Form H2064, Gap in Enrollment for Medicaid Managed Care Members

Instructions

Updated: 4/2013

Purpose

To notify Operations Coordination of:

• a gap in enrollment for STAR+PLUS managed care members;
• claims filed with the managed care organization (MCO) during an enrollment gap; and
• claims denied by the MCO.

To notify the MCO of:

• a gap in enrollment for managed care members;
• authorization to pay claims during a gap period; and
• a provider filing claims.

Procedure

When to Prepare

The long-term services and supports provider completes the Provider Section when a member has a gap in managed care enrollment during a time frame when they are Medicaid eligible.

Form Retention

MCOs must keep records, documents and forms for a minimum of three years and 90 days after the end of the contract or case closure.

Form Submission

HPO_STAR_PLUS@hhsc.state.tx.us.

 

Detailed Instructions

Provider Section

Name of Provider – Enter the name of the provider.

Contact Name – Enter the name of the contact.

Phone Number – Enter the contact's phone number.

Name of Member — Enter the name of the member.

Medicaid No. — Enter the member's nine-digit Medicaid number.

Dates of Service — Enter the begin and end dates of service.

Claim Filed with MCO? — Check "Yes" if the claim has been filed with the MCO; check "No" if the claim has not been filed with the MCO.

Name of MCO — Enter the name of the MCO.

Claim Denied?— Check "Yes" if the filed claim was denied; check "No" if the filed claim was not denied.

Reason for Denial — If the claim was denied, enter the reason for denial.

Operations Coordination Section

Date Received — Operations Coordination staff enter date the form was received from the provider.

Gap Confirmed — Operations Coordination staff check "Yes" if the gap is confirmed and "No" if it is not confirmed.

Gap Resolved — Operations Coordination staff check "Yes" if the gap is resolved and "No" if it is not resolved.

If not resolved, provide reason — If the gap is not resolved, document the reason it is not resolved.

This authorizes the MCO . . . — Operations Coordination staff add the dates of service and the name of the provider submitting the claim.

Date emailed to MCO — Enter the date the form was emailed to the MCO.

Estimated Risk Group — Enter the estimated risk group.

Note: Provider's claims must meet MCO claims requirements.

MCO Section

Date Received — Enter the date the form was received from the MCO.

Claim Adjudicated On — Enter the date the claim was adjudicated.