2005-12 Panel Report Cover Letter

(DO NOT CHANGE THIS AREA)

Provider Full Name Address 1 Address 2 City, State Zip

Important Information for PCCM Primary Care Providers: December 2005

Conference Call in December The Texas Medicaid & Healthcare Partnership (TMHP) has scheduled a conference call to address Primary Care Case Management (PCCM) questions and concerns. All PCCM primary care providers, specialists, and hospitals are invited to participate.

Date: Tuesday, December 6, 2005 Time: 12 p.m. – 1 p.m., Central Standard Time Participant Call In Number: 1-800-377-4562

To obtain additional information, go to www.tmhp.com and click on the link “PCCM Conference Calls.” Mental Health and Counseling Services for Adults Effective December 1, 2005, Medicaid clients age 21 years and older can receive mental health and counseling services provided by a licensed psychologist, licensed professional counselor, licensed clinical social worker, or a licensed marriage and family therapist. Clients are limited to thirty (30) sessions per calendar year regardless of provider. More than thirty (30) sessions require prior authorization, which can be requested by faxing a completed Request for Extended Outpatient Psychotherapy/Counseling form to TMHP/Special Medical Prior Authorization at 1-512-514-4213. The form is located on page D-72 of the 2005 Texas Medicaid Provider and Procedures Manual

For additional information, refer to the November/December 2005 Texas Medicaid Bulletin #191, page 19 or call the TMHP Contact Center at 1-800-926-9126. Protecting Pediatric Patients from the Flu Vaccination with inactivated influenza vaccine is recommended for children who are at increased risk for complications from influenza. Children enrolled in Medicaid must be immunized according to the Recommended Childhood Immunization Schedule for the United States, and vaccines should be administered during the Texas Health Steps (THSteps) medical checkup, unless medically contraindicated or excluded from immunization for reasons of conscience, including a religious belief. Information about what constitutes an increased risk may be found in the November/December 2005 Texas Medicaid Bulletin #191, page 13.

Children may receive this immunization from their primary care provider if that provider is also a THSteps provider, or the client may receive this service from any THSteps provider without a referral from their primary care provider. The influenza vaccine is available free of charge to THSteps medical providers and other qualified Medicaid providers who are enrolled in the Department of State Health Services (DSHS) Texas Vaccines For Children (TVFC) program. Providers can obtain enrollment forms for TVFC through local and regional health departments. Additional information about the TVFC program can be found at http://www.dshs.state.tx.us/immunize/tvfc/ or call 1-800-252-9152 and press “0” to be connected with a representative for a specific geographic area. PCCM Provider and Hospital List The Primary Care Case Management (PCCM) Primary Care Provider and Hospital List is published quarterly. The December 2005 issue is the last publication for calendar year 2005. The next updated PCCM Primary Care Provider and Hospital List will be available in March 2006. Printed copies of the publication are sent only to new PCCM clients. Providers and clients can access the most recent publication on the TMHP website at www.tmhp.com.

The list consists of all primary care providers, specialists, and hospitals enrolled in PCCM as of the publication deadline. Information for multi-specialty clinics, rural health clinics, and federally qualified health centers will appear under family practice, internal medicine, pediatrics, and OB/GYN headings in the December 2005 Primary Care Provider and Hospital List. Please note that group providers will be listed in all specialties unless otherwise requested. For example, if a federally qualified health center offers family practice, OB/GYN, and pediatrics services but not internal medicine, it must request to be omitted from the internal medicine category. Transition Period Ended November 30, 2005 For dates of service September 1, 2005, through November 30, 2005, clients enrolled in Primary Care Case Management (PCCM) could receive services from a provider other than the primary care provider listed on their Medicaid Identification Form (form H3087 or 3087). During this transition period, services received by the client did not require a referral from the primary care provider listed on their form H3087 or 3087.

Beginning December 1, 2005, clients must receive medical services from the primary care provider listed on their form H3087 or 3087. The client’s listed primary care provider must also approve referrals to specialists. For services that require a primary care provider referral, specialists must include the primary care provider’s assigned Texas Provider Identifier (TPI) as the referring provider in the appropriate field of the claims submission form. Providers must continue to verify client eligibility before treatment and all prior authorization policies remain in effect.

For additional information, call the PCCM Provider Helpline at 1-888-834-7226 or visit the TMHP website at www.tmhp.com/Providers. Prior Authorization – Changes for the Better The Primary Care Case Management (PCCM) Prior Authorization process has changed to streamline the utilization management process for providers. Concurrent review is no longer required, and many inpatient services only require notification prior to claim submission. The changes are described in detail in the June 2005 PCCM Special Bulletin No. 188 and the July/August 2005 Texas Medicaid Bulletin No. 189. The new PCCM Inpatient/Outpatient Authorization form for faxed requests is also included in the June 2005 PCCM Special Bulletin No. 188 on page 16.

Providers may continue to submit requests by telephone Monday through Friday, 7 a.m. – 7 p.m., Central Standard Time. Providers may also continue to utilize the VoiceCert system by calling 1-888-302-6167, Option #1 for the PCCM Inpatient Prior Authorization Department, and Option #2 for the PCCM Outpatient Prior Authorization Department. Requests may also be faxed to 1-512-302-5039.