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Section

Certified Respiratory Care Practitioner (CRCP) Services

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16.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1.1 Medicaid Managed Care Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3.1 Procedure Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3.2 Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4.1 Claim Filing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Section 16

16.1 Enrollment

To enroll in the Texas Medicaid program, a CRCP must be certified by the Department of State Health Services (DSHS) to practice under Texas Occupation Code, Chapter 604. For CRCPs, Medicare certification is not a prerequisite for Medicaid enrollment. A provider cannot be enrolled if his license is due to expire within 30 days; a current license must be submitted. CRCPs must enroll as individual providers and comply with all applicable federal, state, and local laws and regulations. Important: All providers are required to read and comply with Section 1, Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to the Texas Medicaid Program, it is a violation of Texas Medicaid Program rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1617(a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to the Texas Medicaid Program, providers can also be subject to Texas Medicaid Program sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance. Refer to: "Provider Enrollment" on page 1-2 for more information about enrollment procedures.

Respiratory therapy services provided by a Medicaid provider enrolled as a CRCP may be reimbursed when services are reasonable, medically necessary, and prescribed by the client's physician. These services are for all age groups and do not require the client to be homebound. Medicaid coverage of CRCP services is available to clients who meet the following criteria: · Are ventilator-dependent for life support at least six hours per day. · Are ventilator-dependent for at least 30 consecutive days as an inpatient in one or more hospitals, skilled nursing facilities (SNF), or intermediate care facilities (ICF). · Require respiratory care as an inpatient in a hospital, SNF, or ICF and would be eligible to have payment made for such inpatient care. · Have adequate social support services available for care at home. · Prefer care at home.

16.3.1 Procedure Codes

Procedure code 1-99503 is allowable for CRCP services. Procedure Code Client Age 1-99503 1-99503 Birth to 20 years of age 21 to 999 years of age Reimbursement Rate $66.68 $71.68

16.1.1 Medicaid Managed Care Enrollment

Certain providers may be required to enroll with Medicaid Managed Care to be reimbursed for services provided to Medicaid Managed Care clients. Contact the individual Medicaid Managed Care health plan for enrollment information. Refer to: "Managed Care" on page 7-1 for more information.

The recommended frequency for procedure code 1-99503 is as follows: one visit daily for the initial seven days of home ventilation therapy; one visit every fourth day through the initial 30 days of home ventilation therapy; and one visit every four weeks thereafter. Procedure code 1-99503 includes, but is not limited to, the following: · Respiratory therapy services and treatments prescribed by the client's physician. · Education of the client and/or appropriate family members/support people about the in-home respiratory care (must include the use and maintenance of required supplies, equipment, and techniques appropriate to the situation). Procedure code 1-99503 may be reimbursed once per day, up to 24 visits per year.

16.2 Reimbursement

Respiratory therapy services provided by a participating CRCP are reimbursed the lesser of the provider's billed charges or the rate calculated in accordance with 1 TAC §355.8089. Refer to: "Reimbursement" on page 2-2 for more information about reimbursement.

16.3.2 Prior Authorization

The CRCP must request and receive prior authorization from TMHP for in-home respiratory therapy services. Prior authorization requests must include the dated physician's order, all pertinent medical records, and other information to justify the medical necessity/dependency of ventilator support and/or requested therapy services. Authorization may be given for up to 12 months and may be extended

16.3 Benefits and Limitations

TMHP must prior authorize all in-home respiratory therapy services.

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Certified Respiratory Care Practitioner (CRCP) Services

based on an interim report from the physician that documents the medical necessity and appropriateness of continued in-home respiratory therapy services. All supporting documentation must be included with the request for authorization. Providers should send requests and documentation to the following address: Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization 12357-A Riata Trace Parkway, Suite 150 Austin, TX 78727 Fax: 1-512-514-4213

16.4 Claims Information

CRCP services must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. Refer to: "TMHP Electronic Data Interchange (EDI)" on page 3-1 for information on electronic claims submissions. "Claims Filing" on page 5-1 for general information about claims filing. "CMS-1500 Claim Filing Instructions" on page 5-22. Blocks that are not referenced are not required for processing by TMHP and may be left blank. Electronic billers must submit the prior authorization number (PAN) on the electronic claim form. Providers should consult the software vendor for the location of this field in the software.

16.4.1 Claim Filing Resources

Refer to the following sections and/or forms when filing claims: Resource Automated Inquiry System (AIS) TMHP Electronic Data Interchange (EDI) CMS-1500 Claim Filing Instructions TMHP Electronic Claims Submission with the TMHP website Communication Guide Certified Respiratory Care Practitioner (CRCP) Claim Example Acronym Dictionary Number xiii 3-1 5-22 5-13 A-1 D-8 F-1 16

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