Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook

Medicaid Managed Care
Handbook
Table of Contents
1 General Information 5
2 Overview of Medicaid Managed Care 5
2.1 Managed Care Services 6
2.1.1 Medical Services 6
2.1.2 Prescription Drug/Pharmacy Services 6
2.1.2.1 Prescription Drug Prior Authorizations 7
2.1.2.1.1 Emergency 72-Hour Prescriptions 7
2.1.2.1.2 Formulary 8
2.2 Provider Enrollment and Responsibilities 8
2.2.1 Enrollment, Contracting, and Credentialing 8
2.2.2 Online Provider Lookup (OPL) 9
2.2.3 Terminated Enrollment 9
2.2.4 Excluded Entities and Providers 9
2.2.5 Accounts Receivable 9
2.2.6 Educating Clients about Managed Care 9
2.3 General Information About Client Enrollment in Managed Care 10
2.3.1 Managed Care Enrollment Broker 11
2.3.2 Eligibility Verification Resources 11
2.3.3 Client Rights 12
2.3.3.1 Advance Directives 13
2.3.3.2 PCP/Main Dentist and Health/Dental Plan Changes 14
2.3.4 Client Responsibilities 14
2.4 PCP/Main Dentist Guidelines for Medicaid Managed Care Clients 15
2.4.1 Enrolling as a PCP or Main Dentist 16
2.4.2 PCP Requirements for THSteps Medical Services 16
2.4.3 PCP and Main Dentist Changes 16
2.4.4 Continuous Access 17
2.4.4.1 After-Hours Guidelines 17
2.4.4.2 Unacceptable Telephone Arrangements 17
2.5 Cultural Competency and Sensitivity 18
2.5.1 Limited English Proficiency 18
2.6 Reimbursement 19
2.6.1 Coinsurance and Deductible Payments for Dual-Eligible Clients 19
2.6.2 Third Party Liability (TPL) 19
2.6.3 Health Insurance Premium Payment Program 19
2.6.4 Providers With Unsatisfied Medicaid Accounts Receivables 19
2.7 Managed Care Plan Changes 20
2.7.1 Client-Initiated Plan Changes 20
2.7.2 Plan Administrator-Initiated Changes 20
2.7.3 Managed Care Organization (MCO) Clients Who Transition to Medicaid
Fee-For Service (FFS) 21
2.7.3.1 Submission Guidelines 21
2.7.3.2 Documentation Requirements 21
2.7.3.3 New Services and Extension of Services 22
2.7.3.4 Loss of Eligibility 22
2.8 Authorizations for Managed Care Services 22
2.9 Claims Filing for Managed Care Services 22
2.9.1 Newborn Claims Filing for MCO Services 24
2.9.2 Filing Deadlines 24
2.9.3 System Requirements for MCO and Dental Plan Claim Submissions Through TMHP 25
2.10 MCO/Dental Plan Appeals, Complaints, and Fair Hearings 25
2.10.1 Medicaid Managed Care Complaints and Fair Hearings 26
3 STAR Program 26
3.1 STAR Program Clients 26
3.2 STAR Client Enrollment 30
3.2.1 Expedited Enrollment of Pregnant Women (Program Type 40) 31
3.2.2 Enrollment of Newborns 32
3.2.3 Timely Notification and Assignment of Medicaid ID for Newborns 33
3.3 STAR Program Benefits 33
3.3.1 Spell of Illness 33
3.3.2 Prescriptions 33
3.3.3 National Drug Code 34
3.3.4 Behavioral Health Billing 34
4 * STAR Kids Program 34
4.1 * STAR Kids Client Enrollment 34
5 STAR+PLUS Program 35
5.1 STAR+PLUS Program Clients 35
5.1.1 STAR+PLUS Program Dual-Eligible Clients 36
5.1.2 Clients Who Are Ineligible For The STAR+PLUS Program 37
5.2 STAR+PLUS Client Enrollment 37
5.2.1 Enrollment of Newborns 38
5.3 STAR+PLUS Program Benefits 39
5.3.1 Prescriptions 39
5.3.2 Spell of Illness 39
5.3.3 Service Coordination and Care Management 39
5.3.4 Behavioral Health Billing 39
6 NorthSTAR Program 40
6.1 NorthSTAR Program Clients 40
6.2 NorthSTAR Client Enrollment 41
6.3 NorthSTAR Program Benefits 41
6.3.1 Hospital Billing 41
6.3.2 Behavioral Health Billing 42
6.3.3 Prior Authorization Requirements 42
6.4 Complaints and Appeals 42
7 STAR Health Program 43
7.1 STAR Health Program Clients 43
7.2 STAR Health Client Enrollment 44
7.3 STAR Health Program Benefits 44
7.3.1 STAR Health Mental Health Rehabilitation Mental Health Claims Submissions 45
8 Children’s Medicaid Dental Services 47
8.1 Overview 47
8.2 Children’s Medicaid Dental Services Model 47
8.3 Client Eligibility 47
8.4 Client Enrollment 47
8.5 Children’s Medicaid Dental Plan Choices 48
8.6 Authorizations for Children’s Medicaid Managed Care Dental Services (Non-orthodontia Services) 48
8.7 Children’s Medicaid Dental Orthodontia Services 48
9 * Carve-Out Services 49
9.1 Family Planning Carve-Out Services 50
9.1.1 Professional and Outpatient Claims 50
9.1.1.1 Claim Forms for Submission to TMHP 50
9.1.2 Inpatient Claims 51
9.1.3 Provider Working With Clients Enrolled in the Christus Health Plan 51
10 PCCM and Managed Care Claims Processed by TMHP Before March 1, 2012 52
10.1 PCCM Appeals 52
10.2 PCCM Cost and Reporting 52
10.2.1 PCCM Outpatient Services Cost Reporting 52
11 Other State Health-Care Programs 53
12 Contact Information 53
 

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.