The Program of All-Inclusive Care for the Elderly (PACE) organization staff prepare Form 1140 to notify the Texas Health and Human Services Commission (HHSC) when an applicant is enrolling in PACE. Form 1140 is used by HHSC staff to facilitate enrollment coordination and to complete data entry into the Service Authorization System Online (SASO), based on the information contained on the form.
When to Prepare
Form 1140 is prepared by PACE organization staff to notify HHSC when an applicant meets eligibility criteria to enroll in PACE.
The PACE organization staff complete Sections 1 and 2 of Form 1140 and send the form to the designated PACE consultant with HHSC. The PACE consultant verifies if the applicant is receiving services through other HHSC programs or is enrolled in managed care, and facilitates enrollment coordination to ensure there is no overlap or duplication of services. The PACE consultant will notify HHSC programs or managed care the date the applicant must be disenrolled from those services to enroll in PACE. The PACE consultant completes Sections 3 and 4 of Form 1140 and returns the form to the PACE organization once enrollment coordination is completed. PACE organization staff review the form to ensure all information is accurate and send the form to the HHSC regional office for data entry into SASO. The HHSC regional office completes the “HHSC Regional Office Use Only” section of the form and returns the SASO form to the PACE organization once data entry is completed.
Retain Form 1140 for the length of time specified in the program rules.
PACE Organization Name — Enter the name of the PACE organization.
Contract Number — Enter the contract number of the PACE organization.
Transmittal Date Coordination — Enter the date the PACE organization staff send the form to the designated PACE consultant for enrollment coordination.
Transmittal Date Data Entry — Enter the date the PACE organization staff send the form to the HHSC regional office for data entry, after enrollment coordination is completed.
Applicant Name (Last, First) — Enter the last and first name of the applicant. Note: To avoid processing delays, the PACE organization staff must resolve issues related to different names on official documentation before submitting the SASO form.
Medicaid Number — Enter the applicant’s nine-digit Medicaid number.
Social Security Number — Enter the applicant’s nine-digit Social Security number.
Applicant Residence Address — Enter the street address, city and state for the applicant.
ZIP Code — Enter the applicant’s ZIP code.
County — Enter the county where the applicant resides.
Enrollment — Check the appropriate box for Initial or Money Follows the Person (MFP) and enter the Begin Date of enrollment, which must be the first day of the month.
Name and Address of Nursing Facility for MFP — Enter the name and address of the nursing facility if the applicant is enrolling through the MFP option.
Name of HHSC Medicaid Eligibility Specialist — Enter the name of the Texas Health and Human Services Commission (HHSC) Medicaid Eligibility specialist.
Initial Service Authorization — Check the box for 39 — Dual Eligible (Medicare and Medicaid), or 39A — Medicaid Only.
Eligibility for PACE Enrollment — Enter the date for “Medical Necessity Approval” from Texas Medicaid and Healthcare Partnership (TMHP), and the date “Medicaid Eligibility is Verified” with the HHSC Medicaid Eligibility specialist as being approved in the Texas Integrated Eligibility Redesign System (TIERS).
Comments from PACE Organization — PACE organization staff may enter additional information relevant for enrollment coordination and data entry.
Name, Title and Phone Number of PACE Staff Completing Form — Enter the name, title and phone number for PACE organization staff completing the form.
Coordination for Enrollment into PACE: To be completed by PACE consultant — The PACE consultant checks the appropriate box to indicate if the applicant is receiving services through:
- Other Community-based Services, including the name of the service and date of disenrollment;
- Managed Care, including the date of disenrollment from STAR+PLUS program services or the date of disenrollment from STAR+PLUS Waiver; or
- No other services are currently being received.
Comments from HHSC — HHSC PACE consultant and regional office staff may enter comments for PACE organization staff regarding enrollment coordination and requests for additional information for data entry.
Submit completed form to the HHSC regional office for data entry. — The PACE organization staff send the completed form to the HHSC regional office for data entry once all enrollment coordination activities have been completed and the SASO form has been checked for accuracy by the PACE organization staff.
HHSC Regional Office Use Only
Data entered by and Date — HHSC staff enter his/her name and the date the information is entered into SASO, or the date the form is returned to the PACE organization without data entry (due to errors).
Form returned to PACE organization without data entry and Date — HHSC staff check the box and enter the date the SASO form is returned to the PACE organization because of errors. The PACE organization staff must submit a new SASO form to the HHSC regional office and PACE consultant after corrections are completed.