T EXAS MEDICAID BULLETIN

Transcription

1 T EXAS MEDICAID BULLETIN Bimonthly update to the Texas Medicaid Provider Procedures Manual SEPTEMBER/OCTOBER 2006 NO. 198 IN THIS EDITION Scheduled System Maintenance System maintenance for the TMHP claims processing system is scheduled as follows: 6:00 p.m. to 11:59 p.m., Sunday, September 10, :00 p.m. to 11:59 p.m., Sunday, October 8, 2006 During system maintenance some applications related to the claims engine will be unavailable. Specific details regarding the affected applications are posted on the TMHP website at Current Procedural Terminology (CPT) is copyright 2005 American Medical Association (AMA) and Current Dental Terminology (CDT) is copyright 2004 American Dental Association (ADA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT or CDT. The AMA and the ADA assume no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use. All Providers Scheduled System Maintenance Ultrasound Policy Correction Cost Settlements for Small and Rural Hospitals STAR Program Expansion to Nueces Service Area STAR+PLUS Expansion MMRV Available Through TVFC Influenza Information for the Season Influenza Vaccine Reimbursement Updates Certification of Funds Process Pricing Update for Procedure Code Medicare Crossover Claims Forwarded Through COBC HCPCS 2nd Quarter Update Changes to Prior Authorization for Private Duty Nursing Fee Schedule Updates Medicaid Eligibility Verification Form H1027 and Children in Foster Care National Provider Identifier Deadline Providing Health Care Services for Rita Evacuees Medicaid Buy-In Program for Employed Individuals with Disabilities...11 Billing for Physician Evaluation and Management Procedure Codes Changing Issues Impacting Claims Medicare Adjusted Claims Policy Radiology Services Update Third Party Biller Enrollment Procedure Code Changes Texas Medicaid Benefits Changes Durable Medical Equipment Providers Incontinence Supplies and External Urinary Collection Devices Forms and Prior Authorization for Mobility Aids Procurement Hospital Providers Inpatient Hospital Rate Change Primary Care Case Management Providers PCCM Claims Being Reprocessed Providers Can Serve Both PCCM and HMO Clients School Health and Related Services Providers District-Specific Interim Rates for SHARS Providers Implemented Texas Health Steps Providers Compass21 Update Excluded Providers Forms EFT Form Provider Information Change Form Wheelchair/Scooter/Stroller Seating Assessment Form Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Medicaid Eligibility Verification Form H

2 All Providers Ultrasound Policy Correction The following are corrections to information located in the 2006 Texas Medicaid Provider Procedures Manual,, Section , Ultrasound of the Pregnant Uterus, on pages through Procedure codes 4/I/ T and 4/ I/T were inadvertently omitted from the procedure code table located on page These procedure codes may be billed for an ultrasound of the pregnant uterus. Additionally, procedure codes G and G were inadvertently inserted into the list of codes located on page that may be reimbursed to providers of genetic services. Procedure codes G and G are not eligible for reimbursement to providers of genetic services. For more information, call the TMHP Contact Center at Cost Settlements for Small and Rural Hospitals The following table outlines the cost settlement processes for hospitals with 100 beds or less, critical access hospitals, sole community hospitals, and rural referral centers. The table indicates whether these hospitals are subject to C part II operating and capital reductions (C part II), a 2.5 percent outpatient cost reduction (OP), or a lower of cost or charges rule (LCC), and if a traditional or Primary Care Case Management (PCCM) inpatient settlement is received. Hospital Type (A) C pt II (B) 2.5% OP (C) LCC (D) Traditional Program 100 DOS after August 31, 1989 (E) Traditional Program 100 DOS after August 31, Beds Yes Yes Yes Yes Yes Yes Critical Access No Yes No Yes Yes Yes Sole Community No Yes Yes Yes Yes Yes Rural Referral Center Yes Yes Yes No Yes Yes The following explains the information in the table above: A) B) (F) PCCM Program 200 DOS after August 31, 2005 Providers are subject to C part II operating and capital reductions. If the reductions apply, the provider is not required to file a cost report with the reductions incorporated. Providers are subject to a 2.5 percent outpatient reduction. The provider is not required to file a cost report with the reduction applied. C) Providers are subject to the LCC rule. D) E) Providers receive an inpatient settlement for traditional Medicaid if costs before the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 ceiling are greater than diagnosis-related group (DRG) payments for hospital fiscal years beginning September 1, The provider is not required to file a cost report with this portion of the settlement included. Providers receive an inpatient settlement for traditional Medicaid if costs before the TEFRA ceiling are greater than DRG payments for dates of service (DOS) on or after September 1, The provider is not required to file a cost report with this portion of the settlement included. Texas Medicaid Bulletin, No September/October 2006

3 All Providers F) Providers receive an inpatient settlement for PCCM (Program 200) if costs before the TEFRA ceiling are greater than DRG payments and the hospital is located in a county with a population of less than 50,000 (based on the 2000 census, see list of qualifying counties below). The provider is not required to file a cost report with this portion of the settlement included. Qualifying Counties With a Population of Less Than 50,000 Andrews Aransas Archer Armstrong Atascosa Austin Bailey Bandera Baylor Bee Blanco Borden Bosque Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Coke Coleman Collingsworth Colorado Comanche Concho Cooke Cottle Crane Crockett Crosby Culberson Dallam Dawson Deaf Smith Delta DeWitt Dickens Dimmit Donley Duval Eastland Edwards Erath Falls Fannin Fayette Fisher Floyd Foard Franklin Freestone Frio Gaines Garza Gillespie Glasscock Goliad Gonzales Gray Grimes Hale Hall Hamilton Hansford Hardeman Hardin Hartley Haskell Hemphill Hill Hockley Hood Hopkins Houston Howard Hudspeth Hutchinson Irion Jack Jackson Jasper Jeff Davis Jim Hogg Jim Wells Jones Karnes Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox Lamar Lamb Lampasas La Salle Lavaca Lee Leon Limestone Lipscomb Live Oak Llano Loving Lynn McCulloch McMullen Marion Martin Mason Matagorda Maverick Medina Menard Milam Mills Mitchell Montague Moore Morris Motley Navarro Newton Nolan Ochiltree Oldham Palo Pinto Panola Parmer Pecos Polk Presidio Rains Reagan Real Red River Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San Augustine San Jacinto San Saba Schleicher Scurry Shackelford Shelby Sherman Somervell Stephens Sterling Stonewall Sutton Swisher Terrell Terry Throckmorton Titus Trinity Tyler Upshur Upton Uvalde Val Verde Van Zandt Waller Ward Washington Wharton Wheeler Wilbarger Willacy Wilson Winkler Wise Wood Yoakum Young Zapata Zavala For more information, contact Dick Bledsoe, TMHP Medicaid Audit, at richard.bledsoe@tmhp.com or September/October Texas Medicaid Bulletin, No. 198

4 All Providers STAR Program Expansion to Nueces Service Area The State of Texas Access Reform (STAR) Program expanded to the Nueces Service Area on September 1, The new Nueces Service Area includes Aransas, Bee, Calhoun, Jim Wells, Kleberg, Nueces, Refugio, San Patricio, and Victoria Counties. Medicaid recipients in these counties received program information and enrollment materials and have selected a health maintenance organization (HMO). Medicaid clients in the Nueces Service Area who receive supplemental security income (SSI), are institutionalized, dual eligible, medically needy, or foster children are not eligible for STAR Program enrollment. Additional HMO Choices Additional HMOs have been approved to participate in the STAR Program in the Bexar, Dallas, Harris, Tarrant, and Lubbock Service Areas. Current health plan options for clients in the STAR Program include: Service Area Bexar Dallas El Paso Harris/Harris Expansion Lubbock Nueces Tarrant * New STAR HMO STAR HMO Choices Community First Health Plans, Aetna Medicaid*, Superior HealthPlan Amerigroup Community Care, Parkland HEALTHfirst, Unicare Health Plans of Texas* El Paso First, Superior HealthPlan Amerigroup Community Care, United Healthcare of Texas*, Molina Healthcare of Texas*, Community Health Choice, Texas Children s Health Plan FIRSTCARE STAR, Superior HealthPlan* Amerigroup Community Care*, Driscoll Children s Health Plan*, Superior HealthPlan* Amerigroup Community Care, Aetna Medicaid*, Cook Children s Health Plan* STAR PCCM Phase Out PCCM is phasing out as an option for Medicaid clients in the STAR Program through December Effective December 1, 2006, STAR clients, except SSI-related clients, will no longer have PCCM as a choice. STAR SSI-related clients will no longer have PCCM as a choice effective January 1, SSI includes many Medicaid clients who have disabilities. These changes affect PCCM clients in the following STAR Service Areas: Service Area Bexar Dallas El Paso Harris/Harris Expansion Lubbock Counties Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall El Paso Brazoria, Fort Bend, Galveston, Harris, Montgomery, Waller Crosby, Floyd, Garza, Hale, Hockley, Lamb, Lubbock, Lynn, Terry Medicaid clients in the affected areas must select a health plan offered through an HMO. In July 2006, HHSC mailed out initial notification letters and enrollment kits to clients, with information about the available HMOs in their area as well as instructions for choosing a health plan. Even though PCCM will be phased out of the above areas, the provider s contract with PCCM is not terminated. Providers may contract simultaneously with PCCM and an HMO(s). By remaining enrolled in PCCM, providers ensure continuity of care through the transition. In addition, PCCM providers in these areas are encouraged to continue providing health care services to PCCM clients who live in contiguous areas not affected by the managed care changes. For more information about STAR Program changes and the affected service areas, refer to the July/August 2006 Texas Medicaid Bulletin, No. 197, or call the TMHP Contact Center at STAR is a managed care program for Medicaid recipients who receive cash assistance (Temporary Assistance to Needy Families [TANF]), are pregnant, have limited income, or their children have limited income. Texas Medicaid Bulletin, No September/October 2006

