Body
Revision 25-1; Effective Feb. 19, 2025
3710 Managed Care Data in the Texas Integrated Eligibility Redesign System
Revision 25-1; Effective Feb. 19, 2025
3711 County Code Issues Affecting Enrollment
Revision 25-1; Effective Feb. 19, 2025
The Service Authorization System Online (SASO) reflects the residence county as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Correction to the county code must be done in TIERS. Program Support Unit (PSU) staff must inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by faxing Form H1746-A, MEPD Referral Cover Sheet (PDF), to correct the county code. Incorrect county code records in TIERS can cause enrollment problems for applicants or members in STAR+PLUS.
Supplemental Security Income Cases
TIERS derives the county based on the residential Zoning Improvement Plan (ZIP) code provided by the Social Security Administration (SSA) if an individual receives Supplemental Security Income (SSI). A ZIP code may appear incorrectly in TIERS because of one of the following reasons:
- data entry error; or
- a ZIP code crosses county lines.
Either of these issues can cause TIERS to assign the wrong county.
Non-SSI Cases
TIERS contains the county code entered by the MEPD specialist if the individual has any SSI type program (TP) other than TP 12 or TP 13. The following may be the cause of an individual not having TP 12 or TP 13:
- an individual moves without notifying the MEPD specialist; or
- an MEPD specialist enters an incorrect county code.
What to Do to Resolve Address Issues Affecting Enrollment
- Perform an inquiry in TIERS.
- Identify the TP in TIERS by cross referencing Appendix III, Medicaid Type Program Codes for STAR+PLUS HCBS Program and CFC.
- Refer the matter to the MEPD specialist to correct the residence county field if the TP is anything but 12 or 13 and the residence county is incorrect.
- If the TP is 12 or 13:
- Determine the residence ZIP code recorded in TIERS.
- If the residence ZIP code is not correct, the individual must report the correct ZIP code to SSA.
- PSU staff must email the Data Integrity Unit (DIU) mailbox the following information if the residence ZIP code in TIERS is correct but the county is incorrect:
- individual’s name as recorded in TIERS;
- individual’s Medicaid identification (ID) number;
- residence ZIP code; and
- residence county as it should be reflected in TIERS.
The DIU can update TIERS to correct the error. The correction takes place during the next TIERS cutoff processing, usually around the 20th day of the month. SASO should reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff.
3712 Service Interruptions Resulting from County Code Mismatches in TIERS
Revision 25-1; Effective Feb. 19, 2025
Participation in managed care programs is based on an individual’s residence county, as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Therefore, service interruptions can occur when the TIERS record shows the wrong residence county code.
The Service Authorization System Online (SASO) reflects the residence county as recorded in TIERS and is updated through a monthly interface. As a result of this, incorrect county code data in SASO must be corrected in TIERS. The manner in which this correction occurs depends on the individual’s type program (TP).
PSU must complete the following activities if a residential county code is incorrect and the individual receives services under:
- Perform an inquiry in TIERS.
- Identify the TP in TIERS by cross referencing Appendix III, Medicaid Type Program Codes for STAR+PLUS HCBS Program and CFC.
- For TP 12 or 13 in TIERS: advise the applicant, member or authorized representative (AR) to contact the Social Security Administration (SSA) to request a correction. The Data Integrity Unit (DIU) can correct problems in TIERS that result from Zoning Improvement Plan (ZIP) codes that cross county lines. In these situations, SSA assigns a default county code in the computer program matrix, which is transferred to TIERS data files. Results of correction requests to the DIU mailbox, take place during the next TIERS cutoff, usually around the 20th day of the month. SASO will reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff. Describe the needed change in the email and send the following information:
- individual’s name as recorded in TIERS;
- individual’s Medicaid identification (ID) number; and
- correct ZIP code and residence county as it should be reflected in TIERS.
- For TP 03, TP 18, TP 19, TP 21, TP 50, TP 87 or TP 88 in TIERS: fax Form H1746-A, MEPD Referral Cover Sheet (PDF), to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist assigned to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and request a correction.
- For Supplemental Nutrition Assistance Program (SNAP): fax Form H1746-A to the MEPD specialist assigned to the HEART case record and request a correction.
- For TP 12 or 13 in TIERS: advise the applicant, member or authorized representative (AR) to contact the Social Security Administration (SSA) to request a correction. The Data Integrity Unit (DIU) can correct problems in TIERS that result from Zoning Improvement Plan (ZIP) codes that cross county lines. In these situations, SSA assigns a default county code in the computer program matrix, which is transferred to TIERS data files. Results of correction requests to the DIU mailbox, take place during the next TIERS cutoff, usually around the 20th day of the month. SASO will reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff. Describe the needed change in the email and send the following information:
3720 Administrative Payment Process
Revision 25-2; Effective June 6, 2025
Program Support Unit (PSU) staff must authorize the managed care organization (MCO) to start services on the date the member who is aging out of the following programs becomes eligible for the STAR+PLUS Home and Community Based Services (HCBS) program:
- the Texas Health Steps-Comprehensive Care Program (THSteps-CCP);
- the Medically Dependent Children Program (MDCP); or
- was approved for a nursing facility diversion (NFD) slot.
The start of care (SOC) date for the STAR+PLUS HCBS program may not be the first of the month. The MCO must follow the administrative payment process for STAR+PLUS services provided between the eligibility date and the managed care enrollment date, as applicable, if the eligibility date is not the first of the month. The administrative payment process must be used for the Texas Health and Human Services Commission (HHSC) to issue payment to the MCO and for the MCO to pay the provider.
The MCO must complete the following activities once PSU staff authorize the MCO to provide services:
- prepares Form 1500, Health Insurance Claim; and
- submits Form 1500 to the MCO within the 95-day filing deadline.
The MCO verifies the following within five business days of receiving Form 1500 from the provider:
- the provider was authorized to deliver the services billed on the form;
- the information on the form meets the clean claim requirements, defined in the Uniform Managed Care Manual (UMCM), Section 2.0; and
- the claim met the 95-day filing deadline.
Once the MCO verifies this information, the MCO:
- sends Form 1500 by secure email to the PSU staff if approved; or
- denies payment by the MCO denial process if the provider:
- is not authorized to deliver the services;
- did not meet the clean claim requirements; or
- did not meet the 95-day filing deadline.
PSU staff must complete the following activities within two business days of receiving Form 1500:
- verify the member is Medicaid eligible and has a valid Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP);
- prepare Form 4116, Authorization for Expenditures;
- email Form 4116, Form 1500, a screenshot of the Service Authorization screen from Service Authorization Services Online (SASO), and screenshots of the Medicaid eligibility and Managed Care enrollment screens in Texas Integrated Eligibility Redesign System (TIERS) to the Enrollment Resolution Services (ERS) unit mailbox; and
- create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and upload applicable documents.
The assigned ERS unit staff must complete the following activities within two business days from the receipt of the email from PSU staff:
- verify the member is Medicaid eligible; and
- review the claim to determine if it will be paid or denied.
The ERS unit staff complete the following activities if the decision is to approve to pay the administrative payment:
- email the approved Form 4116 to the Contract Compliance and Support (CCS) unit mailbox for processing; and
- notify by email the PSU staff who emailed the request that the administrative payment was approved.
The following activities occur if the decision is to approve the administrative payment:
- the CCS Unit sends the approved payment voucher to the state comptroller for processing and payment to the MCO; and
- the MCO pays the provider within one week of receipt of payment from the state comptroller.
The ERS unit staff will notify by email the PSU staff who submitted the request for administrative payment if the decision is to deny the administrative payment. This email response also includes the reason for denial.
PSU staff must complete the following activities within two business days of receipt of email from ERS unit staff:
- notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub;
- upload the email from ERS unit and the MCO notification to the HEART case record; and
- close the HEART case record.