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TDHconnect WorkshopsTMHP will be conducting TDHconnect 3.0 provider workshops for LTC providers. For more information, see page 4

www.tmhp.comTexas Medicaid & Healthcare Partnership, a state Medicaid contractor

New Provider ResourcesNew resources for LTC providers. SeeResource section beginning on page 4.

LTC Bulletin No. 17

Twelve-Month Claims Submittal .............................................. 2DHS ....................................................................................................2TDMHMR ............................................................................................2

Frequently Accessed LTC Websites ........................................ 2

LTC Call Center and Help Desk ............................................... 2

LTC Claim Form 1290 ............................................................... 3

PASARR Medical Necessity Determinations ........................... 3

Reminders ................................................................................. 4

TMHP TDHconnect Workshops for LTC Providers ................. 4

Resources for LTC Questions ................................................. 4DHS LTC .............................................................................................4DHS – Provider Claims Services ........................................................5General Table – All Providers .............................................................6TDMHMR/ICF–MR ..............................................................................6TMHP ..................................................................................................7Your TMHP Provider Relations Representatives by Territory .............8

Glossary .................................................................................... 9

Forms ...................................................................................... 19Long Term Care Claim Form 1290 Example ....................................19

February 2004, No. 17

Twelve-Month Claims Submittal

DHS

A provider is not entitled to payment if a claim is submitted more than 12 months from the end of the service month. Claims are denied with the Explanation of Benefit (EOB) F0250, “Late billing, claim must be filed 12 months from the end of the month of service or 12 months from the end of the eligibility add date.” Information on the same subject can be found at the following websites:• For Community Care providers:

www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccadletters.html under Community Care Information Letters

• For nursing facilities and therapy providers: www.dhs.state.tx.us/providers/ltc-policy/index.html under Communications ■

TDMHMR

The Code of Federal Regulations (CFR), Title 42, 447.45(d)(1) states that a Medicaid agency must require providers to submit claims no later than 12 months from the date of service. Since January 6, 2003, the Texas Department of Mental Health and Mental Retardation (TDMHMR) has requested provider agencies to submit claims for services to TDMHMR within this time frame. Although the rules were effective January 5, 2003, they were not applied to claims until after January 5, 2004. An information letter and a copy of the CFR were sent to TDMHMR providers. ■

Frequently Accessed LTC Websites• Texas Medicaid & Healthcare Partnership

(TMHP) website: LTC has a page on the TMHP website at www.tmhp.com/LTC%20Programs/default.aspx. Refer to this web page for helpful information about the LTC Program.

• Department of Human Services (DHS) websites: To access LTC letters, Community Care Providers: www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccadletters.html under Community Care Information Letters.Nursing Facilities and Therapy providers:www.dhs.state.tx.us/providers/ltc-policy/index.html under Communications.To access LTC Bill Code Crosswalk: www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html.

• MHMR website: www.mhmr.state.tx.us. ■

LTC Call Center and Help Desk Long Term Care and Nursing Facility calls have been combined into one queue within the LTC Call Center.

The Long Term Care Call Center operates Monday through Friday, 7 a.m. to 7 p.m. CST (excluding holidays). When contacting the LTC Call Center, provid-ers will be prompted to enter their nine-digit LTC provider/contract number using a telephone keypad.When calling about CARE Forms 3618, 3619, and 3652, providers will need to have their four-digit vendor/site ID number available. When inquiring about a specific client, providers must have the client number avail-able.

When a provider calls, the LTC Call Center system automatically populates the representa-tive’s screen with that provider’s specific information, such as name and telephone num-ber. LTC call center representatives can instantly view a provider’s contact history, complete with prior communication dates, dis-cussion topics, and any notes made by other representatives the provider has spoken to pre-viously. These enhancements will enable the representative to research and respond to inquiries more quickly.

