Provider Orientation STAR, STAR+PLUS, and CHIP MHTPS

Transcription

1 Provider Orientation STAR, STAR+PLUS, and CHIP MHTPS

2 Agenda Molina Story Programs Texas Programs Service Area Item 2 Program Overview Item Members 3 Enrollment Who Must Enroll Eligibility Program ID Cards Benefits Cost Sharing Medical Transportation Value Added Services Rights & Responsibilities Claims & Billing Claims Submission Claims Submission Requirements LTSS Submission Requirements Coding Edits Newborn Claims Submission Claims Submission Tips Claims Payment Electronic Fund Transfers Providers Contract Requirements Provider Access & Availability Cultural Competency Provider Web Portal Roles & Responsibilities Support Health Services Prior Authorizations Requesting Prior Authorizations Prior Authorization Requirements Case Management Service Coordination Pharmacy Services Behavioral Health Services Complaints & Appeals Quality Improvement Program Texas Health Steps (THSteps) FREW Overview Questions 2

3 Programs 3

4 Texas Programs Service Areas (SA) STAR STAR+PLUS CHIP Bexar Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson Dallas Collin, Dallas, Ellis, Hurt, Kaufman, Navarro, Rockwall El Paso El Paso, Hudspeth Harris Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton Hidalgo Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata Jefferson Chambers, Harden, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker Rural 164 rural counties X X X X X X X X X X X *Hidalgo CHIP is covered under RSA X X X X 4

5 Service Areas Active Molina Service Areas. 5

6 Program Overview STAR State of Texas Access Reform The STAR program offers Medicaid services to members through a managed care system. STAR+PLUS is a Texas Medicaid managed care program designed to provide health care, acute and long-term services and support through a managed care system. CHIP Provides low-cost insurance for children under the age of 19 whose families earn too much to qualify for Medicaid, but cannot afford private insurance. CHIP Perinate Is a state and federally funded CHIP program: Non-Medicaid eligible pregnant women and their Medicaid/Non-Medicaid eligible newborns. 6

7 Members 7

8 Enrollment HHSC Eligibility Process Maximus Enrollment Broker Assist with Health Plan Enrollment & Changes Molina Health Plan Receives a monthly file of assigned Members from Enrollment Broker Assist Member with PCP changes and administers health care services. 8

9 Who Qualifies? STAR State of Texas Access Reform TANF/TANF-related recipients Pregnant Women Children receiving Medicaid assistance only STAR+PLUS Mandatory Supplemental Security Income (SSI) consumers age 21 or older Medicaid Buy-In (MBI) Community Based Alternatives (CBA) waiver consumers Consumers eligible because they are in a Social Security exclusion program such as: -Disabled Adult Children Program, and -Widow/Widower Program. Voluntary SSI-eligible children (under age 21) SSI children that do not volunteer, will be in traditional Medicaid. 9

10 Who Qualifies? Continued CHIP Eligibility is determined by the state administrative services contractor and members are enrolled in CHIP for a continuous 12-enrollment period. During the 10 th month, the member must initiate the renewal process to ensure continued enrollment. Members are encouraged to ensure that the application is successfully processed. CHIP Perinate The unborn children of uninsured pregnant women who are Texas residents and Have a household income greater than 185% FPL, and at or below 200% FPL Have a household income at or below 200% FPL, but do not qualify for Medicaid because of immigration status. 10

11 Eligibility Providers should verify eligibility before each service Ways Item 2 to verify eligibility Item Molina 3 Provider Web Portal Molina s Interactive Voice Response System (IVR) Monthly PCP Roster AIS line/txmedconnect Calling Customer Services at: STAR/STAR+PLUS for Bexar, Harris, Dallas, Jefferson, El Paso, & Hidalgo CHIP Rural Service Area

12 STAR Member ID Card STAR Members receive two ID Cards : State issues Medicaid ID Card and Molina issues Member ID Card 12

13 STAR+PLUS Member ID Card STAR+PLUS Members receive two ID Cards: State issues Medicaid ID Card and Molina issues Member ID Card 13

14 CHIP Member ID Card CHIP Members only receive one ID Card from Molina Healthcare 14

15 CHIP Perinate Member ID Card CHIP Perinate Members only receive one ID Card from Molina Healthcare 15

16 STAR Covered Services Covered Services include, but are not limited to, Medically Necessary: Ambulance services Audiology services Behavioral Health Services Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center Birthing services provided by a licensed birthing center Chiropractic services Dialysis Durable medical equipment and supplies Early Childhood Intervention (ECI) services Emergency Services Family planning services Home health care services Hospital services, including inpatient and outpatient Laboratory Mastectomy, breast reconstruction, and related follow-up procedures Medical checkups and Comprehensive Care Program (CCP) Services for children (birth through age 20) through the Texas Health Steps Program Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps Outpatient drugs and biologicals; administered by CareMark Drugs and biologicals provided in an inpatient setting Podiatry Prenatal care Primary care services Preventive services Radiology, imaging, and X-rays Specialty physician services Therapies physical, occupational and speech Transplants Vision 16

17 STAR+PLUS Headline Goes Here Covered Medical Services Covered Services include, but are not limited to, Medically Necessary: Ambulance services Audiology services Behavioral Health Services Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center Birthing services provided by a licensed birthing center Cancer screening, diagnostic, and treatment Chiropractic services Dialysis Durable medical equipment and supplies Early Childhood Intervention (ECI) services Emergency Services Family planning services Home health care services Hospital services, including inpatient and outpatient Laboratory Mastectomy, breast reconstruction, and related follow-up procedures Medical checkups and Comprehensive Care Program (CCP) Services for children (birth through age 20) Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps Optometry, glasses, & contact lenses Outpatient drugs and biologicals; administered by CareMark Drugs and biologicals provided in an inpatient setting Podiatry Prenatal care Primary care services Preventive services Radiology, imaging, and X-rays Specialty physician services Therapies physical, occupational and speech Transplants Vision 17

18 STAR+PLUS Headline Goes Here Covered Long Term Care Services Covered Services include, but are not limited to, Medically Necessary: Day Activity and Health Services (DAHS) Item 3 Personal Assistance Services (PAS) Home Delivery Meals Adaptive Aids Adult Foster Care Home Services Adult Day Care Services Assisted Living Emergency Response Services Medical Supplies Minor Home Modifications Nursing Services Respite Care (short-term supervision) Therapies (occupational, physical and speech) 18

19 CHIP Covered Services Covered Services include, but are not limited to, Medically Necessary: Inpatient General Acute and Inpatient Rehabilitation Hospital Services Skilled Nursing Facilities (Including Rehabilitation Hospitals) Outpatient Hospital, Comprehensive Rehabilitation Hospital, Clinic and Ambulatory Health Care Center Physician / Physician Extenders Professional Services Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies Home and Community Health Services Inpatient Mental Health Services Outpatient Mental Health Services Inpatient Substance Abuse Treatment Services Outpatient Substance Abuse Treatment Services Rehabilitation Services Hospice Care Services Emergency Services, including Emergency Hospitals, and Ambulance Services Transplants Vision Benefits Chiropractic Services Tobacco Cessation Program Case Management and Care Coordination Services Drug Benefits, administered by CareMark There is no lifetime maximum on benefits; however, 12-month period or lifetime limitations do apply to certain services. Copays apply until a family reaches its specific cost-sharing maximum. 19

20 CHIP Perinate Covered Services Covered Services include, but are not limited to, Medically Necessary: Inpatient General Acute and Inpatient Rehabilitation Hospital Services Outpatient Hospital, Comprehensive Rehabilitation Hospital, Clinic and Ambulatory Health Care Center Physician / Physician Extenders Professional Services Prenatal Care and Pre-Pregnancy Family Services and Supplies Emergency Services, including Emergency Hospitals, and Ambulance Services Case Management and Care Coordination Services There is no lifetime maximum on benefits; however, 12-month enrollment period or lifetime limitations do apply to certain services. Co-pays do not apply to CHIP Perinate Members. CHIP Perinate Newborns are eligible for 12-months continuous coverage, beginning with the month of enrollment as a CHIP Perinate. 20

21 CHIP Cost Sharing Co-pay amounts vary from $0 to $100 based on Federal Poverty Levels Item (FPL) 1 and type of service On Member s ID Card By contacting Customer Service Co-pay amounts can be found: Upon meeting cost-sharing limits the Member must contact Maximus to report they have reached their maximum out of pocket Maximus will notify Molina Healthcare of cost-sharing limit being met. Molina Healthcare will re-issue the Member a new Member ID Card, indicating no co-pay amount ($0) Federal law prohibits charging premiums, deductibles, coinsurance, copayments, or any other cost-sharing to Native American or Alaskan Natives Members. 21

22 Medical Transportation The Medical Transportation Program (MTP) is provided by HHSC To get a ride or learn more call: (Monday Friday, 8 a.m. to 5 p.m.) ; MED-TRIP TTY: Medicaid and Children with Special Health Care Needs (CSHCN) Services Program can receive transportation services to get to and from a provider, dentist, hospital or pharmacy. HHSC will: Help coordinate a ride or assist Pay for a bus ride or ride sharing service Pay a friend or relative by the mile for the round trip Provide gas money directly to the Member/parent /guardian 22

23 Headline Value Goes Added Here Services Effective September 1, Hour Nurse Advice Line Value Added Benefits STAR STAR+PLUS CHIP You can talk to a nurse 24 hours a day, 365 days a year. The phone numbers are: English: (888AskUs50) Spanish: (866Mi TeleSalud) Annual School/Sports Physical Members 5-19 years of age will get a once a year physical for school or sports. X X X X X Weight Watchers program Members who are 15 or older and have a BMI of 30 or above can get coupons for Weight Watchers meetings. $20 Gift Card for getting all childhood vaccinations on time Members under the age of 21 who have all of their childhood vaccinations on time are can receive a $20 gift. Stop-Smoking Program Molina uses a national stop-smoking program, called Quit for Life. This benefit is for members who are 18 or older and all members who are pregnant of any age, who want to stop smoking. (Limited to $50 value in the STAR+PLUS Dallas Service Area) X X X X X X 23

24 Value Headline Added Goes Here Services Continued Effective September 1, 2012 Value Added Benefits STAR STAR+PLUS CHIP $20 Gift Card for Yearly Texas Health Steps for members under 21 Members under the age of 21 who get all of their Texas Health Steps checkups every year and for infants who get all their 6 visits in the first 16 months of life can receive a $20 gift card. $20 Gift Card for early pregnancy exam Members who have an exam in the first three months of pregnancy can receive a $20 Gift card after verification by their primary care physician. $20 Gift Card for Post-partum exam Members who complete a post-partum exam within days can receive a $20 Gift Card. Car Seat for Newborns (STAR El Paso Only) Members can receive an infant car seat for newborns up to six months of age. Adult Dental Services Molina will pay up to $250 for dental exams, x-rays and cleaning per year for member age 21 and over. $20 Gift Card for diabetic retinopathy exam Members who complete a recommended diabetic retinopathy exam can receive a $20 gift card. Limited to non-dual Medicaid only members. X X X X X X X X 24

25 Value Headline Added Goes Here Services Continued Effective September 1, 2012 Value Added Benefits STAR STAR+PLUS CHIP $20 Gift Card for a HbA1c blood test Members who complete a recommended HbA1c blood test can receive a $20 gift card. Limited to non-dual Medicaid only member $20 Gift Item Card 2 for cholesterol blood test Members who complete a recommended cholesterol blood test can receive a $20 gift card. Limited to non-dual Item Medicaid 3 only members. Allergy-Free Bedding CHIP members with asthma who sign up and finish the 3-month Breath with Ease Program can get allergy-free bedding that includes an allergy-free pillowcase and mattress cover. Extra Help with Getting a Ride Help getting a ride or up to $25 gas card for doctor visits every three months for CHIP Members who need a ride. $20 Gift Card for Yearly Well Child for CHIP members under 21 years of age Members under the age of 21 who have all of their Well Child checkups every year and for infants who have all their 6 visits in the first 16 months of life can received a $20 gift card. $20 OTO (Over-the-Counter) Card for medicines and medical supplies CHIP members can receive a $20 card for OTO medicines and medical supplies. Help getting a ride Help getting a ride for doctor visits. You can get a gas card for $25 for medical visits. You can get this benefit every three months for medical visits. This is for Members who need a ride. X X X X X X (CHIP RSA only) X (CHIP RSA Only) 25

26 Member Rights You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to: Be treated fairly and with respect. Know that your medical records and discussions with your providers will be kept private and confidential. You have the right to a reasonable opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to: Be told how to choose and change your health plan and your primary care provider. Choose any health plan you want that is available in your area and choose your primary care provider from that plan. Change your primary care provider. Change your health plan without penalty. Be told how to change your health plan or your primary care provider. You have the right to ask questions and get answers about anything you do not understand. That includes the right to: Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated. Be told why care or services were denied and not given. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to: Work as part of a team with your provider in deciding what health care is best for you. Say yes or no to the care recommended by your provider. 26

27 Member Rights Continued You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to: Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan. Get a timely answer to your complaint. Use the plan s appeal process and be told how to use it. Ask for a fair hearing from the state Medicaid program and get information about how that process works. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need. Get medical care in a timely manner. Be able to get in and out of a health care provider s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act. Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information. Be given information you can understand about your health plan rules, including the health care services you can get and how to get them. You have the right to not be restrained or secluded when it is for someone else s convenience, or is meant to force you to do something you do not want to do, or is to punish you. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services. 27

28 Member Responsibilities You must learn and understand each right you have under the Medicaid program. That includes the responsibility to: Learn and understand your rights under the Medicaid program. Ask questions if you do not understand your rights. Learn what choices of health plans are available in your area. You must abide by the health plan s and Medicaid s policies and procedures. That includes the responsibility to: Learn and follow your health plan s rules and Medicaid rules. Choose your health plan and a primary care provider quickly. Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan. Keep your scheduled appointments. Cancel appointments in advance when you cannot keep them. Always contact your primary care provider first for your non-emergency medical needs. Be sure you have approval from your primary care provider before going to a specialist. Understand when you should and should not go to the emergency room. You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to: Tell your primary care provider about your health. Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated. Help your providers get your medical records. 28

29 Member Responsibilities Continued You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility Item 1 to: Item Work 2 as a team with your provider in deciding what health care is best for you. Understand how the things you do can affect your health. Do the best you can to stay healthy. Treat providers and staff with respect. Talk to your provider about all of your medications. 29

30 Claims & Billing 30

31 Claims Submission Timely filing of claims is 95 days from the date of service Methods for submitting claims: Item Electronic 2 Submission Approved vendors: EMDEON Payor ID for all Molina Provider Web Portal Paper - P.O. Box Long Beach, CA TMHP Single Source Portal A request for correction or adjustment must be submitted within 120 days from denial date shown on original Explanation of Payment (EOP) or Remittance Advise (RA) Members may not be balance billed for any Covered Services May collect any Member Co-pays, or Payment for non-covered services, only with Member 31 acknowledgement statement

32 Claims Submission Requirements Use standard, nationally recognized codes: CPT Codes HCPCS Revenue Code Modifiers when appropriate ICD-9 NDC as required by TMHP POA as required by TMHP 10%20Present%20on%20Admission%20Reporting.pdf Covered Services and codes our outlined in Texas Medicaid Provider Manual Claims must contain following provider identification numbers: National Provider Identification (NPI) attested on the TMHP Master Provider File EPSDT Texas Provider Identification (TPI) when billing THStep services LTSS provider may have an API Both billing provider NPI and rendering provider s NPI are required on claims 32

33 LTSS Submission Requirements LTSS Payment Matrix 33

34 Verisk Headline Goes Health Here fka HealthCare Insight (HCI) Molina s Claims editing service partner through September 4, 2012: The code editing rules used by HCI are industry standard rules and guidelines as Item published 1 and defined in CPT and by CMS, such as National Correct Coding Initiative Item edits. 2 These edits are used by most, if not all health care claims payers in the United Item States. 3 HCI coding edits help identify: Nationally recognized Fraud, Waste and Abuse billing patterns Unbundled and fragmented billings Other common billing errors such as duplicate billings Benefits of using HCI: Control healthcare costs in CMS Medicare/Medicaid programs Creates consistent and equitable reimbursement for all billing providers Edits applied: Currently applied post payment Effective July 1, 2012 edits will be applied pre-payment Effective September 4, 2012 Molina Healthcare will manage all coding edits 34

35 Billing Maternity Claims Delivery charges should be billed with the appropriate CPT codes: & = Vaginal Delivery & = C-Section Delivery Codes must be billed with one of the following modifiers (59409, 59410, 59514, 59515, 59612,59614, 59620, or 59622): U1 Medically necessary delivery prior to 39 weeks of gestation U2 Delivery at 39 weeks of gestation or later U3 Non-medically necessary delivery prior to 39 weeks of gestation TH = Postpartum Care after discharge 35

36 Newborn Claims Submission Routine Newborn Care - STAR: Initial care should be billed under the Mother s Medicaid Number (PCN), or identification number, for the first 90 calendar days Routine Newborn Care - CHIP: Newborns are not automatically eligible Mother must apply for baby s coverage Routine Newborn Care - CHIP Perinate: Newborns are automatically eligible Issued their own Medicaid identification number 36

37 Claims Submission Tips Report services performed correctly Reporting the most comprehensive CPT code that describes the services performed do not unbundle and do not fragment a procedure into component parts. Use appropriate modifiers and condition indicators, when appropriate Use age and gender appropriate codes. Report units correctly Avoid downcoding or up coding Make sure you are billing with the correct NPI/Tax ID/TPI combination that is attested to with Medicaid/TMHP. Claims must contain following provider identification numbers: National Provider Identification (NPI) attested on the TMHP Master Provider File EPSDT Texas Provider Identification (TPI) when billing THStep services LTSS provider may have an API Claims billed with a Group or Clinic NPI should also include the rendering provider s NPI 37

38 Claims Payment Claims Payment Timeline: Molina has up to 30 days to pay all clean claims Claim is submitted in the correct format and contains all of the elements required to adjudicate the claim. On average claims submitted electronically are paid in 9 days On average paper claims are paid in 14 days Payment Methods Paper or Live Check Electronic Fund Transfers (EFT) 38

39 Electronic Fund Transfers (EFT) FIS ProviderNet Item To 1 Register, go to: Item Customer 3 Service during registration process Provider.Services@fisglobal.com or Elements required to Register for EFT/ERA (Electronic Funds Transfer and Electronic Remit Advice) Internet access Valid address NPI Tax ID Mailing address as reflected on recent EOP (Explanation of Payment) Recent Molina Healthcare Check Number Bank information, including account and routing numbers 39

40 Electronic Headline Goes Fund Here Transfers (EFT) Contact Information Molina ERA/EFT Contact information: Customer Service Phone Number: (866) Customer Service Website, direct link to EDI page: mon/edi/pages/home.aspx 40

41 Providers 41

42 Contract Headline Goes Requirements Here Behavioral Health To the extent Provider is a primary care physician: Provider shall have screening and evaluation procedures for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders. (UMCC Att. B-1, ) To the extent Provider provides inpatient psychiatric services: Provider shall schedule Members for outpatient follow-up and/or continuing treatment prior to discharge. The outpatient treatment must occur within seven days from the date of discharge. Behavioral health providers must contact Members who have missed appointments within twenty-four (24) hours to reschedule appointments. (UMCC Att. B- 1, ) 42

43 Contract Headline Goes Requirements Here Early Childhood Intervention (ECI) Providers must cooperate and coordinate with local Early Childhood Item 1 Intervention (ECI) programs to comply with federal Item 2 and state requirements relating to the development, review and evaluation of Individual Family Service Plans (IFSP). Provider understands and agrees that any Medically Necessary health and behavioral health services contained in an IFSP must be provided to the Member in the amount, duration, scope and setting established in the IFSP. (UMCC Att. B-1, ) 43

44 Contract Headline Goes Requirements Here Family Planning If a Member requests contraceptive services or family planning services, Item 1 Provider must also provide the Member counseling and Item 2 education about family planning and available family planning Item 3 services. Provider shall not require parental consent for Members who are minors to receive family planning services. Provider shall comply with state and federal laws and regulations governing Member confidentiality (including minors) when providing information on family planning services to Members. (UMCC Att. B-1, ) 44

45 Contract Headline Goes Requirements Here Liability In the event Health Plan becomes insolvent or ceases operations, Provider understands and agrees that its sole recourse against Health Plan will be through the Health Item 1 Plan s bankruptcy, conservatorship, or receivership estate. (UMCC Att. A, 4.05(f).) Item 2 Provider understands and agrees that the Health Plan s Members may not be held liable for the Health Plan s debts in the event of the entity s insolvency. (UMCM, Ch 8.1, 37) Provider understands and agrees that HHSC does not assume liability for the actions of, or judgments rendered against, Health Plan, its employees, agents or subcontractors. Further, Provider understands and agrees that there is no right of subrogation, contribution, or indemnification against HHSC for any duty owed to Provider by the Health Plan or any judgment rendered against the Health Plan. HHSC s liability to Provider, if any, will be governed by the Texas Tort Claims Act, as amended or modified (Tex. Civ. Pract. & Rem. Code et seq.). (UMCC Att. A, 4.05(f).) 45

46 Contract Headline Goes Requirements Here Marketing Marketing. Provider agrees to comply with HHSC s marketing Item 1 policies and procedures, as set forth in the UMCC Item 2 (which includes UMCM). (UMCC Att. B-1, 8.1.6, UMCM, Ch. 4.) Provider is prohibited from engaging in direct marketing to enrollees that is designed to increase enrollment in a particular health plan. The prohibition should not constrain Providers from engaging in permissible marketing activities consistent with broad outreach objectives and application assistance. (UMCC Att. B-1, 8.1.6, UMCM Ch. 4.) 46

47 Contract Headline Goes Requirements Here Medicaid Provider Agreement Acute care providers serving Medicaid Members must enter into Item 1 and maintain a Medicaid provider agreement with HHSC or its Item agent 2 to participate in the Medicaid Program, and must have a Item Texas 3 Provider Identification Number (TPIN). All Providers, both CHIP and Medicaid, must have a National Provider Identifier (NPI) in accordance with the timelines established in 45 C.F.R. Part 162, Subpart D (for most Providers, the NPI must be in place by May 23, 2007.) (UMCC Att. B-1, ) 47

48 Contract Headline Goes Requirements Here Member Communications Health Plan is prohibited from imposing restrictions upon Provider s Item 1 free communication with a Member about the Member s Item 2 medical conditions, treatment options, Health Plan referral Item 3 policies, and other Health Plan policies, including financial incentives or arrangements and all managed care plans with whom Provider contracts. (UMCC Att. A, 7.02, and BBA ) 48

49 Contract Headline Goes Requirements Here Primary Care Physicians(PCPs) To the extent Provider is a primary care physician: Provider shall be accessible to Members 24 hours per day, 7 days per week. (UMCC Att. B-1, ) Provider shall provide preventative care to children under age 21 in accordance with AAP recommendations for CHIP Members and the THSteps periodicity schedule published in the THSteps Manual for Medicaid Members; and (ii) to adults in accordance with the U.S. Preventative Task Force requirements. (UMCC Att. B-1, ) Provider shall assess the medical needs and behavioral health needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members care with specialty care providers after referral. (UMCC Att. B-1, ) 49

50 Contract Headline Goes Requirements Here Texas Health Steps (THSteps) Provider shall send all THSteps newborn screens to the Texas Department Item 1 of State Health Services (DSHS), formerly the Texas Department Item 2 of Health, Bureau of Laboratories or a DSHScertified Item 3 laboratory. Provider shall include detailed identifying information for all screened newborn Members and each Member s mother to allow HHSC to link the screens performed at the hospital with screens performed at the two-week follow-up. (UMCC Att. B-1, ) 50

51 Contract Headline Goes Requirements Here Tuberculosis Provider shall coordinate with the local tuberculosis (TB) control Item 1 program to ensure that all Members with confirmed or suspected Item 2 TB have a contact investigation and receive Directly Observed Item 3 Therapy (DOT). Provider shall report to the Texas Department of State Health Services (DSHS) or the local TB control program any Member who is non-compliant, drug resistant, or who is or may be posing a public health threat. (UMCC Att. B-1, ) 51

52 Contract Requirements Women, Infants and Children (WIC) Services Provider shall coordinate with the WIC Special Supplemental Item 1 Nutrition Program to provide medical information Item 3 necessary for WIC eligibility determinations, such as height, weight, hematocrit or hemoglobin. (UMCC Att. B-1, ) 52

53 Provider Access and Availability Appointment availability is imperative to keep our members healthy. The following schedule should be followed regarding appointment availability: Routine exams should be provided within 14 days of request Preventive health services for children within 60 days Preventive health services for adults within 90 days Urgent care should be received within 24 hours of the request Emergency care should be received immediately A contracted PCP must ensure that he/she will be available or accessible or arrange coverage by another qualified healthcare professional 24 hours a day, seven days a week. 53

54 Cultural Competency Cultural competency begins with understanding culture Culture Item 1 is learned beliefs, values and traditions that affect how Item 2 individuals of a particular group perceive, think, interact, behave, and make judgments about their world Components to interact effectively with people of different cultures: Awareness of one s own culture Attitude towards other culture Knowledge of differences in cultures It is important to recognize that people of different cultures have different ways of communicating, behaving and problem-solving 54

55 Cultural Competency Stereotypes may lead to racial and ethnic disparities in healthcare Item 1 Most Item 2 people are unaware of their biases and how the behavior displays or exposes a perception of stereotypes and biases Stereotyping can lead to discrimination. Patients are less likely to utilize care due to lack of trust, fear, or perceived discrimination. Cultural sensitivity can start with open communication Open communication by: Ask open-ended questions and seek clarification Show respect for cultural beliefs Listen without interrupting 55 Don t appear rushed, even if you are

56 Cultural Competency Tip Spend some time learning about various cultures Be aware of how culture affects perceptions and pay attention to challenges presented Wait until it is clear that the person has finished speaking before you respond Withhold judgment until comprehension of the message is complete. Restate or paraphrase your understanding of the message and reflect it back for verification Your viewpoint may be different but consider the other s position and perspective Look for feelings or intent beyond the words Before you hang up the phone, ask if there is anything else you can help the member with 56

57 Provider Web Portal Overview 57

58 New Provider Registration 58

59 Role of Primary Care Providers (PCPs) Accessible to Members 24 hours a day, 7 days a week Responsible for providing, arranging, and coordinating all aspects of the Member s health Providing medically necessary routine, urgent and emergent services within the health care professional s scope of practice Providing screening and evaluation for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders with the scope of his/her practice. Providing preventative health services 59

60 Specialty Providers Responsibilities Responsible for providing consulting expertise, specialty diagnostic, surgical and other medical care. On-call coverage 7 days a week, twenty-four (24) hours a day, either personally or by a reasonable call coverage arrangement with other appropriate individuals. Responsible for submitting a report of the Member s treatment to the Member s PCP. 60

61 Hospital Responsibilities Providing services to the Members admitted by participating providers in accordance with the Physician s orders. Hospital will admit Members upon orders of a participating provider, and with prior authorization, excluding emergency services. Notifying Molina of all admissions of Members during regular working hours, but in no event later than twenty-four (24) hours or the next working day following the admission of a Member. 61

62 Provider Support You are important! External Provider Service Representative 26 representative(s) throughout the Great State of Texas 3 Provider Service Managers Dallas/El Paso Harris/Jefferson Bexar/Hidalgo Immediate Customer Service Monday Friday 8am 5pm Providing excellent customer service to our provider community is a top priority at Molina Healthcare. Provider Website 62

63 Health Services 63

64 Prior Authorizations Services rendered by contracted providers that require prior authorization are furnished on the Prior Authorization/Pre- Service Review Guide Available at All services rendered by a non-contracted provider, except emergency care and family planning; require prior authorization 64

65 Requesting Prior Authorizations Authorizations may be requested via: Provider Web Portal Item Fax: Item Phone: (Bexar, Harris, Dallas, Jefferson, El Paso & Hidalgo Service Area) (CHIP Rural Service Area) Prior Authorization request will be processed within 72 hours Member name and Medicaid/CHIP Identification Number Diagnosis with the ICD-9 code Procedure with the CPT, HCPCS code Date of injury/date of hospital admission and third party liability information (if applicable) Facility name (if applicable) and NPI number Specialist or name of attending physician & NPI number Clinical information supporting the request 65

66 Prior Authorizations Requirements Providers must verify Member eligibility before providing services. Item is ultimately 1 the admitting physician s responsibility to obtain authorization Item 2 for services and to provide the necessary clinical and patient Item 3 information to process authorization requests Failure to obtain prior authorization for specified services will result in denial of payment for services rendered. Providers may not bill members for denied services. To avoid unnecessary prior authorization denials, the request must contain correct and complete information, including documentation for medical necessity. Molina will honor existing TMHP authorizations for 3/1/2012 expansion Member s as set forth below: Acute Care Providers Up to 90 days LTSS Providers Up to 120 days 66

67 LTTS Headline Prior Goes Authorizations Here Requirements Services are unbundled in STAR+PLUS. Example: Medical supplies & DME equipment will not be provided by the home care agency, such services will be provided by contracted DME provider. Assisted Living Facility: When requesting authorization please identify the type of facility the member resides in. Personal Assistant Services (PAS) Providers can submit referrals to Molina Healthcare for members to be assessed for PAS services (new services or an increase in existing services) via fax. Once fax is received with referral for PAS services member will be contacted to verify request. After request is confirmed, member s information will be assigned to Service Coordinator by zip code for an initial or increase PAS assessment. The most efficient way to request an assessment for a member is to have the member contact the Service Coordination dept at to request an initial or increase assessment. 67

68 LTTS Headline Prior Goes Authorizations Here Requirements Continued Adult Day Care Centers (ADC) All new prior authorization should be faxed with a completed 3050 Molina will issue prior authorization effective on the date the request and completed 3050 is received Molina will take up to 5 days to review the prior authorization request All Adult Day Care services rendered during this review period will be authorized and paid Upon completing the review Molina will contact the requesting Adult Day Care to communicate the results of our review. For renewal or transfer of existing member, fax prior authorization request and Molina will authorize on the receipt date of the referral request. DME Referrals Providers can submit referrals to Molina Healthcare for members to be assessed for DME supplies via fax. Once fax is received with referral for DME supplies Service Coordinator by zip code will review and determine if supplies meet criteria. 68

69 Case Management Case Management Services are available to support providers with managing medical cases for complex Members with special healthcare Item 2 needs, offering: Item Educate 3 Members about Case Management Coordinate multiple resources to include various available community resources Develop individual care plans Referrals to Case Management Providers, Nurses, Social Workers and Members or their representative can refer Members for Case Management by contacting Molina at

70 Service Coordination Service Coordinators Members are assigned to Service Coordinators by status (waiver or non waiver) and zip code. Service Coordinators are remote staff; therefore, providers should contact the Service Coordination department at and speak with a Care Specialist. All Care Specialists can assist with basic inquiries. If additional follow up is needed, the assigned Service Coordinator will contact the provider or member within 24 hours. 70

71 Communication Headline Goes Here with Service Coordination Providers can communicate with the Service Coordination department via phone or fax. Phone number Fax number Providers can fax in member case information on 2067 forms. See example below. 71

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73 Pharmacy Services 73

74 Pharmacy Services Pharmacy services are covered by Molina Healthcare instead of the Texas Vendor Drug Program (VDP). Effective March 1, 2012 The Vendor Drug Program (VDP) Drug Formulary and Preferred Drug List (PDL) is used. HHSC Drug Formulary can be found at: Pharmacy Basics Members will need to get prescription drugs and medical supplies at pharmacies and suppliers that accept Molina Healthcare. Diabetic supplies for Hidalgo and El Paso Service Areas may also be obtained from a Molina contracted DME provider. The drugs that are eligible for coverage are determined by the State s Vendor Drug Program (VDP). Within the VDP Drug Formulary there is also a Preferred Drug List (PDL) that must be used prior to drugs that are not on the PDL. (STAR and STAR+PLUS only) All medications must have a written prescription for member to receive services at the network pharmacy. Molina Healthcare will handle all pharmacy inquiries from our members and providers. Examples of inquires include: Members questions about pharmacy or prescription coverage Providers claims questions and PA requests; , prompt #1. 74

75 Pharmacy Benefit Manager (PBM) CVS/Caremark is Molina Healthcare s Pharmacy Benefit Manager (PBM). CVS/Caremark processes Molina Healthcare s pharmacy claims. CVS/Caremark maintains the pharmacy network for Molina. The pharmacies bill CVS/Caremark electronically for the claims at the point of sale. 75

76 Pharmacy Prior Authorization Non-Preferred drugs and also specialty drugs require a Prior Authorization. Prior Authorization request can be faxed to Molina Healthcare of Texas at If a prescribed drug is not found on the Formulary then it is not eligible for coverage. Prior authorization can not be obtained. 72 Hour Override Policy A 72-hour emergency supply of prescribed medication should be dispensed any time a prior authorization is not available and a prescription must be filled without delay for a medical condition. Pharmacies are able to enter an override code (instructions are on the reject messaging and also on the VDP website) if it follows outlined parameters. Drugs not on formulary will NOT be eligible for 72 hour supply or allow prior authorization. 76

77 Participating Pharmacies Molina Healthcare will only pay for prescriptions filled at network pharmacies. Most in-state pharmacies accept Molina Healthcare. HHSC requires that all pharmacies be participants in the Texas VDP network before being allowed entry into Molina s network. Molina Healthcare will not reimburse members for prescriptions filled at nonparticipating pharmacies services rendered at these pharmacies are considered not covered. It is recommended that if members plan to travel out-of-state, they should fill their prescription drugs before traveling out-of-state. To find a network pharmacy please visit : 77

78 Behavioral Health 78

79 Behavioral Health Services Molina Healthcare of Texas managers all Behavioral Health Services for all Products and Services areas, excluding the Dallas Service Area for STAR & STAR+PLUS. Prior Authorization Phone Number Prior Authorization Fax Number Dallas Service Area STAR & STAR+PLUS Behavioral Health Services are managed by NorthSTAR. Phone Number

80 Prior Authorizations Services rendered by contracted providers that require prior authorization are furnished on the CHIP Prior Authorization Guide STAR & STAR+PLUS Prior Authorization Guide Available at All services rendered by a non-contracted provider, except emergency care and family planning; require prior authorization 80

81 Requesting Prior Authorizations Authorizations may be requested via: Provider Web Portal Item Fax: Item Phone: Prior Authorization request will be processed within 72 hours Member name and Medicaid/CHIP Identification Number Diagnosis with the ICD-9 code Procedure with the CPT, HCPCS code Facility name (if applicable) and NPI number Specialist or name of attending physician & NPI number Clinical information supporting the request 81

82 Behavioral Health Requirements Behavioral Health Service Providers are required to refer Members with known or suspected and untreated physical health problems or disorders to their PCP for examination and treatment, with the Member s or the Member s legal guardian s consent Behavioral Health Providers must send initial and quarterly (or more frequently if clinically indicated) summary reports of a Members behavioral health status to the PCP, with the Member s or the Member s legal guardian s consent Providers must ensure that all Members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge The outpatient treatment must occur within seven days from the date of discharge Providers must contact Members who have missed appointments within 24 hours to reschedule appointments 82

83 Complaints & Appeals 83

84 Provider Complaints Complaint: A complaint is defined as a verbal or written expression by a provider which Item indicates 1 dissatisfaction or dispute with Molina s policies, procedures, claims, or any Item other 2 aspect of Molina s functions. Item Complaints 3 are processed for resolution within 30 calendar days of receipt. Providers will receive written notice detailing the decision. Providers not satisfied with a complaint decision may file an appeal. All Complaints must include: Provider s name Date of the incident Description of the incident Timeframes An acknowledgement letter is sent within five business days of receipt of the complaint A resolution letter is sent within 30 calendar days of receipt of the complaint Submit a Provider Complaint to: Molina Healthcare of Texas Attention: Provider Dispute Resolution Department Park Row Blvd., Suite 110 Houston, TX

85 Provider Appeals An appeal is the mechanism which allows the right to appeal actions of Molina to a provider who: Has a claim for reimbursement or a request for authorization of service delivery denied or not acted upon with reasonable promptness; or Is aggrieved by any rules, policies, procedures, or decisions by Molina. The provider must file an appeal within 120 days from the date of the complaint resolution letter received from Molina. Submit a Provider Appeal to: Fax Molina Healthcare of Texas Attention: Provider Dispute Resolution Department Park Row Blvd., Suite 110 Houston, TX

86 Quality Improvement 86

87 Quality Improvement Philosophy Molina Healthcare maintains the following values, assumptions, and operating principles for the Quality Improvement Program (QIP): The QIP provides a structure for promoting and achieving excellence in all areas through continuous improvement. Improvements are based on industry best practice or on standards set by regulators or accrediting organizations. The QIP is applicable to all disciplines comprising the health plan, at all levels of the organization. Teams and teamwork are essential to the improvement of care and services. Data collection and analysis is critical to problem-solving and process improvement. Each employee is highly valued as a contributor to quality processes and outcomes. Compliance with CMS Standards and the State of Texas regulations demonstrates Molina Healthcare's commitment to quality improvement. Information about the QIP is available for members and providers upon request. 87

88 Quality Improvement Program Goals Molina Healthcare has defined the following goals for the QI Program: Design and maintain programs that improve the care and service outcomes within identified member populations, ensuring the relevancy through understanding of the health plan s demographics and epidemiological data. Define, demonstrate, and communicate the organization-wide commitment to and involvement in achieving improvement in the quality of care, member safety and service. Improve the quality, appropriateness, availability, accessibility, coordination and continuity of the health care and service provided to members. Through ongoing and systematic monitoring, interventions and evaluation improve Molina Healthcare structure, process, and outcomes. Use a multidisciplinary committee structure to facilitate the achievement of quality improvement goals. Facilitate organizational efforts to achieve CMS, Federal, and Texas regulatory compliance. Facilitate organizational efforts to achieve regulatory compliance 88

89 Provider Headline Goes Assistance Here with Quality Improvement Contracted Providers are responsible for: Ensuring Member have timely access to quality healthcare services. Assisting and cooperating with medical record reviews. Assisting and cooperating with HEDIS data collection. Participating in: Appointment availability surveys Provider satisfaction surveys Provider orientation and other training activities 89

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91 THSteps Headline Goes Here A federally mandated health care program focusing on prevention, diagnosis and treatment. Known in Texas as Texas Health Steps (THSteps). Known nationally as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Jointly funded by state and federal funds Administered by HHSC/DSHS Serves children from birth through age 20. Self-referral Molina Members may self-refer to any participating THSteps provider. 91

92 THSteps Program Goals Detect and treat medical and dental concerns for eligible Item 1 Medicaid clients. Provide Item 3 continuing preventive health care to infants, toddlers, children, adolescents, and young adults. Provide appropriate case management. Link clients with PCP to establish a Medical Home. Link clients with providers for preventive and on-going care. 92

93 THSteps Medical Checkups Based on the American Academy of Pediatrics (modified to meet Item 1 Federal and State requirements) AAP Item 2 Comprehensive assessment Purpose Early detection of health problems Offer guidance on a child s growth and development Comprehensive assessment of the infant, child or adolescent To detect problems and address before medical/dental problems become more complex Make appropriate referrals To provide anticipatory guidance to family to encourage healthy behaviors and enhance parenting knowledge of family 93

94 THSteps Components History includes documenting the family and neonatal histories as well as the child's physical and mental health and development, immunizations, feeding and nutrition, and a complete review of body systems. Physical Examination A comprehensive unclothed physical exam is required at each visit. Measurements Height (3-20 years of age), weight (0-20 years of age), length (0-2 years of age), Body Mass Index (2-20 years of age years of age), Fronto-occipital circumference birth through 24 months, and Blood pressure (3-20 years of age) are taken and compared with national standards to identify significant deviations from the norm. Immunizations. Nutritional Assessment - Dietary practices are assessed to identify unusual eating habits and to help determine quality and quantity of the child's nutritional intake. Developmental Assessment - A developmental assessment must be conducted and completed according to the requirements of the Texas Medicaid Provider Procedures Manual. Sensory Screening - A vision and hearing screening is conducted and completed according to the requirements in the Texas Medicaid Provider Procedures Manual. Laboratory Screening - Several laboratory tests (such as total hemoglobin, hematocrit, HDL cholesterol, and others) help assess the total health of the client. Health Education/Anticipatory Guidance - Health education is a mandatory part of the medical checkup. Health education and counseling face-to-face with parent(s) or guardian(s) and clients helps them understand what to expect in the child's development and provides information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. 94

95 THSteps Components Comprehensive Health & Developmental History Developmental Screening - A developmental and autism screening must be performed for each age-appropriate group using the following standardized screening tools: the Ages and Stages Questionnaire (ASQ), Ages and Stages Questionnaire: Social Emotional (ASQ:SE), or the Parents' Evaluation of Developmental Status (PEDS) for developmental screening at specified ages, and the Modified Checklist for Autism in Toddlers (M-CHAT) as required at 18 months of age. Providers may receive separate reimbursement, in addition to reimbursement for the checkup, when using these tools as part of the checkup at the specified ages. Mental Health - An emergency mental health referral for evaluation and/or treatment must always be made when suicidal thoughts, threats, or behaviors and/or homicidal thoughts, threats, or behaviors are identified during a mental health screening. Whenever an urgent mental health crisis is suspected, every effort must be made to secure a prompt mental health evaluation and any medically necessary treatment for the client. A clinician conducting the mental health screen may choose to evaluate and provide mental health services if the clinician has the appropriate training and credentials, or refer the client to a qualified mental health specialist. Clinicians who do not have these qualifications must refer clients to a qualified mental health specialist for such care. Nutritional Screening - Dietary practices should be assessed to identify unusual eating habits such as pica, extended use of baby bottle feedings, or eating disorders in older children and adolescents. For nutritional problems, further assessment is indicated. Tuberculosis (TB) Screening - Administer the Tuberculosis (TB) Questionnaire annually beginning at 12 months of age. Administer the TB skin test when the screening tool indicates a risk for possible exposure. The TB Questionnaire can be found on the Texas Health Steps website at or on the back side of the Child Health Clinical Record forms found on the same site. TB risk levels by county may be found on the Tuberculosis website at 95

96 THSteps Components Comprehensive Unclothed Physical Examination A complete physical examination is required at each visit. A comprehensive unclothed physical examination includes all the components listed below: Measurements - Requires documentation of: Item Length 2 - Birth through 30 months old; Height - 3 years old through 20 years old; Head circumference - Birth through 24 months old; Weight - Birth through 20 years old; Body Mass Index (BMI) - 2 years old through 20 years old; and, Blood pressure - 3 years old through 20 years old. All measurements and blood pressure should be compared with the National Center for Health Statistics growth charts to identify significant deviations from norms. Sensory Screening Vision Services-Requires subjective and objective screening at various ages; see Periodicity Schedule for details. Hearing Services-Requires subjective and objective screening at various ages; see Periodicity Schedule for details. Dental Services Limited oral screening for caries and general health of the teeth and oral mucosa is part of the physical examination. In addition to the federal requirements, Texas Health Steps policy requires referral to a dentist at six months of age and every six months thereafter until the dental home has been 96 established.

97 THSteps Components Comprehensive Unclothed Physical Examination Continued Laboratory Screening - Requires various laboratory tests including blood lead level appropriate to age and risk, total hemoglobin or hematocrit, or others based on risk such as hyperlipedemia. All Item laboratory 1 work (with the exception of screening for hyperlipidemia, Type 2 Diabetes, syphilis, HIV and Item point 2 of care testing for blood lead level in the provider s office) must be performed by the Department of State Health Services (DSHS) Laboratories. Laboratory services are provided by DSHS at no cost to the provider. Tests on the exceptions list may be sent to the laboratory of the provider s choice. Health Education - Health education and counseling including anticipatory guidance must be provided at each checkup and documentation must include the time period recommended for the next appointment. Health education should be face-to face with the parent(s), caregiver(s) or teen or young adult client. Health education is designed to help parents and caregivers understand what to expect in terms of the child's development and to provide information for all ages about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. Age-appropriate topics include, but are not limited to nutrition and crib safety (infants), reading and toilet training (toddlers), puberty and physical changes (older children) and mental health and communications with family and trusted adults (adolescents). Lead risk assessment should be done through anticipatory guidance. Suggested topics are found on the back side of the Texas Health Steps Child Health Record forms at 97

98 How to bill THSteps THSteps Medical Checkups: 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, THSteps Follow-up Visits: Oral Evaluation and Fluoride Varnish: with U5 (Note: Must be certified by the State to perform) Must include diagnosis code V202 Must include benefit code EP1 Must include 2 digit modifier to indicate practitioner (AM, SA, TD,U7) FQHC provider must submit using modifier EP for all THSteps medical checkups RHC providers should file using POS 72 98

99 Immunization Administration Administration procedure codes 90460, 90461, 90471, 90472, 90473, Item 1 and must be submitted on claims. Administration Item 2 procedure codes and are benefits for the administration of vaccines and toxoids that require counseling for clients who are birth through 18 years of age. Each vaccine or toxoid and its administration must be submitted on the claim in the following order: Vaccine or toxoid procedure code Administration procedure code(s) All of the administration procedure codes that correspond to a single vaccine or toxoid procedure code must be submitted on the same claim as the vaccine or toxoid procedure code. 99

100 Children of Migrant Farm Workers Children, Item 1 of a migrant farm worker (MFW) who are due Item 3 for THSteps medical checkup, may receive their checkup, on an accelerated basis, before leaving the area Please allow these children of MFW to obtain THSteps services expeditiously. 100

101 THSteps Help Help Links: Helpful Information: 101

102 THStep Lawsuit Frew Overview 102

103 What is the Lawsuit? The class action lawsuit filed against the State of Texas by plaintiffs represented by Texas Rural Legal Aid on behalf of more than 1.5 million indigent Item 1 children entitled to health benefits through EPSDT, is now commonly known as Frew V. Janek, commonly referred as FREW. Because the allegations of the case are wide-ranging, it is almost certain that they pertain to one or more of your responsibilities or activities in providing services under the Texas Medicaid Program. 103

104 FREW Consent Decree As part of the FREW Consent Decree and Corrective Action Orders Item 1 the Texas Department of State Health Services (DSHS) developed Item 2 a new child health record for THSteps checkups. The Item 3 child health record form is available for each checkup visit from 5 days - age 20. The forms are intended to assist the provider in documenting all of the required components of the checkup. Instructions for the form can be found at: 104

105 Questions 105