Texas Medicaid

Uniform Managed Care Manual

Chapter 1

• Introduction
• 1.1 — Materials Submitted for HHSC Review

Chapter 2: Texas Claims Procedures

• 2.0 — Claims Manual
• 2.1 — Uniform Billing for STAR+PLUS
  • 2.1.1 — Long Term Services and Supports Billing
  • 2.1.2 — Long Term Services and Supports Codes and Modifiers
  • 2.1.3 — STAR+PLUS Attendant Care Enhanced Payment Methodology
• 2.2 Pharmacy Claims Manual

Chapter 3: Critical Elements

• 3.1 — MMC Provider Directory
• 3.2 — CHIP Provider Directory
• 3.3 — MMC/CHIP Provider Manual
• 3.4 — MMC Member Handbook
• 3.5 — CHIP Member Handbook
• 3.6 — MMC Member ID Card
• 3.7 — CHIP Member ID Card
• 3.8 — CHIP Perinate Member ID Card
• 3.9 — Integrated Care Management Provider Directory
• 3.10 — Integrated Care Management Provider Manual
• 3.11 — Integrated Care Management Member Handbook
• 3.12 — Integrated Care Management Member ID
• 3.13 — STAR Health Provider Directory
• 3.14 — STAR Health Provider Manual
• 3.15 — STAR Health Member Handbook
• 3.16 — STAR Health Member ID
• 3.17 — CHIP Dental Provider Directory
• 3.18 — MMC-CHIP Dental Provider Manual
• 3.19 — CHIP Dental Member Handbook
• 3.20 — CHIP Dental Member ID Card
• 3.21 — MMC Notices of Actions Required
• 3.22 — Incomplete Prior Authorizations
• 3.23 — STAR Health Dental Services Provider Manual
• 3.24 — MMC Texas Health Steps Outreach Materials
• 3.25 — MMC Dental Provider Directory
• 3.26 — Medicaid Dental Member Handbook
• 3.27 — Medicaid Dental Member ID Card

Chapter 4: Marketing Policies and Procedures

• 4.1 — MMC Marketing Policies and Procedures
• 4.2 — CHIP Marketing Policies and Procedures
• 4.3 — Uniform Managed Care Marketing Policy and Procedures Manual
• 4.4 — Dental Value-Added Services Template
• 4.5 — Physical and Behavioral Health Value-Added Services Template

Chapter 5: Deliverables, Report Formats, Due Dates

• 5.0 — Consolidated Deliverables Matrix
• 5.1 — Deliverables Naming Conventions
• 5.2 — MIS Deliverables/Formats
• 5.3 — Financial Reports/Formats
  • 5.3.1 — FSR & Instructions
    • 5.3.1.1 — CHIP FSR Template For transactions occurring prior to 3/1/12
    • 5.3.1.2 — CHIP FSR Instructions For transactions occurring prior to 3/1/12
    • 5.3.1.3 — STAR FSR Template For transactions occurring prior to 3/1/12
    • 5.3.1.4 — STAR FSR Instructions For transactions occurring prior to 3/1/12
    • 5.3.1.5 — STAR+PLUS FSR Template For transactions occurring prior to 3/1/12
    • 5.3.1.6 — STAR+PLUS FSR Instructions For transactions occurring prior to 3/1/12
    • 5.3.1.7 — CHIP Perinatal FSR Template For transactions occurring prior to 3/1/12
    • 5.3.1.8 — CHIP Perinatal FSR Instructions For transactions occurring prior to 3/1/12
    • 5.3.1.9 — ICM ASO FSR
    • 5.3.1.10 — ICM ASO FSR Instructions
    • 5.3.1.11 — STAR Health FSR Template For transactions occurring prior to 3/1/12
    • 5.3.1.12 — STAR Health FSR Instructions For transactions occurring prior to 3/1/12
    • 5.3.1.13 — CHIP Dental FSR
    • 5.3.1.14 — CHIP Dental FSR Instructions
    • 5.3.1.15 — Medicaid Dental FSR
    • 5.3.1.16 — Medicaid Dental FSR Instructions
    • 5.3.1.17 — Admin FSR Template
    • 5.3.1.18 — Admin FSR Instructions
    • 5.3.1.19 — CHIP FSR Template
    • 5.3.1.20 — CHIP FSR Instructions
    • 5.3.1.21 — STAR FSR Template
    • 5.3.1.22 — STAR FSR Instructions
    • 5.3.1.23 — STAR MRSA FSR Template
    • 5.3.1.24 — STAR MRSA FSR Instructions
    • 5.3.1.25 — STAR+PLUS FSR Template
    • 5.3.1.26 — STAR+PLUS FSR Instructions
    • 5.3.1.27 — STAR Health FSR Template
    • 5.3.1.28 — STAR Health FSR Instructions
  • 5.3.2 — MCO Disclosure Statement
    • 5.3.2.1 — MCO Disclosure Statement Change Notification
  • 5.3.3 — CMS 1513 Report
  • 5.3.4 — Third Party Recovery (TPR) Report
    • 5.3.4.1 — TPR Report Format and Certification
    • 5.3.4.2 — TPR Report Instructions
  • 5.3.5 — Delivery Supplemental Payment (DSP) Report
    • 5.3.5.1 — DSP CHIP Format
    • 5.3.5.2 — DSP Medicaid Format
    • 5.3.5.3 — DSP File Submission Instructions
    • 5.3.5.4 — DSP File Specifications
    • 5.3.5.5 — DSP Appeal Form CHIP
    • 5.3.5.6 — DSP Appeal Form Medicaid
  • 5.3.6— FQHC Report and Instructions
    • 5.3.6.1 — FQHC Template
    • 5.3.6.2 — FQHC Instruction
  • 5.3.7 — RHC Report and Instructions
    • 5.3.7.1 — RHC Template
    • 5.3.7.2 — RHC Instruction
  • 5.3.8 — OON Utilization Report
  • 5.3.9 — Disproportionate Share Hospital Report
    • 5.3.9.1 — Disproportionate Share Hospital Report Instructions
    • 5.3.9.2 — Disproportionate Share Hospital Report Template
  • 5.3.10— Data Certification
    • 5.3.10.1 — Certification Form
    • 5.3.10.2 — Certification Instructions
  • 5.3.11 — Audit Reports
  • 5.3.12 — Bariatric Supplemental Payment (BSP) Report
    • 5.3.12.1 — Medicaid BSP Instructions
    • 5.3.12.2 — Medicaid BSP Report Format
    • 5.3.12.3 — Medicaid BSP Appeals Form
• 5.4 — Operational Deliverable/Report Formats
  • 5.4.1 — Provider Network Reports
    • 5.4.1.1 — Provider Termination Report
    • 5.4.1.2 — PCP Network and Capacity Report
    • 5.4.1.3 — STAR Health PCP TH Steps Enrollment Report
    • 5.4.1.4 — STAR Health Network Summary Report
    • 5.4.1.5 — Dental Provider Termination Report
    • 5.4.1.6 — Main Dental Home Network & Capacity Report
  • 5.4.2 — Complaints and Appeals Report
    • 5.4.2.1 — CHIP Member Appeals
    • 5.4.2.2 — CHIP Overturned
    • 5.4.2.3 — Medicaid Member Appeals
    • 5.4.2.4 — Medicaid Overturned
    • 5.4.2.5 — Member Complaint Report
    • 5.4.2.6 — Provider Complaint Report
    • 5.4.2.7 — CHIP Dental Program Member Appeals
    • 5.4.2.8 — CHIP Dental Program Member Complaints
    • 5.4.2.9 — CHIP Dental Program Provider Complaints
    • 5.4.2.10 — CHIP Dental Program Overturned
    • 5.4.2.11 — Medicaid Dental Member Appeals
    • 5.4.2.12 — Medicaid Dental Member Complaints
    • 5.4.2.13 — Medicaid Dental Provider Complaints
    • 5.4.2.14 — Medicaid Dental Overturned
  • 5.4.3 — Hotline Reports
    • 5.4.3.1 — Behavioral Health Crisis Hotline Report
    • 5.4.3.2 — Member Hotline Status
    • 5.4.3.3 — Provider Hotline Status
    • 5.4.3.4 — STAR Health BH Services Hotline Report
    • 5.4.3.5 — STAR Health Member Services Hotline Report
    • 5.4.3.6 — STAR Health Provider Hotline Status
    • 5.4.3.7 — STAR Health NurseHotlineReport
    • 5.4.3.8 — CHIP Dental Member Hotline
    • 5.4.3.9 — CHIP Dental Provider Hotline
    • 5.4.3.10 — Medicaid Dental Provider Hotline
    • 5.4.3.11 — Medicaid Dental Member Hotline
  • 5.4.4 — HUB Reports
    • 5.4.4.1 — HUB Report Format
    • 5.4.4.2 — HUB Status Determination Form
    • 5.4.4.3 — HUB Best Practices Report Instructions
    • 5.4.4.4 — HUB Progress Assessment Report Form
    • 5.4.4.5 — HUB Progress Assessment Report Instructions
    • 5.4.4.6 — HUB Change Request Instructions
• 5.4.5 — LTSS Utilization Reports
  • 5.4.5.1 — STAR+PLUS Quarterly CDS Utilization Report
• 5.5 — Fraud Deliverable/Report Format
  • 5.5.1 — MCO Open Case List Report Template
• 5.6 — Claims Deliverables and Format
  • 5.6.1 — Claims Summary Report
    • 5.6.1.1 — Claims Summary Report Template
    • 5.6.1.2 — Claims Summary Report Instructions
    • 5.6.1.3 — STAR Health Dental Claims Summary Report
    • 5.6.1.4 — Dental Claims Summary Report
    • 5.6.1.5 — Dental Claims Summary Report Instructions
  • 5.6.2 — Claims Lag Reports
    • 5.6.2.1 — CHIP Claims Lag Report Template
    • 5.6.2.2 — STAR Claims Lag Report Template
    • 5.6.2.3 — STAR+PLUS Claims Lag Report Template
    • 5.6.2.4 — Claims Lag Report Instructions
    • 5.6.2.5 — STAR Health Claims Lag Report Template
    • 5.6.2.6 — STAR Health Claims Lag Report Instructions
    • 5.6.2.7 — CHIP Dental Claims Lag Report Template
    • 5.6.2.8 — Dental Claims Report Instructions
    • 5.6.2.9 — Medicaid Dental Claims Lag Report
    • 5.6.2.10 — STAR MRSA Claims Lag Report Template
• 5.7 — Quality Reports
  • 5.7.1 — QIP-QAPI Summary Format
• 5.8 — Report of Legal and Other Proceedings
• 5.9 — STAR Health Reports
  • 5.9.1 — STAR Health Liaison Summary Report
  • 5.9.2 — STAR Health PMUR Report
  • 5.9.3 — STAR Health Service Management Summary Report
• 5.10 — CHIP Craniofacial Anomalies Report
  • 5.10.1 — CHIP Craniofacial Anomalies Quarterly Report Instructions
  • 5.10.2 — CHIP Craniofacial Anomalies Pre & Post Surgical Orthodontic Procedures Quarterly Report Template
• 5.11 — Affiliate Report
• 5.12 — Federal Reports
  • 5.12.1 — CHIP Federal Report
• 5.13 Pharmacy Reports
  • 5.13.1 — MCO Drug Utilization Review (DUR) Quarterly Report Template
  • 5.13.2 — MCO DUR Quarterly Report Instructions
  • 5.13.3 — Pharmaceutical Delivery Fee Payment Methodology
  5.14 Geo-Mapping Reports
  • 5.14.1 — STAR Geo-Mapping Report
  • 5.14.2 — STAR+PLUS Geo-Mapping Report
  • 5.14.3 — CHIP Geo-Mapping Report
  • 5.14.4 — STAR Health Geo-Mapping Report
  • 5.14.5 — STAR Health and Medicaid Dental Geo-Mapping Report
  • 5.14.6 — CHIP Dental Geo-Mapping Report

Chapter 6: Financial

• 6.1 — Cost Principles for Expenses
• 6.2 — Financial Incentive Methodology
  • 6.2.1 — Performance Measures for Capitation Rate At Risk
  • 6.2.2 — Performance Measures for Capitation Rate At-Risk Instructions
  • 6.2.3 — Geo-Mapping Provider Layouts
  • 6.2.4 — Geo-Mapping Methodology
  • 6.2.5 — STAR Health 1% At Risk Premium
  • 6.2.6 — Quality Challenge Award Performance Indicators
  • 6.2.7 — Medicaid Dental Performance Measures for Capitation Rate At Risk
  • 6.2.8 — CHIP Dental Performance Measures for Capitation Rate At Risk
  • 6.2.9 — Medicaid Dental Quality Challenge Award
  • 6.2.10 — CHIP Dental Quality Challenge Award
• 6.3 — CHIP Cost Sharing
• 6.4 — Performance Bonds
  • 6.4.1 — Performance Bond Instructions
  • 6.4.2 — STAR Performance Bond
  • 6.4.3 — STAR+PLUS Performance Bond
  • 6.4.4 — CHIP Performance Bond
  • 6.4.5 — MMC/CHIP Performance Bond

Chapter 7: Management Information Systems (MIS)

• 7.1 — Joint Interface Plans (JIP)
• 7.2 — TXMedCentral

Chapter 8: Provider

• 8.1 — Provider Contract Checklist
• 8.2 — Medicaid/CHIP Out-of-Network Rules
• 8.3 — Long-Term Services and Supports Provider Layout

Chapter 9: Disease Management (DM)

• 9.1 — Disease Management Requirement for STAR, CHIP, and STAR+PLUS
• 9.2 — ICM Disease Management Requirements
• 9.3 — STAR Health Disease Management Requirements

Chapter 10: Contract Management Tools

• 10.1 — Performance Indicator Dashboard
  • 10.1.1 — Performance Indicator Dashboard for Administrative & Financial Measures
  • 10.1.2 — Information Pertaining to the Performance Indicator Dashboard
  • 10.1.3 — STAR Health Performance Indicator Dashboard for Administrative & Financial Measures
  • 10.1.4 — CHIP Dental Dashboard for Administrative and Financial Measures
  • 10.1.5 — Medicaid Dental Dashboard - Admin & Financial Measures
  • 10.1.7 — Performance Indicator Dashboard for Quality Measures
  • 10.1.8 — STAR Health Performance Indicator Dashboard for Quality Measures
  • 10.1.9 — CHIP Dental Performance Indicator Dashboard for Quality Measures
  • 10.1.10 — Medicaid Dental Dashboard for Quality Measures
• 10.2 — Performance Improvement
  • 10.2.1 — Performance Improvement Goal – Sub-Goal Template
  • 10.2.2 — Performance Improvement Goal – Sub-Goal Example
  • 10.2.3 — Performance Improvement Goal Instructions
  • 10.2.4 — Performance Improvement Project Submission Instructions
  • 10.2.5 — Performance Improvement Project Template
  • 10.2.6 — Dental Performance Improvement Project Overarching Goals
  • 10.2.7 — MMC/CHIP Performance Improvement Project Overarching Goals

Chapter 11: Member

• 11.1 — STAR+PLUS Medicaid Estate Recovery Program
• 11.2 — STAR+PLUS ESRD Disenrollment
• 11.3 — STAR+PLUS Ventilator Dependent Member Disenrollment
• 11.4 — STAR+PLUS Policy for 1915c Nursing Facility Waiver Services
• 11.5 — MMC Member Disenrollment Policy
• 11.6 — MMC Member Disenrollment Form
• 11.8 — ICM Medicaid Estate Recovery Program
• 11.9 — ICM Policy for 1915c Nursing Facility Waiver Services

Chapter 12: Frew

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

Chapter 14: CHIP Dental

• 14.1 — CHIP Dental Tier Schedule