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2012 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook

Medicaid Managed Care Handbook
Table of Contents
1. General Information MMC-7
2. Overview of Medicaid Managed Care MMC-7
2.1 Managed Care Services MMC-8
2.1.1 Medical Services MMC-8
2.1.2 Prescription Drug/Pharmacy Services MMC-8
2.1.2.1 Prescription Drug Pror Authorizations MMC-9
2.1.2.1.1 Emergency 72-Hour Prescriptions MMC-9
2.1.2.1.2 Formulary MMC-10
2.2 Provider Enrollment and Responsibilities MMC-10
2.2.1 Enrollment, Contracting, and Credentialing MMC-10
2.2.2 Online Provider Lookup (OPL) MMC-11
2.2.3 Terminated Enrollment MMC-11
2.2.4 Excluded Entities and Providers MMC-11
2.2.5 Accounts Receivable MMC-11
2.2.6 Educating Clients about Managed Care MMC-11
2.3 General Information About Client Enrollment in Managed Care MMC-12
2.3.1 Managed Care Enrollment Broker MMC-13
2.3.2 Eligibility Verification Resources MMC-13
2.3.3 Client Rights MMC-13
2.3.3.1 Advance Directives MMC-15
2.3.3.2 PCP/Main Dentist and Health/Dental Plan Changes MMC-15
2.3.4 Client Responsibilities MMC-16
2.4 PCP/Main Dentist Guidelines for Medicaid Managed Care Clients MMC-16
2.4.1 Enrolling as a PCP or Main Dentist MMC-18
2.4.2 PCP Requirements for THSteps Medical Services MMC-18
2.4.3 PCP and Main Dentist Changes MMC-18
2.4.4 Continuous Access MMC-19
2.4.4.1 After-Hours Guidelines MMC-19
2.4.4.2 Unacceptable Telephone Arrangements MMC-19
2.5 Cultural Competency and Sensitivity MMC-19
2.5.1 Limited English Proficiency MMC-20
2.6 Reimbursement MMC-21
2.6.1 Coinsurance and Deductible Payments for Dual-Eligible Clients MMC-21
2.6.2 Third Party Liability (TPL) MMC-21
2.6.2.1 TPL Overview and Provider Responsibilities for Medicaid Managed
Care Clients MMC-21
2.6.3 Health Insurance Premium Payment Program MMC-22
2.7 Managed Care Plan Changes MMC-22
2.7.1 Client-Initiated Plan Changes MMC-23
2.7.2 Plan Administrator-Initiated Changes MMC-23
2.8 Authorizations for Managed Care Services MMC-23
2.9 Claims Filing for Managed Care Services MMC-24
2.9.1 Newborn Claims Filing for MCO Services MMC-25
2.9.2 Filing Deadlines MMC-26
2.10 MCO/Dental Plan Appeals, Complaints, and Fair Hearings MMC-26
2.10.1 Medicaid Managed Care Complaints and Fair Hearings MMC-26
3. STAR Program MMC-27
3.1 STAR Program Clients MMC-27
3.2 STAR Client Enrollment MMC-31
3.2.1 Expedited Enrollment of Pregnant Women (Program Type 40) MMC-32
3.2.2 Enrollment of Newborns MMC-33
3.2.3 Timely Notification and Assignment of Medicaid ID for Newborns MMC-33
3.3 STAR Program Benefits MMC-34
3.3.1 Spell of Illness MMC-34
3.3.2 Prescriptions MMC-34
3.3.3 National Drug Code MMC-34
4. STAR+PLUS Program MMC-34
4.1 STAR+PLUS Program Clients MMC-35
4.1.1 STAR+PLUS Program Dual-Eligible Clients MMC-35
4.1.2 Clients Ineligible for the STAR+PLUS Program MMC-36
4.2 STAR+PLUS Client Enrollment MMC-37
4.2.1 Enrollment of Newborns MMC-38
4.3 STAR+PLUS Program Benefits MMC-38
4.3.1 Prescriptions MMC-38
4.3.2 Spell of Illness MMC-38
4.3.3 Service Coordination and Care Management MMC-39
5. NorthSTAR Program MMC-39
5.1 NorthSTAR Program Clients MMC-40
5.2 NorthSTAR Client Enrollment MMC-40
5.3 NorthSTAR Program Benefits MMC-41
5.3.1 Hospital Billing MMC-41
5.3.2 Behavioral Health Billing MMC-41
5.3.3 Prior Authorization Requirements MMC-41
5.4 Complaints and Appeals MMC-41
6. STAR Health Program MMC-42
6.1 STAR Health Program Clients MMC-42
6.2 STAR Health Client Enrollment MMC-43
6.3 STAR Health Program Benefits MMC-43
6.3.1 STAR Health Mental Health Rehabilitation Mental Health Claims Submissions MMC-45
7. Children's Medicaid Dental Services MMC-46
7.1 Overview MMC-46
7.2 Children's Medicaid Dental Services Model MMC-46
7.3 Client Eligibility MMC-46
7.4 Client Enrollment MMC-47
7.5 Children's Medicaid Dental Plan Choices MMC-47
7.6 Authorizations for Children's Medicaid Managed Care Dental Services
(Non-orthodontia Services) MMC-47
7.7 Children's Medicaid Dental Orthodontia Services MMC-47
8. Carve-Out Services MMC-48
8.1 Authorization Requests for Carve-Out Services MMC-49
8.2 Claims Filing for Carve-Out Services MMC-49
9. PCCM and Managed Care Claims Processed by TMHP Before March 1, 2012 MMC-49
9.1 PCCM Appeals MMC-49
9.2 PCCM Cost and Reporting MMC-49
9.2.1 PCCM Outpatient Services Cost Reporting MMC-50
10. Other State Health-care Programs MMC-50
11. Contact Information MMC-50
Index MMC-51

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.