Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
Subchapter N - REHABILITATIVE SERVICES
Section 554.1306 - Fee-for-Service Payment for Rehabilitative Services

Universal Citation: 26 TX Admin Code ยง 554.1306

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

(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).

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