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Texas Department of State Health Services TDSHS Primary Care Group 2008 TIHCA Conference A True

11/20/2008. 2. Objective. Address challenges and key issues facing CIHCP staff regarding aspects of bill payment. Provide an opportunity for you to: test your program knowledge; share observations and experiences; and hear possible solutions for solving problems related to your role in the hea

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Texas Department of State Health Services TDSHS Primary Care Group 2008 TIHCA Conference A True

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    1. 11/20/2008 1 Texas Department of State Health Services (TDSHS) Primary Care Group 2008 TIHCA Conference A True / False Test of Your CIHCP Knowledge

    2. 11/20/2008 2 Objective Address challenges and key issues facing CIHCP staff regarding aspects of bill payment. Provide an opportunity for you to: test your program knowledge; share observations and experiences; and hear possible solutions for solving problems related to your role in the health care setting.

    3. 11/20/2008 3 Basic Health Care Services County programs shall provide basic health care services and in addition may provide other medically necessary services or supplies that the county determines to be cost-effective. Hospital districts and public hospitals shall endeavor to provide the basic health care services a county is required to provide.

    4. 11/20/2008 4 General Principles (Section Four, Service Delivery) A county shall provide the health care services established by TDSHS in the handbook or less restrictive health care services. Services or supplies must be reasonable and medically necessary for diagnosis and treatment. In addition to providing basic health care services, a county may provide other department-approved optional health care services that the county determines to be cost-effective.

    5. 11/20/2008 5 TDSHS-established Basic Health Care Services (Section Four, Service Delivery) Physician Services Annual physical examinations Immunizations Medical Screening Services Laboratory and X-ray Services Family Planning Services Skilled Nursing Facility Services Prescription Drugs Rural Health Clinic Services Inpatient Hospital Services Outpatient Hospital Services

    6. 11/20/2008 6 TDSHS-established Optional Health Care Services (Section Four, Service Delivery) Advanced Practice Nurse Services Ambulatory Surgical Center (Freestanding) Services Colostomy Medical Supplies and Equipment Counseling Services Dental Care Diabetic Medical Supplies and Equipment Durable Medical equipment Emergency Medical Services Home and Community Health Care services Physician Assistant Services Vision Care, Including Eyeglasses Federally Qualified Health Center Services Other medically necessary services or supplies that the local governmental municipality/entity determines cost effective

    7. 11/20/2008 7 Statement #1 A providers signature is required on the UB-04 billing form for it to be payable by the CIHCP.

    8. 11/20/2008 8 Answer #1 FALSE Chapter 61 does not address claim forms. However, the backside of the UB-04 claim form states Submission of this claim form constitutes certification that the billing information as shown on the face hereof is true, accurate and complete.

    9. 11/20/2008 9 Statement #2 The county responsibilities that are defined in Chapter 61 are only intended for those county programs that receive state assistance from the DSHS.

    10. 11/20/2008 10 Answer #2 FALSE The responsibilities that are defined in Chapter 61 are directed to all counties regardless of the acceptance of state assistance.

    11. 11/20/2008 11 Statement #3 A county is not liable for the cost of a health care service that is in excess of the payment standards established by the DSHS.

    12. 11/20/2008 12 Answer #3 TRUE Chapter 61, Section 61.034 (a).

    13. 11/20/2008 13 Statement #4 Bill payment disputes between a provider and a county or a provider and a hospital district shall be submitted to the DSHS.

    14. 11/20/2008 14 Answer #4 FALSE The DSHS does not determine disputes regarding bill payment. However, eligibility and residency disputes may be submitted to the DSHS.

    15. 11/20/2008 15 Statement #5 Counties, hospital districts, and public hospitals only have to verbally explain to a client the procedure for appealing a denial for assistance. Be sure to review CIHCP Handbook Section Four, Service Delivery, pages 65-75 for specific instructions on what is covered and what is not. Be sure to review CIHCP Handbook Section Four, Service Delivery, pages 65-75 for specific instructions on what is covered and what is not.

    16. 11/20/2008 16 Answer #5 FALSE Chapter 61, Section 61.024 (j) states the entity shall provide written notification which will include an explanation of the procedure to appeal.

    17. 11/20/2008 17 Statement #6 Counties, hospital districts, and public hospitals have a per client liability for each state fiscal year of $30,000.00.

    18. 11/20/2008 18 Answer #6 FALSE Chapter 61, Section 61.035, only states the maximum county liability.

    19. 11/20/2008 19 Statement #7 The $30,000.00 payment limitation has been met if a public hospital spent $10,000.00 on a CIHCP client at their facility and then $20,000.00 when that client was transferred out to a non-affiliated hospital.

    20. 11/20/2008 20 Answer #7 FALSE Chapter 61, Section 61.061 states payment rates and limits that relate to county services apply to inpatient and outpatient hospital services if: the hospital cannot provide the services or emergency services that are required; AND the services are provided by an entity other than the hospital.

    21. 11/20/2008 21 Statement #8 The $30,000.00 county liability is applied to the fiscal year in which the service was provided.

    22. 11/20/2008 22 Answer #8 TRUE Chapter 61, Section 61.035.

    23. 11/20/2008 23 Statement #9 An incomplete claim, initially received within the 95 day filing deadline, was returned to the provider for missing information. When the provider resubmitted the claim it was received outside the 95 days. This is no longer a payable claim.

    24. 11/20/2008 24 Answer #9 TRUE & FALSE Chapter 61 does not address claim forms. The CIHCP Handbook does not define the required elements of claim forms.

