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Reminder: HCS and TxHmL Claim Details Cannot Overlap Multiple Service Authorizations

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This is an update to the article titled “Update: HCS and TxHmL Claim Details Cannot Overlap Multiple Service Authorizations,” which was published on this website on September 11, 2023. This reminder provides additional resources and information.

The Texas Health and Human Services Commission (HHSC) advises Home and Community-based Services (HCS) and Texas Home Living (TxHmL) providers and financial management services agencies (FMSAs) that accurate service utilization budgets are calculated when a claim detail’s dates of service (DOS) do not cross multiple Individual Plan of Care (IPC) service authorization periods. If a billed claim detail has DOS that cross multiple IPC service authorization periods, all claim detail billed units are subtracted from the most recent IPC service authorization period budget. Refer to the following example on the HHSC website.

One IPC Service Authorization Period per Claim Detail

To prevent inaccurate service utilization balances, HHSC implemented an edit that will deny a claim detail if the DOS crosses multiple IPC service authorization periods. If this denial occurs, the provider or FMSA should submit a new and corrected claim by splitting the claim detail into two claim details, allowing the accurate IPC authorization period to be used to satisfy the number of units billed on each claim detail. The explanation of benefits (EOB) that is received when the edit is activated is provided in the table below. The edit became effective on July 26, 2023.

EOBEOB Description
F0268A unique service authorization for this client is not available for these dates such as overlapping more than one authorization

Review Claims If a Service Utilization Balance Appears to Be Incorrect

If a provider or FMSA suspects that an individual’s service utilization balance is inaccurate, or if the provider or FMSA has run out of available units for billing, they should review claims that were billed prior to July 26, 2023, with DOS that cross multiple IPC service authorization periods. Providers and FMSAs can adjust these claims by correcting and splitting the claim into two claim details. Each claim detail’s DOS and number of units billed should correspond to the appropriate IPC service authorization period and number of units available.

Providers and FMSAs can consult the Remittance and Status (R&S) Report, TexMedConnect’s MESAV, or the X12 270-271 report for help with reconciling billed claim information or checking the client’s service utilization balance.

Providers and FMSAs are encouraged to check the MESAV before billing to ensure that their claims are being billed for the correct time frames and service authorizations.

Refer to the following for assistance with R&S Reports or TexMedConnect:

  • R&S Report information can be found on the Texas Medicaid & Healthcare Partnership (TMHP) Learning Management System (LMS). After logging in, search for Remittance and Status (R&S) Reports for LTC Providers: A Quick Reference Guide. Additional information is available on TMHP’s YouTube channel in the HCS and TxHmL waiver programs playlist.
  • Instructions for TexMedConnect's MESAV can be found on the TMHP LTC Reference Material page. Under “User Guides,” click Long-Term Care (LTC) User Guide for TexMedConnect.
  • Additional claims adjustments resources can be found on TMHP’s 1915(c) Waiver Programs Reference Materials page under Claims Resources. The following topics are discussed on the webinar recordings accessible from TMHP LTC Portal for HCS and TxHmL Providers and FMSAs Webinar:
    • May 2023 Webinar: Claim Adjustments recap.
    • February 2023 Webinar: Claims Adjustment follow-up.
    • December 2022 Webinar: How to do batch billing using TexMedConnect (TMC) and claim adjustments.

TMHP can provide a list of claims with DOS that cross multiple IPC service authorization periods. To obtain a list or for any other assistance, call the TMHP LTC Help Desk at 800-626-4117, and select option 1.

For reconsideration of denials related to timely filing, contact HHSC Provider Claims Services at 512-438-2200, and select option 5.