Revision 18-2; Effective September 3, 2018

 

 

 

5100 TxMedCentral

Revision 18-2; Effective September 3, 2018

 

 

5110 TxMedCentral Naming Convention and File Maintenance

Revision 18-2; Effective September 3, 2018

 

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 posted to MCO's ISPXXX folder in TxMedCentral and should not be posted 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 posted 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 posted to the STAR+PLUS Waiver SPW folder and should not be posted 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
## 3676 123456789 ABCD A 2

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

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

Form H2065-D, Notification of Managed Care Program Services

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

This file would be named ##_2067_123456789_ABCD_2S.doc if posted 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 posted the form. The new naming convention for posting 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

This form file posted by the MCO would be named ##_2067_123456789_ABCD_1M_MFP.doc if posted by the MCO.

This form file posted by the MCO would be named ##_2067_123456789_ABCD_1S_MFP.doc if posted by PSU staff.

TxMedCentral Folders

The STAR+PLUS MCOs use the following folders for all STAR+PLUS HCBS program related postings. 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 Waiver, 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

File Maintenance

Due to the volume of forms being posted to TxMedCentral, it is mandatory to purge older documents from time to time. PSU staff must electronically back up documents from the XXXISP and XXXSPW 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 18-2; Effective September 3, 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 work directly with member files posted to TxMedCentral. TxMedCentral files must be backed up daily on a compact disc (CD) before they are accessed, organized or member forms printed.

 

5130 Managed Care Data in TIERS

Revision 18-2; Effective September 3, 2018

 

 

5130.1 County Code Issues Affecting Enrollment

Revision 18-2; Effective September 3, 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. Incorrect county records in TIERS can cause enrollment problems for applicants or members in STAR+PLUS.

Supplemental Security Income Cases

If the individual receives Supplemental Security Income (SSI), TIERS derives the county based on the residential ZIP code provided by the Social Security Administration (SSA). If this data is incorrect, it can result in one of two problems:

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

Either of these could cause TIERS to assign a wrong county.

Non-SSI Cases

If the individual has any type program (TP) other than 12 or 13, TIERS contains the county code entered by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Common problems are:

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

What to Do to Mitigate Issues Affecting Enrollment

  1. Perform an inquiry into TIERS or the Financial Wizard in SASO 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, use Form H1270, Data Integrity SAVERR Notification, to send the following information to the Data Integrity Unit:
    • 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 Data Integrity Unit can force correct the problem in TIERS. The correction will take place during the next TIERS cutoff process, 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 the Texas Integrated Eligibility Redesign System

Revision 18-2; Effective September 3, 2018

 

Because participation in managed care programs is based on an individual's residence county code as recorded in the Texas Integrated Eligibility Redesign System (TIERS), service interruptions can occur when TIERS records show the wrong residence county code.

The Service Authorization System Online (SASO) reflects the residence county as recorded in TIERS and is updated through monthly interfaces. 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 12/13 in TIERS, the individual or his or her authorized representative (AR) must call the Social Security Administration (SSA) to request a correction. The Data Integrity Unit can correct problems in TIERS that result from 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 using Form H1270, Data Integrity SAVERR Notification, 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 "Other Corrections" section of Form H1270 and email the form and following information to the Data Integrity Unit:
    • individual's name as recorded in TIERS;
    • Medicaid identification (ID) number;
    • correct ZIP code; and
    • and residence county as it should be reflected in TIERS.
  • TP 03/BP 13, contact the Medicaid for the Elderly and People with Disabilities (MEPD) specialist assigned to the case and request a correction.
  • TP 03, TP 18, TP 19, TP 21, TP 50, TP 87 or TA 88 in TIERS, contact the MEPD specialist assigned to the case and request a correction.
  • Supplemental Nutrition Assistance Program (SNAP), contact the Texas Works advisor assigned to the case and request a correction.

 

5131 Identifying Managed Care Members in the Texas Integrated Eligibility Redesign System

Revision 18-2; Effective September 3, 2018

 

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 window, enter the individual's information and select Search. The individual's managed care status is shown on this window in the managed care section of the Individual-Summary screen.

Specific managed care information is located under Individual Managed Care History. 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.

County — Individual's county of residence.

Program — For managed care members, "STARPLUS" will appear in this field.

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

 

5200 Service Authorization System

Revision 18-2; Effective September 3, 2018

 

 

5210 Managed Care Data in the Service Authorization System

Revision 18-2; Effective September 3, 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 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 June 30, 2018.

 

5220 Closing Institutional Service Records in the Service Authorization System

Revision 18-2; Effective September 3, 2018

 

For individuals being discharged from a nursing facility (NF) who are to begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program and still have active Category 1 services open in the Service Authorization System Online (SASO), Provider Claims Services has established a hotline to assist Program Support Unit (PSU) staff in closing the NF authorization. The 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 hotline, PSU staff must identify himself or herself as a Texas Health and Human Services Commission (HHSC) employee and report the member has been discharged from the NF, providing the discharge date. The Provider Claims Services (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 Money Follows the Person Demonstration Entitlement Tracking and Service Authorization System Data Entry

Revision 18-2; Effective September 3, 2018

 

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) sends Form H2067, Managed Care Programs Communication, with the total number of days the member spent in the NF. This information is sent after the 365th day. The tables below are intended to assist Program Support Unit (PSU) staff in making accurate entries in the Service Authorization System Online (SASO).

Example 1 — No institutionalization during the 365-day period

Begin Date

End Date

Service Group

Service Code

Comments

Fund Code

02-13-17 06-15-18 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the managed care organization (MCO) capitation payment. SASO record entered by PSU staff. Blank
06-15-18 06-14-19 19 12 PSU staff enter the SASO record and enter fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU staff enter the remaining individual service plan (ISP) period without the 19MFP fund code. Blank

Example 2 — Institutionalization during the 365-day period

Begin Date

End Date

Service Group

Service Code

Comments

Fund Code

02-13-17 06-15-18 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the MCO capitation payment. SASO record entered by PSU staff. Blank
06-15-18 06-14-19 19 12 PSU staff enter SASO record and enter fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU staff enter the remaining ISP period without the 19MFP fund code. Blank

The MCO has notified PSU staff this member spent a total of 15 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:

06-15-19 06-29-19 19 12 PSU staff enter the MFPD period for the 15 days the individual was in the hospital. 19MFP
06-30-19 06-30-19 19 12 MFPD period reached the 365th day on 06-29-10. ISP had one day remaining. Blank

Example 3 — Institutionalization during the 365-day period

Begin Date

End Date

Service Group

Service Code

Comments

Fund Code

02-13-17 06-15-18 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the MCO capitation payment. SASO record entered by PSU staff.  Blank
06-15-18 06-14-19 19 12 PSU staff enter SASO record and enter fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU staff enter the remaining ISP period without the 19MFP fund code. Blank
07-01-19 06-30-20 19 12 PSU staff enter reassessment ISP. Blank

The MCO has notified PSU staff this member spent a total of 25 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:

06-15-19 06-30-19 19 12 PSU staff enter the MFPD period for the 16 of the 25 days the individual was in the hospital. 19MFP
07-01-19 07-09-19 19 12 PSU staff enter the MFPD period for the last 9 of the 25-day period in which the individual was in the hospital. 19MFP
07-10-19 06-30-20 19 12 PSU staff enter the remainder of the reassessment ISP period. Blank

Example 4 — Institutionalization in NF during MFPD period

(The difference between Example 2 and Example 4 is that for NF stays, PSU staff have to correct STAR+PLUS HCBS program or NF overlaps.)

Begin Date End Date Service Group Service Code Comments Fund Code
02-13-17 06-15-18 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the MCO capitation payment. SASO record entered by PSU staff. Blank
06-15-18 06-14-19 19 12 PSU staff enter SASO record and enter fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU staff enter the remaining ISP period without the 19MFP fund code. Blank
08-15-18 08-29-18 1 1 The NF begin and end dates are derived from forms submitted by NFs. Blank

PSU staff become aware this individual spent a total of 15 days in the NF during the MFPD period. PSU staff must correct SASO as follows:

06-15-18 08-14-18 19 12 PSU staff must correct STAR+PLUS HCBS program or NF overlap. 19MFP
08-30-18 06-14-19 19 12 PSU staff complete overlap entries. 19MFP
06-15-19 06-29-19 19 12 PSU staff enter the MFPD period for the 15 days the individual was in the NF. 19MFP
06-30-19 06-30-19 19 12 MFPD period reached the 365th day on 06-29-10. ISP had one day remaining. Blank

 

 

5300 Long Term Care Online Portal

Revision 18-2; Effective September 3, 2018

 

 

5310 Using the Long Term Care Online Portal

Revision 18-2; Effective September 3, 2018

 

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 reimbursement rates. 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; or
  • annual assessment.

The MCO has the ability to correct or inactivate assessment forms submitted within specific time frames. Corrections are completed when data submitted incorrectly is updated; inactivation is completed when data needs to be removed from the TMHP LTC Online Portal.

The MCO is given access to the TMHP LTC Online Portal to:

  • check and verify MN status and Resource Utilization Groups (RUGs);
  • review actions placed in a workflow status that result from the submittal of the MN/LOC Assessment at initial enrollment or annual assessment;
  • 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.

Staff with access and responsibility to manage workflows related to their job duties include Claims Management System (CMS) coordinators, Provider Claims Services (PCS) coordinators and Program Support Unit (PSU) staff.

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 program;
  • assessment forms are out of sequence;
  • corrections are made to assessments after submission to SASO records have already been generated based on the initial assessment submitted;
  • 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.

MCO and CMS coordinators:

  • may filter the workflow messages by choosing specific criteria, such as individual name or type of MN/LOC Assessment;
  • 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 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.

Enrollment Resolution Services (ERS) may:

  • filter the workflow messages by choosing specific criteria, such as individual name or type of MN/LOC Assessment; and
  • 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 18-2; Effective September 3, 2018

 

When an individual is aging out of the Texas Health Steps Comprehensive Care Program, 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:

  • 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; or
  • 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.

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

  • verify the member is Medicaid eligible and has a valid medical necessity level of care (MN/LOC) 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, State of Texas Purchase Voucher;
  • create an HHS Enterprise Administrative Report and Tracking System (HEART) case that includes the:
    • Services Authorization screen from SASO;
    • Medicaid eligibility screen from TIERS;
    • Managed Care enrollment screen from TIERS;
    • Form 1500; and
    • Form H4116.
  • email Form 4116, Form 1500 and the screen prints to Enrollment Resolution Services (ERS) within the Texas Health and Human Services Commission (HHSC) Medicaid/Children’s Health Insurance Program (CHIP) Division, with copies to the Contract Compliance and Support (CCS) Unit, and titles the subject line of the email as "Administrative Payment."

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

  • 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, ERS staff:

  • email the approved Form 4116 to CCS 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 deny the administrative payment, ERS staff notify by email the PSU staff who emailed the request that the administrative payment has been denied and the reason for the denial.

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

  • 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.

Within two business days of receipt of email from the ERS, PSU staff who submitted the request for administrative payment:

  • notify the MCO of the approval or denial decision by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral;
  • download the email from ERS and the MCO notification to the case in HEART; and
  • close the case in HEART.

 

5500 Safeguard Procedures for Wire Third Party Query and State Online Query

Revision 18-2; Effective September 3, 2018

 

The Social Security Administration (SSA) clarified the treatment of printed copies of Wire Third Party Query (WTPY) and State Online Query (SOLQ) responses. Federal guidelines require states to comply with the same safeguard procedures addressed in the Internal Revenue Service (IRS), Publication 1075, "Tax Information Security Guidelines for Federal, State, and Local Agencies and Entities." In keeping with SSA's guidance, the STAR+PLUS HCBS program will follow IRS safeguard procedures for printed copies of WTPY and SOLQ in those rare instances in which printing an SSA document is necessary.

Guidelines for Printing WTPY and SOLQ Inquiry Screens

Printing WTPY/SOLQ inquiry screens is not specifically prohibited; implement the following requirements when WTPY/SOLQ inquiry screens must be printed:

  • Do not file copies of WTPY/SOLQ inquiries in any member-specific file.
  • When necessary, PSU staff must document the type of information verified, the WTPY/SOLQ request number and the date it was viewed. Example: RSDI of $795 verified by viewing WTPY/SOLQ request #1234789 on 10/05/10.
  • Appropriately destroy the printed WTPY/SOLQ copy immediately after documenting the applicable information, and log the destruction according to requirements for destroying federal tax information.

The office must keep each destruction log for five years from the date of the last entry. PSU staff should not place WTPY/SOLQ print outs in agency confidential trash bins without being shredded. Copies of the inquiry screen can never be transferred to any off-site storage or destruction facility.

These requirements do not apply to print outs from the Texas Integrated Eligibility Redesign System (TIERS). PSU staff can access IRS Publication 1075 on the Internet by going to www.irs.gov (link is external) and searching for Publication 1075.