IN THIS EDITION. Resubmitting Corrected Claims. Bimonthly update to the Texas Medicaid Provider Procedures Manual

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1 T EXAS MEDICAID BULLETIN Bimonthly update to the Texas Medicaid Provider Procedures Manual MAY/JUNE 2006 NO. 195 Resubmitting Corrected Claims This is a clarification of the 2006 Texas Medicaid Provider Procedures Manual Section , on page 5-7. Claims lacking the information necessary for processing are listed on the Remittance and Status (R&S) report with an Explanation of Benefits (EOB) code that requests the missing information. Providers must resubmit a signed, completed, and corrected claim to TMHP within 120 days of the date on the R&S report to be considered for payment. A copy of the R&S report on which the denied claim appears must be included with the completed or corrected claim. These claims may be resubmitted electronically only if the following information remains the same as on the original claim: Texas Provider Identifier (TPI) Client Medicaid Number Dates of Service Total Billed Amount Paper claims may be resubmitted for payment consideration by mailing them to the following address: Texas Medicaid & Healthcare Partnership Claims PO Box Austin, TX Each corrected claim submitted to TMHP must be accompanied by a copy of the corresponding page of the R&S report specifying the reason for the claim. Claims will be processed as adjustments or appeals and will be located in the Adjustments section of the R&S report. Note: Claims still within the original 95 day fi ling deadline may be submitted as new day claims without a copy of the R&S report attached. For more information, call the TMHP Contact Center at IN THIS EDITION All Providers Resubmitting Corrected Claims Inpatient Hospital Billing Updates Changes to the Contact Center Telephone Menu Revenue Codes for Outpatient Hospital Services Revised Sterilization Consent Form Procedure Code Changes CMS-1500 Claims Functionality Online Scheduled System Maintenance The HCFA-1450 (UB-92) Claim Form RSV Prophylaxis Limitation Change Provider Education Series HCFA-1450 (UB-92) Updates Immune Globulin Benefits Expanded for the Texas Medicaid Program Prior Authorization for Radiology Services Updated Authorization Criteria for Lung, Liver, and Heart Transplants Changes to Organ Transplant Authorization Managed Care Providers Enrollment of STAR+PLUS Newborns Primary Care Case Management Providers Providing a Medical Home in Primary Care Case Management PCCM Nurse Helpline Always Available Self-Referred Services in Primary Care Case Management...20 PCCM Provider Enrollment Medicaid STAR Program Changes Texas Health Steps Medical Providers Corrected Formula in Certification of Funds Letters School Health and Related Services Providers Complete Medical Checkups and Follow-Up Visits Excluded Providers Forms Sterilization Consent Form (English) Sterilization Consent Form (Spanish) Sterilization Consent Form Instructions Electronic Funds Transfer Authorization Agreement Provider Information Change Form HCFA-1450 (UB-92) Claim Form Radiology Prior Authorization Request Form Current Procedural Terminology (CPT) is copyright 2005 American Medical Association (AMA) and Current Dental Terminology (CDT) is copyright 2004 American Dental Association (ADA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT or CDT. The AMA and the ADA assume no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.

2 All Providers Inpatient Hospital Billing Updates The following is an update to information related to admission dates, transfers, and continuous stays for providers submitting HCFA-1450 (UB-92) inpatient hospital claims. Admission Dates The Texas Medicaid claims processing system has been updated to automatically identify whether a client s claim should be paid under traditional Medicaid, Primary Care Case Management (PCCM), or through the client s health maintenance organization (HMO) based on the client s program eligibility at the time of admission. HMO claims are denied by TMHP and should be submitted by the provider to the appropriate HMO. Providers are no longer required to enter the date the client was first admitted into the hospital from which the client is being transferred. Providers must now enter the actual dates the client was admitted into each facility (see Client Transfers, below). Note: Inpatient authorization requirements are based on the requirements that are specifi ed by the program in which the client is enrolled on the date of the original admission. Providers must adhere to the authorization requirements for claims to be considered for reimbursement. Providers are reimbursed at the rate in eff ect on the date of admission. Client Transfers When more than one hospital provides care for a client, the hospital that provides the most significant amount of care receives consideration for a full diagnosis related group (DRG) payment. The other hospitals are paid a per diem rate based on the lesser of the mean length of stay for the DRG or the eligible days in the facility. The DRG modifier, PT, on the Remittance and Status (R&S) report indicates per diem pricing related to a client transfer. Services must be medically necessary and are subject to the Texas Medicaid Program s utilization review requirements. The Texas Health and Human Services Commission (HHSC) performs a post-payment review to determine if the hospital that provided the most significant amount of care received the full DRG. If the review reveals that the hospital that provided the most significant amount of care did not receive the full DRG, an adjustment is initiated. The following are examples of client transfers: Example DRG facility to DRG facility: Client was discharged from facility A and readmitted within 24 hours to facility B DRG facility to Tax Equity and Fiscal Responsibility Act (of 1982) (TEFRA) facility: Client was discharged from a DRG facility and readmitted within 24 hours to a TEFRA facility Payment This would be considered a transfer, and the facility that rendered the most complex level of care would receive the full DRG. The other facility would be paid a per diem, not to exceed the maximum amount for the full DRG. This would be considered a transfer. The DRG hospital could receive the full DRG or a per diem, depending on whether or not the facility rendered the most complex level of care. The TEFRA hospital would receive the TEFRA interim reimbursement rate that was effective at the time of admission. Continuous Stays Client transfers within the same facility, or readmissions to the same facility within 24 hours of a previous acute hospital or facility discharge are considered one continuous stay. These readmissions are considered a continuous stay regardless of the original or readmission diagnosis. Texas Medicaid Bulletin, No May/June 2006

3 All Providers The Texas Medicaid Program does not recognize specialty units within the same hospital as separate entities; therefore, these transfers must be billed as one admission under the Texas Provider Identifier (TPI). Admissions that were billed inappropriately are identified and denied during the utilization review process and may result in an intensified review. The following is an example of a continuous stay: Example DRG facility to DRG facility: Client was discharged from facility A and readmitted within 24 hours to facility A Payment For more information, call the TMHP Contact Center at Changes to the Contact Center Telephone Menu This would be considered a continuous stay and the provider would receive one DRG payment for the entire stay. TMHP will revise the selections on the Contact Center telephone menu in June TMHP will publish any further updates to the telephone menu in the 2006 Medicaid Automated Inquiry System (AIS) User Guide as improvements are made. The user guide is available by mail, by fax, or on the TMHP website at The following changes will be implemented: Area Before Changes After Changes Main Menu 5 Options 3 Options Claim Status Inquiry (CSI) Benefit Limitation Telephone Numbers Automated Inquiry System (AIS) Provider Enrollment Ambulance Authorization Family Planning All Other Inquiries Family Planning CSI was accessed through the main menu The vision benefit option was forwarded to a customer service representative Previously, the following program telephone numbers did not have the ability to access the main menu of the Customer Service line: Comprehensive Care Program (CCP) EDI Helpdesk THSteps Medical AIS Provider Electronic Data Interchange (EDI) Access Family Planning CSI through the AIS option Providers will be able to retrieve a clients last eye exam via AIS The following telephone numbers are now directed to the main menu of the Customer Service line: CCP EDI Helpdesk THSteps Medical THSteps Dental Ambulance Prior Authorization THSteps Dental Previously, hospitals could call TMHP at to obtain a prior authorization when discharging a client or transporting the client to another facility. Hospitals will call TMHP at to obtain an ambulance prior authorization when discharging a client or transporting the client to another facility. For more information, call the TMHP Contact Center at May/June Texas Medicaid Bulletin, No. 195

4 All Providers Revenue Codes for Outpatient Hospital Services TMHP has identified an error on the table in Section of the 2006 Texas Medicaid Provider Procedures Manual on page The table is intended to identify revenue codes that require a Health Care Common Procedure Coding System (HCPCS) code to be entered on outpatient claims for accurate claims processing. The table incorrectly lists some revenue codes as Not a benefit, when they should be listed as HCPCS code required. The corrected table follows. Revenue Codes (Outpatient Hospital) HCFA-1450 (UB-92) revenue codes must be used to bill outpatient hospital facility services. In some instances, a HCPCS procedure code is required in addition to the revenue code for accurate claims processing: Revenue Code Description Comments Pharmacy B-250 General classification B-251 Generic drugs B-252 Non-generic drugs B-253 Take Home drugs Not a benefit B-254 Drugs incident to other diagnostic services B-255 Drugs incident to radiology B-256 Experimental drugs Not a benefit B-257 Nonprescription drugs B-258 IV solutions B-259 Other pharmacy B-630* Drugs requiring specific identification HCPCS code required B-631* Single source drug HCPCS code required B-632* Multiple source drug HCPCS code required B-633* Restrictive prescription HCPCS code required B-634* Erythropoietin (EPO) less than 10,000 units HCPCS code required B-635* Erythropoietin (EPO) 10,000 or more units HCPCS code required B-636* Drugs requiring detailed coding HCPCS code required B-637 Self-administrable drugs Not a benefit IV Therapy B-260 General classification B-261 Infusion pump B-262 IV therapy/pharmacy services B-263 IV therapy/drug/supply delivery B-264 IV therapy/supplies B-269 Other IV therapy Medical/Surgical Supplies and Devices B-270 General classification B-271 Nonsterile supply B-272 Sterile supply Texas Medicaid Bulletin, No May/June 2006

5 All Providers Revenue Code Description Comments Medical/Surgical Supplies and Devices B-273 Take-home supplies Not a benefit B-274* Prosthetic/orthotic devices HCPCS code required B-275 Pacemaker B-276 Intraocular lens B-277 Oxygen take-home B-278* Other implants HCPCS code required B-279* Other supplies/devices HCPCS code required B-620* Medical/surgical supplies HCPCS code required B-621 Supplies incident to radiology B-622 Supplies incident to other diagnostic services B-623 Surgical dressings B-624 FDA investigational devices Not a benefit Oncology B-280 General classification B-289 Other oncology Laboratory B-300* General classification HCPCS code required B-301* Chemistry HCPCS code required B-302* Immunology HCPCS code required B-303* Renal patient (home) HCPCS code required B-304* Nonroutine dialysis HCPCS code required B-305* Hematology HCPCS code required B-306* Bacteriology and microbiology HCPCS code required B-307* Urology HCPCS code required B-309* Other laboratory HCPCS code required Laboratory Pathological B-310* General classification HCPCS code required B-311* Cytology HCPCS code required B-312* Histology HCPCS code required B-314* Biopsy HCPCS code required B-319* Other pathology HCPCS code required Radiology Diagnostic B-320* General classification HCPCS code required B-321* Angiocardiography HCPCS code required B-322* Arthrography HCPCS code required B-323* Arteriography HCPCS code required B-324* Chest X-ray HCPCS code required May/June Texas Medicaid Bulletin, No. 195

6 All Providers Revenue Code Description Comments Radiology Diagnostic B-329* Other diagnostic radiology HCPCS code required Radiology Therapeutic B-330* General classification HCPCS code required B-331* Chemotherapy injected HCPCS code required B-332* Chemotherapy oral HCPCS code required B-333* Chemotherapy radiation therapy HCPCS code required B-335* Chemotherapy IV HCPCS code required B-339* Other therapeutic radiology HCPCS code required Nuclear Medicine B-340* General classification HCPCS code required B-341* Diagnostic HCPCS code required B-342* Therapeutic HCPCS code required B-349* Other nuclear medicine HCPCS code required CT Scan B-350* General classification HCPCS code required B-351* Head scan HCPCS code required B-352* Body scan HCPCS code required B-359* Other CT scans HCPCS code required Operating Room Services B-360 General classification B-361 Minor surgery B-369 Other operating room services Anesthesia B-370 General classification B-371 Anesthesia incident to radiology B-372 Anesthesia incident to other diagnostic services B-374 Acupuncture Not a benefit B-379 Other anesthesia Blood B-380* General classification HCPCS code required B-381* Packed red cells HCPCS code required B-382* Whole blood HCPCS code required B-383* Plasma HCPCS code required B-384* Platelets HCPCS code required B-385* Leucocytes HCPCS code required B-386* Other components HCPCS code required Texas Medicaid Bulletin, No May/June 2006

7 All Providers Revenue Code Description Comments Blood B-387* Other derivatives (cryoprecipitates) HCPCS code required B-389* Other blood HCPCS code required Blood Storage and Processing B-390 General classification B-391 Blood administration Not a benefit B-399 Other blood storage and processing Not a benefit Other Imaging Services B-400* General classification HCPCS code required B-401* Diagnostic mammography HCPCS code required B-402* Ultrasound HCPCS code required B-403* Screening mammography HCPCS code required B-404* Positron emission tomography HCPCS code required B-409* Other imaging services HCPCS code required Respiratory Services B-410 General classification B-412 Inhalation services B-413 Hyperbaric oxygen therapy B-419* Other respiratory services HCPCS code required Physical Therapy B-420* General classification HCPCS code required B-421* Visit charge HCPCS code required B-422* Hourly charge HCPCS code required B-423* Group rate HCPCS code required B-424* Evaluation or re-evaluation HCPCS code required B-429* Other physical therapy HCPCS code required Occupational Therapy B-430* General classification HCPCS code required B-431* Visit charge HCPCS code required B-432* Hourly charge HCPCS code required B-433* Group rate HCPCS code required B-434* Evaluation or re-evaluation HCPCS code required B-439* Other occupational therapy HCPCS code required Speech-Language Pathology B-440* General classification HCPCS code required B-441* Visit charge HCPCS code required B-442* Hourly charge HCPCS code required B-443* Group rate HCPCS code required May/June Texas Medicaid Bulletin, No. 195

8 All Providers Revenue Code Description Comments Speech-Language Pathology B-444* Evaluation or re-evaluation HCPCS code required B-449* Other speech-language pathology HCPCS code required Emergency Room B-450 General classification B-456 Urgent care B-459 Other emergency room Pulmonary Function B-460* General classification HCPCS code required B-469* Other pulmonary function HCPCS code required Audiology B-470* General classification HCPCS code required B-471* Diagnostic HCPCS code required B-472* Treatment HCPCS code required B-479* Other Audiology HCPCS code required Cardiology B-480* General classification HCPCS code required B-481* Cardiac cath lab HCPCS code required B-482* Stress test HCPCS code required B-489* Other cardiology HCPCS code required Clinic B-510 General classification B-511 Chronic pain center B-512 Dental clinic B-513 Psychiatric clinic B-514 OB-GYN clinic B-515 Pediatric clinic B-516 Urgent Care clinic B-517 Family Practice clinic B-519 Other clinic Freestanding Clinic B-520 General classification B-523 Family practice clinic B-526 Urgent care clinic B-529 Other freestanding clinic Magnetic Resonance Technology (MRT) B-610* General classification HCPCS code required Texas Medicaid Bulletin, No May/June 2006

9 All Providers Revenue Code Description Comments Magnetic Resonance Technology (MRT) B-611* MRI brain (including brainstem) HCPCS code required B-612* MRI spinal cord (including spine) HCPCS code required B-619* Other MRT HCPCS code required Cast Room B-700 General classification B-709 Other cast room Recovery Room B-710 General classification B-719 Other recovery room Labor Room/Delivery B-720 General classification B-721 Labor B-722 Delivery B-723 Circumcision B-724 Birthing center B-729 Other labor room/delivery EKG/ECG (Electrocardiogram) B-730* General classification HCPCS code required B-731* Holter monitor HCPCS code required B-732* Telemetry HCPCS code required B-739* Other EKG/ECG HCPCS code required EEG (Electroencephalogram) B-740* General classification HCPCS code required B-749* Other EEG HCPCS code required Gastrointestinal Services B-750 General classification B-759 Other gastrointestinal Treatment or Observation Room B-760 General classification B-761 Treatment room B-762 Observation room B-769 Other treatment/observation room Preventive Care Services B-770* General classification HCPCS code required B-771* Vaccine administration HCPCS code required B-779* Other preventive care services HCPCS code required May/June Texas Medicaid Bulletin, No. 195

10 All Providers Revenue Code Description Comments Lithotripsy B-790* General classification HCPCS code required B-799* Other lithotripsy HCPCS code required Other Diagnostic Services B-920* General classification HCPCS code required B-921* Peripheral vascular lab HCPCS code required B-922* Electromyelogram HCPCS code required B-923* Pap smear HCPCS code required B-924* Allergy test HCPCS code required B-925* Pregnancy test HCPCS code required B-929* Other diagnostic service HCPCS code required * HCPCS procedure code is required in addition to revenue code for accurate claims processing. For more information, call the TMHP Contact Center at Revised Sterilization Consent Form The Sterilization Consent Form has been revised. Family Planning providers must begin using the revised Sterilization Consent Form (version 4/2006) for client signature dates on or after April 1, These forms and instructions replace the forms and instructions provided in the 2006 Texas Medicaid Provider Procedures Manual. The forms, and instructions can be found in this bulletin on page: English form: page 27 Spanish form: page 29 Instructions: page 31 For more information, call the TMHP Contact Center at Texas Medicaid Bulletin, No May/June 2006

11 All Providers Procedure Code Changes TMHP implemented the following procedure code changes: No precertification requirement for procedure code Effective for dates of service on or after March 10, 2006, procedure code will no longer require precertification for hospital-based or freestanding ambulatory surgical centers to be considered for reimbursement. Procedure code J2503 Effective February 3, 2006, for dates of service on or after January 1, 2006, procedure code J2503 is payable by the Texas Medicaid, Medicaid Managed Care, and Children with Special Health Care Needs (CSHCN) Services Programs with an allowable fee of $1, Claims submitted from January 1, 2006, through February 3, 2006, that include this procedure code were reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Radiopharmaceutical Drug Pricing Effective for dates of service on or after March 1, 2006, the allowable fee for the following radiopharmaceuticals will change for the Texas Medicaid and Medicaid Managed Care programs: Procedure Code Previous Allowable Fee Allowable Fee effective March 1, 2006 A9500 $ $ A9502 $80.08 $ A9503 $29.30 $37.40 A9504 $ $ A9505 $52.50 $29.73 A9507 $ $ A9508 $29.21 $ A9510 $29.21 $39.10 A9600 $ $ A9605 $1, $ For more information, call the TMHP Contact Center at Scheduled System Maintenance System maintenance for the TMHP claims processing system is scheduled as follows: Sunday, May 28, 2006, 3 p.m. to Monday, May 29, 2006, 6 p.m. Sunday, June 11, 2006, 6 p.m. to 11:59 p.m. During system maintenance some applications related to the claims engine will be unavailable. Specific details regarding the affected applications are posted on the TMHP website at CMS-1500 Claims Functionality Online TMHP has recently made enhancements to the TMHP website that allow CMS-1500 claim submissions and appeals. This functionality allows the submission and appeal of Texas Medicaid, Medicaid Managed Care, and CSHCN Services Program claims that do not require attachments and are not in a zero allowed, zero paid status. Claims are submitted and appealed over secure pages of the TMHP website. Providers must activate an account on the TMHP website to submit or appeal claims online. Billing services and clearinghouses are required to obtain access to protected health information through the provider administrator of each TPI or provider number for which they are contracted to provide services. Detailed instructions about the creation and administration of website accounts can be found in the Website Security Provider Training Manual at Providers may still submit and appeal claims to TMHP using paper claim forms or electronically through TDHconnect. All claims and file transmission records must be retained onsite as is currently required. For more information visit the TMHP website at or call the TMHP Contact Center at May/June Texas Medicaid Bulletin, No. 195

12 All Providers RSV Prophylaxis Limitation Change This is a policy change that affects procedure code for both the Texas Medicaid and CSHCN Services Programs. Effective for dates of service on or after October 1, 2005, Respiratory Syncytial Virus (RSV) prophylaxis injections are covered for up to 6 doses from October through the end of March. Prior authorization is required for RSV prophylaxis injections outside of the months October through March. Claims submitted for dates of service October 1, 2005, through March of 2006 that were denied for the sixth dose of RSV prophylaxis must be resubmitted to be considered for payment, even when prior authorized. Providers must follow the criteria that was published in the September/October 2005 Texas Medicaid Bulletin # 190, page 9, Respiratory Syncytial Virus (RSV) Prophylaxis. Providers are reminded that prophylaxis against RSV is only medically indicated when there is widespread RSV activity in the provider s region or community. Texas RSV surveillance data indicated that in most, if not all regions of the state, the RSV season likely would have ended by mid to late March Providers should not provide RSV prophylaxis beyond the end of March unless there is evidence of continued widespread RSV activity in the region or community. The Texas Department of State Health Services (DSHS) maintains a web site that summarizes statewide data at tx.us. Providers can also contact their local laboratories for data on the status of RSV activity in their region or community. For more information call the TMHP Contact Center at , or the TMHP-CSHCN Contact Center at Provider Education Series: Family Planning Services Physicians, advanced nurse practitioners, certified nursemidwifes, federally qualified health centers (FQHC), and family planning agencies are eligible provider types to provide family planning services to Title XIX Medicaid beneficiaries. The 2006 Texas Medicaid Provider Procedures Manual, Section 21, Family Planning Services, instructs providers to use the family planning (FP) modifier on the specific procedure codes listed and FP diagnoses when billing for family planning services. For codes that require the FP modifier with a family planning diagnosis, reference Section 21.6 of the 2006 Texas Medicaid Provider Procedures Manual. Failure to use the FP modifier as indicated will result in denied claims. TMHP routinely performs retrospective reviews of providers claims. The review includes a comparison of the services billed with the client s clinical record. Section of the 2006 Texas Medicaid Provider Procedures Manual, General Medical Record Documentation Requirements, outlines other mandatory components of medical record documentation, and services that are not supported by the required documentation in the client s record are subject to recoupment. For more information, call the TMHP Contact Center at The HCFA-1450 (UB-92) Claim Form The HCFA-1450 (UB-92) Claim Form in the 2006 Texas Medicaid Provider Procedures Manual, on page 5-27, printed incorrectly. Numbers are missing from the form. For a correct HCFA-1450 (UB-92) Claim Form refer to page 37 of this bulletin. Texas Medicaid Bulletin, No May/June 2006

13 All Providers HCFA-1450 (UB-92) Updates TMHP and HHSC have updated the code requirements necessary for completing the HCFA-1450 (UB-92) Claim Form. The codes will become effective May 28, Following are the updated codes: Description Guidelines Type of 05 Trauma Center Admission Patient Status 09 Admitted as an inpatient to the hospital 40 Expired at home (hospice use only) 41 Expired in a medical facility (hospice use only) 42 Expired place unknown (hospice use only) 43 Discharged/transferred to a federal hospital 50 Hospice Home 51 Hospice Medical Facility 61 Discharged/transferred within the institution to a hospital-basedmedicare approved swing bed 62 Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital 63 Discharged/transferred to a Medicare certified long term care hospital (LTCH) 64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare 65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital 66 Discharged/transferred to a Critical Access Hospital (CAH) Occurrence Span Codes Remarks For inpatient claims enter code 71 if the hospital admission is a readmission within seven days of a previous stay. Enter the dates of the previous stay. Request for 110-day rule for a third party insurance Occurrence Codes Field Description Guidelines Locator 11 Onset of symptoms Indicate the date the patient first became aware of the symptoms or illness being treated. This code replaces code 52 for onset of renal dialysis 50 Date other insurance paid Discontinued 51 Date claim filed with other insurance Discontinued 52 Date renal dialysis initiated Discontinued Note: Occurrence Codes 50 and 51 have been discontinued per Centers for Medicare & Medicaid Services (CMS). Complete blocks 50 through 55 to supply the client s other insurance payment information. Request the 110-day rule in block 84 (remarks). For more information, call the TMHP Contact Center at May/June Texas Medicaid Bulletin, No. 195

14 All Providers Immune Globulin Benefits Expanded for the Texas Medicaid Program Effective for dates of service on or after May 1, 2006, payment consideration for procedure codes J1460, J1470, J1480, J1490, J1500, J1510, J1520, J1530, J1540, J1550, J1560, J1566, J1567, J7504, and J7511 will be limited to the following diagnosis codes: Diagnosis Code Description 042 Human immuno virus dis Chronic Lymphocytic Leukemia 2387 Lymphoproliferative disease, NOS Other specified disorders of metabolism Disorders involving the immune mechanism; Hypogammaglobulinemia, unspecified Disorders involving the immune mechanism; Selective IgA immunodeficiency Disorders involving the immune mechanism; Selective IgM immunodeficiency Disorders involving the immune mechanism; Other selective immunoglobulin deficiencies Disorders involving the immune mechanism; Congenital hypogammaglobulinemia Disorders involving the immune mechanism; Immunodeficiency with increased IgM Disorders involving the immune mechanism; Common variable immunodeficiency Disorders involving the immune mechanism; Other Immunodeficiency with predominant T-cell defect, unspecified DiGeorge s syndrome Wiskott-Aldrich syndrome Nezelof s syndrome Other, deficiency of cell-mediated immunity 2792 Combined Immunity deficiency 2793 Unspecified immunity deficiency 2794 Autoimmune disease, not elsewhere classified 2840 Congenital aplastic anemia Primary thrombocytopenia, unspecified Immune thrombocytopenic purpura Evans syndrome Congenital and hereditary thrombocytopenic purpura Other primary thrombocytopenia 3348 Spinocerebellar disease nec 340 Multiple sclerosis Partial epilepsy, with impairment of consciousness with intractable epilepsy 3530 Brachial plexus lesions 3570 Acute infective polyneuritis (Guillain-Barre Syndrome) Chronic inflammatory demyelinating polyneuritis Critical illness polyneuropathy Texas Medicaid Bulletin, No May/June 2006

15 All Providers Diagnosis Code Description Myasthenia gravis without (acute) exacerbation Myasthenia gravis with (acute) exacerbation 3929 Rheumatic chorea without mention of heart involvement 4461 Acute febrile mucocutaneous lymph node syndrome 5855 Chronic Kidney Disease (CKD), stage V 5856 End stage renal disease 586 Renal failure, unspecified 6463 Habitual aborter 7103 Dermatomyositis 7104 Polymyositis 7140 Rheumatoid arthritis Other and unspecified nonspecific immunological finding 9895 Toxic effect venom V0179 Contact or exposure to other viral diseases V0189 Contact with or exposure to communicable disease; other communicable diseases V0260 Viral hepatitis, carrier V08 Asymptomatic HIV infection status V4281 Organ or tissue replaced by transplant; Other specified organ or tissue; bone marrow V4282 Organ or tissue replaced by transplant; Other specified organ or tissue; peripheral stem cells V4283 Organ or tissue replaced by transplant; Other specified organ or tissue; pancreas V4284 Organ or tissue replaced by transplant; Other specified organ or tissue; intestines V4289 Organ or tissue replaced by transplant; Other specified organ or tissue; other For more information call the TMHP Contact Center at May/June Texas Medicaid Bulletin, No. 195

16 All Providers Prior Authorization for Radiology Services Effective for dates of service on or after May 1, 2006, both traditional Medicaid and PCCM require prior authorization or retrospective authorization for: Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Computed Tomography Imaging (CT) Computed Tomography Angiography (CTA) Authorization is not required for emergency department or inpatient hospital MRI, MRA, CT, or CTA. Prior authorization is required for all outpatient nonemergent CT, CTA, MRI, and MRA studies (i.e. those that are preplanned, scheduled) before services are rendered. Retrospective authorization is required for outpatient emergent studies when the physician determines that a medical emergency that imminently threatens life or limb exists, and the medical emergency requires advanced diagnostic imaging (CT, CTA, MRI, or MRA). Providers must submit a retrospective authorization request no later than two business days after the study is completed. The addition of post 3-D reconstruction (76376 and 76377) CT and MR studies must be prior authorized. No additional payment will be made without prior authorization. Intraoperative MRI of the brain, codes through 70559, is not a benefit of the Texas Medicaid Program. Refer to the end of this document for a list of procedure codes that require prior or retrospective authorization. Providers and facilities are required to use the lowest possible radiation dose consistent with acceptable image quality for CT examinations of children. It is recommended that providers and facilities utilize national standards, such as those by the American College of Radiology, Practice Guidelines for Performing and Interpreting Diagnostic CT examinations, for CT imaging. Nationally accepted guidelines and radiology protocols based on medical literature are utilized in the authorization processes for both emergent and nonemergent studies. These include: American College of Radiology (specifically, the Appropriateness Criteria), American Academy of Neurology, American Academy of Orthopedic Surgeons, American College of Cardiology, the American Heart Association, and the National Comprehensive Cancer Care Network. Prior authorization of nonemergent and emergent retrospective authorization of CT, CTA, MRI, and MRA studies are considered on an individual basis adhering to standard clinical evidence-based guidelines. Documentation must support medical necessity for the study. Providers may request prior or retrospective authorization by: Telephone: Fax: , or Mail: Texas Medicaid & Healthcare Partnership, 730 Cool Springs Blvd, Suite 800 Franklin, TN Please be prepared to provide the following patient information for all requests; Diagnosis Treatment history Treatment plan Medications Previous imaging results Providers may be requested to provide additional documentation. Requests that are faxed or mailed must be accompanied by a Radiology Prior Authorization Form (see page 39 of this bulletin). Complete the demographics box at the top of the form and include the information as outlined above. The Radiology Prior Authorization Form must be completed, signed, and dated by the ordering physician before requesting authorization for CT, CTA, MRI, or MRA studies, regardless of the method of request for authorization. The physician s signature must be current, unaltered, original, and handwritten. A computerized or stamped signature will not be accepted. The physician who ordered the test(s) must keep the completed form with original signature in the client s medical record. In addition, medical record documentation must support the medical necessity of the study. Authorization requirements for both nonemergent and emergent studies must be met in order to be considered for reimbursement. In the absence of authorization, both the technical and professional interpretation components will be denied. Texas Medicaid Bulletin, No May/June 2006