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Providers should call the following telephone numbers to reach a representative:• Long Term Care: 800-626-4117

• Long Term Care Austin local number:512-335-4729

• CARE Form System, forms 3618, 3619, 3652, and MDS: 800-727-5436

LTC Claim Form 1290Providers should use LTC Claim Form 1290 when billing paper claims. A copy of the LTC claim form 1290 can be found on page 19. Be sure to correctly enter the nine-digit provider number in box 1 of Claim Form 1290.

Send paper claims to the following address:Texas Medicaid & Healthcare PartnershipAttention: Long Term CarePO Box 200105Austin, TX 78727-0105

Note: Delivery to TMHP could take three to five business days. Allow seven business days for the claim to appear in the system. Always have your provider number available when calling the LTC Call Center/Help Desk.

Send overnight mail to:Texas Medicaid & Healthcare PartnershipAttention: Long Term Care, B0212357-B Riata Trace ParkwayAustin, TX 78727.

Note: To avoid processing delays when sending overnight mail, make sure to include “Attention: Long Term Care, B02.” Delivery to TMHP could take an additional day, depending on the time of day mailed. Allow two to three days for the claim to appear in the system. Have your overnight mail tracking number available when calling to check status. ■

PASARR Medical Necessity DeterminationsA purpose code 2 (PC-2) with a Y (YES) in Field 34 should not be submitted to TMHP, until the Pre-Admissions Screening and Resi-dent Review (PASARR) nurse has approved medical necessity. Failure to do so may result in the payment being recouped.If a PASARR nurse has approved medical necessity, enter the PASARR nurse’s name and date of approval in the comment section when submitting the PC-2 to TMHP. A PC-2 without a Y in Field 34 without a PASARR nurse’s name and date of approval in comment section will be placed in a pending denial status.Refer to the CARE form instructions listed on the DHS website at www.dhs.state.tx.us/handbooks/instr/3000/F3652-A/ for more detailed information. ■

Option Description

1 LTC claims and CARE forms general inquiry

2 Speak to a nurse

3 Technical support

4 Headlines and topics for paper submitters

5 Request fair hearing

6 Replay option list ■

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Reminders • Download your electronic Remittance & Status (R&S) report weekly. R&S reports are only

available for 30 days. When requesting a report, use dates from Friday to the following Monday.

• Create a financial summary when you create an R&S report.

• Download banner pages weekly from the TMHP website: www.tmhp.com. Select the Find Publications link and then select the Banner Messages folder. Within the Banner Messages folder, you can select the banner message for the LTC Program.The banners contain important, helpful information. Contact the LTC Call Center/Help Desk at 800-626-4117, if you have questions.

• Request a MESAV inquiry before contacting the TMHP LTC Call Center/Help Desk to obtain client information if TMHP rejects your claim. ■

TMHP TDHconnect Workshops for LTC ProvidersTMHP will conduct TDHconnect 3.0 workshops in select cities every quarter during 2004. These workshops are designed to educate LTC providers on claim submission, MESAV inquiries, claims status inquires, Electronic Remittance and Status (ER&S) report, and much more.

Invitations will be mailed to all LTC providers 30 days before the beginning of each quarter’s workshop series. Additionally, workshop information will be posted on the TMHP website at www.tmhp.com. Providers may enroll online to attend the workshops. ■

Resources for LTC Questions

DHS LTC

For questions about Community Care, including Community Care for the Aged and Disabled Pro-gram (CCAD), Community-Based Alternatives (CBA), Community Living Assistance and Sup-port Services (CLASS), Deaf and Blind, Consolidated Waiver, Hospice, and Medically Dependent Children Program (MDCP), refer to the resources in the following table:

If you have questions about… Then contact…

Client service authorizationClient not registeredMissing/wrong service datesForm 2060 scores, priority levelsService group/codeWrong copayment amountMissing/wrong client information

Caseworker/Case Manager

CARE Form 3652Medical necessityTILEDiagnosis

DHS Provider Claims Services Help Desk512-490-4666 telephone512-490-4668 faxhttp://ausmis31.dhs.state.tx.us/cmsmail

Policy questions/SAVERR/client eligibilityApplied income changesClient financial eligibility issuesClient name changes

DHS Provider Claims Services Help Desk512-490-4666 telephone512-490-4668 fax http://ausmis31.dhs.state.tx.us/cmsmail

Client-specific policies/proceduresFinancial/functional eligibility criteriaHow to read/understand Form 2101 or Form 3671

Caseworker/Case Manager

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DHS – Provider Claims Services

For questions about Nursing Facilities, Swing Beds, or Rehabilitation Specialized Services, refer to the resources in the following table:

ContractingProgram policies/procedures/rulesEnrollment proceduresClients not registered to contractMissing/wrong budget/ratesContract numbersMissing/wrong service contract informationProvider-on-hold questions

Contract Manager

ME, CCAD, CBA worker/regional nurse issues not resolved at local/regional level

DHS Provider Claims Services Help Deskhttp://ausmis31.dhs.state.tx.us/cmsmail

Obtaining a copy of LTC Claim Form 1290 www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccadletters.html under Community Care Information Letters or Contract Manager

The CLASS program 877-438-5658 (toll-free)

The DBMP program 512-438-2622

The MDCP 877-438-5658 (toll-free)

Status of claim after it has been transmitted to Fiscal by TMHP (When calling Fiscal, provide the DLN number assigned by TMHP)

The Comptroller’s website:www.window.state.tx.usor DHS Fiscal Office at 512-438-3996 or the Contract Manager ■

If you have questions about… Then contact…

Client service authorizationService datesUnits of service approvedService group/service code

DHS Provider Claims Services Help Desk512-490-4666 telephone512-490-4668 faxhttp://ausmis31.dhs.state.tx.us/cmsmail

Level of serviceTILE changesMedical necessity

DHS Provider Claims Services Help Desk512-490-4666 telephone512-490-4668 faxhttp://ausmis31.dhs.state.tx.us/cmsmail

Provider authorization system (PAS)Provider enrollmentDeductionsMonetary penaltiesProgram enrollment staff issuesProvider-on-hold questions

DHS Provider Claims Services Help Desk512-490-4666 telephone512-490-4668 faxhttp://ausmis31.dhs.state.tx.us/cmsmail

Policy questions/SAVERR/client eligibilityApplied income changesClient financial eligibility issuesClient name changes

DHS Provider Claims Services Help Desk512-490-4666 telephone512-490-4668 faxhttp://ausmis31.dhs.state.tx.us/cmsmail

Hospice Issues DHS Provider Claims Services Help Desk512-490-4666 telephone512-490-4668 faxhttp://ausmis31.dhs.state.tx.us/cmsmail

TPR issues and/or audits 512-490-4635 telephone ■

If you have questions about… Then contact…

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General Table – All Providers

TDMHMR/ICF–MR

For questions about Texas Department of Mental Health and Mental Retardation (TDMHMR) and Intermediate Care Facility for Persons with Mental Retardation (ICF-MR), refer to the resources in the following table:

If you have questions about… Then contact…

Cost report information (days paid, services paid) Information can be obtained by submitting a batch claim status inquiry (CSI) using TDHconnect.

How to prepare a cost report (forms, instructions) www.hhsc.state.tx.us/medicaid/programs/rad/index.html or call 512-338-6468 ■

If you have questions about… Then contact…

CARE Help Desk 512-438-4720

Provider warrants 512-206-5377

Applied income Medicaid Eligibility (ME) worker for client

TPR issues 512-490-4635

Health and Human Services Commission Network (HHSCN)

512-438-4720

ICF/MR Help Desk issuesMedicaid Administration enrollment/deductions Provider vendor holdsProvider eligibilityProvider systems access formsMedicaid administration billingClaims management system billing claim form requestService authorizationClient movement Form 3618Durable Medical Equipment (DME)Medicaid administration UR/UCMR/RC assessment Form 3650LOC claim formLevel of service, LON, LOCUser documentation

512-206-5577

Cost Reports 512-491-1175

Quality Assurance Program (QAP) 512-206-5063 ■

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TMHP

For questions about TMHP, refer to the resources in the following table:

If you have questions about… Then contact…

Using TDHconnect or Claim Form 1290 Claim Form 1290 completionClaim Form 1290 required fieldsClaim adjustment questionsClaim status inquiriesClaim history questionsClaim rejection and denialsResearch batch trackingUnderstanding R&S

Long Term Care Call Center/Help Desk800-626-4117 (outside Austin)512-335-4729 (Austin)Option 1

General inquiry General inquiry about Forms 3652, 3618, 3619Status of Claim Form 3652TILE level

Long Term Care Call Center/Help Desk800-727-5436Option 1 (Customer Service)

Medical necessity Long Term Care Call Center/Help Desk800-727-5436 Option 2 (Nurses)

TDHconnect technical issuesObtain TDHconnect accessModem and telecommunication issuesANSI ASC X12 specification issuesANSI ASC X12 testing and transmissionObtain User ID and passwordsProcess provider agreementsVerify system screens are functioningAssist software developers with electronic data Interchange (EDI) and connectivity

EDI Technical Call Center/Help Desk800-626-4117 (outside Austin)512-335-4729 (Austin)Option 3

Electronic transmission of Forms 3652, 3618, and 3619Weekly status reportsCARE form software (CFS) installationProblems with transmitting forms

Long Term Care Call Center/Help Desk800-727-5436 (Technical Support)Option 3

MDS submission problemsTechnical issuesInterpreting quality indicator (QI) reports

Long Term Care Call Center/Help Desk800-727-5436 (Technical Support)Option 3

Banner messages in audio for paper submitters 800-626-4117 (outside Austin)512-335-4729 (Austin)Option 4

Client appealClient fair hearing requestAppeal/denial process and guidelines

Long Term Care Call Center/Help Desk800-727-5436Option 5 ■

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Your TMHP Provider Relations Representatives by Territory

TMHP staffs a team of provider relations representatives to serve the Texas Medicaid Program provider community. These representatives conduct educational workshops such as Success with Medicaid and TDHconnect. Contact the Provider Relations Representative assigned to your terri-tory to schedule a visit.

Territory Regional Area Training Specialist Telephone Number

1 Amarillo, Lubbock Toni Emmons 512-506-3016

2 Abilene, Midland/Odessa, San Angelo

Wanda Wesson 512-506-3423

3 El Paso Isaac Romero 512-506-3530

4 San Antonio, Eagle Pass, Kerrville

Ralph Cervantes 512-506-3422

5 Laredo, Harlingen Cynthia Gonzales 512-506-7991

6 San Antonio, Corpus Christi, Victoria

Mary Ximenez 512-506-3554

7 Houston, Galveston Ann Perkins 512-506-3447

8 Houston, Katy, Sugarland Delsie Nagy 512-506-3446

9 Houston, Spring, Conroe Alexandra Vera 512-506-3419

10 Beaumont, Nacogdoches Gene Allred 512-506-3425

11 Dallas, Tyler, Waxahachie Sandra Peterson 512-506-3552

12 Dallas, Texarkana Olga Fletcher 512-506-3578

13 Arlington, Fort Worth, Denton, Wichita Falls

Rita Martinez 512-506-7990

14 Austin, Bryan/College Station, Waco

TBD 1-800-925-9126 ■

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GlossaryThe table below is a collection of useful terms and definitions:

AAdjustment Request A change to a previously paid claim. Negative detail lines are

considered adjustments.

AFC Adult Foster Care. Services provided in a 24-hour living arrangement with supervision in an adult foster home for clients who, because of physical, mental, or emotional limitations, are unable to continue independently functioning in their own homes.

ANSI American National Standards Institute

Applied Income The portion of a client’s income that must be contributed toward the cost of Long Term Care.

ASCII American Standard Code for Information Interchange

ASCII File A file containing only letters, numbers, and symbols. An ASCII file is a text file that contains no formatting information except for line feeds and returns.

Atypical Services that are deemed non-medical in nature or those services determined by DHS/MHMR to not have an appropriate National Procedure/Revenue Code. These services will continue to use local codes.

BBanner Page An electronic message from DHS, TDMHMR, or TMHP that

contains new or updated information about the Claims Management System (CMS). You can download these pages from the TMHP EDI Gateway.

Batch One or more transactions grouped together for the purpose of electronic delivery to Claims Management System (CMS) for processing.

Billing Code The specific service that is submitted on a claim also referred to as a local code. See also Procedure Code.

Billing Cycle The period of time between submitting a claim and receiving payment.

Budget Number A two-digit number indicating the budget to bill against. The second modifier field on a paper and electronic claims are used to denote which budget is used (U1=Budget Number 1; U2=Budget Number 2). This item is needed for block grant services. Refer to your contract manager to determine if a budget number is necessary.

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CCAS Claim Adjustment and Service Adjustment segment of the R&S

report that provides reasons, amount, and quantities of any adjustment that the payer made to either the original submitted charge or the units related to the claim or service.

CBA Community-Based Alternatives. A federal waiver program that provides home and community-based services to eligible clients.

Claim A request for payment of services from a provider for a single client that consists of one or more types of services performed for the client and may span multiple months but cannot span fiscal years.

Claim Status Inquiry (CSI) A transaction (276) requesting information on the status of a claim previously submitted to Claims Management System (CMS) for processing

Claim Type A code that identifies the category a claim falls within. Claim Types: 837I, 837P, 837D, Exp, NAT, and paper.

CLASS Community Living Assistance and Support Services. A federal waiver program that provides home and community-based services to eligible clients (Service Group 2).

Client An individual determined by the Texas Department of Human Services or Texas Department of Mental Health and Mental Retardation as eligible for Long Term Care services.

Client Number The number assigned to an individual by DHS. If the client becomes eligible for Medicaid, the client number becomes their Medicaid number.

CMPAS Consumer Managed Personal Attendant Services. Financial intermediary services provided to eligible clients who supervise or have someone who can supervise their attendant. Clients are responsible for interviewing, selecting, training, supervising, and releasing their attendants.

CMS Claims Management System.

Copayment The assessed dollar amount or percentage that the client is responsible for contributing toward the cost of care. This amount is applied to the total amount billed for a service.

CPA Comptroller of Public Accounts.

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DDAHS Day Activity and Health Services. Facilities provide daytime

services to clients residing in the community. Services are designed to address clients’ physical, mental, medical, and social needs. Services include the provision of nursing and personal care, physical rehabilitation, noon meal and snacks, transportation, and social and educational and recreational activities.

DBMD Deaf–Blind with Multiple Disabilities Program. Provides home and community based services to people who are Deaf-Blind with Multiple Disabilities (DB-MD) as a cost-effective alter-native to ICF-MF/RC institutional placement.

Default A value automatically assigned or an option chosen when no value is specified by the user or assigned by a program statement.

Denied Claim A claim denied for payment.

DHS Texas Department of Human Services.

Direct Deposit An electronic transfer of funds from the state Comptroller to reimburse providers and vendors for services provided.

DLN (Claims) Document Locator Number. Unique number assigned by TMHP to identify each warrant request.

DLN (Forms) Document Locator Number. Unique number assigned by TMHP to CARE forms 3618, 3619, and 3652.

DME Durable Medical Equipment. Equipment (adaptive aids) that withstands repeated use and is primarily and customarily used for medical purposes. Equipment and appliances must be medically necessary in each case; for example, wheelchairs, walkers, canes, crutches, trapeze bars, hospital beds, and bedpans.

EEDI Electronic Data Interchange.

Edits Claim processing check points that verify field validity and compliance with LTC business rules.

Emergency Dental Services (EDS)

Emergency dental services provided to clients residing in Nursing Facilities.

EOB Explanation of Benefits. An explanation of the payment or denial of a provider’s claim. The EOB code, which appears on the provider’s R&S, also explains the status of pending claims.

ERS Emergency Response Services. Services provided through an electronic monitoring system which is used by functionally impaired adults who live alone or are socially isolated in the community.

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FFile Acknowledgment A system-generated response to a third-party software

submitter. The acknowledgment indicates the success or failure of a file transmission to the Claims Management System (CMS).

Finalized Claim A claim that has completed processing through the Claims Management System (CMS) and has a paid or denied status.

Financial Summary A section within the Remittance and Status (R&S) report that provides summary information for expedited payments, admin-istrative payments, provider total deductions, provider monthly deductions, and warrant/direct deposits.

HHCPCS Healthcare Common Procedural Coding System.

HDM Home-Delivered Meals. Nutritious meal(s) delivered to a qualified client’s home or residence.

HSP Hospice. Medical, social, and support services for terminally ill clients, with no known curative treatment options, with a prognosis of less than six months to live.

IICF/MR Intermediate Care Facility for Persons with Mental Retardation.

Institutional care and treatment for clients with mental retar-dation with an onset date before age 18. The program is admin-istered by the Texas Department of Mental Health and Mental Retardation (Service Groups 4, 5, and 6).

ICN Internal Control Number. A Claims Management System (CMS)-assigned number to uniquely identify an accepted claim.

Interactive Transaction Real time processing of a transaction taking place while the submitter remains directly or indirectly connected to the processing computer.

LLevel of Service The level of effort necessary for a provider to provide service to

a client.The level of service is a factor in determining the payment rate for services to a client. Level of service includes level of care, level of need, and priority status.

Line Item A claim line of services performed for a client within a specified time period. Several line items, each for different services and/or time periods, may appear on a claim. Also known as “detail line.”

LOC Level of care. Determines a client’s eligibility for a specific program or service.

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LLON Level of Need. The level of effort necessary for a facility to

provide service to an ICF/MR client. The level of need is a factor in determining the payment rate for services to that client.

Long Term Care (LTC) Programs provided for aged and disabled clients through DHS and TDMHMR.

LTC Bill Code Crosswalk A cross-referenced code set used to match National Standard Procedure Codes (procedure, item, and revenue codes) to the local codes (i.e., bill codes). Providers must use the information on the Bill Code Crosswalk associated with the bill code that reflects the service billed when billing for LTC services. The Bill Code Crosswalk includes codes necessary when billing for service. (i.e., revenue codes, procedure code qualifiers, and Healthcare Common Procedural Coding System [HCPCS]/item codes).

MMARS G An internal account, general ledger, purchasing, and accounts

payable system for TDMHMR.

MDCP Medically Dependent Children Program. Provides a variety of services to support families caring for children who are medically dependent and to encourage deinstitutionalization of children in nursing facilities.

Mental Retardation Local Authority (MRLA)

A program of the Texas Department of Mental Health and Mental Retardation (TDMHMR).

MESAV Medicaid Eligibility Service Authorization Verification. MESAV refers to the information given to an authorized provider when inquiring about a specific client for a specific date range. This information can include Medicaid eligibility, medical necessity, applied income/copayment, level of service, and service authorization.

Modifiers A two-digit code used to further define a service and/or assist in determining what to pay during the claims adjudication process.

NNAT Nurse Aide Training. The provision of training and competency

evaluation.

NF Nursing Facilities. Facilities licensed and Medicaid-certified by DHS where eligible clients receive nursing care, appropriate rehabilitative, and restorative services under the Title XIX (Medicaid) Long Term Care program.

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PPACE Program of All-Inclusive Care for the elderly. The provision of

community-based services to frail elderly people who qualify for nursing facility placement. Uses a comprehensive care approach, providing an array of services for a capitated monthly fee that is below the cost of comparable institutional care.

PAS Personal Assistance Services. Non-technical attendant care services provided to eligible persons functionally limited in performing activities of daily living. PAS are provided through the Primary Home Care Program.

Patient Control Number A user-defined number submitted on the claim to identify clients.NOTE: Do not confuse this number with the client/Medicaid number.

Payee Identification Number (PIN)

Also referred to as the Comptroller Vendor ID No., Comptroller Payee ID No., and Texas ID No. The 14-digit number assigned by the state Comptroller’s Office to an individual or entity so that the individual or entity can receive funds issued by the state Comptroller’s office. For Claims Management System (CMS) purposes, the preferred term is Payee Identification Number (PIN).

Pended Claim See Suspended Claim

Per Authorization Unit Type Units approved to equal the cost of the authorized service. This authorization type is associated with the unit rate of one dollar. For example, if a wheelchair costs $500.00, the dollar rate would be 500 units.

Place of Service (POS) Identifies the location (e.g., nursing facility, client’s home, assisted living/residential care facility, and dentist office) where the service (e.g., daily care, PAS, ERS, assisted living/residential care, and dental services) was provided.

Procedure A code that uniquely identifies a procedure, product or service provided to the client. Services provided are described by codes. There are several types of procedure/item codes:

• Bill Codes (local)

• Healthcare Common Procedural Coding System (HCPCS)

• Current Procedural Terminology (CPT)

• American Dental Association (ADA) codes

• Item Codes

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PProcedure Code Qualifier Describes the source of the procedure code entered on the paper

or electronic claim. There are three types of procedure code qualifiers:

• ZZ = Texas LTC local codes (usually referred to as a bill code)

• HC = HCPCS or CPT

• AD = American Dental Association codes

Provider A person, group, or agency who has a contract to provide LTC service(s) to TDHS/TDMHMR clients. Examples include licensed nursing facilities, day activity and health service facil-ities, home and community support agencies, and others.

Provider Number (Provider ID)

The contract number assigned to the Long Term Care provider/provider agency by the state of Texas. For Claims Management System (CMS) purposes, the preferred term is Provider Number.

Provider Support TMHP Call Center/Help Desk assists providers with questions about TDHconnect, the status of claims (electronic and paper), and the process to enroll in electronic claims submission. The Call Center/Help Desk answers questions on client’s Medicaid eligibility, client’s service authorization, and provider’s eligi-bility as they apply to a claim.

RR&S Remittance & Status (R&S) reports. An electronic or paper

report that informs a provider about pending, paid, denied, or adjusted claims.

Record A record is the equivalent to a row on a table. For example, a client record is one client and all information pertaining to that client.

Respite Care The provision of short-term care or supervision services for qualified clients to give their caregivers temporary relief.

RS Rehabilitative services. The program that reimburses nursing facilities or therapy providers for physical, occupational, and speech therapy to Medicaid nursing facility clients. The program requires preauthorization of services.

Rendering Provider The person providing a skilled service to a client.

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RRendering Provider Name The name of the person who provided the service to the client.

This item is required if the service (being billed) is a skilled/professional service and was provided by someone other than the provider agency. For example, dentist, therapist, or other licensed professional. This dentist, etc. is contracted by an agency to provide service. This does not apply to unskilled/nonprofessional services delivered by the provider agency (meals, attendant services, day activities, and health services).

RC Residential care services. The provision of services to eligible clients who require access to care on a 24-hour basis but do not require daily nursing intervention.

Revenue Code (Rev Code) A four-digit standard national code depicting the “revenue” center for the specific services being billed. Revenue codes are used to classify types of services. In some cases, the revenue code must be used in tandem with HCPCS.

SService Authorization An authorization for a DHS/TDMHMR client to receive a

service in a specified period of time from an authorized provider.

Service Code A code used to denote a specific service or category of service.

Service Group The Long Term Care program that provides services to an eligible client.

SS Specialized Services. Reimburses nursing facilities or therapy providers for physical, occupational, speech therapy, and rehabilitation programs provided to Medicaid NF clients identified in the Pre-Admission Screening and Resident Review (PASARR) process as having mental illness, mental retardation, or a related condition.

SSPD/SSPD-24 Special Services to Persons with Disabilities/Special Services to Persons with Disabilities – 24 hours. The provision of services to assist clients to live in the community. Services include the provision of 24-hour attendant care services, inter-preter services, and adult day care.

Suspended Claim A claim that has failed a claims processing edit and is pending further information for resolution.

Swing Beds Certified nursing facility beds located in a hospital for temporary stays of 30 days or less. The program is correctly known as Extented Care Facility (ECF).

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TTDHconnect A Microsoft Windows-based application for personal

computers to support provider claims submissions, Medicaid eligibility/service verification authorization inquiries, claim status inquiries, electronic R&S report, and adjustment request submissions.

TDMHMR Texas Department of Mental Health and Mental Retardation.

Third Party Billing Agency A company authorized by a provider agency to submit claims and perform Medicaid eligibility and service authorization verification inquiries on behalf of the agency.

Third Party Software A claims processing application developed by parties other than TMHP according to the Claims Management System (CMS) standard transaction forms.

TILE Texas Index for Level of Effort. The level of effort required by providers to provide the appropriate service(s) to a client based on an assessment of the client’s medical need. A TILE is used in the calculation of the payment rate for certain services provided to a client. There are different TILEs (values 201 through 211).

Title XIX Medicaid The provisions of Title 42, United States Code Annotated, Sections 1396-1396g, including any amendments thereto of the Social Security Act authorizing grants to states for medical assistance programs (Medicaid).

Title XVIII Medicare The Provisions of Title 42, United States Code Annotated, Sections 1395, including any amendments thereto of the Social Security Act authorizing health insurance and supplementary medical insurance for the aged and disabled (Medicare).

Title XX Federal Grant Grant benefit for provision of Social Services.

TMHP Texas Medicaid & Healthcare Partnership.

TMHP EDI Gateway The informational TMHP EDI Gateway contains and provides download capabilities for user guides and updates, ANSI ASC X12 Provider Specifications manual, banner pages, bulletins, updated reference file information such as explanation of benefits (EOB) codes, service groups, and billing codes.

Transaction The exchange of information between two parties to carry out financial or administrative activities related to health care.

1 7 LT C B ul le t inFeb rua ry 20 04, N o. 17

UUnit The authorized amount of service/units provided to the client.

The units are based on the bill code not the procedure code.

Unit Rate The dollar amount applied to each unit being billed for the particular service. The number of units multiplied by the appli-cable unit rate equals payment amount.

Unit Type For Long Term Care, the unit type denotes the class of units for a specific service. Four unit types exist: daily, weekly, monthly, and per authorization. For example, when billing for a client in a nursing facility, the unit type is daily and the maximum number of units equals the number of days in the given month.

VVendor Number/Site Number Four-digit number assigned by DHS to Nursing Facility

providers to submit CARE forms, 3652, 3618, and 3619.

WWaiver Programs Federally funded programs that allow DHS to provide a array

of supportive, community-based services that are not usually available under the Medicaid Program. The “waiving” of certain Medicaid rules and regulations allows for these innovative services.

Warrants Checks or direct deposits from the Comptroller’s Office to providers and vendors for services rendered.

Weekly Status Reports An electronic or paper report that informs a provider about pending, paid, and denied CARE forms. ■

18 Feb rua ry 20 04, N o. 17LT C B ul le t in 1 8

Forms

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1 9 LT C B ul le t inFeb rua ry 20 04, N o. 17

PRESORTED STANDARDUS POSTAGE PAID

AUSTIN TXPERMIT NO 187

ATTENTION: BUSINESS OFFICE

LTC Bulletin