(THSteps) Medical Workshop Participant Guide

(THSteps) Medical Workshop Participant Guide
Texas Health Steps
(THSteps) Medical Workshop
Participant Guide
Presented by:
2010_0609_v1.4
THSteps Medical Participant Guide
Contents
State Health Programs Team......................................................................................................... 6
Texas Medicaid Managed Care Programs .................................................................................... 7
What is Managed Care?............................................................................................................... 7
Forms of Managed Care in Texas Medicaid.................................................................................. 7
Additional Programs/Services....................................................................................................... 8
THSteps Dental Services .......................................................................................8
Oral Evaluation and Fluoride Varnish in the Medical Home........................................................ 8
Comprehensive Care Program (CCP) ......................................................................................... 9
Women’s Health Program (WHP)............................................................................................. 10
Medicaid for Breast and Cervical Cancer (MBCC).................................................................... 10
Medically Needy Program (MNP)............................................................................................. 10
Enhanced Care Program (Disease Management)........................................................................ 10
Medicaid Vendor Drug Program (VDP).................................................................................... 10
Family Planning Services Title V, X, XX, and XIX..................................................................... 10
Children with Special Health Care Needs (CSHCN) Services Program..................................... 10
Provider Enrollment.................................................................................................................... 11
THSteps Medical Checkup Education Requirements for Registered Nurses (RN)..................... 12
Provider Responsibilities............................................................................................................. 14
Cultural Competence.................................................................................................................. 16
Verifying Client Eligibility.......................................................................................................... 17
TexMedConnect- Step by Step . ................................................................................................ 18
TMHP Electronic Data Interchange.......................................................................................... 20
Automated Inquiry System........................................................................................................ 20
Paper......................................................................................................................................... 21
Limitations to Medicaid Client Eligibility.................................................................................. 23
Other Client Eligibility Factors.................................................................................................. 24
THSteps Program Overview........................................................................................................ 25
The Medical Home Concept...................................................................................................... 25
PCCM THSteps Wants to Partner With Providers..................................................................... 26
THSteps Medical Checkup......................................................................................................... 27
Comprehensive Health History.................................................................................................. 28
Comprehensive unclothed Physical examination........................................................................ 28
Nutritional Screening................................................................................................................. 29
Developmental Screening.......................................................................................................... 29
Mental Health Screening........................................................................................................... 30
Sensory Screening...................................................................................................................... 30
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Tuberculosis (TB) Screening...................................................................................................... 31
Laboratory Testing..................................................................................................................... 32
Immunizations........................................................................................................................... 32
Dental Referral.......................................................................................................................... 32
Anticipatory Guidance............................................................................................................... 33
THSteps Medical Checkup Schedule (Periodicity Schedule)..................................................... 34
Exception to Periodicity............................................................................................................. 35
Billing Exceptions to Periodicity................................................................................................ 35
Follow-Up Visit............................................................................................................................ 36
THSteps Medical Checkup Billing Guidelines........................................................................... 36
Modifiers................................................................................................................................... 36
Diagnosis................................................................................................................................... 36
Referrals and Primary Care Provider Communication................................................................ 37
Immunization and Administration Codes.................................................................................. 37
Immunizations........................................................................................................................... 38
Billing Immunizations and Services Outside of THSteps........................................................... 39
Billing Acute Care and Medical Check-up on Same Day........................................................... 39
Third Party Resources................................................................................................................ 40
Claims Filing............................................................................................................................... 41
Claims ...................................................................................................................................... 41
Benefit Code . ........................................................................................................................... 41
Electronic Claims ..................................................................................................................... 41
Claim Filing Instructions for TexMedConnect........................................................................... 42
Saving a Claim........................................................................................................................... 44
CMS-1500 Paper Claim Form................................................................................................... 45
Filing Paper Claims.................................................................................................................... 46
Tips on Expediting Paper Claims............................................................................................... 46
Appeals......................................................................................................................................... 48
Appeal Methods . ...................................................................................................................... 48
Electronic Appeals..................................................................................................................... 49
Automated Inquiry System (AIS) Appeals.................................................................................. 50
Paper Claim Appeals.................................................................................................................. 51
HHSC Administrative Appeals ................................................................................................. 52
Medical Necessity Appeals......................................................................................................... 52
Complaints by Providers............................................................................................................ 53
Filing Deadlines........................................................................................................................... 54
Filing Deadline Calendar for 2010............................................................................................. 55
Remittance and Status Report..................................................................................................... 56
Accessing R&S Reports.............................................................................................................. 57
R&S Report Sections................................................................................................................. 59
Waste, Abuse, and Fraud............................................................................................................. 66
Definitions................................................................................................................................. 66
Most Frequently Identified Fraudulent Practices........................................................................ 66
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Identifying and Preventing Waste, Abuse, and Fraud................................................................. 66
Reporting Waste, Abuse, and Fraud........................................................................................... 67
Reporting Child Abuse................................................................................................................ 68
DSHS Child Abuse Reporting Form.......................................................................................... 68
Resources..................................................................................................................................... 69
Instructions for Using the TMHP Website................................................................................ 69
Online Fee Lookup.................................................................................................................... 72
Online Provider Lookup............................................................................................................ 73
TMHP Telephone and Fax Communication.............................................................................. 81
Prior Authorization Request Telephone and Fax Communication.............................................. 82
Prior Authorization Status Telephone Communication.............................................................. 82
Written Communication With TMHP...................................................................................... 83
Texas Medicaid/CHIP Vendor Drug Program Contact Information.......................................... 85
Helpful Links ........................................................................................................................... 86
Common Claim Denial Codes.................................................................................................. 89
Acronyms.................................................................................................................................. 90
Texas Health Steps Quick Reference Guide................................................................................ 92
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State Health Programs Team
•
Providers: The crucial players in a quality health-care program. The focus is on providing the
best medical care possible while maximizing reimbursement potential.
•
Clients: Recipients of state health-care program benefits.
•
Texas State Legislature: The State legislature passes legislation that creates state health care
programs and specifies the level of services that can be provided in certain programs. In
addition, the legislature allocates budgetary dollars for the state health-care programs, including
Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.
•
Health and Human Services Commission (HHSC): Oversees operations of the entire
health and human services system in Texas. It administers the Medicaid and Children’s Health
Insurance Program (CHIP), and several other related programs for the state of Texas. HHSC’s
Office of Eligibility Services (OES) determines eligibility for Medicaid.
•
Department of State Health Services (DSHS): Administers and regulates public health,
mental health, substance abuse programs, and the Children with Special Health Care Needs
(CSHCN) Services Program. DSHS also administers, in collaboration with HHSC, the Texas
Health Steps (THSteps) Medical and Dental programs, as well as Case Management for
Children and Pregnant Women (CPW). DSHS also conducts personal care services (PCS)
assessments.
•
Department of Aging and Disability Services (DADS): DADS was created to administer
long-term services and supports for people who are aging and who have cognitive and physical
disabilities. DADS also licenses and regulates providers of these services, and administers the
state’s guardianship program.
•
Department of Assistive and Rehabilitative Services (DARS): The Department of Assistive
and Rehabilitative Services, or DARS, administers programs that ensure Texas is a state
where people with disabilities, and children who have developmental delays, enjoy the same
opportunities as other Texans to live independent and productive lives.
The department has four divisions:Rehabilitation services; Blind services; Early Childhood
Intervention Services; and Disability Determination Services
Through these divisions, DARS administers programs that help Texans with disabilities find
jobs through vocational rehabilitation, ensure that Texans with disabilities live independently in
their communities, and assist families in helping their children under age 3 with disabilities and
delays in development reach their full potential.
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•
Texas Medicaid & Healthcare Partnership (TMHP): Multiple contractors who partner to
provide technology infrastructure, application maintenance, program management, data center
operations, third party recovery activities, and performance engineering expertise.
•
MAXIMUS (Enrollment Broker): In the STAR and STAR+PLUS service areas Maximus is
responsible for assisting clients in the selection of a health-care plan and primary care provider
or changing a health-care plan If a client does not select a plan and a primary care provider,
they will be assigned a primary care provider. Maximus helps clients find THSteps medical,
dental, and case management for Children and Pregnant Women services. They also assist in
arranging for medical transportation services to medical and dental appointments.
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Texas Medicaid Managed
Care Programs
What is Managed Care?
Managed care refers to the body of clinical, financial, and organizational activities designed to
ensure better access to health-care services, improve quality, promote more appropriate utilization of
services, and contain costs.
Forms of Managed Care in Texas Medicaid
•
•
Health Maintenance Organizations (HMO): Organizations licensed by the Texas
Department of Insurance that deliver and manage health-care services under a risk-based
arrangement. The HMO contracts with providers and hospitals to form a network that serves
the HMO members (Medicaid clients).
Primary Care Case Management (PCCM): In this non-capitated model, each PCCM
participant has a primary care provider who provides medical home services. Primary care
providers receive fee-for-service (FFS) reimbursement and a monthly case management fee of
$5.00 for each Medicaid client in their care.
–– The STAR Program provides acute care medical assistance in a Medicaid managed
care environment for clients who reside in the Bexar, Dallas, El Paso, Harris, Harris
Expansion, Lubbock, Nueces, Tarrant, and Travis metropolitan service areas.
–– The STAR+PLUS Program is designed to integrate the delivery of acute and longterm services and supports for SSI and SSI-related clients who reside in the Bexar,
Harris, Harris Expansion, Nueces, and Travis metropolitan service areas.
–– The NorthSTAR Program, administered by DSHS, provides integrated behavioral
health services under contract with a behavioral health organization (BHO) for clients
who reside in the Dallas Service Area.
–– STAR Health, administered by Superior Health Plan, is a statewide program designed
to provide coordinated health-care services to children and youth in foster care and
kinship care.
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THSteps Medical Participant Guide
Additional Programs/Services
THSteps Dental Services
THSteps dental services provide early detection and treatment of dental health problems as well as
preventive dental care for Texas Medicaid clients from birth through 20 years of age.
Providers must receive training and certifi cation from the Department of State Health Services
before reimbursement can occur: Any claims submitted prior to certifi cation will be denied.
First Dental Home
First Dental Home is a legislatively supported dental initiative aimed at improving the oral health
of children who are 6 months of age through 35 months of age and enrolled in Texas Medicaid/
THSteps or the CSHCN Services Program. THSteps Dental Services are provided by a THSteps or
CSHCN dental provider.
Oral Evaluation and Fluoride Varnish in the Medical Home
The Oral Evaluation and Fluoride Varnish in the Medical Home (OEFV) initiative is a legislatively
supported initiative aimed at improving the oral health of children who are 6 months of age
through 35 months of age.
These services can be provided by THSteps-enrolled physicians, physician assistants, and advanced
practice nurses.
In order to participate in the OEFV initiative, physicians, APNs, and PAs must be certified through
DSHS.
To access training information for certification, visit
www.dshs.state.tx.us/dental/OEFV_Training.shtm.
Once certified, the certification code is placed on the THSteps TPI under which the provider bills
the THSteps Medical checkups.
An Oral Evaluation and Flouride Varnish in the Medical Home visit will include:
•
Intermediate oral evaluation
•
Fluoride varnish application
•
Dental Anticipatory guidance
•
Referral to a dental home*
*This service must be performed in conjunction with a THSteps Medical checkup.
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THSteps Medical Participant Guide
When billing in conjunction with a THSteps Medical checkup, utilize CPT code 99429 with U5
modifier.
Checkups must be billed with one of the following medical checkup codes:
•
99381
•
99382
•
99391
•
99392
Providers are reimbursed in addition to the THSteps checkup reimbursement.
Federally Qualified Health Centers and Rural Health Centers do not receive additional encounter
reimbursement.
For more information regarding training contact:
•
Dr. Linda Altenhoff at [email protected] or 1-512-458-7111, Ext. 3001
Comprehensive Care Program (CCP)
Centers for Medicare and Medicaid Services (CMS) requires all 50 states to provide all medically
necessary treatment for correction of physical or mental problems to THSteps-eligible clients when
FFP is available, even if the services are not covered under the state’s Medicaid plan.
Early Childhood Intervention (TCM and CCP)
Early Childhood Intervention (ECI) providers are eligible to enroll as Texas Medicaid Targeted
Case Management (TCM) providers and also can provide CCP services as indicated in the THSteps
section of the Children’s Services Handbook or current Texas Medicaid Provider Procedures
Manual. ECI Providers serve children from birth through 35 months of age who have a disability
and/or developmental delay as defined by ECI criteria. Providers must meet the requirements of the
Texas ECI Program and must be enrolled as Medicaid providers through TMHP to provide services
to these children.
To refer families for services, call the local ECI program or the DARS Inquiries Line at 1-800-6285115. Persons who are deaf or hard of hearing can call the teletypewriter (TTY) number at 1-866581-9328. For brochures or more information, call the DARS Inquiries Line or visit the DARS
website at www.dars.state.tx.us/ecis.
Case Management for Children and Pregnant Women
(CPW)
Case Management for Children and Pregnant Women (CPW) serves children birth through 20
years of age who have a health condition/health risk or women with high-risk pregnancies who
are in need of case management services. Case managers assist families in getting help with access
to medical services, educational/school issues, financial concerns, equipment and supplies, and
community resources.
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Women’s Health Program (WHP)
The Women’s Health Programs (WHP) is designed to expand access to family planning services and
contraception for eligible clients. WHP participants receive limited family planning benefits and do
not have access to full Medicaid coverage..
Medicaid for Breast and Cervical Cancer (MBCC)
The Medicaid for Breast and Cervical Cancer program (MBCC) provides full Medicaid benefits
for qualified women who have been diagnosed with breast or cervical cancer, or a precancerous
condition. The MBCC include full Medicaid benefits and cover precancerous conditions as well.
Medicaid coverage continues as long as the client is receiving cancer treatment and meets MBCC
eligibility criteria.
Medically Needy Program (MNP)
The Medically Needy Program (MNP) provides Medicaid benefits to children (18 years of age or
younger) and pregnant women whose income exceeds the eligibility limits but is not enough to
meet their medical expenses. These services are provided under the Tempory Assistance for Needy
Families (TANF) or one of the Medical Assistance Only (MAO) programs for children.
Enhanced Care Program (Disease Management)
The Texas Medicaid Enhanced Care Program is a disease management program that helps to reduce
health-care costs and strives to improve the health and quality of life of clients with chronic illness.
Medicaid Vendor Drug Program (VDP)
The Medicaid Vendor Drug Program (VDP) benefits clients eligible for Medicaid, CSHCN Services
Program, Kidney Health Care, and CHIP. The VDP makes payments to contracted pharmacies for
outpatient prescription drugs as prescribed by treating physician, or other health-care providers.
Family Planning Services Title V, X, XX, and XIX
Note: The CSHCN
Services Program
is not a Medicaid
program.
However,
many clients
participating
in the CSHCN
Services Program
are also eligible
for Medicaid.
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Family planning services are preventive health, medical, counseling, and educational services that
assist individuals in managing their fertility and achieving optimal reproductive and general health.
Children with Special Health Care Needs
(CSHCN) Services Program
The Children with Special Health Care Needs (CSHCN) Services Program has served children with
special needs since 1933. The CSHCN Services Program provides services to children with
extraordinary medical needs, disabilities, and chronic health conditions.
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Provider Enrollment
Texas Medicaid relies on more than 70,000 providers to render essential and preventive health-care
to Texas Medicaid clients.
As the front-line of services for Medicaid clients, this network of dedicated profes­sionals makes
health care more accessible to more than 2.5 million Texas residents throughout the state.
Texas Medicaid gives health-care professionals the opportunity to give back to their communities
and their fellow Texans. Medicaid providers give quality health-care to those who need it but cannot
afford it.
Why Enroll as a THSteps Provider?
Providers enrolled in THSteps may become medical and dental homes for children who are birth
through 20 years of age, including foster care children. Medical, dental, and case management
providers work together to focus on comprehensive, and early preventive services to help avoid the
need for acute care services. Case Management for Children and Pregnant Women (CPW) services
coordinates with families to help them receive medical, education, and other services.
Provider Enrollment on the Portal
The process of becoming a Texas Medicaid provider is very straight forward. When a provider
enrollment application is completed online, it is submitted immediately to TMHP. Once the
application has been validated, the provider will receive a welcome e-mail. Providers may opt out of
e-mail communication and receive all messages by mail.
Medicaid provider types eligible for enrollment as a THSteps Medical provider are:
–– Physician (MD or DO)
–– Advanced Practice Registered Nurses (APRNs) recognized by the Texas Board of Nursing
(BON) and nationally certified in:
–– Pediatrics
–– Family practice
–– Adult health
–– Women’s health (limited)
–– Certified Nurse Midwives
–– Physician Assistants
–– Rural Health Clinics (RHC)
–– Federally Qualified Health Centers (FQHC)
–– Health-care providers or facilities (public or private) such as:
–– Regional and local health departments
–– Family planning clinics
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THSteps Medical Participant Guide
–– Migrant health clinics
–– Community-based hospitals and clinics
–– Maternity clinics
–– Home health agencies
–– School districts
THSteps Medical Checkup Education
Requirements for Registered Nurses (RN)
THSteps requires RN’s to complete certain online modules prior to providing THSteps Medical
checkups. The online education modules may be accessed at www.txhealthsteps.com.
The RN or the employer must maintain documentation that the available required courses were
completed prior to providing the checkup:
•
•
•
•
•
•
•
•
•
•
•
•
Adolescent Health Screening
Case Management
Cultural Competence
Developmental Screening
Hearing and Vision Screening
Immunization
Introduction to the Medical Home
Mental Health Screening
Newborn Hearing Screening
Newborn Screening
Nutrition
Oral Health for Primary Care Providers
•
Weight Management
As new courses become available, the nurse (and all other providers) are encouraged to take the new
courses.
RN’s who have completed previously required courses are encouraged, but not required, to take the
online courses.
Before a physician delegates a THSteps checkup to an RN, the physician must establish the RN’s
competency to perform the service as required by the physician’s scope of practice. The delegating
physician is responsible for supervising the RN who performs the services. The delegating physician
remains responsible for any service provided to a client. RNs associated with an RHC or an FQHC
may NOT be sole provider of the checkup.
There are two different provider enrollment applications for THSteps.
12
•
Texas Medicaid Enrollment Application for new provid­ers
•
Texas Health Steps Provider Enrollment Application for existing providers
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THSteps Medical Participant Guide
Online Enrollment Procedures
1. Access the Internet and go to www.tmhp.com.
2. Click the link, “Activate my Account.”
3. Then select “New Texas Medicaid Provider.”
4. The following screen will appear. Follow the instructions listed at the top and click the “Next”
button.
