Revision 19-1; Effective June 3, 2019

 

 

5100 TxMedCentral

Revision 18-2; Effective September 3, 2018

 

 

5110 TxMedCentral Naming Convention and File Maintenance

Revision 19-1; Effective June 3, 2019

 

TxMedCentral is a secure Internet bulletin board that the Texas Health and Human Services Commission (HHSC) and managed care organizations (MCOs) use to share information. TxMedCentral uses specific naming conventions only for documents listed below. HHSC and MCO staff must follow these naming conventions any time one of the following documents is filed in TxMedCentral.

 

Form H1700-1, Individual Service Plan (Pg. 1)

The following forms may be used, if appropriate, in development of the individual service plan (ISP). Only Form H1700-1 and Form H1700-2 are uploaded to the MCO's ISP folder in TxMedCentral and should not be uploaded in any other folder:

Two-Digit Plan Identification (ID) Form Number (#) Member ID, Medicaid # or Social Security Number (SSN) Member Last Name (first four letters) Page Number of Form H1700 Sequence Number of Form
## 1700 123456789 ABCD 1 2

This file would be named ##_1700_123456789_ABCD_1_2.doc.

Form H1700-1, completed for non-members, age-outs, and nursing facility (NF) residents transitioning to the STAR+PLUS Home and Community Based Services (HCBS) program, continues to be uploaded to TxMedCentral.

Form H1700-1, completed for members in the community, is submitted to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

 

Form H3676, Managed Care Pre-Enrollment Assessment Authorization

This form is uploaded to the SPW folder and should not be uploaded in any other folder. An "A" or "B" is added to the sequence number to indicate whether Program Support Unit (PSU) or MCO staff uploaded the form.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 3676 123456789 ABCD A or B 2

This file would be named ##_3676_123456789_ABCD_A_2.doc if uploaded by PSU staff.

This file would be named ##_3676_123456789_ABCD_B_2.doc if uploaded by the MCO.

 

Form H2065-D, Notification of Managed Care Program Services

Form H2065-D is uploaded to the SPW folder and should not be uploaded in any other folder.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2065 123456789 ABCD D 2D or 2A
  • Denials will be coded with a “D” (denial) immediately following the form’s sequence number. This denial file would be named ##_2065_123456789_ABCD_D_2D.doc.
  • Approvals will be coded with an “A” immediately following the sequence number. This approval file would be named ##_2065_123456789_ABCD_D_2A.doc.

If a member has an ISP which is electronically generated, Form H2065-D is available in the "LETTERS" tab of the TMHP LTC Online Portal when the member's ISP is selected. Form H2065-D is uploaded to TxMedCentral only for individuals without electronic ISPs.

MCOs must check the TMHP LTC Online Portal to check for updates and notifications electronically generated by Program Support Unit (PSU) staff.

 

Form H2067-MC, Managed Care Programs Communication

This form is uploaded to the SPW folder and should not be uploaded in any other folder. An "M" or "S" is added to the sequence number to indicate whether the MCO or PSU staff uploaded the form.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD 2M or 2S

This file would be named ##_2067_123456789_ABCD_2M.doc if uploaded by the MCO.

This file would be named ##_2067_123456789_ABCD_2S.doc if uploaded by PSU staff.

Additional to the standardized naming convention for Form H2067-MC, a separate naming convention has been developed to address use of Form H2067-MC for NF residents who request transition to the community under the STAR+PLUS Home and Community Based Services (HCBS) program. These individuals are considered expedited cases for application to the STAR+PLUS HCBS program. Both the MCO and PSU staff must be able to readily identify communications specific to these cases.

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

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD 1M or 1S MFP

Form H2067-MC file uploaded by the MCO would be named ##_2067_123456789_ABCD_1M_MFP.doc if uploaded by the MCO.

Form H2067-MC file uploaded by the MCO would be named ##_2067_123456789_ABCD_1S_MFP.doc if uploaded by PSU staff.

