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TEXAS MEDICAID BULLETIN

Bimonthly update to the Texas Medicaid Provider Procedures Manual

NO. 197 JULY/AUGUST 2006

IN THIS EDITION Radiology Prior Authorization Timelines Revised

Effective July 1, 2006, the transition period that the Texas Health and Human Services Commission (HHSC) originally established from May 1, 2006, through June 30, 2006, to allow facilities and providers additional time to conduct education and outreach on the imaging study guidelines, will end. Providers must follow the guidelines as outlined in the "Radiology Prior Authorization Requirements" article located on the Texas Medicaid & Healthcare Partnership (TMHP) website at www.tmhp.com, and also available in the article titled "Prior Authorization for Radiology Services" beginning on page 16 of the May/June 2006 Texas Medicaid Bulletin, No. 195. The articles state that all outpatient non-emergent, and emergent services rendered in a location other than an emergency room department for all computed tomography imaging (CT), computed tomography angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) studies require authorization. All stated guidelines apply with the exception that HHSC has extended the timeline for providers to pursue a retrospective authorization from two business days to seven calendar days. For more information, call the TMHP Contact Center at 1-800-925-9126.

All Providers Radiology Prior Authorization Timelines Revised . . . . . . . . . . . 1 Scheduled System Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . 1 Aphakia Additional Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Antihemophilic Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Ambulatory Blood Pressure Monitoring . . . . . . . . . . . . . . . . . .2 Third Party Biller Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . .3 Colorectal Cancer Screening Expansion of Benefits . . . . . . . . .3 Changes in Medical Consent for Children in Conservatorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Online Prior Authorization Functionality Coming Summer 2006 for Medicaid Providers. . . . . . . . . . . . . . . . . . .4 Correction to "Therapy Rate Changes for Independently Practicing Physicians and Therapists" . . . . . . . . . . . . . . . . . . . 5 New Vaccines Available Through Texas Vaccines for Children Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 MMRV Vaccine Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Texas Medicaid Benefit Updates . . . . . . . . . . . . . . . . . . . . . . . . . 7 Demographic Update Form Information and Instructions . . . .8 HCPCS First Quarter Update . . . . . . . . . . . . . . . . . . . . . . . . . .9 New Texas Medicaid Access Card Now Used in Three Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Physician Assistants Can Enroll As Individual Providers . . . . . 10 Medicaid STAR and STAR+PLUS Program Changes Coming. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Need Help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Primary Care Case Management Providers Primary Care Provider Change List Reinstated for the PCCM Expansion Area. . . . . . . . . . . . . . . . . . . . . . . . . . 14 Primary Care Provider Enrollment . . . . . . . . . . . . . . . . . . . . . . 15 Prior Authorizations Reminder. . . . . . . . . . . . . . . . . . . . . . . . . 16 PCCM Providers and Clients on the Panel Report . . . . . . . . . . 16 Texas Health Steps (THSteps) Medical Providers HIPAA Privacy Clarification . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Texas Health Steps (THSteps) Dental Providers Texas Health Steps (THSteps) Preventive Dental Services . . . 18 Excluded Providers Excluded Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Forms Electronic Funds Transfer Authorization . . . . . . . . . . . . . . . . . 25 Provider Information Change Form . . . . . . . . . . . . . . . . . . . . . 27 Letter From DFPS Commissioner . . . . . . . . . . . . . . . . . . . . . .29

Scheduled System Maintenance

System maintenance for the TMHP claims processing system is scheduled as follows: · 6:00 p.m. to 11:59 p.m., Sunday, July 9, 2006 · 6:00 p.m. to 11:59 p.m., Sunday, August 13, 2006 During system maintenance some applications related to the claims engine will be unavailable. Specific details regarding the affected applications are posted on the TMHP website at www.tmhp.com.

Current Procedural Terminology (CPT) is copyright 2005 American Medical Association (AMA) and Current Dental Terminology (CDT) is copyright 2004 American Dental Association (ADA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT or CDT. The AMA and the ADA assume no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/ DFARS) restrictions apply to government use.

All Providers

Aphakia Additional Benefit

Effective March 1, 2006, eyewear billed with a diagnosis of Aphakia is a benefit of the Texas Medicaid Program for clients from birth through 20 years of age. Claims submitted from October 16, 2003, through March 1, 2006, that include this service will be reprocessed and payments will be adjusted accordingly. Clients 21 years of age and older are eligible to receive this benefit effective for dates of service on or after October 1, 2005. Claims submitted from October 1, 2005, through March 1, 2006, that include this service will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at 1-800-925-9126.

Ambulatory Blood Pressure Monitoring

Effective for dates of service on or after April 1, 2006, ambulatory blood pressure monitoring is a benefit of the Texas Medicaid Program when submitted with diagnosis code 7962 (Elevated blood pressure reading without diagnosis of hypertension). The following table lists the procedure codes and the corresponding allowable fees: Procedure Code 93784 93786 93788 93790 Allowable fee $53.46 $25.09 $14.18 $14.18

Antihemophilic Factor

Effective for dates of service on or after March 1, 2006, diagnosis codes 2863 (congenital deficiency of other clotting factors) and 2869 (other and unspecified coagulation defects) are considered for reimbursement when billed with procedure code J7189. Additionally, procedure codes J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7197, J7198, and J7199 are no longer a benefit for the following provider types: · Podiatrist and podiatry group · Advance practice nurse (APN) · Certified nurse midwife (CNM) · Durable medical equipment (DME) supplier · Licensed clinical social worker (LCSW) · Radiation treatment centers Federally qualified health centers (FQHCs), rural health clinics (RHCs), and hemophilia factor provider types may bill procedure codes J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7197, J7198, and J7199 for reimbursement consideration. For more information, call the TMHP Contact Center at 1-800-925-9126.

Ambulatory blood pressure monitoring is a benefit for patients when hypertension is suspected but not defined physically or by history. Ambulatory blood pressure monitoring has been shown to be effective when used in the differential diagnosis of hypertension not elucidated by conventional studies. The blood pressure monitoring unit is 24 hours. Benefits are limited to the following medical necessities: · Blood pressure measurements taken in the clinic or office are greater than 140/90 mm Hg on at least three separate visits, with two separate measurements made at each visit. · At least two separately documented blood pressure measurements taken outside of the clinic or office that are less than 140/90 mm Hg. · There is no evidence of end-organ damage. Indications for the use of this monitoring are for diagnostic purposes only and should not be used for maintenance monitoring. Other diagnoses may be considered on appeal with supporting medical documentation submitted to the TMHP Medical Director. For more information, call the TMHP Contact Center at 1-800-925-9126.

Texas Medicaid Bulletin, No. 197

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July/August 2006

All Providers

Colorectal Cancer Screening Expansion of Benefits

Effective for dates of service on or after February 1, 2006, the following changes to benefits are in effect: · Procedure code G0121 is a benefit of the Texas Medicaid Program with an allowable fee of $148.93. · Procedure code G0121 is limited to diagnosis code V7651 (Special screening for malignant neoplasms-colon). · Procedure codes G0104, G0105, G0106, and G0120 are no longer limited for diagnosis codes 5582 (Toxic gastroenteritis) and 5583 (Allergic gastroenteritis and colitis). · Procedure codes G0104 and G0106 are a benefit when billed with diagnosis code V7651 (limited to once every 5 years). · The allowable fee for procedure code 45378 was decreased to $148.93. For more information, call the TMHP Contact Center at 1-800-925-9126.

Changes in Medical Consent for Children in Conservatorship

Recently the Texas Department of Family and Protective Services (DFPS) has received a number of inquiries regarding changes in the law dealing with medical consent for children in the conservatorship (custody, foster care) of DFPS. Chapter 266 was added to the Texas Family Code addressing medical services for children in conservatorship. These changes affect the way a provider can obtain valid consent for medical care from the responsible party on behalf of these children. See page 27 of this bulletin for a letter explaining these changes.

Third Party Biller Enrollment

The 78th Texas Legislature enacted H.B. 2292, which teams HHSC with the Texas Department of State Health Services (DSHS) to combat provider, thirdparty, and client fraud. Effective May 31, 2007, third party billers (TPBs) will be required to contract with HHSC before submitting electronic claims. TPBs are persons, businesses, or entities (excluding state agencies) that submit claims on behalf of a provider, but are not the provider or an employee of the provider. For these purposes, an employee is a person for which the provider completes an IRS Form W-2 showing annual income paid to the employee. All others meet the definition of TPB. Effective May 31, 2007, HHSC will require TPBs to enter into a contract before claims can be submitted for payment on behalf of any Medicaid provider. The HHSC Office of Inspector General (OIG), will begin performing criminal background checks for all potential TPBs submitting claims for Medicaid, Medicaid managed care, and Children with Special Health Care Needs (CSHCN) Services Programs. Additionally, criminal background checks will be performed for any person or business entity enrolling

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as a TPB, who meets the definition of "indirect ownership interest" as defined in Title 1 Texas Administrative Code (TAC) §371.160. Enrollment will begin February 11, 2007. The TPB will be required to create an account on the TMHP website at www.tmhp.com and complete the Third Party Biller Application. The application is available on the TMHP website, but must be printed and mailed to TMHP. Once enrolled, the TPB must submit a request to TMHP to submit claims for a provider. The request will then be confirmed by the provider before any claims can be submitted. Providers can confirm the request by logging into their account at www.tmhp. com. This privilege can be terminated by either the provider or the TPB at any time. Health care providers should do the following: · Create an account on www.tmhp.com · Have the TPB create an account on www.tmhp.com · Have the TPB obtain and submit an enrollment packet from www.tmhp.com For more information, call the TMHP Contact Center at 1-800-925-9126, or visit the TMHP website at www.tmhp.com.

July/August 2006

Texas Medicaid Bulletin, No. 197

All Providers

Online Prior Authorization Functionality Coming Summer 2006 for Medicaid Providers

Based on direction provided by the 79th Texas Legislature and the Governor's Medicaid Reform Workgroup to simplify and streamline Medicaid administration, TMHP is developing a process that will allow providers to submit prior authorization requests on the secure pages of the TMHP website. TMHP anticipates the introduction of this online prior authorization capability during summer 2006. Providers will still have the option to request authorizations on paper, via fax, or by telephone. Prior authorizations that are submitted online will be processed using the same guidelines outlined in the 2006 Texas Medicaid Provider Procedures Manual (TMPPM) as are authorizations submitted through existing channels. other required forms maintained in the client record. This includes: - Completion and signatures prior to requesting the authorization online - Original handwritten signatures; computerized or stamped signatures are not accepted by Texas Medicaid In addition, the printed copy of the online request must be maintained in the client's medical record. Any mandatory requirement not present in the client's medical record subjects the associated services to recoupment. Please refer to Section 1.2.9 of the TMPPM.

Providers will soon be able to submit prior authorization requests online via the TMHP website.

Submission of prior authorization requests on the secure pages of the TMHP website does not replace adherance to and completion of forms and documentation requirements outlined in the TMPPM. If the information provided in the online request is insufficient to support medical necessity, TMHP Prior Authorization staff may request providers to submit additional paper documentation to support the medical necessity of the service or services being requested for authorization. Providers submitting prior authorization through the TMHP website are required to adhere to all of the documentation requirements outlined in the TMPPM and other publications. Documentation requirements include, but are not limited to: · Completion and retention in the client's medical record of all required prior authorization forms (TMPPM Appendix B) and documentation supporting medical nesessity of the service requested. · Adherance to signature and date requirements for prior authorization forms and

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Document Retention

Providers are required to register on the website and assign an administrator(s) for each Texas Provider Identifier (TPI) if not already assigned. Users configured with administrator rights automatically have permission to submit prior authorization requests. The TPI administrator must assign submission privileges for non-administrator accounts. Billing services and clearinghouses are required to obtain access to protected health care information through the appropriate administrator of each TPI/provider number for which they are contracted to provide services.

Texas Medicaid Bulletin, No. 197

July/August 2006

All Providers

Before submitting each prior authorization request, the Provider and Authorization Request Submitter must read, understand, and agree to the Certification and Terms and Conditions of the prior authorization request. The Provider and Authorization Request Submitter are both held accountable for their declarations when they acknowledge their agreement and consent. They acknowledge consent by checking the "We Agree" checkbox after reviewing the Certification and Terms and Conditions. Certification Statement: "The Provider and Authorization Request Submitter certify that the information supplied on the prior authorization form and any attachments or accompanying information constitute true, correct, and complete information. The Provider and Authorization Request Submitter understand that payment of claims related to this prior authorization will be from Federal and State funds, and that falsifying entries, concealment of a material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and/or state law. Fraud is a felony, which can result in fines or imprisonment." "By checking `We Agree,' you agree and consent to the Certification above and to the TMHP `Terms and Conditions.' "

Acknowledgement Statement

Terms and Conditions: "I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the States Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or U.S. Dept. of Health and Human Services may request. I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductible, coinsurance, co-payment or similar cost-sharing charge. I certify that the services listed above are/were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction." "NOTICE: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State law." Failure to provide true and accurate information, omit information, or provide notice of changes to the information previously provided may result in termination of the providers Medicaid enrollment and/or personal exclusion from the Medicaid Program. For more information, call the TMHP Contact Center at 1-800-925-9126.

Correction to "Therapy Rate Changes for Independently Practicing Physicians and Therapists"

The following is a correction to information provided in the article titled "Therapy Rate Changes for Independently Practicing Physicians and Therapists" located on page 5 of the March/April 2006, Texas Medicaid Bulletin, No. 194. The therapy rate changes effective for dates of service on or after January 1, 2006, are limited to Traditional Medicaid, Primary Care Case Management (PCCM), and CSHCN Services Program providers. The reimbursement rates are not applicable to health maintenance organizations (HMOs). Refer to the March/April 2006, Texas Medicaid Bulletin, No. 194, for the complete article that includes the new reimbursement rates. For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Contact Center at 1-800-568-2413.

July/August 2006

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Texas Medicaid Bulletin, No. 197

All Providers

New Vaccines Available Through Texas Vaccines for Children Program

The Texas Vaccines For Children Program (TVFC) has two additional vaccines available for providers who are enrolled in TVFC. Effective immediately, providers enrolled in TVFC may begin ordering the meningococcal conjugate vaccine (MCV4), Menactra®. Children who receive MCV4 must be TVFC-eligible and meet one of the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) criteria for highest risk for meningococcal disease listed below: · Adolescents 11 through 18 years of age traveling to countries where N. meningitidis is hyperendemic or epidemic, particularly if contact with the local population will be prolonged · Adolescents 11 through 18 years of age with terminal complement deficiencies and those with anatomic or functional asplenia · Adolescents 11 through 18 years of age who are infected with HIV · Adolescents 11 through 12 years of age at their preadolescent assessment visit · Adolescents at high school entry who were not vaccinated at the preadolescent visit · College freshmen 18 years of age and younger who live in dormitories TVFC strongly recommends administering MCV4 in conjunction with the adolescent dose of Tetanus, Diphtheria, and Pertussis (Tdap) vaccine. The Medicaid billing Current Procedural Terminology (CPT) code for MCV4 is 90734. When using the vaccine obtained through TVFC, pricing must be changed to $.01. MCV4 is similar to the meningococcal polysaccharide vaccine (MPSV4) or Menomune®. MPSV4 has never been offered by the TVFC. However, providers in private practice and local health departments may purchase and use this vaccine independent of the TVFC. Both vaccines prevent the same four serogroups of Neisseria meningitidis (A, C, Y, and W-135). However, MCV4 provides longer lasting immunity and reduces person-to-person transmission. In May 2005, the ACIP and the American Academy of Pediatrics (AAP) issued expanded recommendations for the use of meningococcal vaccine. These recommendations are available at their respective websites (www.cdc.gov/mmwr/ PDF/rr/rr5407.pdf and www.aap.org/advocacy/releases/ MengPolicyFinal.pdf).

Meningococcal Conjugate Vaccine

Measles, Mumps, Rubella, and Varicella (MMRV)

Effective immediately, providers enrolled in the TVFC may begin ordering Merck and Company Incorporated's, combined live attenuated measles, mumps, rubella, and varicella (MMRV) vaccine, ProQuad ®. MMRV is approved for children 12 months to 12 years of age. MMRV is not indicated for vaccination of children less than 1 year of age. MMRV should not be administered for the second dose of MMR except when a dose of varicella vaccine is also indicated, or if the MMR vaccine is not available at the time the second dose of MMR is indicated. It is the responsibility of TVFC providers to use their current inventory of varicella vaccine before changing to MMRV. Providers may also choose to continue using the individual MMR and varicella vaccines. The Medicaid billing CPT code for MMRV is 90710. For dosage interval information, contraindications, and warnings on MMRV, refer to the product package insert or the Merck website: www.merck.com/product/usa/pi_ circulars/p/proquad/proquad_pi.pdf.

Limited MCV4 Vaccine Supply

Sanofi Pasteur, the manufacturer of MCV4, is unable to produce the vaccine in sufficient quantity to vaccinate all of the above-recommended groups nationwide. The TVFC will receive a monthly allocation approved by the CDC and will reallocate the vaccine across the state to ensure that every provider receives some vaccine each month. Emergency orders will not be accepted for MCV4, and the TVFC may cut orders to ensure that all providers with need receive some portion of the state's allocation. The supply of this vaccine may not improve significantly for the next two years.

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MMRV must be stored frozen at an average temperature of 5° F (-15°C) or colder. Any freezer (e.g., chest, frost-free) that reliably maintains an average temperature of 5° F (-15° C) or colder and has a separate sealed freezer door is acceptable for storing MMRV. Protect from light exposure at all times. Store the diluent separately at room temperature (68° F ­ 77° F or 20° C ­ 25° C). Diluent may also be stored in the refrigerator, but not the freezer. For more information, call the TMHP Contact Center at 1-800-925-9126.

July/August 2006

Storage for MMRV

Texas Medicaid Bulletin, No. 197

All Providers

MMRV Vaccine Update

This is an update to a banner message that appeared on providers' May 19, 2006, R&S reports regarding the availability of the MMRV vaccines through the TVFC Program. Following is the complete article. Effective for dates of service on or after March 1, 2006, the MMRV vaccine is available for distribution through TVFC using procedure code 90710. This update will be implemented on July 28, 2006. Providers must bill Texas Health Steps (THSteps) for the administration fee when provided as part of a THSteps medical checkup with type of service (TOS) S. Providers must bill the Texas Medicaid Program for the administration fee when provided outside of a THSteps medical checkup with TOS 1. Claims submitted for dates of service March 1, 2006, through July 27, 2006, that were denied for the administration fee must be appealed to be considered for reimbursement.

Injection Glatiramer Acetate

Effective for dates of service on or after February 1, 2006, Injection Glatiramer Acetate is a benefit of the Texas Medicaid Program. Providers should bill using procedure code J1595, which has an allowable fee of $35.73. Effective for dates of service on or after March 1, 2006, procedure codes 6-77301, I-77301, T-77301, and T-77418 are benefits of the Texas Medicaid Program with the following allowable fees: Procedure Code 6-77301 I-77301 T-77301 T-77418 Allowable fee $1,100.86 $298.67 $802.19 $495.06

Radiation Therapy Benefits

Changes to Hormone Injections Benefits

Effective for dates of service on or after May 1, 2006, the following hormone injection procedure codes no longer have diagnosis restrictions. However, a valid and applicable International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code that indicates the client's physical condition is required for reimbursement consideration. Procedure Code J0725 J0900 J1051 J1060 J1380 J1390 J3120 J3130 J0970 J1070 J1410 J3140 J1000 J1080 J1435 J3150

Texas Medicaid Benefit Updates

TMHP has implemented the following benefit changes:

Adjustment to CORF/ORF Payments

Effective for dates of service on or after January 1, 2006, the fee for procedure code 92506 when submitted with the U4 modifier, increased from a percentage of the billed charges to $280 for comprehensive outpatient rehabilitation facility (CORF)/outpatient rehabilitation facility (ORF) providers.

Additionally, hormone injection procedure code J9165 is no longer a benefit of the Texas Medicaid Program. This is a reminder for home health agencies (HHAs), CORFs/ ORFs, and independent practitioners delivering physical, occupational, and/or speech therapy services under the Texas Health Steps-Comprehensive Care Program (THSteps-CCP). These therapies are always billed as place of service (POS) 2 and may be authorized to be provided in the following locations: home of the client, home of the caregiver/ guardian, client's daycare facility, and client's school. Services provided by the providers listed above on a client's school premises are only permitted when delivered before or after school hours. The only THSteps-CCP therapies that can be delivered in the client's school during regular school hours are those delivered by school districts as School Health and Related Services (SHARS) and billed with POS 9.

7 Texas Medicaid Bulletin, No. 197

Claims submitted from January 1, 2006, through April 7, 2006, that included this procedure code and modifier combination will be reprocessed and payments adjusted accordingly.

CCP Therapy Place of Service Clarification

Essure is Now a Benefit of Texas Medicaid

Effective for dates of service on or after December 1, 2005, the following procedure codes are benefits of the Texas Medicaid Program with the allowable fee indicated: Procedure Code 2-58565 F-58565 2-58340 Allowable fee $1,579.55 Group 4 rate $112.65

July/August 2006

All Providers

Demographic Update Form Information and Instructions

Effective April 16, 2006, the new Demographic Update (DU) Form became available on the TMHP website. Providers may use either the DU Form or the newly revised Provider Information Change (PIC) Form, which is available in the 2006 Texas Medicaid Provider Procedures Manual, to update their address information. Please note the proper usage of each form. The DU Form is only used to make changes to provider addresses on file with TMHP. Providers should use the PIC Form to update physical or mailing addresses, telephone numbers, names, tax identification numbers (TIN), provider status, and other provider information on file with the Texas Medicaid and CSHCN Services Programs. Traditional Medicaid providers who are enrolled with Medicare can change a physical address using the PIC Form and submitting a copy of the Medicare letter that confirms the physical address has been updated with Medicare. To change a mailing address, submit a completed W9 form with the PIC Form. Beginning February 1, 2006, providers must use the revised PIC Form found on page 25 of this bulletin, and also available on the TMHP website. Providers must immediately notify TMHP Provider Enrollment in writing of changes to their address (physical location or accounting), telephone number, name, ownership status, TIN, and any other information about the structure of the provider's organization. Failure to notify TMHP of changes adversely affects claims processing and payment. Providers can use the DU Form on the TMHP website at any time. Providers will be prompted to verify their address(es) and make necessary changes at least once a year. After the update has been completed, the form can be faxed to 1-512-514-4214, or mailed to the address below for processing. Texas Medicaid & Healthcare Partnership Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Important: Providers must create a provider administrator account to access the DU Form on the secure pages of the TMHP website. Nonadministrator users must be assigned by the provider administrator. Only providers or their authorized representatives can access the provider administrator accounts to obtain and complete the DU Form.

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It is the responsibility of each provider to administer the accounts associated with the provider's Texas Provider Identifiers (TPIs).

Providers are responsible for notifying TMHP of any changes in their practice.

To access the DU Form:

DU Form Instructions

1. Log on to the TMHP website at www.tmhp.com. 2. On the homepage, click the My Account link. Enter a user ID and password in the appropriate boxes. The Change/Verify Address Information page opens. At the prompt, verify the accuracy of the following address information by clicking on the Yes or No radio button: - Physical - Mailing - Secondary (this will appear if the information is in the provider's file) 3. If the Yes radio button is clicked, the DU Form does not appear, and the provider can proceed through the website. 4. If the No radio button is clicked, the system proceeds to the DU Form.

5. The provider must complete all of the required fields on the DU Form before it can be printed. 6. Upon completion of the DU Form, the provider must print the form and send the DU Form and any required documentation to the TMHP address that is listed on the form. 7. Providers should keep a copy of the completed DU Form for their records. For more information, call the TMHP Contact Center at 1-800-925-9126.

Texas Medicaid Bulletin, No. 197

July/August 2006

All Providers

HCPCS First Quarter Update

Effective for dates of service on or after May 8, 2006, TMHP will implement the 2006 Healthcare Common Procedure Coding System (HCPCS) first quarter update for the Texas Medicaid and CSHCN Services Programs. The following is a complete list of procedure codes that will be implemented: Procedure Code J-C1820 1-C8950 1-C8951 1-C8952 1-C8953 1-C8954 1-C8955 1-C8957 2-C9726 F-C9726 9-Q1003 1-S0345 1-S0346 1-S0347 NC - Not Covered Allowable fee NC NC NC NC NC NC NC NC NC NC NC NC NC NC

New Texas Medicaid Access Card Now Used in Three Counties

Medicaid clients in Cameron, Hidalgo, and Travis Counties are now issued a Medicaid Access Card--a plastic smart card to automate client check-in and eligibility. In these counties, clients take their Medicaid Access Card in place of the Medicaid Identification Form (Form H3087) to identify themselves as eligible for Medicaid. If a Medicaid client with one of these cards sees a provider for service in an area not using the new process, providers can still verify the client's Medicaid eligibility by utilizing existing processes, or by calling the TMHP Contact Center at 1-800-925-9126. Since March 2004, HHSC has been conducting a voluntary Medicaid Integrity Pilot in six counties. The pilot operations included client authentication using biometrics and automated client eligibility verification. HHSC sponsored the equipment installed in provider offices, and Medicaid clients were issued plastic smart cards in addition to the Medicaid Identification Form (Form H3087). The success of the pilot has prompted HHSC to move forward with the initial implementation of the Medicaid Access Card in three counties: Cameron, Hidalgo, and Travis. HHSC continues its evaluation of new technologies to make processing Medicaid services faster and easier for participating providers, improve access and service delivery to eligible clients, and ensure the efficient use of taxpayer dollars. Major benefits offered by the new system include: · Express client check-in--The overall client check-in process is faster than the current manual process. · Rapid automated client authentication--Automated client authentication ensures that only enrolled clients will receive services. · Quick medicaid eligibility verification--Automated eligibility verification provides a quick real-time validation of current Medicaid eligibility status. · Improved claim approvals--A claim including a successful client authentication and eligibility transaction through the Medicaid Access Card system will not be rejected by HHSC based on eligibility. The system components include a small point-of-service device, very similar to a credit card authorization device, and an attached biometric scanner. The devices are placed at the reception area, within easy reach of Medicaid clients. The system is provided at no cost to providers or clients. For more information regarding the Medicaid Access Card, call 1-800-668-0650.

9 Texas Medicaid Bulletin, No. 197

Deleted procedure codes will no longer be a benefit of the Texas Medicaid and CSHCN Services Programs for dates of service after May 7, 2006. The following is a complete list of procedure codes that will be deleted: Procedure Code 1-Q3019 1-S0133 9-Q3019 2-S2362 1-Q3020 8-S2362 9-Q3020 F-S2362 2-S2363 8-S2363 F-S2363 5-S3701 4-S8093 I-S8093 T-S8093 W-S8260

In addition, the descriptions for procedure codes 1-Q4080, 9-A5513, 9-C1767, 9-C1894, J-C1767, and L-C1767 have changed. Please contact the appropriate copyright holder to obtain procedure code descriptions. Effective for dates of service on or after May 8, 2006, procedure code 1-Q4080 will no longer be a benefit of the CSHCN Services Program and will be reimbursed through the Vendor Drug Program. For more information, call the TMHP Contact Center at 1-800-925-9126.

July/August 2006

All Providers

Physician Assistants Can Enroll As Individual Providers

As a result of Rider 72, Article II, S.B. 1, 79th Legislature, Regular Session, 2005, HHSC has adopted rules at Title 1 of the Texas Administrative Code (TAC), §354.1066 and §354.1067, to enroll physician assistants (PAs) as providers in the Texas Medicaid Program. Effective July 1, 2006, PAs are eligible to enroll and bill as individual providers for services provided with dates of service on or after July 1, 2006. Enrollment as an individual provider is not mandatory. PAs currently treating clients and billing under the supervising physician's number can continue this billing arrangement. To be eligible for Medicaid reimbursement, a provider of medical services (including an out-of-state provider) must complete the Texas Medicaid Provider Enrollment Application and enter into a written provider agreement with HHSC (the single state Medicaid agency). The Texas Medicaid Provider Enrollment Application is available on the TMHP website at www.tmhp.com. TMHP Provider Enrollment Department processes these forms. Providers can request and submit enrollment forms to the following address: Texas Medicaid & Healthcare Partnership Provider Enrollment PO Box 200795 Austin, TX 78720-0795 When completing the enrollment application, PAs should include the following information: · In the "Traditional Services" section on page 2, select "Advanced Practice Nurse." · In "Section A ­ Provider of Service Information" on page 7.1, enter "Physician Assistant" under "Primary Specialty." The enrollment application will be updated in the future to include a selection for PAs. A nine-digit TPI is issued when TMHP determines that a provider qualifies for participation. A potential new provider to the Medicaid Program must follow claims filing procedures while completing the enrollment process to be assigned a TPI. TMHP must receive all claims for Medicaid services within 95 days from each date of service or within 95 days from the date the TPI is issued, whichever occurs later. Claims will be rejected until TMHP has issued an actual TPI. All claims for services rendered to Medicaid clients who do not have Medicare benefits are subject to a filing deadline from the date of service of: · 95 days for in-state providers · 365 days for out-of-state providers Providers who have not been assigned a TPI number and have questions about submitting claims may call 1-800-925-9126. Providers who have already been assigned a TPI number but have questions about submitting claims, may call the same number and select the option to speak with a TMHP Contact Center Representative. To enroll in the Texas Medicaid Program, a PA must be licensed and recognized as a PA by the Texas State Board of Physician Assistant Examiners. The Texas Medicaid Program accepts a signed letter of certification from the Texas State Board of Physician Assistant Examiners as acceptable documentation of appropriate licensure and certification for enrollment. A PA must submit the evidence of credential upon enrollment. Providers must maintain a valid, current license or certification to be entitled for Medicaid reimbursement and cannot enroll in the Texas Medicaid Program if their license or certification is due to expire within 30 days of application. A current license or certification must be submitted. All providers of laboratory services must comply with Clinical Laboratory Improvement Amendments (CLIA) rules and regulations. Providers not complying with CLIA are not reimbursed for laboratory services.

Enrollment

Enrollment in Texas Health Steps (THSteps)

PAs can enroll as THSteps providers. PAs should have expertise or additional education in the areas of comprehensive pediatric assessment.

Texas Medicaid Bulletin, No. 197

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July/August 2006

All Providers

Medicaid Managed Care Enrollment

PAs may be eligible to enroll with Medicaid managed care as primary care providers. Contact the individual Medicaid managed care health plan for enrollment information.

The Medicaid rate for a PA providing Medicaid services and billing under the PA's own TPI is 92 percent of the rate paid to a physician (medical doctor [MD] or doctor of osteopathy [DO]) for the same service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. Note: Payment to physicians for supplies is not a benefit of the Texas Medicaid Program. Costs of supplies are included in the reimbursement for office visits. Important: Laboratory (including pregnancy tests) and radiology services provided during pregnancy must be billed separately from antepartum care visits and received within 95 days from the date of service. Procedures billed by PAs are reviewed retrospectively for appropriateness. Independently enrolled PAs with a valid Medicare provider number are eligible to receive payment of deductible and coinsurance amounts as appropriate on Medicare crossover claims.

Reimbursement

interventions; (6) assisting at surgery; (7) offering counseling and education to meet patient needs; (8) requesting, receiving, and signing for the receipt of pharmaceutical sample prescription medications and distributing the samples to patients in a specific practice setting where the physician assistant is authorized to prescribe pharmaceutical medications and sign prescription drug orders at a site, as provided by the Medical Practice Act, Texas Civil Statutes, Article 4495b, sections 3.06(d)(5) and (6), and its subsequent amendments, or as otherwise authorized by this Act or board rule; (9) the signing or completion of a prescription as provided by the Medical Practice Act, Texas Civil Statutes, Article 4495b, sections 3.06(d)(5) and (6); and (10) making appropriate referrals. 185.12. Tasks Not Permitted to be Delegated to a Physician Assistant. Except at sites designated by the Texas Occupations Code, Chapter 157.052, 157.053, and 157.054, the supervising physician shall not allow a physician assistant to prescribe or supply medication. · Are consistent with rules and regulations promulgated by the Board of Medical Examiners (BME) for the State of Texas or other appropriate state licensing authority · Are covered by the Texas Medicaid Program when provided by a licensed physician (MD or DO) · Are reasonable and medically necessary as determined by HHSC, the single state Medicaid agency, or its designee PAs who are employed or remunerated by a physician, hospital, facility, or other provider must not bill the Texas Medicaid Program for their services if the billing results in duplicate payment for the same services.

Benefits and Limitations

Services performed by PAs are covered if the services meet the following criteria:

· Are within the scope of practice for PAs, as defined by Texas state law as follows: PA Board Rules 185.11. Physician Assistant Scope of Practice. The physician assistant shall provide, within the education, training, and experience of the physician assistant, medical services that are delegated by the supervising physician. The activities listed in paragraphs (1) (9) of this subsection may be performed in any place authorized by a supervising physician, including, but not limited to a clinic, hospital, ambulatory surgical center, patient home, nursing home, or other institutional setting. Medical services provided by a physician assistant may include, but are not limited to: Obtaining patient histories and performing physical examinations; (2) ordering and/or performing diagnostic and therapeutic procedures; (3) formulating a working diagnosis; (4) developing and implementing a treatment plan; (5) monitoring the effectiveness of therapeutic

Claims Information

Providers must submit claims for PA services in an approved electronic format or on a CMS-1500 paper claim form. All services must be filed with modifier U7 on the claim detail(s) to indicate that the client was treated by a PA.

Additional information about benefits and claims filing is available in the 2006 Texas Medicaid Provider Procedures Manual and is available on the TMHP website at www.tmhp.com. For more information, call the TMHP Contact Center at 1-800-925-9126.

Resources

July/August 2006

11

Texas Medicaid Bulletin, No. 197

All Providers

Medicaid STAR and STAR+PLUS Program Changes Coming

Texas Medicaid will change its managed care program for State of Texas Access Reform (STAR) clients, expand managed care to a new STAR Service Area, and expand managed care for Medicaid recipients who are aged or persons with disabilities in various areas across the state. STAR+PLUS, the managed care program for certain Medicaid recipients who are aged or persons with disabilities, will expand to Bexar, Harris/Harris Expansion, Nueces, and Travis Service Areas effective January 1, 2007. Eligible adult Medicaid recipients, including those who qualify for Medicaid based on supplemental security income (SSI) eligibility, who qualify for community based alternative (CBA) waiver services, and dual eligibles in these areas, will be required to enroll in a STAR+PLUS health maintenance organization (HMO). SSI children (under 21 years of age) can participate on a voluntary basis. out, the HMO will authorize inpatient hospital stays, but TMHP will process claims for inpatient hospital care. The El Paso and Lubbock Service Areas will not be part of the initial expansion. HHSC will evaluate the feasibility of expanding these services into additional service areas in the future. The following HMOs have been tentatively selected to provide these services: Service Area Bexar Service Area Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, and Wilson Counties Harris/Harris Expansion Service Area Brazoria, Fort Bend, Galveston, Harris, Montgomery, and Waller Counties Nueces Service Area Aransas, Bee, Calhoun, Jim Wells, Kleberg, Nueces, Refugio, San Patricio, and Victoria Counties Travis Service Area Bastrop, Burnet, Caldwell, Hays, Lee, Travis, and Williamson Counties STAR+PLUS HMOs Molina Healthcare of Texas, Superior HealthPlan, Amerigroup Community Care

STAR+PLUS Expansion

Amerigroup Community Care, Evercare, Molina Healthcare of Texas

Evercare, Superior HealthPlan

Amerigroup Community Care, Evercare

Participation of these HMOs is contingent on successful execution of the contract amendments and HHSC's determination of readiness to provide services. Long term service and support providers will no longer bill for services through the Department of Aging and Disability Services for services provided to STAR+PLUS members. All STAR+PLUS claims will be filed through the respective HMO with which the provider contracts. The services offered to these enrollees are the same as those currently offered to STAR+PLUS enrollees in Harris County, with one exception. Under the hospital carveClients eligible to participate in the STAR+PLUS Program will be notified about the available HMOs in their area.

The STAR Program will expand to the Nueces Service Area. The new Nueces Service Area includes Aransas, Bee, Calhoun, Jim Wells, Kleberg, Nueces, Refugio, San Patricio, and Victoria counties. Most people with Medicaid coverage in those counties will receive enrollment materials

STAR Program Expansion to Nueces Service Area

Texas Medicaid Bulletin, No. 197

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July/August 2006

All Providers

to help them select an HMO. Medicaid clients in the following eligibility groups will not be part of the STAR Program in the Nueces Service Area: supplemental security income (SSI) recipients, institutionalized, dual eligible, medically needy, and foster children. These clients will continue to be part of Medicaid's fee-for-service program. Primary Care Case Management (PCCM) will phase out as an option for Medicaid clients in the STAR Program from July 2006, through December 2006. Effective December 1, 2006, STAR Medicaid clients, except SSIrelated clients, will no longer have PCCM as a health plan choice. Effective January 1, 2007, STAR SSI-related clients will no longer have PCCM as a health plan option. SSI includes many Medicaid clients who have disabilities. This change will affect PCCM clients in these STAR service areas: Service Area Bexar Dallas El Paso Harris/Harris Expansion Lubbock Counties Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall El Paso Brazoria, Fort Bend, Galveston, Harris, Montgomery, Waller Crosby, Floyd, Garza, Hale, Hockley, Lamb, Lubbock, Lynn, Terry

process, HHSC will mail out initial notification letters and enrollment kits to clients in July 2006. The information will inform clients of the available HMOs in their area as well as how to choose a health plan. HHSC asks PCCM providers in the affected areas to preserve each PCCM client's medical home to ensure continuity of care through the transition. In addition, PCCM providers in these areas are encouraged to continue providing health care services to PCCM clients who live in contiguous areas not affected by the managed care changes.

STAR PCCM Phase Out

Additional HMO Choices

HHSC is finalizing new contracts for HMOs participating in the STAR Program. Additional HMOs will participate in the Bexar, Dallas, Harris, Tarrant, and Lubbock service areas.

The following HMOs have been selected to provide services to clients in the STAR Program: Service Area Bexar STAR HMO Choices Community First Health Plans, Aetna Medicaid,* Superior HealthPlan Amerigroup Community Care, Parkland HEALTHfirst, Unicare Health Plans of Texas* Amerigroup Community Care, United Healthcare­Texas,* Molina Healthcare of Texas,* Community Health Choice, Texas Children's Health Plan FirstCare STAR, Superior HealthPlan* Amerigroup Community Care, Aetna Medicaid,* Cook Children's Health Plan*

Dallas

Harris/Harris Expansion

Medicaid clients in the affected areas will need to select a health plan offered through an HMO. To begin the

Lubbock Tarrant

Need Help?

TMHP Contact Center Representatives are available Monday through Friday, from 7 a.m. to 7 p.m., Central Time, to assist providers with general Medicaid questions, such as provider enrollment procedures, claims filing procedures, and benefit information. For more detailed information, or for problem resolution, contact your area Provider Relations Representative. Visit the TMHP website at www.tmhp.com for Provider Relations contact information, or call the TMHP Contact Center at 1-800-925-9126 for assistance.

* New STAR HMO

Clients with additional HMO choices will receive enrollment information regarding the available plans. For more information, call the TMHP Contact Center at 1-800-925-9126.

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Texas Medicaid Bulletin, No. 197

Primary Care Case Management Providers

Primary Care Provider Change List Reinstated for the PCCM Expansion Area

Effective May 15, 2006, providers who have been selected by a PCCM Expansion Area client as their new primary care provider will be authorized to provide services prior to the effective date of the requested change. Prior to providing services, however, providers must verify their selection as the client's new primary care provider on the Primary Care Provider Change List. The list will be updated daily on the TMHP website within the Panel Report webpage. The PCCM Expansion Area counties are identified in the Texas Medicaid Special Bulletin, No. 188. Claims submitted with dates of service on or after April 1, 2006, that were denied because the billing provider was not the PCCM Expansion Area client's assigned primary care provider will be reprocessed within 45 days and payments adjusted accordingly. No action on the part of the provider is necessary. information found in the 2006 Texas Medicaid Provider Procedures Manual, page 7-26, Section 7.5.9.1. For additional information, call the PCCM Provider Helpline at 1-888-834-7226 or the TMHP Contact Center at 1-800-925-9126. At the time that the appointment is made, ask the client for the name of the primary care provider on the client's Medicaid Identification Form H3087. If a different primary care provider is listed, direct the client to go to the provider listed on their Medicaid Identification Form H3087 or to request a change. Providers may not request primary care provider changes for their clients. Federal guidelines prohibit influence by providers on a patient's choice of their primary care provider. Clients can request four primary care provider changes each year. If the client indicates that they have made a primary care provider change, follow the process below: · Access the daily Primary Care Provider Change List located on the Panel Report webpage to confirm selection as the newly requested primary care provider. If the list verifies the primary care provider change with a future effective date, proceed with scheduling an appointment. · If the Primary Care Provider Change List does not reflect the newly requested primary care provider, direct the client to call 1-888-302-6688 to request a primary care provider change. Once the provider has ensured that the primary care provider change request appears on the daily Primary Care Provider Change List, the appointment may be scheduled. If the client arrives at a provider's office and requests services: · Access the daily Primary Care Provider Change List located on the Panel Report webpage to confirm

14 July/August 2006

Scheduling Appointments

In this new transition period, clients in PCCM Expansion Areas may also select any Medicaid enrolled obstetrical and gynecological (OB/GYN) provider, family practitioner, or internal medicine provider for the following services:

Clarification Regarding OB/GYN Care Provided to PCCM Clients

· One well-woman examination per year · Care related to pregnancy · Care for all active gynecological conditions · Diagnosis, treatment, and referral to a Medicaid enrolled specialist for any disease or condition within the scope of the designated professional practice of a licensed obstetrician or gynecologist, including treatment of medical conditions concerning the breasts A referral from the PCCM client's primary care provider is not required as long as the provider rendering services is a Medicaid enrolled OB/GYN, family practitioner, or internal medicine provider. This is an update to

Office Services

Texas Medicaid Bulletin, No. 197

Primary Care Case Management Providers

selection as the newly requested primary care provider. If the Primary Care Provider Change List reflects a future effective date, the client may be treated. · If the change list does not reflect the newly requested primary care provider, providers may allow the client to call 1-888-302-6688 from their office to request a primary care provider change. Once a primary care provider change request has been made from the provider's office, the client may be treated.

24 hours a day, seven days a week. The primary care provider is required to inform clients of how they can access after-hours care. If a client requests after-hours care at an urgent care center, the center should contact the client's primary care provider and refer the client to the PCCM Nurse Helpline at 1-800-304-5468. If the client is seen in an urgent care center, the center is responsible for contacting the primary care provider to obtain the TPI that is required in block 17A of the CMS-1500 claim form for appropriate claims processing.

Case Management Fees

Case management fees will continue to be paid to the provider listed on the client's Medicaid Identification Form (From H3087) until the change to the newly selected primary care provider becomes effective.

Prior Authorizations

For services that require prior authorization, the new primary care provider may request a prior authorization number for the client. For billing purposes, the Texas Provider Identifier (TPI) on the prior authorization request must match the billing TPI on the claim.

PCCM Newborn Default Processing

Primary care providers must provide their TPI to the specialist. The provider's TPI number is placed in block 17A of the CMS-1500 claim form for appropriate claims processing.

Referrals for Specialist Care

The primary care provider has a responsibility to provide continuous health care coverage to care for PCCM clients

Urgent Care Centers as an Alternative to After-hours Care

Newborns of PCCM mothers are automatically enrolled in PCCM. At birth, newborns are assigned the default primary care provider code PCCNEWB01. While the provider is listed as PCCNEWB01, any Medicaid provider can see the newborn. Claims submitted for newborns will be accepted even if a primary care provider has not been identified. Depending on when the Medicaid certification date falls within the default cycle, parents of a newborn may have up to 45 days to select a primary care provider for their baby. If parents do not select a primary care provider by the next default date, a primary care provider is selected for the newborn on the basis of geographic criteria.

For more information, call the TMHP Contact Center at 1-800-925-9126.

Primary Care Provider Enrollment

Providers residing in a non-PCCM designated area, such as Tarrant or Travis County, may enroll with TMHP to become a PCCM primary care provider. Enrollment allows the provider to render services to PCCM-eligible clients residing in adjacent managed care areas. Providers can download the Texas Standardized Credentialing Application from the TMHP website at www.tmhp.com. Additional information about the role of a primary care provider is available in the PCCM Special Bulletin, No.188, which is also available on the website. For more information, call the TMHP Contact Center at 1-800-925-9126.

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Texas Medicaid Bulletin, No. 197

Primary Care Case Management Providers

PCCM Providers and Clients on the Panel Report

A panel report is a monthly listing of clients assigned to a specific provider for the current month. Clients who are assigned to a primary care provider may or may not have been seen by that provider. Primary care providers receive a case management fee of $2.93 for each client listed on their panel report each month. The monthly case management fee is compensation for providing a medical home to PCCM clients who have either been assigned to the provider, or have been selected by the client as his or her primary care provider. A primary care provider contracts to provide or coordinate referrals for primary health care services to all PCCM clients assigned to his or her practice and listed on his or her panel. Primary health care services are all medical services required by a client for the prevention, detection, treatment, and cure of illness, trauma, or disease, which are covered and required under the Texas Medicaid Program. A primary care provider must also ensure that clients under the age of 21 receive all services required by the THSteps Program. When services needed are not available through the primary care provider's office or clinic, the primary care provider should refer clients to an approved Texas Medicaid provider or PCCM-contracted facility. Clients may change primary care providers by calling the PCCM Client Helpline at 1-888-302-6688. If the primary care provider change request is received before the middle of the month, the change will become effective on the first day of the following month. Requests received after the middle of the month usually become effective on the first day of the second month following the request. Until the client has been reassigned, the current primary care provider is responsible for primary care services or coordinating referrals as needed. See the article entitled "Primary Care Provider Change List Reinstated for the PCCM Expansion Area" on page 13 of this bulletin for information about the interim process for primary care provider changes or refer to the PCCM provider webpage on the TMHP website at www.tmhp.com. Primary care providers who prefer to receive a monthly panel report by mail may call the PCCM Provider Helpline at 1-888-834-7226 to request a paper copy. Providers can access an electronic version of the panel report on the TMHP website. To modify the status of the panel, providers can mail or fax the completed Provider Information Change Form located on page 25 of this bulletin, or page B-73 of the 2006 Texas Medicaid Provider Procedures Manual to: Provider Enrollment MC-B05 PO Box 200795 Austin, TX 78720-0795 Fax: 1-512-514-4214 Contact the PCCM Provider Helpline at 1-888-834-7226, to report discrepancies in the panel report. For more information, refer to the 2006 Texas Medicaid Provider Procedures Manual, sections 7.1.5 and 7.5, or call the TMHP Contact Center at 1-800-925-9126.

Prior Authorizations Reminder

This is a reminder for providers of professional services for PCCM clients. Procedures and services that require prior authorization or notification for patients in an inpatient setting include: all non-emergent inpatient admissions (excluding routine deliveries and newborn care), all non-emergent surgical procedures, and surgical procedures performed during hospital admissions. Notification and prior authorization for procedures performed during inpatient admissions must be submitted prior to claim submission. Providers must fax a completed PCCM Inpatient/Outpatient Prior Authorization Form to 1-512302-5039 or call the PCCM Inpatient Prior Authorization Department at 1-888-302-6167. For more information, call the TMHP Contact Center at 1-800-925-9126.

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July/August 2006

Texas Health Steps (THSteps) Medical Providers

HIPAA Privacy Clarification

Texas Health Steps (THSteps) works with a number of patient for health care from one health care provider to partners to provide medical, dental, and case management another." services and care to eligible people in Texas. This is "Payment" is defined to mean activities undertaken by a accomplished by educating clients about existing medical, "health plan to obtain premiums or to determine or fulfill dental, and case management services, assisting in the its responsibility for coverage and provision of benefits recruitment and retention under the health plan" including of qualified providers, and "(D)eterminations of eligibility working to assure that or coverage (including the comprehensive preventive Disclosing patient information to coordination of benefits...)" or services are available "(R)eview of health care services TMHP for treatment and payment through a network of public with respect to medical necessity, and private providers. purposes does not violate HIPAA coverage under a health plan, One of THSteps' partners, appropriateness of care, or justiprivacy requirements. the Texas Access Alliance fication of charges..." (TAA), provides outreach Section 164.506(c) expressly and information services by authorizes a covered entity (a assisting THSteps clients and their parents/guardians in health care provider, a health plan, which is defined in the finding providers, scheduling appointments for medical regulations to include the Medicaid Program, or a health and dental checkups, and case management services. care clearinghouse): When assisting clients and their parents/guardians in scheduling appointments, TAA may do so by conducting 1. To use or disclose PHI for its own treatment, payment, a three-way telephone conversation among the TAA repreor health care operations, sentative, a physician, case manager, or dentist, and the 2. To disclose PHI for treatment activities of any provider, client or the client's parent/guardian. TAA also contacts or medical and dental providers to verify clients' medical and dental appointments. 3. To disclose PHI to another covered entity for payment activities. Recently, some THSteps providers have expressed This authorization for use and disclosure extends to a concerns about possibly violating the Health Insurance business associate of a provider or health plan. TAA is a Portability and Accountability Act (HIPAA) of 1996 when business associate of HHSC, which is a health plan since participating in the three-way telephone conversations or HHSC is the single state agency for the Texas Medicaid when TAA contacts providers to verify the dates of clients' Program (including THSteps). Therefore, TAA can medical and dental appointments. Providers are concerned receive PHI for the same treatment and payment purposes that it may be a violation of HIPAA privacy standards to that HHSC could receive PHI directly. reveal to TAA representatives a patient's protected health information (PHI) (as defined by HIPAA) during these The three-way telephone conversations that include communications. disclosures of PHI by the provider are for treatment and payment purposes (depending on the content of the The HIPAA privacy standards found in 45 Code of Federal conversation) and are allowed without authorization of Regulations (CFR) Parts 160 and 164 do not require a the parent/guardian. These disclosures do not have to be provider to obtain a patient's consent before a provider documented by a covered entity under the Accounting discloses PHI for treatment, payment, and health care for Disclosures provisions of Section 164.528. In addition, operations (§§164.502 and 506). In Section 164.501, while the parent/guardian is on the telephone, the "treatment" is defined to mean "the provision, coordinaprovider may ask if the parent/guardian has any objection tion, or management of health care and related services before PHI is disclosed, although such a request is not by one or more health care providers, including the coorrequired. dination or management of health care by a health care provider with a third party; consultation between health For more information, call the TMHP Contact Center at care providers relating to a patient; or the referral of a 1-800-925-9126.

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July/August 2006

Texas Medicaid Bulletin, No. 197

Texas Health Steps (THSteps) Dental Providers

Texas Health Steps (THSteps) Preventive Dental Services

Effective for dates of service on or after May 1, 2006, claims and documentation submitted that include language, terms, or acronyms indicating a preventive resin was applied are reimbursed as a sealant using procedure code D1351, and not as a restorative procedure. When billed for primary or permanent teeth, procedure code D1351 is a benefit of the Texas Medicaid Program with an allowable fee of $14.41. Reimbursement will be considered on a pertooth basis, regardless of the number of surfaces sealed. When procedure codes D1510 or D1515 have been previously reimbursed, the re-cementation of space maintainers is considered for reimbursement to either the same or a different dental provider when billed with procedure code D1550. Procedure codes D1110, D1120, D1201, D1203, D1204, D1205, and D1351 are not a benefit when billed on the same date of service as any D4000 series periodontal procedure codes. For more information, visit the TMHP website at www.tmhp.com or call the TMHP Contact Center at 1-800-925-9126.

Texas Medicaid Bulletin, No. 197

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July/August 2006

Excluded Providers

Excluded Providers

As required by the Medicare and Medicaid Patient Protection Act of 1987, the Texas Health and Human Services Commission (HHSC) identifies providers or employees of providers who have been excluded from state and federal health care programs. Providers excluded from the Texas Medicaid Program, 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 will be 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. Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by the Texas Medicaid Program for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of HHSC's exclusion list. The HHSC-Sanctions Department submits updates to the exclusion list semi-monthly. Updates appear on the website after the 1st and 15th of each month. Review the entire Texas Medicaid Program exclusion list at www.hhsc.state.tx.us/OIE/Exclusionlist/exclusion.asp. To report Medicaid providers who engage in fraud/abuse, call 1-512-424-6519 or 1-888-752-4888, or write to the following address: Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity MC 1361 PO Box 85200 Austin TX 78708-5200 Provider A.C.T. AMGU, Inc. Andre, Lori A. Arriola, Daniel Baker, Franklin T. Barnes, Donna B. Barrett, David B. Baxter, Konya M Bell, Ynolia T Bennett, Donna Benson, Caroline E. Berry, Jeannine L. Bertran, Tammy D. Betts, Cathi A Bishop, Elizabeth Bly, Terry A. Boss, Laura Boswell, Donna K. 3723 License No. Exclusion Date 20-Mar-04 20-Jun-05 30-Jun-05 02-Sep-05 28-Dec-05 11-May-05 09-Dec-05 10-Aug-05 20-Oct-02 03-Aug-05 15-Sep-05 01-Jul-05 11-May-05 11-May-05 24-Jan-05 14-Nov-05 07-Oct-05 20-Sep-05 City Saint Louis McKinney Irving San Antonio Waco Rockport Athens Dallas Houston Houston Refugio Bastrop Houston Las Cruces Waco Corpus Christi Albuquerque Houston State MO TX TX TX TX TX TX TX TX TX TX TX TX NM TX TX NM TX LVN LVN RN RN MD RN LPC RN LVN LVN LVN RN LVN RN RN LVN Provider Type LPC Add Date 04-May-06 12-May-06 07-Apr-06 28-Apr-06 03-May-06 10-Apr-06 12-May-06 28-Apr-06 17-Apr-06 07-Apr-06 28-Apr-06 08-May-06 10-May-06 28-Apr-06 27-Mar-06 03-May-06 02-May-06 08-May-06

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Texas Medicaid Bulletin, No. 197

Excluded Provider

Provider Bowden, Cinthia L. Boyle, Vicky Braddus, Gay Bradford, Becky H Bradford, Natalie T. Brautigam, Charlotte A. Breaux, Barbara J Brissard, Susan Broaddus, Gay Brown, Michael G. Bryan, Gary L. Buhr, Bonita E. Bundy, Mickey Craig Burger, Nancy J Butler, Walter E Carter, Charlotte Cawthon, Carolyn B. Chabrak, Loretta A Childress, William T Clanton, Heidi H Clark, Sharron F Cleveland, Karla A. Cochran, Karen Cole, Donna L. Courson, Linda D. Crawford, John C. Damota, Mimi H. Daniel, Ronald W. Dassay, Jo M. Davidson, Terry Davis, Celia J. Davis, Delores A. Davis, Rhonda E Dazey, Carrie L. DeLeon, Alfonso Demain, Susan P Demesi, Mowoe Denson, Marilee M.

License No.

Exclusion Date 20-Jun-05 30-Sep-05 14-Apr-05 17-Oct-05 19-Aug-05 01-Mar-05 18-Aug-05 24-Oct-05 14-Apr-05 01-Mar-06 31-Mar-05 08-Aug-05 18-Aug-05

City Palestine Sanger Arlington Abilene Disputanta Cypress Fredericksburg Mathis Arlington Houston Plano Rolla Burkburnett Liberty Hill Lewisville Elgin Grand Prairie Tulsa Amarillo Austin Fort Worth Hastings Austin Conroe San Antonio Lake Charles Conroe Duncanville Gladwin Houston Lubbock Tyler Mobile Mexia Von Ormy Newark Grand Prairie Stamford

State TX TX TX TX VA TX TX TX TX TX TX MO TX TX TX TX TX OK TX TX TX MN TX TX TX LA TX TX MI TX TX TX AL TX TX TX TX TX

Provider Type LVN RN LVN LVN LVN RN LVN RN LVN MD M.D. RN LVN LVN RN RN LVN RN RN LVN LVN RN LVN LVN RN MD RN DDS RN LVN LVN LVN LVN RN LVN Pharm LVN

Add Date 10-May-06 08-May-06 07-Apr-06 27-Apr-06 03-May-06 07-Apr-06 27-Apr-06 27-Apr-06 07-Apr-06 12-May-06 08-May-06 07-Apr-06 27-Apr-06 18-Apr-06 28-Mar-06 07-Apr-06 27-Apr-06 28-Apr-06 27-Apr-06 27-Apr-06 27-Apr-06 10-Apr-06 07-Apr-06 12-May-06 01-May-06 03-May-06 10-Apr-06 10-May-06 10-May-06 04-May-06 01-May-06 07-Apr-06 27-Mar-06 10-May-06 07-Apr-06 07-Apr-06 12-May-06 07-Apr-06

97145

07-Apr-06 17-Jan-06 04-Apr-05 12-Oct-05 09-Mar-05 26-Jul-05 10-Aug-05 18-Oct-05 18-Apr-05 30-Nov-05 18-Oct-05 14-Sep-04 08-Apr-05 27-Apr-05 20-Sep-05 09-Dec-05 02-May-06 08-Aug-05 08-Aug-05 04-Mar-05 13-Dec-05 11-May-05 11-Oct-05 20-Mar-05 28-Jan-05

Texas Medicaid Bulletin, No. 197

20

July/August 2006

Excluded Providers

Provider DeYoung, David Dickey, Douglas G. Digby-Lawhon, Vanisha S. Dillon, Julie A. Dorris, Robert C. Dunsmoir, Helen S Dyer, Morgan C.D. Edoho-Ukwa, Grace Udoko Engle, David P. Fabian, Misty L Field of Hearts Center/ Bobbie's Services Fisher, David Fletcher, Yvonne T Ford, Jo A. Franklin, Ayanna Frierson, Pamela Gagnon, Michael L. Garcia, Shirely A. Garner, Debra A. Genesys Medical Equipment Glenn, Connie J. Goosby, Timothy A. Hall, Stewart Harris, Ronald V. Hartsfield, Archie W Hatala, Janine Hazley, Satavia D. Heffington, Martha A Henson, Shannon R. Hernandez, Jose L. Hickerson, Ruth A. Hildebrand, Margaret M. Holmes, Howard J. Hopp, Randy D. Houle, Joseph P. Howard, Anna N. Hungate, Elizabeth A.

License No.

Exclusion Date 19-Aug-05 19-Apr-05 25-Jan-06 18-Aug-05 28-Oct-05 29-Sep-05 03-Jun-05 20-Jun-05 20-Mar-06

City Houston Victoria Odessa Sweetwater North Zulch Round Rock Midland McKinney Colorado Springs Timpson Nacogdoches Big Spring Luling Crystal Beach Houston Dallas Dallas Victoria Las Vegas Frisco Denison Antigo Rosharon Conroe Nacogdoches River Ridge Houston Gatesville Hobbs Laredo Houston Abilene Houston Gladstone Wichita Falls Port Arthur Corpus Christi

State TX TX TX TX TX TX TX TX CO TX TX TX TX TX TX TX TX TX NV TX TX WI TX TX TX LA TX TX NM TX TX TX TX MO TX TX TX

Provider Type DDS RN LVN LVN DDS RN MD RN LVN

Add Date 27-Mar-06 07-Apr-06 03-May-06 07-Apr-06 10-May-06 02-May-06 08-May-06 08-May-06 07-Apr-06 17-Apr-06 20-Apr-06

165527

20-Oct-05 28-Jan-04 17-Mar-05 30-Apr-06 16-Dec-05 09-Aug-05 25-Aug-05 03-Mar-05 24-Aug-05 07-Mar-05 20-Apr-05 11-Feb-05 25-Jul-05 11-Jul-05 19-Dec-05 28-Jan-04 17-Feb-05 17-Mar-05 20-Mar-06 23-Aug-05 20-Jul-05 31-Oct-05 13-Dec-05 03-Jan-06 05-Apr-05 15-Aug-05 20-Feb-05 27-Sep-05

RN LVN RN RN LVN RN LVN RN RN RN RN Other RN RN RN RN&LV RN LVN LVN RN LVN RN RN

07-Apr-06 04-May-06 12-May-06 27-Mar-06 08-May-06 01-May-06 07-Apr-06 07-Apr-06 25-Apr-06 27-Mar-06 03-May-06 07-Apr-06 10-May-06 18-Apr-06 08-May-06 07-Apr-06 02-May-06 07-Apr-06 07-Apr-06 12-May-06 12-May-06 03-May-06 07-Apr-06 08-May-06 03-May-06 10-May-06

July/August 2006

21

Texas Medicaid Bulletin, No. 197

Excluded Providers

Provider Hyman, Jessica Jennings, Priscilla Johnson, Rosamaria Johnson, Stephanie R. Joshlin III, Coleman Keefer, Javier Kelley, Wayne S Kolb, Veneta G. Langley, Carleatha M. Lassalle, Audrea D. Lawson, Bridgett E. Leatherbury, Linda K Lehr, Stephanie L. Leistritz, Mark B Letz (Schleining), Maxine M Libak, Gary R. Lopez, Lino V. Lozano, Georgina Mack, Ethel Main, Linda S Malatek, Tobie B Marcos, Jesus S. Martinez, Leidy A McBride, Gwendolyn I. McCann, D S McCartney, Luanne McCay, Mary M. McDonald, Gregory K. McGriff, Lloyd Medina, Angela T. Mierisch, Eleane Moer, Jr., Donald L. Moer, Jr., Lawrence Montejano, Salma G. Morales, Susan M. Newberry, Iona A. Nicholas, Barbara

License No.

Exclusion Date 03-May-05 09-May-05 10-Oct-05 30-Aug-05 16-May-05 26-Oct-05 18-Apr-05 10-Nov-05 20-Feb-06 14-Feb-06 21-Mar-05 18-Aug-05 13-May-05 20-Mar-01 15-Feb-05 08-Sep-05 12-Jul-05 13-Apr-05 13-Dec-05 01-Nov-05 19-Oct-05 04-Aug-05 24-May-05 25-Aug-05 21-Sep-05 24-May-05 31-Jan-06 27-May-05 31-Mar-05 14-Feb-06 08-Nov-05 30-Jun-05 30-Jun-05 25-Mar-05 17-Jan-06 01-Nov-05 31-Oct-05

City Houston Overton San Antonio Abilene Converse McAllen El Paso Tyler Bylas Cleburne Mckinney San Antonio Longview Saint Louis Abilien Spokane Kerrville Houston Mobile Amarillo Seguin San Antonio Austin Dallas Frankston Coahoma Garland Rusk Dallas Houston Miami Rockwell Rockwell San Antonio Floresville Abilene Houston

State TX TX TX TX TX TX TX TX AZ TX TX TX TX MO TX WA TX TX AL TX TX TX TX TX TX TX TX TX TX TX FL TX TX TX TX TX TX

Provider Type LVN RN RN LVN LVN RN LVN RN RN LVN LVN LPC LVN RN LVN RN RN LVN RN RN RN RN RN/LV LVN RN RN MD LVN RN LVN LVN RN LVN RN RN

Add Date 07-Apr-06 10-Apr-06 28-Apr-06 03-May-06 10-Apr-06 02-May-06 27-Mar-06 27-Mar-06 03-May-06 12-May-06 10-Apr-06 04-May-06 10-Apr-06 09-May-06 27-Mar-06 10-May-06 07-Apr-06 27-Mar-06 12-May-06 27-Apr-06 27-Apr-06 10-May-06 28-Apr-06 01-May-06 01-May-06 27-Apr-06 08-May-06 07-Apr-06 10-May-06 12-May-06 27-Apr-06 07-Apr-06 07-Apr-06 28-Apr-06 02-May-06 01-May-06 12-May-06

Texas Medicaid Bulletin, No. 197

22

July/August 2006

Excluded Providers

Provider Nichols, Kay Nino, Olga S Nixon, Allison B. Norris, Jo A. Omea, Gretchen A. Onken, Carla B. Ornales, Joey L. Osbourne, Susan Parker, Schmika S. Pasco, Maritone A. Paslay, Cyhtia A. Pate, Richard Pender, Katherine L Perales, Valentine Perez, Virginia M. Perry, Clarissa S Phelps, Marcia A. Pockey, Sandra G. Pope, Rosemary Pope, Shirley B. Pressley, Susan E. Prince Medical, Inc. Prince, Mark R. Prince, Mary S. Prince, Todd J. Pullam, Alvin J Ramage, Ashley K. Ramke, Rebecca S Reuther, Pamela S. Rhodes, Hershel Richard, Nora A. Rivera, Helidoro T. Roberts, Linda F. Robertson, Bird C. Robison, Judy L Roman, Hector M. Rowell, Donna S. Russel, Jesse

License No.

Exclusion Date 24-Oct-05 19-Apr-05 14-Feb-05 13-Dec-05 20-Jan-05 17-Mar-06 17-Mar-06 13-Dec-05 23-Jan-06 25-Jul-05 08-Sep-04 20-Oct-05 15-Feb-05 04-Mar-05 08-Nov-05 22-Mar-06 29-Aug-05 24-Jan-05 13-Apr-05 15-Aug-05 18-Jan-06 24-Mar-06

City Iola Pasadena Ashdown Krum Wylie Seabrook Seguin Addison Beaumont Houston Fort Worth Dickinson Portland Fort Stockton Phoeniz Killeen Hooks Adkins Dallas Houston San Antonio Allen McKinney Allen Carrollton Houston Columbia Port Neches Cleburne Nacogdoches Lakeland Seattle Fort Worth Haltom City Spokane Houston Shreveport Brownsville

State TX TX AR TX TX TX TX TX TX TX TX TX TX TX AZ TX TX TX TX TX TX TX TX TX TX TX MO TX TX TX FL WA TX TX WA TX LA TX

Provider Type RN LVN RN LVN RN RN LVN RN LVN RN LVN LVN RNLVN RN LVN CAN RN RN RN LVN LVN MD

Add Date 10-May-06 07-Apr-06 07-Apr-06 08-May-06 03-May-06 08-May-06 08-May-06 07-Apr-06 10-May-06 28-Apr-06 10-Apr-06 07-Apr-06 07-Apr-06 07-Apr-06 10-Apr-06 29-Mar-06 01-May-06 27-Mar-06 10-Apr-06 07-Apr-06 10-May-06 30-Mar-06 30-Mar-06 30-Mar-06 30-Mar-06 28-Mar-06

J6671

26-Mar-06 24-Mar-06 20-Mar-02 20-Mar-06 08-Apr-05 24-Mar-05 20-Jan-06 14-Feb-05 04-Mar-05 26-Aug-05 08-Sep-05 14-Feb-06 18-Oct-05 27-Sep-05 08-Apr-05 23-Jan-06

RN LVN LVN RNLVN RN LVN RN LVN RN LVN RN LVN

07-Apr-06 27-Mar-06 03-May-06 27-Mar-06 07-Apr-06 07-Apr-06 03-May-06 12-May-06 07-Apr-06 01-May-06 03-May-06 02-May-06

July/August 2006

23

Texas Medicaid Bulletin, No. 197

Excluded Providers

Provider Schlitzer, Greg T. Schultz, Joyce E. Semich, Mary J. Shelton, Kevin T. Simpson, Barbara A Smith, Dollie A. Smith, Trelina Southeast School & Related Services Spotwood, Jeffrey D. Stevens, Barbara A. Studer, Lisa D Thomas, Mary R Tischler, Tobby E Titus, Patrick A. Torres, Alfredo Urbina, Marina Valadez, Alicia Van Zandt, Deborah K. Voges, Kathy Wallace, Beauty F Webber, Heidi Whetsel, Sharon K. Whitewolf, Faeghan B. Williams, Joyce E Williamson, Randolph B. Willis, Jr., Volney Wilson, Donna S. Wood, Trudy J. Yeary, Elizabeth A. York, Christine

License No.

Exclusion Date 02-May-05 17-Oct-05 20-Apr-05 23-May-05 16-Nov-05 24-Jun-05 11-Jul-05 10-Apr-06 20-Nov-05 08-Nov-05 23-Jan-06 11-Jan-05 12-Sep-05 26-Aug-05 28-Oct-05 15-Nov-05 20-Apr-06 10-Jan-06 19-Sep-05 30-Jun-05 30-Jun-05 14-Feb-06 30-Nov-05

City Grand Prairie White Oak Lindale Tyler Amarillo San Antonio Marshall Beaumont Vernon Bermuda Dunes Yantis Webster Meridian Houston San Benito Texas City Gatesville Wills Point Houston Houston San Antonio Alvin Austin Houston Fort Smith Temple Jasper Flower Mound Llano Granbury

State TX TX TX TX TX TX TX TX TX CA TX TX TX TX TX TX TX TX TX TX TX TX TX TX AR TX TX TX TX TX

Provider Type RN RN RN RN RN LVN LVN SHARS NA RN LVN RN RN MD LVN LVN LVN LVN RN LVN LVN RN LVN RN RN RN RN RN RN

Add Date 10-May-06 03-May-06 10-May-06 07-Apr-06 27-Mar-06 07-Apr-06 07-Apr-06 17-Apr-06 12-May-06 12-May-06 01-May-06 01-May-06 27-Apr-06 10-May-06 27-Apr-06 07-Apr-06 28-Apr-06 03-May-06 03-May-06 27-Apr-06 28-Apr-06 12-May-06 12-May-06 28-Mar-06 10-May-06 07-Apr-06 10-Apr-06 12-May-06 07-Apr-06 12-May-06

060609

18-Mar-06 21-Dec-05 19-May-05 20-Mar-05 23-Jan-06 20-Jun-05 14-Feb-06

Texas Medicaid Bulletin, No. 197

24

July/August 2006

Forms

Electronic Funds Transfer (EFT) Authorization Agreement

Enter ONE Texas Provider Identifier (TPI) per Form

NOTE: Complete all sections below and attach a voided check or a photocopy of your deposit slip.

Type of Authorization:

Provider Name

Provider Accounting Address Street Address or PO Box

Bank Name

Bank Phone Number

Bank Address Street Address or PO Box

NEW

CHANGE

Nine­Character Billing TPI

Provider Phone Number

ext.

ABA/Transit Number

Account Number

Type Account (check one)

Checking

Savings

City

State

Zip

City

State

Zip

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period. I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations.

Authorized Signature

Date

Title

Email Address (if applicable)

Contact Name

Phone

Return this form to: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box 200795 Austin TX 78720­0795

DO NOT WRITE IN THIS AREA -- For Office Use

Input By: Input Date:

Page 2 of 2

EFTAG11.17.2003_v1.0

July/August 2006

25

Texas Medicaid Bulletin, No. 197

Forms

Electronic Funds Transfer (EFT) Information

Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider's bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account.

The following items are specific to EFT:

Applications are processed within five workdays of receipt. Pre­notification to your bank takes place on the cycle following the application processing. Future deposits are received electronically after pre­notification. The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider's account during the weekly cycle. Specific deposits and associated R&S reports are cross­referenced by both Texas Provider Identifier (TPI) and R&S number. EFT funds are released by TMHP to depository financial institutions each Friday. The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received.

Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date. However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer's withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer's needs. In all cases, credits received should be posted to the customer's account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date.

TMHP must provide the following notification according to ACH guidelines:

To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or deposit slip with the agreement to the TMHP address indicated on the form.

Contact TMHP Customer Service at 1­800­925­9126 if you need assistance.

Page 1 of 2 EFTAG11.17.2003_v1.0

Texas Medicaid Bulletin, No. 197

26

July/August 2006

Forms

Provider Information Change Form

Traditional Medicaid, Children with Special Health Care Needs (CSHCN), and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page. Check the box to indicate a PCCM Provider

9-digit Texas Provider Identifier (TPI):

Date:

Provider Name:

List any additional TPIs that use the same provider information:

TPI:______________________

TPI:______________________

TPI:______________________

TPI:______________________

TPI:______________________

TPI:______________________

Physical Address*

Accounting/Mailing Address**

Secondary Address

City:

State:

Phone:

Fax:

Email:

City:

ZIP: State:

Phone:

Fax:

Email:

City:

ZIP: State:

Phone:

Fax:

Email:

ZIP:

(

)

(

)

(

)

Type of Change: (Check the appropriate box below.)

Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/Add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance)

Comments:

Tax Information--Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Tax ID Number:

Exact name reported to the IRS for this Tax ID:

Effective Date:

The signature and date are required or the form will not be processed.

Provider Signature:

Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment MC-B05 PO Box 200795 Austin, TX 78720-0795

Date:

Fax: 1-512-514-4214

* The physical address cannot be a PO Box. Traditional Medicaid providers who change their ZIP code must submit a copy of the Medicare letter along with this form. ** All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

July/August 2006

27

Texas Medicaid Bulletin, No. 197

Forms

Instructions for Completing the Provider Information Change Form

Signatures:

The provider's signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers.

Address:

Performing providers (physicians performing services within a group) may not change accounting information. For Traditional Medicaid, changes to the accounting or mailing address require a copy of the W9 form. For Traditional Medicaid, a change in ZIP code requires copy of the Medicare letter.

Tax Identification Number (TIN):

TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN.

General:

Forms will be returned unprocessed if the nine-digit provider number is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment MC-B05 PO Box 200795 Austin, TX 78720-0795 Fax: 1-512-514-4214

Texas Medicaid Bulletin, No. 197

28

July/August 2006

Forms

July/August 2006

29

Texas Medicaid Bulletin, No. 197

Forms

Texas Medicaid Bulletin, No. 197

30

July/August 2006

Notes

July/August 2006

31

Texas Medicaid Bulletin, No. 197

JULY/AUGUST 2006

Texas Medicaid

Bimonthly update to the Texas Medicaid Provider Procedures Manual

No. 197

Look inside for these and other important updates:

Page 3 Page 4 Page 9 Page 12 Third Party Biller Enrollment Online Prior Authorization Coming Soon Texas Medicaid Access Card Update Medicaid STAR Program Changes

ATTENTION: BUSINESS OFFICE

PLACE POSTAGE HERE

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