17 All Providers Reimbursement for outpatient emergent and nonemergent CT, CTA, MRI, and MRA studies requires that the authorization number is added to the claim. Claims for emergency CT, CTA, MRI, and MRA studies provided in the emergency department must be submitted with modifier U6 and must have the appropriate corresponding emergency services revenue code (450 through 459) to be considered for payment. If two CT s, CTA s, MRA s, or MRI s are performed in the emergency room or an out patient setting on the same day without an authorization on file, the second procedure will deny. Providers may submit additional medical necessity documentation for payment reconsideration. Procedure Codes That Require Authorization: The Radiology Prior Authorization Form is located on page 39 of this bulletin and can be found on the TMHP website. For more information, visit the TMHP website at or call the TMHP Contact Center at Updated Authorization Criteria for Lung, Liver, and Heart Transplants Effective for dates of service on or after May 13, 2005, the criteria for authorization of lung, liver, and heart transplants changed. This information updates the information published in the 2006 Texas Medicaid Provider Procedures Manual, Sections Heart Transplants, Liver Transplants, and Lung Transplants. The details of these changes were published in the July/ August 2005 Texas Medicaid Bulletin, No. 189, and appear again below. Changes to Organ Transplant Authorization Lung Transplants Effective for dates of service on or after May 13, 2005, the following authorization criteria for lung transplants must be followed. Lung transplant candidates must be limited to those patients who, based on sound patient selection criteria, would most likely benefit from the lung (single or double) transplant procedure on a long-term basis. In order to be reimbursed by the Texas Medicaid Program, the facility must document the following: A critical medical need with a likelihood of a successful clinical outcome Symptoms at rest directly related to chronic pulmonary disease and resultant severe functional limitation Lung transplantation may be authorized with documentation of end-stage pulmonary diseases in these categories: Obstructive lung disease Restrictive lung disease Cystic fibrosis Pulmonary hypertension Absence of co-morbidities such as: End-stage renal, hepatic, or other organ dysfunction unrelated to primary disorder Multiple organ compromise secondary to infection, malignancy, or condition with no known cure In addition, documented compliance with other medical treatments, regimen, and plan of care including no active alcohol or chemical dependency that interferes May/June Texas Medicaid Bulletin, No. 195

18 All Providers with compliance to a medical regimen is required. Documented psychiatric instability severe enough to jeopardize incentive for adherence to medical regimen is a contraindication for transplant. Prior authorization for a heart/lung transplant must follow criteria for both heart and lung transplants. Requests for a heart/lung transplant will be considered on an individual basis. Liver Transplant Effective for dates of service on or after May 13, 2005, the following applies for liver transplant authorization. To obtain authorization of liver transplantation, documentation of life-threatening complications of acute liver failure or chronic end-stage liver disease is required. Liver transplant candidates must be limited to those patients who, based on sound patient selection criteria, would most likely benefit from the liver transplant procedure on a long-term basis. In order to be reimbursed by the Texas Medicaid Program, the facility must document the following: A critical medical need with a likelihood of a successful clinical outcome Liver disease in one of the following categories: Primary cholestatic liver disease Other cirrhosis: o Alcoholic o Hepatitis C, non-a, non-b o Hepatitis B Fulminant hepatic failure Metabolic diseases Malignant neoplasms Benign neoplasms Biliary atresia Absence of co-morbidities such as: End-stage cardiac, pulmonary, or renal disease unrelated to primary disorder Multiple organ compromise secondary to infection, malignancy, or condition with no known cure In addition, documented compliance with other medical treatments, regimen, and plan of care including no active alcohol or chemical dependency that interferes with compliance to a medical regimen, is required. Documented psychiatric instability severe enough to jeopardize incentive for adherence to medical regimen is a contraindication for transplant. Heart Transplant Effective for dates of service on or after May 13, 2005, age will no longer be a consideration for heart transplant authorization. Criteria for heart transplant are as follows: Conventional and/or standard therapies must first be considered A critical medical need that fits in one of the categories below and where a heart transplant will result in a return to improved functional independence: NYHA Class Stage III or IV cardiac disease Congenital heart disease Valvular heart disease Viral cardiomyopathies Familial and restrictive cardiomyopathies Absence of co-morbidities such as: Severe pulmonary hypertension End-stage renal, hepatic, or other organ dysfunction unrelated to primary disorder Active, uncontrolled HIV infection or AIDSdefining illness Multiple organ compromise secondary to infection, malignancy, or condition with no known cure In addition, documented compliance with other medical treatments, regimen, and plan of care including no active alcohol or chemical dependency that interferes with compliance to a medical regimen, is required. Documented psychiatric instability severe enough to jeopardize incentive for adherence to medical regimen is a contraindication for transplant. For more information, visit the TMHP website at or call the TMHP Contact Center at Texas Medicaid Bulletin, No May/June 2006

19 Managed Care Providers/Primary Care Case Management (PCCM) Providers Enrollment of STAR+PLUS Newborns HHSC has identified an error in the 2006 Texas Medicaid Provider Procedures Manual, Section Enrollment of Newborns on page In the State of Texas Access Reform (STAR)+PLUS Program, newborns are enrolled in the STAR plan offered by the mother s STAR+PLUS plan, if available. If the STAR+PLUS plan does not also provide STAR services in the service area, the newborn is automatically enrolled in traditional Medicaid until the mother selects a STAR plan for the newborn. For more information, call the TMHP Contact Center at PRIMARY CARE CASE MANAGEMENT PROVIDERS Providing a Medical Home in Primary Care Case Management The medical home concept was implemented September 1, 2005, to increase the quality of client care, provide clients with continuity of care, and encourage the appropriate utilization of emergency room services. Primary Care Case Management (PCCM) clients are assigned a primary care provider to serve as the client s medical home. The PCCM primary care provider agrees to provide primary health care services to PCCM clients. Before treating clients, a PCCM provider should encourage clients to see their assigned primary care provider. One of the responsibilities of a primary care provider is to refer clients to an approved Texas Medicaid provider, specialist, or PCCM-contracted facility when services needed are not available through the primary care provider s office or clinic. For more information refer to the 2005 PCCM Special Bulletin No.188, visit the TMHP website at or call the PCCM Provider Helpline at PCCM Nurse Helpline Always Available Clients in PCCM have telephone access to a registered nurse, seven days a week, 24-hours a day including holidays. A skilled nurse can assist PCCM clients with health related questions about topics such as: A baby, child, or adult waking in the night with fever A baby, child, or adult vomiting Questions pertaining to a baby, child, or adult with symptoms of illness The client is required to supply their Medicaid Identification number when calling the nurse helpline. The nurse will ask questions to determine if the situation can be treated at home, if the client will need to visit the primary care provider, or if the client should go to the emergency room. Clients can seek assistance from the PCCM Nurse Helpline at any time by calling the toll-free number at Note: Directing clients to call the PCCM Nurse Helpline does not meet primary care provider 24-hour continuous coverage requirements. For more information, call the PCCM Provider Helpline at May/June Texas Medicaid Bulletin, No. 195

20 Primary Care Case Management (PCCM) Providers Self-Referred Services in Primary Care Case Management Most medical services that PCCM clients receive outside the care of a primary care provider require authorization from the primary care provider before the client can receive services. Authorization given to another provider to treat the PCCM client is called a referral. PCCM clients are encouraged to schedule an appointment with their primary care provider before receiving most medical services; however, some services do not require a referral from the primary care provider. Self-referred services include: OB/GYN PCCM clients can choose to see a Medicaid enrolled OB/GYN who is not their primary care provider for these services: One well-woman examination per year Care related to pregnancy Care for all active gynecological conditions Diagnosis, treatment, and referral to a specialist for any disease or condition within the scope of a designated professional practice of a properly credentialed obstetrician or gynecologist, including treatment of medical conditions concerning the breasts Note: Provider types other than OB/GYN may provide these services with a referral from the primary care provider. Texas Health Steps (THSteps) PCCM clients can choose any THStepsenrolled Texas Medicaid provider to perform THSteps services. If a THSteps medical checkup is performed by a provider who is not the client s primary care provider, the information should be forwarded to the client s primary care provider so the client s medical record can be updated. Eye Care PCCM clients do not need a referral to access necessary covered vision services for refractive errors. However, any diagnosed condition or abnormality of the eye that requires treatment or additional services beyond the scope of an exam for refractive errors must be referred back to the client s primary care provider. Vision care providers who furnish additional services must have a referral from the client s primary care provider. Family Planning Services PCCM clients may go to any Department of State Health Services (DSHS) family planning statecontracted Medicaid facility for family planning services without a referral from the primary care provider. Mental Health and Substance Abuse Treatment Mental health services provided by the following, do not require a referral: A Medicaid-enrolled psychiatrist A psychologist A licensed professional counselor A licensed clinical social worker A licensed marriage and family therapist Mental health case management services and mental health rehabilitative services provided by a DSHS contracted Medicaid provider Substance abuse services provided to clients younger than 21 years of age by a DSHS licensed substance abuse treatment facility Emergency Room Care PCCM clients can seek emergency medical services from the nearest emergency facility. The emergency facility should contact the client s primary care provider within 24 hours, or the next business day after services have been provided. For more information, refer to the 2006 Texas Medicaid Provider Procedures Manual Section on page 7-26, or call the TMHP Contact Center at Texas Medicaid Bulletin, No May/June 2006

21 Primary Care Case Management (PCCM) Providers PCCM Provider Enrollment Effective December 1, 2005, providers who wish to enroll as a primary care provider with PCCM must submit the following to the TMHP-PCCM credentialing department: A completed Texas Department of Insurance Texas Standardized Credentialing application The application addendum A copy of the provider s medical license A current copy of the malpractice insurance face sheet A signed PCCM contract If applicable, a Drug Enforcement Agency (DEA) registration certification and Texas Department of Public Safety (DPS) certification The required documents for enrollment are available at for all applicable provider types. Providers can also call the TMHP Contact Center at , or the Provider Helpline at to request a faxed or mailed application. To avoid delays in the enrollment process, please be sure the following commonly missed sections are fi lled out: Degree and education information Five year work history Continuous access information Signature and date for the attestation and release (pages 11 and 12) The TMHP PCCM credentialing department will notify providers in writing no more than two business days after receipt and identification of an incomplete application. Providers are advised to place the reference number given for the original submission on any documentation that corrects an existing application. If the missing or incomplete information is not received by the PCCM credentialing department within 30 days of notification, the enrollment application will be closed. Providers should mail the completed application to: TMHP Attn: Credentialing/MC-B05 PO Box Austin, TX Overnight mail should be sent to: TMHP Attn: Credentialing/MC-B B Riata Trace Pkwy Austin, TX With the exception of the PCCM contract which must be mailed, all of the forms in the application can be submitted by fax to According to the National Committee of Quality Assurance (the standards by which TMHP credentials all primary care providers) all contracts require an original signature. As part of the enrollment process, PCCM providers are required to have an initial site visit conducted by their TMHP Provider Relations representative. The provider representative must complete the site visit within 30 days of the date of the request. Once applications are reviewed, providers will receive a status notification letter and if applicable, a copy of the providers executed contract. For more information call the TMHP Contact Center at , or the PCCM Provider Helpline at May/June Texas Medicaid Bulletin, No. 195

