DADS Information Letter No. 10-100

August 12, 2010

Page 1

August 12, 2010

To: Nursing Facility (NF) Providers

Subject:DADS Information Letter No. 10-100

Submission Instructions for Form 3618/3619 Transactions

This letter is to remindNF providers that they are required to submit copies of all Form 3618 Resident Transaction Notices and Form 3619 Medicare/Skilled Nursing Facility Patient Transaction Noticesto theappropriate Texas Health and Human Services Commission (HHSC)Medicaid Eligibility for the Elderly and People with Disabilities (MEPD) specialist.

A primary purpose of Form 3618/3619 submission is to inform Texas HHSC staff about transactions and status changes for Medicaid applicants and recipients. The MEPD specialist requires the notification of admission in order to complete the application for Medicaid. The admission Form 3618/3619 is needed to allow the MEPD specialist to certify and establish an applied income amount if the client qualifies for Medicaid. The established Medicaid allows DADS to process authorization for Nursing Facility services.

Providers should retain the original of each Form 3618/3619 transaction notice, and send a copy to the MEPD specialist assigned to their facility informing HHSC staff of all transactions and status changes for each Medicaid applicant and recipient.

If the NF provider does not know who their assigned MEPD specialist is, the attached list provides a contact name and phone number that NF providers can call to obtain the name, number and address of their assigned MEPD specialist. The attached list cannot be used to submit Forms 3618 and 3619 to MEPDspecialists. Providers must call the contact on the attached list and obtain the correct MEPD specialist's correspondence information.

Access DADS Forms and Instructions for complete submission instructions regarding Forms 3618 and 3619:

  • Form 3618 Instructions
  • Form 3619 Instructions

If there are additional questions about the contents of this letter, contact Provider Claims Services (PCS) at 512-438-2200, option 1.

Sincerely,

[signature on file]

Gordon Taylor

Chief Financial Officer

GT:pa

Attachment: Texas Contacts By Region

TEXAS CONTACTS BY REGION

Region 1

Laura Mojica or Paulette Hinckson, MEPD HHSC Clerk III, (806)766-2737

Counties
Armstrong / Bailey / Briscoe / Carson
Castro / Childress / Cochran / Collingsworth
Crosby / Dallam / Deaf Smith / Dickens
Donely / Floyd / Garza / Gray
Hale / Hall / Hansford / Hartley
Hemphill / Hockley / Hutchinson / King
Lamb / Lipscomb / Lubbock / Lynn
Moore / Motley / Ochiltree / Oldham
Parmer / Potter / Randall / Roberts
Sherman / Swisher / Terry / Wheeler
Yoakum

Region 2

Ida Perez or Judith Beagle, MEPD Administrative Assistant (325)625-7919

Counties
Archer / Baylor / Brown / Callahan
Clay / Coleman / Comanche / Cottle
Eastland / Fisher / Foard / Hardeman
Haskell / Jack / Jones / Kent
Knox / Mitchell / Montague / Nolan
Runnels / Scurry / Shackelford / Stephens
Stonewall / Taylor / Throckmorton / Wichita
Wilbarger / Young

Region 3

Daphne Shaw or Tamara Beck, HHSC (972)647-3011

Counties
Collin / Cooke / Dallas / Denton
Ellis / Erath / Fannin / Grayson
Hood / Hunt / Johnson / Kaufman
Navarro / Palo Pinto / Parker / Rockwall
Somervell / Tarrant / Wise

Region 4

Melissa McCann or Aretha Davis, HHSC (903)553-4326

Counties
Anderson / Bowie / Camp / Cass
Cherokee / Delta / Franklin / Gregg
Harrison / Henderson / Hopkins / Lamar
Marion / Morris / Panola / Rains
Red River / Rusk / Smith / Titus
Upshur / Van Zandt / Wood

Region 5

Donna Dickey or Jo Lynn Churchman, HHSC (936)544-2123 ext 221

Counties
Hardin / Jasper / Angelina / Houston
Nacogdoches / Polk / Jefferson / Newton
Orange / Sabine / San Augustine / San Jacinto
Shelby / Trinity / Tyler

Region 6

Lucinda Cervantes or Ellen Balthazar, MEPD Clerk III (713) 696-7157

Counties
Austin / Brazoria / Chambers / Colorado
FortBend / Galveston / Harris / Liberty
Matagorda / Montgomery / Walker / Waller
Wharton

Region 7

John Grizzaffi or Charlene Sparks, HHSC MEPD (979)776-7420

Counties
Bastrop / Bell / Blanco / Bosque
Brazox / Burleson / Burnet / Caldwell
Coryell / Falls / Fayette / Freestone
Grimes / Hamilton / Hays / Hill
Lampasas / Lee / Leon / Limestone
Llano / Madison / McLennan / Milam
Mills / Robertson / San Saba / Travis
Washington / Williamson

Region 8

Asonja Thomas (210)619-8042 or Dorothy Wilson (210) 431-8778

Counties
Atascosa / Bandera / Bexar / Calhoun
Comal / BeWitt / Dimmit / Edwards
Frio / Gillespie / Goliad / Gonzales
Guadalupe / Jackson / Karnes / Kendall
Kerr / Kinney / LaSalle / Lavaca
Maverick / Medina / Real / Uvalde
Val Verde / Victoria / Wilson / Zavala

Region 9

Janis Ambs (972) 337-6193

Counties
Andrews / Borden / Coke / Concho
Crane / Crockett / Dawson / Ector
Gaines / Glasscock / Howard / Irion
Kimble / Loving / Martin / Mason
McCulloch / Menard / Midland / Pecos
Reagan / Reeves / Schleicher / Sterling
Sutton / Terrell / Tom Green / Upton
Ward / Winkler

Region 10

Yanin Cadena or Patricia Webster HHSC (915)775-4543

Counties
Brewster / Culberson / El Paso / Hudspeth
Jeff Davis / Presidio

Region 11

Lucy Montero Perez or Rosemarie Vargas (956)565-7333

Counties
Aransas / Bee / Brooks / Cameron
Duval / Hidalgo / Jim Hogg / Kenedy
Kleberg / Live Oak / McMullen / Nueces
Refugio / San Patricio / Starr / Webb
Willacy / Zapata