Medicaid Basics Workshop Participant Guide

Medicaid Basics Workshop Participant Guide
Workshop Participant Guide
2015 0311
Medicaid Basics Participant Guide
Contents
Objectives................................................................................................................................ 1
Overview................................................................................................................................. 2
What is Medicaid?................................................................................................................ 2
State Health Programs........................................................................................................... 3
Texas Medicaid Managed Care Programs ............................................................................. 4
Managed Care....................................................................................................................... 4
Forms of Managed Care in Texas Medicaid........................................................................... 4
State of Texas Access Reform (STAR).................................................................................... 6
STAR+PLUS......................................................................................................................... 6
NorthSTAR.......................................................................................................................... 7
STAR Health........................................................................................................................ 7
Children’s Medicaid Dental Services...................................................................................... 8
Medicaid Programs and Services.......................................................................................... 10
Texas Health Steps Medical Services.................................................................................... 10
THSteps Dental Services..................................................................................................... 12
Medicaid Children’s Services............................................................................................... 14
Case Management for Children and Pregnant Women........................................................ 15
Medicaid for Breast and Cervical Cancer............................................................................ 17
Medically Needy Program (MNP)...................................................................................... 18
Texas Medicaid Wellness Program ...................................................................................... 19
Medicaid Vendor Drug Program (VDP)............................................................................. 20
E-Prescribing....................................................................................................................... 21
Texas Medicaid Electronic Health Record (EHR) Incentive Program.................................. 22
Additional Programs and Services....................................................................................... 24
DSHS Family Planning Program........................................................................................ 24
DSHS Expanded Primary Health Care............................................................................... 24
DSHS Youth Empowerment Services.................................................................................. 25
Children with Special Health Care Needs (CSHCN) Services Program............................... 25
Texas Women’s Health Program (TWHP)........................................................................... 27
Programs Overview............................................................................................................. 29
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.i
Medicaid Basics Participant Guide
Provider Enrollment............................................................................................................. 33
Medicaid Enrollment.......................................................................................................... 33
Electronic Funds Transfer (EFT)......................................................................................... 38
Provider Responsibilities...................................................................................................... 40
Client Eligibility................................................................................................................... 42
Eligibility and Third-Party Liability..................................................................................... 42
Verifying Client Eligibility.................................................................................................. 42
Your Texas Benefits Medicaid Card..................................................................................... 45
TexMedConnect................................................................................................................. 46
TMHP Electronic Data Interchange (EDI)......................................................................... 49
Automated Inquiry System (AIS)........................................................................................ 49
Limitations to Medicaid Client Eligibility........................................................................... 50
Waste, Abuse, and Fraud...................................................................................................... 51
Definitions.......................................................................................................................... 51
Most Frequently Identified Fraudulent Practices................................................................. 51
Identifying and Preventing Waste, Abuse, and Fraud........................................................... 51
Reporting Waste, Abuse, and Fraud.................................................................................... 52
Child and Elder Abuse, Neglect, or Exploitation................................................................ 53
DSHS Child Abuse Reporting Form................................................................................... 53
Report Elder Abuse, Neglect, or Exploitation...................................................................... 54
Prior Authorization.............................................................................................................. 55
Introduction....................................................................................................................... 55
Examples............................................................................................................................. 55
Prior Authorization Submissions......................................................................................... 57
Submitting Online Prior Authorization Requests................................................................ 57
Search For and Review the Status of Prior Authorization Requests...................................... 62
Online Radiology Prior Authorization Requests.................................................................. 68
Claim Submission................................................................................................................. 70
Claims................................................................................................................................ 70
TMHP Claim Processing Procedures.................................................................................. 70
Electronic Claims................................................................................................................ 72
Claim Form Determination................................................................................................ 74
CSHCN Services Program Dual Eligibility......................................................................... 76
Saving a Claim.................................................................................................................... 78
The International Classification of Diseases, Tenth Revision, Clinical Modification
(ICD-10- CM) transition ................................................................................................... 78
Submitting Paper Claims.................................................................................................... 79
Tips for Expediting Paper Claims........................................................................................ 79
Other Claim Submission Factors......................................................................................... 80
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Medicaid Basics Participant Guide
Third-Party Resources (TPR)............................................................................................... 82
110-Day Rule..................................................................................................................... 84
365-Day Rule..................................................................................................................... 84
Verbal Denial...................................................................................................................... 84
Role of the TMHP TPR Unit............................................................................................. 84
Exceptions.......................................................................................................................... 84
What is Medicare?................................................................................................................. 86
Medicare............................................................................................................................. 86
Medicare Crossover Claims................................................................................................. 87
Remittance and Status (R&S) Report.................................................................................. 88
Accessing R&S Reports....................................................................................................... 89
R&S Report Sections.......................................................................................................... 91
Balancing Your R&S Report............................................................................................... 94
Electronic Remittance and Status (ER&S) Agreement........................................................ 97
Appeals.................................................................................................................................. 98
Appeal Methods.................................................................................................................. 98
Electronic Appeals............................................................................................................... 99
Automated Inquiry System (AIS) Appeals......................................................................... 101
Paper Claim Appeals......................................................................................................... 102
HHSC Administrative Appeals......................................................................................... 103
Complaints by Providers................................................................................................... 105
Claim Submission Deadlines............................................................................................. 107
Preparation for ICD-10 Implementation.......................................................................... 110
Hospital Initiatives Overview............................................................................................. 111
APR-DRGs....................................................................................................................... 111
POA Indicator Requirement............................................................................................. 112
Potentially Preventable Readmissions (PPR)...................................................................... 112
PPR Calculation Methodology......................................................................................... 113
Potentially Preventable Complications (PPC) Reporting................................................... 113
Resources.......................................................................................................................... 113
Resources............................................................................................................................ 114
Instructions for Using the TMHP Website........................................................................ 114
Online Fee Lookup (OFL)................................................................................................ 117
Online Provider Lookup (OPL)........................................................................................ 119
TMHP Telephone and Fax Communication..................................................................... 127
Prior Authorization Request/Status Telephone and Fax Communication........................... 128
Written Communication With TMHP............................................................................. 128
Texas Medicaid/CHIP Vendor Drug Program Contact Information................................. 130
Helpful Links ................................................................................................................... 131
Steps to Resolve Your Medicaid Questions........................................................................ 132
Common Claim Denial Codes.......................................................................................... 133
Acronyms.......................................................................................................................... 134
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Medicaid Basics Participant Guide
Objectives
At the conclusion of the Medicaid Basics, you should be able to:
• List the State health-care programs available to Medicaid clients.
• Enroll to provide additional services or programs.
• Enroll in electronic funds transfer (EFT).
• Identify provider responsibilities.
• Identify the various methods available to verify client eligibility.
• Use client eligibility data to determine programs/benefits.
• Obtain and update prior authorization requests.
• Follow various methods to submit a claim and understand claim submission deadlines.
• Identify Third Party Resources/Liability and processes.
• Obtain a Remittance and Status (R&S) Report using TexMedConnect.
• Appeal a claim and follow appeal filing deadlines.
• Discuss preparation for the ICD-10 implementation.
• Escalate complaints, problems, and issues.
• Use the basic functions of the TMHP website and help resources.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.1
Medicaid Basics Participant Guide
Overview
What is Medicaid?
Medicaid is a jointly funded state and federal health-care program that was established in Texas
in 1967 and is currently administered by the Texas Health and Human Services Commission
(HHSC). Medicaid is an entitlement program, which means that the federal government does
not, and a state cannot, limit the number of eligible people who can enroll.
Medicaid pays for acute health-care services (physician, inpatient, outpatient, outpatient
prescription pharmacy, lab, preventive care, and X-ray services) and long-term services and support
for aged and disabled clients.
Medicaid serves primarily low-income families, non-disabled children, related caretakers of
dependent children, pregnant women, the elderly, and people who have disabilities. Initially,
the program was only available to people receiving cash assistance (Temporary Assistance
for Needy Families [TANF] or Supplemental Security Income [SSI]). During the late 1980s
and early 1990s, Congress expanded Medicaid to include a broader range of people (elderly,
disabled, children, and pregnant women).
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Medicaid Basics Participant Guide
State Health Programs
• 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: 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. HHSC 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 CSHCN Services Program. DSHS also
administers, in collaboration with HHSC, the Texas Health Steps (THSteps) medical and
dental services, as well as Case Management for Children and Pregnant Women. DSHS
also conducts personal care services (PCS) assessments.
• Department of Aging and Disability Services (DADS): Administers long-term services
and support 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): 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 (ECI) 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 who are
36 months of age and younger with disabilities and delays in development reach their full
potential.
• 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.
• Medicaid Vendors such as MAXIMUS (Enrollment Broker): MAXIMUS is responsible
for helping clients throughout the state who are eligible for STAR, STAR+PLUS, or
children’s Medicaid dental services to select a health-care or dental plan and a primary
care provider or main dentist or to change plans. MAXIMUS helps clients find THSteps
medical, dental, and case management services. They also assist in arranging for medical
transportation services to and from medical and dental appointments. Contact MAXIMUS
at 1-800-964-2777 (TDD 1-800-267-5008).
• Institute for Child Health Policy: The Institute is an external quality review organization
that focuses its attention on children in managed care with a special emphasis on children
with special health care needs.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.3
Medicaid Basics Participant Guide
Texas Medicaid
Managed Care Programs
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 appropriate use of
services, and contain costs.
Forms of Managed Care in Texas Medicaid
Texas Medicaid managed care is delivered through the following models:
•
Managed Care Organizations (MCO): Organizations that are licensed by the Texas
Department of Insurance to deliver and manage health-care services under a risk-based
arrangement. The MCO contracts providers and hospitals to form a network that serves the
MCO members (Medicaid clients). The MCO receives a monthly capitation payment from
the state for each Medicaid client who is enrolled in the MCO. The capitation payments are
based on an average projection of medical expenses for the typical client. The arrangement
ensures a fixed price and budget certainty for the state, while the MCO assumes the risk of
providing services that are medically necessary. MCOs accept the risk for all pre-approved
services that are provided to their enrollees.
•
Dental Managed Care (DMO): Clients who are enrolled in Children’s Health Insurance
Program (CHIP) and most Medicaid-enrolled children and young adults who are birth
through 20 years of age receive managed care dental services through a dental plan.
Clients who reside in state supported living centers or Intermediate Care Facilities known
as ICF-MR clients and receive dental services regardless of age through the traditional
fee-for-service (FFS) Medicaid model. Clients in the state’s foster care program who are
enrolled in STAR Health will receive dental services through STAR Health.
For more information on dental services, refer to www.hhsc.state.tx.us/medicaid/
managed-care/plans.shtml
•
4
Pharmacy Benefit Managers (PBM): Clients who are enrolled in Medicaid or CHIP
managed care obtain prescription drug benefits through MCOs. Each MCO contracts with a
PBM that processes prescription claims and works with pharmacies that serve Medicaid and
CHIP managed care clients.
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Medicaid Basics Participant Guide
Managed Care Overview
The percentage of Medicaid clients who receive services through Medicaid managed care has
increased. Texas Medicaid is currently operated through managed care throughout the state.
• State of Texas Access Reform (STAR) provides acute care medical assistance in the
Medicaid managed care environment statewide. The state is divided into the following
service areas: Bexar, Dallas, El Paso, Harris, Hidalgo, Jefferson, Lubbock, Medicaid Rural
Service Areas, Nueces, Tarrant and Travis.
• STAR+PLUS is a Medicaid program for people who have disabilities or are age 65 or older.
People in STAR+PLUS get Medicaid basic medical services and long-term services through
a health plan, also called a managed care plan.
• NorthSTAR is administered by DSHS and provides integrated behavioral health services
under contract with a behavioral health organization (BHO) for clients who reside in the
Dallas service area.
• STAR Health is a statewide program that is administered by Superior Health Plan and
is designed to provide coordinated health-care services to children and youth in state
conservatorship.
•
Note: For more
information
on managed
care programs
and plans, refer
to the current
Texas Medicaid
Provider
Procedures
Manual
(TMPPM)
Medicaid
Managed Care
Handbook
(Vol. 2, Provider
Handbooks).
Children’s Medicaid dental services are administered by dental plans that process dental
authorization requests and claims for most Medicaid fee-for-service and Medicaid managed
care clients who are 20 years of age and younger regardless of their medical benefit plan.
CHIP RSA (Includes the same
counties as MRSA West, MRSA Central,
MRSA Northeast, and Hidalgo Service Areas)
CHIP – Molina, Superior
Sherman
Moore
Oldham
Potter
Carson
Randall
Armstrong
Deaf Smith
Parmer
Lubbock
Hansford
Dallam
Hartley
Swisher
Castro
Managed Care Service Areas
Ochiltree Lipscomb
Hutchinson Roberts
(effective September 1, 2014)
Hemphill
Tarrant
Wheeler
Gray
Hall
Dallas
STAR – Aetna, Amerigroup, Cook Children’s
STAR+PLUS – Amerigroup, Cigna-HealthSpring
CHIP – Aetna, Amerigroup, Cook Children’s
Donley Collingsworth
Briscoe
STAR – Amerigroup, Molina, Parkland
STAR+PLUS – Molina, Superior
CHIP – Amerigroup, Molina, Parkland
Childress
Hardeman
Bailey
STAR – Amerigroup, FirstCare, Superior
STAR+PLUS – Amerigroup, Superior
CHIP – FirstCare, Superior
Cottle
King
Lynn
Garza
Kent
Stonewall
Wilbarger
Foard
Terry
Montague
Archer
Jack
Haskell Throckmorton Young
Gaines
Dawson
Borden
Scurry
Fisher
Jones Shackelford Stephens
Andrews
Martin
Howard
Mitchell
Nolan
Taylor
Cooke
Wise
Palo
Pinto
Eastland
Callahan
Grayson
Denton
Loving
Winkler
Ward
Culberson
Reeves
Ector
Crane
Midland Glasscock Sterling
Upton
Reagan
Irion
Coke
Runnels
Tom Green
Parker
Hood
Erath
Red River
Tarrant
Comanche
Coleman Brown
Hopkins Franklin Morris
Camp
Hunt
Rains
Wood
Upshur
Val Verde
Kerr
Edwards
Real
Milam
Bandera
Uvalde
Medina
Blanco
Lee
Caldwell
Comal
Maverick
Frio
Zavala
Atascosa
Walker
Newton
Tyler
San Jacinto
Hardin
Liberty
Fort Bend
Wharton
De Witt
Chambers
Orange
Jefferson
Galveston
Brazoria
Jackson
Karnes
Matagorda
Victoria
Goliad
Dimmit
La Salle
McMullen Live Oak
Calhoun
Bee
Refugio
Aransas
San Patricio
Webb
Bexar
Duval
Jim Wells
Nueces
Kleberg
STAR – Aetna, Amerigroup, Community First, Superior
STAR+PLUS – Amerigroup, Molina, Superior
CHIP – Aetna, Amerigroup, Community First, Superior
Zapata Jim Hogg Brooks
Starr
Willacy
Cameron
Nueces
Jefferson
STAR – Amerigroup, Community Health Choice, Molina,
Texas Children’s, United
STAR+PLUS – Amerigroup, Molina, United
CHIP – Amerigroup, Community Health Choice, Molina,
Texas Children’s, United
Kenedy
Hidalgo
STAR – Driscoll, Molina, Superior, United
STAR+PLUS – Cigna-HealthSpring, Molina, Superior
STAR – Amerigroup, Scott &
White, Superior
STAR+PLUS – Superior,
United
Jasper
Harris
Colorado
Lavaca
Sabine
Angelina
Polk
Austin Waller
Fayett
e
Guadalupe
Gonzales
Bexar
Shelby
Montgomery
Washington
Bastrop
Hays
Kendall
MRSA – Central
Panola
Trinity
Brazos
Grimes
Williamson
Travis
Wilson
STAR – Blue Cross and Blue Shield of Texas, Sendero, Seton, Superior
STAR+PLUS – Amerigroup, United
CHIP – Blue Cross and Blue Shield of Texas, Sendero, Seton, Superior
Houston
Madiso
n
Burleson
Gillespie
Kinney
Travis
Llano
Kimble
Terrell
Brewster
Robertson
Marion
Harrison
Nacogdoches
San Augustine
Leon
Falls
Bell
Burnet
Rusk
Cass
Anderson Cherokee
Limestone
Coryell
Menard
Mason
Sutton
Presidio
Freestone
McLennan
Concho
Gregg
Navarro
Hill
Hamilton
Mills
Crockett
Smith
Ellis
Henderson
Bosque
STAR – Amerigroup, Superior
STAR+PLUS – CignaHealthSpring, United
Bowie
Titus
Rockwal
Dallas l
Johnson
McCulloch San Saba Lampasas
Schleicher
Pecos
Jeff Davis
Hidalgo
Lamar
Fannin
Collin
Somervell
El Paso
MRSA – Northeast
Wichita
Baylor
Knox
KaufmanVan Zandt
STAR – Amerigroup, FirstCare, Superior
STAR+PLUS – Amerigroup, Superior
STAR – El Paso First, Molina, Superior
STAR+PLUS – Amerigroup, Molina
CHIP – El Paso First, Superior
Motley
Dickens
Delta
MRSA – West
El Paso
Floyd
Crosby
Clay
Yoakum
Hudspeth
Hale
Lubbock
Lamb
Cochran Hockley
STAR – Christus, Driscoll, Superior
STAR+PLUS – Superior, United
CHIP – Christus, Driscoll, Superior
Harris
STAR – Amerigroup, Community Health Choice, Molina,
Texas Children’s, United
STAR+PLUS – Amerigroup, Molina, United
CHIP – Amerigroup, Community Health Choice, Molina,
Texas Children’s, United
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.5
Medicaid Basics Participant Guide
State of Texas Access Reform (STAR)
STAR is a statewide Medicaid managed care program that provides acute care services to clients.
Clients choose a health-care plan and a PCP. The PCP serves as the client’s medical home and
makes referrals for other services to providers that are affiliated with the MCO.
STAR uses the MCO model to provide services in service areas (SAs). SAs are groups of
counties that divide the state into areas. Services are delivered through selected MCOs.
Enrollment
STAR benefits include traditional FFS Medicaid benefits plus:
• Unlimited medically necessary prescriptions for adults
• No limit on necessary hospital days for adults
• Value-added services
STAR+PLUS
STAR+PLUS is a Texas Medicaid managed care program that is designed to provide acute
health-care services and long-term services and support through a managed care system.
STAR+PLUS provides a continuum of care that includes a range of options and the flexibility
necessary to meet individual needs. STAR+PLUS increases the number and type of providers
that are available to Medicaid clients.
Clients who are enrolled in STAR+PLUS choose from the MCOs that are available in their
county, and they receive Texas Medicaid services through that MCO. Through these MCOs,
STAR+PLUS combines traditional health care such as:
• Doctor visits
• THSteps medical checkups
• CCP and long-term services and support, including:
–– Providing help in the client’s home with daily activities
–– Making home modifications
–– Providing respite care (short-term supervision)
–– Providing personal assistance
Enrollment
The following individuals who meet the following requirements are not eligible for enrollment in
STAR+PLUS:
• Medicaid clients who live in nursing facilities, such as a nursing home, Intermediate Care
Facility (ICF), or a state school
• Medicaid clients who receive home and community-based services through a Home and
Community Based Waiver program other than CBA, such as:
–– Children in state foster care
–– Individuals who qualify for the Medically Needy Program
–– Refugees
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Medicaid Basics Participant Guide
NorthSTAR
NorthSTAR is a public behavioral health insurance project. It provides access to providers
for low-income Texans, while improving accountability, interagency cooperation, and
stakeholder involvement.
NorthSTAR was implemented by HHSC and DSHS in 1999.
• Clients who reside in Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall
counties are eligible for behavioral health services, with some exceptions.
• Behavioral health services are rendered by psychiatrists, psychologists, licensed professional
counselors (LPCs), licensed clinical social workers (LCSWs), chemical dependency
treatment facilities, and freestanding psychiatric facilities. Services may also be rendered by
general acute-care hospitals in some instances. This is not an all-inclusive list.
• Providers who provide these services to clients in these counties must enroll in NorthSTAR
to be reimbursed.
For more information, call the NorthSTAR service center at 1-888-800-6799.
STAR Health
STAR Health is a statewide program implemented in 2008 to provide comprehensive and
coordinated health-care services to children who are in state conservatorship. Superior
HealthPlan Network provides an array of health-care, including medical, dental, vision, and
behavioral health services; service coordination; and the Health Passport.
Providers must be contracted by Superior HealthPlan Network to be reimbursed for providing
services to Texas Medicaid clients.
Superior HealthPlan Network also provides:
• An expedited enrollment process so that children can begin receiving services as soon as
they are taken into state conservatorship.
• Improved access to services through a defined network of providers.
•
A medical home that uses a PCP to coordinate care and promote preventive health for every
child in state conservatorship.
• Service coordination to help clients, caregivers, and caseworkers access the services and
information they need.
•
Improved access to health history and medical records using the web-based Health Passport.
• A 7-day, 24-hour nurse hotline for caregivers and caseworkers.
• A medical advisory committee to monitor provider performance.
The Texas Medicaid Vendor Drug Program (VDP) accepts the Department of Family
Protective Services (DFPS) ID number that is assigned to children in foster care.
For more information about Superior HealthPlan Network, call 1-866-439-2042.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.7
Medicaid Basics Participant Guide
Children’s Medicaid Dental Services
Primary and preventive Medicaid dental services are provided through Medicaid managed care
dental plans. Each Medicaid managed care dental plan is responsible for contracting general
dentists, pediatric dentists, and dental specialists to create a delivery network. DentaQuest and
Managed Care of North America (MCNA) Dental are the two managed care dental plans in
Texas.
Most children who are 20 years of age and younger will receive their dental services through a
Medicaid managed care dental plan. Clients have the right to change plans. Clients must call
the Enrollment Broker to initiate a plan change. If a plan change request is received before the
middle of the month, the plan change is effective on the first day of the following month. If the
request is received after the middle of the month, the plan change will be effective on the first
day of the second month following the request.
For more information about MCOs, providers can call the Enrollment Broker Help Line.
The Enrollment Broker Help Line is available 8 a.m. to 8 p.m., Central Time, Monday through
Friday at:
• Telephone: 1-800-964-2777
• Telecommunications device for the deaf (TDD): 1-800-267-5008
8
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Medicaid Basics Participant Guide
Texas Medicaid Benefits by Program
The following table lists information about some of the Texas Medicaid benefits and limitations:
STAR
STAR+PLUS
NorthSTAR
STAR+PLUS Dual
Eligibles
STAR Health
(Foster Care)
Traditional FFS
Medicaid
N/A
No
Yes
Yes: 20 years of
age and younger
Spell of Illness Waived
Yes
Yes
No: 21 years of age
and older
Prescription Drugs
Unlimited
Unlimited for
Medicaid only
N/A
Waiver members
Receive
prescriptions
through Medicare
Part D.
Unlimited
Unlimited: 20
years of age and
younger.
Limited (3 per
month): 21 years
of age and older
through Medicaid
Vendor Drug
Program.
Dual eligible
clients receive
limited
prescription
benefits through
Medicaid Vendor
Drug for excluded
Medicare Part-D
(wrap-around)
drugs listed in
the Medicaid
formulary.
Personal Care Services (PCS)
TMHP authorizes
and pays these
claims for clients
who are 20
years of age and
younger.
MCOs authorize
N/A
and pay these
claims. MCOs
authorize and pay
claims for primary
home care services
for members who
are 20 years of age
and younger.
Part of 1915(b)
The MCO
Long Term Support authorizes and
Services (LTSS).
pays these claims.
MCO authorizes
and pays these
claims.
TMHP authorizes
and pays these
claims for clients
who are 20
years of age and
younger.
Hearing Services for Clients Who are 20 Years of Age and Younger
The MCO
authorizes and
pays these claims.
The MCO
authorizes and
pays these claims.
N/A
TMHP authorizes
and pays these
claims.
TMHP authorizes
and pays these
claims.
TMHP authorizes
and pays these
claims.
The MCO
authorizes and
pays these claims.
TMHP authorizes
and pays these
claims.
Hearing Services for Clients Who are 21 Years of Age and Older
The MCO
authorizes and
pays these claims.
The MCO
authorizes and
pays these claims.
N/A
TMHP pays the
coinsurance/
deductible up
to the Medicaidallowed amount.
Note: Foster care clients who are enrolled in Permanency Care Assistance (PCA) traditional FFS Medicaid are not
considered eligible for enrollment in Medicaid managed care and are not eligible for Medicaid managed care benefits.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.9
Medicaid Basics Participant Guide
Medicaid Programs and Services
Texas Health Steps Medical Services
Overview
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is Medicaid’s comprehensive
preventive care service (medical, dental, and case management) for children who are birth through
20 years of age. In Texas, EPSDT is known as Texas Health Steps (THSteps). The THSteps tollfree helpline (1-877-847-8377) helps eligible clients and their parents or guardians to:
•
Find a qualified medical, dental, case management, or other health-care provider enrolled in
Medicaid.
• Set up appointments to see a provider through THSteps Outreach and Informing Services.
• Arrange transportation or reimbursement for gas to and from appointments.
• Answer questions about eligible services.
THSteps Provider Requirements
Note: Providers
cannot be
enrolled if their
professional license
is due to expire
within 30 days of
application.
10
Medicaid providers may render THSteps preventive services within their scope of practice if
they are enrolled as one of the following provider types:
•
•
•
•
•
•
•
•
Physician or physician group (M.D. or D.O.) Physician assistant (PA)
Clinical nurse specialist (CNS)
Nurse practitioner (NP)
Certified nurse midwife (CNM)
Federally Qualified Health Center (FQHC)
Rural Health Clinic (RHC)
Health-care provider or facility with physician supervision including, but not limited to a:
–– Community-based hospital and clinic
–– Family planning clinic
–– Home health agency
–– Local or regional health department
–– Maternity clinic
–– Migrant health center
–– School-based health center
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Medicaid Basics Participant Guide
THSteps Provider Education
THSteps has an award-winning, online continuing education (CE) program for providers who
render services to children enrolled in Medicaid. The courses cover preventive health, mental
health, oral health, and case management services. Ethics-accredited courses are also available.
