Revision 26-3; Effective Sept. 1, 2026

Grantees must make sure clients are provided services in a timely and nondiscriminatory manner per all Texas Health and Human Services (HHS) policies and adhere to the following guidelines.

• Have a policy in place to identify and reduce barriers to client care, including making sure clinic or reception room wait times are reasonable.
• Have a policy in place that requires qualified staff to assess and prioritize a client’s needs.
• Provide referral sources for people who cannot be served or need a specific service that is outside the scope of BCCS.
• Manage funds to make sure established clients continue to receive services throughout the budget year, including after allocated funds are expended.
• Have a policy in place that defines the timely provision of services and ensures applicants deemed eligible for BCCS are given an appointment as soon as possible – no later than 30 days from the initial request.
• Inform people of BCCS services and encourage them to bring required documents to the first visit for eligibility processing.
• Comply with all applicable civil rights and anti-discrimination laws, regulations, and contract terms and conditions as outlined in the Requirements for Contractors. 

Revision 26-3; Effective Sept. 1, 2026

Grantees must obey state laws governing the reporting of suspected abuse and neglect. Grantees must have written policies and procedures in place for the detection and appropriate reporting of abuse, neglect and exploitation of: 

• the elderly and adults with disabilities, Texas Human Resources Code, Chapter 48;
• child abuse and neglect, Texas Family Code, Chapter 261;

Grantees must provide annual training that includes the requirements outlined in the following sections for Reporting and Emergency or Suspicion of Abuse, Compliance and Monitoring, Human Trafficking and Domestic and Intimate Partner Violence.

Reporting an Emergency or Suspicion of Abuse

For cases that pose an immediate threat to a person, call 9-1-1 or the appropriate local law enforcement agency.

For situations that do not pose an immediate threat, or to report suspected abuse or neglect, grantees should use the secure Texas Abuse Hotline website or call the Texas Abuse Hotline at 800-252-5400.

2210 Human Trafficking

Revision 26-3; Effective Sept. 1, 2026

Grantees must comply with all state and federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000 and Texas Occupations Code Sections 116 and 301, which require health practitioners to complete an HHSC-Approved Human Trafficking Course for every licensure renewal period.

Grantees must display signs about human trafficking in areas where clients and the public can easily see them. This includes lobbies, waiting rooms, front reception desks, and locations where people apply for and receive services.

Grantees must have a written policy on human trafficking, which includes:

• the definition of human trafficking;
• how to identify possible situations of human trafficking;
• what to do and who to report to if human trafficking is suspected;
• mandatory reporting of suspected child human trafficking;
• victim support resources; and
• annual staff training.

Resources for Human Trafficking Policy Development

• Texas Health and Human Services Human Trafficking Resource Center
• Texas Health and Human Services Health Care Practitioner Training Page
• Governor’s Child Sex Trafficking Team
• HHS National Human Trafficking Hotline website or dial 888-373-7888
• Rescue and Restore Campaign by the U.S. Department of Health and Human Services. Contains multiple resources for health care providers, social service personnel and law enforcement for identifying and aiding trafficking victims. Includes slide presentations for training purposes.

2220 Domestic and Intimate Partner Violence 

Revision 26-3; Effective Sept. 1, 2026

Intimate partner violence (IPV) includes physical, sexual or psychological harm by a current or former partner or spouse. Per Texas Human Resources Code, Chapter 51, family violence may also include emotional harm and threat of harm. IPV can exist regardless of the presence of sexual intimacy.

Grantees must comply with all requirements listed in Texas Family Code, Chapter 91 and have a written policy about the assessment and prevention of domestic violence and IPV. Clients who experience IPV are not required to submit information to verify income eligibility if doing so jeopardizes the client's safety or imposes a barrier to receiving services.

Any medical professional who treats a person for injuries they have reason to believe were caused by IPV is required to provide the person with the Notice to Victim (PDF) on the HHSC Family Violence Program webpage.

More information and resources on IPV are on the Centers for Disease Control and Prevention website. Grantees can also contact the National Domestic Violence Hotline at 800-799-7233, which operates 24 hours a day, seven days a week and provides interpretation services in over 200 languages.

