in this edition - tmhp · enhancements to the ltc claims management system ... start preparing for...
TRANSCRIPT
No. 52
What’s New 2Enhancements to the LTC Claims Management System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Proper Handling of Medicaid Overpayments by Long Term Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3New IDT Meeting Alerts and Specialized Services Listings on the LTC Online Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
In This Corner 8Long Term Care Home Page on TMHP .com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Best Practices for Transition of Care from State Mental Health Facilities to Nursing Facilities – Recorded Webinar Series Now Available to Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Avoid Miscellaneous Claims; Start Preparing for FY17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92016 Director of Nursing Academy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Updates 10Updated Local Authority PASRR User Guide Now Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Webinars Available for Nursing Facility, Hospice, Community Services Waiver Programs Providers, and MCOs . . . . . . . . . 10Hospice Frequently Asked Questions (FAQ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Reminders 13Computer-Based Training (CBT) on the Texas Medicaid & Healthcare Partnership (TMHP) Learning Management System (LMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Preadmission Screening and Resident Review (PASRR) Training Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Reminder for Resource Utilization Group Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Provider Resources 14Provider Relations Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15TMHP LTC Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Electronic MDS Submissions Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17DADS Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Acronyms In This Issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
IN THIS EDITION
Highlights
• Important enhancements have been made to the LTC Claims Management System. See page 2.
• Information on how to handle Medicaid overpayments can be found on page 3.
• Changes to IDT Meeting Alerts and Specialized Services Listing on the LTC Online Portal outlined on page 5.
August 2012 No. 51
Provider Bulletin, No. 66
May 2016
LTC Provider Bulletin, No. 66 2 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
What́ s New
What’s New
Enhancements to the LTC Claims Management SystemIn an effort to reduce the number of claim denials and rejections, and align the Texas Medicaid & Healthcare Partnership (TMHP) claims systems with those of the managed care organizations (MCOs), TMHP is planning significant enhancements to the Long Term Care (LTC) Claims Management System on April 29, 2016.
If a third-party vendor is used for claims submission, it is the responsibility of the provider to notify those vendors about these changes to the Claims Management System so that software updates can be made if needed.
The following changes are now reflected in the claim submission process for both TexMedConnect and the Electronic Data Interchange (EDI):
TexMedConnect• A valid External Cause Diagnosis, when required, must be
entered in the third position of the diagnosis table located on the Claim tab. The message “No Match Found” will be displayed if an External Cause Diagnosis is entered as a Principal Diagnosis or Admit Diagnosis on Institutional claims. Additionally, the message “No Match Found” will be displayed when a non-External Cause Diagnosis is entered in the External Cause Diagnosis field (Third Position) on Institutional claims. A validation has been added and if this validation fails, claim submissions will not be accepted.
• Claims with Other Insurance submissions have a validation added to allow entry of either the Employer Name or Group Number. For claim submissions to be accepted, both options cannot be entered. The Employer Name field will be disabled if there are characters in the Group Number field; and The Group Number field will be disabled if there are characters in the Employer Name field.
• Employer/Tax ID will auto populate based on the value contained in the Provider File (Billing National Provider Identifier [NPI]).
• When updating the Billing NPI for a new claim, draft claim, or claim template, the ID Qualifier will automatically default to Employer/Tax ID and Other Information will display the associated Employer/ Tax ID. Previously entered information in these fields will be lost.
• The Attending Provider field on the Provider tab is checked to ensure a valid NPI is entered. If this validation fails, claim submissions will not be accepted. If the NPI submitted is not valid, the following message will display: “NPI failed digit check and is not valid. Please check the NPI and enter a valid NPI number.”
• Claims submitted with dates of service (DOS) spanning both fee-for-service and managed care segments will reject. Providers must submit separate claims for fee-for-service DOS and managed care DOS.
If a third-party vendor is used
for claims submission, it is the
responsibility of the provider
to notify those vendors about
these changes to the Claims
Management System.
LTC Provider Bulletin, No. 66 3 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
What́ s New
Electronic Data Interchange (EDI)• 837I, 837P, and 837D claims now require all NPIs to pass the Luhn algorithm checksum formula to
prevent errors.
• 837I claims now require Attending Provider Name.
• 837I claims now require dates of service to be equal to or within statement begin and end dates.
• 837I claims will not allow both Other Insurance Group Number and Employer Name to be sent.
• 837I claims now require Principal Diagnosis.
• 837I Inpatient Admission claims now require Admitting Diagnosis.
• 837I Inpatient Admission claims now require Admission Date/Hour.
• 837I Inpatient Final claims now require Discharge Hour.
• Claims submitted with dates of service (DOS) spanning both fee-for-service and managed care segments will reject. Providers must submit separate claims for fee-for-service DOS and managed care DOS.
For more information, call the LTC Help Desk at 1-800-626-4117, Option 1. n
Proper Handling of Medicaid Overpayments by Long Term Care ProvidersProvider Medicaid overpayments can occur for a variety of reasons and a provider may receive a Medicaid overpayment for a submitted claim. Providers are discouraged from sending the overpayment amount by check directly to Department of Aging and Disability Services (DADS). To maintain the integrity of the audit trail in DADS payment system, DADS encourages providers to utilize the following instructions to manage Medicaid overpayments that are discovered.
For most instances of Medicaid overpayment, providers should submit an adjustment claim. Consider the following before submitting an adjusted claim:
• If the net of the adjustment claim is a negative amount (amount due to DADS as opposed to a positive amount due to the Provider), the one year claim filing edit will not apply.
• If other insurance paid for a portion of the claim or the entire claim, the adjustment claim should reflect the details of the type of insurance and how much insurance was paid on the claim. Providers should call DADS Provider Recoupments and Holds (PRH) at 512-438-2200, Option 3, regarding submission of provider billed insurance adjustments that deny due to other insurance bill date timing limitations. Note: For users of TexMedConnect, the insurance information is required on the Other Insurance/Finish Tab.
• For assistance with submitting adjustment claims, providers should contact Texas Medicaid & Healthcare Partnership (TMHP) at 1-800-626-4117.
If the reason for the overpayment is due to an excess number of days of Medicare Part A coinsurance; i.e., the provider has received payment for more days than what is reflected on the provider’s Medicare Remittance Advice, a Form 3619 Medicare/Skilled Nursing Facility Patient Transaction Notice correction(s) should be completed on the TMHP Long Term Care (LTC) Online Portal.
LTC Provider Bulletin, No. 66 4 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
What́ s New
• Form 3619 admission and discharge dates should be corrected on the LTC Online Portal to reflect the accurate number of days of coinsurance due.
• Once the forms are corrected and visible on the provider’s Medicaid Eligibility Service Authorization Verification (MESAV), an automatic system adjustment to recoup the overpayment will process the following calendar weekend and will subsequently be reflected on the provider’s weekly Remittance and Status (R&S) Report. Note: For assistance in submitting Form 3619 corrections, providers should contact DADS Provider Claims Services at 512-438-2200, Option 1.
DADS preferred method for handling check overpayments is for the provider to make every effort to resolve the overpayment via submission of an adjusted claim and/or corrected Form 3619; however, there are instances in which submitting a check to DADS to resolve the overpayment is unavoidable. Primarily this occurs if billing in the Claims Management System has stopped as a result of provider closure and/or if billing has decreased as a result of the Nursing Facility (NF) transition to managed care.
See additional information below about circumstances requiring the manual submission of a check to DADS by a provider.
• For providers that are out of business and no longer billing claims in the Claims Management System, submitting a check to resolve overpayment is necessary. If an adjustment claim is processed either by the provider or systematically by the Claims Management System which results in a negative balance, these claims will appear on the pending claims section of the R&S report with a status of “A”— Approved to Pay. Note: A negative claim is an amount that is owed to DADS. When the balance of “A” status claims is negative, and there will be no subsequent positive claim(s) that the provider will submit for processing, then a check must be submitted to DADS to clear the negative balance.
• Since NFs receive the majority of their payments from Managed Care Organizations, there can often be a negative balance of “A” status fee-for-service claims. This occurs mainly due to systematic adjustments related to Health and Human Services Commission (HHSC) Office of Inspector General Resource Utilization Group reviews and/or HHSC Rate Analysis Division rate changes. For active NF contracts, if the pending “A” status claim remains in a negative rollup for over thirty calendar days, the provider must submit a check to DADS to clear the negative balance.
Contact DADS PRH at 512-438-2200, Option 3, if you have questions about a negative balance on your pending R&S.
Note: In the event a provider has a circumstance requiring the manual submission of a check to DADS, all checks should be mailed to DADS Provider Recoupments and Holds at PO Box 149081 (W-406), Austin, TX 78714-9081. n
Use of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is copyright 2015 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regula tion System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to gov ernment use.”
The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2014 American Dental Association. All Rights Reserved. Applicable FARS/DFARS apply.”
LTC Provider Bulletin, No. 66 5 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
What́ s New
New IDT Meeting Alerts and Specialized Services Listings on the LTC Online Portal
New IDT Meeting Alerts on the LTC Online PortalThe Local Intellectual and Developmental Disability Authority (LIDDA) and/or the Local Mental Health Authority (LMHA) are required to confirm the information on the Interdisciplinary Team (IDT) meeting submission on the Long Term Care (LTC) Online Portal within five business days after the IDT meeting was held. Currently, the LIDDA /LMHA must use Form Status Inquiry (FSI) to search for and track the submitted IDT meetings requiring confirmation.
Beginning June 23, 2016, the LTC Online Portal will generate a new alert to enable the LIDDA/LMHA to efficiently track and respond to IDT meetings submitted on the LTC Online Portal. When a Nursing Facility (NF) enters and submits the IDT meeting information on the IDT tab of the Preadmission Screening and Resident Review (PASRR) Level One (PL1), the LTC Online Portal will send a systematic alert to the LIDDA/LMHA that the NF has submitted new or updated information pertaining to an IDT meeting.
The alert will read: “The NF has submitted a new or updated IDT meeting on the LTC Online Portal for an individual for which your LIDDA/LMHA is responsible. Please check the information on the IDT tab of the PL1 for accuracy, and confirm. If you are unable to submit your IDT confirmation on the LTC Online Portal, please contact [email protected].” Alerts can be located by clicking the Alerts link from the blue naviga-tional bar on the LTC Online Portal.
Note: A line indicating that this alert was sent will be added to the IDT tab History.
The LMHA will confirm the IDT meeting information by completing G1200 IDT Confirmation fields A-F on the PL1 IDT tab. The LIDDA will confirm the IDT meeting information by completing G1200 IDT Confirmation fields G-L on the PL1 IDT tab.
For detailed information on confirming the IDT, providers can reference the Long Term Care Preadmission Screening and Resident Review (PASRR) User Guide for Local Authorities.
Specialized Services to be Listed on the PASRR EvaluationBeginning June 23, 2016, modifications to the Preadmission Screening and Resident Review (PASRR) Evaluation (PE) will allow Local Intellectual and Developmental Disability Authorities (LIDDAs) to more efficiently match the specialized services to the areas of assistance required for an individual. Texas Medicaid & Healthcare Partnership will make the following modifications to the PE on the LTC Online Portal:
• PE field B0500, “Recommended Services Provided/Coordinated by the Local Authority,” will be updated to include a comprehensive list of LIDDA specialized services. Additionally, fields have been removed from this list because they are part of other specialized services on the updated list.
• LIDDA and NF recommended services will auto populate in PE fields B0500 and B0600, “Recommended Services Provided/Coordinated by Nursing Facility,” based upon the areas of assistance needed by the individual (PE field B0400, “Does the individual need assistance in any of the following areas?”). The LIDDA may still select options available in B0500 and B0600 independent of the auto population. Note: While the capability to delete specialized services is being removed, the capability to add specialized services remains available.
LTC Provider Bulletin, No. 66 6 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
What́ s New
B0500 Auto Population Details• (1) Alternative Placement Services and (4) Service Coordination will automatically default before selecting
any areas of assistance required for an individual. These services cannot be deleted at any time.
• The B0500 drop down menu will include the following: (5) Employment Assistance, (6) Supported Employment, (7) Day Habilitation, (8) Independent Living Skills Training and (9) Behavioral Support.
• B0500 will auto populate, if not already selected, with (8) Independent Living Skills Training if any one of the following are checked: B0400A, B0400B, B0400E, B0400F, B0400G, or B0400H.
• B0500 will auto populate, if not already selected, with (9) Behavioral Support if B0400E is checked.
• B0500 will auto populate, if not already selected, with (5) Employment Assistance, (6) Supported Employment, and (7) Day Habilitation if B0400I is checked.
Additional information related to the checked box in B0400 is provided in the screen shots below:
LTC Provider Bulletin, No. 66 7 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
In This Corner
Note: (2) Determination of Intellectual Disability (DMR) and (3) Vocational Training from the Recommended Services Provided/Coordinated by Local Authority drop-down menu have been redefined, but will still appear on all previously submitted PEs as shown in the screen shot below. However, these two options can no longer be selected after June 24, 2016.
B0600 Auto Population Details• B0600 will auto populate, if not already selected, with (2) Specialized Occupational Therapy (OT) if either
B0400C or B0400D is checked.
• B0600 will auto populate, if not already selected, with (1) Specialized Physical Therapy (PT) if B0400D is checked.
• B0600 will auto populate, if not already selected, with (5) Durable Medical Equipment (DME) if either B0400D or B0400J is checked.
• B0600 will auto populate, if not already selected, with (3) Specialized Speech Therapy (ST) if B0400K is checked. Note: If the LIDDA deselects a response in B0400, the auto populated choice(s) in B0500 and B0600 will also be deselected.
These modifications will assist LIDDAs with the administration of specialized services applicable to the individual. The mapped services will be used as discussion areas in the IDT meeting. Decisions about specialized services are not finalized until the IDT meeting is held.
Note: When a PE submitted prior to these modifications is printed, the original services selected will still appear, and the new services will display on the right side of the B0500 subsection.
For more information, call the LTC Help Desk at 1-800-626-4117, Option 1. n
LTC Provider Bulletin, No. 66 8 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
In This Corner
In This Corner
Long Term Care Home Page on TMHP.comLong Term Care (LTC) has its own dedicated section on TMHP.com. All the content found under the Long Term Care Tab at www.tmhp.com is up-to-date information and resources such as news articles, LTC Provider Bulletins, User Guides, and webinar information and registration.
Additionally, there are links to the different Texas Medicaid & Healthcare Partnership (TMHP) applications such as TexMedConnect, the LTC Online Portal, the Learning Management System (LMS), and the ability to search all of TMHP.com.
To locate the Long Term Care Tab, click “providers” on the green bar at the top of www.tmhp.com and then click “Long Term Care” on the yellow bar.
The Long Term Care home page features recent news articles by category and news articles that have been posted within the last seven days. In the upper right hand corner, there are links to both the LTC Online Portal and TexMedConnect. Both of these links require a User name and password.
On the left hand navigational bar, there are links to:
• Program Information/FAQ, including frequently asked questions;
• Department of Aging and Disability Services (DADS) Information Letters;
• Reference Material, including manuals, User guides, and other publications;
• Forms, and form instructions, which includes the various downloadable forms needed by Long Term Care providers;
• Provider Support Services, where providers can locate their Provider Relations Representative, find all of the telephone numbers for the Contact Center and relevant state and federal offices;
• Provider Education, which lists all of the provider education opportunities offered by TMHP, workshop and webinar registration, computer-based training modules, a link to the LMS, and written training materials; and
• Helpful Links for Long Term Care Providers.
Providers are encouraged to frequently visit TMHP.com for the latest news and information. n
LTC Provider Bulletin, No. 66 9 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
In This Corner
Best Practices for Transition of Care from State Mental Health Facilities to Nursing Facilities – Recorded Webinar Series Now Available to Providers Recordings of the Best Practices for Transition of Care from State Mental Health Facilities to Nursing Facilities webinar series are now available to providers. The series was completed on January 21, 2016. Follow the links below to view each of the webinars.
• Transition of Care Basics
• Best Practices for Transitioning an Individual with a Mental Illness and/or Intellectual or Develop-mental Disability
• PASRR and Transition of Care
• Barriers to Successful Transition of Care and Ways to Overcome These Barriers – Coming Soon! (providers should monitor the Long Term Care web page at www.tmhp.com for more information)
n n n
Avoid Miscellaneous Claims; Start Preparing for FY17 The State of Texas fiscal year (FY) runs from September 1 through August 31. In the upcoming FY 2017, any claims submitted for FY14 (September 1, 2013, through August 31, 2014) that are received by the Texas Medicaid & Healthcare Partnership (TMHP) on or after this year’s fiscal year-end cutoff in August become Miscellaneous Claims that cannot be paid through the standard Claims Management System payment process. A Miscellaneous Claim occurs when the service dates on a claim are older than two FYs before the current FY. Miscellaneous Claims for services that are less than eight years old or those that total less than $50,000 owed to a single legal entity are paid on a first-come, first-served basis using funds that are appropriated during each legislative session. Any Miscellaneous Claim over $50,000 or for services more than eight years old cannot be paid except as a special line item in the state budget.