5 All Providers STAR+PLUS Expansion STAR+PLUS, the managed care program for certain Medicaid recipients who are aged or who have disabilities, will expand to the Bexar, Harris/Harris Expansion, Nueces, and Travis Service Areas effective January 1, STAR+PLUS delivers health care and long-term services and support (such as helping with daily activities, home modifications, respite, and personal assistance) through HMOs. The following HMOs have been tentatively selected to provide these services: Eligible adult Medicaid recipients are elderly, qualify for Medicaid through community based alternative (CBA) waiver services, or are persons with disabilities who receive SSI. Eligible clients in these service areas will be enrolled in a STAR+PLUS HMO. Children younger than 21 years of age receiving SSI can participate on a voluntary basis. Medicare enrollment does not affect eligibility for STAR+PLUS. For STAR+PLUS participants who are dual eligible (enrolled in both Medicaid and Medicare), the STAR+PLUS HMO is only responsible for longterm services and supports. Primary acute care and pharmacy services for this population are covered through Medicare. Participation in STAR+PLUS will not change the way a client receives their Medicare services. Long-term services and supports will no longer process claims through the Department of Aging and Disability Services (DADS) for STAR+PLUS members. All STAR+PLUS claims will be fi led through the respective HMO with which the provider contracts. Under the STAR+PLUS Program, HMOs will authorize inpatient hospital stays, but TMHP will process claims for inpatient hospital services and supports. Service Area Counties STAR+PLUS HMOs Bexar Service Area Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, and Wilson Counties Molina Healthcare of Texas, Superior HealthPlan, Amerigroup Community Care Harris/Harris Expansion Service Area Brazoria, Fort Bend, Galveston, Harris, Montgomery, and Waller Counties Amerigroup Community Care, Evercare, Molina Healthcare of Texas Nueces Service Area Travis Service Area Aransas, Bee, Calhoun, Jim Wells, Kleberg, Nueces, Refugio, San Patricio, and Victoria Counties Bastrop, Burnet, Caldwell, Hays, Lee, Travis, and Williamson Counties Evercare, Superior HealthPlan Amerigroup Community Care, Evercare Clients eligible to participate in the STAR+PLUS Program will be notified about the available HMOs in their area. For more information, visit the HHSC website at September/October Texas Medicaid Bulletin, No. 198

6 All Providers MMRV Vaccine Available Through TVFC This is an update to a banner message that appeared on providers May 19, 2006, Remittance and Status (R&S) reports regarding the availability of the measles, mumps, rubella, and varicella (MMRV) vaccines through the Texas Vaccines for Children (TVFC) Program. The following is the complete article: Influenza Information for the Season Effective for dates of service on or after March 1, 2006, the MMRV vaccine is available for distribution through the TVFC Program using procedure code This update was implemented on July 28, Providers must bill THSteps for the administration fee when provided as part of a THSteps medical checkup with type of service (TOS) S. Providers must bill the Texas Medicaid Program for the administration fee when provided outside of a THSteps medical checkup with TOS 1. Claims submitted for dates of service March 1, 2006, through July 27, 2006, that were denied for the administration fee must be appealed to be considered for reimbursement. For more information, call the TMHP Contact Center at TVFC offers information for the influenza season. The following table contains inactivated influenza vaccine dosage information available through TVFC pertinent to the influenza season: Product Name Age Dosage Formulation* Number of Doses Route FluZone PF 6 through 35 months.25 ml Preservative-free Intramuscular pre-filled syringe Pediatric Dose 1 or 2 FluZone PF 3 through ml Preservative-free 1 or 2 Intramuscular pre-filled syringe or single dose vial FluZone 3 through 18 years.50 ml 10 dose vials 1 or 2 Intramuscular Fluvirin 4 through 18 years.50 ml 10 dose vials 1 or 2 Intramuscular * Refer to package insert for instructions. Two doses are recommended for children younger than 9 years of age who are receiving influenza vaccine for the first time. Administer at least one month apart. All vaccines prepared for the season, inactivated and live attenuated, will include antigens to protect against A/New Caledonia/20/1999 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens. The Centers for Disease Control and Prevention s (CDC) Advisory Committee on Immunization Practices states that the optimal time to vaccinate those at risk for complications is usually during October and November. TVFC influenza vaccine orders should be placed beginning in September, and once a month each subsequent month, throughout the vaccination season (October through March). When ordering, estimate the number of patients expected monthly and order appropriately. Texas Medicaid Bulletin, No September/October 2006

7 All Providers Children Eligible for TVFC Inactivated Influenza Vaccine The following are priority groups who should receive TVFC influenza vaccine: Children 6 months through 59 months of age Children and adolescents 5 through 18 years of age with chronic disorders of the pulmonary or cardiovascular system, including asthma Children and adolescents 5 through 18 years of age who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic disease (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medication or human immunodeficiency virus [HIV]) Children and adolescents 5 through 18 years of age who are receiving long-term aspirin therapy and may, therefore, be at risk for developing Reye s Syndrome after influenza Children and adolescents 5 through 18 years of age who have any condition that can compromise respiratory function or the handling of respiratory secretions (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) or that can increase the risk for aspiration Children and adolescents 5 through 18 years of age who are residents of nursing homes or other chronic-care facilities that house persons at any age who have chronic medical conditions Females under 19 years of age who will be pregnant during the influenza season Children and adolescents 5 through 18 years of age who are household contacts and out-of-home caregivers of children younger than 6 months of age Children and adolescents 5 through 18 years of age who are household contacts of persons in high-risk groups (e.g., persons 65 years of age or older, transplant recipients, persons with Acquired Immunodeficiency Syndrome [AIDS], and children younger than 2 years of age) For more information about influenza vaccine, contact the health service region or local health department. For more information about billing, call the TMHP Contact Center at , or see Infl uenza Vaccine Reimbursement Updates on this page. Influenza Vaccine Reimbursement Updates Effective for dates of service on or after September 1, 2006, providers must submit claims for influenza vaccines obtained from the TVFC Program for clients 18 years of age and younger using procedure codes 90655, 90656, 90657, or In addition, the related immunization administration codes 90465, 90466, 90471, or must be billed. The procedure codes for these vaccines are processed as information only, but must be included on the claim in order to be considered for reimbursement for the vaccine administration. Influenza vaccines that are not obtained from the TVFC Program will be considered for reimbursement only when using modifier U1 with the applicable influenza vaccine CPT procedure code. Providers can submit influenza vaccine claims on a professional acute care claim or with a Texas Health Steps (THSteps) medical checkup claim. The alternate coding directions regarding procedure code published in previous Medicaid bulletins are no longer applicable. For clients 19 years of age and older, providers should file the claim with the appropriate CPT procedure and immunization administrative codes. For more information, call the TMHP Contact Center at September/October Texas Medicaid Bulletin, No. 198

8 All Providers Certification of Funds Process Certain Medicaid providers are required to certify funds received from the Texas Medicaid Program. The current certification of funds process is based on claims paid during state fiscal year quarters (September 1 to August 31). Effective October 1, 2006, the certification periods will be based on the following federal fiscal year quarters: October 1 through December 31 January 1 through March 31 April 1 through June 30 July 1 through September 30 Changing certification periods to the federal fiscal year quarters aligns with Medicaid reporting requirements to the Centers for Medicare & Medicaid Services (CMS). Since the state fiscal year quarters are changing to federal fiscal year quarters effective October 1, 2006, the fourth quarter certification letters for state fiscal year 2006 will cover June, July, August, and September. Effective October 1, 2006, Certification of Funds letters based on federal fiscal year quarters will have the following changes: The letters will include new language at the direction of CMS. The letters will include a federal, state, and total amount allowing the provider to make the required certification of funds. The letters will include the federal quarter ending date for clarity. The letters will combine both Medicaid fee-forservice (Program 100) and Medicaid Managed Care (Program 200) amounts. The letters will no longer contain the total billed amounts submitted by providers. Providers will receive or have access to the Certification Claims Information Report, which includes all claims included in the certification period. Providers will receive the report through the same mode of transmission as their R&S report (i.e., online or paper). For more information, call the TMHP Contact Center at Pricing Update for Procedure Code Effective for dates of service on or after April 1, 2001, the following procedure codes are now a benefit of the Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Programs when performed by physicians, radiation treatment centers, hospitals, portable X-ray suppliers, radiological labs, and physiology labs in an inpatient or outpatient hospital setting: Procedure Code Allowable Fee* Procedure Code Allowable Fee* RVU RVU RVU RVU RVU RVU RVU RVU RVU RVU 5.43 *Allowable fee in relative value units (RVU) Procedure codes , , , , and are manually reviewed to determine pricing. Claims submitted for dates of service on or after April 1, 2003, through April 14, 2006, that include these procedure codes have been reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at or the TMHP-CSHCN Contact Center at Medicare Crossover Claims Forwarded Through COBC In the coming months, all Medicare crossover claims will be forwarded to TMHP through a Coordination of Benefits Coordinator (COBC), as directed by CMS. This is a change to the current process in which TMHP receives crossover claims directly from each fiscal intermediary. TMHP will continue to process Medicare crossover claims as they are received from the COBC. During the transition period, providers can experience some initial delays in the processing of their Medicare crossover claims. These delays will not extend past the 60-day time period that providers should allow for claims to appear on their R&S report. The filing deadline of 95 days from the date of Medicare s disposition to file with Medicaid remains unchanged. For more information, call the TMHP Contact Center at Texas Medicaid Bulletin, No September/October 2006

9 All Providers 2006 HCPCS 2nd Quarter Update Beginning July 12, 2006, effective for dates of service on or after July 1, 2006, TMHP implemented the 2006 Healthcare Common Procedure Coding System (HCPCS) second quarter update for the Texas Medicaid and CSHCN Services Programs. Texas Medicaid and CSHCN Services Program Additions Table The following is a complete list of procedure codes that have been implemented for Texas Medicaid and CSHCN Services Programs effective July 1, 2006: Procedure Code Allowable 9-K0733 NC J-K0733 $30.21* L-K0733 NC 9-K0734 NC J-K0734 MR* L-K0734 NC 9-K0735 NC J-K0735 MR* L-K0735 NC 9-K0736 NC J-K0736 MR* L-K0736 NC 9-K0737 NC J-K0737 MR* L-K0737 NC C-S5523 NC NC = Not Covered MR = Manually Reviewed * Prior Authorization Required, as well as Authorization for CSHCN Deleted Codes Procedure codes 1-S0116, 1-S0198, 1-S8075, and 2-S9022 are no longer benefits of the Texas Medicaid and CSHCN Services Programs for dates of service on or after June 30, Procedure Code Description Changes The description for procedure code 9-Q1003 has changed. Contact the appropriate copyright holder to obtain the procedure code description. For more information, call the TMHP Contact Center at or the TMHP-CSHCN Contact Center at Changes to Prior Authorization for Private Duty Nursing Effective September 1, 2006, the prior authorization process will change for private duty nursing (PDN) services for Medicaid beneficiaries younger than 21 years of age that are eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. Nursing services are prior authorized when the requested services correct or ameliorate the beneficiary s disability or physical or mental illness or condition. PDN services are prior authorized when the beneficiary requires more individual and continuous care than is available on a pervisit basis through Home Health Skilled Nursing visits. Before a TMHP reviewer determines that the requested nursing services do not meet the criteria, the TMHP Medical Director will contact the treating physician to determine whether additional information or clarification can be provided that would allow for the prior authorization of the requested PDN services. If the TMHP Medical Director is not successful in contacting the treating physician, or cannot obtain additional information or clarification, the TMHP Medical Director will make a decision based on the available information. For more information, call the TMHP Contact Center at Fee Schedule Updates On May 3, 2006, the 2006 Texas Medicaid Fee Schedules for most provider types were posted to the TMHP website at TMHP has identified typographical errors and omitted procedure codes in the initial publication of the 2006 Physician Fee Schedule, 2006 Optometrist Fee Schedule, and the 2006 Podiatrist Fee Schedule. The fee schedules are available on the website as Adobe portable document format (PDF) files (paper replica) and MicroSoft Excel spreadsheets from the TMHP website at Providers may request a paper copy of a fee schedule free of charge by calling the TMHP Contact Center at For more information, call the TMHP Contact Center at September/October Texas Medicaid Bulletin, No. 198

