The Texas Medicaid & Healthcare Partnership (TMHP) has created a new Form to help healthcare providers with the Prior Authorization process. Called the “Prior Authorization Request – TMHP”, this form can be used for all Authorizations, whether they are requests for Initial Authorization, renewal/extension, or change of service. This form is also available in both English and Spanish. The goal of this new Form is to make the Prior Authorization process simpler and more efficient for everyone involved. Healthcare providers can use it to quickly and easily submit Prior Authorization requests to TMHP. And TMHP staff will be able to use it to better track and manage authorizations.
In the list, there is some information about the tmhp. Prior to fill in the form, it can be definitely worth learning more about it.
Question | Answer |
---|---|
Form Name | Tmhp |
Form Length | 81 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 20 min 15 sec |
Other names | you mybenefitscom texas, texas renewer, tmhp provider enrollment application form, texas renewer online |
Texas Medicaid
Provider Procedures Manual
May 2021
Volumes 1 & 2
The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health and Human Services Commission.
PRELIMINARY INFORMATION
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1
MAY 2021
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 |
MAY 2021 |
PRELIMINARY INFORMATION
Table of Contents
Welcome: Texas Medicaid Provider Procedures Manual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Copyright Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Volume 1 - General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Volume 2 - Provider Handbooks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Texas Medicaid Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2
CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
PRELIMINARY INFORMATION |
MAY 2021 |
Welcome: Texas Medicaid Provider Procedures Manual
This manual is a comprehensive guide for Texas Medicaid providers. It contains information about Texas Medicaid
Referto: The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for information about the Medicaid Managed Care, which is administered by Texas Health and Human Services Commission
The Texas Medicaid Provider Procedures Manual is updated monthly on the TMHP website at www.tmhp.com to include revisions to policies and procedures that went into effect in the prior month. The manual is available in portable document format (PDF) as a complete book and as individual sections and handbooks. A hypertext markup language (HTML) version is also be available.
The current version of the manual always appears prominently on the Texas Medicaid Provider Proce- dures Manual web page. All previously published annual editions of the Texas Medicaid Provider Procedures Manual have been archived. Users can access the archives through links on the Texas Medicaid Provider Procedures Manual web page.
Providers can determine what has changed each month by following the Release Notes link on the Texas Medicaid Provider Procedures Manual web page. The release notes include the sections and handbooks that have changed for the current month and the nature of the changes. Most changes have been previ- ously announced in news articles on the TMHP website, and, where appropriate, the release notes link to prior website articles.
Publishing the manual monthly has eliminated the need for the Texas Medicaid Bulletin, which was discontinued following the publication of the September/October 2012 Texas Medicaid Bulletin, No.
243.Special bulletins, such as the annual Healthcare Common Procedure Coding System (HCPCS) bulletin, which is published in January of each year, will continue to be published on an
The Texas Medicaid Provider Procedures Manual is divided into two volumes as follows:
•Volume I: General Information
Volume 1 applies to all
•Volume 2: Provider Handbooks
Each handbook in Volume 2 covers Medicaid policies, procedures, and claims filing requirements for specific products or services. Volume 2 includes the following handbooks:
•Ambulance Services Handbook
•Behavioral Health, Rehabilitation, and Case Management Services Handbook
•Certified Respiratory Care Practitioners (CRCP) Services Handbook
•Children’s Services Handbook
•Clinics and Other Outpatient Facility Services Handbook
•Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook
•Gynecological, Obstetrics, and Family Planning Title XIX Services
•Health and Human Services Commission Family Planning Program Services Handbook
•Healthy Texas Women Program Handbook
3
CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
PRELIMINARY INFORMATION |
MAY 2021 |
•Home Health Nursing and Private Duty Nursing Services Handbook
•Inpatient and Outpatient Hospital Services Handbook
•Medicaid Managed Care Handbook
•Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
•Medical Transportation Program Handbook
•Outpatient Drug Services Handbook
•Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook
•Radiology and Laboratory Services Handbook
•Telecommunications Services Handbook
•Vision and Hearing Services Handbook
Copyright Acknowledgments
Use of the AMA’s copyrighted CPT® is allowed in this publication with the following disclosure:
“Current Procedural Terminology (CPT) is copyright © 2020 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply.”
The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes:
“Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.”
Microsoft Corporation requires the following notice in publications containing trademarked product names:
“Microsoft® and Windows® are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries.”
