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Children's Services Handbook
Table of Contents
1. General Information CH-15
1.1 Medical Transportation Program CH-15
2. Chemical Dependency Treatment Facility Services CH-15
2.1 Overview CH-15
2.2 Enrollment CH-15
2.3 Services/Benefits, Limitations, and Prior Authorization CH-16
2.3.1 Outpatient Counseling CH-16
2.3.2 Prior Authorization CH-17
2.4 Documentation Requirements CH-17
2.5 Claims Filing and Reimbursement CH-17
2.5.1 Claims Information CH-17
2.5.2 Reimbursement CH-18
3. Medicaid Children's Services (CCP) CH-18
3.1 Early Childhood Intervention (ECI) (CCP) CH-18
3.2 CCP Overview CH-19
3.2.1 Client Eligibility CH-19
3.2.2 Enrollment CH-19
3.2.3 Services/Benefits and Limitations CH-20
3.2.4 Prior Authorization and Documentation Requirements CH-21
3.2.4.1 Diagnosis Coding CH-22
3.2.4.2 Drug and Medical Device Approval CH-22
3.2.4.3 Physician Signature CH-22
3.3 Clinician-Directed Care Coordination Services (CCP) CH-22
3.3.1 Services/Benefits and Limitations CH-22
3.3.1.1 Non-Face-to-Face Services CH-24
3.3.1.1.1 Non-Face-to-Face Medical Conferences CH-24
3.3.1.1.2 Non-Face-to-Face Clinician Supervision of a Home Health Client CH-24
3.3.1.1.3 Non-Face-to-Face Clinician Supervision of a Hospice Client CH-24
3.3.1.1.4 Non-Face-to-Face Clinician Supervision of a Nursing Facility Client CH-24
3.3.1.1.5 Other Non-Face-to-Face Supervision CH-24
3.3.1.1.6 Non-Face-to-Face Prolonged Services CH-25
3.3.1.1.7 Non-Face-to-Face Specialist or Subspecialist Telephone Consultation CH-25
3.3.1.1.8 General Requirements for Non-Face-to-Face Clinician-Directed
Care Coordination Services CH-26
3.3.1.1.9 Non-Face-to-Face Care Plan Oversight CH-26
3.3.1.1.10 Medical Team Conference CH-26
3.3.1.2 Face-to-Face Services CH-27
3.3.1.2.1 General Requirements for Face-to-Face Clinician-Directed
Care Coordination Services CH-27
3.3.2 Prior Authorization and Documentation Requirements CH-27
3.3.2.1 Documentation Requirements for the Medical Home Clinician
for a Telephone Consult with a Specialist CH-29
3.3.2.2 Documentation Requirements for the Specialist or Subspecialist
for a Telephone Consult with the Medical Home Clinician CH-29
3.3.3 Claims Information CH-29
3.3.4 Reimbursement CH-30
3.4 Comprehensive Outpatient Rehabilitation Facilities (CORFs)/Outpatient
Rehabilitation Facilities (ORFs) CH-30
3.4.1 Enrollment CH-30
3.4.2 Services/Benefits and Limitations CH-30
3.4.3 Prior Authorization and Documentation Requirements CH-32
3.4.4 Claims Information CH-33
3.4.5 Reimbursement CH-33
3.5 Durable Medical Equipment (DME) Supplier (CCP) CH-33
3.5.1 Enrollment CH-33
3.5.1.1 Pharmacies (CCP) CH-33
3.5.2 Services/Benefits and Limitations CH-34
3.5.2.1 Purchase Versus Equipment Rental CH-35
3.5.3 Prior Authorization and Documentation Requirements CH-36
3.5.3.1 Equipment Accessories CH-36
3.5.3.2 Equipment Modifications CH-36
3.5.3.3 Equipment Adjustments CH-36
3.5.3.4 Equipment Repairs CH-37
3.5.3.5 DME Certification and Receipt Form CH-37
3.5.3.6 Specific CCP Policies CH-37
3.5.4 Cardiorespiratory (Apnea) Monitor CH-38
3.5.4.1 Services/Benefits and Limitations CH-38
3.5.4.2 Prior Authorization and Documentation Requirements CH-38
3.5.5 Croup Tent/Pulse Oximeter CH-39
3.5.5.1 Services/Benefits and Limitations CH-39
3.5.5.1.2 Pulse Oximeter CH-39
