Claims Management Advisory Council Meeting November 14, 2007 Welcome/Introductions Garcia Montoya, Co-chair, DADS Claims Support General Updates & Announcements Maria Clarification Information Letters from DADS will be addressed to Long Term Services and Supports (LTSS) providers. LTSS is a new name for Long Term Care (LTC). November 2008 LTC Provider Bulletin The latest bulletin is available on TMHP.com. Texas Index of Level of Effort (TILE) to Resource Utilization Group (RUG) Conversion Project Trish Risley, DADS Claims Support The project consists of 4 concurrent tracks: Rules This track involves rules changes and State Plan Amendments. Nursing Facility Rules We have received and responded to your comments, and completed rules changes for presentation to the Medical Care Advisory Committee (MCAC) starting in January 2008. OIG Rules changes from the Health and Human Services Commission (HHSC) Office of Investigator General (OIG) are in internal review with stakeholder meetings being scheduled in the next month or two prior to review at the March MCAC meeting. Rates DADS and HHSC are working together to prepare rules involving rate setting for stakeholder review in early December in order to present change proposals at the January MCAC meeting. [Note: This was subsequently rescheduled for the March MCAC agenda.] Community Services (Waiver Programs) These rules changes will be ready for MCAC review in March because of changes being made to rules that are held in common with other programs. Automation This track supports system changes required to implement this project. User testing is now scheduled for the beginning of June 2008. Provider input will be sought in developing test scenarios in March and April. TMHP Design documentation is in review for modifying the TMHP LTC Online Portal to replace the 3652A. The Portal will still be used for submitting Forms 3618 and 3619. Completion is expected by the end of this calendar year. DADS System requirements are being documented for changes to the Service Authorization System (SAS) component of the DADS Claims Management System (CMS). Completion was expected by the end of November with review to follow. Financial Eligibility The business requirements phase has been completed. The estimation and system requirements phase has been started. Training Online and instructor training are being offered; these are different types of instruction and attending one will not provide the information you will need to learn in the other: Web-based RUG training Online TILE training will be replaced by online RUG training. Completion of RUG training will be required for the RN who signs the clinical assessment as complete. This is not a certification, but a completion requirement. This web-based training will be available beginning April 1, 2008, to give people time to complete the training before the conversion to the federal case-mix RUG system. Instructor-led training TMHP workshops now scheduled to begin in June 2008 will focus on http://www.tmhp.com 11/14/07 CM Advisory Council Meeting - Page 1 of 6
using LTC CMS Online Portal and other automation tools. As in the past, these workshops will be offered in multiple locations around the State. Transition A transition workgroup is meeting biweekly regarding everything needed to plan for a smooth transition to the RUG-based methodology. The only type of Form 3652-A that will be allowed for submission after September 1, 2008, is a Purpose Code E to recover a lost payment prior to the conversion to RUG. To support this transition from Forms 3652 to the new RUG-based process, the following decisions have been made: Nursing Facilities There will be a three-month transition to allow Forms 3652-A submitted prior to 9/1/2008 that are still in process to be completed through the medical necessity (MN) determination process, etc. As soon as the September 1 - December 1, 2008, transition ends, the RUG methodology will be in effect, completely replacing the current TILE-based methodology. Therefore it will be extremely important to be timely on submissions during the three-month transition period. Community Services (Waiver Programs) The transition from TILEs to RUGs will be required upon renewal of the Individual Service Plan. After the 9/1/2008 transition is complete, the new form based on RUG will be required instead of the 3652. If there is a significant change in condition prior to the assessment, you would submit the new assessment and at that time it would be transitioned from