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July/August 2004

No. 181

Texas Medicaid

Bimonthly update to the Texas Medicaid Provider Procedures Manual

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Bulletin Contents, No 181

All Providers Case Management for Early Childhood Intervention.............................. 2 Children with Special Health Care Needs .............................................. 2 Coming Soon .......................................................................................... 2 Emergency Room Services .................................................................... 2 New Claim Status and Eligibility Queue ................................................. 3 HIV/STD Conference .............................................................................. 3 Preferred Provider Organization (PPO) Discounts ................................. 4 Recommended Childhood Immunization Schedule ............................... 4 Rehabilitative Services ........................................................................... 4 Reimbursement Methodology for Drugs/Biologicals.............................. 5 Scheduled System Maintenance ............................................................ 5 Stale-Date Check Process ..................................................................... 5 Telemedicine Services and Billing Guidelines ........................................ 6 TMHP EDI Help Desk ............................................................................. 7 CSHCN Providers CSHCN Payment Reduction................................................................... 7 Home Health Providers Home Health Supplies............................................................................ 8 Reimbursement Methodology Update .................................................... 8 SHARS Providers Speech Therapy Referral Requirements .............................................. 10 Texas Health Network Providers Precertification Requests ..................................................................... 10 THSteps-CCP Providers Prior Authorization ................................................................................ 10 Private Duty Nursing............................................................................. 10 RN/LVN Private Duty Nursing Hours.................................................... 11 THSteps-Comprehensive Outpatient Rehabilitation Facilities (CORFs) Cost Report Requirements ................................................................... 12 Revenue Codes .................................................................................... 13 Unallowable Costs for Client Transportation Services ......................... 13 Forms and Guides Recommended Childhood Immunization Schedule ............................. 14 Excluded Providers Excluded Providers............................................................................... 15

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BULLETIN

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CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply.

All Providers

Case Management for Early Childhood Intervention

The 2.5 percent Medicaid payment reduction, which became effective September 1, 2003, was incorrectly applied to payments for some providers billing procedure codes 1-6000X and 1-G9012. Reimbursement for these two procedure codes should have been excluded from the 2.5 percent Medicaid payment reduction. The correction was implemented March 11, 2004, and reimbursement for procedure codes 1-6000X and 1-G9012 has been excluded from the 2.5 percent reduction, retroactively effective back to September 1, 2003. Claims with dates of service on or after September 1, 2003, with procedure codes 1-6000X and 1-G9012 are being reprocessed and reimbursed without the 2.5 percent reduction. No action is required on the provider's part.

Children with Special Health Care Needs

The Children with Special Health Care Needs (CSHCN) Program is the oldest governmentadministered continuous medical assistance program in Texas. Established in 1933 as the Chronically Ill and Disabled Children (CIDC) Services Program, the program has, from its inception, provided assistance to low income children with special health care needs. In July 2001, in response to Senate Bill 374 passed by the 76th Texas Legislature, the program officially changed its name to the Children with Special Health Care Needs Program and implemented a comprehensive health benefits plan providing preventive and therapeutic medical, dental, and behavioral health services to all actively enrolled CSHCN clients. CSHCN is always in need of caring, qualified providers. Skilled, compassionate providers are the key to getting children with special health care needs and their families the services and support they need. Physicians can visit the TMHP website (www.tmhp.com) to download a CSHCN Provider Enrollment Packet. This packet also includes enrollment information for hospitals, providers of physical, occupational and speech therapy, dental services, durable medical equipment, skilled nursing, and expendable medical supplies. Advanced practice nurses or hospice, behavioral health, renal dialysis, respiratory therapy, and vision providers can enroll by calling TDH-CSHCN at 1-800-252-8023 or by downloading the appropriate forms from the TDH-CSHCN website, www.tdh.state.tx.us/cshcn/default.htm. For more information on the CSHCN Program, visit the CSHCN page on the TMHP website, at www.tmhp.com/C6/CSHCN.

Emergency Room Services

Effective for dates of service on or after June 24, 2004, emergency room services for diagnosis code 644.03, Preterm labor threatened, are payable.

Coming Soon

TMHP is conducting CSHCN, Family Planning, Home Health, and Long Term Care workshops in your area. Scheduled for July, August, and September 2004, these free workshops provide valuable information on each program and focus on preventing the problems Medicaid providers most often encounter when filing Medicaid claims. Workshop invitations were mailed in June 2004. Information on these workshops is also available online at the Texas Medicaid & Healthcare Partnership (TMHP) website. Providers can register for the workshop of their choice by visiting www.tmhp.com and selecting Register for a Workshop from the I would like to... links on the right hand side of the page.

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All Providers

New Claim Status and Eligibility Queue

The TMHP Contact Center recently added a new claim status and eligibility queue to assist providers with claim status and client eligibility information. This option was implemented April 5, 2004, and can be accessed by dialing 1-800-925-9126 and choosing the following menu options: 1. Select Option 5 (All Other Inquiries) from the main menu. 2. Enter a Texas Provider Identifier (TPI) number if available (if one is not available, stay on the line for a listing of the next available menu options). 3. Select submenu Option 1 (General Inquiries, Ambulance, Family Planning Title XIX, Provider Enrollment, Children with Special Health Care Needs [CSHCN], Texas Health Network Provider Helpline). 4. Select submenu Option 1 (General Inquiries). 5. Select submenu Option 1 (Claim Status and Eligibility). Contact center representatives in this queue can research up to 10 claim status inquiries or 10 client eligibility verification requests per call. Agents handling claim status requests can provide the status of Medicaid claims processed by TMHP and research applicable Explanation of Benefits (EOB) messages for a better understanding of payments or denials. Providers with Texas Health Network claims requiring more detailed research beyond the status of the claim are directed to the Texas Health Network provider queue for more information. The Texas Health Network provider queue has not moved and can still be reached by dialing 1-800-925-9126, choosing Option 5 from the main menu, entering a TPI number (or holding on the line if one is unavailable), selecting Option 1 from the submenu and Option 5 from the final submenu.

Please remember that claim status and client eligibility information is also available through the TMHP website at www.tmhp.com, or through the Automated Inquiry System at 1-800-925-9126, Option 1.

HIV/STD Conference

The 14th Texas HIV/STD Conference will be held December 13 - 18, 2004, at the Renaissance Austin Hotel in northwest Austin. The conference is sponsored by the Texas Department of Health (TDH) Bureau of HIV and STD Prevention and the University of Texas Health Science Center at San Antonio, in partnership with the following organizations: · The Center for Health Training · National Network of STD/HIV Prevention Training Centers · The Texas/Oklahoma AIDS Education and Training Center (TX/OK AETC) This conference is designed to provide up-todate HIV/STD information for prevention, intervention, and clinical service providers. A separate clinical update will be held on December 17 - 18, 2004, for an additional fee. Conference registration is $125 if postmarked on or before October 15, 2004. Registration increases to $175 after October 15. The following continuing education credits will be offered at the conference: CME, CNE, SW, LNFA, PT, CHES, LPC, CADAC. For more information, please visit the conference website at www.tdh.state.tx.us/ hivstd/conf/2004, or call Ted Fick, Assistant Conference Coordinator, at 1-512-490-2500, ext. 2561.

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All Providers

Recommended Childhood Immunization Schedule

The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) periodically reviews the recommended childhood and adolescent immunization schedule to ensure that the schedule is current with changes in manufacturers' vaccine formulations and reflects revised recommendations for the use of licensed vaccines, including those newly licensed. Recommendations and format of the childhood and adolescent immunization schedule for January­June 2004 were approved by ACIP, the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP) and published in January 2004. A revised childhood and adolescent immunization schedule for July­December 2004 has been published (see page 14) and includes the recommendation that children aged 6­23 months, as well as household and outof-home caregivers for such children, receive annual influenza vaccine, beginning in fall 2004. A catch-up immunization schedule for children and adolescents who start late or who are more than 1 month behind schedule remains unchanged from that published in January 2004. This catch-up schedule and additional information can be obtained by visiting the following website: www.cdc.gov/ mmwr/preview/mmwrhtml/mm5316Immunizationa1.htm.

Preferred Provider Organization (PPO) Discounts

Effective November 03, 2003, PPO discounts are no longer considered a part of other insurance payments. This policy is described on page 4-14 of the 2004 Texas Medicaid Provider Procedures Manual. Electronic submitters must supply the PPO discount amount when submitting other insurance information; however, this information is not included in the total other insurance payment during claims processing. Paper submitters are not required to add the PPO discount to the other insurance payment.

Rehabilitative Services

Effective for dates of service on or after September 1, 2003, the reimbursement rates for rehabilitative services for persons with mental illness are: Procedure Code 8010X 8011X 8012X 8013X 8014X 8015X 8016X 8017X 8018X 8019X and H0002 Reimbursement Rate $33.96 $24.66 $9.32 $6.43 $20.50 $11.68 $12.21 $20.50 $23.75 $34.74

Rates vary for procedure codes H2017 and G0177, depending on the modifier billed with these services. The reimbursement changes are being implemented on July 15, 2004. Claims with dates of service on or after September 1, 2003, paid at a different reimbursement rate are being reprocessed. No action on the provider's part is required. Claims submitted on or after July 15, 2004, are processed with the above listed rates.

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Reimbursement Methodology for Drugs/Biologicals

Effective July 1, 2004, with the 2004 HCPCS implementation, Texas Medicaid fee decisions for blood clotting factors, pneumococcal and hepatitis B drugs/biologicals, infusion drugs furnished through an item of implanted durable medical equipment, and new drugs/biologicals are based on 89.5 percent of the average wholesale price (AWP). For certain, specific drugs/biologicals studied by the Office of Inspector General (OIG)/General Accounting Office (GAO), Medicaid fee decisions are based on the recommended percentages of AWP resulting from those studies (Table 1 in §20 of Chapter 17 of the Medicare Claims Processing Manual, Pub. 100-04). For the remaining drugs/biologicals not listed above, Medicaid fee decisions are based on 85.0 percent of the AWP. HHSC reserves the option to use other data sources to determine Medicaid fees for drugs/biologicals when AWP calculations are determined to be unreasonable or insufficient. These guidelines are applicable to fee decisions for drugs/biologicals that are subject to manual pricing/review effective with claims processed on or after July 1, 2004. HHSC reviews its Medicaid fees for all drugs/ biologicals annually. This year's review is scheduled for late August. Fee adjustments will be effective no earlier than November 1, 2004. In the future, the review is scheduled for March of each year, with any fee adjustments effective June 1 of that year. Medicaid payments for 47 specific drugs/biologicals were excluded from the 2.5 percent Medicaid payment reduction for services on and after September 1, 2003. All Medicaid payments for drugs/biologicals are excluded from the 2.5 percent Medicaid payment reduction for services on and after December 1, 2003.

Scheduled System Maintenance

TMHP routinely performs diagnostic and corrective maintenance to the claims processing system. The next system maintenance is scheduled to occur on July 18, 2004, from 6:00 p.m. to 11:59 p.m., and August 22, 2004, from 6:00 p.m. to 11:59 p.m. During system maintenance, some claims engine related applications are unavailable. Specific details regarding the affected applications are posted on the TMHP website at www.tmhp.com.

Stale-Date Check Process

In June 2004, Texas Medicaid implemented staledating (voiding) procedures for all checks issued. When a check becomes 120 days old, TMHP sends a reminder letter to the payee. This letter notifies the payee of the check's stale date and states that TMHP will void the check if not cashed by this date. TMHP does not guarantee receipt of the 120-day letter, and all checks are voided after 180 days. Provider checks that are stale-dated appear in the Financial Transactions/Void and Stop section of the Remittance and Status (R&S) report. Before staledating, checks may be applied to accounts receivable and/or IRS levies. Once a check has been voided, the associated claims may not be payable, and the transaction is considered final. Texas Medicaid providers are strongly encouraged to receive payment via Electronic Funds Transfer (EFT), which eliminates stale-dating issues for providers. EFT ensures that providers receive payments via direct deposit in a banking account of their designation. To enroll in EFT, please call the TMHP Contact Center at 1-800-925-9126 and select Option 2.

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All Providers

Telemedicine Services and Billing Guidelines

Telemedicine technology is used to provide medical consultation services to healthcare providers in rural or medically underserved areas. To be reimbursed by the Texas Medicaid Program, telemedicine services must use advanced telecommunication technologies that conform to minimum technical standards, as identified by the Texas Department of Health, such as those of the Telecommunications Infrastructure Fund Board (TIFB). Medical consultation services must be provided by a physician at an approved hub site and consist of direct face-to-face, live interactive video communication with the client. The remote site provider must be present with the client during the interactive video telemedicine visit. The remote site may be located in the following places of service: · Practitioner's office · RHC · FQHC · Inpatient or outpatient hospital · Emergency room · ICF-MR state school Nursing facilities, skilled nursing facilities, and client homes are not approved places of service as remote sites for telemedicine services.

Billing Guidelines

Remote site providers are reimbursed for an office visit using codes 1-99201 through 1-99215 with the GT modifier in the office or outpatient hospital. If prolonged physician services 1-99354, 1-99355, or special services 1-99050, 1-99052, and 1-99054 are provided in addition to a telemedicine office visit, then these codes are billed with the GT modifier. When billing for telemedicine services provided in RHCs and FQHCs, providers bill code 1-T1015, Clinic visit/ encounter, all inclusive, with modifiers AM (physician) or SA (APN/CNM) in addition to the GT modifier. Hub site providers are reimbursed only for medical consultations via interactive video, using procedure codes 3-99241 through 3-99275 with the GT modifier. More than one medically necessary telemedicine consultation is allowed for payment on the same day/time and place of service, if the consultations are billed by physicians of different specialties. Office or outpatient consultations by the same provider are limited to one per six-month period. All other consultations during this period are changed to the appropriate outpatient or office evaluation and management code.

Hub Site

The hub site is the location where the consulting physician is physically located. Hub site providers are limited to physicians (as the consultant) at an accredited medical or osteopathic school located in Texas, or a physician at a hospital, teaching hospital, tertiary center, or health clinic affiliated through a written contract or agreement with an accredited medical or osteopathic school located in Texas.

Remote Site

The remote site is where the Medicaid client is physically located. Remote site providers must be located in rural or underserved areas and are limited to the following provider types: · Physicians · Advanced practice nurses (APNs) · Certified nurse midwives (CNMs) · Hospitals · Federally qualified health centers (FQHCs) · Rural health clinics (RHCs)

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Teleradiology and telepathology services are billed using the appropriate CPT code and modifier GT. Hub and remote site providers must be capable of receiving forwarded radiology or pathology information. These services do not require face-to-face interactive video communication. For additional information regarding telemedicine services, please refer to Section 34.3.6 in the 2004 Texas Medicaid Provider Procedures Manual.

have questions regarding files electronically submitted) -- Submenu Option 5 ­ Website account setup or connectivity (for providers having connectivity or account setup issues with TMHP's website) -- Submenu Option 6 ­ All other inquiries · Main Menu Option 2 ­ Acute Care Provider (Traditional Medicaid Services)

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TMHP EDI Help Desk

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The TMHP EDI Help Desk has recently implemented a new menu system to better assist providers needing technical assistance with transmission and software issues. These options were implemented April 19, 2004, and are available by dialing 1-888-863-3638. When calling this number, providers are asked to enter a TPI number and are presented with the following options: · Main Menu Option 1 ­ Long Term Care Provider

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Submenu Option 1 ­ Electronic submitter enrollment (to set up new electronic submitters) Submenu Option 2 ­ TDHconnect software inquiries (for questions related to the TDHconnect electronic software) Submenu Option 3 ­ Submitter testing inquiries (for vendors/providers testing third-party software) Submenu Option 4 ­ Submitted files or FTP connectivity inquiries (for questions about files electronically submitted or problems connecting to TMHP's FTP server) Submenu Option 5 ­ Website account setup or connectivity (for connectivity or account setup issues on TMHP's website) Submenu Option 6 ­ All other inquiries

CSHCN Providers

enrollment (for providers wishing to be set up for new electronic submission) -- Submenu Option 2 ­ TDHconnect software inquiries (for questions related to the TDHconnect electronic software) -- Submenu Option 3 ­ Submitter testing inquiries (for vendors/providers testing third-party software) -- Submenu Option 4 ­ Submitted files or FTP connectivity inquiries (for providers/ submitters that are having problems connecting to TMHP's FTP server or

CSHCN Payment Reduction

Effective for dates of service on or after May 3, 2004, reimbursement rates for procedure codes 1-90657 and 1-90658 have decreased to mirror Medicaid's current rate of $4.01.

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Home Health Providers

Home Health Supplies

A Home Health Agency (HHA) provider may request prior authorization for supplies/DME by using either the Home Health Services Plan of Care (POC) or the Home Health Service (Title XIX) DME/ Medical Supplies Physician Order Form. An HHA may utilize the Home Health Services Plan of Care (POC) to submit for prior authorization of supplies/DME to be used in conjunction with the professional services provided by the agency (skilled nursing, physical therapy, or occupational therapy). The agency's DMEH TPI must be submitted on the POC, and all supplies requested are to be listed in the supplies section on the POC. The POC does not require an MD's signature for prior authorization of professional services/DME and supplies. If the HHA uses the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form, the agency must complete Section A. The physician must complete Section B, and sign before submitting the form to TMHP for prior authorization of the requested supplies/DME.

methodology with statewide visit rates, resulting in each Medicaid home health agency (HHA) being paid according to the same visit rate for the same service. In a letter dated May 12, 2003, HHSC Rate Analysis informed providers that the reimbursement methodology changes had not yet been implemented and could not be implemented before April 1, 2004. The transition from the National Heritage Insurance Company to TMHP impacted the implementation of the new methodology. No implementation date is known at this time. HHAs continue to be paid a percentage of their billed charges for these services until the new methodology is implemented. As soon as an implementation date is determined, notification will be provided to all HHAs.

Transition Rates

To better approximate the amounts that each HHA would receive under the statewide visit rates, the payment percentage calculated by TMHP Medicaid Audits uses the statewide visit rates as the numerator of the calculation (rather than the HHA's actual Medicaid allowable costs from its 2002 cost report desk review). The HHA's billed charges from its 2002 cost report period are still used as the denominator. This "transition" payment percentage reduces the difference between the HHA's billed charges and the statewide visit rates, provided the HHA's billed charges do not change significantly from its 2002 cost report period. Each HHA should review its transition payment percentage resulting from the desk review of its 2002 cost report. If the transition payment percentage does not reduce the payment difference, either because the HHA has changed its billed charges or for some other reason, the HHA should contact the HHSC Rate Analyst for HHAs so that the transition payment percentage can be recalculated to better approximate the amounts that the HHA would receive under the statewide visit rates. When the statewide visit rates are implemented, payments are the lower of the provider's billed charges

Reimbursement Methodology Update

HHSC adopted revised reimbursement methodology rules for Medicaid home health professional services, excluding private duty nursing, at Title 1 of the Texas Administrative Code §355.8021, effective November 1, 2002. The purpose of the rule revisions was to replace the cost-based reimbursement

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or the applicable statewide visit rate. For the period of November 1, 2002, through August 31, 2003, the statewide visit rates for home health professional services were: skilled nursing visit $100.94; physical therapy visit $116.36; occupational therapy visit $118.62; speech-language pathology visit $119.61; and home health aide visit $47.03. If a provider billed $85.00 for a skilled nursing visit delivered on December 1, 2002, when the statewide visit rates are implemented, the provider's payment is based on $85.00 because the provider's billed charges of $85.00 were less than the statewide visit rate of $100.94. If a provider billed $120.00 for a skilled nursing visit delivered on December 1, 2002, when the statewide visit rates are implemented, the provider's payment is based on $100.94 because the statewide visit rate was less than the provider's billed charges of $120.00.

than the statewide visit rate of $100.94. The actual payment is $82.88 ($85.00 less 2.5 percent) because Medicaid payments for services are reduced by 2.5 percent effective September 1, 2003. If a provider billed $120.00 for a skilled nursing visit delivered on October 1, 2003, when the statewide visit rates are in place, the provider's payment is based on $100.94 because the statewide visit rate of $100.94 was less than the provider's billed charges of $120.00. The actual payment is $98.42 ($100.94 less 2.5 percent) because Medicaid payments for services are reduced by 2.5 percent effective September 1, 2003.

Cost Reports

Because the statewide visit rates were effective November 1, 2002, the cost report settlement process for skilled nursing visits, physical therapy visits, occupational therapy visits, speech-language pathology visits, and home health aide visits ends with an HHA's cost report that covers the month of October 2002. Therefore, if an HHA has a fiscal year ending October through December, its 2002 Cost Report was its last required cost report, since its 2002 cost report covered a period through October 31, 2002. If an HHA has a fiscal year ending January through September, its 2003 cost report was its last cost report because the 2003 cost report covers the month of October 2002. There are no cost reports required for 2004 or subsequent years for HHAs providing services covered by the statewide visit rates. These cost report changes are not applicable for HHAs providing PHC, CBA, or other long-term care services. For information regarding cost reports for PHC, CBA, or other long-term care services, please contact the appropriate Rate Analyst. For questions regarding this update, please contact Nancy Kimble, the HHSC Rate Analyst for HHAs by fax at 1-512-491-1983 or by email at [email protected]

Payment Reductions

Effective September 1, 2003, the payments for Medicaid outpatient and professional services were reduced by 2.5 percent through the claims payment system. When the statewide visit rates are implemented, payments for retroactively processed claims for services delivered on or after September 1, 2003, will also be reduced by 2.5 percent. For services delivered on or after September 1, 2003, the statewide visit rates do not change, but the payments are reduced by 2.5 percent. The payment amounts reduced by 2.5 percent are: skilled nursing visit payment of $100.94 reduced by 2.5 percent or $98.42; physical therapy visit payment of $116.36 reduced by 2.5 percent or $113.45; occupational therapy visit payment of $118.62 reduced by 2.5 percent or $115.65; speech-language pathology visit payment of $119.61 reduced by 2.5 percent or $116.62; and home health aide visit payment of $47.03 reduced by 2.5 percent or $45.85. If a provider billed $85.00 for a skilled nursing visit delivered on October 1, 2003, when the statewide visit rates are in place, the provider's payment is based on $85.00 because its billed charges of $85.00 were less

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SHARS Providers/Texas Health Network Providers/THSteps-CCP Providers

SHARS Providers

THSteps-CCP Providers

Speech Therapy Referral Requirements

Effective for SHARS speech therapy services delivered on or after September 1, 2003, to be in compliance with 42 CFR 440.110, the referral for speech therapy services can be either from physicians or other licensed practitioners of the healing arts (LPHA) within the scope of their practice under state law. Since a licensed speech-language pathologist (SLP) meets the criteria as an LPHA, the referral for SHARS speech therapy services can be made by a licensed SLP effective with services delivered on or after September 1, 2003. In order to submit claims for speech therapy referred by a licensed SLP, the client's Individual Education Plan (IEP) must clearly reflect documentation from a licensed SLP to support the medical necessity of these services for the student to be able to participate in the educational program. This change in service referral guidelines is only applicable to SHARS speech therapy and to no other SHARS service.

Texas Health Network Providers

Prior Authorization

THSteps-CCP providers may request prior authorization for CCP services, excluding THSteps-Dental and THSteps-Inpatient Psychiatric Hospital/Facility (freestanding), using the following forms: · THSteps-CCP Prior Authorization Request Form for DME, Supplies, Private Duty Nursing, or Inpatient Rehabilitation · THSteps-CCP Prior Authorization Private Duty Nursing 4 or 6 Month Authorization Form · Nursing Addendum to Plan of Care (THStepsCCP) (3 Pages) · THSteps-CCP ECI Request for Initial/Renewal Outpatient Therapy · Request for Initial Outpatient Therapy (Form TP-1) · Request for Extension of Outpatient Therapy (2 Pages) (Form TP-2) · Wheelchair Seating Evaluation Form (THStepsCCP/Home Health Services) (Next 6 pages) · Pulse Oximeter Form The forms above can be found in Section D of the 2004 Texas Medicaid Provider Procedures Manual.

Precertification Requests

Effective July 1, 2004, the Texas Health Network Concurrent Review Department responds to all written or verbal requests for precertification via a single telephone or fax number designated by the provider at the time of the request. Authorizations are not faxed or called back to multiple numbers. Authorization requests received through VoiCert, are returned via the telephone number identified on the VoiCert request. All correspondence received through fax are responded to via the fax number identified on the request, including requests for additional clinical information. Final DRG confirmation and final approval letters are sent to the last fax number on record for the involved request.

