Provider Handbooks. Children s Services Handbook

Transcription

1 Volume 2 Provider Handbooks Children s Services Handbook This manual is available for download at and is also available on CD. There are many benefits to using the electronic manual, including easy navigation with bookmarks and hyperlinked cross-references, the ability to quickly search for specific terms or codes, and form printing on demand. The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health and Human Services Commission.

2 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CHILDREN S SERVICES HANDBOOK January 2011

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4 CHILDREN S SERVICES HANDBOOK CHILDREN S SERVICES HANDBOOK Table of Contents 1. General Information CH Medical Transportation Program CH Medicaid Children s Services Comprehensive Care Program (CCP) CH Early Childhood Intervention (ECI) (CCP) CH CCP Overview CH Client Eligibility CH Enrollment CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Diagnosis Coding CH Drug and Medical Device Approval CH Physician Signature CH Clinician-Directed Care Coordination Services (CCP) CH Services/Benefits and Limitations CH Non-Face-to-Face Services CH Non-Face-to-Face Medical Conferences CH Non-Face-to-Face Clinician Supervision of a Home Health Client CH Non-Face-to-Face Clinician Supervision of a Hospice Client CH Non-Face-to-Face Clinician Supervision of a Nursing Facility Client CH Other Non-Face-to-Face Supervision CH Non-Face-to-Face Prolonged Services CH Non-Face-to-Face Specialist or Subspecialist Telephone Consultation.....CH General Requirements for Non-Face-to-Face Clinician-Directed Care Coordination Services CH Non-Face-to-Face Care Plan Oversight CH Medical Team Conference CH Face-to-Face Services CH General Requirements for Face-to-Face Clinician-Directed Care Coordination Services CH Prior Authorization and Documentation Requirements CH Documentation Requirements for the Medical Home Clinician for a Telephone Consult with a Specialist CH Documentation Requirements for the Specialist or Subspecialist for a Telephone Consult with the Medical Home Clinician CH Claims Information CH Reimbursement CH Comprehensive Outpatient Rehabilitation Facilities (CORFs)/Outpatient Rehabilitation Facilities (ORFs) CH Enrollment CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Claims Information CH Reimbursement CH Durable Medical Equipment (DME) Supplier (CCP) CH Enrollment CH-30 CH-3

5 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL Pharmacies (CCP) CH Services/Benefits and Limitations CH Purchase Versus Equipment Rental CH Prior Authorization and Documentation Requirements CH Equipment Accessories CH Equipment Modifications CH Equipment Adjustments CH Equipment Repairs CH DME Certification and Receipt Form CH Documentation of Supply Delivery CH Specific CCP Policies CH Blood Pressure Devices CH Services/Benefits and Limitations CH Manual and Automated Blood Pressure Devices CH Hospital-Grade Blood Pressure Devices CH Blood Pressure Device Components, Replacements, and Repairs CH Prior Authorization and Documentation Requirements CH Manual and Automated Blood Pressure Devices CH Hospital-Grade Blood Pressure Devices CH Blood Pressure Device Components, Replacements, and Repairs CH Cardiorespiratory (Apnea) Monitor CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Croup Tent/Pulse Oximeter CH Services/Benefits and Limitations CH Croup Tent CH Pulse Oximeter CH Prior Authorization and Documentation Requirements CH Croup Tent CH Pulse Oximeter CH Donor Human Milk CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Incontinence Supplies for Clients Who Are Birth Through 3 Years of Age CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Mobility Aids CH Services/Benefits and Limitations CH Portable Client Lifts for Outside the Home Setting CH Strollers (a multipositional client transfer system with integrated seat, operated by care giver) ch Stroller Ramps Portable and Threshold CH Feeder Seats, Floor Sitters, Corner Chairs, and Travel Chairs CH Scooters CH Mobility Aids CCP HCPCS Procedure Codes and Limitations CH Prior Authorization and Documentation Requirements CH Portable Client Lifts for Outside the Home Setting CH Strollers (a multipositional client transfer system with integrated seat, operated by care giver) ch Stroller Ramps Portable and Threshold CH Nutritional Products CH-48 CH-4

6 CHILDREN S SERVICES HANDBOOK Services/Benefits and Limitation CH Women, Infants and Children Program (WIC) CH Noncovered Services CH Prior Authorization and Documentation Requirements CH Nutritional Products CH Pediatric Hospital Beds, Cribs, and Equipment CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Hospital Beds and Safety Enclosure CH Positioning Devices CH Repair or Replacement CH Phototherapy Devices CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Retroactive Eligibility CH Special Needs Car Seats and Travel Restraints CH Services/Benefits and Limitations CH Special Needs Car Seats CH Travel Safety Restraints CH Prior Authorization and Documentation Requirements CH Special Needs Car Seats CH Travel Safety Restraints CH Total Parental Nutrition (TPN) CH Services/Benefits and Limitation CH Prior Authorization and Documentation Requirements CH Vitamins and Minerals CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Claims Information CH Reimbursement CH Medical Nutrition Counseling Services (CCP) CH Enrollment CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Claims Information CH Reimbursement CH Orthotic and Prosthetic Services (CCP) CH Enrollment CH Orthotics Services CH Services/Benefits and Limitations CH Noncovered Orthotic Services CH Prior Authorization and Documentation Requirements CH Spinal Orthoses CH Lower-Limb Orthoses CH Foot Orthoses CH Upper-Limb Orthoses CH Other Orthopedic Devices CH Related Services CH Cranial Molding Orthotics CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH-72 CH-5

7 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers, Standing Frames/Braces, and Parapodiums) CH Services/Benefits and Limitations CH Parapodium CH Standing Frame or Brace CH Vertical or Dynamic Stander CH Prior Authorization and Documentation Requirements CH Prosthetic Services CH Services/Benefits and Limitations CH Noncovered Prosthetic Services CH Prior Authorization and Documentation Requirements CH Lower-Limb Prostheses CH Upper-Limb Prostheses CH External Breast Prostheses CH Craniofacial Prostheses CH Related Services CH Claims Information CH Reimbursement CH Personal Care Services (PCS) (CCP) CH Enrollment CH Services/Benefits and Limitations CH Place of Services CH Client Eligibility CH Accessing the PCS Benefit CH The Primary Practitioner s Role in the PCS Benefit CH PCS Provided in Group Settings CH Prior Authorization and Documentation Requirements CH PCS Provider Responsibilities CH Documentation of Services Provided/Retrospective Review CH Claims Information CH Reimbursement CH Private Duty Nursing (CCP) CH Enrollment CH Services/Benefits and Limitations CH PDN Provided During a Skill Nursing Visit for TPN Administration Education CH Criteria CH Client Eligibility Criteria CH Medical Necessity CH Place of Service (POS) CH Amount and Duration of PDN CH Prior Authorization and Documentation Requirements CH Retroactive Client Eligibility CH Start of Care (SOC) CH Prior Authorization of Initial Requests CH Authorization for Revision of Current Services CH Recertifications of Authorizations CH Termination of Authorization CH Client/Provider Notification CH Authorization Appeals CH CCP Prior Authorization Request Form CH Home Health Plan of Care (POC) CH-100 CH-6

8 CHILDREN S SERVICES HANDBOOK Nursing Addendum to Plan of Care (CCP) Form CH The Client s 24-Hour Daily Schedule CH Responsible Adult or Identified Contingency Plan Requirement CH Documentation of Services Provided/Retrospective Review CH Claims Information CH Reimbursement CH Therapy Services (CCP) CH Occupational Therapy (OT) CH Enrollment CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Claims Information CH Reimbursement CH Physical Therapy (PT) CH Enrollment CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Claims Information CH Reimbursement CH Speech Therapy (ST) CH Enrollment CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Claims Information CH Reimbursement CH Inpatient Psychiatric Hospital/Facility (Freestanding) (CCP) CH Enrollment CH Continuity of Hospital Eligibility Through Change of Ownership CH Services/Benefits and Limitations CH Prior Authorization and Documentation Requirements CH Medicaid Clinical Criteria for Inpatient Psychiatric Care For Clients CH Continued Stays CH Court-Ordered Services CH Denials CH Utilization Review CH Retrospective Utilization Review CH Claims Information CH Reimbursement CH Inpatient Rehabilitation Hospital (Freestanding) (CCP) CH Enrollment CH Continuity of Hospital Eligibility Through Change of Ownership CH Services/Benefits and Limitations CH Comprehensive Treatment CH Prior Authorization and Documentation Requirements CH Claims Information CH Reimbursement CH Client Transfers CH School Health and Related Services (SHARS) CH Overview CH Eligibility Verification CH-123 CH-7