To access training information, visit the website at www.txhealthsteps.com/cms/.
Oral Evaluation and Fluoride Varnish in the Medical Home
Oral Evaluation and Fluoride Varnish (OEFV) in the medical home offers additional services
with a medical checkup that are aimed at improving the oral health of children who are 6
months of age through 35 months of age.
Who Is Eligible to Provide OEFV?
THSteps-enrolled physicians, PAs, NPs, and CNS.
Certification
To participate in OEFV, physicians, NPs, CNS, and PAs must be certified through DSHS.
Online training is available and easy to use. To access training information for certification,
visit the website at www.dshs.state.tx.us/dental/OEFV_Training.shtm.
Once certified, the certification code is placed on the THSteps Texas Provider Identifier (TPI)
under which the provider bills their THSteps medical checkups.
What Is Included In The OEFV Visit?
The following services are included in the OEFV visit and must be performed in conjunction
with a THSteps medical checkup:
• Intermediate oral evaluation
• Fluoride varnish application
• Dental anticipatory guidance
• Referral to a dental home
How are Claims for this Service Submitted to Texas Medicaid?
For specific information about submitting claims for OEFV, review the THSteps Medical CBT
available on the TMHP Learning Management System (LMS) at http://learn.tmhp.com or
refer to the Intermediate Oral Evaluation and Fluoride Varnish in the Medical Home section of
the current TMPPM.
Migrant Farmworkers
Flexibility in the periodicity schedule allows children of migrant farmworkers to receive their
THSteps medical and dental checkups before their families migrate to another area for work.
When clients are outside of Texas, they can receive care from any provider who is enrolled or
seeking to enroll in Texas Medicaid.
Clients and providers can find more information about accessing health services while out of
state by accessing the National Center for Farmworkers website at www.NCFH.org.
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Medicaid Basics Participant Guide
THSteps Dental Services
Overview
THSteps dental services provide early detection and treatment of dental health problems and
preventive dental care for Texas Medicaid clients who are birth through 20 years of age.
THSteps Dental Service standards were designed to meet federal regulations and to incorporate
the recommendations of representatives of national and state dental professional groups.
Through outreach and education, THSteps encourages parents and caregivers of eligible clients
to use THSteps dental services checkups and preventive care when clients first become eligible
for Medicaid and each time clients are due for their next dental checkup. Upon request,
THSteps helps parents and caregivers of eligible clients with scheduling appointments and
transportation. Medicaid clients have the freedom to choose their providers and are given
names of enrolled providers.
Clients are eligible to receive dental check-ups at six-month intervals, based on the date of the
client’s last dental check-up.
All THSteps clients who are birth through 20 years of age can be seen by a dentist at any time
if they need emergency dental services for trauma, early childhood caries (ECCs), or any other
appropriate dental or therapeutic procedure. Parents of clients who are birth through 20 years
of age may self-refer for dental services.
For additional information about dental health, refer to the THSteps online educational
modules “Dental Oral Health for Primary Care Providers” and “Dental Screening Oral Health
Exams by Dental Professionals” at www.txhealthsteps.com.
First Dental Home
First Dental Home is a package of services 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. The dental home is provided by a THSteps or CSHCN
Services Program dental provider.
The goal of First Dental Home is to begin preventive dental services for very young children to
decrease the occurrence of ECCs and to provide simple and consistent oral health messages to
parents and caregivers. First Dental Home tries to establish a dental home, because early oral
evaluation allows early identification of dental needs and the start of needed preventive and
therapeutic dental services. Clients can receive services as frequently as three-month intervals
based on their caries risk assessment, and they may be referred to a dental home provider by
their PCP beginning at 6 months of age.
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Medicaid Basics Participant Guide
Benefits
A First Dental Home visit includes, but is not limited to:
• A comprehensive oral examination.
• Oral hygiene instruction by the primary caregiver.
• Dental prophylaxis (if appropriate).
• Topical fluoride varnish application when teeth are present.
• A caries risk assessment.
• Dental anticipatory guidance.
Denials
A First Dental Home examination is limited to ten services per client, per lifetime with at least
60 days between visits by any provider to prevent denials of the service.
A listing of the procedure codes and disallowed combinations of procedure codes on the same
date of service can be found in the current TMPPM, Children’s Services Handbook (Vol. 2,
Provider Handbooks).
Certification
Providers can take free Continuing Education (CE) courses online through the THSteps Online
Provider Education website. The First Dental Home (FDH) course was developed by the Texas
Department of State Health Services and the Texas Health and Human Services Commission.
The goal of the FDH module is to train and certify THSteps dentists who are enrolled in Texas
Medicaid to provide dental homes for children from 6 through 35 months of age. For more
information, visit www.dshs.state.tx.us/dental/firstdentalhomeTraining.shtm.
For more information, contact the Oral Health Program regional staff or staff in the Austin
Central Office at:
Oral Health Program
Department of State Health Services
Mail Code 1938
PO Box 149347, Austin, Texas 78714-9347
1701 North Congress Avenue, Austin, Texas 78701
Telephone (512) 776-7323, Fax (512) 776-7256
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.13
Medicaid Basics Participant Guide
Medicaid Children’s Services
Comprehensive Care Program (CCP)
The Omnibus Budget Reconciliation Act (OBRA) of 1989 mandated the expansion of the
federal EPSDT program to include any medical or dental service that is medically necessary
and for which Federal Financial Participation (FFP) is available, regardless of the limitations
of Texas Medicaid. In Texas, this expansion is referred to as the Comprehensive Care Program
(CCP).
CCP services that may be considered medically necessary, such as prosthetics, orthotics, PCS,
nursing services and occupational therapy (OT), physical therapy (PT), and speech-language
pathology (SLP) services for non-acute conditions, are benefits of Texas Medicaid for clients
(including foster care) who are birth through 20 years of age.
Pharmacies can enroll as CCP providers for medications that are medically necessary but
are not available through the Medicaid VDP. These medications may be considered for
reimbursement through CCP.
Most CCP services require prior authorization. ECI providers are not required to get prior
authorization for PT, OT, speech-language evaluations, and nutrition services that are provided
within the service limitations.
For more information about CCP prior authorization, refer to the Prior Authorization CBT on the
TMHP LMS at http://learn.tmhp.com/.tgel1y4/prior_authorization_for_texas_medicaid.aspx.
The CCP Prior Authorization Form and form instructions can be found in the Provider Forms
section of the TMHP website.
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Medicaid Basics Participant Guide
Case Management for Children and Pregnant Women
Overview
Case Management for Children and Pregnant Women serves children who are birth through
20 years of age and have a health condition or health risk and serves women with high-risk
pregnancies who are in need of case management services. Case managers help families get
medical services, handle educational and school-related issues, address financial concerns, find
equipment and supplies, and find community resources.
Eligibility
To qualify for Case Management for Children and Pregnant Women services, a client must:
• Be eligible for Texas Medicaid.
• Be one of the following:
–– A pregnant woman who has a high-risk condition.
–– A child (birth through 20 years of age) who has a health condition or health risk.
• Need assistance in gaining access to necessary medical, social, educational and other
services related to their health condition, health risk, or high-risk condition.
• Want to receive case management services.
Pregnant women who have a high-risk condition are defined as those who have a medical or
psychosocial condition that places them and their fetuses at a greater than average risk for
complications, either during pregnancy, delivery, or following birth. Children with a health
condition are defined as children who either have, or are at risk for a, medical condition,
illness, injury, or disability that results in the limitation of function, activities, or social roles in
comparison with healthy same-age peers in the general areas of physical, cognitive, emotional,
or social growth and development.
Providers who think they have a client who meets the Case Management for Children and
Pregnant Women requirements can refer the client to THSteps at 1-877-847-8377 to request
case management services. THSteps will refer the client to a provider who will gather intake
information and request prior authorization from DSHS.
Enrollment
Case Management for Children and Pregnant Women providers are not required to enroll in
Medicaid managed care. All claims for services provided by Case Management for Children
and Pregnant Women providers are submitted to TMHP for all Medicaid clients, including
Medicaid managed care clients. Medicaid managed care health plans are not responsible for
reimbursing Case Management for Children and Pregnant Women services.
For more information, refer to the current TMPPM, Behavioral Health & Case Management
Handbook (Vol. 2, Provider Handbooks).
Providers who are interested in becoming a Case Management for Children and Pregnant
Women provider can find additional information on the DSHS website at http://www.dshs.
state.tx.us/caseman/default.shtm.
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Medicaid Basics Participant Guide
Note: Case
Management for
Children and
Pregnant Women
providers do not
need to enroll
with Medicaid
Managed Care.
They can submit
all claims directly
to TMHP.
16
Enrollment for Case Management for Children and Pregnant Women providers is a two-step
process.
• Step 1: Potential providers must submit a DSHS Case Management for Children
and Pregnant Women provider application to the DSHS Health Screening and Case
Management Unit.
• Step 2: Upon approval by DSHS, potential providers must enroll as a Medicaid provider
for Case Management for Children and Pregnant Women and submit a copy of their
DSHS approval letter. Facility providers must enroll as a Case Management for Children
and Pregnant Women group, and each eligible case manager must enroll as a performing
provider for the group.
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Medicaid Basics Participant Guide
Medicaid for Breast and Cervical Cancer
Overview
Medicaid for Breast and Cervical Cancer (MBCC) provides help to qualified women who are
diagnosed with breast or cervical cancer, including precancerous conditions.
Benefits
A woman who is eligible for MBCC receives full Medicaid benefits beginning the day after
she receives a qualifying diagnosis and for the duration of her cancer treatment. Services are
not limited to the treatment of breast and cervical cancer. Medicaid may be able to reimburse
unpaid medical bills after the day of diagnosis for the three months prior to the month in
which the client applies. The woman can continue to receive Medicaid benefits as long as she
meets the eligibility criteria and provides proof that she is receiving active treatment for breast
or cervical cancer.
Client Eligibility
To be eligible for MBCC, a woman must be diagnosed and in need of treatment for one of the
following biopsy-confirmed breast or cervical cancer diagnoses:
• Cervical intraepithelial neoplasia, grade 3 (CIN III)
• Severe cervical dysplasia
• Cervical carcinoma in situ
• Primary cervical cancer
• Ductal carcinoma in situ
• Primary breast cancer
A woman may be eligible if she has a diagnosis of metastatic or recurrent breast or cervical
cancer and a need for treatment.
In addition to the diagnostic requirements listed above, a woman must:
• Be 64 years of age or younger.
• Be a U.S. citizen or an eligible immigrant.
• Not currently receive full Medicaid benefits (including Medicaid for pregnant women),
CHIP, or Medicare Part A or B.
• Have a household income at or below 200 percent of the FPL.
• Not have other insurance coverage for her cancer treatment.
Providers
A woman diagnosed by any qualified provider must go to a clinic that contracts with DSHS for
Breast and Cervical Cancer Services (BCCS) to determine whether she has a qualifying diagnosis
and to apply for MBCC. Women cannot apply for MBCC at an HHSC benefits office. Once
enrolled, any Medicaid provider can serve MBCC clients. Services are not limited to the treatment
of breast and cervical cancer. For the woman to continue receiving MBCC benefits, her treating
physician must certify every six months that she is actively receiving cancer treatments.
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Medicaid Basics Participant Guide
Medically Needy Program (MNP)
Overview
MNP provides access to Medicaid benefits to children who are 18 years of age and younger and
pregnant women who have an income that exceeds the eligibility limits under TANF or one of
the Medical Assistance Only (MAO) programs for children, but that is not enough to meet their
medical expenses. Benefits are available for services within the amount, duration, and scope of
Texas Medicaid. Individuals are considered adults beginning the first day of the month following
their 19th birthday.
Benefits
MNP provides access to Medicaid benefits, including family planning and THSteps medical
services, to:
• Pregnant teens (18 years of age and younger) and women. Individuals who are 20 years of
age and younger may also receive THSteps medical checkups.
• Children who are 18 years of age and younger.
MNP applications are made through HHSC. HHSC determines whether:
• The applicant meets basic Medicaid eligibility requirements.
• The applicant is eligible without spend-down (the difference between the applicant’s net
income and the MNP income limits).
Eligibility
Eligibility for medically needy spend-down is calculated on a month-by-month basis. Eligibility
can be certified for up to six months depending on the size of the client’s medical bills and
spend-down amount. Eligibility can also be certified for up to three months prior to the month
of application. Medically needy spend-down will not reimburse medical bills that are used to reach the spenddown income level, but it can reimburse for other outstanding bills that were incurred in the
three months prior to the acceptance of the application and for care that was obtained once the
client was eligible for Medicaid. Spend-Down
Several factors are considered in determining financial eligibility for MNP. Pregnant women,
infants, and children in the family, countable income and resources are computed the same way
that they are for the categories of regular Medicaid. The same deductions from income apply. MNP can help reimburse for ongoing medical bills, and it can also help reimburse for
outstanding hospital and other medical bills that were incurred in the month of application
and any of the three months before the application for Medicaid. 18
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Medicaid Basics Participant Guide
Medically Needy Clearinghouse (MNC) or Spend-down Unit Correspondence
Bills, claim forms, and current itemized statements can be mailed to:
Texas Medicaid & Healthcare Partnership Medically Needy Clearinghouse
PO Box 202947
Austin, TX 78720-2947
Texas Medicaid Wellness Program
Overview
The Texas Medicaid Wellness Program provides chronic care management services to Medicaid
FFS clients and focuses on high cost, high risk clients who have complex conditions. Providers
can call 1-877-530-7756 to ask questions or to refer a potential client.
Benefits
The program supports eligible Medicaid clients with a series of regional care teams consisting of
the following:
•
•
•
•
•
•
•
Community-based primary registered nurses
Pharmacists
Social workers
Behavioral health specialists
Dieticians
Certified diabetes educators
Community health workers
Other benefits include the following:
• Weight Watchers obesity program
• Additional support and resources available via an internet-based patient portal
Eligibility
Medicaid FFS clients who meet eligibility requirements that are determined through claims
and through their health-care provider can join the wellness program. Clients who are eligible
will receive a letter inviting them to join. They may also get a telephone call from the wellness
program. Providers who have clients who are enrolled in the Texas Medicaid Wellness Program
will receive rosters and summaries for any eligible clients who are linked to their practice as
determined by claim data. Providers can also refer eligible clients to enroll in the program.
Providers have the opportunity to review, approve, or make recommendations for the Texas
Medicaid Wellness Program care plan that is created for each client who is enrolled in the
program.
Providers can refer clients to the program by calling the hotline at 1-800-777-1178.
For more information, visit www.hhsc.state.tx.us/medicaid/Texas-Medicaid-WellnessProgram.html or www.hhsc.state.tx.us/QuickAnswers/Wellness.shtml.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.19
Medicaid Basics Participant Guide
Medicaid Vendor Drug Program (VDP)
VDP reimburses contracted pharmacies for outpatient prescription drugs that are prescribed
by a treating physician or other health-care providers to clients who are eligible for fee-forservice (FFS) Medicaid, the CSHCN Services Program, and Kidney Health Care (KHC). VDP
maintains the drug formulary for CHIP.
All written prescriptions for Medicaid clients must be written on tamper-resistant prescription
pads (TRPP). This is not necessary for prescriptions that are submitted by telephone or fax.
Prescribing providers can access an online drug formulary to determine whether a drug is
a covered benefit. These searchable formulary tools also show which drugs are preferred or
non-preferred and need prior authorization and whether the drug requires a clinical prior
authorization for FFS clients:
• For all state health-care program formulary information, including which products are
preferred: www.txvendordrug.com/formulary/formulary-search.asp.
• For the Enhanced Formulary Medicaid drug formulary and preferred drug list information
with links to selected non-preferred drugs that will guide you to the preferred drugs in that
therapeutic class: www.txvendordrug.com/formulary/enhanced-form-search.shtml.
• For free Medicaid drug information on your mobile device (i.e., Palm, Blackberry,
Windows Mobile telephone, or iPhone): www.epocrates.com
Prescribing providers can submit prior authorization requests for FFS clients:
• By telephone at 1-877-PATEXAS (1-877-728-3927).
• Online using a secure, easy-to-use interface that is available 24 hours a day on the
PAXpress™ website at www.paxpress.txpa.hidinc.com. For instructions on setting up
a user account, visit www.paxpress.txpa.hidinc.com/Account_Reg_Instructions.pdf.
(prior authorizations for non-preferred drugs only).
For Medicaid managed care clients, prescribing providers should contact the clients’ Medicaid
managed care plan or pharmacy benefit manager for drug prior authorization process. For a
listing of contact information, refer to
www.txvendordrug.com/downloads/prescriber_assistance_chart.pdf.
A 72-hour emergency supply of a prescribed drug must be provided when a medication is
needed without delay and prior authorization is not available. This applies to all drugs requiring
a prior authorization, either because they are non-preferred drugs on the Preferred Drug List or
because they are subject to clinical edits. Pharmacies will be paid in full for 72-hour emergency
prescription claims.
The 72-hour emergency procedure should not be used for routine and continuous overrides.
A pharmacist’s dispensing guide is available at www.txvendordrug.com/about/priorauthorization-call-center.shtml.
Providers can access the VDP website at www.txvendordrug.com for a list of pharmacies that
offer free delivery to FFS clients and for more information on the VDP Program.
For more information, refer to Appendix B: Vendor Drug Program in the TMPPM.
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Medicaid Basics Participant Guide
E-Prescribing
Electronic prescribing (e-prescribing) allows providers to use technology to prescribe outpatient
medication for clients who are covered by Texas Medicaid and CHIP, while also enabling
the electronic exchange of drug benefit information and client medication history between
prescribers and payers. The goal of e-prescribing within VDP is to support adoption and
meaningful use of e-prescribing across Medicaid and CHIP to improve the quality, safety, and
efficiency of health-care services provided under Medicaid and CHIP.
The percentage of physicians prescribing electronically in Texas increased from 10 percent in
2008 to 31 percent in 2010. Additionally, certain federal incentive programs are generating
significant opportunities for providers to adopt e-prescribing. For example, the American
Recovery and Reinvestment Act (ARRA) allows for the payment of federal incentives to
Medicaid and Medicare providers for the adoption and meaningful use of certified electronic
health record (EHR) technology. The use of e-prescribing is included as a meaningful use
criteria. Therefore, providers that are eligible to receive the incentives must use e-prescribing
capabilities within a certified EHR. EHR Incentive payments began in 2011.
Once implemented, e-prescribers have the ability to request Medicaid client medication history
using the e-prescribing tool as long as they have client consent and the client allows Medicaid
to share their history. Clients have been notified about e-prescribing and given the option to
opt out, meaning that their medication history will not be shared via the e-prescribing system.
Clients can opt out by telephone or internet. Regardless of the client’s choice, e-prescribers
have the ability to obtain information on client benefits and Medicaid and CHIP formularies
using e-prescribing functionality. Providers also are able to transmit electronic prescriptions to
pharmacies that are capable of receiving electronic prescriptions.
All e-prescribing systems connected to the Surescripts network, including provider, pharmacy,
and payer systems, must be certified by Surescripts prior to connection. Certification of
e-prescribing capabilities requires compliance with national standards.
Providers who wish to participate in e-prescribing can begin by obtaining a certified EHR or an
e-prescribing tool that is connected to the Surescripts network. Information on e-prescribing
can be found on the surescripts website at www.surescripts.com.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.21
Medicaid Basics Participant Guide
Texas Medicaid Electronic Health Record
(EHR) Incentive Program
Under the provisions of the Health Information Technology for Economic and Clinical Health
(HITECH) Act, state Medicaid programs are establishing EHR Incentive Programs. The Texas
Medicaid EHR Incentive Program started in 2011 and provides incentive payments to eligible
professionals (EPs) and eligible hospitals (EHs) as they adopt, implement, or upgrade certified
EHR technology in their first year of participation and demonstrate “meaningful use” (MU)
for up to five remaining participation years.
EPs can receive as much as $63,750 over a six-year period through Medicaid. Payments to EHs
will be derived from a base payment of $2 million which is adjusted for total discharges and the
applicable Medicaid share of case mix.
Some key points about the EHR Incentive program:
• Payment is an incentive for using certified EHRs in a meaningful way; it is not a
reimbursement for expenses incurred.
• Incentives are based on the individual, not the practice.
Note: For
providers in
FQHCs and
RHCs, the client
volume threshold
includes needy
individuals
(encounters with
Medicaid, CHIP,
uncompensated
care, sliding scale
clients). For all
other providers,
only encounters
with Medicaid
clients may be
included in the
calculation.
• EPs and EHs began participating in 2011. The last year a Medicaid EP or EH may begin
participation in the program is 2016. Final payment can be received until 2021 for EPs
and 2018 for EHs.
• EHs may participate in both the Medicaid and Medicare EHR Incentive Programs.
• There are no service payment adjustments for non-participation under the Medicaid EHR
Incentive Program.
Eligibility – Eligible Professionals
EPs under the Medicaid EHR Incentive Program include:
• Physicians (primarily doctors of medicine [M.D.] and doctors of osteopathy [D.O.]).
• Dentists.
• Nurse practitioners (NP).
• Certified nurse-midwives (CNM).
• Physician assistants (PA) who provide services in a Federally Qualified Health Center
(FQHC) or Rural Health Clinic (RHC) that is led by a PA.
To qualify for an incentive payment under the Medicaid EHR Incentive Program, an EP must:
• Meet one of the following client volume criteria:
–– 30 percent of their client volume must be Medicaid clients;
–– 20 percent of a pediatrician’s total client volume must be Medicaid clients; or
–– 30 percent of the total client volume must be Medicaid clients for an EP who works
predominantly in an FQHC or RHC.
• Adopt, implement, or upgrade to a certified EHR in the first year of participation and
demonstrate MU in subsequent years of participation.
• Not be a hospital-based physician. Hospital-based means that 90 percent or more of
services are provided in an emergency department (POS 23) or inpatient (POS 21) setting.
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Medicaid Basics Participant Guide
Eligibility – Eligible Hospitals
EHs under the Medicaid EHR Incentive Program include:
• Acute care and critical access hospitals.
• Children’s hospitals.
To qualify for an incentive payment under the Medicaid EHR Incentive Program an EH
must adopt, implement, or upgrade to a certified EHR in the first year of participation and
demonstrate MU in subsequent years of participation. Acute care and critical access hospitals
must have a minimum 10 percent Medicaid client volume. Children’s hospitals do not have to
have a minimum Medicaid client volume.
Enrollment
To participate, providers are required to enroll and attest to client volumes and other eligibility
criteria using the online portal. For more information on the Texas Medicaid EHR Incentive
Program, refer to the TMHP website at www.tmhp.com/Pages/HealthIT/HIT_EHR.aspx.
After completion of the enrollment and attestation process for the EHR Incentive Program,
providers can access the online portal to review their results and disposition. Providers should
ensure that Medicaid has a current email address, because email communications will be
provided during the enrollment process. After enrollment, providers will be required to attest
online each year to qualify for further incentive payments.
Resources for Additional Information
• Learn more about the EHR incentive program using the self-guided and interactive tool at:
www.texasehrincentives.com
• Get step-by-step instructions for participating at:
www.tmhp.com/Pages/HealthIT/HIT_EHR_GettingStarted.aspx
• Review information on certified EHR technology products at:
www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/
Certification.html
• Get technical assistance through the Regional Extension Centers at:
www.txrecs.org
• Review additional program information at:
–– The Texas Medicaid EHR Incentive Program website
www.tmhp.com/Pages/HealthIT/HIT_EHR.aspx
–– The CMS EHR Incentive Program website
www.cms.gov/EHRIncentivePrograms
• Sign up for email updates at:
https://public.govdelivery.com/accounts/TXHHSC/subscriber/new
–– Enter your email address and register
–– On the subscription topics page, go to the Projects section and select “Health
Information Technology”
• Submit questions by:
–– Sending an email to [email protected]
–– Calling 1-800-925-9126, option 4
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Medicaid Basics Participant Guide
Additional Programs and Services
DSHS Family Planning Program
Overview
The DSHS Family Planning Program helps fund clinic sites across the state to provide
quality, comprehensive, low-cost, and accessible family planning and reproductive health
care services to women and men whose income is at or below 250 percent of the Federal
Poverty Level (FPL).
These services help individuals determine the number and spacing of their children, reduce
unintended pregnancies, positively affect future pregnancy and birth outcomes, and
improve general health.
This program is administered by the Community Health Services Section at DSHS. TMHP
is contracted as the claims processor for these family planning services.
Family Planning and Third Party Liability
Federal and state regulations mandate that family planning client information be kept
confidential. Because seeking information from third-party resources may jeopardize the
client’s confidentiality, prior insurance billing is not a requirement for billing family planning
for any title program.
DSHS Expanded Primary Health Care
The DSHS Expanded Primary Health Care (EPHC) program provides primary, preventive
and screening services to women who are age 18 and older whose income is at or below 200
percent of the FPL. Outreach and direct services are provided through community-based
clinics under contract with DSHS. Community health workers (CHWs) will help ensure
women access the preventive and screening services appropriate to them. The program also
supports the integration of lactation consultants in primary health care settings.
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Medicaid Basics Participant Guide
Overall, the goals of the EPHC program are to:
• Increase the number of women receiving primary and preventive care services
• Increase early detection of breast and cervical cancers
• Avert unintended Medicaid births
• Reduce the number of preterm births
• Reduce the number of cases of potentially preventable hospitalizations related to
hypertension and diabetes.
DSHS Youth Empowerment Services
The DSHS Youth Empowerment Services (YES) Waiver is a Medicaid program that allows
for more flexibility in the funding of intensive community based services for children and
adolescents with severe emotional disturbances and their families.
TMHP is the claims administrator for DSHS YES Waiver providers, and for Mental Health
Case Management, and Mental Health Rehabilitation.
Children with Special Health Care Needs
(CSHCN) Services Program
Overview
The CSHCN Services Program has served children with special needs since 1933. The
CSHCN Services Program provides services to children who have extraordinary medical needs,
disabilities, and chronic health conditions. The CSHCN Services Program is a comprehensive
health benefit program that provides medically necessary health-care benefits, support services,
and case management services. The CSHCN Services Program is not an entitlement program
and is separate from Medicaid. However, some clients may be dually eligible for Medicaid/
CHIP, and the CSHCN Services Program.
The CSHCN Services Program is funded through the Title V block grant from the federal
government for maternal and child health programs and through state funds. Because
CSHCN Services Program funds are limited, there may be a waiting list for health-care
benefits. When funds are available, the program may be able to remove clients from the
waiting list and begin providing benefits through enrolled CSHCN Services Program
providers. It is important to maintain placement on the waiting list by renewing the client’s
eligibility every six months.
Mission
The mission of the CSHCN Services Program is to support family-centered, community-based
strategies for improving the quality of life for children with special health-care needs and their
families.
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Medicaid Basics Participant Guide
Eligibility Criteria
To be eligible for enrollment, the following criteria must be met by clients who apply for the
CSHCN Services Program:
• The applicant must live in Texas and be a bona fide resident who, if a minor child, is also
the dependent of a bona fide Texas resident.
• The applicant must be 20 years of age or younger.
• Persons of any age who have been diagnosed with cystic fibrosis.
• The applicant’s family must meet the CSHCN Services Program financial eligibility criteria.
• The applicant must have a chronic physical or developmental condition that:
–– Will last, or is expected to last, for at least 12 months.
Note: Pharmacies
can enroll as
CSHCN Services
Program providers
to provide DME
and expendable
medical supplies to
CSHCN Services
Program clients.
This is in addition
to entering into
an agreement
with the Medicaid
VDP to provide
outpatient
prescription
medications to
CSHCN Services
Program clients.
–– Result in or, if not treated, may result in limits to one or more major life activities.
–– Requires health and related services of a type or amount beyond those required by
children generally.
–– Must have a physical (body, bodily tissue, or organ) manifestation.
–– May exist with accompanying developmental, mental, behavioral, or emotional
conditions.
–– Is not solely a delay in intellectual development or solely a mental, behavioral, or
emotional condition.
• The applicant’s physician or dentist must complete a Physician/Dentist Assessment Form
(PAF), attesting that the applicant meets the program’s Medical Certification Definition
and provide a diagnosis, with a valid diagnosis code, that meets the medical certification
definition.
Any questions about a client’s eligibility for benefits must be directed to the DSHS-CSHCN
Services Program Central Office at 1-800-252-8023. More information about the CSHCN
Services Program is available on the DSHS website at www.dshs.state.tx.us/cshcn/default.shtm.
There is also a computer-based training module on the TMHP LMS at http://learn.tmhp.com.
Early Childhood Intervention
Texas ECI is available statewide to the families of children who are 35 months of age and
younger and have disabilities or developmental delays. A child is no longer eligible on the day
he or she turns three years of age.
The state agency responsible for ECI services is the Department of Assistive and Rehabilitative
Services (DARS). DARS contracts local ECI programs to take referrals, determine clients’ eligibility for ECI, and provide services, including case management services, to ECI-eligible children.
Texas ECI uses evaluations and assessments to determine eligibility. Clients are eligible for ECI
if they have a developmental delay, a medically diagnosed condition that has a high probability
of resulting in developmental delay, or an auditory or visual impairment as defined by the Texas
Education Agency.
All health-care providers are required by federal and state regulations to refer children who
are 35 months of age and younger to the local ECI program within seven days of identifying
children suspected of having a developmental delay or a medical diagnosis with a high
probability of resulting in a developmental delay.
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Medicaid Basics Participant Guide
Individualized Family Service Plan (IFSP)
Families and professionals work together to develop an Individualized Family Service Plan
(IFSP) for services that are appropriate for the needs of the child and the child’s family.
The interdisciplinary team determines the medically necessary services for each child in the
IFSP. Services must be provided by a qualified ECI provider. A signed IFSP serves as the
authorization for ECI services and documents the medical necessity for ECI services.
ECI Services
ECI services include PT, OT, and speech-language therapy; vision services; audiology services;
specialized skills training services; nutrition services; psychological services; social work; family
education and training; counseling; behavioral intervention; health services; transportation;
assistive technology; nursing services; and medical services.
Targeted Case Management (TCM)
ECI Targeted Case Management (TCM) services are available to help eligible children and
their families get necessary medical, social, educational, developmental, and other appropriate
services. Services include a comprehensive needs assessment, referral and related activities, and
the coordination, monitoring, and follow-up activities that are necessary to meet the needs of
the child.
Referrals
To refer families for services, providers can call their local ECI program, or they can
call the Department of Assistive and Rehabilitative Services (DARS) Inquiry Line at
1-800-628-5115. For additional ECI information, providers can visit the DARS website at
www.dars.state.tx.us/ecis.
Texas Women’s Health Program (TWHP)
Overview
The goal of TWHP is to expand access to family planning services. TWHP clients receive a
limited family planning benefit that supports this goal.
Benefits
TWHP benefits include:
• One family planning exam each year, which may include a clinical breast exam, screening
for cervical cancer, diabetes, sexually transmitted diseases, high blood pressure, and other
health issues.
• Follow-up office or other outpatient family planning visits that are related to the client’s chosen
method of birth control.
• Birth control, except for emergency contraception.
• Counseling on family planning methods, including abstinence.
• Sterilization and sterilization-related procedures.
• Treatment for certain sexually transmitted diseases.
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Medicaid Basics Participant Guide
If a TWHP provider identifies a health problem, such as diabetes or cancer, the provider must
refer the client for treatment services, and the client may have to pay for those additional
services. TWHP only reimburses for the services that are listed above.
Client Eligibility
TWHP provides annual family planning exams, family planning services, and contraception to
women who:
• Are 18 through 44 years of age.
• Are U.S. citizens and eligible immigrants.
• Reside in Texas.
• Have a household income at or below 185 percent of the federal poverty level (FPL).
• Do not currently receive full Medicaid benefits (including Medicaid for pregnant women),
CHIP, or Medicare Part A or B.
• Are not pregnant.
• Are not sterile, infertile, or unable to get pregnant because of medical reasons.
• Do not have other insurance that covers family planning services.
Provider Enrollment
Providers that have completed the Medicaid enrollment process with TMHP are eligible to
participate in TWHP. There is no separate provider enrollment process for providers who would
like to deliver TWHP services, however, providers are required to complete an annual TWHP
certification. To receive TWHP certification, providers must attest that they do not perform
or promote elective abortions, are not affiliated with a provider that does so, and do not use,
display, or operate under a brand name, trademark, service mark, or registered identification
mark of an organization that performs or promotes elective abortions. The following Texas
Women’s Health Program providers are required to certify:
• Physician or physician group with a general surgery, family practice/general practice,
gynecology
• OB/GYN, internal medicine, or pediatric specialty
• Physician assistant
• Federally qualified health center (FQHC)
• Freestanding ambulatory surgical center
• Maternity services clinic
• Multispecialty physician group
• Family planning agency
• Rural health clinic–Freestanding/independent
• Rural health clinic–Hospital-based
For TWHP claims to be considered for reimbursement, providers that are one of the above
listed provider types must annually complete and submit the Texas Women’s Health Program
Certification Form. New providers can complete the form while they are enrolling using
either Provider Enrollment on the Portal (PEP) or the paper enrollment application. Existing
Medicaid providers can complete a TWHP certification through the Provider Information
Management System (PIMS), which can be accessed through the provider’s account on the
TMHP website. The instructions for completing the TWHP certification form through PIMS
are available on the TMHP website at www.tmhp.com/TMHP_File_Library/TWHP/
TWHP PIMS Certification instructions.pdf.
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TWHP and Third Party Liability
Federal and state regulations mandate that family planning client information be kept
confidential. Because seeking information from third-party resources may jeopardize the client’s
confidentiality, third-party billing for TWHP services is not allowed.
Programs Overview
Program
Clients
Description
Program Administrator &
Enrollment
Children with Special
Health Care Needs
(CSHCN) Services Program
Texas residents:
• Who are 20 years of age
and younger and who
meet income and health
condition criteria
• Texas residents of any
age with cystic fibrosis
Designed to help families
of children with special
needs, CSHCN covers many
of the same benefits as
Medicaid; however, CSHCN
benefits are tailored to
meet the specific needs of
the client
Administered by
Department of State
Health Services (DSHS)
Children’s Health
Insurance Program (CHIP)
Texas residents who are:
• 18 years of age or
younger
• Pregnant
• Uninsured
• Unable to qualify for
Medicaid
Health insurance designed
for children in families
who earn too much money
to qualify for Medicaid,
yet cannot afford to buy
private health insurance
Administered by HHSC
Clients access
www.chipmedicaid.org to
enroll or to request a paper
application.
DSHS Family Planning
Program (Program 300 not Medicaid)
Low-income individuals
who may not qualify for
Texas Medicaid
Provides an avenue
for achieving optimal
reproductive and general
health by offering services
such as annual exams,
contraceptives, counseling,
and education
Administered by DSHS and
TMHP
Expanded Primary Health
Care Program
Women age 18 whose
income is at or below
200 percent of the FPL.
Outreach
Provides primary,
preventive
and screening services
and direct services
are provided through
community-based clinics
under contract with DSHS.
Administered by DSHS and
TMHP
Family Planning Services
and Supplies for Seton
Managed Care Health Plan
Medicaid clients
Provides services for
preventive health, medical
services, counseling
services, and educational
services that assist
individuals in managing
their fertility and achieving
optimal reproductive and
general health
Administered by TMHP,
Traditional Medicaid
TMHP supports the
CSHCN Services Program
by processing claims,
enrolling providers, issuing
prior authorizations, and
developing, and sending
communication materials
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Medicaid Basics Participant Guide
Program
Clients
Description
Program Administrator &
Enrollment
Health Insurance Premium
Payment (HIPP)
Medicaid-eligible clients
who have group health
insurance available
through an employer
Reimburses qualified
Medicaid families for
the cost of premiums for
health insurance obtained
through an employer or
private health insurance
plan
Administered by TMHP
Insurance Premium
Payment Assistance (IPPA)
CSHCN Services Program
clients who have private
health insurance coverage
available
Reimburses families for the
cost of premiums paid to
provide health insurance
for a CSHCN Services
Program client
Administered by TMHP
and HHSC
Long Term Care
Medicaid clients with
chronic diseases or
disabilities
Provides long term care
through a variety of
programs to help clients
perform activities of daily
living (ADLs)
Administered by the
Department of Aging and
Disability Services (DADS)
Medically Needy Program
(MNP) (Spend Down)
Pregnant women and
children who are 18 years
of age or younger
Provides Medicaid benefits
for individuals and families
whose income exceeds
the eligibility limits under
Temporary Assistance for
Needy Families (TANF)
or one of the Medical
Assistance Only (MAO)
programs for children, but
is not enough to cover
medical expenses
Administered by TMHP
Medical Transportation
Program (MTP)
Clients who are eligible
for Medicaid or the CSHCN
Services Program
Provides transportation
to appointments as well
as additional benefits
such as in-flight oxygen,
meals, and lodging, when
applicable
Administered by TMHP
Medicaid Qualified
Medicare Beneficiary
(MQMB)
Dual eligible Medicaid
and Medicare clients
Provides access to
Medicaid benefits not
covered by Medicare as
well as Medicaid payment
of Medicare deductible
and/or coinsurance
Administered by TMHP
Qualified Medicare
Beneficiary (QMB)
Dual eligible Medicaid
and Medicare clients
Pays the Medicare
deductible and/or
coinsurance liabilities,
and the Medicare Part B
premium
Administered by TMHP
30
To enroll, call HIPP at
1-800-440-0493
To enroll, call the IPPA
Client Helpline at 1-800440-0493
TMHP is responsible for
processing claims and
enrolling three of the nine
provider types of MTP
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Medicaid Basics Participant Guide
Program
Clients
Description
Program Administrator &
Enrollment
Supplemental Security
Income (SSI)
Individuals who are aged,
blind, or disabled and
have limited income or
resources
Provides cash for clients
to meet basic needs for
food, clothing, and shelter
through a federal income
supplement
Administered by the
U.S. Social Security
Administration (SSA)
Temporary Assistance for
Needy Families (TANF)
Families whose income
falls below the income and
resource limits set for the
program
Provides financial
assistance through
monthly cash payments
for children and their
families who are living
under the same roof to
help pay for food, clothing,
housing, utilities, furniture,
transportation, telephone,
laundry, household
equipment, medical
supplies not paid for by
Medicaid, and other basic
needs
Administered by HHSC
Texas Health Steps
(THSteps)
Texas Medicaid clients who
are birth through 20 years
of age
Provides regular medical
and dental checkups for
clients
Administered by TMHP
or MCO
Case Management for
Children and Pregnant
Women
Medicaid-eligible pregnant
women with a high-risk
condition, or children
(birth through 20 years
of age) with a health
condition or health risk
Helps clients get
necessary medical, social,
educational, and other
services related to their
medical or high-risk
conditions
Administered by DSHS;
TMHP is the Claims
Administrator
Comprehensive Care
Program (CCP)
Texas Medicaid clients who
are birth through 20 years
of age
Provides medically
necessary, prior authorized
treatments to THStepseligible clients in order to
correct physical or mental
problems
Administered by TMHP
and MCO
Provides gynecological
exams, related health
screenings, and birth
control through Texas
Medicaid
Administered by TMHP
Clients must be Medicaideligible
Texas Women’s Health
Program (TWHP)
Uninsured women who
are 18 through 44 years
of age, meet income
requirements, and are
U.S. citizens or qualified
immigrants
To enroll, call
1-800-772-1213
Clients enroll by visiting
their local HHSC office
Clients enroll by visiting a
participating clinic or their
local HHSC office
Clients must not currently
receive full Medicaid
benefits, CHIP, or Medicare
Part A or B
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Medicaid Basics Participant Guide
Program
Clients
Description
Program Administrator &
Enrollment
Vendor Drug Program
(VDP)
Clients who are eligible for:
• Medicaid
• CSHCN
• Kidney Health Care (KHC)
Provides services
through over 4,000
Texas pharmacies, and
makes payment for
prescriptions of covered
outpatient drugs to those
pharmacy providers who
are contracted with the
program. Benefits for most
clients in managed care are
delivered through Medicaid
and CHIP MCOs
Administered by HHSC
VDP maintains CHIP Drug
formulary
32
TMHP provides technical
support and processes
claims
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Medicaid Basics Participant Guide
Provider Enrollment
Medicaid Enrollment
Texas Medicaid relies on its network of providers to render essential preventive and treatment
services to Texas Medicaid clients.
As the front line of services for Medicaid clients, this network of over 70,000 dedicated
professionals makes health care more accessible to more than 4.1 million Texas residents
throughout the state.
The Texas Medicaid provider network enlists dedicated professionals to help meet the growing
health-care needs of Medicaid clients. This is an opportunity for health-care professionals
to give back to their communities and their fellow Texans who need quality health care but
cannot afford it.
Note: Providers
must enroll in
Texas Medicaid
through TMHP
prior to starting
the credentialing
process with
individual MCOs
to provide services
to Medicaid clients
enrolled in MCOs.
THSteps Enrollment
Providers who enroll in THSteps medical or dental services may become medical or dental
homes for children and young adults who are birth through 20 years of age, including foster
care children. Medical, dental, and case management providers work together to focus
on comprehensive, early preventive services to help avoid the need for acute-care services.
Dental treatment services also help alleviate oral health problems before they escalate. Case
management services help families coordinate and make the most efficient and effective use of
services.
Certain provider types are automatically enrolled as a THSteps medical services provider.
Providers can opt out when completing the Medicaid enrollment form. Providers who change
their mind after Medicaid enrollment must complete a separate enrollment form.
Out-of-State Provider Enrollment
Clients can, and do, travel to cities that are more than 50 miles outside of Texas. It is
important that providers in these areas enroll in Texas Medicaid so that they can treat
all eligible clients. If a provider is located more than 50 miles outside of Texas, they are
considered to be an “out-of-state provider.” If a provider is located less than 50 miles outside
of Texas, they are considered to be a “border state provider.” Out-of-state providers have
different claim filing deadlines.
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Medicaid Basics Participant Guide
Provider Enrollment on the Portal (PEP)
PEP was created to facilitate enrollment in Texas Medicaid and the CSHCN Services Program.
PEP also makes it easier for existing providers to maintain their account information.
The process of becoming a Texas Medicaid provider is very straightforward. Once a provider
enrollment application is completed online, it can be submitted immediately to TMHP.
When the application is received, TMHP sends it to the state. After the application has
been validated as complete and accurate and TMHP receives all required documentation
and signature pages, the provider is enrolled. TMHP will send a welcome email to the
provider.
Note: Providers may opt out of email communication and choose to receive all messages by mail.
Why Enroll Using the PEP process?
• It is faster: No more waiting for the mail to deliver the application or having to fill out the
application by hand.
• It uses less paper: The majority of the information on the application can be submitted
using PEP.
• It is easier: No guessing about which pages are required. Now they will be displayed as
you move through the application process. PEP will automatically populate duplicate data
fields.
• It has less opportunity for error: No worrying about forgetting to answer questions or
trying to squeeze information into a box that is too small. The information entered can be
checked and validated before submission.
• It provides immediate feedback on your application status: You can track the status
of the application online. You can sign up to have deficiency notifications sent to you by
email. This will give you almost instant notice of any issues with your application.
The Affordable Care Act (ACA) of 2012 Re-Enrollment Requirement
Effective January 1, 2013, all providers must re-enroll into the Texas Medicaid Program. CMS
requires that States complete the initial re-enrollment of all providers by March 24, 2016. For
Texas Medicaid, this means that any provider enrolled before January 1, 2013 must re-enroll by
March 24, 2016. You may begin this process as early as today.
After the initial enrollment, providers will be assessed for their risk category to determine
when the provider must re-enroll which is at least every five years. HHSC may require certain
providers to re-enroll more frequently. The new enrollment letters reference a “limited term
enrollment” and will inform each provider of their re-enrollment date.
Providers are now subject to the ACA screening requirements, which screens them according to
their risk category.
Providers must re-enroll at least every five years, but durable medical equipment (DME)
providers must re-enroll at least every three years.
HHSC may require certain providers to re-enroll more frequently.
All newly enrolling and re-enrolling institutional providers will be subject to an application fee
if not paid to Medicare or CHIP previously.
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Medicaid Basics Participant Guide
Enrollment is required for individual providers whose only relationship with Medicaid is
ordering and referring services for Medicaid clients.
For more information about the ACA, please refer to the ACA page on the TMHP website at
www.tmhp.com/Pages/Topics/ACA.aspx.
Online Enrollment Procedures
1. Go to www.tmhp.com, and click Not yet a provider?
2. Click I would like to… in the upper right side of the header.
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Medicaid Basics Participant Guide
3. Click Activate my account.
4. Click New Texas Medicaid Provider.
5. Read the instructions listed on the screen. Select Provider Enrollment from the dropdown menu.
6. Click Next.
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Medicaid Basics Participant Guide
7. Complete the required fields, and check the “I agree to these terms” box. Click Create
Provider Administrator.
Note: Fields
marked with a
red asterisk are
required.
Note: Shortly
after you click the
button, you will
receive an email
at the address
you provided.
This email will
contain your
user name, your
password, and
a link to the
TMHP website.
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Medicaid Basics Participant Guide
Electronic Funds Transfer (EFT) Notification
ElectronicFundsTransfer(EFT)isapaymentmethodusedtodepositfundsdirectlyintoaprovider’sbankaccount.
These funds can be credited to either checking or savings accounts, if the provider’s bank acceptsAutomated
Clearinghouse(ACH)transactions.EFTalsoavoidstherisksassociatedwithmailingandhandlingpaperchecksby
ensuring funds are directly deposited into a specified account.
The following items are specific to EFT:
•
Pre-notification to your bank occurs on the weekly cycle following the completion of enrollment in EFT.
•
Future deposits are received electronically after pre-notification.
•
TheRemittanceandStatus(R&S)reportfurnishesthedetailsofindividualcreditsmadetotheprovider’s
accountduringtheweeklycycle.
•
Specific deposits and associated R&S reports are cross-referenced by both the provider identifiers (i.e.,
NPI,TPI,API)andR&Snumber.
•
EFT funds are released by TMHP to depository financial institutions each Thursday.
•
TheavailabilityofR&SreportsisunaffectedbyEFTandtheycontinuetoarriveinthesamemannerand
timeframeascurrentlyreceived.
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
thesefundsareroutinelymadeavailabletotheirdepositorsasoftheopeningofbusinessontheeffective
date. 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
depositandthecustomer’swithdrawalrequestmayberefused.Whenthisoccurs,thecustomerorcompany
shoulddiscussthesituationwiththeACHcoordinatoroftheirinstitution,whointurnshouldworkoutthebest
waytoservetheircustomer’sneeds.
Inallcases,creditsreceivedshouldbepostedtothecustomer’saccountontheeffectivedateandthusbe
madeavailabletocoverchecksordebitsthatarepresentedforpaymentontheeffectivedate.
To enroll in the EFT program, complete the attached Electronic Funds TransferAuthorizationAgreement. You
must return a voided check or signed letter from your bank on bank letterhead with the agreement to the
TMHP address indicated on the form.
CalltheTMHP Contact Centerat1-800-925-9126ifyouneedassistance.
Rev.0/22/09
38
Page
EFTAuthorization
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Medicaid Basics Participant Guide
Electronic Funds Transfer (EFT) Notification
NOTE: Complete all sections below and attach a voided check or a signed letter from your bank on bank letterhead.
Type of authorization:
 New Change
Provider name:
Billing TPI: (9-digit)
National Provider Identifier (NPI)/Atypical Provider Identifier (API):
Primary taxonomy code:
List any additional TPIs that use the same provider information:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
Provider accounting address:
NumberStreetSuiteCityStateZIP
Provider phone number:
Bank name:
Bank phone number:
ABA/Transit number:
Account number:
Bank address:
Account type: (check one)
 Checking Savings
I(we)herebyauthorizeTexasMedicaid&HealthcarePartnership(TMHP)topresentcreditentriesintothebankaccountreferenced
aboveandthedepositorynamedabovetocreditthesametosuchaccount.I(we)understandthatI(we)amresponsibleforthevalidity
oftheinformationonthisform.Ifthecompanyerroneouslydepositsfundsintomy(our)account,I(we)authorizethecompanytoinitiate
thenecessarydebitentries,nottoexceedthetotaloftheoriginalamountcreditedforthecurrentpayperiod.
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 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
underfederalandstatelaws.
I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state
andfederallaws,rules,andregulations.
Authorized signature:
Date:
Title:
E-mail address: (if applicable)
Contact name:
Contact phone number:
Return this form to:
TexasMedicaid&HealthcarePartnership
ATTN: Provider Enrollment
POBox200795
Austin,TX78720-0795
Page2
Rev.0/22/09
EFTAuthorization
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Medicaid Basics Participant Guide
Provider Responsibilities
Provider responsibilities include the following:
• Verify client eligibility.
• Provide medically necessary services to the Medicaid and CSHCN Services Program
population, without discrimination based on race, color, national origin, age, sex,
disability, political beliefs, or religion.
• Provide services without discrimination against a client who has a third-party resource,
such as other insurance (OI), in addition to Medicaid. For example, you cannot choose to
only accept Medicaid clients who do not have third-party resources.
• Accept reimbursement for Medicaid services as payment-in-full.
• Follow guidelines for limiting their practices. Practices can be limited to specialty,
percentage of overall clients, age, and other categories, but they cannot discriminate
between private-pay and Medicaid clients. This should be documented in the office policies
and procedures and must apply to all clients.
• Follow all guidelines published on the TMHP website and in provider bulletins and
banner messages listed on Remittance & Status (R&S) Reports. Providers need to be
aware of Medicaid benefits and limitations, and are expected to review the TMHP website,
provider bulletins, and banner messages. Provider bulletins are published on the TMHP
website. Banner messages are important messages published on the Banner page of the
weekly R&S Report. News and information are also posted on the TMHP website.
• Follow the Health Insurance Portability and Accountability Act (HIPAA). All providers
must comply with HIPAA regulations to protect client information.
• Ensure medical record documentation supports services rendered. Each page of the medical
record document must include the client’s name and their Medicaid ID 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 to this regulation:
–– Freestanding Rural Health Clinics (RHC) records must be kept for 6 years.
–– Hospital based RHC records must be kept for 10 years.
• Receive correct authorization. It is your responsibility to know which procedures need a
prior authorization and to obtain prior authorization if it is necessary for the services to be
rendered.
• Providers should notify TMHP of any changes to their physical address, telephone or fax
numbers, and any changes to their billing or mailing address within 10 business days. If
providers change billing services but do not notify TMHP, reimbursement checks will be
mailed to the last address on file, unless using Electronic Funds Transfer (EFT).
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Medicaid Basics Participant Guide
• Report Medicaid waste, abuse, and fraud. It is the provider’s responsibility to report
suspected instances of Medicaid waste, abuse, or fraud.
• Report child and elder abuse. Providers have the responsibility of the timely reporting of
suspected cases of child and elder abuse. All providers should make a good faith effort to
comply with all child and elder abuse reporting guidelines and requirements in Chapter
261 of the Texas Family Code and the Human Resources Code Chapter 48 Subsection 51,
relating to investigations of child abuse and neglect.
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Medicaid Basics Participant Guide
Client Eligibility
Although Medicaid clients and CSHCN Services Program clients are encouraged to bring their
identification forms with them to scheduled appointments, it remains the responsibility of the
provider to verify client eligibility.
Eligibility and Third-Party Liability
TMHP cannot make changes to the demographic or eligibility information of a client. Providers
cannot discriminate against a client who has a third-party resource such as other insurance
(OI) in addition to Medicaid. In other words, you cannot choose to only accept Medicaid
clients who do not have a third-party resource. Providers are encouraged to call the Third-Party
Liability (TPL) Unit at 1-800-846-7307 to update a client’s OI information (e.g., termination
of coverage or new insurance coverage). After the TPL Unit has updated the OI information in
the TMHP system, the provider is responsible for submitting an appeal for the OI denial.
When someone calls the TPL Unit to give updated OI information, the TPL Call Center
representative will inform the caller whether the update has been successfully completed and
claims can be resubmitted. If the TPL Call Center representative is not able to immediately
update the OI information, the verification and update process may take up to 10 business days.
Verifying Client Eligibility
Your Texas Benefits Medicaid Card
HHSC has introduced a system that uses digital technology to streamline the process of
verifying a person’s Medicaid eligibility and accessing their Medicaid health history. The two
main elements of the system are:
•
The Your Texas Benefits Medicaid card, which replaced the Medicaid ID letter (Form 3087)
clients received in the mail every month.
• An online website where Medicaid providers can get up-to-date information on a client’s
eligibility, history of services, and treatments that have been reimbursed by Medicaid.
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TexMedConnect
Providers can verify client eligibility electronically using TexMedConnect. Providers may inquire
about a client’s eligibility by electronically submitting one of the following for each client:
• Medicaid or CSHCN Services Program ID 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
Note: The
Medicaid ID
Form (Form
3087) has been
replaced with the
new Your Texas
Benefits Medicaid
card for all
Medicaid clients.
Automated Inquiry System (AIS)
Providers can call the Automated Inquiry System (AIS) to verify client eligibility by:
• Contacting the Medicaid AIS at 1-800-925-9126 or (512) 335-5986.
• Contacting the CSHCN Services Program AIS at 1-800-568-2413.
Paper
Providers can verify the client’s CSHCN Services Program eligibility by using the CSHCN
Services Program Eligibility Form.
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Medicaid Basics Participant Guide
CSHCN Services Program Eligibility Form
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
P.O. Box 149347 • Austin, Texas 78714-9347
1-888-963-7111 • http://www.dshs.state.tx.us
DAVID L. LAKEY, M.D..
COMMISSIONER
Children with Special Health Care Needs Services Program
Automated Inquiry System (AIS):
1-800-568-2413
Phone: 1-800-252-8023 or 512-458-7355
CSHCN Services Program
Case # 9-123456-00
PARENT/GUARDIAN NAME
STREET ADDRESS
CITY, TX ZIPCODE
Name: CLIENT NAME
Birth: 06/05/00
Sex: M
Medicaid/Insurance
Medicaid Number: 123456789
Valid xx/01/2xxx thru xx/03/2xxx
Note: The CSHCN Services Program is not a
Medicaid program, however, many CSHCN
Services Program clients are eligible for Medicaid.
CSHCN Services Program Eligibility Form
This form may be used for services only between the “valid” dates
listed in the box above.
Este formulario se puede usar para conseguir servicios solamente
durante las fechas válidas (valid) indicadas en la casilla de arriba.
This is your NEW CSHCN Services Program Eligibility Form. If
you already have a form, throw away the old one. Take this form
with you when you visit CSHCN Services Program providers. Do
not loan this form to other people. Service providers can copy the
form for their files. If you lose this form, call the CSHCN Services
Program Eligibility Section. Whenever you call or write to the
CSHCN Services Program, use the case number (Case #) shown on
this form.
Éste es su NUEVO formulario de elegibilidad para el Programa de
Servicios de CSHCN. Si usted ya tiene un formulario, tire el
formulario viejo. Lleve este formulario consigo para obtener servicios
de los proveedores del Programa de Servicios de CSHCN. No preste
este formulario a otras personas. Los proveedores pueden hacer una
copia de este formulario para sus archivos. Si usted pierde este
formulario, llame al personal de la Sección de Elegibilidad del
Programa de Servicios de CSHCN. Siempre y cuando usted llame o
escriba al Programa de Servicios de CSHCN, use el número de caso
(Case #) que aparece en este formulario.
You must reapply for the CSHCN Services Program every 6
months. Send a new application and all proofs each time you
reapply for CSHCN Services Program financial eligibility.
Usted tiene que presentar una nueva solicitud para el Programa de
Servicios de CSHCN cada 6 meses. Mande una nueva solicitud y
todos los comprobantes cada vez que usted presente una solicitud para
elegibilidad financiera al Programa de Servicios de CSHCN.
To stay on the CSHCN Services Program after this form runs out
you must fill out a new CSHCN Services Program application and
send the application to the CSHCN Services Program on or after
xx/22/2xxx. However, your application must be received by the
CSHCN Services Program not later than xx/03/2xxx. To get a new
CSHCN Services Program application, call the CSHCN Services
Program at 1-800-252-8023.
Para continuar en el Programa de Servicios de CSHCN después de que
termine su elegibilidad, tiene que rellenar una nueva solicitud del
Programa de Servicios de CSHCN y mandar la solicitud al Programa
de Servicios de CSHCN después del xx/22/2xxx. Sin embargo, el
Programa de Servicios de CSHCN tiene que recibir su solicitud al más
tardar el xx/03/2xxx. Para obtener una nueva solicitud para el
Programa de Servicios de CSHCN, llame al Programa de Servicios de
CSHCN al número 1-800-252-8023.
Provider Information
The client named on this form is eligible for CSHCN Services Program benefits for the period indicated. Service providers may duplicate this
form for their files. Providers must be enrolled in the CSHCN Services Program. Prior authorization is required for some services. The CSHCN
Services Program may revoke eligibility in the event of policy changes, changes in client medical or financial condition, or error. See the
CSHCN Services Program Provider Manual for details. For more information, contact the CSHCN Services Program.
Under certain circumstances, the eligibility form MAY NOT be valid at the time you see this client. Please verify client’s eligibility for CSHCN
Services Program Benefits by calling CSHCN-AIS at 1-800-568-2413 or the TMHP-CSHCN Contact Center at 1-800-568-2413.
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Your Texas Benefits Medicaid Card
Providers can verify eligibility using the Your Texas Benefits Medicaid card just as they did with
the paper Medicaid ID (Form 3087).
• The card’s magnetic stripe has the client’s Medicaid ID number (patient control number
[PCN]). The Your Texas Benefits Medicaid card is designed to work with standard
magnetic card readers that interface with your computer using a standard USB connection.
• A company called Emdeon is offering Medicaid providers an enhanced point-of-sale device
that processes Medicaid eligibility verifications as well as credit card transactions. As with more
standard card reading options, Medicaid providers that choose this device are responsible
for the cost. For more information, refer to www.emdeon.com/pos/. Click Contact Us.
Medicaid providers do not need a card reader to verify client eligibility. Providers can continue
to verify eligibility by manually entering a client’s Medicaid ID number (PCN) when using the
secure provider website at www.yourtexasbenefitscard.com. The PCN is printed on the ID
card. Providers can also:
• Call the TMHP Contact Center at 1-800-925-9126.
• Use TexMedConnect on the TMHP website.
Note: Just because a client has a Your Texas Benefits Medicaid card, it does not guarantee the client
has Medicaid eligibility. Providers must still verify eligibility. Clients will be instructed to keep their
Your Texas Benefits Medicaid card even if their Medicaid eligibility expires. The card can be reused if
the client later regains Medicaid eligibility.
If a client loses their Your Texas Benefits Medicaid card, a provider can still verify eligibility using the
client’s name, SSN, or DOB using the provider website at www.yourtexasbenefitscard.com.
The client should call the client helpdesk at 1-855-827-3748 to request a new card. The
request will be processed in 3 to 4 days. Clients can also print a card image from the client
website.
Additional information about the Your Texas Benefits Medicaid card can be found in the
Resources section of this Participant Guide.
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Medicaid Basics Participant Guide
TexMedConnect
Providers can verify eligibility through the TexMedConnect application on www.tmhp.com.
Providers must create an account to access this application.
1. Go to www.tmhp.com, and click providers in the header bar.
2. Click Go to TexMedConnect.
3. Enter your User name and Password to log in to the system.
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4. Click Eligibility in the left navigation panel.
5. Complete the following required fields:
–– Provider NPI/API and related data
–– Eligibility Dates
6. If necessary, narrow your search by entering additional information in any of the following
combinations:
–– Medicaid or CSHCN ID and Date of Birth
–– Medicaid or CSHCN ID and Last Name
–– Medicaid or CSHCN ID and Social Security Number
–– Social Security Number and Last Name
–– Social Security Number and Date of Birth
–– Date of Birth and Last Name and First NameReview the results for eligibility
information
Note: If you
perform more
than one
interactive
eligibility check,
the Provider
NPI/API on the
Eligibility Search
page defaults to
the most recently
used Provider
NPI/API.
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Medicaid Basics Participant Guide
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TMHP Electronic Data Interchange (EDI)
Providers can use third party software and billing agents to submit claims and other electronic
transactions to TMHP. Providers must set up their software or billing agent services to access
the TMHP EDI Gateway. Providers who use billing agents or software vendors should contact
those organizations for information about installation, settings, maintenance, and their
processes and procedures for exchanging electronic data.
Automated Inquiry System (AIS)
AIS provides the following information and services using a touch-tone telephone:
• Claim status
• Client eligibility
• Benefit limitations
• Medically Needy case status
• Current weekly payment amount
• Claim appeals
• Identify health plan and PCP
AIS also provides the most recent date of service submitted for the client (when applicable) for:
• THSteps medical services
• Family planning
• THSteps dental services
• Vision
Eligibility and claim status information is available using 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.
For more information on the use and benefits of AIS, refer to the Automated Inquiry System
(AIS) User’s Guide, which is available on the TMHP website at
www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_manual.aspx.
Note: Providers
must note the
date and time
that 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 three
years from the
current date.
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Medicaid Basics Participant Guide
Limitations to Medicaid Client Eligibility
Additional information is available in the TMPPM, Section 4: Client Eligibility
• Emergency Only – The client is limited to benefits for an emergency medical condition
only.
• Limited Program – The client has been determined to over-use Medicaid services. These
clients are limited to seeing a specific provider and using a specific pharmacy. Refer to the
current TMPPM for exceptions. In the event of emergency medical conditions, the limited
restriction does not apply.
• Qualified Medicare Beneficiary (QMB) – Medicaid provides reimbursement of Medicare
deductible and coinsurance liabilities only. These clients are not eligible for regular
Medicaid benefits.
• Hospice – The client waives the right to Medicaid services related to the terminal condition
but not to services for conditions unrelated to the terminal condition. DADS Hospice
reimburses the provider for all services related to the treatment of the terminal illnesses.
When the services are unrelated to the terminal illness, Medicaid reimburses its providers
directly.
• Presumptive Eligibility (PE) – Issued to pregnant women to give the earliest possible access
to prenatal care. Clients are eligible only for medically necessary outpatient services and
family planning services. Labor, delivery, inpatient, and THSteps services are not benefits.
• The Texas Women’s Health Program (TWHP) – TWHP only covers office or other
outpatient family planning visits if the primary purpose of the visit is related to
contraceptive management as outlined by the program.
• CHIP Perinatal Program – CHIP perinatal benefits for 12 months to the unborn children
of non-Medicaid eligible women. This program allows pregnant women who are ineligible
for Medicaid because of income or immigration status to receive prenatal care and provides
CHIP benefits to the child upon delivery for the duration of the eligibility period.
For more information and examples, review the Client Eligibility CBT on the TMHP LMS at
http://learn.tmhp.com.
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Waste, Abuse, and Fraud
Definitions
• Waste: Practices that spend carelessly or inefficiently use resources, items, or services.
• Abuse: Practices that are inconsistent with sound fiscal, business, or medical practices
and that result in unnecessary program cost or in reimbursement for services that are not
medically necessary; do not meet professionally recognized standards for health care; or do
not meet standards required by contract, statute, regulation, previously sent interpretations
of any of the items listed, or authorized governmental explanations of any of the foregoing.
• Fraud: Any act that constitutes fraud under applicable federal or state law, including any
intentional deception or misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit to that person or some other person.
Most Frequently Identified Fraudulent Practices
The most common types of waste, abuse, and fraud include:
• Billing for services not performed
• Billing for unnecessary services
• Upcoding or unsubstantiated diagnosis
• Billing outpatient services as inpatient services
• Over-treating or lack of medical necessity
Identifying and Preventing Waste, Abuse, and Fraud
The 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 HHS programs in Texas
• Health and welfare of the clients in those programs
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Medicaid Basics Participant Guide
OIG oversees HHS activities, providers, and clients through compliance and enforcement
activities designed to:
• Identify and reduce waste, abuse, fraud, and misconduct
• Improve efficiency and effectiveness throughout the HHS system
OIG is required to set up clear objectives, priorities, and performance standards that help:
• 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
Before reporting waste, abuse, or fraud, gather as much information as you can about the
provider or client.
Examples of provider information include the following:
• Name, address, and telephone 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
• Type of provider (physician, physical therapist, pharmacist, etc.)
• Names and numbers of other witnesses who can aid in the investigation
• Copies of any documentation you can provide (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
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 following:
• The person’s name
• The person’s date of birth and SSN, 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.hhs.state.tx.us and select Reporting 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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Child and Elder Abuse,
Neglect, or Exploitation
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 employees on reporting requirements.
This policy needs to be part of the provider’s office policy and procedure manual and must
address the appropriate steps that your employees should 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 DFPS (1-800-647-7410) or law enforcement and to document
the report in the client’s record.
• To document reports made by telephone to the Texas Department of Family and Protective
Services (1-800-252-5400, 24/7) or law enforcement.
• To document decisions to not report suspected child abuse based on the existence of an
affirmative defense.
All documentation of the report must be kept in the client’s record.
Providers can report abuse online at www.txabusehotline.org and use a printout 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 in which 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.
If the report is an emergency, call 9-1-1 or your local law enforcement agency.
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Medicaid Basics Participant Guide
Report Elder Abuse, Neglect, or Exploitation
The Texas Department of Family and Protective Services (DFPS) has a central location to
report the abuse, neglect, or exploitation of the elderly or adults with disabilities.
The law requires that any person who believes that a person who is 65 years of age or older or
an adult with disabilities is being abused, neglected, or exploited must report the circumstances
to DFPS. A person who makes a report is immune from civil or criminal liability, provided that
they make the report in good faith.
The name of the person who makes the report is kept confidential. Any person who suspects
abuse and does not report it can be held liable for a Class B misdemeanor. Time frames for
investigating reports are based on the severity of the allegations.
Online reports can take up to 24 hours to process. Call the Texas Abuse Hotline at
1-800-252-5400 if:
• You believe your situation requires action in less than 24 hours.
• You prefer to remain anonymous.
• You have insufficient data to complete the required information on the report.
• You do not want an email to confirm your report.
For more information on this policy, to report abuse, or to obtain the new DSHS Child Abuse
Reporting Form, refer to the following websites:
54
Title
Website
DSHS Child Abuse Screening,
Documenting, and Reporting Policy
www.dshs.state.tx.us/childabusereporting/gsc_pol.shtm
DSHS Child Abuse Reporting Form
www.dshs.state.tx.us/childabusereporting/docs/DSHS_
Child_Abuse_Reporting_Form.pdf
Texas Abuse, Neglect, and Exploitation
Reporting System
www.txabusehotline.org
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Medicaid Basics Participant Guide
Prior Authorization
Introduction
Prior authorization is the process of obtaining advanced approval of benefits for a health-care
service. TMHP processes prior authorizations for Medicaid clients who are not enrolled in a
Medicaid managed care plan, including clients who are enrolled in traditional Medicaid.
Some of the services and items that are benefits of Texas Medicaid are performed infrequently or are
very costly. To verify that these services and items are medically necessary, TMHP requires providers
to request prior authorization for these services and items. Providers can submit a request for prior
authorization on the TMHP website, by fax, mail, or in some cases, by telephone. These requests
are reviewed by a team of nurses and specialists who are in TMHP’s prior authorization group. They
review the request for completeness and documentation of medical necessity. If the medical necessity
of an item or service is questionable, it can be forwarded to a medical director for review.
If a service or item requires prior authorization and the provider fails to obtain it, the claim for
that service will be denied. Authorization is a condition of reimbursement, not a guarantee of
reimbursement.
Examples
The following list includes examples of services that require prior authorization (this is not an
all-inclusive list):
Home Health:
• Skilled nursing (SN) visits
• Home health aide (HHA)
• Physical therapy (PT)
• Occupational therapy (OT)
• Durable medical equipment (DME)/medical supplies
• Oxygen therapy
• Chest physiotherapy devices
• System in-home use
• Wheelchair/scooter/stroller
• Total parenteral nutrition (TPN)
• Enteral equipment and supplies
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Medicaid Basics Participant Guide
Note: Prior
authorization
for THSteps
dental services
is not available
electronically.
Requests must be
made on paper by
mail.
Texas Health Steps (THSteps) Dental Services:
• Some therapeutic services
• Orthodontic services
Comprehensive Care Inpatient Psychiatric (CCIP):
• Psychiatric hospital initial admission
• Psychiatric inpatient extended stay
Comprehensive Care Program (CCP):
Note: A signed
Individualized
Family Service
Plan (IFSP)
serves as the
authorization
for ECI physical
therapy,
occupational
therapy, and
speech language
pathology services
and documents the
medical necessity
for these services.
• CCP outpatient therapy (PT, speech-language pathology [SLP], and OT)
• Donor human milk request
• Pulse oximeter
• Palivizumab (Synagis)
• Apnea monitor
• Bed/crib
• Formula
• Photo therapy
• Private duty nursing (PDN)
• Vitamins and minerals
Ambulance:
• Nonemergency transports
• Out-of-state emergency transports
Special Medical Prior Authorizations (SMPA):
Note: Prior
authorization
forms can be
found in the
TMPPM and
on the TMHP
website at
www.tmhp.com.
• Doctor of Dentistry services as a limited physician
• Extended outpatient psychotherapy/counseling request
• Transcutaneous electrical nerve stimulators (TENS)
• Transplants
Prior Authorization Requests and TPL:
If a client’s primary coverage is private insurance and Medicaid is secondary, prior authorization
is required for Medicaid reimbursement. If the service requires a prior authorization, the prior
authorization must be requested before providing the service.
For information about prior authorizations, refer to the current TMPPM, Section 5: Fee-forService Prior Authorizations.
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Prior Authorization Submissions
Prior authorizations can be submitted to TMHP on paper by fax or mail. Prior authorization
mailing addresses and fax numbers are located in the Resources section of this Participant
Guide.
Prior authorization requests can be submitted electronically using the TMHP website at
www.tmhp.com for most services, including CCP, home health, CCIP, ambulance, SMPA,
obstetric ultrasounds, radiology, and substance abuse services. Electronic requests do not
accept attachments. Exceptions include, but are not limited to, THSteps dental services, family
planning, and the Children with Special Health Care Needs (CSHCN) Services Program. It
is important to review the prior authorization guidelines in the TMPPM. The method used to
request prior authorization depends on the service being requested.
To be considered for reimbursement, all CCP services require prior authorization.
Additional resources include:
• Prior Authorization CBT available on the TMHP Learning Management System (LMS) at
http://learn.tmhp.com
• CCP PA Form and instructions at www.tmhp.com/Provider_Forms/Medicaid/
Other PA request forms and form instructions are available in the Forms section of the TMHP
website.
Note: Providers
must maintain
on file all
documentation
with signatures,
required for the
requested services,
as outlined in
the TMPPM.
This may include
paper copies of
the required prior
authorization
forms, regardless
of the submission
method.
Submitting Online Prior Authorization Requests
1. Go to www.tmhp.com, and click providers in the header.
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Medicaid Basics Participant Guide
2. Click I would like to… in the upper right side of the header.
3. Click Submit a prior authorization request.
Note: Texas
Medicaid
providers who
do not have
an existing
account must set
up a provider
administrator
account to access
online claim
submission and
other secure
functions of the
TMHP website.
58
4. Enter your User name and Password.
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5. On the first screen, complete the following information.
–– Provider/Supplier ID: Select the requesting provider’s or supplier’s valid National
Provider Identifier (NPI)/Atypical Provider Identifier (API) from the drop-down
menu. Menu selections are based on the access privileges of the user as determined by
the provider administrator.
–– Client ID: Enter the valid nine-digit client ID for which the prior authorization is
being requested.
–– Authorization Area: Select the appropriate authorization area for the request.
Authorization areas include ambulance, CCIP, CCP, home health, OB ultrasound,
SMPA, and substance abuse.
–– Submission Type: Select the appropriate submission type for the request.
–– Requested Authorization Dates: Use the calendar drop-down menu or type in the
dates of service for which the authorization is being requested in a mm/dd/yyyy format.
Important: When selecting CCIP in the
Authorization Area, an additional question will
appear under the “From” and “Through” fields. You
must select Yes or No from the drop-down menu.
Important: When selecting Ambulance in the
Authorization Area, the authorization period is
limited to six months. This will be noted next to the
“From” and “Through” fields.
6. Click Next Step. When the button is clicked, the system verifies client eligibility for the
requested prior authorization dates and checks for duplicate prior authorizations.
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Medicaid Basics Participant Guide
7. On the next screen, verify that the information on the screen has been automatically
populated correctly. Complete any remaining information. Questions on this screen are
based on the services or items that were requested. All fields designated with a red dot are
required fields and must be completed before submitting the request.
Note: The
Additional
Questions section
on this screen will
vary depending
on the type of PA
requested. This
example shows
the Additional
Questions section
for a DME Pulse
Oximeter request.
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8. Read the terms and conditions, and click to check the “We Agree” box.
Certification and Terms and Conditions: Before submitting each prior authorization
request, the provider and authorization request submitter must read, understand, and agree
to the certification and the terms and conditions of the prior authorization request.
9. After checking the “We Agree” checkbox, the “Submit Request” button at the bottom of
the page becomes enabled. To submit the request to TMHP, click Submit Request. The
prior authorization is then checked against a series of validation edits that confirm whether
all of the required fields have been populated.
After a request has been completed and has passed all of the validation edits, the prior
authorization request is saved, and the user is given a prior authorization number (PAN) and
the current status of the authorization (i.e., “In Process”).
Receipt of the prior authorization number does not mean that the prior authorization has been
approved. Providers must check the status to determine whether their authorization has been
approved. TMHP will issue a response to an authorization request within three business days
after the date of receipt.
Attachments to Online Prior Authorization Requests
Attachments cannot be submitted with online prior authorization requests. If it is necessary
to submit an attachment with a prior authorization request, providers must submit the
request and attachments on paper by mail or fax. Providers who submit attachments for an
authorization request that was submitted using the online portal must include the PAN on all
attachments.
Note: Case
Management
for Children
and Pregnant
Women prior
authorizations go
to DSHS by fax at
(512) 776-7574
or online at www.
cpwforms.dshs.
state.tx.us/cpw/.
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Medicaid Basics Participant Guide
Search For and Review the Status of
Prior Authorization Requests
Providers can search for and review the status of prior authorization requests online using the
TMHP website. This search functionality is available for all prior authorizations that are currently
in the TMHP system, including those submitted by mail, by fax, by telephone, or online.
1. Go to www.tmhp.com, and click providers in the header.
2. Click I would like to… in the upper right side of the header.
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3. Click Search for/extend an existing prior authorization.
The next screen gives you three choices:
1) Find an existing authorization request by entering a PAN.
2) Search for a request by requesting provider.
3) Search for a request by facility or performing provider.
For this example, we will search using NPI numbers and dates.
4. Click the radio button next to “Or search for a request by requesting provider.”
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Medicaid Basics Participant Guide
5. Select the provider’s or supplier’s NPI from the drop-down menu.
6. Enter the nine-digit client ID.
This is an optional field. If this field is not populated, the search will include all of the
potential clients associated with the selected NPI in the TMHP system.
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7. Use the drop-down calendar menu or type in the dates for which the prior authorization
was requested. The prior authorization date is required in the “From” field. The prior
authorization date is optional for the “Through” field.
If the “Through” field is not populated with a date, the search defaults to the current date.
8. Click Search.
A list of prior authorization requests that meet the criteria is displayed.
9. To view a specific prior authorization request, click the blue, underlined number in the
“Auth #” column.
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Medicaid Basics Participant Guide
Each prior authorization request will have at least two statuses—the complete status of the
entire prior authorization request and the status of each detail.
The status can be found in the “Status” column in the Authorization Information section of the
prior authorization request being viewed. The complete prior authorization request has one of
the following five statuses:
•
In Process: TMHP has received the prior authorization request but is still in the process of
reviewing it. TMHP has not determined whether the prior authorization will be approved.
•
Pending: TMHP has received and reviewed the prior authorization request and has determined
that more information is necessary before determining the final status. TMHP staff will contact
the requesting provider or supplier by telephone, fax, or mail for additional information.
•
Approved: TMHP has approved at least one procedure detail in the prior authorization request.
Refer to the procedure details section to identify which procedure details have been approved.
• Denied: TMHP has denied the prior authorization request. TMHP has sent the requesting
provider or supplier correspondence about the denial by mail or fax.
• Void: TMHP has voided the authorization request because the requested service does not
require prior authorization or, based on provider contact, the provider no longer wants to
request authorization for the services.
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THSteps Dental Mandatory Prior Authorization
Request Form
THSteps Dental Mandatory Prior Authorization Request Form
Submit to:
THSteps Dental
Prior Authorization Unit
PO Box 202917
Austin, TX 787202917
Note: All information is required—print clearly or type
Patient Information
Name:
Date of Birth:
/
/
Address:
Medicaid Number:
□M □F
E
Gender:
Check the following diagnostic tools submitted for review with the authorization request:
Restorative and intermediate care facility for the mentally retarded (ICF-MR)
□
Orthodontic case,
FM X-ray
□
□
FM X-ray □
Models
□
Periapicals
□
Documentation
PL
Panorex
□
□
Photos
□
I certify all primary dentition have been exfoliated (D8080). □
HLD
□
Photos
Panorex
□
□
Documentation
□
Cephlometric X-ray
□
Other □
M
Date of service diagnostic tools were produced:
Proposed treatment plan:
Tooth
Number or
Letter
SA
Procedure Code
Surface
Charge
This form cannot be submitted online.
Submit paper forms to the address
listed at the top of the form.
Note: All information is required—print clearly or type
Signature of dentist:
Date:
Printed or typed name of dentist:
/
/
Dentist telephone:
Dentist address:
Performing Dentist Identifying Numbers
TPI:
NPI:
Taxonomy:
Benefit Code:
Effective Date_01112008/Revised Date_01112008
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Medicaid Basics Participant Guide
Online Radiology Prior Authorization Requests
Online prior authorization is available for computed tomography (CT), computed tomography
angiography (CTA), magnetic resonance imaging (MRI), magnetic resonance angiography
(MRA), positron emission tomography (PET) scan, and cardiac nuclear imaging. Prior
authorization for outpatient, nonemergent CT, CTA, MRI, MRA, PET scan, and cardiac
nuclear imaging is required for Texas Medicaid fee-for-service (FFS).
MedSolutions, Inc. performs radiology authorization services on behalf of TMHP.
Providers can submit radiology prior authorization requests online or by telephone, fax, or mail
as follows:
• Online:
1. Go to the Provider section of the TMHP website at www.tmhp.com.
2. Click I would like to... in the right side of the header.
3. Click Submit a radiology prior authorization.
• Telephone: 1-800-572-2116
• Fax: 1-800-572-2119
• Mail:
Texas Medicaid & Healthcare Partnership
730 Cool Springs Blvd., Suite 800
Franklin, TN 37067
• Direct to MedSolutions, Inc.: www.medsolutionsonline.com
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Radiology Prior Authorization Request Form
This form is used to obtain prior authorization for elective outpatient services or update an existing outpatient authorization. All fields
marked with an asterisk (*) are required. The information in Section 2 is only required for updated or retroactive authorizations. Forms that
are submitted without all of the required information will be returned for correction.
Telephone number: 1-800-572-2116
Fax number: 1-800-572-2119
*Date of Request:
/
/
Please check the appropriate action requested:
□ CT Scan
□ CTA Scan
□ MRI Scan □ MRA Scan □ PET Scan
□ Cardiac Nuclear Scan □ Update/change codes from
original PA request
Client Information
*Name:
*Medicaid number:
*Date of Birth:
/
/
Facility Information
*Name:
Reference number:
E
*Address:
TPI:
*NPI:
Taxonomy:
Benefit Code:
PL
Requesting/Referring Physician Information
*Name:
License number:
*Address:
*Telephone:
*Fax number:
TPI:
*NPI:
Benefit Code:
Section 1
Service Types
Date of Service:
*Outpatient Service(s)
/
□
/
*Primary:
SA
Diagnosis Codes
M
Taxonomy:
Emergent/Urgent Procedure
□
*Procedures Requested:
Secondary:
*Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications,
and previous imaging results:
*Requesting/Referring Physician (Signature Required):
*Print Name:
*Date:
/
/
Section 2—Updated Information (when necessary)
*Date of Service:
/
Diagnosis Codes
*Primary:
/
*Procedures Requested:
Secondary:
*Clinical documentation supporting medical necessity for a procedure code change includes treatment history, treatment plan,
medications, and previous imaging results:
*Requesting/Referring Physician (signature required):
*Print Name:
*Date:
/
/
Physician must complete and sign this form prior to requesting
authorization.
Requesting/Referring Physician License No.:
*Requesting/Referring Physician NPI:
Requesting/Referring Physician TPI:
Effective Date_02012010/Revised Date_10012009
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Medicaid Basics Participant Guide
Claim Submission
Claims
A claim is a request for reimbursement for services rendered. Claims are submitted to TMHP.
Texas Medicaid cannot make reimbursement to clients; the provider who performs the
service must submit an assigned claim. Federal regulations prohibit providers from charging
clients a fee for completing or submitting Medicaid claim forms. Providers are not allowed to
charge TMHP for submitting claims. The cost of submitting claims is part of the usual and
customary rate for doing business. Providers cannot charge Texas Medicaid or submit claims to
Medicaid clients for missed appointments. Only claims for services rendered are considered for
reimbursement.
Claims can be submitted electronically or on paper. Many claims are submitted to TMHP
electronically using TexMedConnect. When providers submit claims electronically, claims are
processed more quickly and accurately, which results in a faster reimbursement.
Note: Providers may submit electronic claims to TMHP using TexMedConnect or EDI for services
rendered to Medicaid managed care clients whose benefits are administered by a Medicaid managed
care organization (MCO) or a Medicaid managed care dental plan. For more information, see the
FAQ at www.tmhp.com/News_Items/2012/02-Feb/02-17-12 MC FAQ.pdf.
TMHP Claim Processing Procedures
Medicaid claims are subject to the following procedures:
• TMHP verifies that all of the required information is present.
•
70
At the end of each week, claims that have been submitted under the same provider identifier
and program and that are ready for disposition are reimbursed to the provider with an
explanation of each reimbursement or denial. The explanations are included in the Remittance
and Status (R&S) Report, which can be received as a downloadable portable document format
(PDF) version. A Health Insurance Portability and Accountability Act (HIPAA)-compliant
835 transaction file is also available for those providers who wish to import claim dispositions
into a financial system or who use third-party billing services or software. An R&S Report
is generated for providers who have weekly claim or financial activity, whether or not they
received a reimbursement. The report identifies pending, paid, denied, and adjusted claims.
If no claim activity or outstanding account receivables exist for the provider during the time
period, that provider’s R&S Report is not generated for the week.
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Procedure Coding
The procedure coding system used by Texas Medicaid is called the Healthcare Common
Procedure Coding System (HCPCS). HCPCS provides health-care providers and third-party
agents a common coding structure that uses a five-character numeric or alphanumeric base for
all codes.
HCPCS consists of two levels of codes: the Current Procedural Terminology (CPT®) Professional
Edition (Level I) and the HCPCS codes that have been approved and released by Centers for
Medicare & Medicaid Services (CMS) (Level II).
Modifiers describe and qualify the services provided. A modifier is placed after the fivedigit procedure code. Up to four modifiers may apply per service. For additional modifier
requirements, refer to the current TMPPM Section 6: Claims Filing.
Benefit Code
A benefit code is an additional data element that is used to identify state programs.
Providers who participate in the following programs must use the associated benefit code when
submitting claims and prior authorization requests:
Program
Benefit Code
Comprehensive Care Program (CCP)
CCP
CSHCN Services Program
CSN
THSteps Medical
EP1
THSteps Dental
DE1
Family Planning Agencies*
FP3
Hearing Aid Dispensers
HA1
Maternity
MA1
County Indigent Health Care Program
CA1
Early Childhood Intervention (ECI) Providers
EC1
Tuberculosis (TB) Clinics
TB1
Texas Medicaid Program Home Health DME
DM2
CSHCN Services Program Home Health DME
DM3
Case Management Intellectually Disabled Providers
MH2
*Agencies only: Benefit codes should not be used by individual family planning providers.
National Drug Code (NDC)
All Texas Medicaid FFS and family planning providers must submit an NDC on professional
or outpatient electronic and paper claims for physician-administered prescription drugs. With
the exception of vitamins and minerals, procedure codes in the A code series do not require an
NDC.
More information on NDC can be found in the current TMPPM, Vol. 1 General Information.
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Medicaid Basics Participant Guide
Electronic Claims
Claims can be submitted electronically to TMHP through billing agents who interface
directly with the TMHP electronic data interchange (EDI) Gateway. TMHP uses the HIPAAcompliant American National Standards Institute (ANSI) ASC X12 4010A file format through
secure socket layer (SSL) and virtual private networking (VPN) connections for maximum
security. Providers must retain all claim and file transmission records, which they may be
required to submit for pending research on missing claims or appeals.
Electronic Rejections
The most common reasons for electronic professional claim rejections include:
•
Client information does not match: The client’s information does not match the patient
control number (PCN) or the client’s Medicaid identification (ID) number on the TMHP
eligibility file. The name, date of birth, sex, and nine-digit PCN must be an exact match with the
client’s identification number on TMHP’s eligibility record. Providers who use TexMedConnect
can send an interactive eligibility request to obtain an exact match with TMHP’s record.
Providers can verify eligibility using the TMHP website or call the Automated Inquiry System
(AIS) at 1-800-925-9126 to verify client information. A lack of complete client eligibility
information causes a rejection and possible delayed reimbursement. To prevent delays when
submitting claims electronically:
–– Always include the first and last name of the client in the appropriate fields on the claim.
–– Always enter the client’s complete, nine-digit Medicaid ID number (PCN). Valid
Medicaid ID numbers begin with 1, 2, 3, 4, or 5. CSHCN Services Program client ID
numbers begin with a 9.
–– When submitting claims for newborns, use these guidelines:
ˏˏ
If the mother’s name is “Jane Jones,” use “Boy Jane Jones” for a male child and
“Girl Jane Jones” for a female child.
ˏˏ
Enter “Boy Jane” or “Girl Jane” in first name field and “Jones” in last name field.
Always use “boy” or “girl” first and then the mother’s full name. An exact match
must be submitted for the claim to be processed.
ˏˏ
Do not use “NBM” for newborn male or “NBF” for newborn female.
• Referring/Ordering Physician field blank or invalid: The referring physician’s national
provider identifier (NPI) must be present on claims that order or refer services for clients.
Providers who use third-party software should consult the software vendor for this field’s
location on the electronic claim entry form.
• Performing Physician ID field blank or invalid: When the billing provider is a group
practice, the performing provider NPI for the physician who performed the service must
be submitted. Providers who use third-party software should consult the software vendor
for this field’s location on the electronic claim form.
• Facility Provider field blank or invalid: When the place of service (POS) is anywhere
other than home or office, such as a hospital setting for example, the facility’s provider NPI
must be submitted. Providers who use third-party software should consult the software
vendor for this field’s location on the electronic claims entry form.
• Invalid Type of Service or Invalid Type of Service/Procedure code combination: Some
procedure codes require a modifier to denote the procedure’s type of service (TOS).
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Resubmission of TMHP EDI Rejections
To meet the claim submission deadline, providers who receive a rejection from the TMHP EDI
gateway may resubmit an electronic claim within 95 days of the date of service (DOS). Proof
of timely filing must be submitted upon appeal within 120 days of the rejection.
TMHP EDI Batch Numbers and Julian Dates
All electronic transactions are assigned an eight-character batch ID immediately upon receipt
by the TMHP EDI gateway. The batch ID format allows electronic submitters to determine
the exact day and year that a batch was received. The batch ID format is JJJYSSSS, where each
character is defined as follows:
• JJJ: The three J characters represent the Julian date that the file was received by the TMHP
EDI gateway. The first character (J) is displayed as a letter, where E = 0, F = 1, G = 2, and
H = 3. The last two characters (JJ) are displayed as numbers. All three characters (JJJ)
together represent the Julian date.
• Y: The Y character represents the last digit of the calendar year when the TMHP EDI
gateway receives the file. For example, a “9” in this position indicates the year 2009.
• SSSS: This is a unique 4-character sequence number assigned by TMHP EDI gateway to
the claim filed.
For example, the batch ID E089LDS1 means that the TMHP EDI gateway received the file on
January 8, 2009.
Note: This
unique sequence
number will
allow an increase
in the number of
claims processed
using the TMHP
EDI gateway
each day.
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Medicaid Basics Participant Guide
Claim Form Determination
CMS-1500
The following provider types can submit claims electronically or use the CMS-1500 paper
claim form:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Note: FQHCs
can use CMS1500 or CMS1450, but must
use CMS-1500
when submitting
claims for
THSteps services.
74
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ambulance
Ambulatory surgical center (ASC) (freestanding)
Blind and visually impaired children (BVIC)
Early Childhood Intervention (ECI)
Case Management for Children and Pregnant Women
Certified nurse-midwife (CNM)
Certified registered nurse anesthetist (CRNA)
Certified respiratory care practitioner (CRCP)
Chemical dependency treatment facilities
Chiropractor
Clinical nurse specialist (CNS)
Dentist (doctor of dentistry practicing as a limited physician)
DME – home health services supplier (CCP and home health services)
Family planning agency that does not also receive funds from DSHS Family Planning
Program and EPHC
Federally Qualified Health Center (FQHC)
Genetic service agency
Hearing aid
In-home TPN supplier
Laboratory
Licensed dietitian (CCP only)
Licensed clinical social worker (LCSW)
Licensed professional counselor (LPC)
Maternity service clinic (MSC)
Mental health (MH) rehabilitative services
Nurse practitioner (NP)
Occupational therapist (CCP only)
Optician/optometrist/opthamologist
Orthotic and prosthetic supplier (CCP only)
Physical therapist
Physician (group and individual)
Physician assistant (PA)
Tuberculosis clinic
Podiatrist
Private duty nurse (PDN) (CCP only)
Psychologist
Radiology
School Health and Related Services (SHARS)
Speech language pathologist (CCP only)
THSteps medical services
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UB-04 CMS-1450
The following provider types can submit claims electronically or on the UB-04 CMS-1450
paper claim form:
• ASC (hospital-based)
• Comprehensive outpatient rehabilitation facilities (CORFs) (CCP only)
• FQHC
• Home health agency
• Hospital
–– Inpatient (acute care, rehabilitation, military, and psychiatric hospitals)
Note: FQHCs
must use CMS1500 when
submitting claims
for THSteps
services.
–– Outpatient
• Renal dialysis center
• Rural Health Clinic (RHC) (freestanding and hospital-based)
ADA Dental
Providers and Intermediate Care Facilities (ICF) submit claims for dental services electronically
or on a J515 American Dental Association (ADA) claim form.
TMHP is responsible for processing and reimbursing all FFS and ICF claims for THSteps
dental services.
2017 Claim Form
This claim form is used by DSHS Family Planning providers and EPHC providers who submit
claims for family planning services, and it includes fields for pregnancy and birth control.
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Medicaid Basics Participant Guide
CSHCN Services Program Dual Eligibility
If a client has Medicaid and CSHCN Services Program benefits, claims must be submitted to
Medicaid before they are submitted to the CSHCN Services Program.
Instructions for Submitting Claims Using TexMedConnect
1. Go to www.tmhp.com, and click providers in the header.
2. Click Go to TexMedConnect in the upper right corner.
3. Enter your User name and Password.
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4. Click Claims Entry in the left-side navigation pane.
5. Select the appropriate billing provider information.
A list of NPIs/APIs and related data, such as taxonomy code, physical address, and benefit
code selections, is displayed based on the user’s logon information.
6. Enter the client’s Medicaid ID number for the claim (optional).
The system populates most of the required fields on the Patient tab.
7. Select the appropriate claim type from the drop-down menu.
8. Click Proceed to Step 2.
Note: Required
fields are
indicated by a
red dot. Fields
without a red dot
are optional.
Note: If you do
not enter the
Medicaid ID
number, you must
manually enter
all of the required
fields on the
Patient tab.
The Claims Entry screen appears for the selected claim type.
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Medicaid Basics Participant Guide
9. Proceed through each tab, and enter claim information.
10. On the Other Insurance/Submit Claim tab, select the other insurance information if it
applies.
11. Read the terms and conditions, and click to check the “We Agree” checkbox.
Note: The
TexMedConnect
Acute Care User
Manual and
computer-based
training (CBT)
can be found in
the ComputerBased Training
section of the
TMHP LMS at
http://learn.
tmhp.com.
Note: After a
claim has been
submitted, an
internal claim
number (ICN) is
generated.
12. Click Submit.
Saving a Claim
At the bottom of the screen, four choices will be available:
• Save Draft: Adds the claim to the draft list for completion/submission at a later time.
• Save Template: Adds the claim to the template list for quicker claims creation in the
future.
• Save to Batch: Adds the claim to the pending claims list for batch submission.
• Submit: Submits one claim at a time.
Details for submitting claims to TMHP can be found in the current TMPPM Section 6:
Claims Filing. Additional information can also be found in the Claim Forms CBT at
http://learn.tmhp.com.
The International Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10- CM) transition
Texas state health-care programs must transition medical diagnosis and inpatient procedure
coding from ICD-9-CM to the ICD-10 code sets.
The Centers for Medicare & Medicaid Services (CMS) is publishing new claim forms to
include this information.
For more information refer to the ICD-10 Codes Update page at www.tmhp.com/Pages/
CodeUpdates/ICD-10.aspx.
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Submitting Paper Claims
Providers must send paper claims to TMHP at the following address:
Texas Medicaid & Healthcare Partnership
Claims
PO Box 200555
Austin, TX 78720-0555
Providers who are 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
PO Box 203638
Austin, Texas 78720-3638
Tips for Expediting Paper Claims
Use the following guidelines to enhance the accuracy and timeliness of paper claim processing.
General requirements
• 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
• 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, 10 point. 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.
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Medicaid Basics Participant Guide
Attachments
• Use paper clips on claims or appeals if they include attachments. Don’t use glue, tape, or
staples.
• Place the claim form on top when sending new claims, 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 multi-page claims for
the same client.
• Use the CMS-approved Medicare Remittance Advice Notice printed from Medicare
Remit Easy Print (MREP) (professional services) or PC-Print (institutional services) when
sending a Remittance Advice from Medicare or the paper MRAN received from Medicare
or a Medicare intermediary. You may also download a TMHP-approved MRAN template
from the TMHP website at www.tmhp.com.
• Submit claim forms with MRANs and R&S Reports.
Other Claim Submission Factors
Third-Party Resources
Before submitting claims to Medicaid, claims must be submitted to any third-party resources.
The TPR Unit toll-free telephone number is 1-800-846-7307.
Providers are not required to submit claims to a third-party resource when submitting claims
for THSteps medical and dental services, Case Management for Children and Pregnant
Women, and Family Planning services. If the provider chooses to submit claims to the thirdparty resource, the provider must follow these rules:
• Claims involving third-party resource, including Medicare, must be received within 95
days of the date of disposition.
• When a claim is submitted to a third-party resource 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 when appealing.
For more information, refer to the current TMPPM Section 4: Client Eligibility.
Texas Medicaid Managed Care
Before submitting claims to Medicaid, verify that the client is enrolled in Texas Medicaid
managed care and has selected or has been assigned to one of several managed care programs
including STAR, STAR Health, and STAR+PLUS eligibility. This can be verified using the
Your Texas Benefits Medicaid card, TexMedConnect, or AIS.
Providers must call the client’s managed care organization to verify the PCP. For more
information, refer to the current TMPPM, Medicaid Managed Care Handbook.
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Managed Care Billing
Managed care dental plans handle managed care claims for all clients who are not enrolled in
FFS Medicaid. Providers who have questions or concerns about managed care claims for clients
eligible under a Medicaid managed care organization can contact:
• STAR Health at 1-866-287-3252.
• STAR+PLUS at 1-866-512-8274.
• Advantage by Superior at 1-866-512-8305.
• DentaQuest Medicaid Provider Call Center at 1-800-896-2374.
• MCNA Medicaid Provider Call Center at 1-855-PRO-MCNA (1-855-776-6262)
or email at [email protected]
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Medicaid Basics Participant Guide
Third-Party Resources (TPR)
Texas Medicaid maintains an effective third-party resources program that helps reduce
Medicaid costs by shifting expenses for services to third-party payers. Third-party payers are
entities or individuals that are legally responsible for reimbursing the medical claims of
Medicaid clients. As a condition of eligibility, Medicaid clients assign to Medicaid their rights
(and the rights of any other eligible individuals on whose behalf the client has legal authority
under state law to assign such rights) to medical support and reimbursement for medical care
from any third party.
As a condition of Medicaid
eligibility, all other medical
insurance information must be
reported to Medicaid, including
prescription insurance. If the other
insurance is canceled, new insurance
coverage is obtained, or there are
general questions about third-party
resources, the Medicaid Third-Party
Liability (TPL) hotline is available
at 1-800-846-7307 for updating
records and answering questions.
State and Federal rules, laws and regulations require states to ensure
that Medicaid clients use all of the other resources available to them
to reimburse for all or part of their medical care before turning to
Medicaid. Medicaid reimburses only after the third party has met its
legal obligation, with some exceptions:
• ECI Targeted Case Management
• THSteps
• Family Planning
• Case Management for Children and Pregnant Women
A third-party resource (TPR) is any individual, entity, or program that
is, or may be, liable to reimburse for any medical assistance provided to
a client under the approved state plan. Although there are many third
parties which may be obligated to reimburse for services, providers need
mainly to be concerned with other insurance (OI) identified by the client.
The following are the most common TPR sources:
• Other health insurance including assignable indemnity contracts
• Health maintenance organization (HMO)
• Public health programs available to clients with Medicaid such as Medicare and Tricare
• Profit and nonprofit health plans
• Self-insured plans
• No-fault automobile insurance such as personal injury protection (PIP) and automobile
medical insurance
• Liability insurance
• Life insurance policies, trust funds, cancer policies, or other supplemental policies
• Workers’ Compensation
• Other liable third parties
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With some exceptions, all OI, including Medicare, must reimburse before claims are submitted
to Medicaid for reimbursement. Non-TPR sources are secondary to Texas Medicaid and may
only reimburse benefits after Texas Medicaid. The following are the most common non-TPR
sources. If providers have questions about others that are not listed, they should contact a
provider relations representative.
• Department of Assistive and Rehabilitative Services (DARS), Blind Services
• Texas Kidney Health Care Program
• Crime Victims’ Compensation Program
• Muscular Dystrophy Association
• CSHCN Services Program
• Texas Band of Kickapoo Equity Health Program
• Maternal and Child Health (Title V)
• State Legalization Impact Assistance Grant (SLIAG)
• Adoption cases
• Home and community-based waivers programs through DADS
Claims must be submitted to the OI first, and the provider is to wait for reimbursement/
disposition before submitting claims to Medicaid. If claims are submitted to Medicaid before
the OI, the claim will be denied with EOB 00260: Client is covered by other insurance which
must be billed prior to this program. The OI information that is on file with TMHP will be
printed on the R&S Report. If a claim is reimbursed by Medicaid and the provider later finds
out the client has OI, the provider must refund the reimbursed amount to Medicaid before
submitting a claim to the OI.
Co-Payments
TMHP will process and reimburse health maintenance organization (HMO) copays for private
and Medicare preferred provider organization (PPO) copays. The client must be eligible for
reimbursement under Medicaid guidelines.
Reference the TMPPM for more information about Co-Payments.
Submitting OI Claims
OI claims can be submitted electronically using TexMedConnect or third-party software. The
format of third-party software can differ, so it is recommended that when using such software
providers contact their vendor to determine which fields to use to enter OI information.
OI claims can also be submitted on paper with CMS-1500 and UB-04 CMS-1450 paper claim
forms. Use boxes 9, 11, 19, and 29 on the CMS-1500, and use Occurrence codes on the UB04.
Provide complete OI information, including the following:
• Name and address of OI company
• Policy and group number information
• OI telephone number (if available)
• Specific information on reimbursement or denial
• Specific date of reimbursement or denial
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Medicaid Basics Participant Guide
Note: When
dealing with
private HMO
and PPO claims,
providers should
submit claims
for copayments
to Medicaid, not
the client.
• Specific date of disposition
• Preferred provider organization (PPO) discount is not required
110-Day Rule
A provider can submit a claim to Medicaid if the primary payer (OI) has not reimbursed the
claim within 110 days. The provider is still required to provide complete OI information and
to indicate that they are using the 110-day rule. The provider has from the 110th day from OI
submission to 365th day from the DOS to file the claim to Medicaid.
365-Day Rule
TMHP must receive a completed claim within 365 from the DOS, regardless of the OI status.
Verbal Denial
Providers may call the OI resource and receive a verbal denial. Providers have 95 days from the
date of the verbal denial to submit the claim to Medicaid or the CSHCN Services Program.
The OI record can be updated either when the provider submits the claim or calls the TPR
Unit at 1-800-846-7307.
Role of the TMHP TPR Unit
TMHP cannot make changes to the demographic or eligibility information of a client.
Providers are encouraged to call the TPR Unit at 1-800-846-7307 to update a client’s OI
information (e.g., termination of benefits or new insurance benefits). After the TPR Unit has
updated the information in the TMHP system, the provider is responsible for submitting an
appeal for the OI denial.
When calling the TPR Unit to give updated OI information, the TPR Unit representative
will inform the caller whether the update has been successfully completed and claims can
be resubmitted. If the TPR Unit representative is not able to immediately update the OI
information, the verification and update process may take up to 10 business days.
Exceptions
•
84
THSteps Medical and Dental Services: THSteps medical and dental providers are not
required to bill other insurance before submitting claims to Medicaid; however, if the provider
is aware of other insurance, the provider must decide whether he or she wants to bill the other
insurance or not. If the provider wants to bill the other insurance, that must be done prior to
submitting claims to Medicaid. (The TPR may make a higher payment than Medicaid). If the
provider decides to submit the claim to Medicaid first, the provider then accepts the Medicaid
reimbursement as payment in full, and Medicaid, not the provider, then has the right to
recover from the other insurance.
CPT only copyright 2014 American Medical Association. All rights reserved.
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Medicaid Basics Participant Guide
• Family Planning Services: Providers do not have to submit claims to OI; they may submit
claims to TMHP directly. Federal regulations protect the client’s confidential choice of
birth control and family planning services. Confidentiality is jeopardized when seeking
information from TPRs.
• Case Management for Children and Pregnant Women: Providers do not have to submit
claims to OI; they may submit claims to TMHP directly.
• Personal Care Services (PCS): Providers do not have to submit claims to OI; they may
submit claims to TMHP directly.
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Medicaid Basics Participant Guide
What is Medicare?
Medicare
Medicare is the federal health insurance program for people who are 65 years of age or older,
certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD),
which is permanent kidney failure that requires dialysis or a transplant. Clients pay part of their
health-care costs through monthly premiums, deductibles, and copays. Medicaid is the payer of
least and last resort; it pays secondary to Medicare.
Parts of Medicare
Medicare Part A (Hospital Insurance)
Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility (not custodial
or long-term care), hospice care, and some home health care. Clients typically do not pay a
premium for Part A.
Medicare Part B (Professional Serivces)
Medicare Part B provides professional services like doctors’ services, outpatient care,
preventative services, and other medical services that Part A does not provide. Part B is
optional, and the client must pay a premium.
Medicare Part C (Medicare Advantage Plans)
A Medicare Advantage Plan is a type of Medicare health plan that is offered by a private
company that is contracted by Medicare to provide clients with Medicare Parts A and B and
sometimes Medicare Part D benefits. Medicare Advantage Plans include health maintenance
organizations (HMOs), preferred provider organizations (PPOs), private fee-for-service plans,
special needs plans, and Medicare Medical Savings Account plans. Clients who are enrolled
in a Medicare Advantage Plan receive all of their Medicare services through the plan, which
means that none of their services are paid for directly by traditional Medicare. Most Medicare
Advantage Plans offer prescription drug coverage.
Medicare Part D (prescription drug coverage)
Medicare Part D provides prescription drug benefits. Since January 1, 2006, everyone with
Medicare, regardless of income, health status, or prescription drug usage, has received their
prescription drug benefits through an insurance or other private company that has been
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Medicaid Basics Participant Guide
approved by Medicare. Plans can vary in cost and the drugs covered. If a client decides not to
join a Medicare Prescription Drug Plan when they first become eligible for one and the client
doesn’t have other creditable prescription drug coverage or get extra help, then it is likely that
they will have to pay a late enrollment penalty. Medicaid is one of the qualifying sources of
extra help.
Part D adds prescription drug coverage to Medicare, some Medicare Cost Plans, some
Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These
plans are offered by insurance and other private companies that have been approved by
Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the
same rules as Medicare Prescription Drug Plans.
Since Medicaid serves clients of all ages, it is possible for an individual to be able to receive
both Medicare and Medicaid. These clients are referred to as “dual eligible.” We will discuss
“dual eligible” clients more when we discuss claims.
For more information about Medicare, refer to the Medicare website at www.medicare.gov.
Medicare Crossover Claims
When a service is a benefit of both Medicare and Medicaid, the claims must be submitted
to Medicare first. Providers should not submit a claim to Medicaid until Medicare has
dispositioned the claim. The reimbursement received from Medicare and the coinsurance
and deductible reimbursement from Medicaid must be considered payment in full. If the
Medicare reimbursement is equal to or exceeds the Medicaid allowed amount or encounter
reimbursement for the service, Texas Medicaid will not reimburse for coinsurance and
deductible. These guidelines exclude clients who live in a nursing facility.
Providers must accept Medicare assignment to receive coinsurance and deductible amounts
for Medicaid services provided to clients. If a provider has accepted a Medicare assignment,
the provider may receive reimbursement of the Medicare deductible and coinsurance from
TMHP on behalf of the qualified Medicare beneficiary (QMB) or Medicaid qualified Medicare
beneficiary (MQMB) client.
Providers who accept Medicare or Medicaid assignment cannot legally require the client to pay
the Medicare coinsurance or deductible amounts.
Claims for which traditional Medicare is the primary insurer that are submitted to Medicare
Administrative Contractors (MACs) may be transferred electronically to TMHP through
a Coordination of Benefits Contractor (COBC) for claims processed as assigned. Providers
should contact their MAC for more information. This benefit allows providers to receive
disposition from both carriers while only submitting the claim once. Providers should allow
60 days from the date of Medicare’s disposition for a claim to be shown on the Medicaid R&S
Report. Claims that have been denied and have gone through the appeal process by Medicare
are not automatically transferred to TMHP.
If crossover claims are not transferred electronically, providers must submit a paper claim to
TMHP.
For clients who are eligible for both Medicare and Medicaid (known as “dual eligible”) and
are enrolled in a Part C Medicare Advantage Plan, the provider must submit a paper claim to
TMHP.
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Medicaid Basics Participant Guide
Remittance and Status
(R&S) Report
Note: Providers
receive an
R&S Report
that details
Texas Medicaid
activities
and provides
individual
program
summaries.
Combined
provider
reimbursements
are made based
on the provider’s
settings for Texas
Medicaid FFS.
The R&S Report provides information on pending, paid, denied, and adjusted claims. R&S
Reports give providers detailed information about the status of claims submitted to TMHP
and any accounts receivables that are established as a result of inappropriate reimbursement.
These accounts receivable are recouped from each week’s claim reimbursements until the
entire amount is recouped to Texas Medicaid. All claims for the same provider identifier and
program processed for payment are reimbursed at the end of the week, either by a single
check or with electronic funds transfer (EFT). If there is no claim activity or no outstanding
accounts receivable exist for a particular week, the provider does not receive an R&S Report.
Providers are responsible for reconciling their records to the R&S Report to determine whether
reimbursements and denials were received.
Providers must retain copies of all R&S Reports for a minimum of five years. Providers must
not use R&S Report originals for appeal purposes. Providers must submit copies of the R&S
Report pages with their appeal documentation. Claims should appear on the R&S Report
within two to three weeks of submission. If a claim does not appear on the R&S Report within
two to three weeks of submission, providers should perform a claim status inquiry to determine
whether the claim was accepted or rejected. If the claim does not appear in the system,
providers who submit claims electronically should check their EDI rejection reports, and
providers who file on paper should check to see whether their claim was returned unprocessed.
R&S Report Delivery Options
TMHP offers two options for the delivery of the R&S Report:
•
PDF version: The PDF version of the R&S Report is an electronic, printable 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.
Newly-enrolled providers are initially set up to receive the PDF version of the R&S Report.
• Electronic R&S (ER&S) 835 file: Using HIPAA-compliant EDI standards, the ER&S
835 file can be downloaded through the TMHP EDI gateway using third-party software.
The ER&S 835 file is available on Thursday the week the provider payments are released.
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Medicaid Basics Participant Guide
Accessing R&S Reports
1. Go to www.tmhp.com, and click providers in the header.
2. Click Go to TexMedConnect in the upper right corner.
3. Enter your User name and Password.
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Medicaid Basics Participant Guide
4. Click R&S in the left-side navigation pane on the TexMedConnect screen.
5. Click the appropriate NPI for the R&S Report you want to access.
6. Select the appropriate program.
7. Choose the appropriate R&S Report list by date.
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Medicaid Basics 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.
• Claims – Paid or Denied: Claims in the “Claims - Paid or Denied” section were 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 ID number.
• Financial Transactions: The “Financial Transaction” section of the R&S Report describes
any amounts that are added or taken out of the weekly reimbursement. All accounts
receivable, IRS levies, payouts, refunds, reissues, and voids appear here.
Note: Banner
messages
(and their
corresponding
bulletin articles)
are updates
to, and take
precedence over,
the TMPPM.
Banner messages
are published
weekly.
• Claims Payment Summary: The “Claims Payment Summary” section summarizes all
payments, adjustments, and financial transactions that are 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: The “Claims in Process” section can 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 more
information, refer
to the TMPPM.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.91
92
TPI: 1234567-01
NPI/API: 1234567890
Taxonomy: 193400000X
Benefit Code:
Report Seq. Number: 35
R&S Number:
2460000
Mail all other correspondence to:
Texas Medicaid & Healthcare Partnership
12357-B Riata Trace Parkway
Austin, Texas 78727-6422
1.0
$201.03
$201.03
123456789
201.03
00A01
IF YOUR CLAIM HAS NOT APPEARED ON AN R&S REPORT AS PAID, DENIED OR PENDING WITHIN 30 DAYS OF SUBMISSION TO TMHP, PLEASE CONTACT
TELEPHONE INQUIRY AT 1-800-925-9126 AND/OR SEE CLAIMS FILING INSTRUCTIONS IN YOUR PROVIDER MANUAL.
**************************************************************************************************************************************
PENDING CLAIM TOTALS
DOE, JANE 100020030200712345678910
01/15/2008 01/15/2008 1 99213
78605
THE EXPLANATION OF PENDING STATUS (EOPS) CODES LISTED ARE NOT FINAL CLAIM DENIALS OR PAYMENT DISPOSITIONS. THE EOPS CODES IDENTIFY THE REASONS
WHY A CLAIM IS IN PROCESS. BECAUSE THESE CLAIMS ARE CURRENTLY IN PROCESS, NEW INFORMATION CANNOT BE ACCEPTED TO MODIFY THE CLAIM UNTIL THE
CLAIM FINALIZES AND APPEARS AS FINALIZED ON YOUR R&S REPORT. PLEASE REFER TO THE LAST SECTION OF THIS REPORT FOR THE MESSAGES THAT CORRESPOND
TO THE EOPS CODES USED ON THIS REPORT.
***************************************************** THE FOLLOWING CLAIMS ARE BEING PROCESSED *************************************************
~
Page 12 Of
________________________________________________________________________________________________________________________________________________
PATIENT NAME
CLAIM NUMBER
MEDICAID # PATIENT ACCT #
MEDICAL RECORD #
MEDICARE #
EOPS EOPS EOPS EOPS
DIAGNOSIS
PATIENT ACCT #
---SERVICE DATES-------BILLED---------ALLOWED----FROM
TO
TOS PROC
QTY
CHARGE
QTY
CHARGE
POS
PAID AMT
EOPS EOPS EOPS EOPS EOPS
MOD MOD
________________________________________________________________________________________________________________________________________________
(800) 925-9126
TEXAS PROVIDER
PO BOX 848484
DALLAS, TX 75888-1234
(214) 555-4141
Mail original claim to:
Texas Medicaid & Healthcare Partnership
P.O. Box 200555
Austin, Texas 78720-0855
Texas Medicaid & Healthcare Partnership
Remittance and Status Report
Date: 02/01/2009
Medicaid Basics Participant Guide
R&S Pending Claims
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
~
TPI: 1234567-01
NPI/API: 1234567890
Taxonomy: 193400000X
Benefit Code:
Report Seq. Number: 33
99999999
R&S Number:
Mail all other correspondence to:
Texas Medicaid & Healthcare Partnership
12357-B Riata Trace Parkway
Austin, Texas 78727-6422
R&S Claims Payment Summary
*** AFFECTING PAYMENT THIS CYCLE ***
AMOUNT
COUNT
254.25
21
1,110.00
**********************PAYMENT TOTAL FOR CHECK 000000099999999 IN THE AMOUNT OF 156.71.**********************
PENDING CLAIMS
|
*** AMOUNT AFFECTING 1099 EARNINGS ***
|
THIS CYCLE
YEAR TO DATE
CLAIMS PAID
|
254.25
1,673.67
|
SYSTEM PAYOUTS
|
|
MANUAL PAYOUTS
(REMITTED BY SEPARATE CHECK OR EFT)
|
|
AMOUNT PAID TO IRS FOR LEVIES
|
|
AMOUNT PAID TO IRS FOR BACKUP WITHHOLDING
|
|
ACCOUNTS RECEIVABLE RECOUPMENTS
-97.54
|
-97.54
-97.54
|
AMOUNTS STOPPED/VOIDED
|
-1,544.72
|
SYSTEM REISSUES
|
|
CLAIM RELATED REFUNDS
|
|
|
NON-CLAIM RELATED REFUNDS
|
HELD AMOUNT
|
|
PAYMENT AMOUNT
156.71
|
156.71
31.41
________________________________________________________________________________________________________________________________________________
PAYMENT SUMMARY FOR TAX ID 123456789
Page 31 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: 09/10/2013
Medicaid Basics Participant Guide
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Medicaid Basics Participant Guide
Balancing
Your R&S
Report
The weekly Remittance and Status (R&S)
Report provides detailed information
about the status of claims that have been
submitted to TMHP. The report provides
information on pending, paid, denied, and
adjusted claims and identifies accounts
receivables established as a result of
appeals filed by the provider, adjustments
received from Medicare, utilization review,
and mass adjustments initiated by TMHP.
These receivables are recouped from claim
payments.
This guide will show you how to balance
your R&S Report when recoupments are
taken.
Source: www.tmhp.com/News_Items/2011/07-Jul/07-29-11 Balancing Your RS Report.pdf
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Balancing Your Remittance and Status (R&S) Report
Medicaid Basics Participant Guide
To balance your R&S Report when recoupments are taken, follow these steps:
1
Go to the PAID/DENIED CLAIMS section of your R&S Report. On the TOTAL FOR
MEDICAID line, locate the PAID AMT.
-----BILLED----QTY
CHARGE
-----ALLOWED----QTY
CHARGE
$2,744.00
$590.39
TOTAL FOR MEDICAID
2
$12,426.00
$8,822.00
$8,822.00
Go to the ADJUSTMENT PAID/DENIED section. On the TOTAL FOR MEDICAID line,
locate the PAID AMT, which will show the total amount paid for traditional Medicaid
adjustments:
TOTAL FOR MEDICAID
4
$590.39
Next, locate the PAID AMT. for Managed Care in the PAID/DENIED section:
TOTAL FOR MANAGED CARE
3
PAID AMT.
$41,257.00
$26,269.84
$26,184.08
Locate the PAID AMT for Managed Care in the ADJUSTMENTS PAID/DENIED section:
TOTAL FOR MANAGED CARE
Texas Medicaid & Healthcare Partnership
$16,911.00
$4,282.00
$4,282.10
2
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Balancing Your Remittance and Status (R&S) Report
Medicaid Basics Participant Guide
5
Add these four amounts together. The total will equal the number in the AMOUNT column on
the CLAIMS PAID line at the top of the FINANCIAL SUMMARY PAGE:
*** AFFECTING PAYMENT THIS CYCLE ***
CLAIMS PAID
6
AMOUNT
COUNT
$39,878.57
19
Go to the FINANCIAL TRANSACTIONS section of your
R&S Report. The section will list all of the original claims that
were listed in the ADJUSTMENT PAID/DENIED section and
the amount of each that was applied to the recoupment.
$590.39
0
$ 8 , 8 2 2 . 00 8
$26,184. .10
2
+ 4,28
.57
$39,878
*********************** FINANCIAL TRANSACTIONS **********************
ACCOUNTS RECEIVABLE
YOUR PAYMENT WAS REDUCED BY THE APPLIED AMOUNTS SHOWN BELOW FOR THE REASONS
INDICATED.
The last page of the FINANCIAL TRANSACTIONS section will show the total accounts
receivable on the TOTAL line:
TOTAL
7
$21,624.65
Subtract the total accounts receivable (listed in step 6) from
the total paid claims amount (step 5). The final amount
should equal the number on the PAYMENT AMOUNT line. If
the total paid claims amount is more than the total accounts
receivable, you will receive a payment and the accounts
receivable will be paid. If the total paid claims amount is less
than the total accounts receivable, the accounts receivable
balance will be carried over to the next week’s R&S Report.
PAYMENT AMOUNT
$18,253.92
3
96
.57
8
7
8
,
9
3
$
4.65
2
6
,
1
2
$
92
$18,253.
Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
Medicaid Basics 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
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— A STATE MEDICAID CONTRACTOR
Page 1 of 2
ERSAG05/2007 v1.1
Medicaid Basics 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 to TMHP:
• Electronic
• AIS
• Paper
TMHP must receive all appeals of denied claims and requests for adjustments on reimbursed
claims within 120 days of the date of disposition of the R&S Report on which that claim
appears. 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 for which the claim was
denied and either correct the claim data or submit additional documentation that supports 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.
1. A first-level appeal is a provider’s initial standard 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 of the required information to be
considered. For detailed instructions, refer to the current TMPPM Section 7: Appeals and
in the CSHCN Services Program Provider Manual.
2. A second-level appeal is a provider’s final medical or standard administrative appeal to
HHSC of a claim that meets all of the following requirements:
–– The claim has been denied or adjusted by TMHP.
–– The claim has been appealed as a first-level appeal to TMHP.
–– The claim has been denied again by TMHP for the same reasons.
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.
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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
CSHCN Services Program requests for administrative review must be submitted to Texas
Department of State Health Services (DSHS) at the following address:
CSHCN Services Program
Administrative Review
Purchased Health Services Unit, MC-1938
Texas Department of State Health Services
PO Box 149347
Austin, TX 78714-9347
Electronic Appeals
Claims with a finalized status can be appealed online using TexMedConnect on the TMHP
website at www.tmhp.com. To appeal a claim, follow these steps:
1. Go to www.tmhp.com, and click providers in the header.
2. Click Go to TexMedConnect in the upper right corner.
3. Enter your User name and Password.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.99
Medicaid Basics Participant Guide
4. Click Appeals in the left-side navigation pane of the TexMedConnect screen.
5. Enter the claim number you want to appeal, and click Lookup.
6. Click Appeal Claim to continue the appeal process.
Note: If the
appeal is
successfully
submitted, an
ICN number will
be generated. If
there are errors
on the appeal,
error messages
will appear. If
necessary, correct
the error and
re-submit the
appeal.
100
7. Most of the fields will automatically populate with the claim information.
8. Select the appeal type: Adjustment or Void.
9. Verify that all of the required fields have been completed.
10. Make all of the changes that are appropriate for the appeal you want to submit.
11. Read the certification, terms, and conditions and click to check the “We Agree” box.
12. You have the option of submitting the appeal, saving the appeal as a draft, or saving the
appeal to batch.
13. Click Submit Claim.
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
Medicaid Basics Participant Guide
Automated Inquiry System (AIS) Appeals
The following appeals may be submitted using AIS:
• Client Eligibility: The client’s correct Medicaid ID number (PCN), name, and date of
birth are required.
• Provider Information (Excluding Medicare Crossovers): The correct provider NPI
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:
–– Medicaid ID (PCN)
–– Date of birth (DOB)
–– Date of onset
–– X-ray date
–– POS
–– Quantity billed
–– 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 (e.g., 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 Explanation of Pending Status (EOPS)
messages
• Claims denied as past the 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 current TMPPM Section 7: Appeals to determine
whether these appeals can be billed electronically. If these appeals cannot be billed electronically, a
paper claim must be submitted.
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Medicaid Basics Participant Guide
AIS Appeals Guide
To access the AIS automated appeals guide, providers can call 1-800-925-9126
(1-800-568-2413 for the CSHCN Services Program). Providers may submit up to three fields
per claim and 15 appeals per call. If during any step invalid information is entered three times,
the call transfers to the TMHP Contact Center for assistance.
Paper Claim Appeals
After determining that a claim cannot be appealed electronically or using AIS, the claim may
be appealed on paper with the following steps:
1. Provide a copy of the R&S Report page where the claim is reported.
2. On the copy, circle the claim being appealed. Circle one claim per R&S Report page.
3. Identify the information that was incorrectly provided and note the correct information
that should be used to appeal the claim on the bottom of the R&S Report. Specify the
reason for appealing the claim on the bottom of the R&S report.
4. Attach radiographs or other necessary supporting documentation.
5. Optional: Attach a copy of the original claim. Claim copies are helpful when appealing and
required for Medicare Crossover appeals.
6. Do not copy supporting documentation on the opposite side of the R&S Report.
Submitted pages should be one-sided.
Note: It is strongly recommended that providers submitting paper appeals retain a copy of the
documentation being sent. It is also recommended that paper documentation be sent by certified
mail with a return receipt requested to establish TMHP’s receipt of the claim and the date the claim
was received. The provider is urged to retain copies of multiple claim submissions if the Medicaid
provider identifier is pending.
Medicare crossovers and inpatient hospital appeals related to medical necessity denials or DRG
assignment or adjustment must be submitted on paper with the appropriate documentation.
102
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
Medicaid Basics Participant Guide
Submit correspondence, adjustments, and appeals (including routine inpatient hospital claims)
to the following address:
Texas Medicaid & Healthcare Partnership
Appeals/Adjustments
PO Box 200645
Austin, TX 78720-0645
Exception: Hospitals appealing HHSC OIG UR Unit final technical denials, admission denials,
DRG revisions, continued-stay denials for Tax Equity and Fiscal Responsibility Act (of 1982)
(TEFRA) hospitals, or cost/day outliers must appeal to HHSC at the following address:
Texas Health and Human Services Commission
Medical and UR Appeals, H-230
PO Box 85200
Austin, TX 78708-5200
Paper appeals may be submitted for TPI-only claims submitted before the end of the NPI
Implementation contingency period, but only for claims with at least one detail that indicates
a paid status. TPI-only claims on which all details have been denied cannot be appealed with
a TPI only. Paper appeals for claims on which all details have been denied must be submitted
with both a TPI and NPI for billing and performing providers.
HHSC Administrative Appeals
An administrative appeal is a request for a review of (not a hearing on) claims denied by
TMHP or a claims processing entity for technical and non-medical reasons. There are two
types of administrative appeals:
• Exception requests to the 95-day claim filing deadline: A provider’s formal written
request for a 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 “Exceptions to the 95-Day Filing
Deadline” in the current TMPPM Section 7: Appeals.
• Standard Administrative Appeal: A provider’s formal written request for a review of (not
a hearing on) a claim or prior authorization that was denied by TMHP for technical or
non-medical reasons. An administrative claims appeal is a request for a review as defined in
Title 1 TAC §354.2201(2).
An administrative appeal must be:
• Submitted in writing to HHSC Claims Administrator Contract Management by the
provider delivering the service or claiming reimbursement for the service.
• Received by HHSC Claims Administrator Contract Management after the appeals process
with TMHP or the claims processing entity has been exhausted, and it must contain
evidence of appeal dispositions from TMHP or the claims processing entity such as:
–– All correspondence and documentation from the provider to TMHP or the claims
processing entity, including copies of supporting documentation submitted during the
appeal process.
–– All correspondence from TMHP or the claims processing entity to the provider
including TMHP’s final decision letter or such from the claims processing entity.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.103
Medicaid Basics Participant Guide
• Complete and contain all of the information necessary for consideration and
determination by HHSC Claims Administrator Contract Management, including:
–– A written explanation specifying the reason/request for appealing the claim.
–– Supporting documentation for the request.
–– All R&S Reports identifying the claims/services in question.
–– Identification of the incorrect information and the corrected information that is to be
used to appeal the claim.
–– A copy of the original claim, if available. Claim copies are helpful when the appeal
involves medical policy or procedure coding issues. Also provide a corrected signed
claim.
–– A copy of supporting medical documentation that is necessary or requested by TMHP.
–– Provider’s internal notes and logs or ticket numbers from the TMHP Contact Center
when pertinent (cannot be used as proof of timely filing).
–– Memos from the state, TMHP, or claims processing entity indicating any problems,
policy changes, or claims processing discrepancies that may be relevant to the appeal.
–– Other documents, such as receipts (i.e., certified mail along with a detailed listing
of the claims enclosed), in-service notes, minutes from meetings, if relevant to the
appeals. Receipts can be helpful when the issue is late filing.
• Received by HHSC Claims Administrator Contract Management within 120 days of the
date of disposition by TMHP or the claims processing entity as evidenced by the weekly
R&S Report.
Providers that have submitted their claims electronically must identify the batch submission ID
with the date on the electronic claims report. This report must indicate the TMHP-assigned
batch ID. The report must include the individual claim that is being appealed. This required
information constitutes proof of timely filing.
Note: Only reports accepted/rejected from TMHP or the claims processing entity to the vendor will
be honored unless the provider is a direct submitter (TexMedConnect). Office notes indicating claims
were submitted on time or personal screen prints of claim submissions are not considered proof of
timely filing.
HHSC Claims Administrator Contract Management only reviews appeals that are received
within 18 months of the DOS. All claims must be reimbursed within 24 months of the DOS
as outlined in 1 TAC §354.1003.
Providers must adhere to all claim and appeal submission deadlines for an appeal to be
reviewed by HHSC Claims Administrator Contract Management. The claim and appeal
submission deadlines are described in 1 TAC §354.1003.
Additional information requested by HHSC Claims Administrator Contract Management
must be returned to HHSC Claims Administrator Contract Management within 21 calendar
days of the date of the letter from HHSC Claims Administrator Contract Management. If the
information is not received within 21 calendar days, the case is closed.
A determination made by HHSC Claims Administrator Contract Management is the final
decision for claim appeals. No additional consideration is available. Therefore, ensure that all
documents pertinent to the appeal are submitted. New evidence is required for an additional
appeal to HHSC Claims Administrator Contract Management.
104
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
Medicaid Basics Participant Guide
Providers must mail appeal requests 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 are defined as disputes about the medical necessity of services.
Providers must appeal to TMHP and exhaust the appeal/grievance process before submitting
an appeal to HHSC.
Medical necessity appeals related to utilization review (UR) decisions made by HHSC’s Office
of Inspector General (OIG) UR Department must be appealed to HHSC, not to TMHP.
When submitting appeals to HHSC, providers must submit copies of all supporting
documentation, including information sent to TMHP.
Complaints by Providers
A complaint is defined as any dissatisfaction expressed in writing by the provider, or on
behalf of that provider, concerning Texas Medicaid. The term complaint does not include the
following:
• A misunderstanding or a problem of misinformation that is resolved promptly by clearing
up the misunderstanding or supplying the appropriate information to the provider’s
satisfaction.
• A provider’s oral or written dissatisfaction with an adverse determination.
Complaints to HHSC for Fee-for-Service (FFS)
Texas Medicaid FFS providers may submit 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. Texas Medicaid FFS providers must exhaust the appeals/grievance
process with TMHP before submitting a complaint with HHSC Claims Administrator
Contract Management.
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 submitting 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.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.105
Medicaid Basics Participant Guide
• 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,
in-service notes, minutes from meetings, etc., if relevant to the complaint. Receipts can be
helpful when the issue is late filing.
Complaints about FFS may be mailed to HHSC at:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code 91X
PO Box 204077
Austin, TX 78720-4077
Medicaid Managed Care Complaints and Fair Hearings
Medicaid managed care providers may submit complaints to HHSC if they find they did not
receive full due process from the respective managed care health plan.
Providers can send complaints to [email protected]
Appeals, grievances, or dispute resolution is the responsibility of each managed care HMO.
Providers must exhaust the complaints or grievance process with their managed care HMO
before filing a complaint with HHSC.
For HMO appeals and fair hearing process, refer to the respective health plan’s policies and
procedures.
Once the MCO’s or dental plan’s complaints or grievance process has been exhausted,
complaint requests may be sent to HHSC. STAR, STAR+PLUS, STAR Health, and dental
plan complaint requests may be emailed or mailed to HHSC: STAR, STAR+PLUS, and
dental plan complaints may be emailed to [email protected] STAR Health
complaints may be emailed to [email protected] STAR, STAR+PLUS, STAR
Health, and dental plan complaints may be mailed to HHSC at the following address:
Health and Human Services Commission
Health Plan Management
4900 N. Lamar Blvd.
MC H320
Austin, TX 78751
106
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
Medicaid Basics Participant Guide
Claim Submission Deadlines
Texas Medicaid and the CSHCN Services Program share many of the same claim submission
deadlines. The table below shows the most common deadlines.
Medicaid
CSHCN Services
Program
New Claims: All claims, except where noted in the provider
manuals, must be received within 95 days of the date of service.
ü
ü
Other Insurance: Claims involving OI, including Medicare, must
be received within 95 days of the date of disposition. When
a service is submitted 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.
ü
ü
Appeals: Appeals must be received within 120 days of the date
of the R&S Report on which the denial appears.
ü
ü
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:
• 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.
• 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.
• 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, or computer- or modem-generated error reports.
• Submission of claims within the 365-day federal filing deadline when services are
authorized retroactively.
• 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 claim submission deadlines and exceptions, refer to the current TMPPM
Section 6: Claims Filing and the CSHCN Services Program Provider Manual.
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.107
Medicaid Basics Participant Guide
Filing Deadline Calendar for 2015
Note: If the 95th or 120th day falls on a weekend or a holiday, the filing deadline is extended to the next business day.
Date of Service
or Disposition
01/01
01/02
01/03
01/04
01/05
01/06
01/07
01/08
01/09
01/10
01/11
01/12
01/13
01/14
01/15
01/16
01/17
01/18
01/19
01/20
01/21
01/22
01/23
01/24
01/25
01/26
01/27
01/28
01/29
01/30
01/31
02/01
02/02
02/03
02/04
02/05
02/06
02/07
02/08
02/09
02/10
02/11
02/12
02/13
02/14
02/15
02/16
02/17
02/18
02/19
02/20
02/21
02/22
02/23
02/24
02/25
02/26
02/27
02/28
03/01
108
(001)
(002)
(003)
(004)
(005)
(006)
(007)
(008)
(009)
(010)
(011)
(012)
(013)
(014)
(015)
(016)
(017)
(018)
(019)
(020)
(021)
(022)
(023)
(024)
(025)
(026)
(027)
(028)
(029)
(030)
(031)
(032)
(033)
(034)
(035)
(036)
(037)
(038)
(039)
(040)
(041)
(042)
(043)
(044)
(045)
(046)
(047)
(048)
(049)
(050)
(051)
(052)
(053)
(054)
(055)
(056)
(057)
(058)
(059)
(060)
95 Days
04/06
04/07
04/08
04/09
04/10
04/13
04/13
04/13
04/14
04/15
04/16
04/17
04/20
04/20
04/20
04/21
04/22
04/23
04/24
04/27
04/27
04/27
04/28
04/29
04/30
05/01
05/04
05/04
05/04
05/05
05/06
05/07
05/08
05/11
05/11
05/11
05/12
05/13
05/14
05/15
05/18
05/18
05/18
05/19
05/20
05/21
05/22
05/26
05/26
05/26
05/26
05/27
05/28
05/29
06/01
06/01
06/01
06/02
06/03
06/04
(096)
(097)
(098)
(099)
(100)
(103)
(103)
(103)
(104)
(105)
(106)
(107)
(110)
(110)
(110)
(111)
(112)
(113)
(114)
(117)
(117)
(117)
(118)
(119)
(120)
(121)
(124)
(124)
(124)
(125)
(126)
(127)
(128)
(131)
(131)
(131)
(132)
(133)
(134)
(135)
(138)
(138)
(138)
(139)
(140)
(141)
(142)
(146)
(146)
(146)
(146)
(147)
(148)
(149)
(152)
(152)
(152)
(153)
(154)
(155)
120 Days
05/01
05/04
05/04
05/04
05/05
05/06
05/07
05/08
05/11
05/11
05/11
05/12
05/13
05/14
05/15
05/18
05/18
05/18
05/19
05/20
05/21
05/22
05/26
05/26
05/26
05/26
05/27
05/28
05/29
06/01
06/01
06/01
06/02
06/03
06/04
06/05
06/08
06/08
06/08
06/09
06/10
06/11
06/12
06/15
06/15
06/15
06/16
06/17
06/18
06/19
06/22
06/22
06/22
06/23
06/24
06/25
06/26
06/29
06/29
06/29
(121)
(124)
(124)
(124)
(125)
(126)
(127)
(128)
(131)
(131)
(131)
(132)
(133)
(134)
(135)
(138)
(138)
(138)
(139)
(140)
(141)
(142)
(146)
(146)
(146)
(146)
(147)
(148)
(149)
(152)
(152)
(152)
(153)
(154)
(155)
(156)
(159)
(159)
(159)
(160)
(161)
(162)
(163)
(166)
(166)
(166)
(167)
(168)
(169)
(170)
(173)
(173)
(173)
(174)
(175)
(176)
(177)
(180)
(180)
(180)
Date of Service
or Disposition
03/02
03/03
03/04
03/05
03/06
03/07
03/08
03/09
03/10
03/11
03/12
03/13
03/14
03/15
03/16
03/17
03/18
03/19
03/20
03/21
03/22
03/23
03/24
03/25
03/26
03/27
03/28
03/29
03/30
03/31
04/01
04/02
04/03
04/04
04/05
04/06
04/07
04/08
04/09
04/10
04/11
04/12
04/13
04/14
04/15
04/16
04/17
04/18
04/19
04/20
04/21
04/22
04/23
04/24
04/25
04/26
04/27
04/28
04/29
04/30
(061)
(062)
(063)
(064)
(065)
(066)
(067)
(068)
(069)
(070)
(071)
(072)
(073)
(074)
(075)
(076)
(077)
(078)
(079)
(080)
(081)
(082)
(083)
(084)
(085)
(086)
(087)
(088)
(089)
(090)
(091)
(092)
(093)
(094)
(095)
(096)
(097)
(098)
(099)
(100)
(101)
(102)
(103)
(104)
(105)
(106)
(107)
(108)
(109)
(110)
(111)
(112)
(113)
(114)
(115)
(116)
(117)
(118)
(119)
(120)
95 Days
06/05
06/08
06/08
06/08
06/09
06/10
06/11
06/12
06/15
06/15
06/15
06/16
06/17
06/18
06/19
06/22
06/22
06/22
06/23
06/24
06/25
06/26
06/29
06/29
06/29
06/30
07/01
07/02
07/03
07/06
07/06
07/06
07/07
07/08
07/09
07/10
07/13
07/13
07/13
07/14
07/15
07/16
07/17
07/20
07/20
07/20
07/21
07/22
07/23
07/24
07/27
07/27
07/27
07/28
07/29
07/30
07/31
08/03
08/03
08/03
(156)
(159)
(159)
(159)
(160)
(161)
(162)
(163)
(166)
(166)
(166)
(167)
(168)
(169)
(170)
(173)
(173)
(173)
(174)
(175)
(176)
(177)
(180)
(180)
(180)
(181)
(182)
(183)
(184)
(187)
(187)
(187)
(188)
(189)
(190)
(191)
(194)
(194)
(194)
(195)
(196)
(197)
(198)
(201)
(201)
(201)
(202)
(203)
(204)
(205)
(208)
(208)
(208)
(209)
(210)
(211)
(212)
(215)
(215)
(215)
120 Days
06/30
07/01
07/02
07/03
07/06
07/06
07/06
07/07
07/08
07/09
07/10
07/13
07/13
07/13
07/14
07/15
07/16
07/17
07/20
07/20
07/20
07/21
07/22
07/23
07/24
07/27
07/27
07/27
07/28
07/29
07/30
07/31
08/03
08/03
08/03
08/04
08/05
08/06
08/07
08/10
08/10
08/10
08/11
08/12
08/13
08/14
08/17
08/17
08/17
08/18
08/19
08/20
08/21
08/24
08/24
08/24
08/25
08/26
08/27
08/28
(181)
(182)
(183)
(184)
(187)
(187)
(187)
(188)
(189)
(190)
(191)
(194)
(194)
(194)
(195)
(196)
(197)
(198)
(201)
(201)
(201)
(202)
(203)
(204)
(205)
(208)
(208)
(208)
(209)
(210)
(211)
(212)
(215)
(215)
(215)
(216)
(217)
(218)
(219)
(222)
(222)
(222)
(223)
(224)
(225)
(226)
(229)
(229)
(229)
(230)
(231)
(232)
(233)
(236)
(236)
(236)
(237)
(238)
(239)
(240)
Date of Service
or Disposition
05/01
05/02
05/03
05/04
05/05
05/06
05/07
05/08
05/09
05/10
05/11
05/12
05/13
05/14
05/15
05/16
05/17
05/18
05/19
05/20
05/21
05/22
05/23
05/24
05/25
05/26
05/27
05/28
05/29
05/30
05/31
06/01
06/02
06/03
06/04
06/05
06/06
06/07
06/08
06/09
06/10
06/11
06/12
06/13
06/14
06/15
06/16
06/17
06/18
06/19
06/20
06/21
06/22
06/23
06/24
06/25
06/26
06/27
06/28
(121)
(122)
(123)
(124)
(125)
(126)
(127)
(128)
(129)
(130)
(131)
(132)
(133)
(134)
(135)
(136)
(137)
(138)
(139)
(140)
(141)
(142)
(143)
(144)
(145)
(146)
(147)
(148)
(149)
(150)
(151)
(152)
(153)
(154)
(155)
(156)
(157)
(158)
(159)
(160)
(161)
(162)
(163)
(164)
(165)
(166)
(167)
(168)
(169)
(170)
(171)
(172)
(173)
(174)
(175)
(176)
(177)
(178)
(179)
95 Days
08/04
08/05
08/06
08/07
08/10
08/10
08/10
08/11
08/12
08/13
08/14
08/17
08/17
08/17
08/18
08/19
08/20
08/21
08/24
08/24
08/24
08/25
08/26
08/27
08/28
08/31
08/31
08/31
09/01
09/02
09/03
09/04
09/08
09/08
09/08
09/08
09/09
09/10
09/11
09/14
09/14
09/14
09/15
09/16
09/17
09/18
09/21
09/21
09/21
09/22
09/23
09/24
09/25
09/28
09/28
09/28
09/29
09/30
10/01
(216)
(217)
(218)
(219)
(222)
(222)
(222)
(223)
(224)
(225)
(226)
(229)
(229)
(229)
(230)
(231)
(232)
(233)
(236)
(236)
(236)
(237)
(238)
(239)
(240)
(243)
(243)
(243)
(244)
(245)
(246)
(247)
(251)
(251)
(251)
(251)
(252)
(253)
(254)
(257)
(257)
(257)
(258)
(259)
(260)
(261)
(264)
(264)
(264)
(265)
(266)
(267)
(268)
(271)
(271)
(271)
(272)
(273)
(274)
120 Days
08/31
08/31
08/31
09/01
09/02
09/03
09/04
09/08
09/08
09/08
09/08
09/09
09/10
09/11
09/14
09/14
09/14
09/15
09/16
09/17
09/18
09/21
09/21
09/21
09/22
09/23
09/24
09/25
09/28
09/28
09/28
09/29
09/30
10/01
10/02
10/05
10/05
10/05
10/06
10/07
10/08
10/09
10/13
10/13
10/13
10/13
10/14
10/15
10/16
10/19
10/19
10/19
10/20
10/21
10/22
10/23
10/26
10/26
10/26
(243)
(243)
(243)
(244)
(245)
(246)
(247)
(251)
(251)
(251)
(251)
(252)
(253)
(254)
(257)
(257)
(257)
(258)
(259)
(260)
(261)
(264)
(264)
(264)
(265)
(266)
(267)
(268)
(271)
(271)
(271)
(272)
(273)
(274)
(275)
(278)
(278)
(278)
(279)
(280)
(281)
(282)
(286)
(286)
(286)
(286)
(287)
(288)
(289)
(292)
(292)
(292)
(293)
(294)
(295)
(296)
(299)
(299)
(299)
Continued on page 2
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
Medicaid Basics Participant Guide
Date of Service
or Disposition
95 Days
120 Days
Continued from page 1
06/29
06/30
07/01
07/02
07/03
07/04
07/05
07/06
07/07
07/08
07/09
07/10
07/11
07/12
07/13
07/14
07/15
07/16
07/17
07/18
07/19
07/20
07/21
07/22
07/23
07/24
07/25
07/26
07/27
07/28
07/29
07/30
07/31
08/01
08/02
08/03
08/04
08/05
08/06
08/07
08/08
08/09
08/10
08/11
08/12
08/13
08/14
08/15
08/16
08/17
08/18
08/19
08/20
08/21
08/22
08/23
08/24
08/25
08/26
08/27
08/28
(180)
(181)
(182)
(183)
(184)
(185)
(186)
(187)
(188)
(189)
(190)
(191)
(192)
(193)
(194)
(195)
(196)
(197)
(198)
(199)
(200)
(201)
(202)
(203)
(204)
(205)
(206)
(207)
(208)
(209)
(210)
(211)
(212)
(213)
(214)
(215)
(216)
(217)
(218)
(219)
(220)
(221)
(222)
(223)
(224)
(225)
(226)
(227)
(228)
(229)
(230)
(231)
(232)
(233)
(234)
(235)
(236)
(237)
(238)
(239)
(240)
10/02
10/05
10/05
10/05
10/06
10/07
10/08
10/09
10/13
10/13
10/13
10/13
10/14
10/15
10/16
10/19
10/19
10/19
10/20
10/21
10/22
10/23
10/26
10/26
10/26
10/27
10/28
10/29
10/30
11/02
11/02
11/02
11/03
11/04
11/05
11/06
11/09
11/09
11/09
11/10
11/12
11/12
11/13
11/16
11/16
11/16
11/17
11/18
11/19
11/20
11/23
11/23
11/23
11/24
11/25
11/30
11/30
11/30
11/30
11/30
12/01
(275)
(278)
(278)
(278)
(279)
(280)
(281)
(282)
(286)
(286)
(286)
(286)
(287)
(288)
(289)
(292)
(292)
(292)
(293)
(294)
(295)
(296)
(299)
(299)
(299)
(300)
(301)
(302)
(303)
(306)
(306)
(306)
(307)
(308)
(309)
(310)
(313)
(313)
(313)
(314)
(316)
(316)
(317)
(320)
(320)
(320)
(321)
(322)
(323)
(324)
(327)
(327)
(327)
(328)
(329)
(334)
(334)
(334)
(334)
(334)
(335)
10/27
10/28
10/29
10/30
11/02
11/02
11/02
11/03
11/04
11/05
11/06
11/09
11/09
11/09
11/10
11/12
11/12
11/13
11/16
11/16
11/16
11/17
11/18
11/19
11/20
11/23
11/23
11/23
11/24
11/25
11/30
11/30
11/30
11/30
11/30
12/01
12/02
12/03
12/04
12/07
12/07
12/07
12/08
12/09
12/10
12/11
12/14
12/14
12/14
12/15
12/16
12/17
12/18
12/21
12/21
12/21
12/22
12/23
12/28
12/28
12/28
(300)
(301)
(302)
(303)
(306)
(306)
(306)
(307)
(308)
(309)
(310)
(313)
(313)
(313)
(314)
(316)
(316)
(317)
(320)
(320)
(320)
(321)
(322)
(323)
(324)
(327)
(327)
(327)
(328)
(329)
(334)
(334)
(334)
(334)
(334)
(335)
(336)
(337)
(338)
(341)
(341)
(341)
(342)
(343)
(344)
(345)
(348)
(348)
(348)
(349)
(350)
(351)
(352)
(355)
(355)
(355)
(356)
(357)
(362)
(362)
(362)
Date of Service
or Disposition
08/29
08/30
08/31
09/01
09/02
09/03
09/04
09/05
09/06
09/07
09/08
09/09
09/10
09/11
09/12
09/13
09/14
09/15
09/16
09/17
09/18
09/19
09/20
09/21
09/22
09/23
09/24
09/25
09/26
09/27
09/28
09/29
09/30
10/01
10/02
10/03
10/04
10/05
10/06
10/07
10/08
10/09
10/10
10/11
10/12
10/13
10/14
10/15
10/16
10/17
10/18
10/19
10/20
10/21
10/22
10/23
10/24
10/25
10/26
10/27
10/28
10/29
10/30
(241)
(242)
(243)
(244)
(245)
(246)
(247)
(248)
(249)
(250)
(251)
(252)
(253)
(254)
(255)
(256)
(257)
(258)
(259)
(260)
(261)
(262)
(263)
(264)
(265)
(266)
(267)
(268)
(269)
(270)
(271)
(272)
(273)
(274)
(275)
(276)
(277)
(278)
(279)
(280)
(281)
(282)
(283)
(284)
(285)
(286)
(287)
(288)
(289)
(290)
(291)
(292)
(293)
(294)
(295)
(296)
(297)
(298)
(299)
(300)
(301)
(302)
(303)
95 Days
12/02
12/03
12/04
12/07
12/07
12/07
12/08
12/09
12/10
12/11
12/14
12/14
12/14
12/15
12/16
12/17
12/18
12/21
12/21
12/21
12/22
12/23
12/28
12/28
12/28
12/28
12/28
12/29
12/30
12/31
01/04
01/04
01/04
01/04
01/05
01/06
01/07
01/08
01/11
01/11
01/11
01/12
01/13
01/14
01/15
01/19
01/19
01/19
01/19
01/20
01/21
01/22
01/25
01/25
01/25
01/26
01/27
01/28
01/29
02/01
02/01
02/01
02/02
(336)
(337)
(338)
(341)
(341)
(341)
(342)
(343)
(344)
(345)
(348)
(348)
(348)
(349)
(350)
(351)
(352)
(355)
(355)
(355)
(356)
(357)
(362)
(362)
(362)
(362)
(362)
(363)
(364)
(365)
(004)
(004)
(004)
(004)
(005)
(006)
(007)
(008)
(011)
(011)
(011)
(012)
(013)
(014)
(015)
(019)
(019)
(019)
(019)
(020)
(021)
(022)
(025)
(025)
(025)
(026)
(027)
(028)
(029)
(032)
(032)
(032)
(033)
120 Days
12/28
12/28
12/29
12/30
12/31
01/04
01/04
01/04
01/04
01/05
01/06
01/07
01/08
01/11
01/11
01/11
01/12
01/13
01/14
01/15
01/19
01/19
01/19
01/19
01/20
01/21
01/22
01/25
01/25
01/25
01/26
01/27
01/28
01/29
02/01
02/01
02/01
02/02
02/03
02/04
02/05
02/08
02/08
02/08
02/09
02/10
02/11
02/12
02/16
02/16
02/16
02/16
02/17
02/18
02/19
02/22
02/22
02/22
02/23
02/24
02/25
02/26
02/29
(362)
(362)
(363)
(364)
(365)
(004)
(004)
(004)
(004)
(005)
(006)
(007)
(008)
(011)
(011)
(011)
(012)
(013)
(014)
(015)
(019)
(019)
(019)
(019)
(020)
(021)
(022)
(025)
(025)
(025)
(026)
(027)
(028)
(029)
(032)
(032)
(032)
(033)
(034)
(035)
(036)
(039)
(039)
(039)
(040)
(041)
(042)
(043)
(047)
(047)
(047)
(047)
(048)
(049)
(050)
(053)
(053)
(053)
(054)
(055)
(056)
(057)
(060)
Date of Service
or Disposition
10/31
11/01
11/02
11/03
11/04
11/05
11/06
11/07
11/08
11/09
11/10
11/11
11/12
11/13
11/14
11/15
11/16
11/17
11/18
11/19
11/20
11/21
11/22
11/23
11/24
11/25
11/26
11/27
11/28
11/29
11/30
12/01
12/02
12/03
12/04
12/05
12/06
12/07
12/08
12/09
12/10
12/11
12/12
12/13
12/14
12/15
12/16
12/17
12/18
12/19
12/20
12/21
12/22
12/23
12/24
12/25
12/26
12/27
12/28
12/29
12/30
12/31
01/01
(304)
(305)
(306)
(307)
(308)
(309)
(310)
(311)
(312)
(313)
(314)
(315)
(316)
(317)
(318)
(319)
(320)
(321)
(322)
(323)
(324)
(325)
(326)
(327)
(328)
(329)
(330)
(331)
(332)
(333)
(334)
(335)
(336)
(337)
(338)
(339)
(340)
(341)
(342)
(343)
(344)
(345)
(346)
(347)
(348)
(349)
(350)
(351)
(352)
(353)
(354)
(355)
(356)
(357)
(358)
(359)
(360)
(361)
(362)
(363)
(364)
(365)
(001)
95 Days
02/03
02/04
02/05
02/08
02/08
02/08
02/09
02/10
02/11
02/12
02/16
02/16
02/16
02/16
02/17
02/18
02/19
02/22
02/22
02/22
02/23
02/24
02/25
02/26
02/29
02/29
02/29
03/01
03/02
03/03
03/04
03/07
03/07
03/07
03/08
03/09
03/10
03/11
03/14
03/14
03/14
03/15
03/16
03/17
03/18
03/21
03/21
03/21
03/22
03/23
03/24
03/25
03/28
03/28
03/28
03/29
03/30
03/31
04/01
04/04
04/04
04/04
04/05
(034)
(035)
(036)
(039)
(039)
(039)
(040)
(041)
(042)
(043)
(047)
(047)
(047)
(047)
(048)
(049)
(050)
(053)
(053)
(053)
(054)
(055)
(056)
(057)
(060)
(060)
(060)
(061)
(062)
(063)
(064)
(067)
(067)
(067)
(068)
(069)
(070)
(071)
(074)
(074)
(074)
(075)
(076)
(077)
(078)
(081)
(081)
(081)
(082)
(083)
(084)
(085)
(088)
(088)
(088)
(089)
(090)
(091)
(092)
(095)
(095)
(095)
(096)
120 Days
02/29
02/29
03/01
03/02
03/03
03/04
03/07
03/07
03/07
03/08
03/09
03/10
03/11
03/14
03/14
03/14
03/15
03/16
03/17
03/18
03/21
03/21
03/21
03/22
03/23
03/24
03/25
03/28
03/28
03/28
03/29
03/30
03/31
04/01
04/04
04/04
04/04
04/05
04/06
04/07
04/08
04/11
04/11
04/11
04/12
04/13
04/14
04/15
04/18
04/18
04/18
04/19
04/20
04/21
04/22
04/25
04/25
04/25
04/26
04/27
04/28
04/29
05/02
(060)
(060)
(061)
(062)
(063)
(064)
(067)
(067)
(067)
(068)
(069)
(070)
(071)
(074)
(074)
(074)
(075)
(076)
(077)
(078)
(081)
(081)
(081)
(082)
(083)
(084)
(085)
(088)
(088)
(088)
(089)
(090)
(091)
(092)
(095)
(095)
(095)
(096)
(097)
(098)
(099)
(102)
(102)
(102)
(103)
(104)
(105)
(106)
(109)
(109)
(109)
(110)
(111)
(112)
(113)
(116)
(116)
(116)
(117)
(118)
(119)
(120)
(123)
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.109
Medicaid Basics Participant Guide
Preparation for ICD-10
Implementation
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10CM) and ICD-10-PCS (inpatient procedure code) code sets will replace ICD-9-CM codes
that are used to report medical diagnoses and inpatient procedures through Health Insurance
Portability and Accountability Act (HIPAA) standard transactions.
ICD-10 code set implementation will affect diagnosis and inpatient procedure coding for all
entities that use standard transactions that are identified in HIPAA. Health-care providers,
payers, clearinghouses, and billing services must be prepared to comply with the ICD-10 code
set implementation.
Early preparation for the ICD-10 code set implementation will help alleviate future operational
and budgetary issues. Providers should consider the following actions when preparing for ICD-10
code set implementation:
•
•
•
•
•
Testing claims 6 to 10 months before ICD-10 code set implementation
Assessing revenue risk and developing a strategy to handle delayed reimbursement
Training and educating billing staff on the new coding
Developing a transition plan that includes tactics, timing, resource, and budget allocations
Considering full remediation or General Equivalency Mapping (GEM) instead of a
crosswalk ICD-10 code set
• Evaluating super bills for ICD-10 code set updates
• Meeting with billing system vendors to confirm software changes for the documentation and
claims processing specifications that will be required to submit claims with ICD-10 code sets
• Conducting test transactions using ICD-10 code sets with vendors and payers
• Considering changes in the documentation requirements for ICD-10 code sets for the
most common client conditions
• Changing reports that contain ICD-9-CM codes to ICD-10 code sets
• Monitoring any Texas Medicaid policy and billing changes that will be required by ICD-10
code sets
• Evaluating and reconfiguring current benefit plan structures to identify changes to
coinsurance, copayments, deductibles, and other plan elements that are more specific to
the precise ICD-10 code sets
Providers should also monitor the ICD-10 Implementation page on the TMHP website www.
tmhp.com/Pages/CodeUpdates/ICD-10.aspx for updated information as it becomes available.
Additional information is available on the CMS website at:
www.cms.gov/Medicare/Coding/ICD10.
110
CPT only copyright 2014 American Medical Association. All rights reserved.
— 2015 0311
Medicaid Basics Participant Guide
Hospital Initiatives Overview
On September 1, 2012, Texas Medicaid stopped using Medicare Severity Diagnosis Related
Groups (MS-DRG) and implemented the All Patient Refined Diagnosis Related Groups (APRDRG) to calculate Prospective Payment System (PPS) inpatient hospital claims.
APR-DRGs
APR-DRGs were chosen because they are suitable for use with a Medicaid population,
especially for neonatal and pediatric care, and because they incorporate sophisticated clinical
logic to capture the differences in complications and comorbidities that can significantly affect
the use of hospital resources.
APR-DRG requires that Present on Admission (POA) indicators be submitted for each
diagnosis on claims that have dates of admission on or after September 1, 2012.
The use of APR-DRG is necessary to develop a methodology for analyzing Potentially
Preventable Events (PPE) and to provide provider-specific reports that define these events.
There are many reasons for transitioning to APR-DRGs:
1. APR-DRGs are better suited to the Medicaid population.
–– APR-DRGs were developed for an all-patient population by 3M and the National
Association of Children’s Hospitals and Related Institutions.
–– MS-DRGs are only intended for Medicare.
2. APR-DRGs have been extensively tested and analyzed.
–– They have been used for performance analysis by the state of Texas.
–– Over 2,000 hospitals and provider organizations have licenses for APR-DRG.
3. APR-DRGs have a DRG algorithm that is used extensively for risk-adjusting performance
measures such as mortality, readmissions, or complications.
APR-DRG Definitions
Severity of Illness (SOI)—The extent of physiologic decompensation or an organ system’s loss
of function.
Risk of Mortality (ROM)—The likelihood of dying.
Resource Intensity—The relative volume and types of diagnostic, therapeutic, and bed services
used in the management of a particular disease.
Severity of illness and risk of mortality are dependent on the patient’s underlying condition
(i.e., the base APR DRG).
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High severity of illness and risk of mortality are characterized by multiple serious diseases and
the interaction of those diseases.
Every secondary diagnosis (DX) and all procedures are evaluated to determine their impact on
a case. For example:
• TX Medicaid will accept 25 Diagnoses and 25 Procedures.
• 3 byte DRG + 1 byte SOI + 1 byte ROM.
• Effects are additive not absolute.
POA Indicator Requirement
POA indicators are necessary to accurately calculate APR-DRG payments.
Effective for dates of admission on or after September 1, 2012, POA indicators are required on
all Medicaid inpatient hospital claims.
Effective for dates of admission on or after September 1, 2012, POA indicators are required on
Medicare crossover hospital claims.
Section 2702 of the Patient Protection and Affordable Care Act of 2010 prohibits Medicaid
payments for any amounts expended for providing medical assistance for health-care-acquired
conditions. Claims that are submitted without the POA indicators will be denied.
Potentially Preventable Readmissions (PPR)
HHSC identifies PPRs in the Medicaid population and reports results confidentially to each
hospital. Each hospital must distribute the information to its care providers.
A PPR is a readmission that is clinically-related to the initial hospital admission and may have
resulted from a deficiency in the process of care and treatment or lack of post discharge followup care.
“Clinically related” is defined as a requirement that the underlying reason for readmission
be plausibly related to the care rendered during or immediately following a prior hospital
admission. A clinically related readmission may have resulted from the process of care and
treatment during the prior admission (e.g. readmission for a surgical wound infection) or
from a lack of post admission follow-up (lack of follow-up arrangements with a primary care
physician) rather than from unrelated events that occurred after the prior admission (broken
leg due to trauma) within a specified readmission time interval.
A readmission is considered to be clinically related to a prior admission and potentially
preventable if there was a reasonable expectation that it could have been prevented by one or
more of the following:
• The provision of quality care in the initial hospitalization
• Adequate discharge planning
• Adequate post-discharge follow up
• Improved coordination between inpatient and outpatient Health Care Teams
Effective September 1, 2012, HHSC implemented quality-based payments to hospitals on the
basis of the results of the PPR analysis.
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PPR Calculation Methodology
The methods used to calculate PPR are as follows:
1. Calculate the number of days between subsequent admission and prior admission.
2. Apply the readmission time interval (15 days).
3. Determine the preliminary classification of admission.
4. Determine whether the readmission is clinically related to initial admission.
5. Identify the readmission chains.
6. Reclassify the readmission and initial admission if they are not clinically related.
7. Assign the final PPR classification.
–– Initial PPR
–– Only admission
–– Transfer admission
–– PPR
Potentially Preventable Complications (PPC) Reporting
A “potentially preventable complication” is defined as a harmful event or negative outcome
with respect to a person, including an infection or surgical complication, that:
• Occurs after the person’s admission to a hospital or long-term care facility.
• May have resulted from the care, lack of care, or treatment provided during the hospital or
long-term care facility stay, rather than from a natural progression of an underlying disease.
PPC reporting became effective on November 1, 2012.
Resources
For more information about APR-DRG, POA, PPR, or PPC, please
visit the TMHP Hospital Initiatives page on the TMHP website at
www.tmhp.com/Pages/Medicaid/Hospital_Home.aspx or email [email protected]
To purchase the APR-DRG grouper application, contact 3M at 1-800-367-2447, or
visit them online at http://solutions.3m.com.
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Resources
Instructions for Using the TMHP Website
The TMHP website at www.tmhp.com is designed to streamline provider participation. Using
the website, providers can submit claims and appeals, download provider manuals and bulletins,
verify client eligibility, view R&S Reports, 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.
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 top bar of the
homepage, and click the
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.
Information on the TMHP Website
The provider manuals and guides are separated into their associated program and can be
located by clicking the appropriate program name in the yellow tool bar and then clicking
Reference Material in the menu.
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Provider Manuals and Guides:
• Texas Medicaid Provider Procedures Manual
• Children with Special Health Care Needs Services Program Provider Manual
• Texas Medicaid Quick Reference Guide
• CMS-1500 Online Claims Submission Manual
• Medicaid Automated Inquiry System (AIS) User Guide
• CSHCN Services Program Automated Inquiry System (AIS) User Guide
• TexMedConnect instructions for Acute Care and Long Term Care
Web Articles and Banner Messages:
• Banner messages
• Web articles that include important Medicaid policy and procedure updates
The provider forms are separated into their associated program and can be located by clicking
the appropriate program name in the yellow tool bar and then clicking Forms in the menu.
Provider Forms:
• Medicaid forms
• CSHCN Services Program forms
• Enrollment forms
Fee Schedules and Reference Codes:
• Fee schedules
• Acute care reference codes
• Long Term Care (LTC) Programs reference codes
Provider Education:
TMHP offers a variety of computer-based training (CBT) modules using its Learning
Management System (LMS) server in the Provider Education section of the TMHP website.
Providers with Internet access can access this online training at anytime, from anywhere, at
their own pace.
Additional CBT modules are in production and will be available when completed.
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Functions on the TMHP Website
On the TMHP website, you can:
• Enroll as a provider.
• Update a National Provider Identifier (NPI) or change the taxonomy code associated with
an NPI.
• Use TexMedConnect to submit 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.
• Search or extend an existing prior authorization.
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Online Fee Lookup (OFL)
Using the OFL
Providers can narrow search criteria for fees using the OFL.
You do not need to be logged into the Online Portal to use the new functionality; however, to
view your specific “Contracted” rate, you will need to log in.
1. Go to www.tmhp.com, and click providers in the header.
2. Click Fee Schedules.
3. Click Fee Search or Batch Search. From the Fee Schedule home page you can view the
static fee schedules or perform a fee or batch search.
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4. Using the OFL, you can 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) have two additional options. MCOs can upload out-ofnetwork (OON) files and no longer need to upload the files to TexMedConnect.
MCOs will continue to receive error reports if errors are found in the files. Response files will
be available within 36 hours.
To learn more about the OFL tool, refer to the OFL User Guide at www.tmhp.com/Homepage
File Library/OFL_User_Guide.pdf.
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Online Provider Lookup (OPL)
Using the OPL to Find a Provider
1. Go to www.tmhp.com, and click Looking for a provider? in the left side menu.
2. Enter your provider search criteria:
–– Health Plan
–– Last Name/Facility Name
–– MCO Plan Name
Note: Fields
marked with
a red asterisk
are required.
Click more
information for
instructions on
how to complete
the adjacent field.
–– Provider Type
–– ZIP Code
3. Click Search to obtain a list of providers who meet the search criteria.
Note: Click Clear
Form to remove
the information
from the screen
and start over. The
next screen displays
a list of providers
who meet the
search criteria.
Click View Map
to display a map
of the provider’s
location.
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4. Click the provider name to receive detailed information about that provider.
–– Click Back To Results to return to the provider list.
–– Click Print to display a printer-friendly page for printing.
–– Click View Map to display a map of the provider’s location.
–– Click more information for a description of the Primary Care Provider symbol
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Using the Advanced Search in OPL
Click Advanced Search on the menu bar.
The advanced search option allows providers to narrow their search using several additional
search options:
• Accepting new patients
• Provider specialty
• Provider subspecialty
• Extended hours
• Medicaid waiver program
• Other services offered
• Languages spoken
• Client age
• Client gender
• County served by the provider
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Notice that the criteria entered in the “Provider Type” drop-down menu changes the information displayed in the
“Provider Specialty” drop-down menu.
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Updating Address Information
1. Click on the link from the My Account page to change or verify their address information.
2. Click Edit to activate a section
for editing. Providers can:
–– Update address
information.
–– Update telephone 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 whether they offer
additional services.
–– Limit the gender or age of
clients served.
3. The “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 will appear with
the new information in the OPL
immediately.
The more complete a providers’
information is, the better chance
they have of appearing in the results
of a user’s 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: Texas Medicaid VDP providers should update their information through the Pharmacy Benefit Access
Helpdesk at 1-800-435-4165. Additional information about the Texas Medicaid VDP is available online at
www.txvendordrug.com/index.shtml.
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Provider Information Management System (PIMS)
Providers with certain provider types must verify and, if necessary, update key demographic
information every six months in the Provider Information Management System (PIMS) to
ensure that their information is correct in the OPL. Affected provider types include, but are not
limited to, physicians, nurses, dentists, and DME providers.
Affected providers that have not verified their demographic information within the last six
months will be unable to use any applications from their accounts on the TMHP secure portal,
including TexMedConnect Acute Care. These restrictions will be removed as soon as a provider
verifies and, if necessary, updates their key demographic information on PIMS including
incorrect address information.
While a restriction is in effect, users with administrative rights will no longer be able to bypass
the Review Required page of the OPL without addressing demographic updates for each NPI
listed on the page.
Nonadministrative users will not be able to perform work functions on NPIs that are listed
on the Review Required page. Nonadministrative users will be advised to notify users with
administrative rights so that they can verify demographic information and remove the block.
Nonadministrative users can determine the identity of the administrative users for each NPI by
clicking Provider Administrator Lookup, which is located on the My Account page.
For more information, call the TMHP Contact Center at 1-800-925-9126, the CSHCN Services
Program Contact Center at 1-800-568-2413, or visit the TMHP website at www.tmhp.com.
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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: (
)
Email:
)
Email:
State
Zip Code
State
Zip Code
Secondary Address
Street Address
City
Telephone: (
)
Fax Number: (
Type of Change (check the appropriate box)
…
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:
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 …
No …
Additional services offered (check one): HIV …
High Risk OB …
Hearing Services for Children …
Texas Medicaid & Healthcare Partnership (TMHP)
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
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 (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
(512) 514-4222 (fax)
Comprehensive Care Program (CCP)
(CCP prior authorization status and general CCP and Home Health Services information)
1-800-846-7470 (voice)
(512) 514-4211 (fax)
Comprehensive Care Inpatient Psychiatric (CCIP) Unit (prior authorization and general
information)
1-800-213-8877 (voice)
(512) 514-4211 (fax)
Family Planning (Tubal Ligation/Vasectomy Consent Forms) Fax
(512) 514-4229 (fax)
Health Insurance Premium Payment (HIPP) and Insurance Premium Payment Assistance (IPPA)
1-800-440-0493 (voice)
1-866-409-1188 (fax)
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)
(512) 514-4209 (fax)
Hysterectomy Acknowledgment Statements Fax
(512) 514-4218 (fax)
Long Term Care (LTC) Operations
1-800-626-4117
LTC—Nursing Facilities
1-800-727-5436
Medicaid Audit/Cost Reports
(512) 506-6117
Medicaid Audit Fax
(512) 506-7811 (fax)
Radiology Prior Authorization
1-800-572-2116 (voice)
1-800-572-2119 (fax)
Provider Enrollment Fax
(512) 514-4214 (fax)
Telephone Appeals
1-800-745-4452
Texas Health Steps (THSteps) Dental Inquiries
1-800-568-2460
THSteps Medical Services Inquiries
1-800-757-5691
Third Party Liability (TPL) (Option 2)
1-800-846-7307
Third Party Liability (TPL) Fax
(512) 514-4225 (fax)
TMHP Electronic Data Interchange (EDI) Help Desk
1-888-863-3638
TMHP EDI Help Desk Fax
(512) 514-4228 (fax)
(512) 514-4230 (fax)
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Prior Authorization Request/Status Telephone and Fax Communication
Contact
Telephone Number
Fax Number
Ambulance Authorization (includes out-of-state transfers)
1-800-540-0694
(512) 514-4205
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
(512) 514-4209
CCP
(512) 514-4212
CCIP and Substance Abuse
Option 1: Status, provide additional information, verify or request
a CCIP prior authorization
Option 2: Substance abuse prior authorization status
1-800-213-8877
(512) 514-4211
Obstetric Ultrasound Authorizations
1-888-302-6167
(512) 302-5039
Outpatient Psychotherapy/Counseling
(512) 514-4213
Personal Care Services
1-888-648-1517
Radiology Services Prior Authorization
1-800-572-2116
Special Medicaid Prior Authorization Fax (Including Transplants)
1-888-693-3210
(512) 514-4213
Written Communication With TMHP
All CMS-1500 forms (excluding ambulance, radiology/laboratory, immunization services, rural health, and mental
health rehabilitation) that are 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
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Correspondence
Address
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
Health Insurance Premium Payment (HIPP)
HIPP Program
PO Box 201120
Austin, TX 78720-9774
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
Medically Needy Clearinghouse (MNC) or Spend-Down Unit
correspondence
Texas Medicaid & Healthcare Partnership
Medically Needy Clearinghouse
PO Box 202947
Austin, TX 78720-2947
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
TPL/Tort correspondence
Texas Medicaid & Healthcare Partnership
Third Party Liability/Tort
PO Box 202948
Austin, TX 78720-2948
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Texas Medicaid/CHIP Vendor Drug Program Contact Information
Contact/ Correspondence
Address/ Number
Vendor Drug Program Email Address
[email protected]
Searchable Formulary List
www.txvendordrug.com/formulary/formulary-search.asp
Epocrates
www.epocrates.com
Enhanced Formulary
www.txvendordrug.com/formulary/enhanced-form-search.shtml
Vendor Drug Program Traditional FFS Prior
Authorization
Call:1-877-728-3927 or 1-877-PA-Texas
Note: This number is for prescribing providers or provider representatives only.
An online drug information resource for all state health-care
programs.
Epocrates lets providers use mobile devices (i.e., Palm,
Blackberry, Windows Mobile telephone, or iPhone) to access
the preferred drug list and information about drugs covered
by Medicaid. To register for this service, go to the Epocrates
website and sign up for Epocrates Rx.
Note: Epocrates is an outpatient prescription online Medicaid
formulary resource.
Medicaid-only formulary information with links from
selected non-preferred drugs to the preferred drugs in that
therapeutic class and clinical edit criteria.
Note: The Vendor Drug Enhanced Formulary is maintained by
the Vendor Drug Program’s prior authorization vendor, Health
Information Designs, Inc. (HID).
Online: https://paxpress.txpa.hidinc.com
(for prior authorizations for non-preferred drugs only)
Pharmacy Benefit Access
1-800-435-4165
Monday - Friday 8:30 a.m. to 5:15 p.m. CT
This number is for pharmacy providers only.
Vendor Drug Program Fax Numbers
Central Office: (512) 730-7471
Pharmacy Benefits Access: (512) 491-1958
Formulary: (512) 491-1961
Drug Utilization: (512) 491-1962
Contract Management: (512) 730-7466
Vendor Drug Program Address
Physical address:
Health and Human Services Commission
Medicaid/CHIP Vendor Drug Program (MC-2250)
4900 N Lamar Blvd
Austin, TX 78758
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Helpful Links
Item
Link
Texas Health and Human Services
www.hhs.state.tx.us
The Texas Medicaid & Healthcare Partnership
www.tmhp.com
TMHP Provider Relations Representative
www.tmhp.com/Pages/SupportServices/PSS_Reg_Support.aspx
Texas Department of State Health Services
www.dshs.state.tx.us
Texas Vendor Drug Program
www.txvendordrug.com
Preferred Drug List Program
www.txvendordrug.com/pdl
Explanation of Benefits Codes
www.tmhp.com/Pages/Topics/EOB.aspx
Expanded Primary Health Care Program
www.dshs.state.tx.us/ephc/Expanded-Primary-Health-Care.aspx
MRAN Type 30 Form and instructions
www.tmhp.com/Provider_Forms/Medicaid/MRAN Form Crossover Claim
Type 30.pdf
MRAN Type 31 Form and instructions
www.tmhp.com/Provider_Forms/Medicaid/MRAN Form Crossover Claim
Type 31.pdf
MRAN Type 50 Form and instructions
www.tmhp.com/Provider_Forms/Medicaid/MRAN Form Crossover Claim
Type 50.pdf
STAR
www.hhsc.state.tx.us/medicaid/managed-care/star/
STAR+Plus
www.hhsc.state.tx.us/medicaid/managed-care/starplus/
NorthSTAR
www.dshs.state.tx.us/mhsa/northstar/northstar.shtm
STAR Health
www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-star.asp
THSteps Medical Services
www.dshs.state.tx.us/THSteps/default.shtm
THSteps Dental Services
www.dshs.state.tx.us/dental/default.shtm
Family Planning
www.dshs.state.tx.us/famplan/default.shtm
Case Management for Children and Pregnant
Women
www.dshs.state.tx.us/caseman/default.shtm
Texas Medicaid Wellness Program
www.hhsc.state.tx.us/medicaid/Texas-Medicaid-Wellness-Program.html
The Children with Special Health Care Needs
(CSHCN) Services Program
www.tmhp.com/Pages/CSHCN/CSHCN_home.aspx
www.dshs.state.tx.us/cshcn
Medicaid for Breast and Cervical Cancer (MBCC)
www.dshs.state.tx.us/bcccs/treatment.shtm
Medical Transportation Program (Medicaid and
CSHCN Services Program)
www.dshs.state.tx.us/cshcn/mtp.shtm
Early Childhood Intervention (ECI)
www.dars.state.tx.us/ecis
CHIP
www.hhsc.state.tx.us/medicaid/managed-care/chip/
HIPP Program
www.GetHIPPTexas.org
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Medicaid Basics Participant Guide
Steps to Resolve Your Medicaid Questions
1. Texas Medicaid Provider Procedures Manual (TMPPM)
A provider’s first resource for Medicaid information. Available on the TMHP website.
2. Remittance and 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.
3. TMHP Website
At www.tmhp.com, providers can find the latest information on TMHP news, bulletins, and trainings.
Providers can also verify client eligibility, submit claims, check claim status, view R&S Reports, view panel
reports, and view many other helpful links.
4. TMHP Telephone Numbers
–– TMHP Contact Center: 1-800-925-9126
–– Telephone Appeals: 1-800-745-4452
–– THSteps Dental Inquiries: 1-800-568-2460
–– THSteps Medical Inquiries: 1-800-757-5691
–– TMHP EDI Help Desk: 1-800-925-9126, option 3
5. Automated Inquiry System (AIS)
AIS is a provider’s resource for verifying client eligibility, claim status, and benefit limitations and is available 23
hours a day, with daily down time from 3 a.m. to 4 a.m. Call 1-800-925-9126, and choose an option from the
menu.
6. TMHP Contact Center
The contact center is a provider’s resource for general Medicaid information and is available from 7 a.m. to 7
p.m. (CST), call 1-800-925-9126.
7. Provider Relations Representatives
If you have questions about enrollment, retention, a claim, or Medicaid policy, contact the provider relations
representative in your region. You can find Provider Relations resources in the Provider Support Services section
of the TMHP website.
–– Enrollment and Retention
www.tmhp.com/Pages/ProviderEnrollment/PE_Reg_Support.aspx
–– Claims and Medical Policy
www.tmhp.com/Pages/SupportServices/PSS_Reg_Support.aspx
Provider calls are addressed by the TMHP Contact Center at 1-800-925-9126 or the CSHCN
Services Program Contact Center at 1-800-568-2413. You can also email Provider Relations at
[email protected]
132
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— 2015 0311
Medicaid Basics Participant Guide
Common Claim Denial Codes
•
EOB 01140: “UNABLE TO ASSIGN PROGRAM/BENEFIT PLAN”
Steps to correct:
1. Verify the client’s information matches eligibility.
2. Ensure the client was eligible for the date of service.
3. Verify the billing provider is enrolled in the client’s program.
4. Verify the provider’s enrollment is active.
5. Confirm the claim was not submitted using “Billing Provider” and not “Performing Only” provider
participating in a group or NPI.
•
EOB 01361: “PROF/OUTPT DUPLICATE”
Steps to correct:
1. Search for past claims that are in the paid status.
2. Verify if and when original claim was received before you submit another claim.
3. If necessary, appeal the paid claim.
•
EOB 00207: “SERVICE NOT A BENEFIT”
Step to correct: Verify that services billed are covered for the program billed.
•
EOB 00100: “BILLED AMOUNT REQUIRED”
This denial is usually associated with dual eligible Medicare claims that are not crossing over successfully.
Step to correct: Submit a paper claim that includes all of the following:
1. The Medicare Remittance Advice (RA) or Remittance Notice (RN), which is issued by Medicare.
2. The appropriate, completed paper CMS-1500 or UB-04 CMS-1450 paper claim form.
3. The appropriate TMHP Standardized Medicare and MAP Remittance Advice Notice Template Form. (The
TMHP MRAN template is optional if you submit the original paper version from Medicare.)
•
EOB 00565: “RECEIVED PAST THE 95-DAY FILING DEADLINE”
Steps to correct:
1. Verify the claim was submitted within 95 days from the first DOS.
2. Appeal claim with proof of timely filing attached. (i.e. R&S of past claim, Postal or Express carrier receipt with
tracking information.)
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Medicaid Basics Participant Guide
Acronyms
Acronym
Term
Acronym
Term
ACD
Augmentative Communicative Device
FFP
Federal Financial Participation
ADA
American Dental Association
FFS
Fee-For-Service
AIS
Automated Inquiry System
FPL
Federal Poverty Level
API
Atypical Provider Identifier
FQHC
Federally Qualified Health Center
APRN
Advanced Practice Registered Nurse
FSS
Family Support Services
ASC
Ambulatory Surgical Center
HCPCS
BCCS
Breast and Cervical Cancer Services
Healthcare Common Procedure Coding
System
BON
Board of Nursing
HHS
Health and Human Services
CAD
Coronary Artery Disease
HHSC
Health and Human Services Commission
CAH
Critical Access Hospital
HIPAA
CBT
Computer-Based Training
Health Insurance Portability and
Accountability Act
CCP
Comprehensive Care Program
HIPP
Health Insurance Premium Payment
CHF
Congestive Heart Failure
ICD-10
International Classification of Diseases, Tenth
Revision
CHIP
Children’s Health Insurance Program
ICN
Internal Control Number (as in 24-digit ICN)
CMS
Centers for Medicare & Medicaid Services
IFSP
Individualized Family Service Plan
CNM
Certified Nurse Midwife
IPPA
Insurance Premium Payment Assistance
CNS
Clinical Nurse Specialist
LCSW
Licensed Clinical Social Worker
COPD
Chronic Obstructive Pulmonary Disease
LMS
Learning Management System
CSHCN
Children with Special Health Care Needs
LMSW
Licensed Master Social Worker
CSI
Claim Status Inquiry
LPC
Licensed Professional Counselor
DADS
Department of Aging and Disability
Services
LTC
Long Term Care
MAO
Medical Assistance Only
DARS
Department of Assistive and Rehabilitative
Services
MBCC
Medicaid for Breast and Cervical Cancer
MCO
Managed Care Organization
MD
Doctor of Medicine
MMIS
Medicaid Management Information System
MNC
Medically Needy Clearinghouse
MNP
Medically Needy Program
MQMB
Medicaid Qualified Medicare Beneficiary
MRAN
Medicare Remittance Advice Notice
MREP
Medicare Remit Easy Print
MSRP
Manufacturer’s Suggested Retail Price
MTP
Medical Transportation Program
NDC
National Drug Code
NP
Nurse Practitioner
NPI
National Provider Identifier
OBRA
Omnibus Budget Reconciliation Act of 1989
OEFV
Oral Evaluation and Fluoride Varnish
OFL
Online Fee Lookup
OHP
Oral Health Program
OI
Other Insurance
DFPS
Department of Family Protective Services
DME
Durable Medical Equipment
DO
Doctor of Osteopathy
DOB
Date of Birth
DOS
Date(s) of Service
DRS
Developmental Rehabilitation Services
DSHS
Department of State Health Services
ECC
Early Childhood Caries
ECI
Early Childhood Intervention
EDI
Electronic Data Interchange
EFT
Electronic Funds Transfer
EHR
Electronic Health Records
EOB
Explanation of Benefits
EOPS
Explanation of Pending Status
EPSDT
Early and Periodic Screening, Diagnosis,
and Treatment
ER&S
Electronic Remittance and Status Report
FDH
First Dental Home
134
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— 2015 0311
Medicaid Basics Participant Guide
Acronym
Term
OIG
Office of Inspector General
OON
Out-of-Network
OPL
Online Provider Lookup
OT
Occupational Therapy
PA
Physician Assistant
PAF
Physician/Dentist Assessment Form
PAN
Prior Authorization Number
PBM
Pharmacy Benefit Manager
PCN
Patient Control Number
PCP
Primary Care Provider
PCS
Personal Care Services
PE
Presumptive Eligibility
PEP
Provider Enrollment on the Portal (tool)
PIC
Provider Information Change (Form)
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
SHN
Superior HealthPlan Network
SLP
Speech-Language Pathology
SSI
Supplemental Security Income (Program)
SSN
Social Security Number
STAR
State of Texas Access Reform
TAC
Texas Administrative Code
TANF
Temporary Assistance to Needy Families
THSteps
Texas Health Steps
TMHP
Texas Medicaid & Healthcare Partnership
TMPPM
Texas Medicaid Provider Procedures Manual
TOS
Type of Service
TP
Type Program
TPI
Texas Provider Identifier
TPN
Total Parenteral Nutrition (i.e.,
Hyperalimentation)
TPL
Third Party Liability
TPR
Third Party Recovery
TPR
Third Party Resources
TVFC
Texas Vaccines for Children
UB-04
Uniform Bill 04 CMS-1450 (claim form)
VDP
Medicaid Vendor Drug Program
TWHP
Texas Women’s Health Program
2015 0311 — CPT only copyright 2014 American Medical Association. All rights reserved.135
The Medicaid Basics Participant Guide is produced by TMHP Training and Organizational Development Services Group. This is
intended for educational purposes in conjunction with the Medicaid Basics series. Providers should regularly consult the TMPPM,
CSHCN Services Program Provider Manual, web articles, and banner messages for updated policy and procedure information.
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