Current through Reg. 49, No. 38; September 20, 2024
(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.
