T exas Medicaid Bulletin

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1 T exas Medicaid Bulletin Bimonthly update to the Texas Medicaid Provider Procedures Manual November/December 2008 No. 219 Medicare Paper Claims Providers that receive paper Medicare Remittance Advice Notices (MRANs) from Medicare or a Medicare intermediary may submit these MRANs to the Texas Medicaid & Healthcare Partnership (TMHP). All Medicare crossover paper claims must include a completed claim form. Paper Medicare crossover claims may also be submitted to TMHP using the Centers for Medicare & Medicaid Services (CMS) approved software Medicare Remit Easy Print (MREP) for professional services or PC Print for institutional services. Providers submitting paper MRANs from Medicare, MREP, or PC Print are not required to submit the TMHP Standardized MRAN form. Providers that do not receive paper MRANs from Medicare or a Medicare intermediary or cannot retrieve MRANs from MREP or PC Print, must submit the TMHP Standardized MRAN form. The TMHP Standardized MRAN form is available in the 2008 Texas Medicaid Provider Procedures Manual and on the TMHP website at The TMHP Standardized MRAN form must be typed or computer generated. Handwritten forms are not accepted and are returned to the provider. Use of the American Medical Association s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: CDT 2007/2008 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply. INSIDE All Providers 1 Medicare Paper Claims Vaccine/Toxoid Reimbursement Changes New Vaccine/Toxoid Availability Incontinence Procedure Limitations Clarification Pulse Oximeter Probe Benefit Changes HHSC Response to Recent Hurricanes Payment Error Rate Measurement Frequently Asked Questions Prior Authorization Reminder Automated Maintenance Process for Electronic Submitters HCPCS Procedure Code Additions Reimbursement Rates Adopted Following Public Hearings Benefit Criteria for Anesthesia Services Have Changed Texas Medicaid Claims Reprocessing Services Provided by LCSWs, LMFTs, LPCs, and Psychologists. 23 Scheduled System Maintenance Updates to Previously Published Information Updated Tips for Expediting Paper Claims Claims Submission for Inpatient Hospital Clients Partial SDA Rebase for DRG Inpatient Hospital Providers Prior Authorization Request Changes for Breast and Colorectal Cancer Screening False Claim Employee Education Reminder for FQHC Providers Revised Texas Medicaid Fee Schedules Reminder for Rural Health Clinic Providers Family Planning Providers 34 Limitation for Family Planning Contraceptives Gynecological and Reproductive Health Services Benefit Contraceptive Device Now Payable to FQHCs and RHCs Managed Care Providers 35 Help Available for PCCM Providers with Clients Who Frequently Miss Appointments No Referral or Prior Authorization Needed for PCCM Evacuees STAR Health Mental Health Rehabilitation Claims Must Be Submitted to Integrated Mental Health Services Primary Care Provider Flyers Available for PCCM Providers Continued on page 2

2 Vaccine/Toxoid Reimbursement Changes Vaccines/toxoids that the Advisory Committee on Immunization Practices (ACIP) identifies as routine, or medically necessary, are benefits of Texas Medicaid. The administration of these vaccines/toxoids is also a benefit of Texas Medicaid. The administration of vaccines/toxoids to clients who are birth through 20 years of age is a benefit of Texas Health Steps (THSteps) when provided as part of a THSteps periodic visit. A THSteps provider that bills for vaccines/toxoids with diagnosis or age restrictions will continue to be subject to those restrictions. Providers must include on the claim the diagnosis code of the condition necessitating the vaccine/toxoid. The administration of vaccines/toxoids to clients who are birth through 20 years of age is a benefit of the THSteps Comprehensive Care Program (THSteps CCP) when provided as part of an acute medical visit outside of a THSteps periodic visit. All providers must assess the immunization status of clients who are birth through 18 years of age at every encounter, or birth through 20 years of age when part of a THSteps medical checkup. Providers must administer any medically indicated vaccines/toxoids unless medically contraindicated or because of the parent s reason of conscience, including a religious belief. The reason the indicated vaccine/toxoid was not administered must be documented in the client s medical record. The following procedure codes may be used when billing for vaccine/toxoid administration for clients who are birth through 20 years of age: Procedure Codes 1/S /S /S /S /S /S /S /S Only one vaccine administration fee may be reimbursed to any provider for each vaccine/toxoid administered per client, per day. Reimbursement for administration fees requires that the procedure codes for the administered vaccines/toxoids be submitted in addition to the administration fee. Vaccine/toxoid administration fees will be reimbursed based on the number of state defined components administered per injection. The provider must bill an administration fee without a modifier when a vaccine/ toxoid with one state defined component is administered. A vaccine/toxoid billed without a modifier has a reimbursement rate of $8.00. The provider must bill an administration fee with statedefined modifier U2 when a vaccine/toxoid with two statedefined components is administered. A vaccine/toxoid billed with modifier U2 has a reimbursement rate of $ The provider must bill an administration fee with state defined modifier U3 when a vaccine/toxoid with three state defined components is administered. The legislation that created the federal Vaccines for Children (VFC) program requires that the Department of Health and Human Services establish a maximum reimbursement limit for the amount a provider can be reimbursed for administrations of vaccines to Texas Vaccines for Children (TVFC) eligible children. The provider may not charge more than $14.85 for administration of a TVFC vaccine if the child is eligible for TVFC. A vaccine/toxoid billed MORE CONTENTS Continued from page 1 THSteps CCP Providers 37 New Medicaid Rates for Personal Care Services Adopted THSteps Dental Providers 37 THSteps Therapeutic Dental Services Benefits to Change THSteps Therapeutic Dental Services Reimbursement Rate Change Provider Enrollment and Claims Filing for Dental Providers Oral/Facial Photographic Images Claims Reprocessing THSteps Medical Providers 39 Group Provider Claims for THSteps THSteps Checkup Benefit Changes Women s Health Program Providers 40 Claims Submitted by Women s Health Program Providers Excluded Providers 41 Excluded Providers Forms 42 Primary Care Case Management (PCCM) Office Flyer Primary Care Case Management (PCCM) Referral Form Provider Information Change Form Electronic Funds Transfer (EFT) Authorization Agreement Texas Medicaid Bulletin, No November/December 2008

3 with modifier U3 for a client not eligible for VFC has a reimbursement rate of $ Descriptions for the U2 and U3 modifiers are as follows: Modifier U2 U3 Description State defined modifier: Administration of vaccine/toxoid with two state defined components State defined modifier: Administration of vaccine/toxoid with three state defined components The following vaccine/toxoid procedure codes are a benefit for clients who are birth through 20 years of age: Number of State Procedure Code Defined Components 1/S 90632* 1 1/S 90633* 1 1/S /S /S /S /S 90648* 1 1/S 90649* 1 1/S 90655* 1 1/S 90656* 1 1/S 90657* 1 1/S 90658* 1 1/S 90660* 1 1/S 90669* 1 1/S 90680* 1 1/S-90698* 3 1/S 90700* 1 1/S 90702* 1 1/S /S /S /S /S 90707* 1 1/S 90710* 2 1/S 90713* 1 1/S 90714* 1 1/S 90715* 2 1/S 90716* 1 Number of State Procedure Code Defined Components 1/S /S /S 90723* 3 1/S 90732* 1 1/S /S 90734* 1 1/S 90740* 1 1/S /S 90744* 1 1/S 90746* 1 1/S /S 90748* 2 1/S * Indicates a vaccine/toxoid distributed through TVFC Vaccines/toxoids may be reimbursed with modifier U1 when the vaccine/toxoid is not available for distribution through TVFC. Providers will be notified by TVFC when vaccine/toxoids are not available. Vaccines/toxoids may be reimbursed as part of a THSteps periodic visit or as part of an acute medical visit (through THSteps CCP). Not available is defined as: a new vaccine approved by the ACIP that has not been negotiated or added to a TVFC contract; TVFC has not established funding for a new vaccine; or national supply or distribution issues limit availability. Modifier U1 may not be used for failure to enroll in TVFC or to maintain sufficient TVFC vaccine/ toxoid inventory. The description for the U1 modifier is State defined modifier: Vaccines/toxoids privately Contact Information For additional information about Texas Medicaid, call the TMHP Contact Center at For additional information about PCCM articles in this bulletin, call the PCCM Provider Helpline at For additional information about articles pertaining to the Children with Special Health Care Needs (CSHCN) Services Program, call the TMHP CSHCN Contact Center at November/December Texas Medicaid Bulletin, No. 219

4 purchased by provider when TVFC vaccine/toxoid is not available. Single or multiple antigen vaccines/toxoids that are comparable to vaccines/toxoids available for distribution through TVFC will not be covered when the provider chooses to use a different ACIP recommended product; however, the administration fee may be reimbursed. Vaccines/toxoids available through TVFC for clients who are birth through 18 years of age will not be reimbursed by Texas Medicaid. These vaccines/toxoids will be processed as informational details. Providers may need to bill the vaccine for $.01 so that the claim can be processed but may not otherwise charge Medicaid for the vaccine obtained from TVFC. When the vaccine is available through TVFC, reimbursement for vaccines/toxoids administered to clients who are birth through 18 years of age will be denied even if the provider is not enrolled in TVFC. Providers must not bill the client for vaccines/toxoids available through TVFC. The administration fee may be reimbursed through Texas Medicaid only when the vaccine/toxoid is identified by procedure code on the claim. The specific diagnosis code of the condition necessitating the vaccine/toxoid is required when billing with the administration fee in combination with the appropriate vaccine procedure code. For clients who are birth through 20 years of age, diagnosis code V202 may be used unless there is a more specific diagnosis code. Additional age based reimbursement limitations: For clients who are birth through 18 years of age. The state mandated administration of the hepatitis B vaccine to newborns before discharge from the hospital has been established as the accepted standard of care and will not be considered as a reason to upgrade to a different diagnosis related group (DRG). The administration of the hepatitis B vaccine to newborns is included in the DRG payment and will not be reimbursed separately. For clients who are 21 years of age or older. Administration of vaccines/toxoids for clients 21 years of age and older is a benefit when the vaccine is medically necessary. Procedure codes , , , and may be used when billing for vaccine/toxoid administration for clients 21 years of age and older. The following vaccine/toxoid procedure codes are benefits for clients who are 21 years of age and older: Procedure Codes * *Only for female clients 21 years of age and older Only one vaccine administration fee may be reimbursed to any provider for each vaccine/toxoid administered per client, per day. Modifiers U1, U2, and U3 do not apply when submitting claims for the vaccine administration and vaccine/toxoids for clients 21 years of age and older. The administration fee may be reimbursed through Texas Medicaid when the vaccine/toxoid is identified by procedure code on the claim. The specific diagnosis code of the condition necessitating the vaccine/toxoid is required when billing with the administration fee in combination with the appropriate vaccine procedure code. For all clients The National Childhood Vaccine Injury Act (NCVIA) requires providers to record specific information in a client s medical record each time a vaccine is administered. The following information is required: The vaccine/toxoid given. The date of the vaccine/toxoid administration (day, month, year). The vaccine lot number. The name of the vaccine manufacturer. The signature and title of the person administering the vaccine/toxoid. The organization name and address of the clinic location. The publication date of the Vaccine Information Statement issued to the client, parent, or guardian. The client s medical records are subject to retrospective review to determine appropriate utilization and reimbursement of this service. The NCVIA mandates that health care providers report the following to the Vaccine Adverse Event Reporting System (VAERS): Any reaction listed by the vaccine manufacturer as a contraindication to subsequent doses of the vaccine. Texas Medicaid Bulletin, No November/December 2008

