Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
Effective for dates of service on or after December 1, 2024, two new provider types—doula and community health worker—as well as updated case management services benefit language will be added for the Children and Pregnant Women (CPW) program. The revised language for Case Management services will be published in the Texas Medicaid Provider Procedures Manual (TMPPM), Behavioral Health and Case Management Services Handbook, section 3 (Case Management for Children and Pregnant Women).
Eligibility
Clients who are Medicaid-eligible but not yet enrolled may have Medicaid coverage assigned retroactively.
Referral Process
CPW referrals can be received from any source and best completed through the use of the Texas Health and Human Services (HHSC) CPW Referral & Intake Form (CM-01A), located on the HHSC CPW website. The following information should be received through the referral process:
- The health conditions, health risk, or high-risk condition of the client who would receive case management services
- How the health condition, health risk, or high-risk condition impacts the client’s level of functioning
Enrollment
Providers of CPW services must be at least 18 years of age, enrolled in Texas Medicaid, and approved by HHSC to deliver CPW services. The provider shall not be approved as a provider of CPW services unless one of the following qualifications is met:
- The provider is an advanced practice registered nurse who holds a license under Texas Occupations Code Chapter 301.
- The provider is a registered nurse who holds a license under Texas Occupations Code Chapter 301 and has a baccalaureate degree in nursing.
- The provider is a registered nurse who holds a license under Texas Occupations Code Chapter 301 and has an associate degree in nursing with at least two years’ cumulative paid full-time work experience or two years of supervised, full-time educational internship or practicum experience in the past 10 years working with children up to 21 years of age and pregnant women.
- The provider is a social worker who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 505 that is appropriate for the individual’s practice, including the practice of independent social work in the state of Texas.
- The provider is a community health worker as defined by Section 48.001 of the Health and Safety Code and is certified by the Department of State Health Services.
- The provider is a doula who is certified in alignment with nationally recognized standards and, as determined by HHSC, has:
- Five years of experience within the last seven years as a doula.
- Attendance at three births within the last seven years.
- At least three written professional letters of recommendation.
- The provider is a doula who does not have five years of experience but is certified in alignment with nationally recognized standards and, as determined by HHSC, has:
- Attendance at three births.
- At least three written professional letters of recommendation.
- Training in core competencies that must include:
- Childbirth education.
- Lactation support [or proof of being a certified lactation counselor (CLC) or International Board-Certified Lactation Counselor (IBCLC)].
- Nonmedical comfort measures, prenatal support, and labor support techniques.
- Chronic and acute health conditions during the perinatal period.
- Cultural competency.
A federally qualified health center (FQHC) that has obtained HHSC approval may be eligible to provide CPW case management services. FQHCs must:
- Use the FQHC provider type, specialty code, and taxonomy to deliver CPW services.
- Use their own individual National Provider Identifier (NPI) to deliver services.
Providers must also:
- Complete a preplanning process with HHSC.
- Complete the HHSC standardized case management training provided by HHSC.
- Complete Health Insurance Portability and Accountability Act (HIPAA) training.
Note: CPW Authorization to Disclose Protected Health Information forms in English or Spanish, located on the HHSC CPW website, must be completed as necessary to help clients access services. - Receive an approval letter from HHSC to enroll as a state Medicaid provider of CPW services.
Providers may be a group or an individual or perform services under the guidance of an FQHC.
Provider and Case Manager Responsibilities
Providers and their case managers must:
- Operate in accordance with the laws, rules, regulations, and standards of care relating to the practice of their respective licenses or certifications.
- Provide services according to policies and procedures as published.
- Cease providing services and notify HHSC if the professional license or certification of a provider is suspended or revoked.
- Provide services convenient to clients, either in their home, an office setting, or other place of the client’s preference.
- Have knowledge of and coordinate services with providers of health and health-related services, noncovered services, and other active community resources.
- Develop and maintain a quality management system for the provision of services.
- Submit claims for rendered case management services. If no claims are submitted for 24 months, the provider will be disenrolled.
Providers may be disenrolled by HHSC for failure to comply with provisions of the Texas Medicaid & Healthcare Partnership (TMHP) Provider Agreement or any applicable law, rule, or policy of the program or if they don’t provide services for 12 months or longer.
