| (a) The Health and Human Services Commission or its
designee (HHSC) pays an eligible provider on behalf of an eligible
recipient for a service that is a benefit of the Texas Medicaid Program
when the service is medically necessary for diagnosis or treatment,
or both, of illness or injury, or when the service is appropriately
authorized for prevention of the occurrence of a medical condition,
and is prescribed by a physician or other qualified practitioner,
as appropriate to the particular benefit, in accordance with federal
or state law or policy and the utilization review provisions of this
chapter.
(b) Subject to the qualifications, limitations, and
exclusions set forth in this chapter, Medicaid payment for a covered
service is made only to an eligible provider of that service. The
provider must accept payment of the reasonable charge, reasonable
costs, or stipulated fee for service, as appropriate to the eligible
provider, as the full and complete payment. The provider may not charge
or take other recourse against any eligible recipient for a service
for which payment is made or will be made, except as may otherwise
be specifically provided. An eligible provider may charge an eligible
recipient for a service that is outside the amount, duration, and
scope of benefits of the Texas Medicaid Program. Payment for a covered
service is not made to any eligible recipient.
(c) An eligible provider may not bill or take other
recourse against an eligible recipient for a denied or reduced claim
for a service that is within the amount, duration, and scope of benefits
of the Texas Medicaid Program if the denial or payment reduction results
from any of the following, as determined by HHSC:
(1) the provider's failure to submit a claim, including
claims that are not received by HHSC;
(2) the provider's failure to submit a claim within
the claims filing period established by HHSC;
(3) the filing of an unsigned or otherwise incomplete
claim, including but not limited to, failure to submit a valid hysterectomy
acknowledgment statement or sterilization consent form when these
forms are required for the applicable procedures;
(4) the filing of an incorrect claim;
(5) the provider's failure to resubmit a claim within
the resubmittal period established by HHSC;
(6) the provider's failure to appeal a claim within
the appeal filing period(s) established by HHSC;
(7) errors made in the claims preparation, submission,
or appeal processes that are attributable to the provider as discerned
by HHSC.
(d) HHSC does not pay claims for services that are
not reasonable and medically necessary according to the criteria established
by HHSC, as cited at §354.1149(a) of this chapter (relating to
Exclusions and Limitations). An eligible provider may bill an eligible
recipient only if:
(1) a specific service is provided at the request of
the recipient; and
(2) the provider has obtained and kept a written acknowledgment,
signed by the recipient, that states: "I understand that, in the opinion
of (provider's name), the services or items that I have requested
to be provided to me on (dates of service) may not be covered under
the Texas Medicaid Program as being reasonable and medically necessary
for my care. I understand that the Texas Health and Human Services
Commission or its designee determines the medical necessity of the
services or items that I request and receive. I also understand that
I am responsible for payment of the services or items I request and
receive if these services or items are determined not to be reasonable
and medically necessary for my care."
(e) An attempt by the eligible provider to bill or
recover money from an eligible recipient beyond the conditions stated
in subsections (d) and (g) of this section is in noncompliance with
these rules and constitutes a violation of the agreement between HHSC
and the provider for participation in the Texas Medicaid Program.
(f) Before providing a service to an eligible recipient,
a provider who does not participate in the Texas Medicaid Program
should inform the eligible recipient that the provider will not file
a Medicaid claim for any service provided to the recipient. A recipient
receiving a service from a provider who does not participate in the
Texas Medicaid Program is directly responsible for the payment of
that service. HHSC has no liability for reimbursement for any service
provided to an eligible recipient by a provider who does not participate
in the Texas Medicaid Program.
(g) An eligible recipient is responsible for any service
the eligible recipient receives that is outside the amount, duration,
and scope of benefits of the Texas Medicaid Program, as determined
by HHSC. An eligible provider must inform the recipient of this responsibility.
(h) Each eligible provider must provide covered Medicaid
services to eligible Medicaid recipients in the same manner, to the
same extent, and of the same quality as services provided to other
patients. A service made available to other patients must be made
available to an eligible recipient if the service is covered by the
Texas Medicaid Program. The provider may not bill the recipient for
a covered service.
|
| Source Note: The provisions of this §354.1131 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective October 26, 1984, 9 TexReg 5271; amended to be effective May 8, 1985, 10 TexReg 1293; amended to be effective March 21, 1988, 13 TexReg 1107; amended to be effective August 1, 1988, 13 TexReg 3528; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 24, 2013, 38 TexReg 8187 |
