5400, Administrative Payment Process

Revision 18-0; Effective September 4, 2018

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 diversion (NFD) 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 Form 1500 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 (UMCM), §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 must:

  • verify the member is Medicaid eligible and has a valid Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP);
  • print the Service Authorization screen from Service Authorization Services Online (SASO) and the Medicaid eligibility and Managed Care enrollment screens in the Texas Integrated Eligibility Redesign System (TIERS);
  • prepare Form 4116, Authorization for Expenditures;
  • create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record that includes the:
    • Services Authorization screen print from SASO;
    • Medicaid Eligibility screen print from TIERS;
    • Managed Care Enrollment screen print from TIERS;
    • Form 1500; and
    • Form 4116.
  • email Form 4116, Form 1500 and the screen prints to the Enrollment Resolution Services (ERS) mailbox.

Within two business days from the receipt of the email from PSU staff, the assigned ERS staff will:

  • verify the member is Medicaid eligible; and
  • review the claim to determine if it will be paid or denied.

If the decision is to approve to pay the administrative payment, the ERS staff will:

  • email the approved Form 4116 to the Contract Compliance and Support (CCS) Unit mailbox for processing; and
  • notify by email the PSU staff who emailed the request that the administrative payment has been approved.

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

  • The CCS Unit 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, the ERS staff will notify the PSU staff via email, who submitted the request for administrative payment. This email response will also include the reason for denial.

Within two business days of receipt of email from ERS staff, PSU staff will:

  • notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • upload the email from ERS and the MCO notification to the HEART case record; and
  • close the HEART case record.