Revision 20-1; Effective September 1, 2019

 

The contractor must bill for services as described in the Texas Administrative Code (TAC), Chapter 10, Guardianship Services, and the Texas Health and Human Services Commission (HHSC) contract.

 

Unit Rate

HHSC pays the contractor for services rendered in accordance with the terms and conditions of the HHSC guardianship contract. Payment shall be made on a fee-for-service basis for guardianship of the person, as specified in TAC Title 40, Part 1, Chapter 10, Subchapter C, §10.327-329.

 

Required Billing Reports

  • Monthly Status Report for Delivered Services maintained by HHSC
  • Monthly Wards Served Report maintained by the contractor

 

Billing Procedures

HHSC Responsibilities — HHSC maintains a database of all wards and related case activity performed by the contractor. This information is compiled into a monthly report called the Monthly Status Report for Delivered Services. The report includes ward summary information, including:

  • a current list of all wards served by the contractor;
  • new referrals assigned to the contractor; and
  • names of deceased wards for whom the contractor remains as guardian until discharged by the court.

Contractor's Responsibilities — The contractor maintains a database of all wards and related case activity performed by the contractor. This information is compiled into a monthly report called the Monthly Wards Served Report. The report must be emailed to the Oversight and Community Support (OCS) contract manager and a copy to the OCS administrative assistant by the 10th day of each month for the preceding month. The report includes ward summary information, including:

  • a current list of all wards served by the contractor;
  • new referrals assigned to the contractor; and
  • names of deceased wards for whom the contractor remains as guardian until discharged by the court.

The OCS contract manager compares the two reports, the Monthly Status Report and the Monthly Wards Served Report. If there are discrepancies between the two reports, the contract manager or designee contacts the contractor to discuss those discrepancies. After discrepancies are resolved, the contract manager emails the contractor notifying the contractor of authorization to electronically bill for payment through the Texas Medicaid & Healthcare Partnership (TMHP), Claims Management System, for contracted services provided to HHSC wards. The contractor waits for the "authorized to bill" email notification from the contract manager before electronic claims are submitted for billing.

 

Electronic Claims Processing

Contractor’s Responsibilities – It is the contractor’s responsibility to set up an electronic billing account through TMHP. To set up an electronic billing account, the contractor contacts the TMHP Electronic Data Interchange (EDI) help desk at 1-800-626-4117, Option 3. Contractors obtain a personal identification number (PIN) for claims processing. The contractor provides the HHSC electronic billing contract number when the contractor calls to set up the account.

HHSC Responsibilities – It is HHSC’s responsibility to set up a provider billing account in the Provider Electronic System for the contractor. After the provider billing account is created, the system auto generates an electronic billing contract number. The electronic billing contract number is not the same number as the HHSC Guardianship Provider Services contract number. HHSC provides this number to the contractor as soon as it is obtained. Only the electronic billing contract number can be used to process claims and electronically bill for services provided by contractors.

It is also HHSC’s responsibility to enter new ward referrals into the electronic billing system. When a referral is accepted by a contractor, the referral is entered in the Single Service Authorization System by HHSC. HHSC pre-establishes and enters the rate ($275 for guardian of the person) and enters the billable units, one time per month, to be billed in the electronic billing system per ward by the contractor. The HHSC contract manager notifies the contractor when new referrals have been entered in the electronic billing system.

The contractor is encouraged to submit an electronic claim for payment through TMHP, Claims Management System, on a monthly basis after the service has been provided. If the contractor’s claims are denied by the system, the contractor contacts the TMHP help desk to inquire about denied claims. After calling the help desk and the claims issue continues to be unresolved, the contractor must submit a billing issues form for each claim denied to the HHSC contract manager, one form per ward.

 

Reimbursement Time Frames

When a new referral for a ward is made by HHSC and accepted by the contractor by the 15th day of the month, the ward is added to the electronic billing. If the referral is accepted on or after the 16th day of the month, the ward is added to the next month’s billing. If a ward authorized under a contract dies or the guardianship is otherwise terminated by the courts, the contractor may electronically bill for a maximum of 60 days following the death of a ward. It is the contractor’s responsibility to report the death of the ward timely to the HHSC contract manager. If payment continues to be made to a contractor because the contractor failed to notify HHSC within the established time frame, HHSC may withhold future payment for reimbursement of overpayment to the contractor.

 

Report of a Death/Termination of a Ward

The contractor is required to complete a report of death/service termination to report the death or termination of a ward. The contractor is required to email the form to the HHSC OCS contract manager, OCS administrative assistant and the guardianship supervisor. Refer to HHSC regional offices and contact information for the HHSC regional office designated areas.

When HHSC receives this form, the date of the ward's death is entered into the HHSC database and the electronic billing system by the OCS contract manager or designee. The ward's date of death is cued for the 60-day time frame, allowing the contractor to complete case activities to be discharged as guardian. For a ward who is deceased or whose services have been terminated, HHSC removes the ward's name from the Monthly Status Report for Delivered Services based on the date indicated on the Report of Death/Service Termination Form and the contractor removes the ward’s name from the Monthly Wards Served Report maintained by the contractor.

 

Status of a Claim

To inquire about the status of a claim or denied claims, contact the TMHP EDI help desk at 1-800-626-4117, Option 3. If the issue is not resolved, the contractor submits a billing issues form for each denied claim, one per ward, to the HHSC guardianship contract manager with a copy to the HHSC guardianship administrative assistant.