Bill Payment

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Texas Department of State Texas Department of State Health Services (TDSHS) Health Services (TDSHS)

Primary Care Group Primary Care Group

2008 TIHCA Conference2008 TIHCA Conference

A True / False Test A True / False Test of Your CIHCP Knowledge…of Your CIHCP Knowledge…

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ObjectiveObjective

Address challenges and key issues Address challenges and key issues facing CIHCP staff regarding aspects of facing CIHCP staff regarding aspects of bill paymentbill payment. .

Provide an opportunity for you to:Provide an opportunity for you to: test your program knowledge;test your program knowledge; share observations and experiences; and share observations and experiences; and hear possible solutions for hear possible solutions for solvingsolving

problemsproblems related to your role in the health related to your role in the health care setting.care setting.

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Basic Health Care ServicesBasic Health Care Services

County programs County programs shall provide basic health shall provide basic health care servicescare services and in addition may provide and in addition may provide other medically necessary services or supplies other medically necessary services or supplies that the county determines to be cost-effective.that the county determines to be cost-effective.

Hospital districts and public hospitals Hospital districts and public hospitals shall shall endeavor to provide the basic health care endeavor to provide the basic health care servicesservices a county is required to provide. a county is required to provide.

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General PrinciplesGeneral Principles(Section Four, Service Delivery)(Section Four, Service Delivery)

A county shall provide the health care services A county shall provide the health care services established by TDSHS in the handbook or established by TDSHS in the handbook or less less restrictive health care services.restrictive health care services.

Services or supplies must be reasonable and medically Services or supplies must be reasonable and medically necessary for diagnosis and treatment.necessary for diagnosis and treatment.

In addition to providing basic health care services, a In addition to providing basic health care services, a county may provide other department-approved county may provide other department-approved optional health care services that the county determines optional health care services that the county determines to be cost-effective.to be cost-effective.

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TDSHS-established Basic Health Care ServicesTDSHS-established Basic Health Care Services((Section Four, Service DeliverySection Four, Service Delivery))

Physician ServicesPhysician Services Annual physical examinationsAnnual physical examinations ImmunizationsImmunizations Medical Screening ServicesMedical Screening Services Laboratory and X-ray ServicesLaboratory and X-ray Services Family Planning ServicesFamily Planning Services Skilled Nursing Facility ServicesSkilled Nursing Facility Services Prescription DrugsPrescription Drugs Rural Health Clinic ServicesRural Health Clinic Services Inpatient Hospital ServicesInpatient Hospital Services Outpatient Hospital ServicesOutpatient Hospital Services

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TDSHS-established Optional Health Care TDSHS-established Optional Health Care ServicesServices

(Section Four, Service Delivery)(Section Four, Service Delivery) Advanced Practice Nurse ServicesAdvanced Practice Nurse Services Ambulatory Surgical Center (Freestanding) ServicesAmbulatory Surgical Center (Freestanding) Services Colostomy Medical Supplies and EquipmentColostomy Medical Supplies and Equipment Counseling ServicesCounseling Services Dental CareDental Care Diabetic Medical Supplies and EquipmentDiabetic Medical Supplies and Equipment Durable Medical equipmentDurable Medical equipment Emergency Medical ServicesEmergency Medical Services Home and Community Health Care servicesHome and Community Health Care services Physician Assistant ServicesPhysician Assistant Services Vision Care, Including EyeglassesVision Care, Including Eyeglasses Federally Qualified Health Center ServicesFederally Qualified Health Center Services Other medically necessary services or supplies that the local governmental Other medically necessary services or supplies that the local governmental

municipality/entity determines cost effectivemunicipality/entity determines cost effective

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Statement #1Statement #1

A provider’s signature is A provider’s signature is required on the UB-04 required on the UB-04 billing form for it to be billing form for it to be payable by the CIHCP.payable by the CIHCP.

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Answer #1Answer #1 FALSEFALSE

Chapter 61 does not address claim Chapter 61 does not address claim forms. However, the backside of the forms. However, the backside of the UB-04 claim form states “Submission UB-04 claim form states “Submission of this claim form constitutes of this claim form constitutes certification that the billing certification that the billing information as shown on the face information as shown on the face hereof is true, accurate and hereof is true, accurate and complete”.complete”.