Revision 24-2; Effective Sept. 20, 2024

2310 Confidentiality

Revision 26-3; Effective Sept. 1, 2026

All grantees must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for protection of privacy.

A BCCS provider must maintain all health care information as confidential to the extent required by law. 

HIPAA requires grantees to develop and distribute a notice that provides a clear explanation of privacy rights and practices. 

This Notice of Privacy Practices must be given to clients:

• at the first appointment, 
• on request, 
• at a minimum, every three years.

The notice must be posted in a clear and easy to find location for clients to review. It must be on the organization’s website. 

Grantees must make sure all employees and volunteers receive training about client confidentiality during orientation. Grantees also must make them aware that violation of the law about confidentiality may result in civil damages and criminal penalties. All employees, volunteers, subrecipients, board members and advisory board members must sign a confidentiality statement during orientation.

Grantees must monitor client records to make sure only appropriate staff and HHSC may access the records. 

Grantees must document the client’s preferred method of communication, such as cell phone, email, work phone or text, and preferred language in the client’s record. 

Each client must receive verbal assurance of confidentiality, an explanation of what confidentiality means, and any applicable exceptions, such as abuse reporting. Grantees must also provide clients with a copy of their signed confidentiality policy or agreement and the grantee must maintain a copy in the client's record.

2320 Nondiscrimination and Limited English Proficiency

Revision 26-3; Effective Sept. 1, 2026

HHSC contracts require grantees to comply with state and federal antidiscrimination laws including state rules in Texas Administrative Code (TAC) Title 1, Part 15, Chapter 395, Subchapter B, Section 395.11.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights Office webpage and the Requirements for Contractors webpage.

Grant Terms and Conditions

To ensure compliance with nondiscrimination laws, regulations and policies, grantees must:

• sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations;
• have a written policy that states the agency does not discriminate based on:
  • race;
  • color;
  • national origin including limited English proficiency (LEP);
  • sex;
  • age;
  • religion; or
  • disability;
• have a policy that addresses client rights and responsibilities that is applicable to all people who request services;
• have procedures to notify the HHSC Civil Rights Office of any program- or service-related discrimination allegation or complaint within 10 calendar days after the allegation or complaint;
• make sure all grantee staff are trained in the grantee's nondiscrimination policies;
• notify all people who apply for services of the grantee's nondiscrimination policies and complaint procedures; and
• prominently display Civil Rights Posters in English and Spanish as applicable in common areas, including lobbies and waiting rooms, the front reception desk and locations where clients apply for services. 

More information about nondiscrimination laws and regulations is on the HHSC Civil Rights Office.

Limited English Proficiency – LEP

To comply with civil rights requirements related to LEP, grantees must:

• take reasonable steps to make sure people with LEP have meaningful access to its programs and services;
• not require a person with LEP to use friends or family members as interpreters;
  • a family member or friend may serve as a person’s interpreter if the person requests it; and
  • the family member or friend does not compromise the effectiveness of the service or violate client confidentiality; and
• make people with language service needs, including people with LEP and disabilities, aware that the grantee will provide an interpreter free of charge.

2330 Termination of Services

Revision 26-3; Effective Sept. 1, 2026 

Grantees must never deny services to an eligible client because of an inability to pay. 

Grantees have the right to terminate services to a client if:

• the client is disruptive, unruly, threatening or uncooperative to the extent the client seriously impairs the grantee’s ability to effectively and safely provide services; or
• the client’s behavior jeopardizes their own safety, or the safety of clinic staff or others.

A termination of services policy must be included in the grantee’s policy.

If a grantee denies, modifies, suspends or terminates services to a client, an explanation must be documented in the client’s record. A client has the right to appeal the denial, modification, suspension or termination of services by following the Resolution of Complaints process.

2340 Resolution of Complaints

Revision 26-3; Effective Sept. 1, 2026 

Grantees must make sure clients can express concerns about the care they’ve received and ensure any complaints or concerns are handled in a consistent and timely manner. A grantee’s policy must explain the process clients may follow if they are not satisfied with the care received, including:

• Grantees must investigate and resolve a complaint or concern within 30 business days, beginning on the day they are notified by the aggrieved client.
• Clients may contact a grantee during and after the resolution of an investigation to receive more information on the grantee's decision or to help correct the issue.
• Grantees must provide the client with contact information to the HHS Office of the Ombudsman. If a client has requested more help from the Ombudsman, a grantee must not terminate services to that client until a final decision is rendered by HHSC, unless there is a viable risk to the safety of the aggrieved client, clinic staff or others.
• All complaints and concerns must be documented in the client’s record.

2350 Freedom of Choice

Revision 26-3; Effective Sept. 1, 2026

Clients have the right to choose health care providers without coercion or intimidation. Acceptance of health care services does not preclude eligibility for, or receipt of, any other service or assistance.

2360 Research, Human Subject Clearance

Revision 26-3; Effective Sept. 1, 2026

To participate in proposed research that would involve the use of BCCS clients as subjects, the use of BCCS client records or any data collected from clients, BCCS grantees must get prior approval from their own internal Institutional Review Board (IRB) and from HHSC. For information about the process, grantees should visit the Institutional Review Board Home.

Grantees must have a policy in place that shows approval will be obtained from the HHSC BCCS program, as well as the IRB, before instituting any research activities. The grantee must also make sure all staff are made aware of this policy through training. Documentation of training on this topic must be maintained. Federal BCCS funds may not be used for research.

Revision 26-3; Effective Sept. 1, 2026

Grantees must obtain the client’s written and voluntary general consent to receive services before they receive any clinical services. A general informed consent explains the types of services provided and how client information may be shared with other entities for reimbursement or reporting purposes. If a client does not receive services for a period of three years or more, a new general consent must be signed before beginning delivery of services.

A client’s verbal consent for general treatment may be obtained by phone. This type of consent is acceptable for treatment provided through telemedicine. To record a client’s verbal consent, the agency staff who obtains the consent must read the consent form to the applicant and document that the applicant affirms by giving their verbal consent for treatment. The document must include the date and time of the applicant’s consent and the agency staff’s signature at the time the consent is obtained. The client must sign the consent at their next visit to the clinic.

Consent information must be effectively communicated to every client in an understandable manner. This communication must allow the client to participate, make sound decisions about their own medical care, and address any disabilities that impair communication in compliance with LEP regulations. 

Grantees must not require a married client’s spouse to consent to the client’s services. Only the client may give consent unless they are legally incapable of doing so. In such cases, a parent, legal guardian or caregiver must consent on their behalf. Consent must never be obtained in a manner that could be perceived as coercive.

Clients who enter BCCS for services must also sign consent that authorizes the grantee to enter or view client protected health information in the statewide Med-IT^® database. If this statement is not included in the general consent, another consent must be developed for the client to sign. This document must be included with the general consent in the client health record.

Grantees should consult a qualified attorney to determine the appropriateness of all consent forms used by their health care agency.

2410 Texas Medical Disclosure Panel Informed Consent

Revision 26-3; Effective Sept. 1, 2026

The Texas Legislature established the Texas Medical Disclosure Pane (TMDP) to:

• determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their clients or people authorized to consent for their clients; and
• establish the general form and substance of such disclosure.

The grantee must make sure informed consent is obtained from the client for procedures per TMDP. The treatments and procedures by a health care provider or physician that require disclosure of specific risks and hazards to a client or person authorized to consent for the client are in List A of TAC Title 25, Part 7, Chapter 602. The procedures that do not require disclosure of specific risks and hazards are in List B of TAC Title 25, Part 7, Chapter 603.

The TMDP has established several procedure-specific disclosure and consent forms for use.

Revision 26-3; Effective Sept. 1, 2026

Grantees must have an organized and secure client record system. The grantee must make sure the record is organized, readily accessible and available to the client on request with a signed release of information. Records must be kept confidential, secure and:

• safeguarded against loss or use by unauthorized people;
• secured by lock when not in use to prevent access by unauthorized people; and
• maintained in a secure environment in the facility and during transfer between clinics and between home and office visits.

Written consent is required for the release of personally identifiable information. Written consent is not required:

• when personally identifiable information is necessary to provide services to the client; or
• with appropriate safeguards for confidentiality as required by law.

HIV information should be handled per federal and state law. 

Grantees should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other form that does not identify clients. Upon request, clients transferring to other providers must be given a copy or summary of their record to expedite continuity of care. Electronic records are acceptable as medical records.

