Texas Medicaid and CHIP - Uniform Managed Care Manual

Managed care is a system where the overall care of a patient is overseen by a single provider or organization as a way to improve quality and control costs. The manual below defines procedures that Managed Care Organizations (MCOs) must follow in order to meet certain requirements in the HHSC managed care contracts, and to provide interpretation on contractual provisions that need clarification.

People needing accessibility assistance with these documents should send an email to Managed_Care_UMCM@hhsc.state.tx.us.

Uniform Managed Care Manual

Chapter 1

Chapter 2: Texas Claims Procedures

Chapter 3: Critical Elements

Chapter 4: Marketing Policies and Procedures

Chapter 5: Deliverables, Report Formats, Due Dates

Chapter 6: Financial

  • 6.1Cost Principles for Expenses
  • 6.2 – Financial Incentive Methodology
    • 6.2.1 – Performance Measures for Capitation Rate At Risk (withdrawn 9/1/16)
    • 6.2.2 – Performance Measures for Capitation Rate At-Risk Instructions (withdrawn 9/1/16)
    • 6.2.3 – Geo-Mapping Provider Layouts (withdrawn 3/1/17)
    • 6.2.4 – Geo-Mapping Methodology (withdrawn 3/1/17)
    • 6.2.5 – STAR Health 1% At Risk Premium (withdrawn 10/12/09)
    • 6.2.6 – Quality Challenge Award Performance Indicators (withdrawn 8/1/16)
    • 6.2.7Medicaid Dental Pay for Quality (P4Q) Program Measures (withdrawn 4/18/22)
    • 6.2.8CHIP Dental Pay for Quality (P4Q) Program Measures (withdrawn 4/18/22)
    • 6.2.9 – Medicaid Dental Quality Challenge Award (withdrawn 12/1/13)
    • 6.2.10 – CHIP Dental Quality Challenge Award (withdrawn 12/1/13)
    • 6.2.11 – Performance Measures for Pay for Quality (P4Q) (withdrawn 10/3/17)
    • 6.2.12 – Medicaid/CHIP Pay for Quality (P4Q) Technical Specifications (withdrawn 10/3/17)
    • 6.2.13 – Dental Pay for Quality (P4Q) Program Methodology (withdrawn 09/16/19)
    • 6.2.14Medical Pay-for-Quality (P4Q) Program
    • 6.2.15Dental Pay-for-Quality (P4Q) Program
    • 6.2.16 – QIPP Payment Validation (withdrawn 3/8/19)
  • 6.3CHIP Cost Sharing
  • 6.4 – Performance Bonds

Chapter 7: Management Information Systems (MIS)

Chapter 8: Provider

Chapter 9: Disease Management (DM)

Chapter 10: Contract Management Tools

  • 10.1 – Performance Indicator Dashboard
    • 10.1.1 – Performance Indicator Dashboard for Administrative and Financial Measures (withdrawn 1/15/16)
    • 10.1.2 – Information Pertaining to the Performance Indicator Dashboard (withdrawn 4/15/11)
    • 10.1.3 – STAR Health Performance Indicator Dashboard for Administrative and Financial Measures (withdrawn 9/1/16)
    • 10.1.4 – CHIP Dental Dashboard for Administrative and Financial Measures (withdrawn 9/1/16)
    • 10.1.5 – Medicaid Dental Dashboard - Admin and Financial Measures (withdrawn 9/1/16)
    • 10.1.7 – Performance Indicator Dashboard for Quality Measures (withdrawn 6/1/18)
    • 10.1.8 – STAR Health Performance Indicator Dashboard for Quality Measures (withdrawn 6/1/18)
    • 10.1.9 – CHIP Dental Performance Indicator Dashboard for Quality Measures (withdrawn 6/1/18)
    • 10.1.10 – Medicaid Dental Dashboard for Quality Measures (withdrawn 6/1/18)
    • 10.1.11LTSS Quality Measures Template
    • 10.1.12LTSS Quality Measures Technical Specifications
    • 10.1.13 – STAR Kids Performance Indicator Dashboard for Quality Measures (withdrawn 6/1/18)
    • 10.1.14Performance Indicator Dashboard for Quality Measures
  • 10.2 – Performance Improvement

Chapter 11: Member

Chapter 12: Frew

  • 12.1FWC Annual Report and Log Instructions
  • 12.2 – FWC Plan Template (withdrawn 9/1/17)
  • 12.3FWC Annual Report Template
  • 12.4MMC THSteps Report Instructions
  • 12.5MMC THSteps Annual Report Template
  • 12.6Annual Report Refusal Tracking Log
  • 12.7 – ICM Children of Migrant Farmworkers Plan Template (withdrawn 9/10/09)
  • 12.8 – ICM Children of Migrant Farmworkers Annual Report Template (withdrawn 9/10/09)
  • 12.9MMC THSteps Annual Report Template (STAR Health)
  • 12.10 – ICM 90 Day Report Instructions (withdrawn 4/20/09)
  • 12.11 – ICM 90 Day Report Template (withdrawn 4/20/09)
  • 12.12 – ICM 90 Day Refusal (withdrawn 4/20/09)
  • 12.13 – MMC THSteps Quarterly Report Template (STAR and STAR+PLUS) (withdrawn 9/1/15)
  • 12.14 – MMC New Member Quarterly Refusal Tracking Log (withdrawn 9/1/15)
  • 12.15 – MMC THSteps Quarterly Report Template (STAR Health) (withdrawn 9/1/15)
  • 12.16Migrant Rewards Summary Matrix
  • 12.17 – Frew Managed Care Rewards and Sanctions Default Assignment Methodology (withdrawn 2/1/16)
  • 12.18Frew Incentives and Disincentives
  • 12.19Frew QMR Instructions
  • 12.20Frew QMR MCO Response Template
  • 12.21 – Frew Annual Healthcare Provider Training Report Instructions (withdrawn 2/1/16)
  • 12.22 – Frew Annual Healthcare Provider Training Report Template (withdrawn 2/1/16)
  • 12.23 – Frew Provider Recognition Report Instructions (withdrawn 2/1/16)
  • 12.24 – Frew Provider Recognition Report Template (withdrawn 2/1/16)
  • 12.25Migrant Incentives Supporting Documentation
  • 12.26 – Migrant Incentive Supporting Documentation Log Instructions (withdrawn 9/1/17)
  • 12.27 – FWC Plan and Annual Report Instructions for Dental Services (withdrawn 6/1/16)
  • 12.28 – FWC Plan Template for Dental Services (withdrawn 6/1/16)
  • 12.29 – FWC Annual Report Template for Dental Services (withdrawn 6/1/16)
  • 12.30 – Migrant Incentive Process - Summary Matrix for Dental Services (withdrawn 6/1/16)
  • 12.31 – Migrant Incentive Process - Support Doc Log for Dental Services (withdrawn 6/1/16)
  • 12.32 – Migrant Incentive Process - Dental Services (withdrawn 6/1/16)
  • 12.33 – Frew QMR Dental Plan Response Template Instructions (withdrawn 9/1/17)
  • 12.34 – Frew QMR Dental Plan Response Template (withdrawn 9/1/17)
  • 12.35 – Frew Annual Dental Provider Training Report Instructions (withdrawn 2/1/16)
  • 12.36 – Frew Annual Dental Provider Training Report Template (withdrawn 2/1/16)
  • 12.37 – Frew Dental Provider Recognition Report Instructions (withdrawn 2/1/16)
  • 12.38 – Frew Dental Provider Recognition Report Template (withdrawn 2/1/16)
  • 12.39 – MMC THSteps Medical Utilization Instructions (withdrawn 2/1/16)
  • 12.40 – MMC THSteps Medical Utilization Report (withdrawn 2/1/16)

Chapter 13: Supplemental Payments.

Chapter 14: CHIP Dental

  • 14.1 – CHIP Dental Tier Schedule (withdrawn 3/1/12)

Chapter 15: Utilization Management

Chapter 16: Policy Guidance

Chapter 17: Reserved

Chapter 18: Record Retention Requirements

Chapter 19: HHSC Operational Review