Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 392 - PURCHASE OF GOODS AND SERVICES FOR SPECIFIC HEALTH AND HUMAN SERVICES COMMISSION PROGRAMS
Subchapter G - CONTRACTING WITH PROVIDERS FOR CERTAIN DSHS PROGRAMS
Section 392.605 - Kidney Health Care Provider Requirements and Effective Dates
Universal Citation: 1 TX Admin Code ยง 392.605
Current through Reg. 49, No. 38; September 20, 2024
(a) Definitions. The terms in this section have the same meaning as those defined in Title 25, Part 1, §61.2 (relating to Definitions).
(b) Requirements. To qualify as a provider for the Kidney Health Care (KHC) program, as described in Title 25, Part 1, Chapter 61, Subchapter A (related to Kidney Health Care), a provider must do as follows.
(1) Outpatient dialysis facilities must:
(A) execute an agreement with the
program;
(B) have Medicare
certification and a Medicare End-Stage Renal Disease (ESRD) provider
number;
(C) be a current Texas
Medicaid provider;
(D) be licensed
by the department as an ESRD facility;
(E) reimburse the program for any
overpayments upon request; and
(F)
not be on suspension as a KHC provider, as a Texas Medicaid provider, as a
Medicare certified ESRD facility, or as a licensed Texas ESRD
facility.
(2) An
out-of-state outpatient dialysis facility must:
(A) meet all the requirements in paragraph
(1)(A) - (C) and (E) of this subsection;
(B) be licensed by its state, if
applicable;
(C) be a Medicaid
provider in its state; and
(D) not
be on suspension as a KHC provider, as a Texas Medicaid provider, as a Medicaid
provider in its state, as a Medicare-certified ESRD facility, or by the ESRD
licensing authority of its state.
(3) Any outpatient dialysis facility may be
given interim approval according to the following:
(A) client applications for KHC benefits may
be submitted by the facility during the period of interim approval.
(B) interim approval extends no longer than
six months from the date the program mails the agreement to the
facility.
(C) if interim approval
lapses, the unexecuted agreement is nullified and a new agreement with term
dates and the period of interim approval may be initiated by the
program.
(D) claims for outpatient
dialysis services shall not be considered for payment by the program until the
program has a fully executed agreement with the facility.
(E) claim filing deadlines apply, as
contained in Title 25, Part 1 §61.8 (relating to Claim Filing
Deadlines).
(4) A
pharmacy, including a mail order pharmacy, must execute an agreement as a KHC
provider through the Health and Human Services Commission Pharmacy Contracts
and Rebates unit or designated contractor.
(5) A physician or certified registered nurse
anesthetist (CRNA) must:
(A) execute an
agreement with the program;
(B) be
licensed to practice medicine in the State of Texas, if a physician;
(C) be certified to practice within the scope
of his or her certification in the State of Texas, if a CRNA;
(D) be a Texas Medicaid provider;
(E) not be on suspension as a KHC provider,
as a physician licensed to practice medicine in the State of Texas, as a CRNA
certified to practice within the scope of the certification in the State of
Texas, or as a Texas Medicaid provider; and
(F) reimburse the program for any
overpayments upon request.
(6) An out-of-state physician and a CRNA
must:
(A) meet all the requirements in
paragraph (5)(A), (D) and (F) of this subsection;
(B) be licensed to practice medicine in the
state in which services are provided, if a physician; or
(C) be certified to practice within the scope
of his or her certification in the state in which services are provided, if a
CRNA; and
(D) not be on suspension
as a KHC provider, as a Texas Medicaid provider, as a physician licensed to
practice medicine in the state in which services are provided, as a CRNA
certified to practice within the scope of the certification in the state in
which services are provided.
(7) A hospital or ambulatory surgical center
(ASC) must:
(A) execute an agreement with the
program;
(B) be in compliance with
all applicable laws to provide hospital or ASC services in the State of
Texas;
(C) be a current Texas
Medicaid provider;
(D) have
Medicare certification;
(E) not be
on suspension as a KHC provider, as a hospital authorized under applicable law
to provide hospital services in the State of Texas, as an ASC licensed to
provide ASC services in the State of Texas, as a Texas Medicaid provider, or as
a Medicare certified hospital or ASC; and
(F) reimburse the program for any
overpayments upon request.
(8) An out-of-state hospital or ASC must:
(A) meet all the requirements in paragraph
(7)(A), (C), (D) and (F) of this subsection;
(B) be licensed to provide hospital or ASC
services in the state in which services are provided;
(C) not be on suspension as a KHC provider,
as a Texas Medicaid provider, as a Medicaid provider in its state, as a
hospital licensed to provide hospital services in the state in which services
are provided, as an ASC licensed to provide ASC services in the state in which
services are to be provided, or as a Medicare certified hospital or
ASC;
(9) A Medicare
Prescription Drug Plan (PDP) must:
(A)
execute an agreement with the program;
(B) be Medicare approved as a PDP and
maintain approval;
(C) share and
exchange data in an acceptable format with the program for the coordination of
drug benefits under the Medicare PDP (Part D);
(D) accept a program payment for premiums;
and
(E) reimburse the program for
any overpayments upon request.
(c) Effective dates.
(1) The effective date of all outpatient
dialysis facility agreements shall be on or after the Medicare ESRD
certification date.
(2) The
effective date of all pharmacy agreements shall be determined by the Health and
Human Services Commission Pharmacy Contracts and Rebates unit or its designated
contractor.
(3) The effective date
of all other provider agreements, listed in subsection (a)(5) - (9) of this
section, shall be the first day of the sixth month prior to the program's
receipt of the completed and signed provider agreement.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
