Revision 15-4, Effective October 14, 2015
A provider is entitled to payment for services only if the provider:
- has prior approval for eligible individuals; and
- bills according to Texas Department of Aging and Disability Services (DADS) requirements.
A provider is entitled to payment if the requirements are met according to Texas Administrative Code (TAC) Chapter 49, Contracting for Community Services.
The provider is not entitled to payment if the rules in TAC §98.211(b), Billing and Payment, are not met.
If DADS rejects a claim because of errors, the provider must research the errors and return the corrected claim to DADS. The provider must attach a copy of the MY 363 Output Report to the claim if the corrected claim is submitted 95 days or more after the end of the service month.
A provider may address any questions about claim rejections or error(s), or both, to the regional contract manager.
At the facility’s designated time of the month, the provider collects all units from Form 3683, Day Activity and Health Services Daily Attendance Record, and submits to DADS via Texas Medicaid & Healthcare Partnership (TMHP).
To obtain an enrollment application for the electronic billing systems, visit the Texas Medicaid & Healthcare Partnership (TMHP) website.
To ask about the status of manual or electronic billing reimbursement claims, contact Texas Medicaid & Healthcare Partnership or the DADS contract manager.
Reimbursement payments are made by warrant or direct deposit.
DADS and HHSC do not allow special handling of payments. Special handling includes sending payments by overnight express services or making warrants available at DADS.
A provider may choose to have reimbursements received as a direct deposit to the bank of its choice. Information packets regarding direct deposit may be obtained by calling claims correction, Fiscal Management Services, 512-438-4005.
Form 3254, Community Services Contract (Provider Agreement). III. Recording, B, includes:
“A provider must keep financial records and supporting documents, individual files, service delivery records and any other records pertinent to the services for which a claim for payment is submitted to the Department or its agent. These records must be accurate and sufficiently detailed to document the extent of services provided under this contract and to support claims for payment submitted to the Department and its agent. These records must be retained in the form in which they are regularly kept by the Contractor for a minimum of six years after the end of the federal fiscal year in which the services were provided. If any litigation, claim or audit involving these records begins before the expiration of the six-year period, the Contractor must keep the records until all litigation, claims or audit findings are resolved. The matter is considered resolved when a final order is issued in litigation or when the Department and Contractor enter into a written agreement.”
DAHS providers must follow additional document retention requirements in order to comply with cost reports, budgets and other cost surveys, as stated in TAC Chapter 49, Contracting for Community Care Services.
Additional record maintenance on personnel, attendance and transportation requirements are located in §98.209, Record Maintenance.
HHSC Rule: 1 TAC §355.105, General Reporting and Documentation Requirements, Methods and Procedures
Contract violation may result in DADS withholding all of a provider’s payments until the provider submits an acceptable cost report.
See Appendix II-A, Reimbursement Methodology, for cost reporting requirements.
Rules related to record retention are located in TAC Chapter 49, Contracting for Community Services.
A provider must maintain the following forms:
- Form 2059, Summary of Client’s Need for Service;
- Form 2101, Authorization for Community Care Services;
- Form 2067, Case Information;
- Form 3682, Day Activity and Health Services Daily Transportation Record; and
- Form 3683, Day Activity and Health Services Daily Attendance Record.
- Form 3050, DAHS Health Assessment/Individual Service Plan;
- Form 3055, Physician’s Orders (DAHS); and
- Other records containing individual medical information.
The provider must keep personnel records on staff as indicated in TAC Chapter 49, Contracting for Community Services.
The provider must keep personnel records in accordance to requirements in §98.209 (a), Record Maintenance.
A provider must maintain daily records of individual attendance and transportation records in accordance with TAC §98.209 (b) and (c), Record Maintenance.
A provider may include the transportation time as part of the unit of service if the provider gives transportation to an individual to and from a:
- facility approved to provide therapies; or
- non-therapy medical facility.
Additionally, if a facility staff member escorts or stays with the individual during the visit, a provider may also include the escort time as part of the unit of service.
If the provider did not provide transportation but did provide an escort to a facility approved to provide therapies or a non-therapy medical facility, the provider may include the escort time as part of the unit of service.
A provider may only include transportation time as part of the unit of service if:
- transportation is provided in a facility-owned vehicle; or
- the provider had a subcontract for transportation services with a public or private transportation entity.
A provider may not include as part of the unit of service transportation provided by public transportation.
If the provider purchases tickets or passes for public transportation, the provider is not providing the transportation. The provider can claim the costs (tickets or passes) associated with this transportation on the annual cost report, but time spent in transit cannot be claimed in the unit of services.
A provider cannot charge the individual if it does provide the transportation.
Record retention is addressed in Chapter 49, Contracting for Community Services.
DAHS providers are responsible for maintaining records pertinent to the services for which a claim or cost report is submitted. Form 3050, DAHS Health Assessment/Individual Service Plan, requires providers to document treatments, monitoring and interventions, including the frequency for each. The DAHS provider may use monthly nursing notes, daily progress notes or other forms of clinical documentation, such as medication logs, to meet documentation requirements.
Example: An individual requires assistance with personal care each day the individual attends DAHS. The individual’s notes completed monthly by the licensed nurse contain a statement that assistance with personal care was provided each day, as required in the individual’s service plan. This statement is sufficient to show that daily assistance was provided to the individual.
Medical care/treatments should be documented based on the frequency that they are provided. For example, if the blood pressure or glucose is checked on a daily basis, the readings should be documented on a daily basis. This documentation could be combined with monthly nursing notes documenting skilled care, and would meet documentation requirements for the tasks indicated on the individual’s service plan.