5110 File Maintenance

Revision 18-0; Effective September 4, 2018

Due to the volume of forms being uploaded to TxMedCentral, it is mandatory to purge older documents from time to time. Program Support Unit (PSU) staff must electronically back up documents from the managed care organization’s (MCO’s) ISP and SPW folder on a daily basis to prevent loss of form history. Documents must be easily accessible to PSU staff whenever needed. Texas Health and Human Services Commission (HHSC) requires these backup documents be maintained for five years.

5120 Maintenance Requirements for Member Information and Forms

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must establish and maintain a case record for each STAR+PLUS Home and Community Based Services (HCBS) program member. PSU staff must not update documents directly in TxMedCentral. Instead, PSU staff must move files daily to a secure location. Documents must be easily accessible to PSU staff whenever needed.

5130 Managed Care Data in the Texas Integrated Eligibility Redesign System

Revision 18-0; Effective September 4, 2018

5130.1 County Code Issues Affecting Enrollment

Revision 18-0; Effective September 4, 2018

The Service Authorization System Online (SASO) reflects the residence county as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Correction to the county code must be done in TIERS. Program Support Unit (PSU) staff must inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by faxing Form H1746-A, MEPD Referral Cover Sheet, to correct the county code. Incorrect county code records in TIERS can cause enrollment problems for applicants or members in STAR+PLUS.

Supplemental Security Income Cases

If an individual receives Supplemental Security Income (SSI), TIERS derives the county based on the residential Zoning Improvement Plan (ZIP) code provided by the Social Security Administration (SSA). If the ZIP code is incorrect, it can be because of one of two common problems:

• an incorrect ZIP code; or
• a ZIP code crosses county lines.

Either of these issues can cause TIERS to assign the wrong county.

Non-SSI Cases

If the individual has any SSI type program (TP) other than TP 12 or TP 13, TIERS contains the county code entered by the MEPD specialist. When not having TP 12 or TP 13, common problems are when:

• an individual moves without notifying the MEPD specialist; or
• an MEPD specialist enters an incorrect county code.

What to Do to Resolve Address Issues Affecting Enrollment

1. Perform an inquiry in TIERS and determine the TP.
2. If the TP is anything but 12 or 13 and the residence county is incorrect, refer the matter to the MEPD specialist to correct the residence county field.
3. If the TP is 12 or 13:

• Determine the residence ZIP code recorded in TIERS.
• If the residence ZIP code is not correct, the individual must report the correct ZIP code to SSA.

4. If the residence ZIP code in TIERS is correct but the county is incorrect, PSU staff email the Data Integrity Unit (DIU) at the CCC_Data _Intergrity_Program mailbox the following information:

• individual's name as recorded in TIERS;
• individual's Medicaid identification (ID) number;
• residence ZIP code; and
• residence county as it should be reflected in TIERS.

The DIU can update TIERS to correct the problem. The correction will take place during the next TIERS cutoff processing, usually around the 20th day of the month. SASO should reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff.

5130.2 Service Interruptions Resulting from County Code Mismatches in TIERS

Revision 18-0; Effective September 4, 2018

Because participation in managed care programs is based on an individual's residence county, as recorded in the Texas Integrated Eligibility Redesign System (TIERS), service interruptions can occur when the TIERS record shows the wrong residence county code.
The Service Authorization System Online (SASO) reflects the residence county as recorded in TIERS and is updated through a monthly interface. Therefore, incorrect county code data in SASO must be corrected in TIERS. The manner in which this correction occurs depends on the individual's type program (TP). If a residential county code is incorrect and the individual receives services under:

• TP 12 or 13 in TIERS, the individual or his or her authorized representative (AR) must contact the Social Security Administration (SSA) to request a correction. The Data Integrity Unit (DIU) can correct problems in TIERS that result from Zoning Improvement Plan (ZIP) codes that cross county lines. In these situations, SSA assigns a default county code in the computer program matrix, which is transferred to TIERS data files. Results of correction requests to the DIU di_managedcare mailbox, take place during the next TIERS cutoff, usually around the 20th day of the month. SASO will reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff. Describe the needed change in the email and send the following information:
  • individual's name as recorded in TIERS;
  • individual’s Medicaid identification (ID) number; and
  • correct ZIP code and residence county as it should be reflected in TIERS.
• TP 03, TP 18, TP 19, TP 21, TP 50, TP 87 or TP 88 in TIERS, Program Support Unit (PSU) staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist assigned to the HEART case record and request a correction.
• Supplemental Nutrition Assistance Program (SNAP), PSU staff must fax Form H1746-A to the MEPD specialist assigned to the HEART case record and request a correction.

5131 Identifying Managed Care Members in TIERS

Revision 24-1; Effective Feb. 22, 2024

Program Support Unit (PSU) staff must verify if an individual, applicant or member is enrolled in managed care by checking the Texas Integrated Eligibility Redesign System (TIERS). TIERS contains a managed care segment for all individuals, applicants or members who are currently or have been enrolled in managed care.

PSU staff must complete the following activities in TIERS:

• Enter the individual's, applicant’s or member’s information in the Individual-Search screen and select Search. The results of the search will appear in the Search Results field.
• Select the hyperlink of the individual’s name in the Search Results field. The Individual-Summary screen will appear.
• Hover over the Individual # field and select Managed Care from the dropdown menu. The managed care information will appear in the Individual Managed Care History field. The data elements in the Individual Managed Care History field include:
  • Provider — The name of the provider contracted by the MCO to deliver services to members.
  • Plan — The name and plan code of the MCO providing Medicaid services to the member.
  • Program — For managed care members, "STARPLUS" will appear in this field.
  • County — Individual's county of residence.
  • Begin Date — The date enrollment began under this plan.
  • End Date — The date enrollment ended under this plan.
  • Status — Describes the type of action.
  • Eligibility — Choices are "candidate" (applicant), "enrolled" (active) and "suspended" (closed).
  • Candidature — Describes the individual's status.

5210 Managed Care Data in SASO

Revision 18-0; Effective September 4, 2018 
  
The STAR+PLUS Home and Community Based Services (HCBS) program is authorized by the managed care organization (MCO) and registered by Program Support Unit (PSU) staff in the Service Authorization System Online (SASO) with a Service Group (SG) 19 and Service Code (SC) 12 or 13. If the member's individual service plan (ISP) is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal registers the appropriate SG/SC combination, which is verified by PSU staff. Service codes are based on the following:

• Service Code 12: Use this service code when registering initial service authorizations or annual re-determination service authorizations received up to 90 days prior to the end date of the current ISP.
• Service Code 13: Use this service code if an ISP is received after the end date of the most recent ISP. Register one service authorization using Service Code 13 effective the day after the end date of the most recent ISP and with an end date that is the end of the month in which the new ISP was received. Register a second service authorization using Service Code 12 with an effective date one day after the Service Code 13 service authorization ends and an end date of one year minus a day from the effective date of the ISP.

Example: A reassessment ISP is received on June 5, 2019, for an ISP that ended May 31, 2019. To register this reassessment, register one service authorization record using "Service Code 13 — Nursing" with a begin date of June 1, 2019, and an end date of June 30, 2019. Then, register a second service authorization record using "Service Code 12 — Case Management" with a begin date of July 1, 2019, and an end date of May 31, 2020.

Example of automatic registration: A reassessment ISP is submitted to the TMHP LTC Online Portal on June 5, 2019, for an ISP that ended May 31, 2019. One service authorization record with "Service Code 13 — Nursing" will be system-generated with a begin date of June 1, 2019, and an end date of June 30, 2019. A second service authorization record with "Service Code 12 — Case Management" will be system-generated with a begin date of July 1, 2019, and an end date of May 31, 2020.

5220 Closing Institutional Service Records in SASO

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must contact Provider Claims Services (PCS) at the established hotline to assist in closing a Service Authorization System Online (SASO) Category 1 nursing facility (NF) authorization for individuals being discharged from an NF and will begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program. The Texas Health and Human Services Commission (HHSC) Long Term Care (LTC) PCS hotline is 512-438-2200. Select Option 1 when prompted to do so.

PSU staff should call the hotline directly to request the NF record in SASO be closed so non-institutional services can be authorized. PSU staff must confirm the member has been discharged from the NF and community services are negotiated to begin on or after the date of discharge.

When calling the HHSC LTC PCS hotline, PSU staff must identify themselves as HHSC employees and report the member has been discharged from the NF, providing the discharge date. The PCS representative will close all Group 1 service authorizations and enrollment records in SASO, including the Service Code 60 record. This procedure applies whether or not the individual is leaving the NF using the Money Follows the Person (MFP) option.

5230 MFPD Entitlement Tracking and SASO Data Entry

Revision Notice 23-3; Effective Aug. 21, 2023

Time spent in a nursing facility (NF) does not count toward the Money Follows the Person Demonstration (MFPD) 365-day period. Therefore, the MCO will track to ensure MFPD members receive the full 365-day entitlement period. The entitlement period begins the date the member is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program. The managed care organization (MCO) uploads Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, indicating the total number of days the member spent in the NF. The MCO must send this information to Program Support Unit (PSU) staff after the 365th day. PSU staff may refer to the table below for help making  accurate entries in the Service Authorization System Online (SASO).

Example 1 — No institutionalization during the 365-day period

Example 2 — Institutionalization during the 365-day period

Example 3 — Institutionalization during the 365-day period

5310 Using the TMHP Long Term Care Online Portal

Revision 24-1; Effective Feb. 22, 2024

The managed care organization (MCO) must submit the Medical Necessity and Level of Care (MN/LOC) Assessment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to process a determination of MN and the Resource Utilization Group (RUG) value. MCOs submit the MN/LOC Assessment as an:

• initial MN/LOC Assessment for an applicant or individual being assessed for the STAR+PLUS Home and Community Based Services (HCBS) program;
• annual MN/LOC Assessment for a member's ongoing eligibility for the STAR+PLUS HCBS program; 
• a significant change in status MN/LOC Assessment for a STAR+PLUS HCBS program member requesting a change to their RUG.

