CSHCN Provider Bulletin

Transcription

1 May 2004 No. 50 CSHCN Provider Bulletin The Children with Special Health Care Needs Program The Importance of Self-Determination e Arc of the United States. Reprint by permission. Self-determination is highly valued in our society. People who are self-determined make choices based on their preferences as well as on their beliefs and abilities. ey take control over and participate in decisions that impact the quality of their lives. ey take risks and assume responsibility for their actions and advocate on behalf of themselves and others. Self-determination is a major benefit of adulthood. Many people with developmental and other disabilities have not had the opportunity to become self-determined or to learn the skills and have the daily experiences that will enable them to take more control and make choices in their lives. Instead, they often experience over-protection and segregation, are not included in decisions that impact their lives, and have limited opportunities to make choices as well as limited options from which to choose. Many people assume that people with disabilities cannot become self-determined. However, research and practice has shown that, when given adequate support, learning opportunities, and experiences, people with developmental and other disabilities can learn to become more self-determined, to assume greater control over and responsibility for their lives, and can improve the quality of their lives. Regardless of the type of disability, everyone has the right to receive care in the least restrictive setting, and nowadays this is fortunately becoming a more prevalent reality. It is important to remember the principles of self-determination when interacting with the people we serve, and never underestimate what determined people can do! IN THIS EDITION General Interest The Importance of Self-Determination...1 People First...2 Transition...2 Administrative 2004 CSHCN Provider Manual...3 Bankrupt and Out of Business Providers...3 New and Improved Physician Assessment Form...4 Returned Mail...4 TMHP Website...5 Upcoming Workshops...6 Updated Mailing List...6 Coding and Reimbursement Filing Deadline Changes...6 Behavioral Health Services...7 ICD-9-CM Update...8 Licensed Clinical Social Worker...9 Medical Nutritional Products...9 Car Seats...10 Fiscal Agent Payment Deadlines...11 Inpatient Hospital Claims...11 Hepatitis A Vaccine Expansion...12 Forms and Guides CSHCN Authorization Form...14 CSHCN Physician/Dentist Assessment Form Day Julian Date Calendar Day Julian Date Calendar...19

2 General Interest People First Actions Speak Louder Than Words People have the right to be treated with respect. For adults and children who are blind and/or disabled, this means being recognized as individuals and not as disabilities. A growing movement being adopted by community organizations, state agencies, and individual caregivers focuses on the language used to describe people with disabilities. Referred to as people-first or preferred language, it encourages the speaker or writer to put the person first. Literally. For example, a proponent of people-first language would refer to a person who is blind instead of a blind person, or a person with a disability instead of a disabled person. In the above example it would seem that peoplefirst language is both politically and grammatically correct. After all, taken literally, disabled person means the whole person is disabled; whereas person with a disability refers to one who simply has a disability. While words alone may not change people s attitudes toward individuals with disabilities, they can be a good place to start. Consistent usage of people-first language does force the speaker or writer to recall one s reasons for referring to an individual or a group in a particular way in effect, reminding one of the importance of putting the person first. But more important than the language used to describe an individual or group is the lengths to which society will go to include those outside the majority. More than a decade after the enactment of the Americans with Disabilities Act (ADA), many services and opportunities remain inaccessible to people with disabilities. e 2000 National Organization on Disability (NOD) Survey of Americans with Disabilities shows large gaps existing in the areas of education, employment, transportation, and health care. For example, only 32 percent of people with disabilities within working age (18 to 64) are employed either full- or part-time, compared to 81 percent of those who are not disabled. People with disabilities are three times as likely to live in poverty, and four times as likely, when compared to people without disabilities, to have special needs not covered by their health insurance. ese disparities exist despite a desire on the part of people with disabilities to be more active in their communities and society as a whole. Not wanting to be marginalized, the vast majority of people with disabilities wish not only to be treated equally, but to contribute equally. And while gains have been made through the enacting of laws, the creation of community participation programs, and the adoption of people-first language, much more can be done. e CSHCN Program and its participating providers and their staff are in a unique position to support the goals of people with disabilities. By modeling behaviors and promoting measures that support inclusiveness and understanding, CSHCN providers can directly, and positively, affect the lives of adults and children with disabilities and, in doing so, indirectly influence the attitudes of those without disabilities. Seeing people with disabilities participating in and contributing to society, is to see them first and foremost as people. Transition Growing up these days isn t always easy, but it can be especially difficult for children with special health care needs. Just a few decades ago, the majority of children with severe disabilities did not reach adulthood, but now more than 90 percent do. 1 In fact, nearly one-half million children with special health care needs transition into adulthood each year. 2 Transition is defined as, the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-oriented health care systems. CSHCN Bulletin, No May 2004

3 General Interest / Adminstrative In a consensus statement on health care transitions for young adults with special health care needs, the American Academy of Pediatrics and the American College of Physicians American Society of Internal Medicine state: Transition in health care for young adults with special health care needs is a dynamic, lifelong process that seeks to meet their individual needs as they move from childhood to adulthood. e goal is to maximize lifelong functioning and potential through the provision of high-quality, developmentally appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood. It is patient-centered, and its cornerstones are flexibility, responsiveness, continuity, comprehensiveness, and coordination. 3 Transition is important because individuals with disabilities deserve to have health care that is developmentally appropriate. ough there are many barriers to successful transition, it is nonetheless an essential goal. Here are some suggestions for how health care providers can support successful transition: Have an orientation to patient care that is future-focused. Anticipate change and allow for flexibility in health care planning. Foster personal and medical independence, including the child as a member of the treatment team (recognize and support the evolution of family-centered care to personcentered care and planning). In collaboration with patients and families, begin developing a plan for transitioning from pediatric to adult health care by age Blum RW. Transition to adult health care: setting the stage. J Adolesc Health.1995; 17 :3 5 2 Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Public Health.1994; 82 : Pediatrics, Volume 110, Number 6, December 2002, Supplement 2004 CSHCN Provider Manual e 2004 CSHCN Provider Manual will be mailed to all CSHCN providers in May At about the same time, providers can download an electronic copy of the manual by visiting the Texas Medicaid & Healthcare Partnership (TMHP) website at Click on the Find Publications/File Library link on the right hand side of the page, choose Provider Manuals, then CSHCN. If you do not receive your copy of the manual in the mail by the end of May 2004, or if you need assistance downloading the manual from the website, please contact TMHP at Bankrupt and Out of Business Providers Effective June 1, 2004, new Compass21 system logic is being implemented to add provider enrollment and payment denial codes to flag providers who are bankrupt, out of business, or terminated and have outstanding accounts receivable (A/R) balances. ese codes are used to suspend the enrollment process and identify providers attempting to re-enroll in the Texas Medicaid Program by obtaining a new Texas Provider Identifier (TPI). In addition, the new payment denial codes deny claims that are being submitted by providers identified as out of business. Any pending enrollment due to these codes will not be processed until TMHP has direction from the Texas Health and Human Services Commission (HHSC) to re-enroll the provider and set up the A/R balance on the new TPI. May CSHCN Bulletin, No. 50

4 Administrative New and Improved Physician/Dentist Assessment Form e Physician/Dentist Assessment Form (PAF) is important in determining client eligibility. e PAF provides CSHCN with vital information about the client s medical condition, qualifies the client as medically eligible for the program, and is used when clients are considered for removal from the waiting list. e PAF must be updated at least annually by a physician (or dentist if applicable) who has seen the client at least once within the past 12 months, but may be updated at any time that a client s medical condition changes. It is important that all client eligibility information be as current as possible. e PAF recently has been revised. e new PAF is more streamlined, and the urgent needs questions have been reworded for clarity. Providers will begin seeing the new form as part of a revised client application packet in late spring When the new application form is available, please destroy all other versions of the PAF and PAF addenda you may have in your office or facility. Only the new version will be accepted for initial referrals and renewals once the new version is issued. e new form is on two separate pages to facilitate faxing. On the back of page one, you will find instructions on how to complete the form. On the back of page 2, the instructions are repeated in Spanish for those families who are unable to read English. CSHCN feels it is important that families understand the questions the program asks about their children. English language samples of the new form and its instructions are included on pages 15 through 17 of this bulletin. CSHCN would like to thank all the providers around the state who offered suggestions and tested the draft forms. Your assistance is appreciated. Important Information About Urgent Need Questions on the Physician Assessment Form In September of 2003, the CSHCN Program began requesting additional information on the PAF about the urgency of the client s/applicant s need for health care. is information is one of the factors used in deciding which clients on the CSHCN Program waiting list should be removed first, when funds are available. Please be sure to complete questions 4a, 4b, and 4c on the PAF. If you answer yes to any of these questions, provide a narrative explanation of why you believe this client has an urgent need for health care services. Remember, you know your patients needs better than anyone. Answer these questions as if the client has no other way to access health care beyond the CSHCN Program. Whether or not a client has other sources for payment of health care is considered separately from this medical information when determining which clients have an urgent need for health care. Once again, thanks for all you do to care for children with special health care needs in Texas. Returned Mail e TMHP Children s Services Unit has received numerous returned authorization letters. If you have moved, please contact the TMHP Provider Enrollment Department at the address below. TMHP ATTN: Provider Enrollment, MC-B05 PO Box Austin, TX CSHCN Bulletin, No May 2004

5 Administrative TMHP Website If you have not visited the TMHP website, please do so. An invaluable communication tool, this website incorporates all information previously available on the National Heritage Insurance Company (NHIC) and TexMedNet websites and introduces several new features to the CSHCN provider community. Creating a User Account While user names and passwords are not required to access most information on the website (publications, FAQs, etc.), providers will need to create an account to access client- and providerspecific information and to take advantage of the website s new and improved features (claim status inquiry, client eligibility verification, etc.). To create an account, follow these steps: 1) Launch your web browser and go to 2) Select Activate My Account from the I Would Like to links located on the right hand side of the page. 3) Select Activate My Account Now. 4) Enter the following information: a. User name (create a user name) b. First name c. Last name d. address e. Confirm address (re-enter address) f. Password (create a password) g. Confirm password (re-enter password) 5) Select a Provider Type from the drop down list (Acute Care or Long Term Care). 6) Enter your 9-digit Texas Provider Identifier (TPI) if you are an Acute Care provider in the form field provided. 7) Acute Care providers must provide one of the following pieces of information: 1) EDI Submitter ID 2) Tax ID (EIN) 3) Social Security Number 4) Medical License Number (5 characters) 8) Read the Terms of Use. 9) Click I Agree to ese Terms. 10) Click the Activate Account button. A confirmation page will indicate that your account has been created. A confirmation will be sent to the address you provided in step 4. Website Features After creating an account, CSHCN providers can take advantage of the new and enhanced features available through the TMHP website: Workshop Information and Online Registration Register online to attend a scheduled provider workshop in your area. CSHCN workshops will be conducted in July 2004 (see Upcoming Workshops, on page 6). Workshop information is posted on the TMHP website as schedules are finalized. Web Chat Correspond with a call center representative online and in real-time, using the new web chat feature. Web chat is available from 7:00 a.m. to 7:00 p.m., CST, for EDI, provider enrollment, and prior authorization inquiries. Online Client Eligibility Verification Online Claim Status Inquiry May CSHCN Bulletin, No. 50

6 Administrative / Coding and Reimbursement Upcoming Workshops TMHP will be conducting CSHCN workshops during the month of July 2004 in the Austin, Houston, Dallas, San Antonio, Corpus Christi, Weslaco, El Paso, Amarillo, Tyler, Odessa, Beaumont, Abilene, and Laredo areas. ese workshops are designed to increase providers understanding of CSHCN Program policies and will answer many of the questions providers have about filing CSHCN claims. Watch for your invitation in the mail. In addition, workshop locations, dates, and times are posted on the TMHP website at as schedules are finalized. Please visit the TMHP website regularly for updated workshop information and to register for the workshop most convenient for you. e CSHCN workshop information will be labelled as such. Workshops listed under Physician or Hospital are not CSHCN workshops. Updated Mailing List After many years, CSHCN is updating its mailing list for this provider bulletin. All CSHCN providers automatically receive the bulletin. However, it is not necessary to be a CSHCN provider to receive the bulletin, and you may be receiving it in error. In most cases, you (or an associate or predecessor) were enrolled as a CSHCN provider at some point in time. You may no longer be accepting CSHCN clients, or are unsure whether your provider status is active. Providers may obtain information about enrollment status by contacting TMHP at Non-CSHCN providers who no longer wish to receive this bulletin can request that their names be removed from the CSHCN mailing list. ank you for your help with this update. Filing Deadline Changes On August 1, 2004, HHSC will implement new filing deadlines for appeals of denied claims and requests for adjustments on paid claims. ese deadlines are intended to help ensure that all claims are finalized within 24 months from their dates of service. Providers must file all claims and appeals promptly; the Medicaid and CSHCN fiscal agent cannot pay claims or appeals beyond the 24-month payment deadline (see Fiscal Agent Payment Deadlines, on page 11). Appeal and Adjustment Filing Deadlines Beginning August 1, 2004, providers must file corrections, appeals, or adjustment requests within 120 days from the date of disposition. is change applies to both paper and electronic submissions. e date of disposition refers to the date of the Remittance and Status (R&S) report on which the last action on the claim appears. After July 31, 2004, HHSC or TMHP will no longer process appeal or adjustment requests received more than 120 days after the date of disposition. For example, a request for an appeal received on August 2, 2004, will be processed only if the date of disposition is between April 2, 2004, and August 2, If the date of disposition is more than 120 days old, or before April 2, 2004, the request will deny for late filing. All requests for appeals or adjustments received through July 31, 2004, will be processed if received within 180 days from the date of disposition. For example, a request for an appeal received on July 31, 2004, will be processed if the date of disposition is between January 30, 2004, and July 31, Background HHSC contracted with TMHP to process CSHCN and Medicaid claims as a fiscal agent starting on January 1, Proposed rules CSHCN Bulletin, No May 2004

7 Coding and Reimbursement concerning appeal and adjustment filing deadlines for CSHCN were published March 26, 2004, in the Texas Register (29 TexReg 3097, 38.10). CSHCN is adopting the new filing deadline rule in July 2004; however, the new 120-day appeal, correction, and adjustment deadline is being implemented for both CSHCN and Medicaid at the same time on August 1, Note: A revised 180-Day Julian Date Calendar and a new 120-Day Julian Date Calendar can be found on pages 18 and 19 of this bulletin. Behavioral Health Services e CSHCN Program may cover mental health care benefits for CSHCN clients when medically necessary. CSHCN may cover medically necessary inpatient admissions at an acute care or freestanding inpatient psychiatric facility for up to 5 days to allow stabilization of a behavioral health crisis while efforts are made to move the client to a more appropriate program to receive the necessary psychiatric/psychological treatment that is needed. CSHCN clients can receive behavioral health services if deemed medically necessary. Outpatient services also may be covered, with a maximum of 30 visits per calendar year by all behavioral health practitioners. (Lab and radiology services are not counted toward the 30-visit maximum.) Visits strictly for pharmacological management are billed as regular evaluation and management visits, not behavioral health visits; therefore, they do not count toward the 30-visit maximum. Psychologists, LPCs, LMFTs, LMSW-ACPs, freestanding inpatient psychiatric facilities, and psychiatrists billing for services other than pharmacological management who wish to enroll as behavioral health providers with CSHCN, may submit an application to: Texas Department of Health CSHCN Provider Enrollment 1100 W. 49 th St. Austin, TX ese providers bill TDH-CSHCN for their services. TMHP-CSHCN does not process these CSHCN cliams. Psychiatrists providing only pharmacological management and supervision of acute care hospitalizations must submit applications for enrollment to TMHP. ese claims are billed to TMHP- CSHCN. Please remember that all CSHCN providers must also be actively enrolled in the Texas Medicaid Program. CSHCN does not provide outpatient behavioral health benefits for CSHCN clients who also are enrolled in Medicaid or the Children s Health Insurance Program (CHIP). As of February 1, 2004, CHIP reinstituted behavioral health benefits for their clients. For additional information concerning this coverage, please refer to the HHSC CHIP website, Click on Policy Changes HB 2292 & Consolidation, then click on CHIP Mental Health and Substance Abuse Benefits Update (updated 01/22/04). e retroactive coverage period is September 1, 2003, through January 31, If you treated a CHIP client during this time period and were not otherwise reimbursed, you may file a claim with the child s CHIP health plan through May 31, Providers who file claims for retroactive reimbursement do not need to have been enrolled in the CHIP health plan s network at the time services were provided. (To provide CHIP services on or after February 1, 2004, providers must be enrolled in the health plan s network or have the service authorized by the child s CHIP health plan.) May CSHCN Bulletin, No. 50

8 Coding and Reimbursemenr ICD-9-CM Update Each year the Centers for Medicare & Medicaid Services (CMS) issues its changes to the hospital inpatient prospective payment system and new fiscal year rates. ese changes result in new, revised, or invalid diagnosis codes, procedure codes, diagnosis related groups (DRGs), and major diagnostic categories (MDCs), published annually in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Typically, these changes take effect on November 1 of each year. However, due to HIPAA implementation and the transition to a new claims administrator, the ICD-9-CM implementation was delayed. e new codes are valid for CSHCN claims with dates of service on or after April 1, More detailed information concerning code changes for Nebulizers and Electroencephalograms follows. Nebulizers Effective April 1, 2004, the following revised diagnosis codes are payable for Nebulizers to support the 2004 ICD-9-CM update: Diagnosis Code Description Obstructive chronic bronchitis, without exacerbation Obstructive chronic bronchitis, with acute exacerbation Extrinsic asthma, unspecified Extrinsic asthma, with acute exacerbation Intrinsic asthma, unspecified Intrinsic asthma, with acute exacerbation Chronic obstructive asthma, unspecified Chronic obstructive asthma, with acute exacerbation Asthma, unspecified Asthma, unspecified, with (acute) exacerbation e following diagnosis codes have been added: Diagnosis Code Description 4803 Pneumonia due to SARS-associated coronavirus Exercise induced bronchospasm Cough variant asthma 5173 Acute chest syndrome CSHCN Bulletin, No May 2004

9 Coding and Reimbursement Electroencephalogram (Ambulatory) Effective April 1, 2004, the invalid diagnosis code 3311 (Pick s Disease) will no longer be payable for electroencephalography. e following diagnosis codes are payable for electroencephalography to support the 2004 ICD-9-CM update: Diagnosis Code Description Pick s disease Other frontotemporal dementia Dementia with Lewy bodies Encephalopathy, unspecified Metabolic encephalopathy Other encephalopathy Epicranial subaponeurotic hemorrhage (massive) Other injuries to scalp Concussion, with loss of consciousness of 30 minutes or less Concussion, with loss of consciousness from 31 to 59 minutes Licensed Clinical Social Worker e Texas Medicaid Program has been informed of a recent change of licensure designation for licensed master social worker-advanced clinical practitioner (LMSW-ACP). e Texas State Board of Social Worker Examiners announced that effective September 1, 2003, LMSW-ACPs are now designated as licensed clinical social workers (LCSW). e Social Work Licensing Board indicates that there will be a transition period for all licensees. Reportedly, many licensees have stated that, in order to avoid confusion, they will not begin using the new credentials until they are in receipt of the new license. All licensees must begin using the new titles by September 1, At the direction of HHSC, the LMSW-ACP designation will not change until the 2005 manual revision cycle. e CSHCN program will follow this direction. Medical Nutritional Products When submitting a CSHCN Authorization Form for medical nutritional products, please note that the form requires that you report the number of cans as opposed to number of units. A copy of this form can be found on page 14 of this bulletin. May CSHCN Bulletin, No. 50

10 Coding and Reimbursement Special Needs Car Seats CSCHN recently changed the Special Needs Car Seats and Travel Restraints policy to improve the safety requirements and quality assurance review in the authorization of these products. CSHCN may reimburse special needs car seats and travel restraints when medically necessary and appropriate. All children must be transported as safely as possible. However, because of certain health problems, not all children can ride in many of the car seats found in stores. Children with breathing disorders, casts, neuromuscular deficits, or other health care needs may need to use special needs car seats or travel restraints. ese special needs car seats and travel restraints are covered by CSHCN in the category of custom durable medical equipment (DME) items and, as such, a manufacturer recognized on the CSHCN Custom DME Authorized Manufacturers List must manufacture them. In addition, special needs car seats and travel restraints may be provided only through a network of trained providers. e following procedures are effective for services provided on and after June 1, 2004: Vendors providing special needs car seats must be CSHCN approved custom DME providers and must have received approved training from the manufacturer of the product requested. e comprehensive training must include correct use of car seats for children with special health care needs and the proper installation of top tethers. Vendors must demonstrate proficiency in the installation of the top tethers during this training. A photocopy of the training certification of the provider must accompany each request for authorization for CSHCN payment. Authorizations will not be provided to a vendor until training has been completed and the CSHCN claims contractor (TMHP) receives a copy of the training certificate with each car seat authorization requested. Vendors must provide the name of the individual installing the car seat on the CSHCN Equipment Authorization Request Form or documentation must accompany this form indicating that the top tether was factory installed by the vehicle s manufacturer prior to vehicle purchase. Installation of the top tether is essential for proper use of the car seat and must be provided by the vendor. Vendors may not bill CSHCN for the installation of the top tether. Vendors providing the service must keep a statement on record that has been signed and dated by the child s parent or guardian and the vendor stating: A top tether was installed by a manufacturer-trained vendor in the automobile in which the child will be transported. Parent training in the correct use of the car seat was provided by a manufacturertrained vendor. e parent received instruction and demonstrated the correct use of the car seat to a manufacturer-trained vendor. Car seat accessories, available from the manufacturers for correct positioning, may be authorized when medically necessary. Only car seat modifications or accessories that have been crash tested with the car seat and provided by the manufacturer of the car seat may be authorized. If you have questions or need additional information, contact the TDH-CSHCN staff occupational therapist, Terry Irons, OTR, by calling , extension 3689, or terry.irons@tdh.state.tx.us. CSHCN Bulletin, No May 2004

11 Coding and Reimbursement Fiscal Agent Payment Deadlines As of January 1, 2004, TMHP, as the state s Medicaid and CSHCN fiscal agent, is required to finalize all claims, including appeals or adjustments, within 24 months. e matrix below describes the new payment deadlines. NOTE: Payment deadlines should not be confused with the claims filing deadlines that are in place for claim submissions, appeals, and adjustments (see Filing Deadline Changes, on page 6). Payment Deadlines All Providers (except Long Term Care) Claims Medicare Crossover Claims Refugee Claims Retroactive SSI Eligibility Claims County Indigent Retroactive Eligibility Claims CSHCN and Medicaid payments cannot be made after 24 months from the date of service or discharge date on inpatient claims. e crossover file create date is the date in which the file is received by Medicaid. e state has 24 months from the create date to pay the crossover claim. For paper submissions, the state has 24 months from the Medicare Remittance Advice date (attachment date). (For information only - does not apply to CSHCN claims.) e payable period for all Refugee Medicaid payments is the federal fiscal year (October September) in which each date of service (discharge date for inpatient claims) occurs plus one additional Federal Fiscal year. (For information only - does not apply to CSHCN claims.) e payment deadline is derived from the client s eligibility add date; to allow 24 months from the add date for the retroactive SSI eligible client. (For information only - does not apply to CSHCN claims.) e payment deadline is derived from the client s eligibility add date; to allow 24 months from the add date for the retroactive County Indigent eligible client. (For information only - does not apply to CSHCN claims.) New payment deadline system edits will be implemented in June TMHP is identifying those claims that have been processed and paid beyond the designated payment deadlines during the months of January through May Claims meeting the criteria are being adjusted for the purpose of recouping funds that were paid after the payment deadline as defined by the new payment deadline rules. Inpatient Hospital Claims Inpatient hospital services submitted on the UB92 (HCFA-1450) claim form or the equivalent electronic format must be billed using appropriate revenue codes. Procedural coding guidelines have not changed due to HIPAA implementation. Incorrect submission of HCPCS coding on inpatient claims will cause claim denials. May CSHCN Bulletin, No. 50

12 Coding and Reimbursement Hepatitis A Vaccine Expansion Effective immediately, the Texas Department of Health (TDH) is recommending routine administration of Hepatitis A vaccine for children in 23 additional Texas counties, including Gonzales County. Pursuant to Health and Safety Code , TDH shall require hepatitis A vaccine for children in high incidence geographic areas specified by TDH. e complete list of counties approved to administer Hepatitis A vaccine is included below. Texas Vaccines For Children Program e Texas Vaccines for Children (TVFC) Program will provide Hepatitis A vaccine for eligible children 18 years of age or younger attending schools or childcare facilities located in or residing in any of the designated counties. e vaccine is available to TVFC-enrolled providers located in these and surrounding counties who provide health services to these children. TVFC vaccine is available for use in completing the vaccine series if a child moves from one county where the vaccine is recommended or mandated to a county where the vaccine is not recommended. TVFC vaccine is also available to any enrolled provider in the state to vaccinate American Indian and Alaskan Native children who are 18 years of age or younger. Please note that revisions to the existing school rules are currently proposed to the Texas Board of Health. If these proposed rules are adopted, school and childcare facility requirements, including those for Hepatitis A vaccine, may change. e following 40 counties are recommended for routine administration of Hepatitis A vaccine: Andrews* Cooke* Ector Guadalupe Hood* Lamb* Smith Tom Green Atascosa* Dallam* Ellis* Gregg Jack* McLennan Somervell* Travis Bosque* Dallas Gaines* Hale Johnson Martin* Stephens* Victoria* Castro* Deaf Smith* Galveston Harris Kleberg Midland Tarrant Wise* Comal Donley* Gonzales* Hays Knox* Montague* Titus* Yoakum* *Newly added counties as of December 2003 e following 39 counties require Hepatitis A vaccine for entry into school or childcare: Bexar Culberson Frio Jim Hogg McMullen Presidio Sutton Webb Brewster Dimmitt Grayson Kenedy Moore Randall Terrell Willacy Brooks Duval Hidalgo Kinney Nueces Real Terry Zapata Cameron Edwards Hudspeth La Salle Pecos Reeves Uvalde Zavala Crockett El Paso Jeff Davis Maverick Potter Starr Val Verde CSHCN Bulletin, No May 2004

13 Coding and Reimbursement e following table is a brief reference guide for the administration of Hepatitis A vaccine. Route of Administration Vaccine Schedule in Months Dosage* Number of Doses in Series Side Effects and Adverse Events Intramuscular (IM) 0 = 1 st dose; 6-12 months later = 2 nd dose (0 represents the initial dose; subsequent numbers represent months after the initial dose) 0.5 ml (Pediatric Formulation) 2 (Two) Local Reactions: soreness and redness at injection site; headache; malaise. At this time, over 65 million doses of Hepatitis A vaccine have been administered, and no serious adverse events have been reported * e pediatric formulation of Havrix (manufactured by Glaxo SmithKline Biologics Division) may be administered to children 18 years of age; however, if using Vaqta (Merck Vaccine Division), the adult formulation (1.0 ml) must be used in persons 18 years of age. Additional information on vaccine storage, route of administration, vaccination schedule, dosage, vaccine efficacy, side effects, and adverse events is available in the Centers for Disease Control and Prevention (CDC) document, Prevention of Hepatitis A rough Active or Passive Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) via the internet at preview/mmwrhtml/rr4812a1.htm. Immunization for Hepatitis A is a benefit of the CSHCN Program. Refer to the November 2003 CSHCN Provider Bulletin, pages 2-4, for specific information on billing procedures. For additional information please contact the TDH Immunization Division at , or , or visit the TDH Immunization Division s website at May CSHCN Bulletin, No. 50

14 Forms and Guides CSHCN Bulletin, No May 2004

15 Forms and Guides CSHCN Physician/Dentist Assessment Form (For Application to CSHCN) Page 1 of 2 Please complete and sign this form for the person applying for the Children with Special Health Care Needs Program (CSHCN). If you need more copies or have questions, please refer to the instruction sheet or call Send the completed form to the parent/guardian or to the clients local CSHCN office. Name of Client/Applicant (Last, First, Middle): CSHCN Case No. (if known): Date of Birth: Address (Street, City, State, Zip): Parent/Guardian Name: Telephone No.: ( ) 1) DIAGNOSIS AND EVALUATION SERVICES (screening exam): Is this a request for Diagnosis and Evaluation Services to determine whether the client/applicant has a chronic physical or developmental condition? (Please check the box.) Yes Please indicate the appropriate V-Code: and go to the Physician/Dentist Data section on the reverse side. (Only CSHCN-enrolled providers will be reimbursed for Diagnosis and Evaluation Services.) No Please complete the remainder of this form. 2) MEDICAL CERTIFICATION DEFINITION: The client/applicant must be either: 2a) A person younger than 21 years of age who has a chronic physical or developmental condition that: Will last or is expected to last for at least 12 months; and Results or, if not treated, may result in limits to one or more major life activities; and Requires health and related services of a type or amount beyond those required by children generally; and Has a physical (body, bodily tissue or organ) manifestation; and May exist with accompanying developmental, mental, behavioral, or emotional conditions; but Is not solely a delay in intellectual development or solely a mental, behavioral, and/or emotional condition. OR 2b) A person of any age who has cystic fibrosis. I certify that the client/applicant meets the above definition. Yes No Primary Diagnosis (must meet definition 2a or 2b): ICD-9-CM Code & Descriptor (required): OTHER DIAGNOSES AND CONDITIONS: ICD-9-CM code: ICD-9-CM code: ICD-9-CM code: Descriptor: Descriptor: Descriptor: 3) QUESTIONS FOR INITIAL APPLICATION TO CSHCN: (If renewing, go to the next section) Is the applicants condition a result of a traumatic injury or accident? Yes No If yes, date of trauma or accident? If hospitalized, date of discharge home? Date of admission to rehab. facility? For applicants less than 1 year old: Was the child born before 36 weeks gestation? Yes No If yes, date of discharge home after birth? Has the child spent 14 consecutive days out of the hospital? Yes No Form T3 01E revised 12/03/03 NOT VALID WITHOUT THE SIGNATURE OF A PHYSICIAN OR DENTIST ON PAGE 2 May CSHCN Bulletin, No. 50

16 Forms and Guides Instructions for Completing the Physician/Dentist Assessment Form (PAF) Children with Special Health Care Needs Program CSHCN Dear Doctor: Thank you for helping this family to apply for benefits from the Children with Special Health Care Needs Program (CSHCN). The Physician/Dentist Assessment Form (or PAF) is a key part of the application process. The PAF is just two pages long, with a block that identifies the applicant plus six other short sections for you to complete. Please fill in the applicants identifying information and then go on to Part 1. 1) DIAGNOSIS AND EVALUATION SERVICES (screening exam): Please complete Part 1 only if you need to do a workup or further examinations or tests to determine if the applicant meets the CSHCN medical certification definition (see Part 2). Please note that whenever CSHCN has a waiting list, applicants cannot get diagnosis and evaluation services. To find out if CSHCN currently has a waiting list, call ) MEDICAL CERTIFICATION DEFINITION: Please pay particular attention to Part 2. It contains the definition of a child with special health care needs for CSHCN purposes. The primary diagnosis should reflect a chronic illness or disability that affects the child and meets the definition. The form has spaces to add as many as three additional diagnoses. 3) QUESTIONS FOR INITIAL APPLICATION TO CSHCN: Complete Part 3 only if this is the first time the applicant has ever applied to CSHCN. If the client is renewing his or her CSHCN application, please leave Part 3 blank. 4) DETERMINATION OF URGENT NEED FOR SERVICES: Part 4 is very important, especially when CSHCN has a waiting list. Your answers to Part 4 help CSHCN physicians determine which children need health care services most urgently. This information is a factor in determining the order in which to remove clients from the waiting list whenever available funds make it possible to do so. If you answer yes to Part 4a and/or 4b, your explanation is required. When answering 4a, please base your answer on what would happen if the applicant had no resources to pay for health care. 5) FUNCTIONAL NEEDS: The Texas Legislature requires CSHCN to collect this information. Please check all appropriate boxes. 6) SERVICES NEEDED: Please talk with the family and then check the blocks for any and all services the client/applicant may require. This information will help CSHCN plan for effective services now and in the future. It will not affect the applicants eligibility for services. 7) PHYSICIAN/DENTIST DATA: Part 7 must be filled out completely. Phone numbers are especially important. Remember that to process the application, we must have your signature and the date. Thank you again for all you do to help the clients and families of CSHCN! CSHCN Bulletin, No May 2004

17 Forms and Guides CSHCN Physician/Dentist Assessment Form (Continued) CLIENT/APPLICANTS NAME: CSHCN#: DOB: / / Page 2 of 2 4) DETERMINATION OF URGENT NEED FOR SERVICES: 4a) Would an inability to get healthcare services cause a permanent increase in disability, intense pain or suffering, or death? Please base your answer on what would happen if the applicant had no resources to pay for health care. Yes No If Yes, explanation required: 4b) Is the family or client/applicant actively planning to move the client/applicant to a nursing home, group home, or similar institution in the next 6 months? Yes No If Yes, explanation required: 4c) If there is additional information related to the complexity or severity of the clients/applicants condition or need for care that the CSHCN Program should know, please indicate below or attach additional narrative. 5) FUNCTIONAL NEEDS: Check appropriate blocks indicating the client/applicants functional needs or limitations Physical Developmental Behavioral Emotional 6) SERVICES NEEDED: Check all blocks that apply for services the client/applicant may require. Data is for CSHCN Program planning purposes and does not affect eligibility. bone marrow transplant case management dental services drugs durable medical equipment expendable medical supplies family support services help with drug co-payments hemophilia blood factor products home health/nursing services inpatient hospital Insurance Premium Payment Assistance mental health services outpatient services (including PT, OT & SLP) physician services pulmozyme renal dialysis/renal transplant inhaled tobramycin total parenteral nutrition transportation/meals/lodging vision services other growth hormone 7) PHYSICIAN/DENTIST DATA Must Be Completed for All Applications Name of Physician/Dentist: (type or print) TPI#: Tax ID#: Specialty: Mailing Address: (Street, City, State, Zip) Contact Persons Name: (type or print) Phone: ( ) Fax: ( ) PHYSICIAN/DENTIST SIGNATURE: DATE: Form T3 01E revised 12/03/03 May CSHCN Bulletin, No. 50

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20 May 2004 No. 50 CSHCN Provider Bulletin The Children with Special Health Care Needs Program PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE