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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook

Children’s Services Handbook
Table of Contents
1. General Information CH-15
1.1 Medical Transportation Program CH-15
1.2 Rates Reduction CH-15
2. Medicaid Children’s Services Comprehensive Care Program (CCP) CH-15
2.1 CCP Overview CH-15
2.1.1 Client Eligibility CH-16
2.1.2 Enrollment CH-16
2.1.3 Services, Benefits, and Limitations CH-16
2.1.4 Prior Authorization and Documentation Requirements CH-17
2.1.4.1 Diagnosis Coding CH-18
2.1.4.2 Drug and Medical Device Approval CH-18
2.1.4.3 Physician Signature CH-18
2.2 Clinician-Directed Care Coordination Services (CCP) CH-18
2.2.1 Services, Benefits, and Limitations CH-18
2.2.1.1 Non-Face-to-Face Services CH-20
2.2.1.1.1 Non-Face-to-Face Medical Conferences CH-20
2.2.1.1.2 Non-Face-to-Face Clinician Supervision of a Home Health Client CH-20
2.2.1.1.3 Non-Face-to-Face Clinician Supervision of a Hospice Client CH-20
2.2.1.1.4 Non-Face-to-Face Clinician Supervision of a Nursing Facility Client CH-20
2.2.1.1.5 Other Non-Face-to-Face Supervision CH-20
2.2.1.1.6 Non-Face-to-Face Prolonged Services CH-21
2.2.1.1.7 Non-Face-to-Face Specialist or Subspecialist Telephone Consultation CH-21
2.2.1.1.8 General Requirements for Non-Face-to-Face Clinician-Directed Care
Coordination Services CH-22
2.2.1.1.9 Non-Face-to-Face Care Plan Oversight CH-22
2.2.1.1.10 Medical Team Conference CH-22
2.2.1.2 Face-to-Face Services CH-23
2.2.1.2.1 General Requirements for Face-to-Face Clinician-Directed Care
Coordination Services CH-23
2.2.2 Prior Authorization and Documentation Requirements CH-23
2.2.2.1 Documentation Requirements for the Medical Home Clinician for a
Telephone Consult with a Specialist CH-25
2.2.2.2 Documentation Requirements for the Specialist or Subspecialist for a
Telephone Consult with the Medical Home Clinician CH-25
2.2.3 Claims Information CH-25
2.2.4 Reimbursement CH-26
2.3 Comprehensive Outpatient Rehabilitation Facilities (CORFs)and Outpatient
Rehabilitation Facilities (ORFs) CH-26
2.3.1 Enrollment CH-26
2.3.2 Services, Benefits, and Limitations CH-26
2.3.3 Occupational Therapy CH-27
2.3.3.1 Services, Benefits, and Limitations CH-27
2.3.3.2 Prior Authorization and Documentation Requirements CH-28
2.3.4 Physical Therapy CH-29
2.3.4.1 Services, Benefits, and Limitations CH-29
2.3.4.2 Prior Authorization and Documentation Requirements CH-30
2.3.5 Speech Therapy CH-31
2.3.5.1 Services, Benefits, and Limitations CH-31
2.3.5.2 Prior Authorization and Documentation Requirements CH-31
2.3.6 Claims Information CH-32
2.3.7 Reimbursement CH-33
2.4 Durable Medical Equipment (DME) Supplier (CCP) CH-33
2.4.1 Enrollment CH-33
2.4.1.1 Pharmacies (CCP) CH-33
2.4.2 Services, Benefits, and Limitations CH-33
2.4.2.1 Purchase Versus Equipment Rental CH-35
2.4.3 Prior Authorization and Documentation Requirements CH-35
2.4.3.1 Equipment Accessories CH-36
2.4.3.2 Equipment Modifications CH-36
2.4.3.3 Equipment Adjustments CH-36
2.4.3.4 Equipment Repairs CH-36
2.4.3.5 DME Certification and Receipt Form CH-36
2.4.3.6 Documentation of Supply Delivery CH-37
2.4.3.7 Specific CCP Policies CH-37
2.4.4 Blood Pressure Devices CH-38
2.4.4.1 Services, Benefits, and Limitations CH-38
2.4.4.1.1 Manual and Automated Blood Pressure Devices CH-38
2.4.4.1.2 Hospital-Grade Blood Pressure Devices CH-39
2.4.4.1.3 Blood Pressure Device Components, Replacements, and Repairs CH-39
2.4.4.2 Prior Authorization and Documentation Requirements CH-39
2.4.4.2.1 Manual and Automated Blood Pressure Devices CH-40
2.4.4.2.2 Hospital-Grade Blood Pressure Devices CH-40
2.4.4.2.3 Blood Pressure Device Components, Replacements, and Repairs CH-41
2.4.5 Cardiorespiratory (Apnea) Monitor CH-41
2.4.5.1 Services, Benefits, and Limitations CH-41
2.4.5.2 Prior Authorization and Documentation Requirements CH-41
2.4.6 Croup Tent/Pulse Oximeter CH-42
2.4.6.1 Services, Benefits, and Limitations CH-42
2.4.6.1.1 Croup Tent CH-42
2.4.6.1.2 Pulse Oximeter CH-42
2.4.6.2 Prior Authorization and Documentation Requirements CH-42
2.4.6.2.1 Croup Tent CH-42
2.4.6.2.2 Pulse Oximeter CH-43
2.4.7 Diabetic Equipment and Supplies CH-44
2.4.7.1 Services, Benefits, and Limitations CH-44
2.4.7.2 Prior Authorization and Documentation Requirements CH-44
2.4.7.2.1 Tubeless External Insulin Pump Rentals CH-45
2.4.7.2.2 Purchase of Tubeless External Insulin Pump CH-45
2.4.8 Donor Human Milk CH-46
2.4.8.1 Services, Benefits, and Limitations CH-46
2.4.8.2 Prior Authorization and Documentation Requirements CH-46
2.4.9 Incontinence Supplies CH-47
2.4.9.1 Services, Benefits, and Limitations CH-47
2.4.9.1.1 Skin Sealants, Protectants, Moisturizers, Ointments CH-47
2.4.9.1.2 Diapers, Briefs, and Liners CH-48
2.4.9.1.3 Diaper Wipes CH-48
2.4.9.1.4 Underpads CH-48
2.4.9.1.5 External Urinary Collection Devices CH-48
2.4.9.2 Prior Authorization and Documentation Requirements CH-49
2.4.10 Mobility Aids CH-49
2.4.10.1 Services, Benefits, and Limitations CH-49
2.4.10.1.1 Portable Client Lifts for Outside the Home Setting CH-49
2.4.10.1.2 Wheeled Mobility Systems CH-50
2.4.10.1.3 Seating Assessment CH-51
2.4.10.1.4 Fitting of Custom Wheeled Mobility Systems CH-51
2.4.10.1.5 Stroller Ramps—Portable and Threshold CH-52
2.4.10.1.6 Feeder Seats, Floor Sitters, Corner Chairs, and Travel Chairs CH-52
2.4.10.1.7 Special-Needs Car Seats CH-52
2.4.10.1.8 Travel Safety Restraints CH-53
2.4.10.2 Prior Authorization and Documentation Requirements CH-53
2.4.10.2.1 Portable Client Lifts for Outside the Home Setting CH-53
2.4.10.2.2 Wheeled Mobility System CH-53
2.4.10.2.3 Seating Assessments CH-54
2.4.10.2.4 Stroller Ramps—Portable and Threshold CH-55
2.4.10.2.5 Special-Needs Car Seats CH-55
2.4.11 Nutritional Products CH-56
2.4.11.1 Services, Benefits, and Limitations CH-56
2.4.11.2 Women, Infants, and Children Program (WIC) CH-57
2.4.11.3 Noncovered Services CH-57
2.4.11.4 Prior Authorization and Documentation Requirements CH-58
2.4.11.4.1 Nutritional Products CH-59
2.4.11.5 Managed Care Clients CH-60
2.4.12 Hospital Beds, Cribs, and Equipment CH-60
2.4.12.1 Services, Benefits, and Limitations CH-60
2.4.12.2 Prior Authorization and Documentation Requirements CH-61
2.4.12.2.1 Hospital Beds and Safety Enclosure CH-62
2.4.12.2.2 Positioning Devices CH-62
2.4.12.2.3 Repair or Replacement CH-62
2.4.13 Phototherapy Devices CH-63
2.4.13.1 Services, Benefits, and Limitations CH-63
2.4.13.2 Prior Authorization and Documentation Requirements CH-64
2.4.13.2.1 Retroactive Eligibility CH-65
2.4.14 Special Needs Car Seats and Travel Restraints CH-65
2.4.14.1 Services, Benefits, and Limitations CH-65
2.4.14.1.1 Special Needs Car Seats CH-65
2.4.14.1.2 Travel Safety Restraints CH-65
2.4.14.2 Prior Authorization and Documentation Requirements CH-66
2.4.14.2.1 Special Needs Car Seats CH-66
2.4.14.2.2 Travel Safety Restraints CH-66
2.4.15 Total Parental Nutrition (TPN) CH-66
2.4.15.1 Services, Benefits, and Limitations CH-66
2.4.15.2 Prior Authorization and Documentation Requirements CH-67
2.4.16 Vitamin and Mineral Products CH-69
2.4.16.1 Services, Benefits, and Limitations CH-69
2.4.16.2 Prior Authorization and Documentation Requirements CH-73
2.4.17 Claims Information CH-74
2.4.18 Reimbursement CH-74
2.5 Early Childhood Intervention (ECI) Services CH-74
2.5.1 Enrollment CH-74
2.5.2 Services, Benefits, Limitations, and Prior Authorization CH-75
2.5.2.1 Therapy CH-75
2.5.2.1.1 Occupational Therapy (OT) CH-75
2.5.2.1.2 Physical Therapy (PT) CH-76
2.5.2.1.3 Speech Therapy (ST) CH-76
2.5.2.2 Specialized Skills Training (SST) CH-77
2.5.2.3 Targeted Case Management (TCM) CH-77
2.5.3 Documentation Requirements CH-78
2.5.4 Claims Filing and Reimbursement CH-78
2.5.4.1 Claims Information CH-78
2.5.4.1.1 Billing Units Based on 15 Minutes CH-79
2.5.4.1.2 Managed Care Clients CH-79
2.5.4.2 Reimbursement CH-79
2.6 Medical Nutrition Counseling Services (CCP) CH-79
2.6.1 Enrollment CH-79
2.6.2 Services, Benefits, and Limitations CH-79
2.6.3 Prior Authorization and Documentation Requirements CH-82
2.6.4 Claims Information CH-83
2.6.5 Reimbursement CH-83
2.7 Orthotic and Prosthetic Services (CCP) CH-83
2.7.1 Enrollment CH-83
2.7.2 Orthotics Services CH-83
2.7.2.1 Services, Benefits, and Limitations CH-83
2.7.2.1.1 Noncovered Orthotic Services CH-84
2.7.2.2 Prior Authorization and Documentation Requirements CH-85
2.7.2.2.1 Spinal Orthoses CH-86
2.7.2.2.2 Lower-Limb Orthoses CH-86
2.7.2.2.3 Foot Orthoses CH-87
2.7.2.2.4 Upper-Limb Orthoses CH-88
2.7.2.2.5 Other Orthopedic Devices CH-88
2.7.2.2.6 Related Services CH-89
2.7.3 Cranial Molding Orthosis CH-90
2.7.3.1 Services, Benefits, and Limitations CH-90
2.7.3.2 Prior Authorization and Documentation Requirements CH-90
2.7.4 Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers,
Standing Frames/Braces, and Parapodiums) CH-91
2.7.4.1 Services, Benefits, and Limitations CH-91
2.7.4.1.1 Parapodium CH-91
2.7.4.1.2 Standing Frame or Brace CH-91
2.7.4.1.3 Vertical or Dynamic Stander CH-92
2.7.4.2 Prior Authorization and Documentation Requirements CH-92
2.7.5 Prosthetic Services CH-92
2.7.5.1 Services, Benefits, and Limitations CH-92
2.7.5.1.1 Noncovered Prosthetic Services CH-93
2.7.5.2 Prior Authorization and Documentation Requirements CH-93
2.7.5.2.1 Lower-Limb Prostheses CH-94
2.7.5.2.2 Upper-Limb Prostheses CH-97
2.7.5.2.3 External Breast Prostheses CH-98
2.7.5.2.4 Craniofacial Prostheses CH-98
2.7.5.2.5 Related Services CH-98
2.7.6 Claims Information CH-99
2.7.7 Reimbursement CH-99
2.8 Personal Care Services (PCS) (CCP) CH-99
2.8.1 Enrollment CH-99
2.8.2 Services, Benefits, and Limitations CH-100
2.8.2.1 Place of Services CH-102
2.8.2.2 Client Eligibility CH-102
2.8.2.2.1 Accessing the PCS Benefit CH-103
2.8.2.2.2 The Primary Practitioner’s Role in the PCS Benefit CH-103
2.8.2.3 PCS Provided in Group Settings CH-104
2.8.3 Prior Authorization and Documentation Requirements CH-104
2.8.3.1 PCS Provider Responsibilities CH-105
2.8.3.2 Documentation of Services Provided/Retrospective Review CH-105
2.8.4 Claims Information CH-105
