- THCA

Volume XXX, Number 6
June 2015

Clarification on Reimbursement for GDT by MCOs

There has been some confusion regarding how Medicaid only therapy services (GDT) will be reimbursed by the MCOs. The therapy policy direction shared by HHSC indicates that the MCOs should pay either the employee rate or the contracted rate, depending on which type of therapist is providing the service.

Specifically the policy can be found in #4 “Rates: MCOs will not negotiate rates for physician ordered rehabilitative services or goal directed therapies. MCOs are directed to pay the NF (submitting a claim on a therapist’s behalf) or the contracted therapist rates as identified on the HHSC Rate Analysis website. These rates range from $37.70 to $101.39 depending on whether the therapist is an in-house/employed therapist (share same NPI/tax id as NF), or a contracted therapist.”

The Nursing Facility Implementation and Add-On Therapy Guideline can be found in the following policy direction from HHSC.

The September 5, 2014 directive from HHSC to the STAR+PLUS Managed Care Organizations states:

“Effective immediately, MCOs must modify systems and make other necessary adjustments to accommodate the following with regards to nursing facility (NF) physician ordered rehabilitative services or goal directed therapy services (a NF add-on service). This update relates only to therapy provided as a nursing facility add-on service (i.e., ancillary service provided outside of the NF unit rate/daily rate), and there are no changes to services provided as part of the NF unit rate (including therapies provided under the daily rate).

Enrollment: HHSC will maintain current enrollment practices, as outlined in Texas Administrative Code (TAC), §19.1906, for contracted therapy providers serving NF residents.

Claims Submission and Processing:
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1. NFs may continue to submit claims on behalf of employed therapists (e.g., therapists who have the same National Provider Identifier (NPI) and tax identification number as the NF) or contracted therapists.
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2. MCO must accept and adjudicate therapy claims submitted by the NF on its own behalf, or on behalf of contracted therapists, through its MCO portal or as forwarded by TMHP.
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3. MCO cannot accept therapy claims through its portal that are submitted by a contracted therapist who is not a Medicaid enrolled provider.
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4. MCO must accept and adjudicate therapy claims received from Medicaid enrolled and contracted NF add-on providers through its own portal.
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5. NFs must submit NF unit rate and coinsurance claims separately from NF add-on service claims.
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6. NFs will have up to 95 days from the date of service to submit claims for therapy services provided through an employed or contracted therapist.
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7. MCOs will have up to 30 days to adjudicate therapy claims.

Service Authorization: MCOs will be responsible for determination of medical necessity and will authorize therapy services, as they will do for all NF add-on services.

Rates: MCOs will not negotiate rates for physician ordered rehabilitative services or goal directed therapies. MCOs are directed to pay the NF (submitting a claim on a therapist’s behalf) or the contracted therapist rates as identified on the HHSC Rate Analysis website. These rates range from $37.70 to $101.39 depending on whether the therapist is an in-house/employed therapist (share same NPI/tax id as NF), or a contracted therapist.

This policy direction applies only to add-on therapy services provided to NF residents, and is not applicable to other NF add-on services, including Durable Medical Equipment (DME). All other NF add-on service providers must: