Appendices

Appendix I-A, Unusual End Dates Report

Revision 19-7; Effective June 3, 2019

 

The Unusual End Dates report lists individual service plans (ISPs) with questionable end dates.

 

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last medical necessity (MN) registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

  • "Y" means the MN was approved.
  • "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

 

Program Support Unit (PSU) Entry Fields

Comments – PSU staff must enter appropriate comments after researching the ISP end dates. For example, an ISP with:

  • an end date of Oct. 30, 2018, is questionable because there are 31 days in October.
  • an end date of Nov. 1, 2018, is questionable because ISPs end on the last day of the month.
  • a begin date of Jan. 1, 2018, and an end date of Dec. 31, 2018, is questionable because ISPs are not open-ended, nor do they end prior to the begin date.

Unusual End Dates is a periodic report sent on an as-needed basis. The PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-B, Individual Service Plan Expiring Report

Revision 19-7; Effective June 3, 2019

 

The Individual Service Plan (ISP) Expiring report is a check and balance method for the ISP expiring at the end of the report month.

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last medical necessity (MN) registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

  • "Y" means the MN was approved.
  • "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

 

Program Support Unit (PSU) Entry Fields

Date 2065D Sent – Enter the date PSU staff uploaded Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral if the:

  • MN column has "N" (denied);
  • PSU research shows the MN is denied;
  • Managed care organization notifies PSU staff of the MN denial;
  • PSU staff learn of the MN denial by any other method;
  • PSU staff learn of no unmet need at the annual reassessment for the new ISP;
  • PSU staff learn of loss of eligibility; or
  • PSU staff learn of any other denial reasons.

If the MN column has "Y" (approved), leave the field blank.

Date MN Registered in SAS - The date the MN is registered in SASO.

Date ISP Registered – Enter the date PSU staff registered the ISP in SASO, if uploaded to TxMedCentral or Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

Date ISP Posted – The date Form H1700-1, Individual Service Plan (Pg. 1), was uploaded by the MCO to TxMedCentral or TMHP LTC Online Portal.

Comments – PSU staff may enter appropriate comments.

Note: Enter information in the “Comments” field in situations where Form H2065-D is completed but the “Date ISP Registered” is not filled out. The reason entered must provide sufficient detail to ensure clarity.

For expired ISP, Date MCO Contacted – Enter the date the MCO was contacted if the ISP has expired.

Date MCO Contacted, 2nd attempt – Enter the 2nd attempt date the MCO was contacted if the ISP has expired.

Date MCO Contacted, 3rd attempt – Enter the 3rd attempt date the MCO was contacted if the ISP has expired.

The ISP Expiring Report is a monthly report. PSU staff are required to research, resolve and respond within 14 days of receipt.

 

Scan Call for ISP Expiring Report process:

  • PSU staff provide the ISP Expiring Report five business days prior to the scheduled scan call.
  • The MCOs research and provide a written status for each member whose ISP expires within 45 days, indicating the status of the member’s reassessment. The MCO must return a completed report to PSU staff two business days prior to the scan call.
  • PSU staff review the MCO's responses to determine if the MCO needs to provide clarification regarding any member's ISP status. During the scan call, only the ISP status about which PSU staff have questions are reviewed. There will no longer be a need to review each member for the status of the ISP if the MCO's response is sufficient.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-C, Mismatched ISP and MN End Dates Report

Revision 19-7; Effective June 3, 2019
 

The Mismatched Individual Service Plan (ISP) and Medical Necessity (MN) End Dates report shows ISP end dates with MN end dates that do not match.

 

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last MN registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

  • "Y" means the MN was approved.
  • "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

 

Program Support Unit (PSU) Entry Fields

Comments (Date and Action taken) – PSU staff must enter appropriate comments after researching the ISP/MN end dates, which should match. For example, an ISP ends on May 31, 2019, and the MN ends on April 30, 2019. PSU staff must research the reason for the mismatch.

There may be valid situations in which the two dates will not match. For example, a Money Follows the Person (MFP) case has an ISP registered for one day. The MN will not match the one-day registration in this case.

Mismatched ISP and MN End Dates is a periodic report sent on an as-needed basis. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-D, STAR+PLUS HCBS Program and Nursing Facility Overlap Report

Revision 19-7; Effective June 3, 2019

 

The STAR+PLUS HCBS Program and Nursing Facility Overlap Report shows overlapping STAR+PLUS Home and Community Based Services (HCBS) program and nursing facility (NF) registrations in the Service Authorization System Online (SASO).

 

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

TP – The member's two-digit Medicaid Type Program.

Plan – The two-digit managed care organization (MCO) plan code.

