Fillable 801 Seventh Avenue Fort Worth, Texas 76104-2796 (Cook Children's Health Plan)

Fill Online, Printable, Fillable, Blank 801 Seventh Avenue Fort Worth, Texas 76104-2796 (Cook Children's Health Plan) Form

Use Fill to complete blank online COOK CHILDREN'S HEALTH PLAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

801 Seventh Avenue Fort Worth, Texas 76104-2796 (Cook Children's Health Plan)

On average this form takes 45 minutes to complete

The 801 Seventh Avenue Fort Worth, Texas 76104-2796 (Cook Children's Health Plan) form is 377 pages long and contains:

  • 2 signatures
  • 39 check-boxes
  • 153 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Cook Children's Health Plan forms online.

BROWSE COOK CHILDREN'S HEALTH PLAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CCHP STAR Kids PM 122020
1
801 Seventh Avenue
Fort Worth, Texas 76104-2796
888-243-3312
cookchp.org
STAR Kids
Provider Manual
Tarrant Service Area
Denton, Hood, Johnson, Parker, Tarrant, Wise
December 2020
1
CCHP STAR Kids PM 122020
2
Introduction
Welcome to Cook Children’s Health Plan. Thank you for joining one of the most
established and respected healthcare systems in the southwest. As a valued partner in
our network, we will work together to deliver an inspiring
Promise – to improve the
health of every child through the prevention and treatment of illness, disease and
injury.
Childhood is simple, until it isn’t. When things get complicated, Cook Children’s is here
to help. Our provider manual will serve as a useful reference when working with Cook
Children’s Health Plan and with our shared Members who receive services through the
Texas Health and Human Services Commission STAR Kids program.
Background
A century ago, the first children's hospital in Fort Worth opened with 30 beds and a
promise to provide every child in the area access to medical care. From these humble
beginnings Cook Children's has grown to become one of the country's leading
integrated pediatric health care systems.
Based in Fort Worth, Texas, we’re proud of our long and rich tradition of serving our
community. For 100 years we’ve worked to improve the health of children from across
our primary service area of Denton, Hood, Johnson, Parker, Tarrant and Wise counties.
We combine the art of caring with leading technology and extraordinary collaboration to
provide exceptional care for every child. This has earned Cook Children's a strong, far-
reaching reputation with patients traveling from around the country and the globe to
receive life-saving pediatric care.
Our not-for-profit organization is comprised of eight companies, including our Medical
Center, Physician Network, Home Health Company, Northeast Hospital, Pediatric
Surgery Center, Health Plan, Health Services Inc., and Health Foundation. With more
than 60 primary, specialty and urgent care locations throughout Texas, families can
access our top-ranked specialty programs and network of services to meet the unique
needs of their child.
Cook Children’s Health Plan
Since 1998 Cook Children’s Health Plan has provided essential coverage to low-income
families in our six-county service area who qualify for government-sponsored programs,
including Medicaid STAR Kids. Enrollment in Medicaid and CHIP has grown to more
than 120,000 Members, including children and expectant mothers. Members receiving
services associated with STAR and CHIP are supported by a plan network of more than
570 doctors, more than 1,300 specialists and 43 hospitals. In November 2016, STAR
Kids was integrated into Cook Children’s Health Plan.
Program Objective
Cook Children’s Health Plan is committed to providing services for children with
disabilities who have Medicaid coverage to:
•
Improve coordination and customization of care
2
CCHP STAR Kids PM 122020
3
•
Access to care
•
Improve health outcomes
•
Improve quality of care
•
Continually strive to improve both member and provider satisfaction
3
CCHP STAR Kids PM 122020
4
Quick Reference Phone Guide
Quick Reference Topic Description
General Correspondence Address
Cook Children’s Health Plan
P.O. Box 961295
Fort Worth, TX 76161-1295
Website: cookchp.org
Member Services
Telecommunication Device for the Deaf
(TTY/TDD )(for deaf or hearing impaired)
For verification of eligibility and benefits:
Toll Free: 888-243-3312
Fax : 682-885-8401
Email: CCHPCustomerScv@cookchildrens.org
TTY/TDD: 682-885-2138
TTY/TDD Toll Free 844-644-4137
Our representatives speak English and Spanish to
help you. We have an interpreter service that can
help with other languages.
Care Management
For Prior Authorizations, Medical Necessity Denials &
Appeals, Case Management, Baby Steps Program,
and Disease Management:
Toll Free: 888-243-3312
TTY/TDD: 682-885-2138
TTY/TDD Toll Free 844-644-4137
STAR Kids Fax: 682-303-0005
STAR Kids Toll Free Fax: 844-843-0005
Email: CCHPPriorAuthorizations@cookchp.org
Our representatives are available 8 a.m. to 5 p.m.,
Monday to Friday, except for state holidays.
Interpreter Services and TTY/TDD are available for
Utilization Management questions.
For Emergencies and/or Behavioral Health crisis
after hours/weekends, Members should call 911 or go
to the nearest emergency department. If the call is
not an emergency, leave a message and your call will
be returned the next business day.
Pharmacy assistance is available 8 a.m. To 5 p.m.,
Monday to Friday, except for state holidays.
4
CCHP STAR Kids PM 122020
5
Claims and Billing
For claim status, payments inquiries, and appeals:
Toll Free: 888-243-3312
Fax Number: 682-885-2148
To submit Paper Claims:
Cook Children’s Health Plan
Attention: Claims Department
PO Box 961295
Fort Worth, TX 76161-1295
To submit Appeals:
Cook Children’s Health Plan
Attention: Claims Department
PO Box 2488
Fort Worth, TX 76113-2488
Fax: 682-885-8404
Email: CCHPClaimAppeals@cookchildrens.org
Compliance
Member and Provider Complaints:Toll Free:
888-243-3312
Email: CCHPCompliance@cookchildrens.org
To report Fraud, Waste and Abuse:
Toll Free: 888-243-3312
Email: CCHPCompliance@cookchildrens.org
Network Development
For credentialing, contracting, provider demographic
updates and changes:
Toll Free: 888-243-3312
Fax: 682-885-8403
Email:
CCHPNetworkDevelopment@cookchildrens.org
Outreach
Questions about Migrant Farm Workers
Texas Health Steps and Well Child Appointments:
Toll Free: 888-243-3312
Fax Number: 682-303-2244
Email: OutreachCCHP@cookchildrens.org
Provider Relations
Provider Education and Training
Toll Free: 888-243-3312
Fax Number: 682-885-8436
Email: CCHPProviderRelations@cookchildrens.org
5
CCHP STAR Kids PM 122020
6
Vision Services
National Vision Administrators (NVA)
Toll Free: 888-830-5630
Fax: 888-830-5560
Email: Providers@e-nva.com
Behavioral Health Services
Beacon Health Options
TTY/TDD
Toll Free: 855-481-7045
Fax: 855-371-9227
TTY/TDD Toll Free 855-8539-5876
Email:
TexasProviderRelations@BeaconHealthOptions.com
Website: beaconhealthoptions.com/Providers/login/
Beacon Health Options is available 24 hours a day,
seven days a week. They have bilingual staff in
English and Spanish and also interpreter services for
other languages free of charge. Call Beacon or use
the TTY/TDD option if you have questions regarding
Utilization Management issues related to behavioral
health and substances abuse services.
For Emergencies and/or behavioral health crisis after
hours/weekends, Members should call 911 or go to
the nearest emergency department.
Pharmacy
Navitus Help Desk
Toll Free: 877-908-6023
Fax: 866-808-4649
Email: ProviderRelations@navitus.com
Website: navitus.com
Dental Services
DentaQuest:
MCNA:
United Healthcare Dental:
(Medicaid (STAR) Members under the age of 21)
Toll Free: 800-516-0165
Toll Free: 855-691-6262
Toll Free: 877-901-7321
Dental Value Add – Liberty Dental Toll Free: 888-902-0349
TTD/TTY: 866-222-4306
Nurse Advice Line Toll Free: 833-926-2408
Childhood Lead Poisoning Prevention/DSHS Main: 512-458-7151
Comprehensive Care Program/TMHP Toll Free: 800-925-9126
6
CCHP STAR Kids PM 122020
7
Department of Assistive and Rehabilitative
Services (DARS) Inquiries
Toll Free: 800-628-5115
Department of Family and Protective Services
(DFPS) Toll Free: 800-252-5400
Early Childhood Intervention (ECI) Toll Free: 800-628-5115
Family Planning Program Main: 512-458-7796
HHSC Help Line (members) Toll Free: 800-252-8263
HHSC Vendor Drug Services
(Providers only)
Toll Free: 800-435-4165
Maximus – Enrollment Broker Toll Free: 877-782-6440
Medical Transportation Program (MTP) Toll Free: 877-633-8747
Office of the Inspector General Hotline (OIG)
Medicaid Fraud & Abuse
Toll Free: 800-436-6184
Texas CHIP Program Helpline Toll Free: 800-647-6558
Texas Health Steps Program
Toll Free: 877-847-8377
Texas Medicaid Managed Care Helpline
Ombudsman Managed Care Assistance Team Toll
Free: 866-566-8989
TTD/TTY: 866-222-4306
Texas Vaccines for Children Program Toll Free: 800-252-9152
To enroll as a Texas Health Steps provider, call
TMHP
Toll Free: 800-925-9126
7
CCHP STAR Kids PM 122020
8
Women, Infants, and Children (WIC) Nutrition
Program
Toll Free: 800-942-3678
8
CCHP STAR Kids PM 122020
9
Table of Contents
Introduction 2
Background and Program Objectives 2
Quick Reference Phone Guide 4
Table of Contents 9
Section 1: Provider Responsibilities 14
Role of Primary Care Provider 14
Primary Care Provider Medical Home Responsibilities 14
Role of a Home Health 15
Primary Care Provider Medical Home vs Health Home 15
Role of Specialty Care Provider 15
Specialist as a Primary Care Provider 15
Network Limitations 16
Verifying Member Eligibility 16
Appointment Availability 16
After Hours Access 17
Monitoring Access 18
Routine, Urgent and Emergency Services 18
Ambulance Transportation 20
Referrals 21
Member’s Right to Designate an OB/GYN 22
Access to Second Opinion 23
Advance Directives 23
Long Term Services and Support 24
Service Delivery Options 25
Employment Assistance and Supported Employment 25
Community First Choice 26
Electronic Visit Verification 28
Texas Vaccines for Children 34
Texas Agency Administered Programs 34
Updates in Provider Information 35
Credentialing and Recredentialing 35
Termination 36
Marketing Guidelines for Providers 37
Fraud, Waste and Abuse 38
Abuse, Neglect and Exploitation 39
Medical Record Documentation 42
Access to Records 44
Audit or Investigation 45
Medical Transportation Program 46
Cultural Competency 47
Newsletter 48
Interpreter/Translation Services 48
Services for Hearing, Visual, & Access Impaired 50
9
CCHP STAR Kids PM 122020
10
Telemedicine, Telehealth, and Telemonitoring Access 51
Section 2: STAR Kids Medicaid Member Enrollment and Eligibility 52
Enrollment 52
Disenrollment 52
Member Removal from a Provider Panel 53
Pregnant Women & Infants 53
Newborn Process 54
Health Plan Changes 54
STAR Kids Medicaid Member Eligibility 55
Verifying Member Eligibility 55
Your Texas Benefits Medicaid Card 57
Temporary Medicaid Identification 57
TexMedConnect 58
Automated Inquiry System (AIS) 58
Verifying Health Plan Eligibility 58
Cook Children’s Health Plan Identification Card 59
Dual Eligible Members 59
Member Listing for Primary Care Provider 60
STAR Kids Member Rights and Responsibilities 60
Section 3: STAR Kids Covered Services 64
Covered Services 64
Limitations and Exclusions 68
Added Benefits 68
Family Planning Services 68
Value Added Services 68
Durable Medical Equipment and Other Products Normally Found
In a Pharmacy 68
Coordination with Non-Medicaid Managed Care Covered Services 69
Texas Health Steps Dental Services (including Orthodontia) 69
Texas Health Steps Environmental Lead Investigation (ELI) 69
Early Childhood Intervention (ECI) 70
Early Childhood Intervention Specialized Skills Training (SST) 71
Case Management for Children and Pregnant Women (CPW) 71
Texas School Health and Related Services (SHARS) 71
DARS Blind Children’s Vocational Discovery and Developmental
Program 72
Tuberculosis Services 73
Medical Transportation Program through Texas Health and Human
Services Commission 73
Hospice 74
Waiver Programs 74
Long Term Services and Support 76
Role of the Pharmacy 82
Member Prescriptions 82
Formulary and Preferred Drug List 82
10
CCHP STAR Kids PM 122020
11
Emergency Prescription Supply 83
Pharmacy Prior Authorization 84
Cancellation of Product Orders 84
Main Dental Home 84
Role of Main Dental Home 85
How to Help a Member Find Dental Care 85
Emergency Dental Services 85
Non-Emergency Dental Services 85
Members with Special Healthcare Needs 86
Access to Specialists 87
Designation of a Specialist as a Primary Care Provider 87
Out-of-Network Providers and Continuity of Care 88
Pre-Existing Conditions 90
Ambulance Transportation 90
Section 4: Texas Health Steps 92
Who Can Perform Texas Health Steps Examinations 92
How Do I Become a Texas Health Steps Provider 92
Texas Health Steps Medical Checkups Periodicity Schedule 93
Exceptions to the Periodicity Schedule 95
Texas Vaccines for Children 96
ImmTrac 96
Texas Health Steps Billing 96
Children of Migrant Farm Workers 97
Outreach 97
Section 5: Claims and Billing 99
Statutory Requirements 99
Claims Information 99
Claims Filing Deadline 100
Filing Deadline Calendar 100
Clean Claim 100
Prompt Payment Requirements 100
Paper Claims Submission 102
Tips on Submitting Paper Claims 103
Electronic Filing 104
Electronic Claim Acceptance 104
Electronic Funds Transfers and Electronic Remittance Advice 105
Pharmacy Claim Submission 106
Claim Status Assistance 106
Secure Provider Portal 106
Automated System 107
Provider Reimbursement 108
Long Term Service and Support Provider Reimbursement 108
Long Term Service and Support Enrollment Changes 108
Span of Coverage – Inpatient Hospital Stay 109
Service Authorization Requests 110
11
CCHP STAR Kids PM 122020
12
Pharmacy Authorizations 110
Claim Documentation Requirements 111
Coordination of Benefits 114
Overpayments 115
Corrected Claims Process 116
Federally Qualified Health Centers (FQHC) and Rural Health Centers 118
Obstetrics and Prenatal Care 118
Emergency Services Claims 120
Special Billing 120
Co-payments 121
Billing Members 121
Member Acknowledgement Statement 122
Private Pay Statement 122
Out-of-Network Claim Submission 123
Out-of-Network Precertification 124
Out-of-Network Reimbursement 124
Section 6: Denials and Appeals 125
Reconsideration 125
Appealing a Claim Denial 125
Submitting a Claim Appeal 125
Medical Necessity Appeals 126
Provider Appeal Process to HHSC (related to claim recoupment) 126
Retaliation 128
Section 7: Care Management and Service Coordination 129
Service Coordination Teams 129
Utilization Management – Specialty Provider Referral 129
Members Self Refer 129
Observation Stays 130
High Risk Pregnancy Notification 130
Delivery Notification 130
Service Coordination Description 130
Role of Service Coordinator 131
Purpose of Service Coordination 131
Service Coordination Levels 132
Screening and Assessment Instrument 134
Individual Service Plan (ISP) 135
Service Planning and Authorization Requests 136
Prior Authorization Determinations 137
Inpatient Authorization and Levels of Care 138
Medically Necessary Services 138
Medicaid Member Medical Necessity Denials & Appeals 140
Medicaid Member Access to State Fair Hearing 142
Care Transition (Discharge Planning) and Youth to Adult 143
Adult Transition Planning 144
Continuity of Care Transition Plan 145
12
CCHP STAR Kids PM 122020
13
Section 8: Quality Management Program (QMP) 146
Practice Guidelines 147
Performance Improvement Projects 147
Quality Indicators 147
Utilization Management Reporting Requirements 148
Review Process 149
Section 9: Complaints 150
Provider Complaint Process to Cook Children’s Health Plan 150
Provider Complaint Process to Health and Human Services Commission 150
Member Complaint Process to Cook Children’s Health Plan 151
Member Complaint Process to Health and Human Services Commission 152
Retaliation 152
Section 10: Behavioral Health Program 153
Definition of Behavioral Health 153
Behavioral Health Scope of Services 153
Primary Care Provider Requirements for Behavioral Health 154
Role of a Health Home 154
Referrals 155
Member Consent for Disclosure of Information 155
Covered Services 157
Non Covered Services 158
Accessible Intervention and Treatment 158
Prior Authorization 159
Emergency Services 159
Emergency Screening and Evaluation 159
Beacon Clinician Availability 160
Outpatient Benefits 160
Inpatient Benefits 160
Attention Deficit Hyperactivity Disorder (ADHD) 160
Coordination of Care 161
Court Ordered Commitments 162
Members Discharged from Inpatient Psychiatric Facilities 162
Transitioning Members from One Behavioral Health Provider
to Another 162
Treatment Record Review 162
Screening for Depression 162
Targeted Case Management (TCM) and Mental Health Rehabilitative
Services (MHR) 164
Focus Studies and Utilization Reporting Requirements 165
Behavioral Health Quality Improvement Studies 165
Section 11: Glossary of Terms 166
Section 12: Appendix 168
13
CCHP STAR Kids PM 122020
14
Primary Care Provider Responsibilities
Role of the Primary Care Provider
Primary Care Providers (PCP) are responsible for furnishing all primary care related
services within the scope of the Provider’s practice and are responsible for arranging
and coordinating referrals for all medically necessary health care services required by
the Member. STAR Kids Primary Care Providers in the Cook Children’s Health Plan
(CCHP) network are located in and around the following counties: Tarrant, Wise,
Johnson, Parker, Hood and Denton.
The following provider types may serve as Primary Care Providers:
•
Pediatricians
•
Family/General Practice
•
Internists
•
Obstetrics/Gynecologists (OB/GYN)
•
Advanced Practice Nurses – (when practicing under the supervision of a
physician specializing in Family Practice, Internal Medicine, Pediatrics or
Obstetrics/Gynecology)
•
Certified Nurse Midwives (CNM) – (when practicing under the supervision of a
physician specializing in Family Practice, Internal Medicine, Pediatrics or
Obstetrics/Gynecology
•
Physician Assistants (PAs) – (when practicing under the supervision of a
physician specializing in Family Practice, Internal Medicine, Pediatrics or
Obstetrics/Gynecology)
•
Federally Qualified Health Centers (FQHCs)
•
Rural Health Clinics (RHCs)
•
Community Clinics
•
Specialist Physicians – (who are willing to provide a medical home to selected
Members with special needs and conditions)
Primary Care Provider Medical Home Responsibilities
A Primary Care Provider must assess the medical and behavioral health needs of
Members for referral to Specialty Care Providers (SCP), provide referral care as
needed, coordinate the Member’s care with specialty Providers after the referral, and
serve as a Medical Home to Members. The Medical Home concept establishes a
relationship between the Primary Care Provider and the patient in which the physician
provides comprehensive primary care to the patient and facilitates partnerships between
the physicians, patient, acute care and other care Providers when appropriate. Dual
Eligible STAR Kids Members are not required to have a Primary Care Provider.
Through the Medical Home the Member has an ongoing relationship with the physician
who is trained to be the first contact for the Member and to provide continuous and
comprehensive care. The physician is responsible for providing all of the care the
14
Section 1: Provider Responsibilities
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 1: Provider Responsibilities
CCHP STAR Kids PM 122020
15
Member needs or for coordinating with other qualified Providers to provide care
including preventative care, acute care, chronic care and end of life care.
Primary Care Providers who provide covered services for STAR Kids Members must
either have admitting privileges at a hospital that is part of the Cook Children’s Health
Plan provider network, or make referral arrangements with an in network provider who
has admitting privileges to a network hospital.
Role of a Health Home
Cook Children’s Health Plan is committed to providing a consistent and integrated
source of healthcare for our STAR Kids Members through a person-centered Health
Home. Primary Care Providers coordinate with Members, caregivers, other Providers,
STAR Kids Service Coordinators, and state and non-state entities to assure that the
Member’s medical and behavioral health needs are met. Other Primary Care Provider
requirements include screening, identification, and referral to medically necessary or
functionally necessary covered services and assessment and coordination of non-
clinical services that impact the Member’s health. Cook Children’s Health Primary Care
Providers must provide patient and family-centered care that serves the goals of
improving Member care, outcomes, and satisfaction.
Primary Care Provider Medical Home vs Health Home
The medical home and health home models are similar in nature in promoting well-
coordinated, patient-centered, high-quality and effective care. Although the terms often
are used interchangeably, distinction between the two should be noted. The health
home model of service delivery expands on the medical home model by enhancing
coordination and integration of medical and behavioral health care to better meet the
needs of patients, particularly those with multiple chronic conditions.
Specialty Care Provider Responsibilities
Role of the Specialty Care Provider
The Specialty Care Provider provides diagnostic treatments and/or management
options, tests and treatment plans, as requested by the Primary Care Provider. Primary
Care and Specialty Care Providers shall work together to maintain ongoing
communication regarding the Member’s care and treatment. Specialty Care Providers
shall offer Member access to covered services twenty-four (24) hours a day seven (7)
days a week. Such access shall include regular office hours on weekdays and
availability by telephone outside of such regular hours including weekends and holidays.
Specialist as a Primary Care Provider
Specialist physicians may be willing to provide a medical home to selected Members
with special needs and conditions. Members that have disabilities, special health care
needs, chronic or complex health care needs have the right to request a specialist
physician as a Primary Care Provider (PCP). Members, their legally authorized
representative or Primary Care Providers, or the Member’s designee may initiate the
request. In order to accept such a request, the Specialist physician must agree to
15
CCHP STAR Kids PM 122020
16
provide all primary care services, (i.e. immunizations, well child care/annual check-ups,
coordination of all health care services required by the Member).
The Member or their Legally Authorized Representative must also sign the agreement.
The Cook Children’s Health Plan Medical Director reviews and determines Cook
Children’s Health Plan approval for Specialist (physician) as a Primary Care Provider
(PCP). The request form to be used for review and approval of a Specialist to act as a
Primary Care Provider is located in the Appendix section of this provider manual.
Network Limitations
Cook Children’s Health Plan Members must seek services from Cook Children’s Health
Plan network Providers. Providers may refer to any contracted specialist or OB/GYN
within the Cook Children’s Health Plan network. Providers must ensure that all
necessary prior authorizations are obtained prior to providing services. To determine if a
covered service requires a prior authorization Providers may use the Prior Authorization
Lookup tool located on our website at cookchp.org.
This section does not apply to STAR Kids Dual Eligible Members.
Verifying Member Eligibility
Prior to providing care to Members, Providers are responsible for verifying a Member’s
eligibility, identifying which health plan a Member is assigned to, identifying the name of
the assigned Primary Care Provider and verifying covered services and whether they
require prior authorization. Additional information on verifying eligibility is located in the
Member Enrollment and Eligibility section of this Provider Manual.
Availability and Accessibility
Appointment Availability
Access to Primary Care Providers, Specialty Care Providers, Ancillary Providers, and
Network Facility Providers must be available to Members for routine, urgent, and
emergent care as follows:
Waiting times for appointments:
•
Emergency services must be provided upon Member presentation at the service
delivery site, including at non-network and out of area facilities
•
Treatment for an Urgent Condition, including urgent specialty care, must be
provided within twenty-four (24) hours
•
Routine primary care must be provided within fourteen (14) days
•
Routine specialty care must be provided within twenty-one (21) days
•
Initial outpatient behavioral health visits must be provided within ten (10) days.
•
Initial outpatient behavioral health visits must be provided within seven (7) days
upon discharge from an inpatient psychiatric setting.
•
Community-based services for non-MDCP STAR Kids Waiver Members must be
initiated within seven (7) days from the date the health plan authorizes services
unless the referring provider or Member states otherwise.
16
CCHP STAR Kids PM 122020
17
•
Primary Care Providers must make referrals for specialty care on a timely basis,
based on the urgency of the Member’s medical condition, but no later than five
(5) days.
•
Prenatal care must be provided within fourteen (14) days, except for high-risk
pregnancies or new Members in the third trimester, for whom an appointment
must be offered within five days, or immediately, if an emergency exists
•
Preventive health services for adults must be offered within ninety (90) days
•
Preventive health services for children, such as Texas Health Steps medical
checkups must be offered in accordance with the Texas Health Steps periodicity
schedule published in the Texas Medicaid Provider Procedures Manual.
o
For a New Member birth through age twenty (20), overdue or upcoming
Texas Health Steps medical checkups, must be offered as soon as
practicable, but in no case later than fourteen (14) days of enrollment for
newborns, and no later than ninety (90) days of enrollment for all other
eligible child Members.
o
The Texas Health Steps annual medical checkup for an Existing Member
age thirty six (36) months and older is due on the child’s birthday. The
annual medical checkup is considered timely if it occurs no later than 364
calendar days after the child’s birthday.
After Hours Access
Primary Care Providers must be accessible to Members twenty-four (24) hours a day,
seven (7) days a week. It is important to keep Cook Children’s Health Plan updated with
changes to your on-call Providers. The answering service or paging mechanism must
provide a response to a Member call within thirty (30) minutes. The following are
acceptable and unacceptable telephone arrangements for contacting Primary Care
Providers after their normal business hours:
Acceptable after-hours coverage:
1. The office telephone is answered after-hours by an answering service that meets
language requirements of the Major Population Groups and that can contact the
Primary Care Provider (PCP) or another designated medical practitioner. All calls
answered by an answering service must be returned within thirty (30) minutes.
2. The office telephone is answered after normal business hours by a recording in the
language of each of the Major Population Groups served, directing the Member to
call another number to reach the Primary Care Provider (PCP) or another provider
designated by the Primary Care Provider (PCP). Someone must be available to
answer the designated provider’s telephone. Another recording is not acceptable.
3. The office telephone is transferred after office hours to another location where
someone will answer the telephone and be able to contact the Primary Care
Provider or another designated medical provider, who can return the call within
thirty (30) minutes
Unacceptable after-hours coverage:
1. The office telephone is only answered during office hours.
17
CCHP STAR Kids PM 122020
18
2. The office telephone is answered after-hours by a recording that tells Members to
leave a message.
3.
The office telephone is answered after-hours by a recording that directs Members
to go to an Emergency Room for any services needed; and
4. Returning after-hours calls outside of thirty (30) minutes.
Monitoring Access
Cook Children’s Health Plan is required to systematically and regularly verify that
covered services furnished by network Providers are available and accessible to
Members in compliance with the standards established by the Health and Human
Services Commission. The survey must be conducted each fiscal year and will include
verification of Provider directory information and monitor adherence to provider
requirements.
At a minimum, the challenge survey will include verification of the following elements:
•
provider name
•
address
•
phone number
•
office hours
•
days of operation
•
practice limitations
•
languages spoken
•
provider type / provider specialty
•
length of time a patient must wait between scheduling an appointment and
receiving treatment
•
accepting new patients (Primary Care Providers only)
•
Texas Health Steps provider (Primary Care Providers only)
Cook Children’s Health Plan will enforce access and other network standards as
required by the Health and Human Services Commission and take appropriate action
with noncompliant Providers.
Routine, Urgent and Emergency Services
Cook Children’s Health Plan follows the Texas Health and Human Services Commission
definition of emergency medical condition and emergency behavioral health condition.
Based on the following definitions, Cook Children’s Health Plan Members may call 911
or seek care from any provider in an office, clinic, or emergency room. Treatment for
emergency conditions does not require prior authorization or a referral from the
Member’s Primary Care Provider. Emergency Care staff should contact the Member’s
Primary Care Provider (PCP) or Cook Children’s Health Plan toll free at 888-243-3312 if
a Member presents with a non-emergent condition.
Routine Care
Routine Care means health care for covered preventive and medically necessary Health
Care Services that are non-emergent or non-urgent. A non-emergent condition is a
condition that is neither acute nor severe and can be diagnosed and treated
18
CCHP STAR Kids PM 122020
19
immediately, or that allows adequate time to schedule an office visit for a history,
physical or diagnostic studies prior to diagnosis and treatment.
Urgent Condition
Urgent Condition means a health condition including an Urgent Behavioral Health
situation that is not an emergency but is severe or painful enough to cause a prudent
layperson, possessing the average knowledge of medicine, to believe that his or her
condition requires medical treatment evaluation or treatment within twenty-four (24)
hours by the Member’s Primary Care Provider or Primary Care Provider designee to
prevent serious deterioration of the Member’s condition or health.
Urgent Behavioral Health Situation
Urgent Behavioral Health Situation means a behavioral health condition that requires
attention and assessment within twenty-four (24) hours but which does not place the
Member in immediate danger to himself or herself or others and the Member is able to
cooperate with treatment.
Emergency Medical Condition
Emergency Medical Condition means a medical condition manifesting itself by acute
symptoms of recent onset and sufficient severity (including severe pain), such that a
prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical care could result in:
•
placing the patient’s health in serious jeopardy
•
serious impairment to bodily functions
•
serious dysfunction of any bodily organ or part
•
serious disfigurement
•
in the case of a pregnant woman, serious jeopardy to the health of a woman or
her unborn child
Emergency Behavioral Health Condition
Emergency Behavioral Health Condition means any condition, without regard to the
nature or cause of the condition, which in the opinion of a prudent layperson possessing
an average knowledge of health and medicine:
•
requires immediate intervention and/or medical attention without which Members
would present an immediate danger to themselves or others, or
•
renders Members incapable of controlling, knowing or understanding the
consequences of their actions
Care for non-life-threatening emergency must be treated within six (6) hours
Cook Children’s Health Plan will pay for professional, facility, and ancillary services
provided in a hospital emergency department that are medically necessary to perform
the medical screening examination and stabilization of a Member presenting with an
Emergency Medical Condition or an Emergency Behavioral Health Condition, whether
rendered by in network Providers or out-of-network Providers.
19
CCHP STAR Kids PM 122020
20
Cook Children’s Health Plan will pay for Post-Stabilization Care Services obtained
within or outside the network that are not pre-approved by a provider or other health
plan representative, but administered to maintain, improve, or resolve the Member’s
stabilized condition if:
•
Cook Children’s Health Plan does not respond to a request for pre-approval
within one (1) hour
•
Cook Children’s Health Plan cannot be contacted
•
Cook Children’s Health Plan representative and the treating physician cannot
reach an agreement concerning the Member’s care and a network physician is
not available for consultation. In this situation, the health plan will give the
treating physician the opportunity to consult with a network physician and the
treating physician may continue with care of the patient until a network physician
is reached. The health plan’s financial responsibility ends as follows:
o
the network physician with privileges at the treating hospital assumes
responsibility for the Member’s care
o
the network physician assumes responsibility for the Member’s care through
transfer
o
the health plan representative and the treating physician reach an agreement
concerning the Member’s care
o
the Member is discharged
Cook Children’s Health Plan does not require prior authorization or notification when
Member presents with an emergency medical condition or an emergency behavioral
condition for emergency room or ambulance services.
Ambulance Transportation
Cook Children’s Health Plan covers emergency and medically necessary non-
emergency ambulance transportation.
•
Emergency Ambulance Transportation
In the event a Member’s condition is life-threatening or potentially life-threatening
and requires the use of special equipment, life support systems and close
monitoring by trained attendants while in route to the nearest medical facility, the
ambulance transport is considered an emergency service and does not require
Cook Children’s Health Plan prior authorization.
Facility to facility transportation is considered emergent when meeting the
definition found in 1 TAC §353.2. Facility to facility transport is considered
emergent when the service is not eligible at the first facility.
•
Non-Emergency Ambulance Transportation
Non-emergency ambulance transportation is defined as ambulance transport
provided for a Cook Children’s Health Plan Member to or from a scheduled
medical appointment, to or from a licensed facility for treatment, or to the
Member’s home after discharge when the Member has a medical condition such
that the use of ambulance is the only appropriate means of transportation. Non-
20
CCHP STAR Kids PM 122020
21
emergency ambulance transportation services must be prior authorized and
coordinated by Cook Children’s Health Plan before an ambulance is used to
transport a Member in circumstances not involving an emergency.
The Provider of record, the Ambulance Provider or those acting on their behalf may
request approval for an ambulance by using the STAR Kids Standard Prior
Authorization Request Form for Health Care Services found on our website
cookchp.org. Cook Children’s Health Plan will provide the approval or denial for the
prior authorization to the requesting provider and the ambulance provider.
The Ambulance Provider is responsible for ensuring the prior authorization was
approved prior to transport as nonpayment will result without a prior authorization.
Retrospective review may be performed to ensure that documentation supports the
medical necessity of the transport
Referrals
The Primary Care Provider may arrange for a referral to an in network specialist
provider when a Member requires specialty care services. A specialist may refer to
another in network specialist if the Primary Care Provider is notified and concurs with
the referral. Primary Care Providers are responsible for coordinating appropriate
referrals to other Providers and specialists, and manage, monitor and document the
services of other Providers. Referral documentation must be included in the Member
medical record.
This section does not apply to STAR Kids Dual Eligible Members.
Referrals from a network Primary Care Provider to a network Specialist (for evaluation
only), network facility, or contractor does NOT require prior authorization. Some
treatment(s) may require a prior authorization when performed by an in network
provider. Providers should ensure authorization is not required prior to performing
treatment(s).
All Out-of-Network referrals MUST receive prior authorization from Cook Children’s
Health Plan before the Out-of-Network referral can occur. Out-of-Network referrals may
be permitted when services are unavailable from a Cook Children’s Health Plan in
network provider, facility or contractor.
The Provider is responsible for initiating the prior authorization process when a Member
requires medical services or inpatient admission.
Members may access the following services without a Primary Care Provider referral:
•
Network Ophthalmologist or Therapeutic Optometrist to provide Eye Health
Care services other than surgery
•
Emergency Services
•
OB/GYN Care
•
Behavioral Health Services
21
CCHP STAR Kids PM 122020
22
Vision Services
Cook Children’s Health Plan has contracted with a vision provider for routine vision
screenings. A vision screening is an examination by an Optometrist or other provider to
determine the need for and to prescribe corrective lenses and frames. The Providers for
these services are listed in the Provider Directory or Members may call the vision
provider indicated on the Member’s ID card. Member’s may select and have access to,
without a Primary Care Provider referral, a network ophthalmologist or therapeutic
optometrist to provide Eye Health Care Services, other than surgery. For a medical
diagnosis, the Member should contact their Primary Care Provider to be referred to an
Ophthalmologist.
Behavioral Health
Cook Children’s Health Plan has contracted with a behavioral health provider network to
provide mental health and substance abuse services to Members. Members may call
the behavioral health provider indicated on the Member’s ID card.
Behavioral Health Referrals
We all recognize that the prevalence of psychosocial complaints and chemical
dependency disorders are high. Providers should make every effort to elicit and
diagnose these problems. Cook Children’s Health Plan considers it to be part of the
Provider’s scope of care to provide basic screening and evaluation procedures for
detection and treatment of, or referral for, any known suspected behavioral health
problems and disorders from attention deficit disorder, to chemical dependency,
depression, and anxiety states.
Should you encounter any Member who appears to be in need of mental health or
chemical dependency services, please direct that Member to the behavioral health
provider network indicated on the Member’s ID card. In such instances, a referral is not
required. Should Cook Children’s Health Plan alter its arrangements for such services,
the health plan will notify the provider.
Member’s Right to Designate an OB/GYN
Cook Children’s Health Plan allows the Member to pick any OB/GYN, whether that
doctor is in the same network as the Member’s Primary Care Provider or not. The
Member has the right to designate their OB/GYN as their Primary Care Provider.
This section does not apply to STAR Kids Dual Eligible Members.
Attention to Female Members
Members have the right to pick an OB/GYN without a referral from your Primary Care
Provider. An OB/GYN can give the Member:
•
One well-woman checkup each year
•
Care related to pregnancy
•
Care for any female medical condition
•
A referral to a specialist doctor within the network
22
CCHP STAR Kids PM 122020
23
All high risk pregnancies and teen pregnancies are required to be reported to the Care
Management Team at Cook Children’s Health Plan. Please refer to the High Risk
Pregnancy Notification and Delivery Notification forms located in the Appendix section
of this provider manual.
Access to Second Opinion
Cook Children’s Health Plan ensures that each Member has the right to a second
opinion regarding the use of any medically necessary covered service. Either a Member
or an in network provider may request a second opinion. The second opinion must be
obtained from a network provider when available. If a network provider is not available,
the Member may obtain the second opinion from an Out-of-Network provider at no
additional cost to the Member. In state Providers are considered prior to considering out
of state Providers. All Out-of-Network requests require prior authorization from Cook
Children’s Health Plan. The health plan may also request a second opinion. The
reasons include, but are not limited to:
•
a Member or Provider voices a concern about care
•
when an experimental or investigational service is requested
•
possible outcomes or risks of requested treatment are identified by Cook
Children’s Health Plan
When Cook Children’s Health Plan requests a second opinion, the health plan will
arrange the appointment and notify the Member and Primary Care Provider of the date
and time of the appointment. Cook Children’s Health Plan will request that the
consulting provider send his/her opinion to the Primary Care Provider and the health
plan.
Advance Directive
Federal and state law requires Providers to maintain written policies and procedures for
informing and providing written information to all adult Members eighteen (18) years of
age and older about their rights to refuse, withhold, or withdraw medical treatment and
mental health treatment through advance directives (Social Security Act §1902[a][57]
and §1903[m][1][A]). The Provider’s written policies and procedures must comply with
provisions contained in 42 CFR §§434.28 and 489, Subpart I, relating to the following
state laws and rules:
•
A Member’s right to self-determination in making healthcare decisions
•
The Advance Directives Act, Chapter 166, Texas Health and Safety Code, which
includes:
o
A Member’s right to execute an advance written directive to physicians and
family or surrogates, or to make a non-written directive to administer,
withhold, or withdraw life sustaining treatment in the event of a terminal or
irreversible condition
o
A Member’s right to make written and non-written Out-of-Hospital Do-Not-
Resuscitate (DNR) orders
o
A Member’s right to execute a Medical Power of Attorney to appoint an
agent to make healthcare decisions on the Member’s behalf if the Member
becomes incompetent
23
CCHP STAR Kids PM 122020
24
•
Chapter 137, The Texas Civil Practice and Remedies Code, which includes a
Member’s right to execute a Declaration for Mental Health Treatment in a document
making a declaration of preferences or instructions regarding mental health
treatment
Providers must comply with the requirements of state and federal laws, rules and
regulations relating to advance directives.
Cook Children’s Health Plan Members who have questions or would like additional
information about Advance Directive can call Cook Children’s Health Plan STAR Kids
Customer Care Department at 844-843-0004.
Long Term Services and Support (LTSS)
Role of Long Term Services and Support Providers
Long Term Services and Supports provide assistance with activities of daily living (such
as eating, bathing, and dressing) and instrumental activities of daily living (such as
preparing meals, managing medication, and housekeeping). Long Term Services and
Supports include, but are not limited to, nursing facility care, adult daycare programs,
home health aide services, personal care services, private duty nursing, transportation,
and supported employment as well as assistance provided by a family caregiver. Care
planning and care coordination services help Members and families navigate the health
system and ensure that the proper Providers and services are in place to meet
Members’ needs and preferences; these services can be essential for LTSS Members
who often have substantial acute care needs as well.
LTSS Providers are required to provide covered health services to Members within the
scope of their health plan agreement and specialty license. In addition, LTSS Providers
have certain responsibilities for the STAR Kids program and the Members they serve.
These responsibilities include but are not limited to the following:
•
Contacting Cook Children’s Health Plan to verify Member eligibility and obtain
authorizations for service as appropriate
•
Providing continuity of care
•
Coordinating with Medicaid and Medicare
•
Coordinating Medicaid/Medicare benefits for dual eligible if applicable
•
Notifying Cook Children’s Health Plan of any change in the STAR Kids Member’s
physical condition or eligibility
Cook Children’s Health Plan must require that LTSS Providers submit periodic cost
reports and supplemental reports to HHSC in accordance with 1 Tex. Admin. Code
Chapter 355, including Subchapter A (Cost Determination Process) and 1 Tex. Admin.
Code § 355.403 (Vendor Hold). If an LTSS provider fails to comply with these
requirements, HHSC will notify Cook Children’s Health Plan to hold payments to the
LTSS provider until HHSC instructs the health plan to release the payments. HHSC will
forward notices directly to LTSS Providers about such costs reports and information that
is required to be submitted.
24
CCHP STAR Kids PM 122020
25
Service Delivery Options
There are three options available to Members desiring to self-direct the delivery of
Personal Care Services (PCS), Personal Care Services or acquisition, maintenance and
enhancement of skills in CFC, and, for the MDCP STAR Kids in home or out of home
respite, Supported Employment, and Employment Assistance. The three options are:
•
Consumer Directed Services Option
o
The Member is required to select a Financial Management Services
Agency (FMSA) to handle functions such as processing payroll,
withholding taxes, and filing tax-related reports to the Internal Revenue
Service and the Texas Workforce Commission for these services.
o
The FMSA is also responsible for providing training on being an employer,
verifying provider qualifications (including criminal history and registry
checks), and approving the budget.
•
Service-Related Option
•
Agency Option
Cook Children’s Health Plan will provide information, including the risks and benefits
about the three options to all eligible Members.
In addition to providing information concerning the three options, Cook Children’s Health
Plan will provide Member orientation in the option selected by the Member. Cook
Children’s Health plan will provide information regarding all available options:
•
at initial assessment
•
at annual reassessment or annual contact with the Member
•
at any time when a Member requests the information
•
in the Member Handbook
Cook Children’s Health Plan will contract with Providers who are able to offer PCS, in
home or out of home respite, Community First Choice services, Supported Employment,
and Employment Assistance and will educate/train Cook Children’s Health Plan network
Providers regarding the three options.
Provider Responsibilities for Employment Assistance (EA) and Supported
Employment (SE)
Employment Assistance is provided as an HCBS STAR Kids Waiver service to a
Member to help the Member locate competitive employment or self-employment. EA
services include, but are not limited to, the following:
•
identifying a Member’s employment preferences, job skills, and requirements for
a work setting and work conditions
•
locating prospective employers offering employment compatible with an
Member’s identified preferences, skills, and requirements
•
contacting a prospective employer on behalf of an Member and negotiating the
Member’s employment
Supported Employment (SE) services provide assistance as HCBS STAR Kids Waiver
service to a Member who, because of a disability, requires intensive, ongoing support to
25
CCHP STAR Kids PM 122020
26
be self-employed, work from home, or perform in a work setting at which Members
without disabilities are employed. SE provides the supports necessary in order to
sustain paid employment. SE Services include, but are not limited to, the following:
•
employment adaptations, supervision, and training related to a Member’s
diagnosis
•
if the Member is under age twenty-two (22), ensure provision of SE, as needed, if
the services are not available through the local school district
•
if the Member is under age twenty-two (22), SE may be provided through the
SPW if documentation is maintained in the Member’s record, that the service is
not available to the Member under a program funded under the Individuals with
Disabilities Education Act (20 U.S.C. §1401 et seq)
The Provider must develop and update quarterly a plan for delivering EA/SE including
documentation of the following information:
•
name of the Member
•
member’s employment goal
•
strategies for achieving the Member’s employment goal, including those
addressing the , member’s anticipated employment support needs
•
names of the people, in addition to the Member, whose support is or will be
needed to ensure successful employment placement, including the
corresponding level of support those persons are providing or have committed to
providing
•
any concerns about the effect of earnings on benefits, and a plan to address
those concerns
•
progress toward the Member’s employment goal
•
if progress is slower than anticipated, an explanation of why the documented
strategies have not been effective, and a plan improve the effectiveness of the
Member’s employment search
Community First Choice (CFC):
Provider Responsibilities
•
The CFC services must be delivered in accordance with the Member’s service
plan.
•
The program provider must maintain current documentation which includes the
Member’s service plan, ID/RC (if applicable), staff training documentation,
service delivery logs (documentation showing the delivery of the CFC services),
medication administration record (if applicable), and nursing assessment (if
applicable).
•
The HCS or TxHmL program provider must ensure that the rights of the Members
are protected (e.g., privacy during visitation, to send and receive sealed and
uncensored mail, to make and receive telephone calls, etc.).
•
The program provider must ensure, through initial and periodic training, the
continuous availability of qualified service Providers who are trained on the
current needs and characteristics of the Member being served. This includes the
delegation of nursing tasks, dietary needs, behavioral needs, mobility needs,
allergies, and any other needs specific to the Member that are required to ensure
26
CCHP STAR Kids PM 122020
27
the Member’s health, safety, and welfare. The program provider must maintain
documentation of this training in the Member’s record.
•
The program provider must ensure that the staff members have been trained on
recognizing and reporting acts or suspected acts of abuse, neglect, and
exploitation. The program provider must also show documentation regarding
actions that must be taken when from the time they are notified that a Adult
Protective Services investigation has begun through the completion of the
investigation ( e.g., providing medical and psychological services as needed,
restricting access by the alleged perpetrator, cooperating with the investigation,
etc.). The program provider must also provide the Member/LAR with information
on how to report acts or suspected acts of abuse, neglect, and exploitation and
the Adult Protective Services hotline 800-252-5400.
•
The program provider must address any complaints received from a Member/
LAR and have documentation showing the attempt(s) at resolution of the
complaint. The program provider must provide the Member/LAR with the
appropriate contact information for filing a complaint.
•
The program provider must not retaliate against a staff member, service provider,
Member (or someone on behalf of a Member), or other person who files a
complaint, presents a grievance, or otherwise provides good faith information
related to the misuse of restraint, use of seclusion, or possible abuse, neglect, or
exploitation.
•
The program provider must ensure that the service Providers meet all the
personnel requirements (age, high school diploma/GED OR competency exam
and three references from non-relatives, current Texas Driver’s License and
insurance if transporting, criminal history check, employee misconduct registry
check, nurse aide registry check, OIG checks). For CFC ERS, the program
provider must ensure that the provider of ERS has the appropriate licensure.
•
For CFC ERS, the program provider must have the appropriate licensure to
deliver the service.
•
Per the CFR §441.565 for CFC, the program provider must ensure that any
additional training requested by the Member/LAR of CFC PAS or habilitation
(HAB) service Providers is procured.
•
The use of seclusion is prohibited. Documentation regarding the appropriate use
of restrictive intervention practices, including restraints must be maintained,
including any necessary behavior support plans.
•
The program provider must adhere to the MCO financial accountability
standards.
•
The program provider must prevent conflicts of interest between the program
provider, a staff member, or a service provider and a Member, such as the
acceptance of payment for goods or services from which the program provider,
staff member, or service provider could financially benefit.
•
The program provider must prevent financial impropriety toward a Member,
including unauthorized disclosure of information related to a Member’s finances
and the purchase of goods that a Member cannot use with the Member’s funds.
27
CCHP STAR Kids PM 122020
28
Electronic Visit Verification (EVV)
What is EVV?
•
Electronic Visit Verification (EVV) is a telephone and computer-based system that
electronically verifies service visits and documents the precise time service
provision begins and ends.
•
EVV is a method by which a person, including but not limited to a personal care
attendant, who enters a STAR Kids Member’s home to provide a service will
document their arrival time and departure time using a telephonic or computer-
based application system. This visit information will be recorded and used as an
electronic version of a paper time sheet for an attendant and used to support
claims to the MCO for targeted EVV services.
Do Providers have a choice of EVV vendors?
•
Provider selection of EVV vendor
o
DataLogic (Vesta) is the only EVV vendor approved by HHSC at this time.
▪
During the contracting process with Cook Children’s Health Plan, a
provider is required to complete the Vesta EVV Agency Information
Form and submit it directly to DataLogic (Vesta)
▪
A Provider should include a copy of the completed form in the
contracting packet submitted to the MCO.
▪
The forms is located at:
▪
http://vestaevv.com/wp-content/uploads/2019/06/VestaEVV-
Agency-Information_v5282019.pdf
•
Provider EVV default process for non-selection
o
Mandated Providers that do not make an EVV vendor selection or who do not
implement use of their selected vendor, are subject to contract actions and
are defaulted to a selected vendor by HHSC. The Provider will receive a
default letter detailing out the vendor that they have been defaulted to and
when they are required to be implemented with the vendor. The EVV vendor
training must occur prior to using the HHSC-approved EVV system.
Can a provider elect not to use EVV?
EVV will be required to document delivery of the following STAR Kids services:
•
Personal Care Services (PCS)
•
Community First Choice attendant care and habilitation (PAS/HAB)
•
MDCP In Home Respite
•
MDCP flexible family support services
28
CCHP STAR Kids PM 122020
29
Is EVV required for CDS employers?
No, EVV is optional for CDS employers until otherwise stated.
If you are a CDS Employer, there are3 EVV options:
•
Phone and Computer (Full Participation): The telephone portion of EVV will
be used by your Consumer Directed Services (CDS) Employee(s) and you will
use the computer portion of the system to perform visit maintenance.
•
Phone Only (Partial Participation): This option is available to CDS employers
who can participate in EVV, but may need some assistance from the FMSA with
visit maintenance. You will use a paper time sheet to document service delivery.
Your CDS employee will call-in when they start work and call-out when they end
work. Your FMSA will perform visit maintenance to make the EVV system match
your paper time sheet.
•
No EVV Participation: If you do not have access to a computer, assistive
devices, or other supports, or you do not feel you can fully participate in EVV, you
may choose to use a paper time sheet to document service delivery.
How do Providers with assistive technology (ADA) needs use EVV?
•
If you use assistive technology, and need to discuss accommodations related to
the EVV system or materials, pleased contact the HHSC-approved EVV vendors.
DataLogic (Vesta) Software, Inc.
EVV use of alternative device (AD) process and required AD forms
Upon determining a client needs a small alternative device:
•
Provider agency has fourteen (14) calendar days to order a small alternative
device from the vendor
o
EVV vendor has ten (10) business days to process and ship the device
•
Effective May 1, 2019, Provider agencies can electronically order a small
alternative device through the EVV vendor system.
o
The electronic process allows provider agencies to:
▪
Order a new or replacement small alternative device
▪
Track small alternative device order(s)
▪
Manage, assign and un-assign small alternative device
▪
Manage shipping addresses
•
The AD process is found at:
https://hhs.texas.gov/laws-regulations/handbooks/evvpph/section-3000-
electronic-verification-methods
Contact: Email: Phone:
Sales & Training info@vestaevv.com 888- 880-2400
Tech Support support@vesta.net
Website: www.vestaevv.com
29
CCHP STAR Kids PM 122020
30
•
SADs are ordered electronically through DataLogic (Vesta) EVV Vendor system.
o
Contact DataLogic at 888-880-2400 for questions.
•
Where do I submit the SAD agreement/order form?
o
Send the completed form to DataLogic via fax 956-412-1464 or email
info@vestaevv.com
•
Equipment provided by an EVV contractor to a Provider, if applicable, must be
returned in good condition.
A provider agency representative must place the alternative device in the Member’s
home on or before the first service delivery date after receiving the device.
•
The provider agency representative should ask the Member/LAR where they
would like the device to be placed.
•
The location of the device should be accessible to the attendant at all times.
•
The provider agency should explain to the Member/LAR what the purpose of the
alternative device is and how the device works.
•
Effective June 1, 2018, provider agencies may choose to utilize the EVV vendor
zip tie when placing the device in the Member’s home.
o
If a Member disagrees with the agency policy on installing the device with
or without a zip tie, the provider agency must document the issue in the
Member’s file, and use their preferred method.
The alternative device must be in the home at all times. If the alternative device
does not remain in the home at all times, visits may be subject to recoupment and
a Medicaid fraud referral may be made to the Office of Inspector General.
EVV Mobile Application
Attendants may use the EVV vendor mobile application for clocking in and out of the
EVV vendor system.
•
No protected health information (PHI) is stored on the phone while utilizing the
EVV mobile application
•
The cell phone used for the EVV mobile app has to be a smartphone and has an
Apple iOS or Google Android mobile platform.
•
The smart phone should not be a rooted or jailbroken mobile phone
o
Rooting is the process of getting around the Android’s security architecture
and gaining access to the Android operating system code.
o
Jailbreaking is the process of removing the limitations put in place by a
device’s manufacturer.
•
The EVV system will not allow the agency to register a rooted or jailbroken
phone.
•
The attendant is responsible for keeping their phone charged.
o
Attendant’s failure to keep their phone charged, resulting in being unable
to clock in and out, is a failure to use the EVV system.
•
The provider agency and attendant understands Cook Children’s Health Plan,
the EVV vendor and HHSC are not liable for:
o
Any cost incurred while using the EVV mobile app
Any virus(es) on the smartphone
30
CCHP STAR Kids PM 122020
31
o
Hacked, broken, damaged, lost or stolen smartphone
o
Non-working smartphone
EVV Aggregator
The EVV Aggregator is a centralized database that collects, validates, and stores
statewide EVV visit data transmitted by an EVV system.
•
Provides validated provider contract or enrollment data to EVV vendors.
•
Accepts or rejects confirmed EVV visit transactions using standardized validation
edits and returns results to EVV vendors.
•
Stores all accepted and rejected EVV visit transactions.
•
Matches EVV claim line items to accepted EVV visit transactions in the EVV
Aggregator and sends matching results to the appropriate payer for EVV claims
processing.
•
Texas Medicaid & Healthcare Partnership (TMHP), the Texas Medicaid claims
administrator, is responsible for operating and maintaining the EVV Aggregator
and EVV Portal.
EVV Portal
The EVV Portal is an online system that allows users to perform searches and view
reports associated with the EVV visit data in the EVV Aggregator.
•
Users can:
o
View EVV visit transactions ready for billing
o
Access standard EVV reports and run queries on EVV visit data
o
Check the status and identify reasons for rejection of submitted EVV visit
transactions
EVV Compliance
All Providers providing the mandated services must use the EVV system and must
maintain compliance with the following requirements:
•
The Provider must enter Member information, Provider information, and service
schedules (scheduled or non-scheduled) into the EVV system for validation
either through an automated system or a manual system.
•
The Provider must ensure that attendants providing services applicable to EVV
are trained and comply with all processes required to verify service delivery
through the use of EVV.
•
Ninety percent (90%) adherence to Provider compliance plan
o
HHSC EVV Initiative Provider Compliance Plan – A set of requirements
that establish a standard for EVV usage that must be adhered to by
Provider agencies under the HHSC EVV initiative.
o
Provider agencies must achieve and maintain an HHSC EVV initiative
Provider compliance plan score of at least Ninety percent (90%) per
review period. Reason codes must be used each time a change is made
to an EVV visit record in the EVV System.
31
CCHP STAR Kids PM 122020
32
Provider Agencies must complete any and all required visit maintenance in the EVV
system within sixty (60) days of the visit (date of service). Visit maintenance not
completed prior to claim submission is subject to claim denial or recoupment. Provider
Agencies must submit claims in accordance with their contracted entity claim
submission policy. No visit maintenance will be allowed more than sixty (60) days after
the date of service and before claims submission, unless an exception is granted.
•
To request a change on visits greater than sixty (60) days of the visit (date of
service), a provider can submit an HHSC EVV visit maintenance unlock request
to CCHPEVV@cookchildrens.org.
•
HHSC EVV Visit Maintenance Unlock Request form is located at cookchp.org
o
The HHSC compliance plan is located at:
▪
https://hhs.texas.gov/laws-regulations/handbooks/evvpph/
section-6000-compliance-plan
o
The MCO compliance plan is located at:
▪
http://www.cookchp.org/SiteCollectionDocuments/CCHP_EVV-
Compliance-Plan.pdf
•
The Provider Agency must ensure quality and appropriateness of care and
services rendered by continuously monitoring for potential administrative quality
issues.
•
The Provider Agency must systematically identify, investigate, and resolve
compliance and quality of care issues through the corrective action plan process.
•
Providers should notify the appropriate MCO, or HHSC, within forty-eight (48)
hours of any ongoing issues with EVV vendors or issues with EVV Systems.
•
Any Corrective action plan required by an MCO is required to be submitted by
the Network Provider to the MCO within ten (10) calendar days or receipt of
request.
•
MCO Provider Agencies may be subject to termination from the MCO network for
failure to submit a requested corrective action plan in a timely manner.
EVV Complaint Process Complaints regarding an EVV vendor should be directed to
HHSC at:
•
Electronic_Visit_Verification@hhsc.state.tx.us
Will there be a cost to the provider for the access and use of the selected EVV
vendor system?
•
There is no cost to the provider associated with the use of the HHSC contracted
EVV system.
Providers of Home Health Services Responsibilities
The HHSC EVV Provider Compliance Plan for Contracted Provider Agencies (excluding
Consumer-Directed Services CDS) can be found at: https://
hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-Providers/
resources/electronic-visit-verification.
32
CCHP STAR Kids PM 122020
33
•
Non-CDS EVV Providers must adhere to the Provider Compliance plan found at:
cookchp.org or by contacting Cook Children’s Health Plan at 888-243-3312 for
the most current version.
•
Use of reason codes
o
Provider agencies must adhere to the standardized, approved preferred and
non-preferred reason codes established by HHSC when completing visit
maintenance in the EVV system.
o
Reason Codes must be used each time a change is made to an EVV visit
record in the EVV System. Additional information regarding reason codes can
be found at: cookchp.org select Electronic Visit Verification
Will training be offered to Providers?
•
Effective September 1, 2019, Providers must complete all required EVV training.
Required EVV training:
o
HHSC-approved EVV Vendor System (Provided by EVV Vendor)
o
EVV Aggregator and EVV Portal (Provided by TMHP)
o
EVV Policies (Provided by Payer)
•
Several resources are available to assist provider agencies with meeting the
training needs related to EVV.
o
HHSC-approved EVV Vendor Software Training is available at: https://
hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-
Providers/resources/electronic-visit-verification/training-materials-
resources
o
Provider agencies may contact the EVV vendor directly at the contacts
listed below:
DataLogic (Vesta) Software, Inc.
o
Reference to the Cook Children’s Health Plan EVV training is available at
cookchp.org
o
Providers can reach out to TMHP at evv@tmhp.com
•
CDS Employers should contact their respective FMSA with any questions
regarding EVV.
Will claim payment be affected by the use of the EVV?
•
Providers must adhere to EVV guidelines in the HHSC Provider Compliance Plan
when submitting a claim.
o
Effective September 1, 2019, Providers are required to submit EVV related
claims to TMHP.
Contact: Email: Phone:
Sales & Training info@vestaevv.com 888-880-2400
Tech Support support@vesta.net
Website: www.vestaevv.com
33
CCHP STAR Kids PM 122020
34
o
Claims must be received within ninety-five (95) calendar days of the EVV
Visit.
•
Providers should check EVV Portal for accepted EVV visit before submitting an
EVV Claim
•
Claims should be submitted after visit maintenance is completed.
What if I need assistance?
•
If you have questions, contact the EVV vendor or contact Cook Children’s Health
Plan at 888-243-3312 or send an email to CCHPEVV@cookchildrens.org and we
will assist you.
Texas Vaccines for Children Program
Since 1994, Texas has participated in the Federal Vaccines for Children Program (VFC).
Our version is called the Texas Vaccines for Children Program (TVFC). The Program
was initiated by the passage of the Omnibus Budget Reconciliation Act of 1993. This
legislation guaranteed vaccines would be available at no cost to Providers, in order to
immunize children (birth through eighteen (18) years of age) who meet the eligibility
requirements.
Qualified Medicaid and CHIP Providers can enroll in the TVFC Program by completing
the TVFC Provider Enrollment Application form from the DSHS TVFC web page
dshs.state.tx.us.
Texas Agency Administered Programs and Case Management Services
Texas Department of Family and Protective Services (DFPS)
Cook Children’s Health Plan works with Texas Department of Family and Protective
Services to ensure that the at-risk population, both children in custody and not in
custody of Texas Department of Family and Protective Services, receive the services
they need. Children who are served by Texas Department of Family and Protective
Services may transition into and out of Cook Children’s Health Plan more rapidly and
unpredictably than the general population, experiencing placements and reunification
inside and out of the Service Area. Providers must coordinate with the DFPS and foster
parents for the care of a child who is receiving services from or has been placed in
conservatorship of DFPS. During this transition, Providers must respond to requests
from DFPS including:
•
provide medical records to Texas Department of Family and Protective Services
•
testify in hearings
•
schedule medical and behavioral health services appointments within fourteen
(14) days unless requested earlier by Texas Department of Family and
Protective Services
•
refer suspected cases of abuse or neglect to Texas Department of Family and
Protective Services
34
CCHP STAR Kids PM 122020
35
A Member in the custody of Texas Department of Family and Protective Services may
continue to receive services until he or she is disenrolled from Cook Children’s Health
Plan due to loss of Medicaid Managed Care eligibility or placement in foster care.
Notification of Updates in Provider Information
Network Providers must inform both Cook Children’s Health Plan and the Health and
Human Services administrative services contractor of any changes to the provider’s
contact information including address, telephone number, group affiliation, etc. CCHP
also requests that Providers inform us of any updates to the panel status, such as an
update from a closed panel to an open panel as well as any changes to age restrictions.
Providers must also ensure that the health plan has current billing information on file to
facilitate accurate payment delivery.
Providers may use the Provider Demographic Information Change Request Form
located in the Appendix section of this provider manual and on our website cookchp.org
.
The form can be faxed to Network Development 682-885-8403 or email
CCHPNetworkDevelopment@cookchildrens.org.
Credentialing and Recredentialing
Cook Children’s Health Plan’s credentialing process is designed to meet NCQA and
state requirements for the evaluation of Providers who apply for participation. Providers
must submit all required information in order to complete the credentialing or
recredentialing process. Incomplete applications cannot be processed until all
requested documentation is received.
New Providers must complete a Letter of Interest Form along with all of the required
documents. The Letter of Interest form is located on our website at cookchp.org, select
Providers, and then select Joining the Network. Send the completed packet to Network
Development by email CCHPNetworkDevelopment@cookchildrens.org or fax
682-885-8403.
Upon receipt of a completed application and any requested documentation, the
credentialing process for a new provider will be completed within ninety (90) days. The
recredentialing process will occur at least every three (3) years. In addition to verifying
credentials, the health plan will consider provider performance data including Member
complaints and appeals, quality of care and utilization management.
Provider Rights
When the credentialing process is initiated for practitioners and organizations, the
applicant is entitled to:
1. Review information submitted to support their credentialing application.
2. Correct erroneous information.
35
CCHP STAR Kids PM 122020
36
3. Receive the status of their credentialing or recredentialing application, upon request.
Providers may contact the Network Development team for Credentialing, Contracting,
and corrections of erroneous information by phone 888-243-3312, fax 682-885-8403 or
email CCHPNetworkDevelopment@cookchildrens.org.
Provider Contracts
Cook Children’s Health Plan believes effective quality improvement requires provider/
practitioner involvement to the fullest extent possible in quality initiatives. Contracts
specifically require Provider/Practitioner to:
•
Cooperate with Quality Improvement activities
•
Provide Cook Children’s Health Plan with access to member medical records
to the extent permitted by state and federal law
•
Allow Cook Children's Health Plan to use their performance data for quality
improvement activities
•
Maintain the confidentiality of Member information and records
Termination
Provider Requests Termination
If a provider chooses to leave the network, a ninety (90) day written notice is required.
Refer to ‘Advance Notice to Members’ in the Term and Termination section of the
Service Agreement.
Please send the written notice:
•
Fax: 682-885-8403
•
Email: CCHPNetworkDevelopment@cookchildrens.org
•
Or mail:
o
Cook Children’s Health Plan
Attention: Network Development
PO Box 2488
Fort Worth, TX 76113-2488
Termination of Provider by Cook Children’s Health Plan
Cook Children’s Health Plan may terminate a provider’s participation in the health plan
in accordance with its participation contract with the provider and any applicable appeal
procedures. Cook Children’s Health Plan will follow the procedures outlined in §843.306
of the Texas Insurance Code if terminating a contract with a provider. At least 90 days
before the effective date of the proposed termination of the provider’s contract, Cook
Children’s Health Plan must provide a written explanation to the provider of the reasons
for the termination. The health plan may immediately terminate a provider contract in a
case involving:
1. imminent harm to patient health
2. an action by a state medical or dental board, another medical or dental
licensing board, or another licensing board or government agency that
36
CCHP STAR Kids PM 122020
37
effectively impairs the provider’s ability to practice medicine, dentistry, or
another profession
3. fraud or malfeasance
Not later than thirty (30) days following receipt of the termination notice, a Provider may
request a review of Cook Children’s Health Plan’s proposed termination by an advisory
review panel, except in a case in which there is imminent harm to patient health, an
action against a license, or fraud or malfeasance. The advisory review panel must be
composed of physicians and Providers, as those terms are defined in §843.306 of the
Texas Insurance Code, including at least one representative in the provider’s specialty
or a similar specialty, if available, appointed to serve on the standing quality assurance
committee or utilization review committee of Cook Children’s Health Plan. The decision
of the advisory review panel must be considered by Cook Children’s Health Plan but is
not binding on the health plan. Within sixty (60) days following the Provider’s request for
review and before the effective date of the termination, the advisory review panel must
make its formal recommendation, and Cook Children’s Health Plan must communicate
its decision to the provider. Cook Children’s Health Plan must provide to the affected
provider, on request, a copy of the recommendations of the advisory review panel and
the health plan’s determination.
A provider’s participation in Cook Children’s Health Plan shall be automatically
terminated for any of the following:
•
loss, suspension, or probation of professional licensure, certification, or
registration
•
loss of either state or federal or both controlled substances registration
•
loss of required professional liability insurance coverage
•
exclusion from the Medicare, Medicaid, or any other federal health care
program
•
failure to meet the board certification requirement unless granted an
exception as set forth in the criteria
Termination for Gifts or Gratuities
Network Providers may not offer or give anything of value to an officer or employee of
the Health and Human Services Commission or the State of Texas in violation of state
law. A “thing of value” means any item of tangible or intangible property that has a
monetary value of more than $50.00 and includes, but is not limited to, cash, food,
lodging, entertainment and charitable contributions. The term does not include
contributions to public office holders or candidates for public office that are paid and
reported in accordance with state and/or federal law. The health plan may terminate the
network provider contract at any time for violation of this requirement.
Marketing Guidelines for Providers
Cook Children’s Health Plan Providers must adhere to marketing guidelines as outlined
in the Health and Human Services (HHSC) Uniform Managed Care Manual and in your
health plan contract. Those guidelines include the following:
37
CCHP STAR Kids PM 122020
38
1. Providers are permitted to inform their patients about the CHIP and Medicaid
Managed Care (MCO) Programs in which they participate.
2. Providers may inform their patients of the benefits, services, and specialty
care services offered through the Managed Care Organizations (MCO) in
which they participate. However, Providers may not recommend one MCO
over another MCO, offer patients incentives to select one MCO over another
MCO, or assist the patient in deciding to select a specific MCO.
3.
At the patients’ request, Providers may give patients the information
necessary to contact a particular MCO or refer the Members to an MCO
Member Orientation.
4. Provider must distribute or display Health-related Materials for all contracted
MCOs or choose not to distribute or display for any contracted MCO:
•
Health-related posters cannot be larger than 16” x 24”
•
Health-related Materials may have the MCO’s name, logo, and contact
information
•
Providers are not required to distribute or display all Health-related
Materials provided by each MCO with whom they contract. A provider
can choose which items to distribute or display as long as the provider
distributes or displays one or more items from each contracted MCO
that distributes items to the provider and the provider does not give the
appearance of supporting one MCO over another
5. Providers must display stickers submitted by all contracted MCOs or choose
to not display stickers for any contracted MCOs. MCO stickers indicating the
Provider participates with a particular MCO/Dental Contractor cannot be
larger than 5" x 7” and cannot indicate anything more than “MCO/Dental
Contractor is accepted or welcomed here”.
6. Providers may choose whether to display items such as children’s books,
coloring books, and pencils provided by each contracted MCO. Items may
only be displayed in common areas.
7. Providers may distribute Applications to families of uninsured children and
assist with completing the Application
8. Providers may direct patients to enroll in the CHIP and Medicaid Managed
Care Programs by calling the HHSC Administrative Services Contractor.
9. The MCO may conduct Member Orientation and health education for its
Members in a private/conference room at a provider’s office, but not in
Common Areas at provider’s office.
10.Bargains, premiums, or other considerations on prescriptions may not be
advertised in any manner in order to influence a Member’s choice of
pharmacy or promote the volume of prescriptions provided by the pharmacy.
Advertisement may only convey participation in the Program.
38
CCHP STAR Kids PM 122020
39
Fraud Information
Reporting Waste, Abuse or Fraud by a Provider or a Client
Medicaid Managed Care
Do you want to report Waste, Abuse, or Fraud?
Let us know if you think a doctor, dentist, pharmacist at a drug store, other health care
Providers, or a person getting benefits is doing something wrong. Doing something
wrong could be waste, abuse or fraud, which is against the law. For example, tell us if
you think someone is:
•
Getting paid for services that weren’t given or necessary
•
Not telling the truth about a medical condition to get medical treatment
•
Letting someone else use their Medicaid ID
•
Using someone else’s Medicaid or CHIP ID
•
Not telling the truth about the amount of money or resources he or she has to get
benefits
To report waste, abuse or fraud, choose one of the following:
•
Call the OIG Hotline at 800-436-6184;
•
Visit https://oig.hhsc.state.tx.us/, click the red “Report Fraud” button to complete
the online form; or
•
You can report directly to your health plan:
Cook Children’s Health Plan
PO Box 2488
Fort Worth, TX 76113-2488
888-243-3312
To report waste, abuse or fraud, gather as much information as possible.
When reporting a provider (a doctor, dentist, counselor, etc.), include:
•
Name, address, and phone number of provider
•
Name and address of the facility (hospital, nursing home, home health agency,
etc.)
•
Medicaid number of the provider and facility, if you have it
•
Type of provider (doctor, dentist, therapist, pharmacist, etc.)
•
Names and phone numbers of other witnesses who can help in the investigation
•
Dates of events
•
Summary of what happened
When reporting about someone who gets benefits, include:
•
The person’s name
•
The person’s date of birth, Social Security number, or case number if you have it
•
The city where the person lives
•
Specific details about the waste, abuse or fraud
Provider’s Annual Medicaid Payments
If a network provider receives annual Medicaid payments of at least $5 million
(cumulative, from all sources), the network provider must:
39
CCHP STAR Kids PM 122020
40
•
Establish written policies for all employees, managers, contractors,
subcontractors and agents of the network provider. The policies must provide
detailed information about the False Claims Act, administrative remedies for false
claims and statements, any state laws about civil or criminal penalties for false
claims, and whistleblower protections under such laws, as described in Section
1902(a)(68)(A) of the Social Security Act.
•
Include as part of such written policies detailed provisions regarding the network
provider’s policies and procedures for detecting and preventing Fraud, Waste
and Abuse.
•
Include in any employee handbook a specific discussion of the laws described in
Section 1902(a)(68)(A) of the Social Security Act, the rights of employees to be
protected as whistleblowers, and the Provider’s policies and procedures for
detecting and preventing Fraud, Waste and Abuse.
Reporting Abuse, Neglect or Exploitation (ANE)
Medicaid Managed Care
Report suspected Abuse, Neglect, and Exploitation:
Cook Children’s Health Plan and Providers must report any allegation or suspicion of
ANE that occurs within the delivery of long-term services and supports to the
appropriate entity. The managed care contracts include Cook Children’s Health Plan
and provider responsibilities related to identification and reporting of ANE. Additional
state laws related to Cook Children’s Health Plan and provider requirements continue to
apply.
The Provider must provide Cook Children’s Health Plan with a copy of the Abuse,
Neglect, and Exploitation report findings within one Business Day of receipt of the
findings from the Department of Family and Protective Services (DFPS). In addition,
the provider is responsible for reporting individual remediation on confirmed allegations
to Cook Children’s Health Plan.
Report to the Health and Human Services Commission (HHSC) if the victim is an
adult or child who resides in or receives services from:
•
Nursing facilities
•
Assisted living facilities
•
Home and Community Support Services Agencies (HCSSAs) – Providers are
required to report allegations of ANE to both DFPS and HHSC
•
Adult day care centers or
•
Licensed adult foster care Providers
•
Contact HHSC at 800-458-9858
Report to the Departments of Family and Protective Services (DFPS) if the victim
is one of the following:
•
An adult with a disability or child residing in or receiving services from one of the
following Providers or their contractors:
40
CCHP STAR Kids PM 122020
41
o
Local Intellectual and Developmental Disability Authority (LIDDA), Local
mental health authority (LMHAs), Community center, or Mental health facility
operated by the Department of State Health Services
o
a person who contracts with a Medicaid managed care organization to
provide behavioral health services
o
a managed care organization
o
an officer, employee, agent, contractor, or subcontractor of a person or entity
listed above and
•
An adult with a disability receiving services through the Consumer Directed
Services option
Contact DFPS at 800-252-5400 or, in non-emergency situations, online at
txabusehotline.org.
Report to Local Law Enforcement:
If a Provider is unable to identify state agency jurisdiction but an instance of ANE
appears to have occurred, report to a local law enforcement agency and DFPS.
Failure to Report or False Reporting:
•
It is a criminal offense if a person fails to report suspected ANE of a person to
DFPS, HHSC, or a law enforcement agency (See: Texas Human Resources
Code, Section 48.052; Texas Health & Safety Code, Section 260A.012; and
Texas Family Code, Section 261.109).
•
It is a criminal offense to knowingly or intentionally report false information to
DFPS, HHSC, or a law enforcement agency regarding ANE (See: Texas Human
Resources Code, Sec. 48.052; Texas Health & Safety Code Section 260A.013;
and Texas Family Code, Section 261.107).
•
Everyone has an obligation to report suspected ANE against a child, an adult that
is elderly, or an adult with a disability to DFPS. This includes ANE committed by a
family member, DFPS licensed foster parent or accredited child placing agency
foster home, DFPS licensed general residential operation, or at a childcare
center.
Providers are required to train staff and inform Members on how to report Abuse,
Neglect and Exploitation in accordance with Texas Human Resources Code, section 48
and Texas Family Code, section 261.
Laws, Rules and Regulations
The network provider understands and agrees that the following laws, rules and
regulations, and all amendments or modifications apply to the network provider
agreement:
1. Environmental protection laws:
a. Pro-Children Act of 1994 (20 U.S.C.§6081 et seq. regarding the provisions
of a smoke-free workplace and promoting the non-use of all tobacco
products;
41
CCHP STAR Kids PM 122020
42
b. National Environmental Policy Act of 1969 (42 U.S.C.§4321 et seq.
) and
Executive Order 11514 (“Protection and Enhancement of Environmental
Quality” ) relating to the institution of environmental quality control
measures;
c.
Clean Air Act and Water Pollution Control Act regulations (Executive Order
11738, Providing for Administration of the Clean Air Act and Federal Water
Pollution Control Act with respect to Federal Contracts, Grants and
Loans”);
d. State Clean Air Implementation Plan (42 U.C.S. § 740 et seq)
regarding
conformity of federal actions to State Implementation Plans under §176(c)
of the Clean Air Act; and
e. Safe Drinking Water Act of 1974 (21 U.S.C. § 349; 42 U.S.C. §300f to
300j-9) relating to the protection of underground sources of drinking
water;
2. State and Federal anti-discrimination laws:
a. Title VI of the Civil Rights Act of 1964, (42 U.S.C. §2000d et seq.) and as
applicable 45 C.F.R. Part 80n or 7 C.F.R. Part 15;
b. Section 504 of the Rehabilitation Act of 1973 (29U.S.C. §794);
c. Americans with Disabilities Act of 1990 (42 U.S.C. §12101 et seq.);
d. Age Discrimination Act of 1975 (42 U.S.C. §6101-6107);
e. Title IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688);
f. Food Stamp Act of 1977 (7 U.S.C. § 200 et seq.);
g. Executive Order 13279, and it’s implementing regulations of 45 C.F.R.
Part 87 or 7 C.F.R. Part 16 and;
h. The HHS agency’s administrative rules, as set forth in the Texas
Administrative Code, to the extent applicable to this Agreement.
3. The Immigration and Nationality Act (8 U.S.C. §1101 et seq.) and all subsequent
immigration laws and amendments;
4. The Health Insurance Portability Act of 1996 (HIPAA) (Public Law 104-191, and
5. The Health Information Technology for Economic and Clinical Health Act
(HITECH Act) at 42 U.S.C. 17931 et. Seq.
Program Violations
Program violations arising out of performance of the contracts are subject to
administrative enforcement by the Health and Human Services Commission Office of
Inspector General (OIG) as specified in 1 Tex. Admin. Code, Chapter 371, Subchapter
G.
Required Medical Record Documentation
The following is a list of standards that medical records must reflect all aspects of
patient care, including ancillary services:
•
each page or electronic file in the record contains the Member’s name and ID
number
•
age, sex, address and phone number are recorded
•
all entries are dated (month, day and year) and the author identified
•
all entries are legible to individuals other than the author
42
CCHP STAR Kids PM 122020
43
•
allergies and adverse reactions (including immunization reactions) are
prominently noted in the record
•
past medical history is recorded for all patients seen three or more times
•
immunizations are noted in the record as complete or up to date
•
medication information is recorded in a consistent and readily accessible
location
•
current problems and active diagnoses are recorded in a consistent and readily
accessible location
•
Member education regarding physical and/or behavioral health problems is
documented
•
notation concerning tobacco, alcohol and substance abuse and documentation
of relevant Member education is present on an age appropriate basis
•
consultations, referrals and specialist reports are included
•
emergency care is documented
•
hospital discharge summaries are included
•
evidence and results of screening for medical, preventive and behavioral health
screening are present
•
diagnostic information is appropriately recorded
•
treatment provided and results of treatment are recorded
•
documentation of the team members involved in the care of Members requiring
a multidisciplinary team
•
documentation in both the physical and behavioral health records showing
appropriate integration of care
•
documentation of individual encounters must provide adequate evidence of, at a
minimum:
º
history and physical examination
º
appropriate subjective and objective information is obtained for the
presenting complaints
•
for Members receiving behavioral health treatment, documentation to include "at
risk" factors (danger to self/others, ability to care for self, affect, perceptual
disorders, cognitive functioning and significant social history)
•
admission or initial assessment includes current support systems or lack of
support systems
•
for Members receiving behavioral health treatment, an assessment is done with
each visit relating to client status/symptoms to treatment process.
Documentation may indicate initial symptoms of behavioral health condition as
decreased, increased, or unchanged during treatment period
•
plan of treatment that includes activities/therapies and goals to be carried out
•
diagnostic tests
•
therapies and other prescribed regimens. For Members who receive behavioral
health treatment, documentation shall include evidence of family involvement, as
applicable, and include evidence that family was included in therapy sessions,
when appropriate
•
follow-up Encounter forms or notes have a notation, when indicated, concerning
follow-up care, call or visit. Specific time to return is noted in weeks, months, or
43
CCHP STAR Kids PM 122020
44
PRN. Unresolved problems from previous visits are addressed in subsequent
visits
•
referrals and results thereof
•
consultation, lab and imaging reports noted to indicate review and follow-up
plans by primary care provider
•
all other aspects of patient care, including ancillary services
•
for Members 18 years of age and older, documentation of advance directives
and/or mental health declaration, or indication of education
Providers are required to maintain medical records, including electronic medical records
that conform to the requirements of the Health Insurance Portability Act (HIPAA) and
other State and Federal laws. Medical records should be kept in a secure location and
accessible only by authorized personnel.
Access to Records
Receipt of Record Review Request
Provider must provide at no cost to the Texas Health and Human Services Commission
(HHSC):
1. All information required under Cook Children’s Health Plan’s managed care
contract with HHSC, including but not limited to, the reporting requirements and
other information related to the provider’s performance of its obligation under the
contract.
2. Any information in its possession sufficient to permit Health and Human Services
Commission to comply with the federal Balanced Budget Act of 1997 or other
federal or state laws, rules, and regulations. All information must be provided in
accordance with the timelines, definitions, formats, and instructions specified by
HHSC.
Upon receipt of a record review request from the Health and Human Services
Commission Office of Inspector General (OIG) or another state or federal agency
authorized to conduct compliance, regulatory, or program integrity functions, a provider
must provide, at no cost to the requesting agency, the records requested within three (3)
business days of the request. If the OIG or another state or federal agency
representative reasonably believes that the requested records are about to be altered or
destroyed or that the request may be completed at the time of the request or in less
than twenty-four (24) hours, the provider must provide the records requested at the time
of the request or in less than twenty-four (24) hours. The request for record review
includes clinical medical or dental Member records; other records pertaining to the
Member; any other records of services provided to Medicaid or other health and human
services program recipients and payments made for those services; documents related
to diagnosis, treatment, service, lab results, charting; billing records, invoices,
documentation of delivery items, equipment or supplies; radiographs and study models
related to orthodontia services; business and accounting records with backup support
documentation; statistical documentation; computer records and data; and/or contracts
with Providers and subcontractors. Failure to produce the records or make the records
44
CCHP STAR Kids PM 122020
45
available for the purpose of reviewing, examining, and securing custody of the records
may result in OIG imposing sanctions against the provider as described in 1 TEX.
ADMIN. CODE Chapter 371 Subchapter G.
Audit or Investigation
Provider must provide at no cost to the following entities or their designees with prompt,
reasonable, and adequate access to the provider contract and any records, books,
documents, and papers that are related to the provider contract and/or the provider’s
performance of its responsibilities under the contract:
1. United States Department of Health and Human Services or its designee
2. Comptroller General of the United States or its designee
3. Managed Care Organization Program personnel from HHSC or its designee
4. Office of Inspector General
5. Medicaid Fraud Control Unit of the Texas Attorney General’s Office or its
designee
6. any independent verification and validation contractor, audit firm, or quality
assurance contractor acting on behalf of HHSC
7. Office of the State Auditor of Texas or its designee
8. State or Federal law enforcement agency
9. a special or general investigating committee of the Texas Legislature or its
designee
10.any other state or federal entity identified by HHSC, or any other entity engaged
by HHSC
Provider must provide access wherever it maintains such records, books, documents,
and papers. The provider must provide such access in reasonable comfort and provide
any furnishings, equipment, and other conveniences deemed reasonably necessary to
fulfill the purposes described herein. Requests for access may be for, but are not limited
to, the following requests:
1. examination
2. audit
3. investigation
4. contract administration
5. the making of copies, excerpts, or transcripts
6. any other purpose HHSC deems necessary for contract enforcement or to
perform its regulatory functions
The Provider understands and agrees that the acceptance of funds under this contract
acts as acceptance of the State Auditor’s Office (SAO), or any successor agency, to
conduct an investigation in connection with those funds. The Provider further agrees to
cooperate fully with the SAO or its successor in the conduct of the audit or investigation,
including providing all records requested at no cost.
45
CCHP STAR Kids PM 122020
46
Medicaid Managed Care Special Access Requirements
Medical Transportation Program
What is MTP?
MTP is a state administered program that provides Non-Emergency Medical
Transportation (NEMT) services statewide for eligible Medicaid clients who have no
other means of transportation to attend their covered healthcare appointments. MTP
can help with rides to the doctor, dentist, hospital, drug store, and any other place you
get Medicaid services.
What services are offered by MTP?
•
Passes or tickets for transportation such as mass transit within and between
cities or states, to include rail, bus, or commercial air
•
Curb to curb service provided by taxi, wheelchair van, and other transportation
vehicles
•
Mileage reimbursement for a registered individual transportation participant (ITP)
to a covered healthcare event. The ITP can be the responsible party, family,
friend, neighbor, or client
•
Meals and lodging allowance when treatment requires an overnight stay outside
the county of residence
•
Attendant services (a responsible adult who accompanies a minor or an
attendant needed for mobility assistance or due to medical necessity, who
accompanies the client to a healthcare service)
•
Advanced funds to cover authorized transportation services prior to travel
Call MTP:
For more information about services offered by MTP, clients, advocates and Providers
can call the toll free line at 877-633-8747. In order to be transferred to the appropriate
transportation provider, clients are asked to have either their Medicaid ID number or zip
code available at the time of the call.
The Medical Transportation Program provides categorically eligible Medicaid and
Children with Special Health Care Needs recipients with the most cost-effective means
of transportation to appointments for their covered medical and dental care services
within the reasonable proximity of their residence.
Medical Transportation Program may also pay for an attendant if a provider documents
the need, the client is a minor, or there is a language barrier. Call LogistiCare, Inc., the
transportation company for our service area toll free at 855-687-3255 or 877-564-9832
during the normal business hours of 8:00AM-5:00PM weekdays at least two (2) working
days in advance of the trip. If the trip requires extended travel beyond the neighboring
county, please call at least five (5) working days in advance.
Depending on the client’s medical need and location, Medical Transportation Program
can arrange for transportation by mass transit, van service, taxi, or airplane. Medical
46
CCHP STAR Kids PM 122020
47
Transportation Program can reimburse gas money if the client has an automobile but no
funds for gas. In addition, for clients under twenty-one (21) years of age, Medical
Transportation Program can assist with meals and lodging for medical services when an
overnight stay is medically necessary.
Cultural Competency
Reading/Grade Level Consideration
Because of the cultural diversity of the Cook Children’s Health Plan population, not all
Members have comprehensive reading levels. Therefore, in order to facilitate
understanding all Cook Children’s Health Plan Member materials, such as the Member
Handbook, website and correspondence, will be written at or below a sixth (6
th
) grade
Flesch-Kincaid level in both English and Spanish. This will be accomplished by testing
all text with the Microsoft Word’s readability tool. Other languages will be provided when
the language required is spoken by ten (10) percent or more of the enrolled population.
Additionally, CCHP will provide written translation in languages other than English and
Spanish when requested.
Sensitivity and Awareness
Cultural and linguistic competency is defined as a set of linguistic, human interaction,
and ethnic, cultural, and physical and mental disability awareness skills that permit
effective communication and interaction among human beings. The term culture, in this
definition, also includes the beliefs, rituals, values, institutions and customs associated
with racial, ethnic, religious or social groups and individuals of all nationalities.
Understanding and maintaining sensitivity to all of the factors that impact human
behavior, attitudes and communications is integral to assuring the provision of quality,
compassionate and effective health care services to the Members of Cook Children’s
Health Plan.
Cultural (or multicultural) competency is addressed in this plan from two perspectives:
•
human interaction and sensitivity and
•
culturally effective health care services to Cook Children’s Health Plan Members
by network Providers
Physicians and other health care practitioners are compelled to understand the
customs, rituals, and family values of the various cultural groups (in addition to assuring
effective linguistic translations/communications) of their patients in order to provide
quality and effective health care.
Within the service area of Cook Children’s Health Plan, many diverse cultural groups
are represented. It is the beliefs, customs, languages, rituals, values and other aspects
of the North Texas regional population which must be understood and addressed by
Cook Children’s Health Plan staff and affiliated Providers in order to provide quality
service and quality, effective health care. Cook Children’s Health Plan will, as part of this
Plan, conduct an education and training program on cultural competency described
below:
47
CCHP STAR Kids PM 122020
48
Employee Training
Cook Children’s Health Plan hires a diverse group of employees in all levels of our
organization. Cook Children’s Health Plan does not discriminate with regard to race,
religion or ethnic background when hiring staff. All new employees will be trained on
this Plan during Cook Children’s Health Plan’s new employee orientation. All
employees will have access to the Plan as a guide for providing culturally competent
services to our Members.
Provider Training
Cook Children’s Health Plan contracts with a diverse provider network. Cook Children’s
Health Plan‘s Providers speak a wide array of languages including Spanish,
Vietnamese, Chinese and Hindi to name a few. Cook Children’s Health Plan’s Provider
Directory includes the languages spoken in the provider offices to assist our Members
with selecting a provider that would meet their medical needs as well as having the
ability to directly speak to the provider in their language. All Providers that are new to
the health plan receive an initial orientation which includes information about this Plan.
All Providers also receive education and training on an ongoing basis.
Providers should educate themselves about the health care issues common to different
cultures and ethnicities. When an encounter with a patient is difficult due to cultural
barriers, they should prepare for future visits by researching and asking for the patient’s
input.
Newsletters
Cook Children’s Health Plan develops Member newsletters and Provider newsletters on
a quarterly basis. These newsletters are used to communicate information to our
Members and Providers about any new information of interest. It is also used as a tool
to remind our Members and Providers about various aspects of this plan.
Member Handbook
Cook Children’s Health Plan’s Member Handbook is sent to every new Member that
joins our health plan. The Member Handbook includes information about our Cultural
Competency and Translation Services Plan. Information included in the handbook
consists of an explanation of the translation services available to our Members, the
ability to speak to a Spanish speaking Member Services Representative, the ability to
communicate with our health plan using the TDD/TTY phone as well as information
requesting the Member materials in ways to assist Members with other disabilities such
as materials for the visually impaired.
Language Translation Services
Cook Children’s Health Plan provides several options for the non-English speaking or
hearing-impaired Members (or their parents) to communicate with the health plan. Cook
Children’s Health Plan will coordinate language translation services with the Provider as
needed. These options are described in the sections below.
48
CCHP STAR Kids PM 122020
49
In House Translation Services
Cook Children’s Health Plan employs bilingual staff members in the Member Services,
Claims, and Care Management departments. Bilingual staff is available for Spanish
translation services Monday through Friday from 8:00AM-5:00PM by calling toll free
800-964-2247.
Cyra Communications
Cook Children’s Health Plan subscribes to CyraCom International (CyraCom), a
translation service offering competent translations of most commonly spoken languages
around the world. This service is available to our Members 8:00AM–5:00PM Monday
through Friday, excluding holidays. Cook Children’s Health Plan staff is trained in how to
access this line in order to communicate with Members from essentially all local ethnic
groups. CyraCom interpreters have received special training in terminology and
standard business practices in the HMO and healthcare industries.
All CyraCom operators are trained in the following key areas:
•
Facilitate emergency room and critical care situations
•
Accelerate triage and medical advice
•
Simplify the admitting process
•
Improve billing and collection processes
•
Process insurance claims
•
Process prescriptions
•
Provide outpatient and in home care
•
Change primary care Providers
•
Communicate with non-English speaking family members
Cook Children’s Health Plan Members can access the CyraCom translation services by
calling the main number to Cook Children’s Health Plan at 800-964-2247. Cook
Children’s Health Plan employees will conference in a CyraCom translator who can
facilitate the communication. Network Providers who encounter a Cook Children’s
Health Plan Member who cannot speak English may also contact the health plan for
translation services. Either an in house Cook Children’s Health Plan translator will be
provided via telephone or a CyraCom translator will be conferenced in to assure that
effective communication occurs. Providers are made aware of services available
through information included in the provider manual and periodic Provider Newsletters.
Multi-lingual Written Member Materials
All published Member materials will be available in both English and Spanish.
Whenever a particular segment of the Cook Children’s Health Plan population reaches
ten (10) percent or more of the total population, materials will be translated into the
predominant language of that population.
49
CCHP STAR Kids PM 122020
50
Multi-lingual Web Site
Cook Children’s Health Plan has established and maintains a web site for our Members
in both English and Spanish. Cook Children’s Health Plan’s website is constructed such
that Members with access devices that have industry-standard technological capabilities
can easily access and surf the web site. The web site will be translated into additional
languages as that specific segment of the population reaches ten (10) percent or more
of the total population. The Cook Children’s Health Plan website is located at
cookchp.org.
Multi-lingual Recorded Messages
Cook Children’s Health Plan will record all voice messages on its main business lines
and Member Services Hotline/Call Center in both English and Spanish. When a
particular segment of the Cook Children’s Health Plan population reaches ten (10)
percent or more of the total population, recorded messages will be added to main
business lines and Member Services Hotline/Call Center in the predominant language
of that additional population (or populations).
Provider Directory Language Information
The Provider Directory published by Cook Children’s Health Plan will be in both English
and Spanish (and other languages when needed as described above) and will identify
Providers who are proficient in various languages. This information will help Cook
Children’s Health Plan Members select Providers who are culturally compatible with
their family and who can communicate effectively with the Member(s).
Services for Hearing, Visual, & Access Impaired
Cook Children’s Health Plan has many years of experience within the organization in
communicating with children and family members who are either visually or hearing
impaired or both. In addition, Cook Children’s Health Plan accesses all Cook Children’s
Health Care System resources available on an as-needed basis to assure effective
communications with its hearing and visually impaired Members and their families.
Services for the Hearing Impaired
Cook Children’s Health Plan has a service agreement with Texas Interpreting Services
(TIS). TIS employ staff members who are proficient in sign language communications
for hearing impaired individuals. These services are available to Cook Children’s Health
Plan staff and Providers on an as-needed basis. If a provider is in need of a sign
language interpreter, they can contact Cook Children’s Health Plan in advance of the
scheduled appointment and the health plan will coordinate services with TIS.
Telecommunications Devices for the Deaf (TDD)
Cook Children’s Health Plan employs telecommunications devices that can effectively
communicate with hearing impaired Members. Whenever a “silent call” is received on
the Cook Children’s Health Plan Member and/or Provider Hot Line, staff will handle such
calls by utilizing telephonic communications devices that permit the representative to
communicate with the Member/caller using the TDD/TTY.
50
CCHP STAR Kids PM 122020
51
Internet Member Services Access
In addition, Members who are hearing impaired may communicate via electronic mail
(email) over the internet, whenever the Member has access to such services, for all of
their business relative to STAR.
Services for the Visually Impaired
Cook Children’s Health Plan also provides alternative communication services for
Members/families who are visually impaired. These services include:
•
Verbal communications and assistance via phone or in person to assist the
Member with:
º
Understanding plan benefits
º
Selecting an appropriate primary care provider
º
Resolving billing or other questions
º
Other concerns or questions regarding their plan or plan benefits
•
Audiotape versions of the Member Handbook and other Member
communications regarding the plan or plan benefits and limitations are available
upon request
Access to Services for Members with Physical and Modality Limitations
As part of the inventory of items that Cook Children’s Health Plan Provider Relations
staff checks when performing on site office survey visits to network provider offices/
locations, information is gathered to determine if the facilities provide access for
Members with physical and mobility limitations. The results of the audits are
documented and reported to the Quality Management Committee on a quarterly basis.
Providers are required to meet the minimum standards for access prescribed by the
Americans with Disabilities Act (ADA) and terms and conditions outlined in the Cook
Children’s Health Plan Provider Services Agreement.
Telemedicine, Telehealth, and Telemonitoring Access
Telemedicine, Telehealth, and Telemonitoring are covered services and are benefits of
Texas Medicaid as provided in the Texas Medicaid Provider Procedures Manual. Cook
Children’s Health Plan encourages network participation with Providers offering these
services to provide better access to healthcare for our Members. The health plan will
accept and process provider claims for these services in conformity with the Texas
Medicaid benefit.
51
CCHP STAR Kids PM 122020
52
Enrollment
The Texas Health and Human Services Commission (HHSC) in coordination with the
state Enrollment Broker administer the enrollment process for Medicaid eligible
individuals. Eligible individuals must reside in one of the counties in the Tarrant Service
Area. Medicaid clients who are eligible for STAR Kids choose a Managed Care Plan
and a Primary Care Provider using the official state enrollment form or by calling the
Enrollment Broker. The date that a Medicaid client becomes eligible for STAR Kids
Medicaid and the effective date of enrollment with the Managed Care Plan are not the
same. HHSC will make the final determination regarding Medicaid eligibility.
The Help Line (Enrollment Broker) is available 8:00AM – 8:00PM, Central Time,
Monday through Friday at:
• Telephone: 877-782-6440
• Telecommunications device for the deaf (TDD): 800-267-5008
Automatic Re-enrollment
If a Member loses Medicaid eligibility but becomes eligible again within six (6) months or
less, the Member will automatically be enrolled in the same health plan the Member was
enrolled in prior to losing their Medicaid eligibility or the Member may choose to switch
health plans. The Member will also be re-enrolled with the same Primary Care Provider
as they had before if they pick the same health plan as long as that Primary care
Provider is still in the Cook Children’s Health Plan network.
Disenrollment
Members may request disenrollment from Cook Children’s Health Plan. Any request
from a Member for disenrollment from the Plan will require medical documentation from
their Primary Care Provider or documentation that indicates sufficiently compelling
circumstances that merit disenrollment. The Health and Human Service Commission
(HHSC) will make the final decision regarding eligibility, enrollment, disenrollment and
automatic re-enrollment.
Providers cannot take retaliatory action against Members when a Member is disenrolled
from a managed care plan or from a Provider’s panel.
52
Section 2: STAR Kids Medicaid Member Enrollment and Eligibility
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 2: STAR Kids Medicaid Member Enrollment and Eligibility
CCHP STAR Kids PM 122020
53
Disenrollment from Cook Children’s Health Plan
Cook Children’s Health Plan has a limited right to request a Member be disenrolled from
the Plan without the Member’s consent. The Health and Human Services Commission
must approve the request for disenrollment of a Member for good cause. Cook
Children’s Health Plan will take reasonable measures to correct Member behavior prior
to requesting disenrollment. Reasonable documented measures may include providing
education and counseling regarding the offensive acts or behaviors. The Health and
Human Services Commission may permit disenrollment of a Member under the
following circumstances:
•
Member misuses or loans their Cook Children’s membership card to another
person to obtain services
•
Member’s behavior is disruptive or uncooperative to the extent that Member’s
continued enrollment in the Managed Care Plan seriously impairs the Managed
Care Plan’s or provider’s ability to provide services to either the Member or other
Members, and Member’s behavior is not related to a developmental, intellectual,
or physical disability or behavioral health condition
•
Member steadfastly refuses to comply with managed care restrictions (e.g.,
repeatedly using emergency room in combination with refusing to allow the
Managed Care Plan to treat the underlying medical condition
Cook Children’s Health Plan will work with a Member before asking them to leave
the plan. The Texas Health and Human Services Commission will make the final
determination.
Member Removal from a Provider Panel
Providers may request that a Member be removed from their panel for the following
reasons:
•
The Member gives their Cook Children’s Health Plan identification card to
another person for the purpose of obtaining services
•
The Member continually disregards the advice of their Primary Care Provider
•
The Member repeatedly uses the emergency room in an inappropriate fashion
The request to remove a Member from a Provider Panel must be in writing and sent to
Cook Children’s Health Plan Member Services Department. Providers may contact
Cook Children’s Health Plan at 888-243-3312 with questions regarding this process.
Pregnant Women and Infants
The Medicaid Enrollment Broker processes applications for pregnant women within
fifteen (15) days of receipt. Once an applicant is certified as eligible, a Medicaid ID
number will be issued to verify eligibility and to facilitate provider reimbursement.
53
CCHP STAR Kids PM 122020
54
Pregnant women, including pregnant teens, may be retroactively enrolled in the STAR
Kids Program based on their date of eligibility.
Mothers are encouraged to contact the Enrollment Broker to enroll the newborn in the
STAR program. Mothers are also encouraged to select a Primary Care Provider for the
newborn prior to birth. Primary Care Provider selections can be done by calling Cook
Children’s Health Plan Member Services at 800-964-2247.
Pregnant Teens
Providers are required to contact Cook Children’s Health Plan immediately when a
pregnant STAR Kids teen is identified.
Newborn Process
In the STAR Program, newborns are automatically assigned to the managed care plan
the mother is enrolled with at the time of the newborn’s birth for a period of at least
ninety (90) days. The mother can ask for a health plan change before the ninety (90)
days by calling the Enrollment Broker. The Member cannot change from one health plan
to another plan during an inpatient hospital stay.
Health Plan Changes
STAR Kids Medicaid Clients have the right to change plans. Clients must call the
Enrollment Broker at 877-782-6440 to initiate a plan change. If a plan change request is
received before the middle of the month, the plan change is effective on the first day of
the following month. If the request is received after the middle of the month, the plan
change will be effective on the first day of the second month following the request, as
shown below.
Members can change health plans by calling the Texas Medicaid Managed Care
Program Helpline at 877-782-6440. However, a Member cannot change from one
health plan to another health plan during an inpatient hospital stay.
Example
Request received on or before
Mid-May
Change effective
June 1
Request received after
Mid-May
Change effective
July 1
54
CCHP STAR Kids PM 122020
55
STAR Kids Medicaid Member Eligibility
The Texas Health and Human Services Commission (HHSC) will make the final
determination regarding Medicaid eligibility or STAR Kids. Medicaid clients who are
eligible for STAR Kids choose a Managed Care Plan and a Primary Care Provider using
the official state enrollment form or by calling the Enrollment Broker.
The provider is responsible for requesting and verifying the client’s current eligibility
before providing services. The provider must also verify and abide by prior authorization
or administrative requirements established by the managed care plan.
The Medicaid Member’s managed care plan information can be verified by:
•
Calling the Your Texas Benefits help line at 855-827-3747
•
Checking the client’s health plan ID card
•
Calling the client’s health plan
The Member’s managed care eligibility can also be verified using:
•
The Texas Medicaid & Healthcare Partnership Automated Inquiry System (AIS) at
800-925-9126
•
National Council for Prescription Drug Programs (NCPDP) E1 transaction - the
E1 transaction is submitted through the pharmacy’s point-of-sale system
Verifying Member Medicaid Eligibility and MCO Enrollment
Each person approved for Medicaid benefits gets a Your Texas Benefits Medicaid card.
However, having a card does not always mean the patient has current Medicaid
coverage. Providers should verify the patient’s Medicaid eligibility and MCO enrollment
for the date of service prior to services being rendered. There are several ways to do
this:
•
Use TexMedConnect on the TMHP website at www.tmhp.com
•
Log into your TMHP user account and accessing Medicaid Client Portal for
Providers
•
Call the TMHP Contact Center or the Automated Inquiry System (AIS) at
800-925-9126 or 512-335-5986
•
Call Provider Services at the patient’s medical or dental plan
Important: Do not send patients who forgot or lost their cards to an HHSC benefits
office for a paper form. They can request a new card by calling 800-252-8263. Medicaid
members also can go online to order new cards or print temporary cards.
Important: Providers should request and keep hard copies of any Medicaid Eligibility
Verification (Form H1027) submitted by patients. A copy is required during the appeal
process if the patient’s eligibility becomes as issue.
55
CCHP STAR Kids PM 122020
56
The Medicaid Eligibility Verification (Form H1027) is acceptable as evidence of eligibility
during the eligibility period specified unless the form contains limitations that affect the
eligibility for the intended service. If the client is identified as eligible and no other
limitations of eligibility affect the intended service, proceed with the service. Eligibility
during a previous month does not guarantee eligibility for the current month. The
Medicaid Eligibility Verification (Form H1027) and the Your Texas Benefits Medicaid
card are the only documents that are honored as verification of Medicaid eligibility.
Medicaid Providers can log into their TMHP user account and access the Medicid Client
Portal for Providers. This portal aggregates data (provided from TMHP) into one central
hub - regardless of the plan (FFS or Managed Care). This information is collected and
displayed in a consolidated form (Health Summary) with the ability to view additional
details if need be.
The specific functions available are:
•
Access to a Medicaid patient’s medical and dental health information including
medical diagnosis, procedures, prescription medicines and vaccines on the
Medicaid Client Portal through My Account
•
Enhances eligibility verification available on any device, including desktops,
laptops, tablets, and smart phones with print functionality
•
Texas Health Steps and benefit limitations information
•
A viewable and printable Medicaid Card
•
Display of the Tooth Code and Tooth Service Code for dental claims or
encounters
•
Display the Last Dental Anesthesia Procedure Date
Additionally, an online portal is available to patients at www.YourTexasBenefits.com
where they can:
•
View, print, and order a Your Texas Benefits Medicaid card
•
See their medical and dental plans
•
See their benefit information
•
See Texas health Steps Alerts
•
See broadcast alerts
•
See vaccines
•
See prescription medicines
56
CCHP STAR Kids PM 122020
57
•
Choose whether to let Medicaid doctors and staff see their available medical
and dental information
•
See their benefit and case information, view, print, or order a Medicaid card, set
up and view Texas Health Steps Alerts, choose whether or not to share health
information, and adult patients can now view their available health information
online
If you have questions, call 855-827-3747 or email ytb-card-support@hpe.com.
Note: The YourTexasBenefits.com Medicaid Client Portal displays information for active
patients only. Legally Authorized Representatives can view anyone who is part of their
case.
Your Texas Benefits Medicaid Card
Clients receive a Your Texas Benefits Medicaid Card that can be used to verify the client
eligibility for various state-funded programs, including Medicaid. The front of the card
includes the client’s name, member ID, the ID of the agency that issued the card, and
the date on which the card was sent. The back of the card provides:
•
An eligibility verification contact number. The number can be used to determine:
o
Program eligibility dates
o
Retroactive eligibility (when applicable)
o
Eligible services (when applicable)
o
Medicaid managed care eligibility
•
An eligibility website address for clients and non-pharmacy Providers
•
A non-managed care pharmacy claims assistance contact number
•
The Medicaid Client Hotline contact number 800-252-8263
Patients can “opt out” of electronically sharing their Medicaid health information by
calling 800-252-8263 or online at YourTexasBenefits.com.
Medicaid Eligible Clients will only be issued one card and will only receive a new card
in the event of being lost or stolen. Members can call 855-827-3748 if their Medicaid
ID card is lost or stolen. Members can visit the Your Texas Benefits website
YourTexasBenefits.com or call 800-252-8263 or 2-1-1 if they have questions about their
new card or to confirm if they are eligible for Medicaid.
Temporary Medicaid Identification
When a Member’s Your Texas Benefits Medicaid card has been lost or stolen, HHSC
issues a temporary Medicaid verification Form H1027-A. The Medicaid Eligibility
Verification (Form H1027-A) is acceptable as evidence of eligibility during the eligibility
period specified unless the form contains limitations that affect the eligibility for the
intended service. Providers must accept the temporary form as valid proof of eligibility
and contact the managed care health plan to confirm current eligibility. If the Member is
57
CCHP STAR Kids PM 122020
58
not eligible for medical assistance or certain benefits, the Member is treated as a
private-pay patient.
TexMedConnect
TexMedConnect is a free, web-based, claims submission application provided by TMHP.
Technical support and training for TexMedConnect are also available free from TMHP.
Providers can submit claims, eligibility requests, claim status inquiries, appeals, and
download ER&S Reports (in either PDF or ANSI 835 formats) using TexMedConnect.
TexMedConnect can interactively submit individual claims that are processed in
seconds. Providers can use TexMedConnect on the TMHP website at tmhp.com.
Automated Inquiry System (AIS)
The Automated Inquiry System (AIS) is the contact for prompt answers to Medicaid
client eligibility, appeals, claim status inquiries, benefit limitations, and check amounts.
Contact the TMHP Contact Center or AIS at 800-925-9126 or 512-335-5986 to access
this service. Eligibility and claim status information is available on AIS 23 hours a day, 7
days a week, with scheduled down time between 3 a.m. and 4 a.m., Central Time. All
other AIS information is available from 6a.m. until 6 p.m., Central Time, Monday through
Friday. TMHP call center representatives are available from 7 a.m. to 7 p.m., Central
Time, Monday through Friday. AIS offers fifteen (15) transactions per call.
Verifying Health Plan Eligibility
Providers are responsible for verifying a Member’s eligibility, identifying which health
plan a Member is assigned to, identifying the name of the assigned Primary Care
Provider and verifying covered services and if they require prior authorization for each
visit prior to providing care to Members. There are several ways this can be done:
•
Member identification cards
•
Telephone verification
•
Membership listings
•
Cook Children’s Health Plan Secure Provider Portal
Cook Children’s Health Plan:
Member Services (local) 682-885-2247
Member Services (toll-free) 800-964-2247
Secure Provider Portal cookchp.org
Cook Children’s Health Plan recommends that Providers verify eligibility through all
available means prior to providing care to Members.
58
CCHP STAR Kids PM 122020
59
Pharmacy Providers can verify eligibility electronically through NCPDP E1 Transaction,
National Council for Prescription Drug Programs (NCPDP) E1 transaction. The E1
transaction is submitted through the pharmacy’s point-of-sale system.
Cook Children’s Health Plan Identification Card
The Cook Children’s Health Plan STAR Kids Member identification card identifies the
health plan and Primary Care Provider that has been selected by the Member. If the
Member also received Medicare benefits, Medicare is responsible for most primary and
acute services and some behavioral health services; therefore, the Primary Care
Provider’s name, address, and telephone number are not listed on the Member’s ID
card. The card includes the following essential information:
•
Member Name
•
Member Identification Number
•
Health Plan Telephone Number (the toll-free phone number on the STAR Kids
Member ID card is only for Members. Providers will use existing CHIP and STAR
Health Plan phone number to verify eligibility.)
•
Primary Care Provider’s name and telephone number
While the health plan identification card does identify the Member, it does not confirm
eligibility. This is because Member eligibility can change on a monthly basis without
notice. Provider should use all available resources to confirm current Member eligibility
prior to rendering services. Primary Care Providers should not treat any Member whose
identification materials identify a different Primary Care Provider or health plan.
An example of a STAR Kids Member ID Card is located in the Appendix section of this
Provider Manual.
Dual Eligible Members
Dual eligible Members have both Medicare and Medicaid health insurance coverage.
Medicare or the Member’s Medicare Health Maintenance Organization (HMO) is the
primary payer and will reimburse all Medicare covered services. The state Medicaid
program serves as a secondary payer and will provide all medically necessary covered
services that are not covered by Medicare to dual eligible Members.
Cook Children’s Health Plan Service Coordinators will communicate and coordinate
services with the Member’s Medicare Primary Care Provider to ensure continuity of
care. Dual eligible Members should notify their service coordinators that they have
Medicare coverage, and will provide the name of their chosen Primary Care Provider.
59
CCHP STAR Kids PM 122020
60
Dual eligible STAR Kids Members do not have to select a separate Primary Care
Providers through Cook Children’s Health Plan.
Member Listing for Primary Care Provider
Each Primary Care Provider receives a monthly listing of Members who selected that
provider as their Primary Care Provider. The membership listing is available on our
Secure Provider Portal at cookchp.org.
STAR Kids Member Rights and Responsibilities
Member Rights
1. You have the right to respect, dignity, privacy, confidentiality, and nondiscrimination.
That includes the right to:
a. Be treated fairly and with respect
b. Know that your medical records and discussions with your Providers will be
kept private and confidential
2. You have the right to a reasonable opportunity to choose a health care plan and
primary care provider. This is the doctor or health care provider you will see most of
the time and who will coordinate your care. You have the right to change to another
plan or provider in a reasonably easy manner. That includes the right to:
a. Be told how to choose and change your health plan and your primary care
provider
b. Choose any health plan you want that is available in your area and choose
your primary care provider from that plan
c. Change your primary care provider
d. Change your health plan without penalty
e. Be told how to change your health plan or your primary care provider
3. You have the right to ask questions and get answers about anything you do not
understand. That includes the right to:
a. Have your provider explain your health care needs to you and talk to you
about the different ways your health care problems can be treated
b. Be told why care or services were denied and not given
4. You have the right to agree to or refuse treatment and actively participate in
treatment decisions. That includes the right to:
a. Work as part of a team with your provider in deciding what health care is best
for you
b. Say yes or no to the care recommended by your provider
5. You have the right to use each complaint and appeal process available through the
managed care organization and through Medicaid, and get a timely response to
complaints, appeals and fair hearings. That includes the right to:
60
CCHP STAR Kids PM 122020
61
a. Make a complaint to your health plan or to the state Medicaid program about
your health care, your provider or your health plan
b. Get a timely answer to your complaint
c. Use the plan’s appeal process and be told how to use it
d. Ask for a fair hearing from the state Medicaid program and get information
about how that process works
6. You have the right to timely access to care that does not have any communication or
physical access barriers. That includes the right to:
a. Have telephone access to a medical professional 24 hours a day, 7 days a
week to get any emergency or urgent care you need
b. Get medical care in a timely manner
c. Be able to get in and out of a health care provider’s office. This includes
barrier free access for people with disabilities or other conditions that limit
mobility, in accordance with the Americans with Disabilities Act
d. Have interpreters, if needed, during appointments with your Providers and
when talking to your health plan. Interpreters include people who can speak in
your native language, help someone with a disability, or help you understand
the information
e. Be given information you can understand about your health plan rules,
including the health care services you can get and how to get them
7. You have the right to not be restrained or secluded when it is for someone else’s
convenience, or is meant to force you to do something you do not want to do, or is to
punish you
8. You have a right to know that doctors, hospitals, and others who care for you can
advise you about your health status, medical care, and treatment. Your health plan
cannot prevent them from giving you this information, even if the care or treatment is
not a covered service.
9. You have a right to know that you are not responsible for paying for covered
services. Doctors, hospitals, and others cannot require you to pay copayments or
any other amounts for covered services
10.You have the right to receive information about the organizations, it’s services, it’s
practitioners and Providers and member rights and responsibilities
11. You have the right to a candid discussion of appropriate or medically necessary
treatment options for your conditions, regardless of cost or benefit coverage
12.You have the right to make recommendations regarding the organization’s member
rights and responsibilities policy
Member Responsibilities
1. You must learn and understand each right you have under the Medicaid
program. That includes the responsibility to:
61
CCHP STAR Kids PM 122020
62
a. Learn and understand your rights under the Medicaid program
b. Ask questions if you do not understand your rights
c. Learn what choices of health plans are available in your area
2. You must abide by the health plan’s and Medicaid’s policies and
procedures. That includes the responsibility to:
a. Learn and follow your health plan’s rules and Medicaid rules
b. Choose your health plan and a primary care provider quickly
c. Make any changes in your health plan and primary care provider in the
ways established by Medicaid and by the health plan
d. Keep your scheduled appointments
e. Cancel appointments in advance when you cannot keep them
f. Always contact your primary care provider first for your non-emergency
medical needs
g. Be sure you have approval from your primary care provider before
going to a specialist
h. Understand when you should and should not go to the emergency
room
3. You must share information about your health with your primary care
provider and learn about service and treatment options. That includes the
responsibility to:
a. Tell your primary care provider about your health
b. Talk to your Providers about your health care needs and ask questions
about the different ways your health care problems can be treated
c. Help your Providers get your medical records
4. You must be involved in decisions relating to service and treatment options,
make personal choices, and take action to keep yourself healthy. That
includes the responsibility to:
a. Work as a team with your provider in deciding what health care is best
for you
b. Understand how the things you do can affect your health.
c. Do the best you can to stay healthy
d. Treat Providers and staff with respect
e. Talk to your provider about all of your medications
5. A responsibility to follow plans and instructions for care that they have
agreed to with their practitioners
6. A responsibility to understand their health problems and participate in
developing mutually agreed-upon treatment goals, to the degree possible
7. A responsibility to supply information (to the extent possible) that the
organization and its practitioners and Providers need in order to provide
care
62
CCHP STAR Kids PM 122020
63
If you think you have been treated unfairly or discriminated against, call the U.S.
Department of Health and Human Services (HHS) toll-free at 800-368-1019.
You also can view information concerning the HHS Office of Civil Rights online at
hhs.gov/ocr.
63
CCHP STAR Kids PM 122020
64
Covered Services
STAR Kids benefits are governed by Cook Children’s Health Plan’s contract with the
Health and Human Services Commission (HHSC), and include: medical, vision,
behavioral health, pharmacy and Long Term Services and Supports (LTSS). Medical
Dependent Children Program (MDCP) services are covered for individuals who qualify
for and are approved to receive MDCP.
Cook Children’s Health Plan STAR Kids Members are entitled to all medically necessary
services covered under the Texas Medicaid STAR Kids Program. The health provides a
benefit package that includes all medically necessary services currently covered under
the traditional, Fee-for-Service acute care and Long Term Services and Supports
(LTSS) Medicaid program. The following information provides an overview of benefits
provided for STAR Kids Members.
Benefits include, but may not be limited to:
•
Emergency and non-emergency ambulance services
•
Audiology services, including hearing aids
•
Behavioral Health Services including
º
Inpatient mental health services – The health plan may provide these
services in a free-standing psychiatric hospital in lieu of an acute care
inpatient hospital setting.
º
Mental Health Rehabilitative Services and Mental Health Targeted Case
Management for individuals who are not dually eligible in Medicare and
Medicaid
º
Outpatient mental health services
º
Psychiatry services
º
Substance use disorder treatment services, including
-
Outpatient services, such as:
• Assessment
• Detoxification services
• Counseling treatment
• Medication assisted therapy
º
Residential services, which may be provided in a chemical dependency
treatment facility in lieu of an acute care inpatient setting, including:
-
Detoxification services
-
Substance use disorder treatment (including room and board)
64
Section 3: STAR Kids Covered Services
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 3: STAR Kids Covered Services
CCHP STAR Kids PM 122020
65
•
Prenatal care provided by a physician, certified nurse midwife (CNM), nurse
practitioner (NP), clinical nurse specialist (CNS), and physician assistant (PA) in
a licensed birthing center
•
Birthing services provided by a physician and certified nurse midwife (CNM) in a
licensed birthing center
•
Birthing services provided by a licensed birthing center
•
Cancer screening, diagnostic, and treatment services
•
Chiropractic services
•
Day Activity and Health Services (DAHS)
•
Dialysis
•
Drugs and biologicals provided in an inpatient setting
•
Durable medical equipment and supplies
•
Early Childhood Intervention (ECI) Services
•
Emergency services
•
Family planning services
•
Home health care services provided in accordance with 42 C.F.R
§ 440.70, and
as directed by HHSC
•
Hospital services, inpatient and outpatient
•
Laboratory
•
Mastectomy, breast reconstruction, and related follow-up procedures, including:
º
inpatient services, outpatient services provided at an outpatient hospital and
ambulatory health care center as clinically appropriate; and physician and
professional services provided in an office, inpatient or outpatient setting for:
-
all stages of reconstruction on the breast(s) on which medically
necessary mastectomy procedure(s) have been performed
-
surgery and reconstruction on the other breast to produce symmetrical
appearance
-
treatment of physical complications from the mastectomy and treatment
of lymphedemas; and
-
prophylactic mastectomy to prevent the development of breast cancer
º
external breast prosthesis for the breast(s) on which medically necessary
mastectomy procedure(s) have been performed
•
Medical checkups and Comprehensive Care Program (CCP) Services through
the Texas Health Steps Program (EPSDT), including private duty nursing,
Prescribed Pediatric Extended Care Center (PPECC) services, certified
respiratory care practitioner services, and therapies (speech, occupational,
physical)
•
Oral evaluation and fluoride varnish in the Medical Home in conjunction with
Texas Health Steps medical checkup for children six (6) months through thirty-
five (35) months of age
65
CCHP STAR Kids PM 122020
66
•
Optometry, glasses and contact lenses, if medically necessary
•
Outpatient drugs and biologicals; including pharmacy-dispensed and provider
administered outpatient drugs and biologicals
•
Personal Care Services (PCS)
•
Podiatry
•
Prescribed pediatric extended care center (PPECC) services
•
Primary care services
•
Private Duty Nursing (PDN) services
•
Radiology, imaging, and X-rays
•
Specialty physician services
•
Telemonitoring
•
Telehealth
•
Therapies - physical, occupational and speech
•
Transplantation of organs and tissues
•
Vision services
Breast Pump Coverage
Texas Medicaid covers breast pumps and supplies when medically necessary after a
baby is born. A breast pump may be obtained under an eligible mother’s Medicaid or
client number; however, if a mother is no longer eligible for Texas Medicaid and there is
a need for a breast pump or parts, then breast pump equipment must be obtained under
the infant’s Medicaid client number.
Coverage in
prenatal
period
Coverage
at delivery
Coverage
for newborn
Breast pump coverage & billing
STAR Kids STAR Kids
Medicaid FFS
or STAR**
Medicaid FFS and STAR cover breast
pumps and supplies when medically
necessary for mothers or newborns.
Breast pumps and supplies may be
billed under the mother’s Medicaid ID or
the newborn’s Medicaid ID.
None, with
income at or
below 198%
FPL
Emergency
Medicaid
Medicaid FFS
or STAR**
Medicaid FFS and STAR cover breast
pumps and supplies when medically
necessary for the newborn when the
mother does not have coverage. Breast
pumps and supplies must be billed
under the newborn’s Medicaid ID.
66
CCHP STAR Kids PM 122020
67
**These newborns will be in FFS Medicaid until they are enrolled with a STAR MCO.
Claims should be filed with TMHP using the newborn’s Medicaid ID if the mother does
not have coverage.
Community First Choice (CFC) Services for Those Members Who Qualify for
These Services
The state provides an enriched array of services to Members who would otherwise
qualify for care in a Nursing Facility, an ICF/IDD, or an Institution for Mental Diseases
(IMD).
•
Personal Care Services - CFC - all qualified Members may receive medically and
functionally necessary Personal Assistance Services under CFC
•
Habilitation, acquisition, maintenance and enhancement of skills - all qualified
Members may receive this service to enable the Member to accomplish ADLs,
IADLs and health-related tasks
•
Emergency Response Services - CFC - (Emergency call button) - All qualified
Members may receive necessary Emergency Response Services under CFC
•
Support Management - all qualified Members may receive voluntary training on
how to select, manage and dismiss attendants
Services for MDCP STAR Kids
The following is a list of covered services for Members who qualify for MDCP STAR
Kids services. Cook Children’s Health Plan must provide medically and functionally
necessary services to Members who meet the functional and financial eligibility for
MDCP STAR Kids.
•
Respite Care
•
Supported Employment
•
Financial Management Services
•
Adaptive Aids
•
Employment Assistance
•
Flexible Family Support Services
•
Minor home modifications
•
Transition Assistance Services
Limitations and Exclusions from Covered Services
Please refer to the current Texas Medicaid Provider Procedures Manual for a complete
listing of limitations and exclusions. The limitations and exclusions can be accessed
online at tmhp.com
67
CCHP STAR Kids PM 122020
68
Added Benefits
•
STAR Kids Members are not limited to the 30-day spell-of-illness
•
$200,000.00 annual limit on inpatient services does not apply for STAR Kids
Members
•
unlimited prescriptions for STAR Kids Members who are NOT covered by
Medicare
•
a list of the Value Added Services is located in the Appendix section of this
provider manual
Family Planning Services
Family Planning services, including sterilization, are covered STAR Kids Member
benefits. These services can be provided by an in network provider for Cook Children’s
Health Plan. Family planning services are preventive health, medical, counseling, and
educational services that assist Members in controlling their fertility and achieving
optimal reproductive and general health. Family planning services must be provided by
a physician or under physician supervision.
In accordance with the provider agreement, family planning Providers must assure
Members, including minors, that all family planning services are confidential and that no
information will be disclosed to a spouse, parent, or other person without the Members
permission. Health care Providers are protected by law to deliver family planning
services to minor members without parental consent or notification.
Only family planning patients, not their parents, their spouse or other individuals, may
consent to the provision of family planning services. However, counseling should be
offered to adolescents, which encourages them to discuss their family planning needs
with a parent, adult family Member, or other trusted adult.
Value Added Services
Value added services are extra health care benefits offered by Cook Children’s Health
Plan above the Medicaid program benefits. A list of the Value Added Services is located
in the Appendix section of this provider manual.
Durable Medical Equipment and Other Products Normally Found in a Pharmacy
Cook Children’s Health Plan reimburses for durable medical equipment (DME) and
products commonly found in a pharmacy. Refer to the Texas Medicaid Provider
Procedures Manual, Durable Medical Equipment (DME) and Comprehensive Care
Program (CCP) sections for additional information regarding the scope of coverage of
durable medical equipment and other products commonly found in a pharmacy. For all
qualified Members, this includes medically necessary items such as nebulizers, ostomy
68
CCHP STAR Kids PM 122020
69
supplies or bed pans, and other supplies and equipment. For children and young adults
(birth through age twenty (20), Cook Children’s Health Plan also reimburses for items
typically covered under the Texas Health Steps Program, such as prescribed over-the-
counter drugs, diapers, disposable or expendable medical supplies, and some
nutritional products.
To be reimbursed for durable medical equipment or other products normally found in a
pharmacy for children (birth through age twenty (20), a pharmacy must be enrolled
directly with Cook Children’s Health Plan on a medical services agreement. Pharmacies
that would like to contract directly with Cook Children’s Health Plan to dispense covered
DME may contact Cook Children’s Health Plan Network Development at 888-243-3312.
Once contracted, claims for these supplies would be submitted to Cook Children’s
Health Plan. Please refer to the Claims and Billing section of this provider manual for
additional information related to claim submission.
Call the Cook Children’s Health Plan Member Services Department at 888-243-3312 for
more information about DME and other covered products commonly found in a
pharmacy for children (birth through age twenty (20).
Coordination with Non-Medicaid Managed Care Covered Services
(Non-Capitated Services)
STAR Kids Members are eligible for the services described below. Cook Children’s
Health Plan and our network Providers are expected to refer to and coordinate with
these programs. These services are described in the Texas Medicaid Provider
Procedures Manual (TMPPM).
Texas Health Steps Dental Services (Including orthodontia)
Primary and preventative dental services for STAR Members are covered from birth
through the age of twenty (20) years, except Oral Evaluation and Fluoride Varnish
benefits (OEFV) provided as part of a Texas Health Steps Medical checkup for
Members age six (6) through thirty-five (35) months. Children should have their first
dental checkup at six (6) months of age and every six (6) months thereafter. Services
may include but are not limited to medically necessary dental treatment for exams,
cleanings, x-rays, fluoride treatment, orthodontia, and restorative treatment. Children
under the age of six (6) months can receive dental services on an emergency basis.
Texas Health Steps Environmental Lead Investigation (ELI)
In accordance with current federal regulations, Texas Health Steps requires blood lead
screening at ages notated on the Texas Health Steps Periodicity Schedule and must be
performed during the medical checkup.
69
CCHP STAR Kids PM 122020
70
Providers may obtain more information about the medical and environmental
management of lead poisoned children from the DSHS Childhood Lead Poisoning
Prevention Program by calling toll free 800-588-1248 or visiting the web page at
dshs.state.tx.us/lead.
Early Childhood Intervention (ECI)
Early Childhood Intervention Case Management and Service Coordination is a
statewide program for families with children, birth to three years old, with disabilities and
developmental delays. Early Childhood Intervention teaches families how to help their
children reach their potential through education and developmental services. Services
are provided in the child’s natural environment, such as home, daycare, or
grandparent’s home. Families with children enrolled in Medicaid, or whose income is
below two-hundred percent (200%) of the Federal poverty Level, do not pay for Early
Childhood Intervention services. Federal law requires Providers to refer children to Early
Childhood Intervention within two (2) business days of identifying a developmental
disability or delay. To make a referral, Providers may call the Early Childhood
Intervention Care Line toll free at 888-754-0524 to identify an Early Childhood
Intervention program in the Member’s area.
For information about Early Childhood Intervention resources available to Providers,
call:
•
Early Childhood Intervention Care Line 888-754-0524
•
Cook Children’s Health Plan Care Management Department 888-243-3312
•
Additional resource information available online at https://hhs.texas.gov/
services/disability/early-childhood-intervention-services
A medical diagnosis or a confirmed developmental delay is not needed to refer. As soon
as a delay is suspected, Providers may refer a child to Early Childhood Intervention
even as early as birth. The local program conducts developmental screenings and
assesses the child for developmental delay and eligibility. After a child is accepted and
enrolled, an individual treatment plan is developed, and services are initiated. When a
child is not accepted into the program, Early Childhood Intervention staff will refer the
family to other resources.
Our network Providers must cooperate and coordinate with local Early Childhood
Intervention programs to comply with Federal and State requirements relating to the
developmental, review and evaluation of Individual Family Service Plan. Medically
Necessary Health and Behavioral Health Services contained in an Individual Family
70
CCHP STAR Kids PM 122020
71
Service Plan must be provided to the Member in the amount, duration, scope and
setting established in the Individual Family Service Plan.
Early Childhood Intervention Specialized Skills Training (SST)
Specialized Skills Training (SST) is a rehabilitative service that promotes age-
appropriate development by providing skills training to correct deficits and teach
compensatory skills for deficits that directly result from medical, developmental, or other
health-related conditions.
Specialized Skills Training services are provided by an Early Childhood Intervention
provider. The Early Childhood Intervention provider ensures that Specialized Skills
Training services are provided by an early intervention specialist who meets the criteria
established in 40 TAC Part 2, Chapter 108, Subchapter C, §108.313.
Case Management for Children and Pregnant Women (CPW)
Case Management services are available to assist eligible children with a health
condition or health risk and pregnant women with a high risk condition in access to
medical, social, educational and other services. To be eligible for case management
services, a child or woman must be eligible for Medicaid and:
•
A pregnant woman with a high-risk condition defined as a woman who is pregnant
and has one or more high-risk medical and/or personal/psychosocial conditions
during pregnancy. The woman must be in need of services to prevent illness(es) or
medical condition(s), to maintain function or to slow further deterioration of the
condition and desire case management services or
•
A child (birth through twenty (20) years of age) with a health condition or health risk.
Children with a health condition are defined as children with a health condition/
health risk or children who have, or are at risk for, a medical condition, illness, injury,
or disability that results in limitation of function, activities, or social roles in
comparison with healthy same-age peers in the general areas of physical, cognitive,
emotional, or social growth and development
For additional information about this program or to consult the Children and Pregnant
Women provider list, please visit the Case Management for Children and Pregnant
Women website at dshs.state.tx.us/caseman. To make a referral, call 877-847-8377
from 8:00AM-8:00PM, Central Time, Monday through Friday.
Texas School Health and Related Services (SHARS)
School Health and Related Services (SHARS) is a Medicaid financing program and is a
joint program of the Texas Education Agency and the Texas Health and Human Services
Commission (HHSC). The program allows local school districts/shared services
71
CCHP STAR Kids PM 122020
72
arrangements to obtain Medicaid reimbursement for certain health-related services
provided to students in special education. School districts/shared services
arrangements receive federal Medicaid money for SHARS services provided to students
who meet all three of the following requirements. These students must:
•
are twenty (20) years of age and younger and be eligible for Medicaid
•
meet eligibility requirements for Special Education described in the Individuals
with Disabilities Education Act (IDEA) and
•
have Individual Educational Plans (IEPs) that prescribe the needed services
Covered services include: audiology, counseling, nursing services, occupational
therapy, personal care services, physical therapy, physician services, psychological
services, including assessments, speech therapy, and transportation in a school setting.
These services must be provided by qualified personnel who are under contract with or
employed by the school district.
DARS Blind Children’s Vocational Discovery and Development Program
(Texas Commission for the Blind Case Management)
The Department of Assistive and Rehabilitative Services (DARS) Division for Blind
Services (DBS) is the Medicaid provider of case management for clients who are
twenty-one (21) years of age and younger and blind or visually impaired.
Any child who has a suspected or diagnosed visual impairment may be referred to Blind
Children’s Vocational Discovery and Development program. The Department of
Assistive and Rehabilitative Services Division for Blind Services assesses the impact
the visual impairment has on the child’s development and provides blindness specific
services to increase the child’s skill level in the areas of independent living,
communication, mobility, social, recreational, and vocational discovery and
development. For more information, visit the Department of Assistive and Rehabilitative
Services website dars.state.tx.us.
Blind Children’s Vocational Discovery and Development program services are provided
to help children who are blind and visually impaired to develop their individual potential.
This program offers a wide range of services that are tailored to each child and their
family’s needs and circumstances. By working directly with the entire family, this
program can help children develop the concepts and skills needed to realize their full
potential.
Blind Children’s Vocational Discovery and Development program services include the
following:
72
CCHP STAR Kids PM 122020
73
•
Assisting the client in developing the confidence and competence needed to be
an active part of their community
•
Providing support and training to children in understanding their rights and
responsibilities throughout the educational process
•
Assisting family and children in the vocational discovery and development
process
•
Providing training in areas like food preparation, money management,
recreational activities, and grooming
•
Supplying information to families about additional resources
Tuberculosis Services provided by the Department of State Health Service –
approved Providers (Directly Observed Therapy and Contact Investigation)
All confirmed cases of Tuberculosis (TB) must be reported to the Local Tuberculosis
Control Health Authority (LTCHA) using the most recent Department of State Health
Services forms and procedures within one (1) day of diagnosis for a contact
investigation. Providers must document Members’ referrals to Local Tuberculosis
Control Health Authority in their medical records and notify Cook Children’s Health Plan
of the referrals. Cook Children’s Health Plan must coordinate with the Local
Tuberculosis Control Health Authority to ensure that all Members with confirmed or
suspected tuberculosis have a contact investigation and receive directly observed
therapy. Providers must report to Department of State Health Services or the Local
Tuberculosis Control Health Authority any Member who is non-compliant, drug resistant
or who is or may be posing a public health threat. Cook Children’s Health Plan must
cooperate with the local Tuberculosis Control Health Authority in enforcing the control
measures and quarantine procedures contained in Chapter 81 of the Texas Health and
Safety Code.
Medical Transportation Program through Texas Health and Human Services
Commission
Medical Transportation services are available to Medicaid eligible clients that have no
other means of transportation by the most cost-effective means. Medical Transportation
can reimburse for gas if the Member has an automobile but no funds for gas. The
transportation company for our service area is LogistiCare, Inc. The LogistiCare region
includes fourteen (14) counties: Dallas, Denton, Ellis, Erath, Hood, Hunt, Johnson,
Kaufman, Navarro, Palo Pinto, Parker, Rockwall, Somerville, and Tarrant.
Providers may call LogistiCare for transportation services at the following numbers:
Reservation Line: 855-687-3255 Mon-Fri, 8:00AM-5:00PM
73
CCHP STAR Kids PM 122020
74
Hospice:
Health and Human Services Commission manages the hospice program. Members are
dis-enrolled from Cook Children’s Health Plan upon enrollment into hospice. Medicaid
hospice provides palliative care to all Medicaid eligible clients who sign statements
electing hospice services and are certified by physicians to have six months or less to
live if their terminal illnesses run their normal courses. Services include medical and
support services designed to keep clients comfortable and without pain during the last
weeks and months before death. When clients elect hospice services, they waive their
rights to all other Medicaid services related to their terminal illness. They do not waive
their rights to Medicaid services unrelated to their terminal illness. HHSC can be
contacted at 512-438-3161.
HHSC or DSHS HCBS Waiver Programs
Community Living Assistance and Support Services (CLASS) Waiver Program
The Community Living Assistance and Support Services (CLASS) program provides
home and community-based services to people with related conditions as a cost-
effective alternative to an intermediate care facility for individuals with an intellectual
disability or related conditions (ICF/IID). A related condition is a disability, other than an
intellectual disability, that originated before age twenty-two (22) that affects the ability to
function in daily life.
Deaf Blind with Multiple Disabilities (DBMD) Waiver Program
The Deaf Blind with Multiple Disabilities (DBMD) program provides home and
community-based services to people who are deaf blind and have another disability.
This is a cost-effective alternative to an intermediate care facility for individuals with an
intellectual disability or related conditions (ICF/IID). The DBMD program focuses on
increasing opportunities for consumers to communicate and interact with their
environment.
Home and Community-based Services (HCS) Waiver Program
The Home and Community-based Services (HCS) program provides individualized
services and supports to people with intellectual disabilities who are living with their
families, in their own homes or in other community settings, such as small group homes
where no more than four people live. The local authority provides service coordination.
Ride Help Line: 877-564-9832 Mon-Fri, 8:00AM-5:00PM
Ride Assist & Complaints: 877-564-9834 24 hours a day, 7 days a week
Teletypewriter (TTY): 866-288-3133 24 hours a day, 7 days a week
74
CCHP STAR Kids PM 122020
75
Texas Home Living (TxHmL) Waiver Program
The Texas Home Living (TxHmL) program provides selected essential services and
supports to people with an intellectual disability or a related condition who live in their
own home or their family’s home.
Youth Empowerment Services (YES) Waiver Program
The Youth Empowerment Services (YES) waiver provides comprehensive home and
community-based mental health services to youth between the ages of three (3) and
eighteen (18), up to a youth’s nineteen (19
th)
birthday, who have a serious emotional
disturbance. The YES Waiver not only provides flexible supports and specialized
services to children and youth at risk of institutionalization and/or out-of-home
placement due to their serious emotional disturbance, but also strives to provide hope to
families by offering services aimed at keeping children and youth in their homes and
communities.
Admissions to Inpatient Mental Health Facilities as a Condition of Probation
When inpatient psychiatric services are ordered by a court of competent jurisdiction
under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code,
relating to court-ordered commitments to psychiatric facilities, the court order serves as
binding determination of medical necessity. Any modification or termination of services
must be presented to the court with jurisdiction over the matter for determination.
A “Court-Ordered Commitment” means a confinement of a Member to a psychiatric
facility for treatment that is ordered by a court of law pursuant to the Texas Health and
Safety Code, Title VII, Subtitle C.
Preadmission Screening and Resident Review (PASRR)
Preadmission Screening and Resident Review (PASRR) is a federal requirement to help
ensure that individuals are not inappropriately placed in nursing homes for long term
care.
PASRR requires that all applicants to a Medicaid-certified nursing facility:
•
be evaluated for serious mental illness (SMI) and/or intellectual disability
•
be offered the most appropriate setting for their needs (in the community a
nursing facility, or acute care settings)
•
receive the services they need in those settings
75
CCHP STAR Kids PM 122020
76
Long Term Services and Support
Adaptive Aids (AA) (STAR Kids MDCP Members Only)
Adaptive aids and medical supplies are specialized medical equipment and supplies
which include devices, controls, or appliances that enable members to increase their
abilities to perform activities of daily living, or to perceive, control, or communicate with
the environment in which they live. This service also includes items necessary for life
support, ancillary supplies, and equipment necessary to the proper functioning of such
items, and durable and non-durable medical equipment not available under the Texas
State Plan, such as: vehicle modifications, service animals and supplies, environmental
adaptations, aids for daily living, reachers, adapted utensils, and certain types of lifts.
Community First Choice Services
Community First Choice (CFC) provides certain services and supports to individuals
living in the community who are enrolled in the Medicaid program and meet CFC
eligibility requirements. Services and supports may include:
•
activities of daily living (eating, toileting, and grooming), activities related to living
independently in the community, and health-related tasks (personal assistance
services)
•
acquisition, maintenance, and enhancement of skills necessary for the
individuals to care for themselves and to live independently in the community
(habilitation)
•
providing a backup system or ways to ensure continuity of services and supports
(emergency response services)
•
training people how to select, manage and dismiss their own attendants (support
management)
CFC is available to individuals with a need for habilitation, personal assistance or
emergency response services who receive services in the following waiver programs:
•
Community Living Assistance and Support Services (CLASS)
•
Deaf Blind with Multiple Disabilities (DBMD)
•
Home and Community-based Services (HCS)
•
Texas Home Living (TxHmL)
Day Activity and Health Services (DAHS)
(Only for Members eighteen (18) of age and older)
Licensed day activity and health services (DAHS) facilities provide daytime services to
people who live in the community as an alternative to living in a nursing home or other
institution. Services, which usually are provided Monday through Friday, address
76
CCHP STAR Kids PM 122020
77
physical, mental, medical and social needs. Sometimes, this is called adult day care or
adult day services.
Employment Assistance (EA)
(STAR Kids MDCP Members Only)
Assistance provided to an individual to help the individual locate paid employment in the
community. EA includes: identifying an individual's employment preferences, job skills,
and requirements for a work setting and work conditions; locating prospective
employers offering employment compatible with an individual's identified preferences,
skills, and requirements; and contacting a prospective employer on behalf of an
individual and negotiating the individual's employment. In the State of Texas, this
service is not available to individuals receiving waiver services under a program funded
under section 110 of the Rehabilitation Act of 1973.
Financial Management Services (FMS)
FMS provides assistance to members with managing funds associated with the services
elected for self-direction. The service includes initial orientation and ongoing training
related to responsibilities of being an employer and adhering to legal requirements for
employers. The FMS provider, referred to as the Consumer Directed Services Agency,
also:
•
Serves as the Member’s employer-agent
•
Provides assistance in the development, monitoring, and revision of the
Member’s budget
•
Provides information about recruiting, hiring, and firing staff, including identifying
the need for special skills and determining staff duties and schedule
•
Provides guidance on supervision and evaluation of staff performance
•
Provides assistance in determining staff wages and benefits
•
Provides assistance in hiring by verifying employee’s citizenship status and
qualifications, and conducting required criminal background checks in the Nurse
Aide Registry and Employee Misconduct Registry
•
Verifies and maintains documentation of employee qualifications, including
citizenship status, and documentation of services delivered
•
Collects timesheets, processes timesheets of employees, processes payroll and
payables, and makes withholdings for, and payment of, applicable federal, state,
and local employment-related taxes
•
Tracks disbursement of funds and provides quarterly written reports to the
Member of all expenditures and the status of the Member’s Consumer Directed
Services budget
•
Maintains a separate account for each Member's budget
77
CCHP STAR Kids PM 122020
78
The State allows a relative or legal guardian, other than a legally responsible member,
to be the Member's provider for this service if the relative or legal guardian meets the
requirements for this type of provider.
Flexible Family Support Services (FFSS)
(STAR Kids MDCP Members Only)
FFSS promotes community inclusion in typical child/youth activities through the
enhancement of natural supports and systems and through recognition that these
supports may vary from setting to setting, from day to day, from moment to moment,
hence the need for a diverse provider base. To accomplish this, FFSS Providers may
provide personal care supports for activities of daily livings and instrumental activities of
daily living, skilled care, non-skilled care and delegated skilled care supports to support
inclusion. This service may be reimbursed if part of an approved service plan and if
delivered in a setting where provision of such supports is not already required or
included as a matter of practice.
Minor Home Modifications (MHM)
(STAR Kids MDCP Members Only)
MHM are those physical adaptations to a Member’s home, required by the service plan,
that are necessary to ensure the member's health, welfare, and safety, or that enable
the Member to function with greater independence in the home. Such adaptations may
include the installation of ramps and grab-bars, widening of doorways, modification of
bathroom facilities, or installation of specialized electric and plumbing systems that are
necessary to accommodate the medical equipment and supplies necessary for the
Member’s welfare. Excluded are those adaptations or improvements to the home that
are of general utility, and are not of direct medical or remedial benefit to the Member,
such as carpeting, roof repair, central air conditioning, etc. Adaptations that add to the
total square footage of the home are excluded from this benefit. All services are
provided in accordance with applicable state or local building codes. Modifications are
not made to settings that are leased, owned, or controlled by waiver Providers. The
State allows a Member to select a relative or legal guardian, other than a spouse, to be
the Member’s provider for this service if the relative or legal guardian meets the
requirements to provide this service.
Personal Care Services (PCS)
What is Personal Care Services?
Personal Care Services (PCS) is a Medicaid benefit that helps clients with everyday
tasks. These tasks are called activities of daily living (ADLs) and instrumental activities
of daily living (IADLs). ADL’s include activities such as such as bathing, eating, going to
78
CCHP STAR Kids PM 122020
79
the toilet, dressing and walking. IADL’s include activities such as laundry, light
housework and fixing meals.
To receive Personal Care Services, a Member must:
•
Be birth through age twenty (20) and have Medicaid
•
Have a disability, physical or mental illness or a health problem that lasts for a
long time
•
Have a Practitioner Statement of Need signed by a practitioner (physician,
advanced practice nurse, or physician assistant) who has examined the Member
in the last twelve (12) months
•
Need help with ADLs and IADLs based on the Personal Care Assessment Form
(PCAF)
•
Provide a reason why the Member’s guardian cannot help the Member with
ADL’s and IADL’s
Private Duty Nursing (PDN)
Private Duty Nursing services are nursing services, as described by the Texas Nursing
Practice Act and its implementing regulations, for clients who meet the medical
necessity criteria, and who require individualized, continuous, skilled care beyond the
level of SN visits normally authorized under Texas Medicaid Home Health SN and Home
Health Aide (HHA) Services. PDN services may be provided by a registered nurse (RN)
or a licensed vocational nurse (LVN).
Private Duty Nursing (PDN) services provide nursing care and parent/guardian/
responsible adult training and education intended to:
•
Optimize Member health status and outcomes
•
Promote family-centered, community-based care as a component of an array of
service options by:
o
Preventing prolonged and/or frequent hospitalizations or
institutionalization
o
Providing cost effective and quality care in the most appropriate, least
restrictive environment
Private Duty Nursing is considered medically necessary when a Member has a
disability, physical, or mental illness, or chronic condition and requires continuous,
skillful observations, judgments, and interventions to correct or ameliorate his or her
health status.
To be eligible for Private Duty Nursing services, a Member must meet all the following
criteria:
79
CCHP STAR Kids PM 122020
80
•
Be birth through twenty (20) years of age and eligible for Medicaid and Texas
Health Steps
•
Meet medical necessity criteria for Private Duty Nursing
•
Have a Primary Physician who must:
o
Provide a prescription for Private Duty Nursing
o
Establish a Plan of Care
o
Provide documentation to support the medical necessity of Private Duty
Nursing services
o
Provide continuing medical care and supervision of the Member, including,
but not limited to, examination or treatment within thirty (30) calendar days
prior to the start of Private Duty Nursing services, or examination or
treatment that complies with the Texas Health Steps periodicity schedule,
or is within six (6) months of the Private Duty Nursing extension Start of
Care date, whichever is more frequent (for extensions of Private Duty
Nursing services). This requirement may be waived based on review of
the Member's specific circumstances
o
Provide specific written, dated orders for the Member who is receiving
continuing or ongoing Private Duty Nursing services
o
Require care beyond the level of services provided under Texas Medicaid
(Title XIX) home health services
•
Members who are birth through seventeen (17) years of age must reside with a
responsible adult who is either trained to provide nursing care or is capable of
initiating an identified contingency plan when the scheduled private duty nurse is
unexpectedly unavailable. A parent or guardian of a minor client, or the client’s
spouse may not be reimbursed for PDN services even if he or she is an enrolled
provider or employed by an enrolled provider.
Private Duty Nursing is based on the need for skilled care in the Member's home, nurse
provider’s home, client’s school, client’s daycare facility. The place of service must be
able to support the Member's health and safety needs and it must be adequate to
accommodate the use, maintenance, and cleaning of all medical devices, equipment,
and supplies required by the Member. Necessary primary and backup utilities,
communication, fire, and safety systems must be available at all times. The amount and
duration of Private Duty Nursing must always be commensurate with the Member's
medical needs. Requests for services must reflect changes in the Member's condition
that affect the amount and duration of Private Duty Nursing.
Prescribed Pediatric Extended Care Centers and Private Duty NursingA client has
a choice of Private Duty Nursing (PDN), Prescribed Pediatric Extended Care Center
(PPECC), or a combination of both PDN and PPECC for ongoing skilled nursing. PDN
80
CCHP STAR Kids PM 122020
81
and PPECC are considered equivalent services, and must be coordinated to prevent
duplication. A client may receive both in the same day, but not simultaneously (e.g.,
PDN may be provided before or after PPECC services are provided.) The combined
total hours between PDN and PPECC services are not anticipated to increase unless
there is a change in the client's medical condition or the authorized hours are not
commensurate with the client's medical needs. In accordance with 1 Tex. Admin. Code
§ 363.209(c)(3), PPECC services are intended to be a one-to-one replacement of PDN
hours unless additional hours are medically necessary.
Respite
(STAR Kids MDCP Members Only)
Respite care services are provided to individuals unable to care for themselves, and are
furnished on a short-term basis because of the absence of or need for relief for those
persons normally providing unpaid services. Respite care may be provided in the
following locations: Member’s home or place of residence; adult foster care home;
Medicaid certified NF; and an assisted living facility. Respite care services are
authorized by a Member’s Primary Care Provider as part of the Member’s care plan.
Respite services may be self-directed. Limited to thirty (30) days per year.
Supported Employment (SE)
(STAR Kids MDCP Members Only)
Assistance provided, in order to sustain competitive employment, to an individual who,
because of a disability, requires intensive, ongoing support to be self-employed, work
from home, or perform in a work setting at which individuals without disabilities are
employed. SE includes adaptations, supervision, training related to an individual's
assessed needs, and earning at least minimum wage (if not self-employed).
Transition Assistance Services (TAS)
(STAR Kids MDCP Members Only)
TAS pays for non-recurring, set-up expenses for members transitioning from nursing
homes to the STAR+PLUS HCBS program. Allowable expenses are those necessary to
enable members to establish basic households and may include: security deposits for
leases on apartments or homes; essential household furnishings and moving expenses
required to occupy and use a community domicile, including furniture, window
coverings, food preparation items, and bed and bath linens; set-up fees or deposits for
utility or service access, including telephone, electricity, gas, and water; services
necessary for the member’s health and safety, such as pest eradication and one-time
cleaning prior to occupancy; and activities to assess need, arrange for, and procure
needed resources.
81
CCHP STAR Kids PM 122020
82
Role of the Pharmacy
Cook Children’s Health Plan Members receive pharmacy services through Navitus,
Cook Children’s Health Plan’s contracted Pharmacy Benefit Manager (PBM). Navitus
has a statewide network of contracted pharmacies who are enrolled in the Texas Vendor
Drug Program (VDP), including all of the major pharmacy chains and VDP-enrolled
independent pharmacies. Cook Children’s Health Plan Providers are required to adhere
to the Preferred Drug list (PDL). Members have the right to obtain Medicaid covered
medications from any Cook Children’s Health Plan network pharmacy. These
pharmacies are located on Cook Children’s Health Plan website. Providers and
Members can also call Cook Children’s Health Plan Member Services department to
locate a network pharmacy.
Network pharmacies are required to:
•
perform prospective and retrospective drug utilization reviews
•
coordinate with the prescribing physician
•
ensure Members receive all medications for which they are eligible
•
ensure adherence to the Medicaid and CHIP Formularies administered through
the Texas Vendor Drug Program (VDP) and the Medicaid Preferred Drug List
(PDL)
•
The pharmacy must coordinate the benefits when a Member also receives
Medicare Part D services or has other benefits
Member Prescriptions
Cook Children’s Health Plan covers prescription medications. Our Members can get
their prescriptions at no cost.
•
Members have the right to obtain their prescriptions from any network pharmacy
•
Providers should reference the Medicaid formulary and Medicaid Preferred Drug
List (PDL)
Formulary and Preferred Drug List
The existing Texas Medicaid formulary currently utilized by the Vendor Drug Program
(VDP) will be adopted.
The formulary, along with a list of drugs requiring prior authorization can be found at
Texas Vendor Drug Program (VDP) website at txvendordrug.com. The Medicaid
formulary and Medicaid Preferred Drug List (PDL) are available for smartphones and on
the web at epocrates.com. The Texas Preferred Drug List and the prior authorization
criteria to be used for Cook Children’s Health Plan Members are available at
txvendordrug.com
82
CCHP STAR Kids PM 122020
83
A list of covered drugs and preferred drugs may also be accessed through our
Pharmacy Benefit Manager, Navitus Health Solutions. To contact Navitus Health
Solutions:
•
Navitus Provider Portal at navitus.com
•
Navitus Pharmacy Help Desk 877-908-6023
Emergency Prescription Supply
A seventy-two (72) hour emergency supply of a prescribed drug must be provided when
a medication is needed without delay and prior authorization (PA) is not available. This
applies to all drugs requiring a prior authorization (PA), either because they are non-
preferred drugs on the Preferred Drug List or because they are subject to clinical edits.
The seventy-two (72) hour emergency supply should be dispensed any time a prior
authorization (PA) cannot be resolved within twenty-four (24) hours for a medication on
the Vendor Drug Program formulary that is appropriate for the Member’s medical
condition. If the prescribing provider cannot be reached or is unable to request a priori
authorization (PA), the pharmacy should submit an emergency seventy-two (72) hour
prescription.
A pharmacy can dispense a product that is packaged in a dosage form that is fixed and
unbreakable, e.g., an albuterol inhaler, as seventy-two (72) hour emergency supply.
To be reimbursed for a seventy-two (72) hour emergency prescription supply,
pharmacies should submit the following information:
•
“8” in ‘Prior Authorization Type Code’ (field 461-EU)
•
“801” in ‘Prior Authorization Number Submitted’ (field 462-EV)
•
“3” in ‘Days Supply’ (field 405-D5 in the Claim segment of the billing transaction)
•
The quantity submitted in ‘Quantity Dispensed’ (field 442-E7) should not exceed
the quantity necessary for a three day supply according to the directions for
administration given by the prescriber
•
If the medication is a dosage form that prevents a three day supply from being
dispensed, e.g. an inhaler, it is still permissible to indicate that the emergency
prescription is a three day supply, and enter the full quantity dispense
Please consult the Vendor Drug Program Pharmacy Provider Procedures Manual, the
Texas Medicaid Provider Procedures Manual and this provider manual section for
information regarding reimbursement of seventy-two (72) hour emergency supplies of
prescription claims. It is important that pharmacies understand the seventy-two (72)
hour emergency supply policy procedure to assist Medicaid clients.
83
CCHP STAR Kids PM 122020
84
Call Navitus toll free 877-907-6023 for more information about the seventy-two (72)
hour emergency prescription supply.
Pharmacy Prior Authorization
Navitus processes Texas Medicaid pharmacy prior authorizations for Cook Children’s
Health Plan. The formulary, prior authorization criteria, and the length of the prior
authorization approval are determined by HHSC. Information regarding the formulary
and specific prior authorization criteria can be found at the Vendor Drug Website,
eProcrates, and SureScripts for ePrescribing.
Prescribers can access Prior Authorization (PA) forms online via navitus.com
under the
“Providers” section or have them faxed by Customer Care to the prescribers’ office.
Prescribers will need their NPI and State to access the portal. Completed forms can be
faxed twenty-four (24) hours a day seven (7) days a week to Navitus at 920-735-5312.
Prescribers can also call Navitus Customer Care at 877-908-6023 select the prescriber
option and speak with the prior authorization department between 8:00AM-5:00pm
Monday-Friday Central Time to submit a PA request over the phone. After hours,
Providers will have the option to leave voicemail. Decisions regarding prior
authorizations will be made within twenty-four (24) hours from the time Navitus receives
the prior authorization request. The provider will be notified by fax of the outcome or
verbally if an approval can be established during a phone request.
Pharmacies will submit pharmacy claims to Navitus. Medications that require prior
authorization will be undergo an automated review to determine if the criteria are met. If
all the criteria are met, the claim is approved and paid, and the pharmacy continues with
the dispensing process. If the automated review determines that all the criteria are not
met, the claim will be rejected and the pharmacy will receive a message indicating that
the drug requires prior authorization. At that point, the pharmacy should notify the
prescriber and the above process should be followed.
Cancellation of Product Orders
A Network Provider that offers delivery services for covered products, such as durable
medical equipment (DME), limited home health supplies (LHHS), or outpatient drugs or
biological products must reduce, cancel or stop delivery if the Member or the Member’s
authorized representative submits an oral or written request. The Network Provider must
maintain records documenting the request.
Main Dental Home
Dental plan Members may choose their Main Dental Homes. Dental plans will assign
each Member to a Main Dental Home if he/she does not timely choose one. Whether
84
CCHP STAR Kids PM 122020
85
chosen or assigned, each Member who is six (6) months or older must have a
designated Main Dental Home.
Role of Main Dental Home
A Main Dental Home serves as the Member’s main dentist for all aspects of oral health
care. The Main Dental Home has an ongoing relationship with that Member, to provide
comprehensive, continuously accessible, coordinated, and family-centered care. The
Main Dental Home provider also makes referrals to dental specialists when appropriate.
Federally Qualified Health Centers and individuals who are general dentists and
pediatric dentists can serve as Main Dental Homes.
How to Help a Member Find Dental Care
The Dental Plan Member ID card lists the name and phone number of a Member’s Main
Dental Home provider. The Member can contact the dental plan to select a different
Main Dental Home provider at any time. If the Member selects a different Main Dental
Home provider, the change is reflected immediately in the dental plan’s system, and the
Member is mailed a new ID card within five (5) business days.
If a Member does not have a dental plan assigned or is missing a card from a dental
plan, the Member can contact the Medicaid/CHIP Enrollment Broker’s toll-free
telephone number at 800-964-2777.
Emergency Dental Services
Medicaid Emergency Dental Services
Cook Children’s Health Plan is responsible for emergency dental services provided to
Medicaid Members in a hospital, free standing emergency room or ambulatory surgical
center setting. We will pay for hospital, physician, and related medical services (e.g.,
anesthesia and drugs) including but not limited to:
•
treatment of a dislocated jaw, traumatic damage to teeth and supporting
structures, removal of cysts
•
treatment of oral abscess of tooth or gum origin and
•
treatment and devices for correction of craniofacial anomalies and drugs
Non-Emergency Dental Services
Medicaid Non-emergency Dental Services:
Cook Children’s Health Plan is not responsible for paying for routine dental services
provided to Medicaid Members. These services are paid through Dental Managed Care
Organizations.
85
CCHP STAR Kids PM 122020
86
Cook Children’s Health Plan is responsible for paying for treatment and devices for
craniofacial anomalies and of Oral Evaluation and Fluoride Varnish Benefits (OEFV)
provided as part of a Texas Health Steps medical checkup for Members age six (6)
months through thirty-five (35) months.
OEFV benefit includes (during a visit) intermediate oral evaluation, fluoride varnish
application, dental anticipatory guidance, and assistance with a Main Dental Home
choice.
•
OEFV is billed by Texas Health Steps Providers on the same day as the Texas
Health Steps medical checkup
•
OEFV must be billed concurrently with a Texas Health Steps medical checkup
utilizing CPT code 99429 with U5 modifier
•
Documentation must include all components of the OEVF
•
Texas Health Steps Providers must assist Members with establishing a Main
Dental Home and document Member’s Main Dental Home choice in the
Member’s file
Cook Children’s Health Plan is responsible for paying for treatment and devices for
craniofacial anomalies.
Additional information on Oral Evaluation and Fluoride Varnish can be found in the
Texas Health Steps section of this Provider Manual.
Members with Special Healthcare Needs (MSHCN)
Cook Children's Health Plan offers enhanced care management for Members with
Special Health Care Needs (MSHCN). The enrollment process identifies Members with
Special Health Needs. Primary Care and Specialty Care Providers should also notify
the Cook Children’s Health Plan Care Management Department of covered Members
who may qualify for this program.
A Member can be classified as a Member with Special Health Care Needs if the
answers to the following five (5) questions can be answered ‘yes.’
•
Does the Member have a serious on-going illness, complex on-going condition or
disability?
•
Is the illness, condition, or disability one that has lasted for at least twelve (12)
months in a row or more, or is expected to last for at least twelve months in a row
or more?
•
Does the Member’s illness, condition or disability cause (or without treatment,
can it cause) limits in the member’s ability to function (activities such as walking,
86
CCHP STAR Kids PM 122020
87
talking, running, eating, playing, learning or relating to others); and are these
limits not usual for most people his or her age?
•
Does the Member’s illness, condition, or disability require regular, on-going
treatment and review by doctors, therapists, or other trained health care
professionals?
•
Does the Member need health care or related services more often than most
people do his or her age?
Access to Specialists: Members with Special Health Care Needs have direct access
to in network specialty physicians. Cook Children’s Health Plan does not require
authorization or referrals from primary care Providers. Care Management staff
coordinate care and authorize services if the Member’s specialist is Out-of-Network to
assure access until care is appropriately transitioned in network.
Early identification of Members that may benefit from case management is an integral
component of the program and begins at the time of enrollment. Cook Children’s Health
Plan aggressively attempts to identify Members that may benefit from service
coordination or case management services through use of the following: claims triggers,
Health Needs Risk Assessment, utilization review activities, and referrals from
Members, families, physicians and community agencies. When a Member is designated
as having Member with Special Health Care Needs status, a Care Management team
member will contact the Member or their legally authorized representative to discuss
covered services. The Member or the Member’s legally authorized representative have
the right to request a specialist as a Primary Care Provider, Out-of-Network services
applicable to the child's condition if not available in network, the availability of enhanced
care coordination, and referral to community programs or resources. In collaboration
with the Member, family, and the Member’s health care Providers, the Care
Management team member develops a written service plan that meets the Member’s
health care needs. Referrals to community agencies when appropriate are included in
the service plan.
Designation of a Specialist as a Primary Care Provider
Members that have disabilities, special health care needs, chronic or complex health
care needs have the right to request a specialist physician as a Primary Care
Provider. Members, their legally authorized representative or primary care Providers, or
the Member’s designee may initiate the request. In order to accept such a request, the
specialist physician must agree to provide all primary care services, (i.e. immunizations,
well child care/annual check-ups, coordination of all health care services required by the
Member). The Member or their legally authorized representative must also sign the
agreement. The Cook Children’s Health Plan Medical Director reviews and determines
87
CCHP STAR Kids PM 122020
88
Cook Children’s Health Plan approval for Specialist (physician) as Primary Care
Provider (PCP). The form to be used for approval of a Specialist to act as a Primary
Care Provider is located in the Appendix section of this provider manual.
This section does not apply to STAR Kids Dual Eligible Members
Out-of-Network Providers and Continuity of Care
Cook Children’s Health Plan takes special care to provide continuity in the care of newly
enrolled Members whose physical or behavioral health condition could be placed in
jeopardy if medically necessary covered services are disrupted, compromised, or
interrupted. Upon notification from a Member or provider of the existence of a prior
authorization, Cook Children’s Health Plan ensures Members receiving services through
a prior authorization from either another health plan or fee-for-service receive continued
authorization of those services for the same amount, duration, and scope for the
shortest period of one of the following:
•
Ninety (90) calendar days after the transition to Cook Children’s Health Plan
•
Until the end of the current authorization period or
•
Until Cook Children’s Health Plan has evaluated and assessed the Member and
issued or denied a new authorization
Cook Children’s Health Plan is required to ensure that clients receiving Community
Based Long Term Care Services prior to the Operational Start Date continue to receive
those services for up to six (6) months after the Operational Start Date, unless the
health plan has completed the STAR Kids Screening and Assessment Process and
issued new authorizations. During the transition, an HHSC’s Administrative Services
Contractor or an HHS Agency will provide a file identifying Members with prior
authorizations for acute care services and Members receiving Community Based Long
Term Care Services. The health plan is required to work with HHSC and its
Administrative services Contractor to ensure that all necessary authorizations are in
placed within the health plan’s system for the continuation of Community Based Long
Term Care Services and prior authorized acute care services. The health plan must
describe the process it will use to ensure continuation of these services in its Transition/
Implementation Plan. The health plan will ensure that Community-Based Long Term
Care Service Providers are informed and trained on this process prior to the Operational
Start Date.
Cook Children’s Health Plan allows a pregnant Member past the twenty-four (24th)
week of pregnancy to remain under the care of her current obstetrician/gynecologist
(OB/GYN) through her postpartum checkup, even if the provider is Out-of-Network. If a
Member wants to change her OB/GYN to one who is in the Cook Children’s Health Plan
network, she is allowed to do so if the provider to whom she wishes to transfer agrees
to accept her care in the last trimester of pregnancy.
88
CCHP STAR Kids PM 122020
89
Cook Children’s Health Plan pays a Member’s existing Out-of-Network Providers for
medically necessary covered services until the Member’s records, clinical information,
and care can be transferred to a network provider or until such time as the Member is
no longer enrolled in the health plan, whichever is shorter. Payment is made to Out-of-
Network Providers in the time period required for network Providers. Cook Children’s
Health Plan complies with Out-of-Network provider reimbursement rules as adopted by
the Health and Human Services Commission (HHSC).
With the exception of pregnant Members who are past the twenty-four (24th) week of
pregnancy, Cook Children’s Health Plan does not reimburse a Member’s existing Out-
of-Network Providers for ongoing care for:
•
more than ninety days after a Member enrolls in the health plan or
•
for more than nine months in the case of a Member who, at the time of
enrollment in the health plan, has been diagnosed with and receiving treatment
for a terminal illness and remains enrolled in the health plan
Cook Children’s Health Plan’s obligation to reimburse the Member’s existing Out-of-
Network provider for services provided to a pregnant Member past the twenty-four
(24th) week of pregnancy extends through delivery of the child, immediate postpartum
care, and the follow-up checkup within the first six (6) weeks of delivery.
Cook Children’s Health Plan provides or pays Out-of-Network Providers who provide
medically necessary covered services to Members who move out of the service area
through the end of the period for which capitation has been paid for the Member.
Cook Children’s Health Plan provides Members with timely and adequate access to
Out-of-Network services for as long as those services are necessary and not available
within the network. If services become available from a network provider, Cook
Children’s Health Plan is not obligated to provide a Member with access to Out-of-
Network services.
Cook Children’s Health Plan ensures that each Member has access to a second opinion
regarding the use of any medically necessary covered service. A Member may access a
second opinion from a network provider or Out-of-Network provider if a network is not
available, at no cost to the Member.
Providers are encouraged to call the Cook Children’s Health Plan Care Management
Department at 888-243-3312 for assistance with any continuity of care/transition of care
issues.
89
CCHP STAR Kids PM 122020
90
Pre-Existing Conditions
Cook Children’s Health Plan is responsible for ensuring access to all medically
necessary covered services for each eligible Member beginning on the Member’s date
of enrollment, regardless of pre-existing conditions, prior diagnosis and/or receipt of any
prior health care services.
Ambulance Transportation
Cook Children’s Health Plan covers emergency and medically necessary non-
emergency ambulance transportation.
Emergency Ambulance Transportation
In the event a Member’s condition is life-threatening or potentially life-threatening and
requires the use of special equipment, life support systems and close monitoring by
trained attendants while en route to the nearest medical facility, the ambulance transport
is considered an emergency service and does not require Cook Children’s Health Plan
prior authorization.
Facility-to-facility ambulance transports may be considered emergencies if the required
emergency treatment is not available at the first facility and the Member still requires
emergency care. The transport must be to an appropriate facility, meaning the nearest
medical facility equipped in terms of equipment, personnel, and the capacity to provide
medical care for the illness or injury of the Member.
Non-Emergency Ambulance Transportation
Non-emergency ambulance transportation is defined as ambulance transport provided
for a Member to or from a scheduled medical appointment, to or from a licensed facility
for treatment, or to the Member’s home after discharge when the Member has a medical
condition such as the use of ambulance is the only appropriate means of transportation.
Non-emergency ambulance transportation services must be prior authorized and
coordinated by Cook Children’s Health Plan before an ambulance is used to transport a
Member in circumstances not involving an emergency.
An enrolled physician, nursing facility, health-care provider or other responsible party
must sign and submit the request for prior authorization. The ambulance provider is
responsible for ensuring that the prior authorization was approved prior to transport as
nonpayment will result without a prior authorization. Retrospective review may be
performed to ensure that documentation supports the medical necessity of the
transport.
90
CCHP STAR Kids PM 122020
91
Providers may request approval for an ambulance by using the STAR Kids Standard
Prior Authorization Request Form for Health Care Services found in the Appendix
section of this manual and on our website cookchp.org. Cook Children’s Health Plan will
provide the approval or denial for the prior authorization to the requesting provider and
the Ambulance Provider.
91
CCHP STAR Kids PM 122020
92
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a
federally mandated health care program of prevention, diagnosis, and treatment for
Medicaid recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, Providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website
at hhs.texas.gov.
Who Can Perform THSteps Examinations?
Only Medicaid enrolled THSteps Providers will be reimbursed for performing THSteps
examinations. If the Provider performing the examination is not the Member’s Primary
Care Provider, the performing provider must provide a report to the Primary Care
Provider of record. If the performing Primary Care Provider diagnoses a medical
condition that requires additional treatment, the patient must be referred back to the
Primary Care Provider of record.
How Do I Become a THSteps Provider?
To enroll in Texas Medicaid, Providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways Providers may enroll:
•
To apply online, visit tmhp.com and follow the instructions for completing the
online enrollment process
•
Download, print, and complete the application forms
•
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page.
•
The forms you need are under the Provider Enrollment section. You can also
request an enrollment package from Texas Medicaid & Healthcare Partnership
(TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
Attn: Provider Enrollment
92
Section 4: Texas Health Steps Services
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 4: Texas Health Steps Services
CCHP STAR Kids PM 122020
93
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
(TMHP) Contact Center toll free at 800-925-9126 and select option 2 or send email
correspondence to Provider.Enrollment.Mailbox@tmhp.com.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup
for Members from birth through age twenty (20), in accordance with the Texas Health
Steps Periodicity Schedule. Providers can find an updated Texas Health Steps
periodicity schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Texas Health Steps must be offered for all new members age twenty (20) and younger
who are due, soon due or overdue for checkups or case management services. These
services may be performed no later than:
•
fourteen (14) days from the date of enrollment for newborns
•
ninety (90) days from the date of enrollment for all other eligible child members
Documentation of completed Texas Health Steps components and elements
Each of the six (6) components and their individual elements according to the
recommendations established by the Texas Health Steps periodicity schedule for
children as described in the Texas Medicaid Provider Procedures Manual must be
completed and documented in the medical record.
Any component or element not completed must be noted in the medical record, along
with the reason it was not completed and the plan to complete the component or
element. The medical record must contain documentation on all screening tools used
for TB, growth and development, autism, and mental health screenings. The results of
these screenings and any necessary referrals must be documented in the medical
record. THSteps checkups are subject to retrospective review and recoupment if the
medical record does not include all required documentation.
THSteps checkups are made up of six (6) primary components. Many of the primary
components include individual elements. These are outlined on the Texas Health Steps
Periodicity Schedule based on age and include:
1. Comprehensive health and developmental history which includes nutrition
screening, developmental and mental health screening and TB screening
•
A complete history includes family and personal medical history along with
developmental surveillance and screening, and behavioral, social and emotional
screening.
93
CCHP STAR Kids PM 122020
94
•
The Texas Health Steps Tuberculosis Questionnaire is required annually
beginning at twelve (12) months of age, with a skin test required if screening
indicates a risk of possible exposure.
2. Comprehensive unclothed physical examination which includes measurements;
height or length, weight, fronto-occipital circumference, BMI, blood pressure, and
vision and hearing screening
•
A complete exam includes the recording of measurements and percentiles to
document growth and development including fronto-occipital circumference (0-2
years), and blood pressure (3-20 years). Vision and hearing screenings are also
required components of the physical exam. It is important to document any
referrals based on findings from the vision and hearing screenings
.
3. Immunizations, as established by the Advisory Committee on Immunization
Practices, according to age and health history, including influenza, pneumococcal,
and HPV.
•
Immunization status must be screened at each medical checkup and necessary
vaccines such as pneumococcal, influenza and HPV must be administered at
the time of the checkup and according to the current ACIP “Recommended
Childhood and Adolescent Immunization Schedule-United States,” unless
medically contraindicated or because of parental reasons of conscience
including religious beliefs.
•
The screening provider is responsible for administration of the immunization and
are not to refer children to other immunizers, including Local Health
Departments, to receive immunizations.
•
Providers are to include parental consent on the Vaccine Information Statement,
in compliance with the requirements of Chapter 161, Health and Safety Code,
relating to the Texas Immunization Registry (ImmTrac).
•
Providers may enroll, as applicable, as Texas Vaccines for Children
Providers. For information, please visit https://www.dshs.texas.gov/immunize/
tvfc/.
4. Laboratory tests, as appropriate, which include newborn screening, blood lead
level assessment appropriate for age and risk factors, and anemia.
•
Newborn Screening: Send all Texas Health Steps newborn screens to the DSHS
Laboratory Services Section in Austin. Providers must include detailed
identifying information for all screened newborn members and the member’s
mother to allow DSHS to link the screens performed at the Hospital with screens
performed at the newborn follow up Texas Health Steps medical checkup.
•
Anemia screening at 12 months.
•
Dyslipidemia Screening at nine (9) to twelve (12) years of age and again
eighteen (18) - twenty (20) years of age
•
HIV screening at sixteen (16) - eighteen (18) years
•
Risk-based screenings include:
94
CCHP STAR Kids PM 122020
95
o
Dyslipidemia, diabetes, and sexually transmitted infections including HIV,
syphilis and gonorrhea/chlamydia.
5. Health education (including anticipatory guidance), is a federally mandated
component of the medical checkup and is required in order to assist parents,
caregivers and clients in understanding what to expect in terms of growth and
development. Health education and counseling includes healthy lifestyle practices as
well as prevention of lead poisoning, accidents and disease.
6. Dental referral every six (6) months until the parent or caregiver reports a dental
home is established.
•
Clients must be referred to establish a dental home beginning at 6 months of age
or earlier if needed. Subsequent referrals must be made until the parent or
caregiver confirms that a dental home has been established. The parent or
caregiver may self-refer for dental care at any age.
Use of the THSteps Child Health Record Forms can assist with performing and
documenting checkups completely, including laboratory screening and immunization
components. Their use is optional, and recommended. Each checkup form includes all
checkup components, screenings that are required at the checkup and suggested age
appropriate anticipatory guidance topics. They are available online in the resources
section at www.txhealthsteps.com.
Sports physical exams do not qualify as Texas Health Steps checkups.
Exceptions to the Periodicity Schedule
On occasion, a child may require a Texas Health Steps checkup that is outside the
schedule. Such reasons for an exception to periodicity include:
•
Medical necessity (developmental delay, suspected abuse)
•
Environmental high-risk (for example, sibling of child with elevated lead blood
level)
•
Required to meet state or federal exam requirements for Head Start, day care,
foster care or pre-adoption
•
Required for dental services provided under general anesthesia
Exceptions to periodicity must be billed on the CMS 1500 and should comply with the
standard billing requirements.
If a Provider other than the Primary Care Provider performs the Exception to Periodicity
medical checkup, the Primary Care Provider must be provided with medical record
95
CCHP STAR Kids PM 122020
96
information. In addition, all necessary follow-up care and treatment must be referred to
the Primary Care Provider.
Additional information concerning Texas Health Steps can be accessed at tmhp.com.
Texas Vaccines for Children (TVFC)
The Texas Vaccines for Children (TVFC) Program is a federally funded, state-operated
vaccine distribution program. It provides vaccines free of charge to enrolled Providers
for administration to individual’s birth through eighteen (18) years of age. Providers may
obtain vaccines free of charge from the Texas Vaccines for Children Program and must
not charge the Member for the vaccines. Medicaid does not reimburse for vaccines that
are available through TVFC. Providers may refer to TVFC web site at dshs.state.tx.us/
immunize/tvfc/default.shtm for information about the program and for a list of vaccines
available through the program.
ImmTrac
ImmTrac, the Texas immunization registry, is a free service from the Texas Department
of State Health Services (DSHS). It is a secure, confidential registry that stores
immunization records electronically in one centralized system, available only to
authorized users. Texas law requires health care Providers and “payors” (e.g., health
insurance companies) to report specified immunization information regarding vaccines
administered to children younger than eighteen (18) years of age to the Texas
Department of State Health Services (DSHS). For more information, please visit the
ImmTrac website at immtrac.tdh.state.tx.us/.
Texas Health Steps Billing (THSteps)
A listing of the Texas Health Steps codes for each of the different exam types,
immunizations, TB skin tests, and newborn hereditary/metabolic tests are included in
the Texas Health Steps Quick Reference Guide and the Texas Medicaid Provider
Procedures Manual found on the Texas Medicaid & Health Partnership (TMHP) website
at tmhp.com.
THSteps medical checkups reflect the federal and state requirements for a preventive
checkup. Preventive care medical checkups are a benefit of the THSteps program if
they are provided by enrolled THSteps Providers and all of the required components are
completed. An incomplete preventive medical checkup is not a benefit. The THSteps
periodicity schedule specifies screening procedures required at each stage of the
Members life to ensure that health screenings occur at age-appropriate points in a
Member’s life. Checkups should be scheduled based on the ages on the periodicity
96
CCHP STAR Kids PM 122020
97
schedule to accommodate the need for flexibility when scheduling checkup
appointments.
Components of a medical checkup that have an available CPT code are not reimbursed
separately on the same day as a medical checkup, with the exception of initial point-of-
care blood lead testing, a Tuberculin skin test (TST), developmental and autism
screening, vaccine administration, and Oral Evaluation and Fluoride Varnish (OEFV).
Children of Migrant Farm Workers
Children of Migrant Farmworkers due for a Texas Health Steps medical checkup can
receive their periodic checkup on an accelerated basis prior to leaving the area. A
checkup performed under this circumstance is an accelerated service, but should be
billed as a checkup.
Performing a make-up exam for a late Texas Health Steps medical checkup previously
missed under the periodicity schedule is not considered an exception to periodicity nor
an accelerated service. It is considered a late checkup.
Cook Children’s Health Plan will send written notification to Primary Care Providers
when Children of Migrant Farm Workers (CMFW) are assigned to their membership
listing. For families in need of accelerated services, a representative will facilitate the
appointment with the family, provider’s office, and Medicaid Medical Transportation
Program (MTP) as appropriate.
Providers should notify Cook Children’s Health Plan of a Member when they identify a
migrant farm worker or the child of a migrant farm worker by calling 888-243-3312.
Representatives are available to assist you from Monday to Friday, 8:00AM-5:00PM
Central Standard Time (CST). This will allow Cook Children’s Health Plan to complete
an assessment to better coordinate and accelerate services for that Member.
Outreach
Cook Children’s Health Plan representatives will contact new and Members under the
age of twenty-one (21) that are due a Texas Health Steps medical checkup. Through
outreach, new Members are educated about the importance of receiving timely Texas
Health Steps medical checkups, the periodicity schedule, and any questions that they
may have about the services their child can receive. Outreach assists with scheduling
appointments by facilitating three (3) way conference calls with Providers and the
Medicaid Medical Transportation Program as needed.
97
CCHP STAR Kids PM 122020
98
Additionally, the Outreach representative offers reminder calls two (2) days before the
scheduled appointment. If the Member is unable to make their appointment another
appointment is scheduled during that reminder call.
98
CCHP STAR Kids PM 122020
99
Statutory Requirements
Cook Children’s Health Plan follows the authority of the following entities for claim
processing requirements and timelines:
•
Health and Human Services Commission (HHSC)
•
Texas Department of Insurance (TDI)
•
National Standard Correct Coding Initiative (NCCI)
•
Centers for Medicare and Medicaid Services (CMS)
•
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Statutory and regulatory authority includes, without limitation:
• 42 U.S.C. § 1396a(a)(37) [§ 1902(a)(37) of the Social Security Act]
• 42 U.S.C. § 1396u-2(f) [§ 1932(f) of the Social Security Act]
• Health Insurance Portability and Accountability Act of 1996 (HIPAA),
Public Law 104-191
• 42 C.F.R. § 433.139
• 42 C.F.R. § 438.242
• 42 C.F.R. § 447.45
• 42 C.F.R. § 447.46
• 45 C.F.R. §§ 160 –164
• Texas Insurance Code § 843.349 (e) and (f)
• 1 Tex. Admin. Code § 353.4
Claims Information
A claim is a request for reimbursement, either electronically or by paper, for any health
care service provided. A clean claim must be submitted on an approved standardized
claim format (CMS 1500 or UB-04/CMS 1450) that contains all data fields required by
Cook Children’s Health Plan and the Health and Human Services Commission (HHSC)
for final adjudication of the claim. The claim may be paid or denied. When a claim is
processed and paid or denied, a Provider is issued an Explanation of Payment (EOP)
for the determination.
Cook Children's Health Plan follows the clean claim requirements located on the TMHP
website at tmhp.com Providers should refer to the EDI Companion Guides located on
tmhp.com and the Electronic Data Interchange Requirements located on cookchp.org
for electronic submission requirements.
99
Section 5: Claims and Billing
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 5: Claims and Billing
CCHP STAR Kids PM 122020
100
Claim Filing Deadline
A Provider must file claims/encounter data with Cook Children’s Health Plan within
ninety-five (95) days from the date of service. If a claim is not received by the Health
Plan within ninety-five (95) days of the date of service, the claim will be denied unless
supporting documentation is received explaining why an exception should be
considered.
An exception may include:
1. If the Provider files with the wrong plan within the ninety-five (95) day submission
requirement (e.g., State Claims Administrator but not with Cook Children’s Health
Plan) and produces documentation to that effect, Cook Children’s Health Plan will
honor the initial filing date and process the claim without denying the
resubmission for the sole reason of passing the filing timeframe. The Provider
must file the claim with the correct Managed Care Organization within ninety-five
(95) days of the disposition date from the other (wrong) carrier. The Provider
must submit the original claim and Explanation of Payment (EOP) from the other
carrier.
2. Cook Children’s Health Plan must receive claims on behalf of an individual who
has applied for Medicaid coverage but has not been assigned a Medicaid
number on the date of service within ninety-five (95) days from the date the
eligibility was added to the TMHP eligibility file (add date). Contact Cook
Children’s Health Plan to confirm the Member was included in the eligibility file to
the Health Plan and is showing active coverage for the date of service.
3. If an individual becomes retroactively eligible or loses Medicaid eligibility and is
later determined to be eligible, the ninety-five (95)-day filing deadline begins on
the date that the eligibility start date was added to TMHP files (add date). Contact
Cook Children’s Health Plan to confirm the Member was included in the eligibility
file to the health plan and is showing active coverage for the date of service.
4. After filing a claim to Cook Children’s Health Plan, Providers should review their
Explanation of Payment(s). If within forty-five (45) days the claim does not
appear on the Explanation of Payment as a paid, denied, or incomplete claim,
the Provider should resubmit the claim to Cook Children’s Health Plan within
ninety-five (95) days of the date of service.
Filing Deadline Calendar
Cook Children’s Health Plan follows the most current filing deadline calendar located on
the TMHP website at tmhp.com.
Clean Claim
A clean claim is a request for payment for a service rendered by a provider that:
•
Is submitted timely
•
Is accurate
100
CCHP STAR Kids PM 122020
101
•
Is submitted in a HIPAA compliant format or using the standard claim form,
including a UB-04 or CMS-1500, or successor forms thereto, or the electronic
equivalent of such claim form
•
Requires no further information, adjustment or alteration by the provider or by a
third party in order to be processed and paid by us
•
Clean claim definition are provided at 28 TAC 21.2803
The statutory payment period by which a clean claim must be paid begins to run upon
the receipt date of a clean claim, including a corrected clean claim. Clean claims
received by Cook Children’s Health Plan are adjudicated in adherence to the following
performance requirements and timeframes set by the Health and Human Services
Commission:
1. ninety-eight percent (98%) of all Clean Claims within 30 days of receipt
2. ninety-nine percent (99%) of all Clean Claims within 90 days of receipt
3. ninety-eight percent (98%) of all Appealed Claims within 30 days of receipt
4. one hundred (100%) of all claims, including Appealed Claims, within 24 months
from Date of Service
Timeframes are based on calendar days and are subject to change due to updates in
HHSC requirements, federal and state laws, rules, or regulations. Payment of a clean
claim is considered to have been paid on the date of:
1. Date of issuance of a check for payment and its corresponding Remittance
Advice to the Provider
2. Electronic transmission, if claim paid electronically
3. Delivery of the claim payment, if payment is made through a commercial carrier,
such as UPS or Federal Express
4. Receipt by the Provider, if payment is made other than steps one (1) through
three (3)
Cook Children’s Health Plan will withhold all or part of payment for any claim submitted
by a Provider:
1. Excluded or suspended from the Medicare and Medicaid programs for Fraud,
Abuse, or Waste
2. On payment hold under the authority of HHSC or its authorized agent(s)
3. With debts, settlements, or pending payments due to HHSC, or the state or
federal government
4. For neonatal services provided on or after September 1, 2017, if submitted by a
Hospital that does not have a neonatal level of care designation from HHSC
5. For maternal services provided on or after September 1, 2019, if submitted by a
Hospital that does not have a maternal level of care designation from HHSC
6. If the Provider’s claim for Nursing Facility Unit Rates does not comply with
UMCM Chapter 2.3 criteria for processing Clean Claims
101
CCHP STAR Kids PM 122020
102
In accordance with Texas Health and Safety Code § 241.186, the restrictions on
payment identified in items four (4) – five (5) above do not apply to emergency services
that must be provided or reimbursed under state or federal law.
Payment of clean claims to Providers who render medically necessary covered services
to Members, for whom a capitation has been paid to Cook Children’s Health Plan, shall
be done in an accurate and timely manner, as per our contract.
Cook Children’s Health Plan is subject to remedies, including liquidated damages and
reasonable attorney fees and taxes, if it fails to process and finalize clean claims or a
portion of a clean claim within the statutory thirty (30) day timeframe and performance
requirements. This interest rate is calculated at an annual eighteen percent (18%) rate,
accrued daily, for the period of time the clean claim remains unadjudicated. If the
Provider agreement specifies a contracted penalty rate, then that provision controls and
the Provider must be paid the contracted penalty rate.
If due to a catastrophic event, Cook Children’s Health Plan is unable to meet the
statutory timeframes for claim processing and adjudication, the deadlines may be
extended. However, Cook Children’s Health Plan must notify TDI and HHSC within five
(5) days of the catastrophic event. Within ten (10) days after returning to normal
business operations, Cook Children’s Health Plan must send a certification of the
catastrophic event to TDI in order to be in compliance.
Paper Claims Submission
We accept paper claim submissions using the following claim forms:
•
Institutional of facility paper claim submissions: CMS-1450 (UB-04)
•
Professional claim submissions: CMS-1500 (02-12)
STAR Kids Member claims should be mailed to:
Cook Children’s Health Plan
Attention: Claims Department
P.O. Box 961295
Fort Worth, TX 76161-1295
102
Cook Children’s Health Plan discourages Paper Transactions.
Before submitting paper claims, please review the Electronic Filing section of this Provider
Manual for directions on submitting an electronic transaction.
CCHP STAR Kids PM 122020
103
Claims for Behavioral Health services are reimbursed through Beacon Health Options
and are mailed to:
Beacon Health Options
Attention: Claims Department
P.O. Box 1866
Hicksville, NY 11802-1866
Claims for Vision Services (routine and therapeutic services) are reimbursed through
National Vision Administrators and are mailed to:
National Vision Administrators
Attention: Claims Department
P.O. Box 2187
Clifton, NJ 07015-2187
Tips on Submitting Paper Claims
•
Claims must be submitted on an original red claim form (no black and white or
photocopied forms
•
Print claim data within defined boxes on the claim form
•
Use black ink, but not a black marker. Do not use red ink or highlighters
•
Use all capital letters
•
Print using 10-pitch (12-point) Courier font.
•
Do not use fonts smaller or larger than 12 points. Do not use proportional fonts,
such as Arial or Times Roman
•
Do not use dashes or slashes in date fields
•
Use paper clips on claims or appeals if they include attachments. Do not use
glue, tape, or staples
•
Place the claim form on top when sending new claims, followed by any medical
records or other attachments
•
Number the pages when sending attachments or multiple claims for the same
Member (e.g., 1 of 2, 2 of 2)
•
Do not total the billed amount on each claim form when submitting multi-page
claims for the same Member
All claims must be submitted with a National Provider Identifier (NPI) for the billing and
performing Providers. If an NPI is not included in required Provider identifier fields, the
claim will be denied. Providers billing as a group must give the performing/rendering
Provider identifier on their claims as well as the group Provider identifier.
103
CCHP STAR Kids PM 122020
104
Please Note: Some claims may require additional attachments. Be sure to include all
supporting documentation when submitting your claim. Claims with attachments should
be submitted on paper.
Electronic Filing
Cook Children’s Health Plan encourages all Providers to file claims and or encounter
data electronically if they have not already done so. Providers can use vendor software
or they may use a third party billing agent (e.g., billing companies and clearinghouses)
to participate in Cook Children’s Health Plan’s electronic claims/encounter filing program
through Availity. Availity has the capability to receive electronic professional, institutional
and encounter transactions and generate the electronic Explanation of Payment (EOP).
Submission of a claim to the clearinghouse does not guarantee that the claim was
transmitted or received by Cook Children’s Health Plan. Providers are responsible for
monitoring their error reports to ensure all transmitted claims and encounters appear on
reports.
Cook Children’s Health Plan requires that Providers submit the appropriate Billing
Provider NPI and Taxonomy and the appropriate Rendering Provider NPI and Taxonomy
fields on all claims.
Behavioral Health Providers who wish to file claims electronically should contact the
Beacon Health Options at 855-481-7045.
Vision Providers should contact National Vision Administrators, LLC at 888-830-5560.
For more information please refer to the EDI Companion Guides on tmhp.com.
Electronic Claim Acceptance
Providers should verify that their electronic claims were accepted by Cook Children’s
Health Plan for payment consideration by referring to their Accepted and Rejected
reports. Providers may confirm receipt of submitted claims through our Secure Provider
Portal on our website at cookchp.org. Providers must also track claim submissions
against their claims payments to detect and correct all claim errors. Claims that are
rejected or denied must be corrected and resubmitted within timely filing guidelines for
payment consideration.
Product Clearinghouse CCHP Payer ID Contact Phone
STAR Kids Availity CCHP9 800-282-4548
104
CCHP STAR Kids PM 122020
105
Some of the most common reasons for electronic professional claim rejections or
denials are:
•
Member information does not match – the name, date of birth, sex, and nine-digit
member identification number must be an exact match with the Member’s
identification number
•
Referring/Ordering Physician field blank or invalid – the referring physician’s NPI
must be present when billing for consultations, laboratory, or radiology
•
Performing Physician ID field blank or invalid - when the billing Provider identifier
is a group practice, the performing Provider identifier for the physician who
performed the service must be entered
•
Invalid Type of Service or Invalid Type of Service/Procedure code combination -
in certain cases some procedure codes will require a modifier to denote the
procedure’s type of service (TOS)
•
Other Health Insurance – Verify other health information and if applicable, attach
primary insurance Explanation of Payment with the claim
After filing a claim to Cook Children’s Health Plan, Providers should review their
Explanation of Payment(s). If within forty-five (45) days the claim does not appear on
the Explanation of Payment as a paid, denied, or incomplete claim, the Provider should
resubmit it to Cook Children’s Health Plan within ninety-five (95) days of the date of
service.
Electronic Funds Transfers and Electronic Remittance Advices
Cook Children’s Health Plan is pleased to offer Electronic Funds Transfer (EFT) and
paperless Electronic Remittance Advice (ERA). Through EFT Providers can elect to
receive payments electronically through direct deposit. To enroll in EFT, please visit our
website cookchp.org and select “Providers” to complete the Electronic Fund Transfer
form.
Electronic Remittance Advice (ERA) files are available to our Providers through the
Availity Health Information Network. To enroll for ERA delivery on the Availity Web
Portal, click Enrollments/ ERA Enrollment in the Availity menu, or click ERA Enrollment
in the Additional Enrollments section on the Administrator Dashboard. For information
about using the ERA enrollment service, review the Enrolling Online for Electronic
Remittance Advice topic. You may also call Availity Client Services at 800-282-4548.
Providers may also enroll in ERA by visiting our website at cookchp.org and select
Providers to complete the Multi-Payer Electronic Remittance Advice Enrollment form.
Note* Providers must be enrolled in EFT in order to be eligible for enrollment in ERA.
105
CCHP STAR Kids PM 122020
106
Pharmacy Claim Submission
All paper Pharmacy Provider claims that are clean and payable must be paid within
twenty-one (21) days from the date of claim receipt. All electronic Pharmacy Provider
claims that are clean and payable must be paid within eighteen (18) days from the date
of claim receipt. Pharmacy Providers may submit claims using the electronic
transmission standards set forth in CFR Parts 160, 162 or 164; and by using a universal
claim form that is acceptable to the Pharmacy Benefit Manager, Navitus Health
Solutions.
For a list of covered drugs and preferred drugs, prior authorization process, claim
submission requirements, including allowable billing methods and special billing, or for
general pharmacy questions, Providers may contact Navitus Health Solutions directly
through the Navitus Provider Portal at navitus.com or call the Navitus Pharmacy Help
Desk at 877-908-6023.
Claim Status Assistance
Cook Children’s Health Plan offers several methods to access claim status:
•
Secure Provider Portal
Cook Children’s Health Plan Secure Provider Portal offers tools to assist your
office right at your fingertips. Go to our website at cookchp.org, proceed to the
Provider screen and select Secure Provider Portal. In order to use our Secure
Provider Portal you must first register online.
You will be required to enter information such as your tax identification number,
first name, last name, email address and will be prompted to create a password.
Once you complete and submit the registration form, you will receive an email
confirmation to validate your account.
Multiple staff members within one office or group can have an account. Each
user within the office must create their unique user name and password. Sharing
accounts between staff is not permitted.
Here are some of the features currently available:
•
Verify Patient Eligibility: find out patient coverage, coordination of benefits and
copays by simply entering the necessary search criteria
•
Patient Roster: for Primary Care Providers (PCP), log on to your account and
print a list of Members assigned to you for primary care services.
•
Claims Appeals: Cook Children’s Health Plan Providers are able to file
appeals through the Secure Provider Portal
106
CCHP STAR Kids PM 122020
107
•
Check Claims Status Online: confirm the status of submitted claims
•
Submit and Review Online Authorizations: avoid the fax machine and submit
service authorization requests directly to us online. Check on status of
authorizations by Member and/or authorization number
•
Automated System
The Interactive Voice Response (IVR) is an automated system feature available
to Providers 24 hours a day, 7 days a week. Providers can utilize the automated
feature to verify eligibility and claim status.
Features include:
•
No waiting for a live rep
•
Choose verbal playback or fax back
•
No limits on the amount of status requests
•
Allows you to go back to main menu or speak to live representative
(applicable during regular business hours)
How to use IVR:
•
Call local or toll free 888-243-3312
•
Select option 5 for Provider
•
Select option 3 for Automated System (IVR)
•
Follow the prompts to enter
o
Fax number
o
Tax ID number
o
Member ID
o
Member date of birth
o
Date of service
Cook Children’s Health Plan claim representatives are available to assist you with
general claim inquiries at 888-243-3312. Providers may also fax a claim listing to
682-885-2148 to the attention of the Claims Department. When calling or faxing Cook
Children’s Health Plan please be prepared to provide the following information:
•
Provider’s Name
•
Member Name
•
Member ID Number
•
Dates of Service
•
Amount of the Claim
•
Reason for Inquiry
107
CCHP STAR Kids PM 122020
108
Provider Reimbursement
Cook Children’s Health Plan will reimburse Providers according to their contractual
agreement. Cook Children’s Health Plan cannot reimburse Providers for Medicaid
services unless the Provider is enrolled with Texas Medicaid & Healthcare Partnership
(TMHP) and is included on the state master file. Cook Children’s Health Plan requires
tax identification numbers from all participating Providers. Cook Children’s Health Plan
is required to do back-up withholding from all payments to Providers who fail to give tax
identification numbers or who give incorrect numbers.
Cook Children’s Health Plan will reimburse Providers who render medically necessary
covered services to eligible Members, for whom a capitation has been paid to Cook
Children’s Health Plan. To verify a covered service please contact Cook Children’s
Health Plan at 888-243-3312.
Long Term Service and Support (LTSS) Provider Reimbursement
Cook Children’s Health Plan will not pay the Nursing Facility or Intermediate Care
Facility for individuals with an intellectual disability or related conditions (ICF-IID) daily
rate. Cook Children’s Health Plan will not provide Home and Community Based
Services (HCBS) Waiver services for the following programs: Home and Community
Based Services (HCS), Community Living Assistance and Support Services (CLASS),
Texas Home Living (TxHmL), Deaf Blind with Multiple Disabilities (DBMD), and Youth
Empowerment Services (YES).
Cook Children’s Health Plan will assist in coordinating services for Members enrolled in
HCBS Waiver programs, but will not contract with HCBS Waiver service Providers for
services provided through those HCBS Waivers. For STAR Kids Members who reside in
a nursing facility or ICF-IID, Cook Children’s Health Plan is responsible for coordinating
the Member’s care with facility based LTSS Providers providing non capitated services
to the Member.
LTSS Enrollment Changes with custom DME and Augmentative Device
The following table describes payment responsibility for Medicaid enrollment changes
that occur when a prior authorization exists for custom DME, before the delivery of the
product. For the purpose of this section, MCO means Managed Care Organization (i.e.
Cook Children’s Health Plan).
108
CCHP STAR Kids PM 122020
109
LTSS Enrollment Changes with Home Modification
The following table describes payment responsibility for Medicaid enrollment changes
that occur during a minor home modification service provided to an MDCP STAR Kids
Waiver Member, before completion of the modification.
Span of coverage (Hospital) - Responsibility during a Continuous Inpatient Stay
1
If a Member is disenrolled from a STAR Kids MCO and enrolled in another STAR Kids
MCO during an Inpatient Stay, then the former STAR Kids MCO will pay all facility
charges until the Member is discharged from the Hospital, residential substance use
disorder treatment facility, or residential detoxification for substance use disorder
treatment facility, or until the Member loses Medicaid eligibility. The new STAR Kids
MCO will be responsible for all other covered services on the Effective Date of
Coverage with the STAR Kids MCO.
Scenario Custom DME All Other Covered Services
1
Member moves between STAR
Kids MCOs
Former MCO New MCO
2
Member moves from FFS to
STAR Kids MCO
New MCO New MCO
Scenario
Minor Home
Modification
All Other Covered Services
1
Member moves between STAR
Kids
Former MCO New MCO
Scenario
Hospital Facility
Charge
All Other Covered
Services
1
Member Moves from FFS to STAR
Kids
FFS New MCO
2
Member moves from STAR, STAR
Health or STAR+PLUS to STAR
Kids
Former MCO New MCO
3
Member Moves from CHIP to STAR
Kids
New MCO New MCO
4
Adult Member Moves from STAR
Kids to STAR or STAR+PLUS
Former STAR Kids
MCO
New STAR or
STAR+PLUS MCO
109
CCHP STAR Kids PM 122020
110
This document is not intended to supersede any HHSC Contract. This is a reference
tool determining the span of coverage limitation.
Service Authorization Requests
Prior authorization is the request to the Care Management Department for approval of a
specific service before the service is rendered. Failure to obtain a prior authorization
may result in a denied claim. Out-of-Network services require prior authorization with
the exclusion of emergency room services.
To determine if a covered service requires a prior authorization Providers may use the
Prior Authorization Lookup tool located on our website at cookchp.org. Providers are
encouraged to submit and review a prior authorization request through our Secure
Provider Portal.
Providers may also submit a prior authorization request by fax. The prior authorization
request form is located on our website at cookchp.com.
All services are subject to the plan provisions, limitations, exclusions, and Member
eligibility at the time the services are rendered. Services requiring prior authorization are
not eligible for reimbursement by Cook Children’s Health Plan if authorization is not
obtained and cannot be billed to the Member. The decision to render medical services
lies with the Member and the treating provider.
Pharmacy Prior Authorization
Navitus processes Texas Medicaid pharmacy prior authorizations for Cook Children’s
Health Plan. The formulary, prior authorization criteria, and the length of the prior
authorization approval are determined by HHSC. Information regarding the formulary
and specific prior authorization criteria can be found at the Vendor Drug Website,
eProcrates, and SureScripts for ePrescribing.
Prescribers can access prior authorization (PA) forms online via navitus.com under the
“Providers” section or have them faxed by Customer Care to the prescribers’ office.
Prescribers will need their NPI and State to access the portal. Completed forms can be
5
Member Moves From STAR Kids to
STAR Health
Former STAR Kids
MCO
New STAR Health
MCO
6
Member Retroactively Enrolled in
STAR Kids
New MCO New MCO
7
Member moves between STAR
Kids MCOs
Former MCO New MCO
110
CCHP STAR Kids PM 122020
111
faxed twenty four hours a day, seven days a week (24/7) to Navitus at 920-735-5312.
Prescribers can also call Navitus Customer Care at 877-908-6023 select the prescriber
option and speak with the prior authorization department between 8a-5p M-F Central
Time to submit a PA request over the phone. After hours, Providers will have the option
to leave voicemail. Decisions regarding prior authorizations will be made within twenty-
four (24) hours from the time Navitus receives the PA request. The provider will be
notified by fax of the outcome or verbally if an approval can be established during a
phone request.
Pharmacies will submit pharmacy claims to Navitus. Medications that require prior
authorization will be undergo an automated review to determine if the criteria are met. If
all the criteria are met, the claim is approved and paid, and the pharmacy continues with
the dispensing process. If the automated review determines that all the criteria are not
met, the claim will be rejected and the pharmacy will receive a message indicating that
the drug requires prior authorization. At that point, the pharmacy should notify the
prescriber and the above process should be followed.
Claim Documentation Requirements
Providers must include or adhere to the following documentation guidelines when
considering claim submission.
•
National Provider Identifier (NPI)
– An NPI is required for all claims. An NPI is a
10-digit number assigned randomly by the National Plan and Provider
Enumeration System (NPPES). Cook Children’s Health Plan requires Providers
to submit the appropriate Rendering and Billing NPI and Taxonomy Code
combination as it appears in the attestation record with Texas Medicaid Health
Partnership (TMHP) on all claims. Claims submitted without the appropriate
Rendering or Billing NPI will be rejected or denied.
•
Supervising Physician Provider NPI - The supervising physician provider
National Provider Identifier (NPI) is required on claims for services that are
ordered or referred by one provider at the direction of or under the supervision of
another provider, and the referral or order is based on the supervised provider’s
evaluation of the Member.
•
Ordering or Referring Provider NPI - All claims for services that require a
physician order or referral must include the ordering or referring provider’s NPI. If
the ordering or referring provider is enrolled in Texas Medicaid as a billing or
performing provider, the billing or performing Provider National Provider Identifier
(NPI) must be used on the claim as the ordering or referring provider.
•
Benefit and Taxonomy Codes - Providers must submit the Benefit Code field
(when applicable), Address field, and Taxonomy Code Field and all other
required fields. These fields must be completed before submitting electronic
111
CCHP STAR Kids PM 122020
112
claims. Taxonomy codes do not affect pricing or the level of pricing, but rather are
used to crosswalk the NPI to a TPI. It is critical that the taxonomy code selected
as the primary or secondary taxonomy code during a Provider’s enrollment with
the Texas Medicaid & Healthcare Partnership (TMHP) is included on all electronic
transactions.
Note* Cook Children’s Health Plan requires that Providers submit the appropriate
Billing Taxonomy and the appropriate Rendering Taxonomy on all claims. Claims
submitted without a taxonomy code will be denied.
•
National Drug Code - The National Drug Code (NDC) is an 11-digit number on
the package or container from which the medication is administered. All
Providers must submit a National Drug Code (NDC) for professional or outpatient
claims submitted with physician-administered prescription drug procedure.
Claims that do not have this information will be denied. The description, unit of
measure and unit quantity must also be included in the claim.
A National Drug Code (NDC) is composed of three sets of numbers:
•
The first set is assigned by the Food and Drug Administration (FDA) and
identifies the labeler, that is, the manufacturer, repackager, or distributer of the
drug.
•
The second is the product code. It identifies the specific strength, dosage form,
i.e. capsule, tablet, liquid, etc., and the formulation of a drug for a specific
manufacturer.
•
The third set is the package code, which identifies package sizes and types.
N4 must be entered before the National Drug Code (NDC) on claims. National
Drug Unit of Measure must also be included. The submitted unit of measure
should reflect the volume measurement administered. Refer to the National
Drug Code (NDC) Package Measure column on the Texas National Drug
Code (NDC)-to-Healthcare Common Procedure Coding System (HCPCS)
Crosswalk.
The valid units of measurement codes are:
• F2—International unit
• GR—Gram
• ME—Milligram
• ML—Milliliter
• UN—Unit
Note: Unit quantities are required.
112
CCHP STAR Kids PM 122020
113
•
National Correct Coding Initiative (NCCI) Guidelines - The Patient Protection
and Affordable Care Act (PPACA) mandates that all claims that are submitted to
TMHP be filed in accordance with the NCCI guidelines, including claims for
services that have been prior authorized or authorized with medical necessity
documentation. The Centers for Medicare and Medicaid (CMS), National Council
on Compensation Insurance (NCCI) and Medically Unlikely Edits (MUE)
guidelines can be found in the National Council on Compensation Insurance
(NCCI) Policy and Medicare Claims Processing manuals, which are available on
the Centers for Medicare and Medicaid (CMS) website.
•
CPT and HCPCS Claims Auditing Guidelines - Claims must be filed in
accordance with the Current Procedural Terminology (CPT) and Healthcare
Common Procedure Coding System (HCPCS) guidelines as defined in the
American Medical Association (AMA) and Centers for Medicare & Medicaid
Services (CMS) coding manuals. Claims that are not filed in accordance with the
Current Procedural Terminology (CPT) and Healthcare Common Procedure
Coding System (HCPCS) guidelines may be denied, including claims for services
that were prior authorized or authorized based on documentation of medical
necessity.
If a rendered service does not comply with the Current Procedural Terminology
(CPT) or the Healthcare Common Procedure Coding System (HCPCS)
guidelines, medical necessity documentation may be submitted with the claim for
the service to be considered for reimbursement; however, medical necessity
documentation does not guarantee payment for the service.
Providers must use HIPAA Complaint codes when submitting claims.
•
International Classification of Diseases – Claims must include the most
appropriate International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) diagnosis code that represents the purpose for the
service.
•
Newborn Members without Medicaid - If a Medicaid eligible newborn has not
been assigned a number on the date of service, the Provider must wait until the
identification number is assigned to file the claim. The Provider must submit the
claim with the Member Identification number. The 95-day filing period begins on
the “add date,” which is the date the eligibility is received and added to the
eligibility file. Providers can verify Medicaid eligibility and add date through
TexMed Connect or by calling the Automated Inquiry System (AIS) or the Texas
Medicaid & Healthcare Partnership (TMHP) Contact Center at 800-925-9126
113
CCHP STAR Kids PM 122020
114
after the number is received. Providers must check eligibility regularly to file
claims within the required ninety-five (95) day filing deadline.
Coordination of Benefits
Medicaid is secondary when coordinating benefits with all other insurance coverage,
unless an exception applies under federal law. Coverage provided under Medicaid will
pay benefits for covered services that remain unpaid after all other insurance coverage
has been paid. Cook Children’s Health Plan must pay the unpaid balance for covered
services up to the agreed rates for network Providers and Out-of-Network Providers
with written reimbursement arrangements. Cook Children’s Health Plan must pay the
unpaid balance for covered services in accordance with HHSC’s administrative rules
regarding Out-of-Network payment (1 T.A.C. §353.4) for Out-of-Network Providers with
no written reimbursement arrangement.
All other available third-party resources must meet their legal obligation to pay claims
before Medicaid funds are used to pay for the care of a Medicaid Member, including
Medicare for dual eligible STAR Kids Members. Providers must submit claims to other
health insurers for consideration prior to billing Cook Children’s Health Plan. For
payment consideration, Providers must file the claim with a copy of the Explanation of
Payment (EOP) or rejection letter from the other insurance to:
Cook Children’s Health Plan
PO Box 2488
Fort Worth, TX 76113-2488
Attention: Claims Department
Email: CCHPCOB@cookchildrens.org
If Cook Children’s Health Plan is aware of other third-party resources at the time of
claim submission and the billing provider is not, the claim will deny and the Explanation
of Payment will instruct the provider to bill the appropriate insurance carrier. If we
become aware of the resource after payment for the service was rendered, Cook
Children’s Health Plan will pursue post payment recovery.
Providers have access to verify Coordination of Benefits through the Secure Provider
Portal on the Cook Children’s Health Plan website at cookchp.org by simply entering the
necessary search criteria. Providers may also submit supporting documentation
regarding the termination of primary carrier benefits (making sure to include termination
date and/or Explanation of Payment (EOP) showing denial of claim) by:
114
CCHP STAR Kids PM 122020
115
•
Fax: 682-885-8490
•
Email: CCHPCOB@cookchildrens.org
(Provider will receive a confirmation receipt by return email)
•
Accessing the Secure Provider Portal cookchp.org
Examples of Supporting Documention can include but are not limited to:
•
Letter of Creditable Coverage from primary carrier
•
Explanation of Payment (EOP) showing denial of claim for Member not effective
at the time of service
•
Legible printout from Primary Carrier inquiry received via their portal, by fax, or
by email
In cases where the other payer makes payment, the CMS-1500, CMS-1450, or
applicable ANSI-837 electronic format claim must reflect the other payer information and
the amount of the payment received.
In cases where the other payer denies payment, or applies their payment to the
Member’s deductible, a copy of the applicable denial letter or Explanation of Payment
(EOP) must be attached with the claim that is submitted to Cook Children’s Health Plan.
If this information is not sent with an initial claim filed for a Member with other insurance,
the claim will deny and the Explanation of Payment (EOP) will instruct the Provider to
bill with the appropriate insurance carrier until this information is received.
If a Member has more than one primary insurance carrier (Medicaid would be the third
payor), the claim should not be submitted through EDI or the Secure Provider Portal
and must be submitted on a paper claim.
Overpayments
An overpayment is any payment that a Provider receives in excess of the amount
payable for a service rendered.
Examples of an overpayment that may occur due to (but not limited to) the following
reasons:
•
duplicate payment
•
health plan reimbursement error
•
payment to incorrect provider
•
Payment for the incorrect Member
•
overlapping payment by Cook Children’s Health Plan and a Third Party Resource
(TPR)
•
the provider bills incorrectly or in excess of actual charges
115
CCHP STAR Kids PM 122020
116
When an overpayment is identified by Cook Children’s Health Plan, the refund request
process is initiated. The Provider will receive written notification making them aware
that an overpayment has been made in error. The notification will include the Member
name, Member ID, date of service, billed amount, claim number, check number, and the
reason for the refund request. The Provider will also receive instructions on how the
refund should be submitted and where to send it. The Provider has thirty (30) days from
the date of the letter to respond to Cook Children’s Health Plan. Failure to refund or
respond to a request may result in an offset against future claim payments until the
amount of the overpayment has been fully recovered. If the Provider determines the
request is in accurate, the Provider should contact Cook Children’s Health Plan at
888-243-3312.
To ensure the refund request is applied correctly Providers should include a letter of
explanation or the refund request letter and the Explanation of Payment (EOP).
Providers can submit refund checks to:
Cook Children’s Health Plan
Attention: Finance Department
P.O. Box 2488
Fort Worth, TX 76113-2488
When an overpayment is identified by the provider the provider should contact Cook
Children’s Health Plan. The provider may request for written notification of the
overpayment and is allowed thirty (30) days from the date of the letter to submit the
refund. The provider has the option to refund the overpayment by issuing a check to
Cook Children’s Health Plan or may request a recoupment from future claims payments.
Corrected Claims Process
A corrected claim is a correction or a change of information to a previously finalized
claim in which additional information from the Provider is required. Corrections can be
made, but are not limited to missing or incorrect: Date of Birth, Place of Service (POS),
Units Billed, Beginning Date of Service, Ending Date of Service, Diagnosis Code,
Procedure Code, Unit Billed, Modifiers, Vaccine sequence, Rendering/Referring/
Supervising Provider, Discharge Date, and Present on Admission (POA).
All claims received from a provider must meet the following criteria in order to be
considered as a corrected claim for review:
•
A corrected CMS-1500 (02-12) (HCFA) or CMS-1450 (UB-04) claim form is
required
116
CCHP STAR Kids PM 122020
117
•
Each corrected claim must include: a copy of the EOP and any other
attachments needed if applicable
•
Corrected claims must be submitted within one hundred and twenty (120) days of
the disposition date to meet the timely filing requirements
•
Provider should notate “Corrected Claim” on a paper CMS-1500 (02-12) or
CMS-1450 (UB-04)
•
Submit corrected claims via EDI or mail to:
Cook Children’s Health Plan
Attention: Claims Department
P O Box 961295
Fort Worth, TX 76161-1295
Please note: A written or online appeal is not necessary for corrected claims
•
The UB-04 type of bill code (field 4) shall include a seven (7) in the third position
to indicate the claim is a corrected claim.
If submitting electronically:
The following guidelines must be completed for an ANSI-837P (Professional) and
ANSI-837I (Institutional) claim to be considered a corrected bill.
1. In the 2300 Loop, the CLM segment (claim information), CLM05-3 (claim
frequency type code) must indicate the third digit of the Type of Bill being sent.
The third digit of the Type of Bill is the frequency and can indicate if the bill is an
adjustment claim as follows:
“7” – REPLACEMENT (Replacement of Prior Claim)
2. In the 2300 Loop, the REF segment (claim information), must include the original
claim number issued to the claim being corrected. The original claim number can
be found on your electronic remittance advice. Example:
Claim Frequency Code
CLM*12345678*500***11::7*Y*A*Y*I*P~
REF*F8*(Enter the Claim Original Reference Number)
REF01 must contain ‘F8’
REF02 must contain the original Cook Children’s Health Plan claim number
3. In the 2300 Loop, the NTE segment (free-form ‘Claim Note’), must include the
explanation for the Corrected/Replacement Claim.
NTE01 must contain ‘ADD’
NTE02 must contain the free-form note indicating the reason for the corrected
replacement claim.
117
CCHP STAR Kids PM 122020
118
Example: NTE*ADD*CORRECTED PROCDURE CODE ON LINE 3
For more information please refer to the EDI Companion Guides on tmhp.com.
Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC)
Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) are
reimbursed their assigned encounter rate for services. FQHCs and RHCs must bill a
T1015 procedure code and the applicable modifier for general medical services.
Exception claims (e.g. Texas Health Steps and Family Planning) must be billed as
described in Texas Medicaid Provider Procedure Manual with the most appropriate
procedure code(s) using the required modifier(s) when appropriate and must follow
program-specific rules.
Please Note: To ensure Cook Children’s Health Plan has the correct encounter rate,
Providers must forward new encounter rate letter to the Cook Children’s Health Plan
Network Development Department.
Fax Number: 682-885-8403
Email Address: CCHPNetworkDevelopment@cookchildrens.org
Providers may use the following table to submit claims to Cook Children’s Health Plan:
For more information, Providers should refer to the Texas Medicaid Provider Procedure
Manual at tmhp.com.
Obstetrics and Prenatal Care
Medicaid reimburses prenatal care, deliveries, and postpartum care as individual
services. Providers may choose one of the following options for billing maternity
services:
Service FQHC RHC Codes to Bill
Texas Health Steps CMS-1500 CMS-1500 CPT
Well Child Visits CMS-1500 CMS-1500 CPT
Family Planning CMS-1500 CMS-1500 CPT
Acute Care Visits
CMS-1450
(UB-04)
CMS-1450 (UB-04) T1015
118
CCHP STAR Kids PM 122020
119
•
Providers may itemize each service individually on one claim form and file at the
time of delivery. The filing deadline is applied to the date of delivery.
•
Providers may itemize each service individually and submit claims as the
services are rendered. The filing deadline is applied to each individual date of
service.
When billing for prenatal services, use modifier TH with the appropriate evaluation and
management procedure code to the highest level of specificity. Failure to use modifier
TH may result in recoupment of payment rendered.
Prenatal and postpartum care visits billed in an inpatient hospital are denied as part of
another procedure when billed within the three days before delivery or the six weeks
after delivery. The inpatient intrapartum and postpartum care are included in the fee for
the delivery or Cesarean section and should not be billed separately.
One postpartum care procedure code may be reimbursed per pregnancy for STAR Kids
Members. The claim for the postpartum visit may be submitted with either procedure
code 59430 or with a delivery procedure code (59410, 59515, 59614, or 59622) that
includes postpartum care. The reimbursement amount for the submitted procedure code
covers all postpartum care per pregnancy regardless of the number of postpartum visits
provided. Procedure code 59430 may be reimbursed once per pregnancy for Medicaid
Members following a delivery if the delivery procedure code does not include
postpartum care. Since delivery procedure codes 59410, 59515, 59614, and 59622
include postpartum care, procedure code 59430 will be denied if procedure codes
59410, 59515, 59614, or 59622 were submitted by any Provider for the same
pregnancy.
Failure to submit a postpartum encounter claim when billing 59410, 59515, 59614, and
59622 (which includes postpartum care) may result in recoupment.
Ultrasound of the pregnant uterus is a benefit when medically indicated. Ultrasound of
the pregnant uterus is limited to three per pregnancy. The initial three claims paid for
obstetric ultrasounds do not require prior authorization. If it is necessary to perform
more than three obstetrical ultrasounds on a Member during one pregnancy, the
provider must request prior authorization with documentation of medical necessity.
Please refer to the TMHP manual at tmhp.com for additional information on Obstetrics
and Prenatal Care.
119
CCHP STAR Kids PM 122020
120
Emergency Services Claims
Cook Children’s Health Plan pays for emergency care in and out of the service area.
Emergency care is defined as health care services provided in a hospital emergency
facility or comparable facility to evaluate and stabilize medical conditions of a recent
onset and severity, including but not limited to severe pain, that would lead a prudent
layperson possessing an average knowledge of medicine and health to believe that his
or her condition, sickness, or injury is of such a nature that failure to get immediate
medical care could result in:
•
placing the patient’s health in serious jeopardy
•
serious impairment to bodily functions
•
serious dysfunction of any bodily organ or part
•
serious disfigurement
•
in the case of a pregnant woman, serious jeopardy to the health of the fetus
The Provider should direct the Member to call 911 or go to the nearest emergency room
or comparable facility if the provider determines an emergency medical condition or
emergency behavioral health condition exists. If an emergency condition does not exist,
the emergency provider should direct the Member to their Cook Children’s Health Plan
Primary Care Provider.
Cook Children’s Health Plan does not require that the Member receive approval from
the health plan or the Primary Care Provider prior to accessing emergency care. To
facilitate continuity of care, Cook Children’s Health Plan instructs Members to notify their
Primary Care Provider as soon as possible after receiving emergency care. Providers
are not required to notify Cook Children’s Health Plan Care Management about
emergency care services.
If Cook Children’s Health Plan receives a request for authorization of post-stabilization
treatment, CCHP must respond to the emergent/urgent facility within one (1) hour. If the
facility does not receive a response within one (1) hour, the post-stabilization services
shall be considered authorized in accordance with Texas Department of Insurance
statutes. The provider shall notify Cook Children’s Health Plan of all post-stabilization
treatment requests.
Special Billing
The following value added services require special billing as follows:
School Physicals
These services do not need to be provided by the
Member’s Primary Care Provider. However, services
must be provided by an In Network Provider. Claims
for these services are billed to Cook Children’s Health
Plan using diagnosis code: Z02.5
120
CCHP STAR Kids PM 122020
121
Co-payments
Medicaid Managed Care Members do not have a co-payment responsibility.
Billing Members
Cook Children’s Health Plan reimburses from the Texas Medicaid Healthcare
Partnership (TMHP) fee schedule. Cook Children’s Health Plan Providers have agreed
to accept the reimbursement as payment in full for services rendered to Medicaid
Members.
Members must not be balance billed for the amount above which is paid by the health
plan for covered services. In addition, Providers may not bill a Member if any of the
following occurs:
•
Failure to timely submit a claim, including claims not received by us
•
Failure to submit a claim to us for initial processing within the ninety-five (95) -
day filing deadline
•
Failure to submit a corrected claim within the ninety-five (95)-day filing
resubmission period
•
Failure to appeal a claim within the one hundred and twenty (120) -day
administrative appeal period
•
Failure to appeal a utilization review determination within thirty (30) calendar
days of notification of coverage denial
•
Submission of an unsigned or otherwise incomplete claim
•
Errors made in claims preparation, claims submission or the appeal process
A Member cannot be billed for failing to show for an appointment. Providers may not bill
Cook Children’s Health Plan Members for a third party insurance copayment. Medicaid
Members do not have an out of pocket expense for covered services. Providers may not
bill for or take recourse against a Member for denied or reduced claims for services that
are within the amount, duration and scope of benefits of the Medicaid program.
Increased Frame Allowance
and Vision Services
Claims for these services should be filed directly to
National Vision Administrators LLC (NVA) and
questions on how to file these claims should be
directed to NVA at 888-830-5630.
Prepared Childbirth classes
Claims for these services are billed to Cook
Children’s Health Plan listing the Member’s ID
Number, name, classes taken and billed amount.
This should be sent to Cook Children’s Health Plan,
PO Box 2488, Fort Worth, TX 76113-2488.
121
CCHP STAR Kids PM 122020
122
If a Provider furnishes services to a Medicaid Member that are not covered, including
services that are not medically necessary, he or she must obtain the Member’s
signature on a Member Acknowledgement Statement which informs the Member of his
or her financial responsibility. The Member Acknowledgement Statement form and
Private Pay Agreement form are included in the Appendix section of this provider
manual.
Providers are allowed to bill Members if retroactive eligibility is not granted. If the
Member does become retroactively eligible, the Member should notify the Provider of
his or her change in status. Ultimately, the Provider is responsible for timely filing of
Medicaid claims. If the Member becomes eligible, the Provider must refund any money
paid by the Member when a Medicaid claim is filed.
Member Acknowledgement Statement (Explanation of Use)
A Provider may bill a Cook Children’s Health Plan Member for a service that has been
denied as not medically necessary or not a covered benefit only if both
of the following
conditions are met:
•
The Member requests the specific service or item
•
The Provider obtains and keeps a written Member Acknowledgment Statement
signed by the Member that states:
“I understand that, in the opinion of (Provider’s name), the services or items that
I have requested to be provided to me on (dates of service) may not be covered
under the Texas Medical Assistance program as being reasonable and medically
necessary for my care. I understand that HHSC or its health insuring agent
determines the medical necessity of the services or items that I request and
receive. I also understand that I am responsible for payment of the services or
items I request and receive if these services are determined not to be
reasonable and medically necessary for my care.”
A sample of the Member Acknowledgement Statement is located in the Appendix
section of this provider manual.
Private Pay Statement
A Provider is allowed to bill the following to a Member without obtaining a signed
Member Acknowledgment Statement:
•
Any service that is not a benefit of Texas Medicaid (i.e., cellular therapy).
•
All services incurred on non-covered days because of eligibility or spell-of-
illness limitation. Total client liability is determined by reviewing the itemized
122
CCHP STAR Kids PM 122020
123
statement and identifying specific charges incurred on the non-covered days.
Spell-of-illness limitations do not apply to medically necessary stays for
Medicaid clients who are twenty (20) years of age and younger.
•
All services provided as a private pay patient. If the Provider accepts the
Member as a private pay patient, the Provider must advise the Member that
they are accepted as private pay patient at the time the service is provided
and will be responsible for paying for all services received. In this situation,
HHSC strongly encourages the Provider to ensure that the patient signs
written notification so there is no question how the patient was accepted.
Without written, signed documentation that the Texas Medicaid client has
been properly notified of the private pay status, the Provider cannot seek
payment from an eligible Texas Medicaid client.
•
The patient is accepted as a private pay patient pending Texas Medicaid
eligibility determination and does not
become eligible for Medicaid
retroactively. The provider is allowed to bill the client as a private pay patient if
retroactive eligibility is not granted. If the client becomes eligible retroactively,
the client notifies the Provider of the change in status. Ultimately, the provider
is responsible for filing timely claims. If the client becomes eligible, the
provider must refund any money paid by the client and file claims to Cook
Children’s Health Plan or Texas Medicaid for all services rendered.
A Provider who attempts to bill or recoup money from a Cook Children’s Health Plan
Member in violation of the above situations may be reported to the appropriate fraud
and abuse unit and excluded from the Texas Medicaid Program. Providers are
prohibited from including in the contract with their covered Members language that limits
the Member’s ability to contest claim payment issues, or that binds the Member to the
insurer’s interpretation of the contract terms.
A sample of the Private Pay statement is located in the Appendix section of this provider
manual.
Out-of-Network
Claims Submission
Clean claims for Nonparticipating Providers located in Texas must be received by Cook
Children’s Health Plan within ninety-five (95) days of service. Clean claims for
Nonparticipating Providers located outside of Texas must be received by us within three
hundred and sixty-five (365) days of the date of service. To submit claims for services
provided to STAR Kids Members, Providers must have an active Texas Provider
Identifier (TPI) on file with TMHP, the state’s contracted administrator.
123
CCHP STAR Kids PM 122020
124
Precertification
Nonparticipating Providers must obtain precertification for all non-emergent services
except as prohibited under federal or state law for in network or Out-of-Network facility
and physician services for a mother and her newborn(s) for a minimum of forty-eight
(48) hours following an uncomplicated vaginal delivery or ninety-six (96) hours following
an uncomplicated delivery by Cesarean section. We require precertification of maternity
inpatient stays for any portion in excess of these timeframes.
Reimbursement
Nonparticipating Providers are reimbursed in accordance with a negotiated case rate or,
in absence of a negotiated rate, as follows:
For STAR Kids we reimburse:
•
Out-of-Network, in area service Providers at no less than the prevailing
Medicaid FFS rate, less five (5) percent
•
Out-of-Network, out of area service Providers at no less than one hundred
percent (100%) of the Medicaid FFS rate
124
CCHP STAR Kids PM 122020
125
Reconsideration
Reconsideration is a second review of a service request when additional information is
received by Cook Children’s Health Plan. This level of review is not an element of the
Medicaid or CHIP Appeal or Complaint Processes but provides a means of resolving an
administrative or medical necessity denial without accessing the Complaint or Appeal
Process. If the denial is upheld, the provider, Member or Member’s representative may
pursue the appropriate Complaint or Appeal Process.
Appealing a Claim Denial
Providers should make the initial attempt to resolve a claim issue by calling Cook
Children’s Health Plan Claims Department at 888-243-3312. A Provider may appeal any
disposition of a claim. An appeal is a claim that has been previously adjudicated as a
clean claim and the provider is appealing the disposition through written notification to
the health plan in accordance with the appeal process.
All appeals of denied claims must be received by Cook Children’s Health Plan within
one hundred twenty days (120) from the date of disposition (the date of the Explanation
of Payment on which the claim appears). Payment is considered to have been paid on
the date of issue of a check for payment and its corresponding Explanation of Payment
(EOP) to the Provider by Health Plan, or the date of electronic transmission if payment
is made electronically. Any appeal received after the above stated timely filing day
period will be denied for failure to file an appeal within the required time limits.
Resolution should be received within thirty (30) calendar days from our receipt of the
written appeal.
Telephone communication related to the provider appeal will be documented on an
appeal communication log. Email and fax documentation related to the appeal will be
retained by the health plan for a period of seven (7) years.
Submitting a Claim Appeal
Provider appeals must be submitted in writing and received by the health plan within
one hundred twenty (120) calendar days of the printed disposition date on the
Explanation of Payment. Supporting documentation may include but is not limited to:
•
letter from the provider stating why they feel the claim payment is incorrect
(required)
•
copy of the original claim
•
copy of the health plan explanation of payment
•
explanation of payment from another insurance company
125
Section 6: Denials and Appeals
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 6: Denials and Appeals
CCHP STAR Kids PM 122020
126
•
prior authorization number and/or form or fax documenting the prior authorization
determination
•
eligibility verification documentation
•
electronic acceptance reports confirming the claim was received by the health
plan
•
overnight or certified mail receipt as proof of filing received date by the health
plan
Providers may submit appeals online through our Secure Provider Portal at cookchp.org
and selecting Provider Appeal. Supporting documentation can be uploaded using the
attachment feature. Written appeals may be faxed to 682-885-8404 or mailed to:
Cook Children’s Health Plan
Attention: Appeals
P.O. Box 2488
Fort Worth, TX 76113-2488
Changes or errors in CPT codes are not considered payment appeals. Corrected claims
should be resubmitted to the health plan with a notation of corrected claim.
Medical Necessity Appeals
Cook Children’s Health Plan maintains an internal appeal process for the resolution of
medical necessity appeal requests. Cook Children’s Health Plan will send a letter that
informs the Member and the servicing Provider, and the service Provider of appeal
rights, including how to access expedited and Independent Organization Review
appeals processes at the time a service is denied. The Member, or the Member’s
representative may appeal an adverse determination (medical necessity denial) orally or
in writing. More information on medical necessity appeals is located in the Care
Management section of this Provider Manual.
Provider Appeal Process to HHSC (related to claim recoupment)
Upon notification of a claims payment recoupment, the first step is for the provider to
recheck Member eligibility to determine if a Member eligibility change was made to Fee-
for-Service or to a different managed care organization on the date of service.
1. Member eligibility changed to Fee-for-Service on the date of service
Provider may appeal claim recoupment by submitting the following information to
HHSC
•
A letter indicating that the appeal is related to a managed care disenrollment/
recoupment and that the provider is requesting an Exception Request.
126
CCHP STAR Kids PM 122020
127
•
The Explanation of Benefits (EOB) showing the original payment
. Note:
This is also used when issuing the retro-authorization as HHSC will only
authorize the Texas Medicaid and Healthcare Partnership (TMHP) to grant an
authorization for the exact items that were approved by the plan.
•
The EOB showing the recoupment and/or the plan's "demand" letter for
recoupment. If sending the demand letter, it must identify the client name,
identification number, DOS, and recoupment amount. The information should
match the payment EOB.
•
Completed clean claim. All paper claims must include both the valid NPI
and TPI number. In cases where issuance of a prior authorization (PA) is
needed, the provider will be contacted with the authorization number and the
provider will need to submit a corrected claim that contains the valid
authorization number.
•
Note: Label the request "Expedited Review Request"
at the top of the
letter to ensure the appeal request is reviewed prior to eighteen (18) months
from the date of service.
Mail Fee-for-Service related appeal requests to:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
P.O. Box 204077
Austin, Texas 78720-4077
Prepare a new paper claim for each claim that was recouped, and insert the new
claims as attachments to the administrative appeal letter. Include documentation
such as the original claim and the statement showing that the claims payment was
recouped.
Submission of the new claims is not required before sending the administrative
appeal letter. However, if a provider appeals prior to submitting the new claims, the
provider must subsequently include the new claims with the administrative appeal.
HHSC Claims Administrator Contract Management only reviews appeals that are
received within eighteen (18) months from the date-of-service. In accordance with 1
TAC § 354.1003, Providers must adhere to all filing and appeal deadlines for an
appeal to be reviewed by HHSC Claims Administrator Contract Management and all
claims must be finalized within 24 months from the date of service.
127
CCHP STAR Kids PM 122020
128
2.
Member eligibility changed from one Managed Care Organization (MCO) to
another on the Date-of-Service
Providers may appeal claims payment recoupments and denials of services by
submitting the following information to the appropriate MCO to which the Member
eligibility was changed on the date of service:
•
A letter indicating that the appeal is related to a managed care disenrollment/
recoupment and that the provider is requesting an Exception Request.
•
The explanation of benefits (EOB) showing the original payment. The EOB
showing the recoupment and/or the MCO's "demand" letter for recoupment
must identify the client name, identification number, DOS, and recoupment
amount. The information should match the payment EOB.
•
Documentation must identify the client name, identification number, DOS, and
recoupment amount, and other claims information.
•
Note: Label the request "Expedited Review Request"
at the top of the letter to
ensure the appeal request is reviewed prior to eighteen (18) months from the
date of service.
Submit appeals online at: cookchp.org
Mail Fee-for-Service related appeals to:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
P.O. Box 204077
Austin, Texas 78720-4077
No Retaliation
Cook Children’s Health Plan will not retaliate against any person filing a complaint
against the health plan or appealing a decision made by the health plan.
128
CCHP STAR Kids PM 122020
129
Cook Children’s Health Plan’s Care Management and Service Coordination Program
encompasses:
•
medical management (utilization management, case management/service
coordination, disease/population health management)
•
Population management (predictive modeling, risk assessments/health
screenings, preventive care reminders).
The Care Management/Service Coordination program leverages the integration of all
program functions to deliver a “member-centric” model of care management.
Service Coordination Teams
Cook Children’s Health Plan (CCHP) employs a team approach to Service Coordination
to ensure our Members receive the most effective level of support through a
coordinated approach to care. Service Coordination Teams include nurses, social
workers, behavioral health specialists and integrated case management specialists.
Beacon Health Options Behavioral Health Coordinators serve as the primary Service
Coordinators for Members with a primary behavioral health diagnosis, and are
responsible for coordination across the continuum of care as an adjunct to the CCHP
designated Service Coordination Team and are dedicated to the population of Cook
Children’s Health Plan STAR Kids Membership.
Utilization Management - Specialty Provider Referral
Cook Children’s Health Plan does not require notification to the Health Plan of in-
network provider referrals. The provider is asked to document all referrals in the
Member’s medical record. Member self-referral is not permitted. All Out-of-Network
specialty provider referrals require documentation of medical necessity to be submitted
for prior approval of the Cook Children’s Health Plan Medical Director. Member
eligibility must be confirmed.
Members may self-refer for the following services:
•
Obstetrics & Gynecology - (OB/GYN) Services – Female Members may self-refer to
a participating OB/GYN or GYN specialist to obtain obstetrical or gynecological
related care. Cook Children’s Health Plan Members may also access their Primary
Care Provider for these services.
129
Section 7: Care Management and Service Coordination
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 7: Care Management and Service Coordination
CCHP STAR Kids PM 122020
130
•
Behavioral Health Services – Members may access their mental health/substance
abuse benefits by contacting the behavioral health provider indicated on the
Member’s ID card.
•
Emergency Care – Members are instructed to call their Primary Care Provider as
soon as possible after receiving emergency care. The Primary Care Provider is not
required to send notification to the Care Management Department.
Observation Stays
Observation stays are for hospital short stays of less than forty-eight (48) hours.
High Risk Pregnancy Notification
Cook Children’s Health Plan requests notification when Members are diagnosed with a
high risk pregnancy.
Delivery Notification
All deliveries exceeding routine length of stay and/or routine DRG per the TMPPM must
be reported to the Care Management Department within one (1) business day. An
authorization will be required for these scenarios. Routine deliveries do not require prior
authorization.
Service Coordination Description
Service Coordination provides the Member with initial and ongoing assistance
identifying, selecting, obtaining, coordinating, and using covered services and other
supports to enhance the Member's well-being, independence, integration in the
community, and potential for productivity. MCO must ensure that Service Coordination is
used to:
1. Provide a holistic evaluation of the Member's individual dynamics, needs and
preferences.
2. Educate and help provide health-related information to the Member, the
Member's LAR, and others in the Member's Support Network;
3. Help identify the Member's physical, behavioral, functional, and psychosocial
needs;
4. Engage the Member and the Member's LAR and other caretakers in the
design of the Member's Individual Service Plan (ISP);
5. Connect the Member to Covered and non-covered services necessary to
meet the Member's identified needs;
6. Monitor to ensure the Member's access to covered services is timely and
appropriate;
7. Coordinate Covered and non covered services; and
8. Intervene on behalf of the Member if approved by the Member.
130
CCHP STAR Kids PM 122020
131
Role of Service Coordinator
The purpose of a Service Coordinator is to maximize a Member's health, wellbeing, and
independence. Service Coordination should consider and address the Member’s
situation as a whole, including his or her medical, behavioral, social, and educational
needs. The Service Coordinator must work with the Member’s PCP to coordinate all
covered services, Non-capitated Services, and non covered services available through
other sources. This requirement applies regardless of whether the PCP is in the MCO’s
Network. In order to integrate the Member’s care while remaining informed of the
Member’s needs and condition, the Service Coordinator must actively involve the
Member’s primary and specialty care Providers, including Behavioral Health Service
Providers, and Providers of Non-capitated Services and non-covered services. When
families request information regarding a referral to a Nursing Facility or other long-term
care facility, the MCO must inform the Member and family about options available
through home and community-based service programs, in addition to facility-based
options.
The MCO may allow a Member to receive Service Coordination through an integrated
Health Home if the individual providing Service Coordination and the Service
Coordination structure meet STAR Kids program requirements. The MCO must
reimburse a Health Home that provides Service Coordination to its Members through an
enhanced rate structure, a per-member-per-month fee, or other reasonable
methodology agreed to between the MCO and Health Home. The MCO must employ
Service Coordinators who are experienced in meeting the needs of vulnerable
populations who have Chronic or Complex Conditions. Service Coordination personnel
and management must have expertise in pediatric care and pediatric developmental
challenges, in addition to physical and behavioral health challenges. Service
Coordinators that serve STAR Kids Members must be solely dedicated to serving STAR
Kids Members. The MCO must pair a Member with a Service Coordinator who has
appropriate experience relating to the individual Member’s needs.
Cook Children’s Health Plan Service Coordinators may be reached by calling
844-843-0004 and follow the prompts.
Purpose of Service Coordination
Service Coordination provides the Member with initial and ongoing assistance
identifying, selecting, obtaining, coordinating, and using covered services and other
supports to enhance the Member’s well-being, independence, integration in the
community and potential for productivity. Service Coordination must be used to:
• Provide a holistic evaluation of the Member’s individual dynamics, needs and
preferences;
131
CCHP STAR Kids PM 122020
132
• Educate and help provide health-related information to the Member, the
Member’s legally authorized representative (LAR), and others in the Member’s
support network;
• Help identify the Member’s physical, behavioral, functional, and psychosocial
needs;
• Engage the Member and the Member’s LAR and other caretakers in the design
of the Member’s Individual Service Plan (ISP);
• Connect the Member to covered and non-covered services necessary to meet
the Member’s identified needs; monitor to ensure the Member’s access to
covered services it timely and appropriate;
• Coordinate covered and non-covered services; and
• Intervene on behalf of the Member if approved by the Member.
Our mission is to inform, educate and support our Members, and ensure coordinated
care. Our model is centered on the Member’s personal goals and desires, and the
interventions needed to maximize independence and promote health.
Service Coordination Levels
A named Service Coordinator is furnished to a Member when the health plan
determines one is required through an assessment of the Member’s health and support
needs. Additionally, a named Service Coordinator is furnished to all Members who
request one.
Cook Children’s Health Plan provides three levels of Service Coordination to its
Members. Service Coordination levels are designated by the Member’s service needs,
medical complexity, and psychosocial needs/issues with our most clinically complex
Members receiving the most intensive level of Service Coordination to meet their needs.
Because a Member’s health status may change, the Service Coordination Teams are
designed to service a Member at any level of need, but coordination levels are
designated and tracked in our comprehensive care coordination system to ensure
appropriate tracking and service delivery by service level and identified Member needs.
CCHP provides the following for all STAR Kids Members:
• A description of Service Coordination
• A phone number to contact if the Member needs Service Coordination or is
experiencing problems with Service Coordination
• The name of their Service Coordinator, if applicable
• The phone number and email address of their named Service Coordinator or
information on how to reach a Service Coordinator if the Member does not have
a named Service Coordinator
132
CCHP STAR Kids PM 122020
133
• The minimum number of contacts the Member will receive every year
• The types of contacts the Member will receive and instructions on how to request
additional Service Coordination assistance at any time
• How to access a Member Advocate if the Member has complaints about a
Service Coordinator.
If the named Service Coordinator changes, Cook Children’s Health Plan notifies
Members or their LARs within five business days of the name and phone number of
their new Service Coordinator. Within this same time period, CCHP posts the new
Service Coordinator’s information on the portal or website Members use to obtain plan
information. Members and LARs have the option of requesting CCHP assign a different
Service Coordinator to the Member. If the Member or LAR express a concern or
dissatisfaction with a Service Coordinator, the appropriate Manager or Team Lead of
Service Coordination will assure the Member or LAR that their concerns will be
investigated and to expect a follow-up call the next business day. The Member or LAR
will be provided the Manager’s or Team Lead’s contact information should they need
further assistance. Finally, the Member or LAR will be offered the ability to file a formal
complaint at any time and offered assistance by the Member Care Advocate in doing so.
Cook Children’s Health Plan allows Members to receive Service Coordination through
an integrated health home. The individual providing Service Coordination and the
Service Coordination structure must meet the STAR Kids program requirements. CCHP
maintains responsibility for ensuring the competency of Service Coordinators employed
by health homes through required training and competency assessments ongoing.
Service Coordinators must meet the following requirements as outlined below for each
Service Coordination Level and must possess knowledge of the principles of most
integrated settings, including federal and state requirements.
Level 1 Includes the Following Member Types:
• MDCP STAR Kids Members
• Members with Complex Needs or a history of developmental or behavioral health
issues (multiple outpatient visits, hospitalization, or institutionalization within the
past year)
• Members with SED or SPMI
• Members at risk for institutionalization
All Level 1 Members receive a minimum of four face-to-face Service Coordination
contacts annually, in addition to monthly phone calls, unless otherwise requested by the
Member or Member’s LAR.
133
CCHP STAR Kids PM 122020
134
Level 2 Members:
• Members who do not meet the requirements for Level 1 classification but receive
Personal Care Services (PCS), Community First Choice (CFC), or Nursing
Services
• Members the MCO believes would benefit from a higher level of service
coordination based on results from the STAR Kids SAI and additional MCO
findings
•
Members with a history of substance abuse (multiple outpatient visits,
hospitalization, or institutionalization within the past year)
• Members without SED or SPMI, but who have another behavioral health
condition that significantly impairs function
All Level 2 Members receive a minimum of two face-to-face and six telephonic Service
Coordination contacts annually unless otherwise requested by the Member or Member’s
LAR.
Level 3 Members:
Level 3 Members include those who do not qualify as Level 1 or Level 2. All level 3
Members have access to service coordination services.
All Level 3 Members receive a minimum of one face-to-face visit annually and receive at
least three telephonic service coordination outreach contacts yearly.
Screening and Assessment Instrument (SAI)
The STAR Kids Screening and Assessment Instrument (SAI) is designed as an
assessment for all children on SSI and in specified waiver programs. The SAI contains
trigger items that advance children into various, more extensive modules. The modules
of the SAI are the Core, the personal care services module (PCAM), and the nursing
services module (NCAM). The SAI contains flags for further follow-up by the Managed
Care Organizations (MCOs) on issues such as the need for Durable Medical Equipment
(DME), behavioral health services, and other therapies. Information gathered using the
SAI is used to create an individual service plan (ISP) for each member, as well as
generate potential referrals for additional services the individual might need. For
individuals seeking a medical necessity determination for MDCP or Medicaid state plan
Community First Choice services (CFC), the SAI is used to gather the information used
to make that determination. The SAI contains a module for MDCP clients and potential
clients (MDCP Module) that includes items used exclusively to determine an individual’s
service cost limit (budget), based on Resource Utilization Group III (RUG) modeling.
134
CCHP STAR Kids PM 122020
135
A registered nurse, advance practice nurse, physician assistant, social worker (MSW,
LBSW, or LCSW), or licensed vocational nurse (with a minimum of one year of previous
service coordination or case management experience with pediatric clients) must
administer the SAI Core Module and PCAM, if needed, and these modules may not be
provided by any contracted entity that is or will be providing direct services to the
Member. A registered nurse or advance practice nurse must administer the SAI NCAM
and MDCP module, if needed. The MCO must train all individuals that will administer
the SAI using a training module required by HHSC before the individuals administer the
SAI. For quality monitoring purposes, the MCO must submit data collected through the
SAI to the HHSC Administrative Services Contractor in the format prescribed by HHSC.
The SAI must be completed initially, annually for reassessment, and any time the
individual or Legally Authorized Representative (LAR) report a significant change in
condition that might impact her or her need for services. The SAI will assist in
determination of the Member’s required level of service coordination and how their
needs will potentially be met through service coordination.
Individual Service Plan (ISP)
Each STAR Kids MCO must create and regularly update a comprehensive Person-
Centered Individual Service Plan (ISP) for each STAR Kids Member, unless the Member
or Member's LAR declines the STAR Kids Screening and Assessment Process as
described in Section 8.1.39. The purpose of the ISP is to articulate assessment findings,
short and long-term goals, service needs, and Member preferences. The MCO must use
the ISP to communicate and help align expectations between the Member, their LAR,
the MCO and key service Providers. The MCO must use the ISP to measure Member
outcomes over time. The MCO must ensure that all ISPs must contain the following
information:
1. A summary document describing the recommended service needs identified
through the STAR Kids Screening and Assessment Process;
2. Covered Services currently received;
3. Covered Services not currently received, but that the Member might benefit
from;
4. A description of non-covered services that could benefit the Member;
5. Member and family goals and service preferences;
6. Natural strengths and supports of the Member including helpful family
members, community supports, or special capabilities of the Member;
7. With respect to maintaining and maximizing the health and well-being of the
Member, a description of roles and responsibilities for the Member, their LAR,
others in the Member's Support Network, key service Providers, the
Member's Health Home, the MCO, and the Member's school, if applicable;
135
CCHP STAR Kids PM 122020
136
8. A plan for coordinating and integrating care between Providers and Covered
and Non-Covered Services;
9. Short and long-term goals for the Member's health and well-being;
10.If applicable, services provided to the Member through YES, TxHmL, DBMD,
HCS, CLASS, or third-party resources, and the sources or Providers of those
services;
11. Plans specifically related to transitioning to adulthood for Members age 15
and older; and
12.Any additional information to describe strategies to meet service objectives
and Member goals.
The MCO must ensure that the ISP is informed by findings from the STAR Kids
Screening and Assessment Process, in addition to input from the Member; their family
and caretakers; Providers; and any other individual with knowledge and understanding
of the Member's strengths and service needs who is identified by the Member, the
Member's LAR, or the MCO. To the extent possible and applicable, the MCO must
ensure that the ISP accounts for school-based service plans and service plans provided
outside of the MCO. The MCO is encouraged to request, but may not require the
Member to provide a copy of the Member's Individualized Education Plan (IEP).
Service Planning and Authorization Requests
Service planning for a STAR Kids Member begins with the service coordination team’s
review of any existing and active services and any current Individual Service Plan (ISP).
This review is documented in the care management software system. Any existing
acute care and Long Term Supports and Services (LTSS) are continued until the STAR
Kids Assessment Instrument (SAI) is completed.
Next, an in home assessment is conducted by a Cook Children’s Health Plan service
coordination team assessor (RN, LMSW, LBSW or LVN) using the STAR Kids
Assessment Instrument (SAI). The SAI informs a new individual service plan (ISP.), The
ISP is coordinated for approval review with the Member’s Primary Care Provider /
medical home and the Member and/ or their Legally Authorized Representative (LAR.)
Services are then coordinated with the service provider(s) and authorization is
communicated to the service provider(s). The ISP is provided to the Member’s Primary
Care Provider/medical home and to the Member and/or their LAR.
The SAI is conducted at least annually, upon Member/LAR request and anytime the
Member has a significant change in their condition. Completion of a new SAI leads to
adjustments to the Member’s service plan (ISP) and additional services are approved or
services not needed are stopped. This process involves the Primary Care Provider/
medical home and the Member and/or LAR. Updated ISPs are provided to the
136
CCHP STAR Kids PM 122020
137
Member’s Primary Care Provider (PCP)/medical home and to the Member and/or their
LAR.
Episodic services requiring prior authorization must be reviewed by Cook Children’s
Health Plan for medical necessity prior to the provision of services to the Member.
Please visit cookchp.org to use the prior authorization look up tool by code or to submit
a prior authorization request through our Secure Provider Portal.
The following categories of services require prior authorization:
•
All Out-of-Network services (except family planning and Texas Health Step
services performed by those with valid Medicaid Texas Provider Identifier (TPI) )
•
Inpatient Admissions (all DRGs not related to STAR Kids Member routine delivery
or normal newborn DRGs)
•
Home Health Care
•
Hospice
•
High Cost Injectable Medications
•
Non-emergency transport (requests accepted from facilities or physician
Providers)
•
Plastic/Reconstructive/Cosmetic Procedures
•
Radiation Therapy
•
Therapy (Outpatient/Home/Other locations - does not apply to Early Childhood
Intervention (ECI) services)
•
Transplants
•
Emergency Dental Treatment for Dental Trauma
•
Case by Case Benefit Exceptions
To determine if a covered service requires a prior authorization Providers may use the
Prior Authorization Lookup tool located on our website at cookchp.org.
Included in the prior authorization process are:
•
Verification of eligibility, determination of medical necessity and benefits.
•
Referral of a Member to case or disease management programs when
appropriate
Prior Authorization Determinations
Episodic (Utilization Management) Case Managers process service requests in
accordance with the clinical immediacy of the requested service. If priority is not
specified on the referral request, the request will default to routine status.
•
Routine – within three (3) business days of receipt of all the necessary
information
137
CCHP STAR Kids PM 122020
138
•
Urgent – within one (1) business day of receipt of all the necessary information
•
Emergent – within one (1) hour of receipt of all the necessary information
Prior Authorization is not a guarantee of payment
All services are subject to the plan provisions, limitations, exclusions, and Member
eligibility at the time the services are rendered. Services requiring prior authorization are
not eligible for reimbursement by Cook Children’s Health Plan if authorization is not
obtained and cannot be billed to the Member. The decision to render medical services
lies with the Member and the treating provider.
Prior Authorization Not Required response does not indicate that the service is a
covered benefit
A response from Cook Children’s Health Plan either through the online look up
functionality or when receiving a response from the health plan upon prior authorization
request submission is not to be construed as a statement of benefit coverage for the
requested service. Providers should review and understand STAR Kids covered
benefits. Additionally, it remains the Providers responsibility to review services per the
Texas Medicaid Fee Schedule.
Inpatient Authorization and Levels of Care
Cook Children’s Health Plan Episodic Case Mangers perform timely review of hospital
stays and communicate authorization status to the requesting facility within contractual
requirements. Observation level of care does not require authorization. All inpatient
stays require authorization by CCHP. Facilities are expected to communicate
concurrently when the authorized level does not match the facilities’ billing level. Level
of care appeals received after claims submission are considered payment disputes and
are processed per Cook Children’s Health Plan Claim policies.
Medically Necessary Services
Medically necessary means:
1. For Medicaid Members birth through age twenty (20), the following Texas Health
Steps services:
a. Screening, vision and hearing services
b. Other health care services necessary to correct or ameliorate a defect or
physical or mental illness or condition; a determination of whether a service is
necessary to correct or ameliorate a defect or physical or mental illness or
condition:
i. must comply with the requirements of a final court order that applies to the
Texas Medicaid program or the Texas Medicaid Managed Care Program
as a whole
138
CCHP STAR Kids PM 122020
139
ii. may include consideration of other relevant factors, such as the criteria
described in parts 2)(b-g) and 3)(b-g) of this paragraph
2. For Medicaid Members over age twenty (20), non-behavioral health-related
health care services that are:
a. reasonable and necessary to prevent illnesses or medical conditions or
provide early screening, interventions, or treatments for conditions that cause
suffering or pain, cause physical deformity or limitations in function, threaten
to cause or worsen a disability, cause illness or infirmity of a Member, or
endanger life
b. provided at appropriate facilities and at the appropriate levels of care for the
treatment of a Member’s health conditions
c. consistent with health care practice guidelines and standards endorsed by
professionally recognized health care organizations or governmental
agencies
d. consistent with the Member’s diagnoses
e. no more intrusive or restrictive than necessary to provide a proper balance of
safety, effectiveness, and efficiency
f. not experimental or investigative
g. not primarily for the convenience of the Member or provider
3. For Medicaid Members over age twenty (20), behavioral health services that:
a. are reasonable and necessary for the diagnosis or treatment of a mental
health or chemical dependency disorder, or to improve, maintain, or prevent
deterioration of functioning resulting from such a disorder
b. are in accordance with professionally accepted clinical guidelines and
standards of practice in behavioral health care
c. are furnished in the most appropriate and least restrictive setting in which
services can be safely provided
d. are the most appropriate level or supply of service that can safely be provided
e. could not be omitted without adversely affecting the Member’s mental and/or
physical health or the quality of care rendered
f. are not experimental or investigative
g. are not primarily for the convenience of the Member or provider
Cook Children’s Health Plan provides medically necessary and appropriate covered
services to all Members beginning on the Member’s date of enrollment, regardless of
pre-existing conditions, prior diagnosis and/or receipt of any prior health care services.
139
CCHP STAR Kids PM 122020
140
Medical Necessity Screening Criteria
InterQual® Criteria are utilized by non-physician reviewers (Licensed Nurses/
Therapists) to determine medical necessity and appropriateness for medical inpatient
concurrent review, inpatient site of service appropriateness, home health, inpatient
rehabilitation, and procedures. The Texas Medicaid Provider Procedures Manual and
internally developed criteria are also used to determine medical necessity and
appropriate level of care. All criteria are based upon recognized standards of care. All
criteria are reviewed and approved at least annually by physicians through the Cook
Children’s Health Plan Medical Management and Quality Committees. Criteria utilized in
the medical necessity review of a service request are faxed upon request.
Medicaid Member Medical Necessity Denials & Appeals
Medicaid Member Notices of Action (Denials)
Cook Children’s Health Plan must notify Members and Providers when it takes an
Action. An Action includes the denial or limited authorization of a requested service,
including the type or level of service; the reduction, suspension, or termination of a
previously authorized service; or the denial, in whole or in part, of payment for a service.
Only the Cook Children’s Health Plan Medical Director or the Physician Designee may
render a denial for lack of medical necessity (adverse determination).
Medicaid Standard Member Appeal
When Cook Children’s Health Plan denies or limits a covered benefit (Action), the
Member or his or her authorized representative may file an Appeal within sixty (60) days
from receipt of the Notice of Action. The Member may request that any person or entity
act on his or her behalf with the Member’s written consent. A health care provider may
be an authorized representative. A representative from the health plan can assist the
Member in understanding and using the Appeal process. If the Member needs help in
filing an appeal, they can contact the Member Services Department and a Customer
Care Representative will assist them. The health plan representative can also assist the
Member in writing or filing an Appeal and monitoring the health plan appeal through the
process until the issue is resolved. Appeals received orally must be confirmed by a
written, signed appeal by the Member or his or her authorized representative, unless an
Expedited Appeal is requested.
Within five (5) business days of receipt of the appeal request, Cook Children’s Health
Plan will send a letter acknowledging receipt of the appeal request. The Member may
continue receiving services during the appeal if the appeal is filed within ten (10)
business days of the Notice of Action or prior to the effective date of the denial,
whichever is later. The Member is advised in writing that he or she may have to pay for
140
CCHP STAR Kids PM 122020
141
the services if the denial is upheld. If the appeal resolution reverses the denial, Cook
Children’s Health Plan will promptly authorize coverage. The Member must request to
continue services during the appeal process.
The Standard Appeal Process must be completed within thirty (30) calendar days after
receipt of the request for appeal. The timeframe for a standard appeal may be
extended for a period of up to fourteen (14) calendar days if the Member or his or her
representative requests an extension or if Cook Children’s Health Plan shows there is
need for additional information and how the delay would be in the best interest of the
Member. Cook Children’s Health Plan provides the Member or his or her authorized
representative with a written notice of the reason for the delay.
Appeals are reviewed by individuals who were not involved in the original review or
decision to deny and are health care professionals with appropriate clinical expertise in
treating the Member’s condition or disease. Cook Children’s Health Plan provides a
written notice of the appeal determination to the Appellant. If the appeal decision
upholds the original decision to deny a service, Members receive information regarding
their right to request an external review (Fair Hearing). The Member may request a
State Fair Hearing within one hundred-twenty (120) days.
Medicaid Member Expedited Appeal
Members or their authorized representatives may request an Expedited Appeal either
orally or in writing within sixty (60) days (or ten (10) business days to ensure
continuation of currently authorized services) from receipt of the Notice of Action or the
intended effective date of the proposed Action. A representative from the health plan
can assist the Member in understanding and using the Appeal process. If the Member
needs help in filing an appeal, they can contact the Member Services Department and a
Customer Care Representative will assist them. The health plan representative can also
assist the Member in writing or filing an Appeal and monitoring the health plan appeal
through the process until the issue is resolved.
If Cook Children’s Health Plan denies a request for an Expedited Appeal, the health
plan transfers the appeal to the standard appeal process, makes a reasonable effort to
give the Appellant prompt oral notice of the denial, and follows up within two (2)
calendar days with a written notice. Investigation and resolution of expedited appeals
relating to an ongoing emergency or denial of a continued hospitalization are completed
(1) in accordance with the medical or dental immediacy of the case and (2) not later
than one (1) business day after receiving the Member’s request for Expedited Appeal.
141
CCHP STAR Kids PM 122020
142
Except for an Expedited Appeal relating to an ongoing emergency or denial of continued
hospitalization, the time period for notification to the Appellant of the appeal resolution
may be extended up to fourteen (14) calendar days if the Member requests an
extension or Cook Children’s Health Plan shows that there is a need for additional
information and how the delay is in the Member’s best interest. If the timeframe is
extended, the health plan will provide the Member with a written notice for the delay if
the Member had not requested the delay.
When the timeframe is extended by the Member, the health plan sends a letter
acknowledging receipt of the Expedited Appeal request and the request for an
extension. An individual who was not involved in the original review or decision to deny
and is a health care professional with appropriate clinical expertise in treating the
Member’s condition or disease renders the appeal determination. Cook Children’s
Health Plan provides the Appellant a written notice of the appeal resolution. If the
appeal decision upholds the original decision to deny a service, Members receive
information regarding their right to request an external review (Fair Hearing).
Medicaid Members Access to State Fair Hearing
Can a Member ask for a State Fair Hearing?
If a Member, as a Member of the health plan, disagrees with the health plan’s decision,
the Member has the right to ask for a fair hearing. The Member may name someone to
represent him or her by writing a letter to the health plan telling the MCO the name of
the person the Member wants to represent him or her. A provider may be the Member’s
representative. The Member or the Member’s representative must ask for the Fair
Hearing within ninety (90) days of the date on the health plan’s letter that tells of the
decision being challenged. If the Member does not ask for the Fair Hearing within ninety
(90) days, the Member may lose his or her right to a Fair Hearing.
To ask for a fair hearing, the Member or the Member’s representative should either call
the health plan at 800-862-2488 or send a letter to:
Cook Children’s Health Plan
Attention: Denial and Appeal Coordinator
PO Box 2488
Fort Worth, TX 76101-2488
If the Member asks for a Fair Hearing within ten (10) business days from the time the
Member gets the hearing notice from the health plan, the Member has the right to keep
getting any service the health plan denied, at least until the final hearing decision is
made. If the Member does not request a fair hearing within ten (10) business days from
142
CCHP STAR Kids PM 122020
143
the time the Member gets the hearing notice, the service the health plan denied will be
stopped.
If the Member asks for a fair hearing, the Member will get a packet of information letting
the Member know the date, time and location of the hearing. Most fair hearings are held
by telephone. At that time, the Member or the Member’s representative can tell why the
Member needs the service the health plan denied.
The Health and Human Services Commission (HHSC) will give the Member a final
decision within ninety (90) days from the date the Member asked for the hearing.
If the Member or the Member’s representative is not satisfied with the outcome of the
Cook Children’s Health Plan Appeal Process, they may file a complaint with:
Texas Department of Insurance
Attention: Mail Code 103-6A
PO Box 149104
Austin, TX 78714-9104
Phone: 866-554-4926
Care Transition (Discharge Planning) and Youth to Adult
Cook Children’s Health Plan Service Coordinators work collaboratively with facility
discharge planners and Case Managers to assure a seamless transition from hospital
based care to home, sub-acute care or long term services and supports. Cook
Children’s Health Plan requests that facilities arrange post hospital services from in
network Providers for all Member discharges. This is required for Members with Cook
Children’s Health Plan as primary coverage and it is requested for those with presumed
secondary coverage by the health plan. This practice assures the best outcome should
coverage change unexpectedly due to the family electing to maintain Cook Children’s
Health Plan coverage rather than enrolling the child in other commercial insurance or if
coverage ends due to loss of job or eligibility. Using in network Providers also assists
our health plan Members with primary commercial coverage when using their Cook
Children’s Health Plan coverage for balances for high cost services co-pay/deductibles
and when benefit maximums are reached. Cook Children’s Health Plan has adopted the
Got Transition (gottransition.org) best practice model to facilitate youth members to
adult care. In network Providers are encouraged to adopt this best practice model.
143
CCHP STAR Kids PM 122020
144
Adult Transition Planning
STAR Kids Only
Cook Children’s Health Plan will help to assure that teens and young adult Members
receive early and comprehensive transition planning to help prepare them for service
and benefit changes that will occur following their 21
st
birthday. Each MCO is
responsible for conducting ongoing transition planning starting when the Member turns
15 years old. The MCO must provide transition planning services as a team approach
through the named Service Coordinator if applicable and with a Transition Specialist
within the Member Services Division.
Role of Transition Specialist
Transition Specialists must be an employee of the MCO and wholly dedicated to
counseling and educating Members and others in their support network about
considerations and resources for transitioning out of STAR Kids. Transition Specialists
must be trained on the STAR+PLUS system and maintain current information on local
and state resources to assists the Member in the transition process. Transition planning
must include the following activities:
1. Development of a continuity of care plan for transitioning Medicaid services and
benefits from STAR Kids to the STAR+PLUS Medicaid managed care model without
a break in service.
2. Prior to the age of ten (10), the MCO must inform the Member and the Member’s
LAR regarding LTSS programs offered and, if applicable, provide assistance in
completing the information needed to apply. LTSS programs include CLASS, DBMD,
TxHmL, and HCS.
3. Beginning at the age fifteen (15), the MCO must regularly update the ISP with the
transition goals.
4. Coordination with DARS to help identify future employment and employment training
opportunities.
5. If desired by the Member or the Member’s LAR, coordination with the Member’s
school and Individual Education Plan (IEP) to ensure consistency of goals.
6. Health and wellness education to assist the Member with Self-Management.
7. Identification of other resources to assist the Member, the Member’s LAR, and
others in the Member’s support system to anticipate barriers and opportunities that
will impact the Member’s transition to adulthood.
8.
Assistance applying for community services and other supports under the
STAR+PLUS program after the Member’s 21
st
birthday.
9. Assistance identifying adult healthcare Providers.
144
CCHP STAR Kids PM 122020
145
Continuity of Care Transition Plan
The Member’s Case Manager/ Service Coordinator establishes a transition plan for
those Members who have ongoing care needs at the time eligibility terminates. The
transition plan includes coordination of care with other health plan case managers/
service coordinators as appropriate and with the Member’s/family’s consent;
identification of community resources available to meet the medical and/or psychosocial
needs of the Member when the Member will not have a funding source/insurance; and,
communication of transition plan to the Member’s Primary Care Provider.
Providers are encouraged to call the Cook Children’s Health Plan Care Management
Department at 888-243-3312 for assistance with any continuity of care/transition of care
issues. Providers may refer to the covered services section of this Provider Manual for
additional information related to Continuity of Care.
145
CCHP STAR Kids PM 122020
146
The purpose of Cook Children’s Health Plan’s Quality Management Program is to
assure that attributes of care such as accessibility, quality, effectiveness, and cost are
measured periodically for accuracy and adequacy. The goal is to provide beneficial
feedback to physicians, other Providers and Members so that Cook Children’s Health
Plan can positively influence the quality of healthcare services provided to our
Members. The Quality Management Program also evaluates non-clinical services that
influence Member and provider satisfaction with Cook Children’s Health Plan.
The Cook Children’s Health Plan Quality Management Committee reviews the
performance of the Quality Management Program at least quarterly, using performance
data obtained from internal and external sources based on a reporting calendar. The
scope of monitoring includes health plan performance, and clinical and service
performance in institutional and non-institutional settings, primary care, and major
specialty services including mental health care. The method and frequency of data
collection are defined specifically for each indicator. The integrity of the data is protected
to ensure its validity, reliability, accuracy and confidentiality. Specific goals and data
collection sources are standardized throughout the Cook Children’s Health Plan
whenever possible and include, but are not limited to, the following areas:
•
Continuous Quality Management Indicators
•
Performance Improvement Projects
•
Clinical Practice Guidelines
•
Utilization Management Data
•
Service Accessibility Assessments
•
Drug and Biological Utilization Data.
•
Provider Profiling Reports.
•
Quality of Care Occurrence Reports Member Satisfaction Surveys
•
Member Complaints, Grievances and Appeals
•
Member Services Performance
•
Medical Record and Office Site Visit Reviews.
•
Credentialing and Recredentialing
•
Provider Satisfaction Surveys
•
Delegation Audit and Oversight Reports
•
Results of Quality Management Improvement Plans (sometimes referred to as
“corrective action plans”) imposed upon contracted entities, through delegation
oversight.
146
Section 8: Quality Management Program (QMP)
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 8: Quality Management Program (QMP)
CCHP STAR Kids PM 122020
147
Practice Guidelines
Cook Children’s Health Plan relies on the use of evidence based clinical practice and
medical necessity guidelines to evaluate the quality of care, and to identify opportunities
for clinical improvement. These guidelines are adapted from national guidelines for
practice. All are reviewed, modified if appropriate, and approved by participating
Providers and the Cook Children’s Health Plan Medical Management Committee and
Quality Improvement Committee, which are composed of Primary Care Providers and a
variety of specialists. Clinical Practice Guidelines can be printed from the website at
cookchp.org, or you may call 888-243-3312 to receive a printed copy.
Performance Improvement Projects (PIPs)
Cook Children’s Health Plan is required to conduct at least two focus studies or
Performance Improvement Projects per year based on state requirements; projects
typically last two years but may extend to three years depending on the nature of the
undertaking. Cook Children’s Health Plan utilizes national standards, whenever
possible, to measure the success of the projects. Provider participation is often a critical
component to the success of these projects.
Reports on active PIPS are provided to QMC for quarterly review. The QMC maintains
accountability and authority to review the results, issue recommendations, recommend
the allocation of resources relative to PIPs, and reports these to the Cook Children’s
Health Plan Board of Trustees no less than annually.
PIPs are prioritized based upon the following principles:
•
Relevance to the Cook Children’s Health Plan business plan, mission, or
vision and potential contribution to the achievement of the strategic goals
of CCHCS
•
Relevance to high volume and/or high risk administrative and/or clinical
practices
•
Potential to improve the health of enrolled populations
•
Relevance to quality of clinical care provided
•
Relevance to Provider and/or Member satisfaction
•
Potential to produce measurable results
•
Relevance to state and federal regulatory agency requirements and/or
nationally recognized standards
Quality Indicators
Each year Cook Children’s Health Plan evaluates the effectiveness of its Quality
Improvement Program based on standards for service and quality of care established
by the National Committee for Quality Assurance (NCQA).
147
CCHP STAR Kids PM 122020
148
The following measures are a subset Healthcare Effectiveness Data and Information
Set (HEDIS) measures of quality of health care developed by the NCQA. In addition
are measures created internally to supplement HEDIS studies and are broken out in two
groups, clinical and service studies.
Clinical
•
Well-child visits in the first 15 months of life
•
Well-child visits ages 3, 4, 5, and 6 years old
•
Adolescent well-care visits
•
Childhood Immunization Status
•
Adolescent Immunization Status
•
Lead Screening in Children
•
Appropriate Testing for Children With Pharyngitis
•
Weight Assessment and Counseling for Nutrition and Physical Activity
•
Chlamydia Screening in Women
•
Comprehensive Diabetes Care
•
Controlling High Blood Pressure
•
Follow-up Care for Children Prescribed ADHD Medication
•
Prenatal and Postpartum Care
•
Metabolic Monitoring for Patients on Antipsychotics Medications
•
Provider Satisfaction
•
Member Satisfaction
•
Geographical Access Study
•
Access and Availability Study
•
Primary Care Access Study
•
Behavioral Health Care Access Study
•
Improving Medical Check-Up visits within ninety (90) days of enrollment
•
Potentially Preventable Admissions
•
Potentially Preventable Readmissions
•
Potentially Preventable Emergency Room Visits
Utilization Management Reporting Requirements
The primary responsibility for monitoring appropriate use of health services is vested
with the Medical Director of Cook Children’s Health Plan. The Medical Director will
establish Utilization Management requirements that may be revised from time-to-time to
assure the delivery of quality care in a cost-effective manner. The Medical Director will
be assisted by Registered Nurse Case Managers who will act on behalf of the Medical
Director in communicating with participating Providers. Specific requirements for the
process are as follows:
148
CCHP STAR Kids PM 122020
149
Review Process
Prospective Review
A method for reviewing and authorizing elective procedures/tests, both inpatient and
outpatient, to determine if the case meets established medical quality criteria, and is
being provided in the most efficient and cost-effective manner.
Concurrent Review
A method of reviewing and authorizing current ongoing medical care to ensure that the
level of care is appropriate, that the care meets established quality criteria, and that the
care is being delivered in the most efficient and cost effective setting.
Retrospective Review
A method of reviewing medical care provided prior to the date of review to determine if
care was provided in accordance with established medical quality criteria in the most
appropriate and cost effective setting.
149
CCHP STAR Kids PM 122020
150
Provider Complaint Process
Provider Complaint Process to Cook Children’s Health Plan
A complaint means a dissatisfaction expressed by a Complainant, orally or in writing to
the MCO, about any matter related to the MCO other than an Adverse Benefit
Determination. The complaint process does not include appeals related to medical
necessity or disenrollment decisions. A complaint does not include misinformation that is
resolved promptly by supplying the appropriate information or clearing up a
misunderstanding to the satisfaction of the complainant.
Providers that wish to file a complaint about Cook Children’s Health Plan or one of our
Members can do so by submitting their complaint in writing. Upon receipt of the
complaint the health plan will send an acknowledgement letter to the provider within five
(5) business days. Cook Children’s Health Plan will fully and completely respond to all
provider complaints within thirty (30) calendar days of receiving the complaint.
Telephone communication related to the complaint will be documented in a complaint
log. Email and fax documentation related to the complaint will be retained by the health
plan for a period of seven (7) years.
Providers may submit a written complaint as follows:
•
Faxing a written complaint to: 682-885-2148
•
Submitting a written complaint by email to: CCHPCompliance@cookchildrens.org
•
Mailing a written complaint to:
Cook Children’s Health Plan
Attn: Compliance
PO Box 2488
Fort Worth, TX 76113-2488
Provider Complaint Process to Health and Human Services Commission
If the Provider is not happy with the resolution of the complaint, they have the right to
file a complaint with the Health and Human Services Commission (HHSC). When filing
a complaint with HHSC, Providers must send a letter within sixty (60) calendar days of
receiving Cook Children’s Health Plan’s resolution letter. The letter must explain the
specific reasons you believe Cook Children’s Health Plan’s complaint resolution is
incorrect. The complaint should include:
150
Section 9: Complaints
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 9: Complaints
CCHP STAR Kids PM 122020
151
•
All correspondence and documentation sent to Cook Children’s Health Plan,
including copies of supporting documentation submitted during the complaint
process
•
All correspondence and documentation you received from Cook Children’s
Health Plan
•
All R&S reports of the claims/ services in question, if applicable
•
Provider’s original claim/billing record, electronic or manual, if applicable
•
Provider internal notes and logs when pertinent
•
Memos from the state or health plan indicating any problems, policy changes, or
claims processing discrepancies that may be relevant to the complaint
•
Other documents, such as certified mail receipts, original date-stamped
envelopes, in service notes, or minutes from meetings if relevant to the
complaint. Receipts can be helpful when the issue is late filing
When filing a complaint with Health and Human Services Commission, Providers must
submit a letter to the following address:
Texas Health and Human Services Commission
Re: Provider Complaint
Health Plan Operations, H-320
PO Box 85200
Austin, TX 78708
Member Complaint Process
Member’s Right to File Complaints to Cook Children’s Health Plan
A Member, or the Member’s authorized representative (Member), has the right to file a
complaint either orally or in writing. Cook Children’s Health Plan will resolve all
complaints within thirty (30) calendar days from the date the complaint is received. If the
Member needs help in filing a complaint, they can contact the Member Services
Department and a Customer Care Representative will assist them. Members can file a
complaint with Cook Children’s Health Plan by calling 682-303-0004 or toll free at
844-843-0004 or in writing to:
Cook Children’s Health Plan
Attn: Compliance
PO Box 2488
Fort Worth, TX 76113-2488
151
CCHP STAR Kids PM 122020
152
Member’s Right to File Complaints to Health and Human Services Commission
If the Member is not satisfied with the resolution of the complaint, they may also file a
complaint directly with the Health and Human Services Commission (HHSC). The
Member can call HHSC at toll-free 1-866-566-8989. If making a Complaint in writing,
the Member must send a letter to:
Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, Texas 78711-3247
If the Member has access to the internet, they can submit their complaint at:
hhs.texas.gov/managed-care-help
No Retaliation
Cook Children’s Health Plan will not punish a child or other person for:
•
filing a complaint against Cook Children’s Health Plan or
•
appealing a decision made by Cook Children’s Health Plan
152
CCHP STAR Kids PM 122020
153
Cook Children’s Health Plan has contracted with, and will work in partnership with,
Beacon Health Options LLC to manage the delivery of mental health and substance use
disorder services for STAR Kids Members.
The primary goal of the program is to provide medically necessary care in the most
clinically appropriate and cost-effective therapeutic settings. By ensuring that all Cook
Children’s Health Plan Members receive timely access to clinically appropriate
behavioral health care services, Cook Children’s Health Plan and Beacon Health
Options believe that quality clinical services can achieve improved outcomes for our
Members.
Improved health outcomes can be achieved by providing Members with access to a full
continuum of mental health and substance use services through our network of
contracted behavioral health Providers.
Definition of Behavioral Health
Behavioral Health is defined as both acute and chronic psychiatric and substance use
disorders as referenced in the most recent Diagnostic and Statistical Manual of Mental
Disorders (DSM) of the American Psychiatric Association.
Behavioral Health Scope of Services
Cook Children’s Health Plan will coordinate the behavioral health services, which
include, but are not limited to, the services listed in the STAR Kids covered services
section. These services include acute, diversionary and outpatient services.
Cook Children’s Health Plan will work with participating behavioral health care
practitioners, Primary Care Providers, medical/surgical specialists, organizational
Providers and other community and state resources to develop relevant primary and
secondary prevention programs for behavioral health. These programs may include:
•
educational programs to promote prevention of substance use
•
parenting skills training
•
developmental screening for children
•
Attention Deficit Hyperactivity Disorder (ADHD) screening
•
postpartum depression screening
153
Section 10: Behavioral Health Program
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 10: Behavioral Health Program
CCHP STAR Kids PM 122020
154
Primary Care Provider Requirements for Behavioral Health
Primary Care Providers may provide behavioral health services within the scope of their
practice. Primary Care Providers are responsible for coordinating the Member‘s physical
and behavioral healthcare, including making referrals to behavioral health Providers
when necessary. Primary Care Providers should submit claims to Cook Children’s
Health Plan for consideration and not to Beacon Health Options.
This section does not apply to STAR Kids Dual Eligible Members
Role of a Health Home
Cook Children’s Health Plan and Beacon Health Options are committed to providing a
consistent and integrated source of healthcare for our STAR Kids Members through a
person centered Health Home. Primary Care Providers coordinate with Members,
caregivers, other Providers, STAR Kids Service Coordinators, and state and non-state
entities to assure that the Member’s medical and behavioral health needs are met.
Other Primary Care Provider requirements include screening, identification, and referral
to medically necessary or functionally necessary covered services and assessment and
coordination of non-clinical services that impact the Member’s health.
Referrals
Cook Children’s Health Plan Members can self-refer to any in network behavioral health
provider they do not require referrals from their Primary Care Provider for initial
evaluation for behavioral health treatment from an in network behavioral health provider.
All behavioral health services which require prior authorization must be coordinated
through Beacon Health Options.
The following circumstances indicate that a referral to a physician is recommended:
•
Member is receiving psychoactive medication for an emotional or behavioral
problem or condition
•
Member has significant medical problems that impact his/her emotional well-
being
•
Member is having suicidal and/or homicidal ideations
•
Member has delirium, amnesia, a cognitive disorder, or other condition for which
there is a probable medical (organic) etiology
•
Member has a substance use disorder such as substance-induced psychosis,
substance induced mood disorder, substance induced sleep disorder, etc.
•
Member has or is likely to have a psychotic disorder, major depression, bipolar
disorder, panic disorder, or eating disorder
154
CCHP STAR Kids PM 122020
155
•
Member is experiencing severe symptoms or severe impairment in level of
functioning or has a condition where there is a possibility that a pharmacological
intervention will significantly improve the Member’s condition
•
Member has another condition where there is a significant possibility that somatic
treatment would be of help. Conditions include dysthymia, anxiety, adjustment
disorders, post-traumatic stress disorders, and intermittent explosive disorders
•
Member has a substance abuse problem
Member Consent for Disclosure of Information
The Primary Care Provider is required to obtain consent for disclosure of information
from the Member to permit the exchange of clinical information between the behavioral
health provider and the Member‘s Primary Care Provider. If the Member refuses to
release the information, they will sign the consent for disclosure of information that
indicates their refusal to release the information. The provider will document the
reason(s) for declination in the medical record. A sample Member Consent for
Disclosure of Information form is located in the Appendix section of this provider
manual.
Covered Services
The following is a non-exhaustive, high-level listing of acute care covered services
included under the STAR Kids Program. For a complete listing of the limitations and
exclusions that apply to each Medicaid benefit category, Providers should refer to the
current Texas Medicaid Provider Procedures Manual at tmhp.com. These services are
subject to modification based on federal and state mandates.
A Primary Care Provider referral is not required to access behavioral health services.
STAR Kids covered behavioral health services include, but are not limited to, medically
necessary:
•
Inpatient mental health services
•
Acute inpatient mental health services
•
Outpatient mental health services for children
o
When outpatient psychiatric services are ordered by a court of competent
jurisdiction under the provisions of Chapters 573 and 574 of the Texas
Health and Safety Code, relating to court-ordered commitments to
psychiatric facilities, the court order serves as binding determination of
medical necessity. Any modification or termination of services must be
presented to the court with jurisdiction over the matter for determination.
o
A qualified mental health provider – Community Services (QMHP-CS) is
defined by the Texas Department of State Health Services (DSHS) in Title
155
CCHP STAR Kids PM 122020
156
25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1, §412.303(48).
QMHP-CSs shall be Providers working through a DSHS-contracted Local
Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs
shall be supervised by a licensed mental health professional or physician
and provide services in accordance with DSHS standards. Those services
include individual and group skills training (which can be components of
interventions, such as day treatment and in home services), patient and
family education, and crisis services.
•
Psychiatry services
•
Outpatient substance use disorder treatment services, including:
o
Assessment
o
Detoxification services
o
Counseling treatment
o
Medication-assisted therapy
•
Residential substance use disorder treatment services including:
o
Detoxification services
o
Substance use disorder treatment (including room and board)
These services are not subject to the quantitative treatment limitations that apply
under traditional, fee-for-service Medicaid coverage. The services may be subject to
Cook Children’s Health Plan’s non-quantitative treatment limitations, provided such
limitations comply with the requirements of the Mental Health Parity and Addiction
Equity Act of 2008
•
Emergency services
•
Hospital services, including inpatient and outpatient
o
Cook Children’s Health Plan may provide inpatient services for acute
psychiatric conditions in a free-standing psychiatric hospital in lieu of an
acute inpatient hospital setting
o
Cook Children’s Health Plan may provide substance use disorder
treatment services in a chemical dependency treatment facility in lieu of an
acute care inpatient hospital setting
Behavioral health services that are offered to STAR Kids are:
•
reasonable and necessary for the diagnosis or treatment of a mental health or
chemical dependency disorder, or to improve, maintain, or prevent deterioration
of functioning resulting from such a disorder
•
in accordance with professionally accepted clinical guidelines and standards of
practice in behavioral health care
156
CCHP STAR Kids PM 122020
157
•
furnished in the most appropriate and least restrictive setting in which services
can be safely provided
•
the most appropriate level or supply of service that can safely be provided;
•
could not be omitted without adversely affecting the Member’s mental and/or
physical health or the quality of care rendered
•
not experimental or investigative, and not primarily for the convenience of the
Member or provider
Other elements of Members receiving behavioral health services are:
•
Member may self-refer to any network behavioral health provider.
•
Member has the right to obtain medication from any network pharmacy.
•
Primary Care Provider may refer a Member to a behavioral health provider.
•
Coordination between behavioral health and physical health services.
•
Member has the right to obtain a second opinion.
•
Medical records and referral information must be documented using the most
current edition of DSM classifications.
•
Authorization to release confidential information, such as medical records
regarding treatment, should be signed by the patient or guardian prior to
receiving care from a behavioral health provider.
•
Members under the age of twenty-one (21) will be provided inpatient psychiatric
services, up to the annual limit, who have been ordered to receive the services
by a court of competent jurisdiction.
•
Coordination will be conducted with the Local Mental Health Authority (LMHA)
and state psychiatric facilities regarding admission and discharge planning,
treatment objectives, and projected length of stay for Members committed by a
court of law to the state psychiatric facility.
•
Assessment documents for behavioral health will be made available for the use
of Primary Care Providers.
•
Beacon Health Options and Cook Children’s Health Plan will work together to
ensure that quality behavioral health services are provided to all Members. This
coordination will include focus studies and utilization management reporting.
•
Providers will make contact with the Member within twenty-four (24) hours of a
missed appointment for the purposes of rescheduling.
•
Members who are discharged from an inpatient psychiatric facility will have a
follow-up appointment within seven (7) days from the date of discharge by the
provider.
Non covered Services
Members may access local community resources for behavioral health services that are
not covered. Services may be sought through the local office of the Texas Department
157
CCHP STAR Kids PM 122020
158
of State Health Services (DSHS) or located through the Texas 211 website at
211texas.org.
Members may also receive services through the Local Mental Health Authority (LMHA).
The LMHA accepts patients with chronic mental health disorders (i.e. schizophrenia, bi-
polar disorder, severe major depression). In the event that a Cook Children’s Health
Plan STAR Kids Member will need to access services through the local mental health
authority, the health plan in coordination with Beacon Health Options Case
Management staff will assist the Member through the LMHA system of care.
Accessible Intervention and Treatment
Cook Children’s Health Plan promotes early intervention and health screening for
identification of behavioral health problems and patient education. Providers are
expected to:
•
Screen, evaluate, treat and/or refer (as medically appropriate) any behavioral
health problem. Primary Care Providers may treat for mental health and/or
substance use disorders within the scope of their practice and bill using the DSM
codes.
•
Inform Members how and where to obtain behavioral health services.
•
Understand that Members may self-refer to any behavioral health care provider
without a referral from the Member’s Primary Care Provider.
Providers who need to refer Members for further behavioral health care should contact
Beacon Health Options. Beacon Health Options continuously evaluates Providers who
offer services to monitor ongoing behavioral health conditions, such as regular lab or
ancillary medical tests and procedures.
Prior Authorization
Prior authorization may be required prior to seeing a behavioral health provider. Call
Beacon Health Options customer service toll free at 855-481-7045 for an authorization
or for any questions regarding mental health benefits for Cook Children’s Health Plan
STAR Kids Members. The Behavioral Health Hotline is available twenty-four (24) hours
a day, seven (7) days a week.
Service Coordination
Beacon Health Options Behavioral Health Coordinators serve as the primary Service
Coordinators for Members with a primary behavioral health diagnosis, and are
responsible for coordination across the continuum of care as an adjunct to the CCHP
designated Service Coordination Team and are dedicated to the population of Cook
Children’s Health Plan STAR Kids Membership.
158
CCHP STAR Kids PM 122020
159
Emergency Services
Emergency services are those physician and outpatient hospital services, procedures,
and treatments, including psychiatric stabilization and medical detoxification from drugs
or alcohol, needed to evaluate or stabilize an emergency medical condition. The
definition of an emergency medical condition follows:
Covered inpatient and outpatient services furnished by a provider that is qualified to
furnish such services under the Contract and that are needed to evaluate or stabilize an
Emergency Medical Condition and/or an Emergency Behavioral Health Condition,
including Post-stabilization Care Services. The provider should direct the Member to call
911 or go to the nearest emergency room or comparable facility if the provider
determines an emergency behavioral health condition exists.
Emergency Screening and Evaluation
Plan Members must be screened for an emergency medical condition by a qualified
behavioral health professional from the hospital emergency room, or by an emergency
service program (ESP). This process allows Members access to emergency services as
quickly as possible and at the closest facility or by the closest crisis team.
After the emergency evaluation is completed, the facility or program clinician should call
Beacon Health Options to complete a clinical review, if admission to a level of care that
requires prior authorization is needed.
The facility/program clinician is responsible for locating a bed, but may request
Beacon’s assistance. Beacon Health Options may contact an Out-of-Network facility in
cases where there is not a timely or appropriate placement available within the network.
In cases where there is no in network or Out-of-Network psychiatric facility available,
Beacon Health Options will authorize boarding the Member on a medical unit until an
appropriate placement becomes available.
Beacon Clinician Availability
All Beacon Health Options clinicians are experienced licensed clinicians who receive
ongoing training in crisis intervention, triage and referral procedures. Beacon Health
Options clinicians are available twenty-four (24) hours a day, seven (7) days a week, to
take emergency calls from members, their guardians, and Providers. If Beacon Health
Options does not respond to the call within thirty (30) minutes, authorization for
medically necessary treatment can be assumed and the reference number will be
communicated to the requesting facility/provider by the Beacon Health Options UR
clinician within four (4) hours.
159
CCHP STAR Kids PM 122020
160
Outpatient Benefits
Outpatient behavioral health treatment is an essential component of a comprehensive
health care delivery system. Cook Children’s Health Plan Members may access
outpatient mental health and substance use services by self-referring to a network
provider, by calling Beacon Health Options, or by referral through acute or emergency
room encounters. Members may also access outpatient care by referral from their
Primary Care Provider; however, a Primary Care Provider referral is never required for
behavioral health services.
Inpatient Benefits
Cook Children’s Health Plan and Beacon Health Options are responsible for authorizing
inpatient hospital services, which includes services provided in freestanding psychiatric
facilities for STAR Kids Members.
Attention Deficit Hyperactivity Disorder (ADHD)
Treatment of children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD),
including follow-up care for children who are prescribed ADHD medication, is covered
as outpatient mental health services. Cook Children’s Health Plan will reimburse
Providers for the treatment of Attention Deficit Hyperactivity Disorder in children who are
eligible Members as well as for any follow-up visits with children for whom they have
prescribed medications to treat ADHD.
Cook Children’s Health Plan requests that the Primary Care Provider complete a visit
with a Member prescribed Attention Deficit Hyperactivity Disorder medications within
thirty (30) days of starting the medication to evaluate efficacy and assess adverse side
effects before prescribing further medication.
Coordination, Treatment and Scope of Services
Coordination of Care
Behavioral health service Providers are expected to communicate at least quarterly and
more frequently, if necessary, regarding the care provided to each Member with other
behavioral health service Providers and Primary Care Providers. Behavioral health
service Providers are required to refer Members with known or suspected and untreated
physical health problems or disorders to their Primary Care Provider for examination
and treatment. Copies of prior authorization forms, referral forms and other relevant
communication between Providers should be maintained in both Providers’ files for the
Member. Coordination of care is vital to ensuring Members receive appropriate and
timely care.
160
CCHP STAR Kids PM 122020
161
Coordination between Physical and Behavioral Health
Cook Children’s Health Plan is committed to coordinating medical and behavioral care
for Members who will be appropriately screened, evaluated, treated and/or referred for
physical health, behavioral health or substance use, dual or multiple diagnoses, mental
retardation, or developmental disabilities. Cook Children’s Health Plan and Beacon
Health Options will designate behavioral health liaison personnel to facilitate
coordination of care and case management efforts.
Coordination with the Local Behavioral Health Authority
Cook Children’s Health Plan will coordinate with the Local Mental Health Authority
(LMHA) and state psychiatric facilities regarding admission and discharge planning,
treatment objectives and projected length of stay for Members committed by a court of
law to the state psychiatric facility. Cook Children’s Health Plan will comply with
additional behavioral health services requirements relating to coordination with the
Local Mental Health Authority and care for special populations. Covered services will be
provided to Members with Severe and Persistent Mental Illness (SPMI) Severe
Emotional Disturbance (SED) when medically necessary, whether or not they are
receiving targeted case management or rehabilitation services through the Local Mental
Health Authority.
Court-Ordered Commitments
A “Court-Ordered Commitment” means a confinement of a Member to a psychiatric
facility for treatment that is ordered by a court of law pursuant to the Texas Health and
Safety Code, Title VII, Subtitle C. Cook Children’s Health Plan is required to provide
inpatient psychiatric services as a condition of probation to Members under the age of
twenty one (21), up to the annual limit, who have been ordered to receive the services
by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the
Texas Health and Safety Code, related to Court-Ordered Commitments to psychiatric
facilities.
Cook Children’s Health Plan will not deny, reduce or controvert the medical necessity of
inpatient psychiatric services provided pursuant to a Court-Ordered Commitment for
Members under age twenty-one (21). Any modification or termination of services will be
presented to the court with jurisdiction over the matter for determination. A Member
who has been ordered to receive treatment under the provisions of the Texas Health
and Safety Code cannot appeal the commitment through Cook Children’s Health Plan’s
complaint or appeals process.
161
CCHP STAR Kids PM 122020
162
Cook Children’s Health Plan will comply with utilization review of chemical dependency
treatment. Chemical dependency treatment must conform to the standards set forth in
the Texas Administrative Code.
Members Discharged from Inpatient Psychiatric Facilities
Cook Children’s Health Plan requires that all Members receiving inpatient psychiatric
services must be scheduled for outpatient follow up and/or continuing treatment prior to
discharge. The outpatient treatment must occur within seven (7) days from the date of
discharge. The provider must follow up with the Member and attempt to reschedule
missed appointments.
Transitioning Members from One Behavioral Health Provider to Another
If a Member transfers from one behavioral health provider to another, the transferring
provider must communicate the reason(s) for the transfer along with the information
above (as specified for communication from behavioral health provider to Primary Care
Provider), to the receiving provider.
Treatment Record Reviews
Cook Children’s Health Plan reviews Member records and uses data generated to
monitor and measure provider performance in relation to the Treatment Record
Standards and specific quality initiatives established each year. The following elements
are evaluated:
•
use of screening tools for diagnostic assessment of substance use, and Attention
Deficit Hyperactivity Disorder (ADHD)
•
continuity and coordination with primary care Providers and other treaters
•
explanation of Member rights and responsibilities
•
inclusion of all applicable required medical record elements as listed below
•
allergies and adverse reactions; medications; physical exam
Cook Children’s Health Plan may conduct chart reviews on site at a provider facility, or
may ask a provider to copy and send specified sections of a Member’s medical record
to the health plan or Beacon Health Options. HIPAA regulations permit Providers to
disclose information without patient authorization for the following reasons: “oversight of
the health care system, including quality assurance activities.” Cook Children’s Health
Plan and Beacon Health Options chart reviews fall within this area of allowable
disclosure.
Screening for Depression
Documentation in the medical record is required to demonstrating the use of a nationally
recognized standardized screening instrument AND the outcome of the screen.
162
CCHP STAR Kids PM 122020
163
Although it is expected the instrument will be used most frequently in Primary Care, it is
accepted if the standardized instrument is used in another clinic. Approved screening
instruments include:
•
PRIME-MD (2 question screen used by Whooley & colleagues)
•
MOS Depression items (recommended for patients under age sixty (60)
•
CEB-D (5 item brief version developed as screening instrument for patients age
sixty (60) and over)
•
SSDS-PC
•
PHQ-2 & PHQ-9
•
CESD (5, 10, or 20 item version)
•
BDI-S (13 item version)
•
BDI (21 items)
•
Hamilton Rating Scale for Depression
•
DSM criteria for MDD
•
Williams et al one-item screener
A standardized instrument must be used. The name and a copy of the specific
instrument must be made available to the EPRP abstractor. Selecting questions from
different standardized instruments and creating a ‘new’ tool is NOT acceptable. Any
instrument not included in the list below needs to be discussed with the Office of Quality
and Performance.
Some facilities utilize a 2-step screening process; a first brief screen such as PRIME
MD, then if positive a tool with more sensitivity (e.g. Beck Depression). Another
Depression Screening tool is Center for Quality Assessment and Improvement in Mental
Health (CQAIMH) located at: http://www.cqaimh.org/pdf/tool_phq2.pdf.
A list of depression screening tools is located in the Appendix section of this provider
manual.
Targeted Case Management (TCM) and Mental Health Rehabilitative Services
(MHR)
Definition of Severe and Persistent Mental Illness (SPMI):
•
mental illness with complex symptoms that require ongoing treatment and
management, most often consisting of varying types and dosages of medication
and therapy
Definition of Severe Emotional Disturbance (SED):
•
a serious emotional disturbance means a diagnosable mental, behavioral, or
emotional disorder that severely disrupts a child's or adolescent's ability to
163
CCHP STAR Kids PM 122020
164
function socially, academically, and emotionally, at home, in school, or in the
community, and has been apparent for more than a six month period
Member Access to and Benefits of MHR and TCM
Mental health rehabilitative services and mental health targeted case management are
available to STAR Kids recipients who are assessed and determined to have:
•
a severe and persistent mental illness such as schizophrenia, major depression,
bipolar disorder or other severely disabling mental disorder
•
children and adolescents ages three (3) through seventeen (17) years with a
diagnosis of a mental illness or who exhibit a serious emotional disturbance
Targeted Case Management
•
must be face to face
•
include regular, but at least annual, monitoring of service effectiveness
•
proactive crisis planning and management for individuals
Provider Requirements
•
training and certification to administer Adult Needs and Strengths Assessment
(ANSA) can be found at https://hhs.texas.gov/doing-business-hhs/provider-
portals/behavioral-health-services-Providers/comprehensive-Providers/adult-
needs-strengths-assessment
•
training and certification to administer Child and Adolescent Needs and Strengths
(CANS) can be found at https://hhs.texas.gov/doing-business-hhs/provider-
portals/behavioral-health-services-Providers/comprehensive-Providers/child-
adolescent-needs-strengths-assessment
•
Providers must follow current Resiliency and Recovery Utilization Management
Guidelines (RRUMG) found at https://hhs.texas.gov/about-hhs/process-
improvement/behavioral-health-services/texas-resilience-recovery
•
attestation from Provider entity to MCO that organization has the ability to
provide, either directly or through sub-contract, the Members with the full array of
MHR and TCM services as outlined in the RRUMG
•
HHSC-established qualification and supervisory protocol, this criteria is located in
Chapter 15.1 of the HHSC Uniform Managed Care Manual
Providers must also complete the Mental Health Rehab and/or Targeted Case
Management Request forms and submit them to Beacon Health Options. All
authorizations and claims processing must be submitted to Beacon Health Options.
Authorization forms can be faxed to 855-371-9227.
164
CCHP STAR Kids PM 122020
165
Focus Studies and Utilization Reporting Requirements
Cook Children’s Health Plan, along with Beacon Health Options, has integrated
behavioral health into its Quality Assessment and Performance Improvement (QAPI)
Program to ensure a systematic and ongoing process for monitoring, evaluating and
improving the quality and appropriateness of behavioral health services provided to
health plan Members. Beacon provides data related to, but not limited to: Inpatient
Average Length of Stay, admitting diagnosis, aftercare appointments kept. For
Outpatient services, Beacon reports to the Health Plan, data related to, but not limited
to: penetration rate of outpatient services, diagnosis treated, and number of encounters.
A special focus of these activities is the improvement of physical health outcomes
resulting from behavioral health integration into the Member’s overall care. Cook
Children’s Health Plan will routinely monitor claims, encounters, referrals and other data
for patterns of potential over- and under-utilization, and target areas where opportunities
to promote efficient and effective use of services exist.
Behavioral Health Quality Improvement Studies
Formal quality improvement studies for behavioral health are designed with input from a
multi-disciplinary team/committee to ensure valid findings. Data is collected from an
administrative database, medical record reviews, surveys and office site visits. Clinical
and preventive service studies will in most instances be based on measurement against
clinical guidelines.
In additions, both clinical and service indicators will be trended and reported.
Performance Improvement Projects (PIP) such as HEDIS Follow-Up after
Hospitalization for Mental Illness will be conducted on an annual basis. The findings
from these reviews will be communicated to Providers, as applicable. Questions may
be directed to Cook Children’s Health Plan Quality Management Department toll free at
888-243-3312.
Programmatic success is dependent upon the development of a strong neighborhood
provider, hospital and ancillary provider network that actively interacts with behavioral
health Providers to meet the needs of the Cook Children’s Health Plan Members.
Through both formal and informal interaction with Providers on the results of studies,
provider data sharing, availability of resource information and timely feedback on areas
for improvement, Cook Children’s Health Plan will provide support to assist Providers in
delivering the highest quality of care and service to Members in the most satisfaction
surveys, complaints, grievances, and feedback from the Community/Member Advisory
Committee. Cook Children’s Health Plan has the opportunity to meet and exceed the
needs of the communities that it serves.
165
CCHP STAR Kids PM 122020
166
1915(i) Home and Community Based Services- Adult Mental Health (HCBS-AMH)
Home and Community Based Services-Adult Mental Health (HCBS-AMH) is a state-
wide program that provides home and community–based services to adults with serious
mental illness. The HCBS-AMH program provides an array of services, appropriate to
each Member’s needs, to enable him or her to live and experience successful tenure in
their chosen community. Services are designed to support long term recovery from
mental illness.
Community Living Assistance and Support Services (CLASS) Waiver Program
The Community Living Assistance and Support Services (CLASS) program provides
home and community-based services to people with related conditions as a cost-
effective alternative to an intermediate care facility for individuals with an intellectual
disability or related conditions (ICF/IID). A related condition is a disability, other than an
intellectual disability, that originated before age 22 that affects the ability to function in
daily life.
Deaf Blind with Multiple Disabilities (DBMD) Waiver Program
The Deaf Blind with Multiple Disabilities (DBMD) program provides home and
community-based services to people who are deaf blind and have another disability.
This is a cost-effective alternative to an intermediate care facility for individuals with an
intellectual disability or related conditions (ICF/IID). The DBMD program focuses on
increasing opportunities for consumers to communicate and interact with their
environment.
Dual-Eligible
Medicaid recipients who are also eligible for Medicare
Home and Community-based Services (HCS) Waiver Program
The Home and Community-based Services (HCS) program provides individualized
services and supports to people with intellectual disabilities who are living with their
families, in their own homes or in other community settings, such as small group homes
where no more than four people live. The local authority provides service coordination.
Long Term Services and Supports (LTSS)
LTSS means assistance with daily healthcare and living needs for individuals with a
long-lasting illness or disability.
166
Section 11: Glossary of Terms
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 11: Glossary of Terms
CCHP STAR Kids PM 122020
167
Medical Dependent Children Program (MDCP) Waiver Program
The Medically Dependent Children Program (MDCP) provides services to support
families caring for children who are medically dependent and encourages the transition
of children in nursing homes back to the community.
Texas Home Living (TxHmL) Waiver Program
The Texas Home Living (TxHmL) program provides selected essential services and
supports to people with an intellectual disability or a related condition who live in their
own home or their family’s home.
Youth Empowerment Services (YES) Waiver Program
The Youth Empowerment Services (YES) waiver provides comprehensive home and
community-based mental health services to youth between the ages of 3 and 18, up to
a youth’s 19
th
birthday, who have a serious emotional disturbance. The YES Waiver not
only provides flexible supports and specialized services to children and youth at risk of
institutionalization and/or out-of-home placement due to their serious emotional
disturbance, but also strives to provide hope to families by offering services aimed at
keeping children and youth in their homes and communities.
167
CCHP STAR Kids PM 122020
168
113
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federally
mandated health care program of prevention, diagnosis, and treatment for Medicaid
recipients from birth through twenty (20) years of age.
In Texas, the EPSDT program is known as Texas Health Steps (THSteps). Texas Health
Steps is administered by the Department of State Health Services (DSHS). For more
information regarding Texas Health Steps services, providers should refer to the Texas
Medicaid Provider Procedures Manual at tmhp.com or the Texas Health Steps website at
hhs.texas.gov.
How Do I Become a Texas Health Steps Provider?
To enroll in Texas Medicaid, providers must complete and submit the appropriate Texas
Medicaid enrollment application, including all required forms as indicated in the
application.
There are two ways providers may enroll:
To apply online, visit tmhp.com and follow the instructions for completing the online
enrollment process. Download, print, and complete the application forms.
To submit a paper application, you will need to download the enrollment forms.
You can access these forms by clicking the Forms button on a Medicaid Provider
web page. The forms you need are under the Provider Enrollment section. You
can also request an enrollment package from Texas Medicaid & Healthcare
Partnership (TMHP) by phone at 800-925-9126 or by mail at:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
For enrollment assistance please contact the Texas Medicaid & Healthcare Partnership
Contact Center 800-925-9126 option 2 or send an email to
Provider.Enrollment.Mailbox@tmhp.com to request assistance with enrollment
questions.
Texas Health Steps Medical Checkups Periodicity Schedule
Providers are required to administer a complete Texas Health Steps medical checkup for
Members from birth through age twenty (20), in accordance with the Texas Health Steps
Periodicity Schedule. Providers can find an updated Texas Health Steps periodicity
schedule at dshs.state.tx.us/THsteps/Providers.shtm.
Section 4: Texas Health Steps
Section 12: Appendix
1. Specialist Acting as a PCP Request Form
2. HighRiskPregnancyNotication
3. DeliveryNotication
4. Provider Information Change Form
5. STAR Kids Member ID Card
6. STAR Kids Value Added Services
7. Member Acknowledgement Statement
8. Private Pay Agreement
9. HIPAA compliant Authorization for the Release of Patient Information
10. Depression Screening Tools
Specialist Acting as a
Primary Care Provider
Request Form
Please complete the Specialist Acting as a Primary Care Provider Request Form and return to Care Management
Fax: 682-885-8402 or toll free 844-643-8402
Phone: 888-243-3312
Provider Information
Provider Name: ___________________________________________________________________
Primary Specialty: __________________________Secondary Specialty: _____________________
Physical Address: __________________________ City: _____________ State: _____ Zip: ______
Phone Number: ___________________________ Fax Number: ____________________________
Tax ID Number: ________________ NPI Number: ____________TPI Number: ________________
Contact Name: ____________________________ Title: __________________________________
Contact Phone Number: _______________ Contact Fax Number: ___________________________
Contact Email Address: _____________________________________________________________
Member Information
Member Name: ___________________________________________________________________
Member ID Number: ___________________________ Date of Birth: _________________________
Address: _________________________________ City: ______________State: ______ Zip: ______
Phone Number: _______________________ Alternate Phone Number: ______________________
Parent/Legal Guardian: _____________________________________________________________
Explain medical indication for Specialist acting as a Primary Care Provider for this patient:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________ ___________________
Completed by Date
RevDec19
High Risk Pregnancy Notication
Complete this form, print and fax to 682-885-8402 at the time of pregnancy diagnosis.
Use the CCHP Service Authorization Request Form for authorization if your pregnant patient
requires a hospital or observation stay without delivery, or an out of network referral.
Baby Steps Program 888-243-3312; Fax 682-885-8402
Provider Information
OB Name: ________________________________________________________________________________
OB Phone: ______________________________________OB Fax: _________________________________
OB Ofce Contact: ______________________________ Perinatologist Ofce Contact: ________________
Perinatologist: __________________________________ Perinatologist Phone/Fax: ___________________
Expected Delivery Facility: __________________________________________________________________
Member Information
Member Name: ___________________________________ DOB: ____________________________________
ID: _____________________________________________Member Phone: ___________________________
EDC (Due Date) _______________________LMP: ________________________G: ________ P: ________
Other Health Insurance?: ❏ Yes ❏ No If yes, Insurance Name: _______________________________
Risk Factors/Problems: ____________________________________________________________________
_________________________________________________________________________________________
Medications: ❏ NONE ❏ Yes (If Yes, list): _____________________________________________________
_________________________________________________________________________________________
Rev10/2010sf
RevOct-19
Delivery Notication
Fax completed form to Care Management at 682-885-8402
Delivery Facility: __________________________ Facility Phone: _________________________
Facility Contact: ___________________________ Facility Fax: ___________________________
OB Name: ________________________________ OB Phone: ____________________________
Member Name: ____________________________ DOB: _________________________________
Member ID: _______________________________ Member Phone: ________________________
Other Health Insurance?: ❏ Yes ❏ No If yes, insurance name: __________________
Admit Date: ____________________________
Delivery Date: __________________________
Delivery Type: ❏ SVD ❏C/S
Baby A: ❏ M ❏ F Birth Weight: ___________________________
Baby B: ❏ M ❏ F Birth Weight: ___________________________
Complications/Comments: _________________________________________________________________
________________________________________________________________________________________
Care Management Response
Reference Number ___________________________________ Date __________________
DELNOT120310
RevDec19
Provider Informaon Change Form
Please type or print legibly to avoid processing delays.
❏ Parcipang provider ❏ Non-parcipang provider
Current Provider Informaon
Provider name: __________________________________________ Email: ______________________________________________
Specialty: _____________________________ NPI: ____________________________ Tax ID: _____________________________
Provider Change Informaon
This change aects:
❏ Group pracce ❏ Individual provider ❏ Instuon/Facility Date change will take eect: _______ / _______ / _______
Month Date Year
Type of Change (Please check all that apply)
❏ Add service address ❏ Change name (group or physician): _____________________
❏ Change service address ❏ Change or add hospital aliaon: ______________________
❏ Add TIN
Deactivate TIN
❏ Change TIN
❏ Change billing address ❏ Add specialty: ______________________________________
❏ Add billing address ❏ Delete service address ❏ Add praccing services: ______________________________
New Demographic Informaon
Old Demographic Informaon
New Service Informaon:
(If more than one locaon, aach an addional form for each locaon)
Primary service locaon? ❏ Yes ❏ No
Individual name: ______________________________________
Group name: _________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ___________________________ Tax ID: _______________
Old Service Informaon:
(If more than one locaon, aach an addional form for each locaon)
Individual name: ______________________________________
Group name: _________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ___________________________Tax ID: _______________
New Billing Informaon:
(W-9 form must be submied with all Tax ID updates)
Name: (As shown on your income tax return)
____________________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ________________________________________________
Tax ID: ________________ NPI: _________________________
Old Billing Informaon:
Name: (As shown on your income tax return)
____________________________________________________
Address: ____________________________________________
City: __________________ State: ______ Zip code: _________
Telephone: __________________________________________
Fax: ________________________________________________
Tax ID: ________________ NPI: _________________________
Print name and tle of authorized signature: _____________________________________________________________
Authorized signature: X __________________________________________________ Date: _____________________
Title: ____________________________________________ Email: ___________________________________________
Telephone: ____________________________________________ Fax: _______________________________________
Please fax or email completed form with addional documentaon to:
Fax: (682) 885-8403 | Email: CCHPNetworkDevelopment@cookchildrens.org
Please allow 10 business days to process your request. Tax ID updates cannot be processed without a properly completed W-9 form.
ND-PD01 Rev12-19
Submit form through email
Submit form through emailSubmit form through emailSubmit form through email
Member:
ID no: Plan Eff ective Date:
PCP: PCP Phone:
PCP Eff ective Date:
NAVITUS
BIN: 610602
PCN: MCD
RX Group: CCH
Service Coordinators: 1-844-843-0004
For member pharmacy information: 1-844-843-0004
For pharmacies and prescribers only: 1-877-908-6023
STAR KIDS
MEMBER ID CARD
You will receive a member handbook in a few days. Please read it
carefully. The handbook tells you what benefi ts are covered, what
your rights are and you need to do as a member.
Webportal
You can go to our website at cookchp.org if you need to:
• Find helpful information about this program or your child’s health.
• Change your address or phone number.
• Find doctors and facilities that are in our network.
Customer Care Department: 1-844-843-0004
Our Customer Care Department can:
• Make changes to your account.
• Find a doctor that is close to your home.
• Tell you what benefi ts are covered and put you in touch with
the right people.
Service coordination: 1-844-843-0004
Service coordinators are available to all members and can:
• Make home visits to learn about your needs.
• Approve Long-term Services and Supports.
• Help you get other services (e.g., medical transportation).
• Manage community supports.
• Work closely with all of your doctors.
24-hour nurse advice line: 1-866-971-2665
If you need to speak to a nurse after hours or need general advice
about your child’s health, Cook Children’s Health Plan has a free
nurse advice line. You can call them 24 hours a day, 7 days
a week.
Health home/primary care provider
Your health home can be a doctor or clinic that knows your child and
their health care needs. Your health home might be a primary care
doctor or a clinic that can:
• Take care of your child when he or she is sick.
• Give your children checkups and shots to help them stay healthy.
• Help you manage diseases and chronic conditions, such as
asthma or diabetes.
• Send your child to specialists or other health providers when he
or she needs to go.
Urgent care and emergencies
• If you have an urgent need, Cook Children’s Health Plan has a list
of walk-in and urgent care clinics that can see you after hours.
Go to our website at cookchp.org.
• If you have an emergency, go to the nearest hospital emergency
department or call 9-1-1. Call your health home the next day
to let them know that you were at the hospital or in the
emergency department.
Pharmacy services
Use the same pharmacy, whenever possible, for more personalized
service. If you have any problems getting your medicines, call our
Customer Care Department or your service coordinator and they
will help you.
In case of emergency, call 911 or go to the closest
emergency room. After treatment, call your child’s
PCP within 24 hours or as soon as possible.
Send claims to:
Cook Children’s Health Plan
P.O. Box 961295
Fort Worth, TX 76161
24-hour nurse advice line: 1-866-971-2665
Customer Care Department: 1-844-843-0004
(8 a.m.-5 p.m.) or leave a message 24 hours/7 days a week
Provider Services: 1-888-243-3312 (8 a.m.-5 p.m.)
or leave a message 24 hours/7days a week
For Vision, call National Vision Administrators: 1-877-866-0384
Behavioral Health Services Hotline call Beacon Health:
1-855-481-7045 (24 hours, 7 days a week)
Long-term care benefi ts only: You receive primary, acute and
behavioral health services through Medicare. You receive only
long-term care services through Cook Children’s Health Plan.
Welcome to Cook Children’s
Health Plan STAR Kids
cookchp.org
Thank you for choosing Cook Children’s Health Plan. Below is your Cook Children’s Health Plan (CCHP)
STAR Kids Member ID card. Carry it with you at all times. You will need to show your card when getting
any medical or pharmacy services. If you lose this card or the information on it is incorrect, please call
Member Services at 1-844-843-0004.
Miembro:
Numero de ID: Fecha de efectivo:
PCP: Teléfono de PCP:
Fecha de efectivo del PCP:
NAVITUS
BIN: 610602
PCN: MCD
RX Group: CCH
Coordinadores de Servicios:
1-844-843-0004
Para información sobre Farmacias para Miembros: 1-844-843-0004
Para Farmacias y Prescriptores: 1-877-908-6023
STAR KIDS
TARJETA DE IDENTIFICACIÓN
DE MIEMBRO
Usted recibirá un Manual para Miembros de Cook Children’s Health
Plan dentro de unos días. Por favor, léalo con cuidado. El manual le
indica que benefi cios están cubiertos, cuáles son sus derechos y lo
que tiene que hacer como miembro.
Sitio Web
También puede ir a nuestro sitio web cookchp.org para:
• Encontrar información útil acerca de este programa o la salud de
su hijo.
• Cambiar su domicilio o número de teléfono.
• Encontrar médicos o instalaciones que se encuentran en la red
de CCHP.
Departamento de Servicio al Cliente: 1-844-843-0004
Nuestro departamento de servicio al cliente puede ayudarle a:
• Hacer cambios a su cuenta.
• Encontrar a un médico que este cerca de su casa.
• Decirle que benefi cios están cubiertos y ponerlo en contacto con
las personas adecuadas.
Coordinación de Servicio al Cliente: 1-844-843-0004
Los coordinadores de servicios están disponibles para todos los
miembros y pueden:
• Hacer visitas a su domicilio para averiguar cuáles son sus
necesidades.
• Aprobar servicios y apoyos a largo plazo.
• Ayudar a obtener otros servicios (por ejemplo, transporte medico).
• Manejar Apoyes en la Comunidad.
• Trabajar con todos sus médicos.
Línea de consejos de enfermería de 24 horas:
1-866-971-2665
Si necesita hablar con una enfermera después de horas regulares o
necesita asesoramiento general acerca de su salud, Cook Children’s
Health Plan tiene una línea de consejos de enfermería gratuita. Usted
puede llamar las 24 horas al día, 7 días a la semana.
Hogar medico/proveedor de atención primaria
Su hogar medico puede ser un doctor o clínica que conoce la salud
y necesidades médicas de su hijo. Su hogar medico puede ser un
proveedor de atención primaria o una clínica que pueda:
• Cuidar de usted cuando esté enfermo.
• Ofrecer a sus hijos chequeos médicos y vacunas para
mantenerlos sanos.
• Ayudar a controlar las enfermedades y condiciones crónicas,
como el asma o la diabetes.
• Enviarlo a especialistas y a otros proveedores de salud cuando
sea necesario.
Cuidado Urgente y emergencias
• Si usted tiene una necesidad urgente, Cook Children’s Health
Plan tiene una lista de clínicas de cuidados urgentes y lo pueden
ver después de horas de servicio. Visite nuestro sitio web en
cookchp.org.
• Si usted tiene una emergencia, vaya a la sala de emergencia más
cercana o llame al 9-1-1. Llame a su hogar medico el próximo
día para informarles que estuvo en el hospital o en la sala de
emergencia.
Servicios de Farmacia
Use la misma farmacia cuando sea posible, para un servicio más
personalizado. Si usted tiene algún problema para obtener sus
medicinas, llame a nuestro departamento de Servicio al Cliente o a
su coordinador de servicios, y ellos lo asistirán.
Bienvenido a Cook Children’s
Health Plan STAR Kids
cookchp.org
Gracias por elegir al Cook Children’s Health Plan. Esta es su tarjeta de identifi cación de Cook Children’s
Health Plan (CCHP) STAR Kids. Cárguela siempre con usted. Usted tendrá que mostrar su tarjeta en la
farmacia o al conseguir cualquier servicio médico. Si pierde esta tarjeta o la información que contiene esta
incorrecta, por favor llame al department de Servicios al Cliente al 1-844-843-0004.
En caso de emergencia, llame al 911 o vaya a la
sala de emergencias más cercana. Después de
recibir tratamiento, llame al PCP de su hijo dentro
de 24 horas o tan pronto como sea posible.
Send claims to:
Cook Children’s Health Plan
P.O. Box 961295
Fort Worth, TX 76161
Línea de Consejería de enfermeras disponibles 24 horas al día: 1-866-971-2665
Servicios al Cliente: 1-844-843-0004
(8 a.m.-5 p.m.) o para dejar un mensaje (24 horas al día, 7 días a la semana)
Servicios para Proveedores: 1-888-243-3312 (8 a.m.-5 p.m.)
o para dejar un mensaje (24 horas al día, 7 días a la semana)
Para visión, llame a National Vision Administrators: 1-877-866-0384
Línea gratuita para servicios de la Salud Mental llame a
Beacon Health: 1-855-481-7045 (24 horas, 7 días a la semana)
Solamente para los servicios y apoyos a largo plazo: usted recibe
sus servicios primarios, agudos, y del comportamiento de parte de
Medicare. Usted recibe solamente servicios y apoyos a largo plazo
por Cook Children’s Health Plan.
STAR Kids value added services
VAS_MbrNotif_SKids_090120
Services Description
School/Sports
Physicals
One school or sports physical in addition to a Texas Health Steps checkup per
calendar year for members that are ages 3 through 18.
Extra Vision Services
$125 for prescription eyeglasses (frames and lenses) or $75 for contact lenses and
tting fees.
Special Health Care
Needs (SHCN) Camps
Up to $200 per member toward the enrollment of an approved special health care needs
camp. This benet is one per year.
Healthy Me
Rewards Program
• A $15 gift card for members who complete a Texas Health Steps checkup at
2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months and
18 months of age.
• A $25 gift card for members age 2 to 21 who complete an annual
Texas Health Steps checkup.
Bathtub Kneeler
A (one-time) bathtub kneeling pad per household for Cook Children’s Health Plan members
ages 3 months to 3 years to prevent drowning during bath time.
There are some limits to these benets. Please call us at 1-844-843-0004 to nd out what they are. You can also visit
our website at cookchp.org.
STAR Kids Members can get the following list of services at no cost. These services are for the dates
of September 1, 2020 to August 31, 2021.
CCHP STAR Kids PM 110119
RevOct-19
Member Acknowledgment Statement
“I understand that, in the opinion of (provider’s name), the services or items that I have
requested to be provided to me on (dates of service) may not be covered under Cook
Children’s Health Plan as being reasonable and medically necessary for my care. I
understand that HHSC or its health insuring agent determines the medical necessity of
the services or items that I request and receive. I also understand that I am responsible
for payment of the services or items I request and receive if these services or items are
determined not to be reasonable and medically necessary for my care.”
“Comprendo que, según la opinión del (nombre del proveedor), es posible que Medicaid
no cubra los servicios o las provisiones que solicité (fecha del servicio) por no
considerarlos razonables ni médicamente necesarios para mi salud. Comprendo que
Cook Children’s Health Plan o su agente de seguros de salud determina la necesidad
médica de los servicios o de las provisiones que el miembro solicite o reciba. También
comprendo que tengo la responsabilidad de pagar los servicios o provisiones que
solicité y que reciba si después se determina que esos servicios y provisiones no son
razonables ni médicamente necesarios para mi salud.”
Member Signature Date
Revised 09/23/2020
CCHP STAR Kids PM 110119
RevOct-19
Private Pay Agreement
I understand that _________________________________ is accepting me as a private
pay patient for the period of _____________________, and I will be responsible for
paying for any services that I receive. The provider will not file a claim to Medicaid for
the services that are provided to me.
Signed: _______________________________________________________
Date: _________________________________________________________
Revised 09/23/2020
CCHP STAR Kids PM 110119
1 RevOct-19
HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION
PURSUANT TO 45 CFR 164.508
TO:
Name of Healthcare Provider/Physician/Facility/Medicare Contractor
Street Address
City, State and Zip Code
RE: Patient Name:
Date of Birth: Social Security Number:
I authorize and request the disclosure of all protected information for the purpose of review
and evaluation in connection with a legal claim. I expressly request that the designated record
custodian of all covered entities under HIPAA identified above disclose full and complete
protected medical information including the following:
All medical records, meaning every page in my record, including but not limited to:
office notes, face sheets, history and physical, consultation notes, inpatient,
outpatient and emergency room treatment, all clinical charts, r ports, order sheets,
progress notes, nurse's notes, social worker records, clinic records, treatment
plans, admission records, discharge summaries, requests for and reports of
consultations, documents, correspondence, test results, statements,
questionnaires/histories, correspondence, photographs, videotapes, telephone
messages, and records received by other medical providers.
All physical, occupational and rehab requests, consultations and progress notes.
All disability, Medicaid or Medicare records including claim forms and record of denial
of benefits.
All employment, personnel or wage records.
All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry
records and specimens; radiology records and films including CT scan, MRI, MRA,
EMG, bone scan, myleogram; nerve conduction study, echocardiogram and cardiac
catheterization results, videos/CDs/films/reels and reports.
All pharmacy/prescription records including NDC numbers and drug information
handouts/monographs.
All billing records including all statements, insurance claim forms, itemized bills, and
records of billing to third party payers and payment or denial of benefits for the period
to
.
I understand the information to be released or disclosed may include information relating to
sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS),
Revised 09/23/2020
CCHP STAR Kids PM 110119
2 RevOct-19
immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or
disclosure of this type of information.
This protected health information is disclosed for the following purposes:
This authorization is given in compliance with the federal consent requirements for release of
alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been
specifically considered and expressly waived.
You are authorized to release the above records to the following representatives of
defendants in the above-entitled matter who have agreed to pay reasonable charges made
by you to supply copies of such records:
Name of Representative
Representative Capacity (e.g. attorney, records requestor, agent, etc.)
Street Address
City, State and Zip Code
I understand the following: See CFR §164.508(c)(2)(i-iii)
a. I have a right to revoke this authorization in writing at any time, except to the
extent information has been released in reliance upon this authorization.
b. The information released in response to this authorization may be re-disclosed to
other parties.
c. My treatment or payment for my treatment cannot be conditioned on the signing of
this authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records
requested herein. This authorization shall be in force and effect until two years from date of
execution at which time this authorization expires.
Signature of Patient or Legally Authorized Representative Date
(See 45CFR § 164.508(c)(1)(vi))
Name and Relationship of Legally Authorized Representative to Patient Date
(See 45CFR §164.508(c)(1)(iv))
Witness Signature Date
Revised 09/23/2020
RevJan-20
Depression Screening Tools
Depression Screening Tools are available on the following websites:
Center for Quality Assessment and Improvement
in Mental Health
http://www.cqaimh.org/stable_toolkit.html
Beacon Health Options PCP Toolkit
https://providertoolkit.beaconhealthoptions.com/
Tarrant Service Area
Denton, Hood, Johnson, Parker, Tarrant, Wise
December 2020
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

801 Seventh Avenue Fort Worth, Texas 76104-2796 (Cook Children's Health Plan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document