Part 1.
TEXAS DEPARTMENT OF HUMAN SERVICES
Chapter 19.
NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
The Texas Department of Human Services (DHS) proposes to amend §19.1303,
concerning specialized services in Medicaid-certified facilities; §19.1304,
concerning rehabilitative services system in Medicaid-certified facilities; §19.1402,
concerning Medicaid- certified nursing facility emergency dental services
system; and §19.2609, concerning payment of claims; and new §19.1306,
concerning payment for specialized and rehabilitative services, in its Nursing
Facility Requirements for Licensure and Medicaid Certification chapter. The
purpose of the amendments and new section is to require that claims be submitted
within 12 months of the last day of service and to reflect current practice
regarding payment of claims in Specialized Services, Rehabilitative Services,
and the Emergency Dental Program. New §19.1306 consolidates payment information
previously contained in §19.1303 and §19.1304.
James R. Hine, Commissioner, has determined that for the first five-year
period the proposed sections are in effect, there will be no fiscal implications
for state or local government as a result of enforcing or administering the
sections.
Mr. Hine also has determined that for each year of the first five years
the sections are in effect, the public benefit anticipated as a result of
adoption of the proposed sections will be that DHS will comply with federal
mandates. The proposed policy is a federal requirement for Medicaid programs
found at 42 Code of Federal Regulations 447.45(d). There will be no effect
on small or micro businesses as a result of enforcing or administering the
sections, because current rules have a 180-day deadline for submission of
claims. The proposal also allows exemptions for late claims, if the late submission
is through no fault of the provider. There is no anticipated economic cost
to persons who are required to comply with the proposed sections. There is
no anticipated effect on local employment in geographic areas affected by
these sections.
Questions about the content of this proposal may be directed to Susan Syler
at (512) 438- 3111 in DHS's Long Term Care-Policy section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-194,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
Under §2007.003(b) of the Texas Government Code, DHS has determined
that Chapter 2007 of the Government Code does not apply to these rules. Accordingly,
DHS is not required to complete a takings impact assessment regarding these
rules.
Subchapter N. REHABILITATIVE SERVICES
40 TAC §§19.1303, 19.1304, 19.1306
The amendments and new section are proposed under the Human
Resources Code, Title 2, Chapters 22 and 32, which authorizes DHS to administer
public and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The amendments and new section implement the Human Resources Code, §§22.001-
22.036 and §§32.001-32.052.
§19.1303.Specialized Services in Medicaid-certified Facilities.
Specialized Services are physical, occupational, and
speech therapy evaluations and services provided to eligible Medicaid recipients
identified by the Preadmission Screening and Resident Review (PASARR) team.
[
[
[
[
[
§19.1304.Rehabilitative Services [
[
(a)
[
[
[
[
[
[
[
[
[
[
[
[
(b)
[
§19.1306.Payment for Specialized and Rehabilitative Services.
(a)
The Texas Department of Human Services (DHS) reimburses
nursing facilities and Title XVIII-certified providers for Specialized and
Rehabilitative Services.
(b)
The services must:
(1)
be ordered by the attending physician; and
(2)
have prior authorization by DHS.
(c)
DHS reimburses:
(1)
nursing facilities the maximum allowable Medicaid rate
per visit as determined by the Health and Human Services Commission (HHSC);
(2)
therapy providers the interim rate per visit as determined
by Medicare.
(d)
A visit is defined as one physical, occupational, or speech
therapy service performed for one resident. An evaluation is paid at the same
rate as one visit.
(1)
One evaluation is paid without prior authorization.
(2)
Any additional evaluations must be supported by the attending
physician's documentation that indicates a new illness, injury, or a substantive
change in a pre-existing condition.
(e)
Complete and accurate claims for services must be received
by DHS within 12 months from the last approved treatment day the services
were provided.
(f)
Claims for services delivered before the effective date
of this section must be submitted within 12 months of the effective date of
this section.
(g)
Adjustments to claims must be received by DHS's claim processor
during the applicable 12- month period. Claims and adjustments denied during
the 12-month period through no fault of the provider may be paid upon approval
by DHS.
(h)
Requests for appeals of denials of prior authorizations
or re-certifications must be made in writing by the nursing facility administrator
to Rehabilitative/Specialized Services, Texas Department of Human Services,
P.O. Box 149030 (W-519), Austin, Texas 78714-9030. The request for appeal
must be received by the 30th day from the date of the original denial determination.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on June 10, 2002.
TRD-200203617
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: July 21, 2002
For further information, please call: (512) 438-3734
40 TAC §19.1402
The amendment is proposed under the Human Resources Code,
Title 2, Chapters 22 and 32, which authorizes DHS to administer public and
medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The amendment implements the Human Resources Code, §§22.001-22.036
and §§32.001-32.052.