10 All Providers Medicaid Eligibility Verification Form H1027 and Children in Foster Care Most children in the State of Texas foster care program are automatically eligible for Medicaid. To ensure these children have access to the necessary health care services for which they are eligible, providers can accept the Medicaid Eligibility Verification Form H1027 as evidence of Medicaid eligibility. Although this form may not have a Medicaid number, it is an official state document that establishes Medicaid eligibility. Providers should honor Form H1027 as proof of Medicaid eligibility and must bill the Texas Medicaid Program as soon as a Medicaid ID number is assigned. Medicaid ID numbers will be assigned approximately one month from the initial presentation of the Medicaid Eligibility Verification Form H1027. The form includes a Department of Family and Protective Services (DFPS) client number that provides additional means of identification and tracking for children in foster care. An example of the form is available on page 37 of this bulletin. For more information, call the TMHP Contact Center at National Provider Identifier Deadline The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires all health care entities (i.e., providers, clearinghouses, and large health plans) to begin using a National Provider Identifier (NPI) on standard health care transactions beginning May 23, Each provider (individuals and organizations) must apply for an NPI and, once it is received, must distribute the NPI to all applicable billing vendors. Providers can apply for an NPI online via the National Plan and Provider Enumeration System (NPPES) website at The NPI Enumerator may be contacted by telephone at: (NPI Toll-Free) or (NPI TTY), or by mail: NPI Enumerator PO Box 6059 Fargo, ND When applying for an NPI, providers must include all current (legacy) provider numbers on the NPPES application. Effective May 23, 2007, TMHP will only accept paper and electronic transactions that contain the provider s NPI. Transactions that contain legacy numbers (i.e. TPI, Long Term Care contract, Universal Provider Identifier [UPIN]) will not be processed, and providers will not be reimbursed for services rendered. Appropriate taxonomy codes will also be required on all transactions. Providers should continue to submit claims using their current identifier until this time. Additional information regarding the NPI is available on the CMS website at NationalProvIdentStand/. Educational resources, such as fact sheets, frequently asked questions, tips for health care professionals, and The Medicare Expectations for Subpart Enumeration policy paper are available on the website. The policy paper describes the Medicare Program s expectations concerning the determination of subparts for NPI assignment. To ensure timely claims filing and reimbursement, providers must obtain an NPI as soon as possible and must provide the NPI when billers/payers request it. For more information, call the TMHP Contact Center at Texas Medicaid Bulletin, No September/October 2006

11 All Providers Providing Health Care Services for Rita Evacuees On April 28, 2006, CMS authorized Texas to cover health care services for hurricane Rita evacuees. The amendment covers health care provided to hurricane Rita evacuees who reside in one of the covered counties or parishes* and did not have other health insurance coverage. The coverage period was from September 23, 2005, to January 31, Providers are eligible for reimbursement for services provided in accordance with Texas Medicaid State Plan in place on September 23, 2005, and are reimbursed at the Texas Medicaid rates. Benefits include health care, long-term care, prescription medicines, and medical transportation. Services that were not part of Texas State plan on September 23, 2005, and are not eligible for reimbursement, include: Hearing aids Eyeglasses and contact lenses Services provided by podiatrists, chiropractors, licensed clinical social workers, licensed marriage and family therapists, licensed psychologists, and licensed professional counselors Providers are able to file claims retroactively up to one year after the date of service for services provided during the coverage period. To receive payment for services, providers will need to file claims through the Texas Medicaid system. Providers will receive specific instructions for filing claims as soon as possible. Monitor the TMHP website at for updates. For claims covered under this provision the following information, at a minimum, will be required: client name, Social Security number (if available), date of birth, sex, age, and ZIP Code. The client s ZIP Code must be in a declared disaster area for the claim to be eligible for payment. The claims submitted also must include services provided and dates of service. Claims should not be submitted for services when a provider has received payment from an individual or organization as part of a public or private hurricane relief effort. Uncompensated care claims paid through this provision cannot be counted as uncompensated care in the hospitalspecific disproportionate share hospital limit as defined in section 1923(g)(1)(A) of the Social Security Act.. Claims will be retrospectively reviewed. HHSC will provide more information about claims submissions. Providers are asked to hold claims until they receive filing instructions. Visit the TMHP website for updates at *Individual Assistance Designated Counties and Parishes for Hurricane Rita Louisiana Acadia, Allen, Ascension, Cameron, Calcasieu, Beauregard, Evangeline, Iberia,Jefferson, Jefferson Davies, Lafayette, Lafourche, Livingston, Plaquemines, Sabine, St. Landry, St. Martin, St. Mary, Terrebonne, Vermilion, Vernon, and West Baton Rouge. Texas Angelina, Brazoria, Chambers, Fort Bend, Galveston, Hardin, Harris, Jasper, Jefferson, Liberty, Montgomery, Nacagdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, Tyler, and Walker. Medicaid Buy-In Program for Employed Individuals with Disabilities Effective September 1, 2006, HHSC implemented a statewide Medicaid Buy-In Program, which allows employed individuals with disabilities to receive Medicaid services by paying a monthly premium. Individuals with earnings of up to 250 percent of the federal poverty level are eligible to participate in the program. Applications for the program are accepted through HHSC s regular Medicaid application process. From a provider perspective, there is no distinction between Medicaid Buy-In participants and other Medicaid clients. Participants are eligible for the same Medicaid benefits afforded to other Medicaid clients. Participants will have a Medicaid identification card that indicates the Medicaid services for which they are eligible. Medicaid Buy-In participants in urban service areas will be served through traditional Medicaid (fee-for-service) and those in PCCM expansion counties will be served through PCCM. For more information, visit the HHSC website at or call the TMHP Contact Center at September/October Texas Medicaid Bulletin, No. 198

12 All Providers Billing for Physician Evaluation and Management Procedure Codes Changing Effective for dates of service on or after September 1, 2006, physician evaluation and management procedure codes will be updated in Compass21 to reflect and enforce current policy. To improve consistency in enforcement of guidelines, TMHP and HHSC recently reviewed policies for billing physician evaluation and management procedure codes. Effective September 1, 2006, TMHP will update Compass21 to reflect and enforce the current policy with the following changes: Procedure Code Limitation 99201, 99202, 99203, 99204, Limited one code per day, per provider , 99212, 99213, 99214, Limited one code per day, per provider , 99222, Limited one code per day, per provider. Denied if billed on the same day by the same provider as procedures 99295, 99296, 99298, 99299, or , 99232, Limited one code per day, per provider. Denied if billed on the same day by the same provider as procedures 99295, 99296, 99298, or , 99242, 99243, 99244, Denied if billed on the same day by the same provider as procedures 99281, 99282, 99283, 99284, or , Denied if billed on the same day by the same provider as procedure , 99296, 99298, Limited one code for payment per day, per provider Denied if billed on the same day by the same provider as procedures or Denied if billed on the same day by the same provider as procedures or , 99342, 99343, 99344, Limited one code per day, per provider. Denied if billed on the same day by the same provider as procedures 99281, 99282, 99283, 99284, or , 99348, 99349, Denied if billed on the same day by the same provider as procedures 99341, 99342, 99343, 99344, or , Denied if billed on the same day by the same provider as procedures 99298, or , 99432, 99433, Limited one code per day, per provider. Refer to the following provider manuals for additional information: 2006 Texas Medicaid Provider Procedures Manual, Section 36 Physician Services and Section 26 Newborn Services 2006 CSHCN Provider Manual Part I, Section 16 Physician For more information, call the TMHP Contact Center at or the TMHP-CSHCN Contact Center at Texas Medicaid Bulletin, No September/October 2006

13 All Providers Issues Impacting Claims Incorrectly Denied Procedure Codes TMHP has identified an issue impacting claims submitted for dates of service October 16, 2003, through June 30, 2006, for the Texas Medicaid and CSHCN Services Programs that include the following procedure codes: Procedure Codes A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4338 A4340 A4344 A4346 A4354 A4355 A4356 A4357 A4358 A5102 A5112 A5113 A5114 A5200 These procedure codes may have been incorrectly denied when billed for two or more units during the same calendar month. These claims will be reprocessed and payments adjusted accordingly. Claim adjustments will be reflected on providers R&S reports. No action on the part of the provider is necessary. DME Procedure Codes TMHP has identified an issue with durable medical equipment (DME) procedure codes that have been denied incorrectly for the Texas Medicaid and CSHCN Services Programs. The affected procedure codes should deny when benefit limitations are exceeded within the same calendar month of service. However, the procedure codes were denying incorrectly for dates of service one calendar month before and one calendar month after the submitted date of service. Claims submitted for dates of service October 16, 2003, through June 23, 2006, that include these procedure codes were reprocessed and payments adjusted accordingly. Procedure Codes J0881 and Q0137 TMHP has identified an issue impacting claims that include procedure codes J0881 and Q0137 submitted for dates of service May 19, 2003, through January 1, 2006, for the Texas Medicaid Program. These procedures may have been incorrectly denied when billed without modifier KX. Claims submitted for dates of service May 19, 2003, through January 1, 2006, that include these procedure codes without modifier KX have been reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Procedure Code TMHP has identified an issue impacting claims submitted for dates of service on or after May 3, 2003, through May 5, 2006, where procedure code was denied incorrectly when billed with diagnosis code TMHP has identified impacted claims. These claims have been reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Procedure Code TMHP has identified an issue impacting claims that include procedure code submitted for dates of service November 4, 2005, through May 31, 2006, for the Texas Medicaid Program. Claims submitted by the following provider types that included this procedure code may have denied inappropriately: Family nurse practitioner (FNP) Pediatric nurse practitioner (PNP) Doctor of osteopathy (DO) Medical doctor (MD) Physician group (MD and DO) Registered nurse/certified nurse midwife (RN/CNM) These claims have been reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Procedure Code 9-A4483 TMHP has identified an issue impacting claims that include procedure code 9-A4483 submitted for dates of service September 1, 2003, through May 19, 2006, for the Texas Medicaid and CSHCN Services Programs. Providers may have received payments that were incorrectly reduced by 2.5 percent. Claims submitted for dates of service September 1, 2003, through May 19, 2006, that include this procedure code will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Eligibility File TMHP has identified an issue where the January 4, 2006, eligibility file was not successfully processed for a two-week time period. During this time a small number of claims processed in error based on out-of-date eligibility information. TMHP has identified all impacted claims. These claims will be reprocessed and payments adjusted accordingly. Claim adjustments will be reflected on providers R&S reports. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at or the TMHP-CSHCN Contact Center at September/October Texas Medicaid Bulletin, No. 198

14 All Providers Medicare Adjusted Claims Policy This is a clarification to a banner message that appeared in the February 17, 2006, R&S report about the submission of Medicare-adjusted claims. Providers billing on a HCFA (UB-92) paper claim form must submit the Medicare Remittance Advice (RA)/Remittance and Notice (RN) with a completed claim form. Providers billing on a CMS paper claim form are only required to submit the Medicare RA or RN and are not required to submit a claim form. Following is the complete revised article: TMHP implemented the following paper submission guidelines for Medicare-adjusted claims effective for claims received on or after March 31, 2006: When submitting a Medicare-adjusted claim, send only the adjusted Medicare RA/RN. TMHP does not require the submission of the original RA/RN or the Medicaid R&S report. The Medicare-adjusted claim will be processed as a first time claim submission, which will be referenced in the Claims - Paid or Denied section of the providers R&S report. Providers billing on a HCFA-1450 (UB-92) paper claim form must submit the RA or RN with a completed claim form. Providers who have received a letter requesting a claim form must also return the letter with their claim form submission. Providers billing on a CMS-1500 paper claim form are only required to submit an RA or RN submission. The claim form is optional; however, all the required information must be included on the RA/RN for Medicaid processing. TMHP has implemented system modifications in an effort to decrease the submission of appeals for denied Medicare crossover claims due to duplication. The system modification will allow these claims to be processed on the initial submission. Prior to March 31, 2006, TMHP auto-denied these claims and considered the claim for payment on an appeal basis. For more information, call the TMHP Contact Center at Radiology Services Update The following information is an update to the article titled Prior Authorization for Radiology Services published in the May/June 2006 Texas Medicaid Bulletin, No. 195, on page 16 and on the TMHP website at Effective for dates of service on or after July 1, 2006, the following changes are in effect: The deadline for requesting a retroactive authorization for emergent/ urgent needs has been extended from two days to seven calendar days. The definition of emergent/urgent services considered under the retroactive authorization guidelines has been expanded to include additional studies conducted at the time of the test if medically indicated by the radiologist. Original signature guidelines still apply. The revised Radiology Prior Authorization Request Form, available on the TMHP website and located on page 39 of this bulletin, includes an additional signature line (in Section 2 of the form) to be used when the radiologist at the time of imaging determines that additional studies are needed. This form will need to be signed and submitted to TMHP for retroactive authorization within seven business days and a copy maintained in the medical record. If radiology services are ordered by a referring physician that is not a Medicaid enrolled provider in places of service such as teaching facilities, federally qualified health care centers, and rural health clinics, the Radiology Prior Authorization Request Form must be signed by the referring physician but also include the group/supervising physician s Texas Provider Identifier (TPI). The original Radiology Prior Authorization Request Form published in the May/June 2006 Texas Medicaid Bulletin, No. 195 is no longer accepted as of August 1, For more information, call the TMHP Contact Center at Texas Medicaid Bulletin, No September/October 2006

15 All Providers Third Party Biller Enrollment The 78th Texas Legislature enacted House Bill 2292, which teams HHSC with the Texas Department of State Health Services (DSHS) to combat provider, third-party, and client fraud. Effective May 31, 2007, third party billers (TPBs) will be required to contract with HHSC before submitting electronic claims. TPBs are persons, businesses, or entities (excluding state agencies) that submit claims on behalf of a provider, but are not the provider or an employee of the provider. For these purposes, an employee is a person for which the provider completes an IRS Form W-2 showing annual income paid to the employee. All others meet the definition of TPB. Effective May 31, 2007, HHSC will require TPBs to enter into a contract before claims can be submitted for payment on behalf of any Medicaid provider. The HHSC Office of Inspector General (OIG) will begin performing criminal background checks for all potential TPBs submitting claims for Medicaid, Medicaid Managed Care, and CSHCN Services Programs. Additionally, criminal background checks will be performed for any person or business entity enrolling as a TPB, who meets the definition of indirect ownership interest as defined in Title 1 Texas Administrative Code (TAC) Enrollment for TPBs will begin February 11, The TPB will be required to create an account on the TMHP website at and complete the Third Party Biller Application. The application is available on the TMHP website, but must be printed and mailed to TMHP. Once enrolled, the TPB must submit a request to TMHP to submit claims for a provider. The request will then be confirmed by the provider before any claims can be submitted. Providers can confirm the request by logging into their account at This privilege can be terminated by either the provider or the TPB at any time. Health care providers should do the following: Create an account on the TMHP website at Have the TPB create an account on the TMHP website, on or after February 11, 2007 Have the TPB obtain and submit an enrollment packet from the TMHP website For more information, call the TMHP Contact Center at , or visit the website at Procedure Code Changes Procedure code Effective for dates of service from October 1, 2003, through December 31, 2005, procedure code will be considered for reimbursement when performed in office or home settings. Effective for dates of service from January 1, 2004, through December 31, 2005, procedure code will be considered for reimbursement when performed in an outpatient setting. Claims submitted for dates of service from October 1, 2003, through December 31, 2005, that include this procedure code will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Effective for dates of service on or after January 1, 2006, procedure code was discontinued with the 2006 HCPCS implementation. Procedure code E0316 Effective for dates of service on or after September 1, 2006, procedure code E0316 is a benefit of the Texas Medicaid Program for purchase only. Providers must submit procedure code E0316 instead of procedure code E1399 when billing for safety enclosures for hospital beds. Procedure code E0316 is restricted to clients younger than 21 years of age. For more information, call the TMHP Contact Center at September/October Texas Medicaid Bulletin, No. 198

16 All Providers/Durable Medical Equipment Providers Texas Medicaid Benefits Changes Evaluation and Management Services Benefits Effective for dates of services on or after January 1, 2006, benefits for evaluation and management services changed. The following procedure codes are a benefit when performed in nursing home or specialized nursing home settings: Procedure Codes Procedure codes 99335, 99336, and for domiciliary or rest home visits are only a benefit when performed in nursing home or specialized nursing home settings and are no longer a benefit in the home setting. Procedure codes and for individual physician supervision are a benefit when performed in the home, nursing home, or specialized nursing home settings. Claims submitted for dates of service from January 1, 2006, through June 16, 2006, that include the following procedure codes have been reprocessed and payment adjusted accordingly. Procedure Codes Nursing Facility Procedure Codes Effective for dates of service on or after January 1, 2004, nursing facility procedure codes and are a benefit when performed in nursing home and specialized nursing home settings. Claims submitted for dates of service January 1, 2004, through June 16, 2006, that include these procedure codes have been reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Procedure Code Effective for dates of service on or after September 1, 2003, procedure code is not payable to advanced practice nurse and registered nurse/certified nurse-midwife providers. Claims submitted for dates of service from September 1, 2003, through September 15, 2006, that include procedure code will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. Procedure Codes 70544, 70545, and Effective for dates of service on or after November 1, 2005, procedure codes 70544, 70545, and are benefits of the Texas Medicaid Program when performed in an office, home, nursing home, or specialized nursing facility by a physician (MD) and doctor of osteopathy (DO), physician group (MD, DO), portable X-ray supplier, nephrology facility, or renal dialysis facility. Effective for dates of service on or after May 1, 2006, procedure codes 70544, 70545, and are benefits of the Texas Medicaid Program only for the total component for hospitals (long-term, limited, specialized, private full care, and emergency care only). The technical and interpretation components cannot be billed separately by these providers. Claims submitted for dates of service November 1, 2005, through May 19, 2006, that include procedure codes 70544, 70545, and have been reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at or the TMHP-CSHCN Contact Center at DURABLE MEDICAL EQUIPMENT PROVIDERS Incontinence Supplies and External Urinary Collection Devices This is a clarification of benefits for incontinence supplies provided by durable medical equipment (DME) providers. Skin sealants/protectants/moisturizers/ointments and external urinary collection devices for clients younger than 4 years of age require prior authorization through the Texas Health Steps-Comprehensive Care Program (THSteps-CCP). Documentation of a medical condition resulting in an increased urine and/or stool output beyond the typical output for this age group is required for reimbursement consideration. For more information, call the TMHP Contact Center at Texas Medicaid Bulletin, No September/October 2006

17 Durable Medical Equipment Providers/Hospital Providers/Primary Care Case Management Providers Forms and Prior Authorization for Mobility Aids Procurement Mobility aids, such as wheelchairs and scooters, when prior authorized are considered for reimbursement to DME providers. The guidelines for requesting prior authorization are located in the 2006 Texas Medicaid Provider Procedures Manual.. Refer to Mobility Aids Sections on page 25-36, and on page Providers must submit a completed and signed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form indicating the correct Health Care Common Procedure Coding System (HCPCS) code. Effective for dates of service on or after August 1, 2006, the Wheelchair/Scooter/Stroller Seating Assessment Form must be submitted with requests for a wheelchair or scooter. The form must be completed by a physician or a licensed physical or occupational therapist to obtain prior authorization for custom manual and power wheelchairs, standard power wheelchairs, and scooters. The manufacturer s suggested retail price (MSRP) for each requested item must be included in the request for prior authorization. Providers should verify that the wheelchair requested is appropriate for the client s physical measurements of height, weight, hip width, and hip depth. The Wheelchair/Scooter/Stroller Seating Assessment Form has been revised and replaces the Wheelchair Seating Evaluation Form located on page B-115 of the 2006 Texas Medicaid Provider Procedure Manual. The new form is available on the TMHP website at and on page 29 of this bulletin. Mobility Aids Benefit Changes Effective for dates of service on or after August 1, 2006, benefit criteria changed for the following durable medical equipment: Procedure code E0110 is no longer payable in an outpatient setting or to outpatient facilities. Procedure codes E0955, E2361, and E2366 is no longer payable in an office and other (unspecified) settings. Procedure code E0992 does not have age restrictions. For more information, call the TMHP Contact Center at Inpatient Hospital Rate Change Effective September 1, 2006, HHSC, in accordance with legislative direction, is implementing an initiative that includes a rate reduction that will be applied to inpatient hospital services rendered to non-medicare Supplemental Security Income (SSI) and SSI-related Medicaid clients. The rate reduction will affect hospital providers within the Bexar, Dallas, El Paso, Lubbock, Tarrant, Harris, Nueces, and Travis service areas that are reimbursed by diagnosis-related grouping (DRG). Inpatient hospital services rendered to Primary Care Case Management (PCCM) clients will continue to be reimbursed under current PCCM negotiated rates. Tax Equity and Fiscal Responsibility Act (TEFRA) reimbursed facilities will not be affected by the rate reduction. The legislative direction was included in the General Appropriations Act (Article II, Section 49, S.B. 1, 79th Legislature, Regular Session, 2005). For more information, call the TMHP Contact Center at PRIMARY CARE CASE MANAGEMENT PROVIDERS PCCM Claims Being Reprocessed TMHP has identified an issue impacting claims that include the following procedure codes: Procedure codes S0820 Primary Care Case Management (PCCM) claims containing these procedure codes submitted for dates of service from January 1, 2004, through July 27, 2006, did not have the required two-per-day limitation applied to them. Impacted claims will be reprocessed and payments adjusted accordingly. Claim adjustments will be reflected on providers Remittance and Status (R&S) reports. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at September/October Texas Medicaid Bulletin, No. 198

18 Primary Care Case Management Providers/SHARS Providers Providers Can Serve Both PCCM and HMO Clients In recent months, providers were mailed information about upcoming Medicaid Managed Care program changes affecting PCCM clients in the State of Texas Access Reform (STAR) Program, detailed on page 4 of this bulletin. HHSC mailed out initial notification letters and enrollment kits to clients in July PCCM primary care providers in the STAR metropolitan areas have contracted with health maintenance organizations (HMOs) to provide the best health care options for the clients who will be affected by this change. Providers should consider that choosing an HMO does not require they terminate their contracts with PCCM. Providers may contract simultaneously with an HMO(s) and PCCM. While PCCM Medicaid clients (except Supplemental Security Income [SSI] -related clients) living in the Bexar, Dallas, El Paso, Harris, Harris Expansion, and Lubbock Service Areas will no longer have PCCM as an option for Medicaid covered health care services, PCCM still needs primary care providers. By remaining enrolled in PCCM, providers ensure continuity of care for each PCCM client in those STAR metropolitan areas as they transition to an HMO. In addition, PCCM providers in the STAR metropolitan areas are encouraged to continue to provide ongoing health care services to PCCM clients who live in contiguous areas not affected by the changes. There may be instances where PCCM clients who reside in the rural areas (PCCM Expansion) may choose a PCCM primary care provider in a metropolitan (STAR) service area. Medicaid Managed Care thrives on the doctor/client alliance and the health care services that primary care physicians provide for their patients. For more information about STAR Medicaid program changes and the affected service areas, refer to the July/ August 2006 Texas Medicaid Bulletin, No SCHOOL HEALTH AND RELATED SERVICES PROVIDERS District-Specific Interim Rates for SHARS Providers Implemented Effective for dates of service September 1, 2006, through August 31, 2007, individual school districts providing School Health and Related Services (SHARS) to Medicaid-eligible students will be paid district-specific interim rates. The Centers for Medicare & Medicaid Services (CMS) is requiring all school-based services programs (known as SHARS in Texas) to implement annual cost reporting, cost reconciliation, and cost settlement processes. HHSC will provide district-specific interim rates as close as possible to each district s actual allowable costs for providing each service, which will prevent significant over- or underpayments during the cost settlement process. Procedure Codes Effective for dates of service on or after September 1, 2006, the procedure codes and modifiers in the table on pages 19 and 20 are benefits of the Texas Medicaid Program for SHARS providers. Each school district will be assigned district-specific interim rates for the 40 sets of procedure codes and modifiers listed in the table. Providers must submit procedure codes with the applicable modifiers listed in the table to ensure correct claims processing and reimbursement. The Texas Education Agency (TEA) will send a SHARS ListServ to all members notifying school districts when the district-specific rates are available and will provide the link to the HHSC Rate Analysis website. The HHSC Rate Analysis website will be updated when new districtspecific SHARS rates are added. Providers will be able to access their district-specific interim rates by provider name and TEA county district number from the HHSC Rate Analysis website at programs/rad/index.html. Providers must not fi le claims with dates of service on or after September 1, 2006, until they have been issued their district-specific interim rates for the applicable service. Claims submitted with dates of service on or after September 1, 2006, by providers who have not been issued their district-specific interim rates will be paid $0. Providers will be required to resubmit unpaid claims for reconsideration of payment once their district-specific interim rates have been issued. Texas Medicaid Bulletin, No September/October 2006

19 SHARS Providers Current Procedure Code Mod 1 Mod 2 SHARS Category of Service Unit of Service Audiology U9 Evaluation 15 minutes U9 Individual, by licensed therapist 15 minutes U1 Individual, by licensed/certified assistant 15 minutes U9 Group, by licensed therapist 15 minutes U1 Group, by licensed/certified assistant 15 minutes Speech Therapy GN Evaluation 15 minutes GN U8 Individual, by licensed therapist 15 minutes GN U1 Individual, by licensed/certified assistant 15 minutes GN U8 Group, by licensed therapist 15 minutes GN U1 Group, by licensed/certified assistant 15 minutes Physical Therapy Evaluation 15 minutes GP Individual, by licensed therapist 15 minutes GP U1 Individual, by licensed/certified assistant 15 minutes GP Group, by licensed therapist 15 minutes GP U1 Group, by licensed/certified assistant 15 minutes Occupational Therapy Evaluation 15 minutes GO Group, by licensed therapist 15 minutes GO U1 Group, by licensed/certified assistant 15 minutes GO Individual, by licensed therapist 15 minutes GO U1 Individual, by licensed/certified assistant 15 minutes Counseling UB Individual 15 minutes UB Group 15 minutes Psychological Services AH Individual 15 minutes AH Group 15 minutes Registered Nurse T1002 TD Individual 15 minutes T1002 TD UD Group 15 minutes T1502 TD Medication administration per visit Per visit T1002 U7 Delegation, individual 15 minutes T1002 U7 UD Delegation, group 15 minutes T1502 U7 Delegation, medication administration per visit Per visit Licensed Vocational Nurse/Licensed Practical Nurse T1003 TE Individual 15 minutes T1003 TE UD Group 15 minutes T1502 TE Medication administration per visit Per visit September/October Texas Medicaid Bulletin, No. 198

20 SHARS Providers Current Procedure Code Mod 1 Mod 2 SHARS Category of Service Unit of Service Personal Care Services T1019 U5 School, individual 15 minutes T1019 U5 UD School, group 15 minutes T1019 U6 Bus, individual Per one-way trip T1019 U6 UD Bus, group Per one-way trip Transportation Services T2003 Special transportation Per one-way trip Assessment Services Assessment services Per hour (or /10th of an hour) Medical Services Medical services 15 minutes Certification of Funds The current certification of funds process is based on claims paid within state fiscal year quarters that fall within the dates of September 1, to August 31. Effective October 1, 2006, the certification periods will be based on the following federal fiscal year quarters: October 1 through December 31 January 1 through March 31 April 1 through June 30 July 1, through September 30 Changing certification periods to the federal fiscal year quarters aligns with Medicaid reporting requirements to CMS. The certification of funds must be completed by each school district. Effective October 1, 2006, the certification can no longer use the shared services arrangement (SSA) letter. Certification letters must be signed by the business officer or other financial staff with signature authority. Because certification must be completed by each school district, new Texas Provider Identifiers (TPIs) will be assigned to members of SSAs effective September 1, Refer to the Enrollment section of this article for more details. Since the state fiscal year quarters are changing to federal fiscal year quarters effective October 1, 2006, the fourth quarter certification letters for state fiscal year 2006 will cover June, July, August, and September. Providers currently billing as individual school districts will not require a new TPI and will receive a fourth quarter state fiscal year 2006 Certification of Funds letter covering the state fiscal year four month period (June, July, August, and September). Providers that are members of SSAs and receive new TPIs effective September 1, 2006, will receive a fourth quarter state fiscal year 2006 Certification of Funds letter under their old TPI for June, July, and August. Also, providers will receive a fourth quarter state fiscal year 2006 Certification of Funds letter under their new TPI for September. The Certification of Funds letter for the newly issued TPI will be addressed to the business officer. Providers wishing to designate within the school district, the Business Officer, or other financial staff person with signature authority to receive and sign the Certification of Funds letters may submit a Provider Information Change (PIC) Form to TMHP to update this information. The PIC Form is available on page 32 of this bulletin and is also available on the TMHP website at under Provider Enrollment Forms. Effective October 1, 2006, Certification of Funds letters based on federal fiscal year quarters will have the following changes: The letters will include new language at the direction of CMS. The letters will include a federal, state, and total amount allowing the provider to make the required certification of funds. The letters will include the Federal quarter ending date for clarity. The letters will combine both Programs 100 (Medicaid fee-for-service) and 200 (Medicaid PCCM) amounts. The letters will no longer contain the total billed amounts submitted by providers. Texas Medicaid Bulletin, No September/October 2006

21 SHARS Providers/Texas Health Steps Providers Providers will receive or have access to the Certification Claims Information Report which includes all claims included in the certification period. Providers will receive the report through the same mode of transmission currently on fi le for receipt of the Remittance and Status (R&S) report (i.e., portal or paper). Enrollment SHARS providers currently participating in SSAs/co-ops that bill under the umbrella of a group provider (fiscal agent) with the individual school district identified as a performing provider will be automatically issued a new TPI for each school district associated to a group if actively enrolled. The current performing provider TPIs (individual school districts) consist of a 7-digit base and a 2-digit suffi x. TMHP will issue a new TPI to the individual school district with the same 7-digit base and a new 2-digit suffi x. TMHP will deactivate the old TPI to discontinue payment for any claims received with dates of service on or after September 1, Claims billed with dates of service before September 1, 2006, must continue to be billed under the group TPI identifying the individual school district as the performing provider. The new TPI will be effective for dates of service on or after September 1, The newly issued TPI will be mailed to the individual school district s physical mailing address on fi le with TMHP. Each provider issued a new TPI that wishes to continue with an SSA will be responsible for notifying and providing the fiscal agent of the SSA with their new TPI for billing purposes. TMHP will associate the R&S report and banking (financial) information identified on the current group TPI (fiscal agent) to the individual school district s new TPI. The fiscal agent is required to fi le each school district s claims using the individual TPI for claims with dates of service on or after September 1, TMHP will no longer issue SHARS providers a group TPI for dates of service on or after September 1, Claims with dates of service on or after September 1, 2006, will no longer be paid when billed by SHARS providers with a TPI designated as a group. This change in billing is required in order to address the cost settlement, reconciliation, and certification of funds processes that CMS requires to be implemented at the individual school district level. The financial information in the current Medicaid Claims Processing System is associated at a billing provider level (i.e., the fiscal agent level of the SSA) and does not allow for capturing of the financial information at the performing provider level (i.e., individual school district level). Claims Filing SHARS providers must fi le claims for dates of service during state fiscal year 2007 (i.e., September 1, 2006, through August 31, 2007) in a timely manner so that the cost reporting, cost reconciliation, and cost settlement processes for those services can be completed by August 31, All claims for state fiscal year 2007 dates of service must be submitted within the 365-day fi ling deadline or 95 days from the end of state fiscal year 2007 (i.e., on or before December 4, 2007), whichever comes first. Providers are encouraged to fi le claims 95 days from the date of service to ensure all claims have been received and captured for the cost settlement. Resources For questions related to SHARS district-specific interim rates, providers can Gary Crane, HHSC Rate Analyst, at gary.crane@hhsc.state.tx.us. For questions related to program policy, payment issues, or any questions other than rates, call the TMHP Contact Center at TEXAS HEALTH STEPS PROVIDERS Compass21 Update Effective September 1, 2006, TMHP will update Compass21 to reflect and enforce the current policy surrounding audiometric procedure codes and Texas Health Steps (THSteps) medical checkup procedure codes. Audiometric procedure codes and will not be reimbursed by the Texas Medicaid Program if billed on the same day by the same provider with any of the following THSteps medical check-up procedure codes: Procedure Codes Effective September 1, 2006, TMHP will update Compass21 to reflect and enforce the current policy surrounding cytopathology procedure codes and THSteps medical checkup procedure codes. Cytopathology procedure codes 88142, 88147, and 88164, will not be reimbursed by the Texas Medicaid Program if billed by the same provider on the same day as THSteps medical checkup procedure codes 99384, 99385, 99394, or For more information, call the TMHP Contact Center at September/October Texas Medicaid Bulletin, No. 198

22 Excluded Providers Excluded Providers As required by the Medicare and Medicaid Patient Protection Act of 1987, the Texas Health and Human Services Commission (HHSC) identifies providers or employees of providers who have been excluded from state and federal health care programs. Providers excluded from the Texas Medicaid Program and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client. Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by the Texas Medicaid Program for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of HHSC s exclusion list. The HHSC-Sanctions Department submits updates to the exclusion list semi-monthly. Updates appear on the website after the 1st and 15th of each month. Review the entire Texas Medicaid Program exclusion list at To report Medicaid providers who engage in fraud/abuse, call or , or write to the following address: Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity MC-1361 PO Box Austin TX Provider License Start Date Provider City State Add Date Number Type Avionix Medical Devices, Inc. 20-Jan-05 Midland TX 22-May-06 Baruday, Suzanne M Dec-05 LVN Victoria TX 29-Jun-06 Batson, Vicki B Feb-06 LVN Arlington TX 28-Jun-06 Belcher, Benjamin A. 7-Jul-05 RN Philadelphia PA 22-May-06 Berkel, Mary Dec-05 RN Cedar Park TX 5-Jul-06 Bosley, Lucinda D. 14-Feb-06 RN Garrison TX 22-May-06 Bourque, Sharon A. 27-Sep-05 RN Gainesville GA 22-May-06 Boyd, Jr., Wesley A. 20-Jan-06 Oakdale LA 20-Jul-06 Brock, Stephanie D. 13-Dec-05 LVN Lumberton TX 22-May-06 Broussard, Jerry G. 20-Dec-05 Beaumont TX 23-Jun-06 Brower, Sheri A Feb-06 LVN Porter TX 29-Jun-06 Butts, Frank M. 20-Oct-05 Dallas TX 20-Jul-06 Castellano, Monica Ann 20-Sep-05 Houston TX 22-May-06 Church, Jennifer S Feb-06 LVN Hutto TX 29-Jun-06 Cook, Stephanie A. 20-Jun-05 Checotah OK 29-Jun-06 Cortinas, Lydia M. 14-Jun-06 Stafford TX 12-Jul-06 Cross, Corliss Jan-06 RN Sadler TX 29-Jun-06 Crumley, David N Feb-05 LVN Cedar Park TX 29-Jun-06 Cunningham, Tiffany R. 24-Jun-06 CNA Brownfield TX 13-Jul-06 Daley, Ruth H Jul-06 LVN Benbrook TX 20-Jul-06 Darner, Mark A. 20-Sep-05 DC Arlington TX 01-Jun-06 Texas Medicaid Bulletin, No September/October 2006

23 Excluded Providers Provider License Start Date Provider City State Add Date Number Type Detiveaux, Floyd J. 3-Jun-05 LVN McAllen TX 22-May-06 Diaz, Magdelena J. 20-Feb-05 Houston TX 30-Jun-06 Duncan, Damara N. 12-Jan-06 LVN Wichita Falls TX 22-May-06 Dupuy, Burton Feb-06 RN Carrollton TX 30-Jun-06 Durben, Caryn S Feb-06 LCSW Plainview TX 21-Jun-06 East Harris County 20-Feb-06 OrthP Houston TX 22-May-06 Orthopedics Associate Edoho-Ukwa, Anietie H. 20-Apr-05 McKinney TX 05-Jun-06 Edoho-Ukwa, Ukwa H. 20-Apr-06 Frisco TX 22-Jun-06 Ekong, Affiong I Jul-05 RN Houston TX 31-May-06 Elder, Myra A Jan-06 RN Santa Teresa NM 5-Jul-06 Executive Scientific 15-Jun-06 DME Houston TX 12-Jul-06 Fitzgerald, Tamara Sep-05 LVN Houston TX 21-Jun-06 Garcia, Jesse G. 14-Feb-06 LVN San Antonio TX 22-May-06 Glasgow, Cathy A. 22-Jul-05 RN Whitesboro TX 22-May-06 Gonzales, Dawn D Feb-06 LVN Smithville TX 30-Jun-06 Grotti, Lydia H. J Apr-06 MD Midland TX 21-Jun-06 Groves, Yvonne C. 12-Oct-05 LVN Bronx NY 22-May-06 Harris, Tammy Y. 20-Mar-06 Gatesville TX 26-Jun-06 Hayes, Vanessa L Dec-05 RN Orange TX 29-Jun-06 Hickman, Joyce L. 20-Oct-02 Fort Worth TX 25-Jul-06 Houston, Jeffrey S Aug-05 DDS Plano TX 28-Jun-06 Jackson, Jonathan Elliot. 20-Jan-06 Houston TX 27-Jun-06 Johnson, Barbara D. 23-Nov-05 LVN Center TX 22-May-06 Johnson, Cynthia S. 20-Feb-06 Victoria TX 20-Jun-06 Jones, Sheree M. 14-Feb-06 RN LVN Krum TX 22-May-06 Keffeler, Carlee J. 20-May-06 Heavener OK 23-Jun-06 Keffeler, Daniel A. 23-May-06 Midlothian TX 23-Jun-06 Kincaid, Kim 14-Feb-06 RN McKinney TX 22-May-06 Kindig, Charles Mar-06 LVN Ft Worth TX 21-Jun-06 King, Leila Sep-98 LVN San Antonio TX 24-Jul-06 Kirkpatrick, Carol A. 18-Aug-05 Austin TX 22-May-06 Klein, Ira 9-Dec-05 MD Houston TX 22-May-06 Lamb, Vincent E. 13-Dec-05 LVN Houston TX 22-May-06 Lee (Payton), Joe 23-Dec-03 owner Houston TX 26-Jul-06 Lee, Ruthie Mae 23-Dec-03 owner Houston TX 26-Jul-06 Levalley, Kimberly Annette Dec-05 CNA Childress TX 22-Jun-06 Long, Sylvia 14-Jun-06 Hillsboro TX 12-Jul-06 Lopez, Richard Jan-06 RN Houston TX 12-Jul-06 Magee, Ursula Sep-05 RN Dallas TX 25-May-06 Martinez, Lugardha M. 19-Jan-05 San Angelo TX 30-May-06 Martinez, Synthia K Mar-05 RN Tyler TX 30-Jun-06 Mawhood, Christi 18-Aug-05 RN Katy TX 22-May-06 September/October Texas Medicaid Bulletin, No. 198

24 Excluded Providers Provider License Start Date Provider City State Add Date Number Type McDaniel, Janet 18-Aug-05 Houston TX 22-May-06 Mjoseth, Sherry Dec-05 RN Euless TX 28-Jun-06 Muffoletto, Scott L. 5-Jun-05 RN Live Oak TX 22-May-06 Naples, James J Mar-06 DPM Texarkana TX 19-Jul-06 Norris, Kimberly Annette Dec-05 CNA Childress TX 22-Jun-06 Nsekpong, Michael D. 20-Jun-05 Seagoville TX 12-Jul-06 Okoro, Chijioke V. H Aug-05 MD Forrest City AR 22-Jun-06 Omnia Healthcare Group 20-Oct-05 PT Houston TX 20-Jul-06 Osegueda, Vicki A Feb-06 LVN Cuero TX 29-Jun-06 Patterson, Jenny L Feb-06 LVN Aransas Pass TX 28-Jun-06 Phycare Healthcare Systems 19-Jun-06 Oakdale LA 20-Jul-06 Poepke, Rhonda G Jun-06 LPC Lufkin TX 25-Jul-06 Portinga, Donna J. 14-Jun-06 Wylie TX 12-Jul-06 Rana, Athar F Aug-05 MD Odessa TX 16-Jun-06 Red, Sunny Mar-06 LVN McKinney TX 30-Jun-06 Reece, Henry L. 20-Oct-05 Missouri City TX 20-Jul-06 Ross, Marsha K Mar-06 RN Denton TX 30-Jun-06 Sauceda, Michelle D. 20-Feb-05 RN Arlington TX 22-May-06 Slaton, Mary L Jan-05 RN Kaneohe HI 20-Jul-06 Smith, Nancy A. 14-Feb-06 RN Bulville TX 22-May-06 Smothers Way, Nancy Jul-06 LVN Forth Worth TX 20-Jul-06 Storey, James M Apr-05 LVN Mount Pleasant TX 5-Jul-06 Sturtevant, Tammy L Dec-05 LVN Stephenville TX 30-Jun-06 Svoboda, Maria May-06 LVN El Campo TX 25-May-06 T M M Medical Group 20-Oct-02 Houston TX 26-Jul-06 Thompson, Patricia S. R Aug-05 RN Albany GA 29-Jun-06 Trinity DARC 2285-A 15-Jun-06 Houston TX 12-Jul-06 Upchurch, Yalinda R. 14-Feb-06 RN Elkhart TX 22-May-06 VIP Medical Clinic Inc 20-Oct-02 Houston TX 26-Jul-06 VIP Pharmacy Oct-02 Pharm Houston TX 26-Jul-06 Wang, Tien-Shih Jul-06 DDS Houston TX 19-Jul-06 Warr, Robert B. H Dec-05 MD Texarkana TX 5-Jul-06 Washington, Sandra A. 13-Dec-05 RN Sherman TX 22-May-06 Wikoff, Richard P. L Dec-05 MD Fort Worth TX 27-Jun-06 Winder, Sarah A Jul-06 LVN Nacogdoches TX 26-Jul-06 Wise, Nichelle L. 24-Apr-06 Houston TX 31-May-06 Texas Medicaid Bulletin, No September/October 2006

25 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 Texas Provider Identifier (TPI) and R&S number. EFT funds are released by TMHP to depository financial institutions each Friday. The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received. TMHP must provide the following notification according to ACH guidelines: Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date. However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer s needs. In all cases, credits received should be posted to the customer s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date. To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or deposit slip with the agreement to the TMHP address indicated on the form. Call the TMHP Contact Center at for assistance. September/October Texas Medicaid Bulletin, No. 198

26 Forms Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form NOTE: Complete all sections below and attach a voided check or a photocopy of your deposit slip. Type of Authorization: NEW CHANGE Provider Name Nine Character Billing TPI Provider Accounting Address Bank Name 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: Texas Medicaid Bulletin, No September/October 2006

27 Forms Provider Information Change Form Traditional Medicaid, Children with Special Health Care Needs (CSHCN), and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page. Check the box to indicate a PCCM Provider Date: 9-digit Texas Provider Identifier (TPI): Provider Name: List any additional TPIs that use the same provider information: TPI: TPI: TPI: TPI: TPI: TPI: Physical Address* Accounting/Mailing Address** Secondary Address City: City: City: State: ZIP: State: ZIP: State: ZIP: Phone: ( ) Phone: ( ) Fax: Fax: Fax: Phone: ( ) Type of Change: (Check the appropriate box below.) Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/Add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance) Comments: Tax Information Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS) Tax ID Number: Effective Date: Exact name reported to the IRS for this Tax ID: The signature and date are required or the form will not be processed. Provider Signature: Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Date: Fax: * The physical address cannot be a PO Box. Traditional Medicaid providers who change their ZIP code must submit a copy of the Medicare letter along with this form. ** All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form. September/October Texas Medicaid Bulletin, No. 198

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

29 Forms Wheelchair/Scooter/Stroller Seating Assessment Form (THSteps-CCP/Home Health Services) (Next 6 pages) Instructions A current wheelchair seating assessment conducted by a physical or occupational therapist must be completed for purchase of or modifications (including new seating systems) to a customized wheelchair. Please attach manufacturer information, descriptions, and an itemized list of retail prices of all additions that are not included in base model price. Complete Sections I-VI for manual wheelchairs. Complete Sections I-VII for power wheelchairs. Client Information First name: Medicaid number: Last name: Date of birth: Diagnosis: Height: Weight: I. Neurological Factors Indicate client s muscle tone: Hypertonic Absent Fluctuating Other Describe client s muscle tone: Describe active movements affected by muscle tone: Describe passive movements affected by muscle tone: Describe reflexes present: September/October Texas Medicaid Bulletin, No. 198

30 Forms II. Postural Control Head control: Good Fair Poor None Trunk control: Good Fair Poor None Upper extremities: Good Fair Poor None Lower extremities: Good Fair Poor None III. Medical/Surgical History And Plans: Is there history of decubitis/skin breakdown? Yes No If yes, please explain: Describe orthopedic conditions and/or range of motion limitations requiring special consideration (i.e., contractures, degree of spinal curvature, etc.): Describe other physical limitations or concerns (i.e., respiratory): Describe any recent or expected changes in medical/physical/functional status: If surgery is anticipated, please indicate the procedure and expected date: IV. Functional Assessment: Ambulatory status: Nonambulatory With assistance Short distances only Community ambulatory Indicate the client s ambulation potential: Expected within 1 year Not expected Expected in future within years Texas Medicaid Bulletin, No September/October 2006

31 Forms IV. Functional Assessment: Wheelchair Ambulation: Is client totally dependent upon wheelchair? Yes No If no, please explain: Indicate the client s transfer capabilities: Maximum assistance Minimum assistance Moderate assistance Independent Is the client tube fed? Yes No If yes, please explain: Feeding: Dressing: Maximum assistance Minimum assistance Maximum assistance Minimum assistance Moderate assistance Independent Moderate assistance Independent Describe other activities performed while in wheelchair: V. Environmental Assessment Describe where client resides: Is the home accessible to the wheelchair? Yes No Are ramps available in the home setting? Yes No Describe the client s educational/vocational setting: Is the school accessible to the wheelchair? Yes No Are there ramps available in the school setting? Yes No If client is in school, has a school therapist been involved in the assessment? Yes No Name of school therapist: Name of school: School therapist s telephone number: September/October Texas Medicaid Bulletin, No. 198

32 Forms V. Environmental Assessment Describe how the wheelchair will be transported: Describe where the wheelchair will be stored (home and/or school): Describe other types of equipment which will interface with the wheelchair: VI. Requested Equipment: Describe client s current seating system, including the mobility base and the age of the seating system: Describe why current seating system is not meeting client s needs: Describe the equipment requested: Describe the medical necessity for mobility base and seating system requested: Describe the growth potential of equipment requested in number of years: Describe any anticipated modifications/changes to the equipment within the next three years: Therapist s name: Therapist s title: Therapist s signature: Date: Therapist s telephone number: ( ) - Therapist s employer (name): Therapist s address (work or employer address): Texas Medicaid Bulletin, No September/October 2006

33 Forms VII. POWER WHEELCHAIRS: Complete if a power wheelchair is being requested Describe the medical necessity for power vs. manual wheelchair: (Justify any accessories such as power tilt or recline) Is client unable to operate a manual chair even when adapted? Yes No Is self propulsion possible but activity is extremely labored? Yes No If yes, please explain: Is self propulsion possible but contrary to treatment regimen? Yes No If yes, please explain: How will the power wheelchair be operated (hand, chin, etc.)? Has the client been evaluated with the proposed drive controls? Does the client have any condition that will necessitate possible change in access or drive controls within the next five years? Is the client physically and mentally capable of operating a power wheelchair safely and with respect to others? Yes No Is the caregiver capable of caring for a power wheelchair and understanding how it operates? Yes No How will training for the power equipment be accomplished? Therapist s name: Therapist s title: Therapist s signature: Date: Therapist s telephone number: ( ) - Therapist s employer (name): Therapist s address (work or employer address): September/October Texas Medicaid Bulletin, No. 198

34 Forms Home Health/CCP Measuring Worksheet General Information Client s name: Client s Medicaid number: Date when measured: Date of birth: Height: Weight: Measurer s name: Measurer s telephone number: ( ) - Measurements 1: 2: 3: Top of head to bottom of buttocks Top of shoulder to bottom of buttocks Arm pit to bottom of buttocks 4: Elbow to bottom of buttocks 5: Back of buttocks to back of knee 6: Foot length 7: Head width 8: Shoulder width 9: Arm pit to arm pit 10: Hip width 11: 12: Distance to bottom of left leg (popliteal to heel) Distance to bottom of right leg (popliteal to heel) Additional Comments Texas Medicaid Bulletin, No September/October 2006

35 Forms Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions General Instructions This form must be completed and signed as outlined in the instructions below before DME/medical supplies providers contact TMHP Home Health Services for prior authorization. Either the DME supplier/medicaid provider or the prescribing physician may initiate the form. This completed form must be retained in the records of both the DME supplier/medical provider and the prescribing physician, and is subject to retrospective review. This form becomes a prescription when the physician has signed section B. This form cannot be accepted beyond 90 days from the date of the prescribing physician's signature. The supplier or prescribing physician can complete Section A. Include the most appropriate procedure code description using the Healthcare Common Procedure Coding System (HCPCS). In addition, include the appropriate quantity and the manufacturer's suggested retail price (MSRP) if the item requires manual pricing. A price is not required for those items with a maximum fee listed in the Texas Medicaid Fee Schedule. The appropriate box must be completed to indicate whether this section was completed by the physician or the supplier. If the item requested is beyond the quantity limit or a custom item, additional documentation must be provided to support determination of medical necessity. All fields must be filled out completely. The prescribing physician's TPI is only required if the Physician is a Texas Medicaid provider. Section A: Requested Durable Medical Equipment and Supplies The supplier or prescribing physician can complete Section A. Include the most appropriate procedure code description using the Healthcare Common Procedure Coding System (HCPCS). In addition, include the appropriate quantity and the manufacturer's suggested retail price (MSRP) if the item requires manual pricing. A price is not required for those items with a maximum fee listed in the Texas Medicaid Fee Schedule. The appropriate box must be completed to indicate whether this section was completed by the physician or the supplier. If the item requested is beyond the quantity limit or a custom item, additional documentation must be provided to support determination of medical necessity. Requested Durable Medical Equipment and Supplies Item No. HCPCS Code Quantity Price 1 J-E $ J-E $ Examples of Supplies Item No. HCPCS Code Quantity Price 1 9-A boxes N/A 2 9-A box N/A 3 9-A box N/A 4 5 September/October Texas Medicaid Bulletin, No. 198

36 Forms Section B: Diagnosis and Medical Information Section B is a prescription for DME/supplies and must be filled out by the prescribing physician. The prescribing physician must indicate the ICD-9-CM code with a brief description, corresponding to the item number requested from Section A and complete justification for determination of medical necessity for the requested item(s). If applicable, include height/weight, wound stage/dimensions and functional/mobility. The date last seen must be within the past 12 months. The prescribing physician must indicate the duration of need for the prescribed supplies/dme. The estimated duration of need should specify the amount of time the supplies/dme will be needed, such as six weeks, three months, lifetime, etc. The prescribing physician's TPI (if a Medicaid provider) and license number must be indicated. Signatures from Nurse Practioner's, Physician Assistants, and Chiropractors will not be accepted. Signature stamps and date stamps are not acceptable. Diagnosis and Medical Need Information ICD-9 Requested Section A No. 2 Examples of Supplies Complete justification for determination of medical necessity for requested item(s). Refer to Section A: Requested Durable Medical Equipment and Supplies 1, , 2 Unable to get in and out of the tub or shower Need swing-away arms and legs for transfer secondary to hemiparesis and need oversize chair weighing 400 lbs Refer to Footnote 1 of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. 2. Refer to Footnote 2 of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. ICD-9 Requested Section A No ,4,5 Test TID Complete justification for determination of medical necessity for requested item(s). Refer to Section A: Requested Durable Medical Equipment and Supplies 1,2 1. Refer to Footnote 1 of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. 2. Refer to Footnote 2 of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. Physicians must indicate their professional license number. If the prescribing physician is out of state, the physician must provide the license number and state of professional licensure. Texas Medicaid P0 TPIs, ZO group TPIs, and UPIN numbers are not acceptable as licensure. The Addendum to the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form must be used when prescribing more than 5 items. The Addendum to the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form must accompany the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. Addendums received without this form will not be accepted. Reminder: Reminder: Home health services are not a benefit for clients residing in a nursing facility, hospital, or intermediate care facility. Note for DME: The DME company must also complete the DME Certification & Receipt Form. All equipment is to be assembled, installed, and used pursuant to the manufacturer's instructions and warning. Texas Medicaid Bulletin, No September/October 2006

37 Forms Medicaid Eligibility Verification Confirmación de elegibilidad para Medicaid Texas Health and Human Services Commission/Form H1027-A/ Name of Doctor/Nombre del doctor Name of Pharmacy/Nombre de la farmacia THIS FORM COVERS ONLY THE DATES SHOWN BELOW. IT IS NOT VALID FOR ANY DAYS BEFORE OR AFTER THESE DATES. ESTA FORMA ES VÁLIDA SOLAMENTE EN LAS FECHAS INDICADAS ABAJO. NO ES VÁLIDA NI ANTES NI DESPUÉS DE ESTAS FECHAS. Each person listed below has applied and is eligible for MEDICAID BENEFITS for the dates indicated below, but has not yet received a client number. Do not submit a claim until you are given a client number. Pharmacists have 90 days from the date the number is issued to file clean claims. However, check your provider manual because other providers may have different filing deadlines. Call the eligibility worker named below if you have not been given the client number(s) within 15 days. Each person listed below is eligible for MEDICAID BENEFITS for dates indicated below. The Medicaid Identification form is lost or late. The client number must appear on all claims for health services. Date Eligibility Verified Verification Method BIN Local DCU SAVERR Direct Inquiry Regional Procedure S.O DCU (A & D Staff Only) CLIENT NAME NOMBRE DEL CLIENTE DATE OF BIRTH FECHA DE NACIMIENTO CLIENT NO. CLIENTE NÚM. ELIGIBILITY DATES PERIODO DE ELEGIBILIDAD From/Desde Through/Hasta MEDICARE CLAIM NO. NÚM. DE SOLICITUD DE PAGO DE MEDICARE STAR/STAR+PLUS/PCCM HEALTH PLAN INFORMATION INFORMACIÓN DEL PLAN DE SALUD STAR/STAR+PLUS/PCCM Plan Name and Member Services Toll-Free Telephone No. Nombre del plan y teléfono gratuito de Servicios para Miembros I hereby certify, under penalty of perjury and/or fraud, that the above client(s) have lost, have not received, or have no access to the Medicaid Identification (Form H3087) for the current month. I have requested and received Form H1027-A, Medical Eligibility Verification, to use as proof of eligibility for the dates shown above. I understand that using this form to obtain Medicaid benefits (services or supplies) for people not listed above is fraud and is punishable by fine and/or imprisonment. CAUTION: If you accept Medicaid benefits (services or supplies), you give and assign to the state of Texas your right to receive payments for those services or supplies from other insurance companies and other liable sources, up to the amount needed to cover what Medicaid spent. Por este medio certifico, bajo pena de perjurio y/o fraude, que los clientes nombrados arriba hemos perdido, no hemos recibido o por otra razón no tenemos en nuestro poder la Identificación para Medicaid (Forma H3087) del corriente mes. Solicité y recibí esta Confirmación de Elegibilidad Médica (Forma H1027-A) para comprobar nuestra elegibilidad para Medicaid durante el periodo cubierto especificado arriba. Comprendo que usar esta confirmación para obtener beneficios (servicios o artículos) de Medicaid para alguna persona no nombrada arriba como beneficiario constituye fraude y es castigable por una multa y/o la cárcel. ADVERTENCIA: Si usted acepta beneficios de Medicaid (servicios o artículos), otorga y concede al estado de Texas el derecho a recibir pagos por los servicios o artículos de otras compañías de seguros y otras fuentes responsables, hasta completar la cantidad que se requiere para cubrir lo que haya gastado Medicaid. Signature Client or Representative/Firma Cliente o Representante Date/Fecha Office Address and Telephone No./Oficina y Teléfono Name of Worker (type)/nombre del trabajador Worker BJN Worker Signature Date X Name of Supervisor* (type)/nombre del supervisor* Supervisor* BJN Supervisor Signature Date *or Authorized Lead Worker/*o Trabajador encargado X September/October Texas Medicaid Bulletin, No. 198

38 Forms Form H1027-A Page 2/ Medicaid clients do not have to pay bills which Medicaid should pay. It is very important that you tell your doctor, hospital, drugstore, and other health care providers right away that you have Medicaid. If you do not tell them that you have Medicaid, you may have to pay these bills. If you get a bill from a doctor, hospital, or other health care provider, ask the provider why they are billing you. If you still get a bill, call the Medicaid hotline at for help. If Medicaid will not pay the bill or if Medicaid benefits (services and supplies) are denied, you may request a fair hearing by writing to the address or calling the telephone number listed on the letter you get. NOTE: Family planning clinics and other providers give free physical exams, lab tests, birth control methods (including sterilization) and contraceptive counseling. El cliente de Medicaid no tiene que pagar cuentas médicas que Medicaid debe pagar. Es muy importante que usted diga inmediatamente a su médico, al hospital, a la farmacia y a otros proveedores de servicios médicos que usted tiene Medicaid. Si no les dice que tiene Medicaid, puede que usted tenga que pagar estas cuentas. Si usted recibe una cuenta de un doctor, un hospital, u otro proveedor de servicios médicos, pregunte por qué le mandó la cuenta. Si todavía le mandan una cuenta, llame al número directo de Medicaid al para pedir ayuda. Si Medicaid no va a pagar la cuenta o si se niegan los beneficios de Medicaid (los servicios o los artículos), usted puede pedir por escrito una audiencia imparcial. La dirección y el número de teléfono aparecen en la carta que recibió. NOTA: Las clínicas de planificación familiar y los otros proveedores ofrecen gratis exámenes físicos, análisis de laboratorio, métodos anticonceptivos (inclusive la esterilización) y consejería sobre los anticonceptivos. Provider Information/Información para el proveedor Only those people listed under "CLIENT NAME" have Medicaid coverage. Payment is allowed ONLY for services received during the eligibility dates reflected on the front of this form. PLEASE NOTE: Payment for Family Planning Services is available without the consent of the client s parent or spouse. Confidentiality is required. Family planning drugs, supplies, and services are exempt from the prescription drug and "LIMITED" restrictions. Key to terms that may appear on this form: LIMITED Except for family planning services, and for Texas Health Steps (EPSDT), medical screening, dental, and hearing aid services, the client is limited to seeing the doctor and/or limited to using the pharmacy named on the form for drugs obtained through the Vendor Drug Program. In the event of an emergency medical condition as defined below, the "LIMITED" restriction does not apply. EMERGENCY The client is limited to coverage for an emergency medical condition. This means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (who possesses an average knowledge of health and medicine) would think that the absence of immediate medical attention could reasonably be expected to result in (1) placing the patient s health in serious jeopardy, (2) serious impairment to bodily functions, or (3) serious dysfunction of any bodily organ or part. HOSPICE The client is in hospice and waives the right to receive services related to the terminal condition through other Medicaid programs. If a client claims to have canceled hospice, call the local hospice agency or DHS to verify. QMB The Medicaid agency is providing coverage of Medicare premiums, deductible, and coinsurance liabilities, but the client is not eligible for regular Medicaid benefits. MQMB The Medicaid agency is providing regular Medicaid coverage as well as coverage of Medicare premiums, deductibles, and coinsurance liabilities. PE Medicaid covers only family planning and medically necessary outpatient services. STAR/STAR+PLUS/PCCM HEALTH PLAN The client is enrolled in the Medicaid Managed Care program and is assigned to the health plan named on the form. NOTE TO PHARMACY: Medicaid will pay for more than three prescriptions each month for any Medicaid client who is under age 21, or lives in a nursing facility, or has the STAR/STAR+PLUS Health Plan, or gets services through the Community Living Assistance and Support Services (CLASS), Community Based Alternatives (CBA) and other non-ssi community-based waiver programs. Clients with Medicare who are enrolled in STAR+PLUS may be limited to three prescriptions per month. Texas Medicaid Bulletin, No September/October 2006

39 Forms All Providers RADIOLOGY PRIOR AUTHORIZATION REQUEST FORM This form is used to obtain prior authorization (PA) for elective outpatient services or update an existing outpatient authorization. Phone: Fax: Date of Request: Please check the appropriate action requested: CT SCAN CTA SCAN MRI SCAN MRA SCAN Update/change codes from original PA request Facility Medicaid No. Facility Name: Reference No. PCN No. Client Name: DOB: Requesting/Referring Physician Medicaid No. Requesting/Referring Physician Name: Phone Number: Fax Number: SECTION 1 Service Type: Outpatient Service(s) Emergent/Urgent Procedure Date of Service: Procedure Requested: Diagnosis Codes: Primary-, Secondary- Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications, and previous imaging results: Requesting/Referring Physician (Signature Required) Date Print Name SECTION 2 Updated Information (when necessary) Diagnosis Code(s): Primary- Secondary Date of Service: Procedure codes: Clinical documentation to support medical necessity for procedure code change includes treatment history, treatment plan, medications, and previous imaging results: Requesting/Referring Physician (Signature Required) Date Physician Medicaid No. Print Name (Physician must complete and sign this form prior to requesting authorization.) September/October Texas Medicaid Bulletin, No. 198

40 SEPTEMBER/OCTOBER 2006 No. 198 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual Look inside for these and other important updates: Page 4 Page 6 Page 10 Page 15 STAR Program Expansion Availability of Vaccines Update National Provider Identifier Deadline Third Party Biller Enrollment TEXAS MEDICAID & HEALTHCARE PARTNERSHIP B RIATA TRACE PARKWAY STE 150 AUSTIN, TX A STATE MEDICAID CONTR ACTOR PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE