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Texas Health Steps (THSteps)
43.1 THSteps Medical and Dental Administrative Information 43-5
43.1.1 Overview 43-5
43.1.2 Statutory Requirements 43-5
43.1.3 Medical Transportation Program (MTP) 43-5
43.1.4 Provider Enrollment 43-5
43.1.4.1 Additional Education Requirements for Registered Nurses (RNs) 43-6
43.1.4.2 Medicaid Managed Care Enrollment 43-6
43.1.5 Eligibility for a Medical Check Up 43-7
43.1.5.1 Newborn Eligibility 43-7
43.1.6 Reimbursement 43-7
43.1.7 Benefits and Limitations 43-8
43.1.7.1 Medical Check Up Visits 43-8
43.1.7.2 Follow-up Medical Check Up Visit 43-8
43.1.7.3 Newborn Examination 43-9
43.1.7.4 Medical Check Up, First 6 Days of Life 43-9
43.1.7.5 Exceptions to Periodicity 43-9
43.1.8 Verification of Medical Check Ups 43-10
43.1.9 Claims Information 43-10
43.1.9.1 Procedure Coding for THSteps Medical Check Ups 43-10
43.1.9.2 Immunizations 43-10
43.1.9.4 Claim Filing Resources 43-12
43.1.10 THSteps Medical Check Up Facilities 43-12
43.1.10.1 Medical Home Concept 43-12
43.1.10.2 Continuity of Care and the Medical Home 43-12
43.1.10.3 Mobile Units and the Medical Home 43-13
43.1.11 THSteps Dental Services 43-13
43.1.12 How the THSteps Dental Program Works 43-13
43.1.13 Vision Services 43-13
43.1.14 Hearing Services 43-13
43.1.15 Referrals for Medicaid-Covered Services 43-14
43.1.16 Texas Vaccines for Children Program (TVFC) 43-15
43.1.17 Vaccine Adverse Event Reporting System (VAERS) 43-15
43.1.18 Information and Assistance 43-15
43.1.18.1 Assistance with Program Concerns 43-15
43.1.18.2 Assistance with Claims Concerns 43-15
43.2 Clinical Information 43-15
43.2.1 Documentation of Completed Check Ups 43-15
43.2.2 THSteps Medical Check Ups Periodicity Schedule 43-16
43.2.2.1 THSteps Medical Check Ups Periodicity Schedule for Infants, Children, and Adolescents (Birth Through 20 Years of Age) 43-17
43.2.2.2 THSteps Medical Check Ups Periodicity Schedule for Infants and Children (Birth Through 20 Years of Age) (continued) 43-18
43.2.3 Medical Check Ups for Infants, Children, and Adolescents (Birth Through 20 Years of Age) 43-19
43.2.3.3 Measurements 43-19
43.2.3.4 Nutritional Screening 43-19
43.2.3.5 Developmental Screening 43-20
43.2.3.6 Mental Health 43-21
43.2.3.7 Sensory Screening 43-22
43.2.3.8 Tuberculosis Screening 43-24
43.2.3.9 Immunizations 43-24
43.2.3.10 Dental Screening 43-25
43.2.3.11 Medical Check Up Laboratory Component 43-26
43.2.3.12 Health Education/Anticipatory Guidance 43-26
43.2.3.13 Additional Adolescent Screening 43-26
43.3 Check Up Laboratory Procedures 43-28
43.3.1 Reimbursement 43-28
43.3.2 Laboratory Services 43-28
43.3.3 Laboratory Supplies 43-29
43.3.3.1 Newborn Screening Supplies 43-30
43.3.3.2 Send Comments 43-30
43.3.4 Required Tests 43-30
43.3.4.2 Hemoglobin or Hematocrit 43-30
43.3.4.3 Hemoglobin Type 43-30
43.3.4.4 Hyperlipidemia 43-30
43.3.4.5 Lead Screening and Testing 43-30
43.3.4.6 Newborn Screening 43-31
43.3.4.7 Urinalysis 43-31
43.3.5 Additional Required Laboratory Tests Related to Medical Check Ups for Adolescents 43-31
43.3.5.1 Communicable Disease Reporting 43-31
43.3.5.2 Cervical Cancer Screening 43-31
43.3.5.3 STD Testing 43-32
43.4 THSteps-Comprehensive Care Program (CCP) 43-33
43.4.1 THSteps-CCP Overview 43-33
43.4.1.1 Enrollment 43-33
43.4.1.2 Medicaid Managed Care Enrollment 43-34
43.4.1.3 Communication with THSteps-CCP 43-34
43.4.1.4 Client Eligibility 43-34
43.4.1.6 Prior Authorization and Documentation Requirements 43-36
43.4.1.7 Physician Signature 43-37
43.4.2 Respiratory Syncytial Virus (RSV) Prophylaxis 43-37
43.4.2.1 Reimbursement 43-37
43.4.2.2 Prior Authorization 43-37
43.4.2.3 Benefits and Limitations 43-38
43.4.2.4 Obtaining Palivizumab 43-39
43.4.3 Clinician-Directed Care Coordination Services (THSteps-CCP Only) 43-40
43.4.3.1 Reimbursement 43-40
43.4.3.2 Benefits and Limitations 43-40
43.4.3.3 Prior Authorization Requirements 43-41
43.4.3.4 Non-Face-to-Face Services 43-42
43.4.3.5 Face-to-Face Services 43-43
43.4.4 Comprehensive Outpatient Rehabilitation Facilities (CORFs)/Outpatient Rehabilitation Facilities (ORFs) 43-43
43.4.4.1 Enrollment 43-43
43.4.4.2 Reimbursement 43-43
43.4.4.3 Benefits and Limitations 43-43
43.4.4.4 Claims Information 43-45
43.4.5 Durable Medical Equipment Supplier (THSteps-CCP Only) 43-45
43.4.5.1 Enrollment 43-45
43.4.5.2 Reimbursement 43-46
43.4.5.3 Benefits and Limitations 43-46
43.4.5.4 Physician Signature 43-47
43.4.5.5 Mobility Aids 43-47
43.4.5.6 Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers, Standing Frames/Braces, and Parapodiums) 43-49
43.4.5.7 Apnea Monitor 43-51
43.4.5.8 Croup Tent/Pulse Oximeter 43-51
43.4.5.9 Electronic Blood Pressure Monitoring Device 43-53
43.4.5.10 Incontinence Supplies for Clients Younger Than 4 Years of Age 43-53
43.4.5.11 Pediatric Hospital Cribs/Enclosed Beds/Reflux Wedges and Slings 43-54
43.4.5.12 Medical Nutritional Products 43-55
43.4.5.13 Donor Human Milk 43-56
43.4.5.14 Special Needs Car Seats and Travel Restraints 43-57
43.4.6 Early Childhood Intervention (ECI) (THSteps-CCP Only) 43-58
43.4.6.1 Enrollment 43-58
43.4.6.2 Reimbursement 43-58
43.4.6.3 ECI-THSteps-CCP Services 43-58
43.4.6.4 Claims Information 43-59
43.4.7 Licensed Dietitians (THSteps-CCP Only) 43-59
43.4.7.1 Enrollment 43-59
43.4.7.2 Reimbursement 43-59
43.4.7.3 Benefits and Limitations 43-59
43.4.7.4 Claims Information 43-60
43.4.8 Occupational Therapists (THSteps-CCP Only) 43-60
43.4.8.1 Enrollment 43-60
43.4.8.2 Reimbursement 43-60
43.4.8.3 Benefits and Limitations 43-60
43.4.8.4 Claims Information 43-62
43.4.9 Orthotic and Prosthetic Suppliers (THSteps-CCP Only) 43-62
43.4.9.1 Enrollment 43-63
43.4.9.2 Reimbursement 43-63
43.4.9.3 Benefits and Limitations 43-63
43.4.9.4 Cranial Orthotic Devices 43-63
43.4.9.5 Corrective Shoe, Wedge, and Lift 43-64
43.4.9.6 Claims Information 43-65
43.4.10 Personal Care Services (THSteps-CCP Only) 43-65
43.4.10.2 Reimbursement 43-66
43.4.10.3 PCS Provider Responsibilities 43-66
43.4.10.4 Benefits and Limitations 43-67
43.4.10.5 Client Eligibility 43-67
43.4.10.6 Prior Authorization 43-69
43.4.10.7 Claims Information 43-69
43.4.11 Pharmacies (THSteps-CCP Only) 43-70
43.4.11.2 Reimbursement 43-70
43.4.11.4 Benefits and Limitations 43-70
43.4.11.5 Claims Information 43-71
43.4.12 Physical Therapists (THSteps-CCP Only) 43-71
43.4.12.2 Reimbursement 43-71
43.4.12.3 Benefits and Limitations 43-72
43.4.12.4 Claims Information 43-73
43.4.13 Private Duty Nursing (PDN) THSteps-CCP Only 43-73
43.4.13.2 Reimbursement 43-74
43.4.13.3 Benefits and Limitations 43-74
43.4.13.5 Prior Authorization 43-77
43.4.13.6 Documentation 43-80
43.4.13.7 Claims Information 43-82
43.4.14 Psychiatric Hospital/Facility (Freestanding) (THSteps-CCP Only) 43-83
43.4.14.2 Reimbursement 43-83
43.4.14.3 LoneSTAR Select 015 - Managed Care 43-83
43.4.14.4 Benefits and Limitations 43-84
43.4.14.5 Claims Information 43-87
43.4.15 Rehabilitation Hospital (Freestanding) (THSteps-CCP Only) 43-87
43.4.15.2 Continuity of Hospital Eligibility Through Change of Ownership 43-88
43.4.15.3 Reimbursement 43-88
43.4.15.4 Benefits and Limitations 43-89
43.4.15.5 Claims Information 43-90
43.4.16 Speech-Language Pathologists (THSteps-CCP Only) 43-90
43.4.16.2 Reimbursement 43-90
43.4.16.3 Benefits and Limitations 43-91
43.4.16.4 Prior Authorization, Documentation Requirements 43-91
43.4.16.5 Claims Information 43-92
43.4.16.6 THSteps-CCP Claim Filing Resources 43-92
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