Private Duty Nursing

Providers who wish to provide THStepsComprehensive Care Program Private Duty Nursing (THSteps-CCP PDN) services under the licensedonly home health (LHH) category must enroll as providers under the LHH category. Providers currently offering THSteps-CCP PDN services to THSteps-eligible CCP clients under the licensed and certified home health (LCHH) category of licensure who wish to transfer these CCP clients to the LHH category must first obtain

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a new TPI number. A new TPI may be obtained by re-enrolling with Medicaid (TMHP) using only licensed home health information (do not include a Medicare provider number, etc.) and checking only CCP services on the enrollment application. It is recommended that providers fill out the enrollment application online at www.tmhp.com to make the process more time efficient. When you receive your new TPI number, you may then transfer only your CCP clients to the LHH category (traditional Medicaid clients must be served under a LCHH category). Note: Services for transferred clients were prior authorized with the provider's previous TPI number. It is highly recommended that providers time the transfers to coincide with the recertification period to avoid having to re-prior authorize services under the new TPI number. Providers not currently enrolled or providers who are transferring THSteps-eligible CCP clients to a nonenrolled license: · Must obtain a Medicaid TPI number by enrolling with TMHP. · Fill out a provider enrollment form online with TMHP using only license information and checking only CCP services on the application. · Receive a new TPI number. · Provide CCP PDN services only to THStepseligible CCP clients using that number, as traditional Medicaid clients must be served under a LCHH category.

RN/LVN Private Duty Nursing Hours

The HCFA Common Procedure Coding System (HCPCS) procedure codes T1002 (RN services, up to 15 minutes) and T1003 (LPN/LVN services, up to 15 minutes) became effective October 16, 2003. Requests, extensions, and revisions must be submitted by procedure code (one total for T1002 and one total for T1003) for the total number of RN and/or LVN hours requested. Revisions may be submitted before the end of the authorization period or no later than 10 business days after the end of the authorization period. The agency may bill upon receipt of approval of the revision from TMHP. For additional instruction on requesting revisions please visit the TMHP website at www.tmhp.com/THSteps and click on THSteps-CCP PDN RN/LVN FAQ.

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THSteps-Comprehensive Outpatient Rehabilitation Facilities (CORFs)

Cost Report Requirements

Due to its implementation of a prospective payment system (PPS), Medicare eliminated the requirement for a Comprehensive Outpatient Rehabilitation Facility (CORF) to submit a Medicare cost report as of the CORF's fiscal year ending on or after June 30, 2001 (Provider Reimbursement Manual, Part 2, Chapter 18, Transmittal 5, dated September 1, 2001). As a result, TMHP Medicaid Audit does not receive audited CORF cost reports from Medicare. Texas Medicaid reimbursement for a CORF is determined using a reasonable cost methodology involving a cost settlement. Because the cost settlement is based upon provider-submitted cost reports, a CORF is required to submit a Medicaid cost report to TMHP within 5 months of that CORF's fiscal year end, using the Medicare cost report form. An acceptable, properly completed Medicaid cost report packet includes the following: · An original signature of an officer (administrator or chief financial officer). · A completed and signed Form CMS-339 (revision date November 1995). · A copy of the audited financial statements covering the cost-reporting period. If audited financial statements are not available, please provide a written explanation as to why audited financial statements are not available and submit unaudited financial statements. · A copy of the working trial balance covering the cost-reporting period. Send Medicaid cost report packets to: Texas Medicaid & Healthcare Partnership Attn: Medicaid Audits P.O. Box 200345 Austin, TX 78720-0345

Address overnight or special delivery to: Texas Medicaid & Healthcare Partnership Attn: Medicaid Audits, MC-A04 12365-A Riata Trace Parkway Austin, TX 78727-6422 If a Medicaid cost report is not submitted timely, TMHP sends a nonreceipt letter, allowing an additional 30 days in which to submit a properly completed Medicaid cost report packet. If a properly completed Medicaid cost report packet is not submitted for the CORF by the deadline indicated in the nonreceipt letter, a vendor hold, or suspension, is placed on that CORF's payments. The suspension ends after an acceptable cost report packet has been filed. If a Medicaid cost report is received but determined to be unacceptable, TMHP notifies the provider of what information, documentation, and/or revisions are required to make the cost report acceptable. This notification gives the provider 30 days in which to submit an acceptable cost report. If an acceptable cost report is not received by the deadline indicated in the notification letter, a vendor hold, or suspension, is placed on that CORF's payments. The suspension ends after an acceptable cost report has been filed. According to Section 1.2.3 of the Texas Health and Human Services Commission (HHSC) Medicaid Provider Agreement and 42 CFR §431.107, providers are required to keep any and all records necessary to disclose the extent of services provided to individuals in the Medicaid program and any information relating to payments claimed for furnishing Medicaid services. Therefore, providers must maintain records that are accurate and sufficiently detailed to substantiate the legal, financial, and statistical information reported on the provider's cost report. These records must demonstrate the necessity, reasonableness, and relationship of the costs (e.g., personnel, supplies, and services) to the provision of Medicaid services. These records include, but are not limited to, all accounting ledgers (e.g., general ledger, payroll ledger, accounts receivable ledger, and accounts payable ledger), journals, invoices,

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THSteps-Comprehensive Outpatient Rehabilitation Facilities (CORFs)

purchase orders, vouchers, canceled checks, timecards/ timesheets, payroll registers, mileage logs, loan documents, insurance policies, asset records, inventory records, organization charts, timestudies, functional job descriptions, workpapers used in the preparation of the cost report, trial balances, and cost allocation spreadsheets. TMHP is required to complete the Medicaid cost report settlement process within 11 months of the date a properly completed Medicaid cost report is received from a CORF. TMHP processes the Medicaid cost report as a Final Settlement with a Notice of Program Reimbursement. These cost report requirements and cost report settlement procedures are applicable only to CORFs. If you have any questions regarding the proper completion of your Medicaid CORF cost report or the cost report settlement process, please contact Larry Tabbit at 1-512-506-7393 or Lamont McKenzie at 1-512-506-7395 in TMHP Medicaid Audits. Maureen O'Connor is the TMHP Director of Audits and can be reached at 1-512-506-7621.

Unallowable Costs for Client Transportation Services

Costs associated with client transportation services are unallowable costs for cost-reporting and reimbursement determination purposes for CORFs. There are only two types of client transportation services reimbursed for outpatient services under the Texas Medicaid Program: services provided by ambulance service providers and services provided through the Medical Transportation Program (MTP). Therefore, under the current published rules and the Texas Medicaid State Plan, client transportation services provided by any other outpatient provider are unallowable services for Medicaid reimbursement, including a CORF. Any changes in covered outpatient Medicaid services would require approval from the Centers for Medicare & Medicaid Services. To be reimbursed for client transportation services, a CORF must either be an MTP contractor or subcontract with the current MTP contractor for its area. A CORF cannot apply to become an MTP contractor until the next MTP contracting process opens in its region.

Revenue Codes

When billing for evaluations or assessments, CORFs must use revenue codes 424, 434, or 444 along with the appropriate HCPCS code. The HCPCS code is used to further specify the service rendered and assists in accurate claims processing. HIPAA Special Bulletin 174 indicated that revenue codes 424, 434, and 444 required HCPCS codes; however, this information was not included in the 2004 Texas Medicaid Provider Procedures Manual (section 40.3.2.2). Providers may appeal claims that have denied because of the lacking required information.

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Texas Medicaid Bulletin, No. 181

Forms and Guides

Recommended Childhood Immunization Schedule

Texas Medicaid Bulletin, No. 181

14

July/August 2004

Excluded Providers

Excluded Providers

As required by the Medicare and Medicaid Patient Protection Act of 1987, HHSC identifies providers or employees of providers who have been excluded from state and federal health care programs. Providers excluded from the Medicaid and Title XX programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also are denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client. Review the entire Exclusion List for Texas Medicaid at www.hhsc.state.tx.us/ OIE/exclusionlist/exclusion.asp. Report Medicaid providers who engage in fraud/abuse by calling 1-512-424-6519 or 1-888-752-4888, or by writing to the following address: Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity PO Box 13247 Austin, TX 78711-3247 Provider Ashley, Michael C Barker, Anne M Bauman, David Brown, James W Brown, Laverne M Brown, Rebecca Z Brown's Education and Recovery Center Burke, Barbara S Callaway, Maureen E Casagrande, Amy E Charles P. Akin, DME Cobb, Nancy P Colby, Frances A Cromwell, Daniel M Dallas Fort Worth Medical Center De Los Santos, Ramiro De Los Santos-Garcia, Marilu Decamp, Bonnie L Deshone, Pamela License No. 225874 610331 228417 671913 Exclusion Date 15-Apr-02 29-Jan-04 30-Mar-03 24-May-02 07-Jan-04 10-Feb-04 07-Jan-04 22-Jan-04 09-Dec-03 01-Jul-02 20-Jun-00 04-Jun-03 10-Feb-04 20-Apr-04 26-Dec-02 20-Nov-00 20-Nov-00 09-Mar-04 03-Mar-04 City Kingsland Harlingen McAllen Sanger Houston Stroud Houston Houston Sugarland Hixson Bastrop Plainview New Caney Sugar Land Dallas Eagle Pass Eagle Pass San Marcos Beaumont State TX TX TX OK TX Provider Type RN RN lmsw RN Owner RN Add Date 15-Apr-04 15-Apr-04 24-May-04 13-Apr-04 14-May-04 19-Apr-04 14-May-04 14-May-04 19-Apr-04 13-Apr-04 15-Apr-04 12-Apr-04 19-Apr-04 17-May-04 20-Apr-04 06-Apr-04 06-Apr-04 24-May-04 14-May-04

514825 593905 593972 657297 515728

TN TX TX TX TX

RN RN CNM DME RN RN Hosp M.D. O.M. RN RN

F5182

452685 587982

TX TX

July/August 2004

15

Texas Medicaid Bulletin, No. 181

Excluded Providers

Provider Drescher, Jo Anna Echols, Ira J Ewing, Patricia G Fanning, James E Forgette, Vickie R Gilman, Scott C Gorondy, Larry J Graham, Brenda G Granger, Kathy Y Grigsby, John Hall, Julie A Hall, Terry R Haynie, William B Hensel, Marnnie L Hinkley, Bruce S Hodges, Rebecca Carol Howell, Mark Steven Kane, Linda G Keilman, Christy S Kuehn, Sharon R Levy, David J Levy, Steven Lively, Lori Maternidad DeLosSantos McDonald, Lawana L Medina, Ramon Merrill, Cindy A Mission City Ambulance Mosley, Laura J Neatherly, Colleen K Parma, James F Quave, Sheryl L Reed, Jarrod H Rice, Leisa J Rivera, Angel L Ruffier, Juan C Saint Mary's Clinic LP Scooters To Go - Houston Slief, Mary B

License No. 172000 6553 130114 659305 501590 656772 56940 691390 242218 460449 D9497 158046 107723 612178 640461 530331 D1455 8877 606663 660957 658205 509376 589027 250824 564392 683740 119948 G6006

Exclusion Date 02-Dec-03 20-Nov-03 02-Dec-03 18-Mar-04 11-Aug-03 10-Feb-04 20-Aug-02 26-Mar-04 02-May-04 09-Mar-04 09-Mar-04 20-Apr-04 16-May-90 18-Mar-04 14-Nov-01 12-Jun-04 12-Jun-01 10-Feb-04 13-Nov-03 04-Oct-01 04-Feb-04 01-Jun-04 15-Jan-04 17-Feb-04 19-Sep-03 20-Jan-04 29-Dec-03 12-Apr-04 22-Jan-04 09-Mar-04 18-Dec-03 10-Feb-04 14-Jan-04 12-Apr-04 02-Dec-03 22-Mar-04 17-Feb-04 08-Jan-04 09-Dec-03

City Houston Anahuac Baytown Sherman Amarillo Scottsdale Gunter Hawley Schulenburg Bossier City Carrollton Hurst Lubbock Abilene San Angelo Haltom Morgan Del Norte North Richland Hills Alvord Dallas Spring Eagle Pass Midland Channelview Indianapolis Poteet Cleburne Addison Schulenburg Lenexa Vidor Poteet San Antonio El Paso Eagle Pass Houston Paducah

State TX TX TX

AZ TX TX LA

TX TX TX TX TX CO TX TX TX TX TX IN TX TX TX KS

Provider Type LVN LPC LVN RN RN RN CNA LVN Clien RN RN DC RN CNA 20 LVN LVN RN RN RN

Add Date 15-Apr-04 12-May-04 12-Apr-04 14-May-04 21-Apr-04 12-Apr-04 28-Apr-04 27-May-04 14-May-04 27-May-04 17-May-04 17-May-04 10-May-04 06-May-04 19-May-04 05-May-04 29-Apr-04 06-Apr-04 12-Apr-04 06-Apr-04 20-May-04 07-Apr-04 19-Apr-04 07-Apr-04 07-Apr-04 15-Apr-04 27-May-04 15-Apr-04 18-May-04 17-May-04 17-May-04 28-Apr-04 07-Apr-04 15-Apr-04 12-Apr-04 19-Apr-04 07-Apr-04 16-Apr-04 28-Apr-04

DDS RN Clini RN RN RN RN RN RN RN LVN MD Clnic DME RN

TX TX KY

555718

Texas Medicaid Bulletin, No. 181

16

July/August 2004

Excluded Providers

Provider Sloan, Patricia L Smith, Karen Sue Stein, Hazel Child R Tamling, Vickie Taylor, Michael E Taylor, Tyler D Travis-Lasher, Allison Tripi, Pamela J Tuttle, Earl D Villarruz, Raquel A Waddle, Tom Wages, Jeff A Wallace, Gretchen F Watkins, Roberta L Williams, Edna M Willingham, Jennifer L Wilson II, Herbert Wilson, Roger Dale Witte, Kelly Wood, Pamela S Zmolik, Nancy A

License No. 525683 141127 411672 554218 597160 176022 246122 62909 532120 695845 6796 626944 254891 165549 174304 679738 161168 165198 126277 159478

Exclusion Date 22-Jan-04 12-Jun-01 13-Jun-02 09-Mar-04 04-Dec-00 02-Dec-03 19-Feb-04 02-Dec-03 08-Mar-04 18-Mar-04 18-Mar-04 25-Nov-03 09-Mar-04 02-Dec-03 02-Dec-03 20-Jan-04 11-Jun-01 11-Jun-01 12-May-04 02-Dec-03 02-Dec-03

City Galveston Channelview Burnet Galveston San Antonio Muskogee Houston Phoenix Huntsville Avon Park Fort Worth El Paso Gatesville Nederland Kilgore Royse City South Houston Wichita Falls Boerne Ocean Springs Dallas

State TX TX

OK AZ TX

TX TX TX MO TX

Provider Type RN LVN RN RN RN LVN RN LVN RN RN DC RN RN LVN LVN RN LVN LVN LVN LVN

Add Date 08-Apr-04 26-Apr-04 07-Apr-04 11-May-04 03-May-04 12-May-04 25-May-04 19-Apr-04 25-May-04 14-May-04 08-Apr-04 17-May-04 17-May-04 12-Apr-04 26-Apr-04 03-May-04 21-Apr-04 10-May-04 13-May-04 21-Apr-04 28-Apr-04

July/August 2004

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Texas Medicaid Bulletin, No. 181

Notes

Texas Medicaid Bulletin, No. 181

18

July/August 2004

Notes

July/August 2004

19

Texas Medicaid Bulletin, No. 181

July/August 2004

No. 181

Texas Medicaid

Bimonthly update to the Texas Medicaid Provider Procedures Manual PLACE POSTAGE HERE

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