Superior Health Plan Blog

Primary Care Update – September 2010

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The Spring 2010 Edition of Superior’s Member Newsletter “Healthy Moves” is now available on the Newsletter page.

This entry is filed under News.

Effective September 1, 2010, the Children’s Health Insurance Program (CHIP) Perinatal Program has changed the way professional (non-facility) services provided to a newborn at or below 185 percent of the federal poverty level (FPL) are reimbursed. The federal government has directed HHSC to provide 12 months of continuous Medicaid coverage for these newborns, which impacts the claims payment process.

The primary change in claims payment for newborns at or below 185 percent FPL affects professional charges associated with newborn care. For newborns born on or after September 1, 2010, these charges will be billed to Medicaid, rather than the CHIP Perinatal Program health plan.

Claims for CHIP Perinatal Program clients at or below 185 percent FPL are submitted as follows for services provided to newborns (born September 1, 2010 or after):

• Hospital facility services claims are submitted to and considered for reimbursement   by Texas Medicaid.
• Professional services claims are also submitted to and considered for reimbursement by Texas Medicaid. TMHP will process claims for professional services incurred prior to the newborn’s enrollment in a Medicaid Managed Care health plan (see below).

Providers must continue to submit claims to TMHP for services provided to children enrolled in the Primary Care Case Management program (PCCM) for consideration of reimbursement.

A newborn at or below 185 percent FPL who is born on or after September 1, 2010, will be prospectively enrolled in Medicaid managed care if he or she qualifies and lives in a Medicaid managed care area. Beginning on the date of enrollment in Medicaid managed care, all claims for the newborn must be submitted to Medicaid managed care with the following exception.

If the newborn is enrolled in Medicaid managed care during an inpatient stay, claims for services rendered during the inpatient stay must be billed and considered for payment as follows:

Note that this process only applies to the inpatient stay that coincides with the date of enrollment in Medicaid managed care. If the newborn is admitted to the hospital after the date of enrollment in Medicaid managed care, standard billing procedures will apply.

Important Changes Related to the Establishment of Medicaid Coverage for CHIP Perinatal Newborn

Establishing Medicaid for the newborn requires the submission of the Emergency Medical Services Certification Form H3038 for the mother’s labor with delivery. The mother must establish Emergency Medicaid in order for the newborn to receive Medicaid coverage. Previously, the issuance of a Medicaid number for the newborn under Type Program (TP) 73 was based solely on a report of birth. The TP 73 number could only be used for hospital facility claims submitted to Medicaid for the newborn.

The mother will receive form H3038 in the mail prior to her due date.

Important: If form H3038 is not submitted, emergency Medicaid cannot be established for the mother. In addition, if form H3038 is not submitted, Medicaid cannot be established for the newborn from the date of birth with an additional 12 months of Medicaid coverage.

Establishing Medicaid (and issuance of a Medicaid number) can take up to 45 days after form H3038 is submitted. Medicaid eligibility for the mother and infant can be verified online at www.tmhp.com or by calling 1-800-925-9126. Both the mother’s number (TP 30 for Emergency Medicaid) and the infant’s number (TP 45 for newborn) can be verified via the online look-up or via the telephone line. These numbers can also be obtained through the Automated Inquiry System (AIS) at 1-800-925-9126.

Note: Effective September 1, 2010, infants at or below 185 percent FPL will no longer be issued TP 73 numbers.

Additional Information Related to the CHIP Perinatal Program

Labor with delivery claims payment for mothers at or below 185 percent FPL:

• No changes will be made to the claims payment process.
• Hospital facility services claims will continue to be reimbursed through Emergency Medicaid.
• Professional services claims will continue to be reimbursed through the CHIP Perinatal Program health plan.

Labor with delivery claims payment for mothers and newborns 186 to 200 percent FPL:

• No changes will be made to the claims payment process.
• Both professional and hospital facility services claims will continue to be reimbursed through the CHIP Perinatal Program health plan.

No changes have been made to the prenatal care claims payment process. These claims continue to be reimbursed through the CHIP Perinatal Program health plan, regardless of the mother’s income.

Important Information Related to the Report of Birth

A report of birth remains an important step in ensuring timely Medicaid eligibility for the newborn. A birth must be reported to the state via the typical birth registry process (e.g., use of Texas Electronic Registration system [TER]). In TER, the screen containing the Medicaid/CHIP number should continue to be populated with the mother’s alpha-numeric CHIP Perinatal Program number (e.g., J12345678). In addition, a mother can report the birth by calling 1-877-KIDS-NOW (1-877-543-7669).

This entry is filed under News.

Primary Care Update – August 2010

This entry is filed under News.

The Spring 2010 Edition of Superior’s Provider Newsletter “Superior Physicians” is now available on the Newsletter page.

This entry is filed under News.