§19.1402.[
(a)
Emergency dental services. The Texas Department of Human
Services (DHS) will reimburse nursing facilities the cost of emergency dental
services provided to eligible Medicaid residents residing in
Medicaid-contracted
[
(1)
(No change.)
(2)
Dental care for recipients under the age of 21
is
[
(3)-(4)
(No change.)
(b)
(No change.)
(c)
Reimbursement for Emergency Dental Services. The cost of
emergency dental services provided to eligible Medicaid residents residing
in nursing facilities will be reimbursed to facilities [
[
[
[
[
[
[
[
[
[
[
[
[
[
(d)
[
(1)
The facility must accept payment by DHS as payment in full
for services
.
[
(A)
the recipient requests, and
(B)
are not reimbursable by the
Texas Medical Assistance Program.
(2)
Payments for emergency dental
services are the lower of the:
(A)
dentist's usual fee; or
(B)
maximum fee as determined by the Health and
Human Services Commission (HHSC).
(3)
[
(4)
[
[
[
(5)
[
[
[
(6)
Claims for services delivered
before the effective date of this section must be submitted within 12 months
of the effective date of this section.
(7)
Adjustments to claims must
be received by DHS's claim processor during the applicable 12-month period.
Claims and adjustments denied during the 12-month period through no fault
of the dentist may be paid upon approval by DHS.
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed
with the Office of the Secretary of State on June 10, 2002.
TRD-200203618
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: July 21, 2002
For further information, please call: (512) 438-3734
40 TAC §19.2609
The amendment is proposed under the Human Resources Code,
Title 2, Chapters 22 and 32, which authorizes DHS to administer public and
medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The amendment implements the Human Resources Code, §§22.001-22.036
and §§32.001-32.052.
§19.2609.Payment of Claims.
In order to receive payment for services provided, the nursing facility's
complete and accurate
[
(1)
(No change.)
(2)
Adjustments to claims must be received by DHS's claims
processor during the applicable 12-month period. Claims and adjustments denied
during the 12-month period through no fault of the nursing facility
[
(3)
In the event that Medicaid eligibility for benefits is
established after provision of services, the
12-month
[
(4)
(No change.)
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on June 10, 2002.
TRD-200203619
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: July 21, 2002
For further information, please call: (512) 438-3734
Subchapter F. REIMBURSEMENT
40 TAC §30.62
The Texas Department of Human Services (DHS) proposes to
amend §30.62, concerning Medicaid hospice claims processing requirements,
in its Medicaid Hospice Program chapter. The purpose of the amendment is to
require that claims be submitted within 12 months of the last day of service.
The amendment also reflects current practice.
James R. Hine, Commissioner, has determined that for the first five-year
period the proposed section will be in effect, there will be no fiscal implications
for state or local government as a result of enforcing or administering the
section.
Mr. Hine also has determined that for each year of the first five years
the section is in effect, the public benefit anticipated as a result of adoption
of the proposed section will be that DHS will comply with federal mandates.
The proposed policy is a federal requirement for Medicaid programs found at
42 Code of Federal Regulations 447.45(d). There will be no effect on small
or micro businesses as a result of enforcing or administering the section,
because the new section is not retroactive. Providers will have a full year
to submit current as well as future claims. The proposal also allows for exemptions
for late claims, if the late submission is through no fault of the provider.
There is no anticipated economic cost to persons who are required to comply
with the proposed section. There is no anticipated effect on local employment
in geographic areas affected by this section.
Questions about the content of this proposal may be directed to Susan Syler
at (512) 438- 3111 in DHS's Long Term Care-Policy section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-194,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
Under §2007.003(b) of the Texas Government Code, DHS has determined
that Chapter 2007 of the Government Code does not apply to these rules. Accordingly,
DHS is not required to complete a takings impact assessment regarding these
rules.
The amendment is proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs; and under Texas Government Code §531.021, which
provides the Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The amendment implements the Human Resources Code, §§22.001-22.036
and §§32.001-32.052.
§30.62.Medicaid Hospice Claims Processing Requirements.
(a)
Requirement for payment.
(1)
To receive Medicaid hospice payments, an entity
must be licensed as a hospice, Medicare certified by the
Centers for
Medicare and Medicaid Services (CMS)
[
(2)
A hospice that seeks payment
for Medicaid hospice services must submit a complete and accurate claim for
which the hospice is entitled to payment to DHS's claims processor within
12 months after the date of service. For purposes of this section, date of
service is defined as the last day of the month in which the service was provided.
(A)
If Medicaid eligibility for benefits is established
after provision of services, the 12-month period for submission of claims
starts on the date eligibility is established.
(B)
Medicaid hospice payments are subject to availability
of state and federally appropriated funds.
