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Reprocessing Crossover Claims for Physical, Occupational and Speech Therapy Services

Friday, May 4, 2018   (0 Comments)
Posted by: Lindsey Green
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Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

TMHP has identified an issue that affects Medicare crossover claims (i.e., claims with respect to “dual eligible” recipients who are covered by both Medicare and Medicaid),for Physical (PT), Occupational (OT) and Speech Therapy (ST) services, with dates of service on or after Sept. 1, 2017. These claims paid $0.00 of the allowed coinsurance amount.
Monthly claims reprocessing will occur for all crossover therapy services, starting June 4, 2018, for dates of service on or after Sept. 1, 2017. When claims submitted with modifier UB or U5 are reprocessed, no action on the part of the provider is required. Remittance and Status (R&S) Reports will reflect any additional reimbursement from TMHP. Claims submitted without modifiers UB or U5 will continue to pay $0.00 of the allowed amount, and providers must appeal these with correct modifiers.

As a reminder, all claims submitted to TMHP for Physical, Occupational and Speech Therapy treatment services must use either a UB or U5 modifier on the claim form to ensure proper reimbursement.


Modifier          Description

UB                      Services delivered by a licensed therapy assistant under supervision of a licensed therapist
U5                      Services delivered by a licensed therapist or a physician

Note: Since therapy evaluations and re-evaluations may not be performed by licensed therapy assistants, evaluation and re-evaluation procedure codes do not require a UB or U5 modifier.

For more information, providers may refer to the current Texas Medicaid Provider Procedures Manual, Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook, section 6.3.5 “PT, OT, and ST Reimbursement Guidelines.

For more information, call the TMHP Contact Center at 1-800-925-9126.

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