Texas Department of Aging and Disability Services

Claims Management System

Advisory Council Meeting

May 13, 2009

Welcome/Introductions– Maria Garcia Montoya, Chair, DADS Claims Support

General Updates & Announcements –Maria Montoya, DADS

Quarterly CMS Advisory Council meetings are held at the JohnH.WintersBuilding, 701 W. 51st Street, in Austin. The August 2009 meeting will begin at 10:00 a.m. in Room W-651 (WestTower). Details are provided at the end of these notes with the tentatively proposed August 12, 2009, meeting agenda. Directions are included in a reminder emailed to DADS CMS Council members and stakeholders approximately 2 weeks prior to the meeting.

  • The May 2009 Long Term Care (LTC) Provider Bulletin has been mailed and is available online at An LTC News item was posted notifying providers that the May LTC Nursing Facility/Hospice Workshops are being rescheduled.

February Meeting Action Items

  • NF Portal Messages - An LTC News item was published March 13, 2009, on the LTC homepage of TMHP.com
  • Trends - Monthly CMS (Claims Management System) LTC Status Reports were provided as requested.
  • Monthly RUGs Management Report - The requested nursing facility (NF) Resource Utilization Groups (RUGs) report was provided on April 23, 2009. Maria will research whether the report can be provided regularly on a monthly or quarterly basis.
  • Medicaid Eligibility - Diagrams of the Medicaid eligibility workflow process for the Texas Department of Aging and Disability Services (DADS), the Texas Medicaid & Healthcare Partnership (TMHP), and the Texas Health and Human Services Commission (HHSC) will be presented during today's meeting. HHSC requested a separate meeting to discuss in detail the Form H1826, Power of Attorney for Limited Purposes.

Integrated Care Management (ICM) – Rhonda Pratt

Everyone has worked hard to support the transition from Evercare to DADS. The transition will occur at the end of May 2009, when the State will reassign 23,000 consumers to case managers. Consumers will receive a letter informing them of their new case manager. Providers will also receive a letter.

The ICM managed care program will not exist after June 1, 2009; however, due to enhanced funding available as part of the federal stimulus package, the ICM 1915(c) waivers will continue to operate in the current ICM service areas. This means that the Y and W suffixes will continue to be used with waiver service codes. For details, refer to DADS Information Letter No. 09-47, ICM Contract Termination and Program Changes, revised May 13, 2009.

HHSC is requiring Evercare to complete all activity pending through May 29, 2009, and provide documentation to DADS. Evercare has not taken any new intakes since April 1, 2009. Lena Brown-Owens, the DADS manager of Community Services, is responsible for ensuring that rules and waivers are in alignment.

A new DADS Information Letter,No. 09-61,ICM 1915(c) Waiver (ICMW) and Medical Necessity/Level of Care (MN/LOC) Assessments,will be released soon regarding transition of Forms 3652-A and Medical Necessity and Level of Care (MN and LOC) assessments. [Note: #09-61 was released June 2, 2009: TMHP is transferring completed Forms 3652-A and MN and LOCs to the current Home and Community Support Services Agency (HCSSA) provider.

Providers should also watch for an online DADSNews & Alertnotice announcing dates of half-day sessions being held May 27, 2009, in Arlington and May 28, 2009, in Fort Worth. [seeIntegrated Care Management (ICM) Long-term Services and Supports Provider Forum - ICM Transition(May 15, 2009).]

Attendees noted how helpful it has been to have Rhonda and Lena involved both going into the ICM project and as it is transitioned. Thanks were also extended to Margaret Oliver and Alyson Gindler of TMHP, and to Maria Garcia Montoya in DADS, for their assistance during the transition back to DADS.

Rhonda asked attendees to remind providers to contact her if needed, at (512/438-5813), or Lena at (512/438-5609). Providers also should be encouraged to ensureEvercare provides a copy of the Individual Service Plan to ensure the provider has this information on file.

In response to a question regarding a provider complaint filed with Evercare three months ago but not yet resolved, Rhonda explained that HHSC is the lead in coordinating complaints. Providers should follow up with the HHSC person they filed the complaint with. Diane Eberhart in HHSC (, 512/491-1126) is charged with working with Evercare to resolve complaints and outstanding issues including pending MN and LOCs.

STAR+PLUS – DJ Johnson, HHSC

STAR+PLUS and 1915(b) waivers for STAR+PLUS are still being approved by the federal CMS. NFs were excluded from the 1915(c) waiver service array and will not be a part of the provider network. If a STAR+PLUS member admits to an NF the clock starts and they can remain a member for four months before being un-enrolled. By contract the Health Maintenance Organization (HMO) is still required conduct at least two assessments to see if the individual can return to the community. This is part of the Promoting Independence / Money Follows the Person effort.

HHSC is amending the HMO contracts regarding the carve-out of the NF service as a waiver service; however, the requirement for monitoring their members for four months will be reinforced.

Nursing Facility services as 1915(c) NF Waiver services under STAR+PLUS stopped as of March 1, 2009; therefore NF service is no longer considered in the capitation premium rate analysis. NFs continue to file claims through TMHP for processing. This process did not change.