 

Program Support Unit (PSU) Entry Fields

Date Corrected – The date PSU staff correct the overlap between Service Group (SG) 19, Service Code (SC) 12/13, and SG 1, SC 1/3. PSU staff must not use SC 3A overlapping with SG 19. Only correct overlaps occurring during STAR+PLUS managed care enrollment.

Comments – PSU staff may enter appropriate comments after researching the overlap.

The STAR+PLUS HCBS Program and Nursing Facility Overlap Report is a monthly report. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-E, Monthly Plan Changes Report

Revision 19-7; Effective June 3, 2019

 

The Monthly Plan Changes report gives Program Support Unit (PSU) staff a list of members who have changed managed care organization (MCO) plans. PSU staff must correct the contract number in the Service Authorization System Online (SASO) to reflect all MCO plan changes.

 

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

Current Plan – The two-digit MCO plan code in which the member is currently enrolled.

TP – The member's two-digit Medicaid Type Program.

Prior Plan – The two-digit MCO plan code in which the member was formerly enrolled.

RG – The three-digit Risk Group number.

ISP Begin Date – Enter the begin date of the MCO plan change.

ISP End Date – Enter the end date of the MCO plan change.

 

PSU Entry Fields

Date Completed – PSU staff enter the date SASO corrections were completed.

Comments – Enter any comments relevant to the actions taken.

Monthly Plan Changes is a monthly report. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-F, Loss of Eligibility Report

Revision 19-7; Effective June 3, 2019

 

The STAR+PLUS Loss of Eligibility Report provides to Program Support Unit (PSU) staff a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have lost Medicaid eligibility. PSU staff must conduct coordination activities to either reestablish eligibility or close the authorization(s) in the Service Authorization System Online (SASO).

 

Report Fields

PCN — The member’s nine-digit Medicaid number.

Name — The member’s last name, first name and middle initial (when provided).

RG — The three-digit Risk Group number.

Plan Code — The two-digit managed care organization (MCO) plan code in which the member is currently enrolled.

TP — The member’s two-digit Medicaid Type Program (TP).

 

PSU Entry Field

Eligibility Re-established? — PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) to determine if Medicaid eligibility has been reestablished. If it has, enter "Yes;" if not, enter "No."

If yes, is manual managed care enrollment needed? — If the response to the previous column was "Yes," PSU staff must check TIERS to determine if Medicaid eligibility and managed care enrollment have been established. If manual managed care enrollment is needed, send an email to the Program Enrollment Support (PES) mailbox.

If no, provide the date Form H2065-D was sent. — PSU staff enter the date Form H2065-D, Notification of Managed Care Program Services, was sent.

Was the decision appealed? — PSU staff enter "Yes" or "No." (No further action is necessary if the response to this question is "no.") If "Yes," continue to the next section.

If yes, was eligibility re-established? — PSU staff check TIERS to determine if Medicaid eligibility has been re-established. If it has, enter "Yes;" if not, enter "No." (No further action is necessary if the response to this question is "No.")

If eligibility was re-established, is manual managed care enrollment needed? — If the response to the previous column was "Yes," PSU staff must check TIERS to determine if managed care enrollment have been established. If manual managed care enrollment is needed, send an email to the PES mailbox.

Pending at PSU — Enter “Yes” or “No.”

Pending at MCO — Enter “Yes” or “No.”

Pending at MEPD — Enter “Yes” or “No.”

Comments — Enter any comments relevant to the actions taken.

The STAR+PLUS Loss of Eligibility Report is a monthly report. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt. (The fact that completion of the report itself is due within 14 days of receipt does not negate policy regarding denial notifications. Refer to Section 3622, Notification Requirements. The notification must still be sent within two business days.)

Note: SASO files used by PES staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet

Appendix III, Medicaid Type Program Codes for STAR+PLUS HCBS Program and CFC

Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language

Revision 20-4; Effective September 30, 2020

 

Program Support Unit (PSU) staff must use Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment that is not covered in Appendix IV.

PSU staff must enter the associated STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) section supporting the denial reason on Form H2065-D and H2065-DS, listed in the SPOPH Section column.

Purpose for Form H2065-D Reason for Denial in Plain Language Comments in Plain Language SPOPH Section Service Authorization System Online (SASO) Code
Unable to Contact

You are not eligible for STAR+PLUS HCBS program because HHSC staff or your health plan cannot locate you to complete the assessment required for the program.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque el personal de la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa.

No additional comment should be added. 3632.6 36 – Individual’s Whereabouts Unknown
Voluntarily Declined Services

You are not eligible for STAR+PLUS HCBS program because you voluntarily withdrew from the program.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque abandonó voluntariamente el programa.