9 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL Enrollment CH SHARS Enrollment CH Nonschool SHARS Provider Enrollment CH Private School Enrollment CH Medicaid Managed Care Enrollment CH Services/Benefits, Limitations, and Prior Authorization CH Audiology CH Audiology Billing Table CH Counseling Services CH Counseling Services Billing Table CH Psychological Testing and Services CH Psychological Testing CH Psychological Services CH Nursing Services CH Nursing Services Billing Table CH Occupational Therapy (OT) CH Occupational Therapy Billing Table CH Personal Care Services CH Personal Care Services Billing Table CH Physical Therapy (PT) CH Physical Therapy Billing Table CH Physician Services CH Medical Services Billing Table CH Speech Therapy (ST) CH Referral CH Description of Services CH Provider and Supervision Requirements CH Speech Therapy Billing Table CH Transportation Services in a School Setting CH Transportation Services in a School Setting Billing Table CH Prior Authorization CH Documentation Requirements CH Record Retention CH Claims Filing and Reimbursement CH Claims Information CH Appealing Denied SHARS Claims CH Billing Units Based on 15 Minutes CH Billing Units Based on an Hour CH Reimbursement CH Random Moment Time Study (RMTS) CH Certification of Funds CH Cost Reporting CH Cost Reconciliation and Cost Settlement CH Texas Health Steps (THSteps) Dental CH Enrollment CH THSteps Dental Eligibility CH Categories of Practice CH THSteps Dental and ICF-MR Dental Services CH THSteps Dental Checkup and Treatment Facilities CH Doctor of Dentistry Practicing as a Limited Physician CH-143 CH-8

10 CHILDREN S SERVICES HANDBOOK Medicaid Managed Care Enrollment CH Client Rights CH Complaints and Resolution CH Services/Benefits, Limitations, and Prior Authorization CH THSteps Dental Services CH Eligibility for THSteps Dental Services CH Parental Accompaniment CH Comprehensive Care Program (CCP) CH ICF-MR Dental Services CH THSteps and ICF-MR Provision of Dental Services CH Children in Foster Care CH Written Informed Consent and Standards of Care CH First Dental Home CH Dental Referrals by THSteps Primary Care Providers CH Change of Provider CH Interrupted or Incomplete Orthodontic Treatment Plans CH Periodicity for THSteps Dental Services CH Exceptions to Periodicity CH Tooth Identification (TID) and Surface Identification (SID) Systems CH Supernumerary Tooth Identification CH Medicaid Dental Benefits, Limitations, and Fee Schedule CH Diagnostic Services CH Preventive Services CH Therapeutic Services CH Restorative Services CH Endodontics Services CH Periodontal Services CH Prosthodontic (Removable) Services CH Implant Services CH Prosthodontic (Fixed) Services CH Oral and Maxillofacial Surgery Services CH Adjunctive General Services CH Dental Therapy Under General Anesthesia CH Criteria for Dental Therapy Under General Anesthesia CH Criteria for Dental Therapy Under General Anesthesia, Attachment CH Hospitalization and ASC/HASC CH Orthodontic Services (THSteps) CH Benefits and Limitations CH Completion of Treatment Plan CH Premature Removal of Appliances CH Transfer of Orthodontic Services CH Comprehensive Orthodontic Treatment CH Orthodontic Procedure Codes and Fee Schedule CH Special Orthodontic Appliances CH Handicapping Labio-lingual Deviation (HLD) Index CH HLD Score Sheet CH Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger CH Emergency Services for Medicaid Clients Who Are 21 Years of Age and Older.... CH Long Term Care (LTC) Emergency Dental Services CH Laboratory Requirements CH-194 CH-9

11 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL Mandatory Prior Authorization CH Cone Beam Imaging CH General Anesthesia for Dental Treatment CH Orthodontic Services CH THSteps and ICF-MR Dental Prior Authorization CH Documentation Requirements CH General Anesthesia CH Orthodontic Services CH Utilization Review CH Claims Filing and Reimbursement CH Reimbursement CH Third Party Resources (TPR) CH Claim Submission After Loss of Eligibility CH Claims Information CH Claim Appeals CH Frequently Asked Questions About Dental Claims CH THSteps Medical CH THSteps Medical and Dental Administrative Information CH Overview CH Statutory Requirements CH Texas Vaccines for Children (TVFC) Program CH Vaccine Adverse Event Reporting System (VAERS) CH Referrals for Medicaid-Covered Services CH THSteps Medical Checkup Facilities CH THSteps Dental Services CH How the THSteps Dental Program Works CH Enrollment CH THSteps Medical Provider Enrollment CH Additional Education Requirements for Registered Nurses (RNs) CH Medicaid Managed Care Enrollment CH Services/Benefits, Limitations, and Prior Authorization CH THSteps Medical Checkups CH Medical Home Concept CH Mobile Units and the Medical Home CH Eligibility for a Medical Checkup CH Verification of Medical Checkups CH Medical Checkups for Infants, Children, and Adolescents (Birth Through 20 Years of Age) CH Acute Care Visits CH Exception-to-Periodicity Checkups CH Follow-up Medical Checkup CH Newborn Examination CH THSteps Medical Checkups Periodicity Schedule CH Screening Components With Additional Requirements CH Developmental Screening CH Referrals for Developmental Assessment CH Mental Health CH Sensory Screenings CH Vision Screening CH-222 CH-10

12 CHILDREN S SERVICES HANDBOOK Hearing Screening CH Tuberculosis Screening CH Administrations and Immunizations CH Vaccine Information Statement (VIS) CH Laboratory Procedures CH Laboratory Services CH Laboratory Supplies CH Newborn Screening Supplies CH Laboratory Submission CH Send Comments CH Required Laboratory Tests Related to Medical Checkups CH Additional Required Laboratory Tests Related to Medical Checkups for Adolescents CH Laboratory Reporting CH Dental Screening and Intermediate Oral Evaluation with Fluoride Varnish Application in the Medical Home CH Dental Screening CH Intermediate Oral Evaluation with Fluoride Varnish Application CH Anticipatory Guidance CH Documentation Requirements CH THSteps Medical Checkups Documentation of Completed Checkups CH Separate Identifiable Acute Care Evaluation and Management Visit CH Claims Filing and Reimbursement CH THSteps Medical Checkups CH Claims Information CH Reimbursement CH Claims Resources CH Contact TMHP CH Automated Inquiry System (AIS) CH TMHP Website CH (Dental) Information and Assistance CH Dental Inquiry Line CH (THSteps) Information and Assistance CH Assistance with Program CH Forms CH-238 CH.1 CCP Prior Authorization Request Form Instructions (2 pages) CH-239 CH.2 CCP Prior Authorization Request Form CH-241 CH.3 CCP Prior Authorization Private Duty Nursing 6-Month Authorization CH-242 CH.4 CCP ECI Request for Initial/Renewal Outpatient Therapy CH-243 CH.5 DME Certification and Receipt Form (3 Pages) CH-244 CH.6 Donor Human Milk Request Form CH-247 CH.7 External Insulin Pump CH-248 CH.8 Home Health Plan of Care (POC) CH-249 CH.9 Nursing Addendum to Plan of Care (CCP) (7 Pages) CH-250 CH.10 Psychiatric Inpatient Initial Admission Request Form CH-257 CH.11 Psychiatric Inpatient Extended Stay Request Form CH-258 CH.12 Pulse Oximeter Form CH-259 CH.13 Request for Initial Outpatient Therapy (Form TP-1) CH-260 CH.14 Request for Extension of Outpatient Therapy (Form TP-2) (2 Pages) CH-261 CH-11

13 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.15 THSteps Dental Mandatory Prior Authorization Request Form CH-263 CH.16 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 Pages) CH-264 CH.17 THSteps Referral Form Instructions CH-266 CH.18 THSteps Referral Form CH-267 CH.19 CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services (2 Pages) CH-268 CH.20 Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services Comprehensive Care Program (CCP)... CH-270 CH.21 Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (6 Pages) CH Claim Form Examples CH-277 CH.22 Comprehensive Outpatient Rehabilitation Facility (CORF) (CCP Only) CH-278 CH.23 Diagnosis and Treatment (Referral from THSteps Checkup) CH-279 CH.24 Durable Medical Equipment (CCP Only) CH-280 CH.25 Early Childhood Intervention (CCP Only) CH-281 CH.26 Inpatient Psychiatric Hospital/Facility (CCP Only) CH-282 CH.27 Inpatient Rehabilitation Hospital (CCP Only) CH-283 CH.28 Medical Nutrition Counseling (CCP Only) CH-284 CH.29 Occupational Therapists (CCP Only) CH-285 CH.30 Orthotic and Prosthetic Services (CCP Only) CH-286 CH.31 Physical Therapists (CCP Only) CH-287 CH.32 Private Duty Nurses (CCP Only) CH-288 CH.33 School Health and Related Services (SHARS) CH-289 CH.34 Speech-Language Pathologists (CCP Only) CH-290 CH.35 THSteps New Patient, Immunization, Physical Examination by a Nurse Practitioner, and FQHC Billing CH-291 CH.36 THSteps Established Patient and Referral, TB Skin Test, and Physical Examination by a Physician CH Appendices CH-293 Appendix A: THSteps Forms CH-295 A.1 Claim Forms CH-296 A.2 Child Health Clinical Records CH-296 A.3 Guidelines for Tuberculosis Skin Testing CH-297 A.4 Laboratory Forms CH-297 CH.37 Child Health History (2 Pages) CH-298 CH.38 Child Health Record (Birth 1 Month) (2 Pages) CH-300 CH.39 Child Health Record (2 6 Months) (2 Pages) CH-302 CH.40 Child Health Record (7 12 Months) (2 Pages) CH-304 CH.41 Child Health Record (13 Months 2 Years) (2 Pages) CH-306 CH.42 Child Health Record (3 5 Years) (2 Pages) CH-308 CH.43 Child Health Record (6-10 Years) (2 Pages) CH-310 CH.44 Hearing Checklist for Parents CH-312 CH.45 Hearing Checklist for Parents (Spanish) CH-313 CH.46 Mental Health Interview Tool/Referral Form (Ages 0 2 Years) CH-314 CH.47 Mental Health Interview Tool/Referral Form (Ages 3 9 Years) CH-315 CH.48 Mental Health Interview Tool/Referral Form (Ages Years) CH-316 CH.49 Mental Health Interview Tool/Referral Form (Ages Years) CH-317 CH.50 Mental Health Parent Questionnaire (Ages Birth 2 Years) (2 Pages) CH-318 CH.51 Mental Health Questionnaire (Ages Birth 2 Years) (2 Pages) (Spanish) CH-320 CH.52 Mental Health Parent Questionnaire (Ages 3 9 Years) (2 Pages) CH-322 CH-12