3.5.5.2 Prior Authorization and Documentation Requirements CH-39
3.5.5.2.2 Pulse Oximeter CH-39
3.5.6 Donor Human Milk CH-41
3.5.6.1 Services/Benefits and Limitations CH-41
3.5.6.2 Prior Authorization and Documentation Requirements CH-41
3.5.7 Electronic Blood Pressure Monitoring Device CH-42
3.5.7.1 Services/Benefits and Limitations CH-42
3.5.7.2 Prior Authorization and Documentation Requirements CH-43
3.5.8 Incontinence Supplies for Clients Who Are Birth Through 3 Years of Age CH-43
3.5.8.1 Services/Benefits and Limitations CH-43
3.5.8.2 Prior Authorization and Documentation Requirements CH-44
3.5.9 Medical Nutritional Products CH-44
3.5.9.1 Services/Benefits and Limitations CH-44
3.5.9.1.1 Enteral Nutritional Products CH-45
3.5.9.2 Prior Authorization and Documentation Requirements CH-45
3.5.10 Mobility Aids CH-46
3.5.10.1 Services/Benefits and Limitations CH-46
3.5.10.1.1 Portable Client Lifts for Outside the Home Setting CH-46
3.5.10.1.2 Strollers (a multipositional client transfer system with integrated
seat, operated by care giver) CH-46
3.5.10.1.3 Stroller Ramps-Portable and Threshold CH-47
3.5.10.1.4 Feeder Seats, Floor Sitters, Corner Chairs, and Travel Chairs CH-47
3.5.10.1.6 Mobility Aids - CCP HCPCS Procedure Codes and Limitations CH-47
3.5.10.2 Prior Authorization and Documentation Requirements CH-47
3.5.10.2.1 Portable Client Lifts for Outside the Home Setting CH-48
3.5.10.2.2 Strollers (a multipositional client transfer system with integrated
seat, operated by care giver) CH-48
3.5.10.2.3 Stroller Ramps-Portable and Threshold CH-49
3.5.11 Pediatric Hospital Cribs/Enclosed Beds/Reflux Wedges and Slings CH-50
3.5.11.1 Services/Benefits and Limitations CH-50
3.5.11.2 Prior Authorization and Documentation Requirements CH-50
3.5.12 Phototherapy Devices CH-50
3.5.12.1 Services/Benefits and Limitations CH-50
3.5.12.2 Prior Authorization and Documentation Requirements CH-52
3.5.12.2.1 Retroactive Eligibility CH-53
3.5.13 Special Needs Car Seats and Travel Restraints CH-53
3.5.13.1 Services/Benefits and Limitations CH-53
3.5.13.1.1 Special Needs Car Seats CH-53
3.5.13.1.2 Travel Safety Restraints CH-53
3.5.13.2 Prior Authorization and Documentation Requirements CH-53
3.5.13.2.1 Special Needs Car Seats CH-53
3.5.13.2.2 Travel Safety Restraints CH-54
3.5.14 Claims Information CH-54
3.5.15 Reimbursement CH-54
3.6 Medical Nutrition Counseling Services (CCP) CH-54
3.6.1 Enrollment CH-54
3.6.2 Services/Benefits and Limitations CH-54
3.6.3 Prior Authorization and Documentation Requirements CH-56
3.6.4 Claims Information CH-57
3.6.5 Reimbursement CH-57
3.7 Orthotic and Prosthetic Services (CCP) CH-57
3.7.1 Enrollment CH-57
3.7.2 Services/Benefits and Limitations CH-57
3.7.2.1 Replacement of Orthoses/Prostheses CH-57
3.7.2.2 Training in Using the Orthotic or Prosthetic Device CH-58
3.7.3 Prior Authorization and Documentation Requirements CH-58
3.7.3.1 Repairs, Modifications, and Fittings of Orthosis/Prostheses CH-58
3.7.4 Cranial Molding Orthotics CH-59
3.7.4.1 Services/Benefits and Limitations CH-59
3.7.4.2 Prior Authorization and Documentation Requirements CH-59
3.7.5 Corrective Shoe, Wedge, and Lift CH-60
3.7.5.1 Services/Benefits and Limitations CH-60
3.7.5.1.1 Corrective Shoes CH-60
3.7.5.1.2 Wedge and Lift CH-60
3.7.5.2 Prior Authorization and Documentation Requirements CH-60
3.7.5.2.1 Corrective Shoes CH-60
3.7.5.2.2 Wedges and Lifts CH-60
3.7.6 Dynamic Splint CH-61
3.7.6.1 Services/Benefits and Limitations CH-61
3.7.6.2 Prior Authorization and Documentation Requirements CH-61
3.7.7 Protective Helmets CH-61
3.7.7.1 Services/Benefits and Limitations CH-61
3.7.7.2 Prior Authorization and Documentation Requirements CH-61
3.7.8 Reciprocating Gait Orthoses (RGO) CH-61
3.7.8.1 Services/Benefits and Limitations CH-61
3.7.8.2 Prior Authorization and Documentation Requirements CH-61
3.7.9 Removable Shoe Insert, UCB (University of California at Berkeley) Type CH-61
3.7.9.1 Services/Benefits and Limitations CH-61
3.7.9.2 Prior Authorization and Documentation Requirements CH-61
3.7.10 Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers,
Standing Frames/Braces, and Parapodiums) CH-62
3.7.10.1 Services/Benefits and Limitations CH-62
3.7.10.1.2 Standing Frame or Brace CH-62
3.7.10.1.3 Vertical or Dynamic Stander CH-62
3.7.10.2 Prior Authorization and Documentation Requirements CH-62
3.7.11 Claims Information CH-63
3.7.12 Reimbursement CH-63
3.8 Personal Care Services (PCS) (CCP) CH-63
3.8.1 Enrollment CH-63
3.8.2 Services/Benefits and Limitations CH-64
3.8.2.1 Place of Services CH-66
3.8.2.2 Client Eligibility CH-66
3.8.2.2.1 Accessing the PCS Benefit CH-67
3.8.2.2.2 The Primary Practitioner's Role in the PCS Benefit CH-68
3.8.2.3 PCS Provided in Group Settings CH-68
3.8.3 Prior Authorization and Documentation Requirements CH-68
3.8.3.1 PCS Provider Responsibilities CH-69
3.8.3.2 Documentation of Services Provided/Retrospective Review CH-69
3.8.4 Claims Information CH-70
3.8.5 Reimbursement CH-70
3.9 Private Duty Nursing (CCP) CH-70
3.9.1 Enrollment CH-70
3.9.2 Services/Benefits and Limitations CH-71
3.9.2.1 PDN Provided During a Skill Nursing Visit for TPN Administration
Education CH-74
3.9.2.2 Criteria CH-75
3.9.2.2.1 Client Eligibility Criteria CH-75
3.9.2.2.2 Retroactive Client Eligibility CH-75
3.9.2.2.3 Medical Necessity CH-76
3.9.2.2.4 Place of Service (POS) CH-76
3.9.2.2.5 Amount and Duration of PDN CH-76
3.9.3 Prior Authorization and Documentation Requirements CH-76
3.9.3.1 Start of Care (SOC) CH-78
3.9.3.2 Prior Authorization of Initial Requests CH-78
3.9.3.3 Authorization for Revision of Current Services CH-79
3.9.3.4 Recertifications of Authorizations CH-80
3.9.3.5 Termination of Authorization CH-80
3.9.3.6 Client/Provider Notification CH-81
3.9.3.7 Authorization Appeals CH-81
3.9.3.8 CCP Prior Authorization Request Form CH-81
3.9.3.9 Home Health Plan of Care (POC) CH-81
3.9.3.10 Nursing Addendum to Plan of Care (CCP) Form CH-82
3.9.3.10.1 The Client's 24-Hour Daily Schedule CH-83
3.9.3.11 Responsible Adult or Identified Contingency Plan Requirement CH-83
3.9.3.12 Documentation of Services Provided/Retrospective Review CH-84
3.9.4 Claims Information CH-84
3.9.5 Reimbursement CH-85
3.10 Therapy Services (CCP) CH-85
3.10.1 Occupational Therapy (OT) CH-86
3.10.1.1 Enrollment CH-86
3.10.1.2 Services/Benefits and Limitations CH-86
3.10.1.3 Prior Authorization and Documentation Requirements CH-88
3.10.1.4 Claims Information CH-89
3.10.1.5 Reimbursement CH-89
3.10.2 Physical Therapy (PT) CH-89
3.10.2.1 Enrollment CH-89
3.10.2.2 Services/Benefits and Limitations CH-89
3.10.2.3 Prior Authorization and Documentation Requirements CH-90
3.10.2.4 Claims Information CH-91
3.10.2.5 Reimbursement CH-92
3.10.3 Speech Therapy (ST) CH-92
3.10.3.1 Enrollment CH-92
3.10.3.2 Services/Benefits and Limitations CH-92
3.10.3.3 Prior Authorization and Documentation Requirements CH-92
3.10.3.4 Claims Information CH-94
3.10.3.5 Reimbursement CH-94
3.11 Inpatient Psychiatric Hospital/Facility (Freestanding) (CCP) CH-94
3.11.1 Enrollment CH-94
3.11.1.1 Continuity of Hospital Eligibility Through Change of Ownership CH-94
3.11.2 Services/Benefits and Limitations CH-95
3.11.3 Prior Authorization and Documentation Requirements CH-95
3.11.3.1 Medicaid Clinical Criteria for Inpatient Psychiatric Care For Clients CH-96
3.11.3.2 Continued Stays CH-98
3.11.3.3 Court-Ordered Services CH-98
3.11.3.5 Utilization Review CH-99
3.11.3.6 Retrospective Utilization Review CH-99
3.11.4 Claims Information CH-100
3.11.5 Reimbursement CH-100
3.12 Inpatient Rehabilitation Hospital (Freestanding) (CCP) CH-100
3.12.1 Enrollment CH-100
3.12.1.1 Continuity of Hospital Eligibility Through Change of Ownership CH-100
3.12.2 Services/Benefits and Limitations CH-101
3.12.2.1 Comprehensive Treatment CH-101
3.12.3 Prior Authorization and Documentation Requirements CH-101
3.12.4 Claims Information CH-102
3.12.5 Reimbursement CH-103
3.12.5.1 Client Transfers CH-103
4. School Health and Related Services (SHARS) CH-104
4.1 Overview CH-104
4.1.1 Eligibility Verification CH-104
4.2 Enrollment CH-105
4.2.1 SHARS Enrollment CH-105
4.2.2 Nonschool SHARS Provider Enrollment CH-105
4.2.3 Private School Enrollment CH-106
4.2.4 Medicaid Managed Care Enrollment CH-106
4.3 Services/Benefits, Limitations, and Prior Authorization CH-106
4.3.1 Audiology CH-106
4.3.1.1 Audiology Billing Table CH-107
4.3.2 Counseling Services CH-107
4.3.2.1 Counseling Services Billing Table CH-108
4.3.3 Psychological Testing and Services CH-108
4.3.3.1 Psychological Testing CH-108
4.3.3.2 Psychological Services CH-109
4.3.4 Nursing Services CH-110
4.3.4.1 Nursing Services Billing Table CH-110
4.3.5 Occupational Therapy CH-111
4.3.5.1 Occupational Therapy Billing Table CH-112
4.3.6 Personal Care Services CH-112
4.3.6.1 Personal Care Services Billing Table CH-113
4.3.7 Physical Therapy CH-113
4.3.7.1 Physical Therapy Billing Table CH-114
4.3.8 Physician Services CH-114
4.3.8.1 Medical Services Billing Table CH-115
4.3.9 Speech Therapy CH-115
4.3.9.1 Referral CH-115
4.3.9.2 Description of Services CH-115
4.3.9.3 Provider and Supervision Requirements CH-115
4.3.9.4 Speech Therapy Billing Table CH-116
4.3.10 Transportation Services in a School Setting CH-116
4.3.10.1 Transportation Services in a School Setting Billing Table CH-117
4.3.11 Prior Authorization CH-117
4.4 Documentation Requirements CH-118
4.4.1 Record Retention CH-118
4.5 Claims Filing and Reimbursement CH-118
4.5.1 Claims Information CH-118
4.5.1.1 Appealing Denied SHARS Claims CH-118
4.5.1.2 Billing Units Based on 15 Minutes CH-119
4.5.1.3 Billing Units Based on an Hour CH-119
4.5.2 Reimbursement CH-120
4.5.2.1 Random Moment Time Study (RMTS) CH-120
4.5.2.2 Certification of Funds CH-121
4.5.2.3 Cost Reporting CH-121
4.5.2.4 Cost Reconciliation and Cost Settlement CH-122
5. Texas Health Steps (THSteps) Dental CH-122
5.1 Overview CH-122
5.1.1 THSteps Dental Eligibility CH-122
5.2 Enrollment CH-123
5.2.1 Categories of Practice CH-124
5.2.2 THSteps Dental and ICF-MR Dental Services CH-124
5.2.3 THSteps Dental Checkup and Treatment Facilities CH-124
5.2.4 Doctor of Dentistry Practicing as a Limited Physician CH-124
5.2.5 Medicaid Managed Care Enrollment CH-124
5.2.6 Client Rights CH-125
5.2.7 Complaints and Resolution CH-125
5.3 Services/Benefits, Limitations, and Prior Authorization CH-125
5.3.1 THSteps Dental Services CH-125
5.3.1.1 Parental Accompaniment CH-126
5.3.2 Comprehensive Care Program (CCP) CH-126
5.3.3 ICF-MR Dental Services CH-126
5.3.3.1 THSteps and ICF-MR Provision of Dental Services CH-126
5.3.3.2 Children in Foster Care CH-127
5.3.4 Written Informed Consent and Standards of Care CH-127
5.3.5 First Dental Home CH-127
5.3.6 Dental Referrals by THSteps Primary Care Providers CH-128
5.3.7 Change of Provider CH-129
5.3.7.1 Interrupted or Incomplete Orthodontic Treatment Plans CH-129
5.3.8 Periodicity for THSteps Dental Services CH-129
5.3.8.1 Exceptions to Periodicity CH-130
5.3.9 Tooth Identification (TID) and Surface Identification (SID) Systems CH-131
5.3.9.1 Supernumerary Tooth Identification CH-131
5.3.10 Medicaid Dental Benefits, Limitations, and Fee Schedule CH-132
5.3.11 Diagnostic Services CH-132
5.3.12 Preventive Services CH-136
5.3.13 Therapeutic Services CH-138
5.3.14 Restorative Services CH-139
5.3.15 Endodontics Services CH-142
5.3.16 Periodontal Services CH-144
5.3.17 Prosthodontic (Removable) Services CH-147
5.3.18 Implant Services CH-150
5.3.19 Prosthodontic (Fixed) Services CH-151
5.3.20 Oral and Maxillofacial Surgery Services CH-153
5.3.21 Adjunctive General Services CH-157
5.3.22 Dental Therapy Under General Anesthesia CH-160
5.3.22.1 Criteria for Dental Therapy Under General Anesthesia CH-161
5.3.22.2 Criteria for Dental Therapy Under General Anesthesia, Attachment 1 CH-162
5.3.23 Hospitalization and ASC/HASC CH-163
5.3.24 Orthodontic Services (THSteps) CH-163
5.3.24.1 Benefits and Limitations CH-164
5.3.24.2 Completion of Treatment Plan CH-165
5.3.24.3 Premature Removal of Appliances CH-166
5.3.24.4 Transfer of Orthodontic Services CH-166
5.3.24.5 Comprehensive Orthodontic Treatment CH-167
5.3.24.6 Orthodontic Procedure Codes and Fee Schedule CH-168
5.3.25 Special Orthodontic Appliances CH-168
5.3.26 How to Score the Handicapping Labio-lingual Deviation (HLD) Index CH-171
5.3.26.1 HLD Score Sheet CH-173
5.3.27 Emergency and/or Trauma Related Services for All THSteps Clients and
Clients 5 Months of Age or Younger CH-174
5.3.28 Emergency Services for Medicaid Clients 21 Years of Age or Older CH-174
5.3.28.1 Long Term Care (LTC) Emergency Dental Services CH-175
5.3.28.2 Laboratory Requirements CH-175
5.3.29 Mandatory Prior Authorization CH-175
5.3.29.1 Cone Beam Imaging CH-176
5.3.29.2 General Anesthesia for Dental Treatment CH-176
5.3.29.3 Orthodontic Services CH-176
5.3.30 THSteps and ICF-MR Dental Prior Authorization CH-177
5.4 Documentation Requirements CH-177
5.4.1 General Anesthesia CH-178
5.4.2 Orthodontic Services CH-179
5.5 Utilization Review CH-179
5.6 Claims Filing and Reimbursement CH-180
5.6.1 Reimbursement CH-180
5.6.2 Third-Party Resources (TPR) CH-180
5.6.3 Billing After Loss of Eligibility CH-180
5.6.4 Claims Information CH-180
5.6.5 Claim Appeals CH-181
5.6.6 Frequently Asked Questions About Dental Claims CH-183
6. THSteps Medical CH-185
6.1 THSteps Medical and Dental Administrative Information CH-185
6.1.1 Overview CH-185
6.1.2 Statutory Requirements CH-185
6.1.3 Texas Vaccines for Children (TVFC) Program CH-186
6.1.4 Vaccine Adverse Event Reporting System (VAERS) CH-186
6.1.5 Referrals for Medicaid-Covered Services CH-186
6.1.6 THSteps Medical Checkup Facilities CH-188
6.1.7 THSteps Dental Services CH-188
6.1.7.1 How the THSteps Dental Program Works CH-188
6.2 Enrollment CH-189
6.2.1 THSteps Medical Provider Enrollment CH-189
6.2.1.1 Additional Education Requirements for Registered Nurses (RNs) CH-190
6.2.1.2 Medicaid Managed Care Enrollment CH-190
6.3 Services/Benefits, Limitations, and Prior Authorization CH-191
6.3.1 THSteps Medical Checkups CH-191
6.3.1.1 Medical Home Concept CH-192
6.3.1.2 Mobile Units and the Medical Home CH-192
6.3.1.3 Eligibility for a Medical Checkup CH-192
6.3.1.4 Verification of Medical Checkups CH-193
6.3.1.5 Follow-up Medical Visit CH-193
6.3.1.6 Exception-to-Periodicity Checkups CH-193
6.3.1.7 Medical Checkups for Infants, Children, and Adolescents (Birth
Through 20 Years of Age) CH-194
6.3.1.7.1 Acute Care Visits CH-196
6.3.1.8 Newborn Examination CH-197
6.3.1.9 THSteps Medical Checkups Periodicity Schedule CH-197
6.3.2 Screening Components With Additional Requirements CH-200
6.3.2.1 Developmental Screening CH-200
6.3.2.2 Referrals for Developmental Assessment CH-201
6.3.2.3 Mental Health CH-201
6.3.2.4 Sensory Screenings CH-202
6.3.2.4.1 Vision Screening CH-202
6.3.2.4.2 Hearing Screening CH-202
6.3.2.5 Tuberculosis Screening CH-203
6.3.2.6 Laboratory Procedures CH-204
6.3.2.6.1 Laboratory Services CH-204
6.3.2.6.2 Laboratory Supplies CH-205
6.3.2.6.3 Newborn Screening Supplies CH-206
6.3.2.6.4 Laboratory Submission CH-206
6.3.2.6.5 Send Comments CH-207
6.3.2.6.6 Required Laboratory Tests Related to Medical Checkups CH-207
6.3.2.6.7 Additional Required Laboratory Tests Related to Medical Checkups
for Adolescents CH-208
6.3.2.6.8 Laboratory Reporting CH-210
6.3.2.7 Administrations and Immunizations CH-210
6.3.2.7.1 Vaccine Information Statement (VIS) CH-211
6.3.2.8 Dental Screening and Intermediate Oral Evaluation with Fluoride
Varnish Application in the Medical Home CH-212
6.3.2.8.1 Dental Screening CH-212
6.3.2.8.2 Intermediate Oral Evaluation with Fluoride Varnish Application CH-212
6.3.2.9 Anticipatory Guidance CH-213
6.4 Documentation Requirements CH-213
6.4.1 THSteps Medical Checkups-Documentation of Completed Checkups CH-213
6.4.1.0.1 Separate Identifiable Acute Care Evaluation and Management Visit CH-214
6.5 Claims Filing and Reimbursement CH-214
6.5.1 THSteps Medical Checkups CH-215
6.5.1.1 Claims Information CH-215
6.5.1.2 Reimbursement CH-215
7. Claims Resources CH-216
8. Contact TMHP CH-217
8.1 Automated Inquiry System (AIS) CH-217
8.2 TMHP Website CH-217
8.3 (Dental) Information and Assistance CH-217
8.3.1 Dental Inquiry Line CH-217
8.4 (THSteps) Information and Assistance CH-218
8.5 Assistance with Program CH-218
9. Forms CH-218
CH.1 CCP Prior Authorization Request Form CH-219
CH.2 CCP Prior Authorization Private Duty Nursing 6-Month Authorization CH-220
CH.3 CCP ECI Request for Initial/Renewal Outpatient Therapy CH-221
CH.4 DME Certification and Receipt Form (3 Pages) CH-222
CH.5 Donor Human Milk Request Form CH-225
CH.6 External Insulin Pump CH-226
CH.7 Home Health Plan of Care (POC) CH-227
CH.8 Nursing Addendum to Plan of Care (CCP) (7 Pages) CH-228
CH.9 Psychiatric Inpatient Initial Admission Request Form CH-235
CH.10 Psychiatric Inpatient Extended Stay Request Form CH-236
CH.11 Pulse Oximeter Form CH-237
CH.12 Request for Initial Outpatient Therapy (Form TP-1) CH-238
CH.13 Request for Extension of Outpatient Therapy (Form TP-2) (2 Pages) CH-239
CH.14 THSteps Dental Mandatory Prior Authorization Request Form CH-241
CH.15 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 Pages) CH-242
CH.16 THSteps Referral Form Instructions CH-244
CH.17 THSteps Referral Form CH-245
CH.18 CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed
Care Coordination Services (2 Pages) CH-246
CH.19 Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face
Clinician-Directed Care Coordination Services-Comprehensive Care Program (CCP) CH-248
CH.20 Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health
Services) (6 Pages) CH-249
10. Claim Form Examples CH-255
CH.21 Chemical Dependency Treatment Facility CH-256
CH.22 Comprehensive Outpatient Rehabilitation Facility (CORF) (CCP Only) CH-257
CH.23 Diagnosis and Treatment (Referral from THSteps Checkup) CH-258
CH.24 Durable Medical Equipment (CCP Only) CH-259
CH.25 Early Childhood Intervention (CCP Only) CH-260
CH.26 Inpatient Psychiatric Hospital/Facility (CCP Only) CH-261
CH.27 Inpatient Rehabilitation Hospital (CCP Only) CH-262
CH.28 Medical Nutritional Counseling (CCP Only) CH-263
CH.29 Occupational Therapists (CCP Only) CH-264
CH.30 Orthotic and Prosthetic Services (CCP Only) CH-265
CH.31 Physical Therapists (CCP Only) CH-266
CH.32 Private Duty Nurses (CCP Only) CH-267
CH.33 School Health and Related Services (SHARS) CH-268
CH.34 Speech-Language Pathologists (CCP Only) CH-269
CH.35 THSteps New Patient, Immunization, Physical Examination by a Nurse
Practitioner, and FQHC Billing CH-270
CH.36 THSteps Established Patient and Referral, TB Skin Test, and Physical Examination
by a Physician CH-271
11. Appendices CH-272
A.1 Claim Forms CH-274
A.2 Child Health Clinical Records CH-274
A.3 Guidelines for Tuberculosis Skin Testing CH-274
A.4 Laboratory Forms CH-275
CH.37 Child Health History (2 Pages) CH-276
CH.38 Child Health Record (Birth-1 Month) (2 Pages) CH-278
CH.39 Child Health Record (2-6 Months) (2 Pages) CH-280
CH.40 Child Health Record (7-12 Months) (2 Pages) CH-282
CH.41 Child Health Record (13 Months-2 Years) (2 Pages) CH-284
CH.42 Child Health Record (3-5 Years) (2 Pages) CH-286
CH.43 Child Health Record (6-10 Years) (2 Pages) CH-288
CH.44 Hearing Checklist for Parents CH-290
CH.45 Hearing Checklist for Parents (Spanish) CH-291
CH.46 Mental Health Interview Tool/Referral Form (Ages 0-2 Years) CH-292
CH.47 Mental Health Interview Tool/Referral Form (Ages 3-9 Years) CH-293
CH.48 Mental Health Interview Tool/Referral Form (Ages 10-12 Years) CH-294
CH.49 Mental Health Interview Tool/Referral Form (Ages 13-20 Years) CH-295
CH.50 Mental Health Parent Questionnaire (Ages Birth-2 Years) (2 Pages) CH-296
CH.51 Mental Health Questionnaire (Ages Birth-2 Years) (2 Pages) (Spanish) CH-298
CH.52 Mental Health Parent Questionnaire (Ages 3-9 Years) (2 Pages) CH-300
CH.53 Mental Health Parent Questionnaire (Ages 3-9 Years) (2 Pages) (Spanish) CH-302
CH.54 Mental Health Parent Questionnaire (Ages 10-12 Years) (2 Pages) CH-304
CH.55 Mental Health Parent Questionnaire (Ages 10-12 Years) (2 Pages) (Spanish) CH-306
CH.56 Mental Health Parent Questionnaire (Ages 13-20 Years) (2 Pages) CH-308
CH.57 Mental Health Parent Questionnaire (Ages 13-20 Years) (2 Pages) (Spanish) CH-310
CH.58 Risk Assessment for Lead Exposure: Parent Questionnaire, Form Pb-110 (2 Pages) CH-312
A.5 Tuberculosis Screening and Education Tool CH-314
CH.59 TB Questionnaire CH-315
CH.60 Cuestionario Para la Detección de Tuberculosis CH-316
CH.61 How to Determine TB Risk CH-317
CH.62 PPD Agreement for Texas Health Steps Providers CH-318
CH.63 TVFC Patient Eligibility Screening Record CH-319
CH.64 TVFC Patient Eligibility Screening Record (Spanish) CH-320
CH.65 TVFC Provider Enrollment (3 Pages) CH-321
CH.66 TVFC Questions and Answers (3 Pages) CH-324
B.1 Immunizations Overview CH-328
B.1.1 Vaccine Adverse Event Reporting System (VAERS) CH-328
B.1.2 TVFC Versus Non-TVFC Vaccines/Toxoids CH-328
B.1.3 Exemption from Immunization for School and Child-Care Facilities CH-328
B.2 Recommended Childhood Immunization Schedule CH-329
B.2.1 Recommended Childhood and Adolescent Immunization Schedule, 2010 CH-330
B.3 General Recommendations CH-333
B.3.1 How to Obtain Free Vaccines CH-333
B.3.2 Administrations and Immunizations CH-333
B.3.2.1 Vaccine Procedure Codes and State-Defined Components CH-333
B.3.3 Requirements for TVFC Providers CH-334
B.3.4 How to Report Immunization Records to ImmTrac, the Texas Immunization
Registry CH-335
B.3.4.1 Direct Internet Entry CH-336
B.3.4.2 Electronic Data Transfer (Import) CH-336
B.3.4.3 Obtaining Parental Consent for Registry Participation CH-336
B.4 Texas Vaccines for Children Program Packet CH-336
C.1 Blood Lead Screening Procedures and Follow-up Testing CH-338
C.2 Symptoms of Lead Poisoning CH-338
C.3 Measuring Blood Lead Levels CH-338
C.4 Form Pb-109: Physician Reference on Follow-up Testing and Case Management CH-340
C.5 Lead Poisoning Prevention Educational Materials and Forms CH-341
Appendix D: Texas Health Steps Statutory State Requirements
D.1 Legislative Requirements CH-344
D.2 Texas Health Steps (THSteps) Program CH-344
D.3 Communicable Disease Reporting CH-344
D.4 Early Childhood Intervention (ECI) Referrals CH-344
D.5 Parental Accompaniment CH-344
D.6 Newborn Blood Screening CH-345
D.7 Abuse and Neglect CH-345
D.7.1 Requirements for Reporting Abuse or Neglect CH-345
D.7.2 Procedures for Reporting Abuse or Neglect CH-345
D.7.2.1 Staff Training on Reporting Abuse and Neglect CH-346
E.1 Newborn Hearing (2 Pages) CH-348
E.2 Texas Early Hearing Detection and Intervention (TEHDI) Process CH-350
E.2.1 Birth Screen CH-350
E.2.2 Outpatient Rescreen CH-350
E.2.3 Evaluation using Texas Pediatric Protocol for Audiology CH-350
E.2.4 Referral to an ECI program CH-351
E.2.5 Periodic Monitoring by the Physician or Medical Home CH-351
E.3 JCIH 2007 Position Statement CH-351
Appendix F: THSteps Quick Reference Guide
F.1 Texas Health Steps Quick Reference Guide CH-354
G.1 American Academy of Pediatric Dentistry Periodicity Guidelines (9 Pages) CH-358
G.2 American Dental Association Guidelines for Prescribing Dental Radiographs
(3 Pages) CH-367
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