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Welcome

Welcome to the Texas Health Network Provider Policies and Procedures Manual. The policies and procedures contained in this manual pertain to all providers who deliver services to Medicaid clients who are members of the Texas Health Network.

Online Enhancements

This online edition (in Adobe PDF format) has been formatted to provide enhanced navigation and usability. Throughout, you will find (highlighted in blue) links to various chapters, sections, pages, and World Wide Web sites*. Important telephone numbers have been highlighted in red.

For More Information

For more information, please contact the Texas Health Network Provider Helpline at 1-888-834-7226.

Thank you for your participation in the Texas Health Network.

*Your web browser must be open in order to use the World Wide Web links. If you experience difficulty using the links to the World Wide Web, you may need to specify which browser you would like Acrobat Reader to use. You can do this in Acrobat Reader by choosing File>Preferences>Weblinks. In the dialog box that appears, choose Browse, and navigate to the browser of your choice (i.e. X:\Program Files\Internet Explorer\Iexplorer.exe, where X is the letter assigned to your local hard disk).

Helping membersand their familiesstay healthy

Provider Policies andProcedures Manual

Birch & Davis Health Management CorporationNetwork Administrator

iTexas Health Network Provider Policies and Procedures ManualBDHMC

CONTENTS

Introduction

Quick Reference: Important Telephone Numbers

Answers to Commonly Asked Questions

Unique Features of the Texas Health Network

Terms and Definitions Used in This Manual

Chapters:

Chapter I STAR Covered Services

Chapter II Provider Responsibilities

Chapter III Routine, Urgent, and Emergency Services

Chapter IV Provider Complaints and Appeals

Chapter V Member Eligibility

Chapter VI Reimbursement and Claims Submission

Chapter VII Member Enrollment and Disenrollment

Chapter VIII Texas Health Steps (EPSDT)

Chapter IX Support and Services

Chapter X Continuous Quality Improvement

Chapter XI Office and Medical Records Standards

Chapter XII Fraud and Abuse Policy

Chapter XIII El Paso First Health Network

Texas Health Network Provider Policies and Procedures Manualii BDHMC

TABLES

3-1 Inpatient Precertification and Notification Process (p. III-10)

7-1 Medicaid Program Types: Mandatory Enrollment in Managed Care (p. VII-2)

7-2 Medicaid Program Types: Voluntary Enrollment in Managed Care (p. VII-3)

FIGURES

3-1 Emergency Room Services Guidelines (p. III-5)

3-2 Inpatient Medical Management Process (p. III-13)

13-1 El Paso First Health Network Claims Matrix

APPENDICES

Appendix A Panel Report

Appendix B Texas Health Network Identification Card

Appendix C Texas Health Network Sample Referral Tracking Form

Appendix D Texas Health Network Precertification Request Form

Appendix E Texas Health Network Notification of Hospital Admissions Form

Appendix F Texas Health Network Office Site Review and Medical RecordEvaluation Form

Appendix G Texas Health Network Primary Care Provider Application

Appendix H Behavioral Health Consent Form

Appendix I Provider File Maintenance Form

Appendix J THQA Focus Studies

iiiTexas Health Network Provider Policies and Procedures ManualBDHMC

INTRODUCTION

Thank you for your participation in the TexasHealth Network. Your par ticipation isappreciated and is essential to the success ofMedicaid managed care in Texas.

Texas STAR Program Background

The Texas STAR (State of Texas AccessReform) Program was established in 1993when the Texas Legislature adoptedlegislation which authorized the Texas Healthand Human Services Commission toundertake a comprehensive restructuring ofthe Texas Medicaid Program. Thisrestructuring introduced to the MedicaidProgram two managed care delivery systems:a Health Maintenance Organization (HMO)model, and an enhanced Primary Care CaseManagement (PCCM) model. EligibleMedicaid clients residing in one of the servicedelivery areas and who receive TemporaryAssistance to Needy Families (TANF) or TANF-related benefits, are required to choose fromone of the above options.

HMO Model

The HMO model provides the client a choiceof receiving services from one of theparticipating HMOs in the service area. Theclient then selects a Primary Care Provider(PCP) from among those who have contractedwith the HMO. The health plan is responsiblefor contracting with providers, educating andsupporting their provider network, performingutilization management, as well as the majorityof claims processing.

STAR+Plus Demonstration PilotHarris County Only

STAR+PLUS is a demonstration pilot thatintegrates acute care, long term care, andprimary care into one managed care deliverysystem. The Texas Department of HumanServices (TDHS) is the operating agency forSTAR+PLUS. It is designed to improveaccess to care, emphasize community-basedcare, and provide more accountability andcost control.

Enhanced PCCM Model – The Texas HealthNetwork

The enhanced PCCM model is a primary careprovider network developed by the TexasDepartment of Health (TDH). Texas HealthNetwork members residing in one of theservice delivery area counties are required toselect a PCP from among those who havecontracted with the TDH. The Texas HealthNetwork is a fee-for-service program. Inaddition to the standard covered benefits ofthe Texas Medicaid program, Texas HealthNetwork members, as part of the Texas STARProgram, are eligible for the followingexpanded benefits:

• Unlimited prescriptions

• Unlimited medically necessaryinpatient days

• Annual adult physical exams(performed by the PCP)

Administrative duties are the responsibility ofBirch & Davis Health ManagementCorporation (BDHMC). Claims processing is

http://www.tdh.state.tx.us/


http://www.dhs.state.tx.us/


http://www.birchdavis.com


Texas Health Network Provider Policies and Procedures Manualiv BDHMC

the responsibility of National HeritageInsurance Company (NHIC).

Texas STAR Program Goals

Through the development andimplementation of these two managed caredelivery systems, the principle objectives ofthe Texas STAR Program can be achieved.These goals are:

• Improve access to care for TexasSTAR Program clients

• Increase quality and continuity of care

• Ensure appropriate utilization ofservices

• Improve cost effectiveness

• Improve provider and membersatisfaction

Primary Care Provider

The primary care provider is responsible forestablishing a “Medical Home” for thoseclients who have either selected or who havebeen assigned to them. This means eitherfurnishing or arranging for 24-hour, 7-day aweek availability, providing or coordinating allof the client’s health care needs, anddocumenting all medically necessary servicesin the patient’s medical record. A complete listof the primary care provider’s responsibilitiesare found in Chapter II.

Facilities

Though the primary care provider’s role is acrucial one, the role of the hospital, emergencyroom, and other facilities is equally asimportant and should not be overlooked.Through constant communication with thePCP, and on-going member education, thesefacilities have the opportunity to reduce the

inappropriate use of emergency rooms andservices, reduce the incidence of repeatservices for the same medical condition, andreinforce the need for a medical home.

Specialists

The specialist also plays a crucial role in thesuccess of Medicaid managed care in Texas.Specialists are responsible for furnishingmedically necessary services to Texas HealthNetwork members who have been referred bytheir PCP for specified treatment and/ordiagnosis. In order to ensure continuity of care,the specialist is required to maintaincommunication with the member’s PCP. Thiscommunication ensures that the member’smedical record adequately documents theservices provided, all results or findings, andall recommendations. The Texas HealthNetwork has an open specialty network. TexasHealth Network members may be referred toany specialist that accepts Texas Medicaid.

Birch & Davis Health ManagementCorporation

Texas Health Network administrative dutiesare the responsibility of Birch & Davis HealthManagement Corporation (BDHMC). It is ourgoal to make Medicaid managed caremanageable for you and the Texas HealthNetwork members you serve, and assist youin assessing your readiness for continuedparticipation in managed care.

The pages that follow document in greaterdetail the roles and responsibilities of allinvolved in Medicaid managed care andspecifically the Texas Health Network. We askthat you review this manual with your staff andencourage them to familiarize themselveswith its contents and provisions. We welcomeyour suggestions on improving the policies,procedures, and practices described hereinand look forward to assisting you in yoursuccessful participation in the Texas HealthNetwork.



http://www.eds-nhic.com



vTexas Health Network Provider Policies and Procedures ManualBDHMC

QUICK REFERENCE

These Texas Health Network numbers will be helpful:

Texas Health Network Provider Helpline24 hours a day, 7 days a week

1-888-TDH-PCCM (1-888-834-7226)Fax: 1-512-302-5068

Texas Health Network Utilization Management Helpline(Precertification, Inpatient Notification, Continued Stay Requests, etc.)

24 hours a day, 7 days a week1-888-302-6167

Fax: 1-512-302-5039

FirstHelp™: Clinical Helpline24 hours a day, 7 days a week

1-800-304-5468

Prenatal Care Line(Appointments for obstetrical care for pregnant members)

1-877-518-0899

Texas Health Network Case Management Helpline8:00 a.m. - 5:00 p.m. Monday through Friday

1-888-276-0702

Texas Health Network Member Helpline24 hours a day, 7 days a week

1-888-302-6688

Texas STAR Program Enrollment Broker(Member Enrollment, Plan Changes)

1-800-964-2777

Verification of Member EligibilityVerify electronically using TDHConnect, or call the

Automated Inquiry System (AIS),24 hours a day, 7 days a week

1-800-925-9126or (512) 345-5948 or (512) 345-5949

See the AIS User’s Guide in the Texas MedicaidProvider Procedures Manual

http://www.eds-nhic.com/tdh-nhic2001.htm


Texas Health Network Provider Policies and Procedures Manualvi BDHMC

ANSWERS TOCOMMONLY ASKED QUESTIONS

Q: May I participate in one or more HMOs and the Texas Health Network?

A. Yes. A provider may choose to participate in the Texas Health Network andany HMOs available in his or her service area. In addition, there is no limitationto the number of Texas STAR Program clients a provider may be assigned.However, the Texas Department of Health (TDH) will continue to conductoversight to ensure accessibility and quality of care.

Q: Where do I file my claims?

A: For Texas Health Network members, please file your claims with NHIC, asyou always have. NHIC processes all claims for services provided to TexasHealth Network members.

Q: How will I know which members are on my panel?

A: The Texas Health Network sends you a panel report every month that listsmembers who have selected you or been assigned to you. Each memberlisted is eligible for services throughout the entire month.

Q: What services and procedures require precertification, if any?

A. It’s a short list:

• All non-emergent inpatient admissions (excluding routine deliveries/newborns)

• All non-emergent surgical procedures, including those performed duringauthorized hospital admissions

• Some office and/or outpatient procedures (see Chapter III for the list)

Q: Am I limited to certain specialists for referrals?

A: No, the Texas Health Network has an open specialty referral network. Youmay refer to any Texas Medicaid-approved specialist provider for coveredservices you do not provide. Limitations may apply in the El Paso ServiceArea. See Chapter XIII for more information.

viiTexas Health Network Provider Policies and Procedures ManualBDHMC

Q: Is it true that I have to be on call 24 hours a day, 7 days a week?

A. You must make continuous coverage available to your patients 24 hours aday, 7 days a week, but on-call arrangements are acceptable. See Chapter IIfor details.

Q: Do I have to authorize emergency care?

A: No, members may self-refer for emergency care, family planning services,Texas Health Steps (EPSDT), vision services, behavioral health services,certain case management services, and certain school health services(please refer to pages I-2 and I-3). Each member is encouraged tocommunicate self-referred services back to his or her primary care provider(PCP). As a PCP, you may be called by the ER. In this situation your timelyresponse is required. See Chapter I for more information.

Q: Which clients are eligible for Texas Health Network enrollment?

A. In designated counties, the State has mandated that clients receivingTemporary Assistance to Needy Families (TANF) benefits or TANF-relatedbenefits join an HMO or the Texas Health Network. Individuals receiving Blindand Disabled benefits may voluntarily join the Texas Health Network or anHMO except in Harris County, where it is mandatory that these individualsselect a plan (the STAR+PLUS demonstration pilot project).

Q: Must I offer services to all members who choose me as their PCP?

A. Yes, but an exception may be made if you have been assigned a memberwho is outside your scope of practice, e.g., outside the age range of pediatricpatients you serve.

Q: What if one of my members wants to disenroll from my panel or I want toremove a member from my panel?

A. These situations may occur. Please refer to Chapter VII.

Texas Health Network Provider Policies and Procedures Manualviii BDHMC

In counties offering the Texas Health Network, Medicaid clients are free to select thePrimary Care Provider (PCP) of the member’s choice. This provider becomes themember’s “medical home” and provides or arranges for all services to meet themember’s medical needs.

FEATURES OF THE TEXAS HEALTH NETWORK

As a PCP in the Texas Health Network you receive fee-for-service reimbursementfor the care you provide plus $3.00 per member per month to manage the neededservices for each member patient, whether or not you see the members during themonth.

All providers of services to Texas Health Network members receive:

• Fee-for-service reimbursement for the care you provide

• Services and support, including a toll-free, 24-hour, 7-day helpline to answeryour questions, informational workshops, and data to help you analyze yourpractice

• A local advocate—A Provider Relations Representative available in yourarea who serves as an advocate for providers

• A toll-free, 24-hour, 7-day FirstHelp™ Clinical Helpline for your Texas HealthNetwork members to call for clinical assistance

As part of the Texas STAR Program, Texas Health Network members receive thefollowing:

• All Medicaid-covered services

• Unlimited medically necessary prescriptions

• Adult physical exams

• Unlimited medically necessary inpatient days

• A local advocate—a Member Outreach Representative available in your areawho serves as an advocate for Texas Health Network members, assistingthe member with access to appropriate services

ixTexas Health Network Provider Policies and Procedures ManualBDHMC

TERMS AND DEFINITIONS USED IN THIS MANUAL

The following terms and definitions are used throughout this manual.

AFDC Aid to Families with Dependent Children. See TANF.

AIS Automated Inquiry System. A telephonic system, provided by NHIC, toverify the eligibility of Medicaid clients and obtain the status of claimssubmitted. See NHIC, NAIS.

BDHMC Birch & Davis Health Management Corporation. The firm that is undercontract with the Texas Department of Health to provide NetworkAdministrator services and member services for the Texas Health Network.

CCP Comprehensive Care Program. Expanded medical benefits availablethrough Texas Health Steps (THSteps) for children and youth who requireservices that are not normally provided in the Texas Medicaid Program.

CQI Continuous Quality Improvement. An ongoing process to identifyopportunities to improve the delivery of medical care or services, definecorrective actions, and follow-up to assess the effectiveness of theimprovement efforts.

DHS Department of Human Services.

EB Enrollment Broker. The contractor to the Texas Department of Healthresponsible for the identification and enrollment of eligible Medicaid clientsinto managed care programs. The State contracted Enrollment Broker isMAXIMUS Corporation. The Enrollment Broker assists Medicaid clientsin the initial enrollment into managed care by providing client educationon the Texas STAR Program, assisting members in choosing a plan andprimary care provider (PCP) within that health plan, and by processingplan change requests.

EPSDT Early and Periodic Screening, Diagnosis and Treatment. See THSteps.

H&HS Health and Human Services

NCQA National Committee on Quality Assurance. An organization dedicatedto the definition and measurement of health care quality through processand outcome indicators using standardized data collection methodologies.

NAIS NHIC Automated Inquiry System. A telephonic system, provided byNHIC, to verify the eligibility of Medicaid clients and obtain the status ofclaims submitted. See NHIC, AIS.


http://www.hhsc.state.tx.us/




Texas Health Network Provider Policies and Procedures Manualx BDHMC

NHIC National Heritage Insurance Company. The claims administrator undercontract with the Texas Department of Health to process all traditionalMedicaid claims and all claims for services provided to Texas HealthNetwork members.

PCCM Primary Care Case Management. In the Texas STAR Program, amanaged care fee-for-service option in which a member selects or isassigned a primary care provider who manages his or her health careand who must authorize most other medical services before these serviceswill be reimbursed by the Texas STAR Program.

PCP Primary Care Provider. A physician with a specialty in family practice,general practice, pediatrics, internal medicine or obstetrics andgynecology; a Federally Qualified Health Center; a Rural Health Clinic; aCertified Nurse Midwife; or an Advanced Practice Nurse with a specialtyin pediatrics, family practice, general practice, or women’s health.Specialists providing primary care services to chronically ill or disabledMedicaid clients may serve as PCPs. Texas Health Network membersselect, or are assigned, a PCP to manage their health care.

QARI Quality Assurance Reform Initiative. A set of standards developed bythe Federal Health Care Financing Administration to ensure the qualityof Medicaid managed care programs.

QIP Quality Improvement Plan. Developed by a health plan to meet thestandards established by NCQA or QARI to measure and improve qualityin managed care programs.

QMIC Quality Management and Improvement Committee. Organized by ahealth plan to develop, implement, and assess the effectiveness of a qualityimprovement program.

STAR State of Texas Access Reform. The Texas Medicaid reform initiativethat will move most Medicaid clients into managed care programs. TheTexas STAR Program has two managed care options: a capitated HealthMaintenance Organization, and a fee-for-service Primary Care CaseManagement plan.

TANF Temporary Assistance to Needy Families and TANF-Related. Afederally funded program that provides financial assistance to single parentfamilies with children who meet the categorical requirements. TANFrecipients are eligible for Medicaid services. Federal welfare reformlegislation retitled AFDC to TANF.


xiTexas Health Network Provider Policies and Procedures ManualBDHMC

TDH Texas Department of Health. The State agency responsible for theadministration of the Texas Medicaid Program which includes the TexasSTAR Program.

TDHS Texas Department of Human Services.

THHSC Texas Health and Human Services Commission.

THSteps Texas Health Steps. The Texas Early and Periodic Screening, Diagnosisand Treatment (EPSDT) Program. EPSDT is a federally mandatedMedicaid program designed to prevent, identify, and treat potentiallydisabling diseases in eligible infants, children and youths up to the ageof 21.

THQA Texas Health Quality Alliance. Contractor to the Texas Department ofHealth for the oversight of Quality Improvement Programs and activitiesof managed care organizations participating in the Texas STAR Program.

TMMIS Texas Medicaid Management Information System. The MedicaidManagement Information System (MMIS) that meets required Federalstandards and is a joint effort of the Texas Department of Health, the TexasDepartment of Human Services, and NHIC, the claims administrator.




Contents

Chapter ITexas STAR ProgramCovered Services

Medicaid Covered Services ............................................... 1

Freedom-of-Choice Services (Self-Referred) ..................... 2

Additional Benefits of the Texas STAR Program................ 3

Components of the Adult Physical Exam ........................... 4

OB/GYN Services .............................................................. 5

Case Management Services .............................................. 6

Wellness and Health Promotion Services .......................... 7

Medical Transportation Program (MTP) ............................. 8

Behavioral Health Services ............................................... 9

NorthSTAR Program (Dallas Service Area Only) ............. 10

Texas Health Network Provider Policies and Procedures Manual I-1BDHMC

TEXAS STAR PROGRAM COVERED SERVICES

Overview

Eligible Medicaid clients enrolled in the Texas Health Network can receiveall services detailed in the Texas Medicaid Provider Procedures Manual. Inaddition, as part of the Texas STAR Program, Texas Health Network mem-bers can receive added benefits and services. This chapter describes theservices covered under the traditional Medicaid program as well as addi-tional benefits for Texas Health Network members.

Medicaid Covered Services

Texas Health Network members are entitled to all medically necessary services currentlycovered under the Texas Medicaid Program. These services include:

• Ambulance Services • Maternity Services• Ambulatory Surgical Center • Mental Health Services• Behavioral Health Services • Occupational Therapy• Birthing Center Services • Outpatient Surgeries• Certified Nurse Midwife Services • Physical Therapy• Chemical Dependency Services • Podiatry Services• Chiropractic Services • Respiratory Care• Dental Services • Renal Dialysis Facility Services• Emergency Services • Routine Care (Physician Services)• Family Planning Services • Rural Health Services• Genetics Services • School Health and Related Services• Hearing Aid Services • Speech/Language Therapy• Home Health Services • Texas Health Steps Services• Inpatient Hospital Care • Total Parenteral Hyperalimentation• Inpatient Surgery • Transplant Services• Laboratory and Radiology Services • Vision Care

Please refer to the Texas Medicaid Provider Procedures Manual for details on coverageand limitations, and for specific claims filing procedures for each service listed above.

Except as specified on the following page, PCPs shall provide (directly or through referrals)all Medicaid-covered services.



Texas Health Network Provider Policies and Procedures ManualI-2 BDHMC

Freedom-of-Choice Services (Self-Referred)

Texas Health Network members may select any Medicaid-enrolled provider to access thefollowing services without a referral:

• Emergency Services—In case of a true medical emergency, patients/membersmay seek emergency medical services from the nearest facility. The emergencyfacility is required to contact the member’s PCP within 24 hours or the next businessday after providing services. PCPs or a PCP’s designee must be available to respondto an ER call promptly. If the emergency visit results in an admission, the facility alsomust notify the Texas Health Network within 24 hours or the next business day afterthe admission. (See Chapter III of this manual for details.)

• Family Planning Services—Family planning services include preventive health,medical counseling, and educational services that assist individuals to control theirfertility and achieve optimal reproductive and general health. Texas Health Networkmembers are free to select a Texas Medicaid family planning provider to accessfamily planning services. PCPs are encouraged to provide these services if requestedby a member. Members are not mandated to obtain Family Planning services throughtheir PCP.

• Texas Health Steps (THSteps)—Texas Health Network members are free to selectany THSteps enrolled Texas Medicaid provider to perform THSteps services (EPSDTProgram screenings). All Medicaid clients are eligible for THSteps screening servicesthrough the end of the month of their 21st birthday (in accordance with the medicalscreening, immunization and adolescent screening periodicity schedules publishedin the Texas Medicaid Provider Procedures Manual.) If THSteps screening isperformed by a provider who is not the member’s PCP, this information should beforwarded to the member’s PCP so that the member’s medical record can be updated.(See Chapter VIII of this manual for details.)

• Vision Services—Members do not need a referral to access necessary coveredvision services for refractive errors. However, any diagnosed condition or abnormalityof the eye that requires treatment or additional services beyond the scope of anexam for refractive errors must be referred back to the member’s PCP. Vision careproviders who furnish additional services must have a referral from the member’sPCP. Covered vision services are:

— One eye exam each state fiscal year (September 1 through August 31) for clientsunder 21 years of age unless there is a diopter change of 0.5 or more

— No limitation for clients under 21 years of age on the number of replacements for lostor damaged eyeglasses

— One eye exam every 24 months for assessing the need for eyeglasses for adults,and new eyewear once every 24 months for clients 21 years of age and older unlessthere is a diopter change of 0.5 or more

— Unlimited medically necessary eye exams for a diagnosis of illness or injury



• Behavioral Health Services—Except in the Dallas Service Area (see page I-10),behavioral health services are Freedom-of-Choice services. These include mentalhealth and substance abuse services provided by a psychiatrist, psychologist, LPC,or LMSW-ACP. In addition, many services offered through MHMR do not require areferral: case management for mental health and mental retardation, mental healthrehabilitative services, and mental retardation diagnosis and assessment throughthe Texas Department of Mental Health and Mental Retardation (MHMR).

• ECI—Case management for Early Childhood Intervention (ECI).

• PWI—Case Management for the Pregnant Women and Infants program (PWI).

• School Health and Related Services (SHARS)—Members may select anyqualified provider to access medically necessary and reasonable services to ensurethat Medicaid-eligible children with disabilities receive the benefits mandated byfederal and state legislation that guarantees a free and appropriate public education.

• School-Based Clinic Services—Members may receive services from school-basedclinics without a referral from their PCP.

Additional Benefits of the Texas STAR Program

In addition to the standard covered benefits of the Texas Medicaid Program, Texas HealthNetwork members, as part of the Texas STAR Program, are eligible for the followingexpanded benefits:

• Unlimited Prescriptions—The three prescription permonth limit has been eliminated. Texas Health Networkmembers receive unlimited medically necessaryprescriptions, as listed on the Vendor Drug formulary.

• Unlimited Medically Necessary Inpatient Days—The30-day inpatient “spell of illness” limitation has beenremoved for Texas Health Network members age 21 and over. Members under theage of 21 have this benefit through the Comprehensive Care Program (CCP) ofTHSteps.

• Annual Adult Physical Exams—Annual physical exams performed by the PCPare a covered benefit for members age 21 and older. The annual physical exam isavailable in addition to family planning services. Physical exams are provided tohealthy members for the purpose of promoting health and preventing illness or injury,including counseling concerning family problems, nutrition, exercise, substanceabuse, sexual practices and injury prevention. Providers should encourage theirmembers to schedule a physical exam each year.

http://www.mhmr.state.tx.us/



The annual adult physical exam is permitted once every State fiscal year (September 1through August 31) for each adult member. This exam is reimbursable only when performedby the member’s PCP.

The CPT codes listed below should be used for billing the annual adult physical exam,based on the age of the patient. Reimbursement is at the Medicaid fee schedule rate.

CPT CodesNew Patient:99385 18-39 years (but payable only for members age 21 and older)99386 40-64 years

Established Patient:99395 18-39 years (but payable only for members age 21 and older)99396 40-64 years

Components of the Adult Physical Exam

Depending on the member’s age and health status, the physical exam may include thefollowing components:

• EKGs—The frequency for outpatient EKGs in an asymptomatic adult withoutdemonstrable heart disease or risk factors is as follows:

— A single baseline EKG may be indicated. If the baseline EKG is abnormal, arepeat EKG may be indicated if there is a change in clinical status or to monitorsuspected subclinical progression of the disease that may require a change inclinical management.

— Repeat EKGs for monitoring subclinical progression of the disease are not indi-cated more often than annually. If the baseline EKG is normal, repeat testing isnot indicated more often than every five years unless there is a change in clini-cal findings.

• Routine Chest X-Rays—Routine preventive chest X-rays for the detection ofunsuspected disease are not indicated. Routine chest X-rays solely for hospitaladmissions are not indicated. Routine chest X-rays for employment or for admissionto a long-term care facility are not indicated. Routine chest X-rays related to exposureat the place of employment are not indicated.

• Flexible Sigmoidoscopy—The use of the flexible sigmoidoscope for all screeningendoscopic exams of the intestinal tract has not been approved as the standard ofcare.


• Adult Preventive Care—Maximum frequencies, which will be covered for variousadult preventive services, are listed below. Note that these maximum frequenciesare not applicable if the member’s PCP determines that family history of disease orcurrent clinical symptoms require more frequent screening:

— Mammogram—One baseline between the ages of 35-39 years, every other yearbetween the ages of 40-49 years, annually after age 50

— Sigmoidoscopy—One baseline at age 50-55, every three years beginning oneyear after the baseline

— Baseline Electrocardiogram—Once after age 40

— Hemoglobin/Hematocrit—Annually

— Stool Testing for Blood—Hemocult annually after age 40

— Urinalysis—Annually

— Pap Smear —Annually (included in Family Planning Services)

• Serum Cholesterol/HDL— Annually if the member’s diastolic pressure is 85-89mm/hg or higher; for ages 20-64, once every five years; members at high-risk shouldbe reevaluated every two years

• Prostate-Specific Antigen Testing—Annually for ages 50 and over; clients under50 with family history of prostatic cancer should have an exam annually

• General Screening for Tumor/Mass—Oral cavity, skin, testes, and thyroid screensfor ages 20-39 once every three years; annually for ages 40 and over

If an evaluation and management visit and an adult physical are billed on the same day bythe same provider, the code with the highest reimbursement rate will be paid and the otherwill be denied.

OB/GYN Services

Texas Health Network members may select an OB/GYN as their PCP. As a PCP, the OB/GYN is responsible for providing or arranging for all medically necessary services. EffectiveJanuary 4, 1999, Texas Health Network members may also seek direct services of anyMedicaid enrolled OB/GYN who is not their PCP for the following services:

• One well-woman examination per year

• Care related to pregnancy


• Care for all active gynecological conditions and

• Diagnosis, treatment and referral to a specialist within the network for any diseaseor condition within the scope of the designated professional practice of a properlycredentialed obstetrician or gynecologist, including treatment of medical conditionsconcerning the breasts.

PCPs shall continue to provide their contracted provider number to any Medicaid-enrolledOB/GYN providing these services to Texas Health Network members.

The Texas Health Network assists with the scheduling of members’ initial prenatalappointments via the Prenatal Care Line.

Prenatal Care Line1-877-518-0899

Case Management Services

The goal of the Texas Health Network’s case management program is to facilitatecoordination of health related services required by Texas Health Network members. Thismeans collaborating with providers, members, and their families in identifying problems,resources and removing barriers in accessing treatment and services. Texas Health Networkcase managers are located in all service areas administered by BDHMC.

Services offered by case management staff are as follows:

• The management of high-risk OB in conjunction with the member’s physician

• Pediatric case management services of acute and chronically ill children

• Case management for all chronic and/or complex cases identified and eligiblefor case management services

• Assistance in accessing State and community resources

By offering the above services, the Texas Health Network assists both providers and mem-bers with early expedited access and intervention, increasing the likelihood of improvedhealth outcomes.

Texas Health Network Case Management Helpline1-888-276-0702


Wellness and Health Promotion Services

Health Educators and Wellness Coordinators work in the Texas Health Network serviceareas to provide health education services to members to increase access to care, improvehealthy behaviors and treatment compliance. The intent of wellness and health promotionis to educate members, and enable them to have the knowledge to recognize healthproblems and risky behaviors in order to prevent illness and future health conditions.

Health Educators provide a variety of health education classes on topics such as childhoodillnesses, asthma, diabetes, Texas Health Steps, immunizations, prenatal care and STD’s/HIV. These classes are held at different locations within the community such as schools,WIC clinics, community centers and doctor’s offices. In addition, Health Educators alsoprovide one-to-one education to members through a referral system.

Members can be referred for education on the following subjects:

• A newly diagnosed condition

• Dental health

• Nutrition

• Asthma management

• Diabetic education

• Prenatal education

Wellness Coordinators can assist members in obtaining food, clothing, and other resourcesby linking them with organizations within the community.

Providers interested in scheduling a health education program in their office or referring aTexas Health Network member for health education or community resources can do sothrough the following methods:

• Completing the Texas Health Network Referral Form found in Appendix C of thismanual and faxing to 512-302-0318

• Calling the Intake Department at 1-888-276-0702


Medical Transportation Program (MTP)

The Medical Transportation Program (MTP) was created in 1975 as a result of a federalcourt order. Funded by Title XIX and State funds, MTP provides eligible Medicaid clientswith non-emergency transportation to reasonably close and medically appropriate carefacilities. MTP ensures that Medicaid clients who have no other means of transportationhave access to medical facilities that provide medically necessary Medicaid-coveredservices.

Contacting MTP

Clients should contact the Statewide MTP office to request transportation services at least48 hours before the scheduled medical appointment. The following number should be usedto obtain more information or to schedule transportation services:

Statewide1-877-MEDTRIP(1-877-633-8747)


Behavioral Health Services

Behavioral health services are provided for the treatment of mental disorders, emotionaldisorders, and chemical dependency disorders. Except in the Dallas Service Area (seepage I-10), behavioral health services are Freedom-of-Choice services. Texas HealthNetwork members may self-refer to any Medicaid-enrolled behavioral health provider fortreatment. A referral from the member’s PCP is not required. A PCP may, in the course oftreatment, refer a patient to a behavioral health provider for an assessment or for treatmentof an emotional, mental, or chemical dependency disorder.

Texas Health Network members may receive any behavioral health service that is medicallynecessary, currently covered by the Texas Medicaid Program, and provided by a Medicaid-enrolled behavioral health provider. Behavioral health providers include psychiatrists,psychologists, LMSW-ACPs, LPCs, and TCADA licensed facilities. There are other servicesprovided through the Texas Department of Mental Health and Mental Retardation(TDMHMR) such as case management for mental health and mental retardation, mentalhealth rehabilitation services, and mental retardation diagnosis and assessment services.

Outpatient Behavioral health services that exceed 30 visits per member, per calendar yearmust be prior authorized by the claims administrator, NHIC. All claims for Medicaid managedcare behavioral health covered services are filed to NHIC in accordance with the proceduresspecified in the Texas Medicaid Provider Procedures Manual. Please contact NHIC at1-800-925-9126 for prior authorization.

Behavioral health providers are encouraged to contact a member’s PCP to discuss thepatient’s general health. PCPs are encouraged to maintain contact with the behavioralhealth provider to document behavioral health assessments and treatments, and to informthe behavioral health provider of the member’s health status that may impact the behavioralhealth service delivery. Member approval for this exchange of information is required. PCPsare responsible for documenting referrals to behavioral health providers and self-referralsfor behavioral health services in each member’s medical record.

The Texas Health Network requires precertification (or notification for emergencyadmissions) for inpatient psychiatric care in an acute care facility. Texas Health NetworkUtilization Management staff provides concurrent review on all inpatient psychiatricadmissions in an acute care facility.

In addition, THQA annually conducts focus studies for the purpose of improving the detectionand treatment of specific disorders (i.e., depression and ADHD) by PCPs providingbehavioral health services to Texas Health Network members. These studies are referencedin Chapter X of this manual.

See Appendix H for the Behavioral Health Consent Form







NorthSTAR Program (Dallas Service Area Only)

Program Overview

Effective July 1, 1999, the NorthSTAR program was introduced as an innovative managedcare approach to delivery of mental health and chemical dependency services. The programoffers publicly funded behavioral health (mental health and chemical dependency) servicesto residents of Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall counties. UsingMedicaid, state general revenue, and federal block grant funds, NorthSTAR is designed tocreate a better-coordinated system of public behavioral health care.

NorthSTAR is a pilot project created by the following state agencies:

• Texas Department of Mental Health and Mental Retardation (TDMHMR)

• Texas Commission on Alcohol and Drug Abuse (TCADA)

• Texas Health and Human Services Commission (HHSC)

• Texas Department of Health (TDH)

Working in partnership with the seven counties, these agencies are using the pilot toevaluate a managed care approach to delivery of publicly funded behavioral health care.Expected outcomes include:

• Increased access to care

• Improved quality of services

• Improved member and provider satisfaction

• Improved cost effectiveness

• Integrated mental health and chemical dependency service delivery systems

NorthSTAR Client Enrollment

Individuals who are eligible for Medicaid managed care, and individuals who are eligiblefor MHMR and TCADA services, will be served through NorthSTAR. Most Medicaid, MHMR,and TCADA clients in the seven counties are required to enroll in and receive servicesthrough the NorthSTAR program in order for providers to be eligible for reimbursement.




http://www.tcada.state.tx.us/




NorthSTAR also covers some Medicaid-eligible clients not covered by STAR, such asdual Medicare/Medicaid eligibles.

Other residents of the service area may also receive services through NorthSTAR if theymeet clinical eligibility criteria. Individuals living in the service area who are not eligible forMedicaid, have incomes above 150 percent of the federal poverty level, and meet theclinical eligibility criteria are charged a co-pay for services based on a sliding fee scale.

Medicaid clients who enroll in NorthSTAR also enroll with ValueOptions, the BehavioralHealth Organization (BHO) charged with overseeing the coordination of the client’s care.

Coordination with the Texas STAR Program

TDH manages the Texas STAR Program’s physical health care plans, while TDMHMRand TCADA operate the NorthSTAR behavioral health plan. Medicaid mental health andchemical dependency specialty services for STAR-eligible clients are separated or “carvedout” from the Texas STAR program into NorthSTAR.

The Texas STAR Program is responsible for treatment of behavioral health conditionsprovided by primary care providers (PCPs) and for certain services, such as lab and otherancillary services to diagnose, and treat a behavioral health condition. The Texas STARProgram also covers services necessary to prescribe and monitor behavioral healthmedications for NorthSTAR Medicaid enrollees. Together, The Texas STAR Program andNorthSTAR coordinate physical and behavioral health care.

Coordination of Care

Providers treating Texas Health Network members are responsible for coordinating carewith Behavioral Health Providers (BHP) to ensure continuity of care, and minimize theduplication of services. The Texas Health Network has Care Coordinators available toassist both the PCP and the BHP with coordination of care and referrals.

Referrals and Release of Information

All providers must obtain a release of information from the member before referring care tothe BHO or BHP. This release is valid for 60 days. Providers must use the Authorization toRelease Confidential Information Form found on pages I-13 and I-14 of this manual.

Providers should share pertinent test results from the patient’s medical record with theBHP to coordinate care. NorthSTAR providers shall conduct a physical health assessmentand refer members with physical medical needs to the PCP.





Inpatient Hospital Care

The primary diagnosis upon inaptient admission determines the party responsible for thereimbursement of services provided to Texas Health Network members. Providers shouldcontinue to follow the established guidelines for specialist referrals, admissions, anddischarges according to the utilization management guidelines set forth by either the healthplan or BHO.

In most cases, the BHO is responsible for the reimbursement of inpatient services withbehavioral health diagnoses, emergency room services rendered in psychiatric facilities,and professional services rendered by BHPs. The Texas STAR Program covers inpatientgeneral acute facility services when the primary diagnosis is not a behavioral healthdiagnosis, and the professional services are provided by a physical medicine provider.

If a diagnosis change occurs during an inpatient stay, the health plan and BHO mustcoordinate care and services. When it is determined that the reason for the inpatient stayhas changed from physical health to behavioral health, or the inverse, the party responsiblefor reimbursement of services will also change. Discharge and readmission to anappropriate facility—either psychiatric or medical—will be necessary to meet theseguidelines.

The health plan and BHO Medical Directors, in collaboration with the treating provider, willdetermine the most appropriate setting and treatment plan for those patients who haveboth medical and behavioral health diagnoses. Providers will need to file claims for servicesto the appropriate party according to established claim filing guidelines.

Laboratory Services

Texas Health Network PCPs may continue to refer members to any Medicaid-enrolledlaboratory. For common laboratory tests, the BHP is required to contact the PCP to determineif usable test data exists, and to share test results with the PCP. The PCP is required toshare information on relevant lab tests with the BHP. Providers are responsible for obtaininga signed release of information from the member (see next page).


AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

PATIENT NAME _________________________________________________

I authorize (Name of HMO) and/or (Name of BHO), and/or the following person/agency/group:

Provider/Agency/Group Address City State ZIP

to disclose information and records regarding my treatment, medical and/or behavioralhealth condition to the following professional person/agency, physician and/or facility:

Provider/Agency/Group Address City State ZIP

Information to be released or exchanged include (check all that apply):

______ History and physical

______ Discharge and Summary

______ Behavioral Health Treatment Records

______ Laboratory Reports

______ Physical Health Treatment Records

______ Medication Records

______ Information on HIV or communicable disease treatment

______ Other

The authorized purpose(s) for this release are:

______ Diagnosis and Treatment

______ Coordination of Care

______ Insurance Payment Purposes

______ Other (specify) _____________________________________________

NorthSTAR


AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

I understand that my health and behavioral health records are protected from disclosureunder Federal and/or state law. I may revoke this authorization. This authorization is validuntil I revoke it or sixty (60) days after I have completed treatment, whichever is sooner.Once I revoke this authorization, no information can be released except as authorized orallowed by law. File copy is considered equivalent to the original.

This authorization was explained to me and I signed it of my own free will on:

The _____________ day of ___________________, 20____.

_____________________________ ________________________________Signature of Client Signature of Witness

Signature of Parent, Guardian, or Authorized Representative, if required

The person signing this authorization is entitled to a copy.

TO PERSON RECEIVING THE CONFIDENTIAL INFORMATION:PROHIBITION ON REDISCLOSURE

Federal and state law protects the confidentiality of the information disclosed to you related to the individual’salcohol and drug abuse treatment. Federal regulations (42 CFR Part 2) prohibit you from making any furtherdisclosure of this information unless further disclosure is expressly permitted by the written consent of the person towhom it pertains, or as otherwise permitted by such regulations. Disclosure is limited to the purpose and personsincluded on the authorization form. The Federal rules restrict any use of the information to criminally investigate orprosecute any alcohol or drug abuse patient. State laws may also protect the confidentiality of the client’s records.

NOTICE OF CLIENT’S REFUSAL TO RELEASE INFORMATION:

I have reviewed the above release of information form and refuse to authorizerelease of health and behavioral health information to mental health and/or alcoholand/or drug abuse treatment providers and/or physical health providers.

Executed this _____________ day of ___________________, 20____.

________________________________ __________________________Signature of Client Signature of Witness

____________________________________________________________Signature of Parent, Guardian, or Authorized Representative, if required

NorthSTAR


Provider Reimbursement

Effective July 1, 1999, behavioral health providers do not send claims to NHIC for mostMedicaid clients in the Dallas Service Area. Providers must seek reimbursement throughthe NorthSTAR BHO, ValueOptions. The only exceptions are dual-eligible Medicaid/Medicare NorthSTAR members whose Medicare Part B co-insurance is paid by NHIC.

A few Medicaid clients are not eligible to join ValueOptions (clients who live in nursingfacilities or ICFs/MR Intensive care facilities/Mental Retardation), or IMDs (institutions formental disease), or who are in the custody of the TDPRS (Texas Department of Protectiveand Regulatory Services). NHIC continues to pay their Medicaid claims.

Mental health and chemical dependency specialists, and institutions that provide suchservices, should follow these guidelines to be reimbursed for services to Medicaid clientswho are eligible to join NorthSTAR:

• Join the network of the NorthSTAR BHO to treat its members.

• The BHO may require that you obtain prior approval for non-emergency services. Ifyou do not obtain approval, you may not be paid.

• Effective, July 1, 1999, providers will no longer send claims to NHIC forreimbursement for Medicaid-covered services.

• Effective July 1, 1999, if you bill for a Nor

STAR HMO or NHIC. Consult with each enrollee’s STAR HMO, or NHIC for fee-for-service

thSTAR-eligible client, NHIC will recoupthe dollars paid to you.

The BHO instructs the providers in their respective networks how and where to file claimsfor behavioral health services. If you are not a behavioral health specialist, any servicesyou provide to treat mental health or chemical dependency disorders may be covered by a

enrollees, to confirm covered services.

NorthSTAR Program Assistance

If you are a mental health or chemical dependency specialist or a facility that providessuch services, and you have questions or problems with billing or payment, call theNorthSTAR BHO, ValueOptions.

ValueOptions 1-888-800-6799

If you have further questions or problems, call the NorthSTAR HelpLine at1-877-450-HELP.

http://www.tdprs.state.tx.us/



Guidelines for Working with NorthSTAR Clients

Keep in mind that clients enrolled in NorthSTAR, like any other clients, have these rights:

• To be treated with respect, dignity, privacy and confidentiality, and withoutdiscrimination

• To consent to or refuse treatment and actively participate in treatment decisions

• To use each available complaint process and to receive a timely response tocomplaints

• To receive timely access to care that does not have any communication or physicalaccess barriers

Contents

Chapter IIProvider Responsibilities

Role of the Primary Care Provider ........................................ 1

Contractual Obligations ........................................................ 1

Credentialing Committee...................................................... 3

Credentialing Grievance Committee .................................... 5

Termination/Disenrollment.................................................... 6

Miscellaneous Provisions .................................................... 7

Services to be Provided ....................................................... 8

Continuous Coverage .......................................................... 9

Member Capacity ............................................................... 10

Temporary Panel Closings ................................................. 11

Approach to Referrals ........................................................ 11

Referral Tracking Form ....................................................... 13

Release of Confidential Information ................................... 14

Specialist Responsibilities ................................................. 14

Specialist-to-Specialist Referrals ....................................... 15

Claims for Specialist Services ............................................ 15

Out-of-Network Medical Services ....................................... 16

Texas Health Network Provider Policies and Procedures Manual II-1BDHMC

PROVIDER RESPONSIBILITIES

Overview

All Medicaid clients enrolled in the Texas Health Network are required toselect a primary care provider (PCP). As a PCP, you are responsible forproviding primary and preventive care and managing all acute andeducational medical services. This chapter describes the role of the PCPand specialist in the Texas Health Network and specifies the requirementsfor PCP participation.

Role of the Primary Care Provider

You are responsible for establishing a “medical home” for your patients who enroll in theTexas Health Network and select you as their PCP or are assigned to you. You shouldbuild a relationship with these members and encourage them to think of you as the managerof their health. You and your staff are responsible for teaching your patients how to useavailable health services appropriately. Patients should understand that they should callyour office first, before using any health service, except in emergency situations. The State’sgoal of ensuring continuity of care for its Medicaid clients and providing services in themost cost-effective setting is tied to appropriate utilization of health services deliveryresources. By educating patients to seek your services before accessing other services,you can help the State meet its goal.

Contractual Obligations

PCP obligations are spelled out in the contract between the Texas Department of Healthand each PCP. These obligations are intended to assure members that they have accessto quality health care from trained and credentialed providers. These obligations specifythat a PCP will commit to:

• Maintain any and all licenses in the State of Texas required by the laws governingthe provider’s profession or business.

• Notify BDHMC immediately of any limitation, suspension, or revocation of any licenseor medical staff membership.

• Obtain and maintain an acceptable general liability insurance policy as well as aprofessional liability insurance policy in an appropriate amount. At a minimum, thelimits of liability are $100,000 per occurrence and $300,000 in the aggregate.



Texas Health Network Provider Policies and Procedures ManualII-2 BDHMC

• Meet all TDH credentialing and recredentialing requirements.

• Maintain all medical records relating to Texas Health Network members for a periodof at least five years (six years for freestanding Rural Health Clinics and 10 years forhospital-based Rural Health Clinics) from the initial date of service, or until all auditquestions, appeal hearings, investigations, or court cases are resolved.

• Comply with requests (at no cost to the requestor) from:

— The Texas Health and Human Services Commission (THHSC)

— The Texas Attorney General’s Medicaid Fraud Control Unit

— The Texas Health Network or BDHMC

— The claims administrator

• Comply with State and Federal laws and administrative regulations concerningnondiscrimination on the grounds of race, color, national origin, age, sex, disability,political beliefs, or religion.

— These nondiscrimination requirements apply to participation in, or denial of, anyaid, care, service or other benefits provided by Federal and/or State funding.

— These laws and codes include Title VI of the Civil Rights Act of 1964 (PublicLaw 88-352); Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112);the Americans with Disabilities Act of 1990 (Public Law 101-336); Title 40, Chapter73, of the Texas Administrative Code; and all amendments to each and all re-quirements imposed by the regulations issued pursuant to these acts.

• Comply with Health and Safety Code 85.113, as described in the Texas MedicaidService Delivery Guide under “HIV/AIDS Model Workplace Guidelines.”

• Comply with the U.S. Department of Health and Human Services’ GuidanceMemorandum (1998), Title VI Prohibition Against National Origin Discrimination—Persons with Limited English Proficiency (LEP). See Chapter V for additionalinformation on LEP guidelines.




Additional Criteria for Primary Care Providers

All primary care providers must meet the credentialing/recredentialing criteria specifiedabove. PCPs are also required to meet the following criteria:

• Ability to Perform or Directly Supervise the Ambulatory Primary Care Servicesof Members—Provider performance is monitored on an ongoing basis through theTexas Health Network’s Continuous Quality Improvement Program. BDHMC, asNetwork Administrator of the Texas Health Network, follows up on evidence of poorperformance and addresses identified problems immediately to ensure thathigh-quality care is delivered to members.

• Admitting Privileges—The PCP must maintain admitting privileges with a hospitalwhich is a participating provider in the Texas Health Network, or make arrangementswith another Texas licenced physician who is an eligible Medicaid provider andwho maintains admitting privileges with a contracted Texas Health Network hospital.

• Education Sessions—The Texas Health Network disseminates UM, CQI and casemanagement policies and procedures to each Texas Health Network PCP. TheTexas Health Network also provides a series of educational sessions regarding allaspects of UM, CQI and case management. PCPs are required to attend at leastone educational session on UM, CQI, and case management policies and procedureseach year.

When a PCP’s credentialing file is complete, the Texas Health Network Medical Director,in conjunction with a Credentialing Committee, verify all credentials and present theirfindings to the Texas Department of Health at the Credentialing Committee meeting. TDHreviews the credentials and determines whether the applicant meets TDH credentialingcriteria. The decision to accept a provider as a Texas Health Network PCP is made byTDH in accordance with basic credentialing standards.

Credentialing Committee

Purpose and Function of the Credentialing Committee

The Credentialing Committee is charged with the responsibility of reviewing each providerapplicant’s file to ensure that he or she meets the minimum requirements established inQARI Standard IX, and by the National Committee for Quality Assurance.

The Credentialing Committee shares the responsibility to ensure that physicians and otherhealth care professionals are qualified to perform services as Texas Health Networkproviders.

The Committee reviews each provider applicant’s file and decides whether the providershould be recommended to the TDH as a member of the Texas Health Network provider







network. If TDH approves the recommendation, the provider is accepted as a participatingprovider for two years.

The Credentialing Committee is also charged with the responsibility of recredentialingTexas Health Network providers, which occurs every two years after initial credentialing.

NOTE: The Credentialing Committee also reviews and approvescredentialing policies and procedures for the Texas Health Network.

Members of the Credentialing Committee

The Credentialing Committee is comprised of the following members:

• Chair: Medical Director, TDH Bureau of Managed Care

• Co-Chair: Medical Director, Texas Health Network

• Associate Medical Director, Texas Health Network

• Contracting and Credentialing Manager, Texas Health Network

• CQI Director, Texas Health Network

• Quality Health Services Director, TDH Bureau of Managed Care

If a committee member is unable to attend a meeting, he/she may appoint a designee.

Credentialing Committee Frequency/Logistics

The Credentialing Committee meets monthly, or as required, to review new applicationsfor credentialing/recredentialing. The Texas Health Network Contracting and Credentialingstaff will have previously completed the initial screening for each provider in accordancewith the standards of the National Committee for Quality Assurance.

Credentialing Committee Action

The Texas Health Network Medical Director, as the Co-Chair, is charged with implementingthe credentialing and recredentialing standards for participating providers in the TexasHealth Network. The TDH/BMC also reviews submitted documentation and recommendsacceptance or rejection of each provider.



Based on this action, TDH executes the contract of approved providers. The Texas HealthNetwork then notifies each approved applicant in writing of the status of his or her application.For approved providers, the notification includes:

· A fully executed provider contract

· The date upon which his or her contract is effective

· Conditions of participation in the Texas Health Network

· Recredentialing requirements

Applicants who are not approved are notified by certified mail of the denial, the reason forthe denial, and the process for reconsideration. Applicants may request reconsiderationby submitting evidence that the deficiency(ies) for which the original application was deniedhas/have been corrected.

A provider has 30 days to request a reconsideration of a recredentialing denial to theCredentialing Grievance Committee. Such requests must be in writing and submitted tothe following address:

Texas Health NetworkCredentialing Grievance Committee

6937 North IH-35Austin, TX 78752

1-888-TDH-PCCM (888-834-7226)

Credentialing Grievance Committee

Purpose and Function of the Credentialing Grievance Committee

The Credentialing Grievance Committee considers providers’ requests for reconsiderationof credentialing decisions.

Members of the Credentialing Grievance Committee

The Credentialing Grievance Committee is composed of the following members:

• Medical Director, TDH Health Care Financing or designee

• Medical Director, Texas Health Network



• Contracting and Credentialing Manager, Texas Health Network

• Provider/Member Services Director, Texas Health Network

• CQI Director, Texas Health Network

• State Administered Plan Manager, TDH Bureau of Managed Care

Credentialing Grievance Committee Frequency/Logistics

The Credentialing Grievance Committee convenes within 60 days after receipt of agrievance or request for reconsideration. The provider is notified of the date, time, andlocation of the grievance hearing before the Credentialing Grievance Committee. Theprovider may attend the grievance hearing.

Notification of the Credentialing Grievance Committee’s Decision

The provider is notified in writing of the decision of the Credentialing Grievance Committeewithin 45 days after adjournment of the hearing. The Credentialing Grievance Committeeforwards its recommendations to TDH following the hearing.

A decision of the Credentialing Grievance Committee may be submitted for reconsiderationto:

Texas Department of HealthOffice of General Counsel

1100 West 49th StreetAustin, TX 78756

Termination/Disenrollment

PCP termination and disenrollment provisions are described below:

• You may terminate the agreement by providing the Texas Health Network with ninety(90) days’ prior written notice.

• If you are an individual practitioner, the agreement will terminate automatically uponyour death or the sale of your practice or your termination as a participant in theTexas Medicaid program.



• Clinics shall notify the Texas Health Network within thirty (30) days when a provideremployee leaves the employ of or terminates his or her contract with the clinic or isno longer willing to function as a PCP.

• TDH may terminate an agreement by providing a PCP with thirty (30) days’ priorwritten notice.

Termination or disenrollment notification should be sent to the following address:

Texas Health NetworkContracting and Credentialing Department

6937 North IH-35Austin, TX 78752

Please refer to Appendix I for the Provider File Maintenance Form. For more information,call 1-888-834-7226.

Miscellaneous Provisions

Several other provisions apply to PCP participation in the Texas Health Network:

• A PCP agreement may be modified only by written agreement signed by all parties.

• A PCP agreement is not assignable by a PCP, either in whole or in part, without theprior written consent of the TDH.

• PCP agreements shall be governed and construed in accordance with the laws ofthe State of Texas.

• A PCP shall be required to bring all legal proceedings against TDH in the TexasState courts.

• An agreement shall become effective only upon the PCP’s completion of the providercredentialing process and a determination by the TDH or its designee that the PCPmeets all of the requirements for participation in the Texas Health Network.






Services to be Provided

The Texas Health Network defines the services to be provided and the responsibilities tobe assumed by a PCP as follows:

• The PCP agrees to provide primary care services to Texas Health Network programMembers. Primary care services are all medical services required by a Member forthe prevention, detection, treatment and cure of illness, trauma, or disease, whichare covered and/or required services under the Texas Medicaid program. The PCPmust ensure that Members under the age of 21 receive all services required by theTexas Health Steps program (formerly EPSDT). All services must be provided incompliance with all generally accepted medical standards for the community in whichservices are rendered

• Provide 24-hour, 7-day telephone access to needed medical care for members,either directly or through on-call arrangements. PCPs or the on-call provider mustrespond to an ER call in a timely manner.

• Provide or arrange for medically necessary care within the following guidelines:

— Urgent Care: within 24 hours after the request— Routine Care: within two weeks after the request— Physical/Wellness Exams: within four to eight weeks after the request— Prenatal Care: initial visit within 14 calendar days of the request or by the 12th

week of gestation

• Refer members to an approved Texas Medicaid provider or facility that accepts TexasHealth Network members when the needed services are not available through youroffice or clinic. Specialists to whom you refer members also should scheduleappointments within the timeframes described immediately above.

• Coordinate, monitor, and document medical treatment and covered servicesdelivered by all providers to each member, including treatment during inpatient stays.

• Comply with all precertification and notification requirements of the Texas HealthNetwork.

• Verify the eligibility of each member prior to providing covered services to determinewhether the member is eligible for services under the Texas Health Network on thedate of service.

• Coordinate care for children receiving services from or who have been placed inthe conservatorship of the Texas Department of Protective and Regulatory Services(TDPRS). PCPs are responsible for furnishing or arranging for all medicallynecessary services while the child is under the conservatorship of TDPRS and untilthe child is placed in foster care and is no longer eligible for Texas STAR Programenrollment.

• Cooperate with and participate in the Texas Health Network Quality Improvementand Utilization Management Programs, as described in Chapter X of this manual.





• Maintain hospital admitting privileges at a Texas Health Network-contracted facilityas applicable or maintain a referral relationship with a provider with admittingprivileges.

• Provide preventive services using clinically accepted guidelines and standards.

Continuous Coverage

Continuous coverage is an important feature of the Texas Health Network. 24-hour PCPavailability enables members to access and use services appropriately, instead of relyingon emergency rooms for all after-hours care.

As a PCP, you are responsible for ensuring that Texas Health Network members haveaccess to needed medical care 24 hours a day, 7 days a week.

Continuous coverage can be provided through direct access to your office and/or throughon-call arrangements with another office or service. Members should be informed of yournormal office hours and should be instructed how to access urgent medical care after normaloffice hours.

After-Hours Guidelines

You are required to have at least one of the following arrangements in place to provide24-hour, 7-day a week coverage for Texas Health Network members:

• Have your office phone answered after hours by a medical exchange or a professionalanswering service. If an answering service is used, the following must be met:

— The answering exchange or service must be able to contact you or a designatedback-up provider for immediate assistance.

— The PCP, or designated back-up provider, must be notified of all calls.

— All calls must be returned in a timely manner by the PCP or designated back-up.The Texas Health Network strongly recommends member calls be returned within30 minutes.

— The answering service must meet the language requirements of the majorMedicaid population groups.

• Have your office phone answered after office hours by an answering machine thatinstructs the member (in the language of the major Medicaid population groups) todo one of the following:

— Call the name and phone number of a medical facility where the member canrequest to speak with a medical professional to determine whether emergencytreatment is appropriate.


— Call another number where you can be reached.

— Call the name and phone number of a medical professional serving as yourdesignated back-up. In this situation, the member must be able to speak with theback-up provider or a clinician who can offer immediate assistance.

• Have your office phone transferred after hours to another location where someonewill answer and be able to contact you or your designated back-up provider.

Unacceptable Phone Arrangements

The telephone answering procedures listed below are not acceptable:

• An office phone that is answered only during office hours

• An office phone answered after hours by an answering machine recording that tellsmembers to leave a message

• An office phone answering machine recording that informs members of regular officehours and requests that they call back during those hours

• An office phone that is answered by a recording or an answering service that directsmembers to go to the emergency room

Member Capacity

Previously, a PCP would be assigned no more than 1,500 Texas STAR Program members.This capacity limitation was removed by the Texas Department of Health (TDH) effectiveSeptember 1, 1999. TDH will continue to conduct oversight of all Texas STAR Programproviders to ensure accessibility and quality of care.

Monthly Member Panel Report

Each month the PCP will receive from the Texas Health Network a member panel reportthat lists all Texas Health Network members who have either selected or who have beenassigned to them. This report verifies member assignments for the current month andidentifies those members who are new to the PCP’s practice, those who have been defaultedto them, and those that may be eligible for THSteps services. An example of this report canbe found in Appendix A.

Members appearing on the monthly panel report are eligible for services for the entirecalendar month.



Based on the number of members appearing on the monthly member panel report, thePCP receives a monthly case management fee of $3.00 per member per month. This checkis issued by NHIC, the claims administrator.

Temporary Panel Closings

You may choose to close your panel to new assignments temporarily. To close your paneltemporarily, you should contact the Texas Health Network’s Provider Credentialing andContracting Department in writing (by mail or fax) to request a temporary suspension ofnew enrollments or assignments to your practice. Please include your contracted providernumber on signed letterhead or contact the Credentialing and Contracting Department fora provider file maintenance form (see Appendix I). You also should advise the Texas HealthNetwork 30 days before you expect to reopen your panel for additional Texas Health Networkmember assignments.

Approach to Referrals

Referrals are an integral component of the Texas Health Network’s health care deliveryprogram. Referrals ensure that members gain access to all necessary and appropriatecovered services and that care is delivered in the most clinically suitable and cost-effectivesetting.

Referral procedures are designed to capture the information needed to support and managethe utilization of services by the provider network. Proper documentation of referrals isnecessary for accurate medical record keeping. It also enables the Texas Health Networkto collect and disseminate information for PCP profiling and practice pattern analysis.

As a PCP in the Texas Health Network, you function as the coordinator of health servicesfor your members, whether services are delivered within or outside your office. You areresponsible for arranging and coordinating appropriate referrals to other providers andspecialists, and for managing, monitoring, and documenting the services of other providers.

As a PCP, you are responsible for the appropriate coordination and referral of Texas HealthNetwork members for the following services:

• THSteps Dental (including orthodontics)

• ECI case management services

• MR targeted case management

• PWI Services

• THSteps medical case management



• SHARS

• Texas Commission for the Blind (TCB) case management services

• TB Services

• Vendor drugs

Please refer to the Texas Medicaid Provider Procedures Manual for details.

Open Specialty Referral Network

The Texas Health Network operates an open specialty referral network, which means thatyou may refer patients to any Texas Medicaid-approved specialist provider that acceptsTexas Health Network members for covered health services that you cannot provide.Medically necessary referrals to specialists do not require precertification from the TexasHealth Network.

For all referrals, PCPs should furnish the specialist provider with complete information ontreatment procedures and diagnostic tests performed prior to the referral. The referral shouldspecify:

• The initial diagnosis/diagnoses

• The reason for the referral

• The services requested from the referral specialist

• The number of authorized visits (optional)

You may make a referral to another PCP or a specialist provider during your absence orunavailability. You may make a referral if a member requests a second medical opinion.

After receiving a referral specialist's report, if ongoing treatment for an illness is required,you have the discretion to specify the period of time or number of visits authorized forongoing treatments to be given by the specialist provider.

Your contracted provider number must be entered on all claims submitted by the specialistprovider, indicating that you authorized these services. It is the responsibility of the treatingspecialist provider to ensure that the patient continues to be an eligible Texas HealthNetwork member throughout the period of treatment.

PCPs shall continue to provide their contracted Texas Medicaid providernumber to OB/GYN providers for services directly accessed by TexasHealth Network members.



Referral Tracking Form

At this time, no form for a referral to a specialist is mandated. The Texas Health Networkwill accept any referral form providers wish to use. However, you are encouraged to usethe Texas Health Network referral tracking form. This form reflects accepted practices inthe Texas medical community. The use of this form will simplify:

• Dissemination of necessary information to the specialist

• Documentation for the member’s medical record of the specialist’s diagnosis andtreatment

• Assisting in timely identification of case management and health education needs

The Texas Health Network has revised the current referral form to include several diagnosesthat often reflect a need for case management. The Texas Health Network Health Servicesstaff request that providers complete and fax the form when referring for any of the listeddiagnoses. This allows Texas Health Network staff to track and assist providers with chronicand catastrophic cases. Target diagnoses for this tracking program are:

• Hypertension• Diabetes• Severe respiratory disorders• High-risk pregnancy• Children with special needs• Pediatric cardiac disorders• Asthma• Tuberculosis• Behavioral/Psychiatric disorders

Primary care providers may call or fax the completed Texas Health Network referral form tothe Case Management Department within 24 hours or the next business day after thereferral is made. A sample referral form is included in Appendix C. Please note:

• One copy of the referral form should be given to the specialist.

• One copy should be maintained in the member’s medical record.

Call the Texas Health Network Case Management Intake Department for tracking of referralsand assistance with case management.

Case Management Intake1-888-276-0702

Fax: 1-512-302-0318


Release of Confidential Information

Information concerning the identity, history, diagnosis, evaluation, or treatment of a Medicaidpatient by a person licensed or certified to diagnose, evaluate, or treat any medical, mental,or emotional disorder or drug abuse is normally confidential information that the providermay disclose only to authorized persons.

Family planning information is particularly sensitive, and confidentiality must be ensuredfor all patients, especially minors.

Patient confidentiality must be maintained. The patient or member’s signature is not requiredon the claim form for payment of a claim, but it is strongly recommended that the providerobtain written authorization from the member prior to releasing confidential medicalinformation:

• A release may be obtained by having the member sign the indicated block on theclaim form after he or she has read the statement of release of information printedon the back of the form.

• An authorization for release of such information is not required when the release isrequested by and made to the TDH, BDHMC, TDHS, NHIC, THHSC, the TexasAttorney General’s Medicaid Fraud Control Unit, HHS, THQA, or the Texas HealthNetwork.

• Medical documentation and information may be released to other entities if thepatient/member gives a written consent to release the information.

Specialist Responsibilities

Specialists are responsible for furnishing medically necessary services to Texas HealthNetwork members who have been referred by their PCP for specified treatment or diagnoses.Specialists are responsible for verifying the eligibility of the referred member prior toproviding treatment.

To ensure continuity of care for members, the specialist must maintain communication withthe member's PCP. This communication should ensure that the PCP's medical recordsadequately document the specialist services provided, all results or findings, and allrecommendations. The specialist may use the lower half of the Texas Health NetworkReferral Form for this purpose.

When a PCP refers a member to a specialist, the specialist should review the case with thePCP to fully understand the services being requested. Services requiring more than onevisit should be coordinated with the PCP for approval of additional visits. Referrals from aPCP must be documented in both the PCP's and the specialist's records.








If a specialist determines that a member's condition warrants attention (i.e., hospitalization),the specialist should seek authorization from:

Texas Health Network Utilization Management DepartmentPhone: 1-888-302-6167

Fax: 1-512-302-5039

The specialist should also inform the member's PCP.

OB/GYN Providers: Please contact the member’s PCP to obtain his or herprovider number for inclusion on your claim form .

Emergency treatment does not require precertification.

Specialist-to-Specialist Referrals

Referrals from one specialist to another for a medically necessary service must be authorizedby the member's PCP or by the Texas Health Network Utilization Management Department.The Texas Health Network referral form can be used for this purpose to simplify the approvalof the referral.

Claims for Specialist Services

Claims for specialists' services must reference the PCP's assigned Medicaid provider num-ber as the referring provider in the appropriate field of the electronic submission or paperclaim form. Additional information about reimbursement and claims submission is locatedin the Texas Medicaid Provider Procedures Manual.



Out-of-Network Medical Services

The claims administrator (NHIC) will not reimburse providers for non-emergent,out-of-network medical care or services unless the Texas Health Network member wasreferred by his or her PCP or precertification was obtained directly from the Texas HealthNetwork Utilization Management staff at 1-888-302-6167.

In addition, precertification from the Texas Health Network or a referral from the PCP isrequired for a Texas Health Network member who moves outside of a county in which theTexas Health Network operates, and who requires medically necessary services beforethe member's demographic information is updated in DHS records.

Health care services provided outside the network are eligible for reimbursement withoutprecertification when:

• A medical emergency is documented by the attending provider or anotherprovider.

• The member's health is endangered if travel is required.

• The member's PCP has referred the member to an out-of-network provider be-cause the required services are not available through the existing Texas HealthNetwork provider network.

Please refer to Chapter III for information on precertification requirements.



Contents

Chapter IIIRoutine, Urgent andEmergency Services

Definitions ............................................................................ 1

Emergency Room Review Procedures ................................ 3

Notification of Inpatient Admission ....................................... 3

Observation Room Services ................................................. 4

Procedures Requiring Precertification ................................. 6

Procedures Not Requiring Precertification ........................... 6

Information Required for Precertification .............................. 7

Inpatient Precertification and Notification ............................. 9

Utilization Management ...................................................... 11

Emergency Transportation Services ................................... 14

Non-Emergency Transportation .......................................... 14

Member Acknowledgment Statement ................................. 15

III-1Texas Health Network Provider Policies and Procedures ManualBDHMC

ROUTINE, URGENT AND EMERGENCY SERVICES

Overview

For true emergencies, Texas Health Network members may seek care from anyMedicaid provider in an office, clinic, or emergency room setting. Treatment ofemergency conditions does not require precertification or a referral from themember’s PCP. A medical screening exam is required for any individual whopresents to an Emergency Department and requests an evaluation or treatmentof a medical condition. It includes all services necessary to determine if anemergency medical condition exists, and to stabilize the member. Hospital ERstaff are instructed to notify the PCP of any presenting Texas Health Networkmember, so that appropriate follow-up care can be arranged by the PCP.

Definitions

Routine/Non-Emergent A symptom or condition that is neither acute nor severe andCondition can be diagnosed and treated immediately, or that allows

adequate time to schedule an office visit for a history, physi-cal and/or diagnostic studies prior to diagnosis and treatment.

Urgent Condition A symptom or condition that is not an emergency, but requiresfurther diagnostic work-up and/or treatment within 24 hours toavoid a subsequent emergent situation.

Emergent/Emergency A medical condition, including behavioral health, that mani-fests itself by acute symptoms of sufficient severity (includingsevere pain) such that a prudent layperson, who possessesan average knowledge of health and medicine, could reason-ably expect the failure to treat immediately to result in one orall of the following:

• Placing the health of the individual (or with respect to apregnant woman, the health of the woman or her unbornchild) in serious jeopardy;

• Serious impairment of bodily function;

Texas Health Network Provider Policies and Procedures ManualIII-2 BDHMC

• Serious dysfunction of any bodily organ or part; or

• With respect to a pregnant woman having contractions:

— That there is inadequate time to effect a safe transferto another hospital before delivery, or

— That transfer may pose a threat to the safety of thewoman or the unborn child

— With respect to a behavioral health condition, aperson having symptoms may:

• present a danger to themselves or others, or• render the member incapable of controlling,

knowing, or understanding the consequences ofhis or her actions.

Emergency Services ER providers are authorized by the Texas Health Network tofurnish the medically necessary appropriate treatment of TexasHealth Network members. If the patient requires admission, thehospital must notify the Texas Health Network UM Departmentwithin 24 hours of the admission or the next business day(excluding routine deliveries and newborn care). The hospitalshould notify the PCP of the admission and services renderedwithin 24 hours or the next business day (excluding routinedeliveries and newborn care).

Providers must become actively involved in educating their patients regarding appropriateuse of the emergency room and other emergency services.


Emergency Room Review Procedures

The Emergency Room (ER) physician must perform the medical screening examination, i.e.assess the medical needs of a Texas Health Network member who appears in the ER todetermine the medical necessity of services and the appropriate setting for rendering services.

If a determination is made that the member has a routine/non-emergent condition, the member'sPCP must be notified by phone, fax, or electronic mail, so that follow-up care can be arrangedby the PCP as appropriate.

If a determination is made that the member has an urgent condition, the member's PCP mustbe notified by phone, fax, or electronic mail, so that follow-up care can be arranged within 24hours.

If the member has an emergent condition, the ER must treat the member until the condition isstabilized or until the member can be admitted. If the member is stabilized, the ER staff mustnotify the member’s PCP to arrange for medically necessary hospital admission or follow-upcare. If the ER staff is unable to contact the PCP (or designated on-call provider) within 1 hour,the ER staff should treat the member and report the PCP’s unavailability by contacting theTexas Health Network Provider Helpline at 1-888-834-7226.

All follow-up care for a stabilized Texas Health Network member should be referred to thePCP or the Texas Health Network.

ER providers must determine a patient's status based on the emergent, urgent andnon-emergent definitions listed above. In some cases, medically necessary services areneeded to determine the patient's condition. The necessity of these services must bedocumented in the medical record.

ER providers, including physicians, facility, and ancillary services, are paid for medicallynecessary services required to determine and stabilize the patient's condition.

Notification of Inpatient Admission

The Texas Health Network’s UM Department must be notified of all inpatient services within24 hours after admission or the next business day, excluding routine deliveries and newborncare. All inpatient stays are concurrently reviewed and subject to retrospective review forappropriateness of length of stay and level of care. This notification initiates the concurrentreview process for an inpatient stay (see the notification form in Appendix E). The concurrentreview process must be initiated within 24 hours of admission. The following information should


be included on the notification:

• Facility name and provider number, phone number, fax number and facility UM contactperson

• Last name, first name, middle initial, date of birth, and sex of patient

• Client’s Medicaid number (PCN)

• Date of admission

• PCP name and provider number

• Attending physician name (if not PCP) and provider number

• Admitting diagnosis

• Procedure or service (if known)

Note: If the provider does not meet the notification requirement, the admission will bedenied only up to the date the initial notification is received. Any inpatient days incurredprior to the notification will be denied regardless of medical necessity. Inpatient days onor after the date of notification will be certified if clinical data supplied by the providercontinues to support medical necessity. Denied inpatient days may be submitted forreview on an appeal basis.

Observation Room Services

Some patients, while not requiring hospital admission, may require a period of observation inthe hospital environment as an outpatient. Observation services may be provided in any partof the hospital where a patient placed in observation can be assessed, examined, monitored,and/or treated in the course of the customary handling of patients by the facility.

The decision to admit a patient to inpatient status must be made prior to the 24th hour.Observation services after the 23rd hour are not payable by Medicaid.

If a non-emergent inpatient admission occurs from the observation room without the requiredprecertification request to the Texas Health Network UM Department, the entire hospitaladmission may be denied for payment.

If an emergent inpatient admission occurs from the observation room, the hospital must notifythe Texas Health Network UM Department of the admission within 24 hours or the next busi-ness day. If a member initially placed in observation status is subsequently admitted as aninpatient, the date of the initial placement in observation status serves as the admit date for theinpatient stay.

Figure 3-1 on the next page depicts the emergency admission process.


EMERGENCY ROOM SERVICESGUIDELINES

Member Seeks Health Care in ERScreening Examination Performed

EmergentImmediateemergency

UrgentCare needed

PCP and TexasHealth Network

Notified

Member admitted toinpatient—NotifyPCP and Texas

Health Network UMDept. within 24 hours

or by the nextbusiness day of

inpatient admission

After OfficeHours/Weekend

Non-emergentNon-immediate

care needed

During OfficeHours

PCP must becontacted and

member referredto PCP for

appropriatefollow-up.

Texas Health Network

Figure 3-1

UrgentRefer memberto PCP or tothe on-callprovider fortreatmentwithin 24hours

Non-emergentNotify PCP forfollow-up asappropriate.


Procedures Requiring Precertification

Precertification of the procedures listed below must be requested for Texas Health Networkmembers at least 4 business days prior to services being rendered. Procedures requiringprecertification are listed below.

Office Services

• MRI • All Podiatry Procedures• MRA • pH Probe Tests• All Laser Surgeries • Sleep Studies• Endoscopic Procedures • Specialist-to-Specialist Referrals

Inpatient

• All non-emergent inpatient admissions (excluding routine deliveries/newborns)

• All non-emergent surgical procedures, including procedures performed during certifiedhospital admissions

Outpatient

• MRI • Sleep Studies• MRA • Podiatry Procedures• All Laser Surgeries • Endoscopic Procedures• pH Probe Tests • All non-emergent procedures

Procedures Not Requiring Precertification

The following procedures do not require precertification:

— Surgeries performed on an emergent basis (retrospective notification must occurfor claims payment)

— Application/removal of casts, splints, or strapping (excluding podiatry officeprocedures and services)

— Burns-local treatment (does not include skin grafts)

— Catheterization of blood vessels (excluding heart caths) for diagnosis or therapy(includes venous access, puncture of shunt, etc.)


— Circumcision, newborn and for phimosis (up to age 21)

— Fractures/Dislocations - closed or open treatment

— Incision and drainage of abcesses

— Injection procedures for radiology or in conjunction with surgical procedures

— Intubation/trach tube changes

— Removal of foreign bodies

— Removal of PE tubes with or without grafts

— Repair of lacerations/wounds (includes the eye)

— Replacement of G-tubes

— Replantation of limbs/digits

— Sterilization procedures (male and female)

— Urodynamics

— Esophageal manometry

— Ultrasounds

— Holter monitors

IMPORTANT: The provider is responsible for following up on incomplete precertificationrequests. All other precertification (prior authorization) requirements under the current TexasMedicaid Program remain in place and unchanged for the Texas Health Network. Non-coveredMedicaid services remain unchanged under the Texas Health Network.

Information Required for Precertification

The Texas Health Network requires the following information to support the precertificationrequest:

• Clinical information:

— Date of service— Lab or X-ray results


— Treatment plan— Procedure/service(s) requested— Pertinent history— ICD-9-CM diagnosis codes— CPT or HCPCS procedure codes— Type of setting (inpatient or outpatient hospital, office, or other)

• Demographic information:

— Member’s name, date of birth, and Medicaid number— Requesting provider’s name, provider number, fax number, and phone number— Office contact name for requesting provider— PCP’s name, provider number, and phone number— Facility’s name and provider number

If your precertification request meets the criteria for certification, a precertification number willbe issued. If UM staff do not receive sufficient information to approve the request, you will beinstructed to provide further appropriate information before the service is provided. A sampleprecertification request form is located in Appendix D.

It is the provider’s responsibility to follow up on incomplete precertification requests.

If information submitted is complete and review criteria indicate that the admission or procedureis not medically necessary, the request is routed to the Texas Health Network Medical Directoror physician consultant for review.

After your precertification request has been certified, you will be contacted and given aprecertification number, both by phone/fax and in a follow-up letter. This number must be onyour claim in the “prior authorization number” field. (Refer to the Texas Medicaid ProviderProcedures Manual for specific instructions.) Medical necessity denials are issued only by theTexas Health Network Medical Director.

Please call the Texas Health Network UM Department to request an expedited appeal.

Conditions

Precertification is a condition for reimbursement. Precertification must be obtained from theTexas Health Network Utilization Management Department before services are rendered. It isnot a guarantee of payment.




Denials and Appeals of Requests for Precertification

If your precertification request for admission or service is denied, you will receive a denialletter from the Texas Health Network UM Department. Where appropriate, the hospital or facilityinvolved is also notified of the denial.

If you are dissatisfied with a determination by the Texas Health Network UM Department, youmay file an appeal.

To file an appeal with the Texas Health Network, send a copy of the denial letter you received,a copy of the remittance and status report on which the denied claim appears, an explanationof the appeal, and clinical documentation to support approval of the service(s) within 180days of determination. Appeals may be mailed or faxed to the Texas Health Network Complaintsand Appeals Resolution Unit. Please refer to Chapter IV of this manual for additional informationon the appeal process.

NOTE: For appeals of denied claims, reference the Appeals section of the Texas MedicaidProvider Procedures Manual.

Valid Precertification Timeframe

Approved precertifications are valid for, and must be used within, 180 days from the dateinitially approved by the Texas Health Network. The total number of visits or services is limitedto the number authorized on the approved precertification.

Inpatient Precertification and Notification

Emergency inpatient admissions do not require precertification. The hospital or PCP is requiredto notify the UM Department within 24 hours or by the next business day of all admissions,excluding routine deliveries and newborns.

Notification is not required for routine deliveries or newborns unless the inpatient stay extendsbeyond four days for a C-section, two days for a vaginal delivery, the delivery/newborn care isnon-routine, or conditions exist which may affect DRGs (e.g., 371, 373, 374, 391).

In the case of a scheduled admission when a precertification number has been issued,notification of admission must still occur within 24 hours of the admission.

The table on the following page illustrates the differences between the precertification andnotification processes.


Purpose

Services

Precertification Notification

Clinical information determines themedical necessity of the stay andappropriate level of care

All non-emergent inpatientadmissionsNon-emergent surgicalproceduresSpecific office and/or outpatientprocedures

Physicians or hospitals

At least 4 business days before theservice (or in the case of a non-emergent admission from theobservation room, before the end ofthe 24th hour)

Phone, fax, or mail

Client’s name, date of birth andMedicaid number (PCN)Name, Provider number, fax numberand phone number of requestingproviderPCP name, provider number andphone numberFacility name and provider numberDate of ServiceProcedure/Service(s) requestedType of setting (inpatient or outpatienthospital, office, other)Treatment planPertinent historyLab or X-ray resultsAdmitting diagnosis ICD-9-CMcode(s)CPT procedure code(s)

Communication of an admission statusto initiate concurrent review or DRGconfirmation process

All inpatient admissions(except routinedeliveries and newborns); for example:• Urgent/Emergent inpatient

admissions• Precertified non-emergent

inpatient admissions• Emergency admissions in

transition from observation status• All non-routine deliveries/

newborn care, includingconditions affecting DRG.

Physicians, hospital UM Nurses, orother hospital staff (business office)

Within 24 hours of the admission orby the next business day

Phone or fax

Facility name, provider number, phonenumber, fax number and UM contactpersonClient’s last name, first name, middleinitial, date of birthTexas Health Network client number(PCN)Date of admissionPCP name and provider numberAttending physician name (if not PCP)and provider numberAdmitting diagnosisCPT procedure codes/service (ifknown)Facility’s unique patient identificationnumber, i.e. medical record number

Who

When

How

InformationNeeded

Table 3 -1 Inpatient Precertification and Notification Process


Concurrent Review

The Texas Health Network UM Department performs concurrent and retrospective reviews.Precertification is a requirement for all non-emergent inpatient admissions. Admissions aresubject to denial if precertification is not obtained. Notification of all inpatient stays must bereceived within 24 hours of admission, or the next business day, excluding routine deliveriesand newborns. Clinical information for the concurrent review process, which determinesappropriateness of admission and continued stay, should be received no later than 24 hoursafter notification of admission.

As noted above, the admitting hospital is required to notify the Texas Health Network UMDepartment within 24 hours of the hospital admission or by the next business day of all inpatientadmissions.

Notification can be executed by contacting the Texas Health Network Utilization ManagementHelpline or using the Notification Fax Form in Appendix E.

Texas Health Network Utilization Management 24-Hour Helpline Phone: 1-888-302-6167Option 1 - precertification

Option 2 - concurrent reviewFax: 1-512-302-5039

The clinical information outlined below must be supplied by the hospital to the Texas HealthNetwork Utilization Management Department for review. If staff review indicates that alternativelevel of care is appropriate, the case is reviewed by the Medical Director. If the Medical Directordetermines that services can be managed at an alternative level of care, the UtilizationManagement Nurse communicates this to the facility. Medical necessity denials are issuedonly by a Texas Health Network medical director. If the facility disagrees with the medicalnecessity denial, it may contact the Texas Health Network UM Department to request anexpedited appeal.

The UM Nurse will request the following:

• The member’s Medicaid number (PCN)

• The day (number) of the hospital stay

• The status of the medical/surgical condition


• Progress notes, vital signs, radiology/lab report(s), and treatment(s)

• Facility’s unique patient identification number

• Physician’s orders, including medications and consults

• Level of care during the stay in the facility

• The expected length of stay in the facility

• Discharge planning

• Case management needs

• Health education needs

ICD-9-CM and DRG Confirmation

One of the goals during this daily review is to identify the appropriate ICD-9-CM or DRG forfacility reimbursement. This necessitates discussion of the ICD-9-CM diagnosis and procedurecodes relevant to the current medical/surgical condition of the patient. A final DRG or ICD-9-CM code will be confirmed following discharge. It is the hospital’s responsibility to inform theTexas Health Network of the final coding (to include the DRG, if applicable) within 10 businessdays post discharge. The authorization cannot be released for payment until final coding hasbeen received and verified with clinical information.

The provider needs to notify the Texas Health Network UM Concurrent Review Nurse of thedate the client is discharged so that the DRG can be confirmed.

During the course of admission, the client’s need for discharge planning and case managementservices is assessed.

Retrospective Review

Utilization review includes retrospective evaluation of health care services after they havebeen provided. All inpatient services in contracted and non-contracted facilities are subject toretrospective review. UM Concurrent Review Nurses conduct retrospective review for ICD-9and DRG (if applicable) validation for evaluation of the effectiveness of the concurrent reviewprocess. Charges for inappropriate inpatient stays/days and related services may be recoupedas determined by a medical director during the retrospective review process.

Figure 3-2 describes the Utilization Management Process.


Figure 3-2

Inpatient Medical Management Process

Note: Notification/concurrent review is not required for routine deliveries.


Emergency Transportation Services

Texas Health Network members are eligible to receive emergency transportation or ambulanceservices. Coverage is limited to ambulance services provided to eligible clients in two situations:

• Emergency

• Non-emergency for the severely disabled

When the condition of the member is life threatening (as defined on page III-1) and requiresthe use of special equipment, life support systems, and monitoring by trained attendants whileen route to the nearest appropriate facility, the ambulance transport is considered an emergencyservice.

When the client has a medical condition requiring treatment in another location and is soseverely disabled that the use of an ambulance is the only appropriate means of transportation,the ambulance transport is considered a non-emergency service.

“Severely disabled” is defined as a physical condition that limits mobility and requires theclient to be bed-confined at all times, unable to sit unassisted at all times, or requires continuouslife support systems including oxygen or IV infusion.

Information regarding reimbursement for ambulance services can be found in the TexasMedicaid Provider Procedures Manual.

Non-Emergency Transportation

Additional transportation services are available to eligible Medicaid clients who have no othermeans of transportation. This service is known as the Medical Transportation Program (MTP)and is detailed in Chapter I of this manual.




Member Acknowledgment Statement

A provider may bill a Texas Health Network member for a service that is not medically necessaryor not a covered benefit if both of the following conditions are met:

• The patient requests a specific service or item that in the opinion of the provider maynot be reasonable and medically necessary.

• The provider must obtain and keep a written acknowledgment statement verifying thatthe provider has notified the Medicaid member of financial responsibility for servicesrendered. This acknowledgment must be signed by the member. If the service themember requested is determined not to be medically necessary by the Texas HealthNetwork, TDH or NHIC, the signed acknowledgment statement must indicate that themember has been notified of the responsibility of paying the bill. The acknowledgmentmust state:

“I understand that, in the opinion of (provider's name), theservices or items that I have requested to be provided tome on (dates of service) may not be covered under theTexas Health Network as being reasonable and medicallynecessary for my care. I understand that the TexasDepartment of Health or its health insuring agentdetermines the medical necessity of the services or itemsthat I request and receive. I also understand that I amresponsible for payment of the services or items I requestand receive if these services or items are determined notto be medically necessary for my care."

“Comprendo que, según la opinión del (nombre delproveedor), es posible que Texas Health Network nocubra los servicios o las provisiones que solicité el (fechadel servicio) por no considerarlos razonables nimédicamente necesarios para mi salud. Comprendo queel Departamento de Salud de Texas o su agente deseguros de salud determina la necesidad médica de losservicios o de las provisiones que el cliente solicite oreciba. También comprendo que tengo la responsabilidadde pagar los servicios o las provisiones que soliceté yque reciba si después se determina que esos serviciosy provisiones no fueron o son razonables ni médicamentenecesarios para mi salud.”




A provider may bill a member without a signed acknowledgment statement if:

• The service received is not a benefit of the Medicaid Program. The provider informs themember that the service in question is not a benefit of the Texas Medicaid Program andnotifies the member of financial responsibility.

• The provider accepts the member as a private pay patient. Providers must advisemembers that they are accepted as private pay patients at the time of service and willbe responsible for paying for all services received. In this situation, TDH stronglyencourages that notification be in writing with the member’s signature so there is noquestion how the member was accepted. Without written, signed documentation thatthe Medicaid member has been properly notified of the private pay status, the providershould not seek payment from an eligible member. The following “Private Pay Agreement”is an example of written documentation.

Private Pay Agreement

I understand (provider name) is accepting me as a privatepay patient for the period of _________________, and Iwill be responsible for paying for any services I receive. Theprovider will not file a claim to the Texas Health Network orMedicaid for services provided to me.

Signed:__________________________Date:____________________________

• The member is accepted as a private pay patient pending Medicaid eligibilitydetermination and does not become eligible for Medicaid retrospectively. The provideris allowed to bill the member as a private pay patient if retroactive eligibility is not granted.If the member does become eligible retroactively, the member should notify the providerof the change in status. Ultimately, the provider is responsible for filing timely Medicaidclaims. If the member becomes eligible, the provider must refund any money paid bythe member if a Medicaid claim is filed.

Additional information on claims filing and billing members can be found in Chapter VI of thismanual.


Contents

Chapter IVProvider Complaintsand Appeals

Provider Appeals .................................................................. 1

Provider Complaint and Appeal Procedures ........................ 2

Texas Health Network Provider Policies and Procedures Manual IV-1BDHMC

PROVIDER COMPLAINTSAND APPEALS

Overview

Providers have the right to appeal any of the utilization review decisions reachedby the Texas Health Network. This chapter describes the process for resolutionof provider complaints and grievances.

A denial is issued when a precertification, authorization, or extension of stay request by aphysician or a facility is not approved. A Texas Health Network Medical Director may issue adenial based on medical necessity or technical reasons. Examples include:

Technical Denials

• The provider has not complied with Texas Health Network policies and proce-dures (e.g., a provider fails to provide information necessary for precertification,notification of admission or concurrent review during an inpatient admission).

Medical Necessity Denials

• The provider or the location of service is not within the network.

• The member’s condition/service requested does not warrant the level or locationof care the provider requested (e.g., medical necessity not established).

• The patient is no longer eligible for coverage.

• Texas Medicaid does not cover the service.

The appeals process affords the provider the opportunity to dispute a denial and explain orjustify the original request.

To file an appeal with the Texas Health network, send written request stating the reason thedecision by the Texas Health Network is in question, a copy of the denial letter you received, acopy of the remittance and status report on which the denied claim appears, an explanation ofthe appeal, and clinical documentation to support approval of the service(s) within 180 days ofthe determination. Appeals may be mailed or faxed to the Texas Health Network Complaintand Appeals Resolution Unit.

Texas Health Network Provider Policies and Procedures ManualIV-2 BDHMC

Provider Complaint and Appeal Procedures

Appeal Procedures for Technical Denials

Level I: Review by the Texas Health Network Complaint and Appeals Resolution Unit

The provider may appeal a technical denial only if the provider has evidence that the TexasHealth Network Utilization Management department issued the technical denial in error or didnot provide proper notification of the technical denial.

All requests for provider appeals must be submitted in writing to the following address:

Texas Health NetworkATTN: Complaint and Appeals Resolution Unit

P.O. Box 14685 Austin, TX 78761

or faxed to 1-888-235-8399.

Level II: Review by TDH

If a provider believes they did not receive full consideration under the appeals process, he orshe may file a complaint with TDH. Providers must exhaust the appeals process with theTexas Health Network before filing a complaint with the Texas Department of Health.Complaints (Level II appeals to TDH) must be in writing and include copies of all documentationfrom the provider to the Texas Health Network, and from the contractor to the provider. TheTexas Health Network’s decision letters, specifically, the final decision letter, should be includedas part of the documentation.

Complaints must be received at TDH within 60 calendar days from the date of the contractor'sfinal decision letter. Provider complaints (Level II appeals to TDH) may be mailed to the followingaddress:

Texas Department of HealthMedical Appeals and Provider Resolution Division, Y-929

Provider Complaints1100 West 49th StreetAustin, TX 78756-3172

Providers may request the Texas Health Network forward the complaint to TDH on his or herbehalf. All of the necessary information must be received by TDH in order for the complaint tobe reviewed.

If TDH determines that the provider did not receive full consideration, TDH will work with theprovider and the Texas Health Network to ensure that a proper review is conducted.











Texas Health Network Provider Policies and Procedures Manual IV-3BDHMC

Appeal Procedures for Medical Necessity Denials

Level I: Review by the Texas Health Network Medical Directors

A request for appeal based on medical necessity should be forwarded to the Texas HealthNetwork's Complaint and Appeals Unit. The Texas Department of Health defines Medicalappeals as disputes regarding medical necessity and level of severity.

• Upon receipt of the request, the Complaint and Appeals Resolution Unit Specialistwill document the request to ensure that all information necessary to complete theappeal is in order. The information is forwarded to the Utilization Manager or designee.

• The Utilization Manager or designee reviews information and directs the appeal to aMedical Director.

• The Medical Director reviews the information and makes a determination.

• After a determination is made, a Medical Director forwards the determination to theUtilization Manager or designee who sends the resolution letter to the appealing provider.

• The appealing provider has 90 days from the receipt of this notification to request aLevel II Review.

Level II: Review by the Texas Health Network Grievance Committee

If dissatisfied with the Level I medical necessity denial decision, a provider can request aLevel II appeal by sending the request in writing to the Texas Health Network Complaint andAppeals Resolution Unit within 90 days from receipt of the Level I determination.

Upon receipt of the Level II medical necessity denial request:

• The Utilization Manager and the Member Services Manager convene the GrievanceCommittee.

• The provider is notified of the Grievance Committee hearing at least 10 working daysprior to the date of the hearing.

• If desired, the provider may appear before the Grievance Committee at the hearing orparticipate by telephone.

• A quorum of at least five Grievance Committee members must be present for the hearing.

The Grievance Committee is comprised of the following individuals:

• The Texas Health Network Health Services Director or designee.

• The Texas Health Network CQI Director or designee.

• The PCP Contract Compliance designee.


Texas Health Network Provider Policies and Procedures ManualIV-4 BDHMC

• The Texas Health Network Provider/Member Services Director or designee.

• The BDHMC Project Director is an ad hoc member of the Grievance Committee andmay participate.

• The Texas Health Network Medical Director or Associate Medical Director (not includedin Level I review).

The appealing provider is allowed a maximum of 30 minutes for his or her presentation. Theprovider may also be questioned by the Committee if clarification is required.

All Committee action is by a majority vote, if a quorum of at least five members is present.

The provider is notified in writing of the Grievance Committee's decision within 30 days fromthe date the Level II appeal was filed.

The Member Services Manager is responsible for maintaining appropriate documentation toensure that written details of each level of appeal as well as the outcome of each appealdecision are accurately captured.

Level III: Review by TDH

If a provider believes they did not receive full consideration under the appeals process, he orshe may file a complaint with TDH. Providers must exhaust the appeals process with theTexas Health Network before filing a complaint with the Texas Department of Health.Complaints (Level II appeals to TDH) must be in writing and include copies of all documentationfrom the provider to the Texas Health Network, and from the Texas Health Network to theprovider. The Texas Health Network's decision letters, specifically, the final decision letter,should be included as part of the documentation.

Complaints must be received at TDH within 60 calendar days from the date of the contractor'sfinal decision letter. Providers may request the Texas Health Network forward the complaint toTDH on his or her behalf. All of the necessary information must be received by TDH in order forthe complaint to be reviewed.

If TDH determines that the provider did not receive full consideration, TDH will work with theprovider and the contractor (Texas Health Network) to ensure that a proper review is conducted.Otherwise, the final decision will be upheld.






Contents

Chapter VMember Eligibility

Client Eligibility .................................................................... 1

Eligibility Date and Effective Date ........................................ 2

Eligibility Verification ............................................................ 3

Steps to Determine Eligibility ............................................... 3

Medicaid Identification Form 3087 ....................................... 4

Texas Health Network ID Card ............................................. 4

Member Rights ..................................................................... 5

Change of PCP .................................................................... 6

Member Problem Resolution ................................................ 7

Member Complaints ............................................................. 7

Member Complaint Policy .................................................... 8

Member Complaint Procedures ............................................ 8

Member Satisfaction Committee Meeting Protocol ............... 9

Member Fair Hearing Request ........................................... 10

Member Responsibilities .................................................... 10

Member Education Services .............................................. 11

Cultural Competency and Sensitivity ................................. 12

Linguistic Services ............................................................. 13

Limited English Proficiency (LEP) ...................................... 13

Texas Health Network Provider Policies and Procedures Manual V-1BDHMC

MEMBERELIGIBILITY

Overview

The Texas Department of Human Services is responsible for determining a client’sMedicaid eligiblity. The enrollment broker identifies Medicaid clients who areeligible for or are required to enroll in the Texas STAR Program and assiststhese clients in the selection of a health plan. A client who chooses or is assignedto the Texas Health Network becomes a member of the plan and selects a PCPto manage his or her medical care. A member is responsible for calling his or herPCP for all non-emergency care.

Client Eligibility

The Texas Department of Health has targeted the following client groups in the Texas Medicaidpopulation in designated counties as eligible members of the Texas STAR Program:

• Individuals receiving TANF benefits.

• Individuals receiving TANF-related benefits.

• Individuals receiving Blind and Disabled benefits who live in the community (residingin any Texas STAR Program county except Harris County).

The TANF and TANF-related client groups are composed primarily of women and theirdependent children under the age of 21. These groups comprise nearly 70 percent of theentire Medicaid population. Program goals will best be achieved by improving the health caredelivery system for clients in the TANF and TANF-related groups. Eligible clients in the TANFand TANF-related groups must enroll in one of the Medicaid Managed Care Plans.



Texas Health Network Provider Policies and Procedures ManualV-2 BDHMC

Eligibility Date and Effective Date

Texas STAR Program and STAR+PLUS Program eligibilities are not retroactive except forsome pregnant (TP40) members. Benefits under the STAR Program begin on the first day ofthe next month following selection of a PCP and plan (dual eligible members in STAR+PLUSdo not choose a PCP). For example, a client who has become eligible for Medicaid benefitsfor the first time, may be certified and begin to receive benefits under the Texas Medicaidprogram on the same day. If the client is also determined to be eligible for the Texas STARProgram, or STAR+PLUS Program, a second and separate enrollment process will take place.

The client will not begin to receive services under the Texas STAR or STAR+PLUS Programuntil the first day of the following month (providing enrollment takes place before the “cut-off”date for the following month). Enrollments and disenrollments become effective on the firstday of the month (see examples below).

Client Certified For Texas Medicaid January 1

Medicaid Benefits Begin January 1

Client Selects STAR or STAR+PLUS Plan and PCP January 1

STAR Program Services Begin February 1

A client who becomes Medicaid enrolled after the “cut off” date (approximately the 15th of themonth) will not be Texas STAR or STAR+PLUS enrolled nor appear on a PCP’s panel reportuntil the second month (see examples below).

Client Certified For Texas Medicaid January 1

Medicaid Benefits Begin January 1

Client Selects STAR or STAR+PLUS Plan and PCP January 20

STAR Program Services Begin March 1

In the example above, the client would have traditional Medicaid coverage until Texas STARProgram benefits begin.


Eligibility Verification

All health care providers are responsible for verifying eligibility before medical care is providedto Texas Health Network members, except in cases of emergency. In an emergency, eligibilityshould be determined as soon as possible.

Each Texas Health Network PCP receives a monthly panel report of members assigned tothem for the current month. Each member will have a Medicaid Identification Form 3087 thatindicates eligibility for Medicaid and participation in the Texas Health Network. Also, eachmember will receive a Texas Health Network Identification Card which indicates the PCPassigned.

You should ask to see the Medicaid Identification Form 3087 and the Texas Health NetworkIdentification Card when determining whether the patient is a Texas Health Network member.

The Medicaid Identification Form 3087 indicates Medicaid eligibility for the current month.There is no end date on the Texas Health Network card.

Steps to Determine Eligibility

When a patient identifies himself or herself as a Texas Health Network member, you shouldverify eligibility through one or more of the following steps:

• Request the Texas Health Network Identification Card and the Medicaid IdentificationForm 3087.

• Photocopy the patient’s eligibility identification and retain copies in his or her file.

• PCPs only—Check the current monthly panel report of patients assigned to your practiceto determine whether the patient’s name and Medicaid number appear on the list. If thepatient’s name and Medicaid number are shown, eligibility is guaranteed for that monthonly.

• If the patient does not have either form of identification:

— Inquire using TDHConnect (TexMedNet if your vendor supports eligibility inquiries)

— Call the NAIS 24-hour telephone service to confirm eligibility


AIS Phone Numbers1-800-925-91261-512-345-5949

(See the Texas Medicaid Provider Procedures Manual - AIS User’s Guide)

Medicaid Identification Form 3087

The Medicaid Identification Form 3087 verifies Medicaid eligibility. This form has been amendedby the TDHS for clients who participate in the Texas STAR Program. These changes includethe following:

• A Texas STAR Program logo has been added to the form for easy recognition.

• The name and telephone number of the plan in which theclient is enrolled is shown below the client’s name.

In addition, a watermark (an image of the State Seal) has beenadded to both traditional Medicaid and Texas STAR Program 3087forms for authentication purposes.

Texas Health Network ID Card

All Texas Health Network members are issued an identificationcard that displays the member’s name, member number, date ofbirth and enrollment date, as well as an indicator of any other insurance the member mayhave. The designated PCP name, address, and daytime phone number are also displayed.The card also lists telephone numbers of the Texas Health Network member and clinicalhelplines.

The Texas Health Network ID Card alone does not guarantee eligibility for services.

A sample of the Texas Health Network ID card is in Appendix B.


Member Rights

Members of the Texas Health Network have defined rights and responsibilities. The TexasHealth Network and Primary Care Providers share the responsibility to ensure and protectmember rights, and to assist members to understand and fulfill their responsibilities as planmembers.

A Texas Health Network member has the right to change his/her PCP or change planswithout cause at the frequencies below:

• PCP change—four times annually

• Plan change—monthly

A member may change PCPs more often with cause (e.g., the member has moved and theprovider is no longer easily accessible).

A Texas Health Network member also has the right to:

• Select a PCP from the Texas Health Network Directory to provide his or her “medicalhome”.

• Have privacy and be treated with respect and dignity.

• Be informed of the name, qualifications, and title of any Texas Health Network provider.

• Be informed in advance and in writing of any change in the benefits of the Texas HealthNetwork.

• Know the cost of any service before that service is provided, especially if it is not acovered service. Further information and prohibitions on charges to members for servicesis outlined in Chapter III of this Manual and in the Texas Medicaid Provider ProceduresManual.

• Refuse any part of the treatment plan proposed by his or her PCP.

• Change his or her PCP, as described below.

• Disenroll from the Texas Health Network and select another health plan.

• Notify the Texas Health Network Member Services Helpline and/or the TDH StateMedicaid Program of any concern or complaint about the health care or personaltreatment he or she has received, including issues related to access, availability, quality,or appropriateness of services.

• Be provided with interpretive services if he or she has limited English proficiency.

• Texas Health Network members may also seek direct services of any Medicaid enrolledOB/GYN who is not their PCP.




