Workshop Participant Guide. Medicaid: Beyond the Basics. Presented by: v

Transcription

1 Workshop Participant Guide Medicaid: Beyond the Basics Presented by: v

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3 Contents Texas Medicaid... 1 Third-Party Resources... 2 Medicaid Electronic Programs... 5 Electronic Health Records Incentive Program... 5 Eligibility Eligible Professionals... 5 Eligibility Eligible Hospitals... 6 Enrollment... 6 Resources for Additional Information... 6 E-Prescribing... 7 Medicare... 8 Medicare Participation with Medicaid... 8 Medicare Participation... 8 Medicare Part A... 9 Medicare Part B... 9 Medicare Part C... 9 Medicare Part D Medicare and Medicaid Dual Eligibility Medicare Claims Paper Crossovers Claims Texas Dual Eligible Integrated Care Project Crossover Professional Claim Type Crossover Outpatient Facility Claim Type Return to Provider Correspondence Example of Provider Letter Prior Authorization Missing or Incomplete Requests Prior Authorization Requests for Clients with Other Insurance Primary to Medicaid Guidelines Prior Authorization Quick Reference Prior Authorization Forms by Department Radiology Ambulance CCP Dental Home Health Special Medical Prior Authorizations (SMPA) v CPT only copyright 2014 American Medical Association. All rights reserved. i

4 Outpatient Services Children with Special Health Care Needs (CSHCN) Services Program Other Important Forms Remittance and Status Reports Delivery Options Accessing Remittance and Status Reports Locating PDF R&S Reports R&S Reports: Banner Pages R&S Reports: Claims Paid or Denied How to Read an Internal Control Number (ICN) Program Code Claim Type Media Type R&S Reports: Financial Transactions R&S Reports: The Following Claims Are Being Processed R&S Reports: Claims Payment Summary R&S Reports: Explanation of Benefits Codes Messages Explanation of Benefits Common Claim Denial EOB Codes R&S Reports: Mass Adjustments Mass Adjustments: Adjustments - Paid or Denied Balancing Your R&S Report Resources Instructions for Using the TMHP Website Searching the TMHP Website Information on the TMHP Website Functions on the TMHP Website Locating and Searching the Provider Manual Advanced Search Provider Bulletins and Banner Messages Online Provider Lookup Using the Online Provider Lookup (OPL) Tool to Find a Provider Using the Advanced Search in OPL Updating Address Information Online Fee Lookup Static Fee Schedules (OFL) Fee Search (OFL) Batch Search (OFL) ICD-10 Implementation NCCI Compliance Checking for Updates: ICD, HCPCS Procedure Codes, and NCCI guidelines Steps to Resolve Your Medicaid Questions Section 6401 of The Affordable Care Act (ACA) of Texas Women s Health Program (TWHP) ii CPT only copyright 2014 American Medical Association. All rights reserved. v

5 Overview Benefits Client Eligibility Provider Education TMHP Computer-Based Training THSteps Provider Education Provider Relations Representatives Hospital Initiatives Overview APR-DRGs APR-DRG Definitions POA Indicator Requirement Potentially Preventable Readmissions (PPR) PPR Calculation Methodology Potentially Preventable Complications (PPC) Reporting Resources Child and Elder Abuse, Neglect, or Exploitation DSHS Child Abuse Reporting Form Report Elder Abuse, Neglect, or Exploitation Waste, Abuse, and Fraud Definitions Most Frequently Identified Fraudulent Practices Identifying and Preventing Waste, Abuse, and Fraud Reporting Waste, Abuse, and Fraud Communication With Medicaid and State Programs TMHP Telephone and Fax Communication Prior Authorization Request Telephone and Fax Communication Prior Authorization Status Telephone Communication Written Communication With TMHP Medicaid Vendor Drug Program Pharmacies Can Dispense Limited Home Health Supplies (LHSS) to Medicaid Clients Some Vitamin and Mineral Products to Be Available Through VDP Pharmacies Helpful Links Terms/Acronyms/Abbreviations Frequently Asked Questions (FAQs) Tamper Resistant Prescriptions FAQs v CPT only copyright 2014 American Medical Association. All rights reserved. iii

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7 Texas Medicaid Texas Medical Assistance (Medicaid) was implemented on September 1, 1967, under the provisions of Title XIX of the federal Social Security Act and Chapter 32 of the Texas Human Resources Code. The State of Texas and the federal government share the cost of funding Texas Medicaid. Medicaid provides free health care coverage to millions of Texans, including low-income families and children, pregnant women, the elderly, and people with disabilities. The Health and Human Services Commission (HHSC), the single state Medicaid agency, is responsible for the Title XIX Program. The administration of Texas Medicaid is accomplished through contracts and agreements with medical providers, Texas Medicaid & Healthcare Partnership (TMHP), MAXIMUS, and various managed care organizations (MCOs). Medicaid providers are reimbursed for services through contracts with managed care organizations, fiscal agents, or direct vendor reimbursements. By signing an HHSC Medicaid Provider Agreement (through the enrollment process) and submitting Medicaid claims, each enrolled provider agrees to abide by the policies and procedures of Medicaid, published regulations, and information and instructions in provider manuals, web articles, and other instructional material furnished to the provider. v CPT only copyright 2014 American Medical Association. All rights reserved. 1

8 Third-Party Resources A third-party resource (TPR) is a source of payment for services other than Medicaid, Medicaid MCOs, Medicaid dental plans, the client, or non-tpr sources. Federal and state laws require the use of Medicaid funds for the payment of most medical services only after all reasonable measures have been made to use a client s third-party resources (TPR) or other insurance. To the extent allowed by federal law, a health-care service provider must seek reimbursement from available third party insurance that the provider knows about, or should know about, before billing Texas Medicaid. Client TPR and other insurance information may be verified using the Your Texas Benefits Medicaid card website at Providers that are aware that a client has other health insurance that is not indicated on the Your Texas Benefit Medicaid card website must notify TMHP of the details concerning the type of policy and scope of benefits. Providers and hospitals can notify TMHP by calling TPR at , Option 2; sending a fax to (512) ; or submitting the Other Insurance Form or the Tort Response Form for accidents to the following address: Texas Medicaid & Healthcare Partnership Third-Party Resources Unit PO Box Austin, TX CPT only copyright 2014 American Medical Association. All rights reserved. v

9 OTHER INSURANCE FORM Client Name: Client Medicaid Number: Insurance Company Name: Insurance Company Address 1: Insurance Company Address 2: Insurance Company Phone #: Policy Holder Name: Policy Number: Policy Holder SSN: Employer Name: Employer Phone: Group Number: Type of Coverage: Ins. Eff. Date: Ins. Term. Date: List any family members that are on the policy: COMMENTS: CONTACT: TMHP Third Party Resources (TPR) TMHP Third Party Resources (TPR) fax MAIL CORRESPONDENCE: Texas Medicaid & Healthcare Partnership TPR Correspondence Third Party Resources Unit PO Box Austin, TX F00047 Effective Date_ /Revised Date_ v CPT only copyright 2014 American Medical Association. All rights reserved. 3

10 Tort Response Form Client Information Today s date: / / Client ID number: Date of birth: / / Social Security Number: Last name: First name: Information Provided By: Attorney Insurance Provider Recipient DSHS HHSC Other Name: Accident Information Date of loss: / / Type of accident: Case comments: Telephone: Attorney Information Name: Contact name: Street Address: City: State: Zip Code: Telephone: Insurance Information Company name: Fax number: Contact name: Street Address: City: State: Zip Code: Adjuster s name: Policyholder: Telephone: Fax or Mail completed copy to: Claim number: Policy number: Fax number: Texas Medicaid & Healthcare Partnership Tort Department PO Box Austin, TX Fax: F00093 Effective Date_ /Revised Date_ CPT only copyright 2014 American Medical Association. All rights reserved. v

11 Medicaid Electronic Programs Electronic Health Records 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. EPs and EHs began participating in The last year a Medicaid EP or EH may begin participation in the program is 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 under the Medicaid EHR Incentive Program. Eligibility Eligible Professionals Eligible Professionals (EPs) under the Medicaid EHR Incentive Program include: Physicians (doctors of medicine [M.D.] and doctors of osteopathy [D.O.]). Dentists. Nurse practitioners (NP) (licensed by the Texas Board of Nursing as an NP). Certified nurse-midwives (CNM). Optometrist (authorized in Texas). 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 encounter volume must be from Medicaid clients 20 percent of a pediatrician s total encounter volume must be from Medicaid clients 30 percent of the total encounter volume must be from Medicaid clients, or needy individuals for an EP who works predominantly in an FQHC or RHC v CPT only copyright 2014 American Medical Association. All rights reserved. 5

12 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. Eligibility Eligible Hospitals 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 encounter volume. Children s hospitals do not have to have a minimum Medicaid encounter volume. Enrollment To participate, providers are required to enroll and attest to client encounter volumes and other eligibility criteria using the online portal available through TMHP.com. Providers must be actively enrolled and in good standing as a Medicaid provider. For more information on the Texas Medicaid EHR Incentive Program, refer to the TMHP website at 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 address, because communications will be provided during the enrollment process. After enrollment, providers may 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 Get step-by-step instructions for participating at Review information on certified EHR technology products at Get technical assistance through the Regional Extension Centers at Review additional program information at: The Texas Medicaid EHR Incentive Program website at The CMS EHR Incentive Program website at Sign up for updates at Enter your address and register. On the subscription topics page, go to the Projects section and select Health Information Technology. Submit questions by: Sending an to [email protected] (for Medicaid enrollment) or [email protected] (for program questions). Calling , option 4. 6 CPT only copyright 2014 American Medical Association. All rights reserved. v

13 E-Prescribing Medicaid: Beyond the Basics Participant Guide 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. In Texas, the percentage of physicians prescribing electronically increased from 10 percent in 2008 to 44 percent in Additionally, certain federal incentive programs are generating significant opportunities for providers to adopt E-Prescribing. For example, the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs allow for the payment of federal incentives to Medicaid and Medicare providers for the adoption and Meaningful Use of certified EHR technology. The use of E-Prescribing is a required element of the EHR Incentive Program and thus, providers who are eligible to receive the incentives must use E-Prescribing capabilities within their certified EHR. EHR Incentive payments began in The last year a Medicaid Eligible Professional (EP) or Eligible Hospital (EH) may begin participation in the program is Final payment can be received until 2021 for EPs and 2018 for EHs. Furthermore, as of October, 2013, the Texas Department of Public Safety (DPS) has allowed E-Prescribing of Controlled Substances (EPCS), including the E-Prescribing of Schedule II drugs. Electronically prescribing controlled substances allows for a streamlined E-Prescribing workflow, the reduction of fraud and abuse of controlled substances within Texas and meeting EHR Incentive Program E-Prescribing Meaningful Use requirements. Before beginning to electronically prescribe controlled substances, a provider must confirm that his E-Prescribing software application is EPCS certified, undergo identity proofing and be issued a two-factor identification credential. Currently, approximately 80 percent of Texas pharmacies are enabled for EPCS. 1 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. 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 are also 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. Certifications of E-Prescribing capabilities, including EPCS capabilities, require 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, including EPCS and pharmacies and software vendors who are certified for EPCS can be found on the Surescripts website at 1 State Regulatory Status & Pharmacy Enablement. (2015, April 28). Retrieved from v CPT only copyright 2014 American Medical Association. All rights reserved. 7

14 Medicare The Centers for Medicare & Medicaid Services (CMS) administers Medicare to nearly 50 million Americans. Medicare is the largest health insurance program in the nation, and benefits people who are 65 years of age and older. Medicare also serves some disabled people who are 64 years of age and younger as well as people with end-stage renal disease. Medicare Participation with Medicaid Medicare Participation Under federal law, Medicaid is the payer of last resort, so Medicare-eligible services must first be submitted to and dispositioned (paid or denied) by Medicare. Therefore, in order to be eligible to enroll in Texas Medicaid, a provider must be a Medicare-participating provider. Certain types of providers, however, are not required to meet the Medicare participation requirement, including the following: Note: The provider types are not required to obtain Medicare certification to enroll as a Medicaid provider. However, if Medicare certification is obtained during or after the completion of the Medicaid enrollment application, the provider will be required to submit a new application listing the Medicare certification information for enrollment in Medicaid. Obstetric and gynecology (OB/GYN) providers Pediatric providers Texas Health Steps (THSteps) medical and dental services providers Early Childhood Intervention providers Family Planning providers Comprehensive Care Program (CCP) providers Case Management for Children and Pregnant Women program providers Licensed professional counselors (LPCs) Licensed marriage and family therapists (LMFTs) Some types of providers may apply for an HHSC waiver of the Medicare participation requirement of the application process. The following types of providers are eligible to apply for this waiver: Audiologist Dentist (D.D.S or D.M.D) Physician Nurse Practitioner/Clinical Nurse Specialist (NP/CNS) Optometrist (OD) Orthotists Physician (MD) Physician Assistant (PA) Podiatrist Prosthetists 8 CPT only copyright 2014 American Medical Association. All rights reserved. v

15 Each required provider seeking enrollment must include a valid and current Medicare number in the Texas Medicaid Provider Enrollment Application, and must include with the application a copy of the provider s notice of Medicare participation. Each group and each performing provider of a Medicare group must have a current Medicare provider number. The group enrollment application must include the current and valid Medicare provider number for the group and for each performing provider in the group. Medicaid may reimburse for services provided to Medicare clients who are enrolled in Medicare Part A, B, C, or D. However, methods of reimbursement differ. Note: Only HHSC can approve the Medicare waiver. Medicare Part A Medicare Part A provides inpatient care to clients who are in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also provides hospice care and some home health care. The payment of the Medicare Part A coinsurance and deductibles for Medicaid clients who are Medicare beneficiaries is based on the following: If the Medicare payment amount equals or exceeds the Medicaid payment rate, Medicaid does not pay the Medicare Part A coinsurance or deductible on a Medicare crossover claim. If the Medicare payment amount is less than the Medicaid payment rate, Medicaid pays the Medicare Part A coinsurance or deductible, but the amount of the payment is limited to the lesser of the coinsurance or deductible or the amount remaining after the Medicare payment amount is subtracted from the Medicaid payment rate. Medicare Part B Medicare Part B provides medically necessary physician services and outpatient care. For Medicare crossover claims, Texas Medicaid reimburses the lesser of the following: The coinsurance and deductible payment. The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service. (If this amount is less than the deductible, then the full deductible is reimbursed instead.) If the Medicare payment is equal to or exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid does not make a payment for coinsurance. For Medicare Part B cost sharing obligations, all deductible obligations will be reimbursed at 100 percent of the deductible amount owed, even if the cost sharing comparison results in a lower payment. If Medicaid does not reimburse the coinsurance amount, the provider is not allowed to charge the client. Medicare Part C Medicare Advantage Plans (Part C) provide all of the client s Part A and Part B services and generally provide additional services. Medicare Part C provides services to clients through private insurance companies that have been approved by Medicare. v CPT only copyright 2014 American Medical Association. All rights reserved. 9

16 Contracted HHSC now contracts with the Medicare Advantage Plans (MAPs) and offers a per-client-permonth payment. The payment to the MAP includes all costs associated with the Medicaid cost sharing for dual-eligible clients. MAPs that contract with HHSC will reimburse providers directly for the cost-sharing obligations that are attributable to dual-eligible clients who are enrolled in the MAP. These reimbursements are included in the capitated rate paid to the MAP and must not be submitted to TMHP or charged to a Medicaid client. Providers are responsible for identifying the client s MAP contract number and Plan ID. The Plan ID identifies the product line that has been contracted with HHSC. MAPs that are contracted with HHSC reimburse providers directly for the cost-sharing obligations that are attributable to dual-eligible clients who are enrolled in the MAPs. A list of MAPs that have contracted with HHSC is available in the Medicare section of the TMHP website at The list is updated as additional plans initiate contracts. Non-Contracted For dual eligible clients who are enrolled in a Part C non-contracted MAP, TMHP is responsible for processing and reimbursement of secondary claims. Texas Medicaid reimburses professional and outpatient facility crossover claims the lesser of the following: The coinsurance and deductible amounts The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service Exception: Texas Medicaid will reimburse coinsurance liability for Medicaid Qualified Medicare Beneficiary clients on valid, assigned Medicare claims that are within the amount, duration, and scope of the Medicaid program, and would be covered by Medicaid when the services are provided, if Medicare did not exist. If the Medicare payment is equal to or exceeds the allowed Medicaid fee or encounter rate for the service, Texas Medicaid will not make a payment for coinsurance and deductible. Important: Medicaid payment of a client s coinsurance or deductible liabilities satisfies the Medicaid obligation to provide coverage for services that Medicaid would have paid in the absence of Medicare coverage. The client has no liability for any balance or Medicare coinsurance and deductible related to Medicaid-covered services. Full Amount of Part B and Part C Coinsurance and Deductible Reimbursed Exceptions Texas Medicaid reimburses the full amount of the Medicare Part B and Part C (noncontracted MAPs only) coinsurance and deductible for the following services: Note: Medicare Crossover Claims must be submitted on paper. All ambulance services Services rendered by psychiatrists, psychologists, and licensed clinical social workers Procedure codes R0070 and R0075 for services rendered by physicians Medicare Part D Medicare Part D offers optional drug benefits to all Medicare beneficiaries through private drug plans (PDPs) or Medicare HMOs. 10 CPT only copyright 2014 American Medical Association. All rights reserved. v

17 For dual-eligible clients, the Texas Medicaid Vendor Drug Program (VDP) reimburses VDPcontracted pharmacies for some of the categories of the outpatient wrap-around prescription drugs. Wrap-around drugs are drugs that are not a benefit of Medicare Part D. To be reimbursed by Medicaid, the drug must be listed on the HHSC Medicaid formulary list. The Texas Drug Code Index Formulary Drug Search lists all state health-care program formulary information and preferred drugs. Medicaid: Beyond the Basics Participant Guide The Enhanced Formulary List provides Medicaid-only formulary information, and it includes links from selected non-preferred drugs to the preferred drugs in that therapeutic class and clinical edit criteria. Epocrates provides access to free drug information through a variety of mobile devices, including mobile phones. To learn more about the basic-level Medicare prescription drug plans available in Texas, refer to the Texas MedicareRx website at To learn more about the Medicaid Vendor Drug Program see the Medicaid Vendor Drug Program section at the end of this guide. Medicare and Medicaid Dual Eligibility QMB/MQMB There are two categories of dual-eligible clients: Qualified Medicare Beneficiary (QMB) and Medicaid Qualified Medicare Beneficiary (MQMB). MQMB clients are eligible for traditional Medicaid benefits that are not benefits of Medicare in addition to Medicaid reimbursement of Medicare deductible or coinsurance. QMB clients are not eligible for Medicaid benefits but do qualify for the Medicare deductible and coinsurance liabilities. Medicare Claims When a service is a benefit of Medicare and Medicaid, 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 or deductible reimbursement from Medicaid must be considered payment in full. Providers must accept Medicare assignment to receive coinsurance and deductible amounts from 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 QMB or MQMB client. Providers accepting Medicare or Medicaid assignment cannot legally require the client to pay the Medicare coinsurance or deductible amounts. For crossover claims that are not transferred electronically, providers must submit a paper claim to TMHP. Paper Crossovers Claims Providers are allowed to submit Medicare primary paper claims to TMHP for reimbursement of coinsurance or deductible for claims that fail to cross over from Medicare electronically. v CPT only copyright 2014 American Medical Association. All rights reserved. 11

18 The following paper crossover claims must be submitted to TMHP: The Medicare Remittance Advice (RA) or Remittance Notice (RN), which is issued by Medicare The appropriate, completed paper CMS-1500 or UB-04 CMS-1450 paper claim form Providers that receive paper Medicare Remittance Advice Notices (MRANs) from Medicare or a Medicare intermediary or MRANs using the CMS-approved software Medicare Remit Easy Print (MREP), for professional services, or PC-Print, for institutional services, may submit these MRANs to TMHP. Providers that submit these MRANs are not required to submit the TMHP Standardized MRAN Form. Providers that cannot retrieve the MRAN from MREP or PC-Print, or who don t receive a paper MRAN from Medicare or a Medicare intermediary, must submit the TMHP Standardized MRAN Form. The TMHP Standardized MRAN form and form instructions are available in the current Texas Medicaid Provider Procedures Manual (TMPPM) and on the TMHP website at the following links: Note: The TMHP Standardized MRAN form must be typed or computer generated. Handwritten forms are not accepted and are returned to the provider. MRAN Type 30 Providers who bill professional services on the CMS-1500 paper claim form may submit the Crossover Claim Type 30 template with a copy of a completed claim form. Form and instructions: Template_CT_030.pdf MRAN Type 31 Providers who bill inpatient and outpatient crossover claims on a UB-04 CMS-1450 paper claim form may submit the Crossover Claim Type 31 template with a copy of a completed claim form. Form and instructions: Template_CT_031.pdf MRAN Type 50 Providers who bill inpatient crossover claims on a UB-04 CMS-1450 paper claim form may submit the Crossover Claim Type 50 template with a copy of a completed claim form. Form and instructions: Template_CT_050.pdf Texas Dual Eligible Integrated Crossover Care Professional Project Claim Type 30 The Texas Health and Human Services Commission (HHSC) is offering a new way to serve people who are eligible for both Medicare and Medicaid, known as dual eligibles. The goal of the project is to better coordinate the care those dual eligible members receive. Beginning April 1, 2015, dual eligible members in the Bexar, Dallas, El Paso, Harris and Tarrant service areas will be passively enrolled into a Medicare-Medicaid plan. Please visit the HHSC website to view the Medicare-Medicaid managed care plans that providers must contract with in order to receive reimbursement for dual eligible clients. For more information please visit: 12 CPT only copyright 2014 American Medical Association. All rights reserved. v

19 Crossover Professional Claim Type 30 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form 1 Billing Provider NPI/API: 2 Billing Provider TPI: 3 Billing Provider Name: 4 Billing Provider Medicare ID: 5 Medicaid Client Number: 6 Medicare Paid Date: 7 Client Last Name: 8 Client First Name: n. Reason Code m. Paid l. k. Ded j. Coins Allow 9 Medicare ICN: 10 Client HIC Number: 11 Detail(s) Information Dtl # a. Perf Prov TPI c. d. e. f. g. h. i. From DOS To DOS POS b. Perf Prov NPI SAMo Units CPT Mods Charges Totals Information a. Charges b. Allow Ec. c. Ded d. Coins e. Paid f. Total Pages SAMPLE PLE Crossover Professional Claim Type 30 of 13 Medicare Prev Paid Important: By submitting these forms to TMHP, the provider attests that the information included in the form exactly matches the Medicare RA or RN that was received from Medicare or the MAP. If the information on this crossover claim type form does not exactly match the information on the RA or RN, the claim may be denied. F00041 Effective / Revised v CPT only copyright 2014 American Medical Association. All rights reserved. 13

20 Crossover Professional Claim Type 30 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions Providers that bill professional services on the CMS-1500 paper claim form may submit the Crossover Professional Claim Type 30 template with a copy of a completed claim form. The Remittance Advice (RA) or Remittance Notice (RN) from Medicare, the CMS-approved software Medicare Remit Easy Print (MREP), or the MAP is required when submitting the Crossover Professional Claim Type 30 template. All fields (excluding Medicaid information fields) on the form must be completed using the RA or RN that was received from Medicare or the MAP. Important: All details from the Medicare or MAP RA or RN must be included in the template even if a deductible or coinsurance is not due. The TMHP Standardized MRAN Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Professional Claim Type 30 template: # Field Description Guidelines 1 Billing Provider NPI/API Enter the National Provider Identifier (NPI) for the billing provider. 2 Billing Provider TPI Enter the Medicaid Texas Provider Identifier (TPI) number of the billing provider. 3 Billing Provider Name Enter the billing provider s name. 4 Billing Provider Medicare ID 5 Medicaid Client Number Enter the Medicare Provider ID number of the billing provider listed on the Medicare or MAP RA/RN. Enter the client s nine-digit Medicaid number from the Medicaid identification form. 6 Medicare Paid Date Enter the Medicare Paid Date listed on the Medicare or MAP RA/RN. 7 Client Last Name Enter the client s last name listed on the Medicare or MAP RA/RN. 8 Client First Name Enter the client s first name listed on the Medicare or MAP RA/RN. 9 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the Medicare or MAP RA/RN. 10 Medicare HIC Number Enter the patient s Medicare Health Insurance Claim (HIC) number (Medicare Identification number). Note: Do not use the MAP ID number or any number other than the Medicare HIC number. 11 Details Information 11a Perf Prov TPI Enter the Texas Provider Identifier (TPI) number of the performing provider 11b Perf Prov NPI Enter the National Provider Identifier (NPI) for the performing provider 11c From DOS Enter the first date of service (DOS) for each procedure in a MM/DD/YYYY format. 11d To DOS Enter the last DOS for each procedure in a MM/DD/YYYY format. 11e POS Enter the place of service (POS) listed on the MAP Remittance Advice/Remittance Notice. 11f Units Enter the number of units (quantity billed) from the Medicare or MAP RA/RN. 11g CPT Enter the appropriate Current Procedural Terminology (CPT) procedure code for each procedure/service listed on the Medicare or MAP RA/RN Note: The procedure code that is listed on the Standardized MRAN Template may not match the procedure code that is listed on the attached claim form. 11h Mods Enter the modifier (when applicable) listed on the Medicare or MAP RA/RN for each detail. 11i Charges Enter the Medicare charges (billed amount) listed on the Medicare or MAP RA/RN for each detail. 11j Allow Enter the Medicare allowed amount listed on the Medicare or MAP RA/RN for each detail. 11k Ded Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN for each detail. 11l Coins Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN for each detail. F00041 Effective / Revised CPT only copyright 2014 American Medical Association. All rights reserved. v

21 Crossover Professional Claim Type 30 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions 11m Paid Enter the Medicare paid amount listed on the Medicare or MAP RA/RN for each detail. 11n Reason Code Enter Medicare s reason code listed on the Medicare or MAP RA/RN for each detail. 12 Totals Information 12a Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. Note: A provider may attach additional template forms (pages) as necessary. The combined total charges for all pages should be listed on the last page. All other forms must indicate Continue in this block. 12b Total Allow Enter the Medicare total allowed amount listed on the Medicare or MAP RA/RN. 12c Total Ded Enter the Medicare total deductible amount listed on the Medicare or MAP RA/RN. 12d Total Coins Enter the Medicare total coinsurance amount listed on the Medicare or MAP RA/RN. 12e Total Paid Enter the Medicare total paid amount listed on the Medicare or MAP RA/RN. 12f Total Pages If the crossover claim contains more than 7 detail line items, use multiple pages to identify up to 28 detail line items for the claim (as necessary). Add the number of the pages in the first blank line and the total page count in the second blank line (e.g., 1 of 3, 2 of 3, 3 of 3 ). This field is only required if multiple pages were necessary to capture all of the billed detail line items. If multiple pages are necessary, Boxes 1-10 must be completed on each page that is submitted. 13 Medicare Prev Paid Enter the Medicare previous paid amount listed on the Medicare or MAP RA/RN. F00041 Effective / Revised v CPT only copyright 2014 American Medical Association. All rights reserved. 15

22 1 Medicare Paid Date: Crossover Outpatient Facility Claim Type 31 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form 2 Provider Name: 3 NPI/API: 4 TPI: 5 Medicare ID: 6 Street Address: City: State: ZIP: 7 Bill Type: 8 From DOS: 9 Through DOS: 10 Client Last Name: 11 Client First Name: 12 Medicare HIC: 13 Medicare ICN: AM19 14 Total Charges: 15 Covered Charges: 16 Non Covered Charges/Reason Code: 17 Deductible: 18 Blood Deductible: 19 Coinsurance: 20 Paid Amount Medicare: 21 Detail(s) Information a. Rev Cd b. CPT/Mods d. From DOS e. Units f. Charges g. Allow h. Ded i. Coins j. Blood Ded k. Paid l. Reason Code SAMPL MPL PLE DOS:SA 22 Totals Information a. Charges b. Allow c. Ded d. Coins e. Blood Ded f. Paid g. Total Pages of Important: By submitting these forms to TMHP, the provider attests that the information included in the form exactly matches the Medicare RA or RN that was received from Medicare or the MAP. If the information on this crossover claim type form does not exactly match the information on the RA or RN, the claim may be denied. F00042 Effective / Revised CPT only copyright 2014 American Medical Association. All rights reserved. v

23 Crossover Outpatient Facility Claim Type 31 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions Providers that bill outpatient crossover claims on the UB-04 CMS-1450 paper claim form may submit the Crossover Outpatient Facility Claim Type 31 template with a copy of a completed claim form. The Remittance Advice (RA) or Remittance Notice (RN) from Medicare, the CMS-approved software PC-Print, or the MAP is required when submitting the Crossover Outpatient Facility Claim Type 31 template. All fields (excluding Medicaid information fields) on the form must be completed using the RA or RN that was received from Medicare or the MAP. Important: All details from the Medicare or MAP RA or RN must be included in the template even if a deductible or coinsurance is not due. The TMHP Standardized MRAN Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Outpatient Facility Claim Type 31 template: # Field Description Guidelines 1 Medicare Paid Date Enter the Medicare Paid Date listed on the Medicare RA/RN. 2 Provider Name Enter the billing provider s name. 3 NPI/API Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API) for the billing providers. 4 TPI Enter the Texas Provider Identifier (TPI) for the billing provider. 5 Medicare ID Enter the Medicare Provider ID of the billing provider number listed on the Medicare or MAP RA/RN. 6 Street Address, City, State, ZIP Enter the billing provider s street address, city, state, and ZIP code in the appropriate fields. 7 Bill Type Enter the Medicare Bill Type listed on the Medicare or MAP RA/RN. Note: The Medicare Bill Type may not match the type of bill (TOB) listed on the claim form. 8 From DOS Enter the first date of service (DOS) for all procedures in a MM/DD/YYYY format. 9 Through DOS Enter the last DOS for all procedures in a MM/DD/YYYY format. 10 Client Last Name Enter the patient s last name listed on the Medicare or MAP RA/RN. 11 Client First Name Enter the patient s first name listed on the Medicare or MAP RA/RN. 12 Medicare HIC Number Enter the patient s Medicare Health Insurance Claim (HIC) number (Medicare Identification number). Note: Do not use the MAP ID number or any number other than the Medicare HIC number. 13 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the Medicare or MAP RA/RN. 14 Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. 15 Covered Charges Enter the covered charges listed on the Medicare or MAP RA/RN. 16 Non Covered Charges/Reason Code Enter the noncovered charges listed on the MAP RA/RN followed by the reason code listed on the Medicare RA/RN. 17 Deductible Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN. 18 Blood Deductible Enter the blood deductible listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a blood deductible amount. 19 Coinsurance Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN. 20 Medicare Paid Amount Enter the Medicare paid amount listed on the Medicare or MAP RA/RN. 21 Detail(s) Information 21a Rev Cd F00042 Effective / Revised v CPT only copyright 2014 American Medical Association. All rights reserved. 17

24 Crossover Outpatient Facility Claim Type 31 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions 21b CPT Enter the appropriate Current Procedural Terminology (CPT) procedure code for each procedure/service listed on the Medicare or MAP RA/RN Note: The procedure code listed on the Standardized MRAN Template may not match the procedure code listed on the claim form attached. 21c Mods Enter the modifier (when applicable) listed on the Medicare or MAP RA/RN for each detail. 21d From DOS Enter the first date of service (DOS) for each procedure in a MM/DD/YYYY format. 21e Units Enter the number of units (quantity billed) from the Medicare or MAP RA/RN. 21f Charges Enter the Medicare charges (billed amount) listed on the Medicare or MAP RA/RN for each detail. 21g Allow Enter the Medicare allowed amount listed on the Medicare or MAP RA/RN for each detail. 21h Ded Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN for each detail. 21i Coins Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN for each detail. 21j Blood Ded Enter the Medicare blood deductible amount listed on the Medicare or MAP RA/RN for each detail. 21k Paid Enter the Medicare paid amount listed on the Medicare or MAP RA/RN for each detail. 21l Reason Code Enter Medicare s reason code listed on the Medicare or MAP RA/RN for each detail. 22 Totals Information 22a Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. Note: A provider may attach additional template forms (pages) as necessary. The combined total charges for all pages should be listed on the last page. All other forms must indicate Continue in this block. 22b Total Allow Enter the Medicare total allowed amount listed on the Medicare or MAP RA/RN. 22c Total Ded Enter the Medicare total deductible amount listed on the Medicare or MAP RA/RN. 22d Total Coins Enter the Medicare total coinsurance amount listed on the Medicare or MAP RA/RN. 22e Total Blood Ded Enter the Medicare total blood deductible amount listed on the Medicare or MAP RA/RN. 22f Total Paid Enter the Medicare total paid amount listed on the Medicare or MAP RA/RN. 22g Total Pages If the crossover claim contains more than 10 detail line items, use multiple pages to identify up to 28 detail line items for the claim as necessary. Add the number of the page in the first blank line and the total page count in the second blank line (e.g., 1 of 3, 2 of 3, 3 of 3. This field is only required if multiple pages are necessary to capture all billed detail line items. If multiple pages are necessary, Boxes 1-6 must be completed on each page submitted. F00042 Effective / Revised CPT only copyright 2014 American Medical Association. All rights reserved. v

25 Crossover Inpatient Hospital Claim Type 50 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form 1 Medicare Paid Date: 2 Provider Name: NPI/API: TPI: Medicare ID: 3 Street Address: 4 City: State: ZIP: 5 Bill Type 6 From DOS 7 Through DOS 8 Client Last Name 9 Client First Name 10 Medicare HIC 11 Medicare ICN 12 Total Charges 13 Covered Charges 14 Non Covered Charges/Reason Code 15 DRG Amount 16 Deductible 17 Blood Deductible SAMPLE LE 18 Coinsurance 19 Medicare Paid Amount 20 DRG Code Crossover Inpatient Hospital Claim Type 50 Important: By submitting these forms to TMHP, the provider attests that the information included in the form exactly matches the Medicare RA or RN that was received from Medicare or the MAP. If the information on this crossover claim type form does not exactly match the information on the RA or RN, the claim may be denied. F00043 Effective / Revised v CPT only copyright 2014 American Medical Association. All rights reserved. 19

26 Crossover Inpatient Hospital Claim Type 50 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions Providers that bill inpatient crossover claims on the UB-04 CMS-1450 paper claim form may submit the Crossover Inpatient Hospital Claim Type 50 template with a copy of a completed claim form. The Remittance Advice (RA) or Remittance Notice (RN) from Medicare, the CMS-approved software PC-Print, or the MAP is required when submitting the Crossover Inpatient Hospital Claim Type 50 template. All fields (excluding Medicaid information fields) on the form must be completed using the RA or RN that was received from Medicare or the MAP. Important: All details from the Medicare or MAP RA or RN must be included in the template even if a deductible or coinsurance is not due. The TMHP Standardized MRAN Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Inpatient Hospital Claim Type 50 template: # Field Description Guidelines 1 Medicare Paid Date Enter the Medicare Paid Date listed on the Medicare RA/RN. 2 Provider Name Enter the billing provider s name. NPI/API/TPI Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API)/Texas Provider Identifier (TPI) for the billing provider. Note: NPI/TPI or API/TPI. Medicare ID Enter the Medicare Provider ID of the billing provider number listed on the Medicare or MAP RA/RN. 3 Street Address Enter the billing provider s street address. 4 City Enter the billing provider s city. State ZIP Enter the billing provider s state. Enter the billing provider s ZIP code. 5 Bill Type Enter the Medicare Bill Type listed on the Medicare or MAP RA/RN. Note: The Medicare Bill Type may not match the type of bill (TOB) listed on the claim form. 6 From DOS Enter the first date of service (DOS) for all procedures in a MM/DD/YYYY format. 7 Through DOS Enter the last DOS for all procedures in a MM/DD/YYYY format. 8 Client Last Name Enter the patient s last name listed on the Medicare or MAP RA/RN. 9 Client First Name Enter the patient s first name listed on the Medicare or MAP RA/RN. 10 Medicare HIC Number Enter the patient s Medicare Health Insurance Claim (HIC) number (Medicare Identification number).. Note: Do not use the MAP ID number or any number other than the Medicare HIC number. 11 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the Medicare or MAP RA/RN. 12 Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. 13 Covered Charges Enter the covered charges listed on the Medicare or MAP RA/RN. 14 Non Covered Charges/Reason Code Enter the noncovered charges listed on the MAP RA/RN followed by the reason code listed on the Medicare RA/RN. 15 DRG Amount Enter the diagnosis-related group (DRG) amount listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG amount. 16 Deductible Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN. 17 Blood Deductible Enter the blood deductible listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a blood deductible amount. 18 Coinsurance Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN. 19 Medicare Paid Amount Enter the Medicare paid amount listed on the Medicare or MAP RA/RN. 20 DRG Code Enter the DRG code listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG code. F00043 Effective / Revised CPT only copyright 2014 American Medical Association. All rights reserved. v

27 Return to Provider Correspondence Claims are returned to providers for a number of reasons. When TMHP receives a claim or appeal, it is initially reviewed by a document preparation clerk. If the document preparation clerk determines that the claim cannot be processed as received, the claim is sorted as Return to Provider (RTP) correspondence and it is scanned into the system. Once the claim is scanned into the system, a mailroom specialist retrieves the RTP correspondence and performs a second review of the claim. If the claim does not meet the sort criteria, the mailroom specialist will manually enter the patient control number (PCN) and provider information into the system along with the return reason. A quality analyst performs a final review of every claim. If the quality analyst also determines that the claim does not meet the sort criteria, the claim is processed as RTP correspondence using the provider information and the reason(s) previously entered by the mailroom specialist. An RTP letter is generated and the RTP letter, claim, and supporting documentation are sent back to the submitting provider. The examples below represent the most frequently used RTP messages. These messages are printed in the Your correspondence is being returned for the following reason(s) section of the RTP letter. 1. The MRAN that was submitted is not in the approved format. All paper Medicare crossover claims must be submitted with one of the following HHSC-approved MRANs, MRAN printed from Medicare Remit Easy Print (MREP) (professional services) or PC-Print (institutional services), paper MRAN received from Medicare or a Medicare intermediary or the TMHP Standardized MRAN Form. 2. The TPI on the attached claim(s) is missing or invalid. Refer to the Claims Filing sections of the TMPPM or the CSHCN Services Program Provider Manual. 3. A completed claim form must be attached to crossover claims. 4. The only acceptable R&S Reports are those generated by TMHP. Providers must follow the appeals process outlined in the TMPPM or the CSHCN Services Program Provider Manual. 5. The attached R&S Report is not legible or is not aligned and cannot be scanned into the system for processing. Correct the R&S Report prior to resubmission. 6. The service(s) were filed on an incorrect claim form. Refer to the TMPPM or the CSHCN Services Program Provider Manual and resubmit the corrected claim and applicable documentation, if any. 7. Medicare paper claims (including Medicare denials) must be filed with a completed claim form and one of the approved Medicare Remittance Notices. v CPT only copyright 2014 American Medical Association. All rights reserved. 21

28 8. The R&S Report submitted contains Explanation of Pending Status (EOPS) codes. EOPS codes indicate that your claim is currently in process and should not be resubmitted to TMHP. You must submit an R&S Report that indicates the claim has been finalized (paid or denied) and contains EOB codes. 9. Attach a completed claim form with your Rejection Report circling only one claim per page, using only black ink for claims that have been electronically rejected. For Rejection Reports containing multiple claims per page, you must make multiple copies of the Rejection Report and circle only one claim per page. Note: The electronic rejection report submitted must contain a TMHP Batch Number. 10. For items listed in the Financial section of the R&S Report that you wish to have reprocessed; copy, complete, and attach the Refund Information Form and a check in the appropriate amount to the R&S Report. The Refund Information Form can be found in the Forms Appendix of the TMPPM or the CSHCN Services Program Provider Manual. 11. TMHP cannot identify the enclosed documents because they are not accompanied by a claim or an R&S Report. Resubmit the information on the appropriate claim form. For submissions other than claims and appeals, refer to the TMPPM or the CSHCN Services Program Provider Manual for the appropriate department information. 12. TMHP cannot process multiple Medicare primary claims indicated on the same page. Providers must indicate only one claim per form, using only black ink when using any of the HHSC-approved MRANs. 13. TMHP cannot process multiple claims indicated on the same R&S Report page. Circle one claim per page on the R&S Report using only black ink. If you have multiple claims on the same page on the R&S Report, you must make multiple copies and circle only one claim per page. 14. The attached claim(s) is not legible or is not aligned and cannot be scanned into the system for processing. Correct the claim(s) prior to resending. 15. The attached MRAN is not legible or is not aligned and cannot be scanned into the system for processing. Correct the MRAN prior to resending. 16. The attachment is not legible or is not aligned and cannot be scanned into the system for processing. Correct the attachment prior to resending. 17. The attached claim(s) or document(s) is damaged and cannot be processed. Correct the claim or document prior to resending. 18. Claims filed secondary to Medicare on an approved HHSC MRAN form must not have any details crossed out. Medicaid must process secondary claims in their entirety. 19. The attached dental claim(s) cannot be processed because the Request for Predetermination/ Preauthorization field was checked. For authorization requests, refer to the Appendices of the TMPPM and the CSHCN Services Program Provider Manual for the appropriate form. 20. The client name or date of service on the claim does not match the client name and/or date of service on the attachment. Resubmit the claim with an attachment that has the same client name and/or date of service. 21. The attached claim(s) or document(s) was submitted on paper smaller or larger than 8½ x 11. Resubmit on the correct sized paper. 22 CPT only copyright 2014 American Medical Association. All rights reserved. v

