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4.11 NorthSTAR (Behavioral Health Program in Dallas Service Area Only)
The state implemented a behavioral health organization (BHO) program known as NorthSTAR. NorthSTAR provides mental health and chemical dependency (behavioral health) services.
NorthSTAR replaces traditional Medicaid behavioral health specialty services for those Medicaid clients who are required to join the NorthSTAR Program. Behavioral health specialty providers must not bill TMHP for behavioral health services that are provided to enrollees with behavioral health diagnoses in the NorthSTAR Program. Medicaid providers who are considered behavioral health specialists include psychiatrists, psychologists, LPCs, licensed marriage and family therapists (LMFTs), LMSWs, and TCADA-licensed chemical dependency programs for children and adolescents. In general, acute care hospitals behavioral health specialty services are defined as inpatient stays in which the primary diagnosis is a behavioral health diagnosis.
Behavioral health specialists and hospitals no longer bill TMHP for behavioral health services provided to clients who are enrolled in or eligible for membership in the NorthSTAR Program. If a claim is submitted to TMHP for a NorthSTAR-enrolled client, it will be denied with instructions for the provider to submit the claim to the client's BHO.
Behavioral health providers follow a new set of rules to receive payment for services provided to Medicaid clients who are enrolled in NorthSTAR.
The new rules are as follows. A behavioral health provider must:
• Be a provider of the plan's NorthSTAR network to receive payment for most services provided to the members.
•Obtain prior approval for some nonemergency services. This rule applies when providing treatment to a NorthSTAR member, whether or not in the Dallas service area.
•Provide services to Medicaid clients not eligible to enroll in a NorthSTAR BHO. TMHP will continue to pay these clients Medicaid claims. These clients live in a nursing facility, Intermediate Care Facility for the Mentally Retarded (ICF-MR), the state hospitals' IMD over age 65 program, or children who are in the custody of the Texas Department of Protective and Regulatory Services (in foster care).
•Bill Medicare for Medicare-covered services. TMHP continues to pay deductible and coinsurance charges for Medicare services for these clients.
Exception: Exceptions include emergency care and medically necessary treatment episodes that began before the client joined a NorthSTAR Plan.
Clients enroll in the NorthSTAR plan Value Options. When a Medicaid client requests services, call Value Options at 1-888-800-6799 to verify if the client is a member of NorthSTAR. Also call this number to get information on joining the plan's networks.
If clients would like to join NorthSTAR, they may call MAXIMUS, the state's enrollment broker, at 1-800-964-2777. The MAXIMUS staff is trained to help potential members understand both the STAR and NorthSTAR programs. NorthSTAR also provides behavioral health services to some people who are not Medicaid-eligible. These people are provided a greater variety of services than what is available under the Texas Medicaid Program.
Behavioral health providers do not bill TMHP for services provided to NorthSTAR members.
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