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Section 8: Managed Care
8.1 Medicaid Managed Care 8-5
8.1.1 Overview 8-5
8.1.2 Texas Medicaid Benefits by Program 8-6
8.1.3 Authorizations and Claim Processing Exceptions by Program 8-7
8.1.4 Third Party Resources (TPR) 8-7
8.1.5 The Health Insurance Premium Payment Program 8-8
8.1.6 Client Enrollment 8-8
8.1.6.1 Managed Care Eligibility and Effective Date 8-8
8.1.6.2 Automatic Reenrollment 8-10
8.1.7 Primary Care Provider Changes 8-10
8.1.7.1 Client-Initiated Primary Care Provider Changes 8-10
8.1.7.2 STAR, STAR+PLUS, and PCCM Primary Care Provider Changes 8-10
8.1.7.3 Provider-Initiated Primary Care Provider Changes 8-10
8.1.7.4 Medicaid Managed Care-Initiated Primary Care Provider Changes 8-11
8.1.8 Health Plan Changes 8-11
8.1.8.1 Client-Initiated HMO Plan Changes 8-11
8.1.8.2 Health Plan Managed Care Administrator-Initiated Changes 8-11
8.1.9 Client Rights and Responsibilities 8-12
8.1.9.1 Client Rights 8-12
8.1.9.2 Client Responsibilities 8-13
8.1.9.3 Advance Directives 8-14
8.1.10 Primary Care Provider Requirements and Information 8-15
8.1.10.1 Continuous Access 8-19
8.1.10.1.1 After-Hours Guidelines 8-19
8.1.10.1.2 Unacceptable Telephone Arrangements 8-20
8.1.10.2 Cultural Competency and Sensitivity 8-20
8.1.10.2.1 Limited English Proficiency 8-20
8.1.10.3 Primary Care Provider-to-Client Ratio and Capacity (Does Not Apply to HMOs) 8-22
8.1.11 Medicaid Managed Care Complaints and Fair Hearings 8-22
8.1.12 Prior Authorizations 8-22
8.1.13 TMHP Claims Filing Information 8-22
8.1.13.1 TMHP Paper Claims Submissions 8-23
8.1.13.2 TMHP Electronic Claims Submission 8-24
8.1.13.3 National Drug Code (NDC) Claims 8-24
8.1.13.4 Claims for Pregnant Women in STAR Program (Program Type 40) 8-24
8.2 STAR Program 8-24
8.2.1 Overview 8-24
8.2.1.1 STAR HMO Model 8-24
8.2.2 Client Eligibility 8-25
8.2.3 Client Enrollment 8-26
8.2.3.1 Expedited Enrollment of Pregnant Women (Program Type 40) 8-27
8.2.3.1.1 Enrollment of Newborns 8-28
8.2.3.1.2 Timely Notification and Assignment of Medicaid ID for Newborns 8-28
8.2.4 Service Areas and STAR HMO Choices 8-28
8.2.5 STAR Program Benefits 8-29
8.2.5.1 Spell of Illness 8-29
8.2.5.2 Prescriptions 8-29
8.2.5.3 Annual Adult Well-Check 8-29
8.2.5.4 National Drug Code 8-30
8.2.6 Claims Filing Information 8-30
8.2.6.1 Newborn Claims Submission 8-30
8.2.6.1.1 HMO Newborn Claims Filing 8-30
8.3 STAR+PLUS Program 8-31
8.3.1 Overview 8-31
8.3.1.1 STAR+PLUS HMO Model 8-31
8.3.1.2 Enrollment of Newborns 8-31
8.3.1.3 Service Areas 8-31
8.3.1.4 Client Eligibility 8-32
8.3.1.5 Dual Eligible Clients 8-32
8.3.1.6 Ineligible Clients 8-33
8.3.2 Client Enrollment 8-33
8.3.3 STAR+PLUS Program Benefits 8-33
8.3.4 Spell of Illness Limitation 8-34
8.3.5 Claims Filing Information 8-34
8.3.5.1 STAR+PLUS Mental Health Claims 8-34
8.4 NorthSTAR Program 8-35
8.4.1 Overview 8-35
8.4.2 Provider Requirements and Information 8-35
8.4.3 Service Area 8-35
8.4.3.1 Client Eligibility 8-36
8.4.4 Client Enrollment 8-36
8.4.4.1 NorthSTAR Enrollment Broker 8-36
8.4.4.2 Guidelines for Working with NorthSTAR Clients 8-37
8.4.5 Claims Filing Information 8-37
8.4.5.1 Hospital Billing 8-37
8.4.5.2 Behavioral Health Billing 8-37
8.4.5.3 Prior Authorization Requirements 8-37
8.4.6 Complaints and Appeals 8-37
8.4.6.1 Quality Improvement Monitoring 8-38
8.5 STAR Health Program 8-38
8.5.1 Overview 8-38
8.5.2 STAR Health Model 8-39
8.5.3 Client Eligibility 8-39
8.5.4 STAR Health Program Benefits 8-39
8.5.5 STAR Health Claims Filing 8-39
8.5.5.1 STAR Health Mental Health Rehabilitation Mental Health Claims Submissions 8-40
8.6 PCCM 8-42
8.6.1 Overview 8-42
8.6.2 Contact Numbers 8-43
8.6.3 Client Eligibility 8-43
8.6.4 Client Enrollment 8-44
8.6.5 PCCM+PLUS 8-45
8.6.5.1 PCCM+PLUS Goals 8-45
8.6.5.2 PCCM+PLUS Plan of Care 8-45
8.6.5.3 Services Offered through PCCM+PLUS 8-45
8.6.6 Client Rights and Responsibilities 8-46
8.6.6.1 Client Rights 8-46
8.6.6.2 Client Responsibilities 8-47
8.6.7 Online Provider Lookup 8-48
8.6.8 Primary Care Provider Selection and Changes 8-49
8.6.8.1 Selecting a Primary Care Provider 8-49
8.6.8.1.1 Auto-Assignment 8-49
8.6.8.2 Changing a Primary Care Provider 8-49
8.6.8.3 Provider Initiated Primary Care Provider Changes 8-50
8.6.9 Provider Enrollment 8-50
8.6.9.1 Credentialing Committee 8-51
8.6.9.2 Members of the Credentialing Committee 8-51
8.6.9.3 Credentialing Committee Frequency and Logistics 8-51
8.6.9.4 Credentialing Committee Action 8-51
8.6.9.5 Credentialing Grievance Committee 8-52
8.6.9.5.1 Members of the Credentialing Grievance Committee 8-52
8.6.9.5.2 Credentialing Grievance Committee Frequency/Logistics 8-52
8.6.9.5.3 Notification of the Credentialing Grievance Committee's Decision 8-52
8.6.9.6 Primary Care Provider Termination/Disenrollment 8-52
8.6.9.7 Additional Criteria for Primary Care Providers 8-53
8.6.9.8 Miscellaneous Provisions 8-53
8.6.10 PCCM Reimbursement 8-53
8.6.10.1 Case Management Fee 8-54
8.6.11 Support Services 8-54
8.6.11.1 Provider Support Services 8-54
8.6.11.2 Client Support and Education 8-55
8.6.11.2.1 Linguistic Services 8-56
8.6.11.3 Monthly Client Panel Report 8-57
8.6.12 Covered Services 8-58
8.6.12.2 Behavioral Health Services 8-61
8.6.12.2.1 Outpatient Services 8-62
8.6.12.2.2 Inpatient Services 8-62
8.6.13 Provider Responsibilities 8-63
8.6.13.0.1 Verifying Primary Care Provider Assignment 8-63
8.6.13.0.2 Primary Care Provider Services 8-63
8.6.13.1 Office and Medical Records Standards 8-64
8.6.13.2 Medical Records Standards 8-64
8.6.13.2.1 Content of Medical Record 8-65
8.6.13.2.2 Confidentiality of Medical Records 8-65
8.6.13.2.3 Medical Records Audits 8-66