No additional comment should be added. 3632.3 05 – Client Requests Service Termination
Enrolled in Another 1915 (c) Medicaid Waiver

You are not eligible for STAR+PLUS HCBS program because you voluntarily withdrew from the program.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque abandonó voluntariamente el programa.

You are not eligible for STAR+PLUS HCBS program because you are currently enrolled in [Select one: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); MDCP; Texas Home Living (TxHmL)]. STAR+PLUS HCBS program services cannot be authorized because you can only be enrolled in one Medicaid waiver program at a time.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque actualmente está inscrito en [Select one: el Programa de Servicios de Apoyo y Asistencia para Vivir en la Comunidad; el Programa para Personas Sordociegas con Discapacidades Múltiples; el Programa de Servicios en el Hogar y en la Comunidad; el Programa para Menores Médicamente Dependientes; el Programa de Texas para Vivir en Casa]. No se pueden autorizar los servicios del programa HCBS de STAR+PLUS porque usted no puede estar inscrito a la vez en más de un programa con exención de Medicaid.

3316 39 – Other
Loss of Medicaid Financial Eligibility

You are not eligible for STAR+PLUS HCBS program because you do not meet the financial criteria necessary for the program.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no cumple los criterios económicos necesarios para participar en el programa.

No additional comment should be added. 3632.4 06 – Client Denied Medicaid Eligibility
Medicaid Eligibility Reinstated within Four Months No reason for denial language should be added.

Your Medicaid was reinstated on [DATE]. Your STAR+PLUS HCBS program services will continue without interruption.

Sus beneficios de Medicaid fueron restablecidos el [DATE]. Usted seguirá recibiendo servicios del programa HCBS de STAR+PLUS sin interrupción.

  N/A
Declined Assessment

You are not eligible for STAR+PLUS HCBS program because you did not let your health plan complete the assessment required for the program.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no permitió que el plan médico realizara la valoración que requiere el programa.

No additional comment should be added. 3632.8 39 – Other
Does Not Have an Unmet Need

You are not eligible for STAR+PLUS HCBS program because you do not need services offered through the program.

Usted no puede recibir los servicios del programa HCBS de STAR+PLUS porque no los necesita.

No additional comment should be added. 3242.2 13 – no unmet need (Six hour)
Inability to Obtain Physician Signature

You are not eligible for STAR+PLUS HCBS program because your doctor didn’t tell us you need the level of care provided in a nursing home.

Usted no puede recibir los Servicios en el Hogar y en la Comunidad (HCBS) de STAR+PLUS porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo.

No additional comment should be added. 3632.7 39 – Other
Medical Necessity Denial Reason for Denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

You are not eligible for STAR+PLUS HCBS program. See the Reason for Denial text box on page 1 of this form and the STAR+PLUS HCBS Program Medical Necessity Denial Attachment for more information.

Usted no reúne los requisitos del programa HCBS de STAR+PLUS. Para más información, vea el cuadro “Motivo de la denegación” en la página 1 de este formulario, así como el anexo “Denegación por no existir necesidad médica” del programa HCBS de STAR+PLUS.

3632.5 08 – Loses Level-of-Care (Medical Necessity)
Individual Service Plan Exceeds Cost Limit

You are not eligible for STAR+PLUS HCBS program because the cost of your individual service plan exceeds the maximum amount allowed.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque el costo de su plan individual de servicios excede la cantidad máxima permitida.

No additional comment should be added. 3633.4 18 – Exceeds Cost Ceiling
Failure to Return Form H1200

You are not eligible for STAR+PLUS HCBS program because you did not return the Medicaid application.

Usted no puede recibir Servicios en el Hogar y en la Comunidad (HCBS) de STAR+PLUS porque no entregó su solicitud de Medicaid.

No additional comment should be added. 3230 N/A
Initial Form H2065-D for MFP to Community No reason for denial language should be added.

You’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Please stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program services will begin.

Usted cumple los requisitos del programa STAR+PLUS HCBS. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa STAR+PLUS HCBS.

  N/A
Initial Form H2065-D for MAO MFP to AFC or ALF No reason for denial language should be added.

You’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Please stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program services will begin. We will also send you a notice telling you how much your room and board and copayment will be.

Usted cumple los requisitos del programa STAR+PLUS HCBS. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa STAR+PLUS HCBS. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.

  N/A
Initial Form H2065-D for SSI MFP to AFC or ALF No reason for denial language should be added.

You’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Please stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program services will begin.

Usted cumple los requisitos del programa STAR+PLUS HCBS. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa STAR+PLUS HCBS.

