26 Tex. Admin. Code § 554.1306 - Fee-for-Service Payment for Rehabilitative Services
(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).
Notes
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