29 22. Information on the attached claim(s) or document(s) is highlighted, or printed in red ink. Resubmit the claim or document using black ink and do not highlight any information. 23. Providers must not cross out any details on the R&S Report or MRAN. Resubmit the R&S Report or MRAN circling one claim per page using black ink. 24. The attached claims were not separated from each other. Resubmit after separating each claim. Medicaid: Beyond the Basics Participant Guide 25. TMHP does not accept handwritten TMHP Standardized MRAN forms. Resubmit a typed or computer-generated TMHP Standardized MRAN form. 26. The attached Durable Medical Equipment (DME) Certification of Receipt Form is incomplete. One or more of the following fields is missing: Client Name, Medicaid ID, Telephone Number, Provider Name, National Provider Identifier (NPI), Texas Provider Identifier (TPI), Date of Service (DOS), Procedure Code, Prior Authorization Number, and/or Serial Number. Complete all fields on the form, indicate N/A for fields that are not applicable, and resubmit the completed form. 27. Your resubmission is being returned due to repeated incorrect claims submissions. If you would like assistance with the claims submission process, refer to the TMPPM or the CSHCN Services Program Provider Manual. Additional assistance is available by calling the TMHP Contact Center at or the TMHP-CSHCN Contact Center at TMHP cannot process your R&S Report because the submitted R&S Report does not include the complete claim information. Resubmit a complete R&S Report with all the necessary claim information including the Internal Control Number (ICN). v CPT only copyright 2014 American Medical Association. All rights reserved. 23

30 Example of Provider Letter Mailroom 12357B Riata Trace Parkway Austin, Texas Address Julian Date Clerk# Mailroom Date Any and all information and/or documentation submitted in response to this letter must be received by Texas Medicaid & Healthcare Partnership (TMHP) within 120 days from the date of this letter. Information and/or documentation not received within 120 days will cause your claims to deny. You must attach a copy of this letter with each claim re-submission to show proof of timely filing. No further action will be taken by TMHP until the information requested below has been provided and/or corrected. Your correspondence is being returned for the following reason(s): Not enrolled in the Texas Medicaid Program or need an additional provider number for a new location? Visit for an enrollment application or call TMHP Customer Service at (option 3#). DO 1) Use 10x13 inch envelopes to mail claims. 2) Circle only one claim per page, when sending Remittance Advice (RA) from Medicare. Claims Normally filed on a UB92 must accompany the Medicare RA. 3) Use black ink only (not a black marker). 4) Place the claim form on top when sending new claims, followed by any medical records or attachments. 5) Number pages appropriately when sending attachments, (e.g. 1 of 2, 2 of 2). 6) Paper clip claims or appeals if they include attachments. 7) Detach claims at perforated lines before mailing. 8) Indicate continuation when multiple claims for the same client. DON T 1) Fold claims, appeals or correspondence. 2) Send duplicate copies of information. 3) Use red ink. Red ink does not scan and is difficult to read. 4) Use paper sizes smaller or larger than 8-1/2 x 11. Scan equipment will only accept 8-1/2 x 11 paper, including memos and photos. 5) Mail claims with correspondence for other departments as this may delay processing the claims. 6) Use glue, tape or staples. 7) Use highlighters. Scan equipment will not pick up highlighted information. Circle the information instead. 8) Total each claim when the claim is a continuation of multiple claims for the same client. PROVIDER LETTER21.doc 03/04 24 CPT only copyright 2014 American Medical Association. All rights reserved. v

31 Prior Authorization Some Medicaid services require prior authorization as a condition for reimbursement. Information about whether a service requires prior authorization, as well as the prior authorization criteria, guidelines, and timelines for the service, is contained in the appropriate handbooks in the TMPPM that contain the service. Prior authorization is not a guarantee of reimbursement. Even if a prior authorization has already been approved, reimbursement can be affected for a variety of reasons (e.g., the client is ineligible on the DOS or if the claim is incomplete). In most circumstances, prior authorization must be approved before the service is provided. Prior authorization for urgent and emergency services that are provided after business hours, on a weekend, or on a holiday must be requested on the next business day. Some services may allow different timelines to obtain an authorization for urgent and emergent conditions. The provider should consult the appropriate provider manual for additional information. Business hours are Monday through Friday, from 8:00 a.m. to 5:00 p.m., Central Standard Time. Prior authorization requests that do not meet these deadlines may be denied. To avoid unnecessary prior authorization denials, the request must contain correct and complete information, including documentation for medical necessity. The documentation of medical necessity must be maintained in the client s medical record. The requesting provider may be asked for additional information to clarify or complete a request for prior authorization. Before submitting a prior authorization request or providing an authorized service, the provider must verify the client s eligibility using TexMedConnect or Automated Inquiry System (AIS). Any service provided while the client is not eligible cannot be reimbursed by Texas Medicaid. Providers are responsible for knowing which services require prior authorization. Prior authorizations may be requested electronically using the online portal, by telephone, by fax, or by mail, depending on the type of authorization being requested. 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 federal financial participation (FFP) is available. If prior authorization is granted, the potential service provider (i.e., the DME supplier, pharmacy DME supplier provider, registered nurse [RN], or therapist) receives a letter or notification of approval via the TMHP website, that includes the PAN, the procedures prior authorized, the amount authorized, and the length of the authorization. Providers are notified in writing when additional information is needed to process the request for prior authorization of services. Most prior authorization departments also send client notification letters. All requested information on the form must be completed. If an incomplete authorization request is received, it will be returned to the provider or it will be entered into the system as pending, and a letter will be faxed or mailed to the provider. v CPT only copyright 2014 American Medical Association. All rights reserved. 25

32 Missing or Incomplete Requests Providers will have 14 business days from the request receipt date to respond to an incomplete prior authorization request. Incomplete prior authorization requests are requests received by TMHP with missing, incomplete, or illegible information. Prior to denying an incomplete request, TMHP s Prior Authorization (PA) department will continue to communicate with the requesting provider in an effort to obtain the required additional information. A minimum of three attempts will be made to contact the requesting provider before a letter is sent to the client regarding the status of the request and the need for additional information. If the additional information needed to make a prior authorization determination is not received within 14 business days from the request receipt date, the request will be denied as incomplete. To ensure timely processing, providers should respond to requests for missing or incomplete information as quickly as possible. Prior Authorization Requests for Clients with Other Insurance Primary to Medicaid If a Medicaid client has other health insurance, the provider must submit claims to the client s other insurance prior to billing Medicaid. If a Medicaid-covered service requires prior authorization by Medicaid, the prior authorization must be requested before providing the service whether the other insurance requires prior authorization or not. Medicaid will deny the claim if it isn t dispositioned by the other insurance. One exception is that THSteps Medical and Dental providers are not required to bill other insurance before billing Medicaid. The provider has several billing options. For complete details, see the TMPPM, Children s Services Handbook, Medical Claims Section, and Dental Third Party Resources (TPR) sections. If a client s primary health-care benefit is Medicare, providers must always confirm with Medicare whether a service is a benefit for the client. If a service that requires prior authorization from Medicaid is a Medicare benefit and Medicare approves the service, prior authorization from TMHP is not required for reimbursement of the coinsurance or deductible. If Medicare denies the service, then Medicaid prior authorization is required. TMHP must receive a prior authorization request within 30 days of the date of Medicare s final disposition. The Medicare Remittance that contains Medicare s final disposition must accompany the prior authorization request. If a service that requires prior authorization for Medicaid is not a benefit of Medicare, providers may request a prior authorization from TMHP before they receive a denial from Medicare. If the service is a Medicaid-only service, prior authorization is required. 26 CPT only copyright 2014 American Medical Association. All rights reserved. v

33 Guidelines Medicaid: Beyond the Basics Participant Guide When submitting authorization requests, providers should use the following guidelines or refer to the TMPPM. 1. Use legible forms. When faxing or mailing an authorization request, providers must use a form that is legible. Illegible copies of forms will be returned to the provider. 2. Ensure that the current authorization request form is being used. Requests received on out-of-date forms will be returned to the provider. 3. Ensure that all fields on the form are complete and legible. If an illegible authorization is received, it will be returned to the provider. 4. Ensure that the physician s signature and dates on the form are original and hand written (stamped signatures and dates are not accepted). 5. Submit the authorization request to the correct department. Authorizations received by the wrong department will be returned to the provider. 6. All faxes must include a working fax number to receive faxed responses or correspondence from TMHP and the last four digits of the client s Medicaid or CSHCN Services Program Identification number on the fax coversheet. Note: If no response has been received within three business days after the date that the prior authorization was submitted, providers are encouraged to call TMHP. v CPT only copyright 2014 American Medical Association. All rights reserved. 27

34 Prior Authorization Quick Reference Prior Authorization Department Ambulance Authorization Unit Comprehensive Care Program (CCP) Authorization Unit Description Telephone Fax Mailing Address The Ambulance Authorization Unit processes requests for nonemergency transport. Ambulance authorizations are received by telephone, by fax, and electronically through the TMHP website. The Comprehensive Care Program (CCP) Authorization Unit considers any health-care service or item, for a Texas Medicaid client who is birth through 20 years of age, when the service or item is not covered under another Medicaid benefit and when such service or item is medically necessary and federal financial participation (FFP) is available. The CCP Authorization Unit also considers expanded coverage for current Texas Medicaid services or items when those services or items are subject to limitations (e.g., diagnosis restrictions or quantity). The CCP unit reviews authorization requests received by fax, mail, and submitted electronically through the TMHP website; the CCP unit does not review requests received by telephone (For requests from hospitals only) (Use for CCP authorization status and general information. This telephone number may not be used to request authorization) (512) N/A (512) Texas Medicaid & Healthcare Partnership Comprehensive Care Program Authorization Unit PO Box Austin, TX Note: Personal Care Services can only be authorized by DSHS. Home Health Authorization Unit The Home Health unit reviews authorization requests for some services received by telephone, by fax, by mail, and electronically through the TMHP website. Prior authorizations may be requested for expendable medical supplies, DME, intermittent skilled nursing and aide visits, and occupational or physical therapy visits. Note: All Home Health services that require prior authorization may be requested electronically through the TMHP website. Refer to the current TMPPM, Vol. 1, General Information for a list of Home Health prior authorizations that may be requested electronically through the TMHP website (Use to request prior authorization) (Use for Home Health authorization status and general information. This telephone number may not be used to request authorization) (512) Texas Medicaid & Healthcare Partnership Home Health Services PO Box Austin, TX CPT only copyright 2014 American Medical Association. All rights reserved. v

35 Prior Authorization Department Personal Care Services (PCS) Description Telephone Fax Mailing Address PCS are support services provided to clients who meet the definition of medical necessity and require assistance with the performance of activities of daily living, instrumental activities of daily living, and health-related functions due to a physical, cognitive, or behavioral limitation related to a client s disability or chronic health condition (Use for PCS authorization status and general information. This telephone number may not be used to request authorization) N/A N/A Radiology Services Prior/Retro Authorization Unit Comprehensive Care Inpatient Psychiatric Authorization Unit (CCIP) PCS are provided by someone other than the legal responsible adult of the client who is a minor child or the legal spouse of the client. Note: PCS authorizations can only be submitted to TMHP by DSHS. All computed tomography (CT), computed tomography angiography (CTA), magnetic resonance (MR), magnetic resonance angiography (MRA), positron emission tomography (PET), and cardiac nuclear imaging requests are submitted to MedSolutions at (telephone), or (fax). MedSolutions is the TMHP subcontractor that issues radiology authorizations. Comprehensive Care inpatient Psychiatric Unit Processes Inpatient Psychiatric Hospital/Facility (Freestanding) services requests for medically necessary items and services ordinarily furnished by a Medicaid psychiatric hospital/facility or by an approved out-of-state hospital under the direction of a psychiatrist for the care and treatment of inpatient psychiatric clients who are birth through 20 years of age at the time of the service request and service delivery (CCIP processes requests for traditional Medicaid clients). CCIP prior authorizations may be submitted by fax, by mail, or electronically through the TMHP website. Notifications of late admissions maybe submitted by telephone Texas Medicaid & Healthcare Partnership 730 Cool Springs Blvd, Suite 800 Franklin, TN (512) Comprehensive Care Program Prior Authorization B Riata Trace Parkway, Suite 150 Austin, Texas v CPT only copyright 2014 American Medical Association. All rights reserved. 29