The next screen will change based on the selection made here. Since the selection is Provider
Enrollment (without a National Provider Identifier [NPI]/Texas Provider Identifier [TPI]), the
following screen is displayed.
5. Complete the required fields and check the box, “I agree to these terms.”
Note: Fields marked with a red asterisk are required.
6. Click the “Create Provider Administrator” button.
An e-mail will be sent to address provided. This e-mail will contain the user name and password and
a link back to the TMHP website.
For further training please see the Provider enrollment on the Portal (PEP) CBT available at www.
tmhp.com.
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THSteps Medical Participant Guide
Provider Responsibilities
Verify eligibility
Clients are encouraged to bring their Medicaid Identification form (H3087 or H1027A) with them
to appointments. However, it remains your responsibility to verify eligibility even if the client has
not presented their Medicaid Identification form.
Provide medically necessary services to the Medicaid
and/or CSHCN Services Program population
As a Texas Medicaid and/or CSHCN Services Program provider, you agreed to provide medically
necessary services to the Medicaid and/or CSHCN Services Program population, without
discrimination based on race, religion, or sex.
Provide services without discrimination
Providers cannot discriminate against a client who has a third party resource such as other insurance
in addition to Medicaid. For example, you cannot choose to only accept Medicaid clients who do
not have Third Party Resources.
Accept payment for Medicaid services as payment in full
Providers agree to accept payment for Medicaid services as payment in full.
Follow guidelines for limiting your practice
Practices can be limited to specialty, percentage of overall clients, age, etc., but cannot discriminate
between private pay and Medicaid clients. This should be documented in the office policies and
procedures and should be across the board for ALL clients.
Follow all guidelines in Banners, Bulletins and R & S Reports
Providers need to be aware of Medicaid benefits and limitations, and are expected to review the
Bulletins and Banners. Bulletins are sent bi-monthly. Banners are important messages sent weekly
on the front page of the Remittance and Status (R&S) report. News and information are posted on
the front page of the TMHP website.
Follow HIPAA Compliancy
All Medicaid and CSHCN Services Program providers must comply with HIPAA regulations to
protect client information.
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Ensure medical record documentation supports services rendered
Each page of the medical record document must have: client’s name and their Medicaid number.
Entries into the medical record must be legible (to individuals other than the author) include the
date (month, day and year) and be signed by the performing provider.
Maintain records
All Medicaid records, claims and R&S reports must be kept for a minimum of 5 years. THERE
ARE TWO EXCEPTIONS: Freestanding Rural Health Clinics records must be kept for 6 years.
Hospital based Rural Health Clinics records need to be kept for 10 years.
Receive correct authorization
It is the provider’s responsibility to know which procedures need an authorization and to obtain
prior authorization if it is necessary for the services to be rendered. We will discuss how to obtain a
prior authorization later in the presentation.
Notify TMHP of any changes
Providers should notify TMHP of any changes to their physical address, phone, or fax number as
well as any changes to their billing or mailing address. If providers change billing services but do
not notify TMHP, their checks will go to the last billing address we have on file (if they aren’t using
Electronic Funds Transfer (EFT)).
Report Medicaid waste, fraud, and abuse
It is the provider’s responsibility to report suspected instances of Medicaid or CSHCN Services
Program waste, abuse or fraud.
Report child abuse
Providers have the responsibility of the timely reporting of suspected cases of child abuse. All
Medicaid and CSHCN Services Program providers should make a good faith effort to comply with
all child abuse reporting guidelines and requirements in Chapter 261 of the Texas Family Code
relating to investigations of child abuse and neglect.
Note: Check Banner Messages and Bulletins for the most up to date Medicaid information.
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THSteps Medical Participant Guide
Cultural Competence
Cultural competence is a set of behaviors, attitudes and policies that come together as a system,
agency or among professionals and enable that system, agency or those professionals to work
effectively in cross-cultural situations. Cultural competence is the understanding of diverse
attitudes, beliefs, behaviors, practices, and communication patterns attributable to a variety of
factors (such as race, ethnicity, religion, historical and social context, physical or mental ability, age,
gender, and sexual orientation).
Cultural Competence is important for providers as it will:
•
Increase provider awareness of how cross-cultural interactions affect clinical decisions and
outcomes for clients.
•
Increase awareness of health seeking patterns and behaviors in different cultures.
•
Maximize the quality of care provided to clients.
•
Minimize misunderstandings and miscommunication.
A health care provider is culturally competent when he/she is able to deliver culturally appropriate
and specifically tailored care to patients with diverse values, beliefs, and behaviors.
For more information see the site for the course:
https://cccm.thinkculturalhealth.org/GUIs/GUI_AboutthisSite.asp
Or goto http://www.txhealthsteps.com/catalog for the THSteps Cultural Competence Module.
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Verifying Client Eligibility
Although Medicaid clients are encouraged to bring their identification forms (H3087 or H1027-A)
to scheduled appointments, it remains the responsibility of the provider to verify client eligibility.
Eligibility and Third Party Resources
TMHP cannot make changes to the demographic or eligibility information of a client. Providers are
encouraged to call the Third Party Resources (TPR) Unit (1-800-846-7307) to give updated other
insurance information on a client such as termination of coverage or new insurance coverage.
When calling the TPR Unit to give updated other insurance information, the TPR Call Center
Representative will inform the caller if the update has been successfully completed and claims can
be resubmitted. If the TPR Call Center Representative is not able to immediately update the other
insurance information they will inform the caller that the verification and update process may take
up to 20 business days.
To verify client eligibility, use the following options:
TexMedConnect- Online or electronic verification
To verify client eligibility electronically submit one of the following for each client:
–– Medicaid or Program identification number.
–– One of the following combinations: Social Security Number (SSN) and last name; SSN
and date of birth (DOB); or last name, first name, and DOB. Narrow the search by
entering the client’s county code or sex.
•
Submit verifications in batches limited to 5,000 inquiries per transmission.
Note: To use TexMedConnect you must first create a user account. See the enrollment section of this
guide, the TMPPM, the CSHCN Services Program Manual, or the PEP CBT for more information.
Automated Inquiry System (AIS)- verification
•
Contact Medicaid AIS at 1-800-925-9126, 1-512-335-5986.
•
Contact CSHCN Services Program AIS at 1-800-568-2413.
Paper -verification using paper forms
•
Verify the client’s Medicaid eligibility using form H3087 or H1027-A. Form H3087 will
indicate if the client is in STAR, PCCM, or STAR+PLUS.
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THSteps Medical Participant Guide
Other Methods of Verification
•
Submit a hard-copy list of clients to TMHP. This service is only used for clients with eligibility
that may be difficult to verify. TMHP charges $15 per hour plus $0.20 per page to use this
type of eligibility verification. The list should include names, gender, and dates of birth (if the
Social Security and Medicaid identification numbers are unavailable). TMHP can check the
client’s eligibility manually, verify eligibility, and provide the Medicaid identification numbers.
Mail the client list to:
Texas Medicaid & Healthcare Partnership
Contact Center
12357-A Riata Trace Parkway
Suite 100
Austin, TX 78727
TexMedConnect- Step by Step
Providers can verify eligibility through the TexMedConnect application on www.tmhp.com.
Providers must create an account to access this application.
1. Open the Internet browser and go to www.tmhp.com.
2. Select Access TexMedConnect from the right navigation panel.
3. Enter username and password to log into the system.
4. Click “Eligibility on the left navigator.
5. Enter the following required fields:
–– Provider NPI/API and related data
–– Eligibility Dates
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6. If necessary, narrow the search by entering additional information in any of the following
combinations:
–– Medicaid or CSHCN Services Program ID
–– SSN and Last Name
–– SSN and DOB
–– DOB, Last Name, and First Name
7. Review results for eligibility information
Note: If more than one interactive eligibility check is performed, the Provider NPI/API on the Eligibility
Search page defaults to the most recently used Provider NPI/API.
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THSteps Medical Participant Guide
TMHP Electronic Data Interchange
Providers must set up their software or billing agent services to access the TMHP Electronic Data
Interchange (EDI) Gateway. Providers who use billing agents or software vendors should contact
those organizations for information on installation, settings, maintenance, and their processes and
procedures for exchanging electronic data.
Automated Inquiry System
The Automated Inquiry System (AIS) provides the following information and services through the
use of a touch-tone telephone:
•
Claim status
•
Patient eligibility
•
Benefit limitations
•
Medically Needy case status
•
Family Planning
•
Current weekly payment amount
• Claim appeals
• Identify PCCM Primary Care Provider
Eligibility and claim status information is available on AIS 23 hours a day, 7 days a week with
scheduled down time between 3 a.m. and 4 a.m., Central Time. All other AIS information
is available from 7 a.m. until 7 p.m., Central Time, Monday through Friday. AIS allows 15
transactions per call.
Note: Provider needs to write down the date and time they received client eligibility information as well
as the ticket number given at the time of the call in the event an issue surrounding eligibility should arise.
Eligibility can be verified dating back to 3 years from the current date.
For full instructions on the use and benefits of AIS, refer to the Automated Inquiry System (AIS)
user’s guide on www.tmhp.com or call the TMHP Contact Center at 1-800-925-9126.
20
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Paper
P.O. BOX 149030 952-X
AUSTIN, TEXAS
78714-9030
1 ATFF 01-00001
Texas Health and Human Services Commission
MEDICAID IDENTIFICATION
IDENTIFICACIÓN DE MEDICAID
RETURN SERVICE REQUESTED
DO NOT SEND CLAIMS TO THE ABOVE ADDRESS
07/05/2010
BIN
BP
TP
610098
952-X 123456789
JANE DOE
743 GOLF IRONS
HUNTINGTON TX
Cat.
40
40
Case No.
02
02
123456789
GOOD THROUGH:
VÁLIDA HASTA:
JULY 31, 2010
030731
75949
y
Date Run
CADA PERSONA NOMBRADA ABAJO
PUEDE RECIBIR SERVICIOS DE MEDICAID
op
ANYONE LISTED BELOW
CAN GET MEDICAID SERVICES
READ THE BACK OF THIS FORM!
¡LEA EL DORSO DE LA FORMA!
MEDICARE
NO.
✔ ✔ ✔✔ ✔ ✔
D
o
N
123456789
JANE DOE
12-09-1999
F 06-01-2010
THSTEPS MEDICAL AND DENTAL CHECK-UP DUE / NECESITA SU EXAMEN MEDICO Y DENTAL DE THSTEPS
PRESCRIPTIONS
TPR
DENTAL SERVICES
ELIGIBILITY
DATE
HEARING AID
SEX
EYE GLASSES
DATE
OF BIRTH
EYE EXAM
NAME
ot
ID NO.
MEDICAL SERVICES
¿Tiene menos de 21 años? Por favor, llame a su doctor, enfermera o
dentista para hacer una cita si hay una nota debajo de su nombre.
Aunque no haya ninguna nota, puede usar Medicaid para recibir la
atención médica que necesite.
Las marcas � a la derecha en el mismo renglón donde está su
nombre significan que usted puede recibir esos servicios también.
C
Under 21 years old? Please call your doctor, nurse or dentist to
schedule a checkup if you see a reminder under your name. If
there is no reminder, you can still use Medicaid to get health
care that you need.
A � on the line to the right of your name means that you can
get that service too.
If you have Medicare, effective January 1, 2006, you are
eligible for Medicare Rx and your Medicaid prescription drug
coverage will be limited.
Si tiene Medicare, a partir del 1° de enero de 2006, usted
llenará los requisitos de Medicare Rx y se limitará su cobertura
de medicamentos recetados de Medicaid.
Form H3087-G2/April 2007
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
21
22
y
p
Texas Health and Human Services Commission/Form H1027-A/09-2007
Name of Doctor/Nombre del doctor
Name of Pharmacy/Nombre de la farmacia
N
CAUTION: If you accept Medicaid benefits (services or supplies), you give and
assign to the state of Texas your right to receive payments for those services or
supplies from other insurance companies and other liable sources, up to the
amount needed to cover what Medicaid spent.
CPT only copyright 2008 American Medical Association. All rights reserved.
D
Office Address and Telephone No./Oficina y Teléfono
610098
Plan Name and Member Services Toll-Free Telephone No.
Nombre del plan y teléfono gratuito
de Servicios para Miembros
BIN
Supervisor* BJN
Name of Supervisor* (type)/Nombre del supervisor*
*or Authorized Lead Worker/*o Trabajador encargado
Worker BJN
Name of Worker (type)/Nombre del trabajador
X
Supervisor Signature
X
Worker Signature
Date/Fecha
Date
Date
ADVERTENCIA: Si usted acepta beneficios de Medicaid (servicios o artículos), otorga y
concede al estado de Texas el derecho a recibir pagos por los servicios o artículos de
otras compañías de seguros y otras fuentes responsables, hasta completar la cantidad
que se requiere para cubrir lo que haya gastado Medicaid.
Por este medio certifico, bajo pena de perjurio y/o fraude, que los clientes nombrados
arriba hemos perdido, no hemos recibido o por otra razón no tenemos en nuestro poder
la Identificación para Medicaid (Forma H3087) del corriente mes. Solicité y recibí esta
Confirmación de Elegibilidad Médica (Forma H1027-A) para comprobar nuestra
elegibilidad para Medicaid durante el periodo cubierto especificado arriba. Comprendo
que usar esta confirmación para obtener beneficios (servicios o artículos) de Medicaid
para alguna persona no nombrada arriba como beneficiario constituye fraude y es
castigable por una multa y/o la cárcel.
Signature–Client or Representative/Firma–Cliente o Representante
o
C
t
Medicare
Claim No.
Núm. de Solicitud de
Pago de Medicare
S.O DCU (A & D Staff Only)
Through/Hasta
o
From/Desde
Eligibility Dates
Periodo de Elegibilidad
Regional Procedure
I hereby certify, under penalty of perjury and/or fraud, that the above client(s)
have lost, have not received, or have no access to the Medicaid Identification
(Form H3087) for the current month. I have requested and received Form H1027-A,
Medical Eligibility Verification, to use as proof of eligibility for the dates shown
above. I understand that using this form to obtain Medicaid benefits (services or
supplies) for people not listed above is fraud and is punishable by fine and/or
imprisonment.
Client No.
Cliente Num.
SAVERR Direct Inquiry
Date of Birth
Fecha de
Nacimiento
Local DCU
Verification Method
Client Name
Nombre del Cliente
Date Eligibility Verified
Each person listed below is eligible for MEDICAID BENEFITS for dates indicated below. The Medicaid Identification form is lost or late. The client number must appear
on all claims for health services.
Each person listed below has applied and is eligible for MEDICAID BENEFITS for the dates indicated below, but has not yet received a client number. Do not submit a
claim until you are given a client number. Pharmacists have 90 days from the date the number is issued to file clean claims. However, check your provider manual
because other providers may have different filing deadlines. Call the eligibility worker named below if you have not been given the client number(s) within 15 days.
o
THIS FORM COVERS ONLY THE DATES SHOWN BELOW. IT IS NOT VALID FOR ANY DAYS BEFORE OR AFTER THESE DATES.
ESTA FORMA ES VÁLIDA SOLAMENTE EN LAS FECHAS INDICADAS ABAJO. NO ES VÁLIDA NI ANTES NI DESPUÉS DE ESTAS FECHAS.
Medicaid Eligibility Verification
Confirmación de elegibilidad para Medicaid
THSteps Medical Participant Guide
H1027
— 2010_0609_v1.4
THSteps Medical Participant Guide
Limitations to Medicaid Client Eligibility
Additional and detailed information is available in the latest Texas Medicaid Provider Procedures
Manual.
Emergency
_________________________________________________________________________
_________________________________________________________________________
Limited
_________________________________________________________________________
_________________________________________________________________________
Qualified Medicare Beneficiary (QMB)
_________________________________________________________________________
_________________________________________________________________________
Medicaid Qualified Medicare Beneficiary (MQMB)
_________________________________________________________________________
_________________________________________________________________________
Hospice
_________________________________________________________________________
_________________________________________________________________________
Presumptive Eligibility (PE)
_________________________________________________________________________
_________________________________________________________________________
Women’s Health Program (WHP)
_________________________________________________________________________
_________________________________________________________________________
CHIP Perinatal Program
_________________________________________________________________________
_________________________________________________________________________
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
23
THSteps Medical Participant Guide
Other Client Eligibility Factors
•
Third Party Resources (TPR): Before filing with Medicaid, claims must be filed with a third
party resource: either (P) private insurance or (M) Medicare. The TPR toll-free telephone
number is 1-800-846-7307.
Note: Providers are not required to bill TPR when billing THSteps Medical and Dental, Case
Management for Children and Pregnant Women, and Family Planning services. If the provider
chooses to bill the other insurance, the provider must follow these rules: claims involving other
insurance, including Medicare must be received within 95 days of the date of disposition. When a
service is billed to a third party and no response has been received, the provider must allow 110 days
before submitting a claim to TMHP. However, the federal 365-day filing requirement must still be
met.
•
Texas Medicaid Managed Care Programs:: Clients enrolled in Medicaid managed care select
or are assigned to one of several managed care programs. Providers can verify the client’s
eligibility checked through TexMedConnect, AIS or by viewing the Medicaid ID Forms (Form
H3087 or H1027A).
Most clients enrolled in managed care also select or are assigned a primary care provider. Some
services must be provided by the primary care provider and some service may require a referral
from the primary care provider. Contact the client’s managed care organization to verify the
primary care provider and to obtain additional information regarding administrative policies.
The contact information for the managed care organization is located on the Medicaid ID
Form, or you can locate the managed care organizations’ contact information in the latest Texas
Medicaid Providers Procedures Manual
24
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
THSteps Program Overview
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is Medicaid’s comprehensive
preventive child health service (medical, dental, and case management) for children birth through
20 years of age. In Texas, EPSDT is known as the Texas Health Steps (THSteps) Program.
THSteps focuses on providing regular medical and dental checkups for babies, children, teens, and
young adults. THSteps goal is to identify health problems as early as possible and make referrals for
appropriate follow-up treatment or services.
The THSteps toll-free line (1-877-847-8377) assists eligible clients and their parents or guardians
to:
•
Find a qualified medical, dental, case manager, or other health-care provider enrolled in
Medicaid.
•
Set up appointments to see a provider through THSteps Outreach.
•
Arrange transportation or reimbursement for gas to and from appointments.
•
Answer questions about eligible services.
The Medical Home Concept
The THSteps Medical checkup should be offered as part of the medical home. A medical home is a
model of delivering care that is:
•
Accessible
•
Continuous
•
Comprehensive
•
Coordinated
•
Family-centered
In providing a medical home for the client, the primary care provider directs care coordination
together with the child or youth and/or family. Refer to the TMPPM for further information.
Primary medical care and preventive health services in the medical home occur in coordination with
specialty, community, and other health care services.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
25
THSteps Medical Participant Guide
PCCM THSteps Wants to Partner With Providers
PCCM THSteps can help providers and their clients schedule THSteps medical checkups. The
PCCM THSteps Appointment Center helps providers increase the number of clients who get their
THSteps medical checkups and reduces the number of times that PCCM THSteps Appointment
Center or eligible clients contact the provider’s office about their medical checkup appointment.
The PCCM THSteps Appointment Center will:
•
Work with the provider’s staff to create a weekly or monthly block of available time slots for
appointments. (Note: THSteps clients cannot be restricted to this block of time.)
•
Retrieve the provider’s list of clients from the PCCM THSteps database.
•
Contact clients to schedule appointments for the block of available time slots. The PCCM
THSteps Appointment Center contacts clients on evenings and weekends when many clients
are easier to reach and most providers’ offices are closed
Note: The PCCM THSteps Appointment Center’s hours of operation are:
–– Monday, Tuesday, and Friday from 9 a.m. to 7 p.m., Central Time
–– Wednesday and Thursday from 9 a.m. to 8 p.m., Central Time
–– Saturday from 9 a.m. to 6 p.m., Central Time
•
Help clients make transportation arrangements to get to the appointment.
•
Send providers the schedules of the appointments at least two days in advance so that the
provider’s staff can verify eligibility and pull charts.
•
Send reminder appointment postcards to the provider’s PCCM THSteps clients at no cost to
the provider.
•
Work with the provider’s office to streamline the appointment process.
Providers who want to get started can contact any of the following:
•
The PCCM THSteps Provider Team at [email protected]
•
PCCM Provider Relations THSteps representatives at 1-512-421-3070.
PCCM also offers appointment assistance for those providers who do not want to provide block
appointment times to the call center. Providers can email the PCCM THSteps Provider Team at
[email protected] for additional information.
A PCCM provider who is not enrolled in THSteps but who wants to become a PCCM THSteps
provider can enroll by completing the THSteps Provider Enrollment Application on this website.
“The Provider Enrollment on the Portal” tool is available on the homepage by clicking on the
“Access Provider Enrollment” link under “I would like to” in the right-hand column.
Providers can also download a copy of the paper “THSteps Provider Enrollment Application” available on the TMHP homepage under “Provider Enrollment Forms” in the right-hand column under
the heading titled “Provider Forms.”
26
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
THSteps Medical Checkup
A THSteps Medical checkup is only considered complete if it includes all screenings,
immunizations, and laboratory tests as indicated on the periodicity schedule.
Note: Incomplete medical checkups are subject to recoupment unless there is documentation supporting
why a component was not completed.
The THSteps periodicity schedule specifies screening procedures recommended at each stage of the
client’s life to assure that health screenings occur at age appropriate points in a client’s life.
In the first two years of the client’s life, providers may bill up to nine visits, regardless of the date of
the last medical checkup.
DSHS requires that clients who are 15 years of age or younger be accompanied by a parent,
guardian, or authorized adult to the THSteps medical or dental checkup.
Providers will not be required to submit documentation to TMHP to verify compliance policy
in order for TMHP to process claims. By submitting the claim for reimbursement, the provider
acknowledges compliance with all Medicaid requirements .
The THSteps Online Education Initiative contains a module on the overview of the program as well
as specific modules on the various components.
For more information, refer to the THSteps website at www.txhealthsteps.com.
THSteps Medical Checkup Components must include the following services:
•
Screening Services
•
Comprehensive health and developmental history -- (including assessment of both physical and
mental health development)
•
Comprehensive unclothed physical exam
•
Appropriate immunizations -- (according to the schedule established by the Advisory
Committee on Immunization Practices (ACIP) for pediatric vaccines);
•
Laboratory tests -- Identify as statewide screening requirements the minimum laboratory tests
or analyses to be performed by medical providers for particular age or population groups
–– Lead Toxicity Screening
The expected required components of a medical checkup must be age-appropriate and must include
the following:
•
•
•
•
•
•
•
Comprehensive health history
Comprehensive unclothed physical examination
Blood pressure
Nutritional screening
Developmental screening
Mental health screening
Sensory screening
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
27
THSteps Medical Participant Guide
•
•
•
•
Vision screening
Hearing screening
Tuberculosis screening
Laboratory testing
•
–– Lead screening, and other age appropriate tests
Administration, as necessary
–– Immunizations
•
–– Status
Dental referral
•
Anticipatory guidance
Comprehensive Health History
The first required component of a THSteps Medical checkup is the Comprehensive Initial Health
History which should include the following:
•
Neonatal history (for children under 5 years of age)
•
Physical
•
Mental health
•
Developmental
•
Medical history
The interim health history must be reviewed at each subsequent periodic examination and must be
appropriate for the specific age of the patient and past medical history.
Comprehensive unclothed Physical examination
A complete physical examination is required at each visit, with infants totally unclothed and older
children undressed and suitably draped.
Height for children 3 through 20 years of age, weight for children birth through 20 years of age,
and length for children birth through 24 months of age must be measured. Body Mass Index (BMI)
for children 2 through 20 years of age must be calculated and must be compared with the National
Center for Health Statistics growth charts to identify significant deviations from norms. This exam
should include:
28
•
Fronto-occipital circumference measurement required at every visit birth through 24 months.
•
Blood pressure recorded anually beginning at 3 years of age.
•
A complete physical exam with oral dental exam.
•
Close attention to pallor, and apathy to determine nutritional status.
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Nutritional Screening
Nutritional Screening is a required component of each medical checkup
Nutritional Screening includes examples such as:
•
Assess risk factors for eating disorders and obesity.
•
A complete physical screen with oral dental screen, paying attention to general features, such as
pallor, and apathy are important for determining nutritional status.
•
Screening for anemia as noted on the periodicity schedule or as indicated at other visits.
Note: Children from birth through 35 months of age may also need to be referred to the Early Childhood
Intervention (ECI) program.
Developmental Screening
Developmental screening is a required component of each medical checkup for clients who are birth
through 6 years of age. Developmental screening, as a THSteps medical service, is limited to once
per day per client by the same provider or provider group and are denied unless submitted by the
same provider or provider group for the same date of service as a checkup, exception-to-periodicity
checkup, or follow-up visit. For clients 9 months through 4 years of age, the medical checkups must
include the standardized developmental screenings detailed in the following table. Providers may be
reimbursed for the screens in addition to the checkup visit.
Required Screening Ages and Tools
Screening Ages
Developmental Screening Tools
Autism Screening Tools
9 months
Ages and Stages Questionnaire
(ASQ) or Parents’ Evaluation of
Developmental Status (PEDS)
1 year
ASQ or PEDS (if not
completed at 9 months or with
provider/parental concern)
18 months
ASQ or PEDS
Modified Checklist for Autism
for Toddlers (MCHAT)
24 months
ASQ or PEDS
MCHAT if not completed at 18
months or with provider/ parental concern.
30 months
ASQ or PEDS (if not completed
at 24 months or with provider/
parental concern)
3 years
ASQ, Ages and Stages Questionnaire‑SE (ASQ‑SE), or PEDS
4 years
ASQ, ASQ‑SE, or PEDS
If a developmental or autism screening that is required in the Required Screening Ages and Tools
table is missed, the provider must complete the missed standardized screening at the next checkup.
The provider must also complete a standardized screening when seeing a client who is 6 months
through 6 years of age for the first time.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
29
THSteps Medical Participant Guide
If a provider administers a standardized developmental screening at additional checkups other
than those listed in the Required Screening Ages and Tools table, the provider must document the
rationale for the additional screening, which may be due to provider or parental concerns.
An Early Childhood Intervention (ECI) program serves clients who are birth through 35 months of
age with disabilities or developmental delays. Federal and state laws require a referral be made to an
ECI program within 2 business days of identifying a possible developmental concern.
Note: Refer to the current Texas Medicaid Provider Procedures Manual and/or Medicaid bulletins
for more detailed policy information regarding developmental screening.
Mental Health Screening
Mental Health screening is a required component of the THSteps screen.
Whenever a mental health crisis is suspected, every effort must be made to secure a prompt mental
health evaluation and any medically necessary treatment for the client.
•
An emergency mental health referral for evaluation and/or treatment must always be made
when any of the following are identified during a mental health screening:
–– Suicidal thoughts, threats, or behaviors
–– Homicidal thoughts, threats, or behaviors
•
When the clinician conducting the mental health screen has the appropriate training and
credentials to conduct the mental health evaluation and provide the mental health treatment
(mental or behavioral health problems, mental illnesses, or substance abuse or dependence), the
clinician may choose to provide the mental health services or refer the client to an appropriate
clinician. Clinicians who do not have these qualifications must refer clients to a qualified
mental health specialist for such care.
Providers may use the optional age-based Mental Health Questionnaire which may be found in the
TMPPM.
For concerns about social or emotional development in children birth to 35 months, providers must
refer the client to ECI.
Sensory Screening
Vision screening
Appropriate vision screening is a required component of each medical checkup visit. The screening
must be appropriate to the age, ability, and cooperation of the child.
•
Children from birth through 35 months of age must be referred to Early Childhood
Intervention (ECI) if vision problems are identified.
•
Referral, as indicated, for vision exam/eyewear services, eye examinations are available once per
state fiscal year.
•
Refer to TMPPM for additional requirements.
Hearing Screening
Hearing screening is also a required component at each medical checkup.
30
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
•
Results of Audiometric testing done as part of a school screening program, IF KNOWN, are
acceptable and need not be duplicated, but are to be noted in the patient’s chart or checkup
record if the results are within 12 months of the medical checkup.
•
Children from birth through 35 months of age must also be referred to Early Childhood
Intervention (ECI)
Note: Referral for a hearing aid should only be done after a complete hearing examination by an
audiologist or other qualified provider. The referral can only be by a physician, and must use The
Physician’s Examination Report form.
Effective September 1, 2009, the Program for Amplification for Children of Texas (PACT) is no
longer administered by the Department of State Health Services (DSHS). The hearing services
benefits previously administered through PACT was transitioned to the Health and Human
Services Commission (HHSC) for Texas Medicaid benefits and DSHS-Children with Special
Health Care Needs (CSHCN) Services Program for CSHCN Services Program benefits. Hearing
services available to children is now administered by the Texas Medicaid & Healthcare Partnership
(TMHP). Effective May 2009, TMHP began to reach out to providers who were currently
contracted with DSHS to provide PACT services to Texas Medicaid and CSHCN Services Program
clients. TMHP sent these providers information about how the program would be administered,
how to enroll with Texas Medicaid and the CSHCN Services Program (for those providers not
currently enrolled in one or both programs), and how to obtain reimbursement under the new
administration of the program.
For more information go to: http://www.tmhp.com/C18/Hearing%20Services/
Tuberculosis (TB) Screening
Tuberculosis Screening is a required component of the THSteps Medical checkup. In areas of low
TB prevalence, administer the Tuberculosis (TB) Screening and Education Tool annually beginning
at 1 year of age. In areas of high prevalence, administer the TB skin test at 1 year of age, once
between 4 years of age through 6 years of age, and once between 11 years of age through 17 years of
age. Administer the TB Questionnaire annually beginning at 2 years of age and thereafter at other
medical checkups. The TB Questionnaire is available in the Texas Medicaid Provider Procedures
Manual (TMPPM). This screening must be completed by following the TB questionnaire or
according to the county of residence.
TB questionnaire -available in current TMPPM- developed by the DSHS Infectious Disease
Control Unit to determine if the child or adolescent is at high risk for contracting tuberculosis and
needs skin testing.
TB screenings are administered based on county of residence:
•
High and low prevalence counties have different screening requirements.
–– In areas of low TB prevalence, administer the Tuberculosis (TB) screening and Education
Tool annually beginning at 1 year of age.
–– In areas of high prevalence, administer the TB skin test at 1 year of age, once between 4
years of age through 6 years of age, and once between 11 years of age through 17 years of
age. Administer the TB Questionnaire annually beginning at 2 years of age and thereafter
at other medical checkups. A listing of counties with a high prevalence for TB is available
at: www.dshs.state.tx.us/idcu/disease/tb/statistics/hiprev/default.asp.
–– Or by calling the TB Program at 1-512-458-7447.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
31
THSteps Medical Participant Guide
Laboratory Testing
Laboratory testing is a required component of THSteps Medical checkup and is performed in
accordance with the age and frequency specified on the THSteps Medical checkup periodicity
schedule. All required lab tests for THSteps periodic visits are to be sent to the DSHS lab unless
otherwise noted.
The date of service for the laboratory testing is to be the date the specimen was obtained as part of
the medical checkup, follow-up visit, or exception-to-periodicity visit.
Lead Screening:
In accordance with federal regulations, lead screening is required:
•
By mandatory blood lead testing at 12 and 24 months of age and based on provider discretion
or parent’s concerns.
And
•
By questionnaire at:
–– 6, 15, 18 months.
–– 3 years of age.
–– Annually until 6 yrs of age.
Immunizations
Immunizations are also a part of the THSteps Medical checkup. The child’s immunization status
must be screened and updated, if appropriate, as part of the THSteps Medical Checkup according
to the Recommended Childhood and Adolescent Immunization Schedule for the United States
(based on recommendations by Advisory Committee on Immunization Practices [ACIP]).
The provider completing the checkup is responsible for the administration of immunizations unless
medically contraindicated or excluded from immunizations for reasons of conscience including
religious beliefs.Providers must not refer clients to the local health department or other entities.
Vaccine Information Documentation forms are available from the DSHS immunization Branch at
1-800-252-9152.
Dental Referral
Access to THSteps dental services is mandated by Texas Medicaid and provides reimbursement
for the early detection and treatment of dental health problems for Medicaid clients from birth
through 20 years of age. The limited oral screening by the medical provider, as required within the
comprehensive THSteps physical examination, must occur at all THSteps Medical checkups.
Dental screening is a part of the medical checkup physical examination and must include:
32
•
Inspection of teeth for signs of early childhood caries, and other caries.
•
Inspection of the oral soft tissues for any abnormalities.
•
Anticipatory guidance to include:
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
–– The need for thorough daily oral hygiene practices.
–– Potential gingival manifestations for clients with diabetes and clients under long-term
medications therapy. Information that THSteps eligibility qualifies the client for dental
services.
Dental providers should follow the periodicity schedule for dental exams and referrals:
•
•
At 6 months of age, a client should be referred to a dental home.
From 6 through 35 months of age, a client may be seen once every 3 months based on their
caries risk assessment.
• At 36 months through 20 years of age, a client may be seen at 6-month intervals.
• Clients may be referred to a dental provider beginning at 6 months of age or at any age if the
medical checkup identifies medical necessity.
Note: Emergency dental services are NOT subject to periodicity and may be accessed as needed.
For more information see the dental referral module available at www.txhealthstep.com.
DSHS Legislative Dental Initiatives
•
First Dental Home
•
Oral Evaluation and Fluoride Varnish in the medical home
Dental Referral Process and Guidelines
The medical checkup provider must initiate the referral for a comprehensive THSteps dental
checkup by a THSteps participating dentist, starting at 6 months of age and at six-month intervals
thereafter (unless unusual circumstances and/or medical necessity dictate more frequent dental
checkups).
The medical checkup provider can assist with selection of a dental provider however the dental
provider must be the client’s choice. A formal “referral” is NOT needed in order for a child to
receive THSteps dental services but should be documented on the child’s record. Clients or their
parent/guardian may self-refer.
If the medical checkup identifies a need for Dental services for children less than 1 year of age, a
referral to a THSteps dentist should be made.
Anticipatory Guidance
Another required THSteps checkup component is health education and anticipatory guidance.
Health education is a federally mandated component of the THSteps Medical checkup and includes
anticipatory guidance of what to expect in the next stages in life.
Face-to-face health education and counseling with parents or guardians and clients are required
to assist parents in understanding what to expect in terms of the client’s development and to
provide information about the benefits of healthy lifestyles and practices, and accident and disease
prevention. Anticipatory guidance may also include topics such as dental health, sleep, feeding and
nutrition and exposure to environmental hazards. Written material also may be given but does not
replace face-to-face counseling.
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33
THSteps Medical Participant Guide
THSteps Medical
Checkup Schedule
(Periodicity Schedule)
The Periodicity Schedule is a schedule of medical checkups based on the American Academy of
Pediatrics (AAP) Recommendations for Pediatric Preventive Healthcare. THSteps clients are
eligible for medical checkup services based on the THSteps Medical checkups periodicity schedule.
•
The schedule outlines checkup components such as: laboratory tests, and immunizations that
should be performed according to the age of the client.
Note: The periodicity schedule has been modified based on the scheduling of laboratory tests in federal
EPSDT or state regulations.
Providers should schedule checkups to conform as closely as possible to the ages on the
periodicity schedule while allowing flexibility to accommodate the needs of clients and parents or
caregivers. The due date for medical checkups are based on the child’s date of birth. The Medicaid
Identification Form H3087, issued the month after the client’s birthday, will indicate when the
patient is due for a checkup.
A THSteps statement under the client’s name on the regular client Medicaid ID indicates the
THSteps services for which the client is currently eligible.
•
Four new checkups have been added to the THSteps Periodicity Schedule for the following
ages:
–– 3 to 5 days of age
–– 30 months of age
–– 7 years of age
–– 9 years of age
–– A blank space denotes that the client is not eligible for the particular service based on
available data.
•
This schedule allows for 7 visits birth through 11 months; 7 visits 12 months-4 years; 7 visits
5-11 years, 6 visits 12-17 years, and 3 visits 18-20 years.
•
A check mark on the identification form indicates eligibility for the particular service, such as
an eye exam, eye glasses, hearing aid, dental, prescriptions, and medical services.
Eligibility for a medical checkup can also be verified by accessing TexMedConnect or calling the
TMHP Contact Center.
•
TMHP Contact Center: 1-800-925-9126
•
TexMedConnect: http://www.tmhp.com
THSteps providers must follow the guidelines listed below:
34
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THSteps Medical Participant Guide
•
If providing services to a Foster Care child, providers should follow STAR Health guidelines.
•
THSteps reminders on Medicaid cards are claims driven; claims need to be submitted and
processed in a timely manner before the reminder is updated.
•
If a checkup has been performed, they must not perform another one, even though it is
outstanding on the H3087 form. The only exception is if the checkup meets the guidelines for
an exception to the schedule.
