7000, Medicaid Provider Enrollment

Revision 23-4; Effective Nov. 17, 2023

All grantees must enroll as Medicaid (Title XIX) providers with Texas Medicaid & Healthcare Partnership (TMHP). Grantees must complete the required Medicaid provider enrollment application forms and enter into a written provider agreement with HHSC, the single state Medicaid agency. TMHP Provider Enrollment supplies these forms.

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

 

7100, Reimbursement for HHSC Family Planning Services

Revision 23-4; Effective Nov. 17, 2023

Grantees may seek reimbursement for costs using one of the following two methods:

  • grantees may submit monthly vouchers for expenses outlined in a categorical budget approved by HHSC, as required for categorical cost reimbursement; or
  • grantees may be reimbursed for direct clinical care services using the fee-for-service reimbursement method by submitting claims to TMHP, which are then paid by HHSC.   

Grantees may designate up to 25%  of their total award on a categorical cost reimbursement basis. The remainder of their award will be paid on a fee-for-service basis. Grantees may designate up to 100% of their total award on a fee-for-services basis. Annual award determination and reallocation of funds will be based in part on those grantees that leveraged a higher percentage for direct services. 

Categorical Cost Reimbursement

The categorical portion of FPP funding is used to develop and support grantee infrastructure for the provision of family planning services. These funds may be used for support services that enhance fee-for-service client service delivery. Cost reimbursement awards may be used to fund personnel, fringe benefits, staff travel, contractual   services, equipment, supplies, other direct costs and indirect costs per state and federal requirements, and must be reasonable, allowable and already allocated. 

Costs may be assessed against any of the following categories the grantee identifies during its budget development process:

  • Personnel;
  • Fringe Benefits;
  • Travel;
  • Equipment and Supplies;
  • Contractual;
  • Other; and
  • Indirect Costs.

Note: Indirect costs are costs incurred for a common or joint purpose benefiting more than one project or cost objective of a grantee’s organization, and not readily identified with a project or cost objective. More information on indirect cost rates is available online here.

Up to 25% of funds may be disbursed to grantees through a voucher system as expenses are incurred during the grant period. Grantees must still submit vouchers monthly, even if program income equals or exceeds program expenses, or if the grant reimbursement award has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all client copays and donations. 

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

  • B-13X Form Budget Category monthly expenditures, program income and non-HHSC funding;
  • Form 4116, Authorization for Expenditures;
  • data management form Required Data Collection; and
  • supporting documentation, such as a General Ledger must be submitted monthly with each Voucher Packet .

Categorical Budget Revisions

HHSC, at its sole discretion, may approve fund transfers between categories within the approved budget workbook upon a grantee’s written request. The request must include a detailed explanation that supports the need for the fund transfer. The grantee must seek HHSC  written approval before making any fund transfers. For more information, visit the Texas Grant Management Guide. Grantees must submit a revised budget to HHSC for review any time a budget revision is made.

Fee-for-Service Reimbursement

The fee-for-service (FFS) component of FPP funding reimburses for direct medical services and supplies provided to eligible individuals. Up to 100% of funds may be reimbursed on a fee-for-service basis. Each grantee is responsible for determining a person’s eligibility for clinical services. Grantees must continue to provide services to established clients and to submit and appeal claims for client services even after the grant funding award has been met.

All grantees are required to submit claims for all direct services to TMHP, using the appropriate claim form found on the TMHP website. The Texas Medicaid Provider Procedures Manual (TMPPM) provides detailed instructions of how to complete the form, including required and optional fields. Grantees may also submit claims electronically using a modified CMS-1500 electronic claim form.

All claims or appeals must be filed within certain time frames:

  • Initial Claims Submission – Submitted within 95 days of the date of service on the claim or date of any third-party insurance explanation of benefit (EOB). If the 95th day falls on a weekend or holiday, the filing deadline is extended until the next business day.
  • Appeals – Submitted within 120 days of the date on the Remittance and Status (R&S) Report on which the claim reaches a finalized status. If the 120th day falls on a weekend or holiday, the filing deadline is extended until the next business day. If the claim is denied for late filing due to the initial submission deadline, documentation of timely filing must be submitted along with the claim appeal. Refer to the TMPPM for further information.
  • All claims and appeals must be submitted and processed within 60 days of the end of the grant period.
  • All claims and appeals must continue to be submitted even after the grant funding award has been met.

For answers to questions about claims and payment status, grantees may contact the TMHP Contact Center from 7 a.m. to 7 p.m. (CT), Monday through Friday, at 800-925-9126.

HTW Claims Pending Eligibility Determination

Grantees may provide services to people deemed eligible for FPP who have pending HTW applications. In such instances, grantees may file a claim for reimbursement any time after the person has a current FPP eligibility form on file.

Codes for Reimbursement

Reimbursement is limited to a prescribed set of procedure codes approved by HHSC. For a complete list of valid procedure codes, see Section 9000, Resources, Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program. 

Grantees may submit claims for office visits that reflect various levels of service for new and established clients. A new client is defined as one who has not received clinical services at the grantee’s clinic or clinics during the previous three years. The level of services, which determines the procedure code to be billed for that individual visit, is indicated by a combination of factors such as the complexity of the problem addressed and the time spent with the client by clinic providers.  

The American Medical Association (AMA) publishes materials related to Current Procedural Terminology (CPT) coding that includes guidance on office visit codes [Evaluation and Management Services (E/M)].
Medroxyprogesterone Acetate Injection

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

Retroactive Eligibility

Medicaid Retroactive Eligibility – Copays collected from a person who is found to be eligible retroactively for Medicaid must be refunded to the person. If a claim has been paid and later the person receives retroactive Title XIX (Medicaid) eligibility, TMHP recoups or adjusts the funds paid from FPP and processes the claim as Title XIX. An accounts receivable (A/R) is then established for the adjusted claim. Note: Grantees are responsible for refunding HHSC the amount of any FPP A/R balance that may remain at the end of a state fiscal year.

The grantee’s FPP R&S Reports reflect the retroactive Title XIX adjustment with EOB message “Recoupment is due to Title XIX retro eligibility.” Grantees can get help with reconciling R&S reports through the TMHP Contact Center from 7 a.m. to 7 p.m. CT, Monday through Friday, at 800-925-9126. A TMHP Provider Relations representative is also available for questions about reconciling reports. A representative can be found by region on the TMHP website.   

Claims Submitted with Laboratory Services

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

When this occurs, the laboratory that performed the procedures is responsible for refiling laboratory charges with TMHP to receive Title XIX reimbursement. For claims past the 95-day filing deadline, the laboratory must follow their Medicaid appeals process. Grantees must arrange with their contracted laboratory to recoup any funds paid to the laboratory for lab services for FPP clients before Title XIX retro eligibility determination.  

Donations

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