorizations are authorizations for services to be rendered. Providers must not provide services until a service authorization has been received.

For all service arrays except outpatient services, the request for services must be based on the recommendations resulting from an interdisciplinary team meeting. The CRS counselor approves the service authorizations for the participant.

The service authorization identifies who is to receive services, what services are to be received, and the dates for which services are to be rendered. To continue a service on a service authorization after an end date, the provider must notify the agency about the need to continue the service and obtain approval to continue the service.

Upon approval, the CRS counselor issues an updated service authorization. If the provider provides services outside of the scope of the originally proposed or outlined dates, payment for those services is not guaranteed. All invoices associated with an issued service authorization must be sent to the appropriate CRS office as indicated on the service authorization.

6.3 Consumer Participation

The term consumer participation refers to the monthly contribution the participant may be required to pay for participation in the CRS program. Consumer participation applies to participants in active services, as well as those on the interest list who are both eligible and receiving services.

The CRS program staff members use net monthly income, liquid assets, and family size as they relate to the federal poverty guidelines for the current fiscal year to determine the amount a participant must contribute to the cost of services. This is a monthly amount and is applied only in months that a provided billable service or good requires participation in cost of services.

The participant’s monthly cost to participate cannot exceed the cost of the billable services provided in each month. A consumer participating in the cost of goods or services pays the provider directly and that amount is deducted from the provider's payment from the agency. The cost determined is stated in the service authorization.

The provider is responsible for the billing, collecting, or writing-off the participant's cost owed by the liable party.

For additional information about consumer participation, see TAC§107.714, Consumer (Client) Participation.

6.4 Invoices

When billing the CRS program for services, providers must submit with the invoices:

  • the participant’s Explanation of Benefits; and
  • the denial letters from the insurance company, including denial letters from Medicaid, Medicare or both, or other pay sources.

When the provider’s facility is closed within a participant's dates of service, payment is not made for that date.

Invoices must be submitted at least monthly, and no later than the fifteenth of each month following the service, using one of the following forms:

  • UB-04 Centers for Medicare and Medicaid (CMS) 1450;
  • HHSC generated invoice; or
  • Health Insurance Billing Form (CMS 1500).

To receive payment, a contractor must follow §TAC 20.487 and submit an invoice to the address on the CRS service authorization, comply with the terms and conditions of the CRS contract, and include, at a minimum, the following:

  • contractor's complete name, mailing address, and e-mail (if applicable) address;
  • contractor's phone number;
  • the name and phone number of a person designated by the contractor to answer questions regarding the invoice;
  • HHSC agency number 529, CRS delivery address;
  • CRS service authorization number;
  • HHSC CRS contract number;
  • contractor’s valid Texas identification number (TIN) issued by the comptroller;
  • a description of the goods or services provided, in sufficient detail to identify the order which relates to the invoice. This may include but is not limited to the CPT (current procedural terminology) codes;
  • Maximum Affordable Payment Schedule (MAPS) rate, or general codes set by the program;
  • dates of service;
  • quantity and unit-cost being billed, as documented on the service authorization;
  • if submitting an invoice after receiving an assignment of a contract, the TIN of the original contractor and the TIN of the successor vendor;
  • other relevant information supporting and explaining the payment requested;
  • participant’s Individualized Program Plan (IPP), signed by the interdisciplinary team (IDT) (for initial billing for services only), if applicable;
  • summaries of monthly meetings, signed by the IDT (for monthly services that are not admission or discharge services), if applicable; and
  • discharge summary, signed by the IDT or other appropriate team member (upon final billing).

The provider must:

  • respond to billing-related inquiries and disputed invoices from CRS program staff members within two business days; and
  • submit all documentation requested within five to 10 business days following the request.

The CRS Program must;

  • confirm that goods or services were received in accordance with the service authorization;
  • receive, inspect, and accept delivery of goods or services covered by the invoice; and
  • receive and accept a complete accurate invoice to request payment from the comptroller.

6.5 Use of Comparable Benefits or a Third-Party Payer

If a CRS participant has comparable benefits, the provider must bill the comparable benefit before billing the CRS program.

If comparable services and benefits are available, the CRS program may participate in the cost of services if the combined amount of the CRS payment and the comparable benefit payment does not exceed the maximum amount allowed by the following, as appropriate:

  • Maximum Affordable Payment Schedule (MAPS) rate;
  • contracted payment rate; or
  • retail or negotiated lower price (for non-MAPS, noncontract items).

If the comparable benefit is paid by:

  • major medical insurance, a health maintenance organization, or preferred provider organization, the CRS program may pay the participant's portion (co-payment, coinsurance, and any unmet deductible), not to exceed the MAPS rate, contract rate, or retail price, as applicable.
  • Medicare, the CRS program may pay the participant's portion (co-payment, coinsurance, and any unmet deductible), not to exceed the MAPS rate, contract rate, or retail price, as applicable.
  • Medicaid, the CRS program pays nothing. The CRS program does not supplement a Medicaid payment for a specific service or procedure.
  • Out of Network, the CRS program may pay up to but not exceeding the contracted rate.