SECTION 351.6. Providers

(a) General requirements for participation. The Children with Special Health Care Needs Services Act, Health and Safety Code, §35.004, requires that all providers be approved to participate in the program according to program criteria and procedures.

(1) Providers seeking approval for program participation must submit a completed application to the program or its designee including a signed provider agreement and all documents requested.

(2) All approved program providers must agree to abide by program rules and regulations and not to discriminate against clients based on source of payment.

(3) All program providers must agree to accept the program-allowed amount of payment (regardless of payer) as payment in full for services provided to program clients. Providers may collect allowable insurance or health maintenance organization co-payments in accordance with those plan provisions. Providers may not request or accept payment from the client or client's family for completing any program forms.

(4) The program is the payer of last resort, and program providers must agree to utilize all other public or private benefits available to the client including, but not limited to, Medicaid or Medicaid waiver programs, CHIP, or Medicare, and casualty or liability coverage prior to requesting payment from the program. Providers must agree to attempt to collect payment from the payer of other benefits. The program may pay for certain services for which other benefits may be available but have not been definitively determined. If other benefits become available after the program has paid for the services, the program shall recover its costs directly from the payer of other benefits or shall request the provider of services to collect payment and reimburse the program.

(5) Overpayments made on behalf of clients to program providers must be reimbursed to the program refund account by lump sum payment or, at the discretion of the department, in monthly installments or out of current claims due to be paid the provider. All providers must consent to on-site visits and audits by program staff or its designees.

(6) All approved providers must agree to the following:

(A) maintain and retain all necessary records and claims to fully document the services and supplies provided to a client for full disclosure to the program or its designee;

(B) retain these records and claims for a period of five years from the date of service, the client's 21st birthday, or until all audit questions, appeal hearings, investigations, litigation, or court cases are resolved, whichever occurs last;

(C) provide unconditionally upon request, free copies of and access to all records pertaining to the services for which claims are submitted to the program or its designees; and

(D) allow the department, the Office of Inspector General, HHSC, or designees of these organizations access to its premises; and cooperate and assist with any audit or investigation.

(7) All program providers of services also covered by Medicaid must enroll and remain enrolled as Title XIX Medicaid providers. In order to be reimbursed by Medicaid as the primary payer, a provider must be enrolled on the date of service. The program will not reimburse an enrolled provider for any service covered under Medicaid that was provided to a program client eligible for Medicaid at the time of service. If a service covered by the program is not covered by Medicaid, the provider of that service is not required to enroll as a Medicaid provider. Any provider excluded by Medicaid for any reason shall be excluded by the program.

(8) Providers must comply with applicable Medicare standards.

(9) If a license or certification is required by law to practice in the State of Texas, the provider must maintain the required license or certification and practice within the scope of the license, certification, registration, and any other applicable requirements.

(10) All providers shall be responsible for the actions of their staff members who provide program services.

(11) Any provider may withdraw from program participation at any time by so notifying the program in writing.

(b) Denial, modification, suspension, and termination of provider enrollment.

(1) The program may deny, modify, suspend, or terminate a provider's enrollment for the following reasons:

(A) submitting false or fraudulent claims;

(B) submitting false information on the enrollment application;

(C) failing to provide and maintain quality services or medically acceptable standards;

(D) not adhering to the provider agreement signed at the time of application or renewal for program participation;

(E) conviction of any felony;

(F) conviction of any misdemeanor involving moral turpitude;

(G) disenrollment as a Medicaid provider;

(H) violation of the standards of this chapter;

(I) failure to submit a claim for reimbursement for an extended period of time, as specified by program policy; or

(J) disciplinary action taken against the provider by the licensing authority under which the provider practices in the State of Texas or by the Texas Medicaid Program.

(2) Prior to taking an action to deny, modify, suspend, or terminate the enrollment of a provider, the program shall give the provider written notice of an opportunity of appeal in accordance with §38.13 of this title (relating to Right of Appeal).

(c) Provider types. Approved providers include, but are not limited to:

(1) advanced practice registered nurses;

(2) ambulance providers;

(3) ambulatory surgical centers;

(4) certified home and community support services agencies;

(5) certified respiratory care practitioners;

(6) dentists;

(7) dietitians;

(8) family support services providers;

(9) federally qualified health centers;

(10) genetic counselors;

(11) hearing service professionals;

(12) hospice care providers;

(13) hospitals;

(14) inpatient rehabilitation centers;

(15) licensed speech-language pathologists;

(16) lodging facilities;

(17) medical supply and equipment companies;

(18) mental and behavioral health professionals including, but not limited to, psychiatrists, licensed psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors;

(19) occupational therapists and physical therapists;

(20) optometrists and opticians;

(21) orthotists and prosthetists;

(22) pharmacies;

(23) physicians;

(24) physician assistants;

(25) podiatrists;

(26) renal dialysis centers;

(27) rural health clinics; and

(28) transportation companies or providers.

(d) Requirements for specialty centers.

(1) The program may accept as providers diagnostically specific specialty centers, such as bone marrow or other transplant centers, approved under the credentialing or approval standards and processes of the Texas Medicaid Program if such specialty centers also submit a program provider enrollment application.

(2) Other specialty center standards. The program may establish standards to insure quality of care for children with special health care needs in the comprehensive diagnosis and treatment of specific medical conditions for specialty centers with Texas Medicaid Program separate credentialing standards as well as other specialty centers for which the Texas Medicaid Program has not established separate credentialing or approval standards for providers.

(e) Out-of-state coverage.

(1) Fifty or fewer miles from the Texas border. For clients who would otherwise experience financial hardship or be subject to clear medical risk, the program may cover services that are within the scope of the program and provided by health care providers in New Mexico, Oklahoma, Arkansas, or Louisiana located 50 or fewer miles from the Texas border.

(2) More than 50 miles from the Texas border. The manager of the department unit having responsibility for oversight of the program may approve coverage of services that are within the scope of the program and provided by health care providers located within the United States and more than 50 miles from the Texas border in unique circumstances in which the program participating physician(s), the client, parent or guardian, and the program medical director or assistant medical director agree that:

(A) an out-of-state provider is the provider of choice for quality care;

(B) the medical literature indicates that the out-of-state treatment is accepted medical practice and is anticipated to improve the client's quality of life;

(C) the same treatment or another treatment of equal benefit or cost is not available from Texas program providers; and

(D) the out-of-state treatment should result in a decrease in the total projected program cost of the client's treatment.

(3) The limitations of this paragraph do not apply to coverage for or payment to program providers of selected products or devices including, but not limited to, medical foods or hearing amplification devices which either are always less costly or are only available from out-of-state sources.

(4) For program reimbursement, all program policies and procedures will apply including the requirement that all providers be program providers as defined by this section.

(5) The program may cover costs of transportation and associated meals and lodging for a client and, if necessary, a responsible adult for travel to and from the location of out-of-state services that meet the program approval parameters in this subsection. Travel costs will be negotiated with approval of specific travel options based on overall cost effectiveness.

Source Note: The provisions of this §351.6 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982