Section 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).26 Tex. Admin. Code § 554.1306
The provisions of this §19.1306 adopted to be effective November 1, 2002, 27 TexReg 9387; amended to be effective February 1, 2008, 33 TexReg 761; Amended by Texas Register, Volume 42, Number 35, September 1, 2017, TexReg 4477, eff. 9/10/2017; Entire chapter transferred from Title 40, Pt. 1, Ch. 19 by Texas Register, Volume 45, Number 50, December 11, 2020, TexReg 8871, eff. 1/15/2021