In October 2019, HHSC added new functionality that allows Substance Use Disorder (SUD) Treatment Providers to submit requests for prior authorization and claims directly to the Texas Medicaid and Healthcare Partnership (TMHP) from CMBHS. This functionality is for clients with Medicaid fee-for-service coverage only. For all other types of Medicaid coverage continue to use the existing processes.
The TMHP Provider manual located online is available for reference http://www.tmhp.com/Manuals_HTML1/
TMPPM/Current/index.html#t=TMPPM%2F1_00a_Preliminary_
Information%2F1_00a_Preliminary_Information.htm, OR call TMHP at 1-866-806-7806, Option 1, to check claim status, client eligibility, benefit limitations, current weekly payment amount, and claim appeals.
Eligibility and claim status information is available 23 hours a day, 7 days a week, with scheduled down time between 3 a.m. and 4 a.m., Central Time. All other information is available from 7 a.m. to 7 p.m., Central Time, Monday through Friday. Fifteen transactions are allowed per call.
Before beginning to document services for Medicaid fee-for-service clients in CMBHS with the intent to submit them to TMHP, ensure that the following have been completed:
These are new instructions for an existing process. When using CMBHS for submitting claims to TMHP, have an Electronic Remittance Advice (ERA) form on file with TMHP. This form requests that TMHP create an electronic 835 file for your organization. Your organization (or another organization you specify such as a claims clearing house) must be designated on the form as the recipient of your 835 file. HHSC or DSHS may not be designated on the ERA as the recipient of the electronic 835 file.
Your organization may have already been contacted about this by TMHP and made the necessary changes; if not, contact the TMHP Contact Center: 1-888-925-9126 to verify the status of your ERA form.
TMHP places all electronic files at a secure FTP site. If you are interested in retrieving a file or files, call the TMHP Contact Center for instructions.
The CMBHS Provider Fee Schedule
This is a new process. The purpose of the CMBHS Provider Fee Schedule is to give providers submitting claims to TMHP the opportunity to include their standard/usual fee for a service with every claim they submit to TMHP. The fees entered into the CMBHS Provider Fee Schedule do not impact payment but allow every claim to represent your organization’s standard/usual fee for the service.
The Provider Fee Schedule is located in the top menu of CMBHS. Go to CMBHS > Business Office > Provider Fee Schedule. Enter the standard/usual fee for each service you will be submitting to Medicaid.
Services Offered
There is no change to this process. Make sure that all the service types you provide at each CMBHS location are properly setup on the Services Offered page. Include the new SUD Assessment (Medicaid) Service Type for every location where a Medicaid fee for service client might be served and a claim submitted in CMBHS.
As a condition of claims payment, Medicaid requires some services have prior authorization before the client receives them. After the provider receives the prior authorization, which includes an authorization number from TMHP, a Begin Service can be created in CMBHS with Medicaid Claim as the funding source type. Services can then be provided, and documented, which results in the creation of claims with the prior authorization number. Claims can then be submitted to TMHP for processing and payment.
NOTE: The funding type Medicaid – Documentation does not result in the creation of a claim. Use this funding type in the Begin Service if you will be billing Medicaid outside of CMBHS. Use Medicaid – Documentation for clients with a non-fee-for-service Medicaid type, such as Managed Care Organizations (MCO) since claims will not be submitted for them using CMBHS.
When a request for prior authorization is created and submitted through CMBHS, the request goes to TMHP using an electronic data exchange process. Medical personnel decides whether or not to approve the requested type of service and quantity. The decision will be available to view in CMBHS following a data exchange process.
TMHP determines which services require prior authorization and which do not. There have been no changes because of the recent incorporation of this process into CMBHS.
Currently all residential SUD services that will be billed to Medicaid require a prior authorization. This is also true for Behavioral Management Organizations (BMO) services, who require a Service Authorization as well.
NOTE: Local Behavioral Health Authorities (LBHAs) are now referred to as Behavioral Maintenance Organizations (BMO) in CMBHS.
SUD outpatient services are billed with claim codes that allow either 104 or 135 units of treatment before an authorization is required. TMHP Prior Authorization is not required for initial outpatient services. Once you have exhausted the following units, a TMHP Prior Authorization is needed.
Also, TMHP Prior Authorization is not required for Medication Assisted Therapy (MAT).
To successfully submit a prior authorization request, the location must have Tax ID, NPI number, Benefit Code and a Taxonomy code, in addition to one contact person. The following explains these codes:
These codes can be viewed on the Identifiers tab of the Location Detail page of CMBHS.
Roles that have read/write access for the TMHP Prior Authorization screens:
1. Start at the Client’s Workspace.
2. Click on TMHP Prior Authorization Request from the Service Management tab of the Client Services toolbar on the left. CMBHS displays the TMHP Prior Authorization Request Page.
3. The first three fields are auto-filled by the CMBHS system.
4. TMHP Prior Authorization Form Type – (Required) dropdown list contains all service types that require authorization for this location on the Services Offered page.
NOTE: If the service you are looking for does not display in the dropdown list, contact your local security administrator.
5. Select the appropriate service type row and click the Edit button.
6. Enter the required Requested Begin Date for the Prior Authorization using the mm/dd/yyyy format. The Begin Date cannot be prior to the Admission Date to your facility or earlier than today’s date.
7. Enter the required Requested End Date for the Prior Authorization using the mm/dd/yyyy format.
NOTE: CMBHS verifies that the Begin and End Dates do not overlap with a MCO Segment on the MEV and that Medicaid coverage is indicated for the dates you are requesting.
8. Enter the required quantity (1 unit = 15 min) of service units you are requesting. Click Save.
NOTE: Begin date defaults to current date and cannot be dated to a past date or future dated.
9. Request Required Submitter Certification Statement
a. Read the Prior Authorization Request Submitter Certification Statement and then select the “We Agree” checkbox to continue with the request
b. Click Next to move to the Client & Location tab.
10. Verifying Client & Location Tab Information
CMBHS displays the Client Information as read-only data. The Client Information is pulled from the CMBHS Client Profile and the Chemical Dependency Treatment Facility Information from the Location Detail pages.
NOTE: This information is populating from within CMBHS. If either the Client Information or the Chemical Dependency Treatment Facility Information is not correct, contact the CMBHS Help Line for assistance at 1-866-806-7806. Or, click cmbhstrainingteam@hhsc.state.tx.us to contact the Help Line via email.
b. Enter date in fields ‘Dates From’ and ‘To’ in the format mm/dd/yyyy.
Note:
c. Select a value from drop-down of field ‘Requesting Provider Printed Name’.
d. Enter Provider license number in field ‘Requesting Provider License number’.
11. Completing the Questions Tab
CMBHS displays the Prior Authorization Questions based on the Service Type selected and Prior Authorization Type. Types include Outpatient Withdrawal Management (Ambulatory Detoxification), Residential Withdrawal Management (Detoxification), Residential SUD Treatment, and Outpatient SUD Counseling/Treatment.
The questions on this tab are identical to the questions on the TMHP forms located in the portal or on paper.
12. Entering the Diagnoses Tab
a. CMBHS pre-populates the diagnosis fields using the latest SUD Assessment, if one has been completed, for the client beginning a new episode of care. Otherwise, the diagnosis fields remain blank and until a diagnosis or diagnoses are entered.
NOTE: If an SUD assessment is required by TMHP, then it must be completed according to TMHP requirements.
b. To enter a diagnosis, begin typing the first few letters of the diagnosis in the Select Diagnosis search box. Select the appropriate diagnosis from the display. Up to 18 diagnoses can be entered at a time.
13. Completing the Prior Authorization
a. Select the person completing the Prior Authorization in the Performed By dropdown list.
b. Save the Prior Authorization Request in Ready for Review or Closed Complete document status.
c. CMBHS will display the request in view mode with Submit, Print, and Attachments buttons available at the bottom of your screen. The Edit button may only be used if the document is in “Draft” or “Ready for Review” status.
The other buttons displayed are:
d. Click Print to print a paper copy which will need to be signed with a physical signature. The signature must be that of a QCC.
14. Attaching a Document to the Prior Authorization Page in CMBHS
a. After the authorization has been signed and you have scanned it onto your computer, click the Attachments button. The system displays the Open View Attachment page in a new window. Click the Upload File button.
b. Once successfully attached (uploaded) as a file in CMBHS, it displays as a new row. To upload additional attachments, repeat the above steps.
c. The attachment function is most often used to attach the original prior authorization form with the physical signature to TMHP, but you can also add new attachments to the form by repeating the attachments steps above. If TMHP sends you a Pend Letter requesting additional information, attach the additional document/s and submit the request as above.
NOTE: Keep in mind that at least one signed attachment is required for the initial submission of the Prior Authorization request form with the physical signature.
15. Submitting the Prior Authorization to TMHP
a. Click the Submit button. CMBHS will display a message that the Prior Authorization Request and Attachments have been submitted to TMHP.
NOTE: After submitting a request with an attachment, if the Open View Attachments page (ATT090) shows a “No” for “Received by TMHP,” check the attachment and resubmit it.
16. Checking Authorization Status
17. TMHP Response Details
a. The Request Service Section will display the following:
b. TMHP Prior Authorization Statuses include:
c. Last Update Date is the date the “Refresh Auth” button was last used or when TMHP last updated the status.
d. Once the document has been saved, it will be displayed on the Client Workspace.
An extension is used to request additional units and an extend the end date. An extension button will appear on the TMHP Prior Authorization once the status is approved. An extension cannot be requested after the TMHP Prior Authorization has expired. If the Prior Authorization has expired, a new Prior Authorization will have to be submitted.
1. How to create an Extension:
a. From the client workspace search for the existing TMHP Prior Authorization document in the client document list.
b. Click “Select” and “View” and then the TMHP Prior Authorization document will display.
c. Select the Extend button and the TMHP Prior Authorization Request screen will display the following:
d. In the Request Service Section, select the service to be extended and select Edit”. If you are only using a single row (i.e. date or number of units), the other row’s Begin Date field will need to be blank. Select the line, click edit, remove the date and add/save.
e. The Request Service Section will display the following:
2. TMHP Prior Authorization Status’s include:
NOTE: System refreshes the status every hour.
NOTE: Be sure to submit your request for an Extension with enough time for processing so that the client’s services are not interrupted.
In CMBHS BMOs have existing processes where their SUD and Mental Health sub-contractors request service authorization BMOs must now also request a Prior Authorization from TMHP.
The CMBHS prior authorization process works with the CMBHS BMO process and sub-contractors must follow their LBHA’s process even if CMBHS allows them to use an alternate process.
LBHA sub-contractors must also submit requests for prior authorization for a Medicaid fee for service client. Use the same process as above.
Medicaid will pay for one SUD Assessment for a fee for service client per episode of care without Prior Authorization. There is a new process to document and bill for this service in CMBHS.
1. To start the process, you must create a Begin Service for the SUD Assessment (Medicaid) Service Type and select Medicaid – Claim as the funding source. You can create a second Begin Service if you have not already submitted a claim for a SUD Assessment to TMHP.
2. After completing the SUD Assessment, write a Progress Note, selecting “Counseling” as the Note type.
a. Select SUD Assessment (Medicaid) as the Service Type and Assessment as the service.
3. Submit the claim for the SUD Assessment to TMHP from the Pending Claims page.
4. After TMHP has paid the claim, Service End the SUD Assessment (Medicaid), or wait until Discharge.
5. No other documentation, such as the End Service Assessment, is required for the SUD Assessment (Medicaid) Service Type only.
CMBHS will recognize whether the funding source is Medicaid Claims or Medicaid Documentation and will automatically generate a claim for DSHS wraparound if appropriate for the service. Residential claims are generated through the Day Rate Attendance record. Other billable services are generated through the Progress Notes.
1. Begin Service
a. When creating a Begin Service for a Medicaid fee-for-service client, use the new Medicaid – Claim funding type. Then follow the normal procedures for completing a Begin Service.
2. Claim Submission
a. Claims with the Medicaid – Claims funding source will be submitted to TMHP once you select Submit button on the Pending Claims page.
3. Claim Payment
a. Monitor the Submitted Claims Page and Claims Detail page in CMBHS to verify that your TMHP Medicaid claims are paid. When a claim is not paid, you will receive an Explanation of Benefits (EOB) code and descriptor to indicate the reason for nonpayment.
HHSC pays an additional amount for certain services billed to Medicaid, also known as Wrap Around. For Medicaid wraparound services complete only one Begin Service. Prior to this deployment, providers selected a Wrap Around Service Type on the Begin Service Page, this is no longer the procedure. Moving forward, providers will only select the type of service to be provided to the client (I.E. Intensive Residential, Outpatient). The service type with the label “wrap around” will no longer display.
NOTE: Please refer to the CMBHS On-Line Help for details on how to create a Begin Service.
Once a Begin Service has been created, if there is a funding source change, DO NOT create an End Service. Revise the existing Begin Service to end one funding source and to begin a new funding source. Make sure there are no dates without a funding source or overlapping funding source dates.
NOTE: To change the Service Type or Location, a Service End is required. When a Service Begin is created, the existing Treatment Plan will need to be revised.