TMHP - FAQ

Long Term Care Programs Frequently Asked Questions

How do I use the LTC/Nursing Facilities Bill Code Crosswalk Table?
What is a Retroactive Adjustment?
Do you have records of services that were never billed?
What is PASARR and how does if affect entry to a nursing facility?
How do I know if my MDS assessment was successfully transmitted?
Why submit a 3619 Form?
How is the comments section used on the 3652 CARE form?
When is a 3652 form placed on pending denial status?

Q : How do I use the LTC/Nursing Facilities Bill Code Crosswalk Table?

A : The left side of the LTC/Nursing Facilities Bill Code Crosswalk Table provides the Texas LTC/Nursing Facilities Local Codes for the service group, bill code, service code, and bill code description used to bill for services before HIPAA. The right side of the table identifies the National Standard Codes you will use on your claims effective October 16, 2003 . Your contract and MESAV information will tell you the service codes and service groups for which you have authorization to provide services. To use the table, follow the guidelines below:

1. Find your service group, service code, and, if possible, the bill code you have used in the past to bill for the service(s) and follow the row across to the National Codes section to find the new codes to use effective October 16, 2003 .

2. If the bill code has been mapped to a national HCPCS code, you will find an entry of “HC” or “AD” in the procedure code qualifier field and information in either the HCPCS or CPT code fields (or, in some cases, in the HCPCS or CPT and the revenue code fields). If the bill code only has a national revenue code shown, no entry will be found in the procedure code qualifier field.

3. If there are entries in the modifier fields, you will need to use those modifiers in the designated fields when completing the detail line for that service.

4. If there is a “ZZ” in the procedure code qualifier field, you will continue to use the existing bill code to claim reimbursement.

5. The table contains a field called “End Date.” If this field has an entry, it means that services provided after the stated end date will not be paid.

Q : What is a Retroactive Adjustment?

A : A Retroactive Adjustment is created when a change in client or provider information is sent to TMHP from DADS, and this information affects previously paid claims. The change may affect a client's service authorization, number of units, unit rate, applied income or co-payment, level of service or dates of service; or a change to a provider's contract. Retroactive adjustments are made in either the favor of the state or the provider. These adjustments are generated by the Claims Management System, not by providers. When new information is received at TMHP, a "trigger" is created and retroactive adjustments are generated for claims that match certain criteria, such as a specific billing code, dates of service, etc.

Q : Do you have records of services that were never billed?

A : If you are unsure if you were paid or not for past services, you can run Claim Status Inquiry to see paid claims up to three years ago.

Q: What is PASARR and how does if affect entry to a nursing facility?

A : PASARR is the Preadmission Screening and Resident Review that is required by all nursing facilities that accept Medicare or Medicaid. The Medicare/Medicaid nursing facility must screen all new admissions to determine if an individual has a mental illness, mental retardation, or a related condition.

Q : How do I know if my MDS assessment was successfully transmitted?
A : You may review your Final Validation Report within 24 hours of transmission to verify your file was successfully transmitted. Also, if the line was disconnected, you will get an error window and you will not receive the Initial Feedback Report.

Q : Why submit a 3619 Form?

A : 3619 Forms are submitted to initiate, close or adjust Medicare/Medicaid Co-insurance and to provide information to caseworker about status changes of Medicaid applicant or recipient.

Q : How is the comments section used on the 3652 CARE form?

A : The comments section can be used for additional qualifying data that indicates the need for skilled nursing care, such as: pertinent medical history, level of ability to understand medications, ability to understand changes in condition, abnormal vital signs range of blood glucose levels (note whether fasting or random), previous attempts at outpatient management of medical condition, and results of abnormal lab work.

For hospice recipients, include all of the following items in the comments section: the words "hospice recipient" for all hospice recipients, date, signature and license number of the hospice nurse.

Q : When is a 3652 form is placed on pending denial status?

A : A 3652 for is placed on pending denial status when there may be conflicting information on the form between the TILE fields, the diagnoses, the medications, and the comments section, or there may not be additional information in the comments section that describes what licensed nursing care is being performed.