| (a) HHSC pays a facility for rehabilitative services
provided to a Medicaid eligible resident based on fees determined
in accordance with 1 TAC §355.313 (relating to Reimbursement
Methodology for Rehabilitative and Specialized Services).
(b) A facility must ensure that rehabilitative services
provided to a resident eligible for Medicaid are:
(1) ordered by the resident's attending physician;
and
(2) except as provided in subsection (c)(1) of this
section, pre-certified by DADS.
(c) A session is one physical, occupational, or speech
therapy service provided to one resident. HHSC pays for an evaluation
at the same rate as a session.
(1) HHSC pays for one evaluation that is not pre-certified
by DADS.
(2) To have an additional evaluation pre-certified
by DADS, a facility must submit documentation by the attending physician
that indicates the resident has a new illness or injury, or a substantive
change in a pre-existing condition.
(d) A facility must submit a complete and accurate
claim for services that is received by DADS within 12 months after
the last day services are provided in accordance with a single pre-certification
by DADS.
(e) A resident whose request for pre-certification
of Medicaid rehabilitative services is denied may request a fair hearing
in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform
Fair Hearing Rules).
|
| Source Note: The provisions of this §554.1306 adopted to be effective November 1, 2002, 27 TexReg 9387; amended to be effective February 1, 2008, 33 TexReg 761; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
