13.6.2 Billing Guidelines-Tiers

HHSC negotiates contracts with providers to provide post-acute rehabilitation, which is reimbursed in accordance with 1 TAC §355.9040. Residential services for traumatic brain injury are authorized based on a tiered rate structure. Each tier represents a preauthorized number of hours allotted for providing core therapy services. A week is defined as Sunday through Saturday. To determine the appropriate tier, use the clinical recommendation for services, frequency, and duration. For example, if the interdisciplinary team (IDT) recommends the following core therapy service—PT 2 times per week for 1 hour, OT recommended 3 times a week for 1 hour and Art Therapy 1 times a week for 1 hour—the appropriate tier would be Tier 1.

Based on the participant’s need determined during the initial pre-admission assessment, the provider may request an admission tier of level 2 through level 8. This request is to be submitted in writing using Form 3149, Comprehensive Rehabilitation Services Request for Tier Change, or included in the pre-admission evaluation, which identifies services needed, frequency, duration and requested tier. With prior authorization, the tier may be changed to reflect the level recommended on a weekly basis by the IDT.  Justification must include information related to the participant's needs, goals, and recommended core therapy services.

Note: Additional supporting documentation (i.e., daily therapy notes, etc.) may be requested during utilization review activities.

All post-acute rehabilitation residential services providers must submit billing for services within 30 days of the last date of services. Participants should receive core therapy services at the authorized tier.

The invoice submitted by the provider indicates the tier level and the core therapy services provided to the participant each day of service. The CRS counselor or CRS program staff member then confirms the data in the CRS Data Reporting System to ensure that the total hours for the week do not exceed the approved tier.  For example, a participant is authorized for Tier 4 services, the number of hours of core therapy services provided cannot exceed 28 hours within the week. Payment will be based on the services provided within the authorized tier.

When submitting an invoice, Post-Acute Rehabilitation providers are required to submit a monthly summary that includes a descriptive breakdown of services provided including frequency, duration, progress, or lack of progress made towards the participant's goals, actions to be taken, and preliminary discharge information. Providers are also required to upload service record details of daily services provided in the CRS Data Reporting System, per Chapter 13.2, Required Documentation. Providers will only be required to submit daily therapy documentation if a participant’s file is randomly selected for utilization review. The provider will receive a written request with a time frame outlining when documentation is to be returned to the CRS requestor.

Participant needs are the foundation of the CRS program and as such, minor fluctuations in the delivery of core therapy services is expected to accommodate a participant’s medical needs. If a participant is unable or unwilling to participate in core therapy services for a day or two, the provider must provide appropriate clinical documentation for increasing core therapy service hours on a subsequent day. Core therapy service hours must not be increased for the purposes of maximizing billing. For example, a participant is authorized for Tier 4 services, the participant is ill for three of the seven days that week. Upon recovery, the participant must not be asked to participate in increased hours of core therapy services that could potentially be harmful to the participant simply to ensure that maximum billing occurs for the assigned tier.

Patterns where Base or Base Plus Tier services are provided, followed by days with increased hours of therapy services above the recommended number of hours of core therapy services per day, must be supported by written clinical justification from assigned therapists.

The CRS counselor or other CRS program staff member compares the submitted invoice and the supporting documentation (which includes the approved tier) to what has been submitted in the CRS Data Reporting System. Disparity between the submitted documentation and invoice will be addressed by CRS program staff members and resolution obtained before payment is issued.