STAR+PLUS is continuing regular conference calls with HMOs regarding TILEs to RUGs issues, although there has been a decline in the number of HMO calls involving RUG issues. HHSC expressed appreciation for assistance provided by DADS and TMHP staff.

Medicaid Integrity Contractors (MIC) Audit – Tommy Ford, DADS

Refer to the May 7, 2009, DADS Information Letter No. 09-59, Notice of Activities to be Conducted Under the Authority of the Centers for Medicare and Medicaid Services (CMS) by Medicaid Integrity Contractors (MICs), ,regarding audits being conducted as part of the 2005 Deficit Reduction Act of 2005 (DRA).

Although audits already initiated in Texas involve only NFs, hospitals and pharmacies, MIC audits will be expanded to include all types of Medicaid providers on an ongoing basis.

While the audits are being done by the federal CMS, HHSC is the coordinating agency for the audits with the HHSC Office of Inspector General (OIG) assisting and TMHP also involved. Because several other audits are currently underway, MIC audits will not be performed while being reviewed as part of the Texas Medicaid program Payment Error Rate Measurement (PERM) assessment, although the MIC may audit different years than the PERM audit for the same providers.

The MICaudits are being conducted to identify and prosecute fraud, and to recover all funds possible. The audit contractors work on a commission based on the funds they identify. The State of Texas will repay CMS and then collect the money from the provider.

Auditors will operate under all Health Insurance Portability and Accountability Act (HIPAA) privacy and confidentiality rules. The auditswill consider both federal and state guidelines for billing, including rules, regulations and procedures. For the foreseeable future, DMS will identify approximately 100 Medicaid providers a month for MICaudits in Texas. The audit period is not known, but some providers have been asked for data from Calendar Year 2004.

RUGS Enhancements & MDS 3.0 – Trish Risley & Terri Herrera-Pounds, DADS, and Tabatha Harbers, TMHP

Reminder:TMHP posts pre-release LTC News notices at prior to each software release.

MDSAS Enhancements – Terri: DADS has been releasing every-other-week Minimum Data Set Service Authorization System (MDSAS) software enhancements. After the May 15 release, it is expected that providers would see significant changes in inventory on Monday, May 18. However, providers should keep in mind that the forms could subsequently fail for other reasons.

DADS has tentatively scheduled an automated routine to run on May 29, 2009, to reset the RUG level to the calculated RUG rate on Modifications previously set at the default RUG rate (PC E). It is highly recommended that providers check their Remittance and Status (R&S) Reports following this planned May 29 TMHP release to identify any further changes needed. Because there could be a one-week delay before all changes take effect, providers should check the impacts of these changes on both the June 1 and 8 R&S Reports.

Providers were reminded that these corrections will only be applied to modifications with a timely submission on the original assessment.

While DADS software will remove the Purpose Code (PC) E to pay at the new RUG rate after the DADS enhancements take effect May 15, 2009, a companion fix on the TMHP LTC Online Portal is currently scheduled for implementation May 29, 2009. For information on specific changes, check for the pre-release notes. [Update: As posted on the LTC homepage at tmhp.com on May 29, modifications with a PC E submitted prior to the May 8, 2009, release, and which had a prior on-time original assessment, will be adjusted to pay at the calculated RUG rate (see LTC11: Update on Planned Automation Changes for NFs). DADS had anticipated having this process completed by May 29, 2009, but due to complexities in automating the process, will not have the process completed until mid-June. A subsequent broadcast will be released to notify providers of the planned dates before these changes are run.]

TMHP Enhancements– Tabatha: LTC News notices and DADS Information Letters will be published to provide pre-release information regarding scheduled enhancement releases, including those summarized below.

  • LTC Online Portal Enhancements - MDS 2.0

Phase 1 is presently scheduled for implementation May 29, 2009. The following changes currently are planned:

For Nursing Facility Providers

  • LTCMI Save Function – The LTCMI Save function, now referred to as “Save MDS LTCMI,” will allow providers to save Nursing Facility LTCMI Assessments in Pending LTCMI status on the LTC Online Portal. If the provider has updated the LTCMI section but is not ready to submit the assessment, the provider can save it in its current state. This enhanced functionality will eliminate the need for providers to re-key the information. Notethat once the “SAVE LTCMI” tab has been selected, providers no longer have the option to populate the LTCMI.
  • LTCMI Template Function – The template functionality, now referred to as “Populate MDS LTCMI,” will provide the capability for providers to use a resident’s previously submitted LTCMI to populate a new LTCMI. The enhanced functionality will be similar to that used for other NF forms and Community ServiceMN and LOC assessments, and will reduce the need for providers to re-key all information for the same resident.

For Community Services Waiver Providers

  • MN and LOC with RUG = BC1 – When the portal calculates a RUG of BC1 on the MN and LOC assessment, the form will be rejected to the provider as an invalid form. The provider will be required to correct the form and resubmit.
  • I1aa2 Frequency (of Seizure) – Currently the instruction field for I1aa2 states: This is a two (2) digit numeric field with a valid range of one (1) to ninety-nine (99). The field will be modified to allow a range of 0-99. The instruction will be updated to: This is a two (2) digit numeric field with a valid range of zero (0) to ninety-nine (99).

Phase 2 currently is scheduled for implementation in October 2009, with the following changes currently targeted for inclusion:

  • Suspend Forms awaiting pairs to reduce rejection rate; reduce need for phone calls to clear forms by automatically submitting forms (6 month timer) – Functionality is being developed that would “suspend” 3618 and 3619 forms on the LTC Online Portal until the form completing the pair is received. When the pair is received, TMHP will send the logical pair to DADS for processing. The process will aid in reducing the number of rejections due to forms being submitted out of sequence. Matching criteria is based on same client, same provider, and same form type. Unmatched pairs will be suspended for up to 6 months awaiting a pair. If a valid pair is not received, the form will be moved to a new expired status. Detailed requirements are being developed.
  • MN and LOC Physician Signature Page – Providers will have the ability to create a new Physician’s signature page. Also being added is a “Physician’s Signature on File” checkbox to the LTCMI. The signature page will include references to the specific service group based on the Service Group on the form (i.e., Community Based Alternative), client name, SSN, DOB, Primary Diagnosis Information, Diseases, Other Diagnoses, and a certification statement specific to the services being provided. The Provider’s last name and license number will also display in the signature block below the signature line.
  • Allow Providers to delete unwanted MDS in Pending LTCMI status - Providers will have the ability to delete an MDS Comprehensive assessment in “Pending LTCMI” status from the Form Status Inquiry (FSI) Page. Users will be provided with a link to delete the form, will be given a message to confirm the deletion, and will receive a final confirmation that the form has been deleted.
  • Allow Providers to Sort the Current Activity Screen – Providers will be given the ability to sort the displayed records on the Current Activity screen by clicking on column headings. The columns will have a default sort of Form Type, Medicaid Number, Client Name; however, the provider can then re-sort the order as needed.
  • Allow Purpose Code E to cover more than one Quarter to match Federal CMS allowing Providers to ‘catch up’ with missed assessments – TMHP is implementing system changes to remove the 92-day restrictions for the MDS Purpose Code E new ruling. Currently, a single MDS assessment with a Purpose Code E is allowed to cover a 92-day period. The Federal CMS allows facilities to submit one assessment to ‘catch up’ on missed assessments. Allowing a Purpose Code E to cover more than one quarter will support Federal CMS Resident Assessment Instrument (RAI) regulations for form submission.
  • Third Party Submission of the LTCMI –System modifications will be made to allow third-party vendors to submit the LTCMI (MDS) and MN and LOC assessments directly to the LTC Online Portal as they currently do for 3618 forms, 3619 forms, and the 3652-A Purpose Code E. Validation rules will mimic those of the LTC Online Portal User Interface.
  • Print the Resident’s Name on the LTCMI –The resident’s name as indicated in Section AA.1 will be included on the printed Adobe Portable Document File (PDF) of the LTCMI section of the MDS form. This will allow providers to clearly identify who the form is for.

MDS 2.0– Trish: The planned TMHP enhancements release this October will include a suspension function to help address the high number of Form 3618/3619 rejections being caused by inappropriate sequencing of the form submissions or when a pair of forms is not submitted. Currently 41% of all rejections in the Provider Action Required (PAR) Workflow rejections and 54% of all rejected forms in the DADS Provider Claims Services (PCS) Workflow are caused by incorrect 3618/3619 submission. Because the 3618/3619 admission/discharge forms go through all front-end validations prior to being held awaiting a pair form, 3618s and 3619s should process when the other form in the pair is submitted.

A question was asked about payment being made beyond the12-month limit. DADS can pay beyond the 12-month rule if the billing submission delay is due to a DADS system error. Regardless, providers should always bill within 12 months; even if the claim denies, the system documents that the initial claim bill was submitted within 12 months. Marie Redman, who manages the DADS Provider Claims Services (PCS) hotline, reminded the group that if they cannot bill because the formis in thePCS workflow, the NF can call PCS at 512/438-2200 Option 1for assistance.

Trish emphasized that MDS assessments are primarily rejecting because of submission errors in the DADS Forms 3618 and 3619, not because of the data being submitted in the MDS assessments. Providers should regularly check the LTC Online Portal to identify when they need to submit a missing admit/discharge form. Admission and discharge forms that have rejected because the companion (pair) form is missing are typically located in one of two statuses: Provider Action Required or Submitted to Manual Workflow.

MDS 3.0– Trish: The Federal CMS published another draft of the assessment instrument late last week. The final assessment specifications and final RUG items, as well as train-the-trainer materials, are scheduled to be published in October 2009.

Texas along with many other states will continue to use the RUG III 34-group model. CMS has committed to providing a crosswalk pre-processor to convert MDS 2.0 data items to RUG III 34 Groups. This means that when MDS 3.0 is implemented, only the assessments will change; providers will continue to see the RUGs they are accustomed to. The new assessments are required by the Federal CMS: while all the states must use the new federal assessments, Texas is not changing the way we use the assessments for Medicaid. This is the best news you can have for a transition: that only onearea is changing.