Appendices

Appendix I, PSU User Guide for the SK-ISP Form

6-2019

 

Appendix I, PSU User Guide for the SK-ISP Form

Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language

Revision 20-02; Effective July 23, 2020

 

Program Support Unit (PSU) staff must use Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment that is not covered in Appendix II.

PSU must enter the associated STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) section supporting the denial reason on Form H2065-D and Form H2065-DS, listed in the SKOPH Section column.

Purpose of Form H2065-D Reason for Denial in Plain Language Comments in Plain Language SKOPH Section
Unable to Contact

You are not eligible for MDCP because HHSC staff or your health plan cannot locate you to complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa.

No additional comment should be added. 2120
Voluntarily Declined Services

You are not eligible for MDCP because you voluntarily withdrew from the program.

Usted no puede recibir servicios del MDCP porque abandonó voluntariamente el programa.

No additional comment should be added. 2100
Enrolled in Another 1915(c) Medicaid Waiver

You are not eligible for MDCP because you voluntarily withdrew from the program.

Usted no puede recibir servicios del MDCP porque abandonó voluntariamente el programa.

You are not eligible for MDCP because you are currently enrolled in [Select one: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); STAR+PLUS HCBS program; Texas Home Living (TxHmL)]. MDCP services cannot be authorized because you can only be enrolled in one Medicaid waiver program at a time.

Usted no puede recibir servicios del MDCP porque actualmente está inscrito en [Select one: Programa de Servicios de Apoyo y Asistencia para Vivir en la Comunidad (CLASS); Programa para Personas Sordociegas con Discapacidades Múltiples (DBMD); Programa de Servicios en el Hogar y en la Comunidad (HCS); Programa de Servicios en el Hogar y en la Comunidad de STAR+PLUS; Programa de Texas para Vivir en Casa (TxHmL)]. No se pueden autorizar los servicios del MDCP porque usted no puede estar inscrito a la vez en más de un programa con exenciones.

1200
Loss of Medicaid Financial Eligibility

You are not eligible for MDCP because you do not meet the financial criteria necessary for the program.

Usted no puede recibir servicios del MDCP porque no cumple los criterios financieros necesarios para participar en el programa.

No additional comment should be added. 1200
Medicaid Eligibility Reinstated within Four Months No reason for denial language should be added.

Your Medicaid was reinstated on [DATE]. Your MDCP services will continue without interruption.

Su participación en el programa Medicaid fue restablecida el [DATE]. Usted seguirá recibiendo servicios del MDCP sin interrupción.

 
Declined Assessment

You are not eligible for MDCP because you did not let your health plan complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque no permitió que el plan médico realizara la valoración que requiere el programa.

No additional comment should be added. 2200
Living Arrangement is Not an Allowable Setting

You are not eligible for MDCP because your current home is not an allowable setting to receive services. Code of Federal Regulations at Title 42 CFR $ 441.301(c)(5) describes these services.


Usted no puede recibir beneficios de MDCP porque su hogar actual no es un entorno adecuado para recibir servicios. Estos servicios están descritos en la sección 441.301(c)(5) del título 42 del Código de Reglamentos Federales (CFR).

 

No additional comment should be added. 1200
Does Not Have an Unmet Need

You are not eligible for MDCP because you do not need services offered through the program.

Usted no puede recibir los servicios del MDCP porque no los necesita.

No additional comment should be added. 1200
Inability to Obtain Physician Signature

You aren't eligible for MDCP because your doctor didn't tell us you need the level of care provided in a nursing home.

Usted no puede recibir los servicios del MDCP porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo.

No additional comment should be added. 1200
Medical Necessity Denial Reason for Denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

You are not eligible for MDCP. See the Reason for Denial text box on page 1 of this form and the MDCP Medical Necessity Denial Attachment for more information.

Usted no puede recibir servicios del MDCP. Para más información, vea el cuadro “Motivo de la denegación”, en la página 3 de este formulario, y el anexo “Medical Necessity Denial” (denegación por no existir una necesidad médica) del MDCP.

1200
Individual Service Plan Exceeds Cost Limit

You are not eligible for MDCP because the cost of your individual service plan exceeds the maximum amount allowed.

Usted no puede recibir servicios del MDCP porque el costo de su plan individual de servicios excede la cantidad máxima permitida.

No additional comment should be added. 1200
Initial Form H2065-D for MAO MFP to Community No Reason for Denial language should be added.

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive a second Form H2065-D telling you when your services will begin.

Usted cumple los requisitos del MDCP. Sus servicios no empezarán hasta que usted y su plan médico acuerden una fecha para su salida de la casa de reposo. Permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén vigentes cuando salga de la casa de reposo. Usted recibirá un segundo Formulario H2065-D en el que se le informará cuándo comenzarán sus servicios.

 
Initial Form H2065-D for MFP to AFC No Reason for Denial language should be added.

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive another notice telling you when your MDCP services will begin. We will also send you a notice telling you how much your room and board and copayment will be.

Usted cumple los requisitos del programa MDCP. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa MDCP. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.

 
MFP Services Not Authorized Within 24 Hours

You are not eligible for MDCP because services were not authorized within 24 hours of the nursing facility stay.

Usted no puede recibir servicios del MDCP porque los servicios no se autorizaron en las 24 horas siguientes a su estancia en el centro de reposo.

No additional comment should be added. 2400
Room and Board and Copayment No Reason for Denial language should be added.

You must pay room and board and any copayment. You will pay them every month to your foster care home or assisted living facility.

Usted tiene que cubrir los gastos de alojamiento y comida y de cualquier copago. Deberá pagarlos cada mes al hogar de acogida o centro de vida asistida en el que se encuentre.

 
Institutional Stay Over 90 Days

You are not eligible for MDCP because you have entered an institution for a long-term stay, as described in the Code of Federal Regulations (CFR) at Title 42 CFR §441.301(b)(1).

Usted no puede recibir servicios del MDCP porque ha ingresado en una institución donde tendrá una estancia a largo plazo, como se describe en la sección 441.301(b)(1) del título 42 del Código de Reglamentos Federales (CFR).

You are not eligible for MDCP services while an in-patient of a [Select one: hospital; nursing facility; intermediate care facility for persons with intellectual disability].

Usted no puede recibir servicios del MDCP mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; un centro de atención intermedia para personas con discapacidad intelectual].

1200
Moved Out of State

You are not eligible for MDCP because you are not a Texas resident.

Usted no puede recibir servicios del MDCP porque no reside en Texas.

No additional comment should be added. 1200
Over Age 20

You are not eligible for MDCP because you are 21 or older.

Usted no puede recibir servicios del MDCP porque es mayor de 21 años.

No additional comment should be added. 1200
Other Contact supervisor. No additional comment should be added. 6300

Appendix III, LTSS Billing Matrix and Crosswalk

Appendix IV, MDCP Frequently Asked Questions

Appendix V, Time Calculation

Appendix VI, STAR Kids Transition Activities

Appendix VII, SASO Service Group, Service Code and Termination Code

Appendix VIII, RUG IPC Cost Limits

Appendix IX, STAR Kids TxMedCentral Naming Conventions

Appendix X, Monthly Income/Resource Limits

Appendix XI, HHSC Benefits Portal and TIERS Inquiry Desk Guide

Appendix XII, Create an Appeal Task in the HHSC Benefits Portal

Appendix XIII, Long Term Services and Supports

Appendix XIV, Reserved for Future Use

Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet

Appendix XVI, Medicaid Program Actions

Appendix XVII, Reserved for Future Use

Appendix XVIII, STAR Kids HEART Naming Conventions

Revision 20-3; Effective October 9, 2020

 

This appendix outlines the screenshots Program Support Unit (PSU) staff upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must use the HEART Naming Conventions below when uploading documents to the HEART case record. Refer to Appendix IX, STAR Kids TxMedCentral Naming Conventions, for TxMedCentral naming convention instructions.

When there is more than one of the same form, or screenshot, uploaded, then add a sequence number after the naming convention. For example, the first Form H1746-A sent or received would be uploaded as 1746, the second form sent or received would be uploaded as 1746_2, 1746_3, etc.

All screenshots, forms, documents and emails marked as “Yes,” in the “Required” column, must be included in the HEART case record. Screenshots, forms, documents or emails marked with an “*” in the “Required” column must be included in the HEART case record if used by PSU staff in the HEART transaction.

 

Interest List Release (ILR)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL Yes
Form 2442 (English) 2442 *
Form 2442-S (Spanish) 2442-S *
Form 2602 2602 Yes
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes 
Form H1746-A (form alone or with fax confirmation) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H3676-A Use TxMedCentral Naming Convention Yes
Form H3676-A Upload to TxMedCentral 3676A TXMED Yes
Form H3676-B Use TxMedCentral Naming Convention Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Money Follows the Person (MFP)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual- Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL CLOSURE Yes
Form 2602 2602 Yes
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form 3618 3618 Yes
Form H1200 1200 Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTC Online Portal (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Annual Assessment
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from MCCO MCCO EMAIL *

 

Transition to Adult Programs (MDCP Age-Out)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H2116 2116 *
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from Higher Needs Coordinator HN EMAIL *
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
Emails to and from STAR+PLUS PSU PSU EMAIL *
Emails to and from UR UR EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Denials and Terminations
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
CSIL Closure Screenshot CSIL CLOSURE Yes
Fair Hearing Options for MDCP Denials MN DENIAL ATCH Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Fair Hearings
Item HEART Naming Convention Required
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H4800 4800 *
Form H4800-A 4800A *
Form H4803 4803 Yes
Form H4806 4806 *
Form H4807 4807 *
Copy of TAC §353.1155 for SSI and MN denials TAC 353.1155 Yes
Copy of TAC §19.2401 for MN denials TAC 19.2401 Yes
Copy of Section 6240 for SSI denials SKOPH 6240 Yes
Copy of Section 6250 for MN denials SKOPH 6250 Yes
Fair Hearing Options for MDCP Denials MN DENIAL ATCH Yes
Notice of Hearing Officer’s Decision APPEAL DECISION LTR Yes
HHSC Benefits Portal Screenshot of Hearing Officer's Decision TIERS APPEAL DECISION Yes
Emails to and from CRU CRU EMAIL *
Emails to and from ERS ERS EMAIL Yes
MEPD Communication Tool MEPD EMAIL *

Appendix XIX, Mutually Exclusive Services

Appendix XX, MDCP Program Description

Revision 19-6; Effective March 25, 2019
 

English PDF: The Medically Dependent Children Program
Spanish PDF: El Programa para Niños Médicamente Dependientes

Appendix XXI, Reserved for Future Use

Appendix XXII, Instructions and Access to CARE

Appendix XXIII, Community First Choice Support Management

Appendix XXIV, Reserved for Future Use

Appendix XXV, Acronyms

Appendix XXVI, STAR Kids Plan Codes

Appendix XXVII, MDCP Medical Necessity Denial Attachment

Revision 19-4; Effective March 4, 2019

 

English Word: MDCP Medical Necessity Denial

Spanish Word: Denegación de servicios del MDCP, por no existir necesidad médica

Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide

3-2019

 

PDF Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide