Effective for dates of admission on or after September 1, 2018, hospitals enrolled in Texas Medicaid may be reimbursed for inpatient neonatal services only if the hospitals have received a neonatal level of care designation from the Department of State Health Services in accordance with 25 Texas Administrative Code §§133.181 -133.190.
The neonatal level of care designation applies for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.
Hospitals That Do Not Meet Minimum Requirements for Neonatal Level of Care Designation
A hospital that does not meet the minimum requirements for any level of care designation for neonatal services will not be reimbursed for inpatient neonatal services rendered to Texas Medicaid and CSHCN Services Program clients. Hospitals without a neonatal level of care designation may be reimbursed for emergency services provided or reimbursed under state or federal law to stabilize an infant prior to transport to a facility capable of providing the appropriate level of care.
Claims for inpatient neonatal services submitted by hospitals that do not have a neonatal level of care designation on file will be denied. Providers can appeal the claim with documentation of the emergency services required.
If neonatal inpatient services are rendered by a facility that has applied for (but not yet received) a neonatal designation, the facility must still adhere to existing claim filing deadlines (95 days from the date of discharge). The facility is also responsible for keeping their claim appeals active while awaiting neonatal level of care designations in order to adhere to the 120-day claim appeal deadline.
Requirements to obtain a neonatal level-of-care designation only apply to facilities located in Texas. Those entities physically located outside of Texas but enrolled in Texas Medicaid (i.e. out-of-state or border state facilities) are exempt from requiring a neonatal level of care designation for inpatient services rendered to neonatal clients.
The submitted facility address on the claim must match the physical address of the location that has been issued a neonatal level of care designation. If the facility address is not included on the claim, the submitted billing address must match the physical address of the location that was issued a neonatal level of care designation.
The hospital address submitted to DSHS on the neonatal level of care designation application must match the address billed on the claim. Claims will be rejected if the address submitted on the claim does not match the address on file. For example, numbers must be spelled out as words or left numeric on the claim to match the address submitted to DSHS on the neonatal level of care designation application, “street” or “avenue” must either be spelled out or abbreviated, etc.
|Address on Neonatal Designation Application||Correct||Incorrect (Claim will be rejected)|
|12345 First Street||12345 First Street||12345 1st Street|
|6 Maine Street||6 Maine Street||Six Maine St.|
Providers can refer to the DSHS approval letter for the correct address.
Change of Address for a Neonatal Designation
Neonatal designated address that require updates/corrections must be updated through DSHS not TMHP. Refer to http://www.dshs.texas.gov/emstraumasystems/formsresources.shtm#neonatal to complete the Neonatal Facility Designation application.
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