Revision 22-2; Effective April 1, 2022
Family planning contractors may seek reimbursement for costs using one of the following two methods:
- Contractors may submit monthly vouchers for expenses outlined in a categorical budget approved by HHSC, as required for categorical cost reimbursement; or
- Contractors 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.
Contractors may designate up to 25 percent of their total award on a categorical cost reimbursement basis. The remainder of their award will be paid on a fee-for-service basis. Contractors may designate up to 100 percent of their total award on a fee-for-services basis. Annual award determination and reallocation of funds will be based in part on those contractors that leveraged a higher percentage for direct services.
HHSC FPP Categorical Reimbursement
The categorical portion of the HHSC FPP funding is used to develop and support contractor infrastructure for the provision of family planning services. These funds may be used for support services that enhance HHSC FPP 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 that the contractor identifies during its budget development process:
- Fringe Benefits;
- Equipment and Supplies;
- 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 contractor’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 percent of the HHSC FPP funds may be disbursed to contractors through a voucher system as expenses are incurred during the contract period. Program income must be expended before categorical funds are requested through the voucher process. Contractors must still submit vouchers monthly, even if program income equals or exceeds program expenses, or if the contract reimbursement limit has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all patient copays and donations.
To request reimbursement for the categorical contract, 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.
HHSC FPP Categorical Budget Revisions
HHSC, at its sole discretion, may approve fund transfers between categories upon a contractor’s written request. That request must include a detailed explanation that supports the need for the fund transfer. The contractor must seek HHSC’s written approval before making any fund transfers. The approved budget for the state award summarizes the financial aspects of the program as approved during the state award process. It may include either the state and non-state share or only the state share, depending upon the state awarding agency’s requirements. It must be related to performance for program evaluation purposes, whenever appropriate. The local government is required to report deviations from budget or project scope or objective and request prior approval from the state awarding agency for budget and program plan revisions. For more information, visit the Texas Grant Management Guide. Contractors must submit a revised budget to HHSC for review any time a budget revision is made.
HHSC FPP Fee-for-Service Reimbursement
The fee-for-service component of the HHSC FPP funding pays for direct medical services on a fee-for-services basis. Up to 100 percent of HHSC FPP funds may be reimbursed on a fee-for-service basis. Each contracting agency is responsible for determining an individual’s eligibility for clinical services. HHSC FPP reimburses contractors on a fee-for-service basis for services and supplies that have been provided to eligible individuals. HHSC FPP contractors must continue to provide services to established individuals and to submit and appeal claims for individual services even after the contract funding limit has been met.
All contractors are required to submit claims for all HHSC FPP 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.
Effective May 1, 2017, HHSC FPP providers can submit claims electronically using a modified CMS-1500 electronic claim form.
HHSC FPP 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 contract period.
- All claims must continue to be billed and denied claims appealed even after the contract funding limit has been met.
For answers to questions about claims and payment status, HHSC FPP contractors 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
Contractors must hold claims for HHSC FPP for 45 calendar days from the date of application for individuals who have pending applications for HTW. If an individual’s HTW eligibility has not been determined after 45 calendar days, the contractor may bill the service to:
- HHSC FPP, if the individual has a current HHSC FPP eligibility form on file; or
- HTW Cost Reimbursement (if the contractor receives this funding as well). Additional guidance regarding anticipated eligibility for HTW and pending claims is available in the Healthy Texas Women Cost Reimbursement Manual.
The contractor can file for reimbursement through HHSC FPP or HTW Cost Reimbursement before the 45-day waiting period if a copy of the HTW program denial letter, or a reason for denial, has been provided by the client and is in the individual’s record before filing the claim.
HHSC FPP Codes for Reimbursement
HHSC FPP reimbursement is limited to a prescribed set of procedure codes approved by HHSC. For a complete list of valid HHSC FPP procedures, see Section 9000, Resources, Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program.
HHSC FPP contractors may submit claims for individuals’ 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 contractor’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 individual 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 individual to receive an injection of Medroxyprogesterone acetate (Depo-Provera/DMPA/depo) injection. Rather, contractors should bill the injection fee (96372) with the Depo-Provera contraceptive method (J1050).
Medicaid Retroactive Eligibility – Co-pays collected from an individual who is found to be eligible retroactively for Medicaid must be refunded to the individual. If a claim has been paid and later the individual receives retroactive Title XIX (Medicaid) eligibility, TMHP recoups or adjusts the funds paid from the HHSC FPP and processes the claim as Title XIX. An HHSC FPP accounts receivable (A/R) is then established for the adjusted claim. Note: Contractors are responsible for paying HHSC back the amount of any HHSC FPP A/R balance that may remain at the end of a state fiscal year.
The contractor’s HHSC FPP R&S Reports reflect the retroactive Title XIX adjustment with EOB message “Recoupment is due to Title XIX retro eligibility.” Contractors 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.
Performing Provider Number and Retroactive Eligibility – HHSC family planning claims do not require a performing provider number for reimbursement. However, if a Title XIX retroactive eligibility claim does not have a performing provider number in a TPI format, TMHP will deny the services. A common EOB message for this specific denial is “EOB 00118: Service(s) require performing provider name/number for payment.” A request for reconsideration of claim reimbursement may be sent to TMHP through the appeal methods. Note: The performing provider number requirement applies to all Title XIX submissions.
Claims Submitted with Laboratory Services
If a Title XIX retroactive eligibility claim includes laboratory services and the HHSC FPP contractor 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. Contractors must arrange with their contracted laboratory to recoup any funds paid to the laboratory for lab services for HHSC FPP individuals before Title XIX retro eligibility determination.
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 contract general provisions. All donations must be documented by source, amount and date they were received by the contractor. Contractors must have a written policy on the collection of donations. Individual donations collected by the contractor must be used to support the delivery of family planning services.