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Keep Kids Smiling

Presented by:

2010_0609_1.4

A Texas Health Steps (THSteps) Dental Workshop

Participant Guide

2010_0609_1.4 — CPT only copyright 2008 American Medical Association. All rights reserved. 3

THSteps Dental Participant Guide

ContentsState Health Programs Team ........................................................................................................ 6

THSteps Dental Services .............................................................................................................. 7

Doctor of Dentistry Practicing as a Limited Physician ............................................................... 9

Client Rights ............................................................................................................................... 10

Parental Accompaniment .......................................................................................................... 10

THSteps Medical Services ......................................................................................................... 11Oral Evaluation and Fluoride Varnish Services in the Medical Home Checkup ......................... 11

Provider Enrollment ................................................................................................................... 12Medicaid Enrollment ................................................................................................................ 12

Provider Responsibilities ............................................................................................................ 14

Client Eligibility ......................................................................................................................... 16THSteps Dental Client Eligibility ............................................................................................ 16Eligibility and Third Party Resources ........................................................................................ 16TexMedConnect ....................................................................................................................... 18TMHP Electronic Data Interchange ......................................................................................... 19Automated Inquiry System ....................................................................................................... 20Paper......................................................................................................................................... 21Limitations to Medicaid Client Eligibility ................................................................................. 23Other Claims Filing Factors ...................................................................................................... 24

Periodicity for THSteps Dental Services .................................................................................... 25Exceptions to Periodicity ........................................................................................................... 25

Mandatory Prior Authorization ................................................................................................. 26

Benefits and Limitations ........................................................................................................... 27Criteria for General Anesthesia ................................................................................................ 27

Emergency and Trauma Services ................................................................................................ 28

Change of Provider .................................................................................................................... 29Interrupted or Incomplete Treatment Plans ............................................................................... 29

Intermediate Care Facility for the Mentally Retarded (ICF-MR) Dental Services ................... 30

Claims Filing .............................................................................................................................. 31Electronic Claims ..................................................................................................................... 32Claim Filing Instructions for TexMedConnect .......................................................................... 32Saving a Claim .......................................................................................................................... 34ADA 2006 ADA Dental Claim Form Instruction Table ............................................................ 35Tips on Expediting Paper Claims .............................................................................................. 39

4 CPT only copyright 2008 American Medical Association. All rights reserved. — 2010_0609_1.4


Filing Deadlines .......................................................................................................................... 41Filing Deadine Calendar for 2010 ............................................................................................. 42

Remittance and Status Report .................................................................................................... 43Accessing R&S Reports ............................................................................................................. 44R&S Report Sections ................................................................................................................ 46

Appeals ........................................................................................................................................ 53Appeal Methods ....................................................................................................................... 53Electronic Appeals .................................................................................................................... 54Automated Inquiry System (AIS) Appeals ................................................................................. 55Paper Claim Appeals ................................................................................................................. 56HHSC Administrative Appeals ................................................................................................ 57Complaints by Providers ........................................................................................................... 57

Waste, Abuse, and Fraud ............................................................................................................ 59Definitions ................................................................................................................................ 59Most Frequently Identified Fraudulent Practices ....................................................................... 59Identifying and Preventing Waste, Abuse, and Fraud ................................................................ 59Reporting Waste, Abuse, and Fraud .......................................................................................... 60

Reporting Child Abuse ............................................................................................................... 61DSHS Child Abuse Reporting Form ......................................................................................... 61

Resources .................................................................................................................................... 63Instructions for Using the TMHP Website................................................................................ 63Online Fee Lookup ................................................................................................................... 66Online Provider Lookup ........................................................................................................... 67TMHP Telephone and Fax Communication ............................................................................. 74Prior Authorization Request Telephone and Fax Communication ............................................. 75Prior Authorization Status Telephone Communication ............................................................. 75Written Communication With TMHP ..................................................................................... 76Texas Medicaid/CHIP Vendor Drug Program Contact Information ......................................... 78Helpful Links ........................................................................................................................... 79Common Claim Denial Codes ................................................................................................. 81Acronyms.................................................................................................................................. 82



KEEP KIDS SMILING A Texas Health Steps (THSteps)

Dental Workshop Use of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.”

The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “CDT2009/2010 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association. (c) 2008 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply.”



State Health Programs TeamProviders:• The crucial players in a quality health-care program. The focus is on providing the best medical care possible while maximizing reimbursement potential.

Clients:• Recipients of state health-care program benefits.

Texas State Legislature:• The State legislature allocates budgetary dollars for the state health-care programs, including Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.

Health and Human Services Commission (HHSC):• Oversees operations of the entire health and human services system in Texas. It administers the Medicaid and Children’s Health Insurance Program (CHIP) programs for the state of Texas. It operates the Medicaid acute care program, CHIP, and several other related programs. HHSC’s Office of Eligibility Services (OES) determines eligibility for Title XIX.

Department of State Health Services (DSHS):• Administers and regulates public health, mental health, substance abuse programs, and the Children with Special Health Care Needs (CSHCN) Services Program. DSHS also administers, in collaboration with HHSC, the Texas Health Steps (THSteps) Medical and Dental programs, as well as Case Management for Children and Pregnant Women (CPW). DSHS also conducts personal care services (PCS) assessments.

Department of Aging and Disability Services (DADS):• Administers human services programs for the aging and for people with disabilities and intellectual disabilities. DADS licenses and regulates providers of these services.

Department of Assistive and Rehabilitative Services (DARS):• Administers programs that ensure Texas is a state where people with disabilities and children who have developmental delays enjoy the same opportunities as other Texans to live independent and productive lives.

Texas Medicaid & Healthcare Partnership (TMHP):• Multiple contractors who partner to provide technology infrastructure, application maintenance, program management, data center operations, third party recovery activities, and performance engineering expertise.

MAXIMUS (Enrollment Broker):• In the STAR and STAR+PLUS service areas Maximus is responsible for assisting clients in the selection of a health-care plan and primary care provider or changing a health-care plan. If a client does not select a plan and a primary care provider (PCP), they will be assigned a PCP. Maximus helps clients find THSteps medical and dental providers and assists in coordinating medical transportation services to and from medical and dental appointments.



THSteps Dental ServicesTHSteps dental services provide early detection and treatment of dental health problems and preventive dental care for Texas Medicaid clients who are birth through 20 years of age.

THSteps dental service standards were designed to meet federal regulations and to incorporate the recommendations of representatives of national and state dental professional groups. The Omnibus Budget Reconciliation Act (OBRA) of 1989 mandated the expansion of the federal EPSDT program to include any medical or dental service that is medically necessary and for which Federal Financial Participation (FFP) is available, regardless of the limitations of Texas Medicaid. In Texas, this expansion is referred to as THSteps-Comprehensive Care Program (CCP).

How the THSteps Dental Program Works

Through outreach and education, THSteps-designated staff (HHSC, DSHS, or its designee) encourages parents or caregivers of eligible clients to use THSteps dental checkups and preventive care when clients first become eligible for Texas Medicaid and each time clients are due for their next dental checkup. Upon request, THSteps-designated staff assists parents or caregivers of eligible clients with scheduling appointments and transportation. Medicaid clients have freedom of choice of providers and are given names of enrolled providers.

THSteps periodic dental checkups are due every 6 months. A message reminding the client about the checkup appears on the Medicaid Identification Form (H3087 or H3087 STAR) under the client’s name.

All THSteps clients who are birth through 20 years of age, can be seen by the dentist at any time for emergency dental services for trauma, early childhood caries (ECCs), or any other appropriate dental or therapeutic procedure. Clients who are birth through 20 years of age may self-refer for dental services.

For additional information about dental health, providers can refer to the THSteps online educational modules “Dental Health for Primary Care Providers” and “Dental Examination by Dental Professionals” at www.txhealthsteps.com.

First Dental Home

First Dental Home is a legislatively supported dental initiative aimed at improving the oral health of children who are 6 months of age through 35 months of age and are enrolled in Texas Medicaid/THSteps or the CSHCN Services Program. This service is provided by a THSteps or CSHCN dental provider.

The goal of the initiative is to begin preventive dental services for very young children to decrease the occurrence of early childhood caries and to provide simple and consistent oral health messages to parents and caregivers. First Dental Home tries to establish a dental home; recognizing that earlier oral evaluation allows earlier identification of dental needs and the start of needed preventive and therapeutic dental services. Clients can receive services as frequently as 3-month intervals based on their caries risk assessment and may be referred to a dental home provider by their primary care provider beginning at 6 months of age.



Benefits

A First Dental Home visit (D0145) includes, but is not limited to:

Comprehensive oral examination •Oral hygiene instruction with primary caregiver •Dental prophylaxis, if appropriate •Topical fluoride application using fluoride varnish, if appropriate •Caries risk assessment •Dental anticipatory guidance •

Denials

Procedure codes D0120, D0150, D1120, D1203, or D1206 are denied if procedure code D0145 is billed on the same date of service by any provider. A First Dental Home examination procedure code (D0145) is limited to once per day and 10 times per client lifetime, with at least 60 days between dates of service per provider.

A listing of the procedure codes can be found in the Texas Medicaid Provider Procedures Manual.

Providers must receive training and certification from the Department of State Health Services before reimbursement can occur: Any claims submitted prior to certification will be denied. Training dates, locations, registration forms, and documents are available at:

www.dshs.state.tx.us/dental/firstdentalhomemats.shtm •

https://secure.thstepsproducts.com. •For more information please contact:

Louise Friedman at [email protected] or 512-458-7111, ext. 2110.



Doctor of Dentistry Practicing as a Limited PhysicianA Doctor of Dentistry Practicing as a Limited Physician provider may be reimbursed for a limited range of services to Medicaid eligible clients who are age 21 and older or 21 and younger who are not THSteps eligible. This is only available to clients who have a dental related problem that is causally related to, but secondary to, a life-threatening medical condition.

Note: To be reimbursed, the Doctor of Dentistry practicing as a limited physician must be enrolled in Medicare and are typically an oral maxillofacial surgeon or general dentist.

Prior authorization is required for some services and if the client is 21 years of age or or older. Prior Authorization Requests are to be sent to the Special medical prior authorization team

Special medical requests are accepted via mail and fax:

Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization

12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

Fax: 1-512-514-4213

Doctor of Dentistry practicing as a Limited Physician providers, are not billed using the THSteps dental TPI/NPI provider numbers; they are billed using their Doctor of Dentistry practicing as a limited physician TPI/NPI number.

Providers file claims for services using a CMS-1500 claim form with the Texas Medicaid reimbursement methodology using CPT codes and Diagnostic codes.(refer to the current provider manual).



Client RightsDental providers enrolled in Texas Medicaid enter into a written contract with the HHSC to uphold the following rights of the Medicaid client:

To receive dental services that meet or exceed the standards of care established by the laws •relating to the practice of dentistry and the rules and regulations of the Texas State Board of Dental Examiners (TSBDE).

To receive information following a dental examination regarding the dental diagnosis; scope •of proposed treatment, including alternatives and risks; anticipated results; and the need for administration of sedation or anesthesia, including risks.

To have full participation in the development of the treatment plan and the process of giving •informed consent.

To have freedom from physical, mental, emotional, sexual, or verbal abuse or harm from the •provider or staff.

To have freedom from overly aggressive treatment in excess of that required to address •documented medical necessity.

A provider’s failure to ensure any of the client rights may result in termination of the provider agreement or contract and other civil or criminal remedies.

Parental Accompaniment HRC §§32.024(s)-(s-1) requires, as a condition for provider reimbursement, a child 14 years of age or younger be accompanied by the child’s parent, guardian, or other authorized adult during medical and dental checkups and dental treatment. DSHS implemented this requirement through rules found in 25 TAC §33.2 (Definitions) and 25 TAC §33.6 (THSteps Provider Responsibilities).

The DSHS rules require that the parent, guardian, or authorized adult come with the child to the checkup, and that the parent, guardian, or authorized adult must continue to wait for the child while the checkup, treatment, or service takes place.

Providers will not be required to submit documentation to TMHP to verify compliance with this policy in order for TMHP to process claims. By submitting the claim for reimbursement, the provider acknowledges compliance with all Medicaid requirements. Additional assurances are not necessary.

Exception: School health clinics, Head Start programs, and childcare facilities are exempt from this policy if the clinic, program, or facility encourages parental involvement in the health care of the child and obtains written consent for the services. The consent from the child’s parent or guardian must have been received within the one-year period before the date on which the services are provided and must not have been revoked.

Refer to: HRC §§32.024(s)-(s-1) 25 TAC §33.2 and §33.6.



THSteps Medical Services THSteps Medical Services is the medical counter part to the THSteps Dental providers. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is Medicaid’s comprehensive preventive child health service (medical, dental, and case management) for children birth through 20 years of age. In Texas, EPSDT is known as the Texas Health Steps (THSteps) Program. The THSteps toll-free line (1-877-847-8377) assists eligible clients and their parents or guardians to:

Find a qualified medical, dental, case manager, or other health-care provider enrolled in •Medicaid.

Set up appointments to see a provider through THSteps Outreach. •

Arrange transportation or reimbursement for gas to and from appointments. •

Answer questions about eligible services. •

Oral Evaluation and Fluoride Varnish Services in the Medical Home Checkup

The Oral Evaluation and Fluoride Varnish in the Medical Home initiative are services that allow Texas Health Steps (THSteps) and CSHCN Services Program clients who are 6 through 35 months of age to receive comprehensive oral evaluation, fluoride varnish application, and referral to a dental home during a THSteps medical checkup.

The Oral Evaluation and Fluoride Varnish in the Medical Home is a service provided by a medical provider and does not take the place of a dental checkup. This service is in place to support the First Dental Home initiative and provides a unique opportunity for dental and medical providers to work together in effort to improve the oral health of children.

Note: Medical providers are requested to refer clients to a certified First Dental Home provider when possible.

Physicians, physician assistants and advanced nurse practitioners who are THSteps and CSHCN Services Program providers, are eligible to provide the oral evaluation and fluoride varnish services. Only those providers who have been trained and certified by the Department of State Health Services may offer this service and be reimbursed in addition to the THSteps medical checkup reimbursement.

Providers must complete training and be certified by DSHS Oral Health Program staff to perform these services. Further information regarding training or certification can be found at:

www.dshs.state.tx.us/dental/OEFV.shtm.



Provider Enrollment

Medicaid Enrollment

Providers may enroll online at www.tmhp.com. The next few pages will outline the enrollment procedures.

Why Enroll With Medicaid?

Texas Medicaid relies on a network of providers to render essential preventive and necessary health-care services to Texas Medicaid clients.

As the front-line of services for Medicaid clients, this network of over 70,000 dedicated profes-sionals make health care more accessible to more than 2.5 million Texas residents throughout the state.

The Texas Medicaid provider network enlists dedicated professionals to help meet the growing health-care needs of Medicaid clients. This is an opportunity for health-care professionals to give back to their communities and their fellow Texans who need quality health-care but cannot afford it.

Why Enroll as a THSteps Provider?

Providers that enroll in THSteps may become medical and dental homes for children in need who are birth through 20 years of age, including foster care children. Medical, dental, and case management providers work together to focus on comprehensive, early preventive services to help avoid the need for acute care services. Dental treatment services also help alleviate oral health problems before they escalate. Case management services help families coordinate and make the most efficient and effective use of services.

THSteps Dental Provider Enrollment

To enroll as a THSteps Dental Provider, the provider must be currently licensed by the Texas State Board of Dental Examiners (TSBDE) or licensed in the state where services are performed and must complete an enrollment application for each separate practice location.

A THSteps Dental Provider may enroll as an individual, as a dental group, or as a doctor of dentistry practicing as a limited physician.

Provider Enrollment on the Portal

The process of becoming a Texas Medicaid provider is very straight forward. Once a Provider Enrollment application is completed online, it can be submitted immediately to TMHP. Once the application has been validated and all signature pages and required documentation have been received by TMHP, the provider is enrolled and will receive a welcome e-mail.

www.tmhp.com



Online Enrollment Procedures

Access the Internet and go to www.tmhp.com.1.

Click the link, “2. Activate my Account.”

On the following screen select “3. New Texas Medicaid Provider.”

The following screen will appear. Follow the instructions listed at the top and click the “4. Next” button.

The next screen will change based on the selection made here. Since we chose Provider Enrollment (without a National Provider Identifier [NPI]/Texas Provider Identifier [TPI]), the following screen is displayed.

Complete the required fields and check the box, “5. I agree to these terms.”

Note: Fields marked with a red asterisk are required.

Click the “6. Create Provider Administrator” button.

Shortly after you click the button, you will receive an e-mail at the address provided. This e-mail will contain a copy of your username and password and a link back to the TMHP website.



Provider Responsibilities

Verify eligibility

Clients are encouraged to bring their Medicaid Identification form (H3087 or H1027A) with them to appointments. However, it remains your responsibility to verify eligibility even if the client has not presented their Medicaid Identification form.

Provide medically necessary services to the Medicaid and/or CSHCN Services Program population

As a Texas Medicaid and/or CSHCN Services Program provider, you agreed to provide medically necessary services to the Medicaid and/or CSHCN Services Program population, without discrimination based on race, religion, or sex.

Provide services without discrimination

Providers cannot discriminate against a client who has a third party resource such as other insurance in addition to Medicaid. For example, you cannot choose to only accept Medicaid clients who do not have Third Party Resources.

Accept payment for Medicaid services as payment in full

Providers agree to accept payment for Medicaid services as payment in full.

Follow guidelines for limiting your practice

Practices can be limited to specialty, percentage of overall clients, age, etc., but cannot discriminate between private pay and Medicaid clients. This should be documented in the office policies and procedures and should be across the board for ALL clients.

Follow all guidelines in Banners, Bulletins and R & S Reports

Providers need to be aware of Medicaid benefits and limitations, and are expected to review the Bulletins and Banners. Bulletins are sent bi-monthly. Banners are important messages sent weekly on the front page of the Remittance and Status (R&S) report. News and information are posted on the front page of the TMHP website.

Follow HIPAA Compliancy

All Medicaid and CSHCN Services Program providers must comply with HIPAA regulations to protect client information.



Ensure medical record documentation supports services rendered

Each page of the medical record document must have: client’s name and their Medicaid number. Entries into the medical record must be legible (to individuals other than the author) include the date (month, day and year) and be signed by the performing provider.

Maintain records

All Medicaid records, claims and R&S reports must be kept for a minimum of 5 years. THERE ARE TWO EXCEPTIONS: Freestanding Rural Health Clinics records must be kept for 6 years. Hospital based Rural Health Clinics records need to be kept for 10 years.

Receive correct authorization

It is the provider’s responsibility to know which procedures need an authorization and to obtain prior authorization if it is necessary for the services to be rendered. We will discuss how to obtain a prior authorization later in the presentation.

Notify TMHP of any changes

Providers should notify TMHP of any changes to their physical address, phone, or fax number as well as any changes to their billing or mailing address. If providers change billing services but do not notify TMHP, their checks will go to the last billing address we have on file (if they aren’t using Electronic Funds Transfer (EFT)).

Report Medicaid waste, fraud, and abuse

It is the provider’s responsibility to report suspected instances of Medicaid or CSHCN Services Program waste, abuse or fraud.

Report child abuse

Providers have the responsibility of the timely reporting of suspected cases of child abuse. All Medicaid and CSHCN Services Program providers should make a good faith effort to comply with all child abuse reporting guidelines and requirements in Chapter 261 of the Texas Family Code relating to investigations of child abuse and neglect.

Note: Check Banner Messages and Bulletins for the most up to date Medicaid information.



Client EligibilityAlthough Medicaid clients are encouraged to bring their identification forms (H3087 or H1027-A) to scheduled appointments, it remains the responsibility of the provider to verify client eligibility.

THSteps Dental Client Eligibility

Dentists may provide covered services to Medicaid clients as long as the Medicaid and THSteps eligibility is current. Clients are THSteps eligible through the end of the month of their 21st birthday.

Orthodontic services that begin before the 21st birthday, and are completed within 36 months, may be continued even if the client reaches 21 years of age, or before the treatment plan is completed; or the client loses Medicaid eligibility.

Clients are not eligible for Comprehensive Care Program (CCP) services on or after their 21st birthday. The CCP services provide for all medically necessary dental treatment. Clients are not eligible for dental benefits if the Medicaid ID states any of the following:

Emergency Care Only•

Presumptive Eligibility (PE)•

Qualified Medicare Beneficiary (QMB)•

Women’s Health Program (WHP)•

Eligibility and Third Party Resources

TMHP cannot make changes to the demographic or eligibility information of a client. Providers are encouraged to call the Third Party Resources (TPR) Unit (1-800-846-7307) to give updated other insurance information on a client such as termination of coverage or new insurance coverage.

When calling the TPR Unit to give updated other insurance information, the TPR Call Center Representative will inform the caller if the update has been successfully completed and claims can be resubmitted. If the TPR Call Center Representative is not able to immediately update the other insurance information they will inform the caller that the verification and update process may take up to 20 business days.

To verify client eligibility, use the following options:

TexMedConnect

Verify electronically through TexMedConnect. Providers may inquire about a client’s eligibility •by electronically submitting one of the following for each client:

Medicaid or Program identification number. –



One of the following combinations: Social Security Number (SSN) and last name; SSN –and date of birth (DOB); or last name, first name, and DOB. Narrow the search by entering the client’s county code or sex.

Submit verifications in batches limited to 5,000 inquiries per transmission.•

For more information go to the TMHP website: www.tmhp.com.

Automated Inquiry System (AIS)

Contact Medicaid AIS at • 1-800-925-9126, 1-512-335-5986, 1-512-335-6033, 1-512-335-6217, or 1-512-345-6476.

Contact TMHP CSHCN Services Program AIS at • 1-800-568-2413.

For more information go to the TMHP website: www.tmhp.com.

Paper

Verify the client’s Medicaid eligibility using form H3087 or H1027-A. Form H3087 will will •indicate if the client is in STAR, PCCM, or STAR+PLUS.

Other

Submit a hard-copy list of clients to TMHP. This service is only used for clients with eligibility •that is difficult to verify. A charge of $15 per hour plus $0.20 per page payable to TMHP applies to this eligibility verification. The list includes names, gender, and dates of birth if the Social Security and Medicaid identification numbers are unavailable. TMHP can check the client’s eligibility manually, verify eligibility, and provide the Medicaid identification numbers. Mail the lists to the following address:

Texas Medicaid & Healthcare Partnership Contact Center

12357-A Riata Trace Parkway Suite 100

Austin, TX 78727



TexMedConnect

Providers can verify eligibility through the TexMedConnect application on www.tmhp.com. Providers must create an account to access this application.

Open your Internet browser and go to www.tmhp.com1.

Select 2. Access TexMedConnect from the right navigation panel.

Enter your username and password to log into the system.3.

Click “Eligibility on the left navigator4.

Enter the following required fields:5.

Provider NPI/API and related data –

Eligibility Dates –

If necessary, narrow your search by entering additional information in any of the following combinations:6.

Medicaid or CSHCN Services Program ID –SSN and Last Name –SSN and DOB –

DOB, Last Name, and First Name –



Review results for eligibility information7.

Note: If you perform more than one interactive eligibility check, the Provider NPI/API on the Eligibility Search page defaults to the most recently used Provider NPI/API.

TMHP Electronic Data Interchange

Providers must set up their software or billing agent services to access the TMHP Electronic Data Interchange (EDI) Gateway. Providers who use billing agents or software vendors should contact those organizations for information on installation, settings, maintenance, and their processes and procedures for exchanging electronic data.



Automated Inquiry System

The Automated Inquiry System (AIS) provides the following information and services through the use of a touch-tone telephone:

Claim status•

Patient eligibility•

Benefit limitations•

Medically Needy case status•

Family Planning•

Current weekly payment amount•

Claim appeals. •

Identify PCCM Primary Care Provider•

Eligibility and claim status information is available on AIS 23 hours a day, 7 days a week with scheduled down time between 3 a.m. and 4 a.m., Central Time. All other AIS information is available from 7 a.m. until 7 p.m., Central Time, Monday through Friday. AIS allows 15 transactions per call.

Note: Provider needs to write down the date and time they received client eligibility information as well as the ticket number given at the time of the call in the event an issue surrounding eligibility should arise. Eligibility can be verified dating back to 3 years from the current date.

For full instructions on the use and benefits of AIS, refer to the Automated Inquiry System (AIS) User’s Guide available on www.tmhp.com or call the TMHP Contact Center at 1-800-925-9126 for faxed instructions.

Note: Texas Health Steps (THSteps)-eligible clients who qualify for medically necessary services beyond the limits of this Home Health Services benefit may receive those services through THSteps-CCP.



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Limitations to Medicaid Client EligibilityAdditional and detailed information is available in the Texas Medicaid Provider Procedures Manual.

Emergency Care Only_________________________________________________________________________

_________________________________________________________________________

Limited_________________________________________________________________________

_________________________________________________________________________

Qualified Medicare Beneficiary (QMB) _________________________________________________________________________

_________________________________________________________________________

Medicaid Qualified Medicare Beneficiary (MQMB)_________________________________________________________________________

_________________________________________________________________________

Hospice_________________________________________________________________________

_________________________________________________________________________

Presumptive Eligibility (PE)_________________________________________________________________________

_________________________________________________________________________

Women’s Health Program (WHP)_________________________________________________________________________

_________________________________________________________________________

CHIP Perinatal Program _________________________________________________________________________

_________________________________________________________________________



Other Claims Filing Factors

TPR:• third party resources—before filing with Medicaid, claims must be filed with a third party resource: either (P) private insurance or (M) Medicare. The TPR toll-free telephone number is 1-800-846-7307.

Note: Providers are not required to bill TPR when billing THSteps Medical and Dental, Case Management for Children and Pregnant Women, and Family Planning services. If the provider chooses to bill the other insurance, the provider must follow these rules: Claims involving other insurance, including Medicare must be received within 95 days of the date of disposition. When a service is billed to a third party and no response has been received, the provider must allow 110 days to elapse before submitting a claim to TMHP. However, the federal 365-day filing requirement must still be met. See current Texas Medicaid Provider Procedures Manual for more information.

Texas Medicaid Managed Care Programs:• Clients enrolled in Medicaid managed care select or are assigned to one of several managed care programs. Providers can verify the client’s eligibility checked through TexMedConnect, AIS or by viewing the Medicaid ID Forms (Form H3087 or H1027A).

Most clients enrolled in managed care also select or are assigned a primary care provider. Some services must be provided by the primary care provider and some service may require a referral from the primary care provider. Contact the client’s managed care organization to verify the primary care provider and to obtain additional information regarding administrative policies. The contact information for the managed care organization is located on the Medicaid ID Form, or you can locate the managed care organizations’ contact information in the latest Texas Medicaid Providers Procedures Manual.



Periodicity for THSteps Dental ServicesClients must be referred to a First Dental Home provider beginning at 6 months of age to establish a dental home. Clients from 6 months of age through 35 months of age may be seen as frequently as 3-month intervals based on their caries risk assessment. For clients 3 years of age through 20 years of age, dental checkups may occur at 6-month (181-day) intervals. Clients beginning at 6 months of age must be referred to a dental provider and may be referred at any age if the medical checkup identifies medical necessity. Texas Medicaid has adopted the American Academy of Pediatric Dentistry’s (AAPD) “Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children” to serve as a guide and reference for dentists when scheduling and providing services to THSteps clients. These guidelines can be found in “American Academy of Pediatric Dentistry Periodicity Guidelines” in the current TMPPM.

Exceptions to Periodicity

If a periodic dental checkup has been conducted within the last six months, the client still may be able to receive another periodic dental checkup in the same six-month period. For THSteps clients, exceptions to the six-month periodicity schedule for dental checkup services may be approved for one of the following reasons:

Medically necessary service, based on risk factors and health needs (includes clients birth •through 6 months of age).

Required to meet federal or state exam requirements for Head Start, daycare, foster care, •preadoption, or to provide a checkup prior to the next periodically-due checkup if the client will not be available when due. This includes clients whose parents are migrant or seasonal workers.

Client requests a second opinion or change service providers (not applicable to referrals).•

Subsequent therapeutic services necessary to complete a case for clients who are 5 months of •age or younger when initiated as emergency services, for trauma, or early childhood caries.

Medical check-up prior to a dental procedure requiring general anesthesia. •

A First Dental Home client can be seen up to 10 times within the 6-month through 35-month •period.

When the need for an exception to periodicity is established, a narrative explaining the reason •for the exception to periodicity limitations must be included on the claim to TMHP, whether electronic or paper.

Note: For ICF-MR clients 21 years of age and older only, the periodicity schedule for preventive services does not apply.



Mandatory Prior AuthorizationMandatory prior authorization is required for consideration of reimbursement to dental providers who render the following services:

Orthodontia • Implants•Fixed prosthetic services •Dental general anesthesia •A combination of inlays/onlays or permanent crowns in excess of four per client •Procedure code D4276 •Procedure code D7272 •Procedure code D7472 •

The authorization for these services is valid for up to 90 days.

To obtain prior authorization for implants and fixed prosthodontics, a prior authorization form together with documentation supporting medical necessity and appropriateness must be submitted. A list of required documentation can be found in the THSteps Dental section of the current TMPPM.

Prior authorization will not be given when films show two abutment teeth (virgin teeth do not require a crown, except for Maryland Bridge) or there is untreated periodontal or endodontic disease, or rampant caries which would contraindicate the treatment.

The prior authorization number is required on claims for processing. If the client is not eligible on the DOS or the claim is incomplete, it will affect reimbursement. Prior authorization is a condition for reimbursement; it is not a guarantee of payment.

Any additional documentation must indicate the client’s name and TPI/NPI. The mailed documents must be the originals. Faxes are not accepted.

Mail prior authorizations requests to:

TMHP Dental Prior Authorization Unit PO Box 202917

Austin, TX 78720-2917

For limited dental services for clients 21 years of age or older (not residing in an ICF-MR facility) whose dental diagnosis is causally related to but secondary to a life-threatening medical condition.

Mail prior authorizations to:

Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization

12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

Fax: 1-512-514-4213



Benefits and Limitations All dental providers must comply with the rules and regulations of the TSBDE, including standards for documentation and record maintenance as stated in the TSBDE Rules 22 TAC §108.7, Minimum Standard of Care, General, and §108.8, Records of the Dentist. Federal Medicaid guidelines require dental services not covered under the Texas Health-Steps (THSteps) dental program, but are medically necessary, appropriate, and allowable, are covered under the Comprehensive Care Program (CCP) as provided in the 1 TAC §33.40(b).

Procedure limitations may be waived when all of the following have been met:

Documentation of medical necessity.•Prior authorized by the TMHP Dental Director, and client is eligible on the date of service.•

Procedure codes, limitations, and maximum fees for benefits can be found in dental fee schedule located at www.tmhp.com and in the current provider manual.

Some examples are provided below:Procedure code Limitations Maximum Fee

D2750* All materials accepted. A 13-20, N, PPXR, CCP $528.00

D2751* All materials accepted. A 13-20, N, PPXR, $528.00

D2752 All materials accepted. A 13-20, N, PPXR, CCP $528.00

D2780 A 13-20, N, PPXR, CCP $264.00

D2781 A 13-20, N, PPXR, CCP $264.00

D2782 A 13-20, N, PPXR, CCP $264.00

D2783 Anterior teeth only (#6-11 and #22-27). A 13-20, N, PPXR, CCP

$264.00

D2790 Posterior teeth only (#1-5; #12-21; and #28-32). All materials accepted. A 13-20, N, PPXR, CCP

$264.00

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoram-ic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required, CCP=Comprehensive Care Program, NC= No charge to Medicaid and may not bill the client, and *= Services payable toan FQHC for a client encounter

Criteria for General Anesthesia

The total points needed to justify treatment under general anesthesia are 22. The points are values given to patient attributes. These attributes are: age; treatment requirements; behavior; ; and additional factors. These points are recorded on The Criteria for Dental Therapy under General Anesthesia form, which can be found in the THSteps Dental section of the current TMPPM.

If criteria for general anesthesia are not met, authorization is considered with supporting medical documentation.

The dental provider is responsible for coordinating with the client’s primary care provider the precertification from the client’s HMO for anesthesia and facility charges.



Emergency and Trauma ServicesPrior authorization is not required for emergency or trauma-related dental services.

Emergency and Trauma Services must be filed separately from other routine dental services.

Also, when filing claims for Emergency and Trauma Services the word “Emergency” or “Trauma” must be submitted in the remarks field of the paper claim form.

When filing electronically be sure to select the emergency/trauma field and submit the reason for emergency or trauma in the comment field.

Services for Children Younger Than 6 Months of AgeWhen filing claims for services for children who are younger than 6 months of age, submit initial visits as an “emergency” and add documentation of medical necessity.

Submit the subsequent visits necessary to the case as an “exception to periodicity” and describe the reason for the exception in the Remarks field of the claim form.



Change of Provider A provider may refer a client to another dental provider for any of the following reasons:

Treatment by a dental specialist such as a pediatric dentist, periodontist, oral surgeon, •endodontist, or orthodontist is indicated and is in the best interest of the THSteps client.

The services needed are outside the skills or scope of practice of the initial provider.•

Change of ownership of Dental Practice.•

A provider may discontinue treatment if there is documented failure to keep appointments by the client, noncompliance with the treatment plan, or conflicts with the client or other family members. In any such action to discontinue treatment, providers must comply with 22 TAC §108.5, “Patient Abandonment.” The client also may select another provider, if desired. HHSC may refer the client to another provider as a result of adverse information obtained during a utilization review or resolution of a complaint from either provider or client.

Interrupted or Incomplete Treatment Plans

Authorizations for orthodontic or extensive restorative treatment plans that have been prior authorized for a provider are not transferable to another provider. If a client’s treatment plan is interrupted and the services are not completed, the new provider must request prior authorization to complete the interrupted, incomplete, and prior authorized treatment plan initiated by the original provider. To complete the treatment plan, the client must be eligible for Medicaid with a current client Medicaid Identification Form (Form H3087) or Medicaid Eligibility Verification Form (Form H1027). If the client does not return for the completion of services and there is documented failure to keep appointments by the client, the dental provider who initiated the services may submit a claim for reimbursement. The claim must be received by TMHP within the 95-day filing deadline from the last DOS.



Intermediate Care Facility for the Mentally Retarded (ICF-MR) Dental ServicesICF-MR dental services are mandated by Medicaid, and reimbursement is provided for treatment of dental problems for Medicaid-eligible residents of ICF-MR facilities who are 21 years of age or older. Residents of ICF-MR facilities who are 20 years of age or younger receive services through the regular THSteps Program. Eligibility for ICF-MR services is determined by DADS. Procedure codes without a CCP designation in the Limitations column of the dental fee schedule may be billed in a routine manner for ICF-MR clients. These procedures must be documented as medically necessary and appropriate. ICF-MR clients are not subject to periodicity for preventive care. For procedure codes with a CCP designation, a provider may request authorization with documentation or provide documentation on the submitted claim.

All THSteps and ICF-MR dental services shall be performed by the Medicaid-enrolled dental provider except for permissible work delegated to a licensed dental hygienist, dental assistant,or dental technician in a dental laboratory on the premises where the dentist practices, or in a commercial laboratory registered with the Texas State Board of Dental Examiners (TSBDE).



Claims Filing

Claims can be filed electronically or by paper. Many claims are submitted to TMHP electronically through TexMedConnect. When providers file claims electronically, claims are processed more quickly and accurately which results in faster reimbursement.

Providers billing for dental services and Intermediate Care Facility for Persons with Mental Retardation (ICF-MR) dental services may bill electronically or use the 2006 American Dental Association (ADA) claim form.

A sample of the ADA Dental Claim form can be found at the ADA website:

www.ada.org/prof/resources/topics/claimform.asp

TMHP is responsible for reimbursing all THSteps dental claims except for THSteps dental claims for Foster Care clients. These claims are processed and reimbursed by Delta Dental.

For dates of service of June 1, 2010 and after, send claims and Prior Authorization requests to:

Delta Dental of California State Government Programs

P.O. Box 537030 Sacramento, CA 95853-7030

If providers have questions or concerns, please contact the Provider Call Center toll-free telephone line at:

STAR Health-• 866-287-3252

STAR+PLUS-• 866-512-8274

Advantage by Superior-• 866-512-8305

Benefit Code A benefit code is an additional data element used to identify state programs.

Providers that participate in the following programs must use the associated benefit code when submitting claims and prior authorization requests:

Program Benefit Code

Comprehensive Care Program (CCP) CCP

THSteps Medical EP1

THSteps Dental DE1



Electronic Claims

Providers that submit electronic claims are required to complete the Benefit Code field (when applicable), Address field, and Taxonomy Code field.

Group billing providers are not required to submit a taxonomy code on all electronic claims.

Billing providers that are not associated with a group are required to submit a taxonomy code on all electronic claims. TMHP will reject claims for non-group billing providers (individuals and facilities) that are submitted without a taxonomy code.

Claims may be submitted electronically to TMHP through billing agents who interface directly with the TMHP EDI Gateway.

Electronic Claim Acceptance

Providers should verify that their electronic professional claims were accepted by Texas Medicaid for payment consideration by referring to their Claim Response report. Providers should also check their Accepted and Rejected reports for additional information. Only claims that have been accepted and appear on the Claim Response report will be considered for payment and made available for claim status inquiry. Rejected claims must be corrected and resubmitted for payment consideration.

Resubmission of TMHP Electronic Data Interchange Rejections

To meet the filing deadline, providers that receive a TMHP Electronic Data Interchange (EDI) rejection may resubmit an electronic claim within 95 days of the date of service (DOS). A paper appeal may also be submitted with a copy of the rejection report within 120 days of the rejection report. A copy of the rejection report must accompany each corrected claim that is submitted on paper.

Claim Filing Instructions for TexMedConnect

Go to the TMHP website at www.tmhp.com.1.

Click the link, “2. Access TexMedConnect.”

Log into the system by entering your username and password.3.

Select 4. Claims Entry from the navigation panel on the left hand side of the screen.

Select the appropriate billing provider information.5.

A list of NPI/API and related data such as taxonomy, physical address, and benefit code selections is displayed based on the user’s logon information.

Enter the Medicaid Identification number for the claim (optional).6.

The system populates most of the required fields on the Client tab.

Note: If you do not enter the Medicaid Identification number, you must to enter all required fields manually on the Client tab.



Select the claim type from the drop-down menu.7.

Click 8. Proceed to Step 2.

The Claims Entry screen appears for the selected claim type.

Proceed through each tab and enter claim information.9.

On the “Other Insurance/Submit Claim” tab, select the source of payment. 10.

Read the terms and conditions and check the “11. We Agree” box.

Click 12. Submit.

Note: The TexMedConnect Acute Care user manual can be found at:

http://www.tmhp.com/File%20Library/File%20Library/Provider%20Manuals /TexMedConnect/TexMedConnect%20Acute%20Care%20manual.pdf



Saving a Claim

Claims cannot be submitted until all required information has been entered correctly. The following message screen appears if the information has been entered incorrectly.

Error fields are indicated with red exclamation marks.

Once all required fields have been completed, the claim can be submitted by clicking on the last tab, “Other Insurance/Submit Claim.”

At the bottom of the screen, four choices will be available:

Save Draft:• Adds claim to the draft list for completion at a later time.

Save Template:• Adds claim to the template list for quicker claims creation in the future.

Save to Batch:• Adds claim to the pending claims list for batch submission.

Submit:• Submits one claim at a time.

Note: After a claim is submitted, an Internal Claim Number (ICN) is generated.



Filing Paper Claims All participating THSteps dental providers are required to submit a 2006 ADA Dental claim form for paper claim submissions to Texas Medicaid. These forms may be obtained by contacting the ADA at 1-800-947-4746.

Important: Claims must contain the billing provider’s full name, address, and provider identifiers.

5.7.3 2006 ADA Dental Claim Form

A sample of the ADA Dental Claim form can be found on the ADA website at

www.ada.org/prof/resources/topics/claimform.asp.

