Adopted Rules Title 1

TITLE 1. ADMINISTRATION

Part 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION

Chapter 354. MEDICAID HEALTH SERVICES

Subchapter A. PURCHASED HEALTH SERVICES

Division 1. MEDICAID PROCEDURES FOR PROVIDERS

1 TAC §354.1003

The Health and Human Services Commission (HHSC) adopts amendments to §354.1003, Time Limits for Submitted Claims. The amended rule is adopted without changes to the proposed text published in the April 27, 2007, issue of the Texas Register (32 TexReg 2332) and will not be republished.

The Centers for Medicare & Medicaid Services (CMS) require that school districts, as public entities, not be paid in excess of their Medicaid-allowable costs incurred for providing school-based services, known in Texas as School Health and Related Services (SHARS). To comply with this CMS requirement and Texas' recently-approved Medicaid state plan language regarding the SHARS reimbursement methodology, HHSC is implementing annual SHARS cost reporting, cost reconciliation, and cost settlement processes beginning with state fiscal year (SFY) 2007.

The current rule allows SHARS claims to be submitted within 365 days from the date of service throughout the year. This schedule of claims submission does not allow sufficient time for HHSC to accurately complete cost reconciliation and cost settlement processes as required by CMS.

The amendment requires initial SHARS claims to be submitted within 365 days from the date of service or 95 days after the end of the state fiscal year, whichever comes first. Thus, for example, claims with dates of service during SFY 2007 would be due on or before December 4, 2007, allowing the vast majority of those claims to be processed through any appeals by September 1, 2008, when the cost reconciliation and cost settlement processes begin.

HHSC did not receive comments regarding the proposed rule during the 30-day comment period, which included a public hearing on May 17, 2007.

The amendment is adopted under the Texas Government Code, §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority; and the Human Resources Code, §32.021 and the Texas Government Code, §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on August 6, 2007.

TRD-200703386

Steve Aragón

Chief Counsel

Texas Health and Human Services Commission

Effective date: August 26, 2007

Proposal publication date: April 27, 2007

For further information, please call: (512) 424-6900

Division 9. AMBULANCE SERVICES

1 TAC §§354.1111, 354.1113, 354.1115

The Texas Health and Human Services Commission (HHSC or Commission) adopts amendments to §§354.1111, Definitions; 354.1113, Additional Claim Information Requirements; and 354.1115, Authorized Ambulance Services, in Title 1, Part 15, Chapter 355, Subchapter A, Division 9, Ambulance Services. Rule 354.1113 is adopted with changes to the proposed text published in the May 4, 2007, issue of the Texas Register (32 TexReg 2430) and will, therefore, be republished. The amendments to §354.1111 and §354.1115 are adopted without changes to the proposed text published in the May 4, 2007, issue of the Texas Register (32 TexReg 2430) and will not be republished.

Background and Purpose

The proposed amendments to §354.1111 reflect the reorganization of the Health and Human Services agencies pursuant to House Bill 2292, 78th Legislature, Regular Session, 2003. The amendment changes the definition of "emergency medical condition" to include psychiatric disturbances or symptoms of substance abuse and to track the definitions of "emergency medical condition" found in 42 Code of Federal Regulations §438.114(a) and §489.24(b). Other definitions are updated or removed from the rule as a result of revisions to the corresponding §354.1113, Additional Claim Information Requirements, and §354.1115, Authorized Ambulance Services.

The proposed amendments to §354.1113 specify what must be included to document medical necessity on ambulance claims, including the requirement that transport documentation substantiate the level of service and mode of transportation. The amendment also requires that a prior authorization number for non-emergency services be obtained before an ambulance is used to transport a recipient. Additionally, the section clarifies the types of supporting documentation that the ambulance provider and requesting provider must maintain and make available if requested by the Office of the Inspector General or the Commission or its designee. Examples of supporting documentation were deleted from the rule and will be included instead in policy.

On adoption, a non-substantive, technical clarification was made to §354.1113(a)(5) to clarify that a prior authorization number (PAN) must be submitted with a claim only if required. Subsection (b) spells out the circumstances in which a PAN is required.

