| (6) maternity care services specific to routine pregnancy
care, labor and delivery, and maternal post-partum care;
(7) infertility treatment;
(8) services provided by a nursing home or facility;
and
(9) services provided while the client is in the custody
of or incarcerated by any municipal, county, state, or federal governmental
entity. Case management or prior approved family support services
not provided by the governmental entity that are needed during the
time when a client is transitioning from custody or incarceration
into a community living setting may be covered.
(d) Authorization and prior authorization of selected
services.
(1) Provider's responsibility. A program provider must
request services in specific terms on department-prepared forms so
that an authorization may be issued and sufficient monies encumbered
to cover the cost of the service. If a service is authorized, payment
may be made to the provider as long as the service is not covered
by a third party resource and all billing requirements are met. Program
authorization should not be considered an absolute guarantee of payment.
Once a service is delivered and if the service requires authorization
for payment, the authorization request for that service must be submitted
within 95 days of the date of service.
(2) Required prior authorization for selected services.
At the program's option, selected services may require authorization
prior to the delivery of services in order for payment to be made.
Prior authorization requests must be submitted prior to the date of
service.
(3) While there is a waiting list for health care benefits,
limitations in reimbursement or prior authorization may be instituted
as provided in §38.16 of this title.
(4) Denied authorization requests are authorization
requests which are incomplete, submitted on the wrong form, lack necessary
documentation, contain inaccurate information, fail to meet authorization
request submission deadlines, are for ineligible persons, services,
or providers, or are for clients who do not qualify for the health
care benefit requested. Denied authorization requests may be corrected
and resubmitted for reconsideration. Authorization requests must meet
authorization request submission deadlines. Denied authorization requests
may be appealed according to §38.13 of this title.
(e) Pilot projects. The program may initiate and participate
in pilot projects. New projects are possible only if funds are available
in the current fiscal year. All pilot projects are limited to no more
than 10% of the fiscal year appropriation.
|
| Source Note: The provisions of this §351.4 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982 |