(C)
Claims for services delivered before the effective
date of this section must be submitted within 12 months of the effective date
of this section.
(D)
Adjustment to claims must be received by DHS's
claim processor during the applicable 12-month period. Claims and adjustments
denied during the 12-month period through no fault of the hospice may be paid
upon approval by DHS.
(b)-(c)
(No change.)
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on June 10, 2002.
TRD-200203620
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: July 21, 2002
For further information, please call: (512) 438-3734
(a)
Specialized services, identified
by the Preadmission Screening and Annual Resident Review (PASARR) team, include
physical, occupational, and speech and/or language pathology evaluations,
and consultation that are preauthorized, coordinated, and paid through the
Texas Department of Human Services' (DHS's) Rehabilitative Services System.
Services provided for residents determined by PASARR to need them under this
system are for the purposes of maintaining the resident's level of functioning
and preventing, to the extent possible, further deterioration. There is no
expectation that the residents' level of functioning will improve measurably
within 30 days. These specialized services are not eligible for reimbursement
under the Texas Index for Level of Effort (TILE) 202. (See §19.2500 of
this title (relating to Preadmission Screening and Annual Resident Review
(PASARR)). Eligibility for specialized services is determined by DHS without
regard to other financial resources.]
(b)
DHS pays the lowest of the
following rates:]
(1)
the maximum allowable Medicaid rate per visit
as determined by the Texas Board of Human Services;]
(2)
the therapy provider's interim rate per visit
as determined by Medicare; or]
(3)
the provider's customary charge per visit.]
System ] in Medicaid-certified Facilities.
(a)
If a facility admits or retains
residents who require physician-prescribed rehabilitative services, the facility
must either furnish therapy as a certified Title XVIII provider of services
or must have written agreements with Title XVIII providers of rehabilitative
services. The facility must ensure that these agreements provide a basis for
effective working arrangements under which therapy is made available to residents
if needed and ordered by the attending physician.]
(b) The
] Rehabilitative Services
[
System
]
are
[
includes
] physical therapy,
occupational therapy, and speech
therapy
[
pathology
]
services
for Medicaid nursing facility residents who are not eligible
for Medicare or other insurance. The cost of therapy services for residents
with Medicare or other insurance coverage or both must be billed to Medicare
or other insurance or both
. [
The attending physician must order
these services in order for provider reimbursement to occur.
]
(c)
Prior authorization by the
Texas Department of Human Services (DHS) is required for residents with only
Medicaid coverage.]
(1)
Requests for appeal of prior authorization
or recertification denials for qualified Medicaid recipients must be made
in writing by the administrator of the contracting Title XIX nursing facility.]
(2)
The request for appeal specified in paragraph
(1) of this subsection must be received by the 35th day from the date of the
original denial determination.]
(d)
DHS pays nursing facilities
for physical, occupational, and speech therapy services provided to residents
who are eligible for Medicaid but are not eligible for Medicare. The cost
of therapy services for residents with Medicare coverage must be billed to
Medicare. DHS also pays Title XVIII-certified physical therapists for physical
therapy services provided to eligible residents. DHS pays whichever of the
following rates is lowest:]
(1)
the maximum allowable Medicaid rate per visit
as determined by the Texas Board of Human Services;]
(2)
the therapy provider's interim rate per visit
as determined by Medicare; or]
(3)
the provider's customary charge per visit.]
(e)
A visit is defined as one
physical therapy service, one occupational therapy service, or one speech
therapy service performed for one resident. An evaluation is paid at the same
rate as one unit of service. One evaluation is paid for an illness or injury
at the unit rate without prior authorization; any additional evaluations performed
on the recipient must be supported by the attending physician's documentation
indicating a new illness or injury or a substantive change in a pre-existing
condition.]
(f)
Claims for services provided
must be received by DHS by the 95th day from the last approved treatment day
the rehabilitation services were provided.]
(1)
Rejected or adjusted claims may be resubmitted.
These claims must be received by the 180th day from the date of the rejection
notification.]
(2)
Corrected claims must be received by the 180th
day from the date of the paid claim.]
(g)
] Coverage for physical therapy,
occupational
therapy
, or speech
therapy
[
pathology
] services includes evaluation and treatment of functions that have
been impaired by illness. Rehabilitative services must be provided with the
expectation that the resident's functioning will improve measurably in 30
days.
Subchapter O. DENTAL SERVICES The ] Medicaid-certified Nursing Facility Emergency Dental Services [ System ].
Medicaid contracted
] facilities or distinct parts.
are
] covered under the Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) program. [
This program pays for authorized and
allowable services listed in the EPSDT section of the Medicaid Provider Procedures
Manual, which is available through the National Heritage Insurance Company
(NHIC).