5 Incontinence Procedure Limitations Clarification Any reaction listed in the Reportable Events Table that occurs within the specified time period after vaccination. Clinically significant adverse events should be reported even if it is unclear whether a vaccine caused the event. A copy of the Reportable Events Table can be obtained by calling VAERS at or by downloading it from Documentation of the injection site is recommended but not required. New Vaccine/Toxoid Availability Effective September 3, 2008, for dates of service on or after June 26, 2008, DTaP IPV Hib vaccine (Pentacel) is a benefit of Texas Medicaid for clients 20 years of age or younger. DTaP IPV Hib contains three state defined components. Procedure code 1/S must be submitted in addition to the most appropriate vaccine administration procedure code and U3 modifier. Procedure code 1/S is processed as informational, and the provider will not be reimbursed for the cost of the vaccine. The administration fee may be reimbursed. Medicaid Providers must obtain the DTaP IPV Hib from the TVFC Program for clients birth through 18 years of age. Providers must resubmit denied claims for DTaP IPV Hib originally submitted before September 3, The following is a clarification of the benefits for incontinence supplies that are provided by durable medical equipment (DME) providers. The following procedure codes require prior authorization even if the maximum benefit limitation allowed has not been exceeded: Procedure Codes 9 A A6250 J E0163* J E0165** J E0167 J E0168* J E0175 * Whether billed alone or with modifiers TF or TG ** Whether billed alone or with modifier TG Refer to the 2008 Texas Medicaid Provider Procedures Manual, Section , Incontinence Supplies, on page for more information. Pulse Oximeter Probe Benefit Changes Effective for dates of service on or after September 1, 2008, pulse oximeter probes (procedure code 9 A4606) no longer require prior authorization for up to a total of four per month for Texas Medicaid (Title XIX) Home Health Services and THSteps CCP. If additional sensor probes are needed, prior authorization must be requested through Home Health Services or through THSteps CCP with documentation supporting medical necessity. HHSC Response to Recent Hurricanes Claim Filing Deadline to Be Waived for Services to Ike Evacuees In response to Hurricane Ike, the Health and Human Services Commission (HHSC) has directed TMHP to Want to Know More? waive the filing deadline for services rendered to Texas Medicaid clients who are Hurricane Ike evacuees. The waiver applies to claims received with dates of service on or after September 9, 2008, and until further notice. Claims submitted after the filing deadline will initially be denied but will then be reprocessed by TMHP with no further action required by the provider. This waiver does not apply to the 365-day federal filing deadline, which will not be overridden. The filing deadline will be waived only for providers whose ZIP codes have been identified by HHSC as an evacuation area. For more information, call the TMHP Contact Center at See page 35 for important information about PCCM evacuees. Current Hurricane Information Available on TMHP and HHSC Websites Information is available for providers that were impacted by the recent hurricanes or are providing services to clients impacted by the recent hurricanes. Providers can find information on the TMHP website at and on the HHSC website at Updated information is posted on these websites as it becomes available, and providers are encouraged to check these pages frequently to get the latest information. November/December Texas Medicaid Bulletin, No. 219

6 Payment Error Rate Measurement Frequently Asked Questions CMS has begun the claims review phase of the fiscal year 2008 Payment Error Rate Measurement (PERM) program. Under PERM, Texas Medicaid and Children s Health Insurance Program (CHIP) claims are subject to review by CMS contractors. A list of frequently asked questions is available below. Question What is PERM? What does PERM do? Why are PERM reviews required? How did the Medicaid and CHIP programs become a part of the PERM reviews? Who will conduct the PERM reviews? When will PERM reviews begin? How many claims will be reviewed? Will I have to provide any information to the PERM reviewers? How will I know if one of my claims is randomly selected for PERM review? Response PERM is a federal program created to implement the requirements of the Improper Payments Information Act (IPIA) of PERM reviews state- and national-level improper payment error rates in specified federal programs. IPIA requires federal agency heads to review the programs they oversee that are at risk of significant erroneous payments, to estimate the amount of improper payments, and to report those estimates to the U.S. Congress. PERM is the program implemented to achieve this task. The U.S. Office of Management and Budget (OMB) identified Medicaid and CHIP as programs at risk of significant improper payments. CMS implemented the PERM reviews to comply with the IPIA. PERM reviews are conducted by CMS through three contractors: Livanta LLC, the Lewin Group, and HealthDataInsights Inc. The Lewin Group will collect the claims universe. Livanta will randomly select a sample of claims to be reviewed and calculate each state s error rate. Livanta will collect policies from the state and medical records from providers. HealthDataInsights Inc. will perform medical and data processing reviews of the selected claims in order to identify any improper payments. PERM reviews are scheduled to occur beginning as early as August 2008 and will continue until August A total of 3,000 medical claims will be reviewed. The claims will be randomly selected by Livanta from claims that were adjudicated from October 1, 2007, through September 30, These claims include the following: 1,000 Texas Medicaid fee-for-service 1,000 CHIP fee-for-service 500 CHIP managed care 500 Medicaid managed care Yes, providers will be asked to submit medical records that support the sampled claims for Texas Medicaid and CHIP fee-for-service claims to Livanta. If a claim is selected in a sample for a service that a provider rendered to either a Texas Medicaid or CHIP client, Livanta will contact the provider by telephone to verify their contact information and verify how the provider wants to receive the medical records request (fax or mail). Livanta will then request a copy of the medical records that support the medical review of the claim. Texas Medicaid Bulletin, No November/December 2008

7 Question Response TMHP will also contact selected providers to verify contact information. Providers may be contacted as early as August Why do I have to comply with this request? These records are confidential and I cannot release them due to the Health Insurance Portability and Accountability Act (HIPAA). Does this request protect me against releasing confidential records to the requesting federal PERM contractor? Do I need a release or authorization from the client? Who is authorized to request these records? Can I charge for providing the records? Also, HHSC will send a prepaid envelope to each provider with a claim selected in the sample and ask the provider to mail a duplicate copy of the selected medical record to HHSC. HHSC will use the medical records during its review of HealthDataInsight s preliminary PERM findings. If HHSC disagrees with the preliminary assessment, HHSC will prepare an appeal. It is a contract requirement. Additionally, failure to provide medical documentation to support the claim upon request can result in the provider being sanctioned under Title 1 Texas Administrative Code (TAC) Part 15, Chapter 371. Providers are required by Section 1902(a)(27) of the Social Security Act to retain the records necessary to disclose the extent of services provided to individuals receiving assistance and to furnish CMS with information about any payments claimed by the provider for rendering services. The furnishing of information includes medical records. In addition, the collection and review of protected health information contained in individual-level medical records for payment review purposes is permissible by HIPAA (45 Code of Federal Regulations [CFR], Parts 160 and 164). Information about the diagnosis, evaluation, or treatment of a client with Medicaid coverage by a person licensed or certified to perform the diagnosis, evaluation, or treatment of any medical, mental or emotional disorder, or drug abuse, is confidential information that the provider may disclose only to authorized people. This policy is explained in the 2008 Texas Medicaid Provider Procedures Manual, Section 1.2.4, Release of Confidential Information, on page 1-8. The client s authorization for release of such information is not required when the release is requested by and made to HHSC, CMS, and their contracted representatives or other entities. The client s authorization for release of such information is not required when the release is requested by and made to the following entities: Department of Aging and Disability Services (DADS) HHSC Department of State Health Services (DSHS) TMHP Department of Family and Protective Services (DFPS) Department of Assistive and Rehabilitative Services (DARS) HHSC Office of the Inspector General (OIG) Texas Attorney General s Medicaid Fraud Control Unit and Antitrust and Civil Fraud Division U.S. Department of Health and Human Services, including CMS and their PERM contractors A provider cannot charge for the release of these documents. In accordance to the 2008 Texas Medicaid Providers Procedures Manual, Section 1.2.3, Retention of Records and Access to Records and Premises, the provider must submit copies of such records within the specified timeframe at no cost to the requestor s organization. November/December Texas Medicaid Bulletin, No. 219

8 Question What if I don t have these records to support the claim s billing? How will I receive the request for records? What do I do once I receive the request? What timeframe do I have to provide these records? How will the federal PERM contractor know what my contact information is in order to send me the PERM medical record request? Who should I call if I have questions about the medical records request? Where can I learn more about PERM? Response Failure to maintain complete and correct documentation in support of claims filed, or failure to provide such documentation upon request, can result in the provider being sanctioned under Title 1 TAC Part 15, Chapter 371. Sanctions may include, but are not limited to, a finding of overpayment for the claims that are not sufficiently supported by the required documentation. In order to obtain medical records for a claim sampled for review, Livanta will call providers to request a copy of the selected medical records. Livanta will also ask the provider whether the written request for the medical records should be sent by fax or by mail. Once a provider receives the request for medical records, the provider must submit the information electronically or as a hard copy to the address indicated on the letter. In addition, a separate, duplicate copy of the medical records must be submitted to HHSC using a prepaid envelope supplied by HHSC. Providers must send these records within 60 calendar days of the request. Livanta, and possibly state officials, will send reminders to providers after 15 days and again after 35 days. If the requested medical record is not submitted within 60 days, the associated claim will be automatically found to be in error. The contact information listed on the provider s eligibility file with Texas Medicaid will be used to contact providers. Providers must notify TMHP of any change in their telephone number, mailing address, or physical address. All providers should check the TMHP system to ensure their current telephone number and addresses are correct. Providers may refer to the online provider lookup on the TMHP website at to verify this information. If the information is incorrect or incomplete, providers must request a change immediately to ensure the PERM medical record request can be delivered. Failure to update telephone numbers or addresses could result in a higher PERM error rate for the state and recoupment of payments from the provider. Contact information can be updated using the online provider lookup on the TMHP website at If a provider has questions about a request for medical records from Livanta, providers should contact the representative that requested the information immediately. The appropriate phone number will be listed on the correspondence received. Providers can review the CMS website at In addition, refer to future TMHP provider notifications as additional information may be added regarding the PERM process. TMHP is also offering additional information within the Success with Medicaid and TexMedConnect workshops. For more information, refer to the workshop registration webpage on the TMHP website at For more information, call the TMHP Contact Center at Texas Medicaid Bulletin, No November/December 2008

9 Prior Authorization Reminder Reminder: If a service has been prior authorized, but a more complex procedure is determined necessary, the provider must update the prior authorization request prior to submitting the claim to allow reimbursement for the more complex procedure. To request an update to an authorization, the provider must contact the appropriate prior authorization department (i.e., the department that issued the authorization) with the procedure performed and documentation supporting the medical necessity of the more complex procedure. For more information, call the TMHP Contact Center at Automated Maintenance Process for Electronic Submitters Effective September 11, 2008, TMHP is enforcing the automated maintenance process for all electronic submitters. Electronic submitters include everyone who has obtained a submitter ID from the Electronic Data Interchange (EDI) Help Desk. Each submitter ID is linked to a submitter folder on the TMHP servers. All electronic submitters are responsible for the maintenance of their submitter folders. Submitter folders have a maximum limit of 7,500 files, and no files can be more than 30 days old. Files that exceed these limits will be purged by TMHP on a daily basis. TMHP will charge a fee to recover files that have been purged, as outlined in the 2008 Texas Medicaid Provider Procedures Manual, Section 3.6, Electronic Transmission Reports on page HCPCS Procedure Code Additions The second quarter 2008 Healthcare Common Procedure Coding System (HCPCS) additions, changes, and deletions that are effective for dates of service on or after July 1, 2008, are available. Deleted procedure codes are no longer benefits of Texas Medicaid or the CSHCN Services Program. The following is a list of new noncovered (NC) procedure codes that do not replace existing procedure codes: Procedure Code 5 G0398 NC 5 G0399 NC 5 G0400 NC 1 C9241 NC 1 C9242 NC 9 C9356 NC 9 C9357 NC 9 C9358 NC Allowable Description Changes The descriptions for the following procedure codes have changed. Providers must contact the appropriate copyright holder to obtain procedure code and modifier descriptions. Procedure Codes 4/I/T C8921 4/I/T C8922 4/I/T C8923 4/I/T C8924 4/I/T C8925 4/I/T C8926 4/I/T C8927 4/I/T C8928 Discontinued Procedure Codes Procedure codes 1 G0377 and 2/8/F G0297 are no longer benefits of Texas Medicaid or the CSHCN Services Program and have no replacements. These procedure codes are no longer reimbursed after June 30, New Modifier Modifier CG was added as a new modifier. Providers must contact the appropriate copyright holder to obtain procedure code and modifier descriptions. November/December Texas Medicaid Bulletin, No. 219

10 Reimbursement Rates Adopted Following Public Hearings Many services were assigned reimbursement rates following public hearings. See the following pages for specific services: Clinical Laboratory Services Anesthesia Services Genetics Dental Services Obstetrical Sonogram Services Hearing Aids Breast Reconstructive Surgery Immunizations Ambulatory Surgical Center Services Durable Medical Equipment Surgical Services ENT Surgery Services Gynecological and Reproductive Health Services DME Associated with Cochlear Implant Device Breast Brachytherapy Medical Services Cesarean Delivery Only Services Texas Medicaid reimbursement rates were adopted following a public hearing on June 17, 2008, for the following services: Procedure Code New Reimbursement Rate Effective Date Clinical Laboratory Services $89.99 January 1, $18.66 January 1, $11.43 January 1, $20.11 January 1, $16.76 January 1, $49.04 January 1, $49.04 January 1, $49.04 January 1, $49.04 January 1, $16.76 January 1, 2007 Anesthesia Services base units, $15.55 conversion factor January 1, base units, $19.83 conversion factor (clients birth September 1, 2007 through 20 years) base units $16.72 conversion factor (clients 21 September 1, 2007 years and older) base units $15.55 conversion factor January 1, base units $19.83 conversion factor (clients birth through 20 years) September 1, 2007 Texas Medicaid Bulletin, No November/December 2008

11 Procedure Code New Reimbursement Rate Effective Date base units $16.72 conversion factor (clients 21 September 1, 2007 years and older) Genetics G $26.73 (0.98 relative value unit [RVUs]), $ January 1, 2007 Dental Services D0145 $15.25 January 1, 2007 February 29, Procedure code D0145 (in association with First Dental Home) is reimbursed at $ effective March 1, 2008 D0273 $14.80 January 1, 2007 D0273 $29.60 September 1, 2007 D1555 $50.00 January 1, 2007 D4230 $ January 1, 2007 D4231 $97.50 January 1, 2007 D8693 $50.00 January 1, 2007 D9120 $20.00 January 1, 2007 D9612 $37.50 January 1, 2007 Obstetrical Sonogram Services $ September 1, 2008 I $39.81 September 1, 2008 T $65.30 (2.28 RVUs, $ conversion factor) September 1, $57.28 September 1, 2008 I $33.51 September 1, 2008 T $23.77 (.83 RVU, $ conversion factor) September 1, $ September 1, 2008 I $45.26 September 1, 2008 T $81.91 (2.86 RVUs, $ conversion factor) September 1, $ September 1, 2008 I $94.81 September 1, 2008 T $ September 1, $ September 1, 2008 I $86.27 September 1, 2008 T $ September 1, $ September 1, 2008 I $73.03 September 1, 2008 T $ (3.89 RVUs, $ conversion factor) September 1, $77.91 September 1, 2008 I $29.79 September 1, 2008 T $48.12 (1.68 RVUs, $ conversion factor) September 1, $95.37 (3.33 RVUs, $ conversion factor) September 1, 2008 November/December Texas Medicaid Bulletin, No. 219

12 Procedure Code New Reimbursement Rate Effective Date I $32.65 (1.14 RVU, $ conversion factor) September 1, 2008 T $62.72 (2.19 RVUs, $ conversion factor) September 1, $83.05 September 1, 2008 I $30.07 September 1, 2008 T $52.98 (1.85 RVUs, $ conversion factor) September 1, $97.95 (3.42 RVUs, $ conversion factor) September 1, 2008 I $40.10 (1.40 RVUs, $ conversion factor) September 1, 2008 T $57.85 (2.02 RVUs, $ conversion factor) September 1, $72.46 (2.53 RVUs, $ conversion factor) September 1, 2008 I $29.50 (1.03 RVUs, $ conversion factor) September 1, 2008 T $42.96 (1.50 RVUs, $ conversion factor) September 1, $66.83 September 1, 2008 I $37.01 September 1, 2008 T $29.82 September 1, $79.91 September 1, 2008 I $28.64 September 1, 2008 T $51.27 (1.79 RVUs, $ conversion factor) September 1, $ (6.22 RVUs, $ conversion factor) September 1, 2008 I $64.15 (2.24 RVUs, $ conversion factor) September 1, 2008 T $ (3.98 RVUs, $ conversion factor) September 1, $ September 1, 2008 I $43.82 September 1, 2008 T $73.60 (2.57 RVUs, $ conversion factor) September 1, $83.46 September 1, 2008 I $35.90 September 1, 2008 T $47.56 September 1, $38.67 September 1, 2008 I $22.63 September 1, 2008 T $16.04 (0.56 RVUs, $ conversion factor) September 1, 2008 Hearing Aids R V5030 $1, July 1, 2008 R V5040 $1, July 1, 2008 R V5050 $1, July 1, 2008 R V5060 $1, July 1, 2008 R V5070 $1, July 1, 2008 R V5080 $1, July 1, 2008 R V5090 $ July 1, 2008 R V5100 $2, July 1, 2008 R V5110 $ July 1, 2008 R V5120 $ July 1, 2008 R V5130 $2, July 1, 2008 R V5140 $2, July 1, 2008 Texas Medicaid Bulletin, No November/December 2008

13 Procedure Code New Reimbursement Rate Effective Date R V5150 $ July 1, 2008 R V5160 $ July 1, 2008 R V5170 $2, July 1, 2008 R V5180 $ July 1, 2008 R V5190 $ July 1, 2008 R V5200 $ July 1, 2008 R V5210 $1, July 1, 2008 R V5220 $2, July 1, 2008 R V5230 $1, July 1, 2008 R V5240 $ July 1, 2008 R V5241 $ July 1, 2008 R V5242 $2, July 1, 2008 R V5243 $1, July 1, 2008 R V5244 $2, July 1, 2008 R V5245 $1, July 1, 2008 R V5246 $2, July 1, 2008 R V5247 $1, July 1, 2008 R V5248 $2, July 1, 2008 R V5249 $1, July 1, 2008 R V5250 $2, July 1, 2008 R V5251 $2, July 1, 2008 R V5252 $2, July 1, 2008 R V5253 $3, July 1, 2008 R V5254 $2, July 1, 2008 R V5255 $2, July 1, 2008 R V5256 $2, July 1, 2008 R V5257 $2, July 1, 2008 R V5258 $4, July 1, 2008 R V5259 $3, July 1, 2008 R V5260 $3, July 1, 2008 R V5261 $3, July 1, 2008 R V5262 $2, July 1, 2008 R V5263 $ July 1, 2008 R V5264 $67.50 July 1, 2008 R V5265 $60.00 July 1, 2008 R V5275 $45.00 July 1, 2008 R V5298 $1, July 1, 2008 R V5299 $ July 1, 2008 Breast Reconstructive Surgery Rate Adopted Effective for dates of service on or after July 1, 2008, procedure code F S2068 is a benefit of Texas Medicaid. Procedure code F S2068 is reimbursed under ambulatory surgical center (ASC) Group 6. The Texas Medicaid reimbursement rate for procedure code F S2068 was adopted following a public hearing on July 21, November/December Texas Medicaid Bulletin, No. 219

14 Immunization Procedure Code Rates Adopted New Texas Medicaid reimbursement rates for immunizations were adopted following a public hearing on July 29, The new rates are in effect, only if the vaccine is not available for a TVFC eligible client or the client is not eligible for TVFC. The new rates are as follows: Procedure Code New Reimbursement Rate Effective Date Immunizations * $45.81 August 1, 2008 S 90632* $45.81 August 1, * $24.70 August 1, 2008 S 90633* $24.70 August 1, $88.69 August 1, 2008 S $88.69 August 1, * $21.78 August 1, 2008 S 90648* $21.78 August 1, * $22.03 August 1, 2008 S 90660* $22.03 August 1, $21.47 August 1, 2008 S $21.47 August 1, $21.91 August 1, 2008 S $21.91 August 1, $16.76 August 1, 2008 S $16.76 August 1, $18.75 August 1, 2008 S $18.75 August 1, * $42.55 August 1, 2008 S 90707* $42.55 August 1, * $ August 1, 2008 S 90710* $ August 1, * $25.71 August 1, 2008 S 90713* $25.71 August 1, * $19.97 August 1, 2008 S 90714* $19.97 August 1, * $35.13 August 1, 2008 S 90715* $35.13 August 1, * $73.46 August 1, 2008 S 90716* $73.46 August 1, $11.69 August 1, 2008 S $11.69 August 1, $42.89 August 1, 2008 S $42.89 August 1, * $75.29 August 1, 2008 S 90723* $75.29 August 1, * $32.70 August 1, 2008 Texas Medicaid Bulletin, No November/December 2008

15 Procedure Code New Reimbursement Rate Effective Date S 90732* $32.70 August 1, * $95.62 August 1, 2008 S 90734* $95.62 August 1, * $ August 1, 2008 S 90740* $ August 1, $24.22 August 1, 2008 S $24.22 August 1, * $24.22 August 1, 2008 S 90744* $24.22 August 1, * $57.26 August 1, 2008 S 90746* $57.26 August 1, * $46.78 August 1, 2008 S 90748* $46.78 August 1, 2008 * TVFC distributed vaccine/toxoid. For more information, refer to the 2008 Texas Medicaid Providers Procedures Manual, section Immunizations. Ambulatory Surgical Centers Rate Changes for 2007 HCPCS Codes Texas Medicaid reimbursement rates for ASC services were adopted following a public hearing on July 29, 2008, for some 2007 HCPCS codes that were effective January 1, The new ASC rates are as follows: Procedure Code New Reimbursement Rate Effective Date Ambulatory Surgical Center Services F ASC Group 3 January 1, 2007 F ASC Group 5 January 1, 2007 F ASC Group 5 January 1, 2007 F ASC Group 5 January 1, 2007 F ASC Group 9 January 1, 2007 F ASC Group 9 January 1, 2007 F ASC Group 6 January 1, 2007 F ASC Group 3 January 1, 2007 F ASC Group 5 January 1, 2007 F ASC Group 5 January 1, 2007 F ASC Group 1 January 1, 2007 F ASC Group 1 January 1, 2007 F ASC Group 1 January 1, 2007 F ASC Group 1 January 1, 2007 F ASC Group 1 January 1, 2007 F ASC Group 9 January 1, 2007 F ASC Group 4 January 1, 2007 F ASC Group 9 January 1, 2007 F ASC Group 9 January 1, 2007 F ASC Group 5 January 1, 2007 F ASC Group 5 January 1, 2007 November/December Texas Medicaid Bulletin, No. 219

16 Procedure Code New Reimbursement Rate Effective Date Ambulatory Surgical Center Services F ASC Group 9 January 1, 2007 F ASC Group 5 January 1, 2007 F ASC Group 4 January 1, 2007 New Rates for ASC, DME, and Surgical Services 2008 HCPCS Codes Texas Medicaid reimbursement rates for ambulatory surgical center (ASC) services and durable medical equipment were adopted following a public hearing on July 29, Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. The following rates were adopted: Procedure Code New Reimbursement Rate Effective Date Ambulatory Surgical Center Services F ASC Group 3 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 2 January 1, 2008 F ASC Group 2 January 1, 2008 F ASC Group 2 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 5 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 1 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 F ASC Group 9 January 1, 2008 Texas Medicaid Bulletin, No November/December 2008

17 Procedure Code New Reimbursement Rate Effective Date F ASC Group 1 January 1, 2008 F ASC Group 2 January 1, 2008 Durable Medical Equipment J E0328 $4, January 1, 2008 L E0328 $ January 1, 2008 J E0329 $7, January 1, 2008 L E0329 $ January 1, 2008 Surgical Services $ January 1, $ January 1, $ January 1, $ January 1, $ January 1, $ January 1, 2008 Rates Assigned After August 18, 2008, Rate Hearing The following Texas Medicaid reimbursement rates were adopted following a public hearing on August 18, 2008: Procedure Code New Reimbursement Rate Effective Date ENT Surgery Services $ September 1, 2008 (4.74 RVUs, $ conversion factor; clients birth through 20 years) $ September 1, 2008 (4.74 RVUs, $ conversion factor clients 21 years and older) $ (clients birth through 20 years) September 1, $ (clients 21 years and older) September 1, 2008 Gynecological and Reproductive Health Services $ (facility) September 1, $ (non facility) September 1, E1399 $ (not otherwise specified with modifier UD) September 1, 2008 DME Associated with Cochlear Implant Device J L8614 $23, September 1, L8614 $23, September 1, 2008 Breast Brachytherapy Medical Services in the office setting $2, September 1, 2008 Cesarean Delivery Only Services $ (24.18 RVUs, $ conversion factor) September 1, $ (3.87 RVUs, $ conversion factor) September 1, 2008 For questions, call the TMHP Contact Center at November/December Texas Medicaid Bulletin, No. 219

18 Benefit Criteria for Anesthesia Services Have Changed Effective for dates of service on or after September 1, 2008, benefit criteria for anesthesia has changed for Texas Medicaid. Anesthesia is a benefit of Texas Medicaid and is payable to anesthesiologists and CRNAs. Anesthesia must be administered by an anesthesia practitioner. An anesthesia practitioner is defined as: An anesthesiologist. A CRNA. A qualified professional as identified by the Texas Medical Board (TMB), performing delegated services. Anesthesia services See also: provided in combination with most medical Reimbursement Rates surgical procedures Adopted Following do not require prior Public Hearings authorization; however, (beginning on page 10) some medical surgical procedures may for a list of anesthesia require prior authorization. Anesthesia may services that have recently been assigned be reimbursed if prior authorization for the reimbursement rates. surgical procedure was not obtained, but services provided by the facility, surgeon, and assistant surgeon will be denied. For time based anesthesia procedure codes, anesthesia practitioners must document interruptions in anesthesia time in the client s medical record. Anesthesia time begins when the anesthesia practitioner begins to prepare the client for the induction of anesthesia in the operating room, or the equivalent area, and ends when the anesthesia practitioner is no longer in personal attendance (i.e., when the client may be safely placed under postoperative supervision). The documented time must be the same in the records or claims of the anesthesiologist and other anesthesia practitioners who were medically directed by the anesthesiologist. One time unit is equal to 15 minutes of anesthesia. Providers must submit the total anesthesia time in minutes on the claim. The claims administrator will convert total minutes to time units. To be reimbursed, providers of anesthesia services must include the following on submitted claims: Appropriate anesthesia procedure codes Correct modifier combination Exact amount of face to face time with the client Procedure codes , , , and are not payable alone, but are payable when combined with the anesthesia service. Documentation supporting the medical necessity for use of the procedure codes must be available to state agencies upon request and is subject to retrospective review. Medical Direction Personal medical direction by an anesthesiologist of an anesthesia practitioner is a benefit of Texas Medicaid if the following criteria are met: No more than four anesthesia procedures are being performed concurrently. Exception: Anesthesiologists may medically direct more than four anesthesia services or simultaneously supervise more than a combination of four CRNAs or other qualified professionals, as defined by the TMB, under emergency circumstances only. The anesthesiologist is physically present in the operating suite. Medical direction is a benefit of Texas Medicaid if the following criteria are met: The anesthesiologist performs a pre anesthetic examination and evaluation. The anesthesiologist prescribes the anesthesia plan. The anesthesiologist personally participates in the critical portions of the anesthesia plan, including if applicable, induction and emergence. The anesthesiologist ensures that a qualified professional can perform the procedures in the anesthesia plan that the anesthesiologist does not perform personally. The anesthesiologist monitors the course of anesthesia administration at frequent intervals. The anesthesiologist remains physically present and available for immediate diagnosis and treatment of emergencies. Texas Medicaid Bulletin, No November/December 2008

19 The anesthesiologist provides postanesthesia care. The anesthesiologist does not perform any other services (except as noted below) during the same time period. The anesthesiologist directing the administration of no more than four anesthesia procedures may provide the following without affecting the eligibility of the medical direction services: Address an emergency of short duration in the immediate area Administer an epidural or caudal anesthetic to ease labor pain Provide periodic, rather than continuous, monitoring of an obstetrical patient Receive clients entering the operating suite for the next surgery Check or discharge clients in the recovery room Handle scheduling matters As noted above, an anesthesiologist may medically direct up to four anesthesia procedures concurrently. Concurrency is defined as the maximum number of procedures that the anesthesiologist is medically directing within the context of a single procedure and whether those other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicaid client. For example, if three procedures are medically directed but only two involve Medicaid clients, the Medicaid claims should be billed as concurrent medical direction of three procedures. The following information must be available to state agencies upon request and is subject to retrospective review: The name of each CRNA and other qualified professional that is concurrently medically directed or supervised and a description of the procedure that was performed must be documented and maintained on file. Signatures of the anesthesiologist, CRNAs, or other qualified professionals involved in administering anesthesia services must be documented in the client s medical record. Monitored Anesthesia Care Monitored anesthesia care may include any of the following: an anesthesiologist. Monitoring of the client s vital physiological signs in anticipation of the need for general anesthesia. Monitoring of the client s development of an adverse physiological reaction to a surgical procedure. Anesthesia Modifiers Each anesthesia procedure code must be submitted with the appropriate anesthesia modifier combination whether billing as the sole provider or for the medical direction of CRNAs or other qualified professionals. When an anesthesia service is billed without the appropriate reimbursement modifiers, or is billed with modifier combinations other than those listed in this article, the claim will be denied. A procedure billed with a modifier indicating that the anesthesia was personally performed by an anesthesiologist (modifier AA) will be denied if another claim has been paid indicating the service was personally performed by, and paid to, a CRNA (modifier QZ) for the same client, date of service, and procedure code. The opposite is also true anesthesia personally performed by a CRNA will be denied if a previous claim indicates the service was personally performed by, and paid to, an anesthesiologist for the same client, date of service, and procedure code. Denied claims may be appealed with supporting documentation of any unusual circumstances. State Defined Modifiers Modifiers U1 (indicating one Medicaid claim) and U2 (indicating two Medicaid claims) are state defined modifiers that must be billed by an anesthesiologist or CRNA. Modifier U1, indicating that only one Medicaid claim will be submitted, cannot be billed by two providers for the same procedure, client, and date of service. Modifier U2, indicating that two Medicaid claims will be submitted, can only be billed by two providers for the same procedure, client, and date of service if one of the providers was medically directed by the other. Denied claims may be appealed with supporting documentation of any unusual circumstances. Anesthesia providers must submit the U1 or U2 modifier with an appropriate pricing modifier when billing for anesthesia procedure codes. Intraoperative monitoring by an anesthesiologist or qualified professional under the medical direction of November/December Texas Medicaid Bulletin, No. 219

20 Anesthesiologist Services Modifiers AA and U1 must be submitted when an anesthesiologist has personally performed the anesthesia service. Anesthesiologists may be reimbursed for medical direction of anesthesia practitioners by using one of the following modifier combinations: Modifier Combination Submitted by Anesthesiologist When is it used? Who will submit claims? Anesthesiologist Directing Non CRNA Qualified Professionals QY and U1 When directing one procedure provided Only the anesthesiologist by a non CRNA qualified professional QK and U1 When directing two, three, or four concurrent procedures provided by non CRNA qualified professionals Only the anesthesiologist AD and U1 (emergency circumstances only) QY and U2 QK and U2 AD and U2 (emergency circumstances only) When directing five or more concurrent procedures provided by non CRNA qualified professionals. Used in emergency circumstances only and limited to six units (90 minutes) per case for each occurrence requiring five or more concurrent procedures Anesthesiologist Directing CRNAs When directing one procedure provided by a CRNA When directing two, three, or four concurrent procedures involving CRNA(s) When directing five or more concurrent procedures involving CRNA(s). Used in emergency circumstances only and limited to six units (90 minutes) per case for each occurrence requiring five or more concurrent procedures Only the anesthesiologist Both the anesthesiologist and CRNA Both the anesthesiologist and CRNA Both the anesthesiologist and CRNA CRNA Services Modifiers QZ and U1 must be submitted when a CRNA has personally performed the anesthesia services, is not medically directed by the anesthesiologist, and is directed by the surgeon. Modifiers QX and U2 must be submitted by a CRNA who provided services under the medical direction of an anesthesiologist. Monitored Anesthesia Care Anesthesiologists and CRNAs may use modifier QS to report monitored anesthesia care. The QS modifier is an informational modifier, and must be billed with any combination of pricing modifiers for reimbursement. Dental General Anesthesia Modifier EP must be used to indicate that the anesthesia was performed with dental services. Supporting documentation for the use of general anesthesia (procedure code ) with the EP modifier, while rendering treatment (to include the dental service fee, the anesthesia fee, and the facility fee) must be retained in the client s medical record regardless of prior authorization, and must reflect compliance with the Criteria for Dental Therapy Under General Anesthesia form (22 point threshold) and the Criteria for Dental Therapy Under General Anesthesia, Attachment 1 form. Texas Medicaid Bulletin, No November/December 2008

21 For clients who do not meet the requirements of the Criteria for Dental Therapy Under General Anesthesia form (22 point threshold) and the Criteria for Dental Therapy Under General Anesthesia, Attachment 1 form, prior authorization is required for the use of general anesthesia (procedure code ) with the EP modifier, while rendering treatment (to include the dental service fee, the anesthesia fee, and the facility fee), regardless of place of service. Supporting documentation, including the appropriate narrative, must be submitted to TMHP for prior authorization. In those areas of the state with Medicaid Managed Care, precertification or approval is required from the client s health maintenance organization (HMO) for anesthesia and facility charges. It is the dental provider s responsibility to obtain precertification from the client s HMO or managed care plan for facility and general anesthesia services. A random, statistically valid, retrospective review of one to two percent of all anesthesiologist s dental records will be conducted to determine if documentation and compliance with all Texas Medicaid policies are reflected in the provider s records. The completed Criteria for Dental Therapy Under General Anesthesia form, the appropriate narrative, and all supporting documentation must be included in the client s dental record. The client s dental record must be available for review by representatives of DSHS or its designee and/or the Health and Human Services Commission (HHSC) or its designee. The dental provider is required to maintain the following documentation in the client s dental record: The medical evaluation justifying the need for anesthesia. Description of relevant behavior and reference scale. Other relevant narrative justifying the need for general anesthesia. Client s demographics, including date of birth. Relevant dental and medical history. Dental radiographs, intraoral/perioral photography, and/or diagram of dental pathology. Proposed Dental Plan of Care. Consent signed by parent/guardian giving permission for the proposed dental treatment and acknowledging that the reason for the use of IV sedation or general anesthesia for dental care has been explained. Dentist s attestation statement and signature, which is on the bottom of the Criteria for Dental Therapy Under General Anesthesia form, or included in the record as a stand alone form. Dental general anesthesia is limited to once every six months per client, per provider. Medically necessary services exceeding this limitation require prior authorization. Dental rehabilitation and restoration services requiring general anesthesia are performed in an outpatient facility. Hospital and outpatient facility admissions are subject to medical necessity review. Services will not be monitored for clients 20 years of age and younger. Reimbursement The anesthesiologist s reimbursement for medical direction of CRNAs and non CRNA qualified professionals is 100 percent of the maximum allowable fee. If multiple CRNAs or anesthesiologists are providing anesthesia services for a client, only one CRNA and one anesthesiologist may be reimbursed. Time Based Fees Reimbursement of time based anesthesia services is derived from the following steps: 1. Divide the total anesthesia time in minutes (the time of all procedures performed, directed, or supervised) by Add the RVUs for the procedure performed (use the procedure with the highest RVUs when multiple procedures are performed at the same time). 3. Multiply this sum by the appropriate conversion factor. The formula for this methodology is as follows: [(Minutes/15) + RVUs] x Conversion Factor = Anesthesia Reimbursement. November/December Texas Medicaid Bulletin, No. 219

22 Texas Medicaid Claims Reprocessing The following claims issues have been identified. All affected claims will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary. Aerosol Treatment Claims Reprocessing TMHP has identified an issue impacting claims submitted for revenue code B 412 with dates of service on or after February 1, 2007 and diagnosis codes 51911, 51919, or These claims may have been denied in error. Effective for dates of service on or after February 1, 2007, revenue code B 412 may be reimbursed with diagnosis codes 51911, 51919, or For the complete list of diagnosis codes that may be submitted with revenue code B 412, providers can refer to the 2008 Texas Medicaid Provider Procedures Manual, Section , Aerosol Treatment, on page Claims Submitted by Integrated Care Management Providers Claims submitted by Integrated Care Management (ICM) providers with dates of service on or after June 1, 2008, may have been denied in error, with the explanation of benefits (EOB) message: Services not provided or authorized by designated (network/primary care) providers. Cochlear Device Claims TMHP has identified an issue impacting claims submitted with dates of service from August 1, 2006, through August 1, 2008, and procedure code J L8614 with modifier NU. These claims may have been denied in error. Refer to the 2008 Texas Medicaid Provider Procedures Manual, Section , Cochlear Implants, on page Durable Medical Equipment TMHP has identified an issue impacting claims submitted with dates of service on or after April 1, 2006, and procedure code 9 A7520 with modifier TF or TG, and procedure code 9 A7521 with modifier TF or TG. These claims may have been denied in error. Magnetic Resonance Angiography (MRA) TMHP has identified an issue impacting claims submitted with dates of service on or after November 1, 2005, and procedure codes 4/I and 4/I in the office setting or T and T in the office, home, and nursing home settings. These claims may have been denied in error. Medicare HMO and PPO Co payments Effective January 1, 2008, TMHP no longer reimburses Medicare HMO and preferred provider organization (PPO) professional or outpatient co payments for clients enrolled in a Medicare Advantage Plan (MAP) Part C HMO. These co payments are not reimbursed by TMHP regardless of the MAP s contract status with HHSC. These co payments are included in the capitated rate paid to the HMO and must not be billed to TMHP or a Medicaid client. MAPs that are contracted with HHSC may reimburse these co payments directly to the provider for dually eligible clients. Effective for dates of service on or after January 1, 2008, TMHP will not reimburse procedure code 1 CP003, 1 CP004, 1 CP007, or 1 CP008. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Oral Hygiene Instruction Claims TMHP has identified an issue impacting claims that were submitted with procedure code D1330 for the same date of service and for the same client as procedure code D1203 or D1204. These claims may have been paid in error. Prior authorization is not required for procedure code D1330. Claims submitted with procedure code D1330 and no prior authorization may have been denied in error. Professional and Institutional Claims for Clients in an IMD Facility This is an update to a banner message that appeared on the May 5, 2008 Remittance and Status (R&S) Report about an issue with claims submitted for professional services rendered to clients while in an institute for mental disease (IMD) that is not a freestanding facility. TMHP has also identified an issue with institutional claims submitted by IMD providers that are not freestanding facilities and professional claims submitted during the client s IMD stay for dates of service on or after January 1, These claims may have been reimbursed incorrectly. Texas Medicaid Bulletin, No November/December 2008

23 Both the institutional and professional claims will be reprocessed, and payments will be adjusted accordingly. Affected claims will be reprocessed in two phases between May 27, 2008, and July 31, No action on the part of the provider is necessary. THSteps Claims Submitted by PCCM Providers TMHP has identified an issue affecting claims submitted by Primary Care Case Management (PCCM) providers with procedure code S and dates of service on or after September 1, These claims were incorrectly reimbursed at the rate of $70.00 instead of $ Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Services Provided by LCSWs, LMFTs, LPCs, and Psychologists Licensed clinical social workers (LCSWs), licensed marriage and family therapists (LMFTs), licensed professional counselors (LPCs), and psychologists must not bill for services provided by people under their supervision. These providers must only bill for services that they personally provide to Texas Medicaid clients and not for services provided by students, interns, or licensed professionals under their supervision. This information is stated in the 2008 Texas Medicaid Provider Procedures Manual, Sections 28.3 (LCSWs), 29.3 (LMFTs), 30.3 (LPCs), and 38.3 (psychologists). Scheduled System Maintenance System maintenance for the TMHP claims processing system is scheduled as follows: Sunday, November 2, 2008, 12:00 a.m. to 2:00 a.m. (yearly daylight savings time change) Sunday, November 9, 2008, 6:00 p.m. to 11:59 p.m. Sunday, December 14, 2008, 6:00 p.m. to 11:59 p.m. During system maintenance, some applications related to the claims engine will be unavailable. Specific details about the affected applications are posted on the TMHP website at Updates to Previously Published Information Procedure Codes and Do Not Require Modifier 26 This is a correction to a banner message that first appeared on the August 31, 2007, R&S Report about procedure codes and The banner message was incorrectly addressed to CSHCN Services Program providers only. The banner message also applies to Texas Medicaid providers. The banner message incorrectly stated that effective August 15, 2007, claims submitted with procedure codes or for the professional component no longer require modifier 26 for billing. Claims submitted with procedure code and modifier 26 or procedure code and modifier 26 may result in incorrect claims processing. The following is the complete, corrected banner message: Claims submitted with procedure code and modifier 26 or procedure code and modifier 26 may result in incorrect claims processing. Providers should no longer bill modifier 26 for these services. Also effective November 1, 2007, procedure codes I and I are no longer benefits of Texas Medicaid when provided by RNs or CNMs. Correction to Benefit Changes for Electromyography and Nerve Conduction Studies This is a correction to an article published in the July/ August 2008 Texas Medicaid Bulletin, No. 216, titled, Benefit Changes for Electromyography and Nerve Conduction Studies. The article incorrectly stated that procedure codes 5/I/T and I/T are denied if submitted with procedure code 5/I/T by the same provider with the same date of service. The total component (type of service 5) was incorrectly left out of this limitation for procedure code The correct information is as follows: Procedure codes 5/I/T and 5/I/T are denied if submitted with procedure code 5/I/T by the same provider with the same date of service. Tetanus Immune Globulin Benefit Changes This is an update to a banner message that appeared on the February 29, 2008, R&S Report regarding the implementation of the tetanus immune globulin benefit. Effective for dates of service on or after August 1, 2008, November/December Texas Medicaid Bulletin, No. 219

24 tetanus immune globulin, procedure code 1 J1670, is no longer diagnosis code restricted for Texas Medicaid. Correction to Eye Surgery by Incision This is a correction to the 2008 Texas Medicaid Provider Procedures Manual, Section , Eye Surgery by Incision, on page The manual incorrectly includes diagnosis codes 36203, 36204, 36205, 36206, and as payable for procedure codes 2/F and 2/ Effective October 1, 2005, procedure codes 2/F and 2/F are no longer payable for diagnosis codes 36203, 36204, 36205, 36206, and Claims that were submitted with these procedure codes and dates of service from October 1, 2005, through April 22, 2008, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Refer to the 2008 Texas Medicaid Provider Procedures Manual, Section , Eye Surgery by Incision, on page for a list of diagnosis codes that may be submitted for these procedure codes. Update to Rate Changes Following Public Hearing on June 17, 2008 This is an update to an article that was posted on the TMHP website at entitled, Rate Changes following Public Hearing on June 17, The Texas Medicaid reimbursement rates below were assigned following a public hearing on June 17, 2008: Procedure Code New Reimbursement Rate Effective Date Osteogenic stimulation J E0747 $3, July 1, 2008 J E0748 $3, July 1, 2008 J E0760 $3, July 1, $37.80 July 1, E0749 $2, July 1, 2008 Home Health Benefits to Change for Nutritional Products, Supplies, and Equipment This is an update to an article published in the July/ August 2008 Texas Medicaid Bulletin, No. 216 titled Home Health Benefits to Change for Nutritional Products, Supplies, and Equipment. The article stated that procedure code 9 B4035 is limited to one per day. Effective August 1, 2008, for dates of service on or after June 1, 2008, procedure code 9 B4035 is limited to a maximum of 31 per month by any provider. Providers may not bill a quantity greater than the number of days in the month for which they are submitting a claim. Claims with a quantity greater than the number of days in that month may be subject to recoupment. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Correction to Changes to Accounts Receivable Bulletin Article This is a correction to an article published in the September/October 2008 Texas Medicaid Bulletin, No. 218 titled Changes to Accounts Receivable. The language throughout the article has been revised for clarity. Effective August 29, 2008, TMHP will implement changes to the accounts receivable process. The TMHP accounts receivable process identifies money that a provider owes to TMHP and subtracts this money from payments to the provider. Previously, TMHP processed accounts receivable separately for providers Texas Medicaid fee for service and managed care program payments. Effective August 29, 2008, TMHP recoups money from all payments until the accounts receivable have been recovered. TMHP recoups money from providers PCCM case management fee payment first and then from other available fee for service and managed care payments. The 1099, Remittance and Status (R&S), and Electronic Remittance and Status (ER&S) reports have also changed. The following examples show how accounts receivable are processed: Outstanding fee for service accounts receivable: TMHP first recovers money from any available PCCM case management fee payments. If there is still an accounts receivable balance for that week s financial cycle, TMHP will recover funds from any available fee for service payments. If there is still an accounts receivable balance for that week s financial cycle, TMHP will recover funds from any available managed care payments. Outstanding managed care accounts receivable: - TMHP first recovers money from any available PCCM case management fee payments. Texas Medicaid Bulletin, No November/December 2008

25 - - If there is still an accounts receivable balance for that week s financial cycle, TMHP will recover funds from any available managed care payments. If there is still an accounts receivable balance for that week s financial cycle, TMHP will recover funds from any available fee for service payments Reports This process change will affect the 2008, 1099 report. Previously, providers received separate 1099 reports for fee for service and managed care payments. Beginning with the report, providers will receive only one 1099 report for each provider identifier. The revised 1099 report will combine information from both programs. Paper R&S Report The summary page of the R&S Report combines information from the fee for service and managed care programs. The Financial Transactions Sub Owner Recoupment page includes the accounts receivable for both programs. A new column has been added to the page to identify the program (Medicaid [fee for service] or Managed Care) from which the money was recouped. The Financial Transactions Accounts Receivable page includes the accounts receivable for both programs. A new column has been added to the page to identify the program (Medicaid [fee for service] or Managed Care) from which the money was recouped. The Original Date in the Accounts Receivable section of the R&S Report has changed to reflect the date on which the accounts receivable first appeared on the R&S Report. ER&S Report The pending and non pending ER&S Reports combine information for both programs. Providers no longer see separate entries for each of the programs. Update to Medicaid Tamper Resistant Prescriptions Pads This is an update to an article that was published in the March/April 2008 Texas Medicaid Bulletin, No. 214, entitled Tamper Resistant Prescription Pads Required Soon. The Centers for Medicare & Medicaid Services (CMS) has stated that special copy resistant paper is not a requirement for EMRs or eprescribing generated prescriptions. These prescriptions may be printed on plain paper and will be fully compliant if they contain at least one feature from each of the following three categories: Prevents unauthorized copying of completed or blank prescription forms. Prevents erasure or modification of information written on the prescription form. Prevents the use of counterfeit prescription forms. For specifics about these categories and more information, visit the Texas Medicaid/CHIP Vendor Drug Program website at tamper_resistant_rx.html or call the TMHP Contact Center at Outpatient Behavioral Health Diagnosis Code Corrections This is a correction to an article published in the January/February 2008 Texas Medicaid Bulletin, No. 212, titled, Outpatient Behavioral Health Diagnosis Code Corrections. The article informed providers of a claims reprocessing effort that was to take place that would impact claims submitted with dates of service on or after January 1, 2006, through September 28, 2007, and diagnosis codes and billed with any of the following procedure codes: Procedure Codes Affected claims have been reprocessed; however, they may have been denied in error. Effective April 1, 2005, the procedure codes identified above are payable with diagnosis codes and Claims submitted between April 1, 2005, and August 6, 2008, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. The following table lists all of the valid diagnosis codes for procedure codes , , , , , , , , , November/December Texas Medicaid Bulletin, No. 219

26 , , , , , , , , , , and (unless otherwise indicated): Diagnosis Codes * 30011* 30012* 30013* 30014* 30015* 30016* 30019* 30020* 30021* 30022* 30023* 30029* 3003* 3004* 3005* 3006* 3007* 30081* 30082* 30089* 3009* * Not payable for procedure code Texas Medicaid Bulletin, No November/December 2008

27 Diagnosis Codes * 99551* 99552* 99553* 99554* 99555* 99559* 99580* 99581* 99582* 99583* 99584* 99585* V110* V111* V112* V113* V118* V119* V170* V400* V401* V402* V403* V409* V6121* V6281* V6282* V6283* V6284* V6289* V7101* V7102* V7109* V790* V791* V792* V793* V798* V799* * Not payable for procedure code In addition to the diagnosis codes listed above, procedure code is also payable for the following diagnosis codes: Diagnosis Codes Correction to NPI Claims Reminder Bulletin Article This is a correction to an article that was published in the September/October 2008 Texas Medicaid Bulletin, No. 218 entitled National Provider Identifier Update. Under the NPI Claims Reminder subheading, the article incorrectly states that providers must enter a physical address in Block 24J of the CMS 1500 claim form. Field 24J must contain only the rendering provider s National Provider Identifier (NPI). In addition, the article incorrectly indicated 32a b instead of 33a b under the instructions for Block 33 of the CMS 1500 claim form, and 23a b instead of 32Ha b under the instructions for Block 32H of the Family Planning 2017 claim form. The article did not indicate when to submit a Texas Provider Identifier (TPI) on the CMS 1500 and ADA Dental Claim Form. All electronic and paper claims must contain the provider identifier(s), name, physical address, city, state, ZIP+4 Code, and telephone number of the billing provider in the appropriate billing provider fields. The billing provider s address must be the same address that was provided during attestation. The facility provider information fields must be completed if services were provided in a place other than the patient s home or the billing provider s facility. The facility provider information fields must contain the name, physical street address, ZIP+4 Code, and NPI of the facility where the service was provided. November/December Texas Medicaid Bulletin, No. 219

28 The following tables identify the paper or electronic fields that indicate the billing or services facility information: CMS 1500 (Professional) Paper Claim Form Block No. Guidelines 17, 17a-b Enter the referring provider s name and NPI. 24J Enter the rendering provider identifiers (NPI and TPI). 32, 32a b Required if services were provided in a place other than the patient s home or the billing provider s facility. Enter the name, physical address, ZIP+4 Code, and the NPI of the facility where the service was provided. 33, 33a b Enter the billing provider s NPI, TPI and physical address provided during attestation, including the ZIP+4 Code. Family Planning 2017 Paper Claim Form Block No. 2a b 32Ha b Guidelines Enter the billing provider s TPI and NPI. Members of a group practice (except pathology and renal dialysis groups) must identify the NPI and the TPI of the doctor or clinic within the group who performed the service. 38, 38a b Required if services were provided in a place other than the patient s home or the billing provider s facility. Enter the name, physical address, ZIP+4 Code, and the NPI of the facility where the service was provided. 39 Enter the billing provider name, physical street address, city, state, ZIP+4 Code, and telephone number. Professional (See 837P Acute Care Companion Guide V4.2) Location 2010AA Loop 2310B Loop 2310D Loop Guidelines 2006 ADA Dental Paper Claim Form Block No. Enter the billing provider s information, including the physical address provided during attestation, with the ZIP+4 Code. Note: ZIP+4 Code in the LU Ref Segment is optional. If group taxonomy, ZIP+4 Code is also optional. Members of a group practice (except pathology and renal dialysis groups) must identify the information of the doctor or clinic within the group who performed the service. If services were provided in a place other than the patient s home or the billing provider s facility, enter the information for the facility where the service was provided. Guidelines 48 Enter the name and physical address of the billing group or individual provider (not the name and address of a provider employed within a group). 49 Enter the billing dentist s NPI for a group or individual provider (not the NPI of a provider employed within a group). 52A Enter the TPI for the billing provider. 54 Enter the NPI of the performing dentist(s) (provider who treated the client). 58 Enter the TPI of the performing dentist(s) (provider who treated the client). Texas Medicaid Bulletin, No November/December 2008

29 Electronic Dental Claim (837D Acute Care Companion Guide V4.2) Location 2010AA loop 2310B loop 2310C loop Guidelines Enter the billing group or individual provider information (not the name and address of a provider employed within a group). Note: If entering a group provider number, the taxonomy code is optional. Enter the performing dentist s information (provider who treated the client). Enter the service facility information. Note: If entering a group provider number, the taxonomy code is optional. CMS 1450 UB 04 Institutional Paper Claim Form Block No. Guidelines 1 Enter the hospital s address provided during attestation. 56 Enter the NPI of the billing provider. 57 Enter the TPI of the billing provider. 76 Enter the attending provider s name (last name and first name) and NPI. 77 Enter operating provider s name (last name and first name) and NPI Other provider s name (last name and first name) and NPI. Other operating physician An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved. Rendering provider The health care professional who performed, delivered, or completed a particular medical service or nonsurgical procedure. Institutional (837I Acute Care Companion Guide V4.2) Block No. 2010AA 2310A 2310B 2310C Guidelines Enter the billing provider s information including the physical address provided during attestation, with the ZIP+4 Code. Enter the attending provider s information. Situational Enter operating provider s information. Situational Enter the other provider s information. Other operating physician An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved. Rendering provider The health care professional who performed, delivered, or completed a particular medical service or nonsurgical procedure. For questions, call the TMHP Contact Center at November/December Texas Medicaid Bulletin, No. 219

30 Updated Tips for Expediting Paper Claims This is an update to the 2008 Texas Medicaid Provider Procedure Manual, section , Quick Tips on Expediting Paper Claims on page 5 6. The Do and Don t tables have been revised to indicate that providers should use 10 pitch (12 point) Courier font on their paper claims. The revised table follows: Quick Tips for Expediting Paper Claims Do Use original claim forms. Use black ink (not a black marker). Print claim data within defined boxes on the claim form. Use all capital letters. Use a laser printer for best results. Use paper clips on claims or appeals if they include attachments. Detach claims at perforated lines before mailing. Use 10x13 inch envelopes to mail claims. Use the HHSC approved Medicare Remittance Advice Notice, or an MRAN printed from Medicare Remit Easy Print (MREP) (professional services) or PC Print (institutional services) when sending the Remittance Advice from Medicare. Ensure all MRANs and R&Ss are accompanied by a claim form. Place the claim form on top when sending new claims, followed by any medical records or attachments. Number the pages appropriately when sending attachments, (e.g., 1 of 2, 2 of 2). Indicate continuation when submitting multiple claims for the same client. Print using 10 pitch (12 point) Courier font. Don t Don t use copies of claim forms. Don t use red ink or highlighters. Don t use dashes or slashed in date fields. Don t use fonts smaller than 12 points. Don t use a dot matrix printer, if possible. Don t use labels, stickers, or stamps. Don t use glue, tape, or staples. Don t fold claim forms, appeals, or correspondence. Don t send duplicate copies of information. Don t use paper smaller or larger than 8 ½ x 11. Scan equipment will accept 8 ½ x 11 paper. Don t mail claims with correspondence for other departments, this may delay claims processing. Don t total each claim form when the claim is a continuation of multiple claims for the same client. Don t use proportional fonts, such as Arial or Times Roman. Help the children in your community who need it most. Enroll in the Children with Special Health Care Needs (CSHCN) Services Program today. Go to to learn more about the Program, then visit the TMHP website at to enroll. Texas Medicaid Bulletin, No November/December 2008

31 Claims Submission for Inpatient Hospital Clients Providers must submit claims to the correct health care plan for clients who are inpatients. Inpatient facilities must submit claims to the plan in which the client was enrolled on the date of admission, even if the client changes health care plans during the inpatient stay. All other provider types must submit claims to the health care plan in which the client was enrolled on the date of service. Client transfers within the same facility or readmissions to the same facility within 24 hours of a previous acute care hospital or facility discharge are considered one continuous stay. The readmissions are considered a continuous stay, even if the provider submits a readmission diagnosis code. Partial SDA Rebase for DRG Inpatient Hospital Providers HHSC will partially rebase the standard dollar amounts (SDAs) for all Texas inpatient hospital providers that are reimbursed using the diagnosis related group (DRG) methodology. This rebasing is limited to a sum certain appropriation made by the Texas Legislature. Letters containing the preliminary SDAs were mailed at the end of August. The new SDAs are effective for admission dates on or after September 1, The letters were mailed to the attention of the Administrator or Chief Financial Officer at the mailing address on file. Prior Authorization Request Changes for Breast and Colorectal Cancer Screening Effective October 1, 2008, the prior authorization criteria have changed for the following procedure codes: Procedure Codes 5 S S S S S S S S S3834 Requests for retrospective authorization for these procedure codes must be submitted no later than seven calendar days from the day after the draw is completed. False Claim Employee Education Attestation Letters Mailed to Providers in Early 2008 Effective January 1, 2007, all providers and other entities that receive or make annual Texas Medicaid payments of $5 million or more must educate employees, contractors, and agents about federal and state fraud and false claims laws and the whistleblower protections available under those laws. The Federal Deficit Reduction Act of 2005, Section 6032, Employee Education About False Claims Recovery, requires any entity that receives or makes annual payments under the State Plan of at least $5 million to: Establish written policies, procedures, and protocols for the education of all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the federal False Claims Act, federal administrative remedies for false claims and statements, any state laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws. Include in the written policies detailed provisions and education regarding the entity s policies and procedures for detecting and preventing fraud, waste, and abuse. Include in any employee handbook for the entity a specific discussion of such laws, the rights of employees to be protected as whistleblowers, and the entity s policies and procedures for detecting and preventing fraud, waste, and abuse. Letters and attestations were previously mailed to entities meeting criteria in early Providers who have failed to return signed attestations will be contacted by TMHP to ensure compliance with the Deficit Reduction Act. Providers will be required to return a signed attestation to TMHP. Providers who fail to return a signed attestation may be subject to vendor hold on provider payments until a signed attestation is received by TMHP. November/December Texas Medicaid Bulletin, No. 219

32 Revised Texas Medicaid Fee Schedules Beginning August 15, 2008, the following revised Texas Medicaid Fee Schedules are available on the TMHP website at Texas Medicaid Fee Schedule PRC401c (advanced practice nurse [nurse practitioner and clinical nurse specialist] and physician assistant) Texas Medicaid Fee Schedule PRD402c (physician) Texas Medicaid Fee Schedule PRD412c (physician/pathologist) Texas Medicaid Fee Schedule PRD413c (physician/ radiologist). The fee schedules can be downloaded as Adobe portable document format (PDF) files (paper replica). Providers can request a free paper copy of a fee schedule by calling the TMHP Contact Center at Fee Schedule Retrieval Improvements The Health and Human Services Commission (HHSC) and TMHP will launch an enhanced method of fee schedule retrieval which will allow providers to link directly to applicable fee schedules based on Provider NPI and related data. Providers will be informed in a future provider notification when the new fee schedules will become available. The Texas Medicaid Fee Schedules are currently posted to the TMHP website at for most provider types. Providers are able to download the fee schedules as Adobe portable document format (PDF) files (paper replica), and excel format. Reminder for FQHC Providers Federally Qualified Health Centers (FQHCs) are paid an all inclusive rate per visit for certain services. All other services are processed as informational. Some services require modifiers to be processed appropriately. The following services may be reimbursed to FQHC providers using their National Provider Identifier (NPI): FQHC Procedure Codes 1 T1015 General Medical Services General medical services must be billed using one of the appropriate modifiers AH, AJ, AM, SA, TD, TE, TH, or U7. THSteps Medical Services S S S S S S S S S THSteps medical services must be billed using modifier EP and one of the following modifiers AM, SA, TD, or U7. 1 G9012 Case Management Comprehensive visit must be billed using modifiers U2 and U5. Follow up face to face visit must be billed using modifiers TS and U5. Follow up telephone visit must be billed using modifier TS. Family Planning Services * * 1 J J7302 * Family planning services must be billed using modifier FP. Vision Care Services /I/T /I/T S S0621 Texas Medicaid Bulletin, No November/December 2008

33 FQHC Procedure Codes Mental Health Services * * * * * * * * * * * * * Procedures cannot be performed by a psychologist. Co payments 1 CP001 1 CP005 1 CP006 THSteps Dental Services D0120 D0140 D0145 D0150 D0160 D0170 D0180 D0330 D0340 D0350 D0470 D1110 D1120 D1203 D1204 D1206 D1351 D1510 D1515 D1520 D1525 D1555 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2750 D2751 D2791 D2792 D2930 D2931 D2932 D2933 D2934 D2940 D2950 D2954 D3220 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3351 D3352 D3353 D4341 D4355 D5211 D5212 D5281 D5610 D5630 D5640 D5650 D5660 D5670 D5671 D5720 D5721 D5740 D5741 D5760 D5761 D7140 D7210 D7220 D7230 D7250 D7270 D7286 D7510 D7550 D7910 D7970 D7971 D7997 D7999 D8050 D8060 D8080 D8210 D8220 D8660 D8670 D8680 D8690 D9110 D9211 D9212 D9215 D9230 D9248 D9930 D9974 D9999 All removable or fixed special orthodontic appliances and comprehensive orthodontic treatment must be billed using procedure code D8210, D8220, or D8080 in addition to the diagnostic procedure code (DPC) remarks code (local code) to specify the specific service performed. The following table identifies the appropriate DPC remark codes to use when billing for removable or fixed special orthodontic appliances and comprehensive orthodontic treatment: DPC Remark Codes Remark Codes for Procedure Code D8210 DPC1004D DPC1005D DPC1006D DPC1007D DPC1010D DPC1011D DPC1013D DPC1014D DPC1017D DPC1022D DPC1023D DPC1024D DPC1027D DPC1032D DPC1037D DPC1038D DPC1039D DPC1040D DPC1041D DPC1046D DPC1047D DPC1048D DPC1053D DPC1054D DPC1055D DPC1056D DPC1058D DPC1062D DPC1063D DPC1064D DPC1065D DPC1066D DPC1067D DPC1069D DPC1070D DPC1071D DPC1073D DPC1074D DPC1075D Remark Codes for Procedure Code D8220 DPC1008D DPC1012D DPC1015D DPC1016D DPC1018D DPC1019D DPC1020D DPC1021D DPC1025D DPC1026D DPC1028D DPC1029D DPC1030D DPC1031D DPC1036D DPC1042D DPC1043D DPC1044D DPC1045D DPC1049D DPC1050D DPC1051D DPC1052D DPC1057D DPC1059D DPC1060D DPC1061D DPC1068D DPC1072D DPC1076D DPC1077D DPC1078D Remark Codes for Procedure Code D8080 DPCZ2009 DPCZ2011 DPCZ2012 For questions, call the TMHP Contact Center at November/December Texas Medicaid Bulletin, No. 219

34 / Family Planning Providers Reminder for Rural Health Clinic Providers Rural health clinic (RHC) providers are paid an all inclusive rate for certain services. All other services are processed as informational. RHC providers may be reimbursed for the services listed in the table below. General services are billed using the RHC s NPI. For all other services, providers must bill using their NPI and benefit code. Providers must use place of service 72 when billing for services on a CMS 1500 claim form. RHC Procedure Codes General Medical Services for Freestanding and Hospital Based 1 T1015 General medical services must be billed using modifiers AJ, AM, SA, TD, TE, TH, or U7. THSteps Medical Service S S S S S S S S S S THSteps medical services must be billed using modifiers AM, SA, TD, or U7. Family Planning Services J7300 Family planning services must be billed using modifier FP. Co payments 1 CP001 1 CP002 1 CP005 1 CP006 For questions, call the TMHP Contact Center at Need Help? TMHP Contact Center Representatives are available from 7:00 a.m. to 7:00 p.m., Central Time, Monday through Friday. The Contact Center is your resource for general Medicaid Program information, requests for billing labels, enrollment queries, and filing procedure issues. Call to speak to a Contact Center Representative. Family Planning Providers Limitation for Family Planning Contraceptives Effective October 1, 2008, Family Planning and Women s Health Program (WHP) providers may dispense up to a one year supply of contraceptives in a 12 month period when billing with procedure codes 1 J7303, 1 J7304, or 1 S4993. Providers must include the appropriate family planning diagnosis code. Gynecological and Reproductive Health Services Benefit Effective for dates of service on or after September 1, 2008, the Essure device (procedure code 9 E1399) is a benefit of Texas Medicaid Title XIX family planning providers when submitted with modifier UD by the following provider types in the following settings: Physician or physician groups in the office setting. Freestanding independent ambulatory surgical centers or hospital based ambulatory surgical centers in the outpatient hospital setting. Procedure code E1399 may be considered for reimbursement for females 10 through 55 years of age. Contraceptive Device Now Payable to FQHCs and RHCs Effective September 1, 2008, procedure code 1 J7302 is payable as an encounter to Federal Qualified Health Centers (FQHCs) and in the rural health clinic (RHC) setting. Procedure code 1 J7302 is a family planning service. FQHCs must bill procedure code 1 J7302 using their FQHC facility provider identifier. Providers rendering this service in the RHC setting must bill procedure code 1 J7302 with place of service 72 and must use the provider identifier of the physician or practitioner who performed the service. RHCs must not bill procedure code 1 J7302 using the RHC facility provider identifier. See also: Reminder for FQHC Providers on page 32 and Reminder for Rural Health Clinic Providers on this page for important policy updates. Texas Medicaid Bulletin, No November/December 2008

35 Managed Care Providers Help Available for PCCM Providers with Clients Who Frequently Miss Appointments Primary Care Case Management (PCCM) providers can take advantage of a free Community Health Services program for clients who frequently miss appointments. The program educates clients about the importance of keeping their appointments, helps clients schedule transportation to medical appointments, and provides other care coordination services. Community Health Services coordinators are located in PCCM counties throughout the state and can direct clients to local services. Providers can also refer clients to Community Health Services for medical education about diagnoses and health related issues. Providers can schedule a community health education program to be held in their office, or they can refer a PCCM client to Community Health Services by: Completing the Primary Care Case Management (PCCM) Community Health Services Referral Request Form and faxing it to Calling Community Health Services at , Monday through Friday, 8:00 a.m. to 5:00 p.m., Central Time. Providers can leave a message after hours, and the call will be returned the next business day. Community Health Services provides the following: Counseling for clients who miss appointments. Counseling for clients who inappropriately use the emergency room. Client education about obtaining PCCM services. Management of high risk pregnancies in conjunction with the client s physician. Pediatric care coordination and education services for acute and chronically ill children. Care coordination for clients with chronic and complex conditions. Assistance in accessing state and community resources. Assistance in improving healthy behaviors and treatment compliance. Assistance in obtaining food, clothing, and other resources from public and private community organizations. Health education on a variety of health related topics. The following topics can be referred for health care management: A newly diagnosed condition. Asthma management. Coronary artery disease. Chronic obstructive pulmonary disease. Dental health. Diabetes management. Effective use of benefits. Hypertension. Nutrition. Otitis media. Prenatal education. Parenting and child development. Puberty education. Safety. Smoking cessation. Refer to the Primary Care Case Management (PCCM) Community Health Services Referral Request Form on page 43 of this bulletin. No Referral or Prior Authorization Needed for PCCM Evacuees HHSC is suspending the requirement for a primary care referral for Medicaid clients who are in the PCCM delivery model and live in a hurricane evacuation area. HHSC is also suspending the prior authorization requirement for Medicaid clients who are in the PCCM delivery model and live in a hurricane evacuation area. However, the services delivered may still be subject to retrospective review for medical necessity. Claims submitted for these clients will initially deny but then will be processed with no additional effort from the provider. This process is applicable only for clients who live in ZIP codes under evacuation orders. November/December Texas Medicaid Bulletin, No. 219

36 Managed Care Providers STAR Health Mental Health Rehabilitation Claims Must Be Submitted to Integrated Mental Health Services STAR Health providers must submit their mental health rehabilitation claims for foster care clients to Integrated Mental Health Services (IMHS). Claims previously submitted to TMHP may have been reimbursed in error. Affected claims will be reprocessed, and adjusted accordingly. Once TMHP reprocess claims paid in error, the claims will be denied. Providers will need to resubmit the claims to IMHS for consideration of payment. IMHS administers mental and behavioral health claims for Superior HealthPlan foster care clients. The following mental health rehabilitation services must be submitted to IMHS: Procedure Code 1 G G0177 HK 1 H H0034 HK 1 H0034 HQ Modifier 1 H0034 HK and HQ 1 H0034 HA 1 H0034 HA and HR or UK 1 H0034 HA and HQ 1 H0034 HA and HQ and HR or UK 1 H H2011 HK 1 H2011 HA 1 H H2014 HQ 1 H2014 HA 1 H2014 HA and HR or UK 1 H H2017 HK 1 H2017 TD 1 H2017 HK and TD Procedure Code 1 H2017 HQ Modifier 1 H2017 HQ and HK 1 H2017 HQ and TD 1 H2017 HQ and HK and TD 1 H2017 ET 1 H2017 HK and ET The services listed above may be reimbursed when rendered to clients who satisfy the criteria of the mental health, priority population and who are determined to need inpatient rehabilitation. These services may be provided to a person with a single severe mental disorder (excluding mental retardation, pervasive developmental disorder, or substance use disorder) or a combination of severe mental disorders as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV TR). For prior authorization requests, call IMHS at STAR Health providers should submit their paper mental health rehabilitation claims for Superior HealthPlan foster care clients to the following address: IMHS Claims PO Box 6300 Farmington, MO Providers should submit their electronic claims to one of the clearinghouses that are trading partners with IMHS. Information about these clearinghouses can be found on the Cenpatico website at Click Providers, click Resources, and then click Electronic Transactions (EDI). Texas mental health providers can use Emdeon or Availity with Payer ID (Texas only). For more information on the use of other clearinghouses, providers should contact IMHS. For more information, call IMHS at or visit the Cenpatico website at Texas Medicaid Bulletin, No November/December 2008

37 Managed Care Providers / THSteps Providers Primary Care Provider Flyers Available for PCCM Providers A primary care provider selection flyer is now available for Primary Care Case Management (PCCM) providers to post in their office or distribute to clients. The flyer provides instructions about changing primary care providers. The PCCM primary care provider selection flyer is available on page 42 of this bulletin and in the Provider section of the TMHP website at If PCCM clients would like to pick a new primary care provider, they should follow the instructions on the flyer. Clients can call the PCCM primary care provider line from the provider s office if they want to. As many as ten clients can request a primary care provider change during each call initiated from a provider s office. If clients choose not to call, providers can assist them by downloading and printing the form from Clients must follow the instructions on the form. Only clients can complete and mail the form because federal guidelines prohibit a provider s influence on a patient s choice of a primary care provider. THSteps CCP Providers New Medicaid Rates for Personal Care Services Adopted Effective for dates of service on or after August 1, 2008, Texas Medicaid increased rates for personal care services (PCS) procedure codes in the Texas Health Steps Comprehensive Care Program (THSteps CCP). The rates were adopted following a public rate hearing on June 13, The increased rates implemented because of recent federal minimum wage changes. The THSteps CCP reimbursement rate for procedure code 1 T1019 with modifier U6 is $2.72. The THSteps CCP reimbursement rate for procedure code 1 T1019 with modifier U7 is $2.52. While PCS is a benefit in THSteps CCP, and School Health and Related Services (SHARS) programs, the increased rates are not applicable to services provided by SHARS providers. See also: Pulse Oximeter Probe Benefit Changes on page 5 for important THSteps-CCP policy updates. THSteps Dental Providers THSteps Therapeutic Dental Services Benefits to Change Effective for dates of service on or after September 1, 2008, Texas Health Steps (THSteps) therapeutic dental benefits changed. Procedure code D0350 must be used when billing photographic images. Documentation is required when medical necessity is not evident on radiographs for the following procedure codes: Procedure Codes D4210 D4211 D4240 D4241 D4245 D4266 D4267 D4270 D4271 D4273 D4275 D4276 D4355 D4910 Procedure code D2980 is limited to clients 1 year of age through 20 years of age. The following procedure codes are limited to clients birth through 20 years of age: Procedure Codes D2140 D2150 D2330 D2331 D2390 D2391 D2392 D2930 D2933 D2934 D2940 D3220 D7111 D7140 Procedure code D2971 is a benefit of Texas Medicaid. Procedure code D2971 will be reimbursed up to four services per lifetime for each tooth by any provider. Procedure codes D6092 and D6093 are benefits of Texas Medicaid and will be reimbursed one service per tooth, once per year, by any provider. Procedure code D9970 is a benefit of Texas Medicaid and will be reimbursed one service per day by any provider. Procedure code D3220 will be denied when billed within six months of procedure codes D3230 and D3240 for the same primary tooth ID by the same provider. Procedure code D3220 will be denied when billed within six months of procedure codes D3310, D3320, and D3330 for the same permanent tooth ID by the same provider. November/December Texas Medicaid Bulletin, No. 219

38 THSteps Providers The reimbursement rate for procedure code D9220 will be increased for dental anesthesiology specialists. The affected providers will be contacted by a TMHP provider relations representative with more information. The reimbursement rate is available on the TMHP website at and will be available in a future Texas Medicaid Bulletin. Dental behavior management services are benefits of THSteps, and may be billed using procedure code D9920. In the Remarks field of the claim form, the provider must indicate medical necessity for the service by listing one of the diagnosis codes below: Diagnosis Code Description Mild mental retardation (IQ 50 70) Moderate mental retardation (IQ 35 49) Severe mental retardation (IQ 20 34) Profound mental retardation (IQ under 20) Unspecified mental retardation Important: To avoid claim denials, either the written description or the corresponding diagnosis code must be included in the Remarks field of the electronic claim form 837 D (or Block 35 of the paper claim form) of the American Dental Association (ADA) Dental Claim Form. Documentation supporting the medical necessity and appropriateness of dental behavior management must be retained in the client s chart, must be available to state agencies upon request, and is subject to retrospective review. Documentation of medical necessity must include: A current physician statement addressing the mental retardation. The statement must be signed and dated within the year prior to the dental behavior management. A description of the service performed (including the specific problem and the behavior management technique applied). Personnel and supplies required to provide the behavioral management. The duration of the behavior management (including session start and end times). Dental behavior management is not reimbursed with an evaluation, prophylactic treatment, or radiographic procedure. Providers may refer to the 2008 Texas Medicaid Provider Procedures Manual, Section , Restorative Services, on page 19 15; Section , Endodontics Services, on page 19 18; Section , Periodontal Services, on page 19 20; Section , Implant Services, on page 19 25; and Section , Adjunctive General Services, on page 19 31, for more information. THSteps Therapeutic Dental Services Reimbursement Rate Change New Texas Medicaid reimbursement rates for THSteps, therapeutic dental services were adopted following a public rate hearing on August 18, 2008: Procedure Code New Reimbursement Rate Effective Date THSteps Therapeutic Dental Services D2971 $ September 1, 2008 D6092 $46.85 September 1, 2008 D6093 $46.85 September 1, 2008 D9920* $ September 1, 2008 D9970 $56.25 September 1, 2008 * The reimbursement rate for procedure code D9920 will be increased only for those providers who are dental anesthesiology specialists. Provider Enrollment and Claims Filing for Dental Providers Dental providers must complete the Dental Enrollment Application for each separate practice location, as stated in the 2008 Texas Medicaid Provider Procedures Manual, Section 19.2, Provider Enrollment, on page Dentists that are enrolled as a dental group must file claims to TMHP with the correct group provider identifier and performing provider identifiers for the practice location where the services were rendered. Claims for dental services provided to children in foster care must be filed with StarDent, the claims processor for Superior HealthPlan. Refer to the 2008 Texas Medicaid Provider Procedures Manual, Section 5, Claims Filing, on page 5 1 for claims filing guidelines. Texas Medicaid Bulletin, No November/December 2008

39 THSteps Providers Oral/Facial Photographic Images Claims Reprocessing TMHP has identified an issue affecting claims that were submitted with procedure code D0350 and dates of service on or after March 1, These claims may have been denied in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Dental providers see also: Reimbursement Rates Adopted After Public Rate Hearing beginning on page 10 for dental services that have recently been assigned reimbursement rates. THSteps Medical Providers Group Provider Claims for THSteps Texas Health Steps (THSteps) medical providers must never submit a rendering or performing provider identifier on claims for THSteps services. Using a performing provider identifier on claims will cause claim denials. Electronic claims for THSteps medical services must be submitted with the THSteps billing provider s National Provider Identifier (NPI), benefit code, and the TMHP attested taxonomy code. Failure to supply the taxonomy code for the billing provider may result in the rejection of claims. Paper claim submissions must be submitted with the billing provider s NPI, Texas Provider Identifier (TPI), and benefit code. THSteps medical claims must be submitted with the appropriate modifier. Refer to the 2008 Texas Medicaid Provider Procedures Manual, Section 43, Texas Health Steps (THSteps). THSteps Checkup Benefit Changes Effective for dates of service on or after September 1, 2008, THSteps medical checkup criteria has changed for Texas Medicaid. Physicians, physician assistants, and advanced practice nurses (APNs) may be reimbursed for periodic THSteps medical checkups under their THSteps provider identifier. APNs must be recognized by the Texas Board of Nursing (BON) and nationally certified in pediatric, family practice, adult health (adolescent clients only), women s health (adolescent female clients only), or certified nurse midwives (newborn and adolescent female clients only). Dental Services as Part of the Medical Checkup The schedule for preventive dental services has changed and now includes an initial dental checkup at 6 months of age with checkups at 6 month intervals thereafter. The THSteps medical checkup provider must refer clients to a dental home for a dental checkup beginning at 6 months of age and at each medical checkup thereafter. Clients and their caretaker may self refer for dental services at any age and may choose any Texas Medicaid dental provider. Intermediate Oral Evaluation and Fluoride Varnish An intermediate oral evaluation with fluoride varnish application (procedure code S with modifier U5) is a benefit for clients 6 months of age through 35 months of age. Federally qualified health centers (FQHCs) must submit modifier EP in addition to modifier U5 when billing procedure code S The intermediate oral evaluation with fluoride varnish application must be billed on the same date of service as a medical checkup or an exception to the periodicity visit (procedure code S 99381, S 99382, S 99391, and S 99392) and is limited to 6 services per lifetime by any provider. November/December Texas Medicaid Bulletin, No. 219

40 THSteps Providers / Women s Health Program Providers An intermediate oral evaluation with fluoride varnish application is limited to THSteps medical checkup providers who have completed the required education and are certified by the Department of State Health Services (DSHS) Oral Health Program to perform the procedure. The intermediate oral evaluation with fluoride varnish application add on component includes the following: An intermediate oral evaluation. Note: The primary care provider must complete the intermediate oral evaluation but may delegate all other components. Fluoride varnish application. Dental anticipatory guidance that explains: The need for thorough daily oral hygiene practices. Potential gingival manifestations for clients with diabetes and clients under long term medication therapy. THSteps eligibility for dental services. Diet, nutrition, and food choices. - - Fluoride needs. Injury prevention. Antimicrobials, medications, and oral health. Additional dental anticipatory guidance if the client has no erupted teeth. Dental Screening as Part of the Medical Checkup Dental screening continues to be part of the complete physical examination and must include the following: Inspection of the teeth for signs of early childhood and other caries. Inspection of the oral soft tissues for any abnormalities. Anticipatory guidance that explains the following: The need for thorough, daily oral hygiene practices. Potential gingival manifestations for clients with diabetes and clients under long term drug therapies. THSteps eligibility for dental services. Women s Health Program Providers Claims Submitted by Women s Health Program Providers TMHP has identified an issue impacting claims that were submitted by Women s Health Program (WHP) providers for certain WHP clients with dates of service on or after June 9, 2008, through July 3, These claims may have been denied in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Texas Medicaid Bulletin, No November/December 2008

41 Excluded Providers Excluded Providers As required by the Medicare and Medicaid Patient Protection Act of 1987, the Texas Health and Human Services Commission (HHSC) identifies providers or employees of providers who have been excluded from state and federal health care programs. Providers excluded from Texas Medicaid and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider will be denied. Providers who submit cost reports cannot include the salaries, wages, or benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client. Medicaid providers are responsible for checking the exclusion list on all employees upon hire and periodically thereafter. Providers are liable for all fees paid to them by Texas Medicaid for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of HHSC s exclusion list. The HHSC Sanctions Department submits updates to the exclusion list periodically and the updates appear on the website weekly. Review the entire Texas Medicaid exclusion list at /Exclusions/Search.aspx. To report Medicaid providers who engage in fraud/abuse, call or , or write to the following address: Provider Brian Klozik, Director HHSC Office of Inspector General, Medicaid Provider Integrity, MC 1361 PO Box Austin TX License Number Start Date Type Provider City State Add Date Barnwell, Terri G May 06 LVN Bridgeport TX 15 Aug 08 Callaway, Cecil O Feb 07 RN Seminole TX 15 Aug 08 Erwin, James L Sep 07 RN Freeport TX 03 Jul 08 Fontenot, Amber J Feb 08 Houston TX 14 Jul 08 Gavin, Nancy L Aug 07 RN Houston TX 14 Aug 08 Goines, Nancy G Sep 07 RN Ft. Worth TX 15 Aug 08 Johnson, Dawn E Jun 07 LVN Forney TX 14 Jul 08 Lewis, Eddie G Dec 07 RN Georgetown TX 14 Jul 08 MacDonald, Gina N Apr 07 RN Scarborough ON 14 Jul 08 Marsh, Feliza R Aug 07 CAN Tyler TX 09 Jul 08 Middleton, Holly Y. 18 Oct 07 Houston TX 15 Aug 08 Mina Medical Equipment Jan 08 DME Mesquite TX 14 Jul 08 and Supplies Moffett, Kathleen M Jun 07 RN Garland TX 14 Aug 08 Moore, Jill L May 07 RN New Market ON 14 Jul 08 Moreland, Courtney A Nov 06 LVN Dallas TX 15 Aug 08 Morgan, Marianne Jan 08 Corpus Christi TX 14 Aug 08 Smith, Jacqueline E Feb 07 RN ARP TX 15 Aug 08 Taylor Jr, Willie L. 20 Dec 07 Lincoln TX 14 Jul 08 Tolbert, Amanda L Jan 08 Houma LA 14 Aug 08 Welch, Tammie M Aug 06 LVN Montgomery TX 15 Aug 08 November/December Texas Medicaid Bulletin, No. 219

42 Forms NOTICE TO PCCM MEDICAID PATIENTS NOTIFICACIÓN PARA PACIENTES PCCM DE MEDICAID In Primary Care Case Management (PCCM), you get to choose your primary care provider. A primary care provider is a doctor, health clinic, or specially trained nurse that helps you take care of most of your health-care needs. En Administración de Casos de Cuidado Primario (PCCM, por sus siglas en inglés), usted puede elegir su proveedor de cuidado primario. Un proveedor de cuidado primario es un doctor, una clínica, o una enfermera con capacitación especial que le ayudara con la mayoría de sus necesidades médicas. If you want this office to be your primary care provider, you can make a change by either phone or mail. Si usted desea que esta oficina sea su proveedor de cuidado primario, puede hacer el cambio por cualquier de los dos, teléfono o correo. Phone Call and say that you want to choose another primary care provider. The call is free. You can call Monday through Friday, 7:00 a.m. to 7:00 p.m., Central Time. (TTD/TTY ). Choosing by phone is faster. Teléfono Llame al e informe que desea elegir otro proveedor de cuidado primario. La llamada es gratuita. Puede llamar de lunes a viernes, de 7:00 a.m. a 7:00 p.m., Hora Central. Teléfonos de texto (TTD/TTY) Es mas pronto elegir por teléfono. Mail To get a form, go online to Fill it out, sign it, and mail to the address listed on the form. Correo Para obtener una forma, visite Complete la forma, fírmela y envíela por correo a la dirección que aparece en la forma. Give the name of the doctor, office, or clinic that you want to pick as your primary care provider. If you want to pick this office as your primary care provider, here is what you should put on your form: Indique el nombre del doctor, la oficina o clínica que desea elegir como proveedor de cuidado primario. Si desea elegir esta oficina como proveedor de cuidado primario, esto es lo que debe escribir en la forma: (Physician, Office or Clinic Name) Attention Physician and Provider Offices: You may post or distribute this notice to your Medicaid patients if you are enrolled as a PCCM primary care provider. Your PCCM patients have the right to change their primary care provider. You may assist them in this process. Revised 09/07 Pub_Docs\Publications\PCCM Office Flyer Texas Medicaid Bulletin, No November/December 2008

43 Forms PCCM Community Health Services Referral Request Form Provider Information Name: Contact name: Telephone: Address: NPI: Name: Medicaid number: Telephone: Client Information Reason for Referral TPI: Name: Medicaid number: Telephone: Client Information Reason for Referral Appointment no show Abuse of emergency room Appointment no show Abuse of emergency room Treatment plan adherence Abuse of doctor/staff Treatment plan adherence Abuse of doctor/staff Other: Case Management/Health Education Needs Other: Case Management/Health Education Needs Asthma Childhood illness Asthma Childhood illness Community resources Cardiac Community resources Cardiac Nutrition Transportation Nutrition Transportation Dental Parenting Dental Parenting Behavioral psych disorder Diabetes Behavioral psych disorder Diabetes Prenatal Exercise Prenatal Exercise Tobacco use Child/Adult with Special Health Care Needs Other: Comments: Name: Medicaid number: Telephone: Client Information Reason for Referral Tobacco use Child/Adult with Special Health Care Needs Other: Comments: Name: Medicaid number: Telephone: Client Information Reason for Referral Appointment no show Abuse of emergency room Appointment no show Abuse of emergency room Treatment plan adherence Abuse of doctor/staff Treatment plan adherence Abuse of doctor/staff Other: Case Management/Health Education Needs Other: Case Management/Health Education Needs Asthma Childhood illness Asthma Childhood illness Community resources Cardiac Community resources Cardiac Nutrition Transportation Nutrition Transportation Dental Parenting Dental Parenting Behavioral psych disorder Diabetes Behavioral psych disorder Diabetes Prenatal Exercise Prenatal Exercise Tobacco use Child/Adult with Special Health Care Needs Other: Comments: Tobacco use Child/Adult with Special Health Care Needs Other: Comments: For Primary Care Case Management Clients Only Fax to Community Health Services at (512) Referrals are also received by telephone at (M-F, 8 a.m. to 5 p.m., CST) Effective Date_ /Revised Date_ November/December Texas Medicaid Bulletin, No. 219

44 Forms Provider Information Change Form Traditional Medicaid, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page. Check the box to indicate a PCCM Provider Date : / / Nine-Digit Texas Provider Identifier (TPI): Provider Name: National Provider Identifier (NPI): Atypical Provider Identifier (API): Primary Taxonomy Code: Benefit Code: List any additional TPIs that use the same provider information: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: Physical Address The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who change their ZIP Code must submit a copy of the Medicare letter along with this form. Street address City County State Zip Code Telephone: ( ) Fax Number: ( ) Accounting/Mailing Address All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form. Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Secondary Address Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Type of Change (check the appropriate box) Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance) Comments: Tax Information Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS) Tax ID number: Effective Date: Exact name reported to the IRS for this Tax ID: Provider Demographic Information Note: This information can be updated on Languages spoken other than English: Provider office hours by location: Accepting new clients by program (check one): Accepting new clients Current clients only No Patient age range accepted by provider: Additional services offered (check one): HIV High Risk OB Participation in the Woman s Health Program? Yes No Patient gender limitations: Female Male Both Signature and date are required or the form will not be processed. Provider signature: Date: / / Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Fax: Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No November/December 2008

45 Forms PO Box Austin, TX Instructions for Completing the Provider Information Change Form Signatures The provider s signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers. Address Performing providers (physicians performing services within a group) may not change accounting information. For Traditional Medicaid and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form. For Traditional Medicaid, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers. Tax Identification Number (TIN) TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN. Provider Demographic Information An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, please visit the OPL at Please review the existing information and add or modify any specific practice limitations accordingly. This will allow clients more detailed information about your practice. General TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable) in order to process the change. Forms will be returned if this information is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Fax: Effective Date_ /Revised Date_ November/December Texas Medicaid Bulletin, No. 219

46 Forms Electronic Funds Transfer (EFT) Information Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account. The following items are specific to EFT: Pre notification to your bank takes place on the cycle following the application processing. Future deposits are received electronically after pre notification. The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider s account during the weekly cycle. Specific deposits and associated R&S reports are cross referenced by both the provider identifiers (i.e., NPI, TPI, and API) and R&S number. EFT funds are released by TMHP to depository financial institutions each Friday. The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received. TMHP must provide the following notification according to ACH guidelines: Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date. However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer s needs. In all cases, credits received should be posted to the customer s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date. To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return the agreement and either a voided check or a statement from your bank written on the bank s letterhead to the TMHP address indicated on the form. Call the TMHP Contact Center at for assistance. A STATE MEDICAID CONTRACTOR Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No November/December 2008

47 Forms Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form NOTE: Complete all sections below and attach a voided check or a statement from your bank written on the bank s letterhead. Type of Authorization: NEW CHANGE Provider Name Nine Character Billing TPI National Provider Identifier (NPI)/Atypical Provider Identifier (API): Provider Accounting Address Bank Name Primary Taxonomy Code: Benefit Code: Provider Phone Number ( ) Ext. ABA/Transit Number Bank Phone Number Account Number Bank Address Type Account (check one) Checking Savings I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period. I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations. Authorized Signature Date Title Address (if applicable) Contact Name Phone Return this form to: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box Austin TX DO NOT WRITE IN THIS AREA For Office Use Input By: Input Date: A STATE MEDICAID CONTRACTOR November/December Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No. 219

48 November/December 2008 No. 219 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual Look inside for these and other important updates: Page 1 Page 5 Page 6 Page 31 Page 35 Medicare Paper Claims HHSC Response to Recent Hurricanes Payment Error Rate Measurement (PERM) FAQs Partial SDA Rebase for DRG Inpatient Hospital Providers Help Available for PCCM Providers with Clients Who Frequently Miss Appointments Texas Medicaid & Healthcare Partnership B Riata Trace Parkway, Ste 150 Austin, TX A STATE MEDICAID CONTR ACTOR PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE

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