5110 File Maintenance

Revision 18-0; Effective September 4, 2018

Due to the volume of forms being uploaded to TxMedCentral, it is mandatory to purge older documents from time to time. Program Support Unit (PSU) staff must electronically back up documents from the managed care organization’s (MCO’s) ISP and SPW folder on a daily basis to prevent loss of form history. Documents must be easily accessible to PSU staff whenever needed. Texas Health and Human Services Commission (HHSC) requires these backup documents be maintained for five years.

5120 Maintenance Requirements for Member Information and Forms

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must establish and maintain a case record for each STAR+PLUS Home and Community Based Services (HCBS) program member. PSU staff must not update documents directly in TxMedCentral. Instead, PSU staff must move files daily to a secure location. Documents must be easily accessible to PSU staff whenever needed.

5130 Managed Care Data in the Texas Integrated Eligibility Redesign System

Revision 18-0; Effective September 4, 2018

5130.1 County Code Issues Affecting Enrollment

Revision 18-0; Effective September 4, 2018

The Service Authorization System Online (SASO) reflects the residence county as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Correction to the county code must be done in TIERS. Program Support Unit (PSU) staff must inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by faxing Form H1746-A, MEPD Referral Cover Sheet, to correct the county code. Incorrect county code records in TIERS can cause enrollment problems for applicants or members in STAR+PLUS.

Supplemental Security Income Cases

If an individual receives Supplemental Security Income (SSI), TIERS derives the county based on the residential Zoning Improvement Plan (ZIP) code provided by the Social Security Administration (SSA). If the ZIP code is incorrect, it can be because of one of two common problems:

  • an incorrect ZIP code; or
  • a ZIP code crosses county lines.

Either of these issues can cause TIERS to assign the wrong county.

Non-SSI Cases

If the individual has any SSI type program (TP) other than TP 12 or TP 13, TIERS contains the county code entered by the MEPD specialist. When not having TP 12 or TP 13, common problems are when:

  • an individual moves without notifying the MEPD specialist; or
  • an MEPD specialist enters an incorrect county code.

What to Do to Resolve Address Issues Affecting Enrollment

  1. Perform an inquiry in TIERS and determine the TP.
  2. If the TP is anything but 12 or 13 and the residence county is incorrect, refer the matter to the MEPD specialist to correct the residence county field.
  3. If the TP is 12 or 13:
  • Determine the residence ZIP code recorded in TIERS.
  • If the residence ZIP code is not correct, the individual must report the correct ZIP code to SSA.
  1. If the residence ZIP code in TIERS is correct but the county is incorrect, PSU staff email the Data Integrity Unit (DIU) at the CCC_Data _Intergrity_Program mailbox the following information:
  • individual's name as recorded in TIERS;
  • individual's Medicaid identification (ID) number;
  • residence ZIP code; and
  • residence county as it should be reflected in TIERS.

The DIU can update TIERS to correct the problem. The correction will take place during the next TIERS cutoff processing, usually around the 20th day of the month. SASO should reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff.

5130.2 Service Interruptions Resulting from County Code Mismatches in TIERS

Revision 18-0; Effective September 4, 2018

Because participation in managed care programs is based on an individual's residence county, as recorded in the Texas Integrated Eligibility Redesign System (TIERS), service interruptions can occur when the TIERS record shows the wrong residence county code.
The Service Authorization System Online (SASO) reflects the residence county as recorded in TIERS and is updated through a monthly interface. Therefore, incorrect county code data in SASO must be corrected in TIERS. The manner in which this correction occurs depends on the individual's type program (TP). If a residential county code is incorrect and the individual receives services under:

  • TP 12 or 13 in TIERS, the individual or his or her authorized representative (AR) must contact the Social Security Administration (SSA) to request a correction. The Data Integrity Unit (DIU) can correct problems in TIERS that result from Zoning Improvement Plan (ZIP) codes that cross county lines. In these situations, SSA assigns a default county code in the computer program matrix, which is transferred to TIERS data files. Results of correction requests to the DIU di_managedcare mailbox, take place during the next TIERS cutoff, usually around the 20th day of the month. SASO will reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff. Describe the needed change in the email and send the following information:
    • individual's name as recorded in TIERS;
    • individual’s Medicaid identification (ID) number; and
    • correct ZIP code and residence county as it should be reflected in TIERS.
  • TP 03, TP 18, TP 19, TP 21, TP 50, TP 87 or TP 88 in TIERS, Program Support Unit (PSU) staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist assigned to the HEART case record and request a correction.
  • Supplemental Nutrition Assistance Program (SNAP), PSU staff must fax Form H1746-A to the MEPD specialist assigned to the HEART case record and request a correction.

5131 Identifying Managed Care Members in TIERS

Revision 24-1; Effective Feb. 22, 2024

Program Support Unit (PSU) staff must verify if an individual, applicant or member is enrolled in managed care by checking the Texas Integrated Eligibility Redesign System (TIERS). TIERS contains a managed care segment for all individuals, applicants or members who are currently or have been enrolled in managed care.

PSU staff must complete the following activities in TIERS:

  • Enter the individual's, applicant’s or member’s information in the Individual-Search screen and select Search. The results of the search will appear in the Search Results field.
  • Select the hyperlink of the individual’s name in the Search Results field. The Individual-Summary screen will appear.
  • Hover over the Individual # field and select Managed Care from the dropdown menu. The managed care information will appear in the Individual Managed Care History field. The data elements in the Individual Managed Care History field include:
    • Provider — The name of the provider contracted by the MCO to deliver services to members.
    • Plan — The name and plan code of the MCO providing Medicaid services to the member.
    • Program — For managed care members, "STARPLUS" will appear in this field.
    • County — Individual's county of residence.
    • Begin Date — The date enrollment began under this plan.
    • End Date — The date enrollment ended under this plan.
    • Status — Describes the type of action.
    • Eligibility — Choices are "candidate" (applicant), "enrolled" (active) and "suspended" (closed).
    • Candidature — Describes the individual's status.