 

TxMedCentral Folders

The STAR+PLUS MCOs use the following folders for all STAR+PLUS HCBS program related uploads. Each MCO has two folders with three-letter identifiers:

  • ISP — Individual Service Plan, which contains Form H1700-1 and Form H1700-2; and
  • SPW — STAR+PLUS HCBS program, which contains:
    • Form H2065-D, Notification of Managed Care Program Services;
    • Form H3676, Managed Care Pre-Enrollment Assessment Authorization; and
    • Form H2067-MC, Managed Care Programs Communication.
Primary Folder: MCO Three-Letter Identifiers Secondary Folder: TxMedCentral Folders by Plan
AMC — Amerigroup MCO AMCISP AMCSPW
EVR — United Healthcare Community Plan MCO EVRISP EVRSPW
MOL — Molina MCO MOLISP MOLSPW
SUP — Superior MCO SUPISP SUPSPW
BRV — Cigna-HealthSpring MCO BRVISP BRVSPW

 

 

5120 Identifying Managed Care Members in the Texas Integrated Eligibility Redesign System

 

 

Revision 19-1; Effective June 3, 2019

 

The Individual-Summary screen in the Texas Integrated Eligibility Redesign System (TIERS) contains a managed care segment for any individual who is currently or has been enrolled in managed care. From the Individual-Search screen, enter the individual's information and select Search. The results of the search will appear in Search Results field. Select the individual’s name on the hyperlink. The Individual - Summary screen will appear. Hover over the Individual # field and select Managed Care. The individual's managed care information will appear.

Specific managed care information is located under Individual Managed Care History field. The data elements across the bottom of the screen are: Provider – Plan – Program – County – Begin Date – End Date – Status – Eligibility – Candidature.

These fields contain the following information:

Provider — Contains the name of the provider contracted by the managed care organization (MCO) to deliver services to members.

Plan — Contains the name 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 — Date enrollment began under this plan.

End Date — 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.

STAR+PLUS Plan Codes

Service Area Plan Name Plan Codes Plan Codes Dates
Bexar Amerigroup 45 Sept 1, 2011
Molina 46 Sept 1, 2011
Superior 47 Sept 1, 2011
Dallas Molina 9F March 1, 2012
Superior 9H March 1, 2012
El Paso Amerigroup 34 March 1, 2012
Molina 33 March 1, 2012
Harris Amerigroup 7P Sept 1, 2011
United Healthcare 7R Sept 1, 2011
Molina 7S Sept 1, 2011
Hidalgo Cigna-HealthSpring H7 March 1, 2012
Molina H6 March 1, 2012
Superior H5 March 1, 2012
Jefferson Amerigroup 8R Sept 1, 2011
United Healthcare 8S Sept 1, 2011
Molina 8T Sept 1, 2011
Lubbock Amerigroup 5A March 1, 2012
Superior 5B March 1, 2012
Medicaid Rural Service Area (RSA) West Texas Amerigroup W5 Sept 1, 2014
Superior W6 Sept 1, 2014
Medicaid RSA Northeast Texas Cigna-HealthSpring N3 Sept 1, 2014
United Healthcare N4 Sept 1, 2014
Medicaid RSA Central Texas Superior C4 Sept 1, 2014
United Healthcare C5 Sept 1, 2014
Nueces United Healthcare 85 Sept 1, 2011
Superior 86 Sept 1, 2011
Tarrant Amerigroup 69 Sept 1, 2011
Cigna-HealthSpring 6C Sept 1, 2011
Travis Amerigroup 19 Sept 1, 2011
United Healthcare 18 Sept 1, 2011

 

5121 Medicare-Medicaid Plan (MMP) Codes

Revision 19-1; Effective June 3, 2019

 

Service Area Plan Name Plan Codes Plan Codes Dates
Bexar Amerigroup 4F 9/1/15
Molina 4G 9/1/15
Superior 4H 9/1/15
Dallas Molina 9J 9/1/15
Superior 9K 9/1/15
El Paso Amerigroup 3G 9/1/15
Molina 3H 9/1/15
Harris Amerigroup 7Z 9/1/15
United Healthcare 7Q 9/1/15
Molina 7V 9/1/15
Hidalgo Cigna-HealthSpring H8 9/1/15
Molina H9 9/1/15
Superior HA 9/1/15
Tarrant Amerigroup 6F 9/1/15
Cigna-HealthSpring 6G 9/1/15

 

5200 Service Authorization System

Revision 18-2; Effective September 3, 2018

 

 

5210 Managed Care Data in the Service Authorization System

Revision 19-1; Effective June 3, 2019

 

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 a service code (SC). 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, 2017, for an ISP that ended May 31, 2017. To register this reassessment, register one service authorization record using "Service Code 13 — Nursing" with a begin date of June 1, 2017, and an end date of June 30, 2017. Then, register a second service authorization record using "Service Code 12 — Case Management" with a begin date of July 1, 2017, and an end date of May 31, 2018.

