Provider Information Texas Health Steps Requirements

Transcription

1 Provider Information Texas Health Steps Requirements 2016

2 THSteps Background Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Federally mandated health care program of prevention, diagnosis and treatment for Medicaid members birth though age 20 Federal Law in 1989 Omnibus Budget Reconciliation Act In Texas, it is referred to as Texas Health Steps or THSteps (Medical and Dental)

3 THSteps Mission Focuses on medical, dental, and case management services Dedicated to expanding recipient awareness of existing medical, dental and case management (CM) services through outreach and informing efforts Recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental and CM services.

4 Texas Health Steps (THSteps) Medical Check-up/Immunization Mandates Part 1: THSteps Medical Checkups and Immunizations All children newly enrolled in Medicaid/STAR Kids need a Texas Health Steps checkup within 60 days of enrollment with Health Plan, unless the Health Plan can verify that they received this service prior to their enrollment. Annual medical checkups for existing Members age 36 months and older are due on the child s birthday. The annual medical checkup is considered timely if it occurs no later than 364 calendar days after the child s birthday. Migrant Farm Worker Children can receive accelerated THSteps medical and dental checkups prior to leaving the area.

5 THSteps Medical Checkup Medical Inclusive of a comprehensive and periodic evaluation of: Medical History and Current Health Status Comprehensive Unclothed Physical Examination Developmental Screening Mental Health Screening Vision & Hearing Screening Immunizations/TB Screening Laboratory Screening Anticipatory Guidance

6 THSteps Medical Checkup Medical Periodicity Schedules Specifies the required screening procedures at each stage of client s life Twelve checkups required up to age three Annual checkups after age three Exceptions to Periodicity Medically necessary (developmental delay or suspected abuse) Environmental high-risk Required for Head Start enrollment, daycare, foster care or preadoption

7 THSteps Medical Checkup Medical Example of Periodicity Schedules: Two Periodicity Schedules: Birth through 10 years of age 11 through 20 years of age

8 Separate Reimbursable Components of THSteps Checkup Medical Initial Point of Care Blood Lead Testing Tuberculin Skin Test (TST) Developmental and Autism screening Vaccine Administration Dental Oral Evaluation and Fluoride Varnish (OEFV)

9 Developmental and Autism Screening Schedule Ages Standardized Screening Tools 9 months Ages and Stages Questionnaire (ASQ) or Parents Evaluation of Developmental Status (PEDS) Autism Screening Tool 18 months ASQ or PEDS Modified Checklist of Autism in Toddlers (M-CHAT) 24 months ASQ or PEDS M-CHAT (as of ) 3 years ASQ, ASQ-SE or PEDS 4 years ASQ, ASQ-SE or PEDS * A review of developmental milestones and mental health is required at all other checkups up to the age of 6 years.

10 Developmental and Autism Screening Codes Medical Developmental screening (procedure code 96110) Autism Screening (procedure code with modifier U6) May be reimbursed if: completed on same day as checkup, during an exception-to-periodicity checkup, or follow-up visit to a THSteps checkup

11 Required/Schedule Laboratory Testing Test Second Newborn Screening Blood Lead Screening Anemia Screening Glucose Total Cholesterol/Hyperlipidemia Lipid Profile HIV Gonorrhea/Chlamydia Syphilis Laboratory Department State Health Services (DSHS) Lab DSHS Lab or Point-of-Care (onsite) DSHS Lab or Point-of-Care DSHS Lab or Provider s Choice DSHS Lab or Provider s Choice DSHS Lab or Provider s Choice DSHS Lab or Provider s Choice DSHS Lab DSHS Lab or Provider s Choice

12 Provider Vaccine Administration Each medical checkup: Assess immunization status. Administer according to the Advisory Committee on Immunization Practices (ACIP) recommendations unless Medically contraindicated Parent s reason of conscience (including religious beliefs). Providers must not refer clients to the local health department or other entity for immunizations.

13 THSteps Support- ImmTrac NOTE: ImmTrac is the Texas immunization registry, a free service from the Texas Department of State Health Services (DSHS). It is a secure, confidential registry that stores children s and adult s, Texas first responders, and first responder family members vaccine information electronically in one centralized system. Join ImmTrac: To get started, please complete the online ImmTrac registration packet: ImmTrac CUSTOMER SUPPORT Phone: (800) ImmTrac@dshs.state.tx.us

14 THSteps Quick Reference Billing Procedure Guide» Manuals/THStepsQRG/THSteps_QRG.pdf

15 Texas Health Steps (THSteps) Dental Mandates Part II: THSteps Dental Checkups Texas Health Steps dental checkups are recommended every 3-6 months, starting at 6 months of age. Dental services include: Preventive Services Treatment Services Medically necessary Orthodontic Services (prior authorization is needed)

16 Dental Oral Evaluation & Fluoride Varnish (OEFV) DENTAL The Medical Home offers limited oral health services. These services are provided in conjunction with the Texas Health Steps Medicaid checkup and includes immediate oral evaluation, fluoride varnish application, dental anticipatory guidance and referral to a dental home. During THSteps medical checkup for ages 6-months through 35- months Limited oral evaluation Fluoride varnish application Referral to dental home

17 Dental Oral Evaluation & Fluoride Varnish (OEFV) Procedure Codes DENTAL To be billed on the same date of service as a medical checkup visit Limited to six services per lifetime by any provider. Procedure code must be billed with modifier U5 and diagnosis code Z00121 or Z00129

18 Dental: Oral Evaluation and Fluoride Varnish (OEFV) Who is eligible to provide this service? Texas Health Steps enrolled physicians, physician assistants, and advanced practice registered nurses. Certification Providers must attend the OEFV training offered by the Department of State Health Services Oral Health Program to become certified to provider and bill for this service. Providers must submit the completed the Oral Evaluation and Fluoride Varnish (OEFV) Certification Request form and fax (or scan and ) it to DSHS ALONG with the continuing education certificate (CE) that was printed when the training module was completed. For more information:

19 Migrant Farm Workers

20 Case Management for Children and Pregnant Women (CPW) PART III: Case Management Case Management services are provided by a licensed social worker or registered nurse to assist Medicaid eligible children and high-risk pregnant women with medically needed services in their community. Who Can Get A Case Manager? Medicaid eligible children ages 0-21 with a health condition Health risk and high-risk pregnant women of any age. What Kind Of Help Can Case Managers assist Patients with? Family problems School/education issues Financial problems Special medical needs Adaptive equipment Therapy needs Overcoming barriers to families Promoting self-reliance Texas Health Steps Hotline or 877-THSteps Monday to Friday, 8 a.m. to 8 p.m.

21 THSteps Brochures Materials are available through the Texas Health Steps Resource Catalog Resources include: Texas Health Steps Medical Checkups Texas Health Steps Dental Checkups Medical Transportation Program Newborn Hearing Screening Care Management for Children and Pregnant Women(CPW) Online Provider Education (OPE) Online training modules at Children with Special Health Care Needs program (CSHCN

22 Additional Information to Support THSteps Medicaid Transportation 72-Hour Emergency Prescription Fill Member Education Request Form (CCHP)

23 Medicaid- Transportation (MTP) LogistiCare Promoting THSteps Medicaid Transportation Texas Health and Human Services Commission (HHSC) contracted with LogistiCare to manage non-emergency medical transportation services for Texas Medicaid clients and Children with Special Care Needs (CSHCN) who have no other way to get a ride to a Medicaidcovered service provided by a Medicaid-enrolled medical provider. Transporting members by rural transit operations, commercial providers, cabs, fixed route, and paratransit bus systems Mileage reimbursement can be provided for members to and from medical appointments who transport themselves, have a family member friend

24 How To Contact LogistiCare Promoting THSteps- MedicaidTransportation To request a routine trip: (TTY: ) Monday to Friday, 8 a.m. to 5 p.m. Ride Help Line Facilities Department Member brochures and Where s My Ride Cards available upon request.

25 Vendor Drug Program Promoting Emergency Access to Medication 72-hour Emergency Override of a Prior Authorization-Required Drug Federal and Texas law required that a 72-hour emergency supply of a prescribed drug be provided when a medication is needed without delay and prior authorization (PA) is not available. This rule applies to non-preferred drugs on the Preferred Drug List (PDL) and any drug that is affected by a clinical or prior authorization edit and would need the prescriber prior approval. The 72-hour emergency supply should be dispensed any time a prior authorization is not available and a prescription must be filled, for any medication or medical condition. If the prescribing provider can not be reached or is unable to request a prior authorization, the pharmacy should submit an emergency 72-hour prescription. This procedure should not be used for routine and continuous overrides. A 72-hour emergency prescription will be paid in full, and it does not count toward the three-prescription limit for adults who have not already received their maximum prescriptions for the month (there is no prescription limit for children under 21).

26 Member Education Form The Member Education Request Form will be updated with STAR Kids option upon HHSC s approval of the form.

27 Please review Provider Manuals at cookchp.org