Change of PCP

A member may request a change of PCP from the Texas Health Network without cause up tofour times in any enrollment year. In addition, a member may request a change for any of thesereasons:

• The member is dissatisfied with the care or treatment they have received.

• The member’s condition or illness would be better treated by another provider type.

• The member’s new address is no longer convenient to the PCP’s location.

• The provider leaves the program (e.g. moves, no longer accepts Medicaid, is removedfrom Medicaid enrollment, or is deceased).

• The member/provider relationship is not mutually agreeable.

A member may be reassigned to another PCP for any of these reasons:

• The member is not included in PCP’s scope of practice.

• The PCP requests that the member be reassigned due to noncompliance with medicaladvice or unacceptable office decorum.

• The PCP is no longer a Texas Health Network provider.

• The PCP exhibits a documented pattern of unacceptable quality of care.

• The PCP is sanctioned by the Texas Health Network.

• The PCP inappropriately limits the member’s access to covered specialty services.

• The member/PCP relationship is not mutually agreeable.

Member and PCP requests for PCP changes received prior to the middle of the month usuallybecome effective on the first day of the following month.

PCP and member requests for PCP changes received after the middle of the month usuallybecome effective on the first day of the second month following the request, as shown below:

Request Receipt Date: Change Effective Date:On or before mid-May June 1After mid-May July 1

The enrollment broker, MAXIMUS Corporation, is responsible for documenting these changes.


Member Problem Resolution

The relationship between a member and his or her PCP may become unsatisfactory to one orboth parties. The PCP or the member should contact the Texas Health Network MemberServices Helpline or write to request assistance in resolving the situation.

The Texas Health Network will initiate one or more of the following steps:

• Contact the member and the provider to assess the situation and provide educationalinformation that may clarify the situation, if applicable.

• Reassign the member to another PCP.

• Refer the situation to the Complaint/Appeal Resolution Team, if applicable (See below).

• Begin complaint/grievance resolution.

• Refer the situation to the Member Outreach Staff for education or to help clarify thesituation.

Member Complaints

A complaint is any dissatisfaction, expressed orally or in writing to the Texas Health Network,with any aspect of the Texas Health Network’s operation, including but not limited todissatisfaction with plan administration, the way a service is provided, an action taken by theTexas Health Network; appeal of an adverse determination, or disenrollment decisions.

A complaint is not (1) a misunderstanding or misinformation that is resolved promptly bysupplying the appropriate information or clearing up the misunderstanding to the satisfactionof the member or (2) a request for a fair hearing to the TDH.

The Texas Health Network provides for due process in resolving member complaints. Themember complaints process and Texas Health Network member rights are described below.

A Texas Health Network member has the right to access the TexasDepartment of Health Fair Hearing Process at any time.

Procedures governing the member complaints process are designed to identify and resolvemember complaints in a timely and satisfactory manner. If a member participates in the FairHearing Process, the TDH Hearing Officer’s decision supersedes the decision of the TexasHealth Network’s Complaint/Appeal Resolution Team. The Texas Health Network does notparticipate directly in the TDH Fair Hearing process, but may be asked to submit informationrelevant to the process.







Member Complaint Policy

The Texas Health Network’s Member Services Department takes seriously and acts on eachmember complaint, whether it is informal, formal, oral, or filed in writing. Depending on thelevel and nature of the complaint, the Texas Health Network Member Services Departmentworks with the member to resolve the issue or directs the complaint to the appropriate TexasHealth Network department:

• Provider/Member Services Division—Complaints that concern the relationshipbetween a member and a PCP or the PCP’s office staff.

• Health Services Division—Complaints that relate to utilization of services (includingemergency room use), denial of continued stay, response to FirstHelp™, and all otherclinical and access issues. This includes a member’s appeal of an adverseprecertification decision.

• Texas Health Network Administration—Complaints that concern the relationshipbetween a member and any Texas Health Network staff person or complaints aboutoverall plan management.

Upon completion or resolution of a complaint, the department processing the complaint refersthe complaint and its resolution to the Complaint/Appeal Resolution Team for membernotification and tracking. If the complaint relates to a medical issue, the Health Services staffmay assist in the notification of members. This process applies only to the resolution of disputeswithin the control of Texas Health Network, such as administrative or medical issues.

The member complaint process does not apply to allegations of negligence against third parties,including participating providers. These complaints are referred to the TDH for review andevaluation, and are resolved by the TDH staff with support from staff at the Texas Health Network.

Member Complaint Procedures

All member complaints are handled by the Member Services Department. The processing ofmember complaints is described below:

• The member can call the Member Helpline at 1-888-302-6688 or write a letter to theTexas Health Network to file a complaint.

— Referrals to other departments, such as Provider/Member Services or Health Ser-vices, are made as appropriate.




— Complaints dealing with the quality of, access to, or continuity of care are referred toPCP Contract Compliance for follow-up and inclusion in the provider file.

• If the complaint cannot be resolved within 10 working days, the member is notified inwriting or by phone of the status of the complaint. All complaints are resolved within 30days.

• If the member wishes, he or she may ask to speak directly with a Texas Health NetworkMember Services Manager. He or she is told, however, that all medical and quality-of-care complaints are first reviewed by the Medical Director.

• If the member is still not satisfied and the issue not resolved, or if the member does notagree with the decision of the Texas Health Network Member Services Manager or theMedical Director, the Member Satisfaction Committee is convened.

At any time, the member may request a Fair Hearing with the TDH Client Resolution Servicesby calling the Medicaid Hotline at 1-800-252-8263. A hearing officer, not involved in the casewill listen to the complaint and ensure that the member is treated fairly. The hearing officerreviews the case, conducts a fair hearing, and notifies the member of the decision within 90days from the date the member requests a fair hearing.

Member Satisfaction Committee Meeting Protocol

Member Satisfaction Committee meetings are conducted as informally as possible. Theemphasis is placed on an exchange of information:

• Prior to any discussion of the complaint, the chairperson, e.g., the Texas Health NetworkMember Services Manager, shall:

— Advise all parties present that the Committee has no authority to take action onissues involving possible professional liability issues, nor to resolve complaints inany manner or prescribe any actions that are in conflict with the laws or rules ofgovernment entities with jurisdiction over the Texas Health Network, or with writtenpolicies of the Texas Health Network.

— The Committee hears these complaints for the purpose of providing recommenda-tions to the TDH.

• The complainant or designee is given a maximum of 30 minutes for his or her presentationand is advised that during this time, the Committee may ask questions to understand,clarify, and evaluate the complaint.

• The Texas Health Network is given a maximum of 30 minutes for its presentation. ThePlan representative is also questioned by the Committee if clarification is required.

• All Committee action is by a majority vote, if a quorum of at least five members is present.




• Failure to obtain such a majority vote constitutes a denial of the complaint.

The Member Satisfaction Committee meets quarterly, and more frequently if needed. MemberSatisfaction Committee minutes become part of the documentation that is attached to theMember Complaint Form in the formal complaint review file:

• Complaint files are maintained until the complaint is resolved and for the period of thecontract and 36 months thereafter.

• The record is made available for inspection by the TDH and other regulatory agencies,as required by law.

• Records are coded to protect the member’s confidentiality, and a single record of themember’s names, ID, and identifying codes are maintained in a locked file.

Within 10 working days of the Member Satisfaction Committee meeting, a written decision issent to the member by certified mail. All complaints are acted upon 60 days from the originalfiling for services provided within the Texas Health Network service area. Complaints receivedfrom providers outside the Texas Health Network service area are resolved within 90 days.

Member Fair Hearing Request

If a member wishes to pursue a complaint beyond the processes described above, he or shecan file a formal complaint against the Texas Health Network. The complaint must be specificand include the determinations made by the Member Complaint Committee. The formalcomplaint will be submitted to the TDH for action. In addition to, or in lieu of, the Texas HealthNetwork’s complaint protocols, members have the right to request a Fair Hearing from theTDH Client Resolution Services by calling the Medicaid Hotline at 1-800-252-8263.

Member Responsibilities

Both the Texas Health Network and PCPs should help Texas Health Network membersunderstand their responsibilities. These include the responsibility to:

• Seek medical care first from his or her PCP, except for emergencies and otherself-referred services

• Provide an accurate and complete personal medical history

• Identify himself or herself as a member of the Texas Health Network when requestingmedical services

• Call the PCP for an appointment before arriving at the office to receive care





• Be on time for appointments

• Call and notify the PCP as soon as possible if he or she will be late for an appointment,or if an appointment must be rescheduled

• Make certain the services requested or recommended are covered by the Texas HealthNetwork and are approved before they are received

• Pay for any non-covered service if he or she has been notified in advance that theservice is not a covered benefit and he or she has signed an acknowledgment form

• Participate in decisions concerning his or her health care and follow the PCP’s medicaladvice

Member Education Services

The Texas Health Network makes important educational services available to its members.The most significant of these are two Helplines:

• FirstHelpTM is a clinical helpline (1-800-304-5468) available 24 hours a day, 7 days aweek, to Texas Health Network members.

• A non-clinical Member Helpline (1-888-302-6688) is also available to Texas HealthNetwork members. This helpline also operates 24 hours a day, 7 days a week, to providemembers with information. The purposes of this helpline are to respond to members’non-clinical questions and concerns, and provide information on how to access healthcare services appropriately. This number is also used to request PCP changes and toregister complaints and grievances.

The Texas Health Network also identifies the health education needs of members and tailorshealth education programs to meet those needs. Health education needs are identified through:

• Member and provider surveys

• Claims records for members who have not sought or complied with treatment

• Medical record reviews of health education activities and unmet health education needs


All health education initiatives include a systematic feedback method for assessing the impactof the initiative. Priority health education efforts address these topics:

• Reducing emergency room visits

• Increasing THSteps screening

• Reducing inappropriate specialty referrals

• Increasing family planning visits

In addition, the Texas Health Network publishes a quarterly newsletter in both English andSpanish for member heads of household. The focus of the newsletter is health-related (suchas dates of upcoming health fairs, the importance of well child care, and the significance ofearly entry into prenatal care), but it also provides useful information about services to improvemembers’ access to health care, such as non-emergent medical transportation, communitychild care resources, and clinical services offered during nontraditional hours of operation.

The Texas Health Network also offers a variety of classes designed to fit the needs of itsmembers. These include classes on self-esteem, prenatal education, HIV, parenting programs,new parent classes, first aid, nutrition, survival skills, self care and wellness education. One-on-one classes are available if needed. The Member Services Department OutreachRepresentatives work with Texas Health Network Health Educators and Wellness Coordinatorsby holding orientations in and around the communities to meet and educate Texas HealthNetwork members.

The Texas Health Network also provides a number of educational and support services toensure that members eligible for THSteps receive all appropriate screening and follow-updiagnosis and treatment services. More information on THSteps is provided in Chapter VIII ofthis manual.

Cultural Competency and Sensitivity

The Texas Health Network values the diversity of the Texas Medicaid population and hasprograms to support multicultural plan membership.

All member materials are written at an appropriate reading level, and printed in both Englishand Spanish. Helplines are staffed by Spanish as well as English-speaking customer servicerepresentatives who, at any time, may access the AT&T multi-language translation service forassistance.

Provider Newsletters and educational workshops include topics that focus on cultural sensitivityand the need for culturally competent staff in PCP offices. Providers are expected to complywith the laws concerning discrimination on the basis of race, color, national origin, or sex (seebelow).


The Texas Health Network staff is culturally diverse, multilingual, and sensitive to the diverseneeds of Texas Medicaid clients.

Linguistic Services

Although it is the provider’s responsibility to ensure that interpretive services are available tohis/her practice, as a Texas Health Network provider you may receive assistance to arrangefor these services for Texas Health Network members. Interpretive services include languageinterpreters, American Sign language interpreters and TDD access. When interpretive servicesare necessary to ensure effective communications regarding treatment, medical history orhealth education you may contact the Texas Health Network Member Helpline at1-800-302-6688. For assistance to members who are hearing impaired, call RELAY TEXAS(TDD) at 1-800-735-2988. If your staff is in need of translation services to meet the Office ofCivil Rights (OCR) requirements on Limited English Proficiency (LEP), you may contact AT&Tat 1-800-752-0093.

Limited English Proficiency (LEP)

Texas Health Network providers are required to provide services in the languages of the majorMedicaid population groups they serve, and to ensure quality appropriate translations. Title VI,section 601, of the Civil Rights Act of 1964 states that “no person in the United States shall onthe basis of race, color, or national origin, be excluded from participating in, be denied thebenefits of, or be subjected to discrimination under any program or activity receiving Federalfinancial assistance.”

The Texas Department of Health and Human Services Office of Civil Rights (OCR) viewsinadequate interpretation as a form of discrimination, and has issued a guidance memorandumon non-discrimination of persons with Limited English Proficiency (LEP).

In accordance with the memorandum, the Texas Health Network requires its providers toimplement policies and procedures that ensure LEP persons’ equal access to the medicalservices to which they are legally entitled.

Meeting the requirements of Title VI may require the PCP to take all or some of the followingsteps at no cost or additional burden to the LEP beneficiary:

• Have a procedure for identifying the language needs of patients/clients.

• Have access to proficient interpreters during hours of operation.

• Develop written policies and procedures regarding interpreter services.

• Disseminate interpreter policies and procedures to staff and ensure staff awareness ofthese policies and procedures and of their Title VI obligations to LEP persons.


In order to meet his or her interpretation requirements, a PCP may choose to incorporate intotheir business practice any of the following (or equally effective) procedures:

• Hire bilingual staff

• Hire staff interpreters

• Use volunteer staff interpreters

• Arrange for the services of volunteer community interpreters (excluding the member’sfamily or friends)

• Contract with an outside interpreter service

• Use a telephone interpreter service such as the AT&T Language Line

• Develop a notification and outreach plan for LEP beneficiaries.

Complaints and reports of non-compliance with Title VI regulations are handled by the OCR.

Additional information, including the complete guidance memorandum on non-discriminationof persons with limited English proficiency issued by the OCR, can be found on the Internet atwww.hhs.gov/progorg/ocr/lepfinal.htm.

If your staff is in need of translation services to meet the OCR’s requirements on LEP, you maycontact AT&T at 1-800-752-0093. If a Texas Health Network member is in immediate need oflinguistic services, please call the Member Helpline at 1-888-302-6688.

Contents

Chapter VIReimbursement andClaims Submission

Medicaid Reimbursement Policy .......................................... 1

PCP Reimbursement ........................................................... 2

THSteps and Family Planning Services ............................... 3

Specialists ............................................................................ 3

Hospitals .............................................................................. 4

Claims Submission Details .................................................. 7

Remittance and Status Report ............................................. 7

TexMedNet Electronic Claims Submission .......................... 8

Provider Certification of Compliance .................................... 8

Billing Members ................................................................... 9

Specified Billing Circumstances........................................... 9

Provider Appeals ................................................................ 10

Texas Health Network Claims Processing Support ............ 10

Texas Health Network Provider Policies and Procedures Manual VI-1BDHMC

REIMBURSEMENT ANDCLAIMS SUBMISSION

Overview

BDHMC is responsible for communicating Texas Health Network reimbursementpolicies and procedures for submitting claims. This chapter provides informationon reimbursement for PCPs, THSteps and Family Planning Providers,Specialists, and In-Network and Out-of-Network Hospitals. It also provides basicinformation on claims submission, remittance and status reports, providercertifications of compliance with various State and Federal laws and regulations,and the limited circumstances under which a provider may bill for services.

Note: The claims administrator, NHIC, processes and adjudicates all claims.Medicaid claims submission requirements specified in the Texas MedicaidProvider Procedures Manual apply to Texas Health Network claims.

Medicaid Reimbursement Policy

The Medicaid policy governing reimbursement for services rendered to Medicaid clients doesnot change for Texas Health Network services. Reimbursement is made by the claimsadministrator (NHIC) in accordance with the limitations and procedures of the Texas MedicaidProgram, the TDH, and the Texas Health Network. Providers who receive payment for servicesagree that the endorsement or deposit of an NHIC check is the acceptance of money fromFederal and State funds and that any falsification or concealment of a material fact related topayment may be grounds for prosecution under Federal and State laws.

Texas Health Network payments are never made directly to members. Texas Health Networkmembers should not be billed for any services rendered unless the provider has obtained asigned Member Acknowledgment Statement or Private Pay Agreement (please refer to pagesIII-15 and III-16 for information on the appropriate use of these forms). Providers are responsiblefor providing blank forms for use within their medical practice.

There is no co-payment for Texas Health Network members.








Texas Health Network Provider Policies and Procedures ManualVI-2 BDHMC

PCP Reimbursement

PCPs receive Medicaid fee-for-service payments for care they provide to Texas Health Networkmembers, in addition to a case management fee.

The fee-for-service reimbursement for the Texas Health Network is based on the Texas MedicaidReimbursement Methodology (TMRM) structure.

Case Management Fee

The case management fee is compensation for managing the medical care of Texas HealthNetwork members who have either selected or been assigned to the PCP's practice as their"medical home":

• The fee is $3.00 per member per month.

• It is paid to the PCP in a separate check no later than the tenth State working day ofeach month. Checks are issued by the claims administrator, NHIC.

• It is based on the total number of Texas Health Network members on the PCP’s monthlymember panel report for each month.

• The number of members actually seen during the month does not impact the total monthlycase management payment.

To facilitate administrative management in PCP offices, two monthly PCP reports are created.The member panel report lists the Texas Health Network members who have selected or whohave been assigned to each PCP's practice. BDHMC provides this report in hard copy at thebeginning of each month. The second report, a case management summary, is produced byNHIC and accompanies the case management check.

If there are any discrepancies in either report, contact your Texas Health Network ProviderRelations Representative. Please call the Provider Helpline prior to returning a check; thisallows the Texas Health Network to do necessary research and provide assistance.

Texas Health Network Provider Helpline1-888-834-7226





THSteps and Family Planning Services

THSteps and family planning services will continue to be reimbursed at their current rates. If aprovider other than the member's PCP furnishes THSteps and/or family planning services to aTexas Health Network member, he or she should contact the PCP listed on the client's TexasHealth Network Identification Card to:

• Discuss the patient’s general health

• Share information about the services furnished

• Discuss the nature and results of tests performed

• Review any recommendations for follow-up care

Communication between and among providers is essential to maintain continuity of care forthe patient and to ensure that the patient's medical record in the PCP's office is complete.

Specialists

Specialty care providers may bill for health care services furnished to Texas Health Networkmembers if the patient was referred by the member's PCP. Reimbursement for specialists isbased on the current Medicaid fee-for-service rates. The PCP's name and Medicaid providernumber must be shown in the referring physician field of the electronic submission (Boxes 17and 17A on the HCFA-1500 claim form), indicating referral from the PCP.

The following programs are exempt from the referral requirement:

• THSteps (medical screenings and dental services)

• Family Planning

• Case Management for High-Risk Pregnant Women and Infants (PWI) and EarlyChildhood Intervention (ECI) services

• School Health and Related Services (SHARS)

• Behavioral Health Services provided by psychiatrists, psychologists, LMSW-ACPs, andLPCs

• Mental health case management, case management for mental retardation diagnosisand assessment services, and mental health rehabilitative services provided throughMHMR



• Routine Vision Services

• School-based Clinic Services

• Emergency Services

Hospitals

Network Hospitals—A network hospital participating in the Texas Health Network is a hospitalthat has a contract with the TDH and receives reimbursement, as specified in the contract, forservices provided to Texas Health Network members. Individual reimbursement arrangementsare negotiated by the TDH or its designated representative with each contracted hospital.

All services, including inpatient services, provided to Texas Health Network members receivingSSI benefits are reimbursed at the traditional fee-for-service Medicaid rate.

Out-of-Network Hospitals—An out-of-network hospital is one that does not have a contractwith the Texas Health Network.

• Out-of-network hospitals are reimbursed only for inpatient services provided to TexasHealth Network members as the result of an emergency admission, and then, only untilthe patient is stabilized.

• Reimbursement for emergency treatment will be made at the current Medicaid rates.

Hospitals that are not contracted with the Texas Health Network but are contracted with theLone Star Select Program are reimbursed under the selective contracting method.

After a patient in an out-of-network hospital is stabilized, additional services are considerednon-covered benefits. The out-of-network hospital may, however, request an exception to thestabilization policy by contacting the Texas Health Network Utilization Management Departmentat 1-888-302-6167:

• The hospital must state the circumstances surrounding the emergency admission andprovide an estimate of the additional number of days required until the patient isdischarged.

• The Texas Health Network grants exceptions based on the information provided by thenon-contracted hospital and issues a precertification for billing purposes if an exceptionis granted.

• Although in some cases, the Texas Health Network Utilization Management Departmentmay require additional time to review the circumstances of the request for exception, itnormally reviews the request and contacts the out-of-network hospital within 36 hoursof its request. The UM Department will either provide the non-contracted hospital with aprecertification or deny the exception request.


• Should a stabilization exception be denied, any inpatient services provided to the TexasHealth Network member at the out-of-network hospital will cease to be a covered benefit24 hours after notification to the hospital.

Non-emergency inpatient admissions are not a covered benefit at out-of-network hospitals.Non-emergency inpatient admissions are considered for reimbursement only if a Texas HealthNetwork member would experience an undue burden traveling to a contracted hospital. In thiscase, a "hardship exemption" may be granted. This exemption permits reimbursement of anon-emergency admission at an out-of-network hospital.

To obtain a hardship exemption, the attending Physician or designee must contact the TexasHealth Network Utilization Management Department at 1-888-302-6167 before anynon-emergency admission to an out-of-network hospital and provide details to substantiatewhy the member would experience an undue burden traveling to a network hospital.

If the details substantiate undue burden, the Utilization Management Department will grantthe exemption and issue a precertification. The physician can then admit the patient to the out-of-network hospital.

NOTE: Under no circumstances will authorization for an undue travel burden be granted aftera patient has been admitted for a non-emergency condition to an out-of-network hospital.

NOTE: Network and out-of-network hospitals are not eligible for an annual costsettlement for services provided to Texas Health Network members.

Fees for Network Hospitals

Emergency Services

Contracted, network hospitals are eligible to bill for any services required in the medicalscreening examination and stabilization of a Texas Health Network member. All services mustbe supported by the clinical record.

If the medical screening examination indicates a non-emergent or urgent condition, thehospital's emergency room should notify the patient’s PCP for follow-up on his or her members.

When treatment is provided to a Texas Health Network member, "professional" and "facility”services must be billed separately.

Reimbursement of emergency facility and ancillary charges for diagnostic tests, monitoring,and treatment is based on the actual services rendered. The hospital is paid at its currentMedicaid reimbursement rate.


Emergency Admissions—Inpatient

If an emergent admission is necessary, the Texas Health Network Utilization ManagementDepartment should be contacted by the hospital within 24 hours or on the next business dayafter the emergency has occurred. Failure to notify the Utilization Management Department ofthe admission will result in denial for non-notification. Inpatient services for out-of-networkhospitals will be reimbursed at the DRG rate paid by the traditional Texas Medicaid Program.

All inpatient services will be subject to concurrent review and retrospective review forappropriateness of services and level of care provided.

Notification of emergency admissions can be telephoned or faxed to:

Texas Health Network Utilization Management Helpline1-888-302-6167

Fax: 1-512-302-5039

Emergency Outpatient Services

If the member presents at a hospital emergency outpatient facility, the physician should providethe medically necessary medical screening examination and stabilization services immediately,and the member should be referred back to the PCP for follow-up care. Reimbursement foremergency outpatient services requires that the medical record document the medicallynecessary services.

The hospital must contact the Texas Health Network Utilization Management Department andthe member's PCP within 24 hours or by the next business day to advise that emergencytreatment has been provided. Reimbursement in cases of emergency treatment will be basedon the actual services rendered. The hospital will be reimbursed at its current Medicaidreimbursement rate.

Non-Emergency Admissions for Inpatient Services

Out-of-network hospitals are reimbursed only if precertification has been obtained through theUtilization Management Department prior to any non-emergent care being provided to a TexasHealth Network member:

• Inpatient services are reimbursed at the DRG rate paid by the traditional Texas MedicaidProgram.

• All inpatient services are subject to retrospective review for appropriateness of servicesand level of care provided.


Non-Emergency Outpatient Clinic Services

All hospitals are reimbursed for outpatient clinic services at their current Medicaid outpatientreimbursement rate.

All services must be authorized by the member's PCP or the Texas Health Network UtilizationManagement Department and will be subject to retrospective review for appropriateness ofservices and level of care provided. Reimbursement for non-emergency services will beconsidered only when authorization has been received from the Utilization ManagementDepartment or the PCP before treatment is provided.

A referral from a PCP or precertification by the Utilization Management Department is requiredbefore an out-of-network provider can render care and can receive reimbursement for servicesother than "Freedom-of-Choice Services" (For a list of these see Chapter I).

Claims Submission Details

All claims for services provided to Texas Health Network members must be submitted to NHICat the claims addresses listed in the Texas Medicaid Provider Procedures Manual.

If the provider of the services is not the member's assigned PCP, the PCP's name and Medicaidprovider number must be entered in the referring provider field of your electronic claimsubmission (boxes 17 and 17A on the HCFA-1500) indicating a referral from the PCP.

If this information is missing or if the treating provider is not the assigned PCP on the date ofservice, the claim will be denied.

For services requiring precertification, enter the precertification number in the prior authorizationfield. It is not necessary to send the Precertification Request Form with the claims submission.

Remittance and Status Report

Each check issued by NHIC for Texas Health Network members will be mailed with a TexasHealth Network Remittance and Status (R&S) Report:

• The Texas Health Network R&S Report provides the same information as the MedicaidR&S Report. (Refer to the Texas Medicaid Provider Procedures Manual for informationon the R&S Report.)

• The Texas Health Network R&S Report has the Texas STAR Program logo in the upperleft hand corner to differentiate it from the traditional Medicaid R&S.





TexMedNet Electronic Claims Submission

Providers who currently have TexMedNet filing capability for the traditional Texas MedicaidProgram may continue to submit claims to NHIC through the same means, i.e., current softwareor vendor.

Providers who currently do not file electronically but are interested in more information aboutelectronic filing should contact their NHIC Provider Relations Representative or the TexMedNetHelp Desk at NHIC for assistance with technical consultation services and software installationat 1-888-863-3638.

These services are available at no charge to the provider.

Provider Certification of Compliance

Providers who submit claims for services to Texas Health Network members are required tocertify compliance with various provisions of State and Federal laws and regulations.

By submitting a claim, the provider certifies that:

• Services were personally rendered by the billing provider or under the personalsupervision of the billing provider.

• The information contained on the claim is true, accurate, and complete.

• All services, supplies, or items billed were medically necessary for the diagnosis and/or treatment of the patient, with the exception of routine check-ups.

• Medical records document all services that have been billed.

• Billed charges are usual and customary and are not higher than the fees charged toprivate-pay patients.

• Services were provided without regard to race, color, sex, national origin, age orhandicap.

The provider of medical care and services agrees to accept Medicaid reimbursement aspayment in full for services covered under the Texas Health Network.

Furthermore, the provider understands that endorsing or depositing a Medicaid check isaccepting money from Federal and State funds and that any falsification or concealment ofmaterial fact related to payment may be grounds for prosecution under Federal and Statelaws.





Billing Members

Before rendering services, providers should always inform members that the cost of servicesnot covered by the Texas Medicaid Program will be charged to the member.

A provider who elects to furnish services not covered by the Texas Health Network, includingservices that have been determined as not medically necessary, must:

• Understand that Texas Health Network reimburses only for services that are medicallynecessary or are benefits of special preventive and screening programs such as familyplanning and THSteps (EPSDT).

• Obtain the member's signature on the Member Acknowledgment Statement or the PrivatePay Agreement specifying that the member will be held responsible for payment ofservices (please refer to pages III-15 and III-16 for information on the appropriate use ofthese forms).

• Understand that all services, including hospital admissions, that are denied by the TexasHealth Network as not medically necessary are included in this policy.

A provider may not bill for, or take recourse against, a member for denied or reduced claims forservices that are within the amount, duration, and scope of benefits of the Medicaid program.

Texas Health Network members, or others on their behalf, must not be “balance-billed” for theamount above that which is paid by the Texas Health Network for covered services.

Specified Billing Circumstances

Your provider contract states that you may not bill a member in any of the followingcircumstances:

• Failure to submit a claim, including claims not received by NHIC.

• Failure to submit a claim to NHIC for initial processing within the 95-day filing deadline.

• Failure to appeal a claim within the 180-day appeal period.

• Failure to submit a claim to NHIC within 95 days of denial by Title XX for Family Planningservices.

• Submission of an unsigned or otherwise incomplete claim, such as the omission of theHysterectomy Acknowledgement Statement or Sterilization Consent Form with claimsfor these procedures. Refer to the Physician Section of the Texas Medicaid ProviderProcedures Manual for more information.







• Errors made in claims preparation, claims submission, or the appeal process.

• Failure to obtain a signed Member Acknowledgment Statement or Private PayAgreement.

A provider attempting to bill or recover money from a member in violationof the above conditions may be subject to exclusion from the Texas HealthNetwork and the Texas Medicaid Program.

Provider Appeals

Providers appealing a claim for services to a Texas Health Network member must follow theprocedures in the Appeals Section of the Texas Medicaid Provider Procedures Manual.

Texas Health Network Claims Processing Support

You may call the Texas Health Network's Provider Helpline (1-888-TDH-PCCM) for informationon the status of your claim. Provider Helpline Agents have access to the NHIC paid and pendingclaims files, which enables them to answer your questions concerning Texas Health Networkclaims.


Contents

Chapter VIIMember Enrollmentand Disenrollment

Member Enrollment .............................................................. 1

Clients Not Eligible for Texas STAR Program Enrollment..... 3

Newborns ............................................................................. 4

Member Disenrollment ......................................................... 4

STAR+PLUS Demonstration Pilot ........................................ 6

Mandatory Enrollment .......................................................... 6

Ineligible Clients................................................................... 7

Texas Health Network Provider Policies and Procedures Manual VII-1BDHMC

MEMBER ENROLLMENTAND DISENROLLMENT

Overview

The enrollment broker, MAXIMUS Corporation, identifies Medicaid clients whoare eligible for or are required to enroll in the Texas STAR Program and assiststhese clients in the selection of a health plan. A client who chooses or is assignedto the Texas Health Network becomes a member of the plan and selects a PCPto manage his or her medical care.

Member Enrollment

The TDH has targeted the following client groups in the Texas Medicaid population in designatedcounties as eligible members of the Texas STAR Program:

• Individuals receiving TANF benefits.

• Individuals receiving TANF-related benefits.

• Individuals receiving Blind and Disabled benefits living in the community (residing inany Texas STAR Program county except Harris County).

The TANF and TANF-related client groups are composed primarily of women and theirdependent children under the age of 21. These groups comprise almost 70% of the entireMedicaid population.

Program goals will best be achieved by improving the health care delivery system for clientsin the TANF and TANF-related groups.

Eligible clients in the TANF and TANF-related groups must enroll in one of the Medicaidmanaged care plans.


Texas Health Network Provider Policies and Procedures ManualVII-2 BDHMC

The third group, the blind and disabled, may choose to enroll in the Texas STAR Program buttheir enrollment is not required.

Beginning December 1, 1997, aged, blind, and disabled clients residing in HarrisCounty were required to enroll in a new Medicaid managed care demonstrationpilot known as STAR+PLUS. See page VII-6 of this chapter for additionalinformation on the STAR+PLUS Program.

TABLE 7-1

MEDICAID PROGRAM TYPES:MANDATORY ENROLLMENT IN MANAGED CARE

ProgramCode

Program Type

01 Regular TANF03 TANF grant below $1007 12 month Medicaid - TANF denied due to earnings20 4 month Medicaid - TANF denied due to child’s earnings37 12 month Medicaid - TANF denied due to eligible income—disre-

gards ending40 Pregnant women at 185% of poverty level43 Children under age 1 at 185% of poverty level44 Children age 6 or older born on or after 10-01-83 at 120% of pov-

erty level45 Newborns of Medicaid-eligible mothers46 Children under age 18 (or 19) born before 10-01-83 at 120% of

poverty level47 Medicaid for deprived children with stepparent or grandparent48 Children under the age of 6 at 133% of poverty level61 TANF-up63 TANF-up grant less than $1064 Extended Medicaid for TANF-up

NOTE: Only clients in the above programs and with CATEGORY CODE 02shown on their Medicaid Identification Form 3087 are required to enroll in theSTAR Program.


TABLE 7-2

MEDICAID PROGRAM TYPES:VOLUNTARY ENROLLMENT IN MANAGED CARE

Clients Not Eligible for Texas STAR Program Enrollment

Texas Medicaid clients who are excluded from the Texas STAR Program are those who:

• Have Medicare eligibility (except for clients residing in Harris County).

• Are residing in a nursing facility, intermediate care facility, or MR facility (except forthose residing in Harris County).

• Would have to travel more than 30 miles, or 45 minutes, to obtain services.

• Have an eligibility period that is retroactive only.

• Are eligible through the Medically Needy Program.

• Live in an area excluded from the Texas STAR Program service area.

• Are refugees.

• Are foster children.

NOTE: The PCP is responsible for coordinating care for children placed in the conservatorshipof the Texas Department of Protective and Regulatory Services (TDPRS) until the child isplaced in foster care and is no longer eligible for Texas STAR Program enrollment.

03 TANF grant below $1012 SSI13 SSI14 SSI18 Disabled19 Disabled under 18 years of age22 Disabled from age 60-6551 Medical assistance only, State paid

NOTE: Clients in the above programs, and with CATEGORY CODE 03 or04 and Base Plan 13 shown on their Medicaid Identification Form 3087who reside in a county other than Harris County are eligible for the STARProgram and may choose whether to participate. See page VII-7 forinformation on clients residing in Harris County.

