Revision 24-4; Effective Dec. 1, 2024
This appendix outlines the screenshots Program Support Unit (PSU) staff must upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.
PSU staff must use the HEART Naming Conventions below when uploading documents to the HEART case record. Refer to Appendix XXXIV, STAR+PLUS MCOHub Naming Conventions, for the MCOHub naming convention instructions.
PSU staff must add a sequence number after the naming convention when more than one of the same form or screenshot is uploaded. For example, PSU staff must name the first Form H1746-A sent or received as 1746_1, the second form sent or received as 1746_2, and the third form sent or received as 1746_3.
PSU staff must include all screenshots, forms, documents and emails marked as Yes in the Required column in the HEART case record. PSU staff must include screenshots, forms, documents and emails marked with an * in the Required column in the HEART case record if used by PSU staff while completing the case.
Interest List Release (ILR)
Item | HEART Naming Convention | Required |
---|
TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
SASO Enrollment Screenshot | SASO EN | Yes |
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
CSIL Closure Screenshot | CSIL CLOSURE | Yes |
Form 2442 (English) | 2442 | * |
Form 2442-S (Spanish) | 2442-S | * |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
Form H1700-1 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form H1700-1 (if received through the MCOHub) | Use the MCOHub Naming Convention | Yes |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H1826 | H1826 | * |
Form H2053-B | 2053B | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | * |
Form H2065-D Generated Manually (English and Spanish) | Use the MCOHub Naming Convention | * |
Form H2065-D Screenshot of Upload to the MCOHub | 2065 MCOHub | * |
Form H2067-MC | Use the MCOHub Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | Yes |
Form H3675 | 3675 | * |
Form H3676-A | Use the MCOHub Naming Convention | Yes |
Form H3676-A Upload to the MCOHub | 3676A MCOHub | Yes |
Form H3676-B | Use the MCOHub Naming Convention | Yes |
TIERS Copayment Budget Screenshot | TIERS COPAY | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from CRU | CRU EMAIL | * |
Emails to and from CCSE | CCSE EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSORT | PSORT EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Note: PSU staff must upload Form 2442 or Form H2065-D in the HEART case record, as appropriate.
Upgrades
Item | HEART Naming Convention | Required |
---|
TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
SASO Enrollment Screenshot | SASO EN | Yes |
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
Form H1700-1 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form H1700-1 (if received through the MCOHub) | Use the MCOHub Naming Convention | Yes |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H1826 | H1826 | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
Form H2065-D Generated Manually (English and Spanish) | Use the MCOHub Naming Convention | Yes |
Form H2065-D Screenshot of Upload to the MCOHub | 2065 MCOHub | Yes |
Form H2067-MC | Use the MCOHub Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | Yes |
TIERS Copayment Budget Screenshot | TIERS COPAY | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from CRU | CRU EMAILS | * |
MEPD Communication Tool | MEPD EMAIL | * |
Money Follows the Person (MFP)
Item | HEART Naming Convention | Required |
---|
TIERS Individual- Medicaid History Screenshot | TIERS ME | Yes |
TIERS Individual- Managed Care Screenshot | TIERS MC | Yes |
SASO Enrollment Screenshot | SASO EN | Yes |
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
CSIL Closure Screenshot | CSIL CLOSURE | Yes |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
Form H1700-1 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form H1700-1(if received through the MCOHub) | Use the MCOHub Naming Convention | Yes |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H1826 | H1826 | * |
Form H2053-B | 2053B | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
Form H2065-D Generated Manually (English and Spanish) | Use the MCOHub Naming Convention | Yes |
Form H2065-D Screenshot of Upload to the MOCHub | 2065 MCOHub | Yes |
Form H2067-MC | Use the MCOHub Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | Yes |
TIERS Copayment Budget Screenshot | TIERS COPAY | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from CRU | CRU EMAILS | * |
Emails to and from CCSE | CCSE EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSORT | PSORT EMAIL | * |
Emails to and from the MFPD Reporting Coordinator | 365-DAY EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Annual Reassessment
Item | HEART Naming Convention | Required |
---|
TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
TIERS Individual- Managed Care Screenshot | TIERS MC | Yes |
SASO Enrollment Screenshot | SASO EN | * |
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1826 | H1826 | * |
Form H1700-1 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form H1700-1(if received through the MCOHub) | Use the MCOHub Naming Convention | Yes |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
Form H2065-D Generated Manually (English and Spanish) | Use the MCOHub Naming Convention | Yes |
Form H2065-D Screenshot of Upload to the MCOHub | 2065 MCOHub | Yes |
Form H2067-MC | Use the MCO Hub Naming Convention | * |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | * |
TIERS Copayment Budget Screenshot | TIERS COPAY | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSORT | PSORT EMAIL | * |
Transition to Adult Programs (MDCP Age-Out)
Item | HEART Naming Convention | Required |
---|
TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
SASO Enrollment Screenshot | SASO EN | Yes |
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
Form 2114 | 2114 | * |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
Form H1700-1 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
Form H1700-1(if received through the MCOHub) | Use the MCOHub Naming Convention | Yes |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H1826 | H1826 | * |
Form H2053-B | 2053B | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
Form H2065-D Generated Manually (English and Spanish) | Use the MCOHub Naming Convention | Yes |
Form H2065-D Screenshot of Upload to the MCOHub | 2065 MCOHub | Yes |
Form H2067-MC | Use the MCOHub Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | Yes |
Form H2116 | 2116 | * |
Form H3675 | 3675 | * |
Form H3676-A | Use the MCOHub Naming Convention | Yes |
Form H3676-A Upload to the MCOHub | 3676A MCOHub | Yes |
Form H3676-B | Use the MCOHub Naming Convention | Yes |
TIERS Copayment Budget Screenshot | TIERS COPAY | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from CCSE | CCSE EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from Higher Needs Coordinator | HN EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
Emails to and from PSORT | PSORT EMAIL | * |
Emails to and from STAR Kids PSU | PSU EMAIL | * |
Emails to and from UR | UR EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Denials and Terminations
Item | HEART Naming Convention | Required |
---|
TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
SASO Enrollment Screenshot | SASO EN | * |
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
CSIL Closure Screenshot | CSIL CLOSURE | * |
Fair Hearing Options for STAR+PLUS HCBS Program Denials | MN DENIAL ATCH | * |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H1826 | H1826 | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | * |
Form H2065-D Generated Manually (English and Spanish) | Use the MCOHub Naming Convention | * |
Form H2065-D Screenshot of Upload to the MCOHub | 2065 MCOHub | * |
Form H2067-MC | Use the MCOHub Naming Convention | * |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | * |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from CRU | CRU EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
Emails to and from IDD Unit | IDD EMAIL | * |
Emails to and from ILM Unit | ILM EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Note: PSU staff must upload Form H2067-MC or Form H2065-D in the HEART case record, as appropriate.
Fair Hearings
Item | HEART Naming Convention | Required |
---|
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
Form 2606 | 2606 | * |
Form 2606-S | 2606-S | * |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H1826 | Form H1826 | * |
Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
Form H2065-D Generated Manually (English and Spanish) | Use the MCOHub Naming Convention | Yes |
Form H2065-D Screenshot of Upload to the MCOHub | 2065 MCOHub | Yes |
Form H2067-MC | Use the MCOHub Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | Yes |
Form H4800 | 4800 | * |
Form H4800-A | 4800A | * |
Form H4800-D | 4800D | * |
Form 4801 | FH COVER LTR | Yes |
Form H4803 | 4803 | Yes |
Form H4806 | 4806 | * |
Form H4807 | 4807 | * |
Appendix XX for All Denials | ELIGIBILITY TAC | Yes |
Copy of Handbook Section Referenced on Form H2065-D | SPOPH [####] | Yes |
Fair Hearing Options for STAR+PLUS HCBS Program Denials | MN DENIAL ATCH | * |
Notice of Hearing Officer’s Decision | APPEAL DECISION LTR | Yes |
HHSC Benefits Portal Screenshot of Hearing Officer’s Decision | TIERS APPEAL DECISION | Yes |
Emails to and from DER Clerk | CLERK EMAIL | * |
Emails to and from CRU | CRU EMAIL | * |
Emails to and from ERS | ERS EMAIL | * |
MEPD Communication Tool | MEPD EMAIL | * |
Disenrollment
Item | HEART Naming Convention | Required |
---|
TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
SASO Enrollment Screenshot | SASO EN | Yes |
SASO Service Plan Screenshot | SASO SP | * |
SASO Service Authorization Screenshot | SASO SA | Yes |
SASO Medical Necessity Screenshot | SASO MN | Yes |
Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
Form H2067-MC | Use the MCOHub Naming Convention | Yes |
Form H2067-MC Screenshot of Upload to the MCOHub | 2067 MCOHub | Yes |
Medicaid Managed Care Member Disenrollment Form | DISENFORM | Yes |
Emails for PSU QA Process | QA EMAIL | * |
Emails to and from MCCO | MCCO EMAIL | Yes |
MEPD Communication Tool | MEPD EMAIL | * |