SECTION 554.1306. Fee-for-Service Payment for Rehabilitative Services

(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).

Source Note: The provisions of this §554.1306 adopted to be effective November 1, 2002, 27 TexReg 9387; amended to be effective February 1, 2008, 33 TexReg 761; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871