36 Prior Authorization Department Substance Abuse Unit Dental Authorization Unit Special Medical Authorization Unit Children with Special Health Care Needs Services Program (CSHCN) Authorization Unit Description Telephone Fax Mailing Address The Substance Abuse unit reviews prior authorizations received by fax for substance use disorder services. In addition, substance use disorder services requests may be submitted electronically. The Dental Authorization Unit processes all requests for prior authorization for dental services and orthodontia. All mailed requests for prior authorization are received by the TMHP mailroom. Requests for orthodontia must include the request form, X- rays or photographs. The Special Medical Prior Authorization unit reviews prior authorization requests for extended outpatient psy chotherapy and counseling services and procedures that are not reviewed by any of the other TMHP prior authorization units. (i.e., ambulance, home health, dental). All Special Medical Prior Authorization requests may be submitted by mail or electronically through the TMHP website. All CSHCN Services Program requests for authorization and prior authorizations must be submitted on a program-approved form and must contain all information necessary for the program to make a determination about coverage. Only complete authorization requests will be accepted by the program. CSHCN providers must mail or fax written authorization requests, along with all other applicable documentation. Refer to Section Four, Prior Authorizations and Authorizations of the current CSHCN Services Program Procedural Manual for additional information regarding authorization and prior authorization Use for Substance Abuse authorization status and general information. This telephone number may not be used to request authorization. (512) N/A N/A N/A Texas Medicaid & Healthcare Partnership Dental Prior Authorization Unit PO Box Austin, TX N/A (512) Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization Department B Riata Trace Parkway, Suite 150 Austin, TX N/A (512) TMHP-CSHCN Services Program Authorization Department B Riata Trace Parkway Ste #150 MC-A11 Austin, TX Note: Outpatient prescription medication prior authorization is obtained by the prescriber or the prescriber representative by calling the Texas Prior Authorization Help Desk at PA-TEXAS ( ). Note: For DARS Early Childood Intervention (ECI) services, the Individual Family Service Plan (IFSP) is used as the prior authorization for services. 30 CPT only copyright 2014 American Medical Association. All rights reserved. v

37 Prior Authorization Forms by Department Please refer to the TMHP website at Forms section as a resource. Radiology Radiology Prior Authorization Request Form Ambulance Nonemergency Ambulance Prior Authorization Request (Texas Medicaid and CSHCN Services Program) CCP CCP Prior Authorization Request Form CCP Prior Authorization Private Duty Nursing 6-Month Authorization CCP ECI Request for Initial/Renewal Outpatient Therapy Donor Human Milk Request Form External Insulin Pump Home Health Plan of Care (POC) Nursing Addendum to Plan of Care (CCP) (7 Pages) CCIP Psychiatric Inpatient Initial Admission Request Form Psychiatric Inpatient Extended Stay Request Form Pulse Oximeter Form Request for CCP Outpatient Therapy CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services (2 Pages) Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services-Comprehensive Care Program (CCP) Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (6 Pages) Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Dental THSteps Dental Mandatory Prior Authorization Request Form THSteps Dental Criteria for Dental Therapy under General Anesthesia (2 Pages) Home Health Home Health Services Plan of Care (POC) Instructions Home Health Services Plan of Care (POC) Home Health Services Prior Authorization Checklist Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions (2 pages) Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form External Insulin Pump Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-Initial Request Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-Extended Request Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy Statement for Initial Wound Therapy System In-Home Use (2 pages) v CPT only copyright 2014 American Medical Association. All rights reserved. 31

38 Statement for Recertification of Wound Therapy System In-Home Use Ventilator Service Agreement Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (6 pages) Special Medical Prior Authorizations (SMPA) Medicaid Certificate of Medical Necessity for Reduction Mammaplasty Request for Extended Outpatient Psychotherapy/Counseling Form Special Medical Prior Authorization (SMPA) Request Psychological/Neuropsychological Testing Request Outpatient Services Obstetric Ultra Prior Authorization Request Texas Medicaid Form Children with Special Health Care Needs (CSHCN) Services Program Additional Nutritional Assessment, Counseling, and Products Form and Instructions Augmentative Communication Devices (ACDs) Form and Instructions Chest Physiotherapy Devices Form and Instructions Stem Cell or Renal Transplant Form and Instructions Dental or Orthodontia Services Form and Instructions Diapers, Pull-ups, Briefs, or Liners Form and Instructions Durable Medical Equipment (DME) Form and Instructions External Insulin Pump Form and Instructions Hospice Services Form and Instructions Inpatient Psychiatric Care Form and Instructions Inpatient Hospital Admission For Use by Facilities Only Form and Instructions Inpatient Rehabilitation Admission Form and Instructions Medical Foods Form and Instructions Omalizumab Form and Instructions Palivizumab (Synagis) Form and Instructions Pulse Oximeter Devices Form and Instructions Renal Dialysis Treatment Form and Instructions Respiratory Care Certified Respiratory Care Practitioner (CRCP) Form and Instructions Inpatient Surgery For Surgeons Only Form and Instructions Outpatient Surgery For Outpatient Facilities and Surgeons Form and Instructions Apnea Monitor Form and Instructions Hemophilia Blood Factor Products Form and Instructions Non-Face-to-Face Clinician-Directed Care Coordinated Services Form and Instructions Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services Extension of Outpatient Therapy (TP2) Form and Instructions Initial Outpatient Therapy (TP1) Form and Instructions) Authorization and Prior Authorization Request 32 CPT only copyright 2014 American Medical Association. All rights reserved. v

39 Other Important Forms Sterilization Consent Form Instructions (2 pages) Sterilization Consent Form (English) Sterilization Consent Form (Spanish) Abortion Certification-Statements Hysterectomy Acknowledgement Form v CPT only copyright 2014 American Medical Association. All rights reserved. 33

40 Remittance and Status Reports The Remittance and Status (R&S) Report provides information on pending, paid, denied, and adjusted claims. TMHP provides weekly R&S Reports to give providers detailed information about the status of claims submitted to TMHP. The R&S Report also identifies accounts receivables established as a result of inappropriate reimbursement. These receivables are recouped from claim submissions. All claims for the same provider identifier and program are processed and reimbursed at the end of the week, either by a single check or electronically with Electronic Funds Transfer (EFT). If no claim activity or outstanding account receivables exist during the cycle week, the provider does not receive an R&S Report. Providers are responsible for reconciling their records to the R&S Report to determine reimbursements and denials received. Note: Providers receive a single R&S Report that details Texas Medicaid activities and provides individual program summaries. 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, but must submit copies of the R&S Report pages with appeal documentation. Delivery Options TMHP offers two options for the delivery of the R&S Report. Although providers may choose any of the following methods, a newly-enrolled provider is initially set up to receive a portable document format (PDF) version of the R&S Report. Portable document format (PDF) version. The PDF version of the R&S Report can be downloaded by registered users of the TMHP website at The report is available each Monday morning, immediately following the weekly claims cycle. Reimbursements associated with the R&S Report are not released until all provider reimbursements are released on the Friday following the weekly claims cycle. The PDF version of the R&S Report is available on the TMHP website for up to 90 days. Note: In the event of a holiday, reimbursements associated with the R&S Report are released the following business day. Electronic version (American National Standards Institute [ANSI] 835): The Electronic Remittance & Status (ER&S) Report. Using Health Insurance Portability and Accountability Act (HIPAA)-compliant EDI standards, the ER&S Report can be downloaded through the TMHP EDI Gateway using TexMedConnect or third party software. The ER&S Report is also available each Monday after the completion of the weekly claims processing cycle. The ER&S Report file is in ANSI 835 format, which is not a valid format for appeals. 34 CPT only copyright 2014 American Medical Association. All rights reserved. v

41 Accessing Remittance and Status Reports Medicaid: Beyond the Basics Participant Guide Locating PDF R&S Reports 1. Go to and click providers in the top menu bar. 2. Click Go to TexMedConnect. 3. Enter your User name and Password and click OK. v CPT only copyright 2014 American Medical Association. All rights reserved. 35

42 4. Click R&S in the left-side navigation pane. 5. Click the appropriate NPI/API. 6. Click the appropriate program. (Programs 100 and 200 are combined in one R&S Report.) 36 CPT only copyright 2014 American Medical Association. All rights reserved. v

43 7. Click the file with the date of the R&S Report that you are looking for. Medicaid: Beyond the Basics Participant Guide Note: For more information about accessing and searching for R&S Reports, refer to the R&S Report computer-based training (CBT) in the TMHP Learning Management System (LMS) at v CPT only copyright 2014 American Medical Association. All rights reserved. 37

44 R&S Reports are made up of several sections that appear in the following order: Banner Messages Claims Paid or Denied Adjustments Financial Transactions Pending Status Claims Claims Payment Summary Explanation of Benefits Codes Messages 38 CPT only copyright 2014 American Medical Association. All rights reserved. v

45 R&S Reports: Banner Pages Medicaid: Beyond the Basics Participant Guide Texas Medicaid & Healthcare Partnership Remittance and Status Report Date: 02/01/2013 Mail original claim to: TEXAS PROVIDER Texas Medicaid & Healthcare Partnership PO BOX P.O. Box DALLAS, TX Austin, Texas (214) Mail all other correspondence to: TPI: Texas Medicaid & Healthcare Partnership NPI/API: B Riata Trace Parkway Taxonomy: X Austin, Texas Benefit Code: Report Seq. Number: 35 (800) R&S Number: ~ Page 1 Of BANNER PAGE (01/24/12 THROUGH 02/14/12) *****ATTENTION ALL MEDICAID PROVIDERS***** Effective for dates of service on or after September 1, 2011, the Texas Medicaid Program is implementing benefit changes for respiratory syncytial virus (RSV) prophylaxis palivizumab (Synagis). Details of these changes are available on the TMHP website at and will also be available in the January/February 2012 Texas Medicaid Bulletin, No For more information, call the TMHP Contact Center at TEXAS PROVIDER YOUR AIS NUMBER IS PO BOX FOR AIS INQUIRY CALL TOLL FREE 1-(800) DALLAS, TX THE PROVIDER MANUAL PROVIDES DETAILS. (214) PHYSICAL ADDRESS ON RECORD: TEXAS PROVIDER PO BOX DALLAS, TX (214) v CPT only copyright 2014 American Medical Association. All rights reserved. 39

46 R&S Reports: Claims Paid or Denied 40 CPT only copyright 2014 American Medical Association. All rights reserved. v

47 How to Read an Internal Control Number (ICN) Medicaid: Beyond the Basics Participant Guide Program Type Media Year Julian Batch # Sequence Program Code 001 Long Term Care 100 Traditional Medicaid 200 Managed Care 300 DSHS Family Planning Program 400 Children with Special Health Care Needs 999 Program Type Could Not Be Determined Based On Information on the Claim Claim Type 020 Physician Supplier/Genetics 021 Dental 023 Outpatient Hospital/HHA 030 Physician Crossover 031 Outpatient Crossover 040 Inpatient Hospital 050 Inpatient Crossover 056 DSHS Family Planning Program 058 Family Planning Title XIX (Filed on 2017 Form) 099 MMIS Conversion Default Claim Type 999 All Claim Types (Default/Summary Claim Type Value For Reporting Purposes) Media Type 010 Paper 011 Paper Adjustment 020 TexMedConnect 021 TexMedConnect Adjustment 030 Electronic 031 Electronic Adjustment 041 AIS Adjustment 051 Mass Adjustment 061 Crossover Adjustment 071 Retroactive Eligibility Adjustment 080 State Action Request 081 State Action Request Adjustment 090 Phone 100 Fax 110 Mail 120 Encounters 121 Encounters Adjustment The Julian Date is the date that the claim is scanned into the system as received. This date is the sequential numbering of the days of the year. This is what is used to calculate the filing deadline for the claim. The batch number is an internal TMHP number.the sequence number is used by TMHP to identify a particular claim within a batch. v CPT only copyright 2014 American Medical Association. All rights reserved. 41

48 R&S Reports: Adjustments Paid or Denied 42 CPT only copyright 2014 American Medical Association. All rights reserved. v

49 R&S Reports: Financial Transactions Medicaid: Beyond the Basics Participant Guide All claim refunds, reissues, voids/stops, recoupment, backup withholdings, levies, and payouts appear in this section of the R&S Report. The Financial Transactions section does not use the R&S Report form headings. Additional subheadings are printed to identify the financial transactions. The following examples are types of financial items: v CPT only copyright 2014 American Medical Association. All rights reserved. 43

50 R&S Reports: The Following Claims Are Being Processed 44 CPT only copyright 2014 American Medical Association. All rights reserved. v

51 R&S Reports: Claims Payment Summary Medicaid: Beyond the Basics Participant Guide v CPT only copyright 2014 American Medical Association. All rights reserved. 45

52 R&S Reports: Explanation of Benefits Codes Messages 46 CPT only copyright 2014 American Medical Association. All rights reserved. v

53 Explanation of Benefits Medicaid: Beyond the Basics Participant Guide An Explanation of Benefits (EOB) is an explanation of benefits in response to the submission of a claim. EOBs provide information about claim disposition or reimbursement. In addition to the EOB code, TMHP provides many different messages to assist providers with submission instructions on a processed claim. Common Claim Denial EOB 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. Validate the billing provider is enrolled in the client s program. 4. Verify the provider s enrollment is active. 5. Confirm the provider is enrolled as a Billing Provider and not as a Performing Only provider participating in a group. 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. v CPT only copyright 2014 American Medical Association. All rights reserved. 47

54 2. Appeal claim with proof of timely filing attached. (i.e., R&S of past claim, Provider Correspondence Letter, TMHP rejection number, Postal or Express carrier receipt with tracking information.) 48 CPT only copyright 2014 American Medical Association. All rights reserved. v

55 R&S Reports: Mass Adjustments Medicaid: Beyond the Basics Participant Guide Mass Adjustments: Adjustments - Paid or Denied v CPT only copyright 2014 American Medical Association. All rights reserved. 49

56 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: Balancing Your RS Report.pdf 50 CPT only copyright 2014 American Medical Association. All rights reserved. v

57 Balancing Your Remittance and Status (R&S) Report 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 ALLOWED----- QTY CHARGE QTY CHARGE PAID AMT. TOTAL FOR MEDICAID $2, $ $ Next, locate the Paid amt. for Managed Care in the Paid/denied section: TOTAL FOR MANAGED CARE $12, $8, $8, 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 $41, $26, $26, Locate the Paid amt for Managed Care in the adjustments Paid/denied section: TOTAL FOR MANAGED CARE $16, $4, $4, v CPT only copyright 2014 American Medical Association. All rights reserved. 51 Texas Medicaid & Healthcare Partnership 2

58 Balancing Your Remittance and Status (R&S) Report 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 *** AMOUNT COUNT CLAIMS PAID $39, 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. $ $8, $26, , $39, *********************** 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 $21, 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. $39, $21, $18, PAYMENT AMOUNT $18, CPT only copyright 2014 American Medical Association. All rights reserved. v Texas Medicaid & Healthcare Partnership

59 Resources Instructions for Using the TMHP Website The TMHP website at is designed to streamline provider participation. Using the website, providers can do the following; submit claims and appeals, view and download current provider manuals, verify client eligibility, view R&S Reports and panel reports, and stay informed with current news and updates. Current news remains on the TMHP website homepage for 10 business days and is then moved to the past news articles. 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 past news articles sections. To use the search feature, type the desired keywords into the search box located in the top bar of the homepage, and click the icon or press Enter. To improve search results, 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 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. v CPT only copyright 2014 American Medical Association. All rights reserved. 53

60 Provider Manuals and Guides: Texas Medicaid Provider Procedures Manual (TMPPM) CSHCN 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 Forms 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 Health Information Technology, Fee Schedules, Provider Education: Fee schedules Acute care reference codes Long Term Care (LTC) Programs reference codes Learning Management System with Computer Based Training 54 CPT only copyright 2014 American Medical Association. All rights reserved. v

61 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. 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. Find a Medicaid specialist in network. v CPT only copyright 2014 American Medical Association. All rights reserved. 55

62 Locating and Searching the Provider Manual 1. Go to the TMHP website at and click providers in the top menu bar. 2. Click Reference Material in the left-side navigation pane. 3. The TMPPM is the default page. From here, you can: a. Click PDF in the Complete Book row to view the TMPPM in portable document format (PDF). b. Click PDF in the Individual chapters row to view a particular chapter of the TMPPM in PDF format. or c. Click HTML to view the complete TMPPM in hypertext markup language (HTML) on the web. 56 CPT only copyright 2014 American Medical Association. All rights reserved. v

63 4. For our example, we will choose the Book PDF option. Click PDF in the book row. Medicaid: Beyond the Basics Participant Guide 5. Once the document opens in Adobe Acrobat Reader, press the Ctrl and F keys simultaneously to begin searching through the document for a word or phrase. 6. When the two keys are depressed, a window in the menu bar will become active. Type the word or phrase you would like to find in this field. When finished, press the enter key to begin the search. Adobe Reader will automatically take you to each instance of the word even if it s a partial word in a longer string. For instance, if you typed resident, Adobe would show you all instances of the word including deviations such as president. To alleviate this, perform an advanced search. Advanced Search 1. Next to the Find window, you ll notice a drop-down arrow. Click the arrow to see your options. Choose Open Full Acrobat Search. v CPT only copyright 2014 American Medical Association. All rights reserved. 57

64 2. The Full Acrobat Search will display. Type the word or phrase that you are looking for and click Search or press the Enter key. a. Whole words only Searches for whole word matches so that similar words with partial matches do not appear in search results. a. Case-Sensitive For a Case-Sensitive search select this check box. For example, if you search for Enter with the Case-Sensitive check box selected, the search will not list occurrences of the word enter. b. Include Bookmarks Searches the text of any bookmarks, as viewed in the Bookmarks panel. c. Include Comments Searches the text of any comments added to the PDF, as viewed in the Comments panel. 3. The Search PDF pane displays the search results and the first occurrence of the word or phrase is highlighted in the document. 4. To view a specific occurrence of the word or phrase in the document, click its link in the Results list. Acrobat highlights the selected occurrence of the word or phrase in the document. 5. Click the icon to collapse the search menu or click New Search to start a new search. 58 CPT only copyright 2014 American Medical Association. All rights reserved. v

65 Provider Bulletins and Banner Messages Medicaid: Beyond the Basics Participant Guide 1. Go to the TMHP website at and click providers in the top menu bar. 2. Click Reference Material in the left-side navigation pane. Note: The 2014 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin is published as needed and is available on the Texas Medicaid Bulletin page at Pages/Medicaid/ medicaid_pubs_ bulletin.aspx. 3. To view provider bulletins, click Texas Medicaid Bulletin or to view banner messages, click Banner Messages. 4. Once the document opens in Adobe Reader, press the Ctrl and F keys simultaneously to begin searching through the document for a word or phrase. 5. When the two keys are depressed, a window in the menu bar will become active. Type the word or phrase you would like to find into this field. When finished, press the enter key to begin the search. Adobe Reader will automatically display each instance of the word, even if it s a partial word in a longer string. v CPT only copyright 2014 American Medical Association. All rights reserved. 59

66 Online Provider Lookup The Online Provider Lookup (OPL) on the TMHP website at is a great resource for both clients and providers, for finding a provider participating in the Medicaid program in a selected area. In order to provide a positive experience with Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program, we must ensure that accurate provider information is available to everyone who needs it. Additionally, non-administrative users will not be able to perform work functions on NPIs that are listed on the Review Required page. Non-administrative users will be advised to notify users with administrative rights so that they can verify demographic information and remove the block. Non-administrative users can determine the identity of the administrative users for each NPI by clicking Provider Administrator Lookup on the My Account page. Using the Online Provider Lookup (OPL) Tool to Find a Provider 1. Go to the TMHP website at and click providers in the top menu bar. 2. Click Looking for a provider? in left-side navigation pane. 60 CPT only copyright 2014 American Medical Association. All rights reserved. v

67 3. Enter your Provider Search Criteria. Health Plan TPI NPI/API Taxonomy Benefit Code Note: Fields marked with a red asterisk are required. Last Name/Facility Name HMO Plan Name Provider Type ZIP Code 4. Click more information for instructions on how to complete the adjacent field. 5. Click Search to obtain a list of providers that meet the search criteria entered or click Clear Form to remove the information and start over. 6. A list of providers that meet the search criteria will display. Click the provider s name to display detailed information for 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. v CPT only copyright 2014 American Medical Association. All rights reserved. 61

68 Click more information for a description of the Primary Care Provider symbol. 62 CPT only copyright 2014 American Medical Association. All rights reserved. v

69 Using the Advanced Search in OPL Clicking Advanced Search on the menu bar generates the following screen: Unlike the basic search option, the advanced search option allows providers to narrow their search using several additional search options such as: Accepting new patients Provider specialty Provider subspecialty Extended hours Medicaid waiver program Other services offered Languages spoken Patient age Patient gender County served by the provider Note: To locate a specialist select Specialist from the drop-down box under the Provider Type field. Next, click the arrow next to the Provider Specialty field to choose a list of provider specialties. v CPT only copyright 2014 American Medical Association. All rights reserved. 63

70 Note: The criteria entered in the Provider Type field changes the information displayed under Provider Specialty. 64 CPT only copyright 2014 American Medical Association. All rights reserved. v

71 Updating Address Information 1. The provider must click the link on the My Account page to change or verify their address information. 2. The provider must click the Edit button to activate a section for editing. The provider can: Update address information. Update telephone numbers and their address. Add or remove counties served. Update business hours. Indicate whether or not they are accepting patients for each plan in which they participate. Indicate languages spoken in their office. Indicate if they offer additional services. Limit the gender or age of clients served. 3. Save and Cancel buttons appear when an area is active for editing. The provider must save the information or cancel their changes before editing any other sections. Once the information is updated by the provider, it should appear with the new information in the Online Provider Lookup immediately. The more complete a provider s 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 update the informa tion in this area, the provider must attest online for NPI-related information, or submit a Provider Information Change (PIC) Form. Reminder: Medicaid Vendor Drug Pharmacy providers should update their vendor drug program information through the VDP Pharmacy Resolution Helpdesk by calling Additional information about the Texas VDP can be found online at v CPT only copyright 2014 American Medical Association. All rights reserved. 65

72 Online Fee Lookup To access the online fee lookup: 1. Go to the TMHP website at and click providers. 2. Click Fee Schedules in the left-side navigation pane. 3. The Fee Schedules/Home screen will display. From here you can: View the static fee schedule Perform a fee search Perform a batch search 66 CPT only copyright 2014 American Medical Association. All rights reserved. v

73 Static Fee Schedules (OFL) The files on the Static Fee Schedule page contain the Texas Medicaid fee schedules for the selected federal fiscal quarter. These fee schedules provide a view of the fees that were in effect within the first seven days of the selected quarter. If you are a Texas Medicaid provider with an active account on the TMHP website at you can limit the fee schedules that appear to those that apply to your provider identifier. If you are not a Texas Medicaid provider with an active account on the TMHP website at and know which fee schedule you want to see, you can open the corresponding Excel or PDF file. If you do not know which fee schedules apply to you, you may use the search feature. To do this you must: 1. Select a provider type and provider specialty from the drop-down menus. 2. Click Search. The screen will display only the applicable fee schedules. You may also view past fee schedules by clicking Archives on the bottom of the screen. v CPT only copyright 2014 American Medical Association. All rights reserved. 67

74 Fee Search (OFL) To search for a single or multiple codes click Fee Search in the left-side navigation pane. Using the OFL, you can search for fees using following options: A single procedure code A list of up to 50 procedure codes A range of procedure codes All procedure codes pertaining to a specific provider type and specialty Note: Providers who log in using their TPI, NPI, or API have the option to perform a contracted rate search. The contracted rate search function allows providers to view contract fees that are specific to them. You may access this function by clicking Contracted Rate Search below the Submit button. If you are not logged in, you may do so by clicking TMHP in the upperright corner of the screen. When you search using one of the following options, you will receive a Batch Request ID: A list of more than 10 procedure codes A range of codes All procedure codes pertaining to a specific provider type and specialty Record the Batch Request ID. This Batch ID will allow you to access your search results with 36 hours of your request. 68 CPT only copyright 2014 American Medical Association. All rights reserved. v

75 Batch Search (OFL) To access your search results, you can click Batch Search on the left-side navigation pane. Enter your batch ID, and click Search. For more detailed instructions you may access the OFL Computer-Based Training on the TMHP Learning Management System (LMS) at v CPT only copyright 2014 American Medical Association. All rights reserved. 69

76 ICD-10 Implementation The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and ICD-10-PCS (inpatient procedure 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. 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 six to ten 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 at for updated information as it becomes available. Additional information is available on the CMS website at NCCI Compliance The Patient Protection and Affordable Care Act (PPACA) mandates that all claims submitted on or after October 1, 2010, must be filed in accordance with the National Correct Coding Initiative (NCCI) guidelines. NCCI was developed by CMS to promote the correct coding of health-care services by providers. NCCI consists of pairs of procedure codes that should not be reported together. For more information, refer to 70 CPT only copyright 2014 American Medical Association. All rights reserved. v

77 Checking for Updates: ICD, HCPCS Procedure Codes, and NCCI guidelines Medicaid: Beyond the Basics Participant Guide Here s how to check for the most recent updates to the International Classification of Diseases (ICD), Healthcare Common Procedure Coding System (HCPCS) Procedure Codes, and NCCI guidelines on the TMHP website: 1. Go to the TMHP website at and click providers in the top menu bar. 2. Click Code Updates in the left-side navigation pane. v CPT only copyright 2014 American Medical Association. All rights reserved. 71

78 3. Click HCPCS Updates, ICD Updates, or NCCI Compliance. Note: The current ICD-9 (Ninth Revision) CM codes will be in effect until ICD-10 implementation. At that time the Code Updates Screen will change reflecting information for ICD-10 (Tenth Revision). Here are the steps to follow to access the NCCI information using the TMHP Website to link to the CMS website: 1. From the Code Updates screen click on NCCI Compliance in the left-side navigation pane. 2. Next, click on right-hand side link under the heading Help Links Centers for Medicare & Medicaid Services (CMS) NCCI web page. 3. Scroll down to the heading: Medicaid NCCI Edit Files. 72 CPT only copyright 2014 American Medical Association. All rights reserved. v

79 Steps to Resolve Your Medicaid Questions Medicaid: Beyond the Basics Participant Guide Step 1 - Provider Manual: A provider s first resource for Medicaid information. Available on the TMHP website. Step 2 - Banner Messages: An additional source of information available in the office and at Step 3 - R&S Report: A provider s first resource for checking claim status. The report provides detailed information on pending, paid, denied, and incomplete claims. Step 4 - TMHP Website at Providers can find the latest information on TMHP news and bulletins. Providers can also verify client eligibility, submit claims, check claim status, view R&S Reports, and view many other helpful links. Step 5 - TMHP Telephone Numbers: TMHP: ; Telephone Appeals: ; THSteps Dental Inquiries: ; THSteps Medical Inquiries: ; TMHP EDI Help Desk: , Option 3. Step 6 - Automated Inquiry System (AIS): A provider s resource for checking client eligibility, claim status, and benefit limitations. Available 23 hours a day, with daily downtime from 3:00 a.m. to 4:00 a.m. Call , and select an option from the menu. Step 7 - TMHP Contact Center: A provider s resource for general Medicaid program information. Available from 7:00 a.m. to 7:00 p.m. Central Standard Time. Call Ensure that you note a Ticket Number for the TMHP agent when calling, in order to provide appropriate citation. Step 8 - Provider Relations Representative: A provider s personal resource for issue escalation as well as educational and trouble-shooting visits. Visit the TMHP website and click Provider, then Provider Support Services, then Provider Relations Reps to contact Provider Relations. Section 6401 of The Affordable Care Act (ACA) of 2012 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. 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 Topics/ACA.aspx. v CPT only copyright 2014 American Medical Association. All rights reserved. 73

80 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. Most providers who render services to TWHP clients are required to complete an annual TWHP certification and family planning attestation prior to serving TWHP clients. Benefits TWHP benefits include: One family planning exam each year, which may include a clinical breast exam, screening for cervical cancer, diabetes, sexually transmitted infections, 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 natural family planning and excluding emergency contraception. Sterilization and sterilization-related procedures. Treatment for certain sexually transmitted infections. 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 or eligible immigrants. Reside in Texas. Have a household income at or below 185 percent of the federal poverty level (FPL). Do not currently receive 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. For details on TWHP, see the TWHP webpage on the TMHP website at TWHP/TWHP_Home.aspx. 74 CPT only copyright 2014 American Medical Association. All rights reserved. v

81 Provider Education TMHP Computer-Based Training TMHP offers a variety of training for providers online using computer-based training (CBT) modules on the TMHP Learning Management System (LMS). Texas Medicaid providers can access this on-demand training from any location with Internet access, anytime, at their convenience. TMHP CBT modules offer a flexible training experience by allowing providers to play, pause, rewind, and even search for specific words or phrases within a CBT module. How to Access Training. 1. Go to enter your User Name and Password and click Login. (Firsttime users can follow the easy, on-screen instructions to create a user account.) 2. Hover over Provider Education in the menu bar and click Computer-Based. v CPT only copyright 2014 American Medical Association. All rights reserved. 75

82 3. Scroll down the list and find the CBT you want to view. Click View Now. TMHP Computer-Based Training Titles CSHCN Services Program Basics Claim Forms Claim Appeals Client Eligibility Crossover Claims DSHS Family Planning Program (DFPP) and Medicaid Title XIX Durable Medical Equipment (DME) Physician Services Prior Authorization Provider Enrollment on the Portal Remittance and Status Reports TexMedConnect for Acute Care Providers TexMedConnect for Long Term Care Providers Third Party Liability Long Term Care (LTC) Community Services Waiver Programs Long Term Care (LTC) Nursing Facility/Hospice Medicaid Basics: Part 1 and Part 2 THSteps Dental Services THSteps Medical Services Medical Transportation Program (MTP) Nursing, Therapies, and Personal Care Online Fee Lookup 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. To access THSteps training information, visit the website at 76 CPT only copyright 2014 American Medical Association. All rights reserved. v

83 Provider Relations Representatives TMHP Recruitment and Retention Representatives are field based Provider Relations Specialists. These specialists provide education and training on the TMHP provider enrollment application process, enrollment requirements for State health care programs, and offer hands-on assistance with application submissions from new and existing Medicaid providers. Your PR Rep also provides enrollment support and training for the CSHCN Services Program, Case Management for Children and Pregnant Women, Pharmacy/Durable Medical Equipment, Personal Care Services, THSteps (Medical and Dental), Family Planning, and Medical Transportation Program (MTP) providers. Claims and Medicaid policy PR Representatives provide education and training on claims submission for new and existing Medicaid providers. Technical support and training are also provided for TexMedConnect software users for Medicaid, Long Term Care, the CSHCN Services Program, Family Planning, and traditional fee-for-service Medicaid providers. For help, providers can call the TMHP Contact Center at , the CSHCN Services Program Contact Center at , or to request a one-on-one provider visit or in-service in your office by at [email protected]. v CPT only copyright 2014 American Medical Association. All rights reserved. 77

84 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 (APR-DRG) 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, 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. MS-DRGs are only intended for Medicare. APR-DRGs were developed for an all-patient population by 3M and the National Association of Children s Hospitals and Related Institutions. 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). 78 CPT only copyright 2014 American Medical Association. All rights reserved. v

85 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. Texas Medicaid will accept 25 Diagnoses and 25 Procedures. Three byte DRG + one byte SOI + one byte ROM. Effects are additive, not absolute. Medicaid: Beyond the Basics Participant Guide POA Indicator Requirement POA indicators are necessary to accurately calculate APR-DRG payments. POA indicators are required on all Medicaid inpatient hospital claims. POA indicators are also 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 follow-up 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 (e.g., lack of follow-up arrangements with a primary care physician) rather than from unrelated events that occurred after the prior admission (e.g., 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 HHSC implements quality-based payments to hospitals on the basis of the results of the PPR analysis. v CPT only copyright 2014 American Medical Association. All rights reserved. 79

86 PPR Calculation Methodology 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. Resources For more information about APR-DRG, POA, PPR, or PPC, refer to the TMHP Hospital Initiatives page on the TMHP website at ( [email protected]. To purchase the APR-DRG grouper application, contact 3M at , or visit them online at 80 CPT only copyright 2014 American Medical Association. All rights reserved. v

87 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 the Texas Department of Family and Protective Services (DFPS) at or to law enforcement and to document the report in the client s record. To document reports made by telephone to DFPS at (24 hours a day, 7 days a week) or to 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 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 or your local law enforcement agency. v CPT only copyright 2014 American Medical Association. All rights reserved. 81

88 Report Elder Abuse, Neglect, or Exploitation 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 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 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: Title DSHS Child Abuse Screening, Documenting, and Reporting Policy DSHS Child Abuse Reporting Form Texas Abuse, Neglect, and Exploitation Reporting System Website Child_Abuse_Reporting_Form.pdf 82 CPT only copyright 2014 American Medical Association. All rights reserved. v

89 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. 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. v CPT only copyright 2014 American Medical Association. All rights reserved. 83

90 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 Social Security number (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 and select Reporting Waste, Abuse, and Fraud. Individuals may also call the OIG hotline at to report waste, abuse, or fraud if they do not have access to the Internet. 84 CPT only copyright 2014 American Medical Association. All rights reserved. v

91 Communication With Medicaid and State Programs TMHP Telephone and Fax Communication Contact TMHP Contact Center (general information) Automated Inquiry System (AIS) TMHP Children with Special Health Care Needs (CSHCN) Services Program Contact Center Automated Inquiry System (AIS) Telephone/Fax Number or (512) CSHCN Services Program Fax (512) Comprehensive Care Program (CCP) (CCP prior authorization status and general CCP and Home Health Services information) Comprehensive Care Inpatient Psychiatric (CCIP) Unit (prior authorization and general information) (voice) (512) (fax) (voice) (512) (fax) Family Planning (Tubal Ligation/Vasectomy Consent Forms) Fax (512) Health Insurance Premium Payment (HIPP) and Insurance Premium Payment Assistance (IPPA) 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) (voice) (512) (fax) Hysterectomy Acknowledgment Statements Fax (512) Long Term Care (LTC) Operations LTC Nursing Facilities Medicaid Audit/Cost Reports (512) Medicaid Audit Fax (512) Radiology Prior Authorization (voice) (fax) Provider Enrollment Fax (512) Telephone Appeals Texas Health Steps (THSteps) Dental Inquiries THSteps Medical Inquiries Third Party Resources (TPR) (Option 2) Third Party Resources (TPR) Fax (512) TMHP Electronic Data Interchange (EDI) Help Desk TMHP EDI Help Desk Fax (512) (512) v CPT only copyright 2014 American Medical Association. All rights reserved. 85

92 Prior Authorization Request Telephone and Fax Communication Contact Telephone/Fax Number Ambulance Authorization (includes out-of-state transfers) Ambulance Authorization Fax (512) Home Health Services Fax (512) CCP Fax (512) CCIP Option 1: Status, provide additional information, verify or request a CCIP Prior Authorization Option 2: Substance abuse services Prior Authorization or other Prior Authorization CCIP Fax (512) Outpatient Psychiatric Fax (512) TMHP Special Medical Prior Authorization Fax (including transplants) (512) Radiology Services Prior Authorization Radiology Services Prior Authorization Fax Special Medicaid Prior Authorization Fax (Including Transplants) (512) Obstetric Ultrasound: Option Prior Authorization Status Telephone Communication Contact 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 Telephone Number CCP Personal Care Services Substance Abuse Services: Option CPT only copyright 2014 American Medical Association. All rights reserved. v

93 Written Communication With TMHP Medicaid: Beyond the Basics Participant Guide All CMS-1500 forms (excluding ambulance, radiology/laboratory, immunization services, rural health, and mental health rehabilitation) sent to TMHP for the first time, as well as claims being resubmitted because they were initially denied as incomplete claims, must be sent to the following address: Texas Medicaid & Healthcare Partnership Claims PO Box Austin, TX The post office box addresses must be used for the specific items listed in the following table: Correspondence 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 All first-time claims Ambulance/CCP requests (prior authorization and appeals) CSHCN Services Program claims Dental prior authorization requests Home Health Services prior authorizations Special Medical Prior Authorization Medicaid audit correspondence Medically Needy Clearinghouse (MNC) or Spend Down Unit correspondence Provider Enrollment correspondence Address Texas Medicaid & Healthcare Partnership Appeals/Adjustments PO Box Austin, TX Texas Medicaid & Healthcare Partnership Claims PO Box Austin, TX Texas Medicaid & Healthcare Partnership Comprehensive Care Program (CCP) PO Box Austin, TX Texas Medicaid & Healthcare Partnership CSHCN Services Program Claims PO Box Austin, TX Texas Medicaid & Healthcare Partnership Dental Prior Authorization Unit PO Box Austin, TX Texas Medicaid & Healthcare Partnership Home Health Services PO Box Austin, TX Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization B Riata Trace Parkway, Suite 150 Austin, TX Texas Medicaid & Healthcare Partnership Medicaid Audit PO Box Austin, TX Texas Medicaid & Healthcare Partnership Medically Needy Clearinghouse PO Box Austin, TX Texas Medicaid & Healthcare Partnership Provider Enrollment PO Box Austin, TX v CPT only copyright 2014 American Medical Association. All rights reserved. 87

94 Correspondence Other provider correspondence Send all other written communication to TMHP TPR/Tort correspondence Address Texas Medicaid & Healthcare Partnership Provider Relations PO Box Austin, TX Texas Medicaid & Healthcare Partnership (Department) B Riata Trace Parkway, Suite 150 Austin, TX Texas Medicaid & Healthcare Partnership Third Party Resources/Tort PO Box Austin, TX CPT only copyright 2014 American Medical Association. All rights reserved. v

95 Medicaid Vendor Drug Program Medicaid: Beyond the Basics Participant Guide The Medicaid Vendor Drug Program (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-for-service (FFS) Medicaid, the CSHCN Services Program, and Kidney Health Care (KHC). VDP maintains drug formulary for the Children s Health Insurance Program (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, fax, or electronic prescription. 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, which drugs need prior authorization, and whether the drug requires a clinical prior authorization for FFS clients. The following websites are available for drug formulary information: For all state health-care program formulary information, including which products are preferred, visit 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, visit For free Medicaid drug information using your mobile device (i.e., Palm, Blackberry, Windows mobile phone, or iphone), visit Prescribing providers can submit prior authorization requests for FFS clients by: Calling PATEXAS ( ). Visiting the secure, easy-to-use interface that is available 24 hours a day on the PAXpress website at For instructions to set up a user account, visit 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, visit Pharmacies Can Dispense Limited Home Health Supplies (LHSS) to Medicaid Clients Pharmacies that are enrolled with VDP can dispense LHHS that are commonly found in a pharmacy to fee-for-service Medicaid clients. Pharmacies can also dispense LHHS to clients who are enrolled in a Medicaid MCO if the pharmacy is enrolled in the client s MCO. For a list of the home health supplies that can be dispensed by pharmacy and for more information, visit v CPT only copyright 2014 American Medical Association. All rights reserved. 89

96 Some Vitamin and Mineral Products to Be Available Through VDP Pharmacies Pharmacies that are contracted with VDP can dispense some vitamin and mineral products to Texas Medicaid fee-for-service clients who are 20 years of age and younger. Pharmacies can also dispense these covered vitamin and minerals products to clients who are enrolled in a Medicaid MCO, if the pharmacy is enrolled in the client s MCO. VDP-contracted pharmacies can honor a physician s prescription for covered vitamins and minerals. To help expedite pharmacy claim processing, prescribing providers are encouraged to include the diagnosis on the prescription. VDP-contracted pharmacies are required to be enrolled with TMHP or have a CCP Prior Authorization Request Form to fill a prescription unless they intend to submit claims to TMHP instead of VDP. VDP-contracted pharmacies that are not enrolled with TMHP may submit claims for vitamin or mineral products to VDP. Claims are subject to post-payment desk reviews to ensure claims from DME providers and pharmacies do not result in duplicate payments for the same client or vitamin and mineral and to validate that prescribed products are appropriate for the client s medical condition. More information about the provision of these products and list of products for fee-for-service clients can be found on the VDP website at Minerals.shtml. Providers should contact the appropriate MCO or pharmacy benefit manager for more information about providing these supplies to Medicaid clients who are enrolled in a Medicaid managed care plan. Providers can access the VDP website at for a list of pharmacies that offer free delivery to FFS clients. Refer to: The current Texas Medicaid Provider Procedures Manual, Appendix B: Vendor Drug Program (Vol. 1, General Information) for more information. 90 CPT only copyright 2014 American Medical Association. All rights reserved. v

97 Helpful Links Item Texas Health and Human Services The Texas Medicaid & Healthcare Partnership Texas Department of State Health Services Texas Vendor Drug Program Preferred Drug List Program MRAN Type 30 Form and instructions MRAN Type 31 Form and instructions MRAN Type 50 Form and instructions State of Texas Access Reform (STAR) STAR+Plus Star Health THSteps Medical Services THSteps Dental Services DSHS Family Planning Program Case Management for Children and Pregnant Women Enhanced Care Program (Disease Management) The Children with Special Health Care Needs (CSHCN) Services Program Medicaid for Breast and Cervical Cancer (MBCC) Medical Transportation Program (Medicaid and CSHCN Services Program) Early Childhood Intervention (ECI) Link Form Crossover Claim Type 30.pdf Form Crossover Claim Type 31.pdf Form Crossover Claim Type 50.pdf html index.html v CPT only copyright 2014 American Medical Association. All rights reserved. 91

98 Terms/Acronyms/Abbreviations Acronym Definition Acronym Definition AAP American Academy of Pediatrics CSHCN Children with Special Health Care Needs ACD Augmentative Communication Devices CSI Claim Status Inquiry ACIP ADA AIS AMA Advisory Committee on Immunization Practices American Dental Association Automated Inquiry System American Medical Association CSR CT CTA DADS Customer Service Representative Computed Tomography Computed Tomography Angiography Department of Aging and Disability Services ANSI APRN APR-DRG American National Standards Institute Advanced Practice Registered Nurse All Patient Refined Diagnosis Related Groups DARS DED DFPP Department of Assistive and Rehabilitative Services Deductible DSHS Family Planning Program ASC BCBS BiPAP BJN BP CAPD CBT CCIP CCP CE CHAMPUS CHIP CLIA CMS CMS-1500 Ambulatory Surgery Center Blue Cross Blue Shield Bi-level Positive Airway Pressure Budget Job Number Base Plan Continuous Ambulatory Peritoneal Dialysis Computer-Based Training Comprehensive Care Inpatient Psychiatric Comprehensive Care Program Continuing Education Civilian Health and Medical Program of the Uniformed Services now called TriCare Children s Health Insurance Program Clinical Laboratory Improvement Amendments Centers for Medicare & Medicaid Services (formerly HCFA) Centers for Medicare & Medicaid Services Claim Form DFPS DME DO DOB DOS DPM DPS DRG DSHS DX E/M ECI ECP EDI EFT EOB EOPS Texas Department of Family and Protective Services Durable Medical Equipment Doctor of Osteopathy Date of Birth Date of Service Doctor of Podiatric Medicine Department of Public Safety Diagnosis-Related Group Department of State Health Services Diagnosis Evaluation and Management Services Early Childhood Intervention Enhanced Care Program Electronic Data Interchange Electronic Funds Transfer Explanation of Benefits Explanation of Pending Status COBC COINS CORF CPAP/BiPAP CPT Coordination of Benefits Contractor Coinsurance Comprehensive Outpatient Rehabilitation Facility Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure Current Procedural Terminology EPSC EPSDT EQRO ER ER&S EV E-Prescribing of Controlled Substances Early and Periodic Screening, Diagnosis, and Treatment External Quality Review Organization Emergency Room Electronic Remittance and Status Report Eligibility Verification CRCP Certified Respiratory Care Practitioner FAQ Frequently Asked Questions 92 CPT only copyright 2014 American Medical Association. All rights reserved. v

99 Acronym Definition Acronym Definition FDH First Dental Home MAO Medical Assistance Only FFP Federal Financial Participation MAP Medicare Advantage Plans FFS Fee-For-Service MBCC Medicaid for Breast and Cervical Cancer FP Family Planning MCO Managed Care Organization FPL Federal Poverty Level MD Doctor of Medicine FQHC Federally Qualified Health Center MGD Managed Care FSS Family Support Services MMIS Medicaid Management Information System GEM General Equivalency Mapping MNP Medically Needy Program HASC Hospital-based Ambulatory Surgical Center MODS Modifier HCPCS HHA HHS HHSC HIC Healthcare Common Procedure Coding System Home Health Agency Health and Human Services Health and Human Services Commission Health Insurance Claim MQMB MR MRAN MREP MS-DRG Medicaid Qualified Medicare Beneficiary Magnetic Resonance Medicare Remittance Advice Notice Medicare Remit Easy Print Medicare Severity Diagnosis Related Groups HIPAA HMO HSC HTML I&D ICD-9-CM ICD-10 ICD-10-CM ICD-10-PCS ICHP ICN ID IPPA IPPB IPV JRA LCSW LMFT LMS LMSW LPC LTC MAC Health Insurance Portability and Accountability Act Health Maintenance Organization Hearing Services for Children (Formerly PACT) HyperText Markup Language Incision and Drainage International Classification of Diseases, Ninth Revision, Clinical Modification International Classification of Diseases, Tenth Revision International Classification of Diseases, Tenth Revision, Clinical Modification International Classification of Diseases, Tenth Revision, Inpatient Procedure Code Set Institute of Child Health Policy Internal Control Number (as in 24-digit ICN) Identification Insurance Premium Payment Assistance Intermittent Positive Pressure Breathing Intrapulmonary Percussive Ventilation Juvenile Rheumatoid Arthritis Licensed Clinical Social Worker Licensed Marriage and Family Therapists Learning Management System Licensed Master Social Worker Licensed Professional Counselor Long Term Care Medicare Administrative Contractors MSRP MTP N/A NCCI NDC NP/CNS NPI OAG OB/GYN OD OFL OI OIG OPL OT PA PACT PAF PAN PCN PCS PDF PDN PDP PE PET Manufacturer s Suggested Retail Price Medical Transportation Program Not Applicable National Correct Coding Initiative National Drug Code Nurse Practitioner/Clinical Nurse Specialist National Provider Identifier Office of Attorney General Obstetric and Gynecology Optometrist Online Fee Lockup Other Insurance Office of Inspector General Online Provider Lookup Occupational Therapy Physician Assistant Program for Amplification for Children of Texas - transitioned to TMHP and known as Hearing Services for Children Physician/Dentist Assessment Form Prior Authorization Number Patient Control Number Personal Care Services Portable Document Format Private Duty Nursing Private Drug Plans Presumptive Eligibility Positron Emission Tomography v CPT only copyright 2014 American Medical Association. All rights reserved. 93

100 Acronym Definition Acronym Definition PIC PIMS POA POC POS PPACA PPC PPO Provider Information Change Provider Information Management System Present On Admission Plan of Care Place of Service Patient Protection and Affordable Care Act Potentially Preventable Complications Preferred Provider Organization TPN TPR TVFC TWHP UB-04 VDP VPN Total Parenteral Nutrition (i.e., Hyperalimentation) Third Party Resources Texas Vaccines for Children Texas Women s Health Program Uniform Bill 04 CMS-1450 Medicaid Vendor Drug Program Virtual Private Networking PPR Potentially Preventable Readmissions PT Physical Therapy QMB Qualified Medicare Beneficiaries R&S Remittance and Status Report RA Remittance Advice REV CD Revenue Codes RHC Rural Health Clinic RIMS Referral Identification Monitoring System RN Remittance Notice RN Registered Nurse ROM Risk Of Mortality RTP Return to Provider SA Service Area SAVERR System or Application, Verification, Eligibility, Referral, and Reporting SMPA Special Medical Prior Authorizations SOI Severity Of Illness SSI Supplemental Security Income (Program) SSL Secure Socket Layer SSN Social Security Number STAR State of Texas Access reform TAC Texas Administrative Code TANF Temporary Assistance to Needy Families (formerly AFDC) TENS Transcutaneous Electric Nerve Stimulator THSteps Texas Health Steps Medical and Dental Services TIERS Texas Integrated Eligibility Redesign System TMHP Texas Medicaid & Healthcare Partnership TMPPM Texas Medicaid Provider Procedures Manual TOB Type Of Bill TOS Type of Service TP Type Program TPI Texas Provider Identifier TPL Third Party Liability 94 CPT only copyright 2014 American Medical Association. All rights reserved. v

101 Frequently Asked Questions (FAQs) Q: When one year conditional enrollments are issued, does the provider receive a new TPI and enrollment date? A: Re-enrollments do not receive a new TPI or a new enrollment date so you must maintain your filing deadlines and submit a re-enrollment application prior to the termination of the conditional enrollment. Q: When a provider has submitted an application, but has not yet been approved, what should the provider do if they are nearing the 365-day federal claims filing deadline? A: Any claims for a new enrollment that is pending should be submitted if they are near the federal filing deadline by submitting them on paper in order to receive a denial. With this denial, you will be able to prove that the claim was submitted once during the 365-day deadline. Q: If a provider has multiple locations, but uses only one address for billing, does the provider need to have all addresses on file? A: All locations should be on file, so TMHP can accurately account for where services are being rendered. This tends to apply to groups with several clinics. Provider files should reflect all addresses for each location under the group and each performing provider s address should be their physical location. If providers are submitting an application and the location on the application is not on the provider file, it will result in delays and deficiencies. To speed up the application process providers can apply online at Click on Access Provider Enrollment to begin the process. Q: How do we submit requests to add alternate secondary locations? A: You can submit a Provider Information Change (PIC) form and the Medicare letter indicating that they have added the locations to your Medicare provider file. Note: A copy of the Provider Information Change (PIC) form and form instructions are available at: Form.pdf v CPT only copyright 2014 American Medical Association. All rights reserved. 95

102 Q: What is the correct way to submit a multiple-page claim? A: CMS-1500 claim form is designed to list six line items in block 24. An approved electronic claim format is designed to list 50 line items. If more than six line items are billed on a paper claim, a provider may attach additional forms (pages) totaling no more than 28 line items. The first page of a multiple-page claim must contain all the required billing information. On subsequent pages of the multiple-page claim, the provider should identify the client s name, diagnosis, information required for services in block 24, and the page number of the attachment (i.e., page 2 of 3) in the top right-hand corner of the form and indicate continued in block 28. The combined total charges for all pages should be listed on the last page in block 28. If the services provided exceed 28 line items on an approved electronic claims format or 28 line items on paper claims, the provider must submit another claim for the additional line items. Q: When can a provider bill for an after-hours charge? A: Texas Medicaid limits reimbursement for after-hours charges (procedure codes 99050, 99056, and 99060) to office-based providers rendering services after routine office hours. An officebased provider may bill an after-hours charge in addition to a visit when providing medically necessary services for the care of a client with an emergent condition after the provider s posted, routine office hours. Office-based physicians may be reimbursed an inconvenience charge when either of the following exists: The physician leaves the office or home to see a client in the emergency room. The physician leaves the home and returns to the office to see a client after the physician s routine office hours. The physician is interrupted from routine office hours to attend to another client s emergency outside of the office. Q: What if a client has TPR/Other insurance that we bill primary to Medicaid and the other insurance applies the paid amount to their deductible, will we be paid? A: TMHP will consider deductibles for reimbursement when the original third party payer applied the payment amount directly to the client s deductible. The explanation of benefit reflecting the application of the payment by the other insurance (third party payer) and a completed signed claim copy must be submitted to TMHP for consideration. Q: If I receive my Medicare MRAN via the U.S. Postal Service, can I use this for my paper Medicare crossover claim submission instead of the MRAN template? A: Providers submitting paper MRANs from Medicare are not required to submit the TMHP standardized MRAN form. 96 CPT only copyright 2014 American Medical Association. All rights reserved. v

103 Tamper Resistant Prescriptions FAQs Medicaid: Beyond the Basics Participant Guide Q: Where can providers obtain tamper-resistant prescription pads? A: Prescribers are encouraged to check with their current suppliers of prescription pads. Providers may also obtain information on vendors of tamper-resistant prescription pads online by using a keyword search of secure prescription pads. The Texas Medical Association has published a list of vendors approved for other states at the link below. These printers meet the baseline requirements set by CMS. For the vendor list: Q: Is HHSC certifying approved printers and suppliers of tamper-resistant prescription pads? A: No. At this time, HHSC is not certifying printers and suppliers. Q: What is the cost of tamper-resistant prescription pads? A: HHSC does not have cost information on prescription pads. Prices are available from independent printers and suppliers. Q: Will the state reimburse providers for the cost of the tamper resistant prescription pads? A: No. Q: Is this requirement limited to Schedule II controlled substances? A: CMS has determined that the prescription forms for Schedule II controlled substances, issued by the Texas Department of Public Safety (DPS) under the Texas Prescription Program, meet the baseline standards for a tamper-resistant prescription. Providers should continue using these pads for all prescriptions for Schedule II controlled substances. All other written prescriptions for Medicaid clients must be executed on tamper resistant paper. Q: Does this apply to Medicaid clients enrolled in Medicaid managed care plans? A: Yes, because all prescriptions for all Medicaid clients in Texas are reimbursed through the Texas Vendor Drug Program. Managed Care entities do not reimburse for outpatient prescription drugs for Texas Medicaid clients, and therefore those prescriptions are not exempt from this requirement. Q: How can a pharmacist determine whether a written prescription is tamper resistant? A: A compliant, written prescription will have the following industry-recognized features: Prevents unauthorized copying of blank or completed forms Prevents erasure or modification of completed forms Prevents counterfeiting There are many suppliers of tamper-resistant prescription pads, so there will be many variations in these features. HHSC strongly encourages providers to use compliant pads that list their security features. Pharmacists are expected to use their best professional judgment. If a prescription appears to be written on plain paper, or the pharmacist has any doubts, the prescriber should be contacted. v CPT only copyright 2014 American Medical Association. All rights reserved. 97

104 Q: If a client presents with a prescription that is not on a tamper-resistant pad and needs the medication right away, can the pharmacy fill the prescription? Yes, the pharmacist may fill the prescription in full as it is written. CMS requires that a compliant prescription be obtained within 72 hours of filling the prescription. A compliant prescription is considered one that has been faxed, telephoned, submitted electronically, or written on a tamper-resistant prescription pad. Note: Prescriptions filled on an emergency basis due to not being written on tamper-resistant paper are not limited to a 72-hour supply of medication. Q: Are drug orders written for a resident of a nursing facility exempt from this rule? A: Yes. Drug orders transmitted directly from a nursing facility to a pharmacy are exempt, as the patient does not directly handle the prescription. Q: Are prescriptions printed in a practitioner s office from a patient s medical record exempt from this requirement? A: No. If the prescription order is presented to the pharmacy on paper, it must contain at least one feature from each of the three categories of tamper-resistance to comply. Faxed and other electronic drug orders that go directly to the pharmacy are exempt. Tamper-resistant printer paper may be used and is available from suppliers of compliant prescription pads. Q: Where can I find more information about Medicaid pharmacy benefits and the Texas Medicaid/CHIP Vendor Drug Program? A: You can find more information online at 98 CPT only copyright 2014 American Medical Association. All rights reserved. v

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108 The Medicaid: Beyond the Basics Participant Guide is produced by TMHP Training and Organizational Development Services and is intended for educational purposes in conjunction with the Medicaid: Beyond the Basics Series. Providers should regularly consult the Texas Medicaid Provider Procedures Manual, CSHCN Services Program Provider Manual, TMHP website, and banner messages for updated information.