TILEs to RUGs. HHSAS* Upgrade Susan Ashley, DADS Accounting Systems [*Health & Human Services Administrative System] An upgrade is being planned that will cause downtime of the financial system that passes payment files from DADS for the State Comptroller of Public Accounts (CPA) to issue provider payments. Current planning indicates that during the upgrade now tentatively scheduled from January 24 through February 6, 2008, there would be no processing of DADS financial payments. Initial notification of this plan was announced November 12, 2007, in Information Letter #07-111 Initial Notice of Planned Payment System (Health and Human Services Administrative System) Downtime. This affects all DADS LTC payments. Payment of acute-care claims, which is made through TMHP rather than CPA, is not involved. The only other health and human services agency s claim payments affected by this downtime are those for the Department of State Health Services (DSHS) Family Planning program. Since CPA would accept the last voucher from DADS on January 24, providers need to be sure their claims have been successfully adjudicated through TMHP and have had time to make it through nightly processing between TMHP, DADS, and CPA in time to be in the queue for CPA to process payments before January 24, 2008. As was done for fiscal year-end processing cutoffs in August, DADS will publish the last date when providers can bill through TMHP for each DADS LTSS (LTC) provider service type: Nursing Facility & Community Service/Waiver Programs State-Operated Community ICF/MR (Claims Management System Service Group 5) Private Community ICF/MR (CMS Service Group 6) Home and Community-based Waiver Services (HCS) and Texas Home Living (TxHmL) providers billing through the MR CARE system. Providers submitting paper forms will need to meet earlier dates to allow time for TMHP to enter their data into the system. DADS is encouraging all providers to submit LTSS (LTC) claims before the actual cutoff date that will be announced in an upcoming Information Letter providers cannot request administrative payments but should bill for all LTSS services that have been provided. http://www.tmhp.com 11/14/07 CM Advisory Council Meeting - Page 2 of 6
Providers will be able to continue submitting claims to TMHP throughout the HHSAS downtime. TMHP and DADS can process the claims so they will be ready to be transferred to the State Comptroller for payment after normal HHSAS processing resumes. Providers should not wait until the last day listed as their billing cutoff in case something gets held up, in order to ensure adequate time to work on a resolution so the claim payment can be transmitted for processing before the shutdown. More information will be released when anticipated dates are identified, probably in mid-december, and as revisions are made in January. HHSC has several upcoming decision dates, but at this point it looks likely that the changes will be implemented as targeted. Consumer Directed Services (CDS) Lena Brown-Owens, DADS Center for Program Coordination (for Elizabeth Jones, DADS community Care Grant Coordinator) There will be changes in the rate methodology for Consumer Directed Service Agencies (CDSAs). There is a separate set of rates for services that are self-directed; the rates will be $1 less than the rate for the service when it is not self-directed, and the Financial Management Service flat monthly fee will not be subtracted. Effective September 1, 2007, the new CDS rate methodology was effective for: Community Based Alternatives (CBA) Medically Dependent Children Program (MDCP) Community Living Assistance and Support Services (CLASS) Integrated Care Management (ICM), Consumer-managed Personal Assistance (CMPAS) Primary Home Care (PHC) For Deaf-Blind with Multiple Disabilities (DBMD), the new rate methodology will be effective June 1, 2008, which coincides with the date of the waiver renewal. The effective date for HSC and TxHmL is pending, but will coincide with the date when CDS is initiated for those programs. To inform providers of these changes, training for CDSAs was conducted in August, followed by a technical assistance conference call in September. Providers received Information Letter No. 07-81: Rate Increase and ISP Adjustments. In October, DADS Case Managers received policy clarification #07-10-001: Consumer Directed Services (CDS) Service Code 63V, Financial Management Services (FMS) Fee, and Service Authorization System (SAS) Authorizations. In November providers received the following information letters: No. 07-111: Initial Notice of Planned Payment System (Health and Human Services Administrative System) Downtime No. 07-119: Training Opportunities Related to the Expansion of Consumer Directed Services (CDS) in the HCS and TxHmL Programs CDS implementation training for HCS and TxHmL providers and MRA staff is being held from November 14 through December 5. CDS contacts are: Elizabeth Jones, 512/438-4855 Elizabeth.Jones@dads.state.tx.us Cheryl Craddock-Melchor, 512/438-4512 Cheryl.Craddockmelchor@dads.state.tx.us DADS CDS Website http://dads.state.tx.us./providers/dcs/index/cfm Integrated Care Management (ICM) Lena Brown-Owens & Rhonda Pratt, DADS Center for Program Coordination The ICM program will begin February 1, 2008, for Community Based Alternatives (CBA), Primary Home Care (PHC) and Day Activity and Health Service (DAHS) providers in the following 13 Dallas and http://www.tmhp.com 11/14/07 CM Advisory Council Meeting - Page 3 of 6
Tarrant Service Area counties: Collin, Dallas, Denton, Ellis, Hood, Hunt, Johnson, Kaufman, Navarro, Parker, Rockwall, Tarrant, and Wise. Provider Services staff sent contract letters to affected LTSS providers in the ICM service areas and advised associations to remind their members to complete all the required contract enrollment forms. It is critical that DADS has the most current provider address and contact information as DADS has been forwarding that information to Evercare for outreach purposes. This will facilitate Evercare s efforts to build an adequate LTSS provider network for ICM. In September the Centers for Medicare and Medicaid Services approved both waivers required to operate the 1915(b) and (c) waiver services (CBA) component of the ICM program. ICM rules have been approved and published in the Texas Register. Two very important Information Letters were recently published on the DADS and TMHP websites, which were updated to include the ICM service code lists for Service Groups 3 and 7: 11/1/07 Letter #07-103 Implementation of the Integrated Care Management (ICM) Program 11/2/07 Letter #07-97 Integrated Care Management (ICM) Program Service Codes and Billing Requirements Prior to Implementation Letter #07-97 specifically lists Consumer Attendant Services, the Consumer Attendant Services (CAS) Service Responsibility Option, and Special Services to Persons with Disabilities (SSPD) as not being included in ICM. Also refer to the November 2007 LTC Provider Bulletin for contacts and information regarding billing prior to the ICM transition. The February 2008 Bulletin will include updated information. ICM providers should also be aware of the 11/12/07 Information Letter #07-111 Initial Notice of Planned Payment System (Health and Human Services Administrative System) Downtime and should bill for services rendered as close to the HHSAS downtime cutoff as possible because then their contracts will be transitioned to the ICM contract effective February 1, 2008. HIPAA* / National Provider Indicator (NPI) Terri Herrera-Pounds, DADS Claims Support [*Health Insurance Portability and Accountability Act] February 29, 2008, is the officially announced end of NPI contingency date for the State of Texas. This means that, beginning March 1, 2008, claims cannot be paid if they are submitted without NPI data. Providers must have submitted their NPI data for DADS to enter into the system before they submit claims using their NPI. Effective March 1, 2008, providers must use the NPI to submit claims, check Medicaid Eligibility Service Authorization Verification (MESAV), perform Claims Status Inquiries (CSIs), and perform TexMedConnect associated functions Later during this meeting TMHP will address the new TexMedConnect software that was implemented this weekend for LTC. TexMedConnect is the NPI-compliant application replacing TDHconnect, which still lets you use your contract number. TDHconnect and the contract number can longer be used after February 29, 2008. February 29, 2008, also is when the dual-strategy option ends for American National Standards Institute (ANSI)-compliant Electronic Data Interchange (EDI) transactions. TMHP implemented ANSIcompliant EDI transactions that use NPI at the end of July 2007. Providers who have not yet obtained their NPI from the National Plan and Provider Enumeration System (NPPES) need to quickly do so AND report their assigned NPI to DADS, as detailed in past DADS information letters and LTC Provider Bulletins. All council representatives were requested to help DADS ensure that their members have their NPI or Atypical Provider Identifier (API). Information Letter #07-110 will be released soon to reiterate the process for obtaining an NPI or API. Maria sent the Council representatives an electronic file listing of providers that have not reported their NPI. [Note: #07-110 released 11/26/07; listing emailed 12/11/07] http://www.tmhp.com 11/14/07 CM Advisory Council Meeting - Page 4 of 6
Personal Care Services (PCS) Mariana Zolondek, HHSC Managed Care/CHIP Regional Coordinator The system is processing and paying claims, although maybe not always at the level submitted. HHSC and TMHP are working through reported provider issues to resolve problems being experienced by some providers. Measures have been taken to keep the workload at a minimum for providers, checking denials and helping providers work through denials, so improvement is being seen. HHSC also is working with staff at DSHS and TMHP. Providers with questions involving PCS claims should continue to call the TMHP Call Center/Help Desk at the following telephone numbers: Austin local telephone number at 1-512-335-4729 Toll-free telephone number (outside Austin) at 1-800-626-4117 or 1-800-727-5436 The Frequently Asked Questions about PCS web page on TMHP.com will be updated in December to categorize the FAQs by topics such as prior authorization, claims, and billing through EDI, as well as to provide information regarding whom to call when. This link can be accessed at: http://www.tmhp.com/homepage%20file%20library/personal%20care%20services%20- %20Frequently%20Asked%20Questions.pdf Marianna advised the group that HHSC meets monthly with representatives from the Texas Association for Home Care (TAHC) to discuss PCS concerns. She requested that providers bring questions and concerns to TAHC prior to the meetings so they can be added to the agenda. TAHC will send the items to HHSC to allow time for advance research. TexMedConnect (NPI-compliant TDHconnect replacement software) Chris Mayfield & Heidi Reed, TMHP TexMedConnect was put into production for LTC Monday, November 12. The next release for LTC and acute care is scheduled for December 14. There has been some confusion regarding whether providers should access the NF/Waiver Account or the LTC Account to access TexMedConnect. Information posted November 6, 2007, in the www.tmhp.com/ltc Programs/ General News announcements and emailed to Council representatives on November 16 clarifies that the NF/Waiver Account is used to submit Forms 3618, 3619 and 3652-A; it cannot be used to access TexMedConnect the Long Term Care Account is used to access TexMedConnect and submit Hospice Forms 3071 and 3074. When first accessing this account, functions may be restricted but additional access may be given as necessary Each individual user should have only one user ID and password but can be authorized access to as many accounts/functions as necessary. Each contract number must have at least 1 administrator, the person who is authorized to grant access to that contract number for all other users. If a provider has multiple contracts, their administrator can access all of that provider s contracts. [Click on My Account along the top bar of the TMHP.com homepage to view the lists of functions the administrator can perform for the Acute Care, Long Term Care and NF/Waiver accounts. Nurse Licensure Validation Chris Mayfield, TMHP System changes made in late August to validate licensure of nurses submitting Forms 3652-A were removed because TMHP was not able to validate Compact licenses for nurses licenses in neighboring states which have agreements that allow them to practice in Texas. Analysis is underway, although there is no anticipated date when the edit will be reinstated. TMHP is http://www.tmhp.com 11/14/07 CM Advisory Council Meeting - Page 5 of 6
researching the volume of out-of-state license numbers involved; 14 states have Compact agreements with Texas. Tentative Agenda for February 13, 2008, Advisory Council Meeting HIPAA / NPI Update on HHSAS Upgrade TILE/RUG TexMedConnect PCS Nurse Licensure Validation ICM Customized Power Wheelchairs Planned 2008 Council Meetings - 10:00 12:00 (unless otherwise announced) Dates: Wednesday, February 13, 2008 Wednesday, May 14, 2008 Wednesday, August 13, 2008 Wednesday, November 12, 2008 Location: Meet in the lobby of TMHP offices: 12365 A (Building 9) Riata Trace Way Parkway Austin, Tx 78727 http://www.tmhp.com 11/14/07 CM Advisory Council Meeting - Page 6 of 6