Revision 23-3; Effective May 22, 2023
This appendix outlines the screenshots Program Support Unit (PSU) staff must 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 IX, STAR Kids TxMedCentral Naming Conventions, for TxMedCentral naming convention instructions.
PSU staff must add a sequence number after the naming convention when more than one of the same form or screenshot is uploaded. For example, PSU staff must name the first Form H1746-A sent or received as 1746_1, the second form sent or received as 1746_2 and the third form sent or received as 1746_3, etc.
PSU staff must upload all screenshots, forms, documents and emails marked as “Yes,” in the “Required” column in the HEART case record. PSU staff must include screenshots, forms, documents and emails marked with an “*” in the “Required” column in the HEART case record if used by PSU staff while completing the case.
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 |
SASO Enrollment Screenshot | SASO EN | Yes |
SASO Service Authorization Screenshot | SASO SA | Yes |
CSIL Closure Screenshot | CSIL CLOSURE | Yes |
Form 2442 (English) | 2442 | * |
Form 2442-S (Spanish) | 2442-S | * |
Form 2442 Screenshot of Upload to TxMedCentral | Use TxMedCentral Naming Convention | * |
Form 2602 | 2602 | * |
Form 2604 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form 2604 (if received through TxMedCentral) | Use TxMedCentral Naming Convention | Yes |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H1826 | H1826 | * |
Form H2053-B | 2053B | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | * |
Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | * |
Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | * |
Form H2067-MC | Use TxMedCentral Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | Yes |
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 CRU | CRU EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSORT | PSORT EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Note: PSU staff must upload Form 2442 or Form H2065-D in the HEART case record, as appropriate.
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 |
SASO Enrollment Screenshot | SASO EN | Yes |
SASO Service Authorization Screenshot | SASO SA | Yes |
CSIL Closure Screenshot | CSIL CLOSURE | Yes |
Form 2604 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form 2604 (if received through TxMedCentral) | Use TxMedCentral Naming Convention | Yes |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
H1826, Case Information Release | H1826 | * |
Form H2053-B | 2053B | * |
Form H2065-D Generated in TMHP LTC Online Portal (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 CRU | CRU EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSORT | PSORT 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 |
Form 2604 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form 2604 (if received through TxMedCentral) | Use TxMedCentral Naming Convention | Yes |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
H1826, Case Information Release | H1826 | * |
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 | * |
Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSORT | PSORT 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 |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
H1826, Case Information Release | H1826 | * |
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 | * |
Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | * |
Form H2116 | 2116 | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from CCSE | CCSE EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from Higher Needs Coordinator | HN EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from STAR+PLUS 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 |
CSIL Closure Screenshot | CSIL CLOSURE | * |
Form 2128 | 120 Day NTCE | * |
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 | * |
H1826, Case Information Release | H1826 | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | * |
Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | * |
Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | * |
Form H2067-MC | Use TxMedCentral Naming Convention | * |
Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | * |
Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants | MN DENIAL ATCH | * |
Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members | MN DENIAL ATCH | * |
Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP | ATCH D | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from CRU | CRU | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSU supervisor for 120-day exception request | EXCEPTION REQ EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Note: PSU staff uploads Form H2067-MC or Form H2065-D in the HEART case record, as appropriate.
Fair Hearings
Item | HEART Naming Convention | Required |
---|---|---|
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form 4801 | FH COVER LTR | Yes |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
H1826 | H1826 | * |
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 H4800-A | 4800A | * |
Form H4803 | 4803 | Yes |
Form H4806 | 4806 | * |
Form H4807 | 4807 | * |
Copy of Handbook Section Referenced on Form H2065-D | SKOPH [####] | Yes |
Appendix XVII, MDCP Eligibility TAC | ELIGIBILITY TAC | Yes |
Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants | MN DENIAL ATCH | * |
Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members | MN DENIAL ATCH | * |
Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP (English) | ATCH D | * |
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 CRU | CRU EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Disenrollment
Item | HEART Naming Convention | Required |
---|---|---|
TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
TMHP LTCOP ISP Termination Screenshot | DISENISP | * |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H2067-MC | Use TxMedCentral Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | Yes |
Medicaid Managed Care Member Disenrollment Form | DISENFORM | Yes |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | Yes |
MEPD Communication Tool | MEPD EMAIL | * |