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2013 Long Term Care Community Services Waiver

1. S5a HHA RN Last Name SSb HHA RN License S5c HHA RN License State v S5d DADS RN Last Name SSe DADS RN License S5f DADS RN License State S5g DADS RN Signature Date __ Fi SSh PACE RN Last Name SSi PACE RN License 5 PACE RN License State S5k HMO RN Last Name SSI HMO RN License ssm HMO RN License State S6 Additional MN Information S6a Tracheostomy Care vi S6b e Ventilator Respirator vi S6c Number of hospitalizations in the last 90 days S d Number of emergency room visits in the last 90 days S6e Oxygen Therapy E S6f Special Ports Central Lines PICC S6g At what developmental level is the individual functioning v S6h e Enter the number of times this individual has fallen in the last 90 days S6i In how many of the falls listed above was the person physically restrained prior to the fall S6j In the falls listed in S6h above how many had the following contributory factors More than one factor may apply to a fall Indicate the number of falls for each contributory factor 6jl Environmental debris slick or wet floors lighting etc l S6j2 Medication s S6j3 Major Change in Medical Condition Myocardial Infarction MI Heart Attack Cerebrovascular Accident CVA Stroke Syncope Fainting etc S6j4 Poor Balance Weakness S6j5 e Confusion Disorientation S6j6
2. E Eq un Z ow OH E gt Nye ZIQ A gt Om mm a Opa AH OARAO Solution v 2014 1013 Individual Identifier Date Medical Necessity and Level of Care Assessment Version 3 0 S a ye Identification Information A0310 Type of Assessment Enter A Reason for Assessment 01 Initial assessment 03 Annual assessment E 04 Significant change in status assessment A0500 Legal Name of Individual A First name B Middle initial SRR a C Last name A0600 Social Security and Medicare Numbers A Social Security Number SEE Ee eee B Medicare number or comparable railroad insurance number A0700 Medicaid Number Enter if pending N if not a Medicaid recipient A0800 Gender Enter i 1 Male 2 Female Code A0900 Birth Date A1000 Race Ethnicity Check all that apply A American Indian or Alaska Native B Asian C Black or African American D Hispanic or Latino E Native Hawaiian or Other Pacific Islander O O O O O L MN and LOC 3 0 V 15 1 of 32 Individual Identifier Date S a ye identification Information A1100 Language A Does the individual need or want an interpreter to communicate with a doctor or health care staff 0 No 1 Yes Specify in A1100B Preferred language 9 Unable to determine B Preferred language SRR A1300 Optional Individual
3. HLR Month Day MN and LOC 3 0 V 15 28 of 32 Individual LTC Medicaid Information S1 Medicaid Information Medicaid Client Indicator 1 Medicaid S1b Individual Address el S2 Claims Processing Information S2a DADS Vendor Site ID Number S2b Contract Provider Number Service Group 3 CBA 11 PACE 17 CWP 18 MDCP 19 Star Plus S2h HHA License Expiration Date S3 Primary Diagnosis S3a_ Primary Diagnosis ICD Code S3b Primary Diagnosis ICD Description S4 For DADS use only RUG MN and LOC 3 0 V 15 Identifier Date S5 Licenses Certification To the best of my knowledge certify to the accuracy and completeness of this information S5a HHA RN Last Name S5b HHA RN License HHA RN License State DADS RN Last Name DADS RN License s5f DADS RN License State S5g DADS RN Signature Date DADS RN Signature s5h PACE RN Last Name S5i PACE RN License PACE RN License State S5k HMO RN Last Name s51 HMO RN License HMO RN License State S5c s5d S5e 55 S5m S6 Additional MN Information Tracheostomy Care 1 Less than once a week 2 1 to 6 times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 Every 2 hours 7 Hourly continuous Ventilator Respirator 1 Less than once a week 2 1 to 6 times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 6 23 h
4. Required If you work for a Home Health Agency Enter the Home Health Agency License number HHA License must be up to seven numeric digits If you do not work for a Home Health Agency Enter all zeros 2h HHA License Expiration Date Required Enter the license expiration date of the Home Health Agency License number HHA License Expiration Date must be in mm dd yyyy format e S3 Primary Diagnosis S3a Primary Diagnosis International Classification of Diseases ICD Code Required Enter a valid ICD code for the individual s primary diagnosis Use your best clinical judgment 36 v 2014 1013 LTC Community Services Waiver Programs User Guide 3b Primary Diagnosis ICD description Optional Click the magnifying glass and the description will be auto populated based on the primary diagnosis ICD code e 4 For DADS use only When a successfully submitted LTCM1I is printed field S4b will show the calculated RUG value Note Zhe RUG value also appears at the top of each page on all successfully submitted MN LOC Assessments e 5 Licenses Certification To the best of my knowledge I certify to the accuracy and completeness of this information S5a HHA RN Last Name Conditional This is a required field for Service Group SG 3 CBA Enter the last name of the RN completing the assessment S5b HHA RN License Conditional This is a r
5. Significant Change in Sta tus Assessment Significant Change in Sta tus Assessment CS 0020 The request cannot be pro cessed because the Annual Assessment is being submitted more than 90 days prior to the Level of Service end date CS 0021 The request cannot be pro cessed because the Annual Assessment has been submitted more than 132 days after the end of the last Level of Service record CS 0023 The request cannot be processed because the individual is enrolled in PACE and has Permanent MN Annual assessments for this indi vidual are not needed This assessment should be Inactivated with Reason for Suggested Action The request cannot be processed be cause the Annual Assessment has been submitted more than 132 days after the end of the last Service Plan Inactivate Annual Assessment and submit an Initial Assessment The request cannot be processed be cause a previous Service Plan cannot be found Please submit an Initial Assess ment The request cannot be processed because an Initial Assessment for the individual cannot be found Please verify data entry or contact the DADS case manager Inactivate Form Inactivate Form Inactivate this assessment by clicking the Inactivate Form button and submit an Annual Assessment within 90 days of the Level of Service end date Inactivate this assessment by click ing the Inactivate Form button and submit an Initial Assessment Waive
6. Cerebro vascular Accident CVA Stroke Syncope Fainting etc Conditional This field is required only if S6h indicates the individual has fallen Valid range includes 0 with a maximum being the number entered in Soh S6j4 Poor Balance Weakness Conditional This field is required only if S6h indicates the individual has fallen Valid range includes 0 with a maximum being the number entered in Soh S6j5 Confusion Disorientation Conditional This field is required only if S6h indicates the individual has fallen Valid range includes 0 with a maximum being the number entered in Soh S6j6 Assault by Individual or Caregiver Conditional This field is required only if S6h indicates the individual has fallen Valid range includes 0 with a maximum being the number entered in Soh 4 LTC Community Services Waiver Programs User Guide 42 S7 Physician s Evaluation amp Recommendation S7a Did an MD DO certify that this individual requires Nursing Facility services or alternative communi ty based services under the supervision of an MD DO Required In order to meet the requirements for these community programs the individual must require Nurs ing Facility services or alternative community based services under the supervision of an MD or DO Submission of the assessment will not be allowed on the LTC Online Portal if No is selected This is a required field for the Initial Asse
7. After attending the Long Term Care Community Services Waiver Programs Workshop you will be able to e Understand the Medicaid Team roles e Identify National Provider Identifier NPI Atypical Provider Identifier API requirements e Obtain an LTC Online Portal administrator account e Understand basic LTC Online Portal features e Understand Medical Necessity MN and the MN determination process e Submit Medical Necessity and Level of Care MN LOC Assessments e Understand and complete the Long Term Care Medicaid Information LTCMI section field by field e Understand the provider workflow process e Understand how to correct or inactivate assessments and the consequences of doing so e Understand how to print completed and blank assessments e Identify assessment statuses and how to resolve issues e Understand Resource Utilization Group RUG training requirements e Explain how to report Medicaid waste abuse and fraud e Identify additional resources v 2014 1013 l LTC Community Services Waiver Programs User Guide Medicaid Team The following groups and individuals make up the Medicaid Team Together they make it possible to deliver Medic aid services to Texans Centers for Medicare amp Medicaid Services CMS The agency in the Department of Health and Human Ser vices that is responsible for federal administration of the Medicare Medicaid and State Children s Health Insur ance Program CHIP
8. Assault by Individual or Caregiver v 2014 1013 33 LTC Community Services Waiver Programs User Guide 7 Physician s Evaluation amp Recommendation S7a services under the supervision of an MD DO Did a military physician providing healthcare according to requirements stipulated in 10 US Code 1094 provide the evaluation and recommendation for this individual MD DO Last Name MD DO License MD DO License State Indicate Physician Signature on file by checking box Required for Initial Assessments The following MD DO information is required if MD DO is not licensed in Texas S7f MD DO First Name S7g MD DO ddress S7h MD DO City O E S7i MD DO State v S7j MD DO ZIP Code S7k MD DO Phone o o oo S9 Medications S7b S c S7d S7e weekly Add Meds 10 Comments Did an MD DO certify that this individual requires nursing facility services or alternative community based List all medications that the individual received during the last 30 days Include scheduled medications that are used regularly but less than OMedication Certification I certify this individual is taking no medications OR the medications listed below are correct 11 Advance Care Planning Slla Does the individual caregiver report having a legally authorized representative S11b
9. Feel free to refer to sections of this LTC User Guide 1 Name three benefits of using the LTC Online Portal 1 FA 3 In order to access the LTC Online Portal what is the first step you must take Name two options in the blue navigational bar When would you see the yellow Form Actions bar How can you tell if a field is required v 2014 1013 81 LTC Community Services Waiver Programs User Guide Review Answers l 82 Name three benefits of using the LTC Online Portal The LTC Online Portal is a web based application that is available 24 hours a day 7 days a week TMHP provides LTC Online Portal technical support by telephone during normal business hours Monday Friday 7 00 am 7 00 pm Central Time The LTC Online Portal provides error messages that must be resolved before submission Providers have the ability to monitor the status of their assessments and to submit additional information when needed In order to access the LTC Online Portal what is the first step you must take Set up an administrator account or a user account if one is already available for that agency You can find information for setting up an administrator account in the How to Create an LTC Online Portal Administrator Account in your User Guide Name two options in the blue navigational bar Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms and Help When would
10. Individual A person enrolled in a program Long Term Services and Supports LTSS Services provided to an individual in the individual s home or other community based setting that are necessary to allow the individual to remain in the most integrated setting possible Medically Dependent Children Program MDCP A 1915 c Medicaid waiver program that provides respite flexible family support services minor home modifications adaptive aids financial management services and transi tion assistance services to children who are 20 years of age and younger as an alternative to Nursing Facility care Program of All Inclusive Care for the Elderly PACE PACE provides community based services to older indi viduals who qualify for Nursing Facility placement PACE uses a comprehensive care approach providing an array of services for a capitated monthly fee that is below the cost of comparable institutional care STAR PLUS Providers A 1915 c Medicaid waiver program approved for the managed care delivery system that is designed to allow individuals who qualify for Nursing Facility care to receive long term services and supports in order to be able to live in the community v 2014 1013 79 LTC Community Services Waiver Programs User Guide This page is intentionally blank 80 v 2014 1013 LTC Community Services Waiver Programs User Guide Appendix A LTC Online Portal Review Test your knowledge by answering the questions on this page
11. LTC Community Services Waiver Programs User Guide 40 S6e Oxygen Therapy Conditional This field is only required and available for data entry if O0100C Oxygen therapy is checked Choose from the drop down box 1 Less than once a week 2 1 to 6 times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 6 23 hours 7 24 hour continuous S6f Special Ports Central Lines PICC Optional Use this field to indicate if the individual has any type of implantable access system or central venous catheter CVC This includes epidural intrathecal or venous access or Peripherally Inserted Central Catheter PICC devices This does not include hemodialysis or peritoneal dialysis access devices Choose from the drop down box 0 N none present 1 Y 1 or more implantable access system or CVC 2 U unknown S6g At what developmental level is the individual functioning Conditional This is a required field for all assessments for individuals who are 20 years of age and younger based on birth date minus date of submission TMHP Received date Not available for data entry if the indi vidual is 21 years of age or older Choose from the drop down box Unknown or unable to assess lt 1 Infant 1 2 Toddler 3 5 Pre School 6 10 School age 11 15 Young Adolescence 16 20 Older Adolescence a OS Soh Enter the number of times this individual has fallen in the las
12. View R amp S Reports View PCCM Panel Reports Submit prior authorization requests This feature is currently unavailable to CSHCN providers but it is coming soon You can administer a Provider Account three to five days after receiving the TMHP enrollment confirmation letter Click the following link t Create a Provider Vendor Administrator Account Malidation will be required to activate an Account How to Yalidate a Provider Vendor Account LTC Community Services Waiver Programs User Guide 8 Choose a Provider Type from the drop down box Note The Provider Types listed immediately below are the only two choices in the drop down box that are applicable for this guide Use NF Waiver Programs to submit MN LOC Assessments on the LTC Online Portal If you already use TexMedConnect you are still required to create an NF Waiver Programs account to submit MN LOC As sessments on the LTC Online Portal Use Long Term Care to access TexMedConnect for submitting claims accessing R amp S Reports and performing Medicaid Eligibility and Service Authorization Verifications MESAVs Ss TMHP Account Activation Use the following guidelines to determine your selection from the Provider Type menu below Option 1 If you are a provider enrolled by TMHP choose Acute Care Option 2 If you are a provider enrolled by DADS and would like to view R amp S reports and submit 3071s and 3074s choose Long Term Care Opt
13. assessment 7 30 2013 Processed Complete PA1 7 25 2013 03 Annual assessment 7 30 2013 Processed Complete PA1 7 23 2013 03 Annual assessment 7 31 2013 Processed Complete IA1 7 16 2013 01 Initial assessment 7 31 2013 Processed Complete PB1 7 23 2013 03 Annual assessment 8 6 2013 Invalid Complete PAI 7 10 2013 03 Annual assessment 8 7 2013 Processed Complete IA1 7 17 2013 01 Initial assessment rt Data to Excel 8 12 2013 Processed Complete IB1 8 8 2013 03 Annual Detail assessment Note FSI can retrieve information from the previous seven years The search is based on the TMHP Received Date There is a 50 record line limit for search results therefore you may need to narrow your search to retrieve specific records Descrip tions of the column headings seen above are e View Detail The hyperlink used to open the assessment e DLN The unique document locator number DLN assigned to each successfully submitted assessment e TMHP Received Date The actual date the assessment was successfully submitted on the LTC Online Portal e SSN 2 0 AA5a 3 0 AOGOOA Medicaid 2 0 AA7 3 0 A0700 Medicare 2 0 AA5b 3 0 AOGOOB First Name and Last Name 2 0 AAla and AA1c 3 0 AO500A and A0500C Information used to identify the individual associated with the assessment e Status The status of the assessment at the time of the search e RUG The assigned Resource Utilization Group RUG value e RN Signature Date Date
14. e g degenerative joint disease DJD osteoarthritis and rheumatoid arthritis RA Osteoporosis Hip Fracture any hip fracture that has a relationship to current status treatments monitoring e g sub capital fractures and fractures of the trochanter and femoral neck Contractures Other Fracture Scoliosis Neurological 14200 Alzheimer s Disease 14300 Aphasia 14400 Cerebral Palsy 14500 Cerebrovascular Accident CVA Transient Ischemic Attack TIA or Stroke 14800 Non Alzheimer s Dementia e g Lewy body dementia vascular or multi infarct dementia mixed dementia frontotemporal dementia such as Pick s disease and dementia related to stroke Parkinson s or Creutzfeldt Jakob diseases 14900 Hemiplegia or Hemiparesis 15000 Paraplegia 15100 Quadriplegia 15199 Tremors 15200 Multiple Sclerosis MS 15250 Huntington s Disease 15299 Muscular Dystrophy 15300 Parkinson s Disease 15350 Tourette s Syndrome 15399 Hydrocephalus 15400 Seizure Disorder or Epilepsy 15499 Type of Seizure Check all that apply LJ A Localized partial or focal OUUOUOUOOOOOO OOOO WOO OLLI No seizures Enter Code 14 Less than 1 seizure week 1 6 seizures week 1 seizure day 2 5 seizures day 6 12 seizures day More than 12 seizures day Traumatic Brain Injury TBI Spina Bifida MN and LOC 3 0 V 15 14 of 32 Individual Identifier Date Section Active Diagnoses Active Diagnoses
15. enter dashes if therapy is ongoing tT IL Day Month 00400 continued on next page 24 of 32 Individual Identifier Date Section O Special Treatments Procedures and Programs 00400 Therapies Continued C Physical Therapy Enter Number of Minutes 1 Individual minutes record the total number of minutes this therapy was administered to the individual individually in the last 7 days Enter Number of Minutes 2 Concurrent minutes record the total number of minutes this therapy was administered to the individual concurrently with one other individual in the last 7 days Enter Number of Minutes 3 Group minutes record the total number of minutes this therapy was administered to the individual as part of a group of individuals in the last 7 days If the sum of individual concurrent and group minutes is zero gt skip to O0400D Respiratory Therapy Enter Number of Minutes 3A Co treatment minutes record the total number of minutes this therapy was administered to the individual in co treatment sessions in the last 7 days Enter Number of Days 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days E 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the last assessment started therapy regimen since the last assessment ended ent
16. lt lt Last Name First Name SSN HH Form Status From Date s22010 To Date 10 1 2010 id 3 Enter data for all required fields as indicated by the red dots Narrow results by entering specific criteria in the additional fields DLN Medicaid Number Last Name First Name SSN Form Status From and To Dates and Reason for Assessment Dates are searched against the TMHP Received Date date of success ful submission 4 Click the Search button and the LTC Online Portal will return any matching submissions records Note FSI search results will only display the Type of Form selected v 2014 1013 15 LTC Community Services Waiver Programs User Guide 5 Click the View Detail link of the requested assessment to open and view the assessment 50 record s returned Not all records returned This search is limited to return 50 records Please narrow your search TMHP RN Received Medicaid Signature Purpose Contract Vendor Reason For Date Medicare Date Code Number Number Assessment 7 1 2013 7 17 2013 Processed Complete BB1 01 Initial assessment 7 22 2013 Processed Complete SSB 7 8 2013 03 Annual assessment 7 24 2013 Denied PAL 7 2 2013 01 Initial assessment 7 29 2013 Processed Complete PA1 7 24 2013 03 Annual assessment 7 29 2013 Processed Complete PD1 7 24 2013 03 Annual assessment 7 29 2013 Processed Complete PB1 7 24 2013 03 Annual
17. s MD DO mailing address from the drop down box This information is used to mail MN determination letters 7j MD DO ZIP Code Conditional This field is required if the MD DO is not licensed in Texas Enter the ZIP Code of the individuals MD DO mailing address This information is used to mail MN determination letters 7k MD DO Phone Optional This field is optional if the MD DO is not licensed in Texas Enter the telephone number of the individual s MD DO This information is used to contact MD DO if necessary v 2014 1013 43 LTC Community Services Waiver Programs User Guide e S9 Medications 30 Day Look back Medication Certification I certify this individual is taking no medications or the medications listed below are correct Required Check the Medication Certification box to verify that the individual has no medications or that the individual has medications and that they are listed correctly in the medication table to include name dose route of administration RA frequency Freq and as necessary number of doses PRN n When a medication is added the information that is required to be entered is Medication Name and Dose Ordered Route of Administration Frequency PRN Number of doses required if the frequency chosen is PRN 59 Medications List all medications that the individual received during the last 30 days Include scheduled medications tha
18. the physician s signature is on file S7e MD DO License State Indicate Physician Signature on file by checking box Required for Initial Assessments 6 Click the Submit Form button to submit the Assessment Submit Form Physician s Signature page for Annual Assessments and Significant Change in Status Assessments optional 1 Once the physicians signature is obtained on the Initial Assessment the Physician s Signature box can be checked on the Annual Assessments and Significant Change in Status Assessments S7e MD DO License State Indicate Physician Signature on file by checking box Required for Initial Assessments 2 Click the Submit Form button to submit the assessment Submit Form Use as template The Use as template feature allows a provider to complete a new assessment by using the information in a previously submitted assessment as a template Various fields will auto populate be sure to check for accuracy Be careful not to confuse this feature with a similarly named feature in TexMedConnect Once you have found and are displaying the assessment using FSI or Current Activity 1 Click the Use as template button the data in this assessment will be used to create a new assessment 22 v 2014 1013 LTC Community Services Waiver Programs User Guide TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activ
19. Actions O Print Physician s Signature Use as template Add Note Inactivate Form Section G Section L Section B Section H Section M Section C Section I Section N Section D Section J Section O Section E Section K Section P Note The steps to inactivate an assessment will be covered in the Inactivations section Save as Draft The Save as Draft feature allows users to save unfinished assessments on the LTC Online Portal Once saved these drafts will be accessible by all users under the vendor contract number to which the draft is linked The user may access the draft by clicking the Drafts link located on the blue navigational bar Note The Save as Draft button will only display in the yellow Form Actions bar until the assessment being entered has been successfully submitted on the portal Drafts will display for 60 days only Form Actions Print Physician s Signature ee we Save as Draft v 2014 1013 2 LTC Community Services Waiver Programs User Guide Other Basic Information Required Fields Within the LTC Online Portal red dots indicate required fields Fields without the red dot are optional J ral TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Form Select For Type of Form e Forr Ty Form Status Inquiry DLN Medicaid Number Last Name First Name SSN ee Form Status From Date 4 24 2
20. Eligibility Worker to verify the individual s name SSN and Medicaid ID Out of State MD DO License Invalid TMHP has performed a manual check on the out of state license and determined it to be invalid If the information on the assessment is incorrect the provider can submit a cor rection within 14 calendar days of original submission to correct the erroneous information This status is only applicable for 3 0 Assessments Out of State MD DO License Valid MHP has performed a manual check on the out of state license and determined it to be valid The assessment will continue through the workflow This status is only applicable for 3 0 Assessments v 2014 1013 LTC Community Services Waiver Programs User Guide e Out of State RN License Invalid TMHP has performed a manual check on the out of state license and deter mined it to be invalid This often happens because the provider entered the wrong state If the information on the assessment is incorrect the provider can submit a correction within 14 calendar days of submission to fix the erroneous information e Overturned Doctor Review Assessment was denied MN and the provider has supplied additional information for review he assessment is pending TMHP doctor review for MN determination Pending Denial need more information This status occurs when the information is reviewed by a TMHP Nurse and does not support MN The provider has up to 21 calendar days to give additional in
21. Enter Code A Individual believes he or she is capable of increased independence in at least some ADLs i 0 No 1 Yes 9 Unable to determine Enter Code B Caregiver believes individual is capable of increased independence in at least some ADLs 0 No 1 Yes No information not assessed MN and LOC 3 0 V 15 11 of 32 Individual Identifier Date S a OnE u Bladder and Bowel H0100 Appliances Check all that apply A Indwelling catheter including suprapubic catheter and nephrostomy tube B External catheter C Ostomy including urostomy ileostomy and colostomy D Intermittent catheterization IOI Z None of the above H0200 Urinary Toileting Program Enter C Current continence promotion program or trial Is an individualized continence promotion program e g scheduled Code toileting prompted voiding or bladder training currently being used to manage the individual s urinary continence 0 No 1 Yes H0300 Urinary Continence Urinary continence Select the one category that best describes the individual Always continent Enter Occasionally incontinent less than 7 episodes of incontinence Frequently incontinent 7 or more episodes of urinary incontinence but at least one episode of continent voiding Code Always incontinent no episodes of continent voiding Not rated individual had a catheter indwelling condom urinary ostomy or no urine output for entire 7
22. Items B Room number titi ti ii A1550 Conditions Related to IDD Status If the individual is 22 years of age or older complete only if A0310A 01 If the individual is 21 years of age or younger complete always il Check all conditions that are related to IDD status that were manifested before age 22 and are likely to continue indefinitely IDD With Organic Condition A Down syndrome C Epilepsy D Other organic condition related to IDD IDD Without Organic Condition E IDD with no organic condition C Z None of the above A2300 Assessment Date Observation end date O OOOO HH Month Day Year MN and LOC 3 0 V 15 2 of 32 Individual Identifier Date Look back period for all items is 7 days unless another time frame is indicated ST iE Hearing Speech and Vision B0100 Comatose Enter Persistent vegetative state no discernible consciousness 0 No gt Continue to B0200 Hearing Code 1 Yes Skip to G0110 Activities of Daily Living ADL Assistance B0200 Hearing Ability to hear with hearing aid or hearing appliances if normally used 0 Adequate no difficulty in normal conversation social interaction listening to TV Code 1 Minimal difficulty difficulty in some environments e g when person speaks softly or setting is noisy 2 Moderate difficulty speaker has to increase volume and speak distinctly 3 Highly impai
23. Limited assistance individual highly involved in activity caregiver provide guided maneuvering 3 Two persons physical assist of limbs or other non weight bearing assistance 8 ADL activity itself did not occur during 3 Extensive assistance individual involved in activity caregiver provide weight bearing support entire period 4 Total dependence full caregiver performance every time during entire 7 day period Activity Occurred 2 or Fewer Times 7 Activity occurred only once or twice activity did occur but only once or twice 1 2 8 Activity did not occur activity or any part of the ADL was not performed by individual or Self Performance Support caregiver at all over the entire 7 day period l Enter Codes in Boxes A Bed mobility how individual moves to and from lying position turns side to side and positions body while in bed or alternate sleep furniture B Transfer how individual moves between surfaces including to or from bed chair wheelchair standing position excludes to from bath toilet C Walk in room how individual walks between locations in room D Walk in home how individual walks in home or community setting E Locomotion in room how individual moves between locations in his her room and adjacent hallway on same floor If in wheelchair self sufficiency once in chair F Locomotion in home how individual moves to and returns from distant areas in his her home or community setting If in wheelchair se
24. MN Determination Process Definition of Medical Necessity Texas Administrative Code TAC Title 40 Part 1 Chapter 19 includes the state rules governing licensed only Nursing Facilities and Medicaid Nursing Facilities 40 TAC 19 101 73 states Medical Necessity is the determination that a recipient requires the services of licensed nurses in an institutional setting to carry out the physician s planned regimen for total care A recipient s need for custodial care in a 24 hour institutional setting does not constitute a medical need A group of health care professionals employed or contracted by the Medicaid claims administrator contracted with HHSC makes individual determinations of Medical Necessity regarding Nursing Facility care These health care professionals consist of physicians and registered nurses General Qualifications for Medical Necessity Determinations TAC Title 40 Part 1 Chapter 19 19 2401 states Medical Necessity is the prerequisite for participation in the Medicaid Title XIX Long term Care program This section contains the general qualifications for a Medical Necessity determination To verify that Medical Necessity exists an individual must meet the conditions described in paragraphs 1 and 2 of this section 1 The individual must demonstrate a medical condition that A is of sufficient seriousness that the individual s needs exceed the routine care which may be given by an untrained perso
25. Number gt m Gi a for Contract Number het TITTEL i E 7 for Contract Number hem 3 The results will display a summary of all assessment submissions or status changes within the last 14 calendar days Note Unlike FSI search results there is not a 50 record line limit for Current Activity search results Home Submit Form Form Status Inquiry Drafts Vendors Letters Printable Forms Current Activity Waiver 3 0 Received Medicaid SSN Medicare Name Status 6 12 2014 4 34 21 PM Denied 6 24 2014 1 22 27 PM Denied 7 16 2014 4 26 46 PM Med ID Check Inactive 7 17 2014 1 47 44 PM Pending Denial need more information 7 19 2014 7 54 51 AM Pending Denial need more information 7 17 2014 8 29 22 AM Denied 6 13 2014 12 37 14 PM Denied 6 27 2014 2 27 44 PM Denied 6 23 2014 5 44 40 AM Denied 6 27 2014 2 45 20 PM Denied Descriptions of the column headings seen above e Waiver 3 0 The unique DLN assigned to each successfully submitted assessment e Received The actual date the assessment was successfully submitted on the LTC Online Portal e SSN A0600A Medicaid A0700 Medicare A0600B First Name and Last Name A0500A and A0500C Information used to identify the individual associated with the assessment e Status The status of the assessment 4 Click the DLN link to display the details of the requested assessment Providers are able to sort the Current Activity results in a variety of ways By clicking on the heading
26. Online Portal v 2014 1013 69 LTC Community Services Waiver Programs User Guide Reporting Medicaid Waste Abuse and Fraud Medicaid fraud An intentional deceit or misrepresentation made by a person with the knowledge that deception could result in some unauthorized benefit to himself or some other person It includes any act that constitutes fraud under applicable federal or state law How to Report Waste Abuse and Fraud Reports may be made through the following website https oig hhsc state tx us This website gives instructions on how to submit a report as well as how to submit additional documentation that cannot be transmitted over the Internet The website also provides information on the types of waste abuse and fraud to report to OIG If you are not sure if an action is waste abuse or fraud of Texas Medicaid report it to OIG and let the investigators decide If you are uncomfortable about submitting a report online there is a telephone number for Client Fraud and Abuse reporting 1 800 436 6184 70 v 2014 1013 LTC Community Services Waiver Programs User Guide HIPAA Guidelines and Provider Responsibilities Providers must comply with HIPAA It is your responsibility to comply with HIPAA to seek legal representation when needed and to consult the manuals or speak to your TMHP Provider Representative when you have questions v 2014 1013 71 LTC Community Services Waiver Programs User Guide Reso
27. Provider Action Required from the drop down box a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Form Status Inquiry Form Select Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessment v Vendor Number SEEE iy TESE Sthettttte Pe Form Status Inquiry DLN Medicaid Number Last Name First Name SSN _ Form Status From Date 412412010 pe Bsa To Date Purpose Code Reason for Assessment Invalid Complete Med ID Check Inactive Medicaid ID Pending Out of State MD DO License Valid Out of State RN License Invalid Overturned Doctor Review Pending Applied Income Pending Denial need more information Pending MD DO License Verification Pending More Info Pending Review Pending RN License Verification Provider Action Required Submitted to manual workflow v 2014 1013 p LTC Community Services Waiver Programs User Guide 5 Click the Search button located on the bottom right of the screen to submit the Inquiry J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Form Status Inquiry Form Select Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessment Vendor Number aw i
28. Required if individual caregiver has reported having a legally authorized representative LAR First Name S12b LAR Last Name MN and LOC 3 0 V 15 32 of 32 TMHP TEXAS MEDICAID HEALTHCARE PARTNERSHIP A STATE MEDICAID CONTRACTOR The LTC Community Services Waiver Programs Workshop User Guide is produced by TMHP Training Services Contents are current as of the time of publishing and subject to change Providers should always refer to provider manuals provider bulletins banner messages and the TMHP and DADS websites for current and authoritative information LTC Community Services Waiver Programs User Guide Addendum LTC Online Portal Community First Choice Addendum LTC Online Portal Medical Necessity and Level of Care Assessment 3 0 Service Group Addition Information included in the Long Term Care LTC Community Services Waiver Programs User Guide has been expanded Effective June 1 2015 Texas Medicaid amp Healthcare Partnership TMHP will implement a modification on the LTC Online Portal When a LTC Community Services Waiver Programs provider or a Managed Care Organization MCO enters information on a Medical Necessity and Level of Care MN LOC Assessment 3 0 field S2c Service Group will have an additional choice from the from the drop down box The additional option is 23 CFC This new option is for use by Community First Choice CFC providers and MCOs This modification allows CFC providers and MCOs
29. Sllc Does the individual caregiver report having a Medical Power of Attorney Silid Does the individual caregiver report having an Out of Hospital Do Not Resuscitate Order 12 LAR Address Required if individual caregiver has reported having a legally authorized representative 12a LAR First Name 12b LAR Last Name 5 Lz Address 12d City Si2e State 12f ZIP Code 12g Phone Does the individual caregiver report having a Directive to Physicians and Family or Surrogates L_ History e 1 Medicaid Information Sla Medicaid Client Indicator Auto Populated This field will be auto populated Slb Individual Address Required Enter the street address where the individual is presently living Individual s Address is used for mailing MN letters Slc City Required Enter the city where the individual is presently living Individual s Address is used for mailing MN letters 34 v 2014 1013 LTC Community Services Waiver Programs User Guide Sld State Required Choose the state where the individual is presently living from the drop down box Individual s Address is used for mailing MN letters Sle ZIP Code Required Enter the ZIP Code where the individual is presently living Individual s Address is used for mailing MN letters S1f Phone Optional Enter the contact telephone number for the in