If a provider submits a claim that has already become a Miscellaneous Claim, the claim is processed as a Transferred Status claim and appears on the pending Remittance and Status (R&S) Reports with a “T” status. The provider should not calculate “T” status claims in the Total Paid Amount on the R&S Report. “T” status claims must be submitted to the Texas Comptroller for Public Accounts for processing and payment, and are subject to the funding limitations described above. The Department of Aging and Disability Services (DADS) Provider Recoupments and Holds (PRH) Unit processes “T” status claims on a monthly basis. Assistance in filing an Application for Payment of Claim Against the State of Texas may be obtained by contacting PRH at (512) 438-2200, Option 3 or Option 4.
Providers should submit their claims in a timely manner to avoid significant delays in payment caused by Miscellaneous Claims. It is also useful to review Remittance and Status (R&S) Reports each week.
For more information on Miscellaneous Claims, refer to DADS Information Letter No. 15-37, “Preparing for the Upcoming Fiscal Year 2015 Fee-for-Service Claims Billing Closeout” For fiscal year-end cutoff date information. n
LTC Provider Bulletin, No. 66 10 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Updates
2016 Director of Nursing AcademyThe Quality Monitoring Program (QMP) of the Department of Aging and Disability Services (DADS) applied for and was awarded civil money penalty (CMP) funds for the creation of a Director of Nursing Academy. This training academy will be presented to Directors of Nursing (DONs), potential DONs, Assistant DONs (ADONs), Corporate Nurses, and Nursing Facility (NF) Administrators who would like to receive education on how to successfully care for individuals inside Texas Nursing Facilities.
Beginning in April of 2016, the DON Academy began presenting in seven locations (eight times) across the state, including Dallas, Abilene, San Angelo, San Marcos, Corpus Christi, Houston, and the Rio Grande Valley. This comprehensive training academy provides participants with the state and federal regulatory information, as well as evidence-based best practices and education on topics such as:
• Leadership;
• Recruitment and Retention;
• Dementia Care;
• Abuse, Neglect, and Exploitation; and
• Culture Change, all aimed at improving the care provided to NF residents.n n n
Updates
Updated Local Authority PASRR User Guide Now AvailableAn updated Long Term Care Preadmission Screening and Resident Review (PASRR) User Guide for Local Authorities is now available on the TMHP website and the TMHP Learning Management System (LMS). The update includes information on the blue navigational bar, the PASRR Specialized Services (PSS) Form on the PASRR Evaluation, and the requirements for the Interdisciplinary Team Meeting. n
Webinars Available for Nursing Facility, Hospice, Community Services Waiver Programs Providers, and MCOsLong Term Care (LTC) training sessions have been upgraded to a webinar format. LTC providers are now able to take advantage of live, online training webinars, as well as replays of those webinars, that cover topics relevant to tasks performed on the LTC Online Portal. These webinars target Nursing Facility (NF) and Hospice providers, Community Services Waiver Programs providers, and managed care organizations (MCOs). The complete live webinar series will follow a biannual April/October schedule until further notice.
Replays of the webinars, as well as audience FAQ’s from the live sessions, will be available on the Texas Medicaid & Healthcare Partnership (TMHP) Learning Management System (LMS) at http://learn.tmhp.com. Other webinar replays are available on the TMHP LMS, including past content for Managed Care Organizations and Nursing Facility providers. Providers are encouraged to monitor the TMHP website at www.tmhp.com for updated information about the availability of the recorded April 2016 webinars.
LTC Provider Bulletin, No. 66 11 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Updates
LTC NF/Hospice Provider Webinar SeriesThe LTC NF/Hospice webinar series is delivered online and includes information that will enable the provider to submit forms, screenings, and assessments accurately and efficiently. Gain a better understanding of the functions and benefits of using the LTC Online Portal to complete and submit the Long Term Care Medicaid Information (LTCMI) associated with the Minimum Data Set (MDS). This webinar series contains updates on the Preadmission Screening and Resident Review (PASRR) and Medical Necessity determination processes.
Sample Topics:• Medical Necessity (MN) process including the Fair Hearing process.
• Minimum Data Set (MDS) submission process.
• The PASRR process, including:
• The Medical Necessity determination on the PASRR Evaluation;
• MDS LTCMI rejection process; and
• Understanding how and when PASRR alerts are generated, how to access alerts and how to respond to alerts.
• How to prepare and complete Department of Aging and Disability Services (DADS) Forms 3071, 3074, 3618, 3619, and PL1 Screening Form, PASRR Evaluations.
• Understanding Document statuses.
• Correcting, Modifying, and Inactivating documents.
• Managing the provider workflow.
LTC Webinar Series for Community Waiver ProvidersThe Community Services Waiver Programs Webinar series is delivered online. This webinar series provides information that will assist Community Services Waiver providers and MCOs in submitting assessments accurately and efficiently. This course describes how to use the LTC Online Portal to complete and submit forms and assessments relevant to Waivers, MCOs, and Community First Choice (CFC) users.
Sample Topics:• Identifying and following the MN process, including the Fair Hearing process.
• Submitting Medical Necessity and Level of Care (MN/LOC) Assessments for state Medicaid payment.
• Submitting H1700-1 HCBS STAR+PLUS Waiver Individual Service Plan (ISP) Forms
• Identifying assessment statuses.
• Managing provider workflow.n n n
LTC Provider Bulletin, No. 66 12 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Updates
Hospice Frequently Asked Questions (FAQ) When updating a 3071 form due to an addition or change of a diagnosis code, do I need to submit all diagnosis codes submitted originally, or can I just include the new/changed diagnosis codes?
When submitting a Form 3071, Individual Election/Cancellation/Update, due to an addition or change of a diagnosis it is acceptable to update only the change.
Since we did not have to submit updated 3071 forms for the International Classification of Diseases, Tenth Revision (ICD-10) change for existing patients, when an update is made to the diagnosis, will I need to list all of the new diagnoses?
Updates to Form 3071, whether a new diagnosis or updating a prior diagnosis, will be listed using the appropriate ICD-10 code. It is not necessary to update each prior diagnosis code when a change occurs.
Will a webinar regarding 3071/3074 policy requirements ever be offered?
At this time policy requirements for Form 3071 and Form 3074 are addressed in the instructions of the forms and in the Medicaid Hospice Provider Manual. The Texas Medicaid & Healthcare Partnership (TMHP) website also has instructions on how to complete the forms.
If there are changes to the diagnoses for a patient, but not to the principal diagnosis, does an updated 3071 form need to be submitted?
Yes, when an individual receiving care from a Hospice provider has a change in diagnosis, an updated Form 3071 must be filed to reflect the change.
On a 3071 Cancellation how is the new ICD-10 dx code entered with alpha and ...’s, or A12.34.X or A12345?
Diagnosis codes should be entered on the LTC Online Portal in an alpha-numeric format omitting decimals. For the given example it would be A12345.
For more clarification on what should be included on an updated Form 3071, contact the Department of Aging and Disability Services (DADS) Hospice policy at [email protected]. n
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Minimum Data Set (MDS) and Medical Necessity and Level of Care (MN/LOC) Changes are Coming October 1, 2016
Watch for details in the upcoming August 2016 Long Term Care Provider Bulletin.
Changes are Coming!
LTC Provider Bulletin, No. 66 13 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Reminders
Reminders
Computer-Based Training (CBT) on the Texas Medicaid & Healthcare Partnership (TMHP) Learning Management System (LMS)The following Long Term Care (LTC)-specific CBTs are currently available on the TMHP LMS:
• LTC Online Portal Basics. This interactive CBT provides a basic overview of the LTC Online Portal, including information about creating an administrator account, and an overview of the features of the blue navigational bar and the yellow Form Actions bar. Demonstrations and simulations appear throughout the CBT to provide opportunities for an interactive experience.
• TexMedConnect for Long Term Care (LTC) Providers. This CBT demonstrates effective navigation and use of the LTC TexMedConnect web application. Providers will learn how to:
• Log in to TexMedConnect;
• Verify a client’s eligibility;
• Enter, save and adjust different types of claims;
• Export Claim Data;
• Find the status of a claim; and
• View Remittance and Status (R&S) Reports.
Accessing the TMHP LMSThe TMHP LMS can be accessed through the TMHP website at www.tmhp.com/Pages/Education/Ed_Reg.aspx, or directly at http://learn.tmhp.com.
Users must have a User name and Password to access CBTs and LTC webinar recordings in the LMS. To obtain a User name and Password, providers must create an account by clicking the Registration link at the top right-hand corner of the LMS home page. After creating an account, providers can access all available training materials in the LMS. For questions about the LTC training CBTs and webinars, call the TMHP Call Center/Help Desk at 1-800-626-4117 or 1-800-727-5436. For LMS log in or access issues, email TMHP Learning Management System (LMS) support at [email protected]. n
Need Help?For questions about the information in this bulletin, call the TMHP-LTC Call Center/Help Desk at 1-800-626-4117. TMHP operates the TMHP Call Center/Help Desk and provides telephone support to LTC providers. The TMHP Call Center/Help Desk is available Monday through Friday, 7:00 a.m to 7:00 p.m., Central Time (excluding holidays).
LTC Provider Bulletin, No. 66 14 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Reminders
Preadmission Screening and Resident Review (PASRR) Training AvailableThe Department of Aging and Disability Services (DADS) PASRR Unit staff have created PASRR training which is available online. Nursing Facility staff can access the DADS PASRR home page for more information regarding PASRR processes and procedures affecting them at www.dads.state.tx.us/providers/pasrr/index.cfm.
DADS PASRR Training• Nursing Facilities (NFs) can access the PASRR 101 Web-based Training to learn more about the role NFs
play in the PASRR process.
• The Preadmission Screening and Resident Review (PASRR) Specialized Services Training explains the Nursing Facility’s role in the PASRR specialized services process.
• The PASRR PL1: Back to Basics CBT reviews the PL1 form in a section-by-section manner.
• The PASRR PE: What Nursing Facilities Need to Know CBT explains the PASRR Evaluation (PE) and how the PE impacts the Nursing Facility (NF).
• The PASRR RULES: TAC Title 40, Part 1, Chapter 19, Subchapter BB CBT discusses the Nursing Facility (NF) Responsibilities Related to Preadmission Screening and Resident Review, found in the Texas Administrative Code (TAC) Title 40, Part 1, Chapter 19, Subchapter BB.
The Department of State Health Services (DSHS) PASRR program staff and the Department of Aging and Disability Services (DADS) PASRR Unit staff have also created PASRR training which is available online.
DSHS PASRR Training• Referring Entitles can access RE PL1 Responsibilities, to access and overview of RE PL1 Responsibilities.
Providers can visit the DSHS PASRR webpage for RE specific information and training.
For more information, users can access the DSHS PASRR Training home page at www.dshs.state.tx.us/mhsa/pasrr/training/. n
Reminder for Resource Utilization Group Training RequirementsProviders are reminded that Resource Utilization Group (RUG) training is required for registered nurses (RNs) who sign assessments as complete. RNs must successfully complete the required RUG training to be able to submit Minimum Data Set (MDS) and Medical Necessity and Level of Care (MN/LOC) Assessments on the Long Term Care Online Portal. Training is valid for two years and must be renewed by completing the online RUG training offered by Texas State University.
It can take from two to seven business days to process and report completions of RUG training from Texas State University to the Texas Medicaid & Healthcare Partnership (TMHP), depending on current volume of enrollments and completions.
To register for the RUG training, or for more information, visit www.txstate.edu/continuinged/CE-Online/RUG-Training.html. n
LTC Provider Bulletin, No. 66 15 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
Provider Relations RepresentativesWhen Long Term Care (LTC) providers need help, the Texas Medicaid & Healthcare Partnership (TMHP) is the main resource for general inquiries about claim rejections/denials and how to use automated TMHP provider systems (the LTC Online Portal and TexMedConnect).
Providers can call TMHP at 1-800-925-9126 with questions and to request on-site visits to address particular areas of provider concern. TMHP webinars for LTC Community Services Waiver Programs and Nursing Facility (NF)/Hospice providers are also offered specifically for LTC providers. For current schedules check the Long Term Care Webinars Page on the TMHP website at www.tmhp.com/Pages/LTC/ltc_webinar.aspx.
The map on this page, and the table below, indicate TMHP provider relations representatives and the areas they serve. Additional information, including a regional listing by county, is available on the TMHP website at www.tmhp.com/Pages/SupportServices/PSS_Reg_Support.aspx.
Territory Regional Area Representative
1 Amarillo, Childress, Lubbock Kendra Davila
2 Midland, Odessa, San Angelo Stacey Jolly
3 Alpine, El Paso, Van Horn Isaac Romero
4 San Antonio, Kerrville, Del Rio, Eagle Pass, Carrizo Springs Yvonne Garza-Garcia
5 Brownsville, Harlingen, McAllen, Laredo Denis Sanchez
6 Corpus Christi, San Antonio, Victoria Araceli Wright
7 Austin, Waco, Bastrop, San Marcos Kim Flanagan
8 Abilene, Witchita Falls Alisa Hinton
9 Dallas, Fort Worth, Denton, Grayson, Corsicana Vanessa Whitley-Parker
10 North Dallas Kirk Crumbley
11 Houston, Bryan College Station Linda Wood
12 Nacogdoches, Beaumont, Galveston Gene Allred
13 Houston, Katy Stephen Hirschfelder
14 Northeast Texas, Palestine, Longview, Marshall Carrita Mitchell
Long Term Care Provider Relations Representative Shawn Sullivan*Austin, Dallas, Houston, and San Antonio territories are shared by 2 or more provider representatives. These territories are divided by ZIP Codes. Refer to the TMHP website at www.tmhp.com for the assigned representative to contact in each ZIP Code.
Provider Resources
LTC Provider Bulletin, No. 66 16 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
TMHP LTC Contact InformationThe Texas Medicaid & Healthcare Partnership (TMHP) Call Center/Help Desk operates Monday through Friday from 7 a.m. to 7 p.m., Central Time (excluding TMHP-recognized holidays).
When calling the TMHP Call Center/Help Desk, providers are prompted to enter their 9-digit Long Term Care (LTC) provider number using the telephone keypad. When the 9-digit LTC provider number is entered on the telephone keypad, the TMHP Call Center/Help Desk system automatically populates the TMHP representative’s screen with that provider’s specific information, such as name and telephone number.
Providers should have their 4-digit Vendor/Facility or Site Identification number available for calls about Forms 3618 and 3619, Minimum Data Set (MDS), Medical Necessity and Level of Care (MN/LOC) Assessment, and Preadmission Screening and Resident Review (PASRR).
Providers must have a Medicaid or Social Security number and a medical chart or documentation for inquiries about a specific individual.
For questions, providers should call the TMHP Call Center/Help Desk at the following telephone numbers:
• Austin local telephone number at (512) 335-4729
• Toll free telephone number (outside Austin) at 1-800-626-4117 or 1-800-727-5436
For questions about... Choose... � General inquiries � Using TexMedConnect � Claim adjustments � Claim status inquiries � Claim history � Claim rejection and denials � Understanding Remittance and
Status (R&S) Reports � Forms
� Forms 3071 and 3074 � Forms 3618 and 3619 � Resource Utilization Group (RUG)
levels � Minimum Data Set (MDS) � LTC Medicaid Information (LTCMI) � Medical Necessity and Level of Care
(MN/LOC) Assessment � PASRR Level 1 Screening and
PASRR Evaluation submission and status messages
Option 1: Customer service/general inquiry
� Medical necessity Option 2: To speak with a nurse
� TexMedConnect – technical issues, account access, portal issues
� Modem and telecommunication issues
� Processing provider agreements � Verifying that system screens are
functioning
� American National Standards Institute (ANSI) ASC X12 specifi-cations, testing, and transmission
� Getting Electronic Data Interchange (EDI) assistance from software developers
� EDI and connectivity � LTC Online Portal, including
technical issues, account access, portal issues
Option 3: Technical support
LTC Provider Bulletin, No. 66 17 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
For questions about... Choose... � Electronic transmission of Forms
3071, 3074, 3618, and 3619 � Form Status Inquiry � Technical issues � Transmitting forms
� Interpreting Quality Indicator (QI) Reports
� Current Activity (formerly Weekly Status Report)
� MDS submission problems � MN/LOC Assessment submission
problems
Option 3: Technical support
� Individual appeals � Individual fair hearing requests
� Appeal guidelines Option 5: Request fair hearing
LTC other insurance information and updates Option 6To repeat this message Option 7
Electronic MDS Submissions Contact InformationIf you have questions about electronic Minimum Data Set (MDS) submissions, contact the QIES Technical Support Office (QTSO) at [email protected] or 1-888-477-7876.
DADS Contact Information
If you have questions about... Contact...12-month claims payment rule Community Services - Community Services Contract Manager
Institutional Services (NFs)—Provider Claims Services: (512) 438-2200, Option 1
IDD Services—Provider Claims Services: (512) 438-2200, Option 1Community Services contract enrollment Email: [email protected]
Voice mail (512) 438-3550Hospice Services contract enrollment Email: [email protected]
Voice mail (512) 438-3550ICF/IID and Nursing Facility contract enrollment (512) 438-2630Days paid and services paid information for cost reports
Use TexMedConnect to submit a batch of CSIs
Rate Analysis contacts Website: www.hhsc.state.tx.us/rad/long-term-svcs/index.shtml. Contact information is listed by program
How to prepare a cost report (forms and instructions)/approved rates posted contact
Website: www.hhsc.state.tx.us/rad/long-term-svcs/index.shtml then select appropriate program
How to sign up for, or obtain direct deposit/electronic funds transfer
Accounting: (512) 438-2410
How to obtain IRS Form 1099-Miscellaneous Income
Accounting: (512) 438-3189
LTC Provider Bulletin, No. 66 18 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
If you have questions about... Contact...Medicaid eligibility, applied income, and name changes
Medicaid for the Elderly and People With Disabilities (MEPD) worker
Integrated Eligibility and Enrollment (IEE) Call Center at telephone number 2-1-1
Website: http://yourtexasbenefits.hhsc.state.tx.us/programs/health/
ID/DD PASRR Policy Questions• PASRR Level 1 Screening Form (PL1)• PASRR Evaluation (PE)MI PASRR Policy Questions• PASRR Level 1 Screening Form (PL1)• PASRR Evaluation (PE)
DADS PASRR Unit 1-855-435-7180Email: [email protected]: www.dads.state.tx.us/providers/pasrr/
DSHS PASRR Office 1-866-378-8440Email: [email protected]: www.dshs.state.tx.us/mhsa/pasrr
Payment Issues – If payment has not been received after more than 10 days from the date of billing
DADS Payment Processing Hotline (512) 438-3989
Personal Needs Allowance (PNA) Provider Claims Services (512) 438-2200, Option 2Service Authorization questions for Local Authorities (LA)
DADS Assigned Regional Claims Management Coordinator
Service Authorization questions for Guardianship Program
DADS Guardianship (512) 438-2843
Deductions and provider-on-hold questions for Institutional Services (Nursing Facilities)
Institutional Services (NFs)—Provider Claims Services: (512) 438-2200, Option 3
Website: https://hhsportal.hhs.state.tx.us/wps/portalDeductions and provider-on-hold questions for Community Services
Community Services Contract Manager or IDD Services: (512) 438-4722
Invalid or inappropriate recoupments for nursing facilities and hospice services
Provider Claims Services: (512) 438-2200, Option 3
Status of warrant/direct deposit after a claim has been transmitted to Accounting (fiscal) by TMHP
Please Note: Allow 5-7 business days for processing of claim(s) before verifying payment information
Comptroller’s website: www.window.state.tx.us Choose the State-to-Vendor-Payment Info-Online-Search link.
Accounting (512) 438-3989 When calling Accounting, provide the Provider/contract number assigned by DADS.
Texas State University Resource Utilization Group (RUG) training
The Office of Continuing Education:
Online course: (512) 245-7118
Website: www.txstate.edu/continuingedLong Term Care (LTC) Provider Recoupments and Holds (PRH) including torts and trusts and/or annuities for which the state is the residual beneficiary
Provider Claims Services: (512) 438-2200, Option 4
Website: https://hhsportal.hhs.state.tx.us/wps/portal
LTC Provider Bulletin, No. 66 19 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
If you have questions about... Contact...Community Care for the Aged and Disabled Programs (CCAD), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Texas Home Living Waiver (TxHmL), and Hospice ProgramsCLASS Program Policy
CLASS Interest Line
(512) 438-3078 or [email protected]
1-877-438-5658HCS Program Policy (512) 438-2339 or [email protected] Program
MDCP Interest List Line
(512) 438-5645 or [email protected]
1-877-438-5658TxHml Program Policy (512) 438-5234 or [email protected] Program Policy
DBMD Interest Line
(512) 438-2622 or [email protected]
1-877-438-5658Waiver/CCAD financial or functional eligibility criteria
Caseworker or Case Manager. For more contact information visit: www.dads.state.tx.us/services/index.cfm
Waiver/CCAD service authorization issues Caseworker or Case Manager. For more contact information visit: www.dads.state.tx.us/services/index.cfm
Waiver/CCAD Program policies/procedures Contract Manager. For more contact information visit: www.dads.state.tx.us/services/index.cfm
Hospice policy questions Email: [email protected] Program service authorization issues Provider Claims Services: (512) 438-2200, Option 1
Website: https://hhsportal.hhs.state.tx.us/wps/portalHome and Community-based Services (HCS) and Texas Home Living Waiver (TxHmL) billing, policy, payment reviews, cost report repayment
Billing: Willie Mae Jones, (512) 438-3493 [email protected]
Billing and Payment Hotline: (512) 438-5359 [email protected]
HCS, TxHmL, CLASS, or DBMD Program Enrollment/Utilization Review (PE/UR): Intellectual Disability-Related Conditions (ID/RC) Assessment Purpose Codes, Level of Need, Level of Care, and Individual Plan of Care (IPC)
HCS or TxHmL: (512) 438-5055, Fax: (512) 438-4249
CLASS or DBMD: (512) 438-4896, Fax: (512) 438-5135
Vendor Holds for HCS/TxHmL (512) 438-5652Consumer rights (consumer/family complaints concerning HCS and TxHmL waiver)
Consumer Rights and Services: 1-800-458-9858
Email: [email protected]
Website: www.dads.state.tx.us/services/crs/index.htmlInvalid or inappropriate CCAD recoupments Provider Claims Services: (512) 438-2200, Option 4
LTC Provider Bulletin, No. 66 20 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
If you have questions about... Contact...Intermediate Care Facility/Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) and Nursing Facility ProgramsPayment information for cost reports (512) 438-3624Quality assurance fee (QAF) (512) 438-3597 or (512) 438-3624Health and Human Services Commission Network (HHSCN) connection problems
(512) 438-4720 or 1-888-952-4357
ICF/IID durable medical equipment (DME), DME authorizations, Home and Community-Based Services (HCS), Texas Home Living Waiver (TxHmL), home modifications, adaptive aids, and dental services approvals
Provider Claims Services: (512) 438-2200, Option 5
Email: [email protected]
ICF/IID/Residential Care (RC) Individual Movement Form IMT/service authorization questions
Provider Claims Services (512) 438-2200, Option 1
Client Assessment Registration (CARE) System Help Desk for ICF/IID
1-888-952-4357: request HHSC Field Support staff
Program enrollment/Utilization Review (PE/UR), Intellectual Disability-Related Conditions (ID/RC) Assessment Purpose Codes, Level of Need, Level of Care, and Individual Plan of Care (IPC)
(512) 438-5055 Fax: (512) 438-4249
Provider contracts and vendor holds for ICF/IID (512) 438-2630Provider access to ICF/IID CARE system (512) 438-2630MDS 3.0, MDS Purpose Code E, and Forms 3618 and 3619 missing/incorrect information
Provider Claims Services: (512) 438-2200, Option 1
Website: https://hhsportal.hhs.state.tx.us/wps/portalRehabilitation and specialized therapy/emergency dental/Customized Power Wheelchair (CPWC) service authorizations
Provider Claims Services: (512) 438-2200, Option 6
Fax: (512) 438-2302
Service authorizations for Nursing Facilities Provider Claims Services: (512) 438-2200, Option 1
Fax: (512) 438-2301
Website: https://hhsportal.hhs.state.tx.us/wps/portalInvalid or inappropriate recoupments for ICF/IIDs HHSC Help Desk: (512) 438-4720 or 1-800-214-4175Consumer Rights and Services
Surrogate Decision Making Program (SDMP) for people receiving community-based services through the ICF/IID program
Consumer Rights and Services: 1-800-458-9858
Email: [email protected]
Website: www.dads.state.tx.us/services/crs/index.html
LTC Provider Bulletin, No. 66 21 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
Acronyms In This Issue
Acronym DefinitionADON Assistant Director of NursingAMA American Medical AssociationANSI American National Standards InstituteCARE Client Assessment RegistrationCBT Computer-Based TrainingCCAD Community Care for Aged and Disabled ProgramsCDT Current Dental TerminologyCFC Community First ChoiceCLASS Community Living Assistance and Support ServicesCMP Civil Money PenaltyCPT Current Procedural TerminologyCPWC Customized Power WheelchairDADS Department of Aging and Disability ServicesDBMD Deaf-Blind with Multiple DisabilitiesDME Durable Medical EquipmentDON Director of NursingDOS Date of ServiceDSHS Department of State Health ServicesEDI Electronic Data InterchangeFAQ Frequently Asked QuestionsFARS/DFARS Federal Acquisition Regulations System/Department of Defense Regulation SystemFSI Form Status InquiryFY Fiscal YearHCS Home and Community-Based ServicesHHSCN Health and Human Services Commission NetworkICD-10 International Classification of Diseases, Tenth RevisionICF/IID Intermediate Care Facility/Facilities for Individuals with an Intellectual Disability
or Related ConditionsID/RC Intellectual Disability/Related ConditionIDT Interdisciplinary TeamIEE Integrated Eligibility and EnrollmentIPC Individual Plan of CareISP Individual Service PlanLA Local AuthorityLIDDA Local Intellectual and Developmental Disability AuthorityLMHA Local Mental Health AuthorityLMS Learning Management System
LTC Provider Bulletin, No. 66 22 May 2016CPT only copyright 2015 American Medical Association. All rights reserved.
Provider Resources
Acronym DefinitionLTC Long Term CareLTCMI Long Term Care Medicaid InformationMCO Managed Care OrganizationMDCP Medically Dependent Children’s ProgramMDS Minimum Data SetMEPD Medicaid for the Elderly and People with DisabilitiesMESAV Medicaid Eligibility Service Authorization VerificationMN Medical NecessityMN/LOC Medical Necessity and Level of CareNF Nursing FacilityNPI National Provider IdentifierOI Other InsurancePASRR Preadmission Screening and Resident ReviewPE PASRR EvaluationPE/UR Program Enrollment/Utilization ReviewPL1 PASRR Level 1PNA Personal Needs AllowancePRH Provider Recoupments and HoldsPSS PASRR Specialized ServicesQAF Quality Assurance FeeQI Quality IndicatorQMP Quality Monitoring ProgramQTSO QIES Technical Support OfficeR&S Remittance and StatusRC Residential CareRE Referring EntitiesRN Registered NurseRUG Resource Utilization GroupSDMP Surrogate Decision Making ProgramTAC Texas Administrative CodeTMHP Texas Medicaid & Healthcare PartnershipTxHmL Texas Home Living Waiver