•
When a THSteps Medical checkup is provided, note it on the H3087, by writing the provider’s
name and date it was performed. Keep a copy of the H3087 in the medical record.
•
Providers can verify Medicaid Fee-for-Service patient eligibility by checking the H3087 to
ensure it is current. The TMHP Contact Center to can also confirm if a checkup has been
performed.
•
To verify STAR Health (Foster Care Managed Care) patient eligibility, verify that the H3087 is
up-to-date and that the THSteps Medical checkup reminder is present or providers can call the
Superior HealthPlan Network.
Exception to Periodicity
THSteps Medical checkups may be done in some cases outside of the specified age or time frames
but are still complete checkups and include all the components on the periodicity schedule for the
age at the visit. In this case, submit a claim as a routine medical checkup if the checkup is due,
rather than as an exception.
Payment is made for medical checkups that are exceptions to the periodicity schedule to allow for
services under the following categories:
•
Medical Necessity (such as: developmental delay, suspected abuse or other medical concerns)
•
State or federal exam requirements for pre-adoption, Head Start, daycare, Early Childhood
Intervention, and foster care
•
Dental services provided under general anesthesia
•
Environmental high-risk (for example, sibling of a child with elevated blood lead levels)
•
Children who may not be available for the next scheduled checkup, including children of
migrant or seasonal workers
Note: School sports physicals are NOT reimbursable. If the client is eligible for regular periodic medical
checkup, a complete medical checkup should be performed.
Billing Exceptions to Periodicity
Claims for periodic THSteps Medical checkups exceeding periodicity include one of the following
modifiers or the claim will be denied.
•
SC - Medically necessary service or supply
•
23 - Unusual Anesthesia. Occasionally, a procedure that usually requires either no anesthesia or
local anesthesia must be done under general anesthesia because of unusual circumstances. This
circumstance may be reported by adding the modifier “-23” to the procedure code of the basic
service or by use of the separate 5-digit modifier code 09923.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
35
THSteps Medical Participant Guide
•
32 - Mandated Services. Services related to mandated consultation and/or related services (e.g.,
PRO, third party payer, governmental, legislative, or regulatory requirement) may be identified
by adding the modifier “-32” to the basic procedure.
Follow-Up Visit
A follow-up visit may be required to complete necessary procedures related to THSteps such as:
•
•
•
Reading a skin test (TB Test)
Immunizations not administered because of contraindications or not up-to-date
Lab work (unsatisfactory specimen, specimen was unable to be processed for some reason, or
was not obtained at the checkup)
• Other components not previously completed
When providers bill a follow-up visit they must not bill on the same day as a THSteps visit. Also,
visits to follow up on treatment initiated during the screen or to make a referral must not be filed as
a THSteps follow-up visit.
A THSteps follow-up medical checkup visit must be billed with a provider NPI number (including
taxonomy code, address, and benefit code). TOS S, using code 99211, along with diagnosis code
V202. Federally Qualified Health Centers must bill with EP modifier.
THSteps Medical Checkup
Billing Guidelines
THSteps providers must bill using the provider 10 digit NPI and the 9 digit TPI for paper claims,
taxonomy, address, and THSteps benefit code.
Modifiers
One of the following modifiers must accompany the checkup code:
• AM-Physician
• SA-Nurse Practitioner
• TD-Registered Nurse
• U7-Physician’s Assistant
FQHC providers must bill all THSteps visits with modifier EP in addition to the modifiers used to
identify who performed the checkup.
Diagnosis
Diagnosis on THSteps claims should always be V202- routine well child exam.
36
•
Provider can submit the applicable diagnosis code, in addition to the V202
•
The decimal point is not needed if the provider bills electronically through TexMedConnect.
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
•
The provider should check with their software vendor as to whether or not to use V202 or the
decimal version.
Referrals and Primary Care Provider Communication
THSteps encourages the provision of the checkup within the medical home. However, THSteps is
a self referred service, so a primary care provider referral isn’t required. In cases of acute illness, the
provider must contact the primary care provider for referral or direction in managed care areas.
The provider performing the THSteps Medical checkup must share the results with the primary
care provider so they can maintain the medical home.
The referral code is used in conjunction with the Condition Indicator and states whether a referral
was made.
•
Y – referral made (used with Condition Indicators S2 and ST).
•
N – no referral made (used with Condition Indicator NU).
Condition Indicator Codes must be used to indicate if a referral was made. The codes are:
•
NU- no referral made. Practitioner performed a THSteps Medical checkup and identified no
other acute or chronic condition.
•
S2- referral made. Practitioner performed a THSteps Medical checkup and during the
comprehensive exam documents an existing/known condition. Practitioner may provide
additional treatment for the condition, or treatment for another newly identified condition.
(example otitis media needing prescription but not requiring an additional office visit to
diagnose to begin treatment).
•
ST – referral made. Practitioner performed a THSteps Medical checkup and during the
comprehensive exam identifies a new/unknown condition or an existing/known condition
needing further diagnosis or treatment. Practitioner refers the patient to a different provider
who is qualified to perform diagnostic or treatment services, or requests the patient to return
for further diagnosis and treatment.
–– Includes only those referrals for which the child was referred to the same or different
provider for another appointment. Does not include treatment initiated at the time of
the visit.
Immunization and Administration Codes
If only one immunization is administered during a checkup, providers should bill procedure code
90471/90473 or 90465/90467 with a quantity of 1 in addition to the appropriate national code
that describes the immunization administered.
If two or more immunizations are administered, providers should bill procedure code 90471/90473
or 90465/90467 with a quantity of 1, and procedure code 90472/90474 or 90466/90468 with a
quantity of 1 or more (depending on the number of vaccines administered), and the appropriate
CPT codes that describe each immunization administered.
The procedure codes that identify each vaccine are considered informational but are required
on the claim, however there must be a one-to-one match with the administration code or the
administration code will be denied.
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37
THSteps Medical Participant Guide
Immunization administration codes are reimbursed based on a scale according to the number of
state-defined components being administered. (See Medicaid Bulletin 209 pg. 158 or the TMPPM
for further information).
•
The provider must bill an administration fee without a modifier when a vaccine/toxoid with
one state-defined component is administered.
•
The provider must bill an administration fee with state-defined modifier U2 when a vaccine/
toxoid with two state-defined components is administered.
•
The provider must bill an administration fee with state-defined modifier U3 when a vaccine/
toxoid with three state-defined components is administered.
•
Modifier U2 or U3 must be used only with the administrative procedure code that pertain to
the vaccine with the appropriate state-defined component. If more than one vaccine is given
that contains different state-defined components, the administrative codes must be submitted
on separate details. For example: Example 90698 contains 3 state-defined components and
90633 contains 1 state-components. The provider would submit two separate details, one detail
with administrative procedure code with U3 modifier, and one administrative procedure code
without a modifier.
Immunizations
For Medicaid clients who are birth through 18 years of age, the Texas Vaccines for Children
(TVFC) program provides free vaccines through local health departments.
•
Medicaid will not reimburse for vaccines available from the TVFC program.
•
Providers must enroll with Texas Vaccine for Children Program to obtain free vaccines.
•
A THSteps periodic visit (THSteps services must be billed with TOS S.) or an acute medical
visit outside of a THSteps periodic visit (TOS-1)
Use the U1 modifier when billing for a vaccine/toxoid not available through TVFC or purchased
privately and as part of a checkup the modifier goes with the vaccine CPT code not the
administration code
•
“Not available” is defined as:
–– A new vaccine approved by the ACIP has not been negotiated or added to a TVFC
contract.
–– Funding for new vaccine has not been established by TVFC.
–– National supply and /or distribution issues.
–– Distribution issues will come via TVFC.
Vaccines or toxoids for clients 19 years of age through 20 years of age may be reimbursed through
THSteps or Acute Medical Visit if the services are provided as part of:
• A THSteps periodic visit (THSteps services must be billed with TOS S.) or an acute medical visit
outside of a THSteps periodic visit (TOS-1)
Immunizations for RHC and FQHC providers are considered inclusive of the encounter and are
not reimbursed separately.
38
•
RHC providers should bill with place of service 72.
•
FQHC’s should bill with modifier EP.
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Immunization administration codes are reimbursed based on a scale according to the number of
state-defined components being administered (see Bulletin 209 pg. 158 for further information);
except for RHC and FQHC, considered inclusive.
•
The provider must bill an administration fee without a modifier when a vaccine/toxoid with
one state-defined component is administered. A vaccine/toxoid billed without a modifier will
be reimbursed at $8.00.
•
The provider must bill an administration fee with state-defined modifier U2 when a vaccine/
toxoid with two state-defined components is administered. A vaccine/toxoid billed with
modifier U2 will be reimbursed at $12.00.
•
The provider must bill an administration fee with state-defined modifier U3 when a vaccine/
toxoid with three state-defined components is administered. A vaccine/toxoid billed with
modifier U3 will be reimbursed at $16.00.
•
TVFC providers may not bill in excess of $14.85 for administration fees for clients who are
birth through 18 if the vaccine was obtained from TVFC.
•
Providers cannot charge Medicaid clients or Medicaid for vaccines provided through
TVFC. Use the U1 modifier when billing for a vaccine/toxoid not available through TVFC.
Immunization policy does not allow the option to privately purchase a vaccine unless it is
unavailable from TVFC.
Billing Immunizations and Services Outside of THSteps
Providers must use their acute care 10 digit NPI, taxonomy, and physical address when billing
outside of THSteps Medical checkups. All Paper claim submissions must be submitted with NPI
and TPI.
If two or more immunizations are administered, providers should bill procedure code 90471
(90465) or 90473 (90467) with a quantity of 1, and procedure code 90472 (90466) or 90474
(90468) with a quantity of 1 or more (depending on the number of vaccines administered), and the
appropriate national codes that describe each immunization administered.
Immunization administration codes are reimbursed based on a scale according to the number of
state-defined components being administered (see Bulletin 209 pg. 158 for further information);
except for RHC and FQHC, considered inclusive.
Use the U1 modifier when billing for a vaccine/toxoid not available through TVFC or purchased
privately and as part of a checkup. Note that the modifier goes with the vaccine CPT code, not the
admin code.
•
“Not available” is defined as:
–– A new vaccine approved by the ACIP has not been negotiated or added to a TVFC
contract.
–– Funding for new vaccine has not been established by TVFC.
–– National supply or distribution issues.
Billing Acute Care and Medical Check-up on Same Day
An office visit can be billed in addition to a THSteps Medical checkup, if the additional evaluation
and treatment is required and performed for the identified condition. This additional service is
billed as an acute care claim to the Texas Medicaid Program and is considered a stand-alone service.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
39
THSteps Medical Participant Guide
Providers must submit a separate claim for an established patient office visit billed on the same day
as the THSteps Medical checkup. This additional claim requires an appropriate established patient
procedure code for the diagnosis and treatment of the identified problem.
If the provider performing the medical checkup can provide treatment for an identified condition,
a separate claim (CMS-1500 or UB-04 CMS-1450) may be submitted for the same DOS as the
checkup with an appropriate established patient office visit for the diagnosis and treatment of the
identified problem.
For the acute care claim, the documentation in the clients record must support an appropriate
level CPT code for E/M of established clients should be selected with the diagnosis supporting this
additional billing.
Not all minor illnesses or conditions, such as follow-up of a mild upper respiratory infection,
identified during the THSteps Medical checkup warrant additional billing.
The billing of an additional office visit is only appropriate if the additional evaluation and treatment
is required and performed for the identified condition(s).
Please refer to the TMPPM for the appropriate procedure codes.
Third Party Resources
Providers are not required to bill TPR when billing THSteps Medical and Dental, Case
Management for Children and Pregnant Women, and Family Planning services. TMHP will seek
payment from the other insurance (OI) source. If the provider chooses to bill the OI, the provider
must follow these rules: Claims involving OI, including Medicare must be received within 95
days of the date of disposition. When a service is billed to a third party and no response has been
received, the provider must allow 110 days to elapse before submitting a claim to TMHP; however,
the federal 365-day filing requirement must still be met.
40
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Claims Filing
Claims
Claims can be filed electronically or by paper. Many claims are submitted to TMHP electronically
through TexMedConnect. When providers file claims electronically, claims are processed more
quickly and accurately resulting in faster reimbursement.
Providers billing for dental services and Intermediate Care Facility for Persons with Mental
Retardation (ICF-MR) dental services may bill electronically or use the 2006 American Dental
Association (ADA) claim form.
Benefit Code
A benefit code is an additional data element used to identify state programs.
Providers that participate in the following programs must use the associated benefit code when
submitting claims and prior authorization requests:
Program
Benefit Code
THSteps Medical
EP1
THSteps Dental
DE1
Electronic Claims
Providers that submit electronic claims are required to complete the Benefit Code field (when
applicable), Address field, and Taxonomy Code field.
Group billing providers are not required to submit a taxonomy code on all electronic claims.
Billing providers that are not associated with a group are required to submit a taxonomy code on
all electronic claims. TMHP will reject claims for non-group billing providers (individuals and
facilities) that are submitted without a taxonomy code.
Claims may be submitted electronically to TMHP through billing agents who interface directly
with the TMHP EDI Gateway. Providers must retain all claim and file transmission records, which
may be required for pending research on missing claims or appeals.
Electronic Claim Acceptance
Providers should verify that their electronic claims were accepted by Texas Medicaid for payment by
referring to their Claim Response report. Providers should also check their Accepted and Rejected
reports for additional information. Only claims that have been accepted and appear on the Claim
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
41
THSteps Medical Participant Guide
Response report (27S file) will be considered for payment and made available for claim status
inquiry. Rejected claims must be corrected and resubmitted for payment consideration.
Resubmission of TMHP Electronic Data Interchange Rejections
To meet the filing deadline, providers that receive a TMHP Electronic Data Interchange (EDI)
rejection may resubmit an electronic claim within 95 days of the date of service (DOS). A paper
appeal may also be submitted with a copy of the rejection report within 120 days of the rejection
report. A copy of the rejection report must accompany each corrected claim that is submitted on
paper.
Claim Filing Instructions for TexMedConnect
1. Go to the TMHP website at www.tmhp.com.
2. Click the link, “Access TexMedConnect.”
3. Log into the system and enter username and password.
4. Select Claims Entry from the navigation panel on the left hand side of the screen.
5. Select the appropriate billing provider information.
A list of NPI/API and related data such as taxonomy, physical address, and benefit code
selections will be displayed.
6. Enter the Medicaid Identification number for the claim (optional).
The system populates most of the required fields on the Client tab.
Note: If the Medicaid Identification number is not entered, all required fields must be entered
manually on the Client tab.
7. Select the claim type from the drop-down menu.
8. Click Proceed to Step 2.
The Claims Entry screen appears for the selected claim type.
9. Proceed through each tab and enter claim information.
42
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
10. On the “Other Insurance/Submit Claim” tab, select the source of payment.
11. Read the terms and conditions and check the “We Agree” box.
12. Click Submit.
Note: The TexMedConnect Acute Care user manual can be found at:
http://www.tmhp.com/File%20Library/File%20Library/Provider%20Manuals
/TexMedConnect/TexMedConnect%20Acute%20Care%20manual.pdf
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
43
THSteps Medical Participant Guide
Saving a Claim
Claims cannot be submitted until all required information has been entered correctly. The following
message screen appears if the information has been entered incorrectly.
Error fields are indicated with red exclamation marks.
Once all required fields have been completed, the claim can be submitted by clicking on the last
tab, “Other Insurance/Submit Claim.”
At the bottom of the screen, four choices will be available:
•
Save Draft: Adds claim to the draft list for completion at a later time.
•
Save Template: Adds claim to the template list for quicker claims creation in the future.
•
Save to Batch: Adds claim to the pending claims list for batch submission.
•
Submit: Submits one claim at a time.
Note: After a claim is submitted, an Internal Claim Number (ICN) is generated.
44
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
CMS-1500 Paper Claim Form
CARRIER
1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA
PICA
MEDICARE
MEDICAID
(Medicare #)
(Medicaid #)
TRICARE
CHAMPUS
(Sponsor’s SSN)
GROUP
HEALTH PLAN
(SSN or ID)
CHAMPVA
(Member ID#)
3. PATIENT’S BIRTH DATE
MM
DD
YY
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
OTHER 1a. INSURED’S I.D. NUMBER
FECA
BLK LUNG
(SSN)
(ID)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SEX
M
F
6. PATIENT RELATIONSHIP TO INSURED
Self
CITY
STATE
Child
Spouse
(
7. INSURED’S ADDRESS (No., Street)
Other
8. PATIENT STATUS
STATE
CITY
Single
Married
Other
Employed
Full-Time
Student
Part-Time
Student
TELEPHONE (Include Area Code)
ZIP CODE
(For Program in Item 1)
ZIP CODE
)
TELEPHONE (Include Area Code)
(
)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED’S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (Current or Previous)
a. INSURED’S DATE OF BIRTH
MM
DD
YY
NO
YES
b. OTHER INSURED’S DATE OF BIRTH
MM
DD
YY
b. AUTO ACCIDENT?
SEX
c. EMPLOYER’S NAME OR SCHOOL NAME
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
NO
YES
d. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
10d. RESERVED FOR LOCAL USE
YES
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.
SIGNED
14. DATE OF CURRENT:
MM
DD
YY
If yes, return to and complete item 9 a-d.
NO
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.
DATE
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY(LMP)
F
b. EMPLOYER’S NAME OR SCHOOL NAME
NO
YES
F
M
PLACE (State)
SEX
M
PATIENT AND INSURED INFORMATION
1.
SIGNED
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
DD
YY
MM
DD
YY
MM
DD
YY
GIVE FIRST DATE MM
FROM
TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM
DD
YY
MM
DD
YY
FROM
TO
17a.
17b. NPI
19. RESERVED FOR LOCAL USE
20. OUTSIDE LAB?
YES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
1.
$ CHARGES
NO
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
3.
2.
24. A.
MM
DATE(S) OF SERVICE
From
To
DD
YY
MM
DD
YY
B.
C.
PLACE OF
SERVICE EMG
4.
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
E.
DIAGNOSIS
POINTER
F.
$ CHARGES
H.
G.
I.
J.
RENDERING
PROVIDER ID. #
EPSDT
ID.
Family
Plan QUAL.
DAYS
OR
UNITS
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER
SSN EIN
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
(For
govt. claims, see back)
YES
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
32. SERVICE FACILITY LOCATION INFORMATION
a.
NUCC Instruction Manual available at: www.nucc.org
NPI
b.
NO
28. TOTAL CHARGE
$
29. AMOUNT PAID
30. BALANCE DUE
$
33. BILLING PROVIDER INFO & PH #
NPI
a.
PHYSICIAN OR SUPPLIER INFORMATION
23. PRIOR AUTHORIZATION NUMBER
$
(
)
b.
APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
45
THSteps Medical Participant Guide
Filing Paper Claims
When submitting paper claims, providers, except those on prepayment review, should send paper
claims to TMHP at the following address:
Texas Medicaid & Healthcare Partnership
Claims
PO Box 200555
Austin, TX 78720-0555
Providers on prepayment review must submit all paper claims and supporting medical record
documentation to TMHP at the following address:
Texas Medicaid & Healthcare Partnership
Attention: Prepayment Review MC–A11 SURS
P.O. Box 203638
Austin, Texas 78720-3638
Tips on Expediting Paper Claims
Use the following guidelines to enhance the accuracy and timeliness of paper claims processing.
General requirements
•
All paper claims must be submitted with a Texas Provider Identifier (TPI) and NPI for the
billing and performing providers. All other provider fields on the claim forms require an NPI
only. If an NPI and TPI are not included in the billing and performing provider fields, or if an
NPI is not included on all other provider identifier fields, the claim will be denied.
•
Use original claim forms. Don’t use copies of claim forms.
•
Detach claims at perforated lines before mailing.
•
Use 10 x 13 inch envelopes to mail claims. Don’t fold claim forms, appeals, or correspondence.
•
Don’t use labels, stickers, or stamps on the claim form.
•
Don’t send duplicate copies of information.
•
Use 8 ½ x 11 inch paper. Don’t use paper smaller or larger than 8 ½ x 11 inches.
•
Don’t mail claims with correspondence for other departments.
Data Fields
46
•
Print claim data within defined boxes on the claim form.
•
Use black ink but not a black marker. Don’t use red ink or highlighters.
•
Use all capital letters.
•
Print using 10-pitch (12-point) Courier font. Don’t use fonts smaller or larger than 12 points.
Don’t use proportional fonts, such as Arial or Times Roman.
•
Use a laser printer for best results. Don’t use a dot matrix printer, if possible.
•
Don’t use dashes or slashes in date fields.
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Attachments
•
Don’t use paper clips, glue, tape, or staples. on claims or appeals if they include attachments.
•
Place the claim form on top when sending new claim, followed by any medical records or other
attachments.
•
Number the pages when sending attachments or multiple claims for the same client
(e.g., 1 of 2, 2 of 2).
•
Don’t total the billed amount on each claim form when submitting multipage claims for the
same client.
•
Submit claim forms with R&S Reports.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
47
THSteps Medical Participant Guide
Appeals
Appeal Methods
An appeal is a request for reconsideration of a previously
dispositioned claim. Providers may use one of three
methods to appeal Medicaid claims:
•
Electronic
•
AIS
•
Paper
2. A second-level appeal is a provider’s final appeal to
HHSC for a claim that meets all of the following
requirements:
–– Claim has been denied or adjusted by TMHP.
–– Claim has been appealed as a first-level appeal to
TMHP.
–– Claim has been denied again for the same
reason(s) by TMHP.
TMHP must receive all appeals of denied claims and
requests for adjustments on paid claims within 120 days
from the date of disposition of the R&S Report. If the
120-day appeal deadline falls on a weekend or holiday, the
deadline is extended to the next business day.
When appealing a claim, providers must first identify the
reason the claim was denied and either correct the claim
data or submit additional documentation supporting the
appeal request.
Standard administrative requests and medical appeals must
be sent first to TMHP or the claims processing entity as a
first-level appeal. After the provider has exhausted all aspects
of the appeals process for the entire claim, the provider may
submit a second-level appeal to HHSC.
This appeal is submitted by the provider to HHSC, which
may subsequently require TMHP to gather information
related to the original claim and the first-level appeal.
HHSC is the sole adjudicator of this final appeal.
All providers must submit second-level administrative
appeals and exceptions to the 95-day filing deadline appeals
to HHSC at the following address:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code 91X
PO BOX 204077
Austin, Texas 78720-4077
1. A first-level appeal is a provider’s initial administrative
or medical appeal of a claim that has been denied or
adjusted by TMHP. This appeal is submitted by the
provider directly to TMHP for adjudication and must
contain all required information to be considered.
Detailed instructions are found in the TMPPM
48
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— 2010_0609_v1.4
THSteps Medical Participant Guide
Electronic Appeals
Claims with a finalized status can be appealed directly from TexMedConnect through the TMHP
website at www.tmhp.com. To appeal a claim, follow these steps:
1. Click Appeals in the left navigation panel.
Note: The user must have appropriate security rights to access this section.
2. Enter the claim number to appeal.
Note:If the claim number is not known, enter information about the claim and click Search. If a match is
found, the CSI Search Details screen will appear.
3. Click Appeal Claim to continue the appeal process.
4. Most fields populate with the claim information.
Note: The claim information can be modified for the appeals. Verify that all required fields are completed
5. Select Appeal type: Adjustment or Void
6. Verify that all required fields are completed
NOTE: Not all fields are copied from the R&S or CSI
7. Make changes to the claim data as appropriate to the reason for the appeal being submitted.
8. Read the certification, terms, and conditions and check the We Agree box.
9. The appeal can be submitted or saved as a draft or saved to batch, “Submit Claim.”
Note: If the appeal is successfully submitted an ICN number is generated. If there are errors on the appeal,
error messages will appear. If necessary, correct the error and re-submit the appeal.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
49
THSteps Medical Participant Guide
Automated Inquiry System (AIS) Appeals
The following appeals may be submitted using AIS:
•
Client Eligibility: The client’s correct Medicaid Identification number, name, and date of birth
are required.
•
Provider Information (Excluding Medicare Crossovers): The correct provider identifier is
required for the billing provider, performing provider, referring provider, and limited provider.
The name and address of the provider are required for the facility and outside laboratory.
•
Claim Corrections: Providers may correct the following:
–– Patient control number (PCN)
–– Date of birth
–– Date of onset
–– X-ray date
–– Place of service (POS)
–– Quantity billed
–– Prior authorization number (PAN)
–– Beginning DOS
–– Ending DOS
The following appeals may not be appealed through AIS:
•
Claims listed on the R&S Report as Incomplete Claims
•
Claims listed on the R&S Report with $0 allowed and $0 paid
•
Claims that require supporting documentation (for example, operative report, medical records,
home health, hearing aid, and dental X-rays)
•
Diagnosis related groups (DRG) assignment
•
Procedure code, modifier, or diagnosis code
•
Medicare crossovers
•
Claims listed as pending or in process with EOPS messages
•
Claims denied as past filing deadline except when retroactive eligibility deadlines apply
•
Claims denied as past the payment deadline
•
Inpatient hospital claims requiring supporting documentation
•
TPR/OI
Providers may appeal these denials either electronically or on paper.
Refer to: “Disallowed Electronic Appeals” in the latestTexas Medicaid Provider Procedures Manual
to determine whether these appeals can be billed electronically. If these appeals cannot be billed
electronically, a paper claim must be submitted.
50
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
AIS Automated Appeals Guide
To access the AIS automated appeals guide, providers can call 1-800-925-9126 (1-800-568-2413
for CSHCN Services Program). Providers may submit up to 3 fields per claim and 15 appeals
per call. If during any step invalid information is entered 3 times, the call transfers to the TMHP
Contact Center for assistance.
Paper Claim Appeals
After determining a claim cannot be appealed electronically or through AIS, appeal the claim on
paper by completing the following steps:
1. Copy the page of the R&S Report where the claim is paid or denied. A copy of other official
notification from TMHP may also be submitted.
2. Circle one claim per R&S Report page in black or blue ink.
3. Identify the reason for the appeal.
4. If applicable, indicate the incorrect information on the claim, and provide the corrected
information that should be used to appeal it.
5. Attach a copy of any supporting medical documentation that is required or has been requested
by TMHP.
6. Attach a completed claim form.(Optional effective 2/5/2010).
Reminder: Do not copy supporting documentation on the opposite side of the R&S Report.
Note: It is strongly recommended that providers maintain a copy of the paper appeal being sent. It is also
recommended that paper documentation be sent by certified mail with a return receipt requested. This
documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were
received by TMHP, which is important if it is necessary to prove that the 120-day appeals deadline has
been met. If a certified receipt is provided as proof, the certified receipt number must be indicated on the
detailed listing along with the Medicaid number, billed amount, DOS, and a signed claim copy. The
provider may need to keep such proof regarding multiple claims submissions if the provider identifier is
pending.
Medicare crossovers and inpatient hospital appeals related to medical necessity denials or DRG
assignment/adjustment must be submitted on paper with the appropriate documentation.
Submit correspondence, adjustments, and appeals (including routine inpatient hospital claims) to
TMHP at the following address:
Texas Medicaid & Healthcare Partnership
Appeals/Adjustments
PO Box 200645
Austin, TX 78720-0645
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
51
THSteps Medical Participant Guide
HHSC Administrative Appeals
An administrative appeal to HHSC is appropriate when a provider has exhausted the appeals
process with TMHP. This is a request for review of (not a hearing on) claims denied by TMHP
or claims processing entity for technical and nonmedical reasons as defined in Title 1 Texas
Administrative Code (TAC) §354.2201(2). There are two types of administrative appeals:
•
Exception requests to the 95-day claim filing deadline: A provider’s formal written request
for review of (not a hearing on) a claim that is denied or adjusted by TMHP for failure to meet
the 95-day claim filing deadline. This exception should meet the qualifications for one of the
five exceptions listed in the TMPPM and should be submitted directly to HHSC.
•
Standard Administrative Appeal: A provider’s formal written request for review of (not
a hearing on) a claim or prior-authorization that is denied by TMHP for technical and/or
nonmedical reasons.
An administrative appeal must be submitted in writing to HHSC Claims Administrator Contract
Management by the provider that delivered the service or is claiming reimbursement for the service.
The appeal must also be received by HHSC Claims Administrator Contract Management after the
appeals process with TMHP or the claims processing entity has been exhausted, and must contain
evidence of appeal dispositions from TMHP or the claims processing entity.
Providers may submit HHSC administrative appeals to the following address:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
PO Box 204077
Austin, Texas 78720-4077
Medical Necessity Appeals
HHSC Claims Administrator Contract Management only reviews appeals that are received within
18 months from the DOS.
All claims must be paid within 24 months from the date of service as outlined in 1 TAC
§354.1003. Providers must adhere to all filing and appeal deadlines for an appeal to be reviewed by
HHSC Claims Administrator Contract Management. The filing and appeal deadlines are described
in 1 TAC §354.1003.
Medical necessity appeals are defined as disputes regarding medical necessity of services. Providers
must appeal to TMHP and exhaust the appeal/grievance process before submitting an appeal to
HHSC.
52
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Complaints by Providers
A complaint is defined as any dissatisfaction expressed in writing by the provider, or on behalf of
that provider, concerning any aspect of Texas Medicaid.
Complaints to HHSC for Fee-for-Service (FFS) and PCCM
FFS and PCCM providers may file complaints to the HHSC Claims Administrator Contract
Management if they find they did not receive full due process from TMHP in the management of
their appeal. FFS and PCCM providers must exhaust the appeals/grievance process with TMHP
before filing a complaint with HHSC Claims Administrator Contract Management.
The complaints must be in writing and received by HHSC Claims Administrator Contract
Management within 60 calendar days from TMHP’s written notification of the final appeal
decision.
When filing a complaint, a provider must submit a letter that explains the specific reasons the
provider believes the final appeal decision by TMHP is incorrect along with copies of the following
documentation:
•
•
•
•
•
•
•
•
All correspondence and documentation from the provider to TMHP, including copies of
supporting documentation submitted during the appeal process.
All correspondence from TMHP to the provider, including TMHP’s final decision letter.
All R&S Reports of the claims/services in question, if applicable.
Provider’s original claim/billing record, electronic or manual, if applicable.
Provider’s internal notes and logs when pertinent.
Memos from the state or TMHP that indicate any problems, policy changes, or claims’
processing discrepancies that may be relevant to the complaint.
Other documents, such as receipts (i.e., certified mail), original date-stamped envelopes, inservice notes, minutes from meetings, etc., if relevant to the complaint.
Receipts can be helpful when the issue is late filing.
Complaint request for Fee-for-Service and PCCM maybe be mailed to HHSC at the following
address:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code 91X
PO Box 204077
Austin, TX 78720-4077
Complaints to HHSC – Managed Care Providers
Medicaid Managed Care providers (HMOs) may file complaints to HHSC Health Plan Operations
if they find they did not receive full due process from the HMOs. HHSC is only responsible for the
management of complaints from managed care providers. Appeals/griev­ances, hearings, or dispute
resolutions are the responsibility of the health plans. Providers must exhaust their appeals/grievance
process with their health plan before filing a complaint with HHSC.
Managed care providers may send complaints to HHSC at the following address:
Texas Health and Human Services Commission
Re: Provider Complaint
Health Plan Management, H-320
PO Box 85200
Austin, TX 7870
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
53
THSteps Medical Participant Guide
Filing Deadlines
•
New Claims: All claims, except where noted in the provider manuals, must be received within
95 days of the date of service.
•
Other Insurance: Claims involving OI, including Medicare, must be received within 95
days of the date of disposition. When a service is billed to a third party and no response has
been received, providers must allow 110 days to elapse before submitting a claim to TMHP;
however, the federal 365-day filing requirement must still be met.
•
Exceptions
–– THSteps Medical: THSteps medical providers do not have to bill private insurance. They
may bill TMHP directly.
–– THSteps Dental:THSteps dental providers are not required to bill private insurance. They
may bill TMHP directly.
–– Case Management for Children and Pregnant Women (CPW): CPW providers are not
required to bill OI first.
–– Family Planning Services: Providers are not required to bill OI first for FP services due to
confidentiality.
–– Personal Care Services (PCS): PCS providers are not required to bill OI first.
•
Appeals: Must be received within 120 days of the date of the R&S Report on which the denial
appears.
Exceptions to the 95-Day Filing Deadline
The Texas Health and Human Services Commission (HHSC) considers exceptions only when one
of the following situations exists:
1. Catastrophic events that substantially interfere with normal business operations of the
provider, damage to or destruction of the provider’s business office or records by a natural
disaster, or destruction of the provider’s business office or records by circumstances that are
clearly beyond the provider’s control including, but not limited to, criminal activity.
2. Delay or error in the eligibility determination of a client or delay because of erroneous written
information from HHSC, another state agency, or health-insuring agent.
3. Delay because of electronic claim or system implementation problems. Providers that
request an exception based on this circumstance must submit a written repair statement,
invoice, computer or modem generated error reports.
4. Submission of claims within the 365-day federal filing deadline when services are authorized
retroactively.
5. Client eligibility is determined retroactively and the provider is not notified of retroactive
coverage. Providers requesting an exception must include a written, detailed explanation of the
facts and activities that illustrate the provider’s efforts in requesting eligibility information for
the client.
For a complete list of filing deadlines and filing deadline exceptions, please refer to the Texas
Medicaid Provider Procedures Manual.
54
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
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Date of Service
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Note:Ifthe95thor120thdayfallsonaweekendorholiday,thefilingdeadlineisextendedtothenextbusinessday.
95 Days
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Filing Deadline Calendar forFiling
2009 Deadline Calendar for 2010
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95 Days
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120 Days
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THSteps Medical Participant Guide
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
55
THSteps Medical Participant Guide
Remittance and Status Report
The R&S Report provides information on pending, paid, denied, and adjusted claims. TMHP
provides weekly R&S Reports to give providers detailed information about the status of claims
submitted to TMHP. The R&S Report also identifies accounts receivables established as a result
of inappropriate payment. These receivables are recouped from claim submissions. All claims for
the same provider identifier and program processed for payment are paid at the end of the week,
either by a single check or with Electronic Funds Transfer (EFT). If no claim activity or outstanding
account receivables exist during the cycle week, the provider does not receive an R&S Report.
Providers are responsible for reconciling their records to the R&S Report to determine payments
and denials received.
Note: Providers receive a single R&S Report that details Texas Medicaid activities and provides
individual program summaries. Combined provider payments are made based on the provider’s settings
for Texas Medicaid FFS.
Providers must retain copies of all R&S Reports for a minimum of 5 years. Providers must not use
R&S Report originals for appeal purposes but must submit copies of the R&S Reports with appeal
documentation. If claims that are submitted to TMHP on paper or electronically do not appear on
a R&S Report within 2 to 3 weeks of submission, providers must check their EDI Transmission
reports for claim rejections. Paper billers may have had claims returned to them.
R&S Report Delivery Options
TMHP offers three options for the delivery of the R&S Report. Although providers can choose any
of the following methods, a newly-enrolled provider is initially set up to receive a PDF version of
the R&S Report.
•
PDF version: The PDF version of the R&S Report is an exact replica of the paper R&S
Report. The PDF version of the R&S Report can be downloaded by registered users of the
TMHP website at www.tmhp.com. The report is available each Monday morning, immediately
following the weekly claims cycle. Payments associated with the R&S Report are not released
until all provider payments are released on the Friday following the weekly claims cycle.
Providers who use the PDF version will not receive paper copies of the R&S Report.
•
Paper version: Paper R&S Reports can be mailed to providers the Friday following the weekly
claims cycle. Reimbursement checks are mailed with the paper R&S Report, if the provider has
not elected EFT.
Note: Additional copies of paper R&S Reports will be charged to the provider if requested more than
30 days after the original R&S Report was issued. There is an initial charge of $9.75 for the request
(additional hours = $9.75) with a charge of $0.32 per page and applicable sales tax of 8.25 percent.
•
56
ANSI 835: Using HIPAA-compliant EDI standards, the Electronic Remittance & Status
(ER&S) report can be downloaded through the TMHP EDI Gateway using TexMedConnect
or third party software. The ER&S Report is also available each Monday after the completion
of the claims processing cycle.
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Accessing R&S Reports
1. Access TexMedConnect on the TMHP website at www.tmhp.com.
2. Enter user name and password.
3. Click the “R&S” link in the left navigator.
4. Choose the correct NPI.
5. Select the appropriate program (programs 100 and 200 are combined on the same R&S Report).
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
57
THSteps Medical Participant Guide
6. Choose the appropriate R&S Report by date.
58
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
R&S Report Sections
R&S Reports include the following sections:
•
Banner Pages: Banner messages are used to inform providers of new policies and procedures.
Note: Banner messages (and their corresponding bulletin articles) update and take precedence over the
TMPPM. Banner messages are published weekly.