Example of automatic registration: A reassessment ISP is submitted to the TMHP LTC Online Portal on June 5, 2017, for an ISP that ended May 31, 2017. One service authorization record with "Service Code 13 — Nursing" will be system generated with a begin date of June 1, 2017, and an end date of June 30, 2017. A second service authorization record with "Service Code 12 — Case Management" will be system-generated with a begin date of July 1, 2017, and an end date of May 31, 2018.

 

5220 Money Follows the Person Demonstration Entitlement Tracking and Service Authorization System Data Entry

Revision 19-1; Effective June 3, 2019

 

Time spent in a nursing facility (NF) does not count toward the 365-day period; therefore, tracking is required to ensure Money Follows the Person Demonstration (MFPD) individuals receive the full 365-day entitlement period. The entitlement period begins the date the individual who agrees to participate in the demonstration is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program. The managed care organization (MCO) uploads Form H2067, Managed Care Programs Communication, to TxMedCentral in the MCO folder, indicating the total number of days the member spent in the NF. This information is sent after the 365th day.

 

5300 Texas Medicaid & Healthcare Partnership Long Term Care Online Portal

Revision 19-1; Effective June 3, 2019

 

 

5310 Using the TMHP Long Term Care Online Portal

Revision 19-1; Effective June 3, 2019

 

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 (LTC) Online Portal to process a determination of MN and associated resource utilization group (RUG) value. MCOs submit the MN/LOC Assessment as an:

  • Initial assessment, submitted when an applicant or individual is being assessed for the STAR+PLUS Home and Community Based Services (HCBS) program or eligibility for Community First Choice (CFC) services.
  • Annual assessment.
  • Significant change in status assessment for members only receiving CFC as an upgrade for HCBS.

The MCO has the ability to correct or inactivate assessments submitted within specific time frames. Corrections are completed when certain data elements require correction (refer to the TMHP Community Waiver User Guide to determine which fields are correctable). Inactivations are completed when a correction is needed after the 14-day correction time frame allowable time to submit corrections has passed and when the field(s) requiring correction are not correctable and to remove the assessment from the TMHP LTC Online Portal.

The MCO has access to the TMHP LTC Online Portal 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 take action in response to workflow messages; and
  • submit Form H1700-1, Individual Service Plan (Pg.1), for initial, change, and reassessment of members with the exception of age-outs and nursing facility (NF) residents transitioning to the STAR+PLUS HCBS program.

More information about submitting Form H1700-1 through the TMHP LTC Online Portal is available in Appendix XXVI, Long Term Care Online Portal User Guide for Managed Care Organizations.

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

Status messages appear in the TMHP LTC Online Portal workflow folder when an MN/LOC Assessment is submitted. Additionally, error messages with status codes appear when TMHP processing cannot be completed. Status messages may be generated when:

  • assessments have missing information;
  • the system cannot match the assessment to an applicant or individual record;
  • the individual is enrolled in another 1915c Medicaid waiver program;
  • assessment forms are out of sequence;
  • corrections are made to assessments after SASO records have been generated based on the assessment;
  • changes occur in MN or LOS status that affect applicant or individual services; or
  • previous SASO records were manually changed within the current individual service plan (ISP) period.

This list is not all inclusive.

Messages will appear in the workflow folder to indicate whether or not the TMHP LTC Online Portal action was processed as complete. In some situations, MN, LOS and DIA records will not be generated to SASO; in other situations, SASO records will be generated but messages may still appear in the workflow for required action.

PSU staff:

  • may update SASO records and/or take specific case actions based on the MN and RUG information found in the TMHP LTC Online Portal;
  • must document responses in the TMHP LTC Online Portal to workflow messages appearing for an individual by clicking on applicable buttons related to the messages; and
  • must check TMHP LTC Online Portal workflow items to process case actions.

CMS coordinators need to contact PSU staff to update SASO records and/or take specific case actions based on the MN and RUG information found in the TMHP LTC Online Portal.

 

5400 Administrative Payment Process

 

Revision 19-1; Effective June 3, 2019

 

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 (NF) diversion 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 the form 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, Chapter 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 follow the requirements in this handbook section.

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

  • Contract Compliance and Support (CCS) 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, ERS staff email the PSU staff who emailed the request that the administrative payment has been denied and the reason for the denial.

Within two business days of receipt of email from the ERS, the PSU staff who submitted the request for administrative payment notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral.