06-2019

 

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Form 2604, STAR Kids Individual Service Plan – Tracking Tool

This form is uploaded to the ISP folder and SKW folder.

Two-Digit Plan Code Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2604 123456789 ABCD   1, 2, 3, etc.
  • The first form file must be named: ##_2604_123456789_ABCD_2.doc.
  • The second form file must be named: ##_2604_123456789_ABCD_MFP_2.doc.

 

Form H3676, Managed Care Pre-Enrollment Assessment Authorization

This form is uploaded to the SKW folder and should not be uploaded in any other folder.

Two-Digit Plan Code Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 3676 123456789 ABCD A 1, 2, 3, etc.
  • If Section A of this form was completed, the first form file must be named: ##_3676_123456789_ABCD_A_1.doc.
  • If Section B of this form was completed as a reponse to Section A being uploaded, the second form file must be named: ##_3676_123456789_ABCD_B_2.doc.

 

 

Form H2067-MC, Managed Care Programs Communication

This form is uploaded to the SKW folder and should not be uploaded in any other folder. An "M" or "S" is added to the sequence number to denote, respectively, whether the managed care organization (MCO) or Program Support Unit (PSU) staff uploaded the form.

Two-Digit Plan Code Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD   1M, 2M, 3M, etc. or 1S, 2S, 3S, etc.
  • The first form file, if uploaded by the MCO, must be named: ##_2067_123456789_ABCD_1M.doc.
  • The second form file, if uploaded by the MCO, must be named: ##_2067_123456789_ABCD_2M.doc.

A separate naming convention has been developed to address use of Form H2067-MC for nursing facility (NF) residents who request transition to the community under Medically Dependent Children Program (MDCP). These individuals are considered expedited cases for application to MDCP services. For this reason, staff from both the MCO and PSU must be able to readily identify communications specific to these cases. In order to achieve rapid identification of forms for these individuals, the acronym for Money Follows the Person, “MFP”, has been added to the naming convention.

An "M" or "S" continues to be added to the sequence number to denote, respectively, whether the MCO or PSU staff uploaded the form. The new naming convention for uploading Form H2067-MC, on both member and non-member cases in a NF, is expanded as follows:

Two-Digit Plan Code Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD MFP 1M, 2M, 3M, etc. or 1S, 2S, 3S, etc.
  • The first form file, if uploaded by the MCO, must be named: ##_2067_123456789_ABCD_MFP_1M.doc.
  • The second form file, if uploaded by the MCO, must be named: ##_2067_123456789_ABCD_MFP_2M.doc.

 

Form 3618, Resident Transaction Notice

This form is uploaded to the SKW folder and should not be uploaded in any other folder.

Form 3618 is used for nursing facility (NF) residents who request transition to the community under MDCP. These individuals are considered expedited cases for application to MDCP services. For this reason, staff from both the MCO and PSU must be able to readily identify communications specific to these cases. In order to achieve rapid identification of forms for these individuals, the acronym for Money Follows the Person, “MFP”, has been added to the naming convention.

Two-Digit Plan Code Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 3618 123456789 ABCD MFP 1, 2, 3, etc.
  • This first form file would be named: ##_3618_123456789_ABCD_MFP_1.doc.

 

Form H2065-D, Notification of Managed Care Program Services

This form is uploaded to the SKW folder and should not be uploaded in any other folder.

Two-Digit Plan Code Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2065 123456789 ABCD   1D, 2D, 3D, etc. or 1A, 2A, 3A, etc.
  • Denials will be coded with a “D” immediately following the form’s sequence number. The first denial form file must be named: ##_2065_123456789_ABCD_D_1D.doc.
  • Approvals will be coded with an “A” immediately following the sequence number. The first approval form file must be named: ##_2065_123456789_ABCD_1A.doc.

 

TxMedCentral Folders

The STAR Kids MCOs use the following folders for all MDCP related uploads. Each MCO has two folders with three-letter identifiers:

  • ISP — Individual Service Plan, which contains Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and Form 2604, STAR Kids Individual Service Plan – Tracking Tool; and
  • SKW — STAR Kids Waiver, which contains:
    • Form H3676, Managed Care Pre-Enrollment Assessment Authorization;
    • Form H2067-MC, Managed Care Programs Communication;
    • Form 3618, Resident Transaction Notice; and
    • Form H2065-D, Notification of Managed Care Program Services.

 

Shared Appendix 33

This appendix appears in the following handbooks:

STAR Kids Handbook (SKH): Appendix IX
STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH): Appendix IX