Medicaid Improves Formulary Search, Covers Consultation Codes

 

 

The Texas Health and Human Services Commission (HHSC) has updated the online search function for the Medicaid formulary . You now can search the formulary by drug name, therapeutic class, or the top 100 drugs used by specialty (primary care specialties to start). Nonpreferred drugs on the list are linked to a list of preferred drugs within the same class. The database also provides information on clinical/therapeutic edits associated with a drug.

 

TMA, the Texas Pediatric Society, and the Texas Academy of Family Physicians recommended that HHSC make these changes. If you'd like to offer feedback, e-mail Helen Kent Davis .

Consultation Codes

Medicaid will continue to pay for services you bill using CPT consultation codes.

Texas Medicaid and the Children With Special Health Care Needs (CSHCN) Services program have no plans to follow Medicare's lead in eliminating payment for these codes. Consultation codes currently payable under Texas Medicaid and the CSHCN program will remain so.

For Medicaid Qualified Medicare Beneficiary clients: If Medicare denies a claim because it doesn't cover the services billed (such as the consultation codes), submit the claim to the Texas Medicaid & Healthcare Partnership (TMHP) with the Medicare explanation of benefits that contains the relevant claim denial. Be sure to submit the claim to TMHP within 95 days of the Medicare disposition date and 365 days of the date of service. These claims will be processed as Medicaid-only claims.

For more information, call the TMHP Contact Center at (800) 925-9126 or the TMHP-CSHCN Services Program Contact Center at (800) 568-2413.

 

 

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