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).

Pasos Sanos de Texas es un programa gratis para niños menores de 21 años que reciben Medicaid.  En el examen los niños también reciben vacunas gratis para que se mantengan saludables. 

Aunque su hijo no esté enfermo, es importante que se le hagan estos exámenes.  Los niños de 3 años o más tienen que hacerse el examen de Pasos Sanos de Texas cada año.  Los bebés tienen que hacerse estos exámenes con más frecuencia.

Durante un examen de Pasos Sanos de Texas, el doctor examinará a su hijo de pies a cabeza, revisando si hay problemas de salud que usted posiblemente no haya detectado.  El doctor también examinará si el crecimiento y desarrollo de su hijo es como el de otros niños de su edad.  Estos exámenes pueden ayudar a encontrar problemas de salud antes de que empeoren y sean más difíciles de tratar.

¿Necesita ayuda?

Comuníquese con el coordinador de Pasos Sanos de Texas de Superior al 1-866-807-9990.  Ellos pueden ayudarle a:

• Encontrar a un doctor para el examen de Pasos Sanos de Texas de su hijo
• Programar una cita para el examen
• Contestar preguntas sobre los exámenes médicos o los exámenes de Pasos Sanos de Texas
• Conseguir que le hagan un examen temprano si su familia va a viajar por un trabajo agrícola de temporada

¿Necesita transporte o dinero para la gasolina?

Si necesita transporte gratis o dinero para la gasolina para ir a los exámenes de su hijo, Medicaid puede ayudar. Llame gratis al 1-877-633-8747 (1-877-MED-TRIP). Puede llamar de lunes a viernes, de 8 a.m. a 5 p.m.

¿Es usted un proveedor interesado en inscribirse con Pasos Sanos de Texas?

Llame a Texas Medicaid & Healthcare Partnership al 1-800-925-9126, o vea más información en su sitio web .

Here are two reference guides on those changes:

Imaging Facilities Reference Guide for Radiology Authorization Changes Effective 8/2/2010

Ordering Physicians Reference Guide for Radiology Authorization Changes Effective 8/2/2010