•
Claims – Paid or Denied: Claims in the “Claims - Paid or Denied” section finalized during
the week before the preparation of the R&S Report. Claims are sorted by claim status, claim
type, and by order of client names. The reported status of each claim will not change unless
further action is initiated by the provider, HHSC, or TMHP.
•
Adjustment to Claims: Adjustments are listed by claim type, client name, and the client’s
Medicaid number.
•
Financial Transactions: The “Financial Transaction” section of the R&S Report describes
any amounts that are added or taken out of the weekly payment. All accounts receivable, IRS
levies, payouts, refunds, reissues, and voids appear here.
•
Claims Payment Summary: The “Claims Payment Summary” section summarizes all
payments, adjustments, and financial transactions listed on the R&S Report. The section
has two categories: one for amounts “Affecting Payment This Cycle” and one for “Amount
Affecting 1099 Earnings.”
•
Claims in Process: In the “Following Claims are Being Processed” section, the R&S Report
may list up to five explanation of pending status (EOPS) codes per claim. The claims listed in
this section are in process and cannot be appealed for any reason until they appear in either
the “Claims Paid or Denied,” or “Adjustments Paid and Denied” sections of the R&S Report.
TMHP is listing the pending status of these claims for informational purposes only.
Note: For additional information please refer the TMPPM.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
59
THSteps Medical Participant Guide
R&S Paid and Denied Claims
60
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
~
TPI: 1234567-01
NPI/API: 1234567890
Taxonomy: 193400000X
Benefit Code:
Report Seq. Number: 33
R&S Number:
99999999
Mail all other correspondence to:
Texas Medicaid & Healthcare Partnership
12357-B Riata Trace Parkway
Austin, Texas 78727-6422
*** AFFECTING PAYMENT THIS CYCLE ***
AMOUNT
COUNT
3,738.10
9
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
54,913.83
**********************PAYMENT TOTAL FOR DIRECT DEPOSIT BY EFT 000000099999999 IN THE AMOUNT OF 17,166.72.**********************
THE AMOUNT OF $4,291.67 WAS HELD AT THE DIRECTION OF THE STATE MEDICAID AGENCY.
PENDING CLAIMS
|
*** AMOUNT AFFECTING 1099 EARNINGS ***
|
THIS CYCLE
YEAR TO DATE
CLAIMS PAID
|
3,738.10
35,676.72
|
SYSTEM PAYOUTS
2,437.19
|
2,437.19
2,437.19
|
MANUAL PAYOUTS
(REMITTED BY SEPARATE CHECK OR EFT)
|
9,242.00
9,242.00
|
AMOUNT PAID TO IRS FOR LEVIES
-554.00
|
|
AMOUNT PAID TO IRS FOR BACKUP WITHHOLDING
-1,363.93
|
|
ACCOUNTS RECEIVABLE RECOUPMENTS
-3,149.88
|
-3,149.88
-9,314.02
|
AMOUNTS STOPPED/VOIDED
|
-310.99
-310.99
|
SYSTEM REISSUES
20,350.91
|
|
CLAIM RELATED REFUNDS
|
-57.81
-57.81
|
NON-CLAIM RELATED REFUNDS
|
-6.19
-6.19
|
HELD AMOUNT
-4,291.67
|
|
PAYMENT AMOUNT
17,166.72
|
11,892.42
37,666.90
________________________________________________________________________________________________________________________________________________
PAYMENT SUMMARY FOR TAX ID 123456789
Page 39 Of
________________________________________________________________________________________________________________________________________________
(800) 925-9126
Texas Provider
P.O. BOX 848484
Dallas, TX 75888-1234
(214) 555-4141
Mail original claim to:
Texas Medicaid & Healthcare Partnership
P.O. Box 200555
Austin, Texas 78720-0555
Texas Medicaid & Healthcare Partnership
Remittance and Status Report
Date: 02/01/2010
THSteps Medical Participant Guide
R&S Claims Payment Summary
61
THSteps Medical Participant Guide
Electronic Remittance and Status (ER&S) Agreement
Before your ER&S Agreement* can be processed, you MUST choose ONE of the following:
*
These changes affect ONLY the ELECTRONIC version of the Remittance & Status Report. To make
changes to the PAPER version of the R&S report, contact TMHP Provider Enrollment.
Set up INITIALLY (first time).
Use Production User ID*:
(9 digits)
CHANGE Production User ID
FROM:
(9 digits)
TO:
(9 digits)
Remove:
(9 digits)
REMOVE Production ID
** The TMHP Production User ID (Submitter ID) is the electronic mailbox ID used for downloading your
Electronic Remittance & Status (ER&S) reports. For assistance with identifying and using your Production
User ID and password, contact your software vendor or clearinghouse.
This information MUST be completed before your request can be processed.
Provider Name (must match TPI/NPI number)
Billing TPI Number
Provider Tax ID Number
Provider’s Physical Address
Billing NPI Number
Provider Phone Number
Provider Contact Title
Contact Phone Number
Provider Contact Name (if other than provider)
Do not complete this block UNLESS the ER&S will be downloaded by anyone OTHER than the provider.
Name of Business Organization to Receive ER&S
Business Organization Phone Number
Business Organization Contact Name
Business Organization Contact Phone No.
Business Organization Address
Business Organization Tax ID
Check each box after reading and understanding the following statements.
If you are unsure about anything that is stated below, contact the TMHP EDI Help Desk at (888) 863-3638.
All three statements must be checked before we can process your Electronic Remittance & Status Agreement.
I (we) request to receive Electronic Remittance and Status information and authorize the information to be
deposited in the electronic mailbox as indicated above. I (we) accept financial responsibility for costs
associated with receipt of Electronic R&S information.
I (we) understand that paper formatted R&S information will continue to be sent to my (our) accounting
address as maintained at TMHP until I (we) submit an Electronic R&S Certification Request form.
I (we) will continue to maintain the confidentiality of records and other information relating to recipients in
accordance with applicable state and federal laws, rules, and regulations.
Provider Signature
Date
Title
Fax Number
DO NOT WRITE IN THIS AREA — For Office Use
Input By:
Input Date:
Mailbox ID:
Effective Date_07302007/Revised Date_06012007
62
CPT only copyright 2008 American Medical Association. All rights reserved. — 2010_0609_v1.4
— A STATE MEDICAID CONTRACTOR
Page 1 of 2
ERSAG05/2007 v1.1
THSteps Medical Participant Guide
ER&S Agreement — Submission Instructions
Before faxing or mailing this agreement, ensure that all required information
is completely filled out, and that the agreement is signed.
Incomplete agreements cannot be processed.
Mail to:
Texas Medicaid & Healthcare Partnership
Attention: EDI Help Desk MC–B14
PO Box 204270
Austin, TX 78720-4270
Fax to:
(512) 514-4228
OR
(512) 514-4230
Effective Date_07302007/Revised Date_06012007
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
— A STATE MEDICAID CONTRACTOR
Page 2 of 2
63
ERSAG05/2007 v1.1
THSteps Medical Participant Guide
Electronic Funds Transfer (EFT) Authorization Agreement
Enter ONE Texas Provider Identifier (TPI) per Form
NOTE:
Complete all sections below and attach a voided check or a statement from your bank written
on the bank’s letterhead.
Type of Authorization:
NEW
CHANGE
Provider Name
Nine–Character Billing TPI
National Provider Identifier (NPI)/Atypical Provider Identifier (API):
Primary Taxonomy
Code:
Benefit Code:
Provider Accounting Address
Provider Phone Number
Bank Name
ABA/Transit Number
Bank Phone Number
Account Number
Bank Address
Type Account (check one)
(
)
Checking
Ext.
Savings
I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the
bank account referenced above and the depository named above to credit the same to such account. I
(we) understand that I (we) am responsible for the validity of the information on this form. If the company
erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary
debit entries, not to exceed the total of the original amount credited for the current pay period.
I (we) agree to comply with all certification requirements of the applicable program regulations, rules,
handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services
Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from
federal and state funds, and that any falsification or concealment of a material fact may be prosecuted
under federal and state laws.
I (we) will continue to maintain the confidentiality of records and other information relating to clients in
accordance with applicable state and federal laws, rules, and regulations.
Authorized Signature
Date
Title
Email Address (if applicable)
Contact Name
Phone
Return this form to:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin TX 78720–0795
DO NOT WRITE IN THIS AREA — For Office Use
Input By:
64
Input Date:
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Electronic Funds Transfer (EFT) Information
Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims
approved for payment directly into a provider’s bank account. These funds can be
credited to either checking or savings accounts, provided the bank selected accepts
Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with
mailing and handling paper checks, ensuring funds are directly deposited into a
specified account.
The following items are specific to EFT:
•
•
•
•
•
•
Pre–notification to your bank takes place on the cycle following the application
processing.
Future deposits are received electronically after pre–notification.
The Remittance and Status (R&S) report furnishes the details of individual credits
made to the provider’s account during the weekly cycle.
Specific deposits and associated R&S reports are cross–referenced by both the
provider identifiers (i.e., NPI, TPI, and API) and R&S number.
EFT funds are released by TMHP to depository financial institutions each Friday.
The availability of R&S reports is unaffected by EFT and they continue to arrive in
the same manner and time frame as currently received.
TMHP must provide the following notification according to ACH guidelines:
Most receiving depository financial institutions receive credit entries on the day before the
effective date, and these funds are routinely made available to their depositors as of the
opening of business on the effective date. Please contact your financial institution
regarding posting time if funds are not available on the release date.
However, due to geographic factors, some receiving depository financial institutions do not
receive their credit entries until the morning of the effective day and the internal records of
these financial institutions will not be updated. As a result, tellers, bookkeepers, or
automated teller machines (ATMs) may not be aware of the deposit and the customer’s
withdrawal request may be refused. When this occurs, the customer or company should
discuss the situation with the ACH coordinator of their institution who, in turn should work
out the best way to serve their customer’s needs.
In all cases, credits received should be posted to the customer’s account on the effective
date and thus be made available to cover checks or debits that are presented for payment
on the effective date.
To enroll in the EFT program, complete the attached Electronic Funds Transfer
Authorization Agreement. You must return the agreement and either a voided check or a
statement from your bank written on the bank’s letterhead to the TMHP address
indicated on the form.
Call the TMHP Contact Center at 1–800–925–9126 for assistance.
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Waste, Abuse, and Fraud
Definitions
•
Waste: Practices that allow careless spending and/or inefficient use of resources.
•
Abuse: Practices that are inconsistent with sound fiscal, business, or medical practices, and
result in an unnecessary program cost, or in reimbursement for services that are medically
necessary or do not meet professionally recognized standards for health care.
•
Fraud: An intentional deceit or misrepresentation made by a person with the knowledge
that deception could result in some unauthorized benefit to himself or some other person. It
includes any act that constitutes fraud under applicable federal or state law.
Most Frequently Identified Fraudulent Practices
•
Billing for services not performed.
•
Billing for unnecessary services.
•
Up coding or unsubstantiated diagnosis.
•
Billing outpatient services as inpatient services.
•
Over treating/lack of medical necessity.
Identifying and Preventing Waste, Abuse, and Fraud
HHSC, Office of Inspector General (OIG) is responsible for investigating waste, abuse, and fraud
in all Health and Human Services (HHS) programs. OIG’s mission is to protect the:
•
Integrity of health and human services programs in Texas.
•
Health and welfare of the clients in those programs.
OIG oversees HHS activities, providers, and clients through compliance and enforcement activities
designed to:
•
Identify and reduce waste, abuse, fraud, or misconduct.
•
Improve efficiency and effectiveness through the HHS system.
OIG is required to set up clear objectives, priorities, and performance standards that help:
66
•
Coordinate investigative efforts to aggressively recover Medicaid overpayments.
•
Allocate resources to cases with the strongest supportive evidence, and the greatest potential for
recovery of money.
•
Maximize the opportunities to refer cases to the Office of Attorney General.
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Human Resources code, Chapter 32 Medical Assistance Program (Medicaid), §32.039
(a) (4) A person “should know” or “should have known” information to be false if the person acts in
deliberate ignorance of the truth or falsity of the information or in reckless disregard of the truth or
falsity of the information, and proof of the person’s specific intent to defraud is not required.
When reporting waste, abuse, or fraud, gather as much information as possible.
Examples of provider information include:
•
Name, address, and phone number of the provider.
•
Name and address of the facility (hospital, nursing home, and home health agency, etc.).
•
Medicaid number of the provider and facility is helpful.
•
Type of provider (physician, physical therapist, and pharmacist, etc.).
•
Names and numbers of other witnesses who can aid in the investigation.
•
Copies of any documentation (examples: records, bills, and memos).
•
Date of occurrences.
•
Summary of what happened—include an explanation along with specific details of the
suspected waste, abuse, or fraud. For example: Dr. John Doe requires employees to bill for extra
quantities or bill higher level of service than actually provided.
•
Names of clients for which services are questionable.
Examples of client information include:
•
The person’s name.
•
The person’s date of birth and Social Security number, if available.
•
The city where the person resides.
•
Specific details about the fraud-such as “Jane Doe failed to report her husband, John Doe, lives
with her and he works at ABC Construction in Anyplace, TX.”
Reporting Waste, Abuse, and Fraud
Individuals with knowledge about suspected Medicaid waste, abuse, or fraud of provider
services must report the information to the HHSC OIG. To report waste, abuse, or fraud, go to
www.hhsc.state.tx.us and select Report Waste, Abuse, and Fraud. Individuals may also call the
OIG hotline at 1-800-436-6184 to report waste, abuse, or fraud if they do not have access to the
Internet.
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Reporting Child Abuse
All Medicaid providers shall make a good faith effort to comply with all child abuse reporting
guidelines and requirements as outlined in Chapter 261 of the Texas Family Code relating to
investigations of child abuse and neglect. All providers shall develop, implement and enforce a
written policy and train staff on reporting requirements.
This policy needs to be part of the provider’s office Policy and Procedure’s Manual and needs to
address the appropriate measures to take when suspected child abuse has occurred.
DSHS Child Abuse Reporting Form
The DSHS Child Abuse Reporting Form shall be used in the following manner:
•
To fax reports of abuse to Department of Family Protective Services (DFPS) (1-800-647-7410)
or reporting to law enforcement officials. All documentation of the report must be kept in the
client record.
• To document reports made by telephone to DFPS (1-800-252-5400, 24/7) or law
enforcement; and
• To document decisions not to report suspected child abuse based on the existence of an
affirmative defense.
Providers may report abuse online at www.txabusehotline.org and use a print-out of the report or a
copy of the confirmation from DFPS with the client’s name and date of birth written on it, instead
of this form, as documentation in the client record.
Note: The website is only for reporting situations that do not require an emergency response.
An emergency is a situation where a child, an adult with disabilities, or a person who is elderly faces
an immediate risk of abuse or neglect that could result in death or serious harm.
To report an emergency, call 9-1-1 or local law enforcement agency.
Online reports can take up to 24 hours to process. Call the Texas Abuse Hotline at
1-800-252-5400 if:
• The situation requires action in less than 24 hours.
• Being anonymous is important.
• There is insufficient data to complete the required information on the report.
• An e-mail should not be sent to confirm the report.
For more information on policy; to report abuse; or to obtain the new DSHS Child Abuse
Reporting Form please refer to the following links:
68
Title
Website
DSHS Child Abuse Screening, Documenting, and
Reporting Policy
http://tinyurl.com/child-abuse-reporting
DSHS Child Abuse Reporting Form
http://tinyurl.com/child-abuse-reporting-form
Texas Abuse, Neglect, and Exploitation Reporting
System
https://www.txabusehotline.org/
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Resources
Instructions for Using the TMHP Website
The TMHP website at www.tmhp.com, was designed to streamline provider participation. Through the website, providers can
submit claims and appeals, download provider manuals and bulletins, verify client eligibility, view Remittance and Status (R&S)
and panel reports, and stay informed with current news and updates. Current news remains on the TMHP website homepage
for 10 business days and is then moved to the news archive (available from the News Archive link on the left hand side of the
main page).
Searching the TMHP Website
Some providers may find it easier to search the TMHP website using
the site’s search function rather than navigating through the news and
archive sections. To use the search feature, providers must type the
desired keywords into the search box located in the upper right-hand
corner of the homepage, and click the green arrow or press Enter. To
improve search results, providers should use logical operators (and, or,
and not) or enclose search phrases in quotation marks. When phrases
are enclosed in quotation marks, the search feature returns only those
pages that contain the exact phrase, rather than returning the pages that
contain any of the words in the phrase.
In addition to the site’s search feature, providers can use popular
search engines, such as Google™, to easily find information
applicable to their provider type. To use Google to search only the
TMHP website, follow these steps:
1. From an internet browser (Internet Explorer, Firefox, etc.), go
to www.google.com.
2. In the search box, type “site:www.tmhp.com” followed by the
keyword(s) for the search (see example).
3. Click Google Search.
Google displays a list of all the pages on the TMHP website that
contain the keyword(s).
Providers can use Google’s advanced search (available by clicking the
Advanced Search link) to filter their results by date, language, and file
format. For example, providers can choose to display only those pages updated within the past three months. Providers can also
exclude certain words or phrases from their results or specify where on the page the desired term should appear (for example, in
the title of the page or in the body of the page).
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Information
The TMHP website has::
Provider Manuals and Guides:
•
Texas Medicaid Provider Procedures
Manual
•
CSHCN Services Program Provider
Manual
•
Texas Medicaid Quick Reference Guide
•
CMS-1500 Online Claims Submission
Manual
•
2008 Automated Inquiry System User
Guide-Medicaid
•
2008 Automated Inquiry System User
Guide-CSHCN Services Program
•
TexMedConnect instructions for Acute
Care and Long Term Care
Provider Forms:
•
Medicaid Forms
•
CSHCN Services Program Forms
•
Enrollment Forms
Bulletins and Banner Messages:
•
Medicaid Bulletins
•
CSHCN Services Program Bulletins
•
Banner Messages
Software, Fee Schedules, Reference Codes:
• Fee Schedules
• Acute Care Reference Codes
•
Long Term Care (LTC) Programs
Reference Codes
•
Workshop Materials
•
Computer Based Training (CBT)
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Functions on the TMHP Website
On the TMHP website, you can:
•
Enroll as a provider into TMHP’s system to access the many benefits available.
•
Attest an API.
•
Use TexMedConnect to file a claim electronically, which reduces errors and speeds up the reimbursement of funds.
•
Review and print documents, review user guides, and search through the library for previous workshop materials.
•
Register for a workshop and view upcoming events.
•
Submit a request for an authorization.
•
View the status of a submitted prior authorization request.
•
Immediately verify the eligibility of a client.
•
View panel reports.
•
Look for a provider by specialty and sub-specialty.
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Online Fee Lookup
TMHP has developed new functionality for the fee schedules called the Online Fee Lookup (OFL). The OFL allows a
search by procedure, provider type, and program to find the associated fee.
It is not necessary to be logged into the Online Portal to use the new functionality; however, to view a specific
“Contracted” rate, log in is necessary.
From www.tmhp.com, scroll down to the Fee Schedules link towards the bottom of the right-hand navigation.
From the Fee Schedule home page, select to view the static fee schedules, or perform a fee search or batch search.
Using the OFL, search for fees using one of these options:
•
•
•
•
A single procedure code
A list of up to 50 procedure codes
A range of codes
All procedure codes pertaining to a specific provider type and specialty.
Managed Care Organizations (MCO’s) have two additional options. MCO’s can upload Out of Network (OON) files
and no longer need to upload the files to TexMedConnect. MCO’s will continue to receive error reports if errors are
found in the files and response files will be available within 36 hours.
To access the fee schedule and Out of Network Batch Submissions, open Internet Explorer and navigate to
www.tmhp.com.
Fee Schedule OFL Search: This allows a user to access the Fee Search to search for reimbursement rates specific to a
provider’s National Provider Identifier (NPI) or Atypical Provider Identifier (API).
Fee Schedule OON Batch Submissions: This allows a user to submit Out of Network files to TMHP for processing.
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To learn more about the OFL tool, please view the Computer Based Training at:
www.tmhp.com/Online%20Learning/CBT%20Library/OFL/index.htm
Online Provider Lookup
Using the Online Provider Lookup Tool (OPL) to Find a Provider
1. Go to www.tmhp.com.
2. Click the link, “Look for a Provider.”
3. Enter Provider Search Criteria:
–– Health Plan
–– TPI
–– NPI/API
–– Taxonomy
–– Benefit Code
–– Last Name/Facility Name
–– HMO Plan Name
–– Provider Type
–– ZIP Code
Note: Fields marked with a red asterisk are required
4. Click the “more information” link for instructions for information on
the adjacent field.
5. Click the “Search” button to obtain a list of providers that meet the
search criteria entered.
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6. Click the “Clear Form” button to remove the information and start over.
The next screen displays a list of providers that meet the search criteria.
–– Click the “View Map” link to display a map of the provider’s location.
7. Click the provider name to receive detailed information on that provider.
–– Click the “Back To Results” link to return to the provider list.
–– Click the “Print” button to display a printer-friendly page for printing.
–– Click the “View Map” link to display a map of the provider’s location.
–– Click the “more information” link for a description of the Primary Care Provider symbol.
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Using the Advanced Search in OPL
Selecting the option, “Advanced Search” on the menu bar generates the following screen:
Unlike the basic search option, the advanced search option allows providers to narrow their search using several additional
search options such as:
•
Accepting new patients
•
Provider specialty
•
Provider subspecialty
•
Extended hours
•
Medicaid waiver program
•
Other services offered
•
Languages spoken
•
Patient age
•
Patient gender
•
County served by the provider
Note: The online provider look up is not currently available for CSHCN Services Program Providers.
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Notice that the criteria entered in the Provider Type field changes the information displayed under “Provider Specialty.”
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Updating Address Information
1. The provider clicks on the link from the My Account page to change/verify their address information.
2. The provider must click on
the “Edit” button to activate
a section for editing. The
provider can:
–– Update address
information
–– Update phone numbers
and their email address
–– Add or remove counties
served
–– Update business hours
–– Indicate whether or
not they are accepting
patients for each plan in
which they participate
–– Indicate languages
spoken in their office
–– Indicate if they offer
additional services
–– Limit the gender or age
of clients served
3. Save and Cancel buttons
appear when an area is active
for editing. The provider
must choose to save the
information or cancel their
changes before editing any
other sections.
Once the information is updated
by the provider, it should appear
with the new information in
the Online Provider Lookup
immediately.
The more complete the
information, the better chance of
appearing in an advanced search.
Note: Information in the grey
area of the page cannot be updated online by the provider. To make updates to informa­tion in this area, the provider must attest
online for NPI related information, or submit a Provider Information Change (PIC) Form. Reminder: Medicaid Vendor Drug
Pharmacy providers should update their vendor drug program information through the VDP Pharmacy Resolution Helpdesk
(1-800-435-4165). Additional information about the Texas Vendor Drug Program can be found online at http://tinyurl.com/
Vendor-Drug.
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Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Instructions for Completing the
Provider Information Change Form
Signatures
• The provider’s signature is required on the Provider Information Change Form for any and all changes requested
for individual provider numbers.
• A signature by the authorized representative of a group or facility is acceptable for requested changes to group
or facility provider numbers.
Address
• Performing providers (physicians performing services within a group) may not change accounting information.
• For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing
address require a copy of the W-9 form.
• For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory
Surgical Centers.
Tax Identification Number (TIN)
• TIN changes for individual practitioner provider numbers can only be made by the individual to whom the
number is assigned.
• Performing providers cannot change the TIN.
Provider Demographic Information
An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view
information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, please
visit the OPL at www.tmhp.com. Please review the existing information and add or modify any specific practice
limitations accordingly. This will allow clients more detailed information about your practice.
General
• TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier
(NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable)
in order to process the change. Forms will be returned if this information is not indicated on the Provider
Information Change Form.
• The W-9 form is required for all name and TIN changes.
• Mail or fax the completed form to:
Texas Medicaid & Healthcare Partnership (TMHP)
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Fax: 512-514-4214
Effective Date_01012009/Revised Date_01212010
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Provider Information Change Form
Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management
(PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this
form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.
Check the box to indicate a PCCM Provider …
Date :
/
/
Nine-Digit Texas Provider Identifier (TPI):
Provider Name:
National Provider Identifier (NPI):
Primary Taxonomy Code:
Atypical Provider Identifier (API):
Benefit Code:
List any additional TPIs that use the same provider information:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
Physical Address—The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who
change their ZIP Code must submit a copy of the Medicare letter along with this form.
Street address
Telephone: (
City
Fax Number: (
)
County
)
State
Zip Code
Email:
Accounting/Mailing Address—All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form
along with this form.
Street Address
Telephone: (
City
)
Fax Number: (
)
State
Zip Code
State
Zip Code
Email:
Secondary Address
Street Address
City
Telephone: (
)
Fax Number: (
Type of Change (check the appropriate box)
)
Email:
…
Change of physical address, telephone, and/or fax number
…
Change of billing/mailing address, telephone, and/or fax number
…
Change/add secondary address, telephone, and/or fax number
…
Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field
…
Other (e.g., panel closing, capacity changes, and age acceptance)
Comments:
Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)
Tax ID number:
Effective Date:
Exact name reported to the IRS for this Tax ID:
Provider Demographic Information—Note: This information can be updated on www.tmhp.com.
Languages spoken other than English:
Provider office hours by location:
Accepting new clients by program (check one):
Accepting new clients …
Patient age range accepted by provider:
No …
Additional services offered (check one): HIV …
High Risk OB …
Hearing Services for Children …
Participation in the Woman’s Health Program? Yes …
No …
Patient gender limitations:
Signature and date are required or the form will not be processed.
Provider signature:
Mail or fax the completed form to:
Current clients only …
Texas Medicaid & Healthcare Partnership (TMHP)
Female …
Male …
Date:
/
Both …
/
Fax: 512-514-4214
Effective Date_01012009/Revised Date_01212010
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TMHP Telephone and Fax Communication
Contact
Telephone/Fax Number
TMHP Contact Center (general information)
Automated Inquiry System (AIS)
1-800-925-9126
or 1-512-335-5986
TMHP Children with Special Health Care Needs (CSHCN) Services Program Contact Center
Automated Inquiry System (AIS)
1-800-568-2413
CSHCN Services Program Fax
1-512-514-4222
Comprehensive Care Program (CCP)
(CCP prior authorization status and general CCP and Home Health Services information)
1-800-846-7470 (voice)
1-512-514-4211 (fax)
Comprehensive Care Inpatient Psychiatric (CCIP) Unit (prior authorization and general information)
1-800-213-8877 (voice)
1-512-514-4211 (fax)
Family Planning (Tubal Ligation/Vasectomy Consent Forms) Fax
1-512-514-4229
Health Insurance Premium Payment (HIPP) and Insurance Premium Payment Assistance (IPPA)
1-800-440-0493
Home Health Services (includes durable medical equipment [DME]):
Option 1 – TMHP in-home care customer service
Option 2 – DME supplier with completed Title XIX form
Option 3 – Registered nurse (RN) with completed plan of care (POC)
1-800-925-8957 (voice)
1-512-514-4209 (fax)
Hysterectomy Acknowledgment Statements Fax
1-512-514-4218
Long Term Care (LTC) Operations
1-800-626-4117
LTC—Nursing Facilities
1-800-727-5436
Medicaid Audit/Cost Reports
1-512-506-6117
Medicaid Audit Fax
1-512-506-7811
PCCM Provider Helpline
1-888-834-7226
PCCM THSteps Client Outreach
1-888-255-9360
PCCM THSteps Provider Relations
1-512-421-3070
Provider Enrollment Fax
1-512-514-4214
Radiology Prior Authorization
1-800-572-2116 (voice)
1-800-572-2119 (fax)
Telephone Appeals
1-800-745-4452
Texas Health Steps (THSteps) Dental Inquiries
1-800-568-2460
THSteps Medical Inquiries
1-800-757-5691
Third Party Resources (TPR) (Option 2)
1-800-846-7307
Third Party Resources (TPR) Fax
1-512-514-4225
TMHP Electronic Data Interchange (EDI) Help Desk
1-888-863-3638
TMHP EDI Help Desk Fax
1-512-514-4228
1-512-514-4230
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Prior Authorization Request Telephone and Fax Communication
Contact
Telephone/Fax Number
Ambulance Authorization (includes out-of-state transfers)
1-800-540-0694
Ambulance Authorization Fax
1-512-514-4205
Home Health Services Fax
1-512-514-4209
CCP Fax
1-512-514-4212
CCIP
1-800-213-8877
CCIP Fax
1-512-514-4211
Outpatient Psychiatric Fax
1-512-514-4213
TMHP Special Medical Prior Authorization Fax (including
transplants)
1-512-514-4213
PCCM Utilization Management Helpline:
Option 1: Inpatient authorization request or notification
of admission
Option 2: Outpatient authorization request
1-888-302-6167
PCCM Utilization Management Fax
1-512-302-5039
Radiology Services Prior Authorization
1-800-572-2116
Radiology Services Prior Authorization Fax
1-888-693-3210
Special Medicaid Prior Authorization Fax (Including Transplants)
1-512-514-4213
Prior Authorization Status Telephone Communication
Contact
Telephone Number
Home Health Services (including DME):
Option 1 – TMHP in-home care customer service
Option 2 – DME supplier with completed Title XIX form
Option 3 – RN with completed POC
1-800-925-8957
CCP
1-800-846-7470
PCCM Utilization Management Helpline:
Option 1 – 1: Inpatient authorization status
Option 2 – 1: Outpatient authorization status
1-888-302-6167 (voice)
1-512-302-5039 (fax)
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CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Written Communication With TMHP
All CMS-1500 forms (excluding ambulance, radiology/laboratory, immunization services, rural health, and mental health
rehabilitation) sent to TMHP for the first time, as well as claims being resubmitted because they were initially denied as
incomplete claims, must be sent to the following address:
Texas Medicaid & Healthcare Partnership
Claims
PO Box 200555
Austin, TX 78720-0555
The post office box addresses must be used for the specific items listed in the following table:
Correspondence
Address
Appeals/adjustments of claims (except zero paid/zero allowed on Remittance & Status [R&S] Reports)
Electronically rejected claims past the 95-day filing deadline
and within 120 days of electronic rejection report
Texas Medicaid & Healthcare Partnership
Appeals/Adjustments
PO Box 200645
Austin, TX 78720-0645
All first-time claims
Texas Medicaid & Healthcare Partnership
Claims
PO Box 200555
Austin, TX 78720-0555
Ambulance/CCP requests (prior authorization and appeals)
Texas Medicaid & Healthcare Partnership
Comprehensive Care Program (CCP)
PO Box 200735
Austin, TX 78720-0735
CSHCN Services Program claims
Texas Medicaid & Healthcare Partnership
CSHCN Services Program Claims
PO Box 200855
Austin, TX 78720-0735
Dental prior authorization requests
Texas Medicaid & Healthcare Partnership
Dental Prior Authorization
PO Box 202917
Austin, TX 78720-2917
Home Health Services prior authorizations
Texas Medicaid & Healthcare Partnership
Home Health Services
PO Box 202977
Austin, TX 78720-2977
Special Medical Prior Authorization
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
Medicaid audit correspondence
Texas Medicaid & Healthcare Partnership
Medicaid Audit
PO Box 200345
Austin, TX 78720-0345
Medical necessity forms 3652, 3618, and 3619, and purpose
code E information
Texas Medicaid & Healthcare Partnership
Long Term Care—Nursing Facilities
PO Box 200765
Austin, TX 78720-0765
Medically Needy Clearinghouse (MNC) or Spend Down Unit
correspondence
Texas Medicaid & Healthcare Partnership
Medically Needy Clearinghouse
PO Box 202947
Austin, TX 78720-2947
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
83
THSteps Medical Participant Guide
Correspondence
Address
Provider Enrollment correspondence
Texas Medicaid & Healthcare Partnership
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Other provider correspondence
Texas Medicaid & Healthcare Partnership
Provider Relations
PO Box 202978
Austin, TX 78720-0978
Send all other written communication to TMHP
Texas Medicaid & Healthcare Partnership
(Department)
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
TPR/Tort correspondence
Texas Medicaid & Healthcare Partnership
Third Party Resources/Tort
PO Box 202948
Austin, TX 78720-2948
Provider Enrollment Contract/Credentialing
Texas Medicaid & Healthcare Partnership
PCCM Contracting/Credentialing
PO Box 200795
Austin, TX 78720-4270
84
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Texas Medicaid/CHIP Vendor Drug Program Contact Information
Vendor Drug Program e-mail address
[email protected]
Searchable Formulary List
http://tinyurl.com/vdp-formulary
Online drug information resource for all state healthcare
programs.
Epocrates
http://www.epocrates.com
Epocrates provides instant access to information on the drugs
covered by Medicaid and preferred drug list on a Palm or
Pocket PC handheld device. To register for the service, go to
the Epocrates website and sign up for Epocrates Rx.
Note: Epocrates is an out-patient Rx on-line Medicaid formulary resource.
Smart Formulary
www.smartformulary.com/tx
Medicaid only on-line formulary resource and preferred drug
list information with links attached to selected non-preferred
drugs.
Vendor Drug Program Prior Authorization Call Center Hot line 1-877-728-3927 or 1-877-PA-Texas
Note: This number is for prescribing providers or representatives only.
Pharmacy Resolution Desk
1-800-435-4165
Monday-Friday 8:30 am to 5:15 pm CT
This number is for pharmacy providers only.
Vendor Drug Program Fax Numbers
Main/Pharmacy Resolution: 512-491-1958
Formulary: 512-491-1961
Drug Utilization Review (DUR): 512-491-1962
Field Administration: 817-321-8064
Contract Management: 512-491-1974
Vendor Drug Program Addresses
Physical Address:
Health and Human Services Commission
Medicaid/CHIP Vendor Drug Program (H-630)
Building H
11209 Metric Blvd.
Austin, TX 78758
Mailing address:
Health and Human Services Commission
Medicaid/CHIP Vendor Drug Program (H-630)
P.O. Box 85200
Austin, TX 78708-5200
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
85
THSteps Medical Participant Guide
Helpful Links
Item
Link
Texas Health and Human Services
http://www.hhs.state.tx.us/
The Texas Medicaid & Healthcare Partnership
www.tmhp.com
Texas Department of State Health Services
http://www.dshs.state.tx.us/
Texas Vendor Drug Program
http://tinyurl.com/Vendor-Drug
Preferred Drug List Program
http://tinyurl.com/pdl-program
Explanation of Benefits Codes
http://tinyurl.com/EOB-codes
MRAN Type 30 Form
http://tinyurl.com/tmhp-mran-30
MRAN Type 30 Form Instructions
http://tinyurl.com/tmhp-mran-30-instructions
Crossover Claim Types 31 and 50 TMHP
Standardized Medicare Remittance Advice Notice
Form
http://tinyurl.com/tmhp-mran-31-50
Crossover Claim Types 31 and 50 TMHP
Standardized Medicare Remittance Advice Notice
Form Instructions
http://tinyurl.com/tmhp-mran-31-50-instructions
STAR
http://tinyurl.com/hhsc-star
STAR+Plus
http://tinyurl.com/hhsc-starplus
NorthSTAR
http://tinyurl.com/dshs-northstar
STAR Health
http://tinyurl.com/starhealth
PCCM
http://tinyurl.com/tmhp-pccm
THSteps Medical
http://tinyurl.com/thstepsmed
THSteps Dental
http://tinyurl.com/dshs-thsteps
Family Planning
http://tinyurl.com/dshs-famplan
Case Management for Children and Pregnant
Women (CPW)
http://tinyurl.com/dshs-cpw
Enhanced Care Program (Disease Management)
http://tinyurl.com/hhsc-ecp
The Children with Special Health Care Needs
(CSHCN) Services Program
http://tinyurl.com/tmhp-cshcn
http://tinyurl.com/dshs-cshcn
Medicaid for Breast and Cervical Cancer
http://tinyurl.com/dshs-mbcc
Medical Transportation Program (Medicaid and
CSHCN Services Program)
http://tinyurl.com/dshs-mtp-cshcn
Early Childhood Intervention (ECI) Program
http://tinyurl.com/dars-eci
86
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
13
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2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
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If answers on risk assessment questionnaires or other screening show a risk factor, further screening is required. Refer to Footnotes for more information about marked items.
Standardized screening tool must be used at these ages.
S
Required as above, unless already provided on a previous checkup at the required age, or the dated results obtained within the previous month, and documented on the health
record with the date of service.
+
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Anticipatory Guidance18
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Key
Required, unless medically contraindicated or because of parent’s reasons of conscience including a religious belief or the dated results obtained within the previous month
� documented on the health record.
Dental Referral
Immunizations
16
Type II Diabetes
Hyperlipidemia
Cervical Cancer Screening
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HIV Screening12
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STD Screening11
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Lead Screening9
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Newborn Hereditary/
Metabolic Testing7
Hgb or Hct8
Laboratory Tests
Tuberculosis Screening
Hearing Screening
Vision Screening
Sensory Screening
Developmental/Autism
Screening3
Mental Health Screening
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Blood Pressure
Body Mass Index (BMI)
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Unclothed Physical
2
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Neonatal
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Family
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19
The columns across the top of the schedule indicate the age a client is periodically eligible for a medical checkup. The first column on the left of the chart identifies each procedure that must be performed at each appropriate age.
(See Key at bottom of page and Footnotes on the following page.)
THSteps Medical Checkups Periodicity Schedule for Infants. Children, and Adolescents (Birth Through 20 Years of Age)
THSteps Medical Participant Guide
87
88
CPT only copyright 2008 American Medical Association. All rights reserved.
START HERE
→
STEP 1:
TEXAS MEDICAID
PROVIDER PROCEDURES
MANUAL
A provider's first resource
for Medicaid information.
Available on CD-Rom or the
TMHP website.
STEP 2:
MEDICAID BULLETINS
An additional source of
information available in the
office and at www.tmhp.com
STEP 3:
REMITTANCE & STATUS
(R&S) REPORT
A provider's first resource
for checking claim status.
The report provides detailed
information on pending,
paid, denied and incomplete
claims.
STEP 5:
TMHP PHONE NUMBERS
TMHP:
1-800-925-9126
Telephone Appeals:
1-800-745-4452
THSteps Dental Inquiries:
STEP 4:
1-800-568-2460
THSteps Medical Inquiries:
TMHP WEBSITE
At www.tmhp.com, providers 1-800-757-5691
T
MHP EDI Help Desk:
can find the latest
information on TMHP news, 1-800-925-9126, option 3
and bulletins. Providers can
also verify client eligibility,
submit claims, check claim
status, view R&S reports,
view panel reports, and view
many other helpful links.
Steps to Resolve Your
Medicaid Questions
A provider’s resource for
checking client eligibility,
claim status, and benefit
limitations. Available 23
hours a day, with daily
downtime from 3 a.m. to
4 a.m. Dial 1-800-9259126, and select an
option from the menu.
STEP 6:
AUTOMATED INQUIRY
SYSTEM (AIS)
STEP 7:
TMHP CONTACT CENTER
A provider's resource for
general Medicaid program
information. Available from
7:00AM-7:00PM (CST), call
1-800-925-9126.
A provider’s personal
resource for issue
escalation as well as
educational and
trouble-shoointg visits. Visit
the TMHP website and
select Provider, then
Regional Support for a
representative in your area.
STEP 8:
PROVIDER RELATIONS
REPRESENTATIVE
Steps
to Resolve
Medicaid
THSteps
MedicalYour
Participant
Guide Questions
— 2010_0609_v1.4
THSteps Medical Participant Guide
Common Claim Denial Codes
•
00103 - Services exceed allowed benefit limitations: Client has exhausted benefits for the service billed.
•
00075 - Missing, invalid, or future dates of service: Claim was submitted without dates of service, incomplete
information for the dates of service, or future dates of service.
•
00100 - A charge was not noted for this service: Billed amount was either not submitted on the claim or was
invalid.
•
00143 - Client not Eligible: The client ID was included on the claim; however, the client does not have Medicaid
eligibility for that DOS or the client associated with that ID had Medicaid either before or after the DOS.
•
00144 - This procedure not covered for this provider type: Procedure code submitted is not billable for the billing
provider.
•
00164 -These services are not in accordance with Medical Policy: Services billed fall outside of the medical policy
guidelines for the program billed.
•
00260 - Client is covered by other insurance which must be billed prior to this program: Medicaid is the method
of last resort. Any other insurance providers must be billed before Medicaid has been. This includes Medicare Part A
coverage.
•
00265 - Client is Medicare Part B Eligible: Client is eligible for Medicare Part B for the DOS and the service
is covered by Medicare Part B, but the claim was not submitted to Medicaid as a crossover with a Medicare EOB
attached. In some cases, claims crossed over directly from Medicare but Medicare denied the line because of an error
on the claim that was originally submitted to Medicare.
•
00266 - QMB Client Eligible for Medicare Crossovers Only: Qualified Medicare Beneficiary (QMB) –
MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has
paid. If service is not covered by Medicare, MEDICAID WILL NOT PAY.
•
00424 - Billing Provider Not Enrolled on DOS: The billing provider’s Medicaid enrollment status is not active.
•
00345 - Claim Exceeds Filing Time Period: The claim was submitted after 120 days from the first DOS with no
proof of timely filing attached.
•
00565 - Received past the 95 day filing deadline: The claim was submitted after 95 days from the first DOS with
no proof of timely filing attached.
•
00572 - It is mandatory that authorization be obtained. Due to lack of approval, the service is nonpayable: The
provider did not request authorization for the service billed, the authorization was not on file at the time the service
was billed, or the authorization for service billed was denied.
•
01361 - Exact Duplicate: Payment has already been made for this claim. This often occurs when a claim is
resubmitted before the original claim has been paid. The original submission pays and the subsequent submission
denies as a duplicate. This also happens when a provider attempts to adjust or correct an incorrectly paid claim by
simply resubmitting the corrected claim.
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
89
THSteps Medical Participant Guide
Acronyms
Acronym
Term
Acronym
Term
AAP
American Academy of Pediatrics
EDI
Electronic Data Interchange
ACD
Augmentative Communicative Device
EFT
Electronic Funds Transfer
ACIP
Advisory Committee on Immunization
Practices
EOB
Explanation of Benefits
ADA
American Dental Association
EOPS
Explanation of Pending Status
AIS
Automated Inquiry System
EPSDT
Early and Periodic Screening, Diagnosis,
and Treatment
AMA
American Medical Association
EQRO
External Quality Review Organization
ANSI
American National Standards Institute
ER&S
Electronic Remittance and Status Report
APN
Advanced Practice Nurse
EV
Eligibility Verification
BCBS
Blue Cross Blue Shield
FDH
First Dental Home
BiPAP
Bi-level Positive Airway Pressure
FFS
Fee-For-Service
BJN
Budget Job Number
FP
Family Planning
BP
Base Plan
FQHC
Federally Qualified Health Center
CAPD
Continuous Ambulatory Peritoneal Dialysis
FSS
Family Support Services
CBT
Computer Based Training
HASC
Hospital-based Ambulatory Surgical Center
CCP
Comprehensive Care Program
HCPCS
CHAMPUS
Civilian Health and Medical Program of the
Uniformed Services—now called TriCare
Healthcare Common Procedure Coding
System
HHA
Home Health Agency
CHIP
Children’s Health Insurance Program
HHSC
Health and Human Services Commission
CMS
Centers for Medicare & Medicaid Services
(formerly HCFA)
HIC
Health Insurance Claim
CORF
Comprehensive Outpatient Rehabilitation
Facility
HIPAA
Health Insurance Portability and Accountability
Act
CPAP
HMO
Health Maintenance Organization
Continuous Positive Airway Pressure
HSC
CPW
Case Management for Children and Pregnant Women
Hearing Services for Children (Formerly
PACT)
ICD-9-CM
CSHCN
Children with Special Health Care Needs
International Classification of Diseases, Ninth
Revision, Clinical Modification
CSI
Claim Status Inquiry
ICHP
Institute of Child Health Policy
CSR
Customer Service Representative
ICN
Internal Control Number (as in 24-digit ICN)
DADS
Department of Aging and Disability Services
IPPA
Insurance Premium Payment Assistance
IPPB
Intermittent Positive Pressure Breathing
DARS
Department of Assistive and Rehabilitative
Services
IPV
Intrapulmonary Percussive Ventilation
DME
Durable Medical Equipment
JRA
Juvenile Rheumatoid Arthritis
DO
Doctor of Osteopathy
LCSW
Licensed Clinical Social Worker
DOB
Date of Birth
LMSW
Licensed Master Social Worker
DOS
Date of Service
LPC
Licensed Professional Counselor
DPM
Doctor of Podiatric Medicine
LTC
Long Term Care
DRG
Diagnosis-Related Group
MCO
Managed Care Organization
DSHS
Department of State Health Services
MD
Doctor of Medicine
ECI
Early Childhood Intervention
MMIS
Medicaid Management Information System
ECP
Enhanced Care Program
MNP
Medically Needy Program
MQMB
Medicaid Qualified Medicare Beneficiary
90
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
Acronym
Term
Acronym
Term
MRAN
Medicare Remittance Advice Notice
TP
Type Program
MREP
Medicare Remit Easy Print
TPI
Texas Provider Identifier
MSRP
Manufacturer’s Suggested Retail Price
TPN
MTP
Medical Transportation Program
Total Parenteral Nutrition (i.e., Hyperalimentation)
NDC
National Drug Code
TPR
Third Party Resources
NPI
National Provider Identifier
TVFC
Texas Vaccines for Children
OI
Other Insurance
UB-04
Uniform Bill 04 CMS-1450
OIG
Office of Inspector General
VDP
Medicaid Vendor Drug Program
OPL
Online Provider Lookup
VPN
Virtual Private Networking
OBFV
Oral Evaluation and Fluoride Varnish in the
Medical Home
WHP
Women’s Health Program
OT
Occupational Therapy,
PACT
Program for Amplification for Children of
Texas - transitioned to TMHP and known as
Hearing Services for Children
PAF
Physician/Dentist Assessment Form
PAN
Prior Authorization Number
PCCM
Primary Care Case Management
PCN
Patient Control Number
PCS
Personal Care Services
PE
Presumptive Eligibility
POC
Plan of Care
POS
Place of Service
PPO
Preferred Provider Organization
PT
Physical Therapy
R&S
Remittance and Status Report
RHC
Rural Health Clinic
SA
Service Area
SAVERR
System or Application, Verification, Eligibility, Referral and Reporting
SSI
Supplemental Security Income (Program)
SSL
Secure Socket Layer
STAR
State of Texas Access reform
TAC
Texas Administrative Code
TANF
Temporary Assistance to Needy Families
(formerly AFDC)
TENS
Transcutaneous Electric Nerve Stimulator
THSteps
Texas Health Steps Medical and Dental
Services
TIERS
Texas Integrated Eligibility Redesign System
TMHP
Texas Medicaid & Healthcare Partnership
TMPPM
Texas Medicaid Provider Procedures Manual
TOS
Type of Service
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
91
THSteps Dental Participant Guide
CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. CPT is a trademark of the
AMA. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.
Texas Health Steps Quick Reference Guide
R
e
m
e
m
b
e
r
:
Use Provider Identifier • Diagnosis Code V202 • Benefit Code EP1
THSteps Medical
Checkup Steps
Billing Procedure Codes
Texas
Health
Quick Reference Guide
THSteps Medical Checkups
99381
99382
99383
99384
99385
99391
99392
99393
99394
99395
THSteps Follow-up Visit
Use procedure code 99211 for a THSteps follow-up visit.
Oral Evaluation and Flouride Varnish
Use procedure code 99429 with U5 modifier.
90721 with (90471/90742 or 90465/90466)
DTaP-Hib
90723* with (90471/90472 or 90465/90466)
DTap-Hep B-IPV
90732* with (90471/90472 or 90465/90466)
Pneumococcal
90733 or 90734* with (90471/90472 or
90465/90466)
Meningococcal
90740*, 90743, 90744*, 90746*, or 90747 with
(90471/90472 or 90465/90466)
Hep B
90748* with (90471/90472 or 90465/90466)
Hib-Hep B
* Indicates a vaccine distributed by TVFC
Modifiers
Immunizations Administered
Each immunization must have a corresponding vaccine code.
• If only one immunization is administered during a checkup,
providers should bill procedure code 90471/90473 or
90465/90467 with a quantity of 1.
• If two or more immunizations are administered, providers
should bill procedure code 90471/90473 or 90465/90467 with
a quantity of 1, procedure code 90472/90474 or 90466/90468
with a quantity of 1 or more (depending on the number of
vaccines administered), and the appropriate national procedure
codes that describe each immunization administered.
Performing Provider
Use to indicate the practitioner who is performing the unclothed
physical examination component of the medical checkup.
AM
SA
TD
23
32
SC
FQHC
Federally qualified health center (FQHC) providers must use
modifier EP for THSteps medical checkup.
Procedure Codes
Vaccine
90632*, 90633*, or 90636 with (90471/90472
or 90465/90466)
Hep A
90645, 90646, 90647, or 90648* with
(90471/90472 or 90465/90466)
Hib
90649* with 90471/90472
HPV
90655*, 90656*, 90657*, or 90658* with
(90471/90472 or 90465/90466) or 90660*
with (90473/90474 or 90467/90468)
Influenza
90669* with (90471/90472 or 90465/90466)
PCV7
90680* or 90681 with (90473/90474 or
90467/90468)
Rotavirus
90696 with (90471/90472 or 90465/90466)
DTaP-IPV
Use one of the indicators below if a referral was made.
90698* with (90471/90472 or 90465/90466)
DTap-IPV-Hib
90700* with (90471/90472 or 90465/90466)
DTaP
Condition
Indicator
90702* with (90471/90472 or 90465/90466)
DT
N
NU
90703 with (90471/90742 or 90465/90466)
Tetanus
Y
ST
New services requested
90707* with (90471/90472 or 90465/90466)
MMR
Y
S2
Under treatment
90710* with (90471/90472 or 90465/90466)
MMRV
90713* with (90471/90472 or 90465/90466)
IPV
90714* or 90718 with (90471/90472 or
90465/90466)
Td
90715* with (90471/90472 or 90465/90466)
Tdap
90716* with (90471/90472 or 90465/90466)
Varicella
* Indicates a vaccine distributed by TVFC
Vaccine/Toxoids
Use to indicate a vaccine/toxoid not available through TVFC
and the number of state defined components administered per
vaccine.
U1
Vaccine/toxoid privately purchased by provider
when TVFC vaccine/toxoid is not available
U2
Administration of vaccine/toxoid with two state
defined components
U3
Administration of vaccine/toxoid with three state
defined components
Condition Indicator Codes
Condition Indicator
Codes
Description
Not used (no referral)
TB Skin Test
Be sure to include a charge of at least $.01 for procedure code
86580, even though this code is not reimbursed separately.
CPT codes, descriptions, and other data only are copyright 2008 American Medical
Association (or such other date of publication of CPT). All Rights Reserved. CPT is a
trademark of the AMA. Applicable Federal Acquisition Regulation System/Department of
Defense Regulation System (FARS/DFARS) restrictions apply to government use.
Texas Health Steps Quick Reference Guide - revised 4/1/2010
92
U7
Exception to Periodicity
Use with THSteps medical check ups procedure codes to indicate
the reason for an exception to periodicity.
CPT only copyright 2008 American Medical Association. All rights reserved.
1
— 2010_0609_1.4
THSteps Dental Participant Guide
Contact Information
THSteps Medical Checkup Claims Inquiries
Laboratory
Call the following number to obtain answers to questions or
determine the status of claims:
Requests for THSteps supplies from the Department of State
Health Services (DSHS) should be made on Form G399 and
submitted to:
1-800-757-5691
THSteps Outreach & Informing Service,
Missed Appointment & Referral Services
1-877-THSteps (847-8377)
THSteps Website
www.dshs.state.tx.us/thsteps/default.shtm
THSteps-Comprehensive Care Program
(THSteps-CCP)
Telephone: 1-800-846-7470
Fax: 1-512-514-4212
Texas Immunization Registry (ImmTrac)
1-800-348-9158
www.dshs.state.tx.us/immunize/immtrac/default.shtm
Texas Vaccines for Children Program (TVFC)
1-800-252-9152
www.dshs.state.tx.us/immunize/tvfc/default.shtm
Texas Medicaid & Healthcare Partnership (TMHP)
www.tmhp.com
Case Management for Children and Pregnant
Women (CPW)
1-512-458-7111 x 2168
www.dshs.state.tx.us/caseman/default.shtm
Early Childhood Intervention (ECI)
1-800-628-5115
www.dars.state.tx.us/ecis
Hearing Evaluation/Hearing Aid
For THSteps Medicaid clients under 21 years of age, Form
H3087 will have a “P” in the column under “Hearing Aid,” which
indicates that prior approval must be obtained from TMHP for
hearing aid services.
Container Preparation
Laboratory Services Section, MC 1947
Department of State Health Services
PO Box 149347
Austin, TX 78714-93471
1-512-458-7661 or 1-888-963-7111, Ext. 7661
Fax: 1-512-458-7672
Technical Questions: 1-512-458-7680
Test Result Inquiries: 1-512-458-7578 or Fax 1-512-458-7533
A written request for Newborn Screening (NBS) specimen
collection form (NBS3) and NBS supplies is required. To obtain
an order form for written requests, call: 1-512-458-7661
The Newborn Screen is the only test performed
by the DSHS Laboratory for Children’s Health Insurance
Program (CHIP) recipients.
To obtain Newborn Screening test results, call the Newborn
Screening Automated Voice Response System (personal
identification number required): 1-512-458-7300
PAP Smear supplies may be ordered from:
Women’s Health Laboratories
2303 SE Military Drive, Suite 1
San Antonio, TX 78223
Customer Service: 1-888-440-5002 or 1-210-531-4596
Fax: 1-210-531-4506
Obtain guidelines for collecting and handling specific types of
specimens at: www.dshs.state.tx.us/lab/default.shtm
Medical Transportation Program (MTP) - Texas
Department of Transportation
1-877-633-8747
www.hhsc.state.tx.us/QuickAnswers/index.shtml
Medicaid Fraud:
To report potential Medicaid fraud, contact one of the following
hotlines, or visit the website:
HHSC Client or Provider Fraud Investigations:
1-800-436-6184
https://oig.hhsc.state.tx.us/Fraud_Report_Home.aspx
Childhood Lead Poisoning Prevention Program
1 800- 588-1248
www.dshs.state.tx.us/lead/default.shtm
Child Health Record Forms
May be downloaded from the THSteps website or cameraready copies may be ordered from:
THSteps Program
PO Box is 149347
Austin, TX 78714
1-512-458-7745
www.thstepsproducts.com
Texas Health Steps Quick Reference Guide - revised 4/1/2010
2010_0609_1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
2
93
THSteps Medical Participant Guide
94
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
THSteps Medical Participant Guide
2010_0609_v1.4 — CPT only copyright 2008 American Medical Association. All rights reserved.
95
THSteps Medical Participant Guide
The THSteps Medical Workshop Participant Guide is produced by TMHP Organizational Development Services. This is
intended for educational purposes in conjunction with the THSteps Medical Workshop Series. Providers should consult the
Texas Medicaid Provider Procedures Manual, CSHCN Services Program Provider Manual, bulletins, and banner messages for
updates.
96
CPT only copyright 2008 American Medical Association. All rights reserved.
— 2010_0609_v1.4
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