SECTION 350.407. Medicaid Service Limitations

Case management services are not reimbursable as Medicaid services when another payor is liable for payment or if case management services are associated with the proper and efficient administration of the state plan. Case management services associated with the following are not payable as optional targeted case management services under Medicaid:

(1) Medicaid eligibility determinations and redeterminations;

(2) Medicaid eligibility intake processing;

(3) Medicaid preadmission screening;

(4) prior authorization for Medicaid services;

(5) required Medicaid utilization review;

(6) Texas Health Steps program administration;

(7) Medicaid "lock-in" provided for under the Social Security Act, §1915(a);

(8) services that are an integral or inseparable part of another Medicaid service;

(9) outreach activities that are designed to locate individuals who are potentially eligible for Medicaid; and

(10) any medical evaluation, examination, or treatment billable as a distinct Medicaid-covered benefit. However, referral arrangements and staff consultation for such services are reimbursable as case management services.

Source Note: The provisions of this §350.407 adopted to be effective September 1, 2011, 36 TexReg 5403; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941