Grantees, providers and subrecipients must maintain all records that pertain to client services, contracts and payments for the period specified by HHSC. Requirements regarding time limits for submitted claims are in TAC Title 1, Part 15, Chapter 354, Section 354.1003.

Requirements for medical record maintenance are in TAC Title 22, Part 9, Chapter 163, Subchapter A. Grantees must follow contract provisions, maintain medical records for at least seven years after the contract closes, and follow the retention standards of the appropriate licensing entity. All records about services must be accessible for examination at any reasonable time to HHSC representatives and as required by law.

2510 Personnel Policy and Procedures

Revision 26-3; Effective Sept. 1, 2026

Grantees must develop and maintain personnel policies and procedures to make sure all staff are hired, trained and evaluated appropriately for their job position, including contracted personnel. The grantee must verify that all staff who provide services to BCCS clients have the appropriate licenses and certifications required by applicable law. All licenses and certifications must be current, valid, in good standing and remain so for the term of the grant. All staff must be appropriately identified with a name badge. 

Personnel policies and procedures, including those for contracted personnel, must include:

• job descriptions that specify any required qualifications and licensure;
• a written orientation plan for new staff that includes a statement of skills, competencies or both as appropriate for the position; and
• a performance evaluation process for all staff.

Grantees must show evidence employees meet all required qualifications and receive required annual training. Job evaluations should include observation of staff and client interactions during clinical, counseling and educational services. 

All medical care for BCCS clients must be provided under the supervision, direction and responsibility of a qualified medical director. The medical director must be a licensed Texas physician.

Grantees must designate:

• one Medicaid for Breast and Cervical Cancer (MBCC) point-of-contact with responsibilities to provide training and technical help to staff who help with and submit MBCC applications; and
• one Evidence-Based Intervention (EBI) point-of-contact with responsibilities to oversee and support HHSC BCCS-sponsored and clinic-level EBI projects. The EBI contact is responsible for providing training and technical assistance to staff who implement EBI projects. The EBI contact, or a designee, is required to attend EBI-specific meetings and webinars.

Grantees must establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. All employees and board members must complete a conflict-of-interest statement during orientation. 

Grantees must establish BCCS program requirements and policies, review them annually, and train staff accordingly. This includes reviewing and updating staff on any updates to the program’s policy manual and required forms that may occur during the grant term.

Grantees must have a documented plan for organized staff development. The plan must have an assessment of:

• training needs;
• quality assurance indicators; and
• changing regulations and requirements.

Staff development must include orientation and in-service training for all personnel and volunteers. Nonprofit entities must provide orientation for board members. Government entities must provide orientation for their advisory committees. All orientation and continuing education must be documented in agency personnel files.

Grantees must notify and provide updated contact information in writing within 30 calendar days of a change to HHSC of:

• chief executive officer (CEO) – signature authority;
• chief financial officer (CFO) – fiscal contact;
• program director or program manager – program contact;
• patient navigator(s) funded by this program;
• EBI Champion; and
• MBCC contact.

Grantees must make sure at least one representative:

• Communicates program information. Person is responsible for disseminating information to BCCS program administrative and clinic staff.
• Has HHSC SharePoint access. Person can view and upload program and grant information via HHSC web-based applications on the SharePoint site.
  • Must have an Outlook or Microsoft Office 365 account.
  • Must sign and submit a Family Clinical Services Extranet and Data Upload Security Agreement form for each staff person who accesses the site. 
• Attends relevant HHSC webinars during the fiscal year.
  • Grantees should aim for representation at one or more relevant technical assistance, training or evaluation webinars.
  • HHSC may designate certain webinars as mandatory, such as for a priority policy or procedure change, and will notify grantees accordingly.
  • To receive participation credit, attendees must complete any required sign-in sheet, registration or survey within the specified time frame.

Revision 24-2; Effective Sept. 20, 2024

2610 Facilities and Equipment

Revision 26-3; Effective Sept. 1, 2026

Grantees must always maintain a safe environment, provide clean and well-maintained facilities where services are delivered, and have appropriate exterior signs to identify funded entity as a health care facility. Appropriate space must be provided for exam rooms, client intake, waiting areas and clinical and administrative staff attendance and functions.

Hazardous Materials and Waste

Grantees must have written policies and procedures to address:

• the handling, storage and disposal of hazardous materials and waste per applicable laws and regulations;
• the handling, storage and disposal of chemical and infectious waste, including sharps; and
• an orientation and education program for personnel who manage or have contact with hazardous materials and waste.

Fire Safety

Grantees must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

Medical Equipment

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, which includes automated external defibrillators (AEDs). Documents must include:

• assessments of the clinical and physical risks of equipment through inspection, testing and maintenance;
• reports of any equipment management problems, failures and user errors;
• an orientation and education program for personnel who use medical equipment; and
• manufacturer recommendations for the care and use of medical equipment.

Radiology Equipment and Standards

All facilities that provide radiology services must:

• possess a current Certificate of Registration from the Department of State Health Services Radiation Control Program;
• comply with Texas Administrative Code (TAC), Title 25, Chapter 289, Texas Regulations for Control of Radiation; and
• post Notice to Employees, Texas Regulations for Control of Radiation (PDF).

For information on X-ray machine registration, review the Texas Department of State Health Services, Radiation Control Program.

Smoking and Vaping Ban

Grantees must have a written policy that prohibits smoking and vaping in any portion of their indoor facilities. If a grantee subcontracts with another entity to provide health services, the subgrantee must comply with this policy.

Disaster Response Plan

Grantees must have written plans that address how staff will respond to emergencies such as fires, flooding, power outages and bomb threats. The disaster plan must identify the procedures and processes to be initiated during a disaster and the staff position responsible for each activity. A disaster response plan must be in writing, formally communicated to staff and kept in the workplace available to employees for review. For an employer with 10 or fewer employees, the plan may be communicated verbally 

For resources on facilities and equipment, review the   Occupational Safety and Health Administration Compliance Assistance Guide.

Clinical Emergencies

Grantees must adequately prepare to handle clinical emergency situations. Each site must:

• have a written plan for the management of on-site medical emergencies and emergencies that require ambulance services.
• have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action. Staff trained in CPR must be present at all hours of clinic operations.
• maintain emergency resuscitative drugs, supplies and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present.
• maintain documents in personnel files that confirm staff are trained in the written plans or protocols.

Suicide Prevention

Grantees must display signs related to suicide prevention, including the 988 Suicide and Crisis Lifeline. These signs must be displayed in areas where clients and the public can easily refer to them, such as lobbies, waiting rooms, front reception desks and locations where people apply for and receive services.

Examples of suitable flyers are on the Substance Abuse and Mental Health Services Administration (SAMHSA) website:

• 988 Suicide & Crisis Lifeline Poster (English)
• 988 Suicide & Crisis Lifeline Poster (Spanish)
• Suicide Warning Signs for Youth Poster
• Texting 988 Poster 1 (Spanish)
• Texting 988 Poster 2 (English)
• 988 Partner Toolkit, SAMHSA

More mental health and suicide prevention resources are available at:

• Behavioral Health Provider Resources
• Suicide Prevention
• Find Resources or a Provider, You're Not Alone, Mental Health Texas

Revision 26-3; Effective Sept. 1, 2026

Quality assurance and quality improvement (QA/QI) support the quality of clinical service delivery. Grantees must use internal QA/QI systems and processes to monitor BCCS services. Grantees must be able to meet the management standards per Title 2 Code of Federal Regulations Part 200.

QA/QI processes are intended to:

• improve screening and diagnostic services;
• link structure and process and include standards, measurement and actions;
• identify and remedy root causes of quality problems;
• meet client needs; and
• focus on high-volume, costly, high-risk or problem-prone aspects of care.

These aims are achieved by assessing performance, making changes based on the assessment and monitoring improvement. Steps to QA/QI include:

• Quality monitoring – The BCCS performance indicators are designed specifically for this purpose and represent aspects of care that align with the purpose of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP.
• Quality assessment – Assessing quality provides organizations with an opportunity to measure performance against standards, such as targets or benchmarks. Quality assessment creates a bridge between monitoring and improvement by establishing a common understanding of the quality of services provided and identifying opportunities for improvement.
• Quality improvement – QI strives to find strategies that will institute a change and continuously improve quality.

A Quality Management (QM) program must be developed and implemented to provide ongoing evaluation of services. Grantees should have a comprehensive quality work plan for internal review, measurement and evaluation of services, the analysis of monitoring data, and the development of strategies for improvement and sustainability.

Grantees who subcontract to provide BCCS services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subrecipients.

2710 QM Committee

Revision 26-3; Effective Sept. 1, 2026

The QM Committee members consist of key organization leaders. This includes the executive director, chief executive officer or both, the medical director and other appropriate staff where applicable. The committee must review and approve a quality work plan for the organization annually. 

The QM Committee must meet at least quarterly to:

• receive reports of monitoring activities;
• make decisions based on the analysis of data collected;
• determine quality improvement actions to be implemented; and
• reassess outcomes and goal achievement.

The committee’s meeting dates, a list of the attendees, minutes of the discussion and actions taken must be maintained.

2720 Comprehensive Quality Work Plan

Revision 26-3; Effective Sept. 1, 2026

The comprehensive quality work plan, at a minimum, must:

• be reviewed annually;
• include clinical and administrative standards by which services will be monitored;
• include a process for credentialing and peer review of clinicians;
• identify those responsible for implementing, monitoring, evaluating and reporting;
• establish timelines for quality monitoring activities;
• identify tools and forms to be used; and
• outline reporting to the QM Committee.

2730 Quality Assurance Activities

Revision 26-3; Effective Sept. 1, 2026

Although each organization’s quality assurance program is unique, the following activities must be undertaken by all agencies that provide client services:

• ongoing eligibility, billing and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
• utilization review;
• defining, reporting, tracking and follow-up of adverse outcomes;
• client satisfaction surveys and reporting of survey data to HHSC in the frequency, manner and format defined by HHSC;
• annual review of facilities to maintain a safe environment, including an emergency safety plan;
• annual review and update of all prescriptive authority agreements (PAAs), including protocols, for mid-level providers;
• annual review of all standing orders (SOs) and clinical protocols;
• up-to-date performance evaluations to include primary license verification, valid Drug Enforcement Administration (DEA) number, as applicable, immunization status and other required licenses or certifications; and
• annual review of all policies and forms.

The review or revision date must be clearly noted on each policy, form, agreement or order used.

2740 Subrecipient Quality and Compliance

Revision 26-3; Effective Sept. 1, 2026

Grantees who subcontract for the provision of services must also address how quality is evaluated and how compliance with policies and basic standards are assessed with the subrecipient. This includes at a minimum:

• annual license and certification verification as the primary source verification;
• clinical record review;
• billing and eligibility review;
• utilization review;
• on-site facility review;
• annual client satisfaction evaluation process; and
• child abuse training and reporting.

Data from these activities must be presented to the QM Committee. Plans to improve quality should result from the data analysis and reports considered by the committee and should be documented.

2750 Clinical Quality Assurance

Revision 25-3; Effective Sept.1, 2025

Ambulatory Surgical Centers

Ambulatory surgical centers providing services must be Centers for Medicare and Medicaid Services (CMS) certified, state-licensed and Joint Commission-accredited, as applicable. Review the HHS Ambulatory Surgical Centers website for more information.

Mammography Quality Assurance

All grantees and subrecipients that provide mammography services must:

• possess a current Certification of Mammography Systems from each mammography unit who must be fully accredited or undergoing accreditation; and
• possess a current mammography facility certificate from the appropriate agency certifying compliance with the U.S. Food and Drug Administration Mammography Quality Standards, at 21 CFR Part 900.

The Mammography Radiation Control Program may be contacted for certification questions and information on inspection results, escalated enforcement or cease and desist status.

Cytology Quality Assurance

Grantees and subrecipients that provide screening and diagnostic cytology services must have current documentation that shows the agency meets all quality assurance standards required by the BCCS program under state and federal laws.

All cytology laboratories that provide services to grantees and subrecipients must:

• possess a current, unrevoked and unsuspended registration certificate issued by the U.S. Department of Health and Human Services per the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88) (42 U.S.C. Section 263a); and
• have a mechanism for expedited notification of Pap tests which are CIN III or greater, such that the clinic is notified by the next business day after the case is signed out.

Human Papillomavirus (HPV) Quality Assurance

Grantees must assure all HPV tests are:

• for high-risk oncogenic types; and
• FDA approved and clinically validated.

Utilization Review

To make sure clients receive high-quality care and funds are expended per program policies, BCCS performs utilization review of billed services. Grantees not in compliance with billing guidelines may be required to refund the BCCS program for services inappropriately billed.

2810 Fee-for-Service Reimbursement

Revision 26-3; Effective Sept. 1, 2026

Client data must be entered in Med-IT^® no later than 45 days after each service was provided. The fee-for-service component of funding pays for direct medical services on a fee-for-service basis. Each grantee is responsible for determining a person’s eligibility for clinical services. HHSC reimburses grantees on a fee-for-service basis for services that have been provided to eligible clients. Grantees must continue to provide services to established clients and submit claims for client services even after the grant funding limit has been met.

Grantees must file claims electronically through the Med-IT^® system. Those claims must be filed within the following time frames:

• Initial claims submission must be submitted within 45 days of the date of service on the claim. If the 45th day falls on a weekend or holiday, the filing deadline is extended until the next business day.
• All claims must be submitted and processed within 60 days after the end of the grant period.
• All claims must continue to be billed even after the grant funding award has been exhausted.

Grantees may contact Med-IT^® Helpdesk for questions about claims and payment status.

HHSC reviews BCCS services and procedures a grantee submits electronically for processing.

Reimbursable Codes

Fee-for-service reimbursement is limited to a prescribed set of procedure codes approved by BCCS. The approved list of reimbursable codes is in Med-IT^® and referenced in the BCCS Appendix VI, BCCS Billing Guideline. Grantees may email the BCCS Program for a Topic Nomination Form to request more services be added to the program.  

Grantees may submit claims for a person’s office visits that reflect different levels of service for new and established people. A new person has not received clinical services at the grantee’s clinics during the previous three years. The level of services, which determines the procedure code to be billed for that client visit, is indicated by a combination of factors such as the complexity of the problem addressed, and the time spent with the client by clinic providers. The American Medical Association (AMA) publishes materials related to Current Procedural Terminology (CPT) coding that includes guidance on office visit codes – Evaluation and Management Services.

2820 Cost Reimbursement

Revision 26-3; Effective Sept.1, 2026

Cost Reimbursement provides funds to grantees that support the overall outcomes of clients served through BCCS Fee-for-Service. These funds must be used for support services that enhance BCCS Fee-for-Service client service delivery. Cost reimbursement awards must be used for client travel and may also be used for categories listed below per state and federal requirements.

Costs must be reasonable, allowable and already allocated. Costs also may be assessed against any of the following optional categories the grantee identifies during its budget development process:

• Administrative Personnel
• Administrative Fringe
• Personnel Travel
• Equipment
• Supplies
• Contractual
• Other allowable direct costs not listed in any previous categories.
• Indirect Cost

Note: Indirect costs are incurred for a common or joint purpose that benefits more than one of a grantee organization’s project or cost objectives. Indirect costs are not readily identified with a project or cost objective. More information is on the HHS Indirect Cost Rates webpage. 

Grantees may request reimbursement for costs by submitting a monthly voucher packet for expenses outlined in a categorical budget approved by HHSC, as required for categorical cost reimbursement. Supporting documents must be submitted with each voucher packet. HHSC will provide grantees with a personalized voucher packet and Financial Status Report (FSR) form at the beginning of each grant year. Grantees must submit the monthly voucher packet and the quarterly FSR to the designated email address on the forms. The packet includes:

• B-13X Form Budget Category monthly expenditures, program income and non-HHSC funding;
• Form 4116, Authorization for Expenditures;
• A detailed general ledger – itemization – that reflects a breakdown of the expenditures reported on the monthly voucher packet and approved budget workbook.

Categorical Budget Revisions

HHSC, at its sole discretion, may approve fund transfers between categories within the approved budget workbook per a grantee’s written request. The request must include a detailed explanation that supports the need for the fund transfer. The grantee must seek HHSC’s written approval before making any fund transfers. Visit the Texas Grant Management Standards (TxGMS), Statewide Procurement Division, Version 2 for more information. Grantees must submit a revised budget to HHSC for review any time a budget revision is made.