February 2004 No. 49 CSHCN Provider Bulletin The Children with Special Health Care Needs Program Welcome to the Texas Medicaid & Healthcare Partnership CONTENTS e Texas Medicaid & Healthcare Partnership (TMHP), headed by Affiliated Computer Services, Inc. (ACS), has assumed CSHCN and Medicaid Claims Administrator duties for the State of Texas, under contract with the Health and Human Services Commission (HHSC). TMHP is also the administrator for the Medicaid Managed Care Primary Care Case Management (PCCM) model known as the Texas Health Network. TMHP comprises the following entities: ACS (Affiliated Computer Services, Inc.), the prime contractor; Accenture, the technology partner; Public Consulting The Texas Medicaid & Healthcare Partnership assumed Medicaid claims administrator duties on January 1, 2004. Group (PCG), the third party resources partner; Mir Mitchell Corporation (MMC), the staffing support partner; and numerous other well-known hardware, software, and telecommunications organizations. To ensure a smooth transition, CSHCN providers will continue to use the same telephone numbers they used to communicate with National Heritage Insurance Company (NHIC) and the Texas Health Network. In addition, CSHCN providers will continue to use the same post office box addresses used to communicate with NHIC. Information for All Providers...1 Welcome to the Texas Medicaid & Healthcare Partnership...1 Children s Services Unit...2 Fiscal Agent...2 TMHP Website...3 What is a Medical Home?...3 CSHCN and Medicaid Disenrollment...4 Your TMHP Provider Relations Representatives (by Territory)...5 Information about Codes and Reimbursement...6 DTP/HIB Vaccine Rates...6 RSV Season Continues...6 Hydrophilic Intermittent Urinary Catheters...7 Nutritional Supplements...7 Tracheostomy Tubes...7
Children s Services Unit e Texas Medicaid & Healthcare Partnership (TMHP), as the new claims administrator, welcomes the opportunity to work with you. We recognize that a strong, open, working relationship must exist among the Texas Department of Health (TDH), HHSC, TMHP, the CSHCN provider community, and the clients they serve. TMHP appreciates the objectives of the HHSC and TDH with regard to the evaluation and authorization of children s healthcare services. To help support these objectives, TMHP is introducing a Children s Services Unit. is unit strives to more efficiently meet the needs of the clients and the goals of the HHSC and TDH. is vision encompasses both CSHCN clients and Medicaid clients who are THSteps-eligible. Objectives: Careful consideration, evaluation, and authorization of medically necessary services for children. Avoidance of duplicative provider effort to achieve authorization under appropriate program and funding sources. Fostering of goodwill with the provider and client communities through consistent communication. Strict adherence to timeframes regarding evaluation and completion of requests. Provision of clear and reasonable notice to recipients explaining any modification, denial, or termination of service. For more information about the Children s Services Unit, call 1-800-568-2413. Fiscal Agent Effective January 1, 2004, TMHP (the Medicaid administrative services contractor) began acting as the state s fiscal agent for the CSHCN and Medicaid pro. Under the fiscal agent arrangement, TMHP is responsible for processing and paying claims, and the state is responsible for covering the cost of claims. e fiscal agent arrangement requires that a provider be designated as either public or nonpublic. Public providers are owned or operated by a city, state, county or other governmental agency or instrumentality, as described in the Code of Federal Regulations. Additionally, any provider/agency that can do intergovernmental transfers to the state would be considered a public provider including those agencies that can certify and provide state matching funds. New providers will be required to self-designate public or non-public status upon enrollment. Current providers are not required to take any action regarding this designation at this time. Payment Deadlines Effective January 1, 2004, HHSC has implemented new payment deadlines as a result of the fiscal agent arrangement. Payment deadlines refer to the maximum time afforded to TMHP to process and pay a claim. e payment deadlines ensure state and federal financial requirements are met. TMHP will be required to finalize all claims, including appeals, as detailed in the matrix below. All Providers (Except Long- Term Care) Claims Payment Deadlines Medicaid/CSHCN payments, excluding crossover claims, cannot be made after 24 months from the date of service or discharge date on inpatient claims. CSHCN Bulletin, no. 49 2 February 2004