22 Primary Care Case Management (PCCM) Providers Medicaid STAR Program Changes The Texas Medicaid Program is changing its managed care program for State of Texas Access Reform (STAR) clients and will expand managed care to the Nueces Service Area. The new Nueces Service Area includes the following Texas counties: Aransas Bee Calhoun Jim Wells Kleberg Nueces Refugio San Patricio Victoria Medicaid beneficiaries who are eligible because they qualify in Temporary Aid to Needy Families (TANF)- related categories will receive enrollment materials to assist in selecting a health maintenance organization (HMO). TANF-related beneficiaries include a large percentage of pregnant women and children who are eligible for Medicaid. Medicaid clients in the following eligibility groups will not be affected by this change: supplemental security income (SSI) recipients, institutionalized, dual eligible, medically needy, and foster children. STAR PCCM Phase Out PCCM will be phased out as a health plan option for Medicaid clients in the STAR program from July through December Effective December 1, 2006, Medicaid beneficiaries who are eligible for STAR in TANF-related categories will no longer have PCCM as a health plan choice. Effective January 1, 2007, STAR SSI-related clients will no longer have PCCM as a health plan option. SSI includes many disabled Medicaid beneficiaries who are adults. This change will affect PCCM clients in the following STAR service areas: Service Areas Bexar Dallas El Paso Harris/Harris Expansion Lubbock Counties Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall El Paso Brazoria, Fort Bend, Galveston, Harris, Montgomery, Waller Crosby, Floyd, Garza, Hale, Hockley, Lamb, Lubbock, Lynn, Terry Medicaid clients in the affected areas must select another health plan offered through an HMO. HHSC will mail out initial notification letters and enrollment kits to clients in July The information will inform clients of the available HMOs in their area as well as how to choose a health plan. HHSC asks that PCCM providers in the affected areas preserve each PCCM client s medical home to ensure continuity of care through the transition. In addition, PCCM providers in these areas are encouraged to continue providing health care services to PCCM clients who live in contiguous areas not affected by the managed care changes. Additional HMO Choices HHSC is finalizing new contracts for all HMOs participating in the STAR program. Additional HMOs will participate in the Bexar, Dallas, Harris, Tarrant, and Lubbock service areas. Clients with additional HMO choices will receive enrollment information regarding the available plans. More information will be available in the upcoming July/ August Texas Medicaid Bulletin, No, 197. Texas Medicaid Bulletin, No May/June 2006

23 School Health and Related Services Providers/Texas Health Steps Medical Providers Corrected Formula in Certification of Funds Letters This is a clarification to the 2006 Texas Medicaid Provider Procedures Manual, Section , on page The formula used by TMHP to compute the State/Local Funds Expended column in the quarterly Certification of Funds Letters is misleading. The calculation is done on a claim level based on the Federal Matching Share in effect on the date of service, not the Total Amount Paid for Previous Quarter. This is of particular importance in quarters when there are different Federal Matching Share percentages. Providers should monitor banner messages on their Remittance and Status (R&S) Reports for changes to the Federal Matching Share percentage. The correct formula should read as follows: (Total Paid Claim Amount Federal Matching Share percentage) x State Share percentage = State/Local Funds Expended. Providers will note that this is a per claim total. The total State/Local Funds Expended column in the Certification of Funds letter is calculated by totaling the amounts calculated for each claim. Providers will also note that this calculation is applied to paid claims only. Adjustments are not included in this calculation. For more information, call the TMHP Contact Center at TEXAS HEALTH STEPS MEDICAL PROVIDERS Complete Medical Checkups and Follow-Up Visits Texas Health Steps (THSteps) medical checkups are an opportunity for a child or adolescent to receive a comprehensive medical checkup. In accordance with THSteps policy, all components of the medical checkup must be completed for the provider to submit a claim. Providers must not refer a child receiving a THSteps checkup to an outside source for laboratory tests, immunizations, or other checkup components. Extenuating circumstances for either the provider or the recipient may impact the ability of a provider to complete a checkup. The following paragraphs present situations that may occur when a complete medical checkup cannot be accomplished, and the appropriate follow-up for the situation. A child may not cooperate with the provider for a specific component such as hearing or developmental screening which requires the child s participation. The provider must document the attempt to complete the component in the child s medical record. The provider may then submit a claim for payment for a medical checkup, and the child should be brought back for a follow-up visit to complete the pending specific component at the first available opportunity. If a child is ill during a checkup visit and an immunization cannot be completed, the provider should document the reason for not completing the immunization in the child s medical record. The child must be scheduled for a follow-up visit. There may be occasions when the child s illness interferes with a significant number of the components of the medical checkup, such as developmental testing, hearing and vision, or immunizations. In this situation, it is the provider s discretion whether to complete the checkup or bill for the visit as an acute-care visit and reschedule the child for a medical checkup. If the parent refuses a specific component such as an immunization or a laboratory test, the provider must provide the parent with information concerning the reason for the component. The medical record must document the education provided and the parent s refusal in the child s record. The visit may be billed as a complete checkup since the provider completed all the components for which consent was given. If the parent leaves the clinical setting before completing all the components, the provider should attempt to contact the parent, caretaker, or client, to provide education concerning the reason for the component, and request that the parent return for a follow-up visit to complete the checkup. The medical record should contain documentation of the provider education and the attempt to reschedule. The visit may be billed as a complete checkup since the provider completed all the components to the best of his or her ability. If a significant number of components were not completed, then the provider may consider rescheduling the checkup and billing an appropriate acute care for those components that were completed. If a checkup component was not completed at a previous THSteps medical checkup and the child presents for another THSteps medical checkup, the provider should attempt to complete all components recommended for the child s current age. This includes bringing the child up-todate for components that were not completed at an earlier age if the procedure is still appropriate for the child s age May/June Texas Medicaid Bulletin, No. 195

24 Texas Health Steps Medical Providers range (e.g., immunizations) and can be completed based on provider discretion. There may be an occasion when the provider does not have adequate supplies. If a provider routinely has a problem with supply shortages, contact the regional THSteps provider relation s staff for assistance. Contact information for the THSteps, Immunizations staff, and Tuberculosis regional staff can be found in the 2006 Texas Medicaid Provider Procedures Manual, Appendix A. For laboratory supplies providers may call , ext For more information, visit the TMHP website at or call the TMHP Contact Center at Texas Medicaid Bulletin, No May/June 2006

25 Excluded Providers Excluded Providers As required by the Medicare and Medicaid Patient Protection Act of 1987, the Texas Health and Human Services Commission (HHSC) identifies providers or employees of providers who have been excluded from state and federal health care programs. Providers excluded from the Texas Medicaid Program and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client. Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by the Texas Medicaid Program for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of HHSC s exclusion list. The HHSC-Sanctions Department submits updates to the exclusion list semi-monthly. Updates appear on the website after the 1st and 15th of each month. Review the entire Texas Medicaid Program exclusion list at To report Medicaid providers who engage in fraud/abuse, call or , or write to the following address: Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity MC 1361 PO Box Austin TX Provider License No# Exclusion Date City State Provider Type Add Date Adams, Carlyn C 08-Nov-05 Sealy TX LVN 06-Mar-06 Bailey, Deborah A 13-Apr-05 Hitchcock TX LVN 08-Mar-06 Bailey, Ross D 08-Nov-05 San Diego CA RN 09-Mar-06 Barnes, Melissa 08-Nov-05 Menard TX RN 22-Feb-06 Bernas, Tomas B Aug-05 Sugar Land TX RN 09-Feb-06 Borel, Avalon D 08-Nov-05 Fort Pok LA LVN 22-Feb-06 Brady, Rennye D Feb-06 Comfort TX LVN 07-Feb-06 Burge, Debra R 08-Nov-05 Poplarville MS RN 22-Feb-06 Cauble, Karen Nov-05 Yorktown TX LVN 23-Jan-06 Cedar Park Home Health Care 03-Mar-06 Austin TX DME 15-Mar-06 Crenshaw, Leonard C Dec-03 Rosharon TX LPC 10-Feb-06 Davis, Marcus A 13-Sep-05 Texarkana TX LVN 22-Feb-06 DeLeon, Rosalinda Feb-06 San Antonio TX LVN 07-Feb-06 Dent, Amy M Nov-05 Littlefield TX RN 30-Jan-06 Diamante, Jay J 10-Nov-05 San Antonio TX LVN 20-Mar-06 Dixon, Shemeka N 04-May-05 Garland TX LVN 10-Mar-06 Dolan, Margaret Joyce Feb-06 Azle TX LVN 22-Feb-06 Fraedrich, Jason M 08-Nov-05 Flintville TN LVN 15-Feb-06 Gabus, Joseph T 18-Jul-02 Huntsville TX C N A 08-Mar-06 Gilvarry, Dana M 08-Nov-05 Houston TX LVN 22-Feb-06 Granville, Geraldine B Nov-05 Alexandria LA RN 23-Jan-06 Graves, Shamarion L Sep-05 Brazoria TX LVN 17-Jan-06 May/June Texas Medicaid Bulletin, No. 195

