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WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.
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AMA/ADA End User License Agreement
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership (TMHP) website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, 515 N. State Street, Chicago, Illinois, 60610. Applications are available at the American Medical Association website, www.ama-assn.org/go/cpt.

U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer databases and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the American Medical Association (AMA) is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with THHS, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the for egoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "accept".

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONTINUED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NO AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

1. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights included in the materials.

2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.

3. U.S. GOVERNMENT RIGHTS. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government Use. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal Procurements.

4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does no t directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with TMHP or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of the Agreement. The ADA is a third party beneficiary to this Agreement.

5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must exit from this computer screen.

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

Last updated on 3/5/2024

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.

EOB	EOB Description
F0268	A 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.