The MCO must generate an amended individual service plan (ISP) when a significant change occurs in a member’s condition. The MCO must keep amended ISPs in the MCO’s member case file. The MCO does not provide the amended ISP to Program Support Unit (PSU) staff and does not enter the amended ISP in the TMHP LTCOP. PSU staff must advise the MCO that PSU staff do not process ISPs resulting from a significant change if the MCO uploads an amended ISP to the MCOHub.

The MCO has access to the TMHP LTCOP to:

• check and verify MN status and RUG;
• review workflow actions that result from the submittal of the MN/LOC Assessment or the individual service plan (ISP);
• manage and act in response to workflow messages; and
• submit Form H1700-1, Individual Service Plan, for initial, change, and reassessment of members except for age-outs and nursing facility (NF) residents transitioning to the STAR+PLUS HCBS program.

Submittal of the MN/LOC Assessment through the TMHP LTCOP creates MN, Level of Service (LOS) and Diagnosis (DIA) records in the Service Authorization System Online (SASO). The RUG value is in the LOS record.

Status messages appear in the TMHP LTCOP workflow folder when an MN/LOC Assessment is submitted. Error messages with status codes appear when TMHP processing cannot be completed. Status messages may generate when:

• assessments have missing information;
• the system cannot match the assessment to an applicant or individual record;
• the individual is enrolled in another Medicaid waiver program;
• assessment forms are out of sequence;
• corrections are made to assessments after submission to SASO records have already been generated based on the assessment;
• changes occur in MN or LOS status that affect the member’s services; or
• PSU staff manually changed historic SASO records within the current ISP period.

This list is not all-inclusive.

PSU staff must:

• document responses in the TMHP LTCOP to workflow messages appearing for an individual by clicking on applicable buttons related to the messages; and
• check TMHP LTCOP workflow items to process case actions.
   

Revision 18-0; Effective September 4, 2018

When an individual is aging out of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP), Medically Dependent Children Program (MDCP) or has been approved for a nursing facility diversion (NFD) slot, the managed care organization (MCO) must authorize services to start on the day of eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program, which may not be the first of the month. If the eligibility date is not the first of the month, the MCO must follow the administrative payment process for STAR+PLUS services provided between the eligibility date and the managed care enrollment date, as applicable. The administrative payment process must be used for the Texas Health and Human Services Commission (HHSC) to issue payment to the MCO and for the MCO to pay the provider.

Once the MCO authorizes services, the provider:

• prepares Form 1500, Health Insurance Claim; and
• submits Form 1500 to the MCO within the 95-day filing deadline.

Within five business days of receiving Form 1500, the MCO verifies the provider was authorized to deliver the services billed on Form 1500. The information on Form 1500 meets the clean claim requirements, as defined in the Uniform Managed Care Manual (UMCM), §2.0, and the claim met the 95-day filing deadline. Once the MCO verifies this information, the MCO:

• sends Form 1500 by secure email to Program Support Unit (PSU) staff if the provider:
  • is authorized to deliver the service;
  • met the clean claim requirements; and
  • submitted the claim to the MCO within the 95-day filing deadline; or  
• denies payment via the MCO denial process if the provider:
  • is not authorized to deliver the services;
  • did not meet the clean claim requirements; or
  • did not meet the 95-day filing deadline.

Within two business days of receiving Form 1500, PSU staff must:

• verify the member is Medicaid eligible and has a valid Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP);
• print the Service Authorization screen from Service Authorization Services Online (SASO) and the Medicaid eligibility and Managed Care enrollment screens in the Texas Integrated Eligibility Redesign System (TIERS);
• prepare Form 4116, Authorization for Expenditures;
• create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record that includes the:
  • Services Authorization screen print from SASO;
  • Medicaid Eligibility screen print from TIERS;
  • Managed Care Enrollment screen print from TIERS;
  • Form 1500; and
  • Form 4116.
• email Form 4116, Form 1500 and the screen prints to the Enrollment Resolution Services (ERS) mailbox.

Within two business days from the receipt of the email from PSU staff, the assigned ERS staff will:

• verify the member is Medicaid eligible; and
• review the claim to determine if it will be paid or denied.

If the decision is to approve to pay the administrative payment, the ERS staff will:

• email the approved Form 4116 to the Contract Compliance and Support (CCS) Unit mailbox for processing; and
• notify by email the PSU staff who emailed the request that the administrative payment has been approved.

If the decision is to approve the administrative payment, the following also occurs:

• The CCS Unit sends the approved payment voucher to the State Comptroller for processing and payment to the MCO; and
• the MCO pays the provider within one week of receipt of payment from the State Comptroller.

If the decision is to deny the administrative payment, the ERS staff will notify the PSU staff via email, who submitted the request for administrative payment. This email response will also include the reason for denial.

Within two business days of receipt of email from ERS staff, PSU staff will:

• notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
• upload the email from ERS and the MCO notification to the HEART case record; and
• close the HEART case record.