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TMB 186 Final Draft indd - Tmhp

TMB 186 Final Draft indd - Tmhp 2025

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The Texas Medicaid Bulletin No. 186, dated March/April 2005, provides updates to the Texas Medicaid Provider Procedures Manual, including changes in billing procedures for Brachial Plexus Injury and Cataract/Vitrectomy surgeries, implementation of a combined payment system for Medicaid programs, and details on new disease management programs for chronic illnesses. It also covers updates on reimbursement rates for various medical procedures, guidelines for the Pneumococcal vaccine administration, and information regarding excluded providers. The bulletin emphasizes the importance of provider education and compliance with updated regulations.

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What does Medicaid cover in Texas?

Medicaid is safety net health insurance that is there for the Texans that need it most, including Texas children, mothers, grandparents and people with disabilities. It helps provide for everything from routine checkups and heart surgeries to home health and at-home nursing care.

Can you ask to be referred to a specialist?

Youre entitled to ask for a referral for specialist treatment on the NHS. However, whether youll get the referral depends on what your GP feels is clinically necessary in your case.

Does Texas Medicaid require referrals for specialists?

The patients health-care plan may play a role in the Referral Decision Process: Medicaid Managed Care requires patients be seen by their PCP for a referral to a specialist. Many private managed-care plans also require patients be seen by their PCP for a specialty referral.

Do I need a referral every time I see the same specialist?

Some insurance plans require that a specialist has a referral/authorization on file before you can be seen. Insurance plans that require this require a referral for every visit to a specialist. Your PCP must be the one to initiate the referral.

Does Texas Medicaid work out of state?

Texas Medicaid pays for Medicaid-reimbursable services provided out-of-state if the: recipient needs services because of a medical emergency documented by the attending physician or other provider; recipients health could be jeopardized by not obtaining services; and. provider enrolls in the Texas Medicaid Program.

TMB 186 Final Draft indd - Tmhp 2025

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