The following requirements apply to program provider reimbursement.
(1) HHSC pays a program provider as described in this
paragraph.
(A) HHSC pays for supported home living, professional
therapies, nursing, respite, in-home respite, employment assistance,
supported employment, and CFC PAS/HAB in accordance with the reimbursement
rate for the specific service.
(B) HHSC pays for host home/companion care, residential
support, supervised living, in-home day habilitation and day habilitation
in accordance with the individual's LON and the reimbursement rate
for the specific service.
(C) HHSC pays for adaptive aids, minor home modifications,
and dental treatment based on the actual cost of the item and, if
requested, a requisition fee in accordance with the HCS Program Billing
Requirements available on the HHSC website.
(D) HHSC pays:
(i) for TAS based on a Transition Assistance Services
(TAS) Assessment and Authorization form authorized by HHSC and the
actual cost of the TAS as evidenced by purchase receipts required
by the HCS Program Billing Requirements; and
(ii) if requested, a TAS service fee in accordance
with the HCS Program Billing Requirements.
(E) HHSC pays for pre-enrollment minor home modifications
and a pre-enrollment minor home modifications assessment based on
a Home and Community-based Services (HCS) Program Pre-enrollment MHM
Authorization Request form authorized by HHSC and the actual cost
of the pre-enrollment minor home modifications and a pre-enrollment
minor home modifications assessment, as evidenced by documentation
required by the HCS Program Billing Requirements.
(F) Subject to the requirements in the HCS Program
Billing Requirements, HHSC pays for TAS, pre-enrollment minor home
modifications, and a pre-enrollment minor home modifications assessment
regardless of whether the applicant enrolls with the program provider.
(G) HHSC pays for CFC ERS based on the actual cost
of the service, not to exceed the reimbursement rate ceiling for CFC
ERS.
(2) To be paid for the provision of a service, a program
provider must submit a service claim that meets the requirements in
40 TAC §49.311 (relating to Claims Payment) and the HCS Program
Billing Requirements or the CFC Billing Requirements for HCS and TxHmL
Program Providers.
(3) If an individual's HCS Program services or CFC
services are suspended or terminated a program provider must not submit
a claim for services provided during the period of the individual's
suspension or after the termination, except that the program provider
may submit a claim for the first day of the individual's suspension
or termination for the following services:
(A) in-home day habilitation;
(B) day habilitation;
(C) supported home living;
(D) in-home respite;
(E) respite;
(F) employment assistance;
(G) supported employment;
(H) professional therapies;
(I) nursing; and
(J) CFC PAS/HAB.
(4) If a program provider submits a claim for an adaptive
aid that costs $500 or more or for a minor home modification that
costs $1,000 or more, the claim must be supported by a written assessment
from a licensed professional specified by HHSC in the HCS Program
Billing Requirements and other documentation as required by the HCS
Program Billing Requirements.
(5) HHSC does not pay a program provider for:
(A) a service or recoups any payments made to the program
provider for a service if:
(i) except for an individual receiving TAS, pre-enrollment
minor home modifications, or a pre-enrollment minor home modifications
assessment, the individual receiving the service was, at the time
the service was provided, ineligible for the HCS Program or Medicaid
benefits, or was an inpatient of a hospital, nursing facility, or
ICF/IID;
(ii) except for TAS, pre-enrollment minor home modifications,
and a pre-enrollment minor home modifications assessment:
(I) the service was provided to an individual during
a period of time for which there was not a signed, dated, and authorized
IPC for the individual;
(II) the service was provided during a period of time
for which there was not a signed and dated ID/RC Assessment for the
individual;
(III) the service was provided during a period of time
for which the individual did not have an LOC determination;
(IV) the service was not provided in accordance with
a signed, dated, and authorized IPC meeting the requirements set forth
in §263.301(c) of this chapter (relating to IPC Requirements);
(V) the service was not provided in accordance with
the individual's PDP or implementation plan;
(VI) the service was provided before the individual's
enrollment date into the HCS Program; or
(VII) the service was not included on the signed, dated,
and authorized IPC of the individual in effect at the time the service
was provided, except as permitted by §263.302(d) of this chapter
(relating to Renewal and Revision of an IPC);
(iii) the service was not provided in accordance with
the HCS Program Billing Requirements or the CFC Billing Requirements
for HCS and TxHmL Program Providers;
(iv) the service was not documented in accordance with
the HCS Program Billing Requirements or the CFC Billing Requirements
for HCS and TxHmL Program Providers;
(v) the program provider did not comply with 40 TAC §49.305
(relating to Records);
(vi) the claim for the service was not prepared and
submitted in accordance with the HCS Program Billing Requirements
or the CFC Billing Requirements for HCS and TxHmL Program Providers;
(vii) the claim for the service did not meet the requirements
in 40 TAC §49.311 (relating to Claims Payment) or the HCS Program
Billing Requirements or the CFC Billing Requirements for HCS and TxHmL
Program Providers;
(viii) the program provider does not have the documentation
described in paragraph (3) of this section;
(ix) HHSC determines that the service would have been
paid for by a source other than the HCS Program if the program provider
had submitted to the other source a proper, complete, and timely request
for payment for the service;
(x) the service was provided by a service provider
who did not meet the qualifications to provide the service as described
in the HCS Program Billing Requirements or the CFC Billing Requirements
for HCS and TxHmL Program Providers;
(xi) the service was paid at an incorrect LON because
the information entered in the HHSC data system from a completed ID/RC
Assessment was not identical to the information on the completed ID/RC
Assessment; or
(xii) the service was not provided;
(B) supervised living or residential support, if the
program provider provided the supervised living or residential support
service in a residence in which four individuals or other persons
receiving similar services live without HHSC's approval as described
in rules governing the HCS Program;
(C) employment assistance, if before including the
employment assistance on an individual's IPC, the program provider
did not ensure and maintain documentation in the individual's record
that employment assistance was not available to the individual under
a program funded under §110 of the Rehabilitation Act of 1973
or under a program funded under the Individuals with Disabilities
Education Act (20 U.S.C. §1401 et seq.);
(D) supported employment, if before including the supported
employment on an individual's IPC, the program provider did not ensure
and maintain documentation in the individual's record that supported
employment was not available to the individual under a program funded
under the Individuals with Disabilities Education Act (20 U.S.C. §1401
et seq.);
(E) host home/companion care, residential support,
or supervised living, if the host home/companion care, residential
support, or supervised living was provided on the day of the individual's
suspension or termination of HCS Program services;
(F) TAS, if the TAS, was not provided in accordance
with a Transition Assistance Services (TAS) Assessment and Authorization
form authorized by HHSC;
(G) pre-enrollment minor home modifications and a pre-enrollment
minor home modifications assessment, if the pre-enrollment minor home
modifications and a pre-enrollment minor home modifications assessment,
was not provided in accordance with a Home and Community-based Services
(HCS) Program Pre-enrollment MHM Authorization Request form authorized
by HHSC;
(H) a CFC service, if the CFC service, was provided
to an individual receiving host home/companion care, supervised living,
or residential support;
Cont'd... |