Section 354.1115, Authorized Ambulance Services, is amended to specifically reflect the requirements found in §32.024(t) of the Human Resources Code concerning prior authorization for non-emergency ambulance transportation. Physicians, nursing facilities, health care providers, or other responsible parties will be required to obtain authorization from the Commission or its designee before an ambulance can be used to transport a recipient in a non-emergency situation. The Commission has 48 hours to respond to the request once it is received. The rule also outlines the circumstances under which the Commission will grant immediate authorization for transport and the process an ambulance provider should follow to receive payment in cases in which the requesting provider did not receive a required prior authorization.

In addition to the amendments described above, non-substantive terminology changes are made throughout the Division, including replacing references to the Texas Department of Health with the Health and Human Services Commission.

Comments

The 30-day comment period ended June 3, 2007. During that period, HHSC held a public hearing on May 24, 2007, during which it received comments regarding one of the proposed rules. A summary of the comments and HHSC's response follows.

Comment: The Texas Ambulance Association, Texas Association of Air Medical Services, and Care Flite, North Central Texas, addressing language in §354.1113(c)(1), suggested deleting the words "or maintained" from the following sentence: "This supporting documentation is limited to documents developed or maintained by the ambulance provider." According to the commenters, this deletion makes clear that, while ambulance providers may maintain many documents, "supporting documentation" is limited to documents developed by the ambulance provider. The commenters stated that: "The intent of the new §354.1113(c) was to make it clear that an ambulance provider is not required to obtain or maintain sending or receiving hospital records, and if HHSC, OIG or the Medicaid contractor wanted to review hospital records during a post-payment audit of an ambulance claim, they would obtain this information directly from the hospitals." In addition, the first sentence of §354.1113(c) already directs providers to maintain supporting documentation, so the proposed language in §354.1113(c)(1) in effect tells an ambulance provider "to maintain that which it maintains."

HHSC Response: HHSC agrees with the comment and will delete the words "or maintained" from §354.1113(c)(1). This deletion eliminates the apparent duplication of the directive in §354.1113(c) to maintain supporting documentation and clarifies that an ambulance provider is required to maintain only supporting documentation developed by the ambulance provider. The deletion also reflects the intent of the rule: to ensure that the ambulance provider maintains sufficient documentation to support the medical necessity of the ambulance transport.

The amendments are adopted under the Texas Government Code, §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority; and the Human Resources Code, §32.021 and the Texas Government Code, §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

§354.1113.Additional Claim Information Requirements.

(a) In addition to the general requirements in §354.1001 of this title (relating to Claim Information Requirements), the following information is required on claims for ambulance services:

(1) Documentation of medical necessity in accordance with codes representing medical conditions as designated by the Commission:

(A) The transport documentation must substantiate the level of service and mode of transport provided;

(B) Reimbursement is recouped when the documentation does not substantiate that the level of service and mode of transport provided accurately matches the level of service and mode of transport claimed; and

(C) The level of service and mode of transport provided must be medically necessary based on the clinical situation and needs of the recipient;

(2) Type of ambulance service provided (e.g, air, ground, or boat);

(3) Origin and destination of each separate trip;

(4) Charges for ambulance services, including base rates and mileage rates; and

(5) Prior authorization number (PAN), if required.

(b) Obtaining a prior authorization number.

(1) A PAN for non-emergency transports must be obtained before an ambulance is used to transport a recipient.

(2) A PAN for out-of-state ambulance transports must be obtained before an ambulance is used to transport a recipient.

(c) Supporting documentation is required to be maintained by both the ambulance provider and the requesting provider including a physician, nursing facility, health care provider or other responsible party. Supporting documentation is to be made available if requested by the Office of Inspector General (OIG) or the Commission or its designee.

(1) An ambulance provider is required to maintain documentation that represents the recipient's medical conditions and other clinical information to substantiate medical necessity and the level of service and mode of transportation requested. This supporting documentation is limited to documents developed by the ambulance provider.

(2) Physicians, nursing facilities, health care providers or other responsible parties are required to maintain physician orders related to requests for prior authorization of non-emergency and out-of-state ambulance services. These providers must also maintain documentation of medical necessity for the ambulance transport.