TMHP - PCCM Announcements

New PCCM Announcements
	PCCM Provider Frequently Asked Questions

	Clarification to “Updates to Services Provided to PCCM Clients by FQHCs and RHCs” Effective 3/1/201
	Information posted January 22, 2010: This is a clarification to an article that was published on this website on January 6, 2010, titled “Update to Services Provided to PCCM Clients by FQHCs and RHCs.” The article listed “Freedom of Choice Services”. These services are called freedom of choice because Medicaid Managed Care clients may self-refer for some services. The following is the updated and correct information. Effective March 1, 2010, FQHC and RHC providers that provide gynecological services to PCCM clients must submit claims with an encounter code and modifier GY in the claim details. Click on the title to view the details.
Previous PCCM Announcements
	Important PCCM Program Updates
	Information posted February 16, 2007: 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). Click on the title to view the details.
	Referral Not Needed for Managed Care Vision Services
	Information posted August 21, 2007: Effective for dates of service on or after September 1, 2007, a primary care provider referral is no longer required for ophthalmologists and therapeutic optometrists who submit claims for services rendered to managed care clients. Click on the title to view the details.
	PCCM Enrollment Issue Identified
	The Texas Health and Human Services Commission (HHSC) recently identified an issue with Primary Care Case Management (PCCM) that may affect a small number of Medicaid clients.
	Providers Can Serve Both PCCM and HMO Clients
	Information Posted July 28, 2006: In recent months, you have received information about upcoming Medicaid managed care program changes affecting PCCM clients in the STAR Medicaid program. Effective December 1, 2006, PCCM Medicaid clients (except SSI-related clients) living in the STAR program service areas of Bexar, Dallas, El Paso, Harris, Harris Expansion, and Lubbock will no longer have PCCM as an option for Medicaid covered health care services. The Health and Human Services Commission mailed out initial notification letters and enrollment kits to affected clients in July 2006. Cllick on the title for complete details.
	Referral Not Needed for FQHCs and RHCs After-Hours Care
	Information posted August 21, 2007: Effective for dates of service on or after September 1, 2007, a primary care provider referral is no longer required for federally qualified health centers (FQHCs) and rural health centers (RHCs) who submit claims for services rendered outside of normal business hours. Click on the title to view the details.
	Verification of PCCM Primary Care Provider on Medicaid ID Required
	Information posted February 23, 2007: 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. Click on the title to view the details.
	Frequently Asked Questions about the New Radiology Prior Authorization Form
	Information Posted July 10, 2006: This article addresses frequently asked questions (FAQs) about the new Radiology Prior Authorization Form and process. The FAQ provides answer to questions about retroactive request deadlines, response times for requests, signatures for electronic requests, and many other scenarios. Click on the title to view the details.
	Role of the Specialist
	Specialists are responsible for furnishing medically necessary services to PCCM patients who have been referred by their PCP for specified treatment or diagnosis. While the specialist does not contract with PCCM, all facility services should be delivered by a Medicaid provider in a PCCM-contracted facility. Click on the title for the full text of this article.
	Change in PCCM Primary Care Provider Assignment Effective February 1, 2007
	Information posted February 2, 2007: Effective February 1, 2007, the primary care provider selection process allows new Primary Care Case Management (PCCM) clients to choose their primary care provider before one is assigned. Previously, PCCM clients were assigned a primary care provider at the time of enrollment. Click on the title for more information.
	Attention PCCM Providers: Activate Your Account Today To Access Your Panel Report
	PCCM Panel Reports are available online. To access the online Panel Report, providers must have an active provider administrator account. To set up an account, click on “Activate My Account” from the “I would like to ……” links on the upper right side of the TMHP home page. Don’t wait! September Panel Reports are available now and case management fees will be paid a few days after the posting of the panel reports. If you wish to receive a paper Panel Report in lieu of the online version, call the PCCM Provider Helpline at 1-888-834-7226. For assistance with the account activation process, call the TMHP Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638.
	PCCM Special Bulletin No. 188
	The PCCM Special Bulletin No. 188 is now available for download from the TMHP.com file library.
General
	PCCM Case Management Fee Issue Identified
	Information posted January 18, 2008: TMHP has identified an issue that may affect Primary Care Case Management (PCCM) primary care providers’ monthly case management fee payments for the month of December 2007. Some PCCM case management payments issued for December 2007 did not reflect the appropriate amount for the number of clients assigned to the primary care provider on the December 2007 Panel Report roster. Click the title to view the details.
	PCCM Primary Care Providers Should Verify Clients’ Medicaid ID Cards
	Information posted July 9, 2007: Reminder: Primary Care Case Management (PCCM) primary care providers must verify that their names are listed on a client’s Medicaid Identification (ID) Form (H3087). Click on the title to view the details.
	PCCM Enrollment Issue Identified
	The Texas Health and Human Services Commission (HHSC) recently identified an issue with Primary Care Case Management (PCCM) that may affect a small number of Medicaid clients.
	PCCM Case Management Fee Issue Identified
	Information Posted June 2, 2006: TMHP has identified an issue that may impact Primary Care Case Management (PCCM) primary care providers’ monthly case management fee payments (per member, per month fee) for the month of May 2006. Some PCCM checks issued for May 2006 did not reflect the appropriate amount in relation to the actual number of clients assigned to the primary care provider on the May 2006 Panel Report Roster. Click on the title for complete details.
	PCCM Enrollment Issue Identified
	The Texas Health and Human Services Commission (HHSC) recently identified an issue with Primary Care Case Management (PCCM) that may affect a small number of Medicaid clients.
	PCCM Conference Calls
	On September 1, 2005, Primary Care Case Management (PCCM), a Medicaid managed care program, expanded to an additional 197 Texas counties. To ensure smooth implementation, TMHP will host a series of conference calls for providers who want additional information on the PCCM expansion.
	Providers Can Serve Both PCCM and HMO Clients
	Information Posted July 28, 2006: In recent months, you have received information about upcoming Medicaid managed care program changes affecting PCCM clients in the STAR Medicaid program. Effective December 1, 2006, PCCM Medicaid clients (except SSI-related clients) living in the STAR program service areas of Bexar, Dallas, El Paso, Harris, Harris Expansion, and Lubbock will no longer have PCCM as an option for Medicaid covered health care services. The Health and Human Services Commission mailed out initial notification letters and enrollment kits to affected clients in July 2006. Click on the title for more details.
	Reimbursement for After-hours Services to PCCM Clients
	Information Posted September 1, 2006: After-hours care for FQHCs and RHCs is defined as care provided on weekends, on federal holidays, or before 8 a.m. and after 5 p.m. Monday through Friday. FQHCs and RHCs who provide after-hours services to Primary Care Case Management (PCCM) clients who have not selected the FQHC or RHC as their primary care provider are required to obtain a referral from the PCCM client's primary care provider. The rule that allows FQHCs and RHCs to be reimbursed for after-hours services provided to a client without a referral from the primary care provider only applies to health maintenance organizations (HMOs). PCCM is not an HMO. Click on the title for more information.
	PCCM Client Notification of a Primary Care Provider Change
	Information posted September 10, 2007: Effective November 1, 2007, Primary Care Case Management (PCCM) clients will receive a notification letter after changing their primary care provider. Click on the title to view the details.
	PCCM Case Management Fee Issue Identified
	Information posted January 18, 2008: TMHP has identified an issue that may affect Primary Care Case Management (PCCM) primary care providers’ monthly case management fee payments for the month of December 2007. Some PCCM case management payments issued for December 2007 did not reflect the appropriate amount for the number of clients assigned to the primary care provider on the December 2007 Panel Report roster. Click the title to view the details.
	Change in PCCM Primary Care Provider Assignment Effective February 1, 2007
	Information posted January 30, 2007: Effective February 1, 2007, the primary care provider selection process allows new Primary Care Case Management (PCCM) clients to choose their primary care provider before one is assigned. Previously, PCCM clients were assigned a primary care provider at the time of enrollment. Click on the title for more information.
	Help Available for PCCM Providers with Clients Who Frequently Miss Appointments
	Information posted August 28, 2008: Primary Care Case Management providers can take advantage of a free Community Health Services program for clients who frequently miss appointments. The program educates clients about the importance of keeping their appointments, helps clients schedule transportation to medical appointments, and provides other care coordination services. Community Health Services coordinators are located in PCCM counties throughout the state and can direct clients to local services. Providers can also refer clients to Community Health Services for medical education about diagnoses and health-related issues. Click on the title to view the details.
	Optometry and Ophthalmology Claims Reprocessing for PCCM Providers
	Information posted December 23, 2008: TMHP has identified an issue affecting non-surgical claims submitted by optometrists and ophthalmologists with dates of service on or after September 1, 2007, for Primary Care Case Management (PCCM) clients. These claims may have been inappropriately denied because of a missing primary care provider referral. Primary care provider referrals are not required for routine vision services. Affected claims will be reprocessed beginning on January 12, 2009. Payments will be adjusted accordingly. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at 1-800-925-9126.
	Anesthesia, Consultation, and Medical Procedure Codes Claims Reprocessing
	Information posted April 24, 2009: TMHP has identified an issue that affects Primary Care Case Management (PCCM) claims for dates of service on or after September 1, 2007, that were billed with procedure code 7-00534, 7-00540, 3-99252, 3-99255, or 1-J1885. These claims may have been reimbursed at an incorrect rate. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Providers should refer to the fee schedule for pricing. For more information call the PCCM Provider Helpline at 1-888-834-7226.