  N/A
Room and Board and Copayment No reason for denial language should be added.

You must pay room and board and any copayment. You will pay them every month to your foster care home or assisted living facility.

Usted tiene que cubrir los gastos de alojamiento y comida y de cualquier copago. Deberá pagarlos cada mes al hogar de acogida o centro de vida asistida en el que se encuentre.

  N/A
Institutional Stay Over 90 Days

You are not eligible for STAR+PLUS HCBS program because you have entered an institution for a long-term stay, as described in the Code of Federal Regulations (CFR) at Title 42 CFR §441.301(b)(1).

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque ha ingresado en una institución donde tendrá una estancia a largo plazo, como se describe en la sección 441.301(b)(1) del título 42 del Código de Reglamentos Federales (CFR).

You are not eligible for STAR+PLUS HCBS program services while an in-patient of a [Select one: hospital; nursing facility; or intermediate care facility for persons with intellectual disability].

Usted no puede recibir servicios del programa HCBS de STAR+PLUS mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; o un centro de atención intermedia para personas con discapacidad intelectual].

3632.2 03 – Admitted to Institution
Moved Out of State

You are not eligible for STAR+PLUS HCBS program because you are not a Texas resident.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no reside en Texas.

No additional comment should be added. 3631.3 01 – Client Leaves the State/County (Catchment Area)
Under Age 21

You are not eligible for STAR+PLUS HCBS because you are 20 or younger.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque es menor de 21 años.

No additional comment should be added. 2100 39 – Other
Other Contact supervisor. No additional comment should be added. 3632.8 39 – Other

 

Appendix V, Medicaid Program Actions

Appendix VI, STAR+PLUS Inquiry Chart

Appendix VII, Acronyms

Revision 19-7; Effective June 3, 2019

 

The following acronyms are used in the STAR+PLUS Home and Community Based Services (HCBS) Program.

Acronym Description
AA Adaptive Aids
ADL Activity of Daily Living
AFC Adult Foster Care
AL Assisted Living
ALF Assisted Living Facility
AO Agency Option
APS Adult Protective Services
CAP Corrective Action Plan
CARE Client Assignment and Registration
CAS Community Attendant Services
CBA Community Based Alternatives
CCAD Community Care for Aged and Disabled
CCSE Community Care Services Eligibility
CCP Comprehensive Care Program
CDS Consumer Directed Services
CFC Community First Choice
CFR Code of Federal Regulations
CHIP Children's Health Insurance Program
CLASS Community Living Assistance and Support Services
CMPAS Client Managed Personal Attendant Services
CMS Claims Management System
CMS Centers for Medicare and Medicaid Services
CNA Certified Nursing Assistant
COLA Cost of Living Adjustment
CRU Centralized Representation Unit
CSHCN Children with Special Health Care Needs
CSIL Community Services Interest List
DAC Disabled Adult Child
DAHS Day Activity and Health Services
DBMD Deaf Blind with Multiple Disabilities
DDS Disability Determination Services
DDU Disability Determination Unit
DER Data Entry Representative
DFPS Department of Family and Protective Services
DIA Diagnosis
DID Determination of Intellectual Disability
DIU Data Integrity Unit
DME Durable Medical Equipment
DOB Date of Birth
DOD Date of Death
DR Designated Representative
DSHS Department of State Health Services
ERS Enrollment Resolutions Services
ERS Emergency Response Service
FBR Federal Benefit Rate
FC Family Care Title XX
FFS Fee-for-Service
FH Fair Hearing
FHO Fair Hearings Officer
FMSA Financial Management Services Agency
GR General Revenue
HCBS Home and Community Based Services
HCS Home and Community-based Services
HCSS Home and Community Support Services
HCSSA Home and Community Support Services Agency
HDM Home-Delivered Meals
HEART Health and Human Services Enterprise Administrative Report and Tracking System
HHS Health and Human Services
HHSC Health and Human Services Commission
HICAP Health Information Counseling and Advocacy Program
HIPAA Health Insurance Portability and Accountability Act
HIPP Health Insurance Premium Payment Program
HMA Health Maintenance Activity
IADL Instrumental Activity of Daily Living
ICF/IID Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions
IDD Intellectual or Developmental Disability
IDT Interdisciplinary Team
ILM Interest List Management
IME Incurred Medical Expense
ISP Individual Service Plan
LAR Legally Authorized Representative
LCSW Licensed Clinical Social Worker
LIDDA Local Intellectual and Developmental Disability Authority
LOC Level of Care
LOS Level of Service
LTC Long Term Care
LTC-R Long Term Care Regulatory
LTSS Long Term Services and Supports
LVN Licensed Vocational Nurse
MAO Medical Assistance Only
MBI Medicaid Buy-In
MC Managed Care
MCO Managed Care Organization
MCCO Managed Care Compliance & Operations
MDCP Medically Dependent Children Program
MDS Minimum Data Set
Med ID Medicaid Identification Card
MEPD Medicaid for the Elderly and People with Disabilities
MERP Medicaid Estate Recovery Program
MESAV Medicaid Eligibility Service Authorization Verification
MFP Money Follows the Person
MFPD Money Follows the Person Demonstration
MHM Minor Home Modification
MMP Medicare-Medicaid Plan
MN Medical Necessity
MN/LOC Medical Necessity and Level of Care
MRSA Medicaid Rural Service Area
MSHCN Members with Special Health Care Needs
NF Nursing Facility
OT Occupational Therapy
OTA Occupational Therapy Assistance
PACE Program of All-inclusive Care for the Elderly
PAS Personal Assistance Services
PCN Patient Control Number
PCP Primary Care Provider;
PCS Personal Care Services
PCS Provider Claims Services
PDN Private Duty Nursing
PES Program Enrollment and Support
PHC Primary Home Care
PNA Personal Needs Allowance
POC Plan of Care
PPECC Prescribed Pediatric Extended Care Center
PPS Premiums Payable System
PSU Program Support Unit
PT Physical Therapy
PTA Physical Therapy Assistance
QIT Qualified Income Trust
QMB Qualified Medicare Beneficiary
R&B Room and Board
RN Registered Nurse
RSDI Retirement and Survivors Disability Insurance
RUG Resource Utilization Group
SASO Service Authorization System Online
SC Service Code
SCSA Significant Change in Status Assessment
SDX State Data Exchange
SE Supported Employment
SG Service Group
SLMB Specified Low-Income Medicare Beneficiaries
SNAP Supplemental Nutrition Assistance Program
SO State Office
SOC Start of Care
SOLQ State On-Line Query
SPT Service Planning Team
SRO Service Responsibility Option
SSA Social Security Administration
SSI Supplemental Security Income
SSN Social Security Number
SSPD Special Services to Persons with Disabilities
ST Speech Therapy
STAR State of Texas Access Reform
STAR+PLUS State of Texas Access Reform Plus
STAR+PLUS HCBS program State of Texas Access Reform Plus Home and Community Based Services program
STS Supplemental Transition Support
TAC Texas Administrative Code
TANF Temporary Assistance to Needy Families
TAS Transition Assistance Services
TDI Texas Department of Insurance
THStep-CCP Texas Health Steps – Comprehensive Care Program
TIERS Texas Integrated Eligibility Redesign System
TMHP Texas Medicaid & Healthcare Partnership
TOA Type of Assistance
TP Type Program
TPR Third-Party Resource
TW Texas Works
TxHmL Texas Home Living
UAP Unlicensed Assistive Person
UMCC Uniform Managed Care Contract
UMCM Uniform Managed Care Manual
WTPY Wire Third Party Query

Appendix VIII, Monthly Income/Resource Limits

Appendix IX, Time Calculation

Appendix X, STAR+PLUS HCBS Cost Limits

Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment

Revision 21-6; Effective June 28, 2021

 

English Word: Appendix XI, Fair Hearing Options for STAR+PLUS HCBS Program Denials

Spanish Word: Appendix XI, Opciones de audiencia imparcial para las denegaciónes del programa HCBS de STAR+PLUS

Appendix XII, STAR+PLUS HCBS Program Description

Revision 19-3; Effective April 10, 2019

 

English Word: Appendix XII, STAR+PLUS HCBS Program Description

Spanish Word: Appendix XII, Servicios en el Hogar y la Comunidad de STAR+PLUS

Appendix XIII, Your Financial Rights in an Assisted Living Facility STAR+PLUS

Revision 18-0; Effective September 4, 2018

 

For information about document accessibility, contact Editorial_Services@hhsc.state.tx.us

Your Financial Rights in an Assisted Living Facility STAR+PLUS

Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program

Revision 18-0; Effective September 4, 2018

 

An individual entering the STAR+PLUS Home and Community Based Services (HCBS) program is designated as having high needs status if:

  • the individual is on ventilator care;
  • the individual has high-skilled nursing needs, such as tracheotomy care, wound care, suctioning or feeding tubes; and/or
  • the individual will exceed the individual service plan (ISP) cost limit and has needs that will require special services or service delivery, and the community support/resources have not been identified.

Appendix XV, Services Available from Other State Agencies

Appendix XV-A, Department of State Health Services

Appendix XV-C, Texas Veterans Commission

Appendix XV-D, Texas Department of Housing and Community Affairs

Appendix XV-E, Department of Family and Protective Services

Appendix XV-F, Rehabilitation Technology Resource Center

Appendix XVI, SASO Service Group, Service Code and Termination Code

Appendix XVII, State Cutoff Dates

Appendix XVIII, Mutually Exclusive Services

Appendix XIX, Nursing Facility Counter Logic

Appendix XX, Reserved for Future Use

Appendix XXI, Reserved for Future Use

Appendix XXII, HHSC Benefits Portal and TIERS Inquiry Desk Guide

Appendix XXIII, Instructions and Access to CARE

Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers

Appendix XXIX, Reserved for Future Use

Appendix XXVI, Reserved for Future Use

Appendix XXVIII, Reserved for Future Use

Appendix XXXI, STAR+PLUS Members Transitioning from an NF in One Service Area to the Community in Another Service Area

Appendix XXXV, Reserved for Future Use

Appendix XXV, Community First Choice Support Management

Appendix XXVII, PSU Users H1700/ISP Form User Guide

6-2016

 

For information about document accessibility, contact accessibility@hhsc.state.tx.us

Link to Guide

Appendix XXX, Relocation Function

Appendix XXXII, Create an Appeal Task in the HHSC Benefits Portal

Appendix XXXIII, STAR+PLUS HEART Naming Conventions

Revision 21-1; Effective January 15, 2021

 

This appendix outlines the screenshots Program Support Unit (PSU) staff upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must use the HEART Naming Conventions below when uploading documents to the HEART case record. Refer to Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, for TxMedCentral naming convention instructions.

When there is more than one of the same form, or screenshot, uploaded, then add a sequence number after the naming convention. For example, the first Form H1746-A sent or received would be uploaded as 1746, the second form sent or received would be uploaded as 1746_2, 1746_3, etc.

All screenshots, forms, documents and emails marked as “Yes,” in the “Required” column, must be included in the HEART case record. Screenshots, forms, documents and emails marked with an “*” in the “Required” column must be included in the HEART case record if used by PSU staff in the HEART transaction.

Interest List Release (ILR)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Authorizing Agent Screenshot SASO AA Yes
SASO Enrollment Screenshot SASO EN Yes
SASO Service Plan Screenshot SASO SP Yes
SASO Service Authorization Screenshot SASO SA Yes
SASO Level of Service Screenshot SASO LS Yes
SASO Diagnosis Screenshot SASO DG Yes
SASO Medical Necessity Screenshot SASO MN Yes
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL CLOSURE Yes
Form 2442 (English) 2442 *
Form 2442-S (Spanish) 2442-S *
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes
Form H1700-1 (if received through TMHP LTCOP) LTCOP ISP Yes
Form H1700-1 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form H1700-2 Use TxMedCentral Naming Convention Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H3675 3675 *
Form H3676-A Use TxMedCentral Naming Convention Yes
Form H3676-A Upload to TxMedCentral 3676A TXMED Yes
Form H3676-B Use TxMedCentral Naming Convention Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Upgrades
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Authorizing Agent Screenshot SASO AA Yes
SASO Enrollment Screenshot SASO EN Yes
SASO Service Plan Screenshot SASO SP Yes
SASO Service Authorization Screenshot SASO SA Yes
SASO Level of Service Screenshot SASO LS Yes
SASO Diagnosis Screenshot SASO DG Yes
SASO Medical Necessity Screenshot SASO MN Yes
CARE Screenshot CARE *
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes
Form H1700-1 (if received through TMHP LTCOP) LTCOP ISP Yes
Form H1700-1 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form H1700-2 Use TxMedCentral Naming Convention Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Money Follows the Person (MFP)
Item HEART Naming Convention Required
TIERS Individual- Medicaid History Screenshot TIERS ME Yes
TIERS Individual- Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Authorizing Agent Screenshot SASO AA Yes
SASO Enrollment Screenshot SASO EN Yes
SASO Service Plan Screenshot SASO SP Yes
SASO Service Authorization Screenshot SASO SA Yes
SASO Level of Service Screenshot SASO LS Yes
SASO Diagnosis Screenshot SASO DG Yes
SASO Medical Necessity Screenshot SASO MN Yes
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL CLOSURE Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes
Form H1700-1 (if received through TMHP LTCOP) LTCOP ISP Yes
Form H1700-1(if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form H1700-2 Use TxMedCentral Naming Convention Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Annual Reassessment
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual- Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Authorizing Agent Screenshot SASO AA Yes
SASO Enrollment Screenshot SASO EN Yes
SASO Service Plan Screenshot SASO SP Yes
SASO Service Authorization Screenshot SASO SA Yes
SASO Level of Service Screenshot SASO LS Yes
SASO Diagnosis Screenshot SASO DG Yes
SASO Medical Necessity Screenshot SASO MN Yes
CARE Screenshot CARE *
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1700-1 (if received through TMHP LTCOP) LTCOP ISP Yes
Form H1700-1(if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form H1700-2 Use TxMedCentral Naming Convention Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from MCCO MCCO EMAIL *

 

Transition to Adult Programs (MDCP Age-Out)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Authorizing Agent Screenshot SASO AA Yes
SASO Enrollment Screenshot SASO EN Yes
SASO Service Plan Screenshot SASO SP Yes
SASO Service Authorization Screenshot SASO SA Yes
SASO Level of Service Screenshot SASO LS Yes
SASO Diagnosis Screenshot SASO DG Yes
SASO Medical Necessity Screenshot SASO MN Yes
CARE Screenshot CARE *
Form 2114 2114 *
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes
Form H1700-1 (if received through TMHP LTCOP) LTCOP ISP Yes
Form H1700-1(if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form H1700-2 Use TxMedCentral Naming Convention Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H2116 2116 *
Form H3675 3675 *
Form H3676-A Use TxMedCentral Naming Convention Yes
Form H3676-A Upload to TxMedCentral 3676A TXMED Yes
Form H3676-B Use TxMedCentral Naming Convention Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from Higher Needs Coordinator HN EMAIL *
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
Emails to and from STAR Kids PSU PSU EMAIL *
Emails to and from UR UR EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Denials and Terminations
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
SASO Authorizing Agent Screenshot SASO AA Yes
SASO Enrollment Screenshot SASO EN Yes
SASO Service Plan Screenshot SASO SP Yes
SASO Service Authorization Screenshot SASO SA Yes
SASO Level of Service Screenshot SASO LS Yes
SASO Diagnosis Screenshot SASO DG Yes
SASO Medical Necessity Screenshot SASO MN Yes
CSIL Closure Screenshot CSIL CLOSURE Yes
Fair Hearing Options for STAR+PLUS HCBS Program Denials MN DENIAL ATCH Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Fair Hearings
Item HEART Naming Convention Required
SASO Authorizing Agent Screenshot SASO AA Yes
SASO Enrollment Screenshot SASO EN Yes
SASO Service Plan Screenshot SASO SP Yes
SASO Service Authorization Screenshot SASO SA Yes
SASO Level of Service Screenshot SASO LS Yes
SASO Diagnosis Screenshot SASO DG Yes
SASO Medical Necessity Screenshot SASO MN Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H4800 4800 *
Form 4800-A 4800A *
Form H4800-D 4800D *
Form H4803 4803 Yes
Form H4806 4806 *
Form H4807 4807 *
Copy of TAC §353.1153 for SSI and MN Denials TAC 353.1153 Yes
Copy of 26 TAC §554.2401 for MN Denials 26 TAC 554.2401 Yes
Copy of Section 3632.4 for SSI Denials SPOPH 3632.4 Yes
Copy of Section 3632.5 for MN Denials SPOPH 3632.5 Yes
Fair Hearing Options for STAR+PLUS HCBS Program Denials MN DENIAL ATCH Yes
Notice of Hearing Officer’s Decision APPEAL DECISION LTR Yes
HHSC Benefits Portal Screenshot of Hearing Officer’s Decision TIERS APPEAL DECISION Yes
Emails to and from DER Clerk CLERK EMAIL *
Emails to and from CRU CRU EMAIL *
Emails to and from ERS ERS EMAIL Yes
MEPD Communication Tool MEPD EMAIL *

Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions

Revision 18-0; Effective September 4, 2018

 

TxMedCentral is a secure Internet bulletin board that the Texas Health and Human Commission (HHSC) and managed care organizations (MCOs) use to share information. TxMedCentral uses specific naming conventions only for the documents listed below. HHSC and MCO staff must follow these naming conventions any time one of the following documents is filed in TxMedCentral.

 

Form H1700-1, STAR+PLUS HCBS Program Individual Service Plan

The following forms may be used, if appropriate, in development of the individual service plan (ISP). Only Form H1700-1, Individual Service Plan (Pg.1), and Form H1700-2, Individual Service Plan (Pg.2), are uploaded to the MCO's ISP folder in TxMedCentral and should not be loaded in any other folder:

  • Form H1700-1 and Form H1700-2;
  • Form H1700-3, Nursing Service Plan;
  • Form H1700-A, Rationale for STAR+PLUS HCBS Program Items/Services;
  • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form H1700-B, Non-STAR+PLUS HCBS Program Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060;
  • Form H2060-B, Needs Assessment Addendum, as applicable; and
  • Form H6516, Community First Choice Assessment.
Two-Digit Plan Identification (ID) Form Number (#) Member ID, Medicaid # or Social Security Number (SSN) Member Last Name (first four letters) Page Number of Form H1700-1 Sequence Number of Form
# # 1700 123456789 ABCD 1 2

This file would be named ##_1700_123456789_ABCD_1_2.doc.

Form H1700-1, completed for non-members, age-outs, and nursing facility (NF) residents transitioning to the STAR+PLUS Home and Community Based Services (HCBS) program, continues to be uploaded to TxMedCentral.

Form H1700-1, completed for members in the community, is submitted to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

 

Form H3676, Managed Care Pre-Enrollment Assessment Authorization

Form H3676 is uploaded to the SPW folder and should not be uploaded in any other folder. An "A" or "B" is added to the sequence number to indicate whether Program Support Unit (PSU) or MCO staff uploaded the form.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
# # 3676 123456789 ABCD A or B 2

This file would be named ##_3676_123456789_ABCD_A_2.doc. if uploaded by PSU staff.

This file would be named ##_3676_123456789_ABCD_B_2.doc if uploaded by the MCO staff.

 

Form H2065-D, Notification of Managed Care Program Services

Form H2065-D is uploaded to the SPW folder and should not be uploaded in any other folder.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
# # 2065 123456789 ABCD D 2D or 2A
  • Denials will be coded with a “D” (denial) immediately following the form’s sequence number. This denial file would be named ##_2065_123456789_ABCD_D_2D.doc.
  • Approvals will be coded with an “A” immediately following the sequence number. This approval file would be named ##_2065_123456789_ABCD_D_2A.doc.

If a member has an ISP which is electronically generated, Form H2065-D is available in the "LETTERS" tab of the TMHP LTC Online Portal when the member's ISP is selected. Form H2065-D is uploaded to TxMedCentral only for individuals without electronic ISPs.

MCOs must check the TMHP LTC Online Portal to check for updates and notifications electronically generated by PSU staff.

 

Form H2067-MC, Managed Care Programs Communication

Form H2067-MC is uploaded to the SPW folder and should not be uploaded in any other folder. An "M" or "S" is added to the sequence number to indicate whether the MCO or PSU uploaded the form.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
# # 2067 123456789 ABCD 2M or 2S  

This file would be named ##_2067_123456789_ABCD_2M.doc. if uploaded by the MCO staff.

This file would be named ##_2067_123456789_ABCD_2S.doc. if uploaded by PSU staff.

Additional to the standardized naming convention for Form H2067-MC, a separate naming convention has been developed to address use of Form H2067-MC for NF residents who request transition to the community under the STAR+PLUS Home and Community Based Services (HCBS) program. These individuals are considered expedited cases for application to the STAR+PLUS HCBS program. Both the MCO and PSU staff must be able to readily identify communications specific to these cases.

An "M" or "S" continues to be added to the sequence number to denote, respectively, whether the MCO or PSU staff have uploaded the form. The new naming convention for uploading Form H2067-MC, on both member and non-member cases in a NF, is expanded as follows:

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
# # 2067 123456789 ABCD 1M or 1S MFP

Form H2067-MC file uploaded by the MCO would be named ##_2067_123456789_ABCD_1M_MFP.doc. if uploaded by the MCO staff.

Form H2067-MC file uploaded by the MCO staff would be named ##_2067_123456789_ABCD_1S_MFP.doc. if uploaded by PSU staff.

TxMedCentral Folders

The STAR+PLUS MCOs use the following folders for all STAR+PLUS HCBS program related uploads. Each MCO has two folders with three-letter identifiers:

  • ISP — Individual Service Plan, which contains Form H1700-1 and Form H1700-2; and
  • SPW — STAR+PLUS HCBS program, which contains:
    • Form H2065-D;
    • Form H3676; and
    • Form H2067-MC.
Primary Folder: MCO Three-Letter Identifiers Secondary Folder: TxMedCentral Folders by Plan
AMC — Amerigroup MCO AMCISP AMCSPW
EVR — United Healthcare Community Plan MCO EVRISP EVRSPW
MOL — Molina MCO MOLISP MOLSPW
SUP — Superior MCO SUPISP SUPSPW
BRV — Cigna-HealthSpring MCO BRVISP BRVSPW

Appendix XXXVI, Long Term Services and Supports

Appendix XXXVII, STAR Kids Transition Activities