14 CHILDREN S SERVICES HANDBOOK CH.53 Mental Health Parent Questionnaire (Ages 3 9 Years) (2 Pages) (Spanish) CH-324 CH.54 Mental Health Parent Questionnaire (Ages Years) (2 Pages) CH-326 CH.55 Mental Health Parent Questionnaire (Ages Years) (2 Pages) (Spanish) CH-328 CH.56 Mental Health Parent Questionnaire (Ages Years) (2 Pages) CH-330 CH.57 Mental Health Parent Questionnaire (Ages Years) (2 Pages) (Spanish) CH-332 CH.58 Risk Assessment for Lead Exposure: Parent Questionnaire, Form Pb-110 (2 Pages).... CH-334 A.5 Tuberculosis Screening and Education Tool CH-336 CH.59 TB Questionnaire CH-337 CH.60 Cuestionario Para la Detección de Tuberculosis CH-338 CH.61 How to Determine TB Risk CH-339 CH.62 PPD Agreement for Texas Health Steps Providers CH-340 CH.63 TVFC Patient Eligibility Screening Record CH-341 CH.64 TVFC Patient Eligibility Screening Record (Spanish) CH-342 CH.65 TVFC Provider Enrollment (3 Pages) CH-343 CH.66 TVFC Questions and Answers (3 Pages) CH-346 Appendix B: Immunizations CH-349 B.1 Immunizations Overview CH-350 B.1.1 Vaccine Adverse Event Reporting System (VAERS) CH-350 B.1.2 TVFC Versus Non-TVFC Vaccines/Toxoids CH-350 B.1.3 Exemption from Immunization for School and Child-Care Facilities CH-350 B.2 Recommended Childhood Immunization Schedule CH-351 B.2.1 Recommended Childhood and Adolescent Immunization Schedule, CH-352 B.3 General Recommendations CH-355 B.3.1 How to Obtain Free Vaccines CH-355 B.3.2 Administrations and Immunizations CH-355 B Vaccine Procedure Codes and State-Defined Components CH-355 B.3.3 Requirements for TVFC Providers CH-356 B.3.4 How to Report Immunization Records to ImmTrac, the Texas Immunization Registry CH-357 B Direct Internet Entry CH-358 B Electronic Data Transfer (Import) CH-358 B Obtaining Parental Consent for Registry Participation CH-358 B.4 Texas Vaccines for Children Program Packet CH-358 Appendix C: Lead Screening CH-359 C.1 Blood Lead Screening Procedures and Follow-up Testing CH-360 C.2 Symptoms of Lead Poisoning CH-360 C.3 Measuring Blood Lead Levels CH-360 C.4 Environmental Lead Investigation (ELI) Services CH-361 C.4.1 Enrollment CH-361 C.4.2 Services/Benefits, Limitations and Prior Authorization CH-361 C Requesting an ELI CH-361 C Prior Authorization CH-362 C.4.3 Documentation Requirements CH-362 C.4.4 Claims Filing and Reimbursement CH-363 C Claims Filing CH-363 C Reimbursement CH-363 C.5 Form Pb-109: Reference for Follow-up Blood Lead Testing and Medical Case Management CH-364 C.6 Lead Poisoning Prevention Educational Materials and Forms CH-365 CH-13

