9200, Reassessment Service Authorization

Revision 18-0; Effective September 4, 2018

When Program Support Unit (PSU) staff authorize STAR+PLUS Home and Community Based Services (HCBS) program services for a reassessment of the individual service plan (ISP) in the Service Authorization System Online (SASO), PSU staff must check or create the following records according to Sections 9210 through 9270:

• Authorizing Agent – Reassessment;
• Enrollment – Reassessment;
• Service Plan – Reassessment;
• Service Authorization – Reassessment;
• Level of Service  – Reassessment;
• Diagnosis – Reassessment; and
• Medical Necessity – Reassessment.

9210 Authorizing Agent – Reassessment

Revision 18-0; Effective September 4, 2018

Check the authorizing agent record for accuracy. If there are no changes, leave the authorizing agent record open-ended. Currently, although the Service Authorization System Online (SASO) will accept multiple authorizing agent records, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal will only accept two authorizing agent records when a SASO file is transmitted to TMHP. Therefore, select “NO” in the ‘Send to TMHP’ field for all updates.

Program Support Unit (PSU) staff will create an authorizing agent record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose individual service plan (ISP) was not transmitted electronically.

9220 Enrollment – Reassessment

Revision 18-0; Effective September 4, 2018

Check the enrollment record for accuracy and to be sure it is open-ended. If it is open-ended, make no changes. If it has an end date, delete the end date or create another record with a new begin date. To ensure that there is not a gap in service, the begin date of the enrollment for the new individual service plan (ISP) year is the day after the end date of the previous ISP year.

Program Support Staff (PSU) staff will create a service plan record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose ISP was not transmitted electronically.

PSU staff confirm enrollment registration in SASO, take a screenshot of the enrollment registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

9230 Service Plan – Reassessment

Revision 18-0; Effective September 4, 2018

A new service plan record may need to be created to register the Resource Utilization Group (RUG) cost limit and the amount of services authorized for the new individual service plan (ISP) year.

Because the ISP is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal automatically generates service plan records in the Service Authorization System Online (SASO).

Program Support Unit (PSU) staff do not need to create a service plan record for electronic ISPs.

PSU staff will create a service plan record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose ISP was not transmitted electronically.

PSU staff confirm service plan registration in SASO, take a screenshot of the service plan registration, and upload the screenshot to the HHS Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

9240 Service Authorization – Reassessment

Revision 18-0; Effective September 4, 2018

If the managed care organization (MCO) uploads a timely reassessment packet, Program Support Unit (PSU) staff create one service authorization record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for the new individual service plan (ISP) year. To ensure there is no gap in service, the begin date of the authorization for the new ISP year is the day after the end date of the previous ISP year.

Because the ISP is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal automatically generates service authorization records in the Service Authorization System Online (SASO).

PSU staff should not need to register service authorization records for electronic ISPs.

PSU staff will create a service authorization record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

PSU staff confirm service authorization registration in SASO, take a screenshot of the service authorization registration in SASO, and upload the screenshot to the HHS Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

If the MCO does not upload a timely reassessment packet, two service authorization records will be required for STAR+PLUS HCBS program eligibility. The first service authorization record for STAR+PLUS HCBS program eligibility will be entered with service group (SG) 19/service code (SC) 13 for the month(s) for which the ISP was late. The second service authorization record for STAR+PLUS HCBS program eligibility will be entered with SG 19/SC 12 for the remaining ISP period.

To enter a service authorization record for an untimely reassessment for STAR+PLUS HCBS program eligibility for an applicant or member whose ISP is not electronic, PSU staff must:

1. Select the Service Authorization field in the Program and Service functional area.
2. Select Add and a blank Service Authorization Details record will appear.
3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
4. Move to the Service Code field and select 13 – NURSING SERVICES from the drop-down menu.
5. Leave the Fund and Term. Code fields at the defaults.
6. Leave the Agency field at the default selection 324 - DHS.
7. Move to the Unit Type field and select 4 – PER AUTHORIZATION from the drop-down menu.
8. Move to the Units field and enter 1.00.
9. Leave Amount field at the default.
10. Move to the Begin Date field and enter the effective date of the new ISP coverage period.
11. Create two service authorization records. For the first record, move to the End Date field and enter the last day of the month the ISP was received. Note: For the second record, repeat steps 1 through 10. Move to the Begin Date field and enter the first of the next month and move to the End Date field and enter the end date of the ISP period.
12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).

13. The NPI field is read-only.
14. Select the Save button.

9250 Level of Service – Reassessment

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a Resource Utilization Group (RUG) value registered in the Service Authorization System Online (SASO). The level of service (LOS) record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the RUG value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The LOS record is system generated from the information stored in the SASO database. The system-generated LOS record will have a begin and end date that matches the new individual service plan (ISP) year.

Program Support Unit (PSU) staff will create an LOS record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

Example: A member with an initial ISP coverage period of December 1, 2019 through November 30, 2020, is authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective December 1, 2019 through November 30, 2020. These new begin and end dates will be system generated in the LOS record.

9260 Diagnosis – Reassessment

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a diagnosis registered in the Service Authorization System Online (SASO). The diagnosis record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information from this form to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is commuted, TMHP submits the decision to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The diagnosis record is system generated from the information stored in the SASO database. The system-generated diagnosis record will have a begin and end date that matches the new individual service plan (ISP) year.

Program Support Unit (PSU) staff will create a diagnosis record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

Example: A member with an initial ISP coverage period of November 1, 2019 through October 31, 2020, is re-authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective November 1, 2019 through October 31, 2020. These new begin and end dates will be system generated in the diagnosis record.

9270 Medical Necessity – Reassessment

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a medical necessity (MN) registered in the Service Authorization System Online (SASO). The MN record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment for the annual reassessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The MN record is system generated from the information stored in the SASO database. The system-generated MN record will have a begin date and an end date that matches the new individual service plan (ISP) year.

Program Support Unit (PSU) staff will create an MN record(s) for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

PSU staff must confirm MN registration in SASO, take a screenshot of the MN registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

Example: A member with an initial ISP coverage period of February 1, 2019 through Jan. 31, 2020, is authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective February 1, 2019 through January 31, 2020. These new begin and end dates will be system generated in the MN record. The MN record must be forced in SASO to register an MN determination for a reassessment when the MN is approved in the TMHP LTC Online Portal but will not convert to SASO because of a mismatch of member information between the MN/LOC Assessment and the Texas Integrated Eligibility Redesign System (TIERS).