2.8.4.1 Managed Care Clients CH-106
2.8.5 Reimbursement CH-106
2.9 Private Duty Nursing (CCP) CH-106
2.9.1 Enrollment CH-106
2.9.2 Services, Benefits, and Limitations CH-107
2.9.2.1 PDN Provided During a Skill Nursing Visit for TPN Administration
Education CH-110
2.9.2.2 Criteria CH-111
2.9.2.2.1 Client Eligibility Criteria CH-111
2.9.2.2.2 Medical Necessity CH-111
2.9.2.2.3 Place of Service (POS) CH-111
2.9.2.2.4 Amount and Duration of PDN CH-112
2.9.3 Prior Authorization and Documentation Requirements CH-112
2.9.3.1 Retroactive Client Eligibility CH-114
2.9.3.2 Start of Care (SOC) CH-114
2.9.3.3 Prior Authorization of Initial Requests CH-115
2.9.3.4 Authorization for Revision of Current Services CH-115
2.9.3.5 Recertifications of Authorizations CH-116
2.9.3.6 Termination of Authorization CH-117
2.9.3.7 Client/Provider Notification CH-117
2.9.3.8 Authorization Appeals CH-117
2.9.3.9 CCP Prior Authorization Request Form CH-117
2.9.3.10 Home Health Plan of Care (POC) CH-118
2.9.3.11 Nursing Addendum to Plan of Care (CCP) Form CH-118
2.9.3.11.1 The client’s 24‑Hour Daily Schedule CH-119
2.9.3.12 Responsible Adult or Identified Contingency Plan Requirement CH-119
2.9.3.13 Special Circumstances CH-120
2.9.3.14 Documentation of Services Provided/Retrospective Review CH-120
2.9.4 Claims Information CH-121
2.9.5 Reimbursement CH-121
2.10 Therapy Services (CCP) CH-121
2.10.1 Occupational Therapy (OT) CH-123
2.10.1.1 Enrollment CH-123
2.10.1.2 Services, Benefits, and Limitations CH-123
2.10.1.3 Prior Authorization and Documentation Requirements CH-124
2.10.1.4 Claims Information CH-125
2.10.1.5 Reimbursement CH-125
2.10.2 Physical Therapy (PT) CH-126
2.10.2.1 Enrollment CH-126
2.10.2.2 Services, Benefits, and Limitations CH-126
2.10.2.3 Prior Authorization and Documentation Requirements CH-127
2.10.2.4 Claims Information CH-128
2.10.2.5 Reimbursement CH-128
2.10.3 Speech Therapy (ST) CH-128
2.10.3.1 Enrollment CH-128
2.10.3.2 Services, Benefits, and Limitations CH-128
2.10.3.3 Prior Authorization and Documentation Requirements CH-129
2.10.3.4 Claims Information CH-130
2.10.3.5 Reimbursement CH-130
2.11 Inpatient Rehabilitation Facility (Freestanding) (CCP) CH-131
2.11.1 Enrollment CH-131
2.11.1.1 Continuity of Hospital Eligibility Through Change of Ownership CH-131
2.11.2 Services, Benefits, and Limitations CH-131
2.11.2.1 Comprehensive Treatment CH-131
2.11.3 Prior Authorization and Documentation Requirements CH-131
2.11.4 Claims Information CH-133
2.11.5 Reimbursement CH-133
2.11.5.1 Client Transfers CH-134
3. School Health and Related Services (SHARS) CH-134
3.1 Overview CH-134
3.1.1 Random Moment Time Study (RMTS) CH-135
3.1.2 Eligibility Verification CH-135
3.2 Enrollment CH-136
3.2.1 SHARS Enrollment CH-136
3.2.2 Nonschool SHARS Provider Enrollment CH-136
3.2.3 Private School Enrollment CH-137
3.3 Services/Benefits, Limitations, and Prior Authorization CH-137
3.3.1 Audiology CH-137
3.3.1.1 Audiology Billing Table CH-138
3.3.2 Counseling Services CH-138
3.3.2.1 Counseling Services Billing Table CH-139
3.3.3 Psychological Testing and Services CH-139
3.3.3.1 Psychological Testing CH-139
3.3.3.1.1 Evaluation/Assessment Billing Table CH-139
3.3.3.2 Psychological Services CH-140
3.3.3.2.1 Psychological Services Billing Table CH-140
3.3.4 Nursing Services CH-140
3.3.4.1 Nursing Services Billing Table CH-141
3.3.5 Occupational Therapy (OT) CH-142
3.3.5.1 Referral CH-142
3.3.5.2 Description of Services CH-142
3.3.5.3 Occupational Therapy Billing Table CH-143
3.3.6 Personal Care Services CH-143
3.3.6.1 Personal Care Services Billing Table CH-144
3.3.7 Physical Therapy (PT) CH-144
3.3.7.1 Referral CH-144
3.3.7.2 Description of Services CH-144
3.3.7.3 Physical Therapy Billing Table CH-145
3.3.8 Physician Services CH-145
3.3.8.1 Physician Services Billing Table CH-146
3.3.9 Speech Therapy (ST) CH-146
3.3.9.1 Referral CH-146
3.3.9.2 Description of Services CH-146
3.3.9.3 Provider and Supervision Requirements CH-146
3.3.9.4 Speech Therapy Billing Table CH-147
3.3.10 Transportation Services in a School Setting CH-147
3.3.10.1 Transportation Services in a School Setting Billing Table CH-148
3.3.11 Prior Authorization CH-148
3.4 Documentation Requirements CH-149
3.4.1 Record Retention CH-149
3.5 Claims Filing and Reimbursement CH-149
3.5.1 Claims Information CH-149
3.5.1.1 Appealing Denied SHARS Claims CH-150
3.5.1.2 Billing Units Based on 15 Minutes CH-150
3.5.1.3 Billing Units Based on an Hour CH-150
3.5.2 Managed Care Clients CH-151
3.5.3 Reimbursement CH-151
3.5.3.1 Quarterly Certification of Funds CH-152
3.6 Cost Reporting, Cost Reconciliation, and Cost Settlement CH-152
3.6.1 Cost Reporting CH-152
3.6.2 Cost Reconciliation and Cost Settlement CH-153
3.6.3 Informal Review of Cost Reports Settlement CH-153
4. Texas Health Steps (THSteps) Dental CH-154
4.1 Enrollment CH-154
4.1.1 THSteps Dental Eligibility CH-155
4.1.2 Categories of Practice CH-155
4.1.3 THSteps Dental and ICF-MR Dental Services CH-155
4.1.4 THSteps Dental Checkup and Treatment Facilities CH-155
4.1.5 Doctor of Dentistry Practicing as a Limited Physician CH-156
4.1.6 Client Rights CH-156
4.1.7 Complaints and Resolution CH-156
4.2 Services, Benefits, Limitations, and Prior Authorization CH-157
4.2.1 THSteps Dental Services CH-157
4.2.1.1 Eligibility for THSteps Dental Services CH-157
4.2.1.2 Parental Accompaniment CH-157
4.2.2 Comprehensive Care Program (CCP) CH-157
4.2.3 ICF-MR Dental Services CH-158
4.2.3.1 THSteps and ICF-MR Provision of Dental Services CH-158
4.2.3.2 Children in Foster Care CH-158
4.2.4 Written Informed Consent and Standards of Care CH-158
4.2.5 First Dental Home CH-159
4.2.6 Dental Referrals by THSteps Primary Care Providers CH-160
4.2.7 Change of Provider CH-160
4.2.7.1 Interrupted or Incomplete Orthodontic Treatment Plans CH-161
4.2.8 Periodicity for THSteps Dental Services CH-161
4.2.8.1 Exceptions to Periodicity CH-161
4.2.9 Tooth Identification (TID) and Surface Identification (SID) Systems CH-162
4.2.9.1 Supernumerary Tooth Identification CH-162
4.2.10 Medicaid Dental Benefits, Limitations, and Fee Schedule CH-163
4.2.11 Diagnostic Services CH-164
4.2.12 Preventive Services CH-167
4.2.13 Therapeutic Services CH-169
4.2.14 Restorative Services CH-170
4.2.15 Endodontics Services CH-173
4.2.16 Periodontal Services CH-175
4.2.17 Prosthodontic (Removable) Services CH-178
4.2.18 Implant Services CH-181
4.2.19 Prosthodontic (Fixed) Services CH-182
4.2.20 Oral and Maxillofacial Surgery Services CH-184
4.2.21 Adjunctive General Services CH-188
4.2.22 Dental Therapy Under General Anesthesia CH-190
4.2.22.1 Criteria for Dental Therapy Under General Anesthesia CH-192
4.2.22.2 Criteria for Dental Therapy Under General Anesthesia, Attachment 1 CH-193
4.2.23 Hospitalization and ASC/HASC CH-194
4.2.24 Orthodontic Services (THSteps) CH-194
4.2.24.1 Benefits and Limitations CH-195
4.2.24.2 Completion of Treatment Plan CH-196
4.2.24.3 Premature Removal of Appliances CH-197
4.2.24.4 Transfer of Orthodontic Services CH-197
4.2.24.5 Comprehensive Orthodontic Treatment CH-198
4.2.25 Special Orthodontic Appliances CH-199
4.2.26 Handicapping Labio-lingual Deviation (HLD) Index CH-202
4.2.26.1 HLD Score Sheet CH-204
4.2.27 Emergency or Trauma Related Services for All THSteps Clients and Clients
Who Are 5 Months of Age and Younger CH-205
4.2.28 Emergency Services for Medicaid Clients Who Are 21 Years of Age and Older CH-205
4.2.28.1 Long Term Care (LTC) Emergency Dental Services CH-206
4.2.28.2 Laboratory Requirements CH-206
4.2.29 Mandatory Prior Authorization CH-206
4.2.29.1 Cone Beam Imaging CH-207
4.2.29.2 General Anesthesia for Dental Treatment CH-207
4.2.29.3 Orthodontic Services CH-208
4.2.30 THSteps and ICF-MR Dental Prior Authorization CH-208
4.3 Documentation Requirements CH-209
4.3.1 General Anesthesia CH-210
4.3.2 Orthodontic Services CH-210
4.4 Utilization Review CH-211
4.5 Claims Filing and Reimbursement CH-211
4.5.1 Reimbursement CH-211
4.5.2 Third Party Resources (TPR) CH-211
4.5.3 Claim Submission After Loss of Eligibility CH-211
4.5.4 Claims Information CH-212
4.5.5 Claim Appeals CH-212
4.5.6 Frequently Asked Questions About Dental Claims CH-214
5. THSteps Medical CH-216
5.1 THSteps Medical and Dental Administrative Information CH-216
5.1.1 Overview CH-216
5.1.2 Statutory Requirements CH-217
5.1.3 Texas Vaccines for Children (TVFC) Program CH-217
5.1.4 Vaccine Adverse Event Reporting System (VAERS) CH-217
5.1.5 Referrals for Medicaid-Covered Services CH-218
5.1.6 THSteps Medical Checkup Facilities CH-219
5.1.7 THSteps Dental Services CH-220
5.2 Enrollment CH-220
5.2.1 THSteps Medical Provider Enrollment CH-220
5.2.1.1 Additional Education Requirements for Registered Nurses CH-221
5.3 Services, Benefits, Limitations, and Prior Authorization CH-222
5.3.1 Eligibility for a Medical Checkup CH-222
5.3.2 Verification of Medical Checkups CH-222
5.3.3 Medical Home CH-223
5.3.4 THSteps Medical Checkups CH-223
5.3.5 Exception-to-Periodicity Checkups CH-226
5.3.6 Follow-up Medical Checkup CH-226
5.3.7 Newborn Examination CH-227
5.3.8 THSteps Medical Checkups Periodicity Schedule CH-227
5.3.9 Mandated Components CH-228
5.3.9.1 Comprehensive Health and Developmental History CH-228
5.3.9.1.1 Nutritional Screening CH-228
5.3.9.1.2 Developmental Surveillance or Screening CH-228
5.3.9.1.3 Mental Health Screening CH-230
5.3.9.1.4 Tuberculosis (TB) Screening CH-230
5.3.9.2 Comprehensive Unclothed Physical Examination CH-230
5.3.9.2.1 Oral Health Screening CH-230
5.3.9.2.2 Sensory Screening CH-230
5.3.9.2.3 Hearing Screening CH-231
5.3.9.2.4 Vision Screening CH-231
5.3.9.3 Immunizations CH-231
5.3.9.3.1 Vaccine Information Statement (VIS) CH-234
5.3.9.4 Health Education and Anticipatory Guidance CH-234
5.3.9.5 Dental Referral CH-234
5.3.9.6 Laboratory Test CH-234
5.3.9.6.1 Laboratory Supplies CH-236
5.3.9.6.2 Newborn Screening Supplies CH-236
5.3.9.6.3 Laboratory Submission CH-236
5.3.9.6.4 Send Comments CH-238
5.3.9.6.5 Laboratory Reporting CH-238
5.3.9.6.6 Required Laboratory Tests Related to Medical Checkups CH-238
5.3.9.6.7 Additional Required Laboratory Tests Related to Medical Checkups
for Adolescents CH-239
5.3.10 Non-Mandated Components CH-240
5.3.10.1 Oral Evaluation and Fluoride Varnish in the Medical Home (OEFV) CH-240
5.4 Documentation Requirements CH-241
5.4.0.1 Separate Identifiable Acute Care Evaluation and Management Visit CH-241
5.5 Claims Filing and Reimbursement CH-242
5.5.1 Claims Information CH-242
5.5.2 Reimbursement CH-243
6. Claims Resources CH-243
7. Contact TMHP CH-244
7.1 Automated Inquiry System (AIS) CH-244
7.2 TMHP Website CH-244
7.3 Dental Information and Assistance CH-244
7.3.1 Dental Inquiry Line CH-245
7.4 THSteps Information and Assistance CH-245
7.5 Assistance with Program CH-245
8. Forms CH-245
CH.1 CCP Prior Authorization Request Form Instructions (2 pages) CH-246
CH.2 CCP Prior Authorization Request Form CH-248
CH.3 CCP Prior Authorization Private Duty Nursing 6-Month Authorization CH-249
CH.4 DME Certification and Receipt Form (3 Pages) CH-250
CH.5 Donor Human Milk Request Form CH-254
CH.6 External Insulin Pump CH-255
CH.7 Home Health Plan of Care (POC) CH-256
CH.8 Nursing Addendum to Plan of Care (CCP) (7 Pages) CH-257
CH.9 Pulse Oximeter Form CH-264
CH.10 Request for Initial Outpatient Therapy (Form TP-1) CH-265
CH.11 Request for Extension of Outpatient Therapy (Form TP-2) (2 Pages) CH-266
CH.12 THSteps Dental Mandatory Prior Authorization Request Form CH-268
CH.13 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 Pages) CH-269
CH.14 THSteps Referral Form Instructions CH-271
CH.15 THSteps Referral Form CH-272
CH.16 CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care
Coordination Services (2 Pages) CH-273
CH.17 Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face
Clinician-Directed Care Coordination Services–Comprehensive Care Program (CCP) CH-275
CH.18 Wheelchair/Scooter/Stroller Seating Evaluation Form (CCP/Home Health Services)
(7 Pages) CH-276
9. Claim Form Examples CH-283
CH.19 Comprehensive Outpatient Rehabilitation Facility (CORF) (CCP Only) CH-284
CH.20 Diagnosis and Treatment (Referral from THSteps Checkup) CH-285
CH.21 Durable Medical Equipment (CCP Only) CH-286
CH.22 Early Childhood Intervention Specialized Skills Training (SST) CH-287
CH.23 Early Childhood Intervention Targeted Case Management with Face-to-Face
Interaction CH-288
CH.24 Early Childhood Therapy CH-289
CH.25 Inpatient Rehabilitation Facility (Freestanding) (CCP Only) CH-290
CH.26 Medical Nutrition Counseling (CCP Only) CH-291
CH.27 Occupational Therapists (CCP Only) CH-292
CH.28 Orthotic and Prosthetic Services (CCP Only) CH-293
CH.29 Physical Therapists (CCP Only) CH-294
CH.30 Private Duty Nurses (CCP Only) CH-295
CH.31 School Health and Related Services (SHARS) CH-296
CH.32 Speech-Language Pathologists (CCP Only) CH-297
CH.33 THSteps New Patient, Immunization Without Counseling no Referral and by a NP CH-298
CH.34 THSteps Established Patient Exception to Periodicity and Referral, Immunizations
with Counseling, and by a Physician CH-299
CH.35 THSteps Established Patient and Referral, TB Skin Test, and Physical Examination
by a Physician CH-300
10. Appendices CH-301
Appendix A: THSteps Forms CH-303
A.1 Claim Forms CH-304
A.2 THSteps Medical Checkup Forms CH-304
A.3 Laboratory Forms CH-305
A.4 Guidelines for Tuberculosis Skin Testing CH-305
A.5 Tuberculosis Screening and Guidelines CH-305
CH.36 How to Determine TB Risk CH-307
A.6 Texas Vaccines For Children (TVFC) CH-308
CH.37 TVFC Patient Eligibility Screening Record CH-308
CH.38 TVFC Patient Eligibility Screening Record (Spanish) CH-309
CH.39 TVFC Provider Enrollment (3 Pages) CH-310
CH.40 TVFC Questions and Answers (3 Pages) CH-313
Appendix B: Immunizations CH-317
B.1 Immunizations Overview CH-318
B.1.1 Vaccine Adverse Event Reporting System (VAERS) CH-318
B.1.2 TVFC Versus Non-TVFC Vaccines/Toxoids CH-318
B.1.3 Exemption from Immunization for School and Child-Care Facilities CH-318
B.2 Recommended Childhood Immunization Schedule CH-319
B.2.1 Recommended Childhood and Adolescent Immunization Schedule, 2012 CH-320
B.3 General Recommendations CH-323
B.3.1 How to Obtain Free Vaccines CH-323
B.3.2 Administrations and Immunizations CH-323
B.3.2.1 Administrations CH-323
B.3.2.2 Immunizations (Vaccine/Toxoids) CH-323
B.3.3 Requirements for TVFC Providers CH-324
B.3.4 How to Report Immunization Records to ImmTrac, the Texas
Immunization Registry CH-325
B.3.4.1 Direct Internet Entry CH-326
B.3.4.2 Electronic Data Transfer (Import) CH-326
B.3.4.3 Obtaining Parental Consent for Registry Participation CH-326
B.4 Texas Vaccines for Children Program Packet CH-326
Appendix C: Lead Screening CH-327
C.1 Blood Lead Screening Procedures and Follow-up Testing CH-328
C.2 Symptoms of Lead Poisoning CH-328
C.3 Measuring Blood Lead Levels CH-328
C.4 Environmental Lead Investigation Services CH-329
C.4.1 Enrollment CH-329
C.4.2 Services, Benefits, Limitations, and Prior Authorization CH-329
C.4.2.1 Requesting an Environmental Lead Investigation CH-329
C.4.2.2 Prior Authorization CH-330
C.4.3 Documentation Requirements CH-330
C.4.4 Claims Filing and Reimbursement CH-331
C.4.4.1 Claims Filing CH-331
C.4.4.2 Reimbursement CH-331
C.5 Form Pb‑109: Reference for Follow-up Blood Lead Testing and Medical
Case Management CH-332
C.6 Lead Poisoning Prevention Educational Materials and Forms CH-333
Appendix D: Texas Health Steps Statutory State Requirements CH-335
D.1 Legislative Requirements CH-336
D.2 Texas Health Steps (THSteps) Program CH-336
D.3 Communicable Disease Reporting CH-336
D.4 Early Childhood Intervention (ECI) Referrals CH-336
D.5 Parental Accompaniment CH-336
D.6 Newborn Blood Screening CH-337
D.7 Abuse and Neglect CH-337
D.7.1 Requirements for Reporting Abuse or Neglect CH-337
D.7.2 Procedures for Reporting Abuse or Neglect CH-337
D.7.2.1 Staff Training on Reporting Abuse and Neglect CH-338
Appendix E: Hearing Screening Information CH-339
E.1 Newborn Hearing (2 Pages) CH-340
E.2 Texas Early Hearing Detection and Intervention (TEHDI) Process CH-342
E.2.1 Birth Screen CH-342
E.2.2 Outpatient Rescreen CH-342
E.2.3 Evaluation using Texas Pediatric Protocol for Audiology CH-342
E.2.4 Referral to an ECI Program CH-343
E.2.5 Periodic Monitoring by the Physician or Medical Home CH-343
E.3 JCIH 2007 Position Statement CH-343
Appendix F: THSteps Quick Reference Guide CH-345
F.1 Texas Health Steps Quick Reference Guide CH-346
Appendix G: THSteps Dental Guidelines CH-349
G.1 American Academy of Pediatric Dentistry Periodicity Guidelines (9 Pages) CH-350
G.2 American Dental Association Guidelines for Prescribing Dental
Radiographs (3 Pages) CH-359
Index CH-363

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