Retroactive SSI Eligibility Claims Payment Deadlines e payment deadline is derived from the client s eligibility add date; to allow 24 months from the add date for the retroactive SSI eligible client. is change should not be confused with provider claims submission deadlines that are currently in place. Until automated system edits for the new payment deadlines are in place, claims paid after the payment deadline will be recouped. e following EOB messages will appear on paper Remittance and Status (R&S) reports for claims received beyond the payment deadlines: is claim cannot be considered due to state payment deadlines. is is a final disposition and no further appeals will be accepted. For electronic R&S reports, the following HIPAA-compliant message will be used: MA44 No appeal rights. Adjudicative decision based on law. TMHP Website If you have not visited the TMHP website, www.tmhp.com, please do so. CSHCN providers are encouraged to utilize this invaluable communication tool. e website incorporates all information that was previously available to providers on the NHIC website, including: Publications, such as provider manuals and CSHCN provider bulletins CSHCN banner messages Workshop information and online registration Instruction guides Links to related state and federal agency sites A map showing TMHP provider relations representatives territories and the name of the representative serving your area New Services Claim Status and Eligibility Inquiries TMHP is pleased to offer a new service to the provider community through the TMHP website. Providers can now submit claim status inquiries and eligibility verification requests on the website, by choosing the provider link and clicking on the function they wish to perform. Interactive responses are provided in less than one minute. For additional navigational assistance with the TMHP website, call 1-800-568-2413. What is a Medical Home? A medical home is not a building, house, or hospital, but rather an approach to providing quality healthcare services in a cost-effective manner. Children and their families who have a medical home find they receive more consistent and comprehensive healthcare. ey have a pediatrician, family doctor, or other healthcare provider whom they know and trust. Having a medical home means that a family partners with their primary care provider (PCP) and other healthcare professionals to direct their healthcare needs. CSHCN clients often require healthcare in a variety of settings, which can be very confusing for families. As a CSHCN provider, you can provide guidance and structure a treatment plan individualized for your clients. A good medical home should be: Accessible is means care is right in or very near the client s community, and the office is physically accessible for the client. e office should work well for the client financially, too. It should accept all forms of insurance, including Medicaid and CSHCN, and assist clients with questions concerning their February 2004 3 CSHCN Bulletin, no. 49
coverage. e office also should be personally accessible. at means the client and/or family can speak directly with the doctor when they need to. Family-Centered In family-centered care, the family is seen as the child s main caregiver and source of strength and support. Doctors and families make decisions about the child s care together, as a team. Continuous e same provider is there from when the child is a baby until the teen years. is provider helps with transitions from one age or stage of development to the next. Comprehensive All medical needs should be addressed from the context of the medical home. at includes primary, secondary, and tertiary care. At a good medical home, a child can get or be referred to health care any time. at means 24 hours a day, 7 days a week. Coordinated At a good medical home, the doctor, child, and family develop a plan of care together. ey share the plan with other providers, agencies, and organizations that are involved in the child s care. e medical home coordinates care from all providers. Compassionate e good medical home shows concern for the well-being of the child and family in actions and words. Culturally Competent A good medical home recognizes and respects the child s and family s language and culture. As a CSHCN provider, you can provide greater satisfaction and better coordination of care by offering a medical home to your clients. For more information about the principles and practices of a medical home for children with special health care needs, the following are some helpful websites: e National Center for Medical Home Initiatives for Children with Special Health Needs: http://www.medicalhomeinfo.org e Center for Medical Home Improvement: http://www.medicalhomeimprovement.org CSHCN and Medicaid Disenrollment Because many CSHCN clients may also be eligible for Medicaid benefits, all enrolled CSHCN providers must maintain Texas Medicaid enrollment to continue participation in CSHCN. If a provider disenrolls from, terminates participation in, or is suspended from Texas Medicaid, TMHP, as directed by TDH-CSHCN, will initiate a simultaneous disenrollment process for the CSHCN Program. e provider will receive notice of the action being taken and given 30 days to request an administrative review by TDH. e notification will advise the provider of the effective date of the termination. TMHP will suspend payment on the CSHCN provider s claims with dates of service on or after the effective termination date documented in the notice. Payment will be suspended until the provider has been given the opportunity to appeal the decision and a final determination is made by TDH. If dissatisfied with TDH s administrative review decision, the provider may request a fair hearing. Requests for fair hearings must be received within 20 days of the date of TDH s determination. If at any time the provider fails to avail himself of the appeal options, the termination will be final and all claims denied. Should the administrative review or fair hearing officer(s) decide in the provider s favor, all claims received will be processed and considered for payment according to CSHCN guidelines. CSHCN Bulletin, no. 49 4 February 2004
Your TMHP Provider Relations Representatives (by Territory) TMHP provider relations representatives provide a variety of services designed to inform and educate the CSHCN provider community on program policies and claims filing procedures. Provider relations representatives assist providers through telephone contact, on-site visits, and scheduled workshops. e map at right and table below indicate the representative serving your area. Territory Regional Area Representative Telephone Number 1 Amarillo, Lubbock Wanda Wesson 512-506-3423 2 Abilene, Midland/Odessa, San Angelo Toni Emmons 800-925-9126 3 El Paso Isaac Romero 512-506-3530 4 San Antonio, Eagle Pass, Kerrville Ralph Cervantes 512-506-3422 5 Laredo, Harlingen Cynthia Gonzales 512-506-7991 6 San Antonio, Corpus Christi, Victoria Mary Ximenez 512-506-3554 7 Houston, Galveston Ann Perkins 512-506-3447 8 Houston, Katy, Sugarland Delsie Nagy 512-506-3446 9 Houston, Spring, Conroe Alexandra Vera 512-506-3419 10 Beaumont, Nacogdoches Gene Allred 512-506-3425 11 Dallas, Tyler, Waxahachie Sandra Peterson 512-506-3552 12 Dallas, Texarkana Olga Fletcher 512-506-3578 13 Arlington, Fort Worth, Denton, Wichita Falls Rita Martinez 512-506-7990 14 Austin, Bryan/College Station, Waco TBD 800-925-9126 February 2004 5 CSHCN Bulletin, no. 49
DTP/HIB Vaccine Rates Effective August 1, 2003, procedure code 1-90720, DTP/HIB vaccine, I.M., will be reimbursed at $35.84 to physicians when provided in the office or outpatient hospital. RSV Season Continues roughout the 2003-2004 RSV season, which in Texas can be through April, Respiratory Syncytial Virus immune globulin may be considered for reimbursement for clients less than 24 months of age who have one of the following diagnoses: Diagnosis Code Description 76500 Extreme immaturity, unspecified weight 76501 Extreme immaturity, less than 500 76502 Extreme immaturity, 500-749 76503 Extreme immaturity, 750-999 76504 Extreme immaturity, 1000-1249 76505 Extreme immaturity, 1250-1449 76506 Extreme immaturity, 1500-1749 76507 Extreme immaturity, 1750-1999 76508 Extreme immaturity, 2000-2499 76510 Other preterm infants, unspecified weight 76511 Other preterm infants, less than 500 76512 Other preterm infants, 500-749 Diagnosis Code Description 76513 Other preterm infants, 750-999 76514 Other preterm infants, 1000-1249 76515 Other preterm infants, 1250-1499 76516 Other preterm infants, 1500-1749 76517 Other preterm infants, 1750-1999 76518 Other preterm infants, 2000-2499 76521 Less than 24 completed weeks of gestation 76522 24 completed weeks of gestation 76523 25-26 completed weeks of gestation 76524 27-28 completed weeks of gestation 76525 29-30 completed weeks of gestation 76526 31-32 completed weeks of gestation 76527 33-34 completed weeks of gestation 76528 35-36 completed weeks of gestation 77070 Chronic respiratory problems after birth Other diagnoses may be prior authorized with documentation of medical necessity. Providers must use procedure code J3490, Unclassified drugs, along with the dosage, name of the medication, and appropriate diagnosis code for consideration of reimbursement. CSHCN Bulletin, no. 49 6 February 2004
Hydrophilic Intermittent Urinary Catheters All hydrophilic intermittent urinary catheters (such as Speedicath, Bard Interglide, and Lofric) may be considered for reimbursement using procedure code A9900, Miscellaneous DME supply, accessory, and/or service component of another HCPCS code, manually priced at manufacturer s suggested retail price (MSRP) less 18 percent, with a maximum fee of $3.53. Nutritional Supplements TMHP-CSHCN is implementing changes to claim submissions for nutritional supplements. Effective immediately, when submitting an electronic claim, the provider must submit the national code and the local code for the product. e local code must be placed in the remarks field in TDHconnect and in the NTE02 field at the 2400 loop in the ANSI and X-12 formats. In the ANSI and X-12 formats, the prefix GPC must be submitted in the first 3 digits of the NTE02 field followed by the 5-digit local code. For paper claims submissions, enter the local procedure code in block 19 of the HCFA-1500 claim form. A letter with additional information was sent to providers regarding electronic claims submission procedures. Refer to this letter dated December 1, 2003, for more details, or call the TMHP Contact Center at 1-800-568-2413. Tracheostomy Tubes CSHCN has revised the coding criteria for tracheostomy tubes to allow the following three levels: Use procedure code A4622 (tracheostomy or laryngectomy tube) for a standard tracheostomy tube. Use procedure code A4622 with modifier TF (intermediate level of care) for a standard tracheostomy tube with special functionality. Use procedure code A4622 with modifier TG (complex/high level of care) for a custom manufactured tracheostomy tube. Procedure code A4623, Tracheostomy, inner cannula (replacement only), is limited to one per month and will be denied when a custommanufactured tracheostomy tube, A4622-TG, has been requested. February 2004 7 CSHCN Bulletin, no. 49
February 2004 No. 49 CSHCN Provider Bulletin The Children with Special Health Care Needs Program TMHP PRSRT STD US POSTAGE PAID PERMIT NO 187 ATTENTION: BUSINESS OFFICE