8.6.13.2.4 Access and Availability Standards 8-67
8.6.14 PCCM-Enrolled FQHCs and RHCs Must Report Medical Staff Changes to TMHP 8-67
8.6.15 Monitoring Provider Performance 8-67
8.6.16 Referrals 8-68
8.6.16.1 Open Specialty Referral Network 8-69
8.6.16.2 Referral Form 8-70
8.6.17 Specialist Responsibilities 8-70
8.6.17.1 Specialist-to-Specialist Referrals 8-70
8.6.18 PCCM Inpatient Authorization Process 8-70
8.6.18.1 Definitions 8-70
8.6.18.2 Professional Services - ER Services 8-71
8.6.18.3 Facility/Hospital Services 8-71
8.6.18.4 Emergency Room Services 8-73
8.6.18.5 Observation Services 8-73
8.6.18.6 Urgent and Emergent Admissions 8-74
8.6.18.7 Obstetrical and Newborn Notification 8-75
8.6.18.8 Scheduled Inpatient Admissions 8-75
8.6.18.9 Appeals of Denied Requests for Authorization 8-75
8.6.18.10 Out-of-Network Inpatient Services 8-76
8.6.19 Outpatient Prior Authorization Process 8-77
8.6.19.1 Requesting Prior Authorization 8-78
8.6.20 Transportation Services 8-79
8.6.20.1 Nonemergency Transportation 8-79
8.6.21 Provider Complaints and Appeals 8-79
8.6.21.1 Conflict Resolution 8-79
8.6.21.2 Provider Complaints 8-80
8.6.21.2.1 Provider Complaint Policy 8-80
8.6.21.2.2 Provider Complaint Procedures 8-80
8.6.21.2.3 Complaints to HHSC-PCCM 8-80
8.6.21.3 Authorization Appeals 8-82
8.6.21.3.1 Appeal Procedures for Denials Other Than Medical Necessity 8-82
8.6.21.3.2 Appeal Procedures for Medical Necessity Denials 8-83
8.6.22 Claims Filing Information 8-83
8.6.22.1 PCCM Newborn Claims Filing 8-84
8.6.22.2 Personal Care Services 8-85
8.6.22.3 Migrant Farm Workers 8-85
8.6.22.4 Network Hospitals 8-85
8.6.22.5 Out-of-Network Hospitals 8-85
8.6.22.6 Emergency Outpatient Services 8-85
8.6.22.7 Nonemergency Outpatient Clinic Services 8-85
8.6.22.8 PCCM Claims Details 8-86
8.6.22.9 National Drug Code (NDC) 8-86
8.6.22.10 Claims for Specialist Services 8-86
8.7 Forms 8-86
8.1 Primary Care Case Management (PCCM) Behavioral Health Consent Form 8-87
8.2 Primary Care Case Management (PCCM) Behavioral Health Consent Form (Spanish) 8-88
8.3 PCCM Community Health Services Referral Request Form 8-89
8.4 Primary Care Case Management (PCCM) Referral Form 8-90
8.5 Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form 8-91
8.6 Primary Care Case Management (PCCM) FQHC and RHC Medical Staff Update Form 8-92
8.7 Primary Care Case Management (PCCM) Pre-Contractual/Recredentialing Site and Medical Record Evaluation Form 8-93
8.8 Primary Care Case Management (PCCM)- Medicaid Primary Care Provider Selection Form 8-94
8.9 Primary Care Case Management (PCCM)- Medicaid Primary Care Provider Selection Form Page 2 8-95
8.10 Provider Information Change Form 8-96
8.11 Instructions for Completing the Provider Information Change Form 8-97
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