    25. 11/20/2008 25 Statement #10 The expenditures paid on eligible county jail inmates by a county may be credited towards state assistance if the county has a Form 100 (CIHCP application) completed by the inmate and a Form 101 (CIHCP worksheet) on file.

    26. 11/20/2008 26 Answer #10 TRUE Chapter 61, Section 61.007 Information Provided by Applicant, states The department by rule shall require each applicant to provide at least the following information: it then lists items (1) (8) which are the questions listed on Form 100.

    27. 11/20/2008 27 Statement #11 A CIHCP applicant may be denied from the program for having health insurance or other health care benefits.

    28. 11/20/2008 28 Answer #11 FALSE Chapter 61, Section 61.022 (a) states The county is payor of last resort and shall provide assistance only if other adequate public or private sources of payment are not available.

    29. 11/20/2008 29 Statement #12 A county may credit towards state assistance expenditures for payment of their CIHCP clients health insurance premiums, co-pays, and deductibles.

    30. 11/20/2008 30 Answer #12 FALSE Chapter 61, Section 61.029 (a) states A county may arrange to provide health care services through. or the purchase of insurance for eligible residents.

    31. 11/20/2008 31 Statement #13 A client receives services at a hospital that has a charity care assistance program. Due to the existence of the charity care program, the CIHCP is not responsible for payment of the health care services received at that hospital.

    32. 11/20/2008 32 Answer #13 FALSE Chapter 61, Section 61.033 (b) states if another source of payment does not adequately cover a health care service the county shall pay for or provide the health care service for which other payment is not available.

    33. 11/20/2008 33 Statement #14 Physical therapy services received in a rehabilitative facility (not a hospital) are covered as an optional health care service.

    34. 11/20/2008 34 Answer #14 TRUE TAC Rule, optional health care service #13 allows an entity to elect to cover other medically necessary services or supplies they determine it to be cost effective.

    35. 11/20/2008 35 Statement #15 A county, public hospital, or hospital district may pay a claim for a 90-day supply of prescription medication.

    36. 11/20/2008 36 Answer #15 TRUE Chapter 61 only states payment for not more than three prescriptions drugs a month.

    37. 11/20/2008 37 Statement #16 When a basic or optional CIHCP service does not fall within the 365-day federal filing deadline for Medicaid reimbursement, programs do not have to provide that service to the CIHCP client.

    38. 11/20/2008 38 Answer #16 FALSE The 365-day federal filing deadline for Medicaid reimbursement should not be used to determine whether a CIHCP client receives covered CIHCP health care services.

    39. 11/20/2008 39 Statement #17 The DSHS calculates the payment rates used for RHC, FQHC, inpatient, and outpatient services.

    40. 11/20/2008 40 Answer #17 FALSE Chapter 61 states the DSHS defines the payment standards in accordance with TANF; however, DSHS does not calculate what each rate will be.

    41. 11/20/2008 41 Statement #18 The DSHS updates the RHC, FQHC, inpatient, and outpatient rates on an annual basis.

    42. 11/20/2008 42 Answer #18 TRUE These rates are updated and posted in the CIHCP Handbook and website by the DSHS annually.

    43. 11/20/2008 43 Statement #19 Regarding the TMHP Fee Schedules, if a CPT code is not listed but the provider states Medicaid has paid them in the past you may negotiate a rate with the provider.

    44. 11/20/2008 44 Answer #19 TRUE You may ask the provider to present to you the explanation of benefits showing the payment from Medicaid.

    45. 11/20/2008 45 Statement #20 CIHCP basic and optional health care services may not always be reimbursed by Medicaid.

    46. 11/20/2008 46 Answer #20 TRUE Medicaid may require prior authorization or additional medical documentation from the provider for payment of that service.

    47. 11/20/2008 47 Statement #21 A client who is on the CIHCP may also receive services from the Womens Health Program.

    48. 11/20/2008 48 Answer #21 TRUE The Womens Health Program does not provide full comprehensive Medicaid benefits.

    49. 11/20/2008 49 Statement #22 Hospital Ambulatory Surgical Center (ASC) rates may be used to pay non-emergency surgeries that are billed as an outpatient hospital service on the UB-04 claim form.

    50. 11/20/2008 50 Answer #22 TRUE CIHCP Handbook, Section 4, page 39.

    51. 11/20/2008 51 Statement #23 Freestanding ASC services should be billed as one inclusive charge on a CMS-1500 claim form and are paid if the county has chosen ASC services as a CIHCP optional service.

    52. 11/20/2008 52 Answer #23 TRUE CIHCP Handbook, Section 4, page 67.

    53. 11/20/2008 53 Statement #24 A woman eligible for the Breast and Cervical Cancer Services may still be eligible for the CIHCP.

    54. 11/20/2008 54 Answer #24 FALSE A woman eligible for MBCC is entitled to full Medicaid coverage beginning the date after the day of diagnosis. (Not limited to the treatment of breast and cervical cancer)

    55. 11/20/2008 55 Statement #25 The 5% reduction of payment for inpatient and outpatient hospital services ceased as of dates of services 08-31-2007.

    56. 11/20/2008 56 Answer #25 FALSE CIHCP Handbook, Section 4, pages 37 and 39. The 5% reduction of payment for inpatient services beginning dates of service 09-01-2004 remains in effect. However, the 2.5% reduction of payment for outpatient services beginning dates of service 09-01-2003 ceased as of dates of service 08-31-2007.

    57. 11/20/2008 57 THE END

    58. 11/20/2008 58 Website www.dshs.state.tx.us/cihcp/default.htm

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