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The county responsibilities The county responsibilities that are defined in Chapter 61 that are defined in Chapter 61

are only intended for those are only intended for those county programs that receive county programs that receive

state assistance from the state assistance from the DSHS.DSHS.

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Answer #2Answer #2

FALSEFALSE

The responsibilities that are The responsibilities that are defined in Chapter 61 are defined in Chapter 61 are directed to all counties directed to all counties regardless of the regardless of the acceptance of state acceptance of state assistance.assistance.

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A county is not liable A county is not liable for the cost of a health for the cost of a health care service that is in care service that is in excess of the payment excess of the payment standards established standards established

by the DSHS.by the DSHS.

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Answer #3Answer #3

TRUETRUE

Chapter 61, Section 61.034 (a).Chapter 61, Section 61.034 (a).

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StatementStatement #4 #4

Bill payment disputes Bill payment disputes between a provider and a between a provider and a county or a provider and a county or a provider and a hospital district shall be hospital district shall be submitted to the DSHS.submitted to the DSHS.

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The DSHS does not determine The DSHS does not determine disputes regarding bill disputes regarding bill payment. However, eligibility payment. However, eligibility and residency disputes may be and residency disputes may be submitted to the DSHS.submitted to the DSHS.

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Counties, hospital districts, Counties, hospital districts, and public hospitals only and public hospitals only

have to verbally explain to a have to verbally explain to a client the procedure for client the procedure for appealing a denial for appealing a denial for

assistance.assistance.

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Answer #5Answer #5

FALSEFALSE

Chapter 61, Section 61.024 (j) Chapter 61, Section 61.024 (j) states “the entity shall provide states “the entity shall provide written notification which will written notification which will include an explanation of the include an explanation of the procedure to appeal.”procedure to appeal.”

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Counties, hospital districts, Counties, hospital districts, and public hospitals have and public hospitals have a per client liability for a per client liability for each state fiscal year of each state fiscal year of

$30,000.00.$30,000.00.

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Answer #6Answer #6

FALSEFALSE

Chapter 61, Section Chapter 61, Section

61.035, only states the 61.035, only states the

maximum county liability. maximum county liability.

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The $30,000.00 payment The $30,000.00 payment limitation has been met if a limitation has been met if a

public hospital spent public hospital spent $10,000.00 on a CIHCP $10,000.00 on a CIHCP

client at their facility and client at their facility and then $20,000.00 when that then $20,000.00 when that client was transferred out client was transferred out

to a non-affiliated hospital. to a non-affiliated hospital.

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Chapter 61, Section 61.061 states Chapter 61, Section 61.061 states “payment rates and limits that relate “payment rates and limits that relate to county services apply to inpatient to county services apply to inpatient and outpatient hospital services if:and outpatient hospital services if:

1)1) the hospital cannot provide the services the hospital cannot provide the services or emergency services that are required; or emergency services that are required; ANDAND

2)2) the services are provided by an entity the services are provided by an entity other than the hospital.” other than the hospital.”

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The $30,000.00 county The $30,000.00 county liability is applied to liability is applied to

the fiscal year in the fiscal year in which the service was which the service was

provided.provided.

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Answer #8Answer #8

TRUETRUE

Chapter 61, Section 61.035. Chapter 61, Section 61.035.

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An incomplete claim, initially An incomplete claim, initially received within the 95 day filing received within the 95 day filing

deadline, was returned to the deadline, was returned to the provider for missing information. provider for missing information. When the provider resubmitted When the provider resubmitted the claim it was received outside the claim it was received outside the 95 days. This is no longer a the 95 days. This is no longer a

payable claim.payable claim.

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Answer #9Answer #9

TRUE & FALSETRUE & FALSE

Chapter 61 does not address Chapter 61 does not address claim forms. The CIHCP claim forms. The CIHCP Handbook does not define the Handbook does not define the required elements of claim required elements of claim forms.forms.

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The expenditures paid on The expenditures paid on eligible county jail inmates eligible county jail inmates by a county may be credited by a county may be credited towards state assistance if towards state assistance if the county has a Form 100 the county has a Form 100

(CIHCP application) (CIHCP application) completed by the inmate completed by the inmate and a Form 101 (CIHCP and a Form 101 (CIHCP

worksheet) on file.worksheet) on file.

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Answer #10Answer #10 TRUETRUE

Chapter 61, Section 61.007 Chapter 61, Section 61.007 Information Provided by Information Provided by Applicant, states “The department Applicant, states “The department by rule shall by rule shall require each require each applicantapplicant to provide at least the to provide at least the following information:” it then following information:” it then lists items (1) – (8) which are the lists items (1) – (8) which are the questions listed on Form 100. questions listed on Form 100.

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A CIHCP applicant may A CIHCP applicant may be denied from the be denied from the program for having program for having health insurance or health insurance or other health care other health care

benefits. benefits.

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Answer #11Answer #11

FALSEFALSE

Chapter 61, Section 61.022 (a) Chapter 61, Section 61.022 (a) states “The county is payor of last states “The county is payor of last resort and shall provide assistance resort and shall provide assistance only if other adequate public or only if other adequate public or private sources of payment are not private sources of payment are not available.”available.”

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A county may credit A county may credit towards state assistance towards state assistance

expenditures for expenditures for payment of their CIHCP payment of their CIHCP client’s health insurance client’s health insurance premiums, co-pays, and premiums, co-pays, and

deductibles. deductibles.

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Chapter 61, Section 61.029 (a) Chapter 61, Section 61.029 (a) states “A county may arrange states “A county may arrange to provide health care services to provide health care services through…. or the through…. or the purchasepurchase of of insurance for eligible insurance for eligible residents.”residents.”

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A client receives services at a A client receives services at a hospital that has a charity hospital that has a charity

care assistance program. Due care assistance program. Due to the existence of the charity to the existence of the charity care program, the CIHCP is care program, the CIHCP is not responsible for payment not responsible for payment of the health care services of the health care services received at that hospital. received at that hospital.

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Answer #13Answer #13FALSEFALSE

Chapter 61, Section 61.033 (b) Chapter 61, Section 61.033 (b) states “…if another source of states “…if another source of payment does not adequately payment does not adequately cover a health care service… the cover a health care service… the county shall pay for or provide county shall pay for or provide the health care service for which the health care service for which other payment is not available.”other payment is not available.”

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Physical therapy services Physical therapy services received in a received in a

rehabilitative facility (not rehabilitative facility (not a hospital) are covered as a hospital) are covered as an optional health care an optional health care

service. service.

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TAC Rule, optional health care TAC Rule, optional health care service #13 allows an entity service #13 allows an entity to elect to cover other to elect to cover other medically necessary services medically necessary services or supplies they determine it or supplies they determine it to be cost effective.to be cost effective.

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A county, public A county, public hospital, or hospital hospital, or hospital district may pay a district may pay a claim for a 90-day claim for a 90-day

supply of prescription supply of prescription medication. medication.

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Chapter 61 only states Chapter 61 only states “payment for not more “payment for not more than three prescriptions than three prescriptions drugs a month.” drugs a month.”

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When a basic or optional When a basic or optional CIHCP service does not CIHCP service does not fall within the 365-day fall within the 365-day

federal filing deadline for federal filing deadline for Medicaid reimbursement, Medicaid reimbursement, programs do not have to programs do not have to provide that service to provide that service to

the CIHCP client. the CIHCP client.

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Answer #16Answer #16FALSEFALSE

The 365-day federal filing The 365-day federal filing deadline for Medicaid deadline for Medicaid reimbursement reimbursement should notshould not be be used to determine whether a used to determine whether a CIHCP client receives covered CIHCP client receives covered CIHCP health care services. CIHCP health care services.

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The DSHS calculates the The DSHS calculates the payment rates used for payment rates used for RHC, FQHC, inpatient, RHC, FQHC, inpatient,

and outpatient and outpatient services. services.

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Chapter 61 states the DSHS Chapter 61 states the DSHS defines the payment standards defines the payment standards in accordance with TANF; in accordance with TANF; however, DSHS does not however, DSHS does not calculate what each rate will calculate what each rate will be. be.

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The DSHS updates the The DSHS updates the RHC, FQHC, inpatient, RHC, FQHC, inpatient, and outpatient rates on and outpatient rates on

an annual basis. an annual basis.

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TRUETRUE

These rates are updated These rates are updated and posted in the and posted in the CIHCP Handbook and CIHCP Handbook and website by the DSHS website by the DSHS annually. annually.

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Regarding the TMHP Fee Regarding the TMHP Fee Schedules, if a CPT code Schedules, if a CPT code

is not listed but the is not listed but the provider states Medicaid provider states Medicaid

has paid them in the has paid them in the past you may negotiate a past you may negotiate a rate with the provider.rate with the provider.

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You may ask the provider You may ask the provider to present to you the to present to you the explanation of benefits explanation of benefits showing the payment from showing the payment from Medicaid.Medicaid.

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CIHCP basic and CIHCP basic and optional health care optional health care

services may not services may not always be always be

reimbursed by reimbursed by Medicaid.Medicaid.

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TRUETRUE

Medicaid may require prior Medicaid may require prior authorization or additional authorization or additional medical documentation from medical documentation from the provider for payment of the provider for payment of that service. that service.

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A client who is on the A client who is on the CIHCP may also CIHCP may also

receive services from receive services from the Women’s Health the Women’s Health

Program.Program.

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The Women’s Health The Women’s Health Program does not provide Program does not provide full comprehensive full comprehensive Medicaid benefits.Medicaid benefits.

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Hospital Ambulatory Hospital Ambulatory Surgical Center (ASC) Surgical Center (ASC)

rates may be used to pay rates may be used to pay non-emergency surgeries non-emergency surgeries

that are billed as an that are billed as an outpatient hospital service outpatient hospital service on the UB-04 claim form.on the UB-04 claim form.

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TRUETRUE

CIHCP Handbook, Section 4, page CIHCP Handbook, Section 4, page 39.39.

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Freestanding ASC services Freestanding ASC services should be billed as one should be billed as one inclusive charge on a inclusive charge on a

CMS-1500 claim form and CMS-1500 claim form and are paid if the county has are paid if the county has chosen ASC services as a chosen ASC services as a CIHCP optional service.CIHCP optional service.

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TRUETRUE

CIHCP Handbook, Section 4, page CIHCP Handbook, Section 4, page 67.67.

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A woman eligible for the A woman eligible for the Breast and Cervical Breast and Cervical

Cancer Services may still Cancer Services may still be eligible for the CIHCP.be eligible for the CIHCP.

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A woman eligible for MBCC is A woman eligible for MBCC is entitled to full Medicaid coverage entitled to full Medicaid coverage beginning the date after the day beginning the date after the day of diagnosis. (Not limited to the of diagnosis. (Not limited to the treatment of breast and cervical treatment of breast and cervical cancer)cancer)

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The 5% reduction of The 5% reduction of payment for inpatient and payment for inpatient and

outpatient hospital outpatient hospital services ceased as of dates services ceased as of dates

of services 08-31-2007.of services 08-31-2007.

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CIHCP Handbook, Section 4, pages CIHCP Handbook, Section 4, pages 37 and 39. The 5% reduction of 37 and 39. The 5% reduction of payment for inpatient services payment for inpatient services beginning dates of service 09-01-beginning dates of service 09-01-2004 remains in effect. However, 2004 remains in effect. However, the 2.5% reduction of payment for the 2.5% reduction of payment for outpatient services beginning dates outpatient services beginning dates of service 09-01-2003 ceased as of of service 09-01-2003 ceased as of dates of service 08-31-2007dates of service 08-31-2007..

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THE ENDTHE END

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WebsiteWebsite

www.dshs.state.tx.us/cihcp/default.www.dshs.state.tx.us/cihcp/default.htmhtm

http://www.dshs.state.tx.us/cihcp/default.htm

http://www.dshs.state.tx.us/cihcp/default.htm

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