SECTION 355.8610. Reimbursement for Clinical Laboratory Services

(a) Clinical diagnostic laboratory tests performed in a practitioner's office or by an independent laboratory, shall be reimbursed as follows.

(1) The lower of the provider's usual customary charge for that service or a maximum fee determined by the Texas Health and Human Services Commission (HHSC), or its designee.

(2) Fees for services provided will be established at a percentage of the Medicare fee schedule.

(b) Clinical diagnostic laboratory tests performed by a hospital laboratory for outpatient services shall be reimbursed as follows.

(1) For services provided on and after the date that the modernized Medicaid Management Information System (MMIS) becomes operational, providers will be reimbursed based on an outpatient prospective payment system (OPPS). The OPPS used for reimbursement is the 3M™ Enhanced Ambulatory Patient Groups (EAPG) calculator. EAPGs are a visit-based classification system intended to reflect the type of resources utilized in outpatient encounters for patients with similar clinical characteristics.

(2) For services provided prior to the date that the modernized MMIS becomes operational, the lower of the provider's usual customary charge for that service or a maximum fee determined by HHSC, or its designee. Fees for services provided will be established at a percentage of the Medicare fee schedule.

Source Note: The provisions of this §355.8610 adopted to be effective September 1, 2003, 28 TexReg 7335; amended to be effective February 26, 2020, 45 TexReg 1217; amended to be effective November 26, 2023, 48 TexReg 6735