(a) Applicability.

(1) This section does not apply to the FC Program.

(2) A provider that chooses to request retroactive payment must comply with the requirements of this section.

(b) Definition of retroactive payment. A retroactive payment is payment by HHSC to a provider for services under the PHC Program or CAS Program that are provided before the date the case worker determines the individual's eligibility for the services.

(c) Reimbursement.

(1) The provider may be reimbursed for services provided before the date HHSC receives a completed, signed, and dated copy of HHSC's Application for Assistance--Aged and Disabled form: (A) for up to three months for an individual who does not have Medicaid eligibility at the time of the request for retroactive payment; and (B) for an indefinite period for an individual who is Medicaid eligible at the time of the request for retroactive payment.

(2) HHSC only reimburses the provider for the: (A) services described in §47.41 of this chapter (relating to Allowable Tasks); (B) number of hours of services allowed the individual as described in §48.2918(c) of this title (relating to Primary Home Care or Community Attendant Services); and (C) allowable costs of the PHC Program or CAS Program, as described in 1 TAC, Chapter 355, Subchapter A, (relating to Cost Determination Process).

(3) HHSC does not reimburse the provider for the retroactive period if: (A) the provider fails to submit the required documentation within the required time frames; or (B) the individual provided services does not meet the requirements described in subsection (d) of this section.

(d) Requirements before requesting retroactive payment. The provider may not request retroactive payment unless:

(1) the individual appears to be Medicaid eligible as defined in §48.1201 of this title (relating to Definition of Program Terms);

(2) the provider obtains a Practitioner's Statement of Medical Need form as described in §47.47 of this chapter (relating to Determination of Medical Need);

(3) the individual requires assistance with at least one ADL as described in §47.41 of this chapter; and

(4) the provider has verified and documented that the individual is not already receiving services under the PHC Program or CAS Program from another provider.

(e) Pre-initiation activities. The provider must complete the pre-initiation activities described in §47.45(a) of this chapter (relating to Pre-Initiation Activities).

(f) Intake referral. On the day that the provider completes the pre-initiation activities, the provider must contact HHSC and make an intake referral by providing HHSC information on the individual to start the eligibility process.

(g) Service initiation. HHSC does not pay a provider for services provided to an individual before the date the provider completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.

(h) Requesting retroactive payment.

(1) A provider's written request for retroactive payment must include: (A) a copy of the service delivery plan; (B) a copy of HHSC's Practitioner's Statement of Medical Need form; and (C) the retroactive payment information, including the: (i) name of the provider; (ii) contact information for the individual; (iii) date services were started; (iv) tasks provided to the individual, including both tasks allowed and not allowed by the PHC Program or CAS Program; (v) weekly hours of service provided to the individual, including hours allotted to tasks allowed and not allowed by the PHC Program or CAS Program; and (vi) cost per hour of service charged to the individual.

(2) The provider must submit the written request for retroactive payment: (A) to the case worker or, if no case worker has been assigned, to HHSC intake staff; and (B) within seven days after the date the provider processes the intake referral.

(i) Charges to individuals who receive services.

(1) The provider may charge an individual for services for which the provider intends to request retroactive payment, unless the individual is Medicaid eligible.

(2) The provider must reimburse the entire amount of all payments made by the individual to the provider for eligible services, even if those payments exceed the amount HHSC will reimburse for the services, if HHSC determines that the individual is eligible for the PHC Program or CAS Program.

(j) Documentation of retroactive payment requests. The provider must maintain documentation of retroactive payment requests in the individual's file.

Source Note: The provisions of this §47.85 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective October 1, 2019, 44 TexReg 5138