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Cost Report Guidance for LTC Providers

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Long-term care (LTC) providers can use the following helpful information when using TexMedConnect’s Claims Data Export tool to generate cost reports.

Claim Status Definitions

The Status and Current Status columns indicate the processing status of a claim:

  • D (Denied): Claim was denied and not paid.
  • M (MCO): Claim was forwarded to the managed care organization (MCO) for processing.
  • P (Paid): Claim was paid.
  • PZ (Paid Zero): $0 net payment was made to the provider for the given reporting period, usually because payment was collected from the provider through a deduction. The total paid amount for the claim may not be $0.
  • I (In Process): Claim has been submitted and is being processed.
  • A (Approved to Pay): Claim is approved for payment.
  • FT (Forced Transfer): The Texas Health and Human Services Commission (HHSC) has force transferred a negative A status claim to prevent it from counting against new provider billing.
  • S (Suspended): Claim processing has been suspended, usually because of a provider hold or missing service authorization for Targeted Case Management.
  • T (Transferred): Claim has service dates older than the current state fiscal year plus two fiscal years and is not processed through the standard claim payment process.
  • PT (Paid Transfer): Transferred claim has been paid.
  • PF (Paid Forced Transfer): Forced transfer claim has been paid.

Note: Claims with a D or M status will not include details and will appear blank in Resource Utilization Group (RUG) sections.

Date Fields

The following date fields are used in the Claims Data Export tool:

  • Begin Date (Column A) and End Date (Column B): These fields display the overall date range of a claim.
  • Detail Begin Date and Detail End Date: These fields display the specific line-item details of a claim.

Cost reports contain claims data based on the requested service begin date and service end date, regardless of the report’s generation date. Reports can be requested for up to one year at a time in six-month increments, and data is available for up to three years before the current date.

Filtering Claims Data

Providers can use filters to customize their report view:

  • Filter by Status: Use the Status or Current Status columns to see claims in a specific status.
  • Filter by Client: Use the Medicaid ID or Client Name fields to see information for a specific client.
  • Sort by Date: Use the drop-down menu in Column A to sort claims in ascending or descending order.
  • Remove duplicate rows: Use the EOB column to display only entries with EOB code F0238 ("This line item is approved to pay").

Exporting CSV Files to Microsoft Excel

Claims data files are provided in a comma-separated values (CSV) text file format. After you download a file, it can be exported into Microsoft Excel by using the following steps:

  1. Right click on the file.
  2. Select Open with and then click Excel.
  3. Once the file opens in Excel, use the Save As function to save it as an Excel file and select a location to save it, such as your desktop.

Additional Information

For further guidance, refer to the following resources:

For more information, contact the TMHP LTC Help Desk at 800-626-4117, option 1.