CPW Outreach Activities
Providers should disseminate accurate information regarding case management services to health, education, and human service professionals, community organizations, and potential clients to generate referrals.
Providers must:
- Ensure that outreach activities do not impede a client’s freedom to choose a provider.
- Refer and adhere to CPW outreach guidance available on the HHSC CPW website when producing outreach materials.
- Comply with the requirements outlined in TAC Title 1, Part 15, Chapter 371, Rule §371.1669, concerning self-dealing.
CPW Services – Initial Intake
CPW providers must complete an initial intake with the client, parent, or legal guardian to determine the client’s eligibility.
The following added information must be obtained during the initial intake and must be documented on the CPW Intake and Referral Form, located on the HHSC CPW website:
- The health-related nonmedical conditions of the eligible client who would receive case management services.
- Detailed information about the client’s current medical needs related to the health condition, risk, high-risk, or nonmedical condition.
The CPW initial intake service is not billable for reimbursement but is a required function of case management services.
Providers who cannot accept a referral based on approved limitations must redirect the referral to the Texas Health Steps Hotline (877-847-8377). The approved limitations are as follows:
- The client resides outside the provider’s service area.
- The provider is not contracted with the MCO that is responsible for delivering services to the client.
- The provider has disenrolled as a CPW provider from TMHP.
- The provider cannot serve the individual’s needs.
Referrals received for clients in STAR Kids must receive an intake to determine whether coordinating school services are needed. All other services are to be provided by the client’s MCO.
If the CPW initial intake indicates that the client is eligible for services and a need for CPW services is identified, the provider must complete a comprehensive visit within 30 business days of the intake date in which eligibility is determined.
If the CPW initial intake indicates that the client is eligible for services and a need for CPW services is identified but the client is not yet enrolled in Medicaid, the case manager must complete a comprehensive visit within 30 business days after the client’s enrollment period is established.
Comprehensive Visits
The comprehensive visit (procedure code G9012 with the appropriate modifier combination) may be reimbursed.
The comprehensive visit must include the completion of all the following:
- Family Needs Assessment
- Service Plan
- Service Plan Consent
The comprehensive visit must be completed within 30 business days of the intake date on which eligibility was determined or retroactive eligibility is established.
The comprehensive visit may be completed in-person or using synchronous audiovisual technology. Comprehensive visits using synchronous audiovisual technology should be provided only if the client, parent, or legal guardian agrees to it.
The Family Needs Assessment (FNA) is completed to determine the need for any medical, educational, social, or other services required to address the client’s short- and long-term health and the overall well-being of the client.
The FNA must include the following documentation using the FNA form, located on the HHSC CPW website:
- A complete personal and family medical, mental health, and medication history.
- Identification of the client’s needs, including any nonmedical health-related needs.
- Assessment and referral for personal family issues that impact the client’s health condition, health risk, or high-risk condition, in addition to a determination of nonmedical needs and related documentation.
- Information from other sources, such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the client.
The Service Plan is part of the comprehensive visit and must be completed and documented during the comprehensive visit using the Service Plan form that is available on the HHSC CPW website. The Service Plan is used to determine a planned course of action based upon the information collected through the needs assessment.
The Service Plan Consent is completed to authorize the provider to share information as necessary for referrals and for services to be provided. The Service Plan Consent form is located on the HHSC CPW website.
The Service Plan and Service Plan Consent forms must have verbal or written consent by the client, parent, or legal guardian, and they must be kept in the client’s medical record, to be made available upon request.
Follow-Up Visits
Follow-up visits (procedure code G9012 with the appropriate modifier combination) may only be conducted and reimbursed after the comprehensive visit has been completed. The follow-up visit and comprehensive visit cannot occur on the same date of service.
Follow-up visits by a case manager are necessary to ensure that the service plan is implemented and adequately addresses the client’s needs.
Follow-up visits shall be conducted as frequently as necessary. At least one annual follow-up is required for clients who are eligible for case management lasting longer than 12 consecutive months. For reimbursement, follow-up visits must be documented and must include the following:
- The current service plan, to include the client’s needs and status.
- Documentation that services are being furnished in accordance with the client’s service plan.
- A description of how the services are addressing the client’s needs as outlined in the service plan.
- Documentation that services are maintained and modified when the client’s needs or status changes.
Activities during the follow-up visit must be documented on the Follow-Up Form that is found on the HHSC CPW website.
Follow-up visits by the case manager for clients who are pregnant with a high-risk condition, or nonmedical needs shall occur as needed during the 12-month postpartum period.
Case Closure
When all needs related to the client’s health condition, health risk, or high-risk pregnancy and all nonmedical needs have been addressed, CPW services must no longer be provided.
The client’s status must be documented on the Case Closure Form that is available on the HHSC CPW website to indicate the outcome of the case.
Note: Providers may choose to close a case if the client, parent, or legal guardian is disruptive, unruly, threatening, or uncooperative to the extent that the client, parent, or legal guardian seriously impairs the provider’s ability to render services or if the client’s, parent’s, or legal guardian’s behavior jeopardizes the client’s own safety or the provider’s. The provider should also contact the appropriate authority when necessary.
Case Transfers
Case transfers must be documented on the Case Transfer form that is available on the HHSC CPW website. The Case Transfer form is completed if the client continues to meet eligibility criteria, but the case needs to be transferred.
The provider must assist a client with a transfer to case management services in another area of Texas.
A client must give approval to a provider to transfer the case management record to the new provider.
Providers must appropriately link clients of a family member that is a migrant worker to resources in the geographic areas in which they live and to which they migrate. This case transfer process is to be documented on the Migrant Information Form that is available on the HHSC CPW website.
Documentation Requirements
All CPW services require documentation to describe and support the services provided.
Providers must maintain accurate demographic information on their provider record with TMHP. Changes to significant provider information must be updated on the Provider Enrollment and Management System (PEMS) within seven calendar days of the change, including changes to the provider’s:
- Group name or doing business as (DBA).
- Location address.
- Telephone number.
- Fax number.
- Email address.
CPW documentation forms are available on the HHSC CPW website.
Signatures or documentation confirming that verbal consent was received must be included on all forms and documents that require signatures.
Documentation of activities not otherwise documented on CPW required forms must be recorded on the Progress Notes form that is available on the HHSC CPW website. Progress notes may include the following information:
- Documentation of phone calls to the client, parent, or legal guardian between billable follow-up visits
- Information that is gathered from other sources, such as family members, medical providers, social workers, and educators on behalf of the client, parent, or legal guardian
Documentation in the client’s record must include the reasons that a CPW service was not provided or completed. This can be documented on the Referral and Intake form during the initial eligibility determination or on the Case Closure form that is available on the HHSC CPW website.
Claims Filing and Reimbursement
The comprehensive visit must not be billed until the FNA and service plan are completed and the Service Plan Consent form is signed or verbal consent is given by the client, parent, or legal guardian.
Claims for a client who receives retroactive eligibility must be submitted within 95 days of the date that the client’s eligibility was added to the TMHP eligibility file (add date) and within 365 days of the date of service.
For a client who has been approved for Medicaid coverage but has not been assigned a Medicaid client number, the 95-day claims filing deadline does not begin until the date the eligibility is added to the TMHP eligibility file.
Procedure code G9012 with any required modifiers may be reimbursed for Case Management for Children and Pregnant Women (CPW) services:
| Procedure Code | Procedure Description | Additional Information |
|---|---|---|
| G9012 | Comprehensive visit (in-person) | Combination modifier U2 and U5 (both required) |
| G9012 | Comprehensive visit (synchronous audiovisual) | Combination modifier U2, U5, and 95 (all required) |
| G9012 | Follow-up visit (in-person) | Combination modifier U5 and TS (both required) |
| G9012 | Follow-up visit (synchronous audiovisual) | Combination modifier U5, TS, and 95 (all required) |
| G9012 | Follow-up visit telephone (audio only) | Combination modifier TS and 93 (both required) |
Comprehensive visits are limited to one service per client, per provider in 12 consecutive months from the intake date.
FQHCs will bill for services using procedure code G9012 with the corresponding modifiers.
CPW services may be provided using synchronous audiovisual technologies if it is clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.
Exclusions
CPW services are not billable:
- For clients who have already received another case management service on the same day from any billing provider.
- When a client is an inpatient at a hospital or other treatment facility.
- When the exact services are duplicated within the client’s MCO.
For more information, call the TMHP Contact Center at 800-925-9126.