                                                                            ACCEPTED
                                                                        03-15-00226-CV
                                                                                6570038
                                                             THIRD COURT OF APPEALS
                                                                        AUSTIN, TEXAS
                                                                   8/19/2015 4:26:24 PM
                                                                      JEFFREY D. KYLE
                                                                                 CLERK
                 No. 03-15-00226-CV
         _________________________________
                                                        FILED IN
                    IN THE                       3rd COURT OF APPEALS
                                                     AUSTIN, TEXAS
            THIRD COURT OF APPEALS               8/19/2015 4:26:24 PM
                 AUSTIN, TEXAS                     JEFFREY D. KYLE
         _________________________________               Clerk


  TEXAS HEALTH AND HUMAN SERVICES COMMISSION,
                                    Appellant,

                           v.

                    LINDA PUGLISI,
                                           Appellee.
         _________________________________

                   On Appeal From
The 53rd Judicial District Court of Travis County, Texas
       Trial Court Case No. D-1-GN-14-000381
        The Honorable Judge Gisela D. Trianna
         _________________________________

             APPELLEE’S SUR-REPLY
         _________________________________

                        MAUREEN O’CONNELL
                        Texas Bar No. 00795949
                        SOUTHERN DISABILITY LAW CENTER
                        1307 Payne Avenue
                        Austin, Texas 78757
                        T: 512.458.5800
                        F: 512.458.5850
                        moconnell458@gmail.com
                        Attorney for Appellee
                                          TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................................i

TABLE OF AUTHORITIES .................................................................................... ii

ARGUMENT ............................................................................................................. 1

    A. HHSC Identifies No Credible Authority to Support its Notion
       of “Covered DME” ....................................................................................... 1

    B.     Linda Puglisi’s Medical Need for the Recommended
           Wheelchair is not Diminished by the Severity of her
           Disability ....................................................................................................... 3

    C.     State Law Governing the Order of Payment for Dually-
           Eligible Beneficiaries Has no Bearing on this Case ..................................... 4

    D. HHSC’s Hearing Decision is Unsupported by Substantial
       Evidence ........................................................................................................ 6

    E.     Neither Detgen nor the DeSario Letter Supports HHSC’s
           Hearing Decision in this Case ....................................................................... 8

    F.     HHSC Denied Linda Puglisi’s Due Process Rights.................................... 10

PRAYER .................................................................................................................. 11

CERTIFICATE OF COMPLIANCE ....................................................................... 12

CERTIFICATE OF SERVICE ................................................................................ 12




                                                              i
                                     TABLE OF AUTHORITIES

CASES

DeSario v. Thomas,
  139 F.3d 80 (2d Cir. 1998) ............................................................................... 2, 8

Detgen v. Janek,
  945 F. Supp. 2d 746 (N.D. Tex. 2013) ............................................................. 8, 9

Lankford v. Sherman,
  451 F.3d 496 (8th Cir. 2006) ............................................................................ 3, 9

Slekis v. Thomas,
   525 U.S. 1098 (1999) ............................................................................................ 2

REGULATIONS

1 TEX. ADMIN. CODE § 354.1039(a)(4)(D) ................................................................ 9

1 TEX. ADMIN. CODE § 354.1041 ............................................................................... 4

42 C.F.R. § 440.240(b) .............................................................................................. 3

STATUTES

42 U.S.C. § 1396a(a)(10)(B)...................................................................................... 3

TEX. HUM. RES. CODE § 32.050(b) ............................................................................ 5

TEX. HUM. RES. CODE § 32.0424 ............................................................................... 4

TEX. HUM. RES. CODE § 32.0425 ........................................................................... 3, 8

OTHER AUTHORITIES

Texas Medicaid Provider’s Procedure Manual §2.3.1.2............................................ 5

Texas Medicaid Provider’s Procedure Manual §2.3.1.3............................................ 5


                                                          ii
                              No. 03-15-00226-CV
                      _________________________________

                                 IN THE
                         THIRD COURT OF APPEALS
                              AUSTIN, TEXAS
                      _________________________________

               TEXAS HEALTH AND HUMAN SERVICES COMMISSION,
                                                 Appellant,

                                        v.

                                  LINDA PUGLISI,
                                                         Appellee.
                      _________________________________

                                On Appeal From
             The 53rd Judicial District Court of Travis County, Texas
                    Trial Court Case No. D-1-GN-14-000381
                     The Honorable Judge Gisela D. Trianna
                      _________________________________

                          APPELLEE’S SUR-REPLY
                      _________________________________

TO THE HONORABLE COURT OF APPEAL:

      Appellee, Linda Puglisi, respectfully files this Sur-Reply to correct several

factual and legal inaccuracies contained within Appellant’s Reply Brief.

                                     ARGUMENT

A.    HHSC Identifies No Credible Authority to Support its Notion of
      “Covered DME.”

      The Texas Health and Human Services Commission (HHSC) acknowledges

that “the power wheelchair, the integrated standing feature, and the power seat

                                         1
systems are all defined as DME.” Appellant’s Reply Brief, p. 2. HHSC also

acknowledges that CMS advised the agency in May 2013 that items of medical

equipment meeting the state’s definition of durable medical equipment (DME) are

covered and reimbursable through the Medicaid home health benefit. Appellant’s

Brief, p. 30; Appellee's Brief, App.1. Nonetheless, HHSC claims that an integrated

standing feature is not covered by Medicaid because it does not meet the state’s

definition of “covered DME.” Appellant’s Reply Brief, p.2. Notably absent from

this argument is any definition of the term “covered DME,” any ascertainable

standard for distinguishing “covered DME” from other DME, or any legal support

for the distinction that HHSC now attempts to make. While HHSC claims the

process for defining “covered DME” is described in its initial brief, Appellant’s

Reply Brief, p.2., no such process or definitions are identified therein. Moreover,

the only legal support offered by HHSC for this distinction is the Second Circuit’s

decision in DeSario v. Thomas. 139 F.3d 80 (2d Cir. 1996), cert. granted, decision

vacated and remanded sub nom, Slekis v. Thomas, 525 U.S. 1098 (1999).

However, this decision was vacated by the U.S. Supreme Court based upon federal

policy concerning DME coverage and this guidance provides no support for the

distinction HHSC attempts to make. Appellant’s Brief, App. 6.

      Contrary to HHSC’s contention, there is nothing “misleading” about Linda

Puglisi’s position that the test for Medicaid coverage of an integrated standing


                                        2
feature is whether it meets the state’s definition of DME. Dozens of judicial

decisions and CMS policy guidance all establish the accuracy of this test for DME

coverage. Appellee’s Brief, pp. 35-44. Nor is there any question that the Texas

Legislature included complex or specialized wheelchair components within the

scope of DME coverage.            TEX. HUM. RES. CODE § 32.0425. Because this

component meets HHSC’s definition of DME, as well as state law defining custom

wheelchairs, the trial court correctly reversed HHSC’s erroneous determination

that the recommended standing feature is not covered by Medicaid. HHSC’s

argument to the contrary is wrong.

B.     Linda Puglisi’s Medical Need for the Recommended Wheelchair is not
       Diminished by the Severity of her Disability.

       HHSC tries to make much of the fact that Linda requires assistance from

caregivers to perform certain activities of daily living (ADLs) due to her spinal

cord injury.1 However, HHSC cannot lawfully deny Linda’s request for a standing

wheelchair based upon the severity of her disability. 42 U.S.C. § 1396a(a)(10)(B);

42 C.F.R. § 440.240(b); See Lankford v. Sherman, 451 F.3d 496 (8th Cir. 2006)

(comparability requirement violated when state covers items of DME for certain

individuals with disabilities but not for others.) In fact, HHSC’s administrative

decisions specifically note that Linda was able to “maneuver and operate” the

1
  Linda has never denied her need for physical assistance from caregivers. But, as found by
HHSC’s Hearing Officer, “[a]ppellant is able to move her hands and fingers and requires the use
of sling arm supports to facilitate some ADLs.” Appellant’s Brief, App. 2, AR 334, FOF 9.
                                              3
recommended wheelchair and was able to independently stand numerous times

during her evaluation with the use of the integrated standing feature. Appellant’s

Brief, App. 2, AR 334, FOF No. 3; App.3, AR 344, FOF No. 4. These decisions

also found that Linda cannot independently transfer to a separate stander, a fact

that supports rather than negates her medical need for an integrated standing

feature on her wheelchair.    Appellant’s Brief, App. 2, AR 334, FOF No.10;

Appellant’s Brief, App.3, AR 344, FOF No. 9. Nothing in the administrative

record disputes Linda’s ability to independently stand with the recommended

wheelchair as needed to ameliorate the pain and associated medical conditions she

experiences from prolonged sitting each day.

      HHSC’s argument concerning medical necessity of the integrated standing

feature finds no support in the agency’s decisions and has no merit before this

Court. Neither the agency’s hearing officer nor its reviewing attorney made any

findings concerning the integrated standing feature that refute the professional

opinion of Linda’s medical providers that the recommended wheelchair will

correct or ameliorate many of the medical conditions she faces and will serve one

or more specific medical purposes for her.

C.    State Law Governing the Order of Payment for Dually-Eligible
      Beneficiaries Has no Bearing on this Case.

      HHSC asserts that, as a state agency, it cannot easily disregard it obligation

to comply with TEX. HUM. RES. CODE § 32.0424; TEX. HUM. RES. CODE §

                                         4
32.050(b) and 1 TEX. ADMIN. CODE § 354.1041, yet nothing about the trial court’s

decision requires it to do so. Each of these provisions relate to payment for

services provided to individuals who are dually eligible for Medicare and

Medicaid, but as previously explained, this case is about Medicaid prior

authorization and not the payment of claims or the order of payment between

Medicare and Medicaid.2 Appellee’s Brief, pp. 11-16.

      HHSC’s erroneous assertions concerning the Texas Medicaid Provider’s

Procedure Manual (TMPPM) is simply more of the same. Importantly, the excerpt

HHSC now quotes from TMPPM §2.3.1.2 no longer represents current policy.

Appellant’s Reply Brief, App. 14. This policy now states that “[f]or eligible

Medicare/Medicaid clients, Medicare is the primary payer and providers must bill

Medicare before submitting a claim to Medicaid.” Appellee’s Sur-Reply, App. 9.

Like HHSC’s other legal references, this policy is inapplicable to the case before

this Court as it relates to payment for services already provided to the beneficiary

and not prior authorization of requested services. As explained in Appellee’s

Brief, pp. 13-14, this case is only about Medicaid prior authorization of the

recommended wheelchair and not about payment for the wheelchair - - two very




2
  Similarly, TMPPM §2.3.1.3 references the MRAN or Medicare Remittance Advisory Notice.
The MRAN is a notice of payments and adjustments sent to the DME supplier by Medicare only
after a service is provided and a claim is submitted to Medicare for payment.
                                            5
different steps in HHSC’s four step process for obtaining an item of DME from

Texas Medicaid.

      Contrary to HHSC’s assertion, no one expects Texas Medicaid to “provide

prior authorizations of DME for a Federal Medicare program or vise versa.”

Appellant's Reply Brief, p. 5. Clearly, HHSC’s only authority is to grant Medicaid

prior authorization for the recommended wheelchair. Given the agency’s failure to

do so, the trial court correctly determined that Linda was entitled to Medicaid prior

authorization of the recommended wheelchair and ordered HHSC to act in

accordance with this determination.