26 Excluded Providers Provider License No# Exclusion Date City State Provider Type Add Date Heinrichs, Barbara D 08-Nov-05 Austin TX LVN 28-Feb-06 Henderson, Kimberly L Nov-05 Farmer s Branch TX LVN 06-Feb-06 Herndon, Richie A 13-Feb-06 Richardson TX 23-Feb-06 Hudson, James C Jan-06 Midland TX RN 14-Feb-06 Inigo, Marisa H Feb-06 Edinburg TX MD 07-Feb-06 Ivory, Carnetha 08-Nov-05 Waco TX LVN 21-Feb-06 Jackson, Ruby J 13-Sep-05 Dallas TX LVN 20-Mar-06 Johnson, Kellion 20-Sep-05 DeSoto TX 23-Feb-06 Jones, James S M Nov-05 Lubbock TX MD 23-Jan-06 Koch, Ida D Nov-05 Mountain Home TX LVN 23-Jan-06 Loera, Rose Marie 07-Feb-06 San Antonio TX NP 10-Feb-06 M&M Counseling TC Feb-06 Pharr TX TCADA 24-Feb-06 Martinez, Carolina 08-Nov-05 Midland TX LVN 20-Mar-06 McKellar, Monica Feb-06 Fort Worth TX LVN 06-Mar-06 Melgoza, Jose 31-Jan-06 Levelland TX C.N.A 30-Jan-06 Mi Casa Family Center 19-Sep-05 San Antonio TX other 22-Feb-06 Misthos, Steven A 20-Feb-06 Mission TX owner 24-Feb-06 Mojica, David R Aug-05 Lamesa TX LVN 21-Mar-06 Montgomery, Selma Anne M 08-Nov-05 Houston TX LVN 22-Feb-06 Morgan, Kevin D PA Jun-05 San Antonio TX PA 06-Feb-06 Nagelmueller, Cynthia A 24-Jan-06 Shiner TX Owner 24-Jan-06 Novak, Teresa 08-Nov-05 San Diego CA RN 10-Mar-06 Pape, Pamela E Nov-05 Waucoma IA RN 09-Feb-06 Patterson, Charlotte D Sep-06 Arlington TX RN 08-Mar-06 Payne, John B 07-Oct-05 Colleyville TX 06-Mar-06 Pitts, John 23-Feb-05 Fort Worth TX RN 20-Mar-06 Polley, Luetricia Joyce 20-Sep-05 Longview TX 06-Mar-06 Puckett, Kristi R Nov-05 Fredericksburg TX RN 17-Jan-06 Raphael, Peter 08-Jun-05 Plano TX MD 28-Feb-06 Redenius, Ronda L Oct-05 Haltom City TX LVN 17-Jan-06 Richardson, Jacqueline O 20-Oct-04 Forth Worth TX Owner 22-Feb-06 Richardson, Sally J 08-Nov-05 Gouverneur NY RN 28-Feb-06 Richardson, Troy L 20-Oct-04 Austin TX 15-Mar-06 Rogers, Veronica F 08-Nov-05 Houston TX LVN 28-Feb-06 Ruff, Kenneth E 08-Nov-05 White Hall AR LVN 16-Feb-06 Saafir, Asha 13-Sep-05 Los Angeles CA RN 20-Mar-06 Sayre, Kathy 08-Nov-05 Keaau HI RN 22-Feb-06 Schiebert, Nancy A Nov-05 Midwest City OK RN 03-Feb-06 Skinner, Dawn 08-Nov-05 Indianapolis IN RN 28-Feb-06 Smith, Lisa A Nov-05 Amarillo TX LVN 30-Jan-06 Stone, Tamatha A Nov-05 Lewisville AR RN 14-Feb-06 Storms, William C 20-Oct-05 McAllen TX LVN 22-Feb-06 Straley, Barbara J Nov-05 Lometa TX LVN 09-Feb-06 Thornhill, Laura 08-Nov-05 Texarkana TX LVN 20-Mar-06 Tucker, Christine B Aug-05 Sherman TX LVN 22-Feb-06 Waddington, Crystal R 20-Jul-05 Hawley TX 23-Feb-06 Wiggins, Donna G Nov-05 Houston TX LVN 09-Feb-06 Williams, Christopher Nov-05 Houston TX LVN 09-Feb-06 Williams, S S 08-Nov-05 Fort Worth TX RN 28-Feb-06 Woodall, Danny Sep-05 Amarillo TX LVN 17-Jan-06 Wright, Evelyn Y 15-Oct-04 Schulenburg TX NP 28-Feb-06 Texas Medicaid Bulletin, No May/June 2006

27 Forms Sterilization Consent Form Notice: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. CONSENT TO STERILIZATION I have asked for and received information about sterilization from (doctor or clinic). When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least 30 days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years of age and was born on (day), (month), (year). I,, hereby consent of my own free will to be sterilized by (doctor or clinic) by a method called. My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form. Client s Signature Date of Signature: / / (month/day/year) NOTICE: You are requested to supply the following information, but it is not required: Race and Ethnicity Designation Ethnicity: Hispanic or Latino Not Hispanic or Latino Race (mark one or more): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White INTERPRETER S STATEMENT If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation. Interpreter Signature: Date: / / 04/2006 STATEMENT OF PERSON OBTAINING CONSENT Before (client s full name), signed the consent form, I explained to him/her the nature of the sterilization operation known as a, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure. Signature of person obtaining consent: Date: / / Facility Name: Facility Address: May/June Texas Medicaid Bulletin, No. 195

28 Forms STERILIZATION CONSENT FORM - PAGE 2 PHYSICIAN S STATEMENT Shortly before I performed a sterilization operation upon (name of individual to be sterilized), on / / at (date of sterilization), I explained to him/her the nature of the sterilization operation (specify type of operation), the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least 30 days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested): Γ Γ Premature delivery - Individual's expected date of delivery: / / (month, day, year) Emergency abdominal surgery: (describe circumstances): Physician s Signature: Date: / / PAPERWORK REDUCTION ACT STATEMENT A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays the currently valid OMB control number. Public reporting burden for this collection of information will vary; however, we estimate an average of one hour per response, including for reviewing instructions, gathering and maintaining the necessary data, and disclosing the information. Send any comment regarding the burden estimate or any other aspect of this collection of information to the OS Reports Clearance Officer, ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, S.W., Washington, D.C Respondents should be informed that the collection of information requested on this form is authorized by 42 CAR part 50, subpart B, relating to the sterilization of persons in federally assisted public health programs. The purpose of requesting this information is to ensure that individuals requesting sterilization receive information regarding the risks, benefits and consequences, and to assure the voluntary and informed consent of all persons undergoing sterilization procedures in federally assisted public health programs. Although not required, respondents are requested to supply information on their race and ethnicity. Failure to provide the other information requested on this consent form, and to sign this consent form, may result in an inability to receive sterilization procedures funded through federally assisted public health programs. All information as to personal facts and circumstances obtained through this form will be held confidential, and not disclosed without the individual s consent, pursuant to any applicable confidentiality regulations. ALL FIELDS IN THIS BOX REQUIRED FOR PROCESSING Medicaid or Family Planning # Date Client Signed: / / (month, day, year) Provider TPI: - Provider/Clinic Phone # ( ) - Provider/Clinic Fax # ( ) - Titled Billed (circle one): V X XIX (Medicaid) XX 04/2006 Texas Medicaid Bulletin, No May/June 2006

29 Forms Sterilization Consent Form (Spanish) Nota: La decisión de no esterilizarse que usted puede tomar en cualquier momento, no causará el retiro o la retención de ningún beneficio que le sea proporcionado por programas o proyectos que reciben fondos federales. CONSENTIMIENTO PARA ESTERILIZACIÓN Yo he solicitado y he recibido información de (médico o clínica) sobre la esterilización. Cuando inicialmente solicité esta información, me dijeron que la decisión de ser esterilizada/o es completamente mía. Me dijeron que yo podía decidir no ser esterilizada/o. Si decido no esterilizarme, mi decisión no afectará mi derecho a recibir tratamiento o cuidados médicos en el futuro. No perderé ninguna asistencia o beneficios de programas patrocinados con fondos federales, tales como A.F. D. C. o Medicaid, que recibo actualmente o para los cuales seré elegible. ENTIENDO QUE LA ESTERILIZACIÓN SE CONSIDERA UNA OPERACIÓN PERMANENTE E IRREVERSIBLE. YO HE DECIDIDO QUE NO QUIERO QUEDAR EMBARAZADA, NO QUIERO TENER HIJOS O NO QUIERO PROCREAR HIJOS. Me informaron que me pueden proporcionar otros métodos de anticoncepción disponibles que son temporales y que permitirán que pueda tener o procrear hijos en el futuro. He rechazado estas opciones y he decidido ser esterilizada/o. Entiendo que seré esterilizada/o por medio de una operación conocida como. Me han explicado las molestias, los riesgos y los beneficios asociados con la operación. Han respondido satisfactoriamente a todas mis preguntas. Entiendo que la operación no se realizará hasta que hayan pasado 30 días, como mínimo, a partir de la fecha en la que firme esta Forma. Entiendo que puedo cambiar de opinión en cualquier momento y que mi decisión en cualquier momento de no ser esterilizada/o no resultará en la retención de beneficios o servicios médicos proporcionados a través de programas que reciben fondos federales. Tengo por lo menos 21 años y nací el (día) de (mes) de (año). Yo,, por medio de la presente doy mi consentimiento de mi libre voluntad para ser esterilizada/o por (médico o clínica) por el método llamado. Mi consentimiento vence 180 días a partir de la fecha en la que firme este documento. También doy mi consentimiento para que se presente esta Forma y otros expediente médicos sobre la operación a: Representantes del Departamento de Salud y Servicios Sociales, o Empleados de programas o proyectos financiados por ese Departamento, pero sólo para que puedan determinar si se han cumplido las leyes federales. He recibido una copia de esta Forma. Firma: Fecha: / / (día, mes, año) Nota: Se ruega proporcione la siguiente información, aunque no es obligatorio hacerlo: Definición de raza y origen étnico Origen étnico: Raza (marque según aplique): Hispano o latino Indígena americano o indígena de Alaska No hispano Asiático o latino Negro o afroamericano Natural de Hawaii u otras islas del Pacífico Blanco DECLARACIÓN DEL INTÉRPRETE Si se han proporcionado los servicios de un intérprete para asistir a la persona que será esterilizada: He traducido la información y los consejos que verbalmente se le han presentado a la persona que será esterilizada/o por el individuo que ha obtenido este consentimiento. También le he leído a él/ella la Forma de Consentimiento en idioma y le he explicado el contenido de esta forma. A mi mejor saber y entender, ella/él ha entendido esta explicación. Firma: Fecha: / / DECLARACIÓN DE LA PERSONA QUE OBTIENE CONSENTIMIENTO Antes de que (nombre de persona) firmara la Forma de Consentimiento para la Esterilización, le he explicado a ella/él los detalles de la operación para la esterilización, el hecho de que el resultado de este procedimiento es final e irreversible, y las molestias, los riesgos y los beneficios asociados con este procedimiento. He aconsejado a la persona que será esterilizada que hay disponibles otros métodos de anticoncepción que son temporales. Le he explicado que la esterilización es diferente porque es permanente. Le he explicado a la persona que será esterilizada que puede retirar su consentimiento en cualquier momento y que ella/él no perderá ningún servicio de salud o beneficio proporcionado con el patrocinio de fondos federales. A mi mejor saber y entender, la persona que será esterilizada tiene por lo menos 21 años de edad y parece ser mentalmente competente. Ella/él ha solicitado con conocimiento de causa y por libre voluntad ser esterilizada/o y parece entender la naturaleza del procedimiento y sus consecuencias. Firma de la persona que obtiene el consentimiento : Fecha Lugar Dirección 04/2006 May/June Texas Medicaid Bulletin, No. 195

30 Forms STERILIZATION CONSENT FORM (SPANISH) PAGE 2 DECLARACIÓN DEL MÉDICO Previamente a realizar la operación para la esterilización a (nombre de persona esterilizada/o), en / / (fecha de esterilización: día, mes, año), le expliqué a él/ella los detalles de esta operación para la esterilización (especifique tipo de operación), del hecho de que es un procedimiento con un resultado final e irreversible, y las molestias, los riesgos y los beneficios asociados con esta operación. Le aconsejé a la persona que sería esterilizada que hay disponibles otros métodos de anticoncepción que son temporales. Le expliqué que la esterilización es diferente porque es permanente. Le informé a la persona que sería esterilizada que podía retirar su consentimiento en cualquier momento y que ella/él no perdería ningún servicio de salud o ningún beneficio proporcionado con el patrocinio de fondos federales. A mi mejor saber y entender, la persona que será esterilizada tiene a lo menos 21 años de edad y parece ser mentalmente competente. Ella/él ha solicitado con conocimiento de causa y libre voluntad ser esterilizada/o y parece entender el procedimiento y las consecuencias de este procedimiento. (Instrucciones para uso alternativo de párrafos finales: Utilice el párrafo 1 que se presenta a continuación, excepto para casos de parto prematuro y cirugía abdominal de emergencia cuando se ha realizado la esterilización a menos de 30 días después de la fecha en la que la persona firmó la Forma de Consentimiento para la Esterilización. Para esos casos, utilice el párrafo 2 que se presenta más adelante. Tache con una X el párrafo que no se aplique). (1) Han transcurrido por lo menos 30 días entre la fecha en la que la persona firmó esta Forma de Consentimiento y la fecha en la que se realizó la esterilización. (2) La operación para la esterilización se realizó a menos de 30 días, pero a más de 72 horas, después de la fecha en la que la persona firmó la Forma de Consentimiento debido a las siguientes circunstancias (marque la casilla apropiada y escriba la información requerida): Parto prematuro Fecha prevista de parto: Cirugía abdominal de urgencia Describa las circunstancias: Firma del médico Fecha DECLARACIÓN SOBRE LEY DE REDUCCIÓN DE TRÁMITES Una agencia federal no debe llevar a cabo o patrocinar la recolección de información, y el público no está obligado a responder a la misma o a facilitar la información, a no ser que dicha solicitud de información presente un número de control válido de la OMB. La carga horaria para el público que completa esta forma variará; sin embargo, se ha estimado un promedio de una hora por cada respuesta, cálculo que incluye el tiempo para revisar las instrucciones, buscar y presentar los datos exigidos y completar la forma. Para enviar sus comentarios sobre la carga horaria estimada o cualquier otro aspecto de la información requerida, escriba a OS Reports Clearance Officer, ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, S.W., Washington, D.C Se debe informar al público que responde a esta forma que la recolección de información solicitada en la misma se autoriza en virtud de 42 CAR parte 50, subparte B, que tiene que ver con la esterilización de personas en programas de salud pública que son financiados por el gobierno federal. El propósito de la recolección de esta información es asegurar que las personas que solicitan la esterilización sean informadas sobre los riesgos, los beneficios y las consecuencias de esta operación, y para asegurar el consentimiento voluntario e informado de todas las personas que se someten al procedimiento de esterilización en programas de salud pública que reciben asistencia federal. Se pide a las personas que llenan la forma que incluyan datos sobre su raza y grupo étnico, aunque esta información no es requerida. Toda la demás información solicitada en esta forma de consentimiento es requerida. Si la persona que llena la forma no proporciona la información requerida o si no firma esta forma de consentimiento, podría resultar en que no recibiera el procedimiento de esterilización financiado por un programa de salud pública patrocinado con fondos federales. Toda la información de datos y circunstancias personales obtenidas por medio de esta Forma son confidenciales y no se divulgarán sin el consentimiento de la persona, en conformidad con todos los reglamentos aplicables de confidencialidad. ALL FIELDS IN THIS BOX REQUIRED FOR PROCESSING Medicaid or Family Planning # Date Client Signed: / / (month, day, year) Provider TPI: - Provider/Clinic Phone # ( ) - Provider/Clinic Fax # ( ) - Titled Billed (circle one): V X XIX (Medicaid) XX 04/2006 Texas Medicaid Bulletin, No May/June 2006

31 Forms Sterilization Consent Form Instructions Per federal regulation 42 CFR 50, Subpart B, all sterilizations require a valid consent form regardless of the funding source. Ensure all required fields are completed for timely processing. Fax or mail the Sterilization Consent Form five business days before submitting the associated claim(s) to expedite the processing of the Sterilization Consent Form and associated claim(s). Fax fully completed Sterilization Consent Forms to TMHP at Claims and appeals are not accepted by fax. Only send Family Planning sterilization correspondence to this fax number. Note: Hysterectomy Acknowledgment forms are not sterilization consents and should be faxed to Clients must be at least 21 years of age when the consent form is signed. If the client was not 21 years of age when the consent form was signed, the consent will be denied. Changing signature dates is considered fraudulent and will be reported to the Office of the Inspector General (OIG). There must be at least 30 days between the date the client signs the consent form and the date of surgery, with the following exceptions: Exception: Premature delivery - There must be at least 30 days between the date of consent and the client's expected date of delivery. In cases of Emergency Abdominal Surgery -There must be at least 72 hours between the date of consent and the date of surgery. Operative reports detailing the need for emergency surgery are required. Listed below are field descriptions for the Sterilization Consent Form. Completion of all sections is required to validate the consent form, with only two exceptions: Exception: Race and Ethnicity Designation is requested but not required. The Interpreter's Statement is not required as long as the consent form is written in the client's language, or the person obtaining the consent speaks the client's language. If this section is partially completed, the consent will be denied for incomplete information. This Sterilization Consent Form may be copied for provider use. Providers are encouraged to frequently recopy the original form to ensure legible copies and to expedite consent validation. Required Fields All of the fields must be legible in order for the consent form to be valid. Any illegible field will result in a denial of the submitted consent form. Resubmission of legible information must be indicated on the consent form itself. Resubmission with information indicated on a cover page or letter will not be accepted. Consent to Sterilization Name of Doctor or Clinic. Name of the Sterilization Operation. Client's Date of Birth (month, day, year) Client's Name (first and last names required). Name of Doctor or Clinic. Name of the Sterilization Operation. Client's Signature. Date of Client Signature - Client must be at least 21 years of age on this date. This date cannot be altered or added at a later date. May/June Texas Medicaid Bulletin, No. 195

32 Forms Interpreter's Statement (If applicable) Name of Language Used by Interpreter. Interpreter's Signature. Date of Interpreter's Signature (month, day, year). Statement of Person Obtaining Consent Client's Name (first and last names are required). Name of the Sterilization Operation. Signature of Person Obtaining Consent-The statement of person obtaining consent must be completed by the person who explains the surgery and its implications and alternate methods of birth control. The signature of person obtaining consent must be completed at the time the consent is obtained. The signature must be an original signature, not a rubber stamp. Date of the Person Obtaining Consent s Signature (month, day, year) - Must be the same date as the client's signature date. Facility Name - Clinic/office where the client received the sterilization information. Facility Address - Clinic/office where the client received the sterilization information. Physician's Statement Client's Name (first and last names are required). Date of Sterilization Procedure (month, day, year) - Must be at least 30 days and no more than 180 days from the date of the client s consent except in cases of premature delivery or emergency abdominal surgery. Name of the Sterilization Operation. Expected Date of Delivery (EDD) - Required when there are less than 30 days between the date of the client consent and date of surgery. Client's signature date must be at least 30 days prior to EDD. Circumstances of Emergency Surgery - Operative report(s) detailing the need for emergency abdominal surgery are required. Physician's Signature - Stamped or computer-generated signatures are not acceptable. Date of Physician s Signature (month, day, year) -This date must be on or after the date of surgery. Paperwork Reduction Act Statement This is a required statement and must be included on every Sterilization Consent Form submitted. Additional Required Fields Medicaid or Family Planning Number - Clients submitted as Titles V, X, and XX may not have a Family Planning number. Please simply indicate the appropriate Title below. Date Client Signed the Consent (month, day, year) Provider TPI - Including the nine-digit provider identification number will expedite the processing of the consent form. Provider/Clinic Phone Number. Provider/Clinic Fax Number (If available). Family Planning Title for Client - Indicate by circling V, X, XIX (Medicaid), or XX. Texas Medicaid Bulletin, No May/June 2006

33 Forms Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form NOTE: Complete all sections below and attach a voided check or a photocopy of your deposit slip. Type of Authorization: NEW CHANGE Provider Name Nine Character Billing TPI Provider Accounting Address Street Address or PO Box City State Zip Bank Name Provider Phone Number ABA/Transit Number ext. Bank Phone Number Account Number Bank Address Street Address or PO Box City State Zip Type Account (check one) Checking Savings I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period. I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations. Authorized Signature Date Title Address (if applicable) Contact Name Phone DO NOT WRITE IN THIS AREA For Office Use Return this form to: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box Austin TX Input By: Input Date: Page 2 of 2 EFTAG _v1.0 May/June Texas Medicaid Bulletin, No. 195

34 Forms Electronic Funds Transfer (EFT) Information Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account. The following items are specific to EFT: Applications are processed within five workdays of receipt. Pre notification to your bank takes place on the cycle following the application processing. Future deposits are received electronically after pre notification. The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider s account during the weekly cycle. Specific deposits and associated R&S reports are cross referenced by both Texas Provider Identifier (TPI) and R&S number. EFT funds are released by TMHP to depository financial institutions each Friday. The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received. TMHP must provide the following notification according to ACH guidelines: Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date. However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer s needs. In all cases, credits received should be posted to the customer s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date. To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or deposit slip with the agreement to the TMHP address indicated on the form. Contact TMHP Customer Service at if you need assistance. Page 1 of 2 EFTAG _v1.0 Texas Medicaid Bulletin, No May/June 2006

35 Forms Provider Information Change Form Traditional Medicaid, Children with Special Health Care Needs (CSHCN), and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page. Check the box to indicate a PCCM Provider Date: 9-digit Texas Provider Identifier (TPI): Provider Name: List any additional TPIs that use the same provider information: TPI: TPI: TPI: TPI: TPI: TPI: Physical Address* Accounting/Mailing Address** Secondary Address City: City: City: State: ZIP: State: ZIP: State: ZIP: Phone: ( ) Phone: ( ) Fax: Fax: Fax: Phone: ( ) Type of Change: (Check the appropriate box below.) Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/Add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance) Comments: Tax Information Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS) Tax ID Number: Effective Date: Exact name reported to the IRS for this Tax ID: The signature and date are required or the form will not be processed. Provider Signature: Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment MC-B05 PO Box Austin, TX Date: Fax: * The physical address cannot be a PO Box. Traditional Medicaid providers who change their ZIP code must submit a copy of the Medicare letter along with this form. ** All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form. May/June Texas Medicaid Bulletin, No. 195

36 Forms Instructions for Completing the Provider Information Change Form Signatures: The provider s signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers. Address: Performing providers (physicians performing services within a group) may not change accounting information. For Traditional Medicaid, changes to the accounting or mailing address require a copy of the W9 form. For Traditional Medicaid, a change in ZIP code requires copy of the Medicare letter. Tax Identification Number (TIN): TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN. General: Forms will be returned unprocessed if the nine-digit provider number is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment MC-B05 PO Box Austin, TX Fax: Texas Medicaid Bulletin, No May/June 2006

37 Forms ST PLY UB-92 APPROVED OMB NO PATIENT CONTROL NO. 4 TYPE OF BILL 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD FROM THROUGH 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D PATIENT NAME 13 PATIENT ADDRESS 14 BIRTHDATE 15 SEX 16 MS 17 DATE ADMISSION 18 HR 19 TYPE 20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO. CONDITION CODES a b OCCURRENCE CODE DATE 33 OCCURRENCE CODE DATE 34 OCCURRENCE CODE DATE 35 OCCURRENCE CODE DATE 36 OCCURRENCE SPAN CODE FROM THROUGH 39 VALUE CODES CODE AMOUNT a b c d 37 A B C 40 VALUE CODES CODE AMOUNT 42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES REL 53 ASG 50 PAYER 51 PROVIDER NO. INFO BEN 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE A B C 57 DUE FROM PATIENT 58 INSURED S NAME 59 P. REL 60 CERT. - SSN - HIC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. A B C A B C 63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION 67 PRIN. DIAG. CD. OTHER DIAG. CODES 68 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE VALUE CODES CODE AMOUNT 76 ADM. DIAG. CD. 77 E-CODE 78 A B C a b c d A B C A B C a b c d 79 P.C. 80 PRINCIPAL PROCEDURE 81 OTHER PROCEDURE OTHER PROCEDURE CODE DATE CODE DATE CODE DATE 84 REMARKS UB-92 HCFA-1450 A OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE CODE DATE CODE DATE CODE DATE C D E OCR/ORIGINAL B 82 ATTENDING PHYS. ID 83 OTHER PHYS. ID x OTHER PHYS. ID A B 85 PROVIDER REPRESENTATIVE 86 DATE I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. a b a b May/June Texas Medicaid Bulletin, No. 195

38 Forms UNIFORM BILL: NOTICE: ANYONE WHO MISREPRESENTS OR FALSIFIES ESSENTIAL INFORMATION REQUESTED BY THIS FORM MAY UPON CONVICTION BE SUBJECT TO FINE AND IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW. Certifications relevant to the Bill and Information Shown on the Face Hereof: Signatures on the face hereof incorporate the following certifications or verifications where pertinent to this Bill: If third party benefits are indicated as being assigned or in participation status, on the face thereof, appropriate assignments by the insured/ beneficiary and signature of patient or parent or legal guardian covering authorization to release information are on file. Determinations as to the release of medical and financial information should be guided by the particular terms of the release forms that were executed by the patient or the patient s legal representative. The hospital agrees to save harmless, indemnify and defend any insurer who makes payment in reliance upon this certification, from and against any claim to the insurance proceeds when in fact no valid assignment of benefits to the hospital was made. If patient occupied a private room or required private nursing for medical necessity, any required certifications are on file. Physician s certifications and re-certifications, if required by contract or Federal regulations, are on file. For Christian Science Sanitoriums, verifications and if necessary reverifications of the patient s need for sanitorium services are on file. Signature of patient or his/her representative on certifications, authorization to release information, and payment request, as required be Federal law and regulations (42 USC 1935f, 42 CFR , 10 USC 1071 thru 1086, 32 CFR 199) and, any other applicable contract regulations, is on file. This claim, to the best of my knowledge, is correct and complete and is in conformance with the Civil Rights Act of 1964 as amended. Records adequately disclosing services will be maintained and necessary information will be furnished to such governmental agencies as required by applicable law. For Medicare purposes: If the patient has indicated that other health insurance or a state medical assistance agency will pay part of his/her medical expenses and he/she wants information about his/her claim released to them upon their request, necessary authorization is on file. The patient s signature on the provider s request to bill Medicare authorizes any holder of medical and non-medical information, including employment status, and whether the person has employer group health insurance, liability, no-fault, workers compensation, or other insurance which is responsible to pay for the services for which this Medicare claim is made. For Medicaid purposes: This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State Laws. 9.For CHAMPUS purposes: This is to certify that: (a) the information submitted as part of this claim is true, accurate and complete, and, the services shown on this form were medically indicated and necessary for the health of the patient; (b) the patient has represented that by a reported residential address outside a military treatment center catchment area he or she does not live within a catchment area of a U.S. military or U.S. Public Health Service medical facility, or if the patient resides within a catchment area of such a facility, a copy of a Non-Availability Statement (DD Form 1251) is on file, or the physician has certified to a medical emergency in any assistance where a copy of a Non-Availability Statement is not on file; (c) the patient or the patient s parent or guardian has responded directly to the provider s request to identify all health insurance coverages, and that all such coverages are identified on the face the claim except those that are exclusively supplemental payments to CHAMPUSdetermined benefits; (d) the amount billed to CHAMPUS has been billed after all such coverages have been billed and paid, excluding Medicaid, and the amount billed to CHAMPUS is that remaining claimed against CHAMPUS benefits; (e) the beneficiary s cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts; and, (f) any hospital-based physician under contract, the cost of whose services are allocated in the charges included in this bill, is not an employee or member of the Uniformed Services. For purposes of this certification, an employee of the Uniformed Services is an employee, appointed in civil service (refer to 5 USC 2105), including part-time or intermittent but excluding contract surgeons or other personnel employed by the Uniformed Services through personal service contracts. Similarly, member of the Uniformed Services does not apply to reserve members of the Uniformed Services not on active duty. (g) based on the Consolidated Omnibus Budget Reconciliation Act of 1986, all providers participating in Medicare must also participate in CHAMPUS for inpatient hospital services provided pursuant to admissions to hospitals occurring on or after January 1, (h) if CHAMPUS benefits are to be paid in a participating status, I agree to submit this claim to the appropriate CHAMPUS claims processor as a participating provider. I agree to accept the CHAMPUSdetermined reasonable charge as the total charge for the medical services or supplies listed on the claim form. I will accept the CHAMPUS-determined reasonable charge even if it is less than the billed amount, and also agree to accept the amount paid by CHAMPUS, combined with the cost-share amount and deductible amount, if any, paid by or on behalf of the patient as full payment for the listed medical services or supplies. I will make no attempt to collect from the patient (or his or her parent or guardian) amounts over the CHAMPUSdetermined reasonable charge. CHAMPUS will make any benefits payable directly to me, if I submit this claim as a participating provider. ESTIMATED CONTRACT BENEFITS Texas Medicaid Bulletin, No May/June 2006

39 Forms RADIOLOGY PRIOR AUTHORIZATION REQUEST FORM This form is used to obtain prior authorization (PA) for elective outpatient services or update an existing outpatient authorization. Phone: Fax: Date of Request: Please check the appropriate action requested: CT SCAN CTA SCAN MRI SCAN MRA SCAN Update/change codes from original PA request Facility TPI No. Facility Name: Reference No. PCN No. Client Name: DOB: Requesting/Referring Physician ID No. Requesting/Referring Physician Name: Phone Number: Fax Number: SECTION 1 Service Type: Outpatient Service(s) Emergent/Urgent Procedure Date of Service: Procedure Requested: Diagnosis Codes: Primary-, Secondary- Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications, and previous imaging results: SECTION 2 Updated Information (when necessary) Diagnosis Code(s): Primary - Secondary- Date of Service: Procedure codes: Clinical documentation to support medical necessity for procedure code change includes treatment history, treatment plan, medications, and previous imaging results : Ordering Physician Signature (signature required) Date Print Name (Physician must complete and sign this form prior to requesting authorization.) May/June Texas Medicaid Bulletin, No. 195

40 MAY/JUNE 2006 No. 195 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual Look inside for these and other important updates: Page 3 Page 10 Page 12 Page 21 Page 22 Changes to the Contact Center Telephone Menu Revised Sterilization Consent Form RSV Prophylaxis Limitation Change PCCM Provider Enrollment Medicaid STAR Program Changes PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE