6000, Reimbursement, Data Collection and Reporting

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Revision 20-0; Effective December 18, 2020

 

This section provides policy requirements for submitting for reimbursement, data collection and required reports.

 

6100 Reimbursement, Data Collection and Reports

Revision 20-0; Effective December 18, 2020

 

Title V MCH FFS contract amounts are ceilings against which contractors may bill for services provided to Title V MCH FFS eligible clients. Once this ceiling has been reached, no further funds will be available for reimbursement. Contractors may only bill for services provided to clients who have been screened for potential Medicaid and other benefit programs and been determined Title V MCH FFS eligible.

Fee-For-Service Reimbursement

Contractors may bill and receive reimbursement for the provision of services, except for multivitamins and other medications, to Title V MCH FFS eligible clients. Although the scopes of care given to an individual Title V MCH FFS eligible client may encompass more than Title V MCH FFS can fund, contractors may only bill for prenatal, infant/child and adolescent health and dental services for children, as outlined in this section per their contract.

Reimbursement is, however, allowable only when these services are delivered as defined and in accordance with nationally recognized guidelines of care.

Continuation of Services

Contractors who have exhausted their awarded funds must continue to serve their existing Title V MCH FFS eligible clients per the Title V MCH FFS policy. It is allowable to obtain other funding to pay for these services as well as continue to charge a co-pay per policy. These co-pays should be recorded as program income for the Title V MCH FFS contract.

Upon award expenditure, contractors are not required to screen new clients for Title V MCH FFS eligibility; however, if screening is completed, the contractor is required to provide services to the Title V MCH FFS eligible clients per Title V MCH FFS policy. No Title V MCH FFS client can be denied services for the inability to pay. For the unscreened clients, it is allowable to make these clients self-pay and consider doing a sliding scale fee.

Children’s Health Insurance Program (CHIP) Perinatal Program Billing

The following table should be used to determine the appropriate funding source for prenatal services.

Scenario Payer of Services
Title V MCH FFS contractor is a CHIP Perinatal Program provider and client is not enrolled in the CHIP Perinatal Program.

Contractors can bill the Title V MCH FFS Program for allowable services provided at clinical prenatal care visits for up to 60 days for women during the CHIP Perinatal Program enrollment process.

In addition, contractors may bill Title V MCH FFS for one comprehensive case management visit.

At first contact, the contractor informs the client of the CHIP Perinatal Program benefits and assists the client with the CHIP Perinatal Program application.

Title V MCH FFS contractor is not a CHIP Perinatal Program provider and client is enrolled in CHIP Perinatal Program. The Title V MCH FFS contractor must refer the client to the designated CHIP Perinatal Program provider for services. Title V MCH FFS funds cannot be used for women who are eligible for CHIP Perinatal and who are enrolled in CHIP Perinatal health plans.
Title V MCH FFS contractor is a CHIP Perinatal Program provider and client is enrolled in CHIP Perinatal Program. The Title V MCH FFS contractor bills the CHIP Perinatal Program for services.
Title V MCH FFS contractor is not a CHIP Perinatal Program provider and client is not enrolled in CHIP Perinatal Program.

Contractors can bill the Title V MCH FFS program for allowable services provided at clinical prenatal care visits for up to 60 days for women during the CHIP Perinatal Program enrollment process. In addition, contractors may bill Title V MCH FFS for one comprehensive case management visit.

The contractor educates the client on the CHIP Perinatal Program benefits and assists the client with the CHIP Perinatal Program enrollment application. The Title V contractor must refer the client to the designated CHIP Perinatal Program provider for services.

Well Visits: Reimbursement Request Guidance

The Title V MCH FFS contractor may not bill for a Texas Health Steps medical checkup until all required components are completed. If the child is brought back to complete components omitted based on unknown Medicaid status during the initial checkup, then the contractor may only bill for a Texas Health Steps medical checkup when those components are completed.

In addition, the contractor may not bill a follow-up visit for components omitted by the provider’s choice due to unknown Medicaid status at the initial visit.

A follow-up visit may not be billed on the same day as a well child/adolescent or sick child visit.

Lead: Reimbursement Request Guidance

Providers conducting follow up on children with elevated lead levels may bill Title V MCH FFS for either a follow-up visit or a sick child visit. However, if the visit is for the sole purpose of drawing a specimen, the provider may bill a follow-up. If the visit includes further assessment and/or treatment of the child, the provider may bill the visit as a sick child visit. Title V MCH FFS will not pay for medications, hospital services, and laboratory specimens submitted to outside laboratories or environmental services.

Non-Reimbursable Expenditures

Title V MCH FFS will not reimburse services for individuals potentially eligible for another funding source who do not complete the respective eligibility process. Clients (or their parents, legal guardians, etc.) who do not fully comply with all requirements to apply for Medicaid, CHIP or CHIP Perinatal services are not eligible for Title V MCH FFS. Contractors will not be reimbursed for services provided to clients who do not access these alternative assistance programs.

Services are often provided to clients whose screening results indicate they are potentially Medicaid, CHIP or CHIP Perinatal eligible, but the client has not yet completed or received notification of acceptance or rejection of an application.

For Medicaid, Title V MCH FFS may cover services delivered on the initial date of contact after the eligibility determination is complete and Medicaid denies eligibility. Such a denial of eligibility must be documented in the client’s file for the contractor to bill the initial day’s services. Once the client’s denial letter is received, the services provided on the initial day of service may be billed to Title V MCH FFS for reimbursement.

Title V MCH FFS will only reimburse for services listed on the respective 185/186 report.

Submission of the Monthly Invoice and Reporting Workbook

At the start of each contract year, contractors will receive a personalized invoice and reporting workbook for their organization from their contract manager. The workbook is required to be completed and sent monthly to HDS.ADS@hhsc.state.tx.us, no later than 30 days after the end of the preceding month. If the contractor has both Title V MCH FFS Prenatal Medical/Dental and Title V MCH FFS Child Health/Dental contracts, they will receive a workbook for each contract.

When the workbook is received at the start of the contract year, contractors should download and save the invoice and reporting workbook by double clicking on the file to open, clicking on “file” at the top of the workbook and selecting “save as.” When done this way, the template (xltx) file saves a new file with an .xlsx extension. This process leaves the template intact for later use in future months.

Each monthly invoice and reporting workbook will cover services provided, or expenses incurred, in a preceding month as applicable to the contract.

Contractors will need to:

  • Complete the date and contact information on the Monthly Reimbursement Request (MRR);
  • Complete the service quantities on the 185 and 186 tabs; and
  • Complete demographic data for the Monthly Activity Report in the workbook.

Additional instructions are included in a separate tab at the end of the workbook.

An important note about the Monthly Activity Report is that this report counts the unduplicated number of clients receiving billable services by age, race and ethnicity on their first visit. Each client is counted once at the beginning of the fiscal year (each September or at the time of their first visit) and is not to be counted in that category again. The count for unduplicated clients includes the client’s first visit for a medical service and/or a dental service provided by each contractor and contract type.

This definition allows an individual client to be counted up to four times within a given fiscal year as they receive different types of services provided by different contract types. A visit is defined as a single complete clinical encounter of a client with a provider.

Incorrect or missing information that requires clarification or follow-up by HHSC Title V MCH FFS staff may delay payment.  

Reconciling Errors on Previously Submitted Workbooks

Errors can occur that result in a contractor receiving payment for more services than delivered in a service month or under-billing for services provided.

Errors that result in over-billing can be corrected by subtracting the over-billing from the next month, adjusting all information. Services not yet billed to Title V MCH FFS can also be added to the next month.

Contractors must maintain records that document the necessary information for services provided and billed for reimbursement. Documentation will be audited during HHSC on-site quality assurance reviews and fiscal monitoring reviews.

Submission and Reporting After Entire Contract Award is Expended

Contractors must continue to submit the monthly invoice and reporting workbook even after contract ceilings have been reached. Any cost over the contract ceiling after deducting program income should be reflected under “Non-HHSC Funding.” This submission is required to continue reporting expenditures on any program income collected monthly and to provide HHSC with statistical information about the use of services.

Submission of Final Invoice and Reporting Workbook

Contractors may have claims after the submission of their August billing. You may claim any additional services by submission of an invoice and reporting workbook prior to October 15. Please mark this as FINAL.

All claims for reimbursement for services delivered must be submitted within 45 days of the end of the contract term as HHSC Title V MCH FFS contracts require closure of the contract attachment within 45 days of the end of the contract term.

Reimbursement requests submitted more than 45 days following the end of the contract term will not be paid.

Submission of Financial Reconciliation Report (FRR)

The FRR must include all reimbursements and adjustments in payment for the contract term and be submitted within 60 days of the completion of the contract year, i.e., October 31, to HDS.ADS@hhsc.state.tx.us.

Altering of Forms

Contractors are required to use the most current version of their organization’s personalized invoice and reporting workbook for ease of processing. None of the billing or the reporting forms may be altered in any manner.

Maintaining Appropriate Supporting Documentation

Contractors must maintain a monthly Title V MCH FFS billing log (automated or manual) to support their monthly Title V MCH FFS invoice and reporting workbook submissions. The log should contain at least the clients name, date of service and procedure code for each service billed. These logs will be audited during HHSC on-site quality assurance reviews and/or fiscal compliance monitoring reviews.