]
on a voucher
system
], provided that the services are not reimbursable by
the
National Heritage Insurance Company (
NHIC
)
or the EPSDT program.
[
The following items must be submitted to DHS, Emergency Dental Service
System, Mail Code W- 519, P. O. Box 149030, Austin, Texas 78714-9030:
]
(1)
a State of Texas Purchase
Voucher completed and signed by the administrator, which includes the name
of the facility, the resident's name, and the procedures performed, and False
Claim Statement: "I understand that payment and satisfaction of this claim
will be from federal and state funds, and that any false claims, statements
or documents, or concealment of a material fact may be prosecuted under applicable
federal or state laws";]
(2)
a copy of the dentist's treatment
notes in which the nature of the emergency is clearly documented; and]
(3)
an itemized bill (statement)
to the facility signed by the treating dentist which includes a statement
regarding whether or not the services were also billed to NHIC. American Dental
Association procedure codes must be used for billing.]
(d)
Maximum Payment.]
(1)
The following words and terms, when used in
this section, shall have the following meanings, unless the context clearly
indicates otherwise.]
(A)
Usual fee--The fee a provider usually charges
private-pay residents for a service.]
(B)
Maximum fee--The highest fee that DHS pays,
through NHIC, for an allowable procedure. Upon request, DHS will furnish in
writing, the maximum fee schedule.]
(C)
Adjusted fee--The fee derived when the dental
consultant may recommend adjusting the charge for a dental procedure that
has a payment limitation as specified in the chart of allowable services,
procedure codes, and limitations included in the Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) dental services section of NHIC's Provider
Procedures Manual. The dental consultants may adjust payment for a specific
dental procedure below the maximum fee for the procedure when DHS has partially
paid for the service on the same tooth or when the degree of difficulty, as
determined by a review of the x-rays or itemized laboratory statement, does
not justify the maximum fee.]
(2)
Payments for emergency dental services rendered
in the Nursing Facility Emergency Dental Service System are the lowest of:]
(A)
the provider's usual fee;]
(B)
the maximum fee as determined by DHS; or]
(C)
the adjusted authorized fee.]
(3)
Maximum fees are those set by DHS. Fees will
change when reset by DHS.]
(e)
] Payment of Claims.
, and neither
]
Neither
the
dentist nor the facility may charge an additional fee to the recipient, his
family, or his trust fund
, except that the dentist may charge the recipient
for services that:
[
.
]
(2)
] DHS reimburses facilities
for services properly rendered in accordance with applicable laws, regulations,
and operational instructions. DHS may withhold or suspend payment for services
that are not properly rendered.
(3) The
] Nursing Facility Emergency
Dental Services [
system
] makes no payment for services that are
available under any other Texas Medical Assistance Program.
(4)
The provider may charge the
recipient only for services that the recipient requests and that are not reimbursable
by the Texas Medical Assistance Program.]
(5)
The Nursing Facility Emergency
Dental Services system will not reimburse for missed appointments.]
(6)
]
Complete and accurate
claims
[
Claims
] for services must be received
within
12 months
[
by the 95th day
] from the date of service.
(A)
Rejected or adjusted claims
may be resubmitted. These claims must be received by the 180th day from the
date of the claim rejection.]
(B)
Corrected claims must be received
by the 180th day from the date of the paid claim].
(f)
Utilization Review. Utilization
review activities required by the Medicaid program are accomplished through
a series of monitoring systems developed to ensure that services are appropriate
to need and in the optimum quality and quantity. Both residents and providers
are subject to utilization review monitoring. The resident's clinical record
documentation by facility staff must support the dentist's assessment and
treatment. The monitoring focuses on the appropriate screening activities,
the necessity of all services and the quality of care as reflected by the
choice of services provided, type of provider involved, and setting in which
care was delivered.]
Subchapter AA. VENDOR PAYMENT
initial monthly
] claim for services
for which the nursing facility is entitled to payment
must be received
by the Texas Department of Human Services' (DHS's) claim processor within
12 months
[
180 days
] after the
date of service
[
end of the service month
].
For purposes of this section,
date of service is defined as the last day of the month in which the service
was provided. Claims for services delivered before the effective date of this
section must be submitted within 12 months of the effective date of this section.
Claims and adjustments received after the 180- day time period
]
may be paid upon approval by DHS. [
An excessive number of late claims
or adjustments may subject the service provider's claims procedures to audit
by DHS.
]
180-day
] period for submission of claims will start on the date eligibility
is established.
Chapter 30.
MEDICAID HOSPICE PROGRAM
Health Care Financing Administration
(HCFA)
] as a hospice, and Medicaid certified by the Texas Department
of Human Services (DHS).
Chapter 49.
CONTRACTING FOR COMMUNITY CARE SERVICES