15 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 Appendix D: Texas Health Steps Statutory State Requirements CH-367 D.1 Legislative Requirements CH-368 D.2 Texas Health Steps (THSteps) Program CH-368 D.3 Communicable Disease Reporting CH-368 D.4 Early Childhood Intervention (ECI) Referrals CH-368 D.5 Parental Accompaniment CH-368 D.6 Newborn Blood Screening CH-369 D.7 Abuse and Neglect CH-369 D.7.1 Requirements for Reporting Abuse or Neglect CH-369 D.7.2 Procedures for Reporting Abuse or Neglect CH-369 D Staff Training on Reporting Abuse and Neglect CH-370 Appendix E: Hearing Screening Information CH-371 E.1 Newborn Hearing (2 Pages) CH-372 E.2 Texas Early Hearing Detection and Intervention (TEHDI) Process CH-374 E.2.1 Birth Screen CH-374 E.2.2 Outpatient Rescreen CH-374 E.2.3 Evaluation using Texas Pediatric Protocol for Audiology CH-374 E.2.4 Referral to an ECI Program CH-375 E.2.5 Periodic Monitoring by the Physician or Medical Home CH-375 E.3 JCIH 2007 Position Statement CH-375 Appendix F: THSteps Quick Reference Guide CH-377 F.1 Texas Health Steps Quick Reference Guide CH-378 Appendix G: THSteps Dental Guidelines CH-381 G.1 American Academy of Pediatric Dentistry Periodicity Guidelines (9 Pages) CH-382 G.2 American Dental Association Guidelines for Prescribing Dental Radiographs (3 Pages) CH-391 Index CH-395 Note: A comprehensive Index, including Volume 1 and all handbooks from Volume 2, is included at the end of Volume 1 (General Information). CH-14

16 CHILDREN S SERVICES HANDBOOK CHILDREN S SERVICES HANDBOOK 1. GENERAL INFORMATION The information in this handbook is intended for dentists, school districts, physicians, physician assistants (PAs), rural health clinics (RHCs), federally qualified health centers (FQHCs), advanced practice registered nurses (APRNs), home health agencies (HHAs), durable medical equipment (DME) suppliers, hospitals, and clinics. The handbook provides information about Texas Medicaid s benefits, policies, and procedures applicable to these providers. Important: All providers are required to read and comply with Section 1: Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide healthcare services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 Texas Administrative Code (TAC) (a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance. All providers are required to report suspected child abuse or neglect as outlined in subsection 1.4, Provider Responsibilities in Section 1, Provider Enrollment and Responsibilities (Vol 1, General Information). 1.1 Medical Transportation Program The Medical Transportation Program (MTP) is funded with federal and state dollars to arrange nonemergency transportation to medical or dental appointments for eligible clients and their attendants. Refer to: Appendix D: Medical Transportation (Vol. 1, General Information) for more information Enrollment 2. MEDICAID CHILDREN S SERVICES COMPREHENSIVE CARE PROGRAM (CCP) 2.1 Early Childhood Intervention (ECI) (CCP) The Texas ECI program is available statewide to families of children who are birth through 35 months of age and who have disabilities or developmental delays. The state agency responsible for ECI services is the Department of Assistive and Rehabilitative Services (DARS). DARS contracts with local ECI programs to take referrals, determine clients' eligibility for ECI, and provide services to ECI-eligible children. To participate in Texas Medicaid, ECI providers must comply with all applicable federal, state, and local laws and regulations pertaining to ECI services. The ECI providers must provide services in accordance with IDEA, Part C and Title 40 TAC, Part 2, Chapter 101, Subchapter 1 and Title 40 TAC, Part 2, Chapter 108. CH-15

17 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 ECI providers enroll as CCP providers. ECI CCP providers who complete occupational therapy (OT), physical therapy (PT), or speech therapy (ST) evaluations and re-evaluations for children in the nonmanaged care areas of the state must submit their claims to TMHP. ECI CCP providers who complete OT, PT, or ST evaluations and re-evaluations for children enrolled in Medicaid Managed Care plans must submit their claims to the appropriate Health Maintenance Organization (HMO). For the children who qualify for Developmental Rehabilitation Services (DRS), the ongoing OT, PT, or ST services and developmental services are considered bundled services that are billed outside of the TMHP claims payment system. These ongoing therapy and developmental services, as stated on the child's IFSP, are reimbursed through the ECI provider's contract with DARS. ECI DRS are reimbursed in accordance with 1 TAC Nutrition, audiology, counseling, and psychological services provided to eligible children by ECI CCP providers are reimbursed through TMHP for children in the non-managed care areas of the state or the appropriate HMO if the child is enrolled in a Medicaid Managed Care health plan. Other ECI services, as defined in Title 40 Texas Administrative Code (TAC), Part 2, Chapter 108, Subchapter E, include case management services, vision services, social work, family education and training, assistive technology, behavioral intervention, and health services. Refer to: Section 4, Early Childhood Intervention (ECI) Targeted Case Management Services in the Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks). ECI Referrals and Assistance to ECI Enrolled Children Medicaid professionals can assist families enrolled in ECI by: Making referrals to the ECI program (refer to Appendix D.4 Early Childhood Intervention (ECI) Referrals). Promptly scheduling appointments for well-child exams., Providing documentation of the well-child exam and medical information to the ECI program upon request. Providing prescriptions, when necessary. For more information on ECI services, providers may visit the ECI website at Refer to: Subsection 2.10, Therapy Services (CCP) in this handbook for more information. Subsection 2.6, Medical Nutrition Counseling Services (CCP) in this handbook for more information. 2.2 CCP Overview CCP is an expansion of the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) service as mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1989, which requires all states to provide all medically necessary treatment for correction of physical or mental problems to Texas Health Steps (THSteps)-eligible clients when federal financial participation (FFP) is available, even if the services are not covered under the state s Medicaid plan. The following CCP provider sections describe the specific requirements of each area of responsibility: Subsection 2.3, Clinician-Directed Care Coordination Services (CCP) in this handbook. Subsection 2.4, Comprehensive Outpatient Rehabilitation Facilities (CORFs)/Outpatient Rehabilitation Facilities (ORFs) in this handbook. Subsection 2.5, Durable Medical Equipment (DME) Supplier (CCP) in this handbook. CH-16

18 CHILDREN S SERVICES HANDBOOK Subsection 2.1, Early Childhood Intervention (ECI) (CCP) in this handbook. Subsection 2.6, Medical Nutrition Counseling Services (CCP) in this handbook. Subsection 2.7, Orthotic and Prosthetic Services (CCP) in this handbook. Subsection 2.8, Personal Care Services (PCS) (CCP) in this handbook. Subsection 2.9, Private Duty Nursing (CCP) in this handbook. Subsection 2.10, Therapy Services (CCP) in this handbook for more information. Subsection 2.11, Inpatient Psychiatric Hospital/Facility (Freestanding) (CCP) in this handbook. Subsection 2.12, Inpatient Rehabilitation Hospital (Freestanding) (CCP) in this handbook Client Eligibility The client must be from birth through 20 years of age and eligible for THSteps on the date of service. If the client s Medicaid Identification (Form H3087) states Emergency Care, PE, or QMB, the client is not eligible for CCP benefits. Clients are ineligible for CCP services beginning the day of their 21st birthday Enrollment CCP providers must meet Medicaid/Health and Human Services Commission (HHSC) participation standards to enroll in the program. All CCP providers must be enrolled in Texas Medicaid to be reimbursed for services. Provider enrollment inquiries and application requests must be sent to the TMHP Provider Enrollment department at: Provider Enrollment Texas Medicaid & Healthcare Partnership PO Box Austin, TX Home and community support services agencies (HCSSAs) that want to provide CCP private-duty nursing (PDN), OT, PT, or ST services under the licensed-only home health (LHH) category must first enroll with TMHP. To enroll with TMHP in the LHH category, an HCSSA must: Complete a provider enrollment form, which can be found on the TMHP website at provide its license information, and check the Only CCP services box on the form. Obtain a Texas Provider Identifier (TPI) for CCP services. Provide CCP PDN, OT, PT, or ST services only to eligible CCP clients and use the TPI number assigned for CCP services. Texas Medicaid home health services must be delivered under the licensed and certified home health (LCHH) category. Refer to: Section 8: Managed Care (Vol. 1, General Information) Services/Benefits and Limitations Payment is considered for any health-care service that is medically necessary and for which FFP is available. CCP benefits are allowable services not currently covered under Texas Medicaid (e.g., speechlanguage pathology [SLP] services for nonacute conditions, PDN, prosthetics, orthotics, apnea monitors and some durable medical equipment [DME], some specific medical nutritional products, medical nutrition services, inpatient rehabilitation, travel strollers, and special needs car seats). CCP benefits also include expanded coverage of current Texas Medicaid services where services are subject to limitations (e.g., diagnosis restrictions for total parenteral nutrition [TPN] or diagnosis restrictions for attendant care services). CH-17

19 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 Requests for services that require a prior authorization must be submitted to TMHP. Prior authorization is a condition for reimbursement, not a guarantee of payment. For information about specific benefits, providers can refer to provider-specific sections of this manual. Payment cannot be made for any service, supply, or equipment for which FFP is not available. The following are some examples: Vehicle modification, mechanical, or structural (such as wheelchair lifts) Structural changes to homes, domiciles, or other living arrangements Environmental equipment, supplies, or services, such as room dehumidifiers, air conditioners, filters, space heaters, fans, water purification systems, vacuum cleaners, and treatments for dust mites, rodents, and insects Ancillary power sources and other types of standby equipment (except for technology-dependent clients such as those who are ventilator-dependent for more than six hours per day) Educational programs, supplies, or equipment (such as a personal computer or software) Equine or hippotherapy Exercise equipment, home spas or gyms, toys, therapeutic balls, or tricycles Tennis shoes Respite care (relief to caregivers) Aids for daily living (toothbrushes, spoons, reachers, and foot stools) Take-home drugs from hospitals (Eligible hospitals may enroll in and bill Vendor Drug Program (VDP). Pharmacies that want to enroll should call ) Therapy involving any breed of animal Prior Authorization and Documentation Requirements Prior authorization is a condition for reimbursement; it is not a guarantee of payment. A prior authorization number (PAN) is a TMHP-assigned number establishing that a service or supply has been determined to be medically necessary and for which FFP is available. It is each provider s responsibility to check the client s Medicaid Identification (Form H3087) at the time each service is provided to verify eligibility. Any service provided while the client is not eligible cannot be reimbursed by TMHP. The responsibility for payment of services is determined by private arrangements made between the provider and client. Prior authorization of CCP services may be requested in writing by completing the appropriate request form, attaching any necessary supportive documentation, and mailing or faxing it to the TMHP-CCP department. Prior authorization may also be requested through the TMHP website. (Providers can refer to subsection 5.4.1, Prior Authorization Requests Through the TMHP Website in Section 5, Prior Authorization (Vol. 1, General Information) for additional information to include, mandatory documentation, and retention requirements). All requested information on the form must be completed, or the request is returned to the provider. Incomplete forms are not accepted. If prior authorization is granted, the potential service provider (such as the DME supplier, pharmacy, registered nurse (RN), or physical therapist) receives a letter that includes the PAN, the procedures prior authorized, and the length of the authorization. Providers are notified in writing when additional information is needed to process the request for services. Written requests for prior authorization are mandatory for the following services: The purchase of apnea monitors and the rental of apnea monitors for clients who are 5 months of age and older or after an initial two months of rental Diapers, wipes, and underpads for clients who are birth through 3 years of age CH-18

20 CHILDREN S SERVICES HANDBOOK Customized and noncustomized DME not authorized under Texas Medicaid (Title XIX) Home Health Services Formula for a client who is birth through 20 years of age if the client does not have a gastrostomy (G-tube)/jejunostomy or nasogastric tube or a metabolic disorder Inpatient freestanding psychiatric services Inpatient freestanding rehabilitation services Gastrostomy buttons (G-buttons) not authorized under Texas Medicaid (Title XIX) Home Health Services Non-face-to-face clinician-directed care coordination services Orthotics and prosthetics PDN PCS Prior authorization requests for PCS services can only be submitted by DSHS. Providers can refer to subsection 2.8, Personal Care Services (PCS) (CCP) in this handbook for the authorization criteria. OT, PT, ST services TPN Providers must submit a CCP Prior Authorization Request Form and documentation to support medical necessity to the CCP department before providing services. Providers must submit the CCP Prior Authorization Request Form when requesting a medically necessary service if the service is not addressed in the Texas Medicaid Provider Procedures Manual and the client is 20 years of age or younger. Important: Documentation to support medical necessity of the service, equipment, or supply (such as a prescription, letter, or medical records) must be current, signed, and dated by a physician (M.D. or D.O.) before services are performed. Providers must keep the information on file. Refer to: CCP provider-specific sections for prior authorization requirements of specific services Diagnosis Coding All providers must obtain the client s medical diagnosis from the physician. This information must be reflected on each claim submitted to TMHP using ICD-9-CM coding Drug and Medical Device Approval Manufacturers may request to have drug or medical device products added as a CCP benefit by sending the information in writing to the following address: HHSC 1100 West 49th Street Austin, TX HHSC reviews the information. Requests for consideration must not be sent to TMHP Physician Signature The dated signature of the physician (M.D. or D.O.) on a prescription or CCP Authorization Request Form must be current to the service date(s) of the request, i.e., the signature must always be on or before the service start date and no older than three months before the current date(s) of service requested. Physician signatures dated after the service start date on initial requests cannot be accepted as documentation supporting medical necessity for dates of service prior to the signature date. A request for prior CH-19