Contents
Volume 1 - General Information
Welcome: Texas Medicaid Provider Procedures Manual
Contents
Introduction
Section 1: Provider Enrollment and Responsibilities
Section 2: Texas Medicaid
Section 3: TMHP Electronic Data Interchange (EDI)
Section 4: Client Eligibility
Section 5:
Section 6: Claims Filing
Section 7: Appeals
4
CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
PRELIMINARY INFORMATION |
MAY 2021 |
Appendix A: State, Federal, and TMHP Contact Information
Appendix B: HIV/AIDS
Appendix C: Acronym Dictionary
Volume 2 - Provider Handbooks
Ambulance Services Handbook
Behavioral Health and Case Management Services Handbook Certified Respiratory Care Practitioner (CRCP) Services Handbook Children’s Services Handbook
Clinics and Other Outpatient Facility Services Handbook
Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook
Health and Human Services Commission Family Planning Program Services Handbook Healthy Texas Women Program Handbook
Home Health Nursing and Private Duty Nursing Services Handbook Inpatient and Outpatient Hospital Services Handbook
Medicaid Managed Care Handbook
Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook Medical Transportation Program Handbook
Outpatient Drug Services Handbook
Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook Radiology and Laboratory Services Handbook
Telecommunication Services Handbook
Vision and Hearing Services Handbook
Introduction
Texas Medicaid Administration
The Texas Medical Assistance (Medicaid) Program was implemented on September 1, 1967, under the provisions of Title XIX of the federal Social Security Act and Chapter 32 of the Texas Human Resources Code.
The state of Texas and the federal government share the cost of funding Texas Medicaid. The Health and Human Services Commission (HHSC), the single state Medicaid agency, is responsible for the Title XIX Program. The administration of the program is accomplished through contracts and agreements with the following:
•Medical providers
•Texas Medicaid & Healthcare Partnership (TMHP), the
•MAXIMUS, the enrollment broker
5
CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
PRELIMINARY INFORMATION |
MAY 2021 |
•Various managed care organizations (MCOs) and dental managed care organization (dental plans), that administer Medicaid Managed Care benefits.
•The Institute for Child Health Policy (ICHP), the quality monitor
•State agencies
Texas Medicaid providers are reimbursed for services through contracts with
By signing an HHSC Medicaid Provider Agreement (through the enrollment process) and submitting Medicaid claims, each enrolled provider agrees to abide by the policies and procedures of Medicaid, published regulations, and the information and instructions in manuals, bulletins, and other instruc- tional material furnished to the provider.
Referto: “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Infor- mation) for addresses and telephone numbers of HHSC and Department of State Health Services (DSHS) regional offices.
6
CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
SECTION 1: PROVIDER ENROLLMENT AND RESPONSIBILITIES
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1
MAY 2021
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 |
MAY 2021 |
SECTION 1: PROVIDER ENROLLMENT AND
RESPONSIBILITIES
Table of Contents
1.1 |
Provider Enrollment |
. 5 |
||
|
1.1.1 |
Provider Enrollment Revalidation Requirements |
. 6 |
|
|
1.1.2 |
NPI and Taxonomy Codes |
. 6 |
|
|
1.1.3 |
Online Enrollment |
. 7 |
|
|
1.1.4 |
Paper Application Enrollment |
. 8 |
|
|
1.1.5 |
Provider Enrollment Identification |
. 8 |
|
|
1.1.5.1 |
Ordering- or |
10 |
1.1.5.2Ordering or
1.1.5.3 Interns and Medical Residents Who Order, Prescribe, or Refer . . . . . . . . . . . . . . 11
1.1.6 Affordable Care Act of 2010 (ACA) Enrollment Requirements. . . . . . . . . . . . . . . . . . . . . . 11
1.1.6.1 Provider Screening Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.1.6.2 Provider Revalidation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.1.6.3 Application Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.1.6.4Ordering- or
Lookup (OPL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.1.7 Surety Bond Enrollment Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.1.7.1 Ambulance Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.1.8 Provider Enrollment Application Determinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.1.9 Enrollment in Medicaid Managed Care Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.1.10 Required Enrollment Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.1.10.1 Application Payment Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.1.10.2 HHSC Medicaid Provider Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.1.10.3 Provider Information Form
1.1.10.4 Principal Information Form
1.1.10.5 Disclosure of Ownership and Control Interest Statement . . . . . . . . . . . . . . . . . . . 17
1.1.10.6 Internal Revenue Service (IRS)
1.1.10.7 Medicaid Audit Information Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.1.10.8 Corporate Board of Directors Resolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.1.10.9 Franchise Tax Account Status Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.1.10.10Certificate of Formation or Certificate of Filing/Articles or Certificate of
Incorporation/Certificate of Fact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.1.10.11 Copy of License, Temporary License, or Certification . . . . . . . . . . . . . . . . . . . . . . . 18 1.1.10.12 Federally Qualified Health Center Affiliation Affidavit . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.13 Physician’s Letter of Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.14 Licensure Renewal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.15 Medicare Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.1.10.16 Group Information Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.2 Payment Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
1.2.1 Using EFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.2.2 Advantages of EFT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.2.3 EFT Enrollment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2
CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
SECTION 1: PROVIDER ENROLLMENT AND RESPONSIBILITIES |
MAY 2021 |
1.2.4 Receiving Paper Checks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.2.5
1.3 |
Provider Deactivation/Disenrollment |
22 |
||
|
1.3.1 |
Excluded Entities and Providers |
22 |
|
1.4 |
Provider Reenrollment |
23 |
||
|
1.4.1 |
Medicare Number |
23 |
|
|
1.4.2 |
Provider Status (Individual, Group, Performing Provider, or Facility) |
23 |
|
|
1.4.3 |
Physical Address |
23 |
|
|
1.4.4 |
Change in Principal Information |
24 |
|
1.5 |
Change of Ownership Requirements |
24 |
||
1.6 |
Claims Filing During Enrollment |
25 |
||
1.7 |
Provider Responsibilities |
25 |
||
|
1.7.1 |
Compliance with Texas Family Code |
25 |
|
|
1.7.1.1 |
Child Support |
25 |
|
|
1.7.1.2 |
Reporting Child Abuse or Neglect |
25 |
|
|
1.7.1.3 |
Procedures for Reporting Abuse or Neglect |
26 |
|
|
1.7.1.4 |
Procedures for Reporting Suspected Sexual Abuse |
26 |
|
|
1.7.1.5 |
Training |
27 |
|
|
1.7.1.6 |
Reporting Abuse and Neglect of the Elderly or Disabled |
27 |
|
|
1.7.1.7 |
Procedures for Reporting Abuse or Neglect of the Elderly or Disabled |
28 |
|
|
1.7.2 |
Maintenance of Provider Information |
28 |
|
|
1.7.2.1 |
Contracted Provider Groups |
29 |
|
|
1.7.2.2 |
NPI Verification |
29 |
|
|
1.7.2.3 |
Online Provider Lookup (OPL) |
29 |
|
|
1.7.2.4 |
Updating NPI and Taxonomy Codes |
31 |
|
|
1.7.2.5 |
Updating Provider Specialty |
31 |
|
|
1.7.3 |
Retention of Records and Access to Records and Premises |
31 |
|
|
1.7.3.1 |
Payment Error Rate Measurement (PERM) Process |
33 |
|
|
1.7.4 |
Medicare Overpayment |
33 |
|
|
1.7.5 |
Credit Balance and Recovery Vendor |
34 |
|
|
1.7.6 |
Release of Confidential Information |
34 |
|
|
1.7.7 |
Compliance with Federal Legislation |
34 |
|
|
1.7.8 |
35 |
||
|
1.7.9 |
Utilization Control — General Provisions |
35 |
|
|
1.7.10 |
Provider Certification/Assignment |
36 |
|
|
1.7.10.1 |
Delegation of Signature Authority |
37 |
|
|
1.7.11 |
Billing Clients |
37 |
|
|
1.7.11.1 |
Client Acknowledgment Statement |
39 |
|
|
1.7.12 |
General Medical Record Documentation Requirements |
40 |
|
|
1.7.13 |
Informing Pregnant Clients About CHIP Benefits |
41 |
|
|
1.7.14 |
Home Health Providers |
42 |
1.7.14.1Home Health Skilled Nursing and Home Health Aide (HHA) Services
Provider Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.7.15 Private Duty Nursing (PDN) Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.7.16 Certified Respiratory Care Practitioner (CRCP) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 1.7.17 Physical, Occupational, and Speech Therapy Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
1.7.17.1 CCP Enrollment for Children’s
1.8 Electronic Health Record Incentive/Promoting Interoperability Program . . . . . . . . . . .45
1.8.1Attesting to Meaningful
3
CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.