5400, Administrative Payment Process

Revision 23-2; Effective June 30, 2023

When an individual is aging out of the Texas Health Steps Comprehensive Care Program (THSteps-CCP), Medically Dependent Children Program (MDCP) or has been approved for a nursing facility (NF) diversion slot, the managed care organization (MCO) must authorize services to start on the day of eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program, which may not be the first of the month. If the eligibility date is not the first of the month, the MCO must follow the administrative payment process for STAR+PLUS services provided between the eligibility date and the managed care enrollment date, as applicable. The administrative payment process must be used for the Texas Health and Human Services Commission (HHSC) to issue payment to the MCO and for the MCO to pay the provider.

Once the MCO authorizes services, the provider:

  • prepares Form 1500, Health Insurance Claim; and
  • submits the form to the MCO within the 95-day filing deadline.

Within five business days of receiving Form 1500, the MCO verifies the provider was authorized to deliver the services billed on Form 1500, the information on Form 1500 meets the clean claim requirements as defined in the Uniform Managed Care Manual, Chapter 2.0, and the claim met the 95-day filing deadline. Once the MCO verifies this information, the MCO:

  • sends Form 1500 by secure email to Program Support Unit (PSU) staff if the provider:
    • is authorized to deliver the service;
    • met the clean claim requirements; and
    • submitted the claim to the MCO within the 95-day filing deadline; or
  • denies payment via the MCO denial process if the provider:
    • is not authorized to deliver the services;
    • did not meet the clean claim requirements; or
    • did not meet the 95-day filing deadline.

Within two business days of receiving Form 1500, PSU staff follow the requirements in this handbook section.

If the decision is to approve the administrative payment, the following also occurs:

  • Contract Compliance and Support (CCS) sends the approved payment voucher to the State Comptroller for processing and payment to the MCO; and
  • the MCO pays the provider within one week of receipt of payment from the State Comptroller.

If the decision is to deny the administrative payment, ERS staff email the PSU staff who emailed the request that the administrative payment has been denied and the reason for the denial.

Within two business days of receipt of email from the ERS, the PSU staff who submitted the request for administrative payment notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub.