Section 306.277 - Medicaid Reimbursement(a) In accordance with § 306.263 of this title (relating to MH Case Management Services Standards), a billable event is a face-to-face contact during which the case manager provides an MH case management service to an: (1) individual who is Medicaid eligible; or(2) LAR on behalf of a child or adolescent who is Medicaid eligible.(b) A unit of service for MH case management services is 15 continuous minutes.(c) The department shall not reimburse a provider for Medicaid MH case management services if: (1) the individual who was provided the service did not meet the eligibility requirements set forth in § 306.259 of this title (relating to Eligibility for MH Case Management Services) at the time the service was provided;(2) the service provided was an integral and inseparable part of another service;(3) the service was provided by a person who was not qualified in accordance with § 306.271(a) of this title (relating to MH Case Management Employee Qualifications);(4) the service provided was not the type, amount, and duration authorized by the department or its designee;(5) the service was not provided or documented in accordance with this subchapter;(6) the service provided is in excess of eight hours per individual per day; or(7) the services provided do not conform to the requirements set forth in the department's MH Case Management Billing Guidelines.(d) The department shall not reimburse a provider for Medicaid MH case management services for coordination activities that are included in the provision of: (1) rehabilitative crisis intervention services, as described in Chapter 419, Subchapter L, specifically § 419.457 of Title 25 (relating to Crisis Intervention Services); or(2) psychosocial rehabilitative services, as described in Chapter 419, Subchapter L, specifically § 419.459 of Title 25 (relating to Psychosocial Rehabilitative Services).(e) If Medicaid-funded MH case management services are continued prior to a fair hearing, as required by 1 TAC § 357.11(relating to Notice and Continued Benefits), the provider may file a claim for such services.(f) An individual is eligible for Medicaid-funded MH case management services if, in addition to the criteria set forth in § 306.259 of this title, the individual is:(1) eligible for Medicaid;(2) not an inmate of a public institution, as defined in 42 CFR § 435.1009;(3) not a resident of an intermediate care facility for persons with mental retardation as described in 42 CFR § 440.150;(4) not a resident of an IMD;(5) not a resident of a Medicaid-certified nursing facility, unless the individual has been determined through a pre-admission screening and resident review assessment to be eligible for the specialized service of MH case management services or the individual is expected to be discharged to a non-institutional setting within 180 days;(6) not a recipient of MH case management services under another Medicaid program (e.g., the Home and Community Services waiver program or Texas Health Steps); and(7) not a patient of a general medical hospital.26 Tex. Admin. Code § 306.277
Adopted to be effective February 14, 2013, 38 TexReg 647; Transferred from T. 25, § 412.413 by Texas Register, Volume 45, Number 03, January 17, 2020, TexReg 469, eff. 2/15/2020.