5210 Managed Care Data in SASO

Revision 18-0; Effective September 4, 2018 
  
The STAR+PLUS Home and Community Based Services (HCBS) program is authorized by the managed care organization (MCO) and registered by Program Support Unit (PSU) staff in the Service Authorization System Online (SASO) with a Service Group (SG) 19 and Service Code (SC) 12 or 13. If the member's individual service plan (ISP) is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal registers the appropriate SG/SC combination, which is verified by PSU staff. Service codes are based on the following:

  • Service Code 12: Use this service code when registering initial service authorizations or annual re-determination service authorizations received up to 90 days prior to the end date of the current ISP.
  • Service Code 13: Use this service code if an ISP is received after the end date of the most recent ISP. Register one service authorization using Service Code 13 effective the day after the end date of the most recent ISP and with an end date that is the end of the month in which the new ISP was received. Register a second service authorization using Service Code 12 with an effective date one day after the Service Code 13 service authorization ends and an end date of one year minus a day from the effective date of the ISP.

Example: A reassessment ISP is received on June 5, 2019, for an ISP that ended May 31, 2019. To register this reassessment, register one service authorization record using "Service Code 13 — Nursing" with a begin date of June 1, 2019, and an end date of June 30, 2019. Then, register a second service authorization record using "Service Code 12 — Case Management" with a begin date of July 1, 2019, and an end date of May 31, 2020.

Example of automatic registration: A reassessment ISP is submitted to the TMHP LTC Online Portal on June 5, 2019, for an ISP that ended May 31, 2019. One service authorization record with "Service Code 13 — Nursing" will be system-generated with a begin date of June 1, 2019, and an end date of June 30, 2019. A second service authorization record with "Service Code 12 — Case Management" will be system-generated with a begin date of July 1, 2019, and an end date of May 31, 2020.

5220 Closing Institutional Service Records in SASO

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must contact Provider Claims Services (PCS) at the established hotline to assist in closing a Service Authorization System Online (SASO) Category 1 nursing facility (NF) authorization for individuals being discharged from an NF and will begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program. The Texas Health and Human Services Commission (HHSC) Long Term Care (LTC) PCS hotline is 512-438-2200. Select Option 1 when prompted to do so.

PSU staff should call the hotline directly to request the NF record in SASO be closed so non-institutional services can be authorized. PSU staff must confirm the member has been discharged from the NF and community services are negotiated to begin on or after the date of discharge.

When calling the HHSC LTC PCS hotline, PSU staff must identify themselves as HHSC employees and report the member has been discharged from the NF, providing the discharge date. The PCS representative will close all Group 1 service authorizations and enrollment records in SASO, including the Service Code 60 record. This procedure applies whether or not the individual is leaving the NF using the Money Follows the Person (MFP) option.

5230 MFPD Entitlement Tracking and SASO Data Entry

Revision Notice 23-3; Effective Aug. 21, 2023

Time spent in a nursing facility (NF) does not count toward the Money Follows the Person Demonstration (MFPD) 365-day period. Therefore, the MCO will track to ensure MFPD members receive the full 365-day entitlement period. The entitlement period begins the date the member is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program. The managed care organization (MCO) uploads Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, indicating the total number of days the member spent in the NF. The MCO must send this information to Program Support Unit (PSU) staff after the 365th day. PSU staff may refer to the table below for help making  accurate entries in the Service Authorization System Online (SASO).

Example 1 — No institutionalization during the 365-day period

Begin DateEnd DateService GroupService CodeCase ProgressionFund Code
02-13-1906-15-1911The applicant discharged from the NF. The NF begin and end dates are derived from forms submitted by the NF.Blank
06-01-1906-01-191912PSU staff enter the one-day registration record in SASO for MCO capitation payment for applicants who are not enrolled with an MCO at the beginning of the MFP process. Blank
06-15-1906-14-201912PSU staff enter SASO record's fund code as 19MFP for the entire period.19MFP
06-15-2006-30-201912PSU staff enter the remaining individual service plan (ISP) period without the 19MFP fund code.Blank

Example 2 — Institutionalization during the 365-day period

Begin DateEnd DateService GroupService CodeCase ProgressionFund Code
02-13-1706-15-1811The applicant discharged from the NF. The NF begin and end dates are derived from forms submitted by the NF.Blank
06-01-1806-01-181912PSU staff enter the one-day registration record in SASO for the MCO capitation payment for applicants who are not enrolled with an MCO at the beginning of the MFP process. Blank
06-15-1806-14-191912PSU staff enter SASO record’s fund code as 19MFP for the entire period.19MFP
06-15-1906-30-191912PSU staff enter the remaining ISP period without the 19MFP fund code.Blank
The MCO has notified PSU staff that this member spent 15 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:
06-15-1906-29-191912PSU staff enter the MFPD period for the 15 days the individual was in the hospital.19MFP
06-30-1906-30-191912MFPD period reached the 365th day on 06-29-19. The ISP has one day remaining.Blank

Example 3 — Institutionalization during the 365-day period

Begin DateEnd DateService GroupService CodeCase ProgressionFund Code
02-13-1906-15-2011The applicant has discharged from the NF. The NF begin and end dates are derived from forms submitted by the NF.Blank
06-01-2006-01-201912PSU staff enter the one-day registration record in SASO for the MCO capitation payment for applicants who are not enrolled with an MCO at the beginning of the MFP process. Blank
06-15-2006-14-211912PSU staff enter the SASO record’s fund code as 19MFP for the entire period.19MFP
06-15-2106-30-211912PSU staff enter the remaining ISP period without the 19MFP fund code.Blank
07-01-2106-30-221912PSU staff update the reassessment ISP dates, if applicable.Blank
The MCO has notified PSU staff that the member spent 25 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:
06-15-2106-30-211912PSU staff enter the MFPD period for 16 of the 25 days the individual was in the hospital.19MFP
07-01-2107-09-211912PSU staff enter the MFPD period for the last 9 of the 25-day period in which the individual was in the hospital.19MFP
07-10-2106-30-221912PSU staff enter the remainder of the reassessment ISP period.Blank