When submitting paper claims, providers, except those on prepayment review, should send paper claims to TMHP at the following address:

Texas Medicaid & Healthcare Partnership Claims

PO Box 200555 Austin, TX 78720-0555

Providers on prepayment review must submit all paper claims and supporting medical record documentation to TMHP at the following address:

Texas Medicaid & Healthcare Partnership Attention: Prepayment Review MC–A11 SURS

P.O. Box 203638 Austin, Texas 78720-3638

ADA 2006 ADA Dental Claim Form Instruction Table

The following table is an itemized description of the questions appearing on the form. Thoroughly complete the 2006 ADA Dental claim form according to the instructions in the table to facilitate prompt and accurate reimbursement and reduce follow-up inquiries.

ADA Block No.

ADA Description Instructions

1 Type of Transaction For Texas Medicaid, check the Statement of Actual Services Box.The other two boxes are not applicable. Do not use the 2006 ADA Dental Claim Form as a Texas Medicaid Program Prior Authorization form. Refer to: “THSteps Dental Mandatory Prior Authorization Request Form” on page B-111.

2 Predetermination/Preauthorization Number

Enter prior authorization number if assigned by Medicaid.

3 Company/Plan Name,Address, City, State, ZIP Code

Enter name and address of Texas Medicaid Contractor payer where the claim is to be sent.



ADA Block No.


4 Other Dental or Medical Coverage? Leave blank if no other dental or medical coverage (skip Blocks 5-11). Check Yes if dental or medical coverage is available other than Texas Medicaid coverage, and complete Blocks 5-11.

5 Name of Policyholder/Subscriber in # 4

Subscriber name if non-Medicaid insurance. This line refers to theinsured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

6 Date of Birth (MM/DD/CCYY) Enter insured’s eight-digit date of birth (MM/DD/CCYY) if non Medicaid insurance. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

7 Gender Check insured’s correct gender if non-Medicaid insurance.

This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

8 Policyholder/Subscriber ID Enter insured’s subscriber identifier if non-Medicaid insurance. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

9 Plan/Group Number Enter insured’s plan/group number if non-Medicaid insurance. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

10 Patient’s Relationship to Person Named in # 5

Enter insured’s relationship to primary subscriber if non-Medicaid insurance. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

11 Other Insurance Company/Dental Benefit Plan Name, Address, City, State, ZIP Code

Information on other carrier, if applicable.

12 Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code

Enter client’s last name, first name, and middle initial exactly as written on the Texas Medicaid Identification Form (Form H3087).

13 Date of Birth (MM/DD/CCYY) Enter client’s eight-digit date of birth (MM/DD/CCYY).

14 Gender Check client’s correct gender.15 Policyholder/Subscriber ID Enter client’s Medicaid number.16 Plan/Group/Number Enter the benefit

code, if applicable, of the billing or performing provider.

17 Employer Name Not applicable to Texas Medicaid.



ADA Block No.


18 Relationship to Policyholder/ Subscriber in #12 Above

Not applicable to Texas Medicaid.

19 Student Status For exception to periodicity, check the full-time student (FTS) box and provide a narrative explanation in Block 35. Note: This block may be left blank on claims submitted for emergency/trauma.

20 Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code

Not applicable to Texas Medicaid.

21 Date of Birth (MM/DD/CCYY) Not applicable to Texas Medicaid.22 Gender Not applicable to Texas Medicaid.23 Patient ID/Account # (Assigned by

Dentist) Optional Used by dental office to identify internal client account number. This block is not required to process the claim.

24 Procedure Date (MM/DD/CCYY) Enter eight-digit date of service (MM/DD/CCYY).

25 Area of Oral Cavity Not applicable to Texas Medicaid.26 Tooth System Not applicable to Texas Medicaid.27 Tooth Number(s) or Letter(s) Enter the Tooth ID as required for procedure

code. Refer to: “Tooth Identification (TID) and Surface Identification (SID) Systems” on page 19-10.

28 Tooth Surface Enter Surface ID as required for procedure code.

Refer to: “Tooth Identification (TID) and Surface Identification SID) Systems” on page 19-10.

29 Procedure Code Use appropriate CDT procedure code.30 Description Enter brief description from the CDT

procedure code.31 Fee Enter usual and customary charges for each

line of service used. Charges must not be higher than the fees charged to private pay clients.

32 Other Fee(s) Enter other fees (e.g., other insurance payment).

33 Total Fee Total all fees in column under Block 31.34 Place an X on each missing tooth Place an X on each missing tooth as required

for procedure code.35 Remarks Use the Remarks space for local orthodontia

codes, a narrative explanation for exception to periodicity (Block 19), a facility name and address if the place of treatment (Block 38) is not a provider’s office, an emergency narrative (Block 45), or additional information, such as reports for 999 codes or multiple supernumerary teeth, or remarks codes.



ADA Block No.


36 Patient/Guardian signature Not applicable to Texas Medicaid.37 Subscriber signature Not applicable to Texas Medicaid.38 Place of Treatment Check only Provider’s office box or Hospital

box. Use Hospital if a day surgery facility was used.

39 Number of Enclosures Texas Medicaid does not require enclosures to accompany aclaim. Do not submit radiographs with claims.

40 Is Treatment for Orthodontics? Check Yes or No as appropriate.41 Date Appliance Placed Not applicable to Texas Medicaid.42 Months of Treatment Remaining Not applicable to Texas Medicaid.43 Replacement of Prosthesis? Not applicable to Texas Medicaid.44 Date Prior Placement Not applicable to Texas Medicaid.45 Treatment Resulting from (Check

applicable box)Providers are required to check the Other Accident box for emergency claim reimbursement. If the Other Accident box is checked, information about the emergency must be provided in Block 35.

46 Date of Accident (MM/DD/CCYY) Not applicable to Texas Medicaid.47 Auto Accident State Not applicable to Texas Medicaid.48 Name, Address, City, State, ZIP Code Name and address of the billing group or

individual provider (not the name and address of a provider employed within a group).

49 NPI Enter required billing dentist’s NPI for a group or an individual (not the NPI for a provider employed within a group).

50 License Number Not applicable to Texas Medicaid.51 Social Security Number(SSN) or Tax

Identification Number (TIN)Not applicable to Texas Medicaid.

52 Telephone Number Enter area code and telephone number of billing group or individual (not the telephone number of a provider employed within a group).

52A Additional Provider ID Enter the nine-digit TPI assigned to the billing dentist or dental entity (not the CSHCN Services Program provider employed within a group).

53 Signed (Treating Dentist) Required-Signature of treating dentist or authorized personnel.

54 NPI Enter the performing dentist’s (provider who treated the client) NPI number.

55 License Number Not applicable to Texas Medicaid.56 Address, City, State, ZIP Code Not applicable to Texas Medicaid.



ADA Block No.


56A Provider Specialty Code This block is optional.57 Telephone Number Not applicable to Texas Medicaid.58 Additional Provider ID Required

Enter performing dentist’s (provider who treated the client) ninedigit TPI.

Tips on Expediting Paper Claims

Use the following guidelines to enhance the accuracy and timeliness of paper claims processing.

General requirements

All paper claims must be submitted with a Texas Provider Identifier (TPI) and NPI for the •billing and performing providers. All other provider fields on the claim forms require an NPI only. If an NPI and TPI are not included in the billing and performing provider fields, or if an NPI is not included on all other provider identifier fields, the claim will be denied.

Use original claim forms. Don’t use copies of claim forms.•

Detach claims at perforated lines before mailing.•

Use 10 x 13 inch envelopes to mail claims. Don’t fold claim forms, appeals, or correspondence.•

Don’t use labels, stickers, or stamps on the claim form.•

Don’t send duplicate copies of information.•

Use 8 ½ x 11 inch paper. Don’t use paper smaller or larger than 8 ½ x 11 inches. •

Don’t mail claims with correspondence for other departments.•

Data Fields

Print claim data within defined boxes on the claim form.•

Use black ink but not a black marker. Don’t use red ink or highlighters.•

Use all capital letters.•

Print using 10-pitch (12-point) Courier font. Don’t use fonts smaller or larger than 12 points. •Don’t use proportional fonts, such as Arial or Times Roman.

Use a laser printer for best results. Don’t use a dot matrix printer, if possible.•

Don’t use dashes or slashes in date fields.•



Attachments

Use paper clips on claims or appeals if they include attachments. Don’t use glue, tape, or •staples.

Place the claim form on top when sending new claim, followed by any medical records or other •attachments.

Number the pages when sending attachments or multiple claims for the same client •(e.g., 1 of 2, 2 of 2).

Don’t total the billed amount on each claim form when submitting multipage claims for the •same client.

If applicable, use the CMS-approved Medicare Remittance Advice Notice (MRAN) printed •from the Medicare Remit Easy Print (MREP) (professional services) or PC-Print (institutional services) when sending a Remittance Advance from Medicare or the paper MRAN received from Medicare or a Medicare Intermediary. You may also download a TMHP-approved MRAN template from the TMHP website at www.tmhp.com.

Submit claim forms with MRANs and R&S Reports.•



Filing DeadlinesNew Claims: All claims, except where noted in the provider manual, must be received within 95 days of the date of service.

Other Insurance: Claims involving OI, including Medicare, must be received within 95 days of the date of disposition. When a service is billed to a third party and no response has been received, providers must allow 110 days to elapse before submitting a claim to TMHP; however, the federal 365-day filing requirement must still be met.

Appeals: Appeals must be received within 120 days of the date of the R&S Report on which the denial appears.

Exceptions to the 95-Day Filing Deadline

The Texas Health and Human Services Commission (HHSC) considers exceptions only when one of the following situations exists:

Catastrophic events1. that substantially interfere with normal business operations of the provider, damage to or destruction of the provider’s business office or records by a natural disaster, or destruction of the provider’s business office or records by circumstances that are clearly beyond the provider’s control including, but not limited to, criminal activity.

Delay or error in the eligibility determination of a client or delay because of 2. erroneous written information from HHSC, another state agency, or health-insuring agent.

Delay because of 3. electronic claim or system implementation problems. Providers that request an exception based on this circumstance must submit a written repair statement, invoice, or computer- or modem-generated error reports.

Submission of claims within the 365-day federal filing deadline 4. when services are authorized retroactively.

Client eligibility is determined retroactively and the provider is not notified of retroactive 5. coverage. Providers requesting an exception must include a written, detailed explanation of the facts and activities that illustrate the provider’s efforts in requesting eligibility information for the client.

HHSC Payment Deadline

The HHSC payment deadline rules for the fiscal agent arrangement ensure that state and federal financial requirements are met. TMHP is required to finalize and/or pay claims, within a determined time frame (see table below), based on provider, claim, or eligibility type.

Medicaid/CSHCN payments, excluding crossovers, cannot be made after 24 months from each DOS on the claim (discharge date for inpatient claims.)Claims and appeals submitted after the designated payment deadlines are denied.

For a complete list of deadlines and deadline exceptions, please refer to the Texas Medicaid Provider Procedures Manuals.



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Remittance and Status ReportThe R&S Report provides information on pending, paid, denied, and adjusted claims. TMHP provides weekly R&S Reports to give providers detailed information about the status of claims submitted to TMHP. The R&S Report also identifies accounts receivables established as a result of inappropriate payment. These receivables are recouped from claim submissions. All claims for the same provider identifier and program processed for payment are paid at the end of the week, either by a single check or with Electronic Funds Transfer (EFT). If no claim activity or outstanding account receivables exist during the cycle week, the provider does not receive an R&S Report. Providers are responsible for reconciling their records to the R&S Report to determine payments and denials received.

Note: Providers receive a single R&S Report that details Texas Medicaid activities and provides individual program summaries. Combined provider payments are made based on the provider’s settings for Texas Medicaid FFS.

Providers must retain copies of all R&S Reports for a minimum of 5 years. Providers must not use R&S Report originals for appeal purposes but must submit copies of the R&S Reports with appeal documentation. If claims that are submitted to TMHP on paper or electronically do not appear on a R&S Report within 2 to 3 weeks of submission, providers must check their EDI Transmission reports for claim rejections. Paper billers may have had claims returned to them.

R&S Report Delivery Options

TMHP offers three options for the delivery of the R&S Report. Although providers can choose any of the following methods, a newly-enrolled provider is initially set up to receive a PDF version of the R&S Report.

PDF version:• The PDF version of the R&S Report is an exact replica of the paper R&S Report. The PDF version of the R&S Report can be downloaded by registered users of the TMHP website at www.tmhp.com. The report is available each Monday morning, immediately following the weekly claims cycle. Payments associated with the R&S Report are not released until all provider payments are released on the Friday following the weekly claims cycle. Providers who use the PDF version will not receive paper copies of the R&S Report.

Paper version:• Paper R&S Reports can be mailed to providers the Friday following the weekly claims cycle. Reimbursement checks are mailed with the paper R&S Report, if the provider has not elected EFT.

Note: Additional copies of paper R&S Reports will be charged to the provider if requested more than 30 days after the original R&S Report was issued. There is an initial charge of $9.75 for the request (additional hours = $9.75) with a charge of $0.32 per page and applicable sales tax of 8.25 percent.

ANSI 835:• Using HIPAA-compliant EDI standards, the Electronic Remittance & Status (ER&S) report can be downloaded through the TMHP EDI Gateway using TexMedConnect or third party software. The ER&S Report is also available each Monday after the completion of the claims processing cycle.



Accessing R&S Reports

Access TexMedConnect on on the TMHP website at www.tmhp.com.1.

Enter your user name and password. 2.

Click the “3. R&S” link in the left navigator.

Choose the correct NPI.4.

Select the appropriate program (programs 100 and 200 are combined on the same R&S Report).5.



Choose the appropriate R&S Report by date.6.



R&S Report Sections

R&S Reports include the following sections:

Banner Pages:• Banner messages are used to inform providers of new policies and procedures.

Note: Banner messages (and their corresponding bulletin articles) update and take precedence over the TMPPM. Banner messages are published weekly.

Claims – Paid or Denied:• Claims in the “Claims - Paid or Denied” section finalized during the week before the preparation of the R&S Report. Claims are sorted by claim status, claim type, and by order of client names. The reported status of each claim will not change unless further action is initiated by the provider, HHSC, or TMHP.

Adjustment to Claims:• Adjustments are listed by claim type, client name, and the client’s Medicaid number.

Financial Transactions:• The “Financial Transaction” section of the R&S Report describes any amounts that are added or taken out of the weekly payment. All accounts receivable, IRS levies, payouts, refunds, reissues, and voids appear here.

Claims Payment Summary:• The “Claims Payment Summary” section summarizes all payments, adjustments, and financial transactions listed on the R&S Report. The section has two categories: one for amounts “Affecting Payment This Cycle” and one for “Amount Affecting 1099 Earnings.”

Claims in Process:• In the “Following Claims are Being Processed” section, the R&S Report may list up to five explanation of pending status (EOPS) codes per claim. The claims listed in this section are in process and cannot be appealed for any reason until they appear in either the “Claims Paid or Denied,” or “Adjustments Paid and Denied” sections of the R&S Report. TMHP is listing the pending status of these claims for informational purposes only.

Note: For additional information please refer to the most current TMPPM.



R&S Paid and Denied Claims Texas Medicaid & Healthcare Partnership

Remittance and Status Report

Date: 03/26/2010

Mail original claim to: TEXAS PROVIDER

Texas Medicaid & Healthcare Partnership PO BOX 848484

P.O. Box 200555 DALLAS, TX 75888-1234

Austin, Texas 78720-0555 (214) 555-4141

Mail all other correspondence to: TPI: 1234567-01

Texas Medicaid & Healthcare Partnership NPI/API: 1234567890

12357-B Riata Trace Parkway Taxonomy: 193400000X

Austin, Texas 78727-6422 Benefit Code: DE1

Report Seq. Number: 13

(800) 925-9126 R&S Number: 246000

~ Page 13 Of

________________________________________________________________________________________________________________________________________________

PATIENT NAME CLAIM NUMBER BENEFIT CLIENT # MEDICAL RECORD # MEDICARE # EOB EOB EOB EOB DIAGNOSIS

PATIENT ACCT #

---SERVICE DATES--- -----BILLED----- -----ALLOWED-----

FROM TO TOS PROC QTY CHARGE QTY CHARGE POS PAID AMT EOB EOB EOB EOB EOB MOD MOD

________________________________________________________________________________________________________________________________________________

********************************************* CLAIMS - PAID OR DENIED ***************************************

DOE, JOHN

100021055555555555555555 DE1 555555555 01147

1087

02/26/2010 02/26/2010 W D9230 1.0 30.00 1.0 28.38 1 28.38 00149

02/26/2010 02/26/2010 W D1351 1.0 40.00 1.0 28.82 1 28.82 00149 2 O

02/26/2010 02/26/2010 W D1351 1.0 40.00 1.0 28.82 1 28.82 00149 3 O

02/26/2010 02/26/2010 W D2391 1.0 140.00 1.0 84.08 1 84.08 00149 30 B

02/26/2010 02/26/2010 W D1351 1.0 40.00 1.0 28.82 1 28.82 00149 14 O

02/26/2010 02/26/2010 W D2391 1.0 140.00 1.0 84.08 1 84.08 00149 31 B

02/26/2010 02/26/2010 W D2391 1.0 140.00 1.0 84.08 1 84.08 00149 18 B

02/26/2010 02/26/2010 W D0330 1.0 80.00 1.0 65.08 1 65.08 00149

$650.00 $432.16 $432.16 CLAIM TOTAL

BONILLA,MARIA

100021033333333333333333 DE1 565656565 01147

1189

02/26/2010 02/26/2010 W D0145 1.0 155.00 1.0 144.97 1 144.97 00149

$155.00 $144.97 $144.97 CLAIM TOTAL

**************************************************************************************************************************************

IF YOU NEED TO APPEAL ANY CLAIM ON THIS PAGE, YOU MAY APPEAL ELECTRONICALLY FOR THE MOST EXPEDITIOUS PROCESSING. OTHERWISE, MAKE

ONE COPY OF THIS PAGE FOR EACH CLAIM TO BE APPEALED, CIRCLE THE CLAIM YOU ARE APPEALING AND DESCRIBE YOUR APPEAL. YOUR APPEAL

MUST BE RECEIVED WITHIN 120 DAYS FROM THE DATE OF THE R&S. FOR INFORMATION REGARDING THE ELECTRONIC PROCESS CALL 1-888-863-3638.



R&S Claims Payment Summary

Texas Medicaid & Healthcare Partnership

Remittance and Status Report

Date: 02/01/2010

Mail original claim to: Texas Provider

Texas Medicaid & Healthcare Partnership P.O. BOX 848484

P.O. Box 200555 Dallas, TX 75888-1234

Austin, Texas 78720-0555 (214) 555-4141

Mail all other correspondence to: TPI: 1234567-01

Texas Medicaid & Healthcare Partnership NPI/API: 1234567890

12357-B Riata Trace Parkway Taxonomy: 193400000X

Austin, Texas 78727-6422 Benefit Code:

Report Seq. Number: 33

(800) 925-9126 R&S Number: 99999999

~ Page 39 Of

________________________________________________________________________________________________________________________________________________

PAYMENT SUMMARY FOR TAX ID 123456789

*** AFFECTING PAYMENT THIS CYCLE *** | *** AMOUNT AFFECTING 1099 EARNINGS ***

AMOUNT COUNT | THIS CYCLE YEAR TO DATE

CLAIMS PAID 3,738.10 9 | 3,738.10 35,676.72

|

SYSTEM PAYOUTS 2,437.19 | 2,437.19 2,437.19

|

MANUAL PAYOUTS (REMITTED BY SEPARATE CHECK OR EFT) | 9,242.00 9,242.00

|

AMOUNT PAID TO IRS FOR LEVIES -554.00 |

|

AMOUNT PAID TO IRS FOR BACKUP WITHHOLDING -1,363.93 |

|

ACCOUNTS RECEIVABLE RECOUPMENTS -3,149.88 | -3,149.88 -9,314.02

|

AMOUNTS STOPPED/VOIDED | -310.99 -310.99

|

SYSTEM REISSUES 20,350.91 |

|

CLAIM RELATED REFUNDS | -57.81 -57.81

|

NON-CLAIM RELATED REFUNDS | -6.19 -6.19

|

HELD AMOUNT -4,291.67 |

|

PAYMENT AMOUNT 17,166.72 | 11,892.42 37,666.90

________________________________________________________________________________________________________________________________________________

PENDING CLAIMS 54,913.83

THE AMOUNT OF $4,291.67 WAS HELD AT THE DIRECTION OF THE STATE MEDICAID AGENCY.

**********************PAYMENT TOTAL FOR DIRECT DEPOSIT BY EFT 000000099999999 IN THE AMOUNT OF 17,166.72.**********************



Electronic Remittance and Status (ER&S) Agreement

Before your ER&S Agreement* can be processed, you MUST choose ONE of the following: * These changes affect ONLY the ELECTRONIC version of the Remittance & Status Report. To make

changes to the PAPER version of the R&S report, contact TMHP Provider Enrollment.

Set up INITIALLY (first time). Use Production User ID*: (9 digits)

CHANGE Production User ID FROM: (9 digits)

TO: (9 digits)

REMOVE Production ID Remove: (9 digits)

** The TMHP Production User ID (Submitter ID) is the electronic mailbox ID used for downloading your Electronic Remittance & Status (ER&S) reports. For assistance with identifying and using your Production User ID and password, contact your software vendor or clearinghouse.

This information MUST be completed before your request can be processed.

Provider Name (must match TPI/NPI number) Billing TPI Number Provider Tax ID Number

Provider’s Physical Address Billing NPI Number Provider Phone Number

Provider Contact Name (if other than provider) Provider Contact Title Contact Phone Number

Do not complete this block UNLESS the ER&S will be downloaded by anyone OTHER than the provider.

Name of Business Organization to Receive ER&S Business Organization Phone Number

Business Organization Contact Name Business Organization Contact Phone No.

Business Organization Address Business Organization Tax ID

Check each box after reading and understanding the following statements. If you are unsure about anything that is stated below, contact the TMHP EDI Help Desk at (888) 863-3638. All three statements must be checked before we can process your Electronic Remittance & Status Agreement.

I (we) request to receive Electronic Remittance and Status information and authorize the information to be deposited in the electronic mailbox as indicated above. I (we) accept financial responsibility for costs associated with receipt of Electronic R&S information.

I (we) understand that paper formatted R&S information will continue to be sent to my (our) accounting address as maintained at TMHP until I (we) submit an Electronic R&S Certification Request form.

I (we) will continue to maintain the confidentiality of records and other information relating to recipients in accordance with applicable state and federal laws, rules, and regulations.

Provider Signature Date

Title Fax Number

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date: Mailbox ID: Effective Date_07302007/Revised Date_06012007

— A STATE MEDICAID CONTRACTOR Page 1 of 2 ERSAG05/2007 v1.1



ER&S Agreement — Submission Instructions

Before faxing or mailing this agreement, ensure that all required information is completely filled out, and that the agreement is signed.

Incomplete agreements cannot be processed.

Mail to: Texas Medicaid & Healthcare Partnership Attention: EDI Help Desk MC–B14

PO Box 204270 Austin, TX 78720-4270

Fax to: (512) 514-4228 OR

(512) 514-4230

Effective Date_07302007/Revised Date_06012007

— A STATE MEDICAID CONTRACTOR Page 2 of 2 ERSAG05/2007 v1.1



Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form

— A STATE MEDICAID CONTRACTOR23


NOTE: Complete all sections below and attach a voided check or a statement from your bank written on the bank’s letterhead.

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

National Provider Identifier (NPI)/Atypical Provider Identifier (API): Primary Taxonomy Code: Benefit Code:

Provider Accounting Address Provider Phone Number ( ) Ext.

Bank Name ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one) Checking Savings

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period.

I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws.

I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations.

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to: Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date:



Electronic Funds Transfer (EFT) Information

— A STATE MEDICAID CONTRACTOR23


Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider’s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account.

The following items are specific to EFT:

• Pre–notification to your bank takes place on the cycle following the application processing.

• Future deposits are received electronically after pre–notification. • The Remittance and Status (R&S) report furnishes the details of individual credits

made to the provider’s account during the weekly cycle. • Specific deposits and associated R&S reports are cross–referenced by both the

provider identifiers (i.e., NPI, TPI, and API) and R&S number. • EFT funds are released by TMHP to depository financial institutions each Friday. • The availability of R&S reports is unaffected by EFT and they continue to arrive in

the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date.

However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer’s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer’s needs.

In all cases, credits received should be posted to the customer’s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date.

To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return the agreement and either a voided check or a statement from your bank written on the bank’s letterhead to the TMHP address indicated on the form.

Call the TMHP Contact Center at 1–800–925–9126 for assistance.



Appeal Methods

An appeal is a request for reconsideration of a previously dispositioned claim. Providers may use one of three methods to appeal Medicaid claims to TMHP:

Electronic•

AIS•

Paper•

TMHP must receive all appeals of denied claims and requests for adjustments on paid claims within 120 days from the date of disposition of the R&S Report on which that claim appears. If the 120-day appeal deadline falls on a weekend or holiday, the deadline is extended to the next business day.

When appealing a claim, providers must first identify the reason the claim was denied and either correct the claim data or submit additional documentation supporting the appeal request.

Standard administrative requests and medical appeals must be sent first to TMHP or the claims processing entity as a first-level appeal. After the provider has exhausted all aspects of the appeals process for the entire claim, the provider may submit a second-level appeal to HHSC.

A first-level appeal is a provider’s initial standard 1. administrative or medical appeal of a claim that has been denied or adjusted by TMHP. This appeal is submitted by the provider directly to TMHP for adjudication and must contain all required information to be considered. Detailed instructions are found in the program provider manual

A second-level appeal is a provider’s final medical or 2. standard administrative appeal to HHSC of a claim that meets all of the following requirements:

Claim has been denied or adjusted by TMHP. –

Claim has been appealed as a first-level appeal to –TMHP.

Claim has been denied again for the same –reason(s) by TMHP.

This appeal is submitted by the provider to HHSC, which may subsequently require TMHP to gather information related to the original claim and the first-level appeal. HHSC is the sole adjudicator of this final appeal.

All providers must submit second-level administrative appeals and exceptions to the 95-day filing deadline appeals to HHSC at the following address:

Texas Health and Human Services Commission HHSC Claims Administrator Contract Management

Mail Code 91X PO BOX 204077

Austin, Texas 78720-4077

Appeals



Electronic AppealsClaims with a finalized status can be appealed directly from TexMedConnect through the TMHP website at www.tmhp.com. To appeal a claim, follow these steps:

Click 1. Appeals in the left navigation panel.

Note: The user must have appropriate security rights to access this section.

Enter the claim number you want to appeal.2.

Note:If you do not know the claim number, enter information about the claim and click Search. If a match is found, the CSI Search Details screen will appear.

Click 3. Appeal Claim to continue the appeal process.

Most fields populate with the claim information. 4.

Note:You can modify the claim information for the appeals. Verify that all required fields are completed

Select Appeal type: Adjustment or Void 5.

Verify that all required fields are completed6.

NOTE: Not all fields are copied from the R&S or CSI

Make changes to the claim data as appropriate to the reason for the appeal you want to submit7.

Read the certification, terms, and conditions and check the We Agree box.8.

You have the option of submitting the appeal, saving the appeal as a draft or saving it to batch, 9. “Submit Claim.”

Note: If the appeal is successfully submitted an ICN number is generated. If there are errors on the appeal, error messages will appear. If necessary, correct the error and re-submit the appeal.



Automated Inquiry System (AIS) Appeals

The following appeals may be submitted using AIS:

Client Eligibility:• The client’s correct Medicaid Identification number, name, and date of birth are required.

Provider Information (Excluding Medicare Crossovers):• The correct provider identifier is required for the billing provider, performing provider, referring provider, and limited provider. The name and address of the provider are required for the facility and outside laboratory.

Claim Corrections:• Providers may correct the following:

Patient control number (PCN) –

Date of birth –

Date of onset –

X-ray date –

Place of service (POS) –

Quantity billed –

Prior authorization number (PAN) –

Beginning DOS –

Ending DOS –

The following appeals may not be appealed through AIS:

Claims listed on the R&S Report as Incomplete Claims•

Claims listed on the R&S Report with $0 allowed and $0 paid•

Claims that require supporting documentation (for example, operative report, medical records, •home health, hearing aid, and dental X-rays)

Procedure code•

Claims listed as pending or in process with EOPS messages•

Claims denied as past filing deadline except when retroactive eligibility deadlines apply•

Claims denied as past the payment deadline•

Providers may appeal these denials either electronically or on paper.

Refer to: “Disallowed Electronic Appeals” in theTexas Medicaid Provider Procedures Manual to determine whether these appeals can be billed electronically. If these appeals cannot be billed electronically, a paper claim must be submitted.



AIS Automated Appeals Guide

To access the AIS automated appeals guide, providers can call 1-800-925-9126 (1-800-568-2413 for CSHCN Services Program). Providers may submit up to 3 fields per claim and 15 appeals per call. If during any step invalid information is entered 3 times, the call transfers to the TMHP Contact Center for assistance.

Paper Claim Appeals

After determining a claim cannot be appealed electronically or through AIS, appeal the claim on paper by completing the following steps:

Copy the page of the R&S Report where the claim is paid or denied. A copy of other official 1. notification from TMHP may also be submitted.

Note: It is no longer necessary to file a new claim when submitting an appeal.

Circle one claim per R&S Report page in black or blue ink.2.

Identify the reason for the appeal.3.

If applicable, indicate the incorrect information on the claim, and provide the corrected 4. information that should be used to appeal it.

Attach a copy of any supporting medical documentation that is required or has been requested 5. by TMHP.

Attach a completed claim form.6.

Reminder: Do not copy supporting documentation on the opposite side of the R&S Report.

Note: It is strongly recommended that providers that submit paper appeals retain a copy of the documentation being sent. It also is recommended that paper documentation be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were received by TMHP, which is important if it is necessary to prove that the 120-day appeals deadline has been met. If a certified receipt is provided as proof, the certified receipt number must be indicated on the detailed listing along with the Medicaid number, billed amount, DOS, and a signed claim copy. The provider may need to keep such proof regarding multiple claims submissions if the provider identifier is pending.

Medicare crossovers and inpatient hospital appeals related to medical necessity denials or DRG assignment/adjustment must be submitted on paper with the appropriate documentation.

Submit correspondence, adjustments, and appeals (including routine inpatient hospital claims) to TMHP at the following address:

Texas Medicaid & Healthcare Partnership Appeals/Adjustments

PO Box 200645 Austin, TX 78720-0645



HHSC Administrative Appeals

An administrative appeal to HHSC is appropriate when a provider has exhausted the appeals process with TMHP. This is a request for review of (not a hearing on) claims denied by TMHP or claims processing entity for technical and nonmedical reasons as defined in Title 1 Texas Administrative Code (TAC) §354.2201(2). There are two types of administrative appeals:

Exception requests to the 95-day claim filing deadline:• A provider’s formal written request for review of (not a hearing on) a claim that is denied or adjusted by TMHP for failure to meet the 95-day claim filing deadline. This exception should meet the qualifications for one of the five exceptions listed in the TMPPM and should be submitted directly to HHSC.

Standard Administrative Appeal:• A provider’s formal written request for review of (not a hearing on) a claim or prior-authorization that is denied by TMHP for technical and/or nonmedical reasons.

An administrative appeal must be submitted in writing to HHSC Claims Administrator Contract Management by the provider that delivered the service or is claiming reimbursement for the service. The appeal must also be received by HHSC Claims Administrator Contract Management after the appeals process with TMHP or the claims processing entity has been exhausted, and must contain evidence of appeal dispositions from TMHP or the claims processing entity.

Medical Necessity Appeals

HHSC Claims Administrator Contract Management only reviews appeals that are received within 18 months from the DOS.

All claims must be paid within 24 months from the date of service as outlined in 1 TAC §354.1003. Providers must adhere to all filing and appeal deadlines for an appeal to be reviewed by HHSC Claims Administrator Contract Management. The filing and appeal deadlines are described in 1 TAC §354.1003.

Providers may submit HHSC administrative appeals to the following address:


Mail Code-91X PO Box 204077

Austin, Texas 78720-4077

Medical necessity appeals are defined as disputes regarding medical necessity of services. Providers must appeal to TMHP and exhaust the appeal/grievance process before submitting an appeal to HHSC.

Medical necessity appeals related to utilization review (UR) decisions made by HHSC’s Office of Inspector General (OIG) Utilization Review (UR) Department must be appealed to HHSC, not TMHP.

Complaints by Providers

A complaint is defined as any dissatisfaction expressed in writing by the provider, or on behalf of that provider, concerning any aspect of Texas Medicaid.



Complaints to HHSC for Fee-for-Service (FFS) and PCCM

FFS and PCCM providers may file complaints to the HHSC Claims Administrator Contract Management if they find they did not receive full due process from TMHP in the management of their appeal. FFS and PCCM providers must exhaust the appeals/grievance process with TMHP before filing a complaint with HHSC Claims Administrator Contract Management.

The complaints must be in writing and received by HHSC Claims Administrator Contract Management within 60 calendar days from TMHP’s written notification of the final appeal decision.

When filing a complaint, a provider must submit a letter that explains the specific reasons the provider believes the final appeal decision by TMHP is incorrect along with copies of the following documentation:

All correspondence and documentation from the provider to TMHP, including copies of •supporting documentation submitted during the appeal process.

All correspondence from TMHP to the provider, including TMHP’s final decision letter.•

All R&S Reports of the claims/services in question, if applicable.•

Provider’s original claim/billing record, electronic or manual, if applicable.•

Provider’s internal notes and logs when pertinent.•

Memos from the state or TMHP that indicate any problems, policy changes, or claims’ •processing discrepancies that may be relevant to the complaint.

Other documents, such as receipts (i.e., certified mail), original date-stamped envelopes, in-•service notes, minutes from meetings, etc., if relevant to the complaint.

Receipts can be helpful when the issue is late filing. •

Complaint request for Fee-for-Service and PCCM maybe be mailed to HHSC at the following address:


Mail Code 91X PO Box 204077

Austin, TX 78720-4077

Complaints to HHSC – Managed Care Providers

Medicaid Managed Care providers (HMOs) may file complaints to HHSC Health Plan Operations if they find they did not receive full due process from the HMOs. HHSC is only responsible for the management of complaints from managed care providers. Appeals/griev ances, hearings, or dispute resolutions are the responsibility of the health plans. Providers must exhaust their appeals/grievance process with their health plan before filing a complaint with HHSC.

Managed care providers may send complaints to HHSC at the following address:

Texas Health and Human Services Commission Re: Provider Complaint

Health Plan Management, H-320 PO Box 85200

Austin, TX 78708



Waste, Abuse, and Fraud

Definitions

Waste:• Practices that allow careless spending and/or inefficient use of resources.

Abuse:• Practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary program cost, or in reimbursement for services that are medically necessary or do not meet professionally recognized standards for health care.

Fraud:• An intentional deceit or misrepresentation made by a person with the knowledge that deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Most Frequently Identified Fraudulent Practices

Billing for services not performed.•

Billing for unnecessary services.•

Upcoding or unsubstantiated diagnosis.•

Billing outpatient services as inpatient services.•

Over treating/lack of medical necessity.•

Identifying and Preventing Waste, Abuse, and Fraud

HHSC, Office of Inspector General (OIG) is responsible for investigating waste, abuse, and fraud in all Health and Human Services (HHS) programs. OIG’s mission is to protect the:

Integrity of health and human services programs in Texas.•

Health and welfare of the clients in those programs.•

OIG oversees HHS activities, providers, and clients through compliance and enforcement activities designed to:

Identify and reduce waste, abuse, fraud, or misconduct.•

Improve efficiency and effectiveness through the HHS system.•

OIG is required to set up clear objectives, priorities, and performance standards that help:

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.•



Human Resources code, Chapter 32 Medical Assistance Program (Medicaid), §32.039

(a) (4) A person “should know” or “should have known” information to be false if the person acts in deliberate ignorance of the truth or falsity of the information or in reckless disregard of the truth or falsity of the information, and proof of the person’s specific intent to defraud is not required.

When reporting waste, abuse, or fraud, gather as much information as you can.

Examples of provider information include:

Name, address, and phone number of the provider.•

Name and address of the facility (hospital, nursing home, and home health agency, etc.).•

Medicaid number of the provider and facility is helpful.•

Type of provider (physician, physical therapist, and pharmacist, etc.).•

Names and numbers of other witnesses who can aid in the investigation.•

Copies of any documentation 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. For example: Dr. John Doe requires employees to bill for extra quantities or bill higher level of service than actually provided.

Names of clients for which services are questionable.•

Examples of client information include:

The person’s name.•

The person’s date of birth and Social Security number, if available.•

The city where the person resides.•

Specific details about the fraud-such as “Jane Doe failed to report her husband, John Doe, lives •with her and he works at ABC Construction in Anyplace, TX.”

Reporting Waste, Abuse, and Fraud

Individuals with knowledge about suspected Medicaid waste, abuse, or fraud of provider services must report the information to the HHSC OIG. To report waste, abuse, or fraud, go to www.hhsc.state.tx.us and select Report Waste, Abuse, and Fraud. Individuals may also call the OIG hotline at 1-800-436-6184 to report waste, abuse, or fraud if they do not have access to the Internet.



Reporting Child AbuseAll Medicaid providers shall make a good faith effort to comply with all child abuse reporting guidelines and requirements as outlined in Chapter 261 of the Texas Family Code relating to investigations of child abuse and neglect. All providers shall develop, implement and enforce a written policy and train staff on reporting requirements.

This policy needs to be part of your office Policy and Procedure Manual and needs to address the appropriate measures your staff is to take when suspected child abuse has occurred.

DSHS Child Abuse Reporting Form

The DSHS Child Abuse Reporting Form shall be used in the following manner:

To fax reports of abuse to DFPS (• 1-800-647-7410) or reporting to law enforcement officials. All documentation of the report must be kept in the client record.

To document reports made by telephone to DFPS (• 1-800-252-5400, 24/7) or law enforcement; and

To document decisions not to report suspected child abuse based on the existence of an •affirmative defense.

Providers may report abuse online at www.txabusehotline.org and use a print-out of the report or a copy of the confirmation from DFPS with the client’s name and date of birth written on it, instead of this form, as documentation in the client record.

Note: The website is only for reporting situations that do not require an emergency response.

An emergency is a situation where a child, an adult with disabilities, or a person who is elderly faces an immediate risk of abuse or neglect that could result in death or serious harm.

If the report is an emergency, call 9-1-1 or your local law enforcement agency.

Online reports can take up to 24 hours to process. Call the Texas Abuse Hotline at 1-800-252-5400 if:

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 e-mail to confirm your report. •



For more information on policy; to report abuse; or to obtain the new DSHS Child Abuse Reporting Form please refer to the following links:

Title Website

DSHS Child Abuse Screening, Documenting, and Reporting Policy

http://tinyurl.com/child-abuse-reporting

DSHS Child Abuse Reporting Form http://tinyurl.com/child-abuse-reporting-form

Texas Abuse, Neglect, and Exploitation Reporting System

https://www.txabusehotline.org/



Resources

Instructions for Using the TMHP Website

The TMHP website at www.tmhp.com, was designed to streamline provider participation. Through the website, providers can submit claims and appeals, download provider manuals and bulletins, verify client eligibility, view Remittance and Status (R&S) and panel reports, and stay informed with current news and updates. Current news remains on the TMHP website homepage for 10 business days and is then moved to the news archive (available from the News Archive link on the left hand side of the main page).

Searching the TMHP Website

Some providers may find it easier to search the TMHP website using the site’s search function rather than navigating through the news and archive sections. To use the search feature, providers must type the desired keywords into the search box located in the upper right-hand corner of the homepage, and click the green arrow or press Enter. To improve search results, providers should use logical operators (and, or, and not) or enclose search phrases in quotation marks. When phrases are enclosed in quotation marks, the search feature returns only those pages that contain the exact phrase, rather than returning the pages that contain any of the words in the phrase.

In addition to the site’s search feature, providers can use popular search engines, such as Google™, to easily find information applicable to their provider type. To use Google to search only the TMHP website, follow these steps:

From an internet browser (Internet Explorer, Firefox, etc.), go 1. to www.google.com.

In the search box, type “site:www.tmhp.com” followed by the 2. keyword(s) for the search (see example).

Click 3. Google Search.

Google displays a list of all the pages on the TMHP website that contain the keyword(s).

Providers can use Google’s advanced search (available by clicking the Advanced Search link) to filter their results by date, language, and file format. For example, providers can choose to display only those pages updated within the past three months. Providers can also exclude certain words or phrases from their results or specify where on the page the desired term should appear (for example, in the title of the page or in the body of the page).



Information

On the TMHP website, you’ll find:

Provider Manuals and Guides:

Texas Medicaid Provider Procedures •Manual

CSHCN Services Program Provider •Manual

Texas Medicaid Quick Reference Guide•

CMS-1500 Online Claims Submission •Manual

2008 Automated Inquiry System User •Guide-Medicaid

2008 Automated Inquiry System User •Guide-CSHCN Services Program

TexMedConnect instructions for Acute •Care and Long Term Care

Provider Forms:

Medicaid Forms•

CSHCN Services Program Forms•

Enrollment Forms•

Bulletins and Banner Messages:

Medicaid Bulletins•

CSHCN Services Program Bulletins•

Banner Messages•

Software, Fee Schedules, Reference Codes:

Fee Schedules•

Acute Care Reference Codes•Long Term Care (LTC) Programs •Reference Codes

Workshop Materials•

Computer Based Training (CBT)•



Functions on the TMHP Website

On the TMHP website, you’ll be able to:

Enroll as a provider into TMHP’s system to access the many benefits available.•

Attest an API.•

Use TexMedConnect to file a claim electronically, which reduces errors and speeds up the reimbursement of funds.•

Review and print documents, review user guides, and search through the library for previous workshop materials.•

Register for a workshop and view upcoming events.•

Submit a request for an authorization.•

View the status of a submitted prior authorization request.•

Immediately verify the eligibility of a client.•

View panel reports.•

Look for a Provider•



Online Fee LookupTMHP has developed new functionality for the fee schedules called the Online Fee Lookup (OFL). You can now narrow your search criteria for fees.

You do not need to be logged into the Online Portal to use the new functionality; however, to view your specific “Contracted” rate, you will need to log in.

From www.tmhp.com, scroll down until you see the Fee Schedules link towards the bottom of the right-hand navigation.

From the Fee Schedule home page you can select to view the static fee schedules, or perform a fee search or batch search.

Using the OFL, you can search for fees using one of these options:

A single procedure code•A list of up to 50 procedure codes•A range of codes•All procedure codes pertaining to a specific provider type and specialty.•

Managed Care Organizations (MCO’s) have two additional options. MCO’s can upload Out of Network (OON) files and no longer need to upload the files to TexMed Connect.

MCO’s will continue to receive error reports if errors are found in the files and response files will be available within 36 hours.

To access the fee schedule and Out of Network Batch Submissions, open Internet Explorer and navigate to www.tmhp.com.

Fee Schedule OFL Search: This allows a user to access the Fee Search to search for reimbursement rates specific to a provider’s National Provider Identifier (NPI) or Atypical Provider Identifier (API).

Fee Schedule OON Batch Submissions: This allows a user to submit Out of Network files to TMHP for processing.

To learn more about the OFL tool, please view the Computer Based Training at: www.tmhp.com/Online%20Learning/CBT%20Library/OFL/index.htm

www.tmhp.com

http://www.tmhp.com

www.tmhp.com/Online%20Learning/CBT%20Library/OFL/index.htm



Online Provider Lookup

Using the Online Provider Lookup Tool (OPL) to Find a Provider

1. Go to www.tmhp.com.

Click the link, “2. Look for a Provider.”

Enter Provider Search Criteria:3.

Health Plan –

TPI –

NPI/API –

Taxonomy –

Benefit Code –

Last Name/Facility Name –

HMO Plan Name –

Provider Type –

ZIP Code –

Note: Fields marked with a red asterisk are required

Click the “4. more information” link for instructions on how to complete the adjacent field.

Click the “5. Search” button to obtain a list of providers that meet the search criteria entered.

Click the “6. Clear Form” button to remove the information and start over

http://www.tmhp.com



The next screen displays a list of providers that meet the search criteria.

Click the “ – View Map” link to display a map of the provider’s location.

Click the provider name to receive detailed information on that provider.7.

Click the “ – Back To Results” link to return to the provider list.

Click the “ – Print” button to display a printer-friendly page for printing.

Click the “ – View Map” link to display a map of the provider’s location.

Click the “ – more information” link for a description of the Primary Care Provider symbol.



Using the Advanced Search in OPL

Selecting the option, “Advanced Search” on the menu bar generates the following screen:

Unlike the basic search option, the advanced search option allows providers to narrow their search using several additional search options such as:

Accepting new patients•

Provider specialty•

Provider subspecialty•

Extended hours•

Medicaid waiver program•

Other services offered•

Languages spoken•

Patient age•

Patient gender•

County served by the provider•

Note: The online provider look up is not currently available for CSHCN Services Program Providers.



Notice that the criteria entered in the Provider Type field changes the information displayed under “Provider Specialty.”



Updating Address Information

1. The provider clicks on the link from the My Account page to change/verify their address information.

The provider must click on 2. the “Edit” button to activate a section for editing. The provider can:

Update address –information.

Update phone numbers –and their email address.

Add or remove counties –served.

Update business hours. –

Indicate whether or –not they are accepting patients for each plan in which they participate.

Indicate languages –spoken in their office.

Indicate if they offer –additional services.

Limit the gender or age –of clients served.

Save and Cancel buttons 3. appear when an area is active for editing. The provider must choose to save the information or cancel their changes before editing any other sections.

Once the information is updated by the provider, it should appear with the new information in the Online Provider Lookup immediately.

The more complete a providers’ information is, the better chance they have of appearing in the results of a user’s advanced search.

Note: Information in the grey area of the page cannot be updated online by the provider. To make updates to 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 (1-800-435-4165). Additional information about the Texas Vendor Drug Program can be found online at http://tinyurl.com/Vendor-Drug.

http://tinyurl.com/Vendor-Drug




Provider Enrollment PO Box 200795 Austin, TX 78720-0795

Instructions for Completing the Provider Information Change Form

Signatures • The provider’s signature is required on the Provider Information Change Form for any and all changes requested

for individual provider numbers.

• A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers.

Address

• Performing providers (physicians performing services within a group) may not change accounting information.

• For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form.

• For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers.

• ual practitioner provider numbers can only be made by the individual to whom the

• Performing providers cannot change the TIN.

Provider Demographic Information

e specific practice

limitations accordingly. This will allow clients more detailed information about your practice.

Gen r•

cable) nge. Forms will be returned if this information is not indicated on the Provider

e and TIN changes.

•ealthcare Partnership (TMHP)

Fax: 512-514-4214

Tax Identification Number (TIN)

TIN changes for individnumber is assigned.

An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, pleasvisit the OPL at www.tmhp.com. Please review the existing information and add or modify any

e al

TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if appliin order to process the chaInformation Change Form.

• The W-9 form is required for all nam

Mail or fax the completed form to:

Texas Medicaid & HProvider Enrollment PO Box 200795 Austin, TX 78720-0795




Provider Information Change Form Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.

Check the box to indicate a PCCM Provider Date : / /

Nine-Digit Texas Provider Identifier (TPI): Provider Name:

National Provider Identifier (NPI): Primary Taxonomy Code:

Atypical Provider Identifier (API): Benefit Code:

List any additional TPIs that use the same provider information:

TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI:

Physical Address—The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who change their ZIP Code must submit a copy of the Medicare letter along with this form.

Street address City County State Zip Code Telephone: ( ) Fax Number: ( ) Email:

Accounting/Mailing Address—All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email:

Secondary Address

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email: Type of Change (check the appropriate box)

Change of physical address, telephone, and/or fax number

Change of billing/mailing address, telephone, and/or fax number

Change/add secondary address, telephone, and/or fax number

Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field

Other (e.g., panel closing, capacity changes, and age acceptance)

Comments:

Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Tax ID number: Effective Date:

Exact name reported to the IRS for this Tax ID:

Provider Demographic Information—Note: This information can be updated on www.tmhp.com.

Languages spoken other than English:

Provider office hours by location:

Accepting new clients by program (check one): Accepting new clients Current clients only No

Patient age range accepted by provider: Additional services offered (check one): HIV High Risk OB Hearing Services for Children

Participation in the Woman’s Health Program? Yes No Patient gender limitations: Female Male Both

Signature and date are required or the form will not be processed. Provider signature: Date: / /

Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Fax: 512-514-4214



TMHP Telephone and Fax Communication

Contact Telephone/Fax Number

TMHP Contact Center (general information)Automated Inquiry System (AIS)

1-800-925-9126 or 1-512-335-5986

TMHP Children with Special Health Care Needs (CSHCN) Services Program Contact CenterAutomated Inquiry System (AIS)

1-800-568-2413

CSHCN Services Program Fax 1-512-514-4222

Comprehensive Care Program (CCP) (CCP prior authorization status and general CCP and Home Health Services information)

1-800-846-7470 (voice)1-512-514-4211 (fax)

Comprehensive Care Inpatient Psychiatric (CCIP) Unit (prior authorization and general informa-tion)

1-800-213-8877 (voice)1-512-514-4211 (fax)

Family Planning (Tubal Ligation/Vasectomy Consent Forms) Fax 1-512-514-4229

Health Insurance Premium Payment (HIPP) and Insurance Premium Payment Assistance (IPPA) 1-800-440-0493

Home Health Services (includes durable medical equipment [DME]):Option 1 – TMHP in-home care customer service Option 2 – DME supplier with completed Title XIX form Option 3 – Registered nurse (RN) with completed plan of care (POC)

1-800-925-8957 (voice)1-512-514-4209 (fax)

Hysterectomy Acknowledgment Statements Fax 1-512-514-4218

Long Term Care (LTC) Operations 1-800-626-4117

LTC—Nursing Facilities 1-800-727-5436

Medicaid Audit/Cost Reports 1-512-506-6117

Medicaid Audit Fax 1-512-506-7811

PCCM Provider Helpline 1-888-834-7226

Radiology Prior Authorization 1-800-572-2116 (voice)1-800-572-2119 (fax)

Provider Enrollment Fax 1-512-514-4214

Telephone Appeals 1-800-745-4452

Texas Health Steps (THSteps) Dental Inquiries 1-800-568-2460

THSteps Medical Inquiries 1-800-757-5691

Third Party Resources (TPR) (Option 2) 1-800-846-7307

Third Party Resources (TPR) Fax 1-512-514-4225

TMHP Electronic Data Interchange (EDI) Help Desk 1-888-863-3638

TMHP EDI Help Desk Fax 1-512-514-4228 1-512-514-4230



Prior Authorization Request Telephone and Fax Communication

Contact Telephone/Fax Number

Ambulance Authorization (includes out-of-state transfers) 1-800-540-0694

Ambulance Authorization Fax 1-512-514-4205

Home Health Services Fax 1-512-514-4209

CCP Fax 1-512-514-4212

CCIP 1-800-213-8877

CCIP Fax 1-512-514-4211

Outpatient Psychiatric Fax 1-512-514-4213

TMHP Special Medical Prior Authorization Fax (including transplants)

1-512-514-4213

PCCM Utilization Management Helpline: Option 1: Inpatient authorization request or notification of admission Option 2: Outpatient authorization request

1-888-302-6167

PCCM Utilization Management Fax 1-512-302-5039

Radiology Services Prior Authorization 1-800-572-2116

Radiology Services Prior Authorization Fax 1-888-693-3210

Special Medicaid Prior Authorization Fax (Including Trans-plants)

1-512-514-4213

Prior Authorization Status Telephone Communication

Contact Telephone Number

Home Health Services (including DME): Option 1 – TMHP in-home care customer service Option 2 – DME supplier with completed Title XIX form Option 3 – RN with completed POC

1-800-925-8957

CCP 1-800-846-7470

PCCM Utilization Management Helpline: Option 1 – 1: Inpatient authorization status Option 2 – 1: Outpatient authorization status

1-888-302-6167 (voice)1-512-302-5039 (fax)



Written Communication With TMHP

All CMS-1500 forms (excluding ambulance, radiology/laboratory, immunization services, rural health, and mental health rehabilitation) sent to TMHP for the first time, as well as claims being resubmitted because they were initially denied as incomplete claims, must be sent to the following address:

Texas Medicaid & Healthcare Partnership Claims

PO Box 200555 Austin, TX 78720-0555

The post office box addresses must be used for the specific items listed in the following table:

Correspondence Address

Appeals/adjustments of claims (except zero paid/zero al-lowed on Remittance & Status [R&S] Reports) Electronically rejected claims past the 95-day filing deadline and within 120 days of electronic rejection report

Texas Medicaid & Healthcare Partnership Appeals/Adjustments PO Box 200645 Austin, TX 78720-0645

All first-time claims Texas Medicaid & Healthcare Partnership Claims PO Box 200555 Austin, TX 78720-0555

Ambulance/CCP requests (prior authorization and appeals) Texas Medicaid & Healthcare Partnership Comprehensive Care Program (CCP) PO Box 200735 Austin, TX 78720-0735

CSHCN Services Program claims Texas Medicaid & Healthcare Partnership CSHCN Services Program Claims PO Box 200855 Austin, TX 78720-0735

Dental prior authorization requests Texas Medicaid & Healthcare Partnership Dental Prior Authorization PO Box 202917 Austin, TX 78720-2917

Home Health Services prior authorizations Texas Medicaid & Healthcare Partnership Home Health Services PO Box 202977 Austin, TX 78720-2977

Special Medical Prior Authorization Texas Medicaid & Healthcare PartnershipSpecial Medical Prior Authorization12357-B Riata Trace Parkway, Suite 150Austin, TX 78727

Medicaid audit correspondence Texas Medicaid & Healthcare Partnership Medicaid Audit PO Box 200345 Austin, TX 78720-0345

Medical necessity forms 3652, 3618, and 3619, and purpose code E information

Texas Medicaid & Healthcare Partnership Long Term Care—Nursing Facilities PO Box 200765 Austin, TX 78720-0765

Medically Needy Clearinghouse (MNC) or Spend Down Unit correspondence

Texas Medicaid & Healthcare Partnership Medically Needy Clearinghouse PO Box 202947 Austin, TX 78720-2947



Correspondence Address

Provider Enrollment correspondence Texas Medicaid & Healthcare Partnership Provider Enrollment PO Box 200795 Austin, TX 78720-0795

Other provider correspondence Texas Medicaid & Healthcare Partnership Provider Relations PO Box 202978 Austin, TX 78720-0978

Send all other written communication to TMHP Texas Medicaid & Healthcare Partnership (Department) 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

TPR/Tort correspondence Texas Medicaid & Healthcare Partnership Third Party Resources/Tort PO Box 202948 Austin, TX 78720-2948

Provider Enrollment Contract/Credentialing Texas Medicaid & Healthcare Partnership PCCM Contracting/Credentialing PO Box 200795 Austin, TX 78720-4270



Texas Medicaid/CHIP Vendor Drug Program Contact Information

Vendor Drug Program e-mail address [email protected]

Searchable Formulary List http://tinyurl.com/vdp-formularyOnline drug information resource for all state healthcare programs.

Epocrates http://www.epocrates.comEpocrates provides instant access to information on the drugs covered by Medicaid and preferred drug list on a Palm or Pocket PC handheld device. To register for the service, go to the Epocrates website and sign up for Epocrates Rx. Note: Epocrates is an out-patient Rx on-line Medicaid formu-lary resource.

Smart Formulary www.smartformulary.com/txMedicaid only on-line formulary resource and preferred drug list information with links attached to selected non-preferred drugs that will guide you to the pre ferred drugs in that thera-peutic class.

Vendor Drug Program Prior Authorization Call Center Hot line 1-877-728-3927 or 1-877-PA-Texas Note: This number is for prescribing providers or representa-tives only.

Pharmacy Resolution Desk 1-800-435-4165 Monday-Friday 8:30 am to 5:15 pm CT This number is for pharmacy providers only.

Vendor Drug Program Fax Numbers Main/Pharmacy Resolution: 512-491-1958 Formulary: 512-491-1961 Drug Utilization Review (DUR): 512-491-1962 Field Administration: 817-321-8064 Contract Management: 512-491-1974

Vendor Drug Program Addresses Physical Address: Health and Human Services Commission Medicaid/CHIP Vendor Drug Program (H-630) Building H 11209 Metric Blvd. Austin, TX 78758 Mailing address: Health and Human Services Commission Medicaid/CHIP Vendor Drug Program (H-630) P.O. Box 85200 Austin, TX 78708-5200



Helpful Links

Item Link

Texas Health and Human Services http://www.hhs.state.tx.us/

The Texas Medicaid & Healthcare Partnership www.tmhp.com

Texas Department of State Health Services http://www.dshs.state.tx.us/

Texas Vendor Drug Program http://tinyurl.com/Vendor-Drug

Preferred Drug List Program http://tinyurl.com/pdl-program

Explanation of Benefits Codes http://tinyurl.com/EOB-codes

MRAN Type 30 Form http://tinyurl.com/tmhp-mran-30

MRAN Type 30 Form Instructions http://tinyurl.com/tmhp-mran-30-instructions

Crossover Claim Types 31 and 50 TMHP Standardized Medicare Remittance Advice Notice Form

http://tinyurl.com/tmhp-mran-31-50

Crossover Claim Types 31 and 50 TMHP Standardized Medicare Remittance Advice Notice Form Instructions

http://tinyurl.com/tmhp-mran-31-50-instructions

STAR http://tinyurl.com/hhsc-star

STAR+Plus http://tinyurl.com/hhsc-starplus

NorthSTAR http://tinyurl.com/dshs-northstar

STAR Health http://tinyurl.com/starhealth

PCCM http://tinyurl.com/tmhp-pccm

THSteps Medical http://tinyurl.com/thstepsmed

THSteps Dental http://tinyurl.com/dshs-thsteps

Family Planning http://tinyurl.com/dshs-famplan

Case Management for Children and Pregnant Women (CPW)

http://tinyurl.com/dshs-cpw

Enhanced Care Program (Disease Management) http://tinyurl.com/hhsc-ecp

The Children with Special Health Care Needs (CSHCN) Services Program

http://tinyurl.com/tmhp-cshcn http://tinyurl.com/dshs-cshcn

Medicaid for Breast and Cervical Cancer http://tinyurl.com/dshs-mbcc

Medical Transportation Program (Medicaid and CSHCN Services Program)

http://tinyurl.com/dshs-mtp-cshcn

Early Childhood Intervention Targeted Case Management (ECI) Program

http://tinyurl.com/dars-eci

http://tinyurl.com/tmhp-mran-30

http://tinyurl.com/tmhp-mran-30-instructions

http://tinyurl.com/tmhp-mran-31-50

http://tinyurl.com/tmhp-mran-31-50-instructions

http://tinyurl.com/dars-eci



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Steps to Resolve Your Medicaid Questions



Common Claim Denial Codes

00103 - Services exceed allowed benefit limitations:• Client has exhausted benefits for the service billed.

00075 - Missing, invalid, or future dates of service:• Claim was submitted without dates of service, incomplete information for the dates of service, or future dates of service.

00100 - A charge was not noted for this service:• Billed amount was either not submitted on the claim or was invalid.

00143 - Client not Eligible:• The client ID was included on the claim; however, the client does not have Medicaid eligibility for that DOS or the client associated with that ID had Medicaid either before or after the DOS.

00144 - This procedure not covered for this provider type:• Procedure code submitted is not billable for the billing provider.

00164 -These services are not in accordance with Medical Policy:• Services billed fall outside of the medical policy guidelines for the program billed.

00260 - Client is covered by other insurance which must be billed prior to this program:• Medicaid is the method of last resort. Any other insurance providers must be billed before Medicaid has been. This includes Medicare Part A coverage.

00265 - Client is Medicare Part B Eligible:• Your client is eligible for Medicare Part B for the DOS and the service is covered by Medicare Part B, but the claim was not submitted to Medicaid as a crossover with a Medicare EOB attached. In some cases, your claim crossed over directly from Medicare but Medicare denied the line because of an error on the claim that was originally submitted to Medicare.

00266 - QMB Client Eligible for Medicare Crossovers Only:• Qualified Medicare Beneficiary (QMB) – MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid. If service is not covered by Medicare, MEDICAID WILL NOT PAY.

00424 - Billing Provider Not Enrolled on DOS:• The billing provider’s Medicaid enrollment status is not active.

00345 - Claim Exceeds Filing Time Period:• The claim was submitted after 120 days from the first DOS with no proof of timely filing attached.

00565 - Received past the 95 day filing deadline:• The claim was submitted after 95 days from the first DOS with no proof of timely filing attached.

00572 - It is mandatory that authorization be obtained. Due to lack of approval, the •service is nonpayable: The provider did not request authorization for the service billed, the authorization was not on file at the time the service was billed, or the authorization for service billed was denied.

01361 - Exact Duplicate:• Payment has already been made for this claim. This often occurs when a claim is resubmitted before the original claim has been paid. The original submission pays and the subsequent submission denies as a duplicate. This also happens when a provider attempts to adjust or correct an incorrectly paid claim by simply resubmitting the corrected claim.



Acronyms

Acronym Term

AAP American Academy of Pediatrics

ACD Augmentative Communicative Device

ACIP Advisory Committee on Immunization Practices

ADA American Dental Association

AIS Automated Inquiry System

AMA American Medical Association

ANSI American National Standards Institute

APN Advanced Practice Nurse

BCBS Blue Cross Blue Shield

BiPAP Bi-level Positive Airway Pressure

BJN Budget Job Number

BP Base Plan

CAPD Continuous Ambulatory Peritoneal Dialysis

CBT Computer Based Training

CCP Comprehensive Care Program

CHAMPUS Civilian Health and Medical Program of the Uniformed Services—now called TriCare

CHIP Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services (formerly HCFA)

CORF Comprehensive Outpatient Rehabilitation Facility

CPAP Continuous Positive Airway Pressure

CPW Case Management for Children and Preg-nant Women

CSHCN Children with Special Health Care Needs

CSI Claim Status Inquiry

CSR Customer Service Representative

DADS Department of Aging and Disability Ser-vices

DARS Department of Assistive and Rehabilitative Services

DME Durable Medical Equipment

DO Doctor of Osteopathy

DOB Date of Birth

DOS Date of Service

DPM Doctor of Podiatric Medicine

DRG Diagnosis-Related Group

DSHS Department of State Health Services

Acronym Term

ECI Early Childhood Intervention

ECP Enhanced Care Program

EDI Electronic Data Interchange

EFT Electronic Funds Transfer

EOB Explanation of Benefits

EOPS Explanation of Pending Status

EPSDT Early and Periodic Screening, Diagnosis, and Treatment

EQRO External Quality Review Organization

ER&S Electronic Remittance and Status Report

EV Eligibility Verification

FDH First Dental Home

FFS Fee-For-Service

FP Family Planning

FQHC Federally Qualified Health Center

FSS Family Support Services

HASC Hospital-based Ambulatory Surgical Center

HCPCS Healthcare Common Procedure Coding System

HHA Home Health Agency

HHSC Health and Human Services Commission

HIC Health Insurance Claim

HIPAA Health Insurance Portability and Accountability Act

HMO Health Maintenance Organization

HSC Hearing Services for Children (Formerly PACT)

ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification

ICHP Institute of Child Health Policy

ICN Internal Control Number (as in 24-digit ICN)

IPPA Insurance Premium Payment Assistance

IPPB Intermittent Positive Pressure Breathing

IPV Intrapulmonary Percussive Ventilation

JRA Juvenile Rheumatoid Arthritis

LCSW Licensed Clinical Social Worker

LMSW Licensed Master Social Worker

LPC Licensed Professional Counselor

LTC Long Term Care

MCO Managed Care Organization

MD Doctor of Medicine

MMIS Medicaid Management Information System



Acronym Term

MNP Medically Needy Program

MQMB Medicaid Qualified Medicare Beneficiary

MRAN Medicare Remittance Advice Notice

MREP Medicare Remit Easy Print

MSRP Manufacturer’s Suggested Retail Price

MTP Medical Transportation Program

NDC National Drug Code

NPI National Provider Identifier

OI Other Insurance

OIG Office of Inspector General

OPL Online Provider Lookup

OBFV Oral Evaluation and Fluoride Varnish in the Medical Home

OT Occupational Therapy,

PACT Program for Amplification for Children of Texas - transitioned to TMHP and known as Hearing Services for Children

PAF Physician/Dentist Assessment Form

PAN Prior Authorization Number

PCCM Primary Care Case Management

PCN Patient Control Number

PCS Personal Care Services

PE Presumptive Eligibility

POC Plan of Care

POS Place of Service

PPO Preferred Provider Organization

PT Physical Therapy

QRG Quick Reference Guide

R&S Remittance and Status Report

RHC Rural Health Clinic

SA Service Area

SAVERR System or Application, Verification, Eligibil-ity, Referral and Reporting

SSI Supplemental Security Income (Program)

SSL Secure Socket Layer

STAR State of Texas Access reform

TAC Texas Administrative Code

TANF Temporary Assistance to Needy Families (formerly AFDC)

TENS Transcutaneous Electric Nerve Stimulator

THSteps Texas Health Steps Medical and Dental Services

TIERS Texas Integrated Eligibility Redesign Sys-tem

Acronym Term

TMHP Texas Medicaid & Healthcare Partnership

TMPPM Texas Medicaid Provider Procedures Manual

TOS Type of Service

TP Type Program

TPI Texas Provider Identifier

TPN Total Parenteral Nutrition (i.e., Hyperali-mentation)

TPR Third Party Resources

TVFC Texas Vaccines for Children

UB-04 Uniform Bill 04 CMS-1450

VDP Medicaid Vendor Drug Program

VPN Virtual Private Networking

WHP Women’s Health Program

The THSteps Medical Workshop Participant Guide is produced by TMHP Organizational Development Services. This is intended for educational purposes in conjunction with the THSteps Medical Workshop Series. Providers should consult the Texas

Medicaid Provider Procedures Manual, CSHCN Services Program Provider Manual, bulletins, and banner messages for updates.

a texas health steps (thsteps) dental workshop participant guide › training_materials › thsteps...

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