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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
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CCHP STAR Kids PM 122020
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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
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CCHP STAR Kids PM 122020
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•
Access to care
•
Improve health outcomes
•
Improve quality of care
•
Continually strive to improve both member and provider satisfaction
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CCHP STAR Kids PM 122020
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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.
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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
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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
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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
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Women, Infants, and Children (WIC) Nutrition
Program
Toll Free: 800-942-3678
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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
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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
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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
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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
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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
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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
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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
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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
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CCHP STAR Kids PM 122020
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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.
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CCHP STAR Kids PM 122020
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•
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.
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CCHP STAR Kids PM 122020
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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
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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.
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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-
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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
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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
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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
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•
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.
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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
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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
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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.
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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
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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
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•
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
o
Any virus(es) on the smartphone
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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.
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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.
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•
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
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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
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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.
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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
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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:
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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.
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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:
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CCHP STAR Kids PM 122020
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•
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:
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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;
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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
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CCHP STAR Kids PM 122020
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•
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
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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
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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.
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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
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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:
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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.
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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.
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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.
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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.
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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
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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.
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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
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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.
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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
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•
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
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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.
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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.
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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:
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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:
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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
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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.
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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)
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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
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•
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
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•
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.
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**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
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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
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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.
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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
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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
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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:
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•
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
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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
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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
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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
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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
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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
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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:
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•
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
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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.
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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
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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 segm