SECTION 354.1131. Payments to Eligible Providers

(a) The Health and Human Services Commission or its designee (HHSC) pays an eligible provider on behalf of an eligible recipient for a service that is a benefit of the Texas Medicaid Program when the service is medically necessary for diagnosis or treatment, or both, of illness or injury, or when the service is appropriately authorized for prevention of the occurrence of a medical condition, and is prescribed by a physician or other qualified practitioner, as appropriate to the particular benefit, in accordance with federal or state law or policy and the utilization review provisions of this chapter.

(b) Subject to the qualifications, limitations, and exclusions set forth in this chapter, Medicaid payment for a covered service is made only to an eligible provider of that service. The provider must accept payment of the reasonable charge, reasonable costs, or stipulated fee for service, as appropriate to the eligible provider, as the full and complete payment. The provider may not charge or take other recourse against any eligible recipient for a service for which payment is made or will be made, except as may otherwise be specifically provided. An eligible provider may charge an eligible recipient for a service that is outside the amount, duration, and scope of benefits of the Texas Medicaid Program. Payment for a covered service is not made to any eligible recipient.

(c) An eligible provider may not bill or take other recourse against an eligible recipient for a denied or reduced claim for a service that is within the amount, duration, and scope of benefits of the Texas Medicaid Program if the denial or payment reduction results from any of the following, as determined by HHSC:

(1) the provider's failure to submit a claim, including claims that are not received by HHSC;

(2) the provider's failure to submit a claim within the claims filing period established by HHSC;

(3) the filing of an unsigned or otherwise incomplete claim, including but not limited to, failure to submit a valid hysterectomy acknowledgment statement or sterilization consent form when these forms are required for the applicable procedures;

(4) the filing of an incorrect claim;

(5) the provider's failure to resubmit a claim within the resubmittal period established by HHSC;

(6) the provider's failure to appeal a claim within the appeal filing period(s) established by HHSC;

(7) errors made in the claims preparation, submission, or appeal processes that are attributable to the provider as discerned by HHSC.

(d) HHSC does not pay claims for services that are not reasonable and medically necessary according to the criteria established by HHSC, as cited at §354.1149(a) of this chapter (relating to Exclusions and Limitations). An eligible provider may bill an eligible recipient only if:

(1) a specific service is provided at the request of the recipient; and

(2) the provider has obtained and kept a written acknowledgment, signed by the recipient, that states: "I understand that, in the opinion of (provider's name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under the Texas Medicaid Program as being reasonable and medically necessary for my care. I understand that the Texas Health and Human Services Commission or its designee determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care."

(e) An attempt by the eligible provider to bill or recover money from an eligible recipient beyond the conditions stated in subsections (d) and (g) of this section is in noncompliance with these rules and constitutes a violation of the agreement between HHSC and the provider for participation in the Texas Medicaid Program.

(f) Before providing a service to an eligible recipient, a provider who does not participate in the Texas Medicaid Program should inform the eligible recipient that the provider will not file a Medicaid claim for any service provided to the recipient. A recipient receiving a service from a provider who does not participate in the Texas Medicaid Program is directly responsible for the payment of that service. HHSC has no liability for reimbursement for any service provided to an eligible recipient by a provider who does not participate in the Texas Medicaid Program.

(g) An eligible recipient is responsible for any service the eligible recipient receives that is outside the amount, duration, and scope of benefits of the Texas Medicaid Program, as determined by HHSC. An eligible provider must inform the recipient of this responsibility.

(h) Each eligible provider must provide covered Medicaid services to eligible Medicaid recipients in the same manner, to the same extent, and of the same quality as services provided to other patients. A service made available to other patients must be made available to an eligible recipient if the service is covered by the Texas Medicaid Program. The provider may not bill the recipient for a covered service.

Source Note: The provisions of this §354.1131 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective October 26, 1984, 9 TexReg 5271; amended to be effective May 8, 1985, 10 TexReg 1293; amended to be effective March 21, 1988, 13 TexReg 1107; amended to be effective August 1, 1988, 13 TexReg 3528; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 24, 2013, 38 TexReg 8187