5110  TxMedCentral Naming Convention and File Maintenance

TxMedCentral is a secure Internet bulletin board that the state and managed care organizations (MCOs) use to share information. TxMedCentral uses specific naming conventions only for documents listed below. Staff must follow these conventions any time one of the following documents is filed in TxMedCentral.

Form H1700-1, Individual Service Plan — SPW (Pg 1)

The following forms may be used, if appropriate, in development of the individual service plan (ISP). Only Form H1700-1 and Form H1700-2 are posted to MCO's ISPXXX folder in TxMedCentral and should not be posted in any other folder:

• Form H1700-1, Individual Service Plan — SPW (Pg. 1) and Form H1700-2, Individual Service Plan — SPW (Pg. 2);
• Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services;
• Form H1700-A1, Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services;
• Form H1700-B, Non-HCBS STAR+PLUS Waiver Services;
• Form 8598, Non-Waiver Services; and
• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

This file would be named ##_1700_123456789_ABCD_1_2.doc.

Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization

This form is posted to the STAR+PLUS Waiver (SPW) folder and should not be posted in any other folder.

This file would be named ##_3676_123456789_ABCD_A_2.doc.

Form 2065-D, Notification of STAR+PLUS Program Services

This form is posted to the SPW folder and should not be posted in any other folder.

• Denials will be coded with a “D” (denial) immediately following the form’s sequence number. This denial file would be named ##_2065_123456789_ABCD_D_2D.doc.
• Approvals will be coded with an “A” immediately following the sequence number. This approval file would be named ##_2065_123456789_ABCD_D_2A.doc.

Form 2067, Case Information

This form is posted to the SPW folder and should not be posted in any other folder. An "M" or "S" is added to the sequence number to indicate whether the MCO or STAR+PLUS Support Unit (SPSU) posted the form.

This file would be named ##_2067_123456789_ABCD_2M.doc.

Note: When an individual transfers from the Community Based Alternatives (CBA) program to the HCBS STAR+PLUS Waiver (SPW), Form 3671-1 must be posted to TxMedCentral substituting 3671 for 1700 in the naming convention.

TxMedCentral Folders

The STAR+PLUS MCOs use the following folders for all SPW related postings. Each MCO has two folders with three-letter identifiers:

• ISP — Individual Service Plan, which contains Form H1700-1 and Form H1700-2; and
• SPW — STAR+PLUS Waiver, which contains:
• Form 2065-D, Notification of STAR+PLUS Program Services;
• Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization; and
• Form 2067, Case Information.

File Maintenance

Due to the volume of forms being posted to TxMedCentral, it is mandatory to purge older documents from time to time. The SPSU must electronically back up documents from the XXXISP and XXXSPW on a daily basis to prevent loss of form history. Documents must be easily accessible to staff whenever needed. The state requires these backup documents be maintained for five years.

5120  Maintenance Requirements for Member Information and Forms

The STAR+PLUS Support Unit (SPSU) must establish and maintain a case record for each STAR+PLUS Waiver individual. Staff must not work directly with individual files posted to TxMedCentral. TxMedCentral files must be backed up daily on a compact disc (CD) before they are accessed, organized or individual forms printed. Perform the following steps on a daily basis:

1. SPSU staff must save TxMedCentral data files to a CD each morning before beginning work. The data files should be copied to a CD before SPSU staff begin working with the TxMedCentral files. SPSU staff members must store these CDs in a secure area. The CDs provide a record of original documents received from the managed care organizations (MCOs).
2. SPSU staff must also save data to their computers so they may open, copy, organize and print the files, as appropriate, in order to complete the work.
3. Printed forms are to be placed in individual files, which are maintained by the SPSU.

The CDs must be labeled with dates and contents, and must be maintained by the SPSU. These CDs are the only permanent records of communication between SPSU and the MCO for the STAR+PLUS service area.

5130  Managed Care Data in TIERS

5130.1  County Code Issues Affecting Enrollment

The Service Authorization System (SAS) reflects the residence county as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Therefore, if the county code is incorrect in TIERS, it must be changed to ensure the correct code appears in SAS. Incorrect county records in TIERS can cause enrollment problems for individuals or applicants in STAR+PLUS service areas.

Supplemental Security Income Cases

If the individual receives Supplemental Security Income (SSI), TIERS derives the county based on the residential ZIP code provided by the Social Security Administration (SSA). Two problems could arise:

• SSA enters an incorrect ZIP code; or
• a ZIP code crosses county lines and TIERS assigns the wrong county.

Non-SSI Cases

If the individual has any TP other than 12 or 13, TIERS contains the county code entered by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Two problems could arise:

• an individual moves without notifying MEPD; or
• an MEPD specialist enters the county code incorrectly.

What to Do

1. Perform an inquiry into TIERS or the Financial Wizard in SAS and determine the TP.
2. If the TP is anything but 12 or 13 and the residence county is incorrect, refer the matter to the MEPD specialist to correct the residence county field.
3. If the TP is 12 or 13:
   • Determine the residence ZIP code recorded in TIERS.
   • If the residence ZIP code is not correct, the individual must report the correct ZIP code to SSA.
4. If the residence ZIP code in TIERS is correct but the county is incorrect, use Form H1270, Data Integrity SAVERR Notification, to send the following information to the Data Integrity Unit:
   • individual's name as recorded in TIERS;
   • individual's number;
   • residence ZIP code; and
   • residence county as it should be reflected in TIERS.

The Data Integrity Unit can force correct the problem in TIERS. The correction will take place during the next TIERS cutoff process, usually around the 20th day of the month. SAS should reflect the corrected county during the first TIERS-to-SAS reconciliation that occurs after TIERS cutoff, usually the day after cutoff.

5130.2  Service Interruptions Resulting from County Code Mismatches in TIERS

Because participation in managed care programs is based on an individual's residence county code as recorded in the Texas Integrated Eligibility Redesign System (TIERS), service interruptions can occur when TIERS records show the wrong residence county code. This affects Community Based Alternatives (CBA) cases because providers cannot deliver services to an individual whose TIERS record indicates he lives in a managed care service area.

The Service Authorization System (SAS) reflects the residence county as recorded in TIERS and is updated through monthly interfaces. Therefore, incorrect county code data in SAS must be corrected in TIERS. The manner in which this correction occurs depends on the individual's Type Program (TP). If a residential county code is incorrect and the individual receives services under:

• TP 12/13 in TIERS, the individual or his/her authorized representative must call the Social Security Administration (SSA) to request a correction.
  
  The Data Integrity Unit can correct problems in TIERS that result from ZIP codes that cross county lines. In these situations, SSA assigns a default county code in the computer program matrix, which is transferred to TIERS data files.
  
  Results of correction requests using Form H1270, Data Integrity SAVERR Notification, take place during the next TIERS cutoff, usually around the 20th day of the month. SAS will reflect the corrected county during the first TIERS-to-SAS reconciliation that occurs after TIERS cutoff, usually the day after cutoff.
  
  Describe the needed change in the "Other Corrections" section of Form H1270 and email the form and following information to the Data Integrity Unit at di_managedcare@hhsc.state.tx.us:
  • individual's name;
  • Medicaid number; and
  • correct ZIP code and residence county as it should be reflected in TIERS.
• TP 03/BP 13, TP 14/BP 13 (CBA only), contact the Medicaid for the Elderly and People with Disabilities (MEPD) specialist assigned to the case and request a correction.
• TP 03, TA 10 (CBA only), TP 18, TP 19, TP 21, TP 50, TP 87 or TA 88 in TIERS, contact the MEPD specialist assigned to the case and request a correction.
• Supplemental Nutrition Assistance Program (SNAP) recipient, contact the Texas Works advisor assigned to the case and request a correction.

5131  Identifying Managed Care Members in TIERS

The Individual-Summary screen in the Texas Integrated Eligibility Redesign System (TIERS) contains a managed care segment for any individual who is currently or has been enrolled in managed care. From the Individual-Search window, enter the individual's information and select Search. The individual's managed care status is shown on this window in the managed care section of the Individual-Summary screen.

Specific managed care information is located under Individual Managed Care History. The data elements across the bottom of the screen are: Provider – Plan – Program – County – Begin Date – End Date – Status – Eligibility – Candidature.

These fields contain the following information:

Provider — Contains the name of the provider contracted by the managed care organization (MCO) to deliver services to members.

Plan — Contains the name of the MCO providing Medicaid services to the member.

County — Individual's county of residence.

Program — For managed care members, "STARPLUS" will appear in this field.

Begin Date — Date enrollment began under this plan.

End Date — Date enrollment ended under this plan.

Status — Describes the type of action.

Eligibility — Choices are "candidate" (applicant), "enrolled" (active) and "suspended" (closed).

Candidature — Describes the individual's status.

5132  When a Member is Placed on Administrative Hold

STAR+PLUS Support Unit (SPSU), Managed Care Operations and managed care organization (MCO) staff encounter individuals whose Texas Integrated Eligibility Redesign System (TIERS) records indicate that they have been placed on administrative hold. When that happens, the SPSU must take the appropriate steps to resolve the problem. Once resolved, as indicated below, the SPSU must notify Managed Care Operations via the Health Plan Operations (HPO) mailbox.

Once a hold is placed on the case, the individual is disenrolled from the STAR+PLUS program at the end of that month. Although the individual cannot receive services while on hold, services are automatically reinstated once the hold is lifted.

Most holds can be resolved within the month, avoiding a break in Medicaid coverage. However, this does create a gap in managed care enrollment. SPSU staff must notify Managed Care Operations via the HPO mailbox to re-enroll the individual for the gap period once Medicaid eligibility is resolved.

Some hold cases result in loss of Medicaid or the hold period is extended over many months. When this happens, the individual must be referred back through the DADS intake and application process to determine if there are any services for which the individual is eligible. If DADS services are authorized and registered in SAS, the SPSU closes any existing SPW service authorizations effective the day of managed care disenrollment. The SPSU must monitor re-enrollment with the MCO and close any existing DADS service authorizations in SAS effective the day before the managed care enrollment date.

Note: If DADS services are not authorized and registered in SAS, no actions are necessary regarding the SPW service authorization.

5210  Managed Care Data in SAS

STAR+PLUS Waiver (SPW) services are authorized by the managed care organization and registered by STAR+PLUS Support Unit staff in the Service Authorization System (SAS) based on the following:

• Service Code 12: Use this service code when registering initial service authorizations or annual re-determination service authorizations received up to 90 days prior to the end date of the current individual service plan (ISP).
• Service Code 13: Use this service code if an ISP is received after the end date of the most recent ISP. Register one service authorization using Service Code 13 effective the day after the end date of the most recent ISP and with an end date that is the end of the month in which the new ISP was received. Register a second service authorization using Service Code 12 with an effective date one day after the Service Code 13 service authorization ends and an end date of one year minus a day from the effective date of the ISP.

Example: A reassessment ISP is received on June 5, 2010, for an ISP that ended May 31, 2010. To register this reassessment, register one service authorization record using "Service Code 13 — Nursing" with a begin date of June 1, 2010, and an end date of June 30, 2010. Then, register a second service authorization record using "Service Code 12 — Case Management" with a begin date of July 1, 2010, and an end date of May 31, 2011.

5220  Closing Institutional Service Records in SAS

For individuals being discharged from a nursing facility who are to begin receiving STAR+PLUS Waiver (SPW) services and still have active Category 1 services open in the Service Authorization System (SAS), Provider Claims Services has established a hotline to assist STAR+PLUS Support Unit (SPSU) coordinators in closing the nursing facility authorization. The hotline is 512-438-2200. Select Option 1 when prompted to do so.

SPSU coordinators should call the hotline directly to request the nursing facility record in SAS be closed so non-institutional services can be authorized. Staff must confirm the member has been discharged from the facility and community services are negotiated to begin on or after the date of discharge.

When calling the hotline, the SPSU coordinator must identify himself/herself as a Department of Aging and Disability Services (DADS) employee and report the member has been discharged from the nursing facility, providing the discharge date. The Provider Claims Services representative will close all Group 1 service authorizations and enrollment records in SAS, including the Service Code 60 record. This procedure applies whether or not the individual is leaving the facility using the Money Follows the Person option.

5230  MFPD Entitlement Tracking and SAS Data Entry

Time spent in a nursing facility does not count toward the 365-day period; therefore, tracking is required to ensure Money Follows the Person Demonstration (MFPD) individuals receive the full 365-day entitlement period. The entitlement period begins the date the individual who agrees to participate in the demonstration is enrolled in STAR+PLUS Waiver (SPW). The tables below are intended to assist STAR+PLUS Support Unit Staff (SPSU) in making accurate entries in the Service Authorization System (SAS).

Example 1 — No institutionalization during the 365-day period

Example 2 — Institutionalization during the 365-day period

Example 3 — Institutionalization during the 365-day period

Example 4 — Institutionalization in NF during MFPD period

(The difference between Example 2 and Example 4 is that for NF stays, the SPSU has to correct SPW/NF overlaps.)

5320  Checking for Form 3618 or Form 3619 in the Long Term Care Portal

STAR+PLUS Support Unit (SPSU) staff are required to access the Texas Medicaid & Healthcare Partnership (TMHP) portal on behalf of the managed care organization (MCO) to verify the following forms have been submitted to TMHP when information has not transmitted to the Service Authorization System (SAS):

• Form 3618, Resident Transaction Notice
• Form 3619, Medicare/Skilled Nursing Facility Patient Transaction Notice

This is only required for cases in which the member has been in the nursing facility (NF) more than four months without automatic disenrollment occurring. SPSU is not responsible to know when these records should be checked; SPSU will be notified by the MCO. Because of Health Insurance Portability and Accountability Act regulations, MCOs are not allowed access to the information in the TMHP system.

Background

When members are admitted to or discharged from an NF, the NF transmits Form 3618/Form 3619 to TMHP via the Long Term Care portal. TMHP interfaces with SAS to import these forms. When functioning normally, this procedure allows the automatic NF counter process to calculate the date on which disenrollment from managed care should occur.

When that process does not function normally, the MCO becomes aware a member who has been in the NF more than four months is still enrolled in managed care. The MCO then contacts SPSU to determine if Form 3618/Form 3619 information appears in the member's SAS record. If the information is not in SAS, SPSU staff must access the TMHP Long Term Care Portal to verify if Form 3618/Form 3619 are in the TMHP system but have not transmitted to SAS. SPSU notifies the MCO of its findings within two business days.