Effective Date: 
9/2017

Documents

 

Instructions

Updated: 9/2017

 

Purpose

Form H2067-MC is the primary communication tool for Program Support Unit (PSU) and managed care organization (MCO) staff to inform one another on activities related to managed care applicants and members.

 

Procedure

When to Prepare

PSU and MCO staff prepare Form H2067-MC to request and share case information not available through data inquiry.

 

Copies/Transmittal

PSU and MCO staff post the original to TxMedCentral in the receiving or sending MCO's folder. Each Form H2067-MC is named in accordance with conventions identified in the STAR+PLUS or STAR Kids Handbook, or for STAR Health, Chapter 16.2 of the Uniform Managed Care Manual (UMCM). PSU uploads a copy to the HHS Enterprise Administrative Report and Tracking System (HEART). The MCO follows established record-keeping procedures for form copies.

 

Form Retention

HEART is the PSU's repository for the electronic case record. Paper copies of Form H2067-MC are not retained by PSU. The MCO must keep copies of the completed form according to the retention requirements found in all Medicaid managed care contracts and federal regulations. MCOs must retain all originals/electronic copies of this form in the member's folder/electronic record for five years after services are terminated.

 

Supply Source

This form may be found at: https://hhs.texas.gov/laws-regulations/handbooks/starplus-handbook/sph-forms

 

Detailed Instructions

Section I, Applicant/Member Information

From: Program Support Unit (PSU) or Managed Care Organization (MCO) — The initiating party enters either the PSU or MCO name.

Program Name —  Check the box for either STAR+PLUS Home and Community Based Services (HCBS) program or Medically Dependent Children Program (MDCP).

To: PSU or MCO — The receiving party enters either the PSU or MCO name.

Service Delivery Area (SDA) — Enter the applicant's/member's SDA.

Applicant/Member Name — Enter the name of the applicant/member the PSU or MCO is communicating about.

Medicaid No. — Enter the applicant's/member's Medicaid number, when applicable.

Social Security No. — Enter the applicant's/member's Social Security number.

Address (Street, City, State, and ZIP Code) Enter the applicant/member's physical address, including street name, city, state and ZIP Code.

Area Code and Telephone No. — Enter the applicant/member's telephone number. For STAR Health members, the primary medical consenter's number is entered here.

Mailing Address, if Different from Above — Enter the mailing address, if different from the physical address.

Alternate Area Code and Telephone No. — Enter an alternate telephone number for the applicant/member, if available. For STAR Health members, the secondary medical consenter's number is entered here.

Section II, Check Applicable Categories

Where indicated, enter the requested date in this section. For each category checked, provide additional information as required by the STAR+PLUS or STAR Kids Handbook and STAR Health Chapter 16.2 of the UMCM and/or as needed in the Comments field.

1. Interest List Release PSU checks this box on applicants released from the interest list when there is a need to communicate information to the MCO.

2. Change in Address, SDA, MCO, or Other Circumstances Check this box if the member, including Money Follows the Person (MFP) members, has a change in address, SDA, MCO or other changes in status. Enter the planned or actual date of the change, the new address, SDA, MCO or other status changes in the Comments section.

3. Medical Necessity Denied — Check this box if the Home and Community-based Services (HCBS) SPW or MDCP applicant’s or member's medical necessity (MN) is denied. Use the Comments section to provide additional information, as needed.

4. Date STAR+PLUS HCBS or MDCP Member is Admitted to Nursing Facility (NF) — Check this box and click in the date field to select the date the member is admitted to an NF.

5. Community First Choice (CFC) Member Requesting STAR+PLUS HCBS program or MDCP — Check this box when a member receiving CFC services has requested, or been identified as having a need for, services available through the STAR+PLUS HCBS program or MDCP.

6. Appeal — Check this box if a member appeals a waiver program denial. Enter the appeal date and/or appeal outcome in the Comments section.

7. Date Money Follows the Person (MFP) Discharged from NF — The MCO checks this box and clicks in the date field to select the date the applicant/member discharges from the NF. Enter the address information of the member's community residence and other information, as needed, in the Comments section.

8. STAR+PLUS HCBS program or MDCP Member Adding/Transferring to CFC — The MCO checks this box if the member will be either adding CFC services or transferring from waiver services to receive only CFC services. Note: For STAR+PLUS HCBS or MDCP members terminating from the program and transferring to CFC services only, click in the date field to select the waiver end date. Use this section to also provide other information, as needed.

9. Date of Death — Check this box and click in the date field to select the applicant's/member's date of death.

10. MFP Demonstration Consent Obtained The MCO checks this box if the MFP Demonstration consent is obtained on a qualifying MFP individual.

11. MFP - Transition from NF to STAR+PLUS HCBS or MDCP — Check this box if an NF resident has requested to transition to STAR+PLUS HCBS or MDCP upon discharge from the facility.

12. MFP Demonstration End Date The MCO checks this box and clicks in the date field to select the date when the 365-day entitlement period concludes.

13. Waiver/Other Program Transfer  Check this box if the member is transitioning between another program (for example, intellectual or developmental disability waivers, HCBS-Adult Mental Health program) and STAR+PLUS HCBS program. Use the comments section to confirm the member has completed a written statement of informed choice. Provide the member's requested begin date for the elected program and the termination date of the current program.

14. STAR+PLUS HCBS program Upgrade Request Received or Need Identified by MCO The MCO checks this box and clicks in the date field to select the date of the MCO's referral to the PSU for STAR+PLUS HCBS services.

15. Other — Check this box if the communication to be shared does not pertain to the available check boxes. In the data field, identify the nature of the information. Examples:

  • The reporting party is unable to locate the applicant/member.
  • The Medical Necessity assessment is delayed pending a physician's signature.
  • The MCO requests PSU check Medicaid eligibility when member status changes to disenrolled.

Comments Provide additional remarks, as needed.

Staff Name — Enter the initiating staff person's name.

Posted Date — Enter the date the form is posted to TxMedCentral.

Area Code and Telephone No. — Enter the staff person's telephone number.

Section III, Response

From: MCO or PSU — The responding party enters either the PSU or MCO name.

To: MCO or PSU — The receiving party enters either the PSU or MCO name.

SDA — Enter the SDA of the responding party.

Comments — Enter comments to the information requested or shared, ensuring a complete and responsive communication to the initiating party.

Staff Name — Enter the responding staff person's name.

Posted Date — Enter the date the form is posted to TxMedCentral.

Area Code and Telephone No. — Enter the staff person's telephone number.

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