T EXAS MEDICAID BULLETIN - TMHP

TEXAS MEDICAID BULLETIN

Bimonthly update to the Texas Medicaid Provider Procedures Manual

SEPTEMBER/OCTOBER 2007 NO. 208 INSIDE

Medlog Reports Accessible All Providers 1
Through TMHP Website
Medlogs Accessible Through TMHP Website . . . . . . . . . . . . . . . . . . . . . . . . .1
Effective August 27, 2007, hospital providers and
comprehensive outpatient rehabilitation facilities Looking For Ways to Better Serve Your Clients? . . . . . . . . . . . . . . . . . . . . . .2
(CORFs) that currently go through the Texas
Medicaid Program audits settlement process are Federal Deficit Reduction Act of 2005 Requirements . . . . . . . . . . . . . . . .3
able to access Medlog reports through their provider
administrator accounts on the TMHP website Three-Dimensional Reconstruction of an Ultrasound . . . . . . . . . . . . . . . .4
at www.tmhp.com. Providers that do not have a
provider administrator account can create one on Authorizations For Clients With Retroactive Eligibility . . . . . . . . . . . . . . . .4
the TMHP website by clicking on the Activate My
Account link on the home page. Reprocessing Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Providers can view their Medlog reports, which New Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
cover time periods of either three or ten months, by
logging in to their account and clicking on the Paid Revised CSHCN Services Program Provider Enrollment Form. . . . . . . . .5
Claims Detail Report link on the Providers page. If
there are no reports available, “No reports” will be Scheduled System Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
displayed. Providers can download the reports from
Delivery Documentation for DME Vendors . . . . . . . . . . . . . . . . . . . . . . . . . . .6
the website as Adobe® Portable Document Format
Order Form Requirements for Incontinence Supplies . . . . . . . . . . . . . . . .7
(PDF) files.
Zero-Paid and Zero-Allowed Electronic Appeals . . . . . . . . . . . . . . . . . . . . .7
The following Medlog reports will be available
online: American Medical Association End-User Guide . . . . . . . . . . . . . . . . . . . . . .7

• INRR100A Medlog—CORF 2nd Quarter 2007 HCPCS Benefit Changes . . . . . . . . . . . . . . . . . . . . . . . . . . 8

• INRR106A Medlog Hospital—Outpatient Women’s Health Program ID Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

• INRR107A Medlog Hospital—Outpatient Denied Claims for Portable X-Ray Suppliers . . . . . . . . . . . . . . . . . . . . . . . . . 9
Managed Care
New Drugs Added as Texas Medicaid Benefits . . . . . . . . . . . . . . . . . . . . . 10
• INRR108A Medlog Hospital—Inpatient
Texas Medicaid Preferred Drug List Now Available . . . . . . . . . . . . . . . . . .11
• INRR109A Medlog Hospital—Inpatient
Managed Care Gynecological and Reproductive Health Services . . . . . . . . . . . . . . . . . . 12

 TMHP Standardized MRAN Templates Update. . . . . . . . . . . . . . . . . . . . . . 15

Copyright Acknowledgments Colorectal Cancer Screening Benefits Are Changing . . . . . . . . . . . . . . . 15
Use of the American Medical Association’s (AMA) copyrighted Current Procedural
Terminology (CPT) is allowed in this publication with the following disclosure: “Current Cochlear Implants Are a Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Procedural Terminology (CPT) is copyright 2007 American Medical Association. All
rights reserved. No fee schedules, basic units, relative values, or related listings are included Modifier 26 Submission Correction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal
Acquisition Regulation System/Department of Defense Regulation System (FARS/ New Integrated Care Management Program . . . . . . . . . . . . . . . . . . . . . . . 16
DFARS) restrictions apply to government use.”
The American Dental Association requires the following copyright notice in all publications Neonatal and Pediatric Critical Care Services . . . . . . . . . . . . . . . . . . . . . . . 18
containing Current Dental Terminology (CDT) codes: “CDT 2007/2008 [including
procedure codes, definitions (descriptions), and other data] is copyrighted by the American Stereotactic Radiosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Dental Association. (c) 2006 American Dental Association. All Rights Reserved. Applicable
Federal Acquisition Regulation System/Department of Defense Acquisition Regulation New Automated Provider Licensure Information System. . . . . . . . . . . 19
System (FARS/DFARS) restrictions apply.”
Mandatory Third-Party Biller Testing for NPI . . . . . . . . . . . . . . . . . . . . . . . . 19

Behavioral Health Providers 19

Reprocessing of Claims for Clients Residing in an IMD Facility . . . . . . 19

Managed Care Providers 20

Freestanding Psychiatric Facilities and Behavioral Health Claims . . . 20

Reminder for STAR+PLUS Dual Eligible Clients . . . . . . . . . . . . . . . . . . . . . 20

PCCM Providers 20

Payment Process for the Billed DRG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

PCCM Primary Care Providers Should Verify Clients’ ID Cards. . . . . . . .21

SHARS Providers 21

SHARS Claims Filing Deadline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Excluded Providers 22

Forms 25

All Providers

Looking for Ways to Better Serve Your Clients?

Have You Considered Becoming a Provider of Case Management for Children and Pregnant Women?

Case Management for Children and Pregnant Women (CPW) is a case management program that provides health-related
case management services to eligible children and pregnant women.
� CPW providers are registered nurses or licensed social workers working as individuals or employed by schools, health

departments, counseling agencies, health clinics and other types of agencies.
� Providers are approved through DSHS and enrolled with TMHP as Medicaid providers.
� Case managers have a minimum of two years experience assessing the psychosocial needs of children and/or pregnant

women, and making community referrals to address their service needs.
� CPW services include assessing the needs of eligible clients, formulating a service plan, making referrals, problem

solving, advocacy and follow-up regarding client and family needs.
� Providers are reimbursed for the assessment/service plan development and follow up contacts. Reimbursement is

$54.58 for face-to-face contacts and $18.00 for telephone contacts. These maximum reimbursement
rates are currently subject to a legislatively-mandated 2.5% reduction.
� CPW case managers submit requests to the Texas Department of State Health Services (DSHS)
for determination of eligibility for case management services.

To be eligible for CPW case management services, a person must:
1. Have Medicaid or be eligible for Medicaid.
2. Be a child (birth through 20 years of age) with a health condition or health risk. Health

condition or health risk is defined as a medical condition, illness, injury or disability that
results in limitation of function, activities or social roles in comparison with same age peers
in the general areas of physical, cognitive, emotional or social growth and development.
3. Need help to access services to prevent illness(es) or medical condition(s), to maintain
function or to slow further deterioration of the condition.
4. Desire health-related CPW case management services.

— OR —
1. Have Medicaid or be eligible for Medicaid.
2. Be pregnant with one or more high-risk medical and/or psychosocial condition(s)

during pregnancy.
3. Need help to access services to have a healthier pregnancy and a healthier baby.
4. Desire health related CPW case management services.

If you are interested in becoming a CPW provider or would like more
information, please ask your TMHP provider relations representative
for the name of the CPW contact for your area or go to:
http://www.dshs.state.tx.us/caseman/contact3.shtm

To make a referral, call the THSteps Outreach and Informing line
1-877-THSTEPS (1-877-847-8377) or call a CPW case management
provider in your area. A list of CPW providers can be found on the DSHS
Case Management Website, http://www.dshs.state.tx.us/caseman/default.shtm.

Texas Medicaid Bulletin, No. 208 Revised 07/2007

2 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Federal Deficit Reduction Act of 2005 Requirements

Effective January 1, 2007, all providers and other entities items or services, performs billing or coding functions,
that receive or make annual Texas Medicaid Program or is involved in monitoring health care provided by
payments of $5 million or more must educate employees, the entity.
contractors, and agents about federal and state fraud • If the contractor is performing administrative
and false-claims laws and the whistleblower protections functions for the State Medicaid Agency, the
available under those laws. contractor would be neither an entity nor a contractor
for the purposes of Section 6032 compliance.
For the purposes of Section 6032 of the Federal Deficit As a condition of receiving Texas Medicaid Program
Reduction Act (DRA): payments, all impacted providers or other entities must:
• Establish written policies for all employees, contractors,
• An “entity” includes a governmental agency, organiza- or agents of the entity that provide detailed
tion, unit, corporation, partnership, provider, or other information about the False Claims Act, administra-
business arrangement (including any Texas Medicaid tive remedies for false claims and statements, any state
Program managed care organization), whether for- laws pertaining to civil or criminal penalties for false
profit or not-for-profit, which receives or makes claims, and whistleblower protections under such laws.
payments, under a state plan approved under Title XIX • Include as part of such written policies, detailed
or under any waiver of such plan, totaling at least $5 provisions regarding the entity’s policies and
million annually. procedures for detecting and preventing fraud, waste,
and abuse.
• If an entity furnishes items or services at more than a • Revise any existing employee handbook to include
single location or under more than one contractual or information on the above laws and employee
other payment arrangement, the provisions of this law protections, as well as policies and procedures for
apply if the aggregate payments to that entity meet the detecting and preventing fraud, waste, and abuse.
$5 million annual threshold. This applies whether the For purposes of compliance, the Health and Human
entity submits claims for payments using one or more Services Commission (HHSC), HHSC operating
provider identification or tax identification numbers. agencies, and HHSC administrative contractors will
incorporate the requirements of Section 6032 into new
• The entity is the largest separate organizational unit provider contracts. Providers with existing contracts
that furnishes Medicaid health-care items or services must comply in accordance with those contracts,
and includes all subunits of that organizational unit which require compliance with all federal and state
that furnish Medicaid health-care items or services. laws, regulations, and rules. HHSC, HHSC operating
agencies, and HHSC administrative contractors will
• A governmental component providing Medicaid health- be implementing monitoring plans and activities to
care items or services for which Medicaid payments are ensure compliance with Section 6032 of the DRA. Each
made would qualify as an entity (e.g., a state mental
health facility or school district providing school-based Additional Information
health services).
For additional information about Medicaid and
• An entity will meet the $5 million annual threshold PCCM articles in this bulletin, call the TMHP
as of January 1, 2007, if it received or made payments Contact Center at 1-800-925-9126.
in that amount in federal fiscal year 2006 (October 1, For additional information about articles
2005, to September 30, 2006). Future determinations pertaining to CSHCN, call the TMHP-
will be made by January 1 of each subsequent year, CSHCN Services Program Contact Center at
based on the amount of Medicaid payments received 1-800-568-2413.
or made during the preceding federal fiscal year.

• An “employee” includes any officer, manager, or
employee of the entity.

• A “contractor” or “agent” includes any contractor,
subcontractor, agent, or other person which or who
on behalf of the entity, furnishes or authorizes the
furnishing of Texas Medicaid Program health-care

September/October 2007 3 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

monitoring agency will send information about monitoring Three-Dimensional
plans and activities to its providers. Reconstruction of an Ultrasound

Additional Resources This is a correction to a banner message that first
appeared on the May 11, 2007, Remittance and Status
Relevant laws and rules include, but are not necessarily (R&S) report about three-dimensional reconstruc-
limited to: tions of ultrasounds. The article incorrectly included
• Section 6032 of the Deficit Reduction Act of 2005 (Public procedure code 4/I/T-73677. The correct procedure
code is 4/I/T-76377. The following is the complete,
Law 109-171) (establishes §1902(a)(68) of the Social corrected article.
Security Act, 42 U.S.C. 1396a(a)) Effective May 7, 2007, prior authorization is required
• The Civil Monetary Penalties Law, 42 U.S.C. 1320a-7a: for procedure codes 4/I/T-76376 and 4/I/T-76377
Civil Monetary Penalties Law when billing for the three-dimensional reconstruction
• The False Claims Act, 31 U.S.C. §3729, 3730, 3731, 3732, of an ultrasound.
and 3733 In an urgent or emergent situation, providers must
• Pertinent Texas Statutes and Rules: submit a retrospective authorization request no later
than seven calendar days after the procedure was
º Texas Human Resources Code Chapter 32, performed.
§32.039 and 32.0391 When requesting prior authorization, providers
must include documentation that indicates a
º Texas Human Resources Code Chapter 36 two-dimensional ultrasound is not sufficient and a
º Texas Government Code Chapter 531, three-dimensional ultrasound is needed. Prior autho-
rization approvals are considered on a case-by-case
Subchapter C, §531.101 et seq. basis. To request prior authorization, providers should
º Texas Administrative Code, Title 1, Part 15, fax the request and supporting documentation to
the Special Medicaid Prior Authorization Unit at
Chapter 371 1-512-514-4213.
Additionally, effective May 7, 2007, obstetrical three-
• Centers for Medicare & Medicaid Services (CMS) dimensional ultrasounds are not a benefit of the Texas
Guidance: Medicaid Program and will not be authorized.
º State Medicaid Directors Letter #06-025
º State Medicaid Directors Letter #07-003 Authorizations For Clients With
º Frequently Asked Questions Retroactive Eligibility
º Official Description of the False Claims Act

• Texas Waste, Abuse, and Fraud Hotline:
1-800-436-6184

• Texas Health and Human Services Commission Office
of Inspector General: https://oig.hhsc.state.tx.us

When authorization is required for a Texas Medicaid
Program service, authorization requests for clients
with retroactive eligibility must be submitted after
the client’s eligibility has been added to the Texas
Medicaid & Healthcare Partnership (TMHP)
eligibility file. For accurate claims processing, an
authorization request must be submitted to TMHP
before a claim submission. Providers have 95 days
from the add date to obtain authorization for services
that have already been performed.
Primary Care Case Management (PCCM) providers
must obtain prior authorization requests within 95 days
of the add date and before claims submission.

Texas Medicaid Bulletin, No. 208 4 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Reprocessing Claims New Benefits

Age Restriction Procedure code 76937

TMHP has identified an issue Effective August 13, 2007, procedure code 76937 is
impacting claims submitted for dates a benefit of the Texas Medicaid Program with the
of service January 1, 2007, through following allowable fees:
May 30, 2007, with procedure codes • 4-76937 (total component), $27.55
2/F-15002, 2/F-15003, 2/F-15004, • I-76937 (professional component), $11.46
and 2-15005. Claims may have been • T-76937 (technical component), $16.09
incorrectly denied for clients who are
older than 20 years of age. Hearing Aid Benefits
Claims for dates of service January 1, 2007, through
May 30, 2007, that contain these procedure codes will be Hearing aids are a benefit for eligible Texas Medicaid
reprocessed, and payments will be adjusted accordingly. Program clients who are 21 years of age and older.
No action on the part of the provider is necessary. Clients must meet the requirements for medical necessity
and have no medical contraindications for a hearing aid.
Crossover Claims Hearing aids for clients who are younger than 21 years
of age are available and reimbursed only through
TMHP has identified an issue impacting Medicare the Program for Amplification for Children of Texas
crossover claims that were submitted for dates of service (PACT).
January 1, 2005, through May 31, 2007, and include For more information, refer to the 2007 Texas Medicaid
procedure codes 1-97605 and 1-97606. These claims may Provider Procedures Manual, Section 23.3.3, “Hearing
have been processed incorrectly. Aid Instrument,” on page 23-4 or call the TMHP
Medicare crossover claims for dates of service Contact Center at 1-800-925-9126.
January 1, 2005, through May 31, 2007, that include
procedure codes 1-97605 and 1-97606 will be Revised CSHCN Services Program
reprocessed, and payments will be adjusted accordingly. Provider Enrollment Form
No action on the part of the provider is necessary.
The Children with Special Health Care Needs (CSHCN)
CLIA Waived Test Services Program Provider Enrollment Application has
been revised. Effective immediately, new providers that
TMHP has identified an issue impacting claims enroll in the CSHCN Services Program must submit the
submitted with dates of service November 16, 2005, revised CSHCN Services Program Provider Enrollment
through June 4, 2007, for procedure code 86703 Application, which is available in the Provider
with modifier QW. Claims submitted by providers Enrollment Forms section of the TMHP website at
that hold only a Clinical Laboratory Improvement www.tmhp.com. Effective August 1, 2007, TMHP will
Amendments (CLIA) Certificate of Waiver may have return all applications that are not submitted on the
been incorrectly denied. Claims submitted with dates revised CSHCN Services Program Provider Enrollment
of service November 16, 2005, through June 4, 2007, Application.
for procedure code 5-86703 with modifier QW will be
reprocessed, and payments will be adjusted accordingly.
No action on the part of the provider is required.

Nonpayable Diagnosis Code

TMHP has identified an issue impacting claims
submitted with dates of service from June 26, 2004,
through June 26, 2007, that include procedure code
J-E0605 with diagnosis code 46611. These claims may
have been incorrectly denied for nonpayable diagnosis
code. These claims will be reprocessed, and payments
will be adjusted accordingly. No action on the part of the
provider is necessary.

September/October 2007 5 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Delivery Documentation for DME Vendors

Durable medical equipment (DME) providers must All claims submitted for DME supplies must:
retain all individual delivery slips or invoices that
document the date of delivery for all supplies provided to • Include the same quantities or units that are
a client for each date of service (DOS) and must disclose documented on the delivery slip or invoice and on
them to HHSC or its designee upon request. the Home Health Services (Title XIX) Durable
Documentation of delivery must include a delivery slip or Medical Equipment (DME)/Medical Supplies
invoice that is signed and dated by the client or caregiver, Physician Order Form.
or a dated carrier tracking document attached to the
delivery slip or invoice. The carrier tracking document • Reflect the number of units by which each product
must contain both the shipping date and the delivery date. is measured. For example, diapers are measured
To avoid claim recoupment, the DME vendor must keep as individual units. If 1 package of 300 diapers
documentation in the client’s record to support a delivery is delivered, the delivery slip or invoice and the
slip or invoice for goods delivered to that client, including: claim must reflect that 300 individual diapers were
• A dated, itemized list of goods that includes the delivered and not that one package or one case was
delivered. Diaper wipes are measured as boxes/
descriptions and quantities of the supplies delivered packages. If 1 box of 200 wipes is delivered, the
to the client. This document could also include prices, delivery slip or invoice and the claim must reflect
shipping weights, shipping charges, and any other that one box or one case was delivered and not that
description. 200 individual wipes were delivered.
• The delivery slip or invoice that was dated and signed
by the client or caregiver and the delivery person or the • Correspond to one dated delivery slip or invoice.
tracking document printed from the shipping carrier’s There must be one dated delivery slip or invoice for
website, if it was delivered by a shipping carrier. If a each claim submitted for each client.
shipping carrier is used by the DME provider to deliver
the supplies, the shipping carrier’s tracking document • Reflect the same date as the delivery slip or invoice
must be printed from the carrier’s website as confirma- and the same timeframe covered by the Home
tion that the supplies were shipped and delivered. The Health Services (Title XIX) Durable Medical
tracking document must contain both the shipping Equipment (DME)/Medical Supplies Physician
date and the delivery date of the supplies, and it must Order Form.
be attached to the delivery slip or invoice. Signatures
are not required on the delivery slip or invoice if the The DME Certification and Receipt Form is still
supplies were delivered by a shipping carrier. required for all equipment delivered.
• The Home Health Services (Title XIX) Durable
Medical Equipment (DME)/Medical Supplies For more information, refer to the article in the
Physician Order Form. January/February 2007 Texas Medicaid Bulletin,
No. 201, titled “Durable Medical Equipment
Updates,” on page 19. Providers can also call the
TMHP Contact Center at 1-800-925-9126.

Each dated delivery slip or invoice must contain: Scheduled System Maintenance

• The client’s full name and address to which System maintenance for the TMHP claims processing
the supplies were delivered. system is scheduled as follows:
• Sunday, September 9, 2007, 6:00 p.m. to 11:59 p.m.
• The item description and the quantities that • Sunday, October 14, 2007, 6:00 p.m. to 11:59 p.m.
were delivered to the client. During system maintenance some applications related to
the claims engine will be unavailable. Specific details about
• The signatures of the client or caregiver and the affected applications are posted on the TMHP website
the delivery person at the time of delivery and at www.tmhp.com.
the date signed. Signatures are not required
on the delivery slip or invoice if the supplies
are delivered by a shipping carrier.

Texas Medicaid Bulletin, No. 208 6 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Order Form Requirements for Zero-Paid and Zero-Allowed
Incontinence Supplies Electronic Appeals

Incontinence supplies do not require prior autho- Effective August 27, 2007, claims listed on the R&S
rization if the amounts are within the maximum report with $0 allowed and $0 paid may be resubmitted
limitations. Prior authorization is required for as electronic appeals. Previously, these claims were only
incontinence supplies if the amounts are greater accepted as new day claims and were not accepted as
than the maximum limitations and they are electronic appeals. Appeals may be submitted through
medically necessary. Incontinence supplies that are a third-party biller or through TexMedConnect, the
billed for a one-month period should be based on new online application that was implemented on
the frequency/quantity ordered by the physician August 27, 2007.
on the Home Health Services (Title XIX) Durable
Medical Equipment (DME)/Medical Supplies TMHP will conduct free
Physician Order Form. TexMedConnect workshops

The Home Health Services (Title XIX) Durable in November.
Medical Equipment (DME)/Medical Supplies
Physician Order Form must reflect the following Zero-paid claims that are still within the 95-day filing
information for incontinence supplies: deadline should be submitted as new day claims, which
process faster than appeals. Claims can be resubmitted
• All quantities in Section A must be for a one- past the 95-day deadline as new day claims if the following
month supply. fields have not changed: provider identifier, Texas Medicaid
Program client number, dates of service, and total billed
• The quantities must be within the policy amount. All other appeal guidelines remain unchanged.
limitations that are listed in the 2007 Texas TMHP will conduct free TexMedConnect workshops in
Medicaid Provider Procedures Manual unless prior November. All providers are encouraged to attend these
authorization is obtained. free workshops. Providers should monitor their mail
for a workshop invitation or visit the TMHP website at
• The quantities must be individualized according to www.tmhp.com for workshop times and locations.
the client’s monthly needs.
American Medical Association End-
• For each one-month supply, the quantity User Agreement
submitted on the claim must not exceed the
quantity on the Home Health Services (Title XIX) Effective June 10, 2007, all users who access the TMHP
Durable Medical Equipment (DME)/Medical website at www.tmhp.com are required to accept
Supplies Physician Order Form. the American Medical Association (AMA) End-User
Agreement for the use of Current Procedural Terminology
The Home Health Services (Title XIX) Durable
Medical Equipment (DME)/Medical Supplies (CPT®). For each computer that accesses the TMHP
Physician Order Form is valid for up to, but no more
than, six months from the date of the physician’s website, the agreement must be accepted every 30 days
signature on the form. from the last date on which the agreement was accepted
by the user. If the end-user agreement is not accepted on a
The Home Health Services (Title XIX) Durable particular computer every 30 days, no user will be able to
Medical Equipment (DME)/Medical Supplies enter the website from that computer.
Physician Order Form is available on page 35 of For additional information about the AMA and CPT,
this bulletin, and in the 2007 Texas Medicaid refer to the AMA website at www.ama-assn.org/ama/pub/
Provider Procedures Manual, Appendix B, “Forms,” category/3113.html.
on page B-44.

September/October 2007 7 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

2nd Quarter 2007 HCPCS Benefit Changes

Second quarter 2007 Healthcare Common Procedure Setting Providers
Coding System (HCPCS) additions, changes, and
deletions that are effective for dates of service on or after Outpatient Advanced practice nurses, physicians,
July 1, 2007, for the Texas Medicaid Program are now hospital hospitals, and rehabilitation centers
available. Deleted procedure codes are no longer benefits Other Advanced practice nurses, School
of the Texas Medicaid Program effective for dates of Health and Related Services (SHARS)
service on or after July 1, 2007. individual providers and group
providers, and physicians
Texas Medicaid Program Policy Updates
Second Quarter 2007 HCPCS Additions
The following Texas Medicaid Program policy changes
have been made to support the Second Quarter 2007 The following is a list of new procedure codes that do not
HCPCS updates. replace existing codes. All procedure codes that require
a rate hearing are indicated with an asterisk in the
Home Health Respiratory Equipment and Allowable column.
Supplies
Procedure Allowable Procedure Allowable
The following procedure codes are benefits of the Texas
Medicaid Program with the following limitations: Code Code

Procedure Code Limitation 1-C1716 NC 1-C1717 NC

J-K0553 1 every 3 months 1-C1719 NC 1-C2616 NC
J-K0554 2 per month
J-K0555 2 per month 1-C2634 NC 1-C2635 NC

1-C2636 NC 1-C2637 NC

1-C2638 NC 1-C2639 NC

Mastectomy and Breast Reconstruction 1-C2640 NC 1-C2641 NC

Procedure codes 2/8-S2066 and 2/8-S2067 are benefits 1-C2642 NC 1-C2643 NC
of the Texas Medicaid Program if they are submitted
with diagnosis code 1740, 1741, 1742, 1743, 1744, 1-C2698 NC 1-C2699 NC
1745, 1746, 1748, 1749, 1750, 1759, 19881, 2330, or
V103. Procedure codes 2/8-S2066 and 2/8-S2067 are 1-C9728 NC J-K0553 *
considered for reimbursement to physicians in the
inpatient and outpatient hospital settings. J-K0554 * J-K0555 *

1-Q4087 NC 1-Q4088 NC

1-Q4089 NC 1-Q4090 NC

1-Q4091 NC 1-Q4092 NC

Speech Language Pathology Services and Speech 1-Q4093 NC 1-Q4094 NC
Therapy
1-Q4095 * 2/8-S2066 *
Procedure code 1-S9152 is a benefit of the Texas
Medicaid Program and may be submitted for reimburse- 2/8-S2067 *
ment of a re-evaluation once every 30 days. Providers
must not use procedure code 1-92506 with the U4 (*) Reimbursement pending rate hearing. (NC) Not covered
modifier to submit claims for a re-evaluation.
Services that are provided before rates have been adopted
Setting Providers through the rate hearing process will be denied as part of
Office another service until the applicable reimbursement rate
Advanced practice nurses, physicians, has been adopted. The client cannot be billed for these
Home and Comprehensive Care Program services. TMHP will reprocess claims after the applicable
Inpatient (CCP) providers reimbursement rates have been adopted. Providers
hospital Home health agencies and CCP should submit claims for the procedure codes as the
providers services are performed so that all filing deadlines are met.
Advanced practice nurses and Providers are responsible for meeting all filing deadlines
physicians and for appealing any claims that are denied between
July 1, 2007, and the date on which the reimbursement
rate is implemented.

Texas Medicaid Bulletin, No. 208 8 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Women’s Health Program ID Card

Identifying Women’s Health Program Clients June 2007 National Provider Identifier (NPI) Special
Bulletin, No. 205.
Effective January 1, 2007, the Women’s Health Program
(WHP) was implemented by HHSC. WHP provides low- TMHP Will Reprocess Certain WHP Claims
income women with gynecological exams, related health
screenings, and contraceptives (except emergency contra- HHSC has identified an error with WHP identification
ception) through the Texas Medicaid Program. However, cards (see banner message 1 from the April 23, 2007,
WHP clients do not have access to the full range of Texas ER&S report). During January through April 2007,
Medicaid Program benefits. WHP coverage includes approximately 800 WHP clients received identifica-
only a limited family planning benefit, including an tion cards that incorrectly indicated that the client had
annual visit and exam. eligibility for services that are not benefits of WHP.
For a full list of services allowable under WHP, Claims for non-WHP services provided to these clients
providers can refer to the January/February 2007 Texas were denied. Affected claims submitted for dates of
Medicaid Bulletin, No. 201, or the WHP website at service January 1, 2007, through April 30, 2007, will be
www.hhsc.state.tx.us/womenshealth.htm. reprocessed, and payments will be adjusted according
to the coverage indicated on the erroneous Texas
Medicaid Program identification cards. No action on
the part of the provider is necessary.

Denied Claims for Portable X-Ray
Suppliers

TMHP has identified an issue impacting claims that
were submitted with the following procedure codes for
dates of service on or after January 1, 2007.

Procedure Codes

76776 77001 77002 77003
77014 77021
77011 77012 77032 77051
77054 77055
The WHP identification card visibly indicates the 77022 77031 77058 77059
program in the black box in the upper right area of the 77073 77074
card. The card also contains a notice to providers that 77052 77053 77077 77078
WHP-covered services are limited to an annual visit and 77081 77082
exam and contraception, except emergency contraception. 77056 77057
Client eligibility may be verified using the following
sources: www.tmhp.com, Automated Inquiry System 77071 77072
(AIS), TDHconnect, or TexMedConnect. WHP clients
will have the following identifiers on the feedback 77075 77076
received from the stated source:
Medicaid Coverage: W – MA – WHP 77079 77080
Program Type: 68 – Medical Assistance – Women’s
Health Pr 77083 77084
Program: 100 – Medicaid Benefit Plan: 100 –
Traditional Medicaid These claims may have been incorrectly denied as
Note: TexMedConnect became available August 27, 2007. not payable to portable X-ray suppliers for the total
For more information about TexMedConnect, refer to the component in the office, or for physicians billing for
interpretations in the inpatient hospital setting.
Claims submitted for dates of service on or after
January 1, 2007, will be reprocessed, and claims will be
adjusted accordingly.
Providers that perform radiology procedures must be
accredited and certified in accordance with Food and
Drug Administration (FDA) guidelines.

September/October 2007 9 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

New Drugs Added as Texas Medicaid Program Benefits

Abatacept (Orencia®) • Inadequate response to one or more DMARDs, such
as methotrexate or TNF antagonists
Effective for dates of service on or after January 1, 2007,
abatacept (Orencia) is a benefit of the Texas Medicaid • The number of anticipated injections and the dosage
Program for clients with moderately to severely active and number of vials per injection
rheumatoid arthritis. These clients may also have an
inadequate response to analgesics, nonsteroidal anti- Prior authorization is a condition for reimbursement;
inflammatory drugs (NSAIDs), Cox-2 inhibitors, and/or it is not a guarantee of payment. Providers may fax
one or more disease-modifying anti-rheumatic drugs or mail the prior authorization request to the TMHP
(DMARDs), such as methotrexate or tumor necrosis Special Medical Prior Authorization Department at:
factor (TNF) antagonists.
Texas Medicaid & Healthcare Partnership
Dates of Service January 1, 2007, through Special Medical Prior Authorization Department
July 14, 2007
12357-B Riata Trace Parkway, Suite 150
For dates of service January 1, 2007, through Austin, TX 78727
July 14, 2007, providers must use procedure code Fax: 1-512-514-4213
1-J3490 to submit claims for abatacept (Orencia). The
paper claim submission must include medical necessity Providers should use procedure code 1-J3490 until
documentation that contains the following information: procedure code 1-J0129 is implemented. A future
banner message will notify providers when they will be
• A diagnosis of rheumatoid arthritis (diagnosis code able to submit the new procedure code.
7140, 7141, 7142, 71430, 7144, or 7149)

• Failure of sufficient response to standard treatment,
such as analgesics, NSAIDs, and Cox-2 inhibitors

• Inadequate response to one or more DMARDs, such
as methotrexate or TNF antagonists

Providers are responsible for meeting all filing deadlines.
When a service becomes a benefit of the Texas Medicaid
Program with a retroactively applied effective date, an
exception to the 95-day filing deadline may be granted.
For more information about exceptions to the 95-day
filing deadline, refer to the 2007 Texas Medicaid Provider
Procedures Manual, Section 5.1.3.1, “Exceptions to the
95-Day Filing Deadline,” on page 5-5. All medical
necessity documentation must be submitted with the
request for the exception.

Dates of Service on or after July 15, 2007

For dates of service on or after July 15, 2007, providers
must obtain prior authorization for procedure code
1-J3490 to request reimbursement for abatacept
(Orencia). The prior authorization request must include
medical necessity documentation that contains the
following information:
• A diagnosis of rheumatoid arthritis (diagnosis code

7140, 7141, 7142, 71430, 7144, or 7149)
• Failure of sufficient response to standard treatment,

such as analgesics, NSAIDs, and Cox-2 inhibitors

Texas Medicaid Bulletin, No. 208 10 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Alglucosidase alfa (Myozyme®) Prior authorization is a condition for reimbursement; it
is not a guarantee of payment. Providers may fax or mail
Effective for dates of service on or after January 1, 2007, prior authorization requests, including all required docu-
alglucosidase alfa (Myozyme) is a benefit of the Texas mentation, to the Texas Health Steps-Comprehensive
Medicaid Program for clients younger than 21 years of age Care Program (THSteps–CCP) Prior Authorization
who are diagnosed with glycogenosis, or Pompe disease. Department at:

Dates of Service January 1, 2007, through Texas Medicaid & Healthcare Partnership
July 14, 2007 Comprehensive Care Program (CCP)
PO Box 200735
For dates of service on or after January 1, 2007, through Austin, TX 78720-0735
July 14, 2007, claims submitted for alglucosidase alfa Fax: 1-512-514-4212
(Myozyme) must include procedure code 1-J3490
and medical necessity documentation that contains Providers should use procedure code 1-J3490 until
laboratory evidence of acid alpha-glucosidase (GAA) procedure code 1-S0147 is implemented. A future banner
deficiency (i.e., below the laboratory-defined cut-off message will notify providers when they will be able to
value as determined by the laboratory performing the submit the new procedure code.
GAA enzyme activity assay). Tissues used for the deter-
mination of GAA deficiency include blood, muscle, or Idursulfase (Elaprase®) Added As a Benefit
skin fibroblasts.
Effective for dates of service on or after July 1, 2007,
Providers are responsible for meeting all filing deadlines. idursulfase (Elaprase) is a benefit of the Texas Medicaid
When a service becomes a benefit of the Texas Medicaid Program for the treatment of clients with Hunter
Program with a retroactively applied effective date, an syndrome (mucopolysaccharidosis II or MPS II). To be
exception to the 95-day filing deadline may be granted. considered for reimbursement, claims must be submitted
For more information about exceptions to the 95-day with procedure code C9232 and diagnosis code 2775. The
filing deadline, refer to the 2007 Texas Medicaid Provider reimbursement rate for procedure code C9232 is $470.45.
Procedures Manual, Section 5.1.3.1, “Exceptions to the
95-Day Filing Deadline,” on page 5-5. All medical Procedure code C9232 is considered for reimbursement
necessity documentation must be submitted with the when performed in the home, office, outpatient hospital,
request for the exception. and nursing home settings by the following types of
providers:
Dates of Service on or after July 15, 2007
POS Provider Type
For dates of service on or after July 15, 2007, providers
must obtain prior authorization for procedure code Office Advanced practice nurses, physicians,
1-J3490 to request reimbursement for alglucosidase federally qualified health centers (FQHC),
alfa (Myozyme). The prior authorization request must and rural health clinics (freestanding/inde-
include medical necessity documentation that contains pendent and hospital-based)
laboratory evidence of acid alpha-glucosidase (GAA) Home Advanced practice nurses and physicians
deficiency (i.e., below the laboratory-defined cut-off
value as determined by the laboratory performing the Outpatient Hospitals and rural health clinics (free-
GAA enzyme activity assay). Tissues used for the deter- hospital standing/independent and hospital-based)
mination of GAA deficiency include blood, muscle, or Nursing Advanced practice nurses and physicians
skin fibroblasts. home



Texas Medicaid Preferred Drug List Now Available

The Texas Medicaid Preferred Drug List is now instant access to information about the drugs
covered by the Texas formulary. To register for the
available through the Epocrates® drug information service, providers should visit the Epocrates website
at www.epocrates.com/products and sign up for
system on the Epocrates website. The Texas Epocrates Rx.
Medicaid Preferred Drug List can be accessed on a

personal computer (PC) and on Palm® or pocket PC

handheld devices. The service is free and provides

September/October 2007 11 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Gynecological and Reproductive Health Services

Effective for dates of service on or after Providers are allowed to use procedure codes 1-99201,
September 1, 2007, the benefit criteria for gynecological 1-99202, 1-99203, 1-99205, 1-99211, 1-99212, 1-99213,
and reproductive health services have changed for the and 1-99215 for other family planning office or
Texas Medicaid Program. outpatient visits. To receive reimbursement as family
planning services, providers must submit the appropriate
Intrauterine Device (IUD) Insertion and procedure code with the FP modifier and family
Removal planning diagnosis. The procedure codes are allowed
for routine contraceptive surveillance, family planning
Procedure code 2-58300 must be submitted with either counseling and education, contraceptive problems,
procedure code 1-J7300 or 1-J7302 for both the insertion suspicion of pregnancy, genitourinary infections, and
and the device to be considered for reimbursement. evaluation of other reproductive system symptoms.
Procedure code 2-58300 may be considered for reim-
bursement when submitted with the same date of service During any visit for a medical problem or follow-up visit,
as an office visit. Procedure code 2-58301 will not be the following must occur:
considered for reimbursement if it is submitted with the
same date of service as an office visit. • An update of the client’s relevant history
Procedure code 2-11976 must be submitted for the • A physical exam, if indicated
removal of implantable contraceptive with diagnosis code • Laboratory tests, if indicated
V2543 to be considered for reimbursement. • Treatment or referral, if indicated
Reimbursement rates for procedure codes 2-58300 • Education/counseling or referral, if indicated
and 2-58301 will be available on the TMHP website • Scheduling of office or clinic visit, if indicated
at www.tmhp.com, by August 20, 2007, and will be Any other evaluation and management office visit will
effective for dates of service on or after September 1,
2007. A future banner message will inform providers not be considered for reimbursement if it is
that the rates are ready for review. submitted with the same date of service
by the same provider as the family
Annual Family Planning Examinations planning annual exam or any other
family planning office visit. Providers
The following limitations have been applied to may appeal denied claims using
annual family planning services: modifier 25 to indicate that the
• For the annual family planning exam, providers additional visit was for a procedure
that was separate and distinct
must submit procedure codes 1-99204 and from the family planning visit.
1-99214 with the FP modifier and diagnosis code Documentation that supports
V2509. the provision of a significant,
• Procedure codes 1-99204 and 1-99214 are limited to separately identifiable
one service per fiscal year if they are submitted with evaluation and management
the FP modifier. service must be maintained
The family planning annual examination (procedure in the client’s medical
codes 1-99204 and 1-99214) must include the record and made available
following: to the Texas Medicaid
• A comprehensive health history and Program upon request. Refer
physical examination, including to the 2007 Texas Medicaid
medical laboratory evaluations as Provider Procedures Manual,
indicated Section 20, “Family Planning” for
• An assessment of the client’s information related to the Family
problems Planning Program.

Texas Medicaid Bulletin, No. 208 12 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Vaginitis Assays Hospital-based rural health clinic providers may be
reimbursed for the following procedure codes:
Vaginitis assay procedure codes 5-87480, 5-87510,
5-87660, and 5-87800 have been included in the • Procedure codes 2/8-11976 and 2/8-58500 in the
gynecological and reproductive health services benefit inpatient hospital and outpatient hospital settings
criteria. The following changes have been implemented
for procedure codes 5-87480, 5-87510, 5-87660, and • Procedure codes 2/F-58300 and 2/F-58301 in the
5-87800: office, inpatient hospital, and outpatient hospital
settings
• If more than one of procedure codes 5-87480, 5-87510,
5-87660, or 5-87800 is submitted by the same Freestanding/independent and hospital-based
provider for the same client with the same date of ambulatory surgical center providers may be reimbursed
service, all of the procedure codes will be denied. for the following ambulatory surgical center procedure
codes in the outpatient hospital setting:
• Optometrists and podiatrists will no longer be
reimbursed for procedure codes 5-87480, 5-87510, Procedure Codes F-58291 F-58292 F-58293
5-87660, and 5-87800. F-58553 F-58554
F-51925 F-58290
• Procedure codes 5-87480, 5-87510, 5-87660, 5-87797, F-58294 F-58552
and 5-87800 are no longer payable in the inpatient
hospital setting. Gynecological Procedures: Office

• A single test may be submitted for reimbursement Gynecological and reproductive health services benefit
using the appropriate procedure code (5-87480, criteria now include the following office visit procedure
5-87510, or 5-87660) that describes the organism codes:
being isolated. Only one procedure code (5-87480,
5-87510, 5-87660, or 5-87800) may be submitted for Procedure Codes 1-99203 1-99205
reimbursement. 1-99213 1-99215
1-99201 1-99202
Procedure code 5-87797 will be denied if it is submitted 1-99211 1-99212
for the same date of service as procedure code 5-87800.
Providers are reminded to code to the highest level of During any visit or follow-up visit for a medical problem,
specificity with a diagnosis to support medical necessity the following must occur:
when submitting procedure code 5-87797. Claims may be
subject to retrospective review if they are submitted with • An update of the client’s relevant history
diagnosis codes that do not support medical necessity. • A physical exam, if indicated
• Laboratory tests, if indicated
Surgery for Masculinized Females • Treatment or referral, if indicated
• Education/counseling or referral, if indicated
Diagnosis code 7527 has been added as a payable • Scheduling of office or clinic visit, if indicated
diagnosis for procedure codes 2/8-57335 and 2/8-56805 Preventative counseling services that use procedure codes
for the Texas Medicaid and Medicaid Managed Care 1-99401, 1-99402, 1-99403, 1-99404, and 1-99429 are
Programs. no longer benefits of the Texas Medicaid Program.

Gynecological Procedures: Anesthesia/Surgery If procedure code 2-59200 is submitted for laminaria
Services insertion, it is now payable when submitted on the
same day as the surgery procedure code.
The following procedure codes will be denied if they are
billed as anesthesia services: Procedure code 1-S4993 is only payable to federally
Procedure Codes qualified health centers (FQHCs) and family planning
7-51597 7-51925 7-58150 7-58180 7-58200 clinics. This service is no longer payable to the County
7-58210 7-58240 7-58260 7-58267 7-58270 Indigent Health Care Program (CIHCP), advanced
7-58275 7-58280 7-58285 7-58301 7-59135 practice nurses, physicians, podiatrists, registered nurse/

Providers should refer to the appropriate anesthesia
Current Procedural Terminology (CPT) codes when
billing anesthesia services for gynecological procedures.

September/October 2007 13 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

nurse midwives, and maternity service clinics in the Procedure Codes 2-58520 2-58540 2-58541
office and outpatient hospital settings. 2-58544 2-58545 2-58546
Procedure code 2-58340 is no longer restricted to 2-58400 2-58410 2-58552 2-58553 2-58554
diagnosis code V252. 2-58542 2-58543 2-58559 2-58560 2-58561
Pelvic examination under anesthesia (procedure code 2-58548 2-58550 2-58565 2-58578 2-58579
2-57410) is considered part of another gynecological 2-58555 2-58558 2-58611 2-58615 2-58660
surgery performed on the same day. If the examination 2-58562 2-58563 2-58670 2-58671 2-58672
is performed as an independent procedure or at the time 2-58600 2-58605 2-58700 2-58720 2-58740
of a non-gynecological surgery, the procedure will be 2-58661 2-58662 2-58760 2-58770 2-58800
considered for reimbursement. Pelvic examination under 2-58673 2-58679 2-58822 2-58823 2-58825
anesthesia is denied if it is submitted with any of the 2-58750 2-58752 2-58925 2-58940 2-58943
following procedure codes for gynecological procedures 2-58805 2-58820 2-58952 2-58953 2-58954
performed by the same provider on the same date of 2-58900 2-58920 2-58970 2-58974 2-58976
service: 2-58950 2-58951
2-58956 2-58960
Procedure Codes 2-56420 2-56440 2-56441 2-58999
2-56605 2-56606 2-56620
2-51597 2-56405 2-56631 2-56632 2-56633 Procedure code 4/I/T-74740 is considered for reim-
2-56501 2-56515 2-56640 2-56700 2-56720 bursement if it is submitted with sterilization diagnosis
2-56625 2-56630 2-56805 2-56810 2-56820 code V252 for the following types of service under the
2-56634 2-56637 2-57010 2-57020 2-57022 following conditions:
2-56740 2-56800 2-57065 2-57100 2-57105
2-56821 2-57000 2-57109 2-57110 2-57111 Type of Place of Service Provider Types
2-57023 2-57061 2-57130 2-57135 2-57150 Service
2-57106 2-57107 2-57170 2-57180 2-57200 4 Office CIHCP providers,
2-57112 2-57120 2-57230 2-57240 2-57250 physicians,
2-57155 2-57160 2-57267 2-57268 2-57270 Outpatient hospital-based rural
2-57210 2-57220 2-57283 2-57284 2-57287 hospital health clinics
2-57260 2-57265 2-57291 2-57292 2-57295 I Office, inpatient Hospitals, hospital-based
2-57280 2-57282 2-57307 2-57308 2-57310 hospital, rural health clinics
2-57288 2-57289 2-57330 2-57335 2-57400 outpatient CIHCP providers,
2-57300 2-57305 2-57420 2-57421 2-57425 hospital physicians
2-57311 2-57320 2-57455 2-57456 2-57460 T Office
2-57410 2-57415 2-57505 2-57510 2-57511 CIHCP providers,
2-57452 2-57454 2-57522 2-57530 2-57531 Independent lab physicians
2-57461 2-57500 2-57550 2-57555 2-57556 Portable X-ray supplier/
2-57513 2-57520 2-57800 2-57820 2-58100 radiological lab/
2-57540 2-57545 2-58140 2-58145 2-58146 physiological lab
2-57700 2-57720 2-58180 2-58200 2-58210
2-58110 2-58120 2-58262 2-58263 2-58267 Procedure codes 2/F-58541, 2/F-58542, 2/F-58543,
2-58150 2-58152 2-58280 2-58285 2-58290 2/F-58544, 2/F-58548, 2/F-58957, and 2/F-58958 are
2-58240 2-58260 2-58293 2-58294 2-58300 now benefits of the Texas Medicaid Program.
2-58270 2-58275 2-58322 2-58323 2-58340 Providers must use procedure code 9-L8699 with the
2-58291 2-58292 2-58350 2-58353 2-58356 UD modifier when seeking reimbursement for the
2-58301 2-58321 Essure device. Procedure code 5-87660 is now payable
2-58345 2-58346 for CIHCP in the office, outpatient hospital, and
independent laboratory settings.

Texas Medicaid Bulletin, No. 208 14 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

TMHP Standardized MRAN Colorectal Cancer Screening
Templates Update Benefits Are Changing

The following is an update to a bulletin article that Effective for dates of service on or after
was published in the 2007 National Provider Identifier September 1, 2007, procedure codes 2/F-G0104,
(NPI) Special Bulletin, No. 205, entitled “New TMHP 2/F-G0105, 4/I/T-G0106, 4/I/T-G0120, and 2-G0121
Standardized MRAN Format Templates Available Now,” are benefits of the Texas Medicaid Program if they are
located on page 9. The article did not include the PC-Print submitted with diagnosis code V1272.
Medicare Remittance Advice Notice (MRAN) as an In addition, procedure codes 2/F-G0104 and
acceptable MRAN for institutional paper crossover claims, 4/I/T-G0106 are no longer benefits of the Texas
or information regarding submission of multiple MRANs. Medicaid Program if they are submitted with the
Effective July 30, 2007, all paper Medicare crossover following diagnosis codes:
claims must be submitted to TMHP on the new TMHP
Standardized MRAN Forms or an MRAN that is Diagnosis Codes 5552 5559 5560
printed from Medicare Remit Easy Print (MREP) 5563 5568 5569
(professional services) or PC-Print (institutional services) 5550 5551 V1006 V160 V1851
and must include a completed claim form. The print 5561 5562
format for the MRAN printed from MREP or PC-Print 5589 V1005
must be either “All Claims” (with one claim circled for
each submission) or “Single Claim.” 
Providers that submit paper crossover claims must submit
only one of the three approved MRAN formats—the Cochlear Implants Are a Benefit
new TMHP Standardized MRAN Forms, MREP,
or PC-Print. Paper crossover claims that contain Cochlear implants are benefits of the Texas Medicaid
multiple MRAN forms (e.g., TMHP Standardized and the Children with Special Health Care Needs
MRAN Forms and any other MRAN) with conflicting (CSHCN) Services Programs. To be considered for reim-
information will not be processed and will be returned to bursement, claims must be submitted in the following
the provider. manner:
The new TMHP Standardized MRAN Forms must • Hospitals, medical suppliers (DME), and medical
be typed or computer-generated. Handwritten TMHP
Standardized MRAN Forms will not be accepted and supply companies must submit procedure code 9-L8614.
will be returned to the provider. Additional information • Ambulatory surgical centers (both freestanding and
about MRANs printed from MREP or PC-Print is
available on the CMS website at www.cms.hhs.gov. hospital-based) must submit procedure code J-L8614
The TMHP Standardized MRAN Forms and with modifier NU.
instructions are available on the TMHP website at Claims may be subject to retrospective review. Refer to
www.tmhp.com and on pages 29 through 34 of this the 2007 Texas Medicaid Provider Procedures Manual,
bulletin. Section 36.4.8, “Cochlear Implants,” on page 36-33
for additional information about the Texas Medicaid
Program’s benefit criteria for cochlear implants.

Modifier 26 Submission Correction

This is a correction to a banner message that first TMHP has determined that these procedure codes
appeared on the March 23, 2007, R&S report. may be submitted without modifier 26 as originally
The banner stated that claims for procedure codes stated in the 2007 Texas Medicaid Provider Procedures
I-93014, I-93018, I-93227, I-93233, I-93237, and Manual, Section 5.2.5.3, “Interpretations,” located on
I-93722 should be submitted with modifier 26. page 5-11.

September/October 2007 15 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

New Integrated Care Management Program

A new non-capitated managed care program, Integrated Services (CLASS), Home and Community Services (HCS),
Care Management (ICM), will be available in the Dallas and Medically Dependent Children’s Program (MDCP)
and Tarrant Service Areas in the near future. The Dallas waiver programs. In addition, persons in institutional
Service Area consists of Collin, Dallas, Ellis, Hunt, settings, including residents of a nursing facility or inter-
Kaufman, Navarro, and Rockwall counties. The Tarrant mediate care facility for the mentally retarded (ICF-MR),
Service Area consists of Denton, Hood, Johnson, Parker, are also excluded from participation in the ICM program.
Tarrant, and Wise counties. The ICM program will
implement 90 days after HHSC receives federal approval Medicare enrollment does not affect eligibility for ICM.
of the 1915(b) and 1915(c) waivers. For ICM clients who are dual-eligible (enrolled in both
Medicaid and Medicare), ICM is only responsible for
Client Eligibility long-term services and supports. Primary acute care and
pharmacy services for this population are covered through
Eligible adult Texas Medicaid Program clients, Medicare. Enrollment in ICM will not change the way
including those who qualify for Medicaid based on SSI a client receives Medicare services. Clients mandated to
eligibility or who qualify for 1915(c) waiver services (the participate and those who are eligible to participate in
Community-based Alternatives Program [CBA]) will ICM will be notified about the availability of the program
automatically be enrolled in ICM. Children younger in their area.
than 21 years of age who receive SSI can participate on a
voluntary basis. Summary of Benefits
Persons enrolled in a 1915(c) Medicaid waiver program
other than the CBA program are excluded from partici- ICM-enrolled clients may receive the same acute care
pation in the ICM program. This includes individuals services that are payable under the traditional Medicaid fee-
enrolled in Community Living Assistance and Support for-service plan and the Primary Care Case Management
(PCCM) plan, including:

• Ambulance and emergency services
• Audiology services (clients 21 years of age and older)
• Behavioral health services (for clients in the Tarrant

Service Area only) including detoxification services and
psychiatry services, and counseling services for adults
only
• Dialysis
• Durable medical equipment (DME) and supplies
• Inpatient and outpatient hospital services, including
laboratory, radiology, imaging, and X-ray services
• Physical, occupational, and speech therapies
• Optometry, glasses, and contact lenses
Additional acute care services for clients younger than
21 years of age include:

• Inpatient and outpatient mental health services (Tarrant
Service Area only)

• Outpatient chemical dependency services (Tarrant
Service Area only)

• Medical check ups and Comprehensive Care Program
(CCP) services for children through the Texas Health
Steps (THSteps) Program

Texas Medicaid Bulletin, No. 208 16 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

ICM clients are provided with two enhanced benefits: Limitations
waiver of the three-prescription per month limit for
Medicaid-only clients, and inclusion of an annual adult The customary Texas Texas Medicaid Program fee-for-
well-check for clients 21 years of age and older. service 30-day spell-of-illness limitation on hospitaliza-
Long term services and supports (LTSS) for ICM clients tion applies to ICM clients.
include the following:
• Traditional Medicaid community-based long term care Only ICM clients who meet the nursing facility level of
care are eligible for 1915(c) CBA waiver services.
(LTC) services
º Primary Home Care (PHC), for clients 21 years ICM clients are eligible to receive certain services from
of age and older, providing assistance with the any applicable Texas Medicaid Program provider without
performance of activities of daily living and authorization from the ICM Contractor. These services
household chores. Effective September 1, 2007, include, but are not limited to, the following:
all clients younger than 21 years of age who are
eligible to participate in the Early and Periodic • THSteps Dental, including orthodontia
Screening, Diagnosis, and Treatment (EPSDT) • Early Childhood Intervention (ECI) Program
Program may be eligible to receive personal care • Mental Health and Mental Retardation (MHMR)
services (PCS). For more information providers
can refer to the Personal Care Services (PCS) targeted case management and mental health rehabili-
Special Bulletin, No. 207. tation
º Day activity and health services (DAHS), • Case Management for Children and Pregnant Women
including nursing and personal care services, (CPW)
physical rehabilitative services, nutrition, and • Texas School Health and Related Services (SHARS)
transportation services. These services are • Texas Commission for the Blind case management
provided by facilities licensed by the Texas • Texas Department of Transportation Medical
Department of Aging and Disability Services Transportation Program (MTP)
(DADS) • Hospice services (all clients except 1915(c) CBA waiver
clients are disenrolled from the ICM Program upon
• CBA Waiver Services for those clients who meet CBA enrollment into hospice)
Waiver eligibility requirements. These services include: • Audiology services and hearing aids for children
º Adaptive aids, medical equipment, and medical younger than 21 years of age through the Program for
supplies Amplification for Children of Texas (PACT)
º Adult foster care • Long-term support and services (LTSS) available
º Assisted living services through DADS
º Emergency response services
º Home-delivered meals Prior Authorization
º In-home skilled nursing care
º Minor home modifications Evercare of Texas, LLC, is responsible for prior authoriza-
º Personal assistant services tion of ICM services. Prior authorization is required for
º Occupational, physical, and speech therapy the same services that currently require prior authoriza-
º Transitional assistance services tion in the Medicaid fee-for-service and PCCM services,
including, but not limited to:
ICM clients who reside in the Dallas Service Area will
continue to receive their behavioral health services from • Emergency and inpatient acute care services
NorthSTAR. Clients who reside in the Tarrant Service • Ambulatory/outpatient services
Area will receive their behavioral health services through • Out-of-network services
the ICM Provider Network. • Durable medical equipment and supplies
Prescription drugs for ICM clients will continue to be • Nutritional products
provided through the HHSC Vendor Drug Program. • Diabetes monitoring supplies
• Cochlear implant

September/October 2007 17 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

• Dental services Stereotactic Radiosurgery
• Outpatient behavioral health over 30 visits per year
Providers may begin to submit requests for prior autho- TMHP has identified a necessary correction to the
rization from Evercare 30 days before the implementa- 2007 Texas Medicaid Provider Procedures Manual,
tion of ICM. To submit a prior authorization request call Section 39.3.11, “Stereotactic Radiosurgery,” on
1-800-349-0550 or fax 1-866-785-1649. page 39-11. Section 39.3.11 includes limitations
that are not accurate for stereotactic radiosur-
Claims Processing gery procedure codes 6/I/T-G0338, T-G0339,
and T-G0340. As published in the November/
Claims submitted for acute care services will be processed by December 2005 Texas Medicaid Bulletin, No. 191,
TMHP. If a claim is denied because of missing or unmatched effective for dates of service on or after August 10,
authorization, the authorization correction should be 2005, TMHP implemented procedure code
coordinated with Evercare. After the updated authorization T-G0339 (allowable fee $1,150.23) and procedure
has been submitted by Evercare to TMHP, the provider may code T-G0340 (allowable fee $821.25) as benefits
appeal the claim. Claims for long-term services and supports of the Texas Medicaid Program.
will be processed by DADS. Procedure code 6/I/T-G0338 was discon-
Specialists may bill for health-care services provided to ICM tinued effective January 1, 2006, and is no
clients if the referral was made by the client’s primary care longer a benefit of the Texas Medicaid Program.
provider. To indicate a referral from the client’s primary care Following is the corrected section 39.3.11:
provider, the name and provider identifier of the primary
care provider must be included on the claim form. A referral 39.3.11 Stereotactic Radiosurgery
is not required if a specialist is providing a service that
does not require a referral from a primary care provider. Stereotactic radiosurgery is a system used to verify
Additional information is available in the 2007 Texas tumor location with precise mapping using live
Medicaid Provider Procedures Manual, Section 7, “Managed radiographic images throughout the procedure. The
Care,” on page 7-1. linear accelerator attached to a robotic arm delivers
multiple, highly focused radiation beams. This
Provider Enrollment high dose radiation can treat multiple sites in one
treatment session. A multidisciplinary team that
Providers must complete a separate enrollment to participate consists of a neurosurgeon, a radiation oncologist,
in the ICM Program. All acute care providers must be and a radiation physicist provides treatment with the
enrolled as Texas Medicaid Program providers and have patient as the central focus. Procedure codes 77371,
an NPI. Physicians or hospital representatives interested 77372, 77373, and 77435 may be used to submit
in receiving an Evercare ICM contract and credentialing claims for stereotactic radiosurgery.
application can contact an Evercare representative at
1-866-574-6088. Texas Medicaid Program LTSS providers
interested in receiving an Evercare ICM contract and creden-
tialing application can contact an Evercare representative at
1-972-866-1696.

Neonatal and Pediatric Critical Care Services

If a hospital discharge procedure code (1-99238 Refer to the May/
or 1-99239) is submitted for reimbursement with June 2007 Texas
the same date of service as an inpatient neonatal Medicaid Bulletin,
critical care procedure code (1-99295 or 1-99296) No. 204, pages 12 and 18 for the Texas Medicaid
or a pediatric critical care procedure code (1-99293 newborn services and hospital critical care visits
or 1-99294), the hospital discharge procedure code benefit criteria changes effective for dates of service
is denied and the critical care procedure code is on or after April, 1, 2007.
considered for reimbursement.

Texas Medicaid Bulletin, No. 208 18 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers/Behavioral Health Providers

New Automated Provider BEHAVIORAL HEALTH PROVIDERS
Licensure Information System
Reprocessing of Claims for Clients
Effective August 31, 2007, a new automated system Residing in an IMD Facility
for handling provider licensure information was
implemented. TMHP now receives licensure information TMHP has identified an issue with Medicare crossover
from the following Texas state boards: claims for professional services that were submitted for
clients who are between 21 and 64 years of age and who
• Texas Medical Board (TMB) are residing in an institute for mental disease (IMD)
• Board of Dental Examiners (BDE) facility. Claims may have been paid in error.
• Board of Nurse Examiners (BNE) Professional services received while a client resides in an
• Examiners of Professional Counselors (EPC) IMD facility must be provided and paid for by the IMD
• Social Worker Examiners (SWE) facility. The reimbursement rate for IMD facilities is all-
A reminder is automatically generated to providers inclusive.
with licenses expiring in 60 days with instructions to Effective July 30, 2007, TMHP began reprocessing
contact the licensing board regarding the renewal of their claims for professional services that were submitted for
licenses. When the license is renewed, the provider will dates of service on or after January 1, 2007, for clients
not need to contact TMHP with renewal information. who are between 21 and 64 years of age and who are
residing in an IMD facility. Payment will be adjusted
If a provider’s license is expired, has been suspended or accordingly and will be reflected on Remittance and
revoked, or is inactive, a termination letter will be sent Status (R&S) reports. No action on the part of the
to the provider, and all claims filed on and after the provider is necessary.
expiration date will be denied.

Mandatory Third-Party
Biller Testing for NPI

Third-party software vendors and clearing-
houses will be required to complete NPI
testing before the NPI contingency period
ends in early 2008.
Providers who use a third-party biller to
submit electronic transactions to TMHP will
need to ensure that their vendor or clearing-
house is signed up for testing with TMHP.
A third-party biller is defined as persons,
businesses, or entities (excluding state
agencies) that submit claims on behalf of
a provider, but are not the provider or an
employee of the provider.
Note: TexMedConnect or TDHconnect users do
not need to test.
For additional information regarding NPI
third-party biller testing, refer to the TMHP
website at www.tmhp.com.

September/October 2007 19 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

Managed Care Providers/PCCM Providers

MANAGED CARE PROVIDERS PCCM PROVIDERS

Freestanding Psychiatric Facilities Payment Process for the
and Behavioral Health Claims Billed DRG

Effective for dates of service on or after June 1, 2007, The following is a clarification of the payment
freestanding psychiatric facility and behavioral health process for the billed diagnosis-related group
claims submitted for clients who are enrolled in a (DRG) in the 2007 Texas Medicaid Provider
STAR+PLUS plan in the Harris County and Harris Procedures Manuals, Section 7.5.14.3, “Facility
County Contiguous Service Areas will be processed by /Hospital Services,” on page 7-35.
the STAR+PLUS health maintenance organizations If the DRG submitted on a claim does not
(HMOs) Amerigroup Community Care, Evercare of match the DRG on the authorization, one of the
Texas, and Molina Community Plus. TMHP will deny following will occur:
claims submitted with dates of service on or after June 1, • If the lesser of the two DRGs can be derived,
2007. Providers must file these types of claims with the
appropriate HMO. the claim will be paid at the lower amount.
• If the lesser of the two DRGs cannot be derived,
Reminder for STAR+PLUS Dual
Eligible Clients the claim will be denied.
Claims are adjudicated based on the authoriza-
Many STAR+PLUS clients are eligible for both tion that was completed at the time of the claim
Medicaid and Medicare. STAR+PLUS health submission. To avoid a DRG mismatch and the
maintenance organizations (HMOs) are not at risk denial of the claim when there is a change to
for the delivery of acute care services needed by these an existing authorization (e.g., a change to the
clients. Most STAR+PLUS clients with Medicare and discharge date, diagnosis, DRG, or procedure),
Medicaid are Medicaid Qualified Medicare Beneficiaries the facility is required to submit an updated
(MQMBs). Primary Care Case Management (PCCM)
Clients enrolled in STAR+PLUS and Medicare choose a Inpatient/Outpatient Authorization Form
Medicaid HMO but do not choose a Medicaid primary before the claim is submitted. The form can be
care provider. These clients receive Medicare benefits submitted either by fax to 1-512-302-5039 or
through a Medicare Risk Product (HMO) or Medicare by contacting the Inpatient Prior Authorization
fee-for-service insurance program. Department at 1-888-302-6167.
To reduce confusion, HHSC has mandated that clients Notification of urgent and emergent admissions
eligible for STAR+PLUS and Medicare continue to is only required before a claim is submitted.
receive all their acute care services as they do currently, Providers are encouraged to submit the notifica-
with Medicare as the primary payor and traditional tion after DRG information is complete to avoid
Medicaid, through TMHP, as the secondary payor. updating the DRG because of a DRG mismatch
Providers must continue billing Medicare acute care and a change to the admitting diagnosis.
services through the client’s Medicare HMO or fee- If the services rendered are different or more
for-service insurer and must follow the rules of the complex than the ones that were authorized,
Medicare insurer. If the client is in both a Medicare and providers should update the authorization before
Medicaid HMO, the client uses the Medicare primary the claim is submitted.
care provider, and providers follow the Medicare HMO’s For non-DRG facilities, the claim will pay at the
medical management rules for authorization, concurrent lower number of inpatient days when the length
review, and so forth. of stay that is billed is different from the length of
For more information refer to the 2007 Texas Medicaid stay that was authorized. If there is a change to an
Provider Procedures Manual, Section 7.3.1.4, “Dual existing authorization, providers should contact the
Eligible Clients,” on page 7-17. Inpatient Prior Authorization Department with the
update before the claim is submitted.

Texas Medicaid Bulletin, No. 208 20 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

PCCM Providers/SHARS Providers

Providers Should Verify Clients’ Medicaid ID Cards

To receive payment for claims, PCCM providers must be Primary care providers must supply their Texas
listed as the primary care provider on the Medicaid ID Provider Identifiers (TPIs) to specialists to ensure that
Form (H3087) with two exceptions: claims are processed appropriately. Claims with invalid
or missing referring provider identifiers will be denied.
• The client’s H3087 does not list any primary care The referring physician’s TPI should be in Block 17a of
provider’s name. the CMS-1500 claim form or in Blocks 78 and 79 of
the UB-04 CMS-1450 claim form. Details of the claim
• The services rendered are exempt from the referral form information can be found in the 2007 National
process. Services exempt from referrals are obstetrics/ Provider Identifier (NPI) Special Bulletin, No. 202.
gynecological (OB/GYN) services, Texas Health Steps Primary care providers may allow clients to call
(THSteps) medical and dental services, eye care, family from their offices to change primary care providers.
planning, mental health and substance abuse services, As many as ten clients can request a primary care
and 24-hour emergency room care. provider change from each call initiated at a provider’s
office. The PCCM Client Helpline number at
For all other services, the treating provider must obtain 1-888-302-6688, is available Monday through Friday,
a referral from the designated primary care provider. 7 a.m. to 7 p.m., Central Time.
Providers who are unable to obtain a referral from a client’s
primary care provider should contact the PCCM Provider
Helpline at 1-888-834-7226, Monday through Friday,
7 a.m. until 7 p.m., Central Time.

SHARS PROVIDERS

SHARS Claims Filing Deadline

School Health and Related Services (SHARS) providers must file claims for dates of service during the state fiscal year
(SFY) 2007 (September 1, 2006, through August 31, 2007) in a timely manner so that cost reporting, cost reconcilia-
tion, and cost settlement processes for those services can be completed by August 31, 2009.
All claims for dates of service during SFY 2007 must be submitted within the 365-day filing deadline or within 95 days
of the last day of SFY 2007, whichever is earlier. Claims for SFY 2007 services are due on or before December 4, 2007,

which is the 95-day filing deadline
for August 31, 2007. This will allow
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.
SHARS providers that did not
participate in the third federal fiscal
quarter (April 1, 2007, through June 30,
2007) Random Moment Time Study
(RMTS) are not eligible to bill for
services provided during that time
period. Additional information about
a provider’s eligibility to bill claims for
the fourth federal fiscal quarter (July 1,
2007, through Sept. 30, 2007) will
be provided, because there will be no
RMTS for that quarter.

September/October 2007 21 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

Excluded Providers

Excluded Providers

As required by the Medicare and Medicaid Patient Protection Act of 1987, HHSC identifies providers or employees of
providers who have been excluded from state and federal health care programs. Providers excluded from the Texas
Medicaid Program and Title XX Programs must not order or prescribe services to clients after the exclusion date.
Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be
denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been
excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client.
Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter.
Providers are liable for all fees paid to them by the Texas Medicaid Program for services rendered by excluded
individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services.
It is strongly recommended that providers conduct frequent periodic checks of HHSC’s exclusion list. The HHSC-
Sanctions Department submits updates to the exclusion list semi-monthly. Updates appear on the website after the
1st and 15th of each month. Review the entire Texas Medicaid Program exclusion list at https://oig.hhsc.state.tx.us/
Exclusions/Search.aspx.
To report Medicaid providers who engage in fraud/abuse, call 1-512-424-6519 or 1-888-752-4888, or write to the
following address:

Vicki Fischer, Director
HHSC Office of Inspector General, Medicaid Provider Integrity, MC-1361

PO Box 85200
Austin TX 78708-5200

Provider License Start Date Type City State Add Date
Number Provider
Allen-Taylor, Tiffani R 143380 13-Jun-06 Grand Prairie TX 21-Jun-07
Allison, Gloria J 221428 13-Jun-06 LVN Jacksonville FL 31-May-07
Anderson, Bruce D 121020 23-May-06 RN Fresno CA 15-May-07
Anderson, Kristina M 173056 08-Aug-06 LVN Fort Worth TX 16-May-07
Ashley, Phinis S 566268 8-Aug-06 LVN Houston TX 3-Jul-07
Bartley, Michael A H6033 15-Feb-07 RN Atlanta GA 21-Jun-07
Bayne, Cathern V 593557 08-Aug-06 MD Amarillo TX 07-Jun-07
Benjamin, Mary L 460531 13-Jun-06 RN Pompano Beach FL 16-Jul-07
Blais, Rocklin A 579165 13-Jun-06 RN Canada S71 2W1 16-May-07
Bonck, Angela K 531617 08-Aug-06 RN Eunice LA 07-Jun-07
Bryant, Alicia F 159854 13-Jun-06 RN Wylie TX 31-May-07
Casey, Elisheba M 710234 29-Aug-06 LVN Brownsville TX 16-May-07
Chandler, Susan S 132610 13-Jun-06 RN Nashville AR 16-May-07
Chavez, Armando J8487 16-May-07 LVN Houston TX 17-Jul-07
Chernivec, Keri L 683802 13-Jun-06 MD Newport NC 16-Jul-07
Claypoole, Bonnie S 580837 29-Jun-06 RN Spring TX 16-May-07
Clingman, Tanya G 107209 08-Aug-06 RN Waco TX 07-Jun-07
Cochran, Gerald D 20-Jun-02 LVN Austin TX 17-May-07
Collins, Eddie A 196393 8-Aug-06 CDT Lafayette LA 3-Jul-07
Copeland, Shelley 639609 08-Aug-06 LVN Amarillo TX 16-May-07
Copley, Tiffany L 662131 20-Mar-06 RN Lubbock TX 17-Jul-07
RN

Texas Medicaid Bulletin, No. 208 22 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

Excluded Providers

Provider License Start Date Type City State Add Date
Number
Coyner, Ginger 629970 19-Jun-06 Provider TX 15-May-07
Crowsley, Jackie L 80644 8-Aug-06 TX 3-Jul-07
Daniels, Phillip S 554179 13-Jun-06 RN Houston TX 31-May-07
Dunagan, Jacqueline L 80681 13-Jun-06 TX 31-May-07
Etheridge, Mandy G 183147 29-Aug-06 LVN Dallas TX 16-May-07
Evans, David R D9131 16-Feb-07 TX 3-Jul-07
Farber, Steven H F8102 01-Feb-07 RN Dallas TX 21-Jun-07
Farwell, Aileen L 681973 13-Jun-06 AL 07-Jun-07
Finding My Way, Inc. 20-Jun-02 LVN Temple LA 17-May-07
Flores, Lisa A 162069 08-Aug-06 TX 16-May-07
Fox, Patrick S 156163 8-Aug-06 LVN Mt. Pleasant TX 3-Jul-07
Franklin Medical Services 20-Oct-02 TX 18-May-07
Gann, Debra A 163898 13-Jun-06 DO Plano TX 31-May-07
Gisolo, Linda M 111212 13-Jun-06 TX 07-Jun-07
Green, Freda J 15-Jun-07 MD Spring TX 11-Jul-07
Hancock, Nicole A 86680 13-Jun-06 TX 16-Jul-07
Haney, Debra L 132159 13-Jun-06 RN Birmingham TX 31-May-07
Harber, Jan E 139396 08-Aug-06 TX 16-May-07
Hargrove, Karen 620439 08-Aug-06 CDT Pollock TX 16-Jul-07
Hart, April M 185759 08-Aug-06 TX 16-Jul-07
Harvey, Paula S 657887 08-Jun-06 LVN Weslaco TX 16-Jul-07
Henry, Cynthia L 170778 08-Aug-06 TX 07-Jun-07
Hernandez, Ramiro E6093 16-May-07 LVN Houston TX 17-Jul-07
Hodnett, Sherril R 12-Jun-07 TX 12-Jun-07
Hoffman, Shelly D 141583 13-Jun-06 DME Rockwall TX 21-Jun-07
Hogan, Ansa E 33036 27-Jun-07 TX 20-Aug-06
Jimenez, Rosario G 31-May-07 LVN Houston TX 04-Jun-07
Jones, Patrick A 147688 08-Aug-06 TX 16-Jul-07
Kilpatrick, Hamilton W C3109 16-Feb-07 LVN Midland TX 16-Jul-07
Kouzbari, Melanie R 690912 13-Jun-06 TX 07-Jun-07
Lattery, Judy C 122845 8-Aug-06 owner Houston TX 3-Jul-07
Lawrence, Shanon L 140270 08-Aug-06 TX 16-May-07
Martin, Bruce W 601505 08-Aug-06 LVN Denton TX 16-Jul-07
Mays Jr, Jimmy W 139523 13-Jun-06 TX 07-Jun-07
Middleton, Julie D 608568 08-Aug-06 LVN Ingleside TX 16-May-07
Middleton, Tony A 138019 08-Aug-06 KY 16-Jul-07
Miller, Candace L 464938 13-Jun-06 RN Houston TX 31-May-07
Ming, Janet D 500229 8-Aug-06 CA 3-Jul-07
Obot, Ita John 11-Aug-06 RN Brenham TX 17-Jul-07
Partridge, Faith 146543 8-Aug-06 TX 3-Jul-07
Poole, Rex D K0543 16-Feb-07 LVN Cleburne TX 31-May-07
Priddy, Frances I 564797 08-Aug-06 LA 21-Jun-07
RN Romayor

LVN Webster

MD El Paso

Houston

LVN Graham

Pharmacist Sugarland

Pasadena

LVN Houston

MD Uvalde

RN Plano

LVN San Antonio

LVN Crane

RN League City

LVN Corpus Christi

RN Texas City

LVN Elizabeth Town

RN Kingsland

RN Citrus Heights

Beaumont

LVN El Paso

MD Marble Falls

RN Baton Rouge

September/October 2007 23 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

Excluded Providers

Provider License Start Date Type City State Add Date
Number Provider
Prough, Dorothea L 662235 11-Aug-06 RN Clanton AL 16-May-07
438804
Reed, Diana C 168697 13-Jun-06 RN Arlington TX 21-Jun-07
Reigle, Brandi O 241014 02-May-07 LVN Brownwood TX 30-May-07
Richards, Janie O 244424 08-Aug-06 RN Mesquite TX 07-Jun-07
Rieger, Susan Y 22061 31-Aug-06 RN Gladewater TX 16-May-07
Riginger, Carol A 95954 30-May-07 LVN Balch Springs TX 30-May-07
Rios, Anna M 571055 13-Jun-06 LVN Bedford TX 16-May-07
Rodriguez, Elvira A 642096 08-Aug-06 RN Alice TX 16-May-07
Roque, Alexander 08-Aug-06 RN Brady TX 21-Jun-07
Rosewood Medical Supplies F7123 15-Jul-07 DME Houston TX 11-Jul-07
Rountree, Randolph G3758 13-Apr-07 MD San Angelo TX 17-Jul-07
Salmond, Ronald 142367 14-Feb-07 MD Austin TX 31-May-07
Sanders, Julie V 152356 08-Aug-06 LVN Aledo TX 16-May-07
Schuetz, Dennise M H1845 8-Aug-06 LVN New Braunfels TX 3-Jul-07
Srungaram, Ramesh K 118873 2-Jun-06 MD Sacramento CA 3-Jul-07
Steen, Priscilla A 153884 13-Jun-06 LVN Port Lavaca TX 16-May-07
Stockton, James D 695350 13-Jun-06 LVN Abilene TX 21-Jun-07
Strain, Kerri R 518363 8-Aug-06 RN Plano TX 3-Jul-07
Thiel, Alison A 08-Aug-06 RN Chowchilla CA 31-May-07
Thompson, Broderick V 170669 20-Jun-02 CDT Pollock LA 16-May-07
Thornhill, Alison D 187420 09-Aug-06 LVN Abilene TX 31-May-07
Tucker, Sean P 088859 08-Aug-06 LVN Fort Worth TX 21-Jun-07
Ussery, Mary M F7671 13-Jun-06 LVN Kerrville TX 16-May-07
Vagefi, Ali 165185 13-Apr-07 MD Tyler TX 10-Jul-07
Vaught, Cedia D 194165 08-Aug-06 LVN Rusk TX 07-Jun-07
Vela, Cecely T 13-Jun-06 LVN Temple TX 16-Jul-07
Williams, Kathryn L H5995 20-May-07 LVN Copperas Cove TX 30-May-07
Williams, Michael L 171437 10-Jan-07 MD Dallas TX 16-Jul-07
Williams, Robin E G8516 01-Aug-06 LVN Vernon TX 16-May-07
Womack, James Chanslor 25-Aug-06 MD New Braunfels TX 16-Jul-07



Texas Medicaid Bulletin, No. 208 24 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Provider Information Change Form

Traditional Medicaid, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case
Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of
the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom
of the page.

Check the box to indicate a PCCM Provider � Date:
9-digit Texas Provider Identifier (TPI): Provider Name:

National Provider Identifier (NPI)/ Primary Taxonomy Benefit
Atypical Provider Identifier (API): Code: Code:

List any additional TPIs that use the same provider information:

TPI:______________________ TPI:______________________ TPI:______________________
TPI:______________________ TPI:______________________ TPI:______________________

Physical Address* Accounting/Mailing Address** Secondary Address

City: ZIP: City: ZIP: City: ZIP:
State: State: State:
Phone: ( ) Phone: ( ) Phone: ( )
Fax: Fax: Fax:
Email: Email: Email:

Type of Change: (Check the appropriate box below.)

� Change of physical address, telephone, and/or fax number
� Change of billing/mailing address, telephone, and/or fax number
� Change/Add secondary address, telephone, and/or fax number
� Change of provider status (e.g., termination from plan, moved out of area, specialist)

Explain in the Comments field
� Other (e.g., panel closing, capacity changes, and age acceptance)
Comments:

Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Tax ID Number: Effective Date:

Exact name reported to the IRS for this Tax ID:

The signature and date are required or the form will not be processed.

Provider Signature: Date:

Mail or fax the Texas Medicaid & Healthcare Partnership (TMHP) Fax: 1-512-514-4214
completed form to: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795

* The physical address cannot be a PO Box. Traditional Medicaid providers who change their ZIP code must submit a copy of the Medicare
letter along with this form.

** All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

Effective Date_07302007/Revised Date 07172007

September/October 2007 25 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Instructions for Completing the
Provider Information Change Form

Signatures:

• The provider’s signature is required on the Provider Information Change Form for any and all
changes requested for individual provider numbers.

• A signature by the authorized representative of a group or facility is acceptable for requested
changes to group or facility provider numbers.

Address:

• Performing providers (physicians performing services within a group) may not change
accounting information.

• For Traditional Medicaid, changes to the accounting or mailing address require a copy of the
W9 form.

• For Traditional Medicaid, a change in ZIP code requires copy of the Medicare letter.

Tax Identification Number (TIN):

• TIN changes for individual practitioner provider numbers can only be made by the individual to
whom the number is assigned.

• Performing providers cannot change the TIN.

General:

• TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider
Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, and benefit code (if
applicable) in order to process the change. Forms will be returned if this information is not
indicated on the Provider Information Change Form.

• The W-9 form is required for all name and TIN changes.
• Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP)
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Fax: 1-512-514-4214

Texas Medicaid Bulletin, No. 208 26 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Electronic Funds Transfer (EFT) Authorization Agreement

Enter ONE Texas Provider Identifier (TPI) per Form

NOTE: Complete all sections below and attach a voided check or a photocopy of your deposit slip.

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

Provider Accounting Address Provider Phone Number ext.
Bank Name ()

ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one)

Checking Savings

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the
bank account referenced above and the depository named above to credit the same to such account. I
(we) understand that I (we) am responsible for the validity of the information on this form. If the company
erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary
debit entries, not to exceed the total of the original amount credited for the current pay period.
I (we) agree to comply with all certification requirements of the applicable program regulations, rules,
handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services
Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from
federal and state funds, and that any falsification or concealment of a material fact may be prosecuted
under federal and state laws.
I (we) will continue to maintain the confidentiality of records and other information relating to clients in
accordance with applicable state and federal laws, rules, and regulations.

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to:
Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment
PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use Input Date:
Input By:

September/October 2007 27 Texas Medicaid Bulletin, No. 208

CPT only cop—yrighAt 2S00T7AATmEericManEMDedIicCalAAsIsoDciaCtioOn.NAlTl rRighAtsCreTseOrveRd. 23

Forms

Electronic Funds Transfer (EFT) Information

Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims
approved for payment directly into a provider’s bank account. These funds can be
credited to either checking or savings accounts, provided the bank selected accepts
Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with
mailing and handling paper checks, ensuring funds are directly deposited into a
specified account.

The following items are specific to EFT:
Pre–notification to your bank takes place on the cycle following the application
processing.
Future deposits are received electronically after pre–notification.
The Remittance and Status (R&S) report furnishes the details of individual credits
made to the provider’s account during the weekly cycle.
Specific deposits and associated R&S reports are cross–referenced by both Texas
Provider Identifier (TPI) and R&S number.
EFT funds are released by TMHP to depository financial institutions each Friday.
The availability of R&S reports is unaffected by EFT and they continue to arrive in
the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

Most receiving depository financial institutions receive credit entries on the day before the
effective date, and these funds are routinely made available to their depositors as of the
opening of business on the effective date. Please contact your financial institution regarding
posting time if funds are not available on the release date.
However, due to geographic factors, some receiving depository financial institutions do not
receive their credit entries until the morning of the effective day and the internal records of
these financial institutions will not be updated. As a result, tellers, bookkeepers, or
automated teller machines (ATMs) may not be aware of the deposit and the customer’s
withdrawal request may be refused. When this occurs, the customer or company should
discuss the situation with the ACH coordinator of their institution who, in turn should work
out the best way to serve their customer’s needs.
In all cases, credits received should be posted to the customer’s account on the effective
date and thus be made available to cover checks or debits that are presented for payment
on the effective date.

To enroll in the EFT program, complete the attached Electronic Funds Transfer
Authorization Agreement. You must return a voided check or deposit slip with the
agreement to the TMHP address indicated on the form.

Call the TMHP Contact Center at 1–800–925–9126 for assistance.

Texas Medicaid Bulletin, No. 208 28 September/October 2007

— A STATE MEDICAID CONTRACTOR CPT only copyright 2007 American Medical Association. All rights reserved.

23

September/October 2007 Revised Crossover Claim Type 30
TMHP Standardized Medicare Remittance Advice Notice Format
CPT only copyright 2007 American Medical Association. All rights reserved.
1 NPI/API

2 Medicare ID

3 TPI

4 Provider Name

5 Medicaid Client
Number

6 Client Last Name

7 Client First Name

8 Medicare Paid Date

9 Medicare ICN

10 Patient HIC Number

11 Detail(s) Information From DOS To DOS POS Units CPT Mods Charges Allow Ded Coins Paid Reason
Code

29

Texas Medicaid Bulletin, No. 208 12 Totals Information Charges Allow Ded Coins Paid Reason
13 Medicare Prev Paid Code

Effective 03192007 - Revised 05312007 Save As Forms

Forms

Crossover Claim Type 30 Instructions

Providers who bill professional services on the CMS-1500 paper claim form must submit the
Crossover Claim Type 30 template with a copy of a completed claim form. All fields (excluding
Medicaid information fields) on the form must be completed using the Remittance Advice (RA)
or Remittance Notice (RN) that was received from Medicare. In addition, all details from the
Medicare RA/RN must be included in the template, regardless of whether a deductible or
coinsurance is due.

The following are the requirements for the Crossover Claim Type 30 template:

Block Field Description Guidelines
No.
1 NPI/API Enter the National Provider Identifier (NPI) for the billing
2 Medicare ID provider.
3 TPI
4 Provider Name Enter the Medicare Provider ID number of the billing
5 Medicaid Client provider listed on the Medicare RA/RN.

Number Enter the Medicaid Texas Provider Identifier (TPI) number
6 Client Last Name of the billing provider.
7 Client First Name
8 Medicare Paid Date Enter the billing provider’s name
9 Medicare ICN
10 Client HIC Number Enter the client’s nine-digit Medicaid number from the
Medicaid Identification form.
11 From DOS
11 To DOS Enter the client’s last name listed on the Medicare RA/RN.
11 POS
11 Units Enter the client’s first name listed on the Medicare RA/RN.
11 CPT
Enter the Medicare Paid Date listed on the Medicare
11 Mods RA/RN.

Enter the Medicare Internal Control Number (ICN) number
listed on the Medicare RA/RN.

Enter the client’s Medicare Health Insurance Claim (HIC)
number (Medicare Identification number) listed on the
Medicare RA/RN.

Enter the first date of service (DOS) for each procedure in
a MM/DD/YYYY format.

Enter the last DOS for each procedure in a MM/DD/YYYY
format

Enter the place of service (POS) listed on the Medicare
RA/RN.

Enter the number of units (quantity billed) from the
Medicare RA/RN.

Enter the appropriate Current Procedural Terminology
(CPT) procedure code for each procedure/service listed on
the Medicare RA/RN.
Note: The procedure code listed on the Standardized
MRAN template may not match the procedure code listed
on the claim form attached.

Enter the modifier (when applicable) listed on the Medicare
RA/RN for each detail.

Texas Medicaid Bulletin, No. 208 30 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Block Field Description Guidelines
No.
11 Charges Enter the Medicare charges (billed amount) listed on the
11 Allow Medicare RA/RN for each detail.
11 Ded
11 Coins Enter the Medicare allowed amount listed on the Medicare
11 Paid RA/RN for each detail.
11 Reason Code
12 Total Charges Enter the Medicare deductible amount listed on the
Medicare RA/RN for each detail.
12 Total Allow
12 Total Ded Enter the Medicare coinsurance amount listed on the
12 Total Coins Medicare RA/RN for each detail.
12 Total Paid
12 Total Reason Code Enter the Medicare paid amount listed on the Medicare
13 Medicare Prev Paid RA/RN for each detail.

Enter Medicare’s reason code listed on the Medicare
RA/RN for each detail.

Enter the Medicare total charges (billed amount) listed on
the Medicare RA/RN.
Note: A provider may attach additional template forms
(pages) as necessary. The combined total charges for all
pages should be listed on the last page. All other forms
must indicate “Continue” in this block.

Enter the Medicare total allowed amount listed on the
Medicare RA/RN.

Enter the Medicare total deductible amount listed on the
Medicare RA/RN.

Enter the Medicare total coinsurance amount listed on the
Medicare RA/RN.

Enter the Medicare total paid amount listed on the
Medicare RA/RN.

Leave this field blank.

Enter the Medicare previous paid amount listed on the
Medicare RA/RN.

September/October 2007 31 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms Crossover Claim Types 31 and 50
TMHP Standardized Medicare Remittance
Medicare Paid Date:
Provider Name: Advice Notice Format
Street Address:
City: NPI/API/TPI: Medicare ID:
State: ZIP:
Bill Type
From DOS
Through DOS
Patient Last Name
Patient First Name
Medicare HIC
Medicare ICN
Total Charges
Covered Charges
Non Covered Charges/Reason
Code
DRG Amount
Deductible
Blood Deductible
Coinsurance
Medicare Paid Amount
DRG Code

Save As

Texas Medicaid Bulletin, No. 208 Effective 03192007 - Revised 05312007

32 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Crossover Claim Types 31 and 50 Instructions

Providers that bill inpatient and outpatient crossover claims on a UB-04 CMS-1450 paper claim
form must submit the Crossover Claim Types 31 and 50 templates with a copy of a completed
claim form. All fields (excluding Medicaid information fields) on the form must be completed
using the Remittance Advice (RA) or Remittance Notice (RN) that was received from Medicare,
regardless of whether a deductible or coinsurance is due.

The following are the requirements for the Crossover Claim Types 31 and 50 templates:

Field Description Guidelines
Medicare Paid Date
Provider Name Enter the Medicare Paid Date listed on the Medicare RA/RN.
NPI/API/TPI
Enter the billing provider’s name.
Medicare ID
Enter the National Provider Identifier (NPI)/Atypical Provider Identifier
Street Address (API)/Texas Provider Identifier (TPI) for the billing provider.
City Note: NPI/TPI or API/TPI.
State Enter the Medicare Provider ID of the billing provider number listed on
ZIP the Medicare RA/RN.
Bill Type
Enter the billing provider’s street address.
From DOS
Enter the billing provider’s city.
Through DOS
Patient Last Name Enter the billing provider’s state.
Patient First Name
Medicare HIC Enter the billing provider’s ZIP code.

Medicare ICN Enter the Medicare Bill Type listed on the Medicare RA/RN.
Note: The Medicare Bill Type may not match the type of bill (TOB)
Total Charges listed on the claim form.

Covered Charges Enter the first date of service (DOS) for all procedures in a
Non Covered MM/DD/YYYY format.
Charges/Reason
Code Enter the last DOS for all procedures in a MM/DD/YYYY format.
DRG Amount
Enter the patient’s last name listed on the Medicare RA/RN.
Deductible
Enter the patient’s first name listed on the Medicare RA/RN.

Enter the patient’s Medicare Health Insurance Claim (HIC) number
(Medicare Identification number) listed on the Medicare RA/RN.

Enter the Medicare Internal Control Number (ICN) number listed on
the Medicare RA/RN.

Enter the Medicare total charges (billed amount) listed on the
Medicare RA/RN.

Enter the covered charges listed on the Medicare RA/RN.

Enter the noncovered charges listed on the Medicare RA/RN followed
by the reason code listed on the Medicare RA/RN.

Enter the diagnosis-related group (DRG) amount listed on the
Medicare RA/RN for inpatient claims, if applicable.
Note: Outpatient claims do not require a DRG amount.
Enter the Medicare deductible amount listed on the Medicare RA/RN.

September/October 2007 33 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Field Description Guidelines
Blood Deductible
Enter the blood deductible listed on the Medicare RA/RN for inpatient
Coinsurance claims, if applicable
Note: Outpatient claims do not require a blood deductible amount.
Medicare Paid Enter the Medicare coinsurance amount listed on the Medicare
Amount RA/RN.
DRG Code
Enter the Medicare paid amount listed on the Medicare RA/RN.

Enter the DRG code listed on the Medicare RA/RN for inpatient
claims, if applicable.
Note: Outpatient claims do not require a DRG code.

Texas Medicaid Bulletin, No. 208 34 September/October 2007

CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

See instructions for completing Title XIX Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. This order form cannot
be accepted beyond 90 days from the date of the physician's signature. Fax completed form to 1-512-514-4209.

Section A: Requested Durable Medical Equipment and Supplies

�This section was completed by (check one): Requesting Physician � Supplier

Client name: Client date of birth: / /

Client Medicaid number: � �Is client under 21 years of age? YES NO
Supplier name:
Supplier address:

Supplier telephone: Supplier Fax: Supplier TPI:

Supplier NPI: Supplier Taxonomy: Supplier Benefit Code:

Physician name: Physician telephone: Physician Fax:

I certify that the services being supplied under this order are consistent with the physician's determination of medical necessity and
prescription. The prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

DME/medical supplies provider representative signature: Date: / /

DME/medical supplies provider representative name (Typed or Printed):

Item HCPCS Code Description of Quantity Price Prior Beyond Custom item?1
DME/medical authorization quantity limit?1
Number
supplies required?

1 �Y �N �Y �N �Y �N
2 �Y �N �Y �N �Y �N
3 �Y �N �Y �N �Y �N
4 �Y �N �Y �N �Y �N
5 �Y �N �Y �N �Y �N

1. If “Yes,” additional documentation must be provided to support determination of medical necessity.

� Check if additional documentation is attached as outlined in the TMPPM.

�Is the DME Provider Medicare certified? YES NO � If yes, indicate Medicare number:

Section B: Diagnosis and Medical Need Information

This is a prescription for DME/supplies and must be filled out by the prescribing physician.

ICD-9 Brief Diagnosis Descriptor Requested Item Number Complete justification for determination of
from Section A2 medical necessity for requested item(s)2

(Refer to Section A, footnote 1)

__ __ __ . __ __

__ __ __ . __ __

__ __ __ . __ __

__ __ __ . __ __

2. Each item requested in Section A must have a correlating diagnosis and medical necessity justification.

Enter all Item numbers from the table in Section A that pertain to each diagnosis.

If applicable, include height/weight, wound stage/dimensions and functional/mobility status in table below.

Height Weight Wound stage/dimensions Functionality/mobility status

Note: The "Date last seen" and "Duration of need" items below must be filled in.
Date last seen by physician: / /

Duration of need for DME: ____________ month (s) Duration of need for supplies: ____________ month (s)

By signing this form, I hereby attest that the information completed in Section “A” is consistent with the determination of the client's

current medical necessity and prescription. By prescribing the identified DME and/or medical supplies, I certify the prescribed items are appropriate
and can safely be used in the client’s home when used as prescribed.

Signature and attestation of prescribing physician: Date: / /

Signature stamps and date stamps are not acceptable

Prescribing physician’s license number:

Prescribing physician’s TPI: Prescribing physician’s NPI:

� Check if all of the information in Section A was complete at the time of the prescribing provider signature

Effective Date_07302007/Revised Date_06012007

September/October 2007 35 Texas Medicaid Bulletin, No. 208

CPT only copyright 2007 American Medical Association. All rights reserved.

SEPTEMBER/OCTOBER 2007 NO. 208

Texas Medicaid
Bimonthly update to the Texas Medicaid Provider Procedures Manual

Look inside for these and other
important updates:

Page 1 Medlog Reports Accessible Through TMHP Website
Page 3 Federal Deficit Reduction Act of 2005 Requirements
Page 8 2nd Quarter 2007 HCPCS Benefit Changes
Page 9 Women’s Health Program ID Card
Page 16 New Integrated Care Management Program

ATTENTION: BUSINESS OFFICE

PLACE POSTAGE TEXAS MEDICAID & HEALTHCARE PARTNERSHIP
HERE 12357 - B RIATA TRACE PARKWAY, STE 150
AUSTIN, TX 78727

A STATE MEDICAID CONTRACTOR