D.    HHSC’s Hearing Decision is Unsupported by Substantial Evidence.

      HHSC accuses Linda of “subverting” the substantial evidence standard of

review while completely disregarding several salient facts concerning the

administrative record.   First, at the fair hearing, Molina Healthcare of Texas

(Molina) had the burden to prove that the documentation provided by Linda’s

medical providers did not establish her medical need for the recommended

wheelchair and that its reasons for denial were correct. Yet, Molina admitted it did

not apply Texas Medicaid’s medical necessity standards, as established in agency

rule and policy, and offered no medical evidence to support its denial. Appellee’s

Brief, p.27-28. Second, Molina provided no written or oral testimony from a

physician or therapist that refuted the professional opinions of Linda’s well-


                                         6
qualified medical providers concerning the secondary complications she faces and

and her need to stand throughout the day to ameliorate these numerous medical

conditions. To be clear, the administrative record contains no medical opinion that

disputes Linda’s medical need to stand or her inability to independently use a

separate stander. Third, neither HHSC’s hearing officer nor reviewing attorney

issued a single finding of fact that refutes the evidence provided by Linda’s

medical providers as to her medical need for the recommended wheelchair.

Finally, HHSC’s administrative decisions do not even address Linda’s medical

need for the integrated standing feature at issue in this case.

      Throughout this case, Linda has consistently identified credible and

probative evidence from the administrative record establishing the numerous

medical conditions she faces due to her disability and her medical need for the

custom power wheelchair recommended by her medical professionals. HHSC

must do more than assert that “there is more than a mere scintilla of evidence in the

record to support the Hearing Officer’s and Reviewing Attorney’s findings and

conclusion.” Appellant’s Reply Brief, p. 7. The agency must identify credible

medical evidence in the administrative record that supports Molina’s reasons for

denying this wheelchair. HHSC’s failure to do so results from the fact the

administrative record is devoid of any such evidence.




                                           7
E.     Neither Detgen nor the DeSario Letter Supports HHSC’s Hearing
       Decision in this Case.

       HHSC begins this confounding argument by claiming that Linda has failed

to assert a “private right to a mobile stander” and that she “cannot claim a private

right” to this DME. Appellant’s Reply Brief pp. 7-8. To the extent HHSC is now

stating that Linda has no right to even request an item of DME the agency’s

designee (TMHP) has categorically excluded from Medicaid coverage, such

argument has no merit.

       Linda Puglisi is an eligible Medicaid beneficiary who is entitled to DME

through the home health benefit when the item requested is covered by Medicaid

and is medically necessary for her. These two issues - Medicaid coverage of the

integrated standing feature and Linda’s medical need for this wheelchair

component - have been fully addressed in Appellee’s Brief pp. 22-44. As to

Medicaid coverage of the standing feature, Linda has previously explained why the

Detgen decision is not controlling here, particularly in light of the fact that the

Texas Legislature chose to include complex or specialized components like the

standing feature at issue in this case in its definition of the custom wheelchair

benefit.3 TEX. HUM. RES. CODE § 32.0425.


3
  HHSC’s reliance on the district court decision in Detgen is also misplaced. 945 F. Supp. 2d.
746 (N.D. Tex. 2013) There, the court erroneously assumed that federal funding was unavailable
for ceiling lifts, as claimed by HHSC. CMS’s letter to the agency on May 21, 2013, corrected
this error. While the availability of federal funding for wheelchair standing features is not at
                                               8
       Moreover, Detgen is inapplicable because the administrative record contains

no evidence from a qualified medical provider that there is a less costly, equally

effective alternative item of DME that will meet Linda's medical need to stand

throughout the day when she is faced with the pain and other medical

complications that occur due to prolonged sitting.4 Unlike the Fifth Circuit’s

finding in Detgen concerning ceiling lifts, HHSC’s exclusion of wheelchair

standing features means the state has denied Linda a medically necessary device

for which there is no alternative that will meet her medical needs.                     And as

explained in Lankford v. Sherman, 451 F.3d 496, 511 (8th Cir. 2006), “[a] state’s

failure to provide Medicaid coverage for non-experimental, medically necessary

services within a covered Medicaid category is both per se unreasonable and

inconsistent with the stated goals of Medicaid.”

       The DeSario Letter also provides no support for HHSC’s categorical

exclusion of standing wheelchair features. As previously explained, CMS has

made clear that states must provide Medicaid beneficiaries a reasonable and

meaningful process by which items of medical equipment will be judged for

coverage.     Pursuant to 1 TEX. ADMIN. CODE § 354.1039(a)(4)(D), medical

issue in this case, CMS has been clear that federal funding is available when an item of medical
equipment meets the state’s definition of DME. Appellee’s Brief, App. 1.
4
  As previously noted, the administrative record contains no medical evidence establishing that a
separate stander is “equally effective” for Linda and her evidence to the contrary demonstrates
that she cannot use a separate stander when she has no access to caregivers. Moreover, the
record contains no evidence as to whether a separate stander would be less costly as this
argument was not made by Molina in the administrative proceeding.
                                               9
equipment may be provided when it is medically substantiated that the requested

item would “serve a specific medical purpose on an individual case basis.”

(Emphasis added.) Here, both Molina and HHSC failed to apply this standard to

Linda’s wheelchair request.5 HHSC cannot escape this critical error by claiming

that “Puglisi never requested exceptional circumstances review.”            Appellant's

Reply Brief. p.8. Both Molina and HHSC were required to apply the correct

medical necessity standards in this case and and they failed to do so.

F.    HHSC Denied Linda Puglisi’s Due Process Rights.

      HHSC does not specifically respond to Linda Puglisi’s assertions concerning

the deprivation of her due process rights other than to state that the “clear solution

is to remand this case to Molina and begin due process anew.” HHSC Reply Brief,

p. 11. This callous response ignores the fact that it has been more than two years

since Linda Puglisi first sought Medicaid prior authorization of the medically

necessary power wheelchair recommended by her treating medical providers and

that she has been without this necessary equipment throughout this period of time.

Remanding this case and requiring Linda to begin this protracted process over

again because of the errors committed by Molina and HHSC is not due process.

To the contrary, this Court should affirm the trial court's reversal of HHSC’s


5
  When asked in discovery whether an exceptional circumstances review of Linda’s prior
authorization request had been conducted, Molina objected to the question and provided no
response. AR 327, Response to Interrogatories No. 10 and 11.
                                           10
flawed administrative decision as this decision is based upon grounds that were

never asserted by Molina in its denial notice to Linda Puglisi. This is the necessary

remedy for the violation of Linda Puglisi’s due process rights.

                                     PRAYER

       Appellee, Linda Puglisi, respectfully requests this Court to affirm the trial

court’s decision in her favor and to grant any other relief to which she may be

entitled.

                                       Respectfully Submitted,

                                         /s/ Maureen O’Connell
                                       MAUREEN O’CONNELL
                                       Texas Bar No. 00795949
                                       SOUTHERN DISABILITY LAW CENTER
                                       1307 Payne Avenue
                                       Austin, Texas 78757
                                       (512) 458-4800 (Phone)
                                       (512) 458-5850 (Fax)
                                       moconnell458@gmail.com

                                       Attorney for Appellee




                                         11
                      CERTIFICATE OF COMPLIANCE

      1.    This brief complies with the type-volume limitation of Tex. R. App.

P. 9.4(i)(2)(B) because it contains 2,344 words, excluding the parts of the brief

exempted by Tex. R. App. P. 9.4(i)(1).

      2.    This brief complies with the typeface requirements of Tex. R. App. P.

9.4(e) because it has been prepared in a proportionally spaced typeface using

Microsoft Word in 14 point Times New Roman.

                                        /s/ Maureen O’Connell
                                       MAUREEN O’CONNELL




                         CERTIFICATE OF SERVICE

      I hereby certify that on this 19th day of August, 2015, a true and correct

copy of the foregoing document was electronically filed, and that a true and correct

copy of the foregoing document was served by electronic mail on the same date to:

      Eugene Clayborn
      Assistant Attorney General
      Office of the Attorney General
      P.O. Box 12548
      Austin, Texas 78711


                                        /s/ Maureen O’Connell
                                       MAUREEN O’CONNELL


                                         12
                 No. 03-15-00226-CV
         _________________________________

                    IN THE
            THIRD COURT OF APPEALS
                 AUSTIN, TEXAS
         _________________________________

  TEXAS HEALTH AND HUMAN SERVICES COMMISSION,
                                    Appellant,

                           v.

                    LINDA PUGLISI,
                                           Appellee.
         _________________________________

                   On Appeal From
The 53rd Judicial District Court of Travis County, Texas
       Trial Court Case No. D-1-GN-14-000381
        The Honorable Judge Gisela D. Trianna
         _________________________________

             APPELLEE’S APPENDIX
         _________________________________


                        MAUREEN O’CONNELL
                        Texas Bar No. 00795949
                        SOUTHERN DISABILITY LAW CENTER
                        1307 Payne Avenue
                        Austin, Texas 78757
                        T: 512.458.5800
                        F: 512.458.5850
                        moconnell458@gmail.com
                        Attorney for Appellee
                                    APPENDIX INDEX

Texas Medicaid Provider’s Procedure Manual.................................................. Tab 9
TAB 9
DURABLE MEDICAL EQUIPMENT, MEDICAL SUPPLIES, AND NUTRITIONAL PRODUCTS HANDBOOK                                    AUGUST201S




         2.3.1.2        Benefits for Medicare and Medicaid Clients
         For eligible Medicare/Medicaid clients, Medicare is the primary payer and providers must bill Medicare
         before submitting a claim to Medicaid. Medicaid pays the Medicare deductible on Part B claims for
         qualified home health clients.
         Home health service prior authorizations may be given for HHA services, certain medical supplies,
         equipment, or appliances suitable for use in the home in one of the following instances:
             When an eligible Medicaid client (enrolled in Medicare) who does not qualify for home health
             services under Medicare because SN care, PT, or OT are not a part of the client's care.
             When the medical supplies, equipment, or appliances are denied by Medicare Part B and are a
             benefit of Home Health Services.
         Federal and state laws require the use of Medicaid funds for the payment of most medical services only
         after all reasonable measures have been made to use a client's third party resources or other insurance.
              Note:   If the client has Medicare Part B coverage, contact Medicare for prior authorization require-
                      ments and reimbursement. If the service is a Part B benefit, do not contact TMHP for prior
                      authorization. Texas Medicaid will only pay the deductible and coinsurance according to
                      current payment guidelines on the electronic crossover claim.
         TMHP will not prior authorize or reimburse the difference between the Medicare payment and the retail
         p1ice for Medicare Part B eligible clients.
           Refer to: Subsection 4.12, "Third Party Liability (TPL)" in Section 4, "Client Eligibility" (Vol. 1,
                     General Information).
                      Section 2.7, "Medicare Crossover Claim Reimbursement" (Vol. 1, General Information) .

         2.3.1.3        Medicare and Medicaid Prior Authorization
         Contact TMHP for prior authorization of Medicaid services (based on medical necessity and benefits of
         Home Health Services) within 30 days of the date on the MRAN.
              Note: For MQMB clients, do not submit prior authorization requests to TMHP if the Medicare
                    denial reason states "not medically necessary." Medicaid only will consider prior authori-
                    zation requests if the Medicare denial states "not a benefit" of Medicare.
         Qualified Medicare Beneficiaries (QMB) are not eligible for Medicaid benefits. Texas Medicaid is only
         responsible for premiums, coinsurance, or deductibles on these clients according to payment guidelines.
         Providers should not submit prior authorization requests to the TMHP Home Health Services Prior
         Authorization Department for these clients.
         To ensure Medicare benefits are used first in accordance with Texas Medicaid regulations, the following
         procedures apply when requesting Medicaid prior authorization and payment of home health services
         for clients.
         Contact TMHP for prior authorization of Medicaid services (based on medical necessity and benefits of
         Home Health Services) within 30 days of the date on the MRAN. Fax a copy of the original Medicare
         MRAN and the Medicare appeal review letter to the TMHP Home Health Services Prior Authorization
         Department for prior authorization.
              Note: Claims for STAR+PLUS MQMB clients (those with Medicare and Medicaid) must always be
                    submitted to TMHP as noted on these pages. The STAR+ PLUS health plan is not responsible
                    for these services if Medicare denies the service as not a benefit.
         When the client is 65 years of age and older or appears otherwise eligible for Medicare such as blind and
         disabled, but has no Part A or Part B Medicare, the TMHP Home Health Services Prior Authorization
         Department uses regular prior authorization procedures. In this situation, the claim is held for a midyear




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DURABLE MEDICAL EQUIPMENT, MEDICAL SUPPLIES, AND NUTRITIONAL PRODUCTS HANDBOOK                                   AUGUST2015




         status determined by HHSC. The maximum length of time a claim may be held in a "pending status" for
         Medicare determination is 120 days. After the waiting period, the claim is paid or denied. If denied, the
         EOB code on the R&S report indicates that Medicare is to be billed.
           Refer to: Subsection 3.2.3, "Home Health Skilled Nursing Services" in the Nursing and Therapy
                     Services Han dbook (Vol. 2, Provider Handbooks).

         2.4        Claims Filing and Reimbursement
         2.4.1        Claims Information
         Providers must use only type of bill (TOB) 321 in Form Locator (FL) 4 of the UB-04 CMS-1450. Other
         TOBs are invalid and result in claim denial.
         Home Health services must be submitted to TMHP in an approved electronic format or on a CMS-1500
         or a UB-04 CMS-1450 paper claim form. Submit home health DME and medical supplies to TMHP in
         an approved electronic fonnat, or on a CMS-1500 or on a UB-04 CMS-1450 paper claim form . Providers
         may purchase UB-04 CMS-1450 and CMS-1500 paper claim forms from the vendor of their choice.
         TMHP does not supply them.
         When completing a CMS-1500 or a UB-04 CMS 1450 paper claim form, providers must include all
         required information on the claim, as TMHP does not key information from attachments. Superbills, or
         itemized statements, are not accepted as claim supplements.
            Refer to: Section 3: TMHP Electronic Data Interchange (EDI) (Vol. l, General Information) for
                      information on electronic claims submissions.
                      Section 6: Claims Filing (Vol. 1, General Information) for general information about claims
                      filing.
                      Subsection 6.6, "UB-04 CMS-1450 Paper Claim Filing Instructions" in Section 6, "Claims
                      Filing" (Vol. 1, General Information ).
                      Subsection 6.5, "CMS-1500 Paper Claim Filing Instructions" in Section 6, "Claims Filing"
                      (Vol. l, General Information ) for instructions on completing paper claims.
         Outpatient claims must have the appropriate revenue code and, if appropriate, the corresponding
         HCPCS code or narrative description. The prior authorization number must appear on the UB-04 CMS-
         1450 claim in Block 63 and in Block 23 of the CMS-1500 claim. The certification dates or the revised
         request date on the POC must coincide with the DOS on the claim. Prior authorization does not waive
         the 95-day filing deadline requirement.

         2.4.1.1        Benefit Code
         Home health DME providers must use benefit code DM2 on all claims and authorization requests. All
         other providers must use benefit code CSN on all claims and authorization requests.

         2.4.2        Reimbursement
         DME and expendable medical supplies are reimbursed in accordance with 1 TAC §355.8021. Providers
         can refer to the Online Fee Lookup COFL) or the applicable fee schedule on the TMHP website at
         www.tmhp.com. Providers may also request a hard copy of the fee schedule by contacting the TMHP
         Contact Center at 1-800-925-9126.
         DME and expendable supplies, other than nutritional products, that have no established fee, are subject
         to manual pricing at the documented MSRP less 18 percent or the provider's documented invoice cost.
         Nutritional products that have no established fee are subject to manual pricing at the documented AWP
         less 10.5 percent or at the provider's documented invoice cost.




                                                                  132
                              CPT ONLY - COPYRJGHT2014 AMF.RICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
