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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook

Children’s Services
Handbook
Table of Contents
1 General Information 13
1.1 Medical Transportation Program 13
1.2 Rates Reduction 13
1.3 NP, CNS, PA, and CNM Claims Submitted by a Physician 14
1.4 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 14
2 Medicaid Children’s Services Comprehensive Care Program (CCP) 14
2.1 CCP Overview 14
2.1.1 Client Eligibility 15
2.1.2 Enrollment 15
2.1.3 Services, Benefits, and Limitations 15
2.1.4 Prior Authorization and Documentation Requirements 16
2.1.4.1 Incomplete Prior Authorization Requests 17
2.1.4.2 Diagnosis Coding 17
2.1.4.3 Drug and Medical Device Approval 17
2.1.4.4 Physician Signature 17
2.2 Managed Care Organization (MCO) Clients Who Transition to Medicaid Fee-For-Service (FFS) 18
2.2.1 Submission Guidelines 18
2.2.2 Documentation Requirements 18
2.2.3 New Services and Extension of Services 19
2.2.4 Loss of Eligibility 19
2.3 Certified Respiratory Care Practitioner Services (CCP) 19
2.4 Clinician-Directed Care Coordination Services (CCP) 19
2.4.1 Services, Benefits, and Limitations 19
2.4.1.1 Non-Face-to-Face Services 21
2.4.1.1.1 Non-Face-to-Face Medical Conferences 21
2.4.1.1.2 Non-Face-to-Face Clinician Supervision of a Home Health Client 21
2.4.1.1.3 Non-Face-to-Face Clinician Supervision of a Hospice Client 21
2.4.1.1.4 Non-Face-to-Face Clinician Supervision of a Nursing Facility Client 21
2.4.1.1.5 Other Non-Face-to-Face Supervision 21
2.4.1.1.6 Non-Face-to-Face Prolonged Services 21
2.4.1.1.7 Non-Face-to-Face Specialist or Subspecialist Telephone Consultation 22
2.4.1.1.8 General Requirements for Non-Face-to-Face Clinician-Directed Care Coordination Services 22
2.4.1.1.9 Non-Face-to-Face Care Plan Oversight 22
2.4.1.1.10 Medical Team Conference 23
2.4.1.2 Face-to-Face Services 23
2.4.1.2.1 General Requirements for Face-to-Face Clinician-Directed Care Coordination Services 23
2.4.2 Prior Authorization and Documentation Requirements 24
2.4.2.1 Documentation Requirements for the Medical Home Clinician for a Telephone Consult with a Specialist 25
2.4.2.2 Documentation Requirements for the Specialist or Subspecialist for a Telephone Consult with the Medical Home Clinician 26
2.4.3 Claims Information 26
2.4.4 Reimbursement 26
2.5 Comprehensive Outpatient Rehabilitation Facilities (CORFs) and Outpatient Rehabilitation Facilities (ORFs) 26
2.6 Durable Medical Equipment (DME) Supplier (CCP) 26
2.6.1 Enrollment 26
2.6.1.1 Pharmacies (CCP) 26
2.6.2 Services, Benefits, and Limitations 27
2.6.2.1 Purchase Versus Equipment Rental 28
2.6.3 Prior Authorization and Documentation Requirements 29
2.6.3.1 Equipment Accessories 29
2.6.3.2 Equipment Modifications 30
2.6.3.3 Equipment Adjustments 30
2.6.3.4 Equipment Repairs 30
2.6.3.5 DME Certification and Receipt Form 30
2.6.3.6 Documentation of Supply Delivery 31
2.6.3.7 Specific CCP Policies 31
2.6.4 Blood Pressure Devices 31
2.6.4.1 Services, Benefits, and Limitations 31
2.6.4.1.1 Manual and Automated Blood Pressure Devices 32
2.6.4.1.2 Hospital-Grade Blood Pressure Devices 33
2.6.4.1.3 Blood Pressure Device Components, Replacements, and Repairs 33
2.6.4.2 Prior Authorization and Documentation Requirements 34
2.6.4.2.1 Manual and Automated Blood Pressure Devices 34
2.6.4.2.2 Hospital-Grade Blood Pressure Devices 34
2.6.4.2.3 Blood Pressure Device Components, Replacements, and Repairs 35
2.6.5 Cardiorespiratory (Apnea) Monitor 35
2.6.5.1 Services, Benefits, and Limitations 35
2.6.5.2 Prior Authorization and Documentation Requirements 35
2.6.6 Pulse Oximeter 36
2.6.6.1 Services, Benefits, and Limitations 36
2.6.6.2 Prior Authorization and Documentation Requirements 36
2.6.7 Diabetic Equipment and Supplies 37
2.6.7.1 Services, Benefits, and Limitations 37
2.6.7.2 Prior Authorization and Documentation Requirements 38
2.6.7.2.1 Tubeless External Insulin Pump Rentals 38
2.6.7.2.2 Purchase of Tubeless External Insulin Pump 39
2.6.8 Donor Human Milk 39
2.6.8.1 Services, Benefits, and Limitations 39
2.6.8.2 Prior Authorization and Documentation Requirements 40
2.6.9 Incontinence Supplies 40
2.6.9.1 Services, Benefits, and Limitations 40
2.6.9.1.1 Skin Sealants, Protectants, Moisturizers, Ointments 41
2.6.9.1.2 Diapers, Briefs, and Liners 41
2.6.9.1.3 Diaper Wipes 41
2.6.9.1.4 Underpads 42
2.6.9.1.5 External Urinary Collection Devices 42
2.6.9.2 Prior Authorization and Documentation Requirements 42
2.6.10 Mobility Aids 42
2.6.10.1 Services, Benefits, and Limitations 42
2.6.10.1.1 Portable Client Lifts for Outside the Home Setting 43
2.6.10.1.2 Wheeled Mobility Systems 43
2.6.10.1.3 Seating Assessment 45
2.6.10.1.4 Fitting of Custom Wheeled Mobility Systems 46
2.6.10.1.5 Modifications, Adjustments, and Repairs 46
2.6.10.1.6 Stroller Ramps—Portable and Threshold 47
2.6.10.1.7 Feeder Seats, Floor Sitters, Corner Chairs, and Travel Chairs 47
2.6.10.1.8 Special-Needs Car Seats 47
2.6.10.1.9 Travel Safety Restraints 47
2.6.10.2 Prior Authorization and Documentation Requirements 47
2.6.10.2.1 Portable Client Lifts for Outside the Home Setting 48
2.6.10.2.2 Wheeled Mobility System 48
2.6.10.2.3 Modifications 49
2.6.10.2.4 Adjustments 49
2.6.10.2.5 Repairs 49
2.6.10.2.6 Seating Assessments 50
2.6.10.2.7 Stroller Ramps—Portable and Threshold 51
2.6.10.2.8 Special-Needs Car Seats 51
2.6.11 Nutritional Products 52
2.6.11.1 Services, Benefits, and Limitations 52
2.6.11.2 Women, Infants, and Children Program (WIC) 53
2.6.11.3 Noncovered Services 53
2.6.11.4 Prior Authorization and Documentation Requirements 53
2.6.11.4.1 Nutritional Products 56
2.6.11.5 Managed Care Clients 58
2.6.12 Hospital Beds, Cribs, and Equipment 58
2.6.12.1 Services, Benefits, and Limitations 58
2.6.12.2 Prior Authorization and Documentation Requirements 59
2.6.12.2.1 Hospital Beds and Safety Enclosure 60
2.6.12.2.2 Positioning Devices 60
2.6.12.2.3 Repair or Replacement 60
2.6.13 Phototherapy Devices 61
2.6.13.1 Services, Benefits, and Limitations 61
2.6.13.2 Prior Authorization and Documentation Requirements 62
2.6.13.2.1 Retroactive Eligibility 63
2.6.14 Special Needs Car Seats and Travel Restraints 63
2.6.14.1 Services, Benefits, and Limitations 63
2.6.14.1.1 Special Needs Car Seats 63
2.6.14.1.2 Travel Safety Restraints 63
2.6.14.2 Prior Authorization and Documentation Requirements 63
2.6.14.2.1 Special Needs Car Seats 63
2.6.14.2.2 Travel Safety Restraints 64
2.6.15 Total Parenteral Nutrition (TPN) 64
2.6.15.1 Services, Benefits, and Limitations 64
2.6.15.2 Prior Authorization and Documentation Requirements 65
2.6.16 Vitamin and Mineral Products 66
2.6.16.1 Services, Benefits, and Limitations 66
2.6.16.2 Prior Authorization and Documentation Requirements 70
2.6.17 Claims Information 71
2.6.18 Reimbursement 72
2.7 Early Childhood Intervention (ECI) Services 72
2.7.1 Enrollment 72
2.7.2 * Services, Benefits, Limitations, and Prior Authorization 72
2.7.2.1 * Guidelines for ECI Services Performed in a Prescribed Pediatric Extended Care Center (PPECC) 73
2.7.2.2 * Therapy 73
2.7.2.2.1 * Physical, Occupational and Speech Therapy Evaluations and Re-evaluations 73
2.7.2.2.2 Occupational Therapy (OT) 74
2.7.2.2.3 Physical Therapy (PT) 74
2.7.2.2.4 Speech Therapy (ST) 75
2.7.2.3 Specialized Skills Training (SST) 76
2.7.2.4 Targeted Case Management (TCM) 77
2.7.3 Documentation Requirements 77
2.7.4 Claims Filing and Reimbursement 77
2.7.4.1 Claims Information 77
2.7.4.1.1 Billing Units Based on 15 Minutes 78
2.7.4.1.2 Managed Care Clients 78
2.7.4.2 Reimbursement 78
2.8 Health and Behavior Assessment and Intervention 79
2.8.1 Services, Benefits, and Limitations 79
2.8.2 Prior Authorization and Documentation Requirements 80
2.8.3 HBAI Services Provided by Psychologists 81
2.8.4 Claims Information 81
2.8.5 Reimbursement 82
2.9 Medical Nutrition Counseling Services (CCP) 82
2.9.1 Enrollment 82
2.9.2 Services, Benefits, and Limitations 82
2.9.3 Prior Authorization and Documentation Requirements 85
2.9.4 Claims Information 85
2.9.5 Reimbursement 85
2.10 Orthotic and Prosthetic Services (CCP) 85
2.10.1 Enrollment 85
2.10.2 Orthotics Services 86
2.10.2.1 Services, Benefits, and Limitations 86
2.10.2.1.1 Noncovered Orthotic Services 87
2.10.2.2 Prior Authorization and Documentation Requirements 87
2.10.2.2.1 Spinal Orthoses 88
2.10.2.2.2 Lower-Limb Orthoses 89
2.10.2.2.3 Foot Orthoses 90
2.10.2.2.4 Upper-Limb Orthoses 91
2.10.2.2.5 Other Orthopedic Devices 91
2.10.2.2.6 Related Services 92
2.10.3 Cranial Molding Orthosis 92
2.10.3.1 Services, Benefits, and Limitations 92
2.10.3.2 Noncovered Services 93
2.10.3.3 Prior Authorization and Documentation Requirements 93
2.10.4 Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers, Standing Frames, Braces, and Parapodiums) 93
2.10.4.1 Services, Benefits, and Limitations 93
2.10.4.1.1 Parapodium 93
2.10.4.1.2 Standing Frame or Brace 94
2.10.4.1.3 Vertical or Dynamic Stander 94
2.10.4.2 Prior Authorization and Documentation Requirements 94
2.10.5 Prosthetic Services 94
2.10.5.1 Services, Benefits, and Limitations 94
2.10.5.1.1 Noncovered Prosthetic Services 95
2.10.5.2 Prior Authorization and Documentation Requirements 96
2.10.5.2.1 Lower-Limb Prostheses 97
2.10.5.2.2 Upper-Limb Prostheses 99
2.10.5.2.3 External Breast Prostheses 100
2.10.5.2.4 Craniofacial Prostheses 100
2.10.5.2.5 Related Services 100
2.10.6 Claims Information 101
2.10.7 Reimbursement 101
2.11 Personal Care Services (PCS) (CCP) 101
2.11.1 Enrollment 101
2.11.2 Services, Benefits, and Limitations 102
2.11.2.1 Place of Services 104
2.11.2.2 Client Eligibility 105
2.11.2.2.1 Accessing the PCS Benefit 106
2.11.2.2.2 The Primary Practitioner’s Role in the PCS Benefit 106
2.11.2.3 PCS Provided in Group Settings 107
2.11.3 * Prior Authorization and Documentation Requirements 108
2.11.3.1 PCS Provider Responsibilities 109
2.11.3.2 Documentation of Services Provided and Retrospective Review 109
2.11.4 * Coordination with PPECC Provider 109
2.11.5 Claims Information 110
2.11.5.1 Managed Care Clients 110
2.11.5.2 PCS for STAR Health Clients 110
2.11.6 Reimbursement 110
2.12 Community First Choice (CFC) Services 111
2.12.1 Enrollment 111
2.12.2 Services, Benefits, and Limitations 111
2.12.2.1 Place of Service 115
2.12.3 CFC Attendant and Habilitation Services in Group Settings 116
2.12.4 Prior Authorization 116
2.12.4.1 CFC Provider Responsibilities 117
2.12.4.2 Documentation Requirements 117
2.12.5 Claims Information 117
2.12.5.1 Managed Care Clients 118
2.13 Private Duty Nursing (PDN)(CCP) 118
2.14 * Prescribed Pediatric Extended Care Centers (PPECC) (CCP) 118
2.14.1 Services, Benefits, and Limitations 118
2.14.1.1 Prior Authorization and Documentation Requirements 121
2.14.1.1.1 Initial Authorization Requests 122
2.14.1.1.2 Revisions to the Plan of Care 126
2.14.1.1.3 PPECC Provider Change During an Existing Authorization Period 127
2.14.1.1.4 Recertification 128
2.14.1.1.5 Termination of Authorizations 129
2.14.1.1.6 Appeal of Authorization Decisions 129
2.14.1.1.7 Documentation Requirements 130
2.14.1.1.8 Exclusions 131
2.14.1.1.9 Claims Filing and Reimbursement 132
2.15 Therapy Services (CCP) 133
2.16 Inpatient Psychiatric Hospital or Facility (Freestanding) (CCP) 133
2.17 Inpatient Rehabilitation Facility (Freestanding) (CCP) 133
2.17.1 Enrollment 133
2.17.1.1 Continuity of Hospital Eligibility Through Change of Ownership 134
2.17.2 Services, Benefits, and Limitations 134
2.17.2.1 Comprehensive Treatment 134
2.17.3 Prior Authorization and Documentation Requirements 134
2.17.4 Claims Information 136
2.17.5 Reimbursement 136
2.17.5.1 Client Transfers 137
3 School Health and Related Services (SHARS) 137
3.1 Overview 137
3.1.1 Random Moment Time Study (RMTS) 138
3.1.2 Eligibility Verification 138
3.2 Enrollment 138
3.2.1 SHARS Enrollment 138
3.2.2 Private School Enrollment 139
3.3 Services, Benefits, Limitations, and Prior Authorization 139
3.3.1 Audiology 139
3.3.1.1 Audiology Billing Table 140
3.3.2 Counseling Services 140
3.3.2.1 Counseling Services Billing Table 140
3.3.3 Psychological Testing and Services 141
3.3.3.1 Psychological Testing 141
3.3.3.1.1 Evaluation or Assessment Billing Table 141
3.3.3.2 Psychological Services 142
3.3.3.2.1 Psychological Services Billing Table 142
3.3.4 Nursing Services 142
3.3.4.1 Nursing Services Billing Table 143
3.3.5 Occupational Therapy (OT) 144
3.3.5.1 Referral 144
3.3.5.2 Description of Services 144
3.3.5.3 Occupational Therapy Billing Table 144
3.3.6 Personal Care Services 145
3.3.6.1 Personal Care Services Billing Table 145
3.3.7 Physical Therapy (PT) 145
3.3.7.1 Referral 145
3.3.7.2 Description of Services 145
3.3.7.3 Physical Therapy Billing Table 146
3.3.8 Physician Services 146
3.3.8.1 Physician Services Billing Table 147
3.3.9 Speech Therapy (ST) 147
3.3.9.1 Referral 147
3.3.9.2 Description of Services 147
3.3.9.3 Provider and Supervision Requirements 148
3.3.9.4 Speech Therapy Billing Table 148
3.3.10 Transportation Services in a School Setting 149
3.3.10.1 Transportation Services in a School Setting Billing Table 150
3.3.11 Prior Authorization 150
3.4 Documentation Requirements 150
3.4.1 Record Retention 150
3.5 Claims Filing and Reimbursement 150
3.5.1 Claims Information 151
3.5.1.1 Appealing Denied SHARS Claims 151
3.5.1.2 Billing Units Based on 15 Minutes 151
3.5.1.3 Billing Units Based on an Hour 152
3.5.2 Managed Care Clients 152
3.5.3 Reimbursement 152
3.5.3.1 Quarterly Certification of Funds 153
3.6 Cost Reporting, Cost Reconciliation, and Cost Settlement 154
3.6.1 Cost Reporting 154
3.6.2 Cost Reconciliation and Cost Settlement 154
3.6.3 Informal Review of Cost Reports Settlement 155
4 Texas Health Steps (THSteps) Dental 155
4.1 Enrollment 156
4.1.1 THSteps Dental Eligibility 157
4.1.2 THSteps Dental and ICF-IID Dental Services 157
4.1.3 THSteps Dental Checkup and Treatment Facilities 158
4.1.4 Doctor of Dentistry Practicing as a Limited Physician 158
4.1.5 Client Rights 158
4.1.6 Complaints and Resolution 158
4.2 Services, Benefits, Limitations, and Prior Authorization 159
4.2.1 THSteps Dental Services 159
4.2.1.1 Eligibility for THSteps Dental Services 159
4.2.1.2 Parental Accompaniment 159
4.2.2 Comprehensive Care Program (CCP) 159
4.2.3 Children’s Medicaid Dental Plan Choices 160
4.2.4 Authorization Transfers for Medicaid Managed Care Dental Orthodontic Services 160
4.2.5 ICF-IID Dental Services 160
4.2.5.1 THSteps and ICF-IID Provision of Dental Services 160
4.2.5.2 Children in Foster Care 161
4.2.6 Written Informed Consent and Standards of Care 161
4.2.7 First Dental Home 161
4.2.8 Dental Referrals by THSteps Primary Care Providers 162
4.2.9 Change of Provider 163
4.2.9.1 Interrupted or Incomplete Orthodontic Treatment Plans 163
4.2.10 Periodicity for THSteps Dental Services 163
4.2.10.1 Exceptions to Periodicity 164
4.2.11 Tooth Identification (TID) and Surface Identification (SID) Systems 164
4.2.11.1 Supernumerary Tooth Identification 165
4.2.12 Medicaid Dental Benefits, Limitations, and Fee Schedule 165
4.2.13 Diagnostic Services 166
4.2.14 * Preventive Services 170
4.2.15 Therapeutic Services 171
4.2.16 Restorative Services 172
4.2.17 Endodontics Services 175
4.2.18 Periodontal Services 177
4.2.19 Prosthodontic (Removable) Services 179
4.2.20 Implant Services 182
4.2.21 Prosthodontic (Fixed) Services 183
4.2.22 Oral and Maxillofacial Surgery Services 184
4.2.23 Adjunctive General Services 187
4.2.23.1 Benefit Limitations for Adjunctive General Services 189
4.2.24 Dental Anesthesia 190
4.2.25 Dental Therapy Under General Anesthesia 191
4.2.26 Hospitalization and ASC/HASC 192
4.2.27 Orthodontic Services (THSteps) 193
4.2.27.1 Benefits and Limitations for Orthodontic Services 194
4.2.27.2 Crossbite Therapy 195
4.2.27.3 Minor Treatment to Control Harmful Habits 195
4.2.27.4 Premature Termination of Comprehensive Orthodontic Treatment 195
4.2.27.5 Other Orthodontic Services 196
4.2.27.6 Non-covered Services 196
4.2.27.7 Comprehensive Orthodontic Treatment 196
4.2.27.8 Orthodontic Procedure Codes and Fee Schedule 197
4.2.28 Special Orthodontic Appliances 198
4.2.29 Handicapping Labio-lingual Deviation (HLD) Index 201
4.2.30 Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger 202
4.2.31 Emergency Services for Medicaid Clients Who Are 21 Years of Age and Older 203
4.2.31.1 Long Term Care (LTC) Emergency Dental Services 203
4.2.31.2 Laboratory Requirements 203
4.2.32 Mandatory Prior Authorization 204
4.2.32.1 Cone Beam Imaging 205
4.2.32.2 General Anesthesia for Dental Treatment 205
4.2.32.3 Orthodontic Services 205
4.2.32.3.1 Initial Orthodontic Services Request 206
4.2.32.3.2 Diagnostic Tools 207
4.2.32.3.3 Authorization Extensions 208
4.2.32.3.4 Crossbite Therapy 208
4.2.32.3.5 Minor Treatment to Control Harmful Habits 208
4.2.32.3.6 Premature Termination of Orthodontic Services 209
4.2.32.3.7 Transfer of Services 210
4.2.32.3.8 Orthodontic Cases Initiated Through a Private Arrangement 210
4.2.33 THSteps and ICF-IID Dental Prior Authorization 210
4.3 Documentation Requirements 210
4.3.1 General Anesthesia 212
4.3.2 Orthodontic Services 212
4.4 Utilization Review 213
4.5 Claims Filing and Reimbursement 213
4.5.1 Reimbursement 213
4.5.2 Claim Submission After Loss of Eligibility 213
4.5.3 Third Party Liability 213
4.5.4 Claims Information 213
4.5.5 Claim Appeals 214
4.5.6 Frequently Asked Questions About Dental Claims 216
5 THSteps Medical 218
5.1 THSteps Medical and Dental Administrative Information 218
5.1.1 Overview 218
5.1.2 Statutory Requirements 218
5.1.3 Texas Vaccines for Children (TVFC) Program 219
5.1.4 Vaccine Adverse Event Reporting System (VAERS) 219
5.1.5 Referrals for Medicaid-Covered Services 219
5.1.6 THSteps Medical Checkup Facilities 221
5.1.7 THSteps Dental Services 221
5.2 Enrollment 222
5.2.1 THSteps Medical Provider Enrollment 222
5.2.1.1 Requirements for Registered Nurses Who Provide Medical Checkups 223
5.3 Services, Benefits, Limitations, and Prior Authorization 223
5.3.1 Eligibility for THSteps Services and Checkup Due Dates 223
5.3.2 Prior Authorization 224
5.3.3 Additional Consent Requirements 224
5.3.4 Verification of Medical Checkups 224
5.3.5 Medical Home 224
5.3.6 THSteps Medical Checkups 225
5.3.7 Exception-to-Periodicity Checkups 228
5.3.8 Medical Checkup Follow-up Visit 229
5.3.9 Newborn Examination 229
5.3.10 THSteps Medical Checkups Periodicity Schedule 230
5.3.11 Mandated Components 230
5.3.11.1 Comprehensive Health and Developmental History 231
5.3.11.1.1 Nutritional Screening 231
5.3.11.1.2 Developmental Surveillance or Screening 231
5.3.11.1.3 Mental Health Screening 232
5.3.11.1.4 Tuberculosis (TB) Screening 233
5.3.11.2 Comprehensive Unclothed Physical Examination 233
5.3.11.2.1 Oral Health Screening 234
5.3.11.2.2 Sensory Screening 234
5.3.11.2.3 Hearing Screening 234
5.3.11.2.4 Vision Screening 234
5.3.11.3 Immunizations 234
5.3.11.3.1 Vaccine Information Statement (VIS) 237
5.3.11.4 Health Education and Anticipatory Guidance 238
5.3.11.5 Dental Referral 238
5.3.11.6 Laboratory Test 238
5.3.11.6.1 Laboratory Supplies 239
5.3.11.6.2 Newborn Screening Supplies 240
5.3.11.6.3 Laboratory Submission 240
5.3.11.6.4 Send Comments 242
5.3.11.6.5 Laboratory Reporting 242
5.3.11.6.6 Required Laboratory Tests Related to Medical Checkups 242
5.3.11.6.7 Additional Required Laboratory Tests Related to Medical Checkups for Adolescents 244
5.3.12 Non-mandated Components 245
5.3.12.1 Oral Evaluation and Fluoride Varnish (OEFV) in the Medical Home 245
5.4 Documentation Requirements 246
5.4.1 Separate Identifiable Acute Care Evaluation and Management Visit 246
5.5 Claims Filing and Reimbursement 246
5.5.1 Claims Information 247
5.5.2 Reimbursement 248
6 Claims Resources 248
7 Contact TMHP 248
7.1 Automated Inquiry System (AIS) 248
7.2 TMHP Website 249
7.3 Dental Information and Assistance 249
7.3.1 Dental Inquiry Line 249
7.4 THSteps Information and Assistance 249
7.4.1 THSteps Inquiry Line 249
7.5 Assistance with Program 249
8 Forms 250
9 Claim Form Examples 250
Appendix A. THSteps Forms 252
A.1 Claim Forms 252
A.2 THSteps Medical Checkup Forms 252
A.3 Laboratory Forms 253
A.4 Guidelines for Tuberculosis Skin Testing 253
A.5 Tuberculosis Screening and Guidelines 253
Appendix B. Immunizations 255
B.1 Immunizations Overview 255
B.1.1 Vaccine Adverse Event Reporting System (VAERS) 255
B.1.2 TVFC Versus Non-TVFC Vaccines/Toxoids 255
B.1.3 Exemption from Immunization for School and Child-Care Facilities 255
B.2 Recommended Childhood Immunization Schedule 256
B.3 General Recommendations 256
B.3.1 How to Obtain Vaccines at No Cost to the Provider 256
B.3.2 Administrations and Immunizations 256
B.3.2.1 Administrations 256
B.3.2.2 Immunizations (Vaccine/Toxoids) 257
B.3.3 Requirements for TVFC Providers 258
B.3.4 How to Report Immunization Records to ImmTrac, the Texas Immunization Registry 259
B.3.4.1 Direct Internet Entry 259
B.3.4.2 Electronic Data Transfer (Import) 259
B.3.4.3 Obtaining Parental Consent for Registry Participation 259
B.4 Texas Vaccines for Children Program Packet 260
Appendix C. Lead Screening 261
C.1 Blood Lead Screening Procedures and Follow-up Testing 261
C.2 Symptoms of Lead Poisoning 261
C.3 Measuring Blood Lead Levels 261
C.4 Environmental Lead Investigation Services 262
C.4.1 Enrollment 262
C.4.2 Services, Benefits, Limitations, and Prior Authorization 262
C.4.2.1 Requesting an Environmental Lead Investigation 263
C.4.2.2 Prior Authorization 263
C.4.3 Documentation Requirements 263
C.4.4 Claims Filing and Reimbursement 264
C.4.4.1 Claims Filing 264
C.4.4.2 Managed Care Clients 264
C.4.4.3 Reimbursement 264
C.5 Lead Poisoning Prevention Educational Materials and Forms 264
Appendix D. Texas Health Steps Statutory State Requirements 266
D.1 Legislative Requirements 266
D.2 Texas Health Steps (THSteps) Program 266
D.3 Communicable Disease Reporting 266
D.4 Early Childhood Intervention (ECI) Referrals 266
D.5 Parental Accompaniment 266
D.6 Newborn Blood Screening 267
D.7 Abuse and Neglect 267
D.7.1 Requirements for Reporting Abuse or Neglect 267
D.7.2 Procedures for Reporting Abuse or Neglect 267
D.7.2.1 Staff Training on Reporting Abuse and Neglect 268
Appendix E. Hearing Screening Information 269
E.1 Texas Early Hearing Detection and Intervention (TEHDI) Process 269
E.1.1 Birth Screen 269
E.1.2 Outpatient Rescreen 269
E.1.3 Evaluation using Texas Pediatric Protocol for Audiology 269
E.1.4 Referral to an ECI Program 270
E.1.5 Periodic Monitoring by the Physician or Medical Home 270
E.2 JCIH 2007 Position Statement 270
Appendix F. Texas Health Steps Quick Reference Guide 271
Appendix G. American Academy of Pediatric Dentistry Periodicity Guidelines 271
 

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