ProgramCodes

Program Types



Newborns

Newborns are the only exception to plan enrollment policy.

Newborns are eligible for Texas STAR Program benefits from the date of birth (DOB), if thebaby is born to a mother who is enrolled in the Texas STAR Program and the baby is Medicaideligible at the time of the birth. The baby will be enrolled in the same plan as the mother at thetime of birth.

As with the traditional Medicaid Program, there may be a delay of up to several months fromthe DOB for a newborn to receive a Medicaid client number. Until the newborn has a PCP, theTexas Health Network ID card will indicate to providers that the client is “Newborn” and instructthem to “Call Plan” to inquire about filing a claim.

PCP Instructions

If you provide care to a newborn who is eligible for the Texas Health Network based on themother’s eligibility, you should wait to submit your claim until the newborn has a Medicaidnumber. However, you may submit claims to the claims administrator (NHIC) before the babyhas an assigned PCP. Claims submitted with no Medicaid number or using the mother’sMedicaid number will be denied until the baby is assigned a Medicaid number.

Until the newborn’s PCP is chosen or assigned, claims submitted to the claims administratorshould show PCCNEWB01 as the referring provider number. Once the baby is assigned aPCP and/or a Medicaid number, normal billing and referral procedures will be in effect. Generally,the answer to the following question determines eligibility:

“Is the mother Texas Health Network eligible on the newborn’s date of birth?”

If Yes: Newborn is a Texas Health Network member as of the DOB.

If No: Newborn is regular Medicaid from DOB until enrolled in theTexas STAR Program with a plan and PCP.

Reminder: A newborn must be in a TANF or TANF-related category to be enrolled in the TexasSTAR Program at the time of birth.

Member Disenrollment

Plan Changes

Members have the right to disenroll from the Texas Health Network or any plan at any time.Members must call the enrollment broker, MAXIMUS Corporation, to initiate a plan change. Ifa plan change request is received before the 15th of the month, the plan change is effective onthe first day of the next month. If the request is received after the 15th of the month, the plan


change will be effective on the first day of the month following the next month. All plan changerequests must be processed by the enrollment broker.

Request For Disenrollment From the Texas Health Network

The Texas Health Network has a limited right to request that a member be disenrolled from theplan without the member’s consent. TDH must approve any request for such disenrollment. Allrequests must be initiated by the Texas Health Network.

In addition, providers may request that a member be disenrolled for the following reasons:

• The member loans their Texas Health Network Identification Card to another person toobtain services.

• The member continually disregards the advice of his or her PCP.

• The member repeatedly uses the emergency room inappropriately.

Any request by a provider to disenroll a member from his or her panel, must be processedthrough the Texas Health Network. The Texas Health Network requests that providers whointend to disenroll a member notify the member about the disenrollment in writing and send acopy of the notification to the Texas Health Network.

Before a request for disenrollment by either the Texas Health Network or a Texas Health Networkprovider can be initiated, reasonable measures must be taken to correct the member’s behavior.Reasonable measures may include education or counseling. The Texas Health Network mustnotify the member of its decision to disenroll the member if all attempts to remedy the situationhave failed.

The Texas Health Network must also notify the member of the availability of appeal procedures,and the TDH fair hearing process. These procedures are discussed in greater detail in ChapterV. Both provider and health plan initiated member disenrollments follow the same complaintprocedure as outlined on pages V-8, V-9.

Neither the Texas Health Network nor a Texas Health Network provider can request adisenrollment based on an adverse change in the member’s health or the utilization of serviceswhich are medically necessary for the treatment of a member’s condition.

Automatic Re-enrollment

If a client loses Medicaid eligibility and then regains eligibility within 30 days, the member isautomatically reassigned his or her previous plan and PCP.



STAR+PLUS Demonstration PilotHarris County Only

STAR+PLUS is a demonstration pilot that will integrate acute care, long term care, and primarycare into one managed care delivery system. The Texas Department of Human Services (TDHS)is the operating agency for STAR+PLUS. It is designed to improve access to care, emphasizecommunity-based care, and provide more accountability and cost control.

Mandatory Enrollment

The State has mandated that the following clients residing in Harris County enroll with aSTAR+PLUS HMO:

• SSI clients 21 and older who are living in the community.

• Clients denied SSI benefits because of cost of living adjustments, but retain theirMedicaid eligibility.

• Clients entering a Title XIX nursing facility after the date of implementation ofSTAR+PLUS.

• Clients who qualify for nursing facility care but elect to receive services in the community(community-based alternative waiver clients).

• Adults in nursing facilities who spend down to Medicaid eligibility in less than 12 monthsafter implementation of STAR+PLUS.

• Medical Assistance only clients who qualify for nursing facility level of care.

STAR+PLUS-eligible clients residing in Harris County who may choose to enroll with either aSTAR+PLUS participating HMO or the Texas Health Network are:

• SSI clients with Severe and Persistent Mental Illness (SPMI).

• SSI-eligible children under age 21.

• Children and adolescents under 21 years with serious emotional disturbances (SED)who are receiving Medicaid-funded rehabilitation services for mental illness throughthe local mental health authority (LMHA).

• ICF-MR/HCS waiting list clients (SSI clients with mental retardation who are on theTDMHMR list to be considered for the Home And Community-Based Services [HCS]waiver program.)




Clients in Harris County eligible for STAR+PLUS who may voluntarily enroll with a STAR+PLUSparticipating HMO or remain in the traditional Medicaid Program are:

• Residents of nursing facilities who are eligible for SSI/MAO.

• Residents of nursing facilities who spend down to MAO after 12 months or more in anursing facility.

Ineligible Clients

Harris County clients not eligible for Texas STAR or STAR+PLUS include those clients who:

• Participate in the CLASS (Community Living Assistance and Support Services) waiverProgram.

• Participate in the MDCP (Medically Dependent Children’s Waiver Program).

• Participate in the HCS (Home and Community Services) waiver Program.

• Participate in the HCS-OBRA (Home and Community Based Services-OBRA) waiverProgram.

• Participate in the Deaf Blind Multiple Disabled Waiver Program.

• ICF-MR residents.

• Residents of State hospitals or institutions for mental diseases.

• Frail Elderly (or 1929B) Program recipients.

• Recipients of non-Title XIX - funded long term care (LTC) services, and recipients ofIn-Home and Family Support Program Services.

• Qualified Medicare Beneficiaries.

• Undocumented aliens.

• Foster children.

• Clients eligible for Medicaid through the Medically Needy Program.

Contents

Chapter VIIITexas Health Steps

Objectives and Outreach ...................................................... 1

Initial Screening ................................................................... 2

Periodic Screening Exams ................................................... 3

Member Eligibility ................................................................. 3

THSteps Screening Protocol ................................................ 4

Immunizations ...................................................................... 4

Exceptions to Periodicity ...................................................... 5

Adolescent Preventive Visits ................................................ 5

Referrals for Diagnosis and Treatment ................................. 5

Coordination of Comprehensive Care Program Services..... 6

PCP Responsibilities ........................................................... 6

Role of TDH/TDHS............................................................... 6

THSteps Medical Case Management................................... 7

Texas Health Network Provider Policies and Procedures Manual VIII-1BDHMC

TEXAS HEALTH STEPS (EPSDT)

Overview

THSteps is the State’s federally mandated Early and Periodic Screening,Diagnosis and Treatment (EPSDT) program.

The Texas Health Network considers full PCP participation in this program asthe most important investment the plan makes in the health of the infants, children,and adolescents under its care. In collaboration with the Texas Department ofHealth, the Texas Health Network has established extensive support andeducational programs for PCPs and plan members to achieve the highestpossible level of compliance with the THSteps periodicity and screeningschedules.

Objectives and Outreach

The Texas Health Network seeks to significantly improve the screening rate for THSteps andto exceed the federally mandated 80 percent screening rate.

The key to meeting this objective is direct outreach to Medicaid clients. Outreach should becentered around a consistent and ongoing emphasis on preventive care.

The Texas Health Network encourages its members to use THSteps preventive medicalcheckup services and the adolescent preventive service visits when they first enroll and eachtime they are periodically due for their next medical checkup.

Providers are encouraged to perform checkups on Texas Health Network members they identifyas eligible for medical checkups and adolescent preventive service visits. They are encouragedalso to notify the client when he or she is due for the next checkup according to the periodicityschedule.

A sample message from PCPs to members might include the following text:

“Your children can get check-ups. In addition to these checkups, there are shotsand tests that may keep your child from getting sick. These services are importantfor your children to stay well. Find out what services your children can get bycalling my office.”

Texas Health Network Provider Policies and Procedures Manual BDHMCVIII-2

The Texas Health Network’s approach to THSteps is focused and effective:

• The member outreach program is interactive and positive.

• Materials are appropriate for various segments of the member population.

• Available services are described in easy-to-understand terms.

• Access to services is made simple.

• PCP enrollment in THSteps is facilitated by the Texas Health Network.

• PCP training in THSteps services is facilitated by the Texas Health Network.

• Feedback to PCPs is used to achieve high rates of screening compliance.

Several channels of communication are opened to send messages to parents and guardiansabout these services, especially checkups that identify health problems early and the follow-upservices available for complete diagnoses and treatments. Contact your Texas Health NetworkProvider Relations Representative if you have comments or suggestions about THSteps.

Initial Screening

The Texas Health Network works with PCP office and clinic sites through educationalworkshops to develop and implement THSteps initial screening procedures in each provider’soffice as described below:

• Within 45 days after enrollment, if the member has not scheduled one, contact eachnewly enrolled Texas Health Network family to schedule an initial examination andarrange transportation if needed.

• If an appointment for the initial screening has not yet been scheduled within 60 days ofenrollment, place follow-up phone calls to all Texas Health Network eligible members.

• Ten days before the scheduled examination, mail a reminder notice to the member.

• Twenty-four hours before each appointment, telephone members to remind them of thescheduled screening date, time, and location.

• Inform the Texas Health Network of any missed initial screening appointment so thatthe plan’s staff may provide additional outreach and work with the PCP and the familyto reschedule the appointment.


Periodic Screening Exams

The Texas Health Network works with PCPs and their staff through educational workshops todevelop and implement THSteps periodic screening procedures in each provider’s office, asdescribed below:

• Within 30 days of the due date, compile a list of members requiring periodic examinationsand mail out a reminder notice suggesting that an appointment be scheduled with theirPCP.

• Within 15 days of the due date for a screening,contact members who have not yetscheduled an appointment.

• Ten days before the due date, if an appointment has not been scheduled, send a secondnotice or telephone the family.

• The day before the appointment, telephone members to remind them of their appointmentdate, time, and location.

• Inform the Texas Health Network of missed periodic screening appointments so theplan’s staff can conduct additional outreach, work with the family and the PCP toreschedule the appointment, and if needed, arrange transportation.

Member Eligibility

THSteps services are covered for members under the age of 21. The screening examinationsand periodicity schedule are age specific. Client eligibility for a medical checkup is determinedby the client’s age on the first day of the month. If a client has a birthday on any day except thefirst day during the month, the new eligibility period begins on the first of the following month.If a client turns 21 during a month, the client continues to be eligible for THSteps servicesthrough the end of that month.

NOTE: The THSteps periodicity schedules for children and adolescentsand the schedule for routine immunizations can be found in the TexasMedicaid Provider Procedures Manual and the Texas Medicaid ServiceDelivery Guide.



THSteps Screening Protocol

Medical check-up services are covered for eligible Texas Health Network members under 21when delivered in accordance with the American Academy of Pediatrics periodicity schedule.The periodicity schedule specifies the screening procedures recommended at each stage ofthe member’s life and identifies the time period, based on the member’s age, when medicalcheckup services are reimbursable.

Major components of the screening examination are:

• A comprehensive health and developmental history, including assessment of bothphysical and mental development.

• A comprehensive, unclothed physical examination.

• Dental screening and referral to a primary care dentist, beginning at age one.

• Nutritional assessment.

• Developmental assessment (Denver II or other appropriate observation screening tool).

• Mental health assessment.

• Vision screening.

• Hearing screening.

• Tuberculosis testing.

• Laboratory screening procedures.

• Age specific routine immunization.

• Health education and anticipatory guidance.

Immunizations

Children must be immunized during medical checkups according to the Texas Department ofHealth (TDH) routine immunization schedule. Refer to the THSteps section in the TexasMedicaid Service Delivery Guide. The screening provider is responsible for administration ofimmunizations and may not refer children to local health departments to receive theimmunizations.

For children not previously immunized, the TDH requires immunizations be given unlessmedically contraindicated or against parental religious beliefs.



http://www.aap.org/





Exceptions to Periodicity

The claims administrator (NHIC) reimburses for medical checkups that are exceptions to theperiodicity schedule to allow for services under the following categories:

• Medically necessary (developmental delay, suspected abuse).

• Environmental high-risk (example: sibling of child with elevated blood lead).

• Required to meet state or federal exam requirements for Head Start, day care, fostercare, or preadoption.

Adolescent Preventive Visits

The protocol for performing adolescent preventive screening visits includes comprehensivehealth guidance for adolescents and their parents, screening for specific conditions relativelycommon to adolescents and their parents, and the use of immunizations to prevent selectedinfectious diseases. Visits for clients ages 11, 13, 15, 17, and 19 years of age are to include theservices outlined in the periodicity schedule found in the Texas Medicaid Provider ProceduresManual.

Referrals for Diagnosis and Treatment

After the screening, you may make referrals as needed for any diagnostic and treatmentprocedures not provided directly by your office or clinic.

The Texas Health Network assists you in ensuring that this service is performed in accordancewith plan guidelines. With this assistance, you can:

• Identify potential specialty diagnosis and treatment providers in the area.

• Remind members of scheduled appointments for diagnosis and treatment.

• Monitor missed diagnosis and treatment appointments; follow-up with family.

• Make arrangements for transportation.

Your Responsibilities — You should request, and the referral provider should deliver, asummary of findings from the referral visit and recommendations for follow-up. This informationshould be incorporated into the member’s medical record in your office. See Chapter II foradditional details.





Coordination of Comprehensive Care Program (CCP) Services

CCP services are an expansion and enhancement of the basic THSteps services covered bythe Texas Medicaid Program. CCP Services include any health care service that is medicallynecessary, appropriate, and is a federally allowable Medicaid service regardless of thelimitations of the Texas Medicaid Program. Refer to the Texas Medicaid Provider ProceduresManual for a complete list of CCP covered services

IMPORTANT: Federal law requires all States to provide medically necessaryand appropriate treatment to correct physical or mental problems for THStepseligible clients — even if the services are not covered under the State’s Medicaidplan or are limited by the State plan. Examples include durable medicalequipment, artificial limbs, private duty-nursing, and several therapy services.

PCP Responsibilities

With assistance from the Texas Health Network and the treatment team (if one is established),you have the responsibility to coordinate, monitor, and document medical care to children withspecial needs. Necessary activities include:

• Obtaining outstanding diagnosis and treatment results.

• Documenting the treatment and the aftercare plan.

• Referring members for specialty medical care.

• Obtaining written reports on treatment progress.

• Ensuring continuity of care.

• Preventing the duplication of services.

Provider/Member Services and Health Services staff can assist you in these efforts.

Role of TDH/TDHS

When TDHS staff members determine a child is eligible for Medicaid, they will educate thechild and family about the THSteps program. TDH has offices in each public health region ofthe State. Staff are responsible for administration of various public health programs and canserve as resources to providers.






THSteps Medical Case Management

The mission of THSteps Medical Case Management, within the Bureau of Children’s Healthand the Division of Genetic Screening and Case Management, is to provide equal access toall services necessary for each THSteps recipient to have an opportunity to develop andmaintain his or her maximum progress toward age-appropriate development, health, wellness,and educational pursuits.

Eligible children must be from one year of age up to 21 years of age,

• Medicaid eligible

• Children with special health care needs

• Children who have a health condition/health risk

• Medically complex children

• Medically Fragile

TDH Regional Telephone Numbers

Region 1 (Northwest Texas/Lubbock, Amarillo, Canyon)1-806-655-7151

Region 5S/6 (Houston, Galveston, Beaumont, Port Arthur)1-713-767-3110

Region 8 (San Antonio, Victoria, Del Rio)1-210-949-2000

Region 2/3 (Arlington, Dallas, Fort Worth, Richardson)1-817-264-4000

Region 9/10 (El Paso, Van Horn)1-915-783-1129

Contents

Chapter IXTexas Health NetworkResponsibilities andSupport Services

Core Texas Health Network Support Services ..................... 1

Support and Education for Members .................................... 3

FirstHelp™ ........................................................................... 3

Texas Health Network Member Helpline .............................. 4

Member Outreach ................................................................. 4

PCP Support for Operation of THSteps ................................ 5

THSteps Outreach Services ................................................. 5

Support to PCPs .................................................................. 6

Claims and Payment Support ............................................... 7

Texas Health Network Provider Policies and Procedures Manual IX-1BDHMC

TEXAS HEALTH NETWORK RESPONSIBILITIESAND SUPPORT SERVICES

Overview

The Texas Health Network provides services and support to PCPs to achieveTexas STAR Program objectives and address provider concerns. As a PCP,you have the challenge and the opportunity to improve health outcomes forMedicaid members and to achieve the goals of the Texas Health Network.The Texas Health Network recognizes that this challenge requires the coop-eration of plan members who will be asked to change the way they haveaccessed Medicaid services in the past. The Texas Health Network providesa broad range of services to guide and assist members in making this change.

Core Texas Health Network Support Services

Texas Health Network Provider Relations Representatives in each service area supportparticipating providers. These representatives also are available to contact providers whoare considering participation as well as those who are unfamiliar with the program. TexasHealth Network core support services to primary care providers include:

Provider Helpline — Knowledgeable Provider Helpline Agents are available to assistyou with a broad range of Medicaid and managed care issues. Toll-free customer servicelines are available 24 hours a day. During normal working hours (Monday through Friday,7:00 a.m. to 6:00 p.m.), these lines are answered directly by Provider Helpline Agents. Foremergencies and urgent situations after hours, an answering service is available to assistyou.

Texas Health Network Provider Helpline1-888-TDH-PCCM (1-888-834-7226)

Texas Health Network Medical Director’s Office1-512-421-3011

Provider Information and Educational Services — Provider Relations Representativesconduct informational and educational workshops, group meetings, and training sessionsfor office practices and groups when requested, as well as on a regularly scheduled basis.On at least an annual basis, the Texas Health Network sponsors a provider informational

Texas Health Network Provider Policies and Procedures ManualIX-2 BDHMC

and educational workshop in each Texas STAR Program region. Topics for the workshopsare selected based on provider interests and suggestions. The Texas Health Networkstructures these workshops at times and places most convenient to providers. Theworkshops are designed to qualify for Continuing Education Units (CEUs) and/or ContinuingMedical Education (CME) Credit. Providers are encouraged to contact the ProviderRelations Department for further information, or to make an appointment for a visit or aneducational presentation.

Enrollment and Recruitment Assistance — Texas Health Network Provider RelationsRepresentatives are available to recruit and enroll new PCPs in the Texas Health Network.Providers who desire to enroll as a PCP must first enroll in the Texas Medicaid Program,then submit a Texas Health Network application. PCPs must be approved by the TexasDepartment of Health and enter into a contractual agreement with the TDH. We can alsoassist you in enrollment as a THSteps Provider.

Medical Director Services — The Texas Health Network Medical Director maintains overallresponsibility for utilization management procedures, quality improvement activities andreporting, health education for both members and providers, precertification requirements,and claim appeals related to the appropriateness of specific medical procedures or services.Texas Health Network providers may contact the Texas Health Network Medical Directorfor specific professional information related to standards of practice.

Provider Directory — The Texas Health Network prepares and distributes a directory ofall providers. This directory is updated on a quarterly basis.

Provider Manual — The Texas Health Network develops and distributes this providermanual which contains significant TDH policies and procedures specific to the Texas HealthNetwork. As indicated previously, this manual complements and supplements the officialTexas Medicaid Provider Procedures Manual. This manual will be updated on at least anannual basis. Texas Health Network providers are invited and encouraged to suggestchanges and improvements to this working document.

Panel Report — The Texas Health Network provides to PCPs a monthly list of memberswho have selected, or been assigned to the PCP for management and coordination oftheir health care. This list is mailed to providers in hard copy at the beginning of everymonth. Members on this list are eligible for Texas Health Network services throughout theentire month.

Practice Profiling Information — The Texas Health Network collects and processes dataso that each PCP may be given periodic practice profiling reports and practice patternanalyses. Specifically, The Texas Health Network prepares reports periodically that describeeach PCP’s practice and referral patterns and compare the PCP’s practice with that ofcomparable peer groups. Peer group data are blinded and providers are not identified asindividuals. The intent of these reports and analyses is to give providers information thatwill enable them to discuss and identify “best practices” to improve health outcomes forplan members.





Member Helpline — The Texas Health Network assists members with PCP changes, andeducates the member on his or her rights and resposibilities as a part of the Texas HealthNetwork.

Texas Health Network Member Helpline:1-888-302-6688

Support and Education for Members

The Texas Health Network provides a range of support services for its members. Theseinclude two Helplines (a 24-hour Clinical Helpline for clinical questions, and a MemberHelpline for general Texas Health Network inquiries). In addition, we provide programs toeducate members on the importance of preventive services and appropriate utilizationpractices.

FirstHelpTM 24-Hour Clinical Toll-Free Line for Members

The Texas Health Network provides a toll-free clinical line for its members. FirstHelpTM isstaffed (nationally) by more than 350 registered nurses who have taken over 2 millioncalls. These nurses use over 560 physician-developed, symptom-based algorithms and1,200 sets of self-care instructions to provide information, triage, and clinical assessmentservices for Medicaid health plan members 24 hours a day, 7 days a week.

The toll-free telephone number of FirstHelpTM is widely publicized to Texas Health Networkmembers. The FirstHelpTM line has several purposes:

• Provide triage, assistance, and reassurance to members who may not have hadaccess to high-quality clinical advice on a 24-hour basis except throughemergency rooms. Use of the FirstHelpTM line has been demonstrated to reduceinappropriate use of emergency services.

• Educate members on how to use services appropriately: when to call theirphysician, when to use an emergency facility, and when to use home-basedtreatment with the advice of a professional.

• Provide support to PCPs so that the responsibility of educating members inappropriate use of health care is shared and reinforced.


The FirstHelpTM line interfaces with the Member Helpline so that non-clinical calls can bereferred appropriately. If a FirstHelpTM nurse determines that a member needs emergencycare, the nurse will direct the member to the nearest emergency facility or contact 911 onthe member’s behalf.

FirstHelpTM 24-Hour, Toll-Free, Clinical Hotline:1-800-304-5468

Texas Health Network Member Helpline

The non-clinical Member Helpline staffed by Member ServicesAgents is the principal resource for members seeking informationor answers to questions. The Helpline also is a resource formembers to express their concerns and file complaints

concerning the operation and management of the Texas HealthNetwork. This Helpline operates with Member Services staff from 7:00 a.m. to 6:00 p.m.,Monday through Friday, and is connected to an answering service after hours that instructsmembers on reaching help in case of urgent or emergent situations. After hours, for clinicalissues, members are referred to the FirstHelpTM toll-free line. For urgent, non-clinical issues,members are referred to a Texas Health Network staff member who is on call.

Texas Health Network Member Helpline1-888-302-6688

Member Outreach

Texas Health Network Member Outreach Representatives are available to educate TexasHealth Network members on how to access health care services appropriately. Outreachstaff offer education on the following topics:

• THSteps • WIC

• Emergency Room Protocol • ECI

• Family Planning

• Behavioral Health

• Case Management


The goal of the outreach staff is to facilitate a mutually beneficial relationship between themember, the provider, and the Texas Health Network. To contact a Member OutreachRepresentative in your area, please call the Member Helpline and they will provide youwith the appropriate contact number.

PCP Support for Operation of THSteps

THSteps is the State’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)program for Medicaid infants, children, and adolescents. The Texas Health Networkapproach to this effort is described in Chapter VIII of this Manual. The Texas MedicaidService Delivery Guide to the Texas Medicaid Provider Procedures Manual describes theTHSteps program in detail.

THSteps Outreach Services

As Network Administrator for the Texas Health Network, BDHMC believes strongly that theTHSteps program is the best investment the Plan can make in the health of its youngmembers. To support that commitment, the Texas Health Network provides the followingactivities to help PCPs screen, diagnose, and treat all eligible members on their panels.

• Works with the enrollment broker to ensure that eligible Medicaid clients are informedabout THSteps services during the managed care plan selection process.

• Sends a letter to each new family enrolled in the Texas Health Network indicatingthat an appointment with their PCP should be scheduled within 30 days for THStepseligible children to receive an initial screening examination. The letter includes abrochure describing:

— THSteps benefits, e.g., routine screening, diagnostic testing, and treatment

— The availability of services that are beyond the normal scope of the MedicaidProgram (CCP services)

— The importance of immunizations, health screenings and follow-up treatment

— How to obtain services

— The role of the PCP in THSteps

• The letter explains that clients may choose any qualified provider to perform THStepsservices, pointing out the advantage of using their PCP - as a positive step that willlead to the development of a trusting, ongoing relationship with their PCP - andexplains the benefits of having a “medical home” and establishing a baseline ofbasic health information for their medical record.






• Sends a birthday card to remind eligible members to obtain their Texas Health Stepsscreen.

• Indicates on the PCPs monthly panel report which members are due for a TexasHealth Steps screen.

• Develops simple, attractive, and culturally sensitive materials for use throughoutthe service area in PCP offices.

The Texas Health Network will identify all PCPs who are not enrolled as THSteps providers.The Texas Health Network will assist interested PCPs in the enrollment process, andensures that they receive the proper materials and training (if needed) to perform THStepsscreenings.

Support to PCPs in theComprehensive Care Program

The Texas Health Network will ensure that your office or clinic receives information andeducation to help you and your staff identify, provide, and coordinate care for children withspecial health needs and complex diseases and illnesses. For example, these childrenmay require treatment and support from a multidisciplinary team of providers. The TexasHealth Network will use a variety of sources to identify these children and will work withyou and specialist providers, the TDH, and community and advocacy organizations to ensurethat an appropriate treatment plan is developed and that the member’s health needs aremet.

The Texas Health Network’s goal is to ensure that each PCP views THSteps as an importantand integral part of his or her practice and understands fully how to properly provide THStepsservices.

In addition to the support described in this chapter, the Texas Health Network provides thefollowing to assist you in providing THSteps services:

• Immediate access through the Provider Helpline staff trained in THSteps servicedelivery to provide knowledgeable technical assistance on request.

• Workshops and in-office meetings to provide tools and information to your office orclinic.

• Information gathering and sharing to ensure that you have access to informationyou need to coordinate, monitor, and document THSteps services to your members.



Claims and Payment Support

All Texas Health Network claims are submitted to and processed by the TDH-contractedclaims administrator, NHIC. The Texas Health Network claims are paid fee-for-service basedon the TDH Medicaid fee schedule. Chapter VI describes the claims and reimbursementpolicies and procedures of the Texas Health Network. The Texas Health Network hasspecially trained Provider Services Representatives who serve as advocates for PCPsand as liaisons to NHIC.

In addition to the claims information and support provided by NHIC, Texas Health Networkproviders may call the Provider Helpline at 1-888-TDH-PCCM (1-888-834-7226) forinformation on the status of any Texas Health Network claim that has been filed. The TexasHealth Network Provider Helpline staff have access to NHIC’s paid and pending claimsfiles to enable them to answer provider questions concerning Texas Health Network claims.The Texas Health Network serves as an advocate for providers to ensure that coveredservices and properly filed claims are processed accurately and promptly.







Contents

Chapter XContinuous QualityImprovement

Definition of Quality .............................................................. 1

CQI Philosophy .................................................................... 1

The Scope of CQI ................................................................. 2

The CQI Process .................................................................. 3

Health Care Financing Administration (HCFA) .................... 3

QARI Guidelines .................................................................. 3

QARI Standards Outline ....................................................... 4

Quality Management & Improvement Committee ............... 10

Responsibilities of the QMIC .............................................. 11

Texas Health Network Provider Policies and Procedures Manual X-1BDHMC

CONTINUOUSQUALITY IMPROVEMENT

Overview

The Texas Health Network operates a comprehensive quality management andimprovement program to assess a variety of factors, e.g., adequacy,appropriateness, and timeliness of care. The Continuous Quality ImprovementProgram (CQIP) uses systematic activities to monitor and evaluate medicalservices according to predetermined objective standards, including the meansto develop and implement corrective actions.

Definition of Quality

The Texas Health Network Medical Director retains ultimate responsibility and authority forthe CQI program and executes this responsibility through routine review and approval of theprogram. The Quality Management and Improvement Committee (QMIC) is responsible fordeveloping, implementing, and evaluating CQI program standards and tools.

Quality is defined by the Texas Health Network as “a degree of excellence or superiority.”

Quality medical care is defined as “medical services that are acceptable, accessible, available,appropriate, timely, effective and of a reasonable cost.”

CQI Philosophy

The Texas Health Network is built around a Continuous Quality Improvement (CQI) processthat ensures that medically necessary care is delivered in a manner that is:

• Appropriate

• Delivered at the highest level of quality possible

• Provided in the least amount of time and in the most effective manner and setting

• Provided at a reasonable cost

Texas Health Network Provider Policies and Procedures Manual BDHMCX-2

CQI is an important element of any managed care program:

• It consists of an assessment of the appropriateness of medical care and treatment in aspecific case or in a profile of cases.

• The CQI process is kept separate and distinct from utilization management to preservethe integrity of the process.

• CQI encompasses and complements all activities of the health care delivery system.

• The CQI process is designed to identify adverse patient outcomes as well as to establisha regular, ongoing program to communicate quality-related information to allprofessionals involved in treatment and review functions within the Texas HealthNetwork.

• Through CQI, quality of care and quality of service problems are identified, informationcollected, performance analyzed, and corrective action initiated with joint efforts of theTexas Health Network Staff and the QMIC.

• Continued monitoring of corrective actions is essential to determine whether furthercorrective action is needed.

The Provider Services staff also reviews credentialing systems used for verifying professional,recredentialing, recontracting, and/or annual performance evaluations and educationalcredentials of Texas Health Network providers. (See Chapter XI of this Manual for moreinformation.)

The Scope of CQI

The scope of quality improvement is broad. It spans the spectrum of health care deliveryservices provided to Medicaid clients:

• All health care delivery settings

— Inpatient— Outpatient— Ambulatory

• All types of services provided

— Preventive— Primary— Specialty and ancillary care— Acute care

• Outcomes - BDHMC cooperates with THQA in evaluations of Texas Health Networkactivities and focuses on priorities defined by TDH




The CQI Process

The CQI process encompasses the following areas:

• Provider accessibility and availability

• Adequacy of the provider network and PCP turnover rates

• Member and provider satisfaction

• Continuity and coordination of care

• Member and provider education

• Member and provider complaints

• Appropriate utilization of health care services

Health Care Financing Administration (HCFA)QARI Guidelines

The recommended CQI standards for managed care organizations issued by HCFA are basedon 16 guidelines developed by a group of managed care medical directors. These standardshelp ensure the provision of quality health care to patients in managed care plans. Correspondingprocedures are implemented at the same time to monitor compliance with these standards.

The HCFA guidelines are similar to those of the National Committee for Quality Assurance(NCQA). Childhood immunizations and prenatal care are among the health care servicesrecommended for continuous monitoring.

Texas Health Network CQI Program is based on the 16 guidelines introduced above. Thesestandards are the Quality Assurance Reform Initiative (QARI) guidelines. The basis for maternaland child health care quality assessment was developed from practice guidelines establishedby the American Academy of Pediatrics and the American Academy of Obstetrics andGynecology.

http://www.ncqa.org/


http://www.hcfa.gov/



http://www.aap.org/


QARI Standards Outline

Presented below is an overview outline of the QARI standards:

STANDARD I - Written Quality Improvement Plan (QIP) Description

QARI identifies the following components of a QIP:

• Goals and Objectives — Written description containing detailed set of Quality Improvementobjectives.

• Scope — Comprehensive description of scope, addressing both clinical and non-clinicalaspects of services such as availability, accessibility, coordination and continuity of care.

• Specific Activities — Quality of care studies and other activities to be undertaken over aprescribed period of time; the methodologies used to accomplish these and the individualsresponsible.

• Continuous Activity — Continuous performance of activities including tracking of issuesover time.

• Provider Review — Review by Physicians and other health professionals of the processfollowed in the provision of health services; also feedback to MCO health care professionalsregarding performance and patient results.

• Focus on Health Outcomes — The QIP methodology addresses health outcomes to theextent consistent with existing technology.

STANDARD II - Systematic Process of Quality Improvement Description

The process of systematic quality improvement objectively monitors and evaluates the qualityand appropriateness of care and service to members and is accomplished through specificquality of care studies and related activities. The process is intended to be one of continuousimprovement.

• Guidelines for Quality of Care Studies - The first step is to identify the clinical or healthservices delivery areas to be monitored. Studies which monitor and evaluate care reflectthe population served by the managed care organization (MCO) or health plan in terms ofage groups, disease categories, and special risk status. For the Medicaid population, theQIP monitors care and services in certain priority areas selected by the State.

• Use of Quality Indicators — Quality indicators are measurable variables relating to aspecified clinical or health services delivery area.


• Use of Clinical Standards/Practice Guidelines — The QIP studies and other activitiesmonitor quality of care against clinical care, health service delivery standards or practiceguidelines specified for each area identified. Standards or guidelines:

— Are based on reasonable scientific evidence and are developed or reviewed by theplan providers.

— Focus on the process and outcomes of health care delivery, as well as access to care.— Need to be combined with a mechanism that can continuously update the standards/

guidelines.— Will address preventive health services and will encompass the full spectrum of all

populations enrolled in the plan.

• Analysis of Clinical Care and Related Services — Appropriate clinicians monitor andevaluate quality through review of individual cases where there are questions about care.For quality issues identified and targeted in clinical areas, the analysis includes the identifiedquality indicators and uses clinical care standards or practice guidelines.

• Implementation of Remedial/Corrective Actions — The QIP includes written proceduresfor taking appropriate remedial action whenever inappropriate or substandard servicesare furnished, or services that should have been furnished were not. These written remedial/corrective action procedures include:

— Specifications of the type of problems requiring corrective action.— Specifications of the person(s) responsible for making final determination— Specific action to be taken— Provision of feedback to appropriate health professionals— Schedule of accountability for implementing corrective actions.— The approach to modifying the corrective action plan if no improvement occurs— Procedures for terminating affiliation with the specific provider

• Assessment of Effectiveness of Corrective Actions — Monitoring and evaluation ofcorrective actions will take place to ensure appropriate changes have been made. Inaddition, changes in practice patterns are tracked. The managed care organization followsup on issues to ensure that actions for improvement have been effective.

• Evaluation of Continuity and Effectiveness of the QIP — The managed care organizationconducts periodic examinations of the scope and content of the QIP to ensure that it coversall types of services in all settings. At the end of each year, a written report on the QIP isprepared which addresses QI studies and other activities completed. Evidence is collectedto determine whether QI activities have contributed to significant improvements in the caredelivered to members.

The Texas Health Quality Alliance (THQA) performs clinical studies on behalf of theTexas Health Network. Addressing both physical and behavioral health needs of thepopulation, these studies are conducted annually. Examples include ADHD, pregnancy,well child, major depression, diabetes, asthma, and substance abuse in pregnancy.Please see Appendix J for the data collection tools. Specific questions related to studydesign should be directed to THQA at 1-800-472-0704.


STANDARD III — Accountability of the Governing Body

The governing body of the organization is the Board of Directors or a designated committee.Responsibilities include:

• Serving as the oversight entity

• Creating QIP progress reports

• Performing annual QIP review

• Modifying the program as necessary

STANDARD IV — Active QI Committee

The QIP delineates an identifiable structure responsible for performing QI functions within themanaged care organization. Responsibilities include:

• Regular meetings

• Established parameters for operation

• Documentation

• Accountability

• Membership

STANDARD V — QIP Supervision

A designated senior executive is responsible for program implementation. The organization’sMedical Director has substantial involvement in QI activities.

STANDARD VI — Adequate Resources

The QIP has sufficient material, resources and staff with the necessary education and trainingexperience to carry out its activities.


STANDARD VII — Provider Participation in the QIP

Participating physicians and other providers are kept informed about the written QIP. Allproviders are required to cooperate with the QIP. Contracts specify that all providers will allowthe managed care organization access to the medical records of its members.

STANDARD VIII — Delegation of QIP Activities

The managed care organization remains accountable for all QIP functions, even if certainfunctions are delegated to other entities. If the managed care organization delegates any QIactivities to contractors:

• There must be written procedures for monitoring

• There must be evidence of continuous and ongoing evaluation of delegated activities

STANDARD IX — Credentialing and Recredentialing (See Chapter XI)

The QIP includes provisions to determine whether physicians and other health careprofessionals, who are licensed by the State and who are under contract to the managed careorganization, are qualified to perform their services. Provisions include:

• Written policies and procedures

• Oversight by the governing body

• Credentialing agent

• Scope

• Process

An initial visit is made to each potential PCP’s office, including documentationof a structured review of the site and medical record keeping practices, to ensureconformance with the Texas Department of Health’s standards.



Recredentialing — A process for the periodic reverification of clinical credentials(recredentialing, re-appointment, or re-certification) is described in the organization’s policiesand procedures. There is evidence that the procedure is implemented at least every two years.The recredentialing, re-certification or re-appointment process also includes review of thedata from:

• Member complaints

• Results of quality reviews

• Utilization management

• Member satisfaction surveys

• Reverification of hospital privileges and current licensure

STANDARD X — Enrollee Rights and Responsibilities

The organization must demonstrate a commitment to treat members in a manner thatacknowledges their rights and responsibilities. The organization must ensure that theconfidentiality of client information and records is protected. At a minimum, the informationprovided to members must include:

• Written policy on member rights

• Written policy on member responsibilities

• Communication of all policies to providers by copying policies to all participatingproviders.

• Communication of the following policies to members upon enrollment:

— Benefits and services included and excluded as a condition of membership andhow to obtain them, including a description of any special benefit provision that mayapply to services obtained outside the network, and the procedures for obtainingout-of-area coverage

— Provision for after-hours and emergency coverage

— The policy on referrals for specialty care

— Charges to members, if applicable

— Procedures for notifying members affected by termination of or change in any ben-efits, services, or delivery office/site

— Procedures for appealing decisions adversely affecting a member’s coverage, ben-efits, or relationship with the organization


— Procedures for changing practitioners

— Procedures for disenrollment

— Procedures for complaints and/or grievances and for recommending changes inpolicies and services

— Member complaint procedures

— Procedures for accommodating member suggestions

— Policies and procedures to ensure access to care

— Written information for members in easily understandable form

— Policies for ensuring confidentiality

— Policies for the treatment of minors

— Member satisfaction assessment

— Information available in languages other than English

STANDARD XI — Standards for Availability and Accessibility

The managed care organization or health plan must have written established standards foraccess to and accessibility of medical care. The State requires the plan to provide care inurgent situations the same day the client calls; for routine care within 2 weeks; and for physicalexams within 4-8 weeks of the initial request. Providers must have regular office hours and adesignated on-call provider when they are not available. The PCP or his/her designee shouldbe available by telephone to clients at all times.

STANDARD XII — Medical Records Standards

The managed care organization or health plan must provide access to client’s medical recordsfor reviews by HCFA, the State Medicaid Agency or agents thereof. Medical records must beavailable and accessible, and there must be both written medical record keeping standardsand a medical record review process.

STANDARD XIII — Utilization Management

Managed care organizations are required to have a written utilization management program,that includes procedures for precertification and concurrent review.



STANDARD XIV — Continuity of Care System

Managed care organizations must have a system developed and implemented which promotescontinuity of care and case management.

STANDARD XV — QIP Documentation

Managed care organizations must have a written Annual Quality Improvement Plan whichincludes a process for quality monitoring.

STANDARD XVI — Coordination of QI Activity with Other Management Activities

The findings, conclusions, recommendations, actions taken, and results of the actions aredocumented and reported to appropriate individuals within the organization and through theestablished QI channels.

• CQI information is used in recredentialing, re-contracting, and/or annual performanceevaluations.

• CQI activities are coordinated with other performance monitoring activities, includingutilization management, risk management, and resolution and monitoring of membercomplaints and grievances.

• There is linkage between QI and other functions, such as:

— Network changes

— Benefits redesign

— Medical management systems

— Practice feedback to physicians

— Patient education

— Member services

Quality Management & Improvement Committee(QMIC)

The QMIC provides oversight for the Texas Health Network Quality Improvement Program.Representatives from the TDH Health Care Financing and Bureau of Managed Care, andBDHMC leadership staff comprise the core of the committee. The Texas Health Network MedicalDirector chairs the QMIC. Other committee members include three participating providers, twonon-participating providers, two Texas Health Network enrolled members from differentgeographic regions, and a non-PCCM Medicaid client.




Responsibilities of the QMIC

The QMIC meets at least quarterly to review current operations and resolve quality-of-careproblems, monitor corrective actions, and follow-up on study findings. The committee’s functionis to:

• Oversee and assist in the formulation of Continuous Quality Improvement (CQI)measures and the development and revision of CQI protocols

• Evaluate and monitor the appropriateness, availability, accessibility and medicalnecessity of services

• Maintain familiarity with current medical practices and ensure their incorporation intoprecertification, concurrent and retrospective review criteria and into practice guidelinesand clinical indicator development

• Implement outcome measures and document member health outcomes

• Review corrective action plans and monitor their implementation.

Other Quality Considerations of the QMIC

A number of Texas Health Network activities provide the QMIC with quality-related informa-tion that will assist the committee in fulfilling its responsibilities. Most of these activities aredescribed in other chapters of this manual. These activities include:

• Provider satisfaction surveys

• Information from the complaints and appeals process for providers (Chapter IV)

• 24-hour access monitoring findings

• Monitoring of THSteps screening rates and compliance (Chapter VIII)

• Contract compliance site visits and medical record reviews (Chapter XI)

• Information from the Utilization Management Staff (Chapter I)

• Information from the credentialing and recredentialing processes (Chapter XI)

• Practice pattern analysis from provider profiling activities.

Contents

Chapter XIOffice and MedicalRecords Standards

Office and Facility Requirements .......................................... 1

Medical Records Standards ................................................. 2

Content of Medical Record ................................................... 2

Confidentiality of Medical Records ....................................... 4

Medical Records Audits ....................................................... 4

Access and Availability Standards ....................................... 5

Monitoring Provider Performance ......................................... 6

Texas Health Network Provider Policies and Procedures Manual XI-1BDHMC

OFFICE AND MEDICALRECORDS STANDARDS

Overview

The Texas Health Network has a responsibility to its members to ensure thatnetwork providers deliver high quality health services in safe, accessible, andwell-equipped offices. The Texas Health Network employs a variety of techniquesto monitor provider performance and implement quality-of-care indicators. Eachprovider agrees to meet minimum operational requirements for continuedparticipation in the Texas Health Network provider network.

Office and Facility Requirements

To ensure that each on-site office or facility used to deliver health care to Texas Health Networkmembers is a safe, sanitary, and accessible place, the Texas Health Network has definedstandards for offices and other facilities:

• A site visit is conducted for each location as part of the evaluation process.

• An office compliance audit ensures that the facility meets defined standards.

• Evaluators use the visit as an opportunity to interact with the provider and his or herstaff.

• Evaluators are prepared to explain the program and promote a strong networkrelationship.

For a provider to be considered for Texas Health Network participation, all office sites must bein compliance with the “conditions of participation” stipulated in the provider contract.

Texas Health Network staff conduct an office on-site review at each primary care site prior tothe acceptance of the provider into the Texas Health Network. Subsequently, Provider Relationsstaff perform routine audits at primary care office sites every two years.

Staff use the on-site review form presented in Appendix F to evaluate a provider’s office:

• Offices that are found to be marginally acceptable receive a follow-up visit within 90days.

• The Texas Health Network may recommend that TDH cancel a provider’s contract ifoffice conditions do not meet defined standards after notice of required corrective actionhas been provided, and time to make changes has been made available.


Texas Health Network Provider Policies and Procedures Manual BDHMCXI-2

Medical Records Standards

A Texas Health Network provider is required to maintain comprehensive and accurate medicalrecords to ensure the quality and continuity of care of his or her patients. Each provider mustmaintain and make available medical records in accordance with the applicable provideragreement.

Content of Medical Record

Each patient’s medical record must include patient identification information, progress notes,and laboratory, referral, and consultation notes. Data to be maintained include:

• Patient identification information

— Patient’s full name, address, and phone number

— Patient’s history, including:

- Past and present medical condition of patient and family

- Past illnesses and surgeries

- X-ray and lab tests

- Immunizations

- Documentation of discussion of Advance Directives (patients 21 and older)

• Present physiological condition:

— Drug or allergy sensitivities

— Current medications

• Progress notes:

— Patient’s complaint or reason for visit

— Results of physical examinations

— Tests, procedures, and medications ordered by physician

— Diagnoses and problems identified

— Health education/preventive services performed


• Laboratory, referral, and consultation notes:

— Laboratory and X-ray reports

— Consultation and referral consultation reports

• Copies of reports concerning hospital admissions including:

— Authorizations

— Surgical reports

— Discharge summaries

Characteristics of Entries

Provider entries in a Texas Health Network member’s medical record should comply with Staterequirements:

• Entries in the medical record should be legible and compiled systematically.

• Entries should be dated and signed by the appropriate practitioner(s).

• Entries should be made in a timely manner (that is, as soon as possible after the patientencounter).

• Medical data and clinical information should be integrated into one record.

• Referral and consultation reports should be included in the member’s medical record.

• Reports concerning hospital admissions, including surgical reports and dischargesummaries, should be included.

• Requests for release of medical records information should be handled only byindividuals who are guided by the Texas Health Network’s confidentiality policy and inaccord with applicable law.

• Records should be stored and filed so that they are readily available for use.

• Only authorized personnel should be permitted access to records.

• Medical records should include retrieval and release information.

IMPORTANT: Upon request, a provider will give the Texas Health Network copiesof member medical records, as outlined in the provider agreement, so that TexasHealth Network staff can implement utilization management, quality improvement,and grievance programs.


Confidentiality of Medical Records

The relationship and all communication between physician and

patient are privileged. Accordingly, the medical record

containing information about the relationship is confidential.

A physician’s code of ethics, as well as Texas and Federal laws,

protect against the disclosure of the contents of medical records

to persons or agencies who are not properly authorized to receive

such information.

For a provider to release the contents of a patient’s medical record to a third party, the patient

must first authorize the disclosure by signing and dating an authorization form. If the record is

for a deceased individual, the executor of the estate must authorize the release.

The policy of Texas Health Network is to allow only medical personnel and health professionals

who are directly involved in the delivery or evaluation of a patient’s records to access the

medical record. All requests for medical record information must be handled according to policy

and law.

An authorization from the patient for release of medical information is not required

when the release is requested by and made to TDH, the Texas Health Network,

THQA, NHIC, THHSC Sanctions Division, the Texas Attorney General’s

Medicaid Fraud Control Unit, or H&HS.

Medical Records Audits

Texas Health Network Provider Relations staff perform a general medical record review of the

PCP’s practice as part of the credentialing and recredentialing process and as part of the

quality improvement program. The medical record evaluation tool presented in Appendix F is

used to evaluate provider medical records as part of the credentialing and recredentialing

process. Other audit tools used by THQA to collect data for focus studies are located in

Appendix J.

Medical record audit results are submitted to the Medical Director and, if necessary, to the

Credentialing Committee for review. Depending upon review findings, the Credentialing

Committee will assist the Medical Director in concluding the audit in one of three ways:

• Recommending that TDH accept the provider.

• Recommending that TDH reject the provider on the basis of poor medical record

documentation and procedures.







• Recommending that TDH accept the provider conditionally with the provision that certainchanges must be made and standards must be met within a specified timeframe.

These recommendations apply to audits of an initial review of a provider as well as those ofsubsequent reviews.

If a provider has been found to be marginally in compliance with requirements, he or she willbe given training and education directed at correcting the deficiency. The Texas Health Networkwill establish a system to audit this provider every 90 days for a maximum of three follow-upaudits:

• Each audit must show substantial improvement over the previous audit.

• Following the third follow-up audit, if no improvement has been noted, the Texas HealthNetwork will work with TDH to apply sanctions and monitor performance closely.

• Subsequent to these measures, if the provider is still not in full compliance, the TexasHealth Network will work with TDH to terminate the provider from the plan.

Medical Records may also be reviewed in conjunction with provider profiling to identifyopportunities to improve care and services.

Access and Availability Standards

The Texas Health Network requires that participating PCPs maintain coverage 24 hours aday, 7 days a week.

On-call coverage is a contractual obligation for any participating primary care site.

A PCP must ensure that his or her scheduling practices follows the standards in Chapter II foremergency, urgent, and routine visits. Texas Health Network staff routinely evaluate and monitorprovider compliance with scheduling requirements. These scheduling requirements aredesigned to enhance access to health services and to provide assurance of service availabilitybased on the urgency of need.





Monitoring Provider Performance

As Network Administrator for the Texas Health Network, BDHMC is responsible for monitoringquality of care and, if necessary, recommending that TDH disenroll providers who do not meetPlan requirements.

The health care industry commonly employs a variety of techniques to monitor providerperformance and develop quality-of-care indicators. Among the indicators used to monitorTexas Health Network providers’ performance are:

• Member Comments and Complaints — The Texas Health Network Member Servicesstaff closely monitor the activities associated with member complaints as they relate toquality assurance and utilization management reviews for specific providerperformances. The reports of these activities are used to trigger separate actions andinquiries about performance.

• Office Site Reviews — Texas Health Network staff undertake a variety of assessmentsas part of quality improvement activities and provider service activities. The results ofthese reviews will be made part of the file of performance factors and indicators assessedduring the recredentialing process.

• Compliance With 24-Hour Access Standards — Texas Health Network staff conductsurveys to assess the degree of compliance with the access standards described above.Member comments and complaints may trigger reviews of specific providers. The resultsof these reviews are considered in the recredentialing process.

• Ability to Perform or Directly Supervise Ambulatory Primary Care Services forMembers — Provider performance is monitored on an ongoing basis through the CQIProgram. Texas Health Network staff follow up evidence of poor performance andaddress identified problems immediately to ensure that high-quality care is delivered toPlan members.

• Admitting Privileges — Texas Health Network staff verify that each provider maintainshis or her membership on the medical staff with admitting privileges at a minimum ofone accredited general hospital or has an acceptable (timely and complete transfer ofpatients and records) arrangement with a PCP who has such admitting privileges.

• Continuing Medical Education Credits — Contracting and credentialing staff monitoreach provider’s activities in the area of continuing medical education credits. The TexasHealth Network also offers workshops that provide PCPs with programs meeting criteriafor CEUs/CMEs.

• Education Sessions — Provider Relations staff provide UM, CQI, and casemanagement policies and procedures to each Texas Health Network PCP. Staff alsoprovide a series of educational sessions regarding all aspects of UM, CQI, and casemanagement. Provider contracts require that each PCP attend at least one educationalsession on UM, CQI, and case management policies and procedures each year.




• Valid DEA Certification — Proof of Drug Enforcement Administration (DEA) certificationmust be submitted as part of the application process and will be maintained by theTexas Health Network in its credentialing files.

• Performance Within Scope of Individual Licensure and Texas Health NetworkCredentialing — The Texas Health Network staff includes in each provider applicationa statement that provides assurance that a certified registered nurse practitioner, nursemidwife, or physician assistant will perform services only within the scope of his or herlicensure, and that the individual will be disciplined immediately if this agreement isviolated.

• Compliance with Fraud and Abuse Policy — The Texas Health Network willrecommend to TDH that a network provider be suspended immediately upon notificationfrom any source that the provider:

— Has been terminated or suspended from participation in the Medicaid or MedicareProgram

— Has lost his or her license

— Has been convicted of a criminal act

As Network Administrator for the Texas Health Network, BDHMC employs the above indicatorsas part of its oversight function. Findings are cataloged and analyzed for patterns of performancethat require special attention. Where warranted, the results are made part of the recredentialingprocess. Failure to adhere to the above standards of performance will be grounds for suspensionor termination.



Contents

Chapter XIIFraud and AbusePolicy

Fraud and Abuse Policy ....................................................... 1

Provider Deficiencies ........................................................... 2

Provider Sanctions ............................................................... 2

Texas Health Network Provider Policies and Procedures ManualBDHMC XII-1

FRAUD AND ABUSEPOLICY

Overview

The Texas Health and Human Services Commission (THHSC) investigatessuspected fraud and/or abuse in the Medicaid program. This chapter examinesthe policy governing fraud and abuse, and describes protective measuresemployed by Texas Health Network to minimize fraud and abuse in the program.

Fraud and Abuse Policy

Federal and State law give authority to the Texas Health and Human Services Commission(THHSC) to identify, investigate and refer cases of suspected fraud and/or abuse in the Medicaidor social services program.

THHSC takes appropriate action to protect clients and the Medicaid program when providersof services are suspected of fraudulent or abusive activities.

• THHSC and TDH are responsible for minimizing the opportunity for provider fraud andabuse, establishing criteria for identifying cases of possible fraud and abuse,investigating cases of program abuse, and recouping all overpayments to a provider.

• In some circumstances, this could result in referral of a provider to the Texas AttorneyGeneral’s Medicaid Fraud Control Unit, which is responsible for full investigation ofsuspected provider fraud. In other circumstances, it could result in administrativesanctions or actions being taken against a provider if deemed appropriate by theMedicaid Provider Sanctions Division.

Per the regulations, THHSC is required to:

• Exclude from participation and reimbursement, or otherwise sanction, any provider whodefrauds or abuses the Medicaid Program

• Suspend any provider receiving reimbursement under the Medicaid Program who hasbeen suspended from Medicare for conviction of a program-related crime, or who is noteligible to participate in Medicare as a result of the Federal Office of the Inspector Generalfor the Department of Health and Human Services directing such action.








Texas Health Network Provider Policies and Procedures ManualXII-2 BDHMC

A determination of fraud may result in State penalties being assessed against a provider underthe State Civil Monetary Penalty Law. A provider may be assessed a penalty of up to $15,000per item or service identified as false. Additionally, a provider who has been assessed civilmonetary penalties may be barred from participation in Medicare, Medicaid, or both.

Cases of fraud and/or abuse may also be referred to the United States Department of Healthand Human Services for consideration and assessment of penalties under the Federal CivilMonetary Penalty Law of the Social Security Act. The provisions of this law allow the Federalgovernment to apply damages and penalties against a provider for violations in the Medicaidand/or Medicare programs.

Individuals having knowledge regarding suspected Medicaid fraud or abuseshould report this information to the Medicaid Fraud Hotline:

Recipient Fraud: 1-800-436-6184Provider Fraud: 1-512-424-6519

Provider Deficiencies

The Texas Health Network Provider Relations staff provides support and guidance in theidentification and resolution of provider problems or deficiencies. They are responsible forreviewing problems and working with the provider or TDH to initiate action to resolve theproblem or correct the deficiency. Providers who fail to correct deficiencies in their operationsmay be subject to prepayment review, fraud or abuse referral, and administrative sanctions.

Provider Sanctions

The Texas Health and Human Services Commission (THHSC) may impose sanctions againsta provider or a provider’s employee who permits, or causes any of the following, or commitsany other fraud or abuse defined by law:

• Submitting a false statement or misrepresentation, or omitting pertinent facts, when claimingpayment under Medicaid or when supplying information used to determine the right topayment under Medicaid.

• Submitting a false statement, information, or misrepresentation, or omitting pertinent factsto obtain greater compensation than that to which the provider is legally entitled.

• Submitting a false statement, information or misrepresentation, or omitting pertinent factsto meet pre-certification requirements.




• Failing to disclose or make available upon request to TDH, THHSC Sanctions Division orauthorized agents, representatives of the United States Department of Health and HumanServices (DHHS), or the Attorney General’s Medicaid Fraud Control Unit any records theprovider is required to maintain. This also includes records of services provided to Medicaidrecipients and payments made for those services, including but not limited to, documentsrelated to diagnosis, treatment, service, lab results, and X-rays.

• Failing to provide and maintain quality services to Medicaid recipients within acceptedmedical community standards or standards required by statute, regulation or contract.

• Failing to comply with the terms of the Medicaid contract or provider agreement, assignmentagreement, the provider certification on the Medicaid claim form, or other rule published byTDH.

• Furnishing or ordering services to patients (whether or not eligible for benefits) under TitleXVIII or a state health care program that substantially exceed the recipient’s needs, are notmedically necessary, are not provided economically, or are of a quality that fails to meetprofessionally recognized standards of health care.

• Rebating or accepting a fee, or part of a fee or charge, for a Medicaid patient referral.

• Violating any provision of the Human Resources Code, Chapter 32, or any rule publishedunder it.

• Submitting a false statement or misrepresentation or omitting pertinent facts on anyapplication, or any documents requested as a prerequisite for Medicaid participation.

• Failing to meet standards required for licensure as required by State or Federal law, TDHrule, provider agreement, or provider manuals for participation in the Medicaid Program.

• Being excluded from Medicare because of fraudulent or abusive practices.

• Charging recipients for allowable services that exceed the amount TDH or its agents payfor except when specifically allowed by TDH.

• Refusing to execute or comply with a provider agreement or amendments when requested.

• Failing to correct deficiencies in provider operations after receiving written notice of themfrom THHSC or TDH or its authorized agents.

• Engaging in any negligent practice resulting in death, injury, or substantial probability ofdeath or injury to the provider’s Medicaid patients or to persons who receive or benefit fromthe provider’s services.

• Pleading guilty or no contest, agreeing to an order of probation without adjudication, orbeing a defendant in a court judgment or finding of guilt for a violation relating to performanceof a provider agreement or program violation of Medicare, the Texas Medicaid Program, orany other state’s Medicaid Program.










• Failing to repay or make arrangements that are satisfactory to THHSC or TDH to repayidentified overpayments or other erroneous payments.

• Failing to abide by applicable statutes regarding handicapped individuals or civil rights.

• Being terminated, suspended, or excluded from participation in any Federal program, havingan unpaid debt under any Federal program or being otherwise sanctioned under any Federalprogram involving the provision of health care, including the Department of Defense, theVeterans Administration and any other state health care program for actions or failure toact that would be considered abusive or fraudulent. This includes any reasons related tothe person’s professional competence, performance or financial integrity. Any appeal bythe provider for an action taken against him under this item does not consider the validity ofa sanction or action taken by Medicare or any other state’s Medicaid Program.

• Submitting or causing to be submitted under Title XVIII or a state health care programclaims or requests for payment containing unjustified charges or costs for items or servicesthat substantially exceed the person’s usual and customary charges or costs for thoseitems or services to the public or private pay patients.

• Failing to comply with Medicaid policies, published Medicaid bulletins, policy notificationletters, provider policy or procedure manuals, contracts, statutes, rules, regulations, orinterpretations for any of the items listed previously sent to the provider.

• Submitting claims with a pattern of inappropriate coding or billing that results in excessivecosts to the Medicaid Program.

• Billing for services or merchandise that were not provided to the recipient.

• Submitting to the Medicaid Program a cost report containing costs not associated with theMedicaid Program or not permitted by Medicaid Program policies.

• Submitting a false statement or misrepresentation that, if used, has the potential of increasingany individual or state provider payment rate or fee.

• Charging recipients for services when payment for the services was recouped by Medicaidbecause of any of the reasons stated in 25 Texas Administration Code (TAC) Section79.2303 (relating to Recovery from Providers).

• Failing to notify and reimburse TDH or its agents for services paid by Medicaid if the provideralso received reimbursement from a liable third party.

• Misapplying, misusing, embezzling, failing to release promptly upon a valid request, orfailing to keep detailed receipts of expenditures relating to any funds or other property intrust for a Medicaid recipient.

• Having an outstanding debt with the State or Federal government.

• Pleading guilty or being convicted of a violation of state or federal statutes relating todangerous drugs, controlled substances, or other drug-related offense.





• Pleading guilty of, being convicted of, or engaging in conduct involving moral turpitude.

• Having a voluntary or involuntary action taken by a licensing agency or board to requirethe provider or employee to comply with professional practice requirements of the boardafter the board receives evidence of noncompliance with licensing requirements.

• Pleading guilty to or being convicted of a violation of any State or Federal statutes relatingto fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconductrelating to the delivery of a health care item or service relating to any act or omission in aprogram operated or financed by any federal, state or local government agency.

• Being convicted in connection with the interference with or obstruction of any investigationinto any criminal offense described in 25 TAC Subsection 79.2112 (f) (relating toAdministrative Sanctions or Actions) or paragraphs (16), (29), (30), or (32) of 25 TACSubsection 79.2105.

• Having its license to provide health care revoked or suspended by any state licensingauthority, or losing this license because of an action based on assessment of the person’sprofessional competence, professional performance, or financial integrity, or surrenderingthis license while a formal disciplinary proceeding is pending before licensing authoritiesand the proceeding concerns the person’s professional competence, professionalperformance, or financial integrity.

• Substantially failing, as a health maintenance organization under Title XIX or any entityfurnishing services under waiver granted by the DHHS under that title, to provide medicallynecessary items or services that are required under law or under contract, if the failure hasadversely affected or is substantially likely to affect adversely the Medicaid recipient ofthese items or services.

• Committing an act as described in the Social Security Act, Subsections 1128A or 1128B.

• Meeting any of the conditions specified in 25 TAC 79.2112(f) or (g), (relating to AdministrativeSanctions or Actions).

• Failing to fully and accurately make any disclosure required by the Social Security Act,Section 1124 or Section 1126.

• Failing to disclose information about the ownership of a subcontractor with whom the personhas had business transactions in an amount exceeding $25,000 during the previous 12months or about any significant business transactions (as defined by DHHS) with anywholly owned supplier or subcontractor during the previous five years.

• Failing, as a hospital, to comply substantially with a corrective action required under theSocial Security Act, Subsection 1886(f)(2)(B).

• Defaulting on repayments of scholarship obligations or items related to health professionaleducation made or secured, in whole or in part, by DHHS when DHHS has taken all reasonablesteps available to DHSS to secure payment.


• Developing false source documents or failing to sign source documents, to retain supportingdocumentation, or to comply with the provisions or requirements of TDH pertaining toelectronic claims submission.

• Failing to comply with the Texas Family Code and being delinquent in child supportpayments.

• Substantially failing, as an eligible organization under a risk-sharing contract as definedin 42 USCA 1359mm, to provide medically necessary items or services that are requiredunder a law or contract, if the failure has adversely affected or has the potential to affect thepatient adversely.

Involvement in any of the aforementioned items could result in exclusionor suspension from the Texas Medicaid Program.

Providers are notified in writing of action to be taken, and of procedures for appeal. Fullinvestigation of criminal Medicaid fraud is the responsibility of the Texas Attorney General’sMedicaid Fraud Control Unit and may result in a felony or misdemeanor criminal conviction.Persons who solicit, receive, offer, or pay any remuneration (including bribes, kickbacks, orrebates) directly or indirectly in relation to referrals, purchases, leases, or arrangements ofservices covered by Medicare or Medicaid may be guilty of a Federal felony offense. Currentlegislation allows for suspension of providers convicted of a criminal offense related to Medicareor Medicaid.

Under the Social Security Act, Section 1909, the penalty for a Medicare/Medicaid felony is amaximum fine of $25,000, maximum imprisonment of five years, or both.


Contents

Chapter XIIIEl Paso First Health Network

History .................................................................................. 1

Covered Services .................................................................1

Provider Eligibility and Responsibilities ............................... 2

Specialist Responsibilities ................................................... 4

Specialist-to-Specialist Referrals ......................................... 4

Provider Credentialing ......................................................... 5

Member Eligibility and Identification ..................................... 6

El Paso First Health Network Services ................................. 7

Precertification ..................................................................... 8

Claims Admisitration .......................................................... 11

Texas Health Network Provider Policies and Procedures ManualBDHMC XIII-1

The El Paso First Health Network

Overview

The information contained in this chapter is specific to providers contractedwith the El Paso First Health Network providing services to El Paso First HealthNetwork members. All other policies and procedures not stated herein arefollowed according to the Texas Health Network Provider Policies and ProceduresManual and the Texas Medicaid Provider Procedures Manual.

History

The El Paso First Health Network is an integrated component of the Texas Health Network,and is designed to offer a second reimbursement option to Texas Health Network providers inthe El Paso Service Area (Culberson, Hudspeth, and El Paso counties). The El Paso FirstHealth Network has contracted with the Texas Department of Health (TDH) to administer themedical care and services provided to Medicaid-eligible clients who choose the El Paso FirstHealth Network as their health plan. Birch & Davis Health Management Corporation (BDHMC),as Network Administrator of the Texas Health Network, conducts oversight and administrativefunctions to ensure a seamless healthcare delivery system.

The El Paso First Health Network is a not-for-profit corporation formed under the Texas StateBoard of Medical Examiners, Section 5.01(a) of the Medical Practice Act. The corporation wasformed as a community partnership between the El Paso County Hospital District, El PasoCounty Medical Society, and the Southwestern Association of Hispanic American Physicians.

The El Paso First Health Network operates under the leadership of the Board of Directors, aseven-person panel composed of a combination of primary care providers (PCPs) andspecialists. This board has the sole authority to direct the medical, professional, and ethicalaspects of the Corporation’s practice of medicine.

Covered Services

In addition to the standard benefits of the Texas Medicaid program, Texas Health Networkmembers are eligible for expanded benefits under the Texas STAR Program. A complete listof these services can be found in Chapter I-1 of this manual.



Texas Health Network Provider Policies and Procedures ManualXIII-2 BDHMC

Freedom-of-Choice ServicesTexas Health Network members who select the El Paso First Health Network may be requiredto obtain a referral for certain freedom-of-choice services (see list below). For all other servicesdesignated as freedom-of-choice services under the Texas STAR Program, members mayselect any Medicaid-enrolled provider to access the services without a referral.

Exceptions to Freedom-of-Choice Services• Vision Services—Any diagnosed condition or abnormality of the eye that requires

treatment or additional services beyond the scope of an exam for refractive errors mustbe referred back to the member’s PCP. A participating El Paso First Health Networkphysician must provide specialty vision care. See Referrals to Specialists in this chapterfor more information. Eyewear services continue to follow the policies and proceduresstated in the Texas Medicaid Provider Procedures Manual.

• School-Based Clinic Services—Members may receive urgent care from a school-based clinic without a referral from their PCP. Routine care requires a referral from thePCP.

For a complete listing of Freedom-of-Choice Services, please refer to Chapter I-2.

OB/GYN Direct AccessMembers may seek the services of an El Paso First Health Network OB/GYN, without a referralfrom their PCP, for the following services:

• One well-woman examination per year• Care related to pregnancy• Care for all active gynecological conditions• Diagnosis, treatment and referral to a specialist within the network for any disease or

condition, within the scope of the designated professional practice of a properlycredentialed obstetrician or gynecologist, including treatment of medical conditionsconcerning the breast.

In addition, El Paso First Health Network members may select a participating OB/GYN astheir PCP. As such, the OB/GYN is responsible for providing or arranging for (directly or throughreferrals) all medically necessary services. Provider responsibilities are detailed below.

Provider Eligibility and Responsibilities

The El Paso First Health Network is an “any willing provider” integrated system developed toinclude El Paso’s traditional community-based providers in the evolution from fee-for-serviceto managed care for special populations.



PCPs shall provide (directly or through referrals) all Medicaid covered services. The PCP isresponsible for issuing referrals to participating providers in the network for covered servicesthat he or she is unable to provide (see Referrals to Specialists below), and for following allother policies and procedures outlined in the Texas Health Network Provider Policies andProcedures Manual.

Contractual ObligationsPCP obligations are outlined in the Provider Agreement between the El Paso First HealthNetwork and each PCP. If the applying provider is currently participating in a plan sponsoredby the El Paso First Health Network, he or she must sign an amendment to his or her currentcontract to participate in the Texas STAR Program. See Chapter II for more information oncontractual obligations.

Access and AvailabilityPCPs participating in the El Paso First Health Network are responsible for ensuring that ElPaso First Health Network members have access to needed medical care 24 hours a day, 7days a week. The El Paso First Health Network monitors compliance with the requirementsfor access and availability on an on-going basis. If a provider is unable to meet the contractualrequirements for access and availability, the El Paso First Health Network may choose toclose the PCP’s panel to new assignments, and reassign the PCP’s current members, untilthe access and availability requirements can be met.

Referrals to SpecialistsReferrals are an integral part of the El Paso First Health Network, and can ensure that El PasoFirst Health Network members receive the care and services needed to meet the goals of theTexas STAR Program.

The El Paso First Health Network operates a closed specialty network. This means that PCPsmust refer members to El Paso First Health Network specialists only. Although PCPs maycontinue to use their current process for referrals, the El Paso First Health Network stronglyurges the use of the referral form in Appendix C. Tracking of referral information assists theplan in improving both the quality and continuity of care El Paso First Health Network membersreceive.

PCPs are required to maintain documentation of communication with the specialist in themember’s medical record, and must supply the specialist with his/her El Paso First HealthNetwork Provider Number for inclusion on the specialist’s claim.

Note: If a specific specialty does not appear in the Texas Health Network PrimaryCare Provider and Hospital List, the PCP should contact an El Paso First HealthNetwork Utilization Review Nurse at 1-915-532-3778 for authorization to refer toan out-of-network provider.


Specialist Responsibilities

Specialists are responsible for furnishing medically necessary services to Texas HealthNetwork members who have selected The El Paso First Health Network, and who have beenreferred by their PCP for specified diagnosis and/or treatment. Specialists are responsible forobtaining precertification from the El Paso First Health Network for services requiringprecertification, and are responsible for verifying member eligibility prior to providing theseservices. To ensure continuity of care for members, the specialist must also maintaincommunication with—and provide adequate information to—the member’s PCP. PCPs mustdocument the services provided—including all results, findings or recommendations—in themember’s medical records.

Upon PCP referral of a member, the specialist should review the case with the PCP to fullyunderstand the services being requested and authorized. The specialist must contact thePCP or the El Paso First Health Network Utilization Management Department for authorizationfor testing. Referrals from a PCP must be documented in both the PCP’s and specialist’srecords.

Specialists must obtain the approval of the PCP or the El Paso First Health Network prior toordering any tests or completing any procedures.

If a determination is made that a member’s condition warrants hospitalization or inpatientsurgery, the specialist should seek precertification from the Texas Health Network UtilizationManagement Department:

Phone: 1-888-302-6167Fax: 1-512-302-5039

If a specialist determines that a member’s condition warrants outpatient surgery, the specialistshould inform the member’s PCP, and seek precertification from the El Paso First HealthNetwork Utilization Management Department:

Phone: 1-877-532-3778Fax: 1-915-532-2286

Specialist-to-Specialist Referrals

Referrals from one specialist to another for a medically necessary service must be authorizedby the member’s PCP and/or the El Paso First Health Network Utilization ManagementDepartment.


Claims for Specialist ServicesClaims for specialist services must reference the PCP’s El Paso First Health Network providernumber in the appropriate field of the electronic submission or paper claim form. The El PasoFirst Health Network follows the general claims instructions set forth in the Texas MedicaidProvider Procedures Manual.

Provider Credentialing

Credentialing And Peer Review CommitteeThe El Paso First Health Network credentials all PCPs and specialists in its network. TheCredentialing and Peer Review Committee (CPRC) is charged by the Board of Directors ofthe El Paso First Health Network with the responsibility of reviewing each applicant’s file toensure that he or she meets the minimum requirements established in QARI Standard IX, andthe National Committee for Quality Assurance (NCQA). For additional information on QARIStandards, see Chapter X.

The CPRC reviews each application and makes recommendations to the Board of Directors.The CPRC is also responsible for the recredentialing of its enrolled providers. Thisrecredentialing occurs every two years after the initial credentialing date.

Appeal of an Adverse Credentialing DecisionProviders who are denied participation in the El Paso First Health Network are notified inwriting and have the right to appeal that determination. Appeals must also be in writing andmade within thirty (30) business days of the date of the denial. The appeal should be directedto:

Chairman, Board of DirectorsEl Paso First Health Network

900 E. Yandell El Paso, TX 79902

Plan TerminationProviders may terminate the agreement with the El Paso First Health Network without causeby giving at least ninety (90) days prior written notice to the El Paso First Health Network.Providers shall continue to provide contracted services to existing members until treatment iscompleted, or until the member can be assigned to another participating provider. The ElPaso First Health Network shall make every effort to minimize the time required in reassigningmembers.





Member Eligibility and Identification

Eligible Medicaid clients who reside in the El Paso Service Area and who receive TemporaryAssistance to Needy Families (TANF) or TANF-related benefits must enroll in the Texas STARProgram. In the El Paso Service Area, individuals receiving Blind and Disabled benefits maychoose to voluntarily enroll in the program, as may Medicaid-eligible members of the TiguaIndian population.

For a more complete listing of mandatory and voluntary eligibles see page F-4, 5 in the TexasMedicaid Provider Procedures Manual by category and program types.

Verifying EligibilityWhen a patient presents as a Texas Health Network or El Paso First Health Network member,providers must verify eligibility through one or more of the following steps:

• Request the Medicaid Identification Form 3087 (to verify Medicaid eligibility).• Request the Texas Health Network Identification Card• Review the monthly Panel report (Appendix A) to identify those patients assigned to

his/her practice.• If the patient does not have either form of identification:

—Call The El Paso First Health Network at 1-877-532-3778 8 a.m. to 8 p.m. CST(7 a.m. to 7 p.m. MST) or

—Use TDH Connect, or—Call AIS 24-hour telephone service at 1-800-925-9126 or 1-512-345-5949.

The Medicaid Identification Form 3087 verifies Medicaid eligibility. The El Paso First HealthNetwork telephone number will appear on the form below the client’s name if they are enrolledwith The El Paso First Health Network.

Plan Identification CardAll Texas Health Network members are issued an identification card upon plan enrollment.This card displays the member’s name, number, date of birth, enrollment date, and indicateswhether or not the member is covered by additional health insurance. The El Paso First HealthNetwork name appears on the center of the card between the member number and the providername. This identification card also lists the designated PCP’s name, address, and daytimetelephone number, in addition to the Member Helpline and FirstHelp™ Clinical Helplinetelephone numbers. A sample Health Plan ID card is located in Appendix B.

Special Needs of the Member PopulationSensitivity to cultural differences is a priority of the Texas Health Network. Located along theMexico-United States border, the El Paso Service Area is comprised of people with diverseethnic, cultural, religious, and racial backgrounds who contribute to the rich heritage of thecommunity.




Knowing and understanding cultural differences, behaving in respectful, sensitive ways, andacknowledging the human dignity of every person are expectations placed upon all TexasHealth Network staff and providers who serve Texas Health Network members. The El PasoFirst Health Network Helpline staff is comprised of local residents who are able to respond tomembers in Spanish as well as English, and can provide additional information about theavailability of local community services.

Interpreter services are always available through the El Paso First Health Network MemberServices Department. Please call The El Paso First Health Network at 1-877-532-3778 toarrange for interpreter services.

El Paso First Health Network Services

Health and Wellness EducationThe Texas Health Network offers a variety of Health and Wellness educational services. HealthEducators and Wellness Coordinators work to assist the PCP in improving the member’s healthstatus by teaching disease prevention and self-management skills. To refer a member forindividual health and wellness education, please call the Texas Health Network at1-888-276-0702.

For more information on Health Education Services, please refer to chapter I.

Case Management ServicesThe El Paso First Health Network Case Management Department is composed of RegisteredNurse Case Managers whose primary role is:

• Telephonic management of high risk pregnancy,• Assisting patients with keeping scheduled appointments,• Arranging for the availability of medical records, and• Assisting with post-discharge care.

The El Paso First Health Network refers its members with case management target diagnoses,and whose needs are beyond the scope of services listed above, to the Texas Health NetworkCase Management Department. The El Paso First Health Network, as an integrated componentof the Texas Health Network, utilizes this Case Management Department, and workscollaboratively with it to coordinate healthcare for its members.

The Texas Health Network Case Management Department is composed of both RegisteredNurses and Social Workers, whose primary responsibilities include:

• Inclusion of member/family in development of their plan of care• Consultation with providers• Assuring consistency and appropriateness of care


• integration of services, and• coordination with appropriate community resources

After receiving the referral from the El Paso First Health Network, the Texas Health NetworkCase Management Department will assess the member for case management appropriateness.If the case management criterion is met, Texas Health Network Case Managers will providecare coordination until the goals of the case management plan have been met.

Providers may contact either the El Paso First Health Network at 1-915-532-3778 or the TexasHealth Network Case Management Intake Unit at 1-888-276-0702 to refer a member for CaseManagement services.

Precertification

Precertification ProcessThe El Paso First Health Network uses a combination of Milliman & Robertson HealthcareGuidelines and Interqual ISD/A criteria in making utilization management and precertificationdeterminations. Providers may request a copy of the guidelines on a procedure basis bymaking a written request to the El Paso First Health Network Utilization ManagementDepartment.

The following procedures require precertification in all places of service except inpatienthospital:

• MRI• MRA• CAT Scans• All Laser Surgeries• Endoscopic Procedures• Podiatry Procedures• pH Probe Tests• Sleep Studies• Specialist to Specialist Referrals• Elective outpatient surgical procedures

Requests for precertification may be made by phone or fax, and must be made four (4) businessdays prior to providing services. The El Paso First Health Network Utilization ManagementDepartment is available between the hours of 8 a.m. to 5 p.m. MST (9 a.m. to 6 p.m. CST).

Phone: 1-915-532-3778Fax: 1-915-532-2286


It is the provider’s responsibility to include sufficient clinical information to process theprecertification request. If initial review of the information submitted indicates the procedure isnot medically necessary, the request will be given to the El Paso First Health Network MedicalDirector for further review and consideration.

If the request for precertification is approved, the provider will be notified by phone and givena precertification number. This number must be entered in the appropriate field of the claimform as specified in the Texas Medicaid Provider Procedures Manual.

Precertification numbers are date sensitive due to clinical and eligibility changes, and arevalid for, and will expire after, thirty (30) days. It is the responsibility of the treating provider toensure that the patient is Medicaid eligible and a member of the El Paso First Health Networkat the time of providing services. The El Paso First Health Network will reissue an expiredprecertification if, following a PCP or specialist-requested review, the precertification requestis still medically appropriate.

Precertification of Inpatient ServicesEl Paso First Health Network members must utilize hospitals that have contracted with theTexas Health Network for all inpatient services. Inpatient services are precertified by BDHMC,and are discussed in detail in Chapter III of this manual.

Claims for facility services should be submitted to the Texas Health Network claims administrator,NHIC, and must adhere to all requirements specified in this and the Texas Medicaid ProviderProcedures Manual.

Appeals of Precertification DenialsThe El Paso First Health Network has defined two levels of appeal and arbitration asopportunities for reconsideration of denials.

Level I AppealInitial requests for appeal of a precertification denial must be made in writing and sent to thefollowing address:

Utilization Management DepartmentEl Paso First Health Network

2501 N. Mesa St.El Paso, TX 79902



Appeals should include the following information:

• Member Name and Medicaid ID Number• Date of Service• Authorization Number, if applicable• Provider Name and Identification• New information regarding the circumstances of care that justify the appeal.

The clinical information regarding the Level I appeal is reviewed by a specialist who is appointedby the El Paso First Health Network Medical Director, and who practices the same specialtyas the appealing physician. Following review, a written determination is rendered.

A written notification of the decision is forwarded to the appealing provider within thirty (30)days of receipt of the appeal. The appealing provider has ninety (90) days from the receipt ofthis notification to request a Level II Appeal.

Level II AppealIf the appealing provider is dissatisfied with the Level I decision, he/she may direct a follow-upappeal to the El Paso First Health Network Utilization Management Department. This secondwritten appeal should contain either new information or justification of further consideration.The El Paso First Health Network Medical Director will convene a meeting of the AppealsCommittee. The Appeals Committee will include providers who were not involved in the originaldenial, including a provider of like-specialty to the appealing provider who will be consideredthe “Expert” opinion. In addition, one member of the Board of Directors will participate on theCommittee.

The appealing provider may either be present at the Appeals Committee meeting or may senda designee. The appealing provider may not participate in the Appeals Committee deliberations.A written determination will be rendered within 30 days from the date the Level II appeal wasfiled.

Should the appealing provider continue to be dissatisfied with the determination, as per theProvider Agreement, arbitration may be initiated by making a written request to the El PasoFirst Health Network Medical Director.

Expedited AppealsIn situations when it is determined that serious medical consequences to the member mayresult from a delay in the reconsideration of the precertification request, an expedited reviewis possible. The provider should contact the El Paso First Health Network Medical Director,who will render an opinion regarding the requested services.


Claims Administration

Claims Processing/ReimbursementThe El Paso First Health Network is responsible for the processing and payment of claims forphysician, radiology and laboratory services provided to El Paso First Health Network membersreceiving TANF and TANF-related benefits. The El Paso First Health Network accepts claimsfor all physician services—both inpatient and outpatient—including those provided foranesthesiology, inpatient hospital visits, consultations, and emergency services. The El PasoFirst Health Network also accepts claims for the professional component of inpatient radiologyand laboratory services.

BDHMC will continue to administer facility services for all Texas Health Network members.NHIC, the Texas Medicaid Program Claims Administrator, will process claims for all facilityservices, all claims for voluntary members, and all claims for members of the Texas HealthNetwork Primary Care Case Management (PCCM) model. Facility services follow the policiesand procedures specified in this and the Texas Medicaid Provider Procedures Manual.

Figure XIII-1 on the following page details the responsibilities of each entity involved in theprocessing and payment of claims for services provided to El Paso First Health Networkmembers.





Figure XIII-1Claims Matrix


Claim SubmissionProviders may submit claims electronically to the El Paso First Health Network using a varietyof formats, including the National Standard Format (NSF 2.0), HCFA 1500 and ANSI X.12-837. For more information on electronic billing please contact the El Paso First Health NetworkInformation Services Department at 1-915-532-3778. Traditional paper claims should be sentto the following address:

ATTN: Claims DepartmentEl Paso First Health Network

P. O. Box 971100El Paso, TX 79997-1100


Filing Deadlines and Claim Filing RequirementsProviders participating in the El Paso First Health Network must adhere to the same 95-dayfiling deadline and claims filing instructions detailed in the Texas Medicaid Provider ProceduresManual.

Questions concerning claims for physician, radiology, or laboratory services should be directedto the El Paso First Health Network at 1-915-532-3778.

Questions regarding the status of claims for all other Medicaid covered services should bedirected to either BDHMC or NHIC. See Chapter VI-II for more information.

Remittance and Status ReportEl Paso First Health Network providers will receive a Remittance and Status Report from theEl Paso First Health Network for physician, laboratory and radiology services provided toTANF and TANF-related El Paso First Health Network members. This Remittance and StatusReport will accompany each check issued by the El Paso First Health Network. Provider checksand Remittance and Status Reports are printed weekly and mailed on Fridays.

Appeals of Claim DenialsProviders have the right to appeal claim denials. Appeals must be received within 180 days ofthe date printed on the Remittance and Status Report on which that claim appears. To appeala claim denial to the El Paso First Health Network, please follow the appeal procedures outlinedin the Texas Medicaid Provider Procedures Manual, Part I, Section 5, and submit to the followingaddress:

El Paso First Health Network2501 N. Mesa St.

El Paso, TX 79902

To electronically submit your appeals to the El Paso First Health Network, please contact theEl Paso First Health Network Provider Relations Department at 1-915-532-2011.




Provider Number 999999999 Texas Health NetworkMonthly Panel Report

JONES, JANE, CNM

1000 UNIVERSITY BLVD

GALVESTON, TX 77550 February 2000

JONES, JANE, CNM

Medicaid Id Last Name First Name MI Birth Date Sex SSN Address

555555554 DOE PATTI 11/15/1995 F 999-99-9999 20100 PORDE PLACE

555555553 DOE JOHN 6/15/1974 M 999-99-9999 462 LANTER ST

555555552 DOE BRYAN 3/27/1962 M 999-99-9999 21555 CHERRY PLACE

555555551 DOE TERRY 9/23/1998 M 999-99-9999 2500 DOGWOOD ST

555555559 SMITH WILMA 3/22/1979 F 999-99-9999 2656 SHORT ST

555555558 SMITH MELISSA 11/15/1973 F 999-99-9999 15691 DEER GLEN

555555557 SMITH MARINA 7/17/1975 F 999-99-9999 17452 MOUNTAIN BLVD

555555556 SMITH DONNA 6/12/1980 F 999-99-9999 27777 MIDWAY ST

555555555 SMITH TERRI 11/3/1976 F 999-99-9999 987 E CHRISTINE ST

Total Members Enrolled with Provider CN00M89A7: 9

This member may be due for THSteps screening. Please continue to verify eligibility with themember’s Form 3087 and through the AIS line at 1-800-925-9126.

Tuesday, February 1, 2000

Case Due for

City Zip Code Number New Default THSteps

PORTER 77365 062929645

NEW CANEY 77357 000907353 Y

NEW CANEY 77357 052534558

NEW CANEY 77357 000783613

HUFFMAN 77336 022300765

CONROE 77302 057049073

NEW CANEY 77357 065453135

SPLENDORA 77372 064865577 Y

SPLENDORA 77327 065476649

Member Name

Member's Medicaid Number Phone

Date of Birth

MEMBER INFORMATIONMEMBER INFORMATIONPCP INFORMATIONPCP INFORMATION

REFERRAL TO TEXAS HEALTH NETWORKREFERRAL TO TEXAS HEALTH NETWORKREFERRING PROVIDER INFORMATION (If Different from PCP)

Provider Signature Referral Date

/ /

/ /

Provider/Facility Name

Medicaid Provider # (if known)

Appointment Time and Date

Address Phone

Reason For Referral ( Check all that apply )

This notice authorizes the following care:

____ Evaluation Only

____ Evaluation and Single Treatment

____ Evaluation and Treatment

Number of Treatments ____

Other (Specify)

Initial consultations are for one visit only for evaluation and development of a treatment plan unless otherwise specified. All consultations require a written report (preferably typed and attached to this form) to the PCP and phone conferences as necessary to assure continuity of care. Referrals are valid for 30 days from the time of issue and it is the consulting provider's responsibility to verify eligibility prior to delivering services. Consulting providers may not authorize secondary referrals. All requests for additional services or visits to other providers must come through the PCP. All claims are subject to retrospective review for purposes of determining eligibility, benefit coverage, appropriateness, and medical necessity. Claims payment may be affected by review findings.

Consultant Comments:

Consultant Signature Date

Please return findings and report to PCP listed above.

Fax to Health Services at (512) 302-0318

CONSULTING PROVIDER/FACILITYCONSULTING PROVIDER/FACILITY

REFER TO TEXAS HEALTH NETWORK FOR CASE MANAGEMENT SERVICES?

[ ] Asthma[ ] Behavioral/Psych Disorders[ ] Children with special needs[ ] Chronic Conditions

[ ] Hypertension[ ] Diabetes[ ] High Risk Pregnancy[ ] Other _____________________

Provider Name

Medicaid Provider Number

Contact Name and Phone Number

Provider Name

Medicaid Provider Number

Contact Name and Phone Number

Revised January 2001

Reason for Referral:

Referral Form

Reason For Referral ( Check all that apply )

REFER TO TEXAS HEALTH NETWORK FOR HEALTH EDUCATION?

[ ] Dental Health[ ] Tobacco Use[ ] Asthma[ ] Diabetes[ ] Exercise[ ] Nutrition[ ] Childhood Illnesses _____________________[ ] Parenting[ ] Other _____________________

[ ] New Diagnosis _____________________[ ] Prenatal[ ] Transportation[ ] Community Resources ___ Housing ___ Utility ___ Food ___ Childcare ___ Other _____________________

TO THE CONSULTANTTO THE CONSULTANT

Precertification Request

PHONE: (888) 302-6167 Fax: (512) 302-5039 Please print all information on this form.

PHONE: (888) 302-6167 Fax: (512) 302-5039 Please print all information on this form.

Date: Name of Person Completing Form:

Office Number:

Fax Number:

Member Name:

Member ID Number:

Primary Care Provider:

Requesting Provider Name:

Facility:

Diagnosis(s):

Service(s)/Procedure(s) you are requesting:

CPT 4 Codes:

Date of Services:

Estimated LOS Required:(number of days requesting)

DOB: Sex: M or F

Provider Number:

Provider Number:

Provider Number:

ICD-9 Code(s):

Medical History (Please attach all documentation relevant to the requested procedure)

BELOW THIS LINE FOR TEXAS HEALTH NETWORK USE ONLY

Approved Denied Precertification Number:

Authorization Dates: From: To:

Services authorized if different than requested:

Precertification Nurse: Medical Director:

Precertification is a condition for reimbursement. It is not a guarantee of payment. It is the responsibility of each provider to verify the member's eligibility prior to the services being rendered.

Inpatient Outpatient Day Surgery 23 hr Observation

Physician's Office Surgical Assist Required

Anesthesia Required Case Management May Be Required

May Require Special Services Upon Discharge (i.e. DME, HomeHealth, Skilled Nursing Facility)

TEXAS HEALTH NETWORKNotification of Hospital Admissions

Today====s Date:________________________ Facility Name:_____________________________ Facility Provider #:_______________________

Facility Fax #:________________________ Facility Ph #:______________________________ Contact Person:_________________________

Hospital UR Nurse and Phone #:__________________________________________________________________

Client Name(last, first, middle)

ClientMedicaid #

(PCN)

Date ofBirth

AdmitDate

Attending MD andPhone #

Diagnosis Precertification /Certification

Number(BDHMC Use Only)

ReferenceNumber(BDHMC Use

Only)

COMMENTS

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Please fax form to: Texas Health Network Fax: (512) 302-5039 Phone: (888) 302-6167Birch & Davis Health Management Corporation

TEXAS HEALTH NETWORK BDHMC Pre-Contractual/Recredentialing Site and Medical Record Evaluation

Provider Name: _________________________Provider #: ______________________________ Address: ______________________________ City: ________________ Zip: _______________ Phone: ________________________________Date: _______________________________

Criteria Meets Criteria

Comments (include provider's comments regarding any criteria not met)

Y N N/A (COP) Condition of Participation OFFICE APPEARANCE: 1) APPEARS CLEAN COP 2) SIGNAGE CLEARLY VISIBLE 3) IN GOOD REPAIR COP 4) NOT ODOROUS 5) ADEQUATE SEATING COP 6) GOOD VISIBILITY FROM RECEPTION AREA

OFFICE SPACE: 7) REST ROOMS AVAILABLE COP 8) REST ROOMS ADEQUATE COP

9) REST ROOM(S) WHEELCHAIR ACCESSIBLE COP

10) NUMBER OF EXAM ROOMS ADEQUATE COP

11) EXAM ROOMS WELL-EQUIPPED COP

EMERGENCY PREPAREDNESS: 12) EMERGENCY EQUIPMENT AVAILABLE

13) WHAT TYPES OF EQUIPMENT

14) STAFF KNOWLEDGEABLE OF EQUIPMENT COP

15) STAFF TRAINED IN CPR

16) EMERGENCY NUMBERS POSTED

SAFETY: 17) SMOKE ALARMS COP

18) FIRE EXTINGUISHER COP

19) EXIT SIGNS COP

20) PASSAGEWAYS CLEAR COP

HANDICAPPED ACCESS: 21) WHEELCHAIR RAMP COP

22) WIDE DOORS COP 23) ELEVATORS (N/A IF SINGLE STORY) COP

STAFF: 24) COURTEOUS COP 25) ANSWER PHONES PROMPTLY COP 26) APPEAR KNOWLEDGEABLE

27) NEAT/WELL GROOMED

MEDICAL RECORDS: 28) INDIVIDUAL CHARTS FOR EACH MEMBER COP

29) STORED IN DEDICATED SPACE COP

30) PERSONAL/BIOGRAPHICAL DATA PRESENT COP

31) PROVIDER IDENTIFICATION & DATE COP

32) LEGIBLE COP

33) ALLERGIES NOTED PROMINENTLY COP

34) HEALTH ED/PREVENTIVE SVS NOTED COP

35) ADVANCE DIRECTIVES OFFERED (ADULTS)

36) CONFIDENTIALITY MAINTAINED COP

Determination: Reviewer: ADDENDUM LEP QUESTION: Do you have access to translation services if needed for members with limited English language skills?

***Offer phone #s for translation services if needed

Texas Health NetworkPrimary Care Provider Application

I am applying to the Texas Health Network as (please check one):

ë A M.D. specializing in (check one of the following):

ë General Practiceë Family Practiceë Internal Medicineë Obstetrics-Gynecologyë Pediatricsë Other (please specify)

ë An Advanced Practicing Nurse specializing in (check one of the following):ë General Practiceë Family Practiceë Women=s Healthë Pediatrics

ë A D.O. specializing in (check one of the following):

ë General Practiceë Family Practiceë Internal Medicineë Obstetrics-Gynecologyë Pediatricsë Other (please specify)

ë A Freestanding Rural Health Clinic

ë A Hospital/Provider Based Rural Health Clinic

ë A Federally Qualified Health Center

ë Certified Nurse MidwifeI would like to have a maximum capacity of ________________Texas Health Network patients .

Section I Provider Practice InformationIf you have more than one office location in which you provide primary care services, please complete the Provider Practice Information for each location. Additional locationinformation should be listed in the space provided on page 2.

NAME: (Last) (First) (MI)

CLINIC/GROUP NAME (if applicable):_________________________________________________________________ Group Medicaid Provider Number

ADDRESS:_______________________________________________________________________________________________________________ Street City Zip County Medicaid Provider Number

TELEPHONE:________________________________________ FAX:___________________________________________________

INTERNET EMAIL ADDRESS: _______________________________________________________

FEDERAL TAX ID #___________________________SOCIAL SECURITY #______-_____-_________

LANGUAGES SPOKEN (self or staff):

AGE RANGE OF PATIENTS SEEN: From__________ To___________

ARE YOU A CURRENTLY ENROLLED THSteps PROVIDER? ____ Yes ____ No If yes, EPSDT # ___________________

PRACTICE LIMITED TO:______Male only _____Female only _____Current PatientsOFFICE HOURS

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Open

Close

Open

Close

PRACTICE LOCATION #2

NAME:______________________________________________________________________________________(Last) (First) (MI)

CLINIC/GROUP NAME (if applicable):__________________________________________________________ Group Medicaid Provider Number

ADDRESS: Street City Zip County Medicaid Provider Number

TELEPHONE:________________________________________ FAX:______________________________________________________

FEDERAL TAX ID #_ _SOCIAL SECURITY # - - _________

LANGUAGES SPOKEN (self or staff): ____________________ _____________________ ______________________


PRACTICE LIMITED TO:______Male only _____Female only _____Current PatientsOFFICE HOURS


Open

Close

Open

Close

PRACTICE LOCATION #3

NAME:______________________________________________________________________________________(Last) (First) (MI)

CLINIC/GROUP NAME (if applicable):__________________________________________________________ Group Medicaid Provider Number

ADDRESS:_________________________________________________________________________________________________________ Street City Zip County Medicaid Provider Number

TELEPHONE:________________________________________ FAX:______________________________________________________

FEDERAL TAX ID #___________________________SOCIAL SECURITY #______-_____-_________

LANGUAGES SPOKEN (self or staff): ____________________ _____________________ ______________________


PRACTICE LIMITED TO: Male only Female only Current PatientsOFFICE HOURS


Open

Close

Open

Close

Section II

Texas Medical License#:______________________________CLIA #(if applicable):_______________________

Ethnicity GWhite GBlack GHispanic GAmerican Indian/Alaskan GAsian/Pacific Islander GOther

Gender GMale GFemale Date of Birth____________________

Federal DEA Number__________________________________________________________________________ Expiration Date

Section III BOARD CERTIFICATION STATUSGNot Board Certified GBoard Qualified Until When:__________________

GBoard Certified Date:_________________American Board of_______________________________________Recertified: GYes GNo If Yes, Please Give Date:___________________________________

GBoard Certified Date:_________________American Board of_______________________________________Recertified: GYes GNo If Yes, Please Give Date:___________________________________

GOsteopathic Board Certified Date:______________Name of Board___________________________________

Section IV Malpractice Insurance Information (attach a copy of cover page of insurance policy)

Full Name of Insurance Carrier:___________________________________________________________________

Amount of Coverage:______________________________________Expiration Date:________________________ Occurrence/Aggregate

Section V Current Hospital Affiliations

Please list your current hospital affiliations. (Attach an additional page if necessary.)

HOSPITAL ADDRESS TYPES OF PRIVILEGES (full, courtesy, etc.)

______________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Do you currently care for your patients that are admitted to the hospital? Yes_____ No______If you see children, do you have active pediatric admitting privileges? Yes_____ No______

Section VI Continuous Coverage Information

What arrangements do you have for continuous coverage? (Please include name and phone number of individuals providingcoverage)

____________________________________________________________________________________________Name/Specialty Telephone Number____________________________________________________________________________________________Address City

____________________________________________________________________________________________Name/Specialty Telephone Number____________________________________________________________________________________________Address City

EDUCATIONPREMEDICAL EDUCATION:

Institution:_____________________________________________Degree/Major_____________________________________

City/State:_____________________________________________Dates:_____________________to_____________________

MEDICAL EDUCATION:

Institution:_____________________________________________Degree/Major_____________________________________

City/State:_____________________________________________Dates:_____________________to_____________________

INTERNSHIP(S):

Institution:_____________________________________________Dates:_____________________to_____________________

Address:________________________________________City:__________________________State:________Zip:_________

Program Director:__________________________Specialty_____________________________Completed? QYes QNo

RESIDENCY(IES):




FELLOWSHIP(S):




TEACHING APPOINTMENT(S):




CONFIDENTIAL PAGE - CREDENTIALING DATA

Within the past 5 years Please check: Yes No

1. Have you ever been rejected for membership or notified by or requested to appearbefore any medical or osteopathic society?

2. Have you been denied the privilege of taking an examination administered by a US Stateand/or Canadian provincial licensing agency?

3. Have you, in any US State, Canadian province and/or other foreign country, been denied a license to practice medicine; or have you ever had your medical license restricted, revoked, suspended or canceled?

4. Have you been denied staff membership with any licensed hospital, nursing home, clinic, health maintenance organization or other hospital care facility with an organized medical staff?

5. Have you been warned, censured, discipline, had admissions monitored, had privilegeslimited, had privileges suspended (except for temporary suspensions forincomplete or delinquent medical records), been put on probation, or beenrequested to withdraw from any licensed hospital care facility with an organizedmedical staff, in which you have trained, been a staff member, or held hospitalprivileges?

6. Have you been requested to resign, withdraw, or otherwise terminate your position with a medical partnership, professional society or association, corporation, health maintenance organization, or other medical practice organization, either public or private, or has such position(s) ever been canceled, revoked or censured?

7. Have you for any reason, lost or been denied certification by a specialty board; or has your eligibility status changed with respect to certification by any specialityboards?

8. Have you voluntarily surrendered a license issued to you by a US State, Canadian province and/or other foreign country licensing agency?

9. Have you been notified or requested to appear before any US State, Canadian province and/or other foreign country licensing or disciplinary agency?

10. Have you been notified of any changes or complaints filed against you with anyUS State, Canadian province and/or other foreign country licensing or disciplinaryagency?

11. Are you now using, or have you used, alcohol (except socially), narcotics, barbiturates, or other drugs affecting the central nervous system, or other drugswhich cause physical or psychological dependence?

CONFIDENTIAL PAGE - CREDENTIALING DATA (Continued)

Within the past 5 years Please check: Yes No

12. Have you now or had any chronic or physical or emotional impairment(s) which would adversely affect your ability to practice medicine and/or surgery?

13. Are you now being treated for any mental illness, drug addiction or alcohol problems?

14. Have you ever been denied a Drug Enforcement Administration (DEA) registration certificate or been called before or warned by the DEA?

15. Have you surrendered your state or federal controlled substance registration (DEA or DPS) or had it restricted in any way?

16. Have you been arrested, fined (over 100, charged with or convicted of a crime (other than minor traffic violation), indicted, imprisoned, or placed onprobation?

17. Have you forfeited collateral for breach or violation of any law, policy regulations, or ordinance whatsoever; been summoned into court as a defendant; or has any law suit ( other than malpractice suits) been filed against you?

18. Have you been a defendant in a legal action involving professional liability (malpractice); has a professional liability claim paid in your behalf; or paid such a claim yourself (only within the last five years)?

19. Are there any professional liability ( malpractice) claims against you pending at this time?

20. Has your professional liability insurance been denied, canceled, or non- renewed?

21. Have you been sanctioned by Medicare and Medicaid and/or expelled orsuspended from receiving payment under the Medicaid or Medicare Program?

22. Do you have or have you had any conditions or impairment which would interfere with your ability to perform the essential functions of the position, withor without accommodations or which poses a potential risk to the health of yourpatients?

NOTE: Please use a separate page to explain all AAYES @@ answers to the previous questions.

ALL QUESTIONS MUST BE ANSWERED TO CONSIDER THIS APPLICATION COMPLETE

ATTACH THE FOLLOWING TO YOUR COMPLETED APPLICATION:

1. Copy of each current Medical License

2. Copy of your current face sheet of your current professional liability insurance policy

3. Copy of your medical degree, internship, residency, and fellowship certifications

4. Copy of your board certification, recertification or letter from specialty board

5. Copy of your current DEA (Federal) certificate

6. Copy of your current DPS (State) Certificate

7. Copy of your current Curriculum Vitae, please include work history

8. Two copies of Provider Agreement with original signatures

ATTESTATION AND CREDENTIALS VERIFICATION RELEASE FORM

I hereby acknowledge and agree that TDH or its designated agent has a valid interest in obtaining and verifying informationconcerning my professional competence, in determining whether to enter into an agreement with me for the provision ofmedical services to members of its prepaid health care plan. Accordingly,

I represent and warrant to TDH or its designated agent that the information contained in the foregoing applicationis true and complete to the best of my knowledge and belief, and I agree to inform TDH or its designated agentpromptly if any material change in such information occurs, whether before or after my entering into an agreementwith TDH or its designated agent for the provision of medical services.

I authorize TDH or its designated agent to consult with hospital administrators, members of medical staff ofhospitals, malpractice carriers, National Practitioner Data Bank, and other persons to obtain and verify informationconcerning my professional competence, character, and moral and ethical qualifications, and I release TDH or itsdesignated agent and its employees and agents from any and all liability for their acts performed in good faith andwithout malice in obtaining and verifying such information and in evaluating my application, and

I consent to the release by any person to TDH or its designated agent of all information that may be reasonablyrelevant to an evaluation of my professional competency, character and moral and ethical qualifications, includingany information relating to any disciplinary action; suspension or curtailment of surgical-medical privilege; malpracticeallegations; felonies and hereby release any such person providing such information from any and all for doing so.

I understand that if I am applying as a primary care provider, an initial site visit may take place to review site andmedical record keeping practices.

Print Full Name_________________________________________________________________ Last First MI

Signature_________________________________________Date_________________________

Birch & Davis Health Management CorporationMarch 8, 1999

DIRECTIONS: This is an Authorization for the Release of Information to your Primary Care Provider (PCP).

Releasing this information to your Primary Care Provider serves you, the member, in many ways. Three of these reasonsare:

1. Your Primary Care Provider has the total responsibility of your medical care.2. A Mental Health or Substance Abuse condition can have medical implications as well. Without having the total picture of

the member’s health, the Primary Care Provider will not be able to treat the member fully.3. If your Primary Care Provider is aware of all medication you are taking, he or she will be more able to ensure no adverse

drug interaction occurs.

PLEASE FILL OUT THE BELOW INFORMATION:

Name Address

( )City, State Phone

authorize

to disclose to Primary Care Provider:Address

( )City, State Phone

do certify this release of information to be from (date) ____________________ to (date) ____________________ andallow the following information to be released: (Please indicate what , if any, information you would like to release.)

Total Medical Records to be released to Primary Care ProviderMedication Information Only to be released to Primary Care ProviderMedical Records to Health Plan

I understand that my records are protected under Federal (42 CFR Part 2) and/or State Confidentiality Regulations. Thisauthorization may be withdrawn at any time in writing except to the extent that the program or person which is to make thisdisclosure has acted in reliance on it. Upon revocation of authorization, further release of information shall cease immediately.File copy is considered equivalent to the original. This release of information expires in thirty (30) days or sixty (60) daysfollowing completion or termination of treatment, whichever is later.

I further acknowledge that the information to be released was fully explained to me and this consent is given of my own free will.

EXECUTED THIS DAY OF ,

(Witness) (Patient)

(Parent, Guardian or Authorized Representative, if required)

The person signing this authorization is entitled to a copy.

TO THE RECIPIENT OF CONFIDENTIAL INFORMATION: PROHIBITION ON DISCLOSURE

If the information disclosed to you is related to substance abuse treatment, these records’ confidentiality is protected by FederalLaw. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consentof the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medicalor other information is not sufficient to release substance abuse records. The Federal Rules restrict any use of the information tocriminally investigate or prosecute any substance abuse patient. State laws may also protect the confidentiality of patient’s records.

Behavioral Health Consent Form

INSTRUCTIONS FOR COMPLETINGPROVIDER INFORMATION CHANGE FORM

SIGNATURES:♦ The provider’s signature is required on the attached document for any/all

changes requested for individual practitioner provider numbers.♦ Signature by the authorized representative of a group or facility is

acceptable for changes requested for group/facility provider numbers.

ADDRESS:♦ Performing providers* may NOT change accounting information.

(* a physician performing services within a group)

TAX IDENTIFICATION NUMBER:♦ T.I.N. changes for individual practitioner provider numbers can only be

made by the individual to which the number is assigned.♦ Performing providers CANNOT change T.I.N.

GENERAL:♦ Forms will be returned unprocessed if the nine-digit provider number is not

indicated on the attached form.♦ W-9 form is required for all name and T.I.N. changes.

PROVIDER INFORMATION CHANGE FORM

Complete this form to update your provider file(s). Fax the completed form or mail to the appropriate entity.PLEASE PRINT OR TYPE THE INFORMATION SUBMITTED ON THIS FORM.

Date: __________________ Nine-digit Medicaid provider number:_______________________________________

If you have more than one Medicaid number that will also be using this same information, list the other provider numbers:

___________________________________________________________________________________________________

Physical Address Accounting/Mailing Address Secondary Address(Cannot be a P.O. Box) (W-9 Form Required) (Plan Use Only)

______________________________ ______________________________ ______________________________

______________________________ ______________________________ ______________________________

______________________________ ______________________________ ______________________________

______________________________ ______________________________ ______________________________Telephone Telephone Telephone

______________________________ ______________________________ ______________________________Fax Fax Fax

Type of Change: (please check the appropriate selection below)! Change of Physical Address, phone and/or fax number! Change of Billing/Mailing Address, phone and/or fax number! Change/Add Secondary Address, phone and/or fax number! Change of provider status (i.e., termination from plan, moved out of area, specialist, etc.), please give explanation! Other (i.e., panel closing, capacity changes, age acceptance, etc.)

Explanation Required: _________________________________________________________________________________

_________________________________________________________________________________

Tax Information: IRS ID Number _____________________________________ Effective Date: _________________

List the exact name reported to the IRS for the above Tax ID number: _____________________________________________

Must be signed and dated or changes cannot be completed:

Provider Signature: ________________________________________ Date: __________________

Email Address: ____________________________________

Send your completed change forms to: If Managed Care, please send this form via mail or faxto NHIC c/o your respective plan.

Texas Health NetworkAttn: Credentialing/Contracting Department NHICP.O. Box 14685 Attn: Provider EnrollmentAustin, TX 78761 12545 Riata Vista CircleFax: (512) 302-4043 Austin, TX 78727

Fax: (512) 514-4214_______________________________ __________ ________________________________ ____________BDHMC representative signature Date NHIC representative signature Date

9/14/98 draft

1MEDICAID MANAGED CARE PHYSICAL HEALTH FOCUS STUDY

WELL CHILDMEDICAL RECORD AUDIT TOOL

Reviewer________________________________ Date of Audit____________ Study Period_______________________________

PCP Number: Type:Member name Last: First: MI:Gender Male FemaleRace Caucasian African Am Hispanic Am Indian Asian OtherCounty of ServiceMedicaid #Date of Birth

Answer all questions by checking the appropriate boxes or filling in the blanks.

Record excluded?yes no

Reason for exclusion

a. not produced b. wrong age c. other----specify ____________________________________

If excluded, stop—do not continue

Comments:

Definition:

Eligibility: Random sample is based on all enrollees with six (6) months of continuous eligibility. The child must havereached the age of 28 months at any time during the reporting period.

9/14/98 draft

2

THSTEPS MEDICAL CHECKUPS Documentation Elements TH Steps Medical Checkups in the First 24 Months of LifeDate of Visit #1 #2 #3 #4 #5 #6 #7 #8 #9 #10

NEWBORN5 Proxy ElementsNeonatal History Physical Exam Including Vital Signs Newborn Screening Laboratory Tests Height/Weight/CircumferenceRecorded and Graphed

Nutrition Evaluation – Breast or BottleFeeding Mentioned

Supplemental ElementsHealth Education/Parenting Family History Environmental Tobacco Exposure 2 TO 24 MONTHS5 Proxy ElementsHealth History/Parental Concerns Physical Exam Including Vital Signs Developmental Screening Height/Weight/CircumferenceRecorded and Graphed

Immunizations Supplemental ElementsLab: i.e., Hemoglobin/Hematocrit andLead Screening

Health Education/Parenting – 2-12 mo.(e.g. Nutrition, Safety), 15-48 mo. (e.g.Environmental Tobacco Exposure,Safety)

Environmental Tobacco Exposure (2-12mo.), Dental Referral (15-48 mo.)

No evidence of required elements

No THSteps Medical Checkups in the First 24 Months of Life

Comments

DefinitionsNewborn Screening Laboratory Tests : Newborn screening [hereditary/metabolic testing (hypothyroidism, PKU, Galactosemia, sicklehemoglobin, congenital adrenal hyperplasia)] is required by Texas law at hospital discharge and between one and two weeks old.Date of second screen should be documented during first office THSteps medical checkup first year of life. If Hemoglobin Type hasbeen done and results are documented in chart, it does not need to be repeated. Hgb type also part of the newborn screening. (Takenfrom the TDH 1998 Texas Medicaid Service Delivery Guide, page 3-5.)THSteps Medical Checkups: THSteps medical checkups are required in accordance with the THSteps Medical Checkups PeriodicitySchedule. Includes newborn office visits and inter-periodicity well child visits and office visits done by PPC or other PCPs outside ofplan. To count as a THSteps medical checkup, medical record documentation must include a note indicating a visit with a primarycare provider, the date on which the well-child visit occurred, and at a minimum, the 5 required elements listed above. A child isconsidered to have received a well-child visit if he or she had a claim/encounter from a PCP that meets the coding definition on page 5of the Well Child Focus Study Instructions. Inpatient, emergency room, mental health, chemical dependency and specialist visitsshould not be counted as a well-child visit. Preventative services may be rendered on the occasion of visits other than well-childvisits. If the specified codes are present, these services may be counted regardless of the primary intent of the visit.

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IMMUNIZATIONSImmunization Date Received Name of

AntigenVaccine LotNumber

Signed orInitialed

Exclusion Codes1=Contraindication2=Against parental religious beliefs

- - Yes No - - Yes No - - Yes No

DPT(DPT or DTaP)

- - Yes No

1 2

- - Yes No - - Yes No

OPV(IPV/OPV)

- - Yes No

1 2

MMR - - Yes No 1 2 - - Yes No - - Yes No - - Yes No

HiB

- - Yes No

1 2

- - Yes No - - Yes No

HBV

- - Yes No

1 2

*Vaccine Lot Number: Name(s) of the specific antigen OR vaccine lot number(s) can be counted for entries made in the medicalrecord at the time the immunization was given.Comments

DefinitionsImmunizations: Children must be immunized during medical checkups according to the TDH Routine Immunization Schedule by ageand immunizing agent. The checkup provider is responsible for administration of immunizations (do not refer to local healthdepartments). For children not previously immunized, TDH requires that immunizations be done unless medically contraindicated oragainst parental religious beliefs. (Taken from the TDH 1998 Texas Medicaid Service Delivery Guide, page 4-1.)

Refer to “Recommended Ages for Administration of Currently Licensed Childhood Vaccines” in the TDH Texas Medicaid ServiceDelivery Guide, page 4-2. According to this guide, a 2-year-old is considered to be up to date if he/she has received the following:

4 Diphtheria, Tetanus, Pertussis Vaccinations (DPT or DTaP)3 Oral Polio Vaccinations (IPV/OPV)1 Measles/Mumps/Rubella (MMR)3 Hepatitis B Vaccinations (HBV)4 Hemophilus Influenza B Vaccinations (HiB)

For immunization information obtained from the patient history, plans may count the immunization if the medical record contains thefollowing information: a dated immunization history or a note indicating the name(s) of the specific antigen and the date theimmunization(s) was given.

Entries made in the medical record at the time the immunization(s) was given must include a note indicating the name(s) of thespecific antigen and the date the immunization(s) was given or the vaccine lot number(s) of the specific antigen and the date theimmunization(s) was given. A certificate of immunization prepared by an authorized health provider or agent must include thespecific dates and types of immunizations administered. All medical record entries must be dated by the child’s second birthday (i.e.,entries made retroactively may not be counted). A note that the “member is up-to-date” with immunizations without a listing of thedates all immunizations were given and the names of the immunization agents does not constitute sufficient evidence ofimmunization.

Look for all immunizations documented on or before the second birthday. Look as far back as possible in the medical recordfor contraindications for immunizations, for evidence that a child is immunocompromised, or for evidence that immunizationsare against parental religious beliefs. These cases may be excluded. See Table 1 of Well Child Focus Study Instructions forContraindications for Childhood Immunizations.

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LEAD SCREENINGLead ScreeningDate

Lead Level Follow-up plan documented in themedical record (follow-up leadscreen, treatment) for AbnormalLead Screening Results (≥≥ 10 ug/dL)

NOTE: Find the highest leadlevel ≥≥ 10 ug/dL and look forfollow-up plan.

Follow-up (follow-up lead screen,treatment) for Abnormal LeadScreening Results (≥≥ 10 ug/dL)

NOTE: Find the highest leadlevel ≥≥ 10 ug/dL and look forfollow-up lead screening ortreatment.

- - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No - - ug/dL Yes No Yes No

Lead ExposureQuestionnaireDate - - - - - - - - - -

Comments

Definitions

Lead Screening: It is mandatory that children be tested in accordance with the THSteps Medical Checkups Periodicity Schedule. Alead concentration of greater than or equal to 10ug/dL are reflected as above the acceptable limit and follow-up activities are to beimplemented.

To identify lead screening, look for laboratory reports that involve actual blood level analysis on or before the second birthday.

To identify a follow-up plan for lead screening results greater than or equal to 10 ug/dL, documentation must address repeat testingand/or medical treatment. This could be noted in the progress notes, physical exam, or other physician documentation.

To identify follow-up for lead screening results greater than or equal to 10 ug/dL, documentation should reflect that repeat testingand/or medical treatment occurred. This could be noted in the progress notes, physical exam, laboratory reports, or other physiciandocumentation.

Lead Exposure Questionnaire: Lead screening involves actual blood lead analysis or completion of a parent questionnaire (withappropriate action taken depending on the answers). Blood lead analyses are mandatory at ages 12 and 24 months. At certainTHSteps periodic visits, the parent questionnaire may be administered. The parent questionnaire is found in the TDH Texas MedicaidService Delivery Guide. There is also an abbreviated questionnaire that may be used for children with previously recorded normalblood level. Look for all questionnaires dated on or before the second birthday.

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MEDICAID MANAGED CARE PHYSICAL HEALTH FOCUS STUDYASTHMA IN CHILDREN

MEDICAL RECORD AUDIT TOOL


PCP Number:Asthma Specialist Number:Member name Last: First: MI:Gender Male Female Race White African Am Hispanic Am Indian Asian Other/UnknownCounty of ServiceMedicaid #Date of Birth

Answer all questions by checking the appropriate box or filling in the blanks.

Record excluded? Yes No

Reason for exclusionRecord not availableWrong ageNo asthmaEnrolled< 6 mo.Other----specify_____________________________________________________


Definitions

Eligibility: Members eligible for the study must meet the following criteria:(a) The member must be a child between the ages of 2 to19 years for at least three months during the study period.(b) The member must have been enrolled continuously in the MCO for at least 6 consecutive months during the study

period. (c) The member must have at least two asthma encounters (493xx) during the study period.

Comments:

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PCP and SPECIALIST VISITS

1. Date of asthma-related visit(s) #1 #2 #3 #4 #5 #6 #7 #8 #9 #10

Specialist visit? (check if “yes”)

Documentation Elements2. Severity of asthma3. Peak flow meter use4. Nebulizer treatments and/or spacers (at home)5. Referred to formal asthma education program6. Education/instruction in asthma disease management7. Demonstrated understanding of asthma disease management8. Medications prescribed or utilized:No medications documentedIllegibleLong-term inhaled anti-inflammatoriesInhaled Corticosteroids (Beclamethasone, Budesonide, Flunisolide, Fluticasone,Triamcinolone acetonide)Cromolyn Sodium or NedocromilLeukotriene Modifiers (Zafirlukast, Zileuton)Quick-relief MedicationsShort-acting beta2 agonists (Albuterol MDI, DPI, or nebulizer or Albuterol HFA, BitolterolMDI or nebulizer, Pirbuterol, Terbutaline)AnticholenergicsIpratropium MDI or nebulizerOral Steroids > 1 monthMethylprednisolone, prednisolone, prednisoneShort Burst Oral Steroids (< 1 month)Methylprednisolone, prednisolone, prednisone9. Flu Immunization10. Symptoms:Documentation addressing physical activity and/or exacerbations in relation to asthma

Comments

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MEDICAID MANAGED CARE BEHAVIORAL HEALTH FOCUS STUDYADHD Treatment Practices for Children (under age 21)



PCP Number: Type:Member name Last: First: MI:Gender Male FemaleRace White African Am Hispanic Am Indian Asian Other Not documentedCounty of ServiceMedicaid #Date of Birth

ADHD diagnosis (member diagnosed during the study period)DSM IV/ICD9CM Codes (circle) Definitions314.0314.00314.01314.09314.1314.2314.8314.9

ADHD: Attention Deficit/Hyperactivity Disorder – ADHD is defined according to the current US standarddiagnostic system in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).This study focuses on ADHD. The DSM-IV Codes are:314.01 ADHD, Combined Type OR Predominantly Hyperactive-Impulsive Type314.00 ADHD, Predominantly Inattentive Type314.09 ADHD Not Otherwise Specified

The ICD-9-CM codes are:314.0 Attention Deficit Disorder314.00 Without mention of hyperactivity314.01 With hyperactivity314.1 Hyperkinesis with developmental delay314.2 Hyperkinetic conduct disorder314.8 Other specified manifestations of hyperkinetic syndrome314.9 Unspecified hyperkinetic syndrome

The study does not include Other Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescencesuch as Conduct Disorder (DSM-IV Code 312.8), Learning Disorders (DSM-IV Codes 315.00-315.9), orMental Retardation (DSM-IV Codes 317-319).

Criteria Response DefinitionsTreated by PCP with medication forADHD during study period

Yes No Medication for ADHD: Medication intended to alleviate the symptoms of ADHD (seeTable 1 of Focus Study Instructions).

Referred to a BH provider OR there isevidence that the member was receivingservices from a BH provider duringstudy period

Yes No Behavioral Health Provider: An individual clinician licensed to provide mental healthservices or a BH organization. Provider types include: Psychiatrists, Psychologists,Licensed Professional Counselors, Licensed Master’s Social Workers (LMSW)–Advanced Clinical Practitioners, LMSWs, LMSW – Advanced Practitioners, RN-Advanced Practice or Clinical Specialist.Behavioral Health Referral: An attempt, documented in the member’s medical record,to refer a member to a behavioral health provider for the specific purpose of alleviatingthe symptoms of ADHD. A behavioral health referral may be documented with one orboth of the following:• Clinician/provider documentation that an attempt was made to make a referral by

giving the member information to make the connection with a behavioral healthprovider.

• Assisting the member in making the connection with a behavioral health provider(i.e. phone call, FAX, letter).

Referred for social intervention ORthere is evidence that the member wasreceiving services for social interventionduring the study period

Yes No Social Intervention: Any social intervention which specifically targets the ADHD andwhich cannot accurately be categorized as a service of a behavioral health provider.Examples include, but are not limited to: school-based intervention, family support, andself-help groups.Social Intervention Referral: An attempt, documented in the member’s medical record,to refer a member for a social intervention. A referral may be documented with one orboth of the following:• Clinician/provider documentation that an attempt was made to make a referral by

giving the member information to make the connection for social intervention;• Assisting the member in making the connection for social intervention (i.e. phone

call, FAX, letter).

Notes:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10

Parent Questionnaire (ADHD Focus Study)

Date:_____/_____/_____ Who answered the Questions: _____Mother _____Father _____Both _____Other:Please Specify:____________________

Please check your answers to the following questions:

1. How did you feel about the services your child received for ADHD?_____1) Very Pleased._____2) Pleased._____3) Mixed Feelings._____4) Displeased._____5) Very Displeased.

2. How did you feel about the information you received about your child’s ADHD?_____1) Very Pleased._____2) Pleased._____3) Mixed Feelings._____4) Displeased._____5) Very Displeased.

3. How did you feel about how much information the doctor asked you to give about your child’s problems?_____1) Very Pleased._____2) Pleased._____3) Mixed Feelings._____4) Displeased._____5) Very Displeased.

4. How did you feel about the amount of time the doctor spent with you and your child?_____1) Very Pleased._____2) Pleased._____3) Mixed Feelings._____4) Displeased._____5) Very Displeased.

11

5. The doctor who worked with your family was:_____1) Very Helpful._____2) Helpful._____3) Sometimes Helpful._____4) Not Helpful._____5) Made Things Worse.

6. Since receiving services, how is your child doing?_____1) Much Better._____2) Better._____3) About the Same._____4) Worse._____5) Much Worse.

7. Since receiving services, how are you able to manage your child’s behavior?_____1) Much Better._____2) Better._____3) About the Same._____4) Worse._____5) Much Worse.

8. Since receiving services, how pleased are you with your child’s progress?_____1) Very Pleased._____2) Pleased._____3) Mixed Feelings._____4) Displeased._____5) Very Displeased.

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PREGNANCY/SUBSTANCE USE IN PREGNANCY MEDICAID MANAGED CARE FOCUSED STUDIESMEDICAL RECORD AUDIT TOOL

Reviewer________________________________ Date of Audit____________ Study Period__________________

Membername

Last: First: MI:

Medicaid #Date of birth / /Race (if notin admindata)

Caucasian African Am Hispanic Am Indian Asian Other/Unknown

Provider Name Number:County ofserviceEnrollmentdates

/ / / / / /

Delivery date / /Pregnancyoutcome

Live birth(s) _______ (Number) Stillborn ______ (Number) Maternal death

Pregnancycomplication

DRG code ____________ ICD-9 code ______________

Please answer all questions by checking the appropriate boxes or filling in the blanks.

Eligible population:STAR members eligible for the study must meet the following criteria:1. The member must have delivered during the study period live or stillborn fetus(es) 20 weeks gestation or greater.2. The member must have been enrolled 42 days after delivery.

Note: Abstractor should include all services provided by other providers outside of plan, if the service and itsresults are well documented in the medical record. If member enrolled in plan multiple times, use all availabledata. For instance, if member dis-enrolled after receiving 1st prenatal visit, then re-enrolled, include data from firstenrollment date and any subsequent visits that are documented in the record.

1. Record excluded?1. Yes2. No

2. Reason for exclusion1. Unable to locate record

2. Birth outside study period3. Not enrolled 42 days after birth4. Birth less than 20 weeks gestational age5. Other please explain ____________________________________

If excluded, stop—do not continueComments:

2 11/6/98

Prenatal CareEnter dates of prenatal and postpartum visits in column.

Element DateEstimated Date of

Confinement (EDC)Last Menstrual Period

(LMP)Visit No.

123456789

101112131415161718192021

Additional visitsPost-partum visit

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Screened prenatally for:

Alcohol Yes No

Tobacco Yes No

Drugs Yes No

Screening method(s):

ACOG or another standardized visit summary form orPatient history

Lab

Other (includes Hollister, Oregon, or undocumentedscreen with documented treatment plan or diagnosis, orother documented screening method)

Screened at delivery for:

Alcohol Yes No

Tobacco Yes No

Drugs Yes No

Screening method(s):

ACOG or another standardized visit summary orPatient history

Lab

Other (includes Hollister, Oregon, or undocumentedscreen with documented treatment plan or diagnosis, orother documented screening method)

Positive Screen or Diagnosis for:

Alcohol prior to realizing she waspregnant/prior to visit—has discontinueduse

present use

Tobacco prior to realizing she waspregnant/prior to visit—has discontinueduse

present use

Drugs prior to realizing she waspregnant/prior to visit—has discontinueduse

present use

If positive screen or diagnosis, amount of self-reported usage or lab level:

Amount:

Amount:

Type:

Amount:

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If member had positive screen orsubstance use diagnosis,

documented evidence that she receivededucation regarding substance useduring pregnancy and/or treatmentoptions

Yes NoEducation Regarding Substance Use and/or Treatment Options: An attempt by theclinician/provider to provide the member education about the effects of substance useon the fetus and/or treatment options. The attempt is to be documented in themember’s medical record and includes information that is given either verbally or bygiving the member a brochure, pamphlet, or other literature.

If member had positive screen orsubstance use diagnosis,

documented evidence that she wasreferred to BH provider during studyperiod

Yes NoBehavioral Health Provider: An individual clinician licensed to provide mental healthor chemical dependency services. Provider types include: Psychiatrists, Psychologists,Licensed Professional Counselors, Chemical Dependency counselors, and LicensedMaster’s Social Workers-Advances Clinical Practitioners.

Behavioral Health Referral: An attempt, documented in the member’s medical record,to refer a member to a behavioral health provider for the specific purpose of substanceuse treatment. A behavioral health referral may be documented with one or both of thefollowing:• Clinician/provider documentation that an attempt was made to make a referral by

giving the member information to make the connection with a behavioral healthprovider; and/or


If member received education orreferral (yes to either above questions),documented evidence that the prenatalprovider followed up concerning

• The member’s decision orunderstanding on behaviorchange/treatment options, OR

• the referral to BH provider

Yes NoFollow Up: Documentation in the member’s medical record, that prenatal provider• questioned the member concerning understanding of effects of substance use on

fetal development and/or treatment options OR• had been informed of member receiving referral to BH provider.

Comments

5 11/6/98

Information on Newborn

Member name Last: First: MI:Newborn#1 name Last: First: MI:Newborn#2 name Last: First: MI:Newborn#3 name Last: First: MI:Newborn Outcome(s) Livebirth: Number Stillborn: Number Died within 28 days after birthNewborn#1 Birthweight

grams

Newborn#2 Birthweight

grams

Newborn#3 Birthweight

grams

Newborncomplications code:

DRG code ________________ ICD-9 code ____________

Pounds to grams:1 pound = 453.6 grams

Comments:

MEDICAID MANAGED CARE BEHAVIORAL HEALTH FOCUS STUDYMAJOR DEPRESSION IN ADULTS

MEDICAL RECORD AUDIT TOOL (10-12-98)


PCP Number: Type:Member name Last: First: MI:Gender Male FemaleRace White African Am Hispanic Am Indian Asian Other/Not documentedCounty of ServiceMedicaid #Date of Birth

Medical diagnosis (any current diagnosis identified during the study period)ICD9-CM Code Diagnosis

Depression diagnosis (member diagnosed during the study period)DSM IV/ICD9CM Codes (circle) Definitions296.20 293.83 300.4 311296.21286.22296.23296.24296.25296.26296.30269.31296.32296.33296.34296.35269.36

Depression: Depression is defined according to the current US standard diagnostic system in the Diagnosticand Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This study focuses on MajorDepression but also includes: Mood Disorder Due to General Medical Condition, Dysthymic Disorder, andDepressive Disorders NOS. The DSM-IV Codes are as follows:

Major Depression (Single Episode 296.2x/Recurrent 296.3x): 296.20 296.22 296.24 296.26 296.31 296.33 296.35296.21 296.23 296.25 296.30 296.32 296.34 296.36

Mood Disorder Due to Dysthymic Disorder: Depressive Disorder NOS:General Medical Condition 300.4 311293.83

The International Classification of Disease, 9 th Edition (ICD-9-CM) codes for Major Depression, DysthymicDisorder, Depressive Disorders NOS, and Mood Disorder Due to a General Medical Condition are the sameas the DSM-IV codes listed here. The study does not include Other Mood Disorders such as BipolarDisorders (DSM-IV Codes 296.4-296.89), or Bereavement (DSM-IV Code V62.82).

Criteria Response DefinitionsTreated by PCP with medicationtargeted for depressive symptomsduring study period

Yes No See Focus Study Instructions, Table 1: List of Medications That Could be Used toTreat Depression

Referred to or were receiving servicesfrom BH provider during study period

Yes No Behavioral Health Provider: An individual clinician licensed to provide mental healthservices. Provider types include: Psychiatrists, Psychologists, Licensed ProfessionalCounselors, and Licensed Master’s Social Workers-Advances Clinical Practitioners.

Behavioral Health Referral: An attempt, documented in the member’s medical record,to refer a member to a behavioral health provider for the specific purpose of alleviatingthe symptoms of depression. A behavioral health referral may be documented with oneor both of the following:• Clinician/provider documentation that an attempt was made to make a referral by

giving the member information to make the connection with a behavioral healthprovider; and/or


Received education regardingdepression and treatment during studyperiod

Yes No Education Regarding Depression and Treatment: An attempt by the clinician/providerto provide the member education for depression and/or its treatment. The attempt is tobe documented in the member’s medical record and includes information that is giveneither verbally or by giving the member a brochure, pamphlet, or other literature.

Notes:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICAID MANAGED CARE FOCUSED STUDYDIABETES IN ADULTS


Reviewer________________________________ Date of Audit____________ Reportingperiod____________________________

1. PCP Number: Type:2. Member name Last: First: MI:3. Gender Male Female4. Race White African Am Hispanic Am Indian Asian Other/Not documented5. County of Service6. Medicaid #7. Date of Birth

Answer all questions by checking the appropriate box or filling in the blanks.

Record excluded? Yes No

Reason for exclusionWrong ageNo diabetesEnrolled< 5 mo. Both Medicare and Medicaid recipient


Definitions

Eligibility: Members eligible for the study must meet the following criteria:(a) The member must be a diabetic between the ages of 18 and 64 years as of December 31 of the reporting

period.(b) The member must have been enrolled on December 31 and have been continuously in the MCO for at least 5

consecutive months during the study period.(c) The member must have been prescribed insulin and/or oral hypoglycemics/antihyperglycemics during the

reporting period on an ambulatory basis, or(d) Must have had two face-to-face encounters with different dates of service in an ambulatory setting or non-

acute inpatient setting or one face-to-face encounter in an acute inpatient or emergency room setting duringthe reporting period with a diagnosis of diabetes.

(e) The member must not be dually-eligible (receiving both Medicaid and Medicare benefits). The member mustonly receive Medicaid benefits.

Comments:

Criteria Response Definitions8. Documented HbA1C performedduring January, 1998 to December,1998?

Yes NoValue:

Documentation must include date of exam and result.

9. Documented eye screening fordiabetic retinal disease?If no,a) Did member NOT take insulin

insulin during January—December,1998?

b) Was the most recent documentedHbA1C less than 8.0%?

c) Does the record indicate an examby eye-care professional withoutevidence of retinopathy duringJanuary, 1997 to December, 1997?

Yes No

Yes No

Yes No

Yes No

• Documentation from an opthalmologist, optometrist, or othereye-care professional summarizing the date and results of theprocedure, OR

• A chart or photograph of retinal abnormalities with the date andsignature of an eye-care professional, OR

• Documentation by PCP summarizing the date and results of anexam by an eye-care professional

(If the member meets at least two of the three criteria, then thismember may be included as meeting the criteria for retinal diseasescreening.)

10. Documented LDL test performedduring the 24-month period January,1997 to December, 1998?

Yes No

Value:

Documentation must include date of exam and result of one of thefollowing:Lipid panel; Lipoprotein, Cholesterol Fractionation Calculation; orLipoprotein, LDL Cholesterol

11. Documented nephropathy screeningduring the 12-month period January1—December 31, 1998?If no,a) evidence of pre-existing

nephropathy?b) Did member NOT take insulin

insulin during January—December,1998?

c) Was the most recent documentedHbA1C less than 8.0%?

d) Does the record indicate anephropathy screening withoutevidence of nephropathy duringJanuary 1 to December 31, 1997?

Yes No

Yes No

Yes No

Yes No

Yes No

Documentation of screening must include date of exam and result ofone of the following:Albumin, Urine, Quantitative; Albumin Urine, MicroalbuminQuantitative; Albumin Urine, Microalbumin Semiquantitative, e.g.Reagent strip assay; or a positive dipstick for microalbuminuria.

Documentation of pre-existing nephropathy must include reference to:Diabetic nephropathy, proteinuria/microalbuminuria/urine protein+,end-stage renal disease/ESRD, chronic renal failure/CRF, renalinsufficiency, acute renal failure/ARF, dialysis, hemodialysis, orperitoneal dialysis. (If documented pre-existing nephropathy, memberqualifies as having met the criteria for nephropathy screening.)

(If the member has pre-existing nephropathy or meets at least two ofthe criteria in items b, c, d, then this member may be included asmeeting the criteria for nephropathy screening.)

12. Documented foot exam during thereporting period?

Yes No Documentation of screening must include date of exam and at leastone of the following findings:Pedal pulses present/absent, sensation in feet present/absent,description of skin integrity on feet, appearance of feet

COMMENTS:

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