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Texas Children’s Health Plan Provider ManualCHIP and STAR/Medicaid service areasAustinBrazoriaChambersFort agordaMontgomeryNewtonOrangePolkSan hplan.org832-828-1004 or toll-free 1-800-731-8527 2019 Texas Children's Health Plan. All rights reserved. 12/19ND-1910-340November 1, 2019
Provider Quick Reference GuideTexas Children’s Health Plan ProviderNetwork ManagementTexas Children’s Health Plan Provider ClaimsMonday - Friday 8:00 a.m. - 5:00 p.m.Contact us for: Updates to provider demographic information Requests for supplies (forms, directories, etc.) Requests for information on accessing ProviderTouCHPoint, Texas Children’s Health Plan’sweb-based provider portal Request for educational in-services, CME,and educational material Concerns with Texas Children’s Health PlanPolicies and ProceduresPhone 832-828-1004Toll-Free 1-800-731-8527Fax 832-825-8750Email providerrelations@texaschildrens.org Claim inquiry, questions and information aboutCHIP or STAR Eligibility/benefits question on all productsProvider line 832-828-1004Telephone TouCHPoint 832-828-1007Provider line 1-800-731-8527Fax 832-825-8778Fair Hearing Contact informationCall 832-828-1004 or 1-866-959-2555, option 1Texas Children’s Health PlanFraud and Abuse HotlinePhone 832-828-1320Fax 832-825-8722Email FraudandAbuse@texaschildrens.orgProvider ComplaintsPhone 832-828-1004Fax 832-825-8750Email For inquiries 832-828-1063Email TCHPNetworkManagement@texaschildrens.orgFax 832-825-9360Claim Submissions, Corrections, and AppealsPhone 832-828-1004Toll-Free 1-800-731-8527Telephone TouCHPoint 832-828-1007Website texaschildrenshealthplan.org/for-providersEFT Enrollment and QuestionsSubmit claims, corrections, and appeals to:Texas Children’s Health Plan ClaimsPO Box 300286Houston, TX 77230-0286Electronic Claims SubmissionChange Healthcare 1-800-735-8254Payor ID STAR 75228 CHIP 76048Texas Children’s Health PlanP.O. Box 841976Dallas, TX 75284-19761thecheckup.orgTexas Children’s Health Plan’s The Checkup makes it easier forproviders to stay current on news, announcements, blogs andmore. To access, go to thecheckup.org. Claims filing deadline is 95 days from date of service Appeals deadline is 120 days from date of lastdisposition of claim Please submit claim as “CORRECTED CLAIM”Texas Children’s Health PlanRefunds Lockbox AddressChange HealthcarePhone 1-800-735-8254Website changehealthcare.comTexas Children’s Health Plan Provider PortalTexas Children’s Health Plan’s online portal offers convenient24-hour access to: Check claim status Verify member eligibility Check authorization status Authorization requests, submissionsand utilization guidelines Claims appeal submissions Batch claims submissions Provider education material Clinical Practice guidelinesWebsite ldrenshealthplan.org
Provider Quick Reference GuideTexas Children’s Health Plan Pharmacy InformationNavitus website navitus.comNavitus toll free provider hotline 1-877-908-6023Navitus customer care 1-866-333-2757Vision ServicesTexas Children’s Health Plan Women’s HealthPhone 832-828-1430Fax 832-825-8745Dental ServicesDentaQuest (STAR) 1-800-516-0165DentaQuest (CHIP) 1-800-508-6775MCNA Dental 1-800-494-6262Texas Children’s Health PlanCare Coordination, Case and Disease ManagementReferrals for assistance with chronic or complex conditions,such as asthma, obesity or diabetes and women’s healthand maternity. Requests for child birth and healtheducation classes.Phone 832-828-1430Fax 832-825-8745Texas Children’s Health PlanNurse Family PartnershipPhone 832-828-1274Fax 832-825-8710Texas Children’s Health Plan24-Hour Nurse Help LineMembers have access to registered nurses 24 hours a day, 7days a week.Phone 1-800-686-3831Authorization InformationPlease call Texas Children’s Health Plan for further informationif you are unsure of prior authorization requirements. The list ofservices are subject to change and will be updated as required.Phone 832-828-1004Toll-Free 1-800-731-8527Medical Prior Authorization RequestsFax 832-825-8760 or 1-844-473-6860Behavioral Health Prior Authorization RequestsFax 832-825-8767 or 1-844-291-7505Website al Health/Substance Abuse HotlineSTAR 1-800-731-8529CHIP 1-800-731-8528Envolve VisionCHIP 1-844-520-3711STAR 1-844-683-2305Texas Children’s Health Plan Laboratory ServicesProviders should refer members for laboratory services toQuest using an appropriate vendor requisition form. Somelaboratory services may require prior viders/provider-resourcesTexas Children’s Health Service CoordinationPhone 1-800-659-5764Fax number 1 346-232-4781Fax number 2 346-232-4782Approved Texas HHSC EVV vendorsDataLogic (Vesta) Software, IncPhone 1-844-880-2400Tech Support Email support@vesta.netWebsite vestaevv.comEVV Questions and ConcernsContact Provider RelationsPhone 832-828-1004Toll-Free 1-800-731-8527Fax 832-825-8750Phone Numbers for State ProgramsCHIP Help Line 1-800-647-6558Early ChildhoodIntervention (ECI) 1-877-787-8999, select language,then select option 3Office of Women’s Healthand Education Services 512-458-7796Medical TransportationProgram (MTP) 1-877-MED-TRIP (633-8747)Texas Health Steps 1-877-847-8377Women, Infants & ChildrenProgram (WIC) 1-800-942-3678Vaccine for Children (VFC) 1-800-252-9152, select option 1,then select language2texaschildrenshealthplan.org
CONTENTSContentsPROVIDER QUICK REFERENCE GUIDE. . . . . . . . 1SECTION I. INTRODUCTION . . . . . . . . . . . . . . . . 8BACKGROUND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8NOTIFICATION OF UPDATES INPROVIDER INFORMATION. . . . . . . . . . . . . . . . . . . . . . 16NOTIFICATION OF UPDATES TOPANEL STATUS AND RESTRICTIONS. . . . . . . . . . . . . . 16STAR PROGRAM OBJECTIVES. . . . . . . . . . . . . . . . . . . . . . 8CREDENTIALING AND RECREDENTIALING. . . . . . . 16CHIP PROGRAM OBJECTIVES. . . . . . . . . . . . . . . . . . . . . . 8TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17STAR KIDS PROGRAM OBJECTIVES. . . . . . . . . . . . . . . . . 8Provider Requests Termination. . . . . . . . . . . . . . . . . . . . . . 17CONTACTING TEXAS CHILDREN’S HEALTH PLAN. . . 8Termination of Provider by Texas Children’s Health Plan. . 17Provider Network Management. . . . . . . . . . . . . . . . . . . . . . . 8COORDINATION WITH TEXAS DEPARTMENT OFFAMILY AND PROTECTIVE SERVICES . . . . . . . . . . . . . 17SECTION II.PROVIDER ROLES & RESPONSIBILITIES. . . . . . . 9ROLE OF A PRIMARY CARE PROVIDER. . . . . . . . . . . . . . 9ROLE OF THE SPECIALTY CARE PROVIDER(SPECIALIST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9STAR, CHIP and CHIP Perinate Newborn Members . . . . . . . 9Specialist as a Primary Care Provider. . . . . . . . . . . . . . . . . . . 9ROLE OF THE CHIP PERINATE PROVIDER. . . . . . . . . . . 9ROLE OF AN OB/GYN. . . . . . . . . . . . . . . . . . . . . . . . . . 10ROLE OF THE PHARMACY. . . . . . . . . . . . . . . . . . . . . . 10ROLE OF A DENTAL PROVIDER. . . . . . . . . . . . . . . . . . 10Role of Main Dental Home. . . . . . . . . . . . . . . . . . . . . . . . 10Helping Members Find Dental Care. . . . . . . . . . . . . . . . . . 10VISION SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10NETWORK LIMITATIONS . . . . . . . . . . . . . . . . . . . . . . . 11REFERRALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11ACCESS TO SECOND OPINION . . . . . . . . . . . . . . . . . 11REPORTING ABUSE, NEGLECT OR EXPLOITATION. 17Report to Texas Health andHuman Services Commission (HHSC). . . . . . . . . . . . . . . . 18Report to the Department ofFamily and Protective Services (DFPS). . . . . . . . . . . . . . . . 18Report to Local Law Enforcement . . . . . . . . . . . . . . . . . . . 18Failure to Report or False Reporting. . . . . . . . . . . . . . . . . . 18FRAUD, WASTE AND ABUSE PREVENTION. . . . . . . . 18Reporting Fraud, Waste or Abuse. . . . . . . . . . . . . . . . . . . . 19Information Needed to Report Fraud, Waste or Abuse . . . 19PROVIDER MARKETING . . . . . . . . . . . . . . . . . . . . . . . . 19REQUIRED MEDICAL RECORD DOCUMENTATION. 20CULTURAL COMPETENCY. . . . . . . . . . . . . . . . . . . . . . 21Reading/Grade Level Consideration . . . . . . . . . . . . . . . . . . 21Sensitivity and Awareness. . . . . . . . . . . . . . . . . . . . . . . . . . 21Language Translation Services. . . . . . . . . . . . . . . . . . . . . . 21AVAILABILITY AND ACCESSIBILITY. . . . . . . . . . . . . . . 12SECTION III.MEMBER ELIGIBILITY AND ENROLLMENT. . . 22VERIFYING MEMBER ELIGIBILITY. . . . . . . . . . . . . . . . . 22Appointment Availability. . . . . . . . . . . . . . . . . . . . . . . . . . . 12Verifying Medicaid Member Eligibility. . . . . . . . . . . . . . . . . 22After Hours Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Verifying Health Plan Eligibility. . . . . . . . . . . . . . . . . . . . . . 22Monitoring Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Texas Children’s Health Plan Identification Card . . . . . . . . 22ROUTINE, URGENT AND EMERGENCY SERVICES . . 13Member Listing for Primary Care Providers. . . . . . . . . . . . 23Routine Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Your Texas Benefits Medicaid Card . . . . . . . . . . . . . . . . . . 23Urgent Condition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Temporary Medicaid Identification. . . . . . . . . . . . . . . . . . . 23Emergency Medical Condition. . . . . . . . . . . . . . . . . . . . . . 14Automated Inquiry System. . . . . . . . . . . . . . . . . . . . . . . . . 23AMBULANCE TRANSPORTATION. . . . . . . . . . . . . . . . 14TexMedConnect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Emergency Ambulance Transportation. . . . . . . . . . . . . . . . 14Non-Emergency Ambulance Transportation. . . . . . . . . . . . 15MEDICAID (STAR) MEMBERENROLLMENT AND ELIGIBILITY. . . . . . . . . . . . . . . . . 23EMERGENCY CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23CONTINUITY OF CARE . . . . . . . . . . . . . . . . . . . . . . . . 15Newborn Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ADVANCE DIRECTIVES. . . . . . . . . . . . . . . . . . . . . . . . . 16Automatic Re-Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 24TEXAS VACCINES FOR CHILDREN PROGRAM. . . . . 16Disenrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24VERIFYING MEMBER ELIGIBILITY. . . . . . . . . . . . . . . . . 11Disenrollment by Texas Children’s Health Plan. . . . . . . . . . 243texaschildrenshealthplan.org
CONTENTSMember Removal from a Provider Panel. . . . . . . . . . . . . . 24Pregnant Women and Infants . . . . . . . . . . . . . . . . . . . . . . 24Pregnant Teens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Health Plan Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25CHIP AND CHIP PERINATENEWBORN COVERED SERVICES. . . . . . . . . . . . . . . . . 37CHIP and CHIP Perinate Newborn Benefitsand Cost Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38STAR Member Rights and Responsibilities. . . . . . . . . . . . . 25CHIP and CHIP Perinate Newborn Exclusionsfrom Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CHIP AND CHIP PERINATE NEWBORN MEMBERENROLLMENT AND ELIGIBILITY. . . . . . . . . . . . . . . . . 27CHIP and CHIP Perinate Newborn DME and Supplies . . . 51Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Reenrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Disenrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Health Plan Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28CHIP Member Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . 28Pregnant Teens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28CHIP and CHIP Perinate Newborn Member Rights andResponsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28CHIP PERINATE MEMBER ENROLLMENT ANDELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Newborn Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Disenrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Plan Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Eligibility Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31CHIP Perinate Member Rights and Responsibilities. . . . . . 32SECTION IV. COVERED SERVICES. . . . . . . . . . . 33MEMBER HANDBOOK. . . . . . . . . . . . . . . . . . . . . . . . . . 33SPELL OF ILLNESS AND ANNUALMAXIMUM LIMITATION. . . . . . . . . . . . . . . . . . . . . . . . . 33COORDINATION WITH OTHERSTATE PROGRAM SERVICES. . . . . . . . . . . . . . . . . . . . . . 33CHIP Copay Requirements. . . . . . . . . . . . . . . . . . . . . . . . . 56Additional Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Value Added Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57CHIP PERINATE COVERED SERVICES . . . . . . . . . . . . . 57CHIP Perinate Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57CHIP Perinate Exclusions from Covered Services. . . . . . . . 63Value Added Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64BREAST PUMP COVERAGE INMEDICAID AND CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . 64SECTION V. TEXAS HEALTH STEPS. . . . . . . . . 65TEXAS HEALTH STEPS . . . . . . . . . . . . . . . . . . . . . . . . . 65BECOMING A TEXAS HEALTH STEPS PROVIDER . . . 65MORE ABOUT TEXAS HEALTH STEPS. . . . . . . . . . . . . 65MEDICAL CHECKUPS AND SCREENINGS . . . . . . . . . 65Medical Checkup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Performing Newborn Screenings. . . . . . . . . . . . . . . . . . . . . 66Newborn Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Performing Adolescent Screenings. . . . . . . . . . . . . . . . . . . . 66Exceptions to Periodicity Allowed. . . . . . . . . . . . . . . . . . . . 66TEXAS HEALTH STEPS ENVIRONMENTALLEAD INVESTIGATION (ELI). . . . . . . . . . . . . . . . . . . . . 66LABORATORY TESTING. . . . . . . . . . . . . . . . . . . . . . . . . 66Coordination with Public Health. . . . . . . . . . . . . . . . . . . . . 33IMMUNIZATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Coordination for Services Not Directly ProvidedThrough Texas Children’s Health Plan. . . . . . . . . . . . . . . . 33VACCINES FOR CHILDREN. . . . . . . . . . . . . . . . . . . . . . 67Texas HHSC Medical Transportation Program (MTP). . . . 34First
1 texaschildrenshealthplan.org Texas Children’s Health Plan Provider Network Management Monday - Friday 8:00 a.m. - 5:00 p.m. Cont
