Texas Children’s Health Plan Provider Manual STAR/Medicaid Children’s Health Insurance Program (CHIP) Austin Hardin Matagorda San Jacinto Austin Hardin Matagorda San Jacinto Brazoria Harris Montgomery Tyler Brazoria Harris Montgomery Tyler Chambers Jasper Newton Walker Chambers Jasper Newton Walker Fort Bend Jefferson Orange Waller Fort Bend Jefferson Orange Waller Galveston Liberty Polk Wharton Galveston Liberty Polk Wharton ND-0113-074 03-2015 Texas Children’s Health Plan Provider and Care Coordination | 832-828-1008 | TexasChildrensHealthPlan.org Table of Contents I. QUICK REFERENCE PHONE LIST ................................................. 10 Texas Children’s Health Plan Phone Numbers ..............................................................................10 Telephone Numbers for Other Organizations ............................................................................... 11 II. INTRODUCTION ...............................................................................12 Texas Children’s Health Plan Overview ........................................................................................12 Products .......................................................................................................................................12 Using the Provider Manual ...........................................................................................................12 Health Insurance Portability and Accountability Act of 1996 .......................................................13 Standards for Medical Records .....................................................................................................14 Role of a Primary Care Provider (Medical Home) ........................................................................16 Primary Care Provider Responsibilities ......................................................................................... 17 Role of a Specialty Care Provider ..................................................................................................19 Network Limitations ....................................................................................................................19 Role of Pharmacy .........................................................................................................................20 Role of Main Dental Home ..........................................................................................................20 III. BEHAVIORAL HEALTH ..................................................................... 21 Definition of Behavioral Health ................................................................................................... 21 Primary Care Provider Requirements for Behavioral Health ......................................................... 21 Behavioral Health Services ...........................................................................................................22 Substance Use Disorder Treatment Benefits ..................................................................................24 Coordination Between Behavioral Health and Physical Health Services .......................................25 Behavioral Health Focus Studies and Utilization Management Reporting ....................................26 IV. QUALITY MANAGEMENT ................................................................ 27 Quality Improvement Program Overview ..................................................................................... 27 Clinical Practice Guidelines .......................................................................................................... 27 Quality Improvement Projects ......................................................................................................28 V. BILLING AND CLAIMS ......................................................................29 Claims Submission .......................................................................................................................29 Monthly Capitation Services ........................................................................................................30 Emergency Services Claims .......................................................................................................... 31 Time Limit for Submission of Claims...........................................................................................32 Clean Claims Payment .................................................................................................................32 Out-of-Network Provider Payments .............................................................................................32 Claims Filing ................................................................................................................................33 Claims Questions/Status ..............................................................................................................33 Claims Appeals .............................................................................................................................33 Texas Children’s Health Plan Provider and Care Coordination | 832-828-1008 2 VI. HELPFUL FORMS ...............................................................................34 Sample Form UB-04 ....................................................................................................................34 Sample Form HCFA 1500 ...........................................................................................................35 Claim Appeal/Resubmission Form ...............................................................................................36 Prior Authorization Request Form ................................................................................................ 37 Case Management Referral Form .................................................................................................38 Primary Care by Specialist Request Form .....................................................................................39 TB-400A ......................................................................................................................................40 TB-400B ...................................................................................................................................... 41 Asthma Action Plan .....................................................................................................................42 Texas Vaccines for Children Program: Provider Enrollment Form ................................................44 Physician Request for Member Education .................................................................................... 47 Physician Request for Removal of Member from Panel .................................................................48 CRAFFT Screening Test ...............................................................................................................49 Behavorial Health Authorization Form .........................................................................................50 VII. PHARMACY PROVIDER RESPONSIBILITIES ................................. 51 Pharmacy Billing and Claims ....................................................................................................... 51 Compounded Prescriptions .......................................................................................................... 51 How to Find A List of Covered Drugs ..........................................................................................52 How to Find A List of Preferred Drugs .........................................................................................52 Process for Requesting a Prior Authorization ................................................................................52 VIII. STAR PROGRAM AND OBJECTIVES ...............................................55 IX. STAR COVERED SERVICES ..............................................................56 General Description .....................................................................................................................56 Added Benefits for STAR Members .............................................................................................. 57 Family Planning Services ..............................................................................................................58 X. STAR VALUE ADDED SERVICES ......................................................59 XI. TEXAS HEALTH STEPS SERVICES .................................................. 60 Texas Health Steps Program .........................................................................................................60 Texas Health Steps Complete Medical Checkup ...........................................................................65 Texas Health Steps Newborn Services ...........................................................................................66 Medical Record Documentation of Texas Health Steps Exams......................................................66 Comprehensive Care Program Services .........................................................................................66 Texas Health Steps Dental ............................................................................................................ 67 Oral Evaluation and Fluoride Varnish .......................................................................................... 67 Texas Health Steps Vision ............................................................................................................