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Important Information for PCCM Primary Care Providers: April 2007
Verification of PCCM Primary Care Provider on Medicaid ID Required
For dates of service beginning April 13, 2007, PCCM clients will be required to obtain care from the primary care provider listed on their Medicaid Identification Form (H3087/3087). The transition period that previously allowed clients to receive health care from any provider while changing their primary care provider will end on April 12, 2007.
Clients can continue to call 1-888-302-6688 to request a primary care provider change. It may take up to 45 days for the change to be listed on the client’s Medicaid ID. The daily Primary Care Provider Change List will not be available after April 12, 2007. If a PCCM client has not yet selected or been assigned to a primary care provider, any primary care provider may provide services. Clients who do not yet have a primary care provider will have on their Medicaid ID either “PCCNEWB01” (newborns) or “PCCPCCM01” (all clients except newborns) in place of the primary care provider’s name.
Providers can continue to verify client eligibility in four ways:
· Medicaid ID
· Electronically via Texas Medicaid and Healthcare Partnership (TMHP) Electronic Data Interchange (EDI)
· Automated Inquiry System (AIS) at 1-800-925-9126
· The current month’s panel report
Primary care providers must continue to provide their Texas Provider Identifier (TPI) numbers to specialists to ensure appropriate claims processing. Claims with invalid or missing provider numbers will be denied.
Primary care providers are required to make arrangements for after-hours care. Referrals are allowed to clinics that offer after-hours care. However, the after-hours provider must include the primary care provider’s TPI number on the claim to receive payment. Administrative referrals will be issued only for urgent situations. For information, call the PCCM Provider Helpline at 1-888-834-7226 or visit www.tmhp.com/C18/PCCM.
Revised EDI Companion Guides Now Available
The revised Electronic Data Interchange (EDI) Companion Guides are now available on the EDI page of the TMHP website, under the Companion Guides for CMS and C21 link. The EDI
Companion Guides include updates related to the enhanced dual strategy approach to submitting electronic claims for the National Provider Identifier (NPI) implementation.
For more information, call the TMHP EDI Help Desk at 1-888-863-3638.
Client Medicaid Identification Form (H3087) Will Change
Beginning May 2007, the Client Medicaid Identification Form (H3087) will change. The “ICF-MR Dental Services” check box has been renamed “Dental Services.” A check mark under this heading shows eligibility for dental services for any Medicaid client during the specified month.
To verify a client’s eligibility for dental services when the check box is not marked, providers may call the TMHP Contact Center at 1-800-925-9126.
Important PCCM Program Updates
The Health and Human Services Commission and TMHP are working closely with the stakeholders representing physicians, hospitals, Federally Qualified Health Centers, and Rural Health Centers to address physician/provider issues about Primary Care Case Management (PCCM).
New features include: 1) Allowing new clients time to select a primary care provider upon enrollment. Clients are no longer assigned a provider at the time of enrollment. ; 2) New clients have a Medicaid Identification Form (H3087/3087) that lists either PCCNEWB01 (newborns) or PCCPCCM01 (all clients except newborns) as the primary care provider. With this listing, any PCCM enrolled primary care provider can render health care services to the client. 3) Clients must see the primary care provider on their Medicaid Identification Form. 4) Primary care providers must continue to provide their TPI numbers to specialists and after-hours clinics to ensure appropriate claims processing. Claims with invalid or missing provider numbers will be denied.
For information on these updates, call the PCCM Provider Helpline at 1-888-834-7226.
TMHP is Phasing Out Paper Remittance and Status (R&S) Reports.
Providers who currently receive paper R&S reports by mail will begin to receive their R&S reports only through the TMHP website at www.tmhp.com. To access R&S reports online, providers must create a provider administrator account on the TMHP website. The transition from paper R&S reports will begin April 15, 2007, and continue through June 15, 2007. The date for the transition from paper R&S reports depends on the Texas Provider Identifier (TPI) of the provider. After the transition, providers will be able to access an exact replica of the paper R&S report online without having to wait to receive it through the mail.
Details of these changes and the schedule for the transition are available on the TMHP website at www.tmhp.com. These details will also be available in the May/June 2007 Texas Medicaid Bulletin, No. 204, and in the May 2007 CSHCN Provider Bulletin, No. 62.
For more information, call the TMHP Contact Center at 1-800-925-9126.