30. Type of A Reason for Assessment Assessment v A0500 Legal Name of A Firstname B Middle initial Individual O e C Last name D Suffix Social Security A Social Security Number and Medicare Numbers B Medicare number or comparable railroad insurance number A0700 Medicaid l Enter if pending N if not a Medicaid recipient Number A0800 Gender v A0900 Birth Date Oo M A1000 Race Ethnicity Check all that apply O American Indian or Alaskan Native OB Asian OC Black or African American OD Hispanic or Latino DE Native Hawaiian or Other Pacific Islander OF White Language eons the individual need or want an interpreter to communicate with a doctor or health care staff x B Preferred language Optional Individual B Room number Items C Conditions Related to IDD Status If the individual is 22 years of age or older complete only if AO3104 0i If the individual is 21 years of age or younger complete always Check all conditions that are related to IDD status that were manifested before age 22 and are likely to continue indefinitely IDD With Organic Condition A Down syndrome B Autism C Epilepsy D Other organic condition related to IDD IDD Without Organic Condition E IDD with no organic condition No IDD Z None of the above A2300 Assessment Date Observation end date CS Note The steps to submit M
31. User Guide e S6 Additional MN Information S6a Tracheostomy Care Conditional This field is only required and available for data entry if O0100E Tracheostomy care is checked and the individual is 21 years of age or younger Choose from the drop down box Less than once a week 1 to 6 times a week Once a day Twice a day 3 11 times a day Every 2 hours N WB WW BW NHN Hourly continuous S6b Ventilator Respirator Do not include BiPAP or CPAP time Conditional This field is only required and available for data entry if O0100F ventilator or respirator is checked Choose from the drop down box Less than once a week l to 6 times a week Once a day Twice a day 3 11 times a day 6 23 hours N WDM RW NHN 24 hour continuous S6c Number of hospitalizations in the last 90 days Required Record the number of times the individual was admitted to hospital with an overnight stay in the last 90 days or since last assessment if less than 90 days Enter 0 zero if no hospital admissions Valid range includes 0 90 S6d Number of emergency room visits in the last 90 days Required Record the number of times the individual visited the emergency room ER without an overnight stay in the last 90 days or since last assessment if less than 90 days Enter 0 zero if no ER visits Valid range includes 0 90 v 2014 1013 39
32. been corrected by the submitting provider There will be a new DLN located in the History trail indicating the replacement DLN for the corrected assessment No further actions are allowed on assessments with a status of corrected Denied The assessment has been reviewed by the TMHP doctor who has determined that the information did not support MN Escalated Needs Review The assessment has been escalated to a DADS case manager for review Form Inactivated This assessment has been inactivated by the submitting provider No further action will be allowed on this assessment ID Invalid Medicaid ID validation failed Contact the Medicaid Eligibility Worker to verify the individual s name SSN and Medicaid ID A new assessment with the correct information will need to be submitted Invalid Complete Per DADS this assessment has been deemed invalid The reason can be found in the History trail A new assessment must be submitted with the correct information Med ID Check Inactive Medicaid ID validation attempted nightly for six months and failed or the request was canceled The provider may restart the assessment once the reason for failed validation has been resolved by the Medicaid Eligibility Worker by clicking the Reactivate Form button Medicaid ID Pending Medicaid ID validation is pending Validation attempts occur nightly until deemed valid invalid or until six months has expired whichever comes first Contact the Medicaid
33. community services consumers in the Community Based Alternatives CBA MDCP Waivers and STAR PLUS Once an individual assessment is open the RUG value can be found next to the DLN as seen in the screen shot below MEDICAL NECESSITY AND LEVEL OF CARE_ASSESSMENT Version 3 0 Current Status Processed Complete Name Form Actions e Print Physician s Signature Use as template Add Note Inactivate Form Section B Section C Section D Section E Section G Section H Section I Section J Section K Section L Section Ml Section N Section O Section P Section Q Section Z Section LTCMI 28 v 2014 1013 LTC Community Services Waiver Programs User Guide Medical Necessity and Level of Care 3 0 Assessment MN LOC Assessments are submitted to determine MN for individuals in the community and for Medicaid reim bursement There are three reasons to submit an MN LOC 3 0 Assessment e A0310A 01 Initial Assessment e A0310A 03 Annual Assessment e A0310A 04 Significant Change in Status Assessment SCSA submitted when authorized by the DADS case manager due to changes in the medical condition of the individual Note A SCSA does not apply for PACE For CBA and MDCP refer to the program handbook to determine if a SCSA must be authorized prior to submission on the TMHP LTC Online Portal For Managed Care Organizations MCO STAR PLUS the SCSA is completed but not submitted on the LTC Online Portal Significant Cha
34. days H0400 Bowel Continence Bowel continence Select the one category that best describes the individual Always continent Enter Occasionally incontinent one episode of bowel incontinence Frequently incontinent 2 or more episodes of bowel incontinence but at least one continent bowel movement Code Always incontinent no episodes of continent bowel movements Not rated individual had an ostomy or did not have a bowel movement for the entire 7 days H0500 Bowel Continence Program 0 No 1 Yes H0600 Bowel Patterns Enter Constipation present i 0 No Code 1 Yes Is an individualized continence promotion program currently being used to manage the individual s bowel continence Code MN and LOC 3 0 V 15 12 of 32 Individual Identifier Date Section Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists in 10100 Cancer with or without metastasis Heart Circulation Anemia e g aplastic iron deficiency pernicious and sickle cell Atrial Fibrillation or Other Dysrhythmias e g bradycardias and tachycardias Coronary Artery Disease CAD e g angina myocardial infarction and atherosclerotic heart disease ASHD Deep Venous Thrombosis DVT Pulmonary Embolus PE or Pulmonary Thrombo Embolism PTE Heart Failure e g congestive
35. ee Mee Smo aemet v Form Status Inquiry DLN Medicaid Number Last Name First Name SSN Form Status Provider Action Required From Date To Date v Purpose Code Reason for Assessment 6 All Waiver 3 0 Medical Necessity and Level of Care Assessments that are set to status Provider Action Required will display Note For confidentiality purposes the assessment details Medicaid etc have been hidden in the User Guide Form Status Inquiry Form Select Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessment v Vendor Number IEEE me Teman k E Form Status Inquiry DLN Medicaid Number Last Name First Name SSN Form Status Provider Action Required From Date To Date 1042010 fw Purpose Code Reason for Assessment 3 record s returned TMHP RN Received Medicaid Medicare Last Signature Purpose Contract endor Reason For DLN Date Name Date Code Number Number Assessment View EEL J oe eee eee wes ee ee s ee oee e enoe lt amam _ 10 4 2010 4e Provider PC2 10 4 2010 01 Initial Detail Action assessment oo Required ees 10 4 2010 meee eeece mene Provider PC2 10 4 2010 04 Significant Action change in status Required assessment 7 Click the View Detail link to open the assessment 56 v 2014 1013 LTC Community Ser
36. either an administrator or user account go to www tmhp com Pages LTC Itc_home aspx Click the Log In to LTC Online Portal button 4 v 2014 1013 LTC Community Services Waiver Programs User Guide If you do not have an account you can create one by following the steps below To do so you will need to have your e Provider contract number assigned by DADS when the provider signs the contract to provide DADS Pro gram services e Vendor number four digit number assigned by DADS when the provider signs the contract to submit assess ments on the LTC Online Portal e Vendor password provider must call the Electronic Data Interchange EDI Help Desk at 1 888 863 3638 to obtain their vendor password The Help Desk is available Monday through Friday 7 00 a m through 7 00 p m Please note that it may take three to five business days to receive the password which is randomly gener ated by TMHP How to Create an LTC Online Portal Administrator Account 1 Go to www tmhp com 2 Click providers in the green bar located at the top of the screen TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR clients providers Wh English Espa ol ATN ww Welcome to Texas Medicaid amp Healthcare Partnership What is TMHP a Click here to find out how you can TMHP Home Thank you for visiting the Texas Medicaid amp Healthcare oo ne Privacy HIPAA Partnership s TMHP Internet website
37. emea e m ame 03 Annual etai assessment ie 10 5 2010 e ee e o Submitted to manual CA2 10 5 2010 e lt 03 Annual etai workflow assessment ie ame 10 5 2010 e eene eao aoe e ID Invalid CA2 10 5 2010 s 03 Annual Detail assessment Click the Correct this form button v 2014 1013 LTC Community Services Waiver Programs User Guide UnLock Form MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Provider Action Required Name i a ania Ta RUG CA2 Note Waiver corrections are allowed within 14 days from the original submission Form Actions Workflow Actions Print Physician s Signature Use as template Correct this form am Add Note __Inactivate Form Resubmit Form 7 Complete only the fields needing correction 8 Click the Submit Form button 9 The original assessment parent is set to status Corrected and the new assessment child DLN is assigned creating the parent child DLN relationship The new child assessment replaces the parent assessment Form 10 5 2010 5 07 24 PM Submitted Pending 10 5 2010 5 07 25 PM MD DO License Verification 10 5 2010 5 07 25 PM TMHP License must be manually verified Corrected 10 5 2010 5 26 04 PM 10 5 2010 5 26 04 PM 106waivermis Form has been corrected by DLN TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts P
38. for Texas Medicaid AE EAN NE or Texas Medicaid and other state health care programs As of January 1 2004 eae Reporting Fraud ACS State Healthcare LLC under contract with the Texas ee Health and Human Services Commission HHSC assumed neaes administration of claims processing for Texas Medicaid and Provider Lookup other state health care programs ACS a XEROX n company meets its new consolidated health care Looking for a TEXAS MEDICAID responsibilities with a team of subcontractors under the name provider s _ _ of TMHP HEALTHCARE PARTNERSHIP Click here to find a state A STATE MEDICAID CONTRACTOR health care provider near you 3 Click Long Term Care in the yellow bar All Sites EJ Advanced Search TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Log in to My Account Go to TexMedConnect Want to enroll as a Medicaid provider Click here for more information and to Ah A enroll today v 2014 1013 5 LTC Community Services Waiver Programs User Guide 4 Click I would like to in the blue bar located at the top of the screen All Sites ea TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Click here to access provider applications and services Long Term Care Home Long Term Care Homepage Program Information Services and Institutional Care to eligible clients The Texas Medicaid amp Healthcare Partnership DAD
39. in the last 7 days Check all that apply 15600 Malnutrition protein or calorie or at risk for malnutrition 15699 At risk for dehydration _ Psychiatric Mood Disorder Anxiety Disorder Depression other than bipolar Manic Depression bipolar disease Psychotic Disorder other than schizophrenia Schizophrenia e g schizoaffective and schizophreniform disorders Post Traumatic Stress Disorder PTSD ADHD Syndrome Pulmonary SS 16200 Asthma Chronic Obstructive Pulmonary Disease COPD or Chronic Lung Disease e g chronic bronchitis and restrictive lung diseases such as asbestosis 16299 Cystic Fibrosis 16300 Respiratory Failure O simn T 16500 Cataracts Glaucoma or Macular Degeneration SSCS Noneof Above O 17900 None of the above active diagnoses within tne last7 days O O O O OoOo OO Other OOOO eee 18000 Additional active diagnoses Enter diagnosis description and ICD code po A A OO DOUOOUO MN and LOC 3 0 V 15 15 of 32 Individual Identifier Date Section J Health Conditions J0100 Pain Management Complete for the individual regardless of current pain level At any time in the last 5 days has the individual Received scheduled pain medication regimen 0 No 1 Yes Received PRN pain medications OR was offered and declined 0 No 1 Yes Received non medication intervention for pain 0 No 1 Yes J0200
40. last 7 days 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the last assessment started therapy regimen since the last assessment ended TI Th enter dashes if therapy is ongoing Day Individual minutes record the total number of minutes this therapy was administered to the individual individually in the last 7 days Concurrent minutes record the total number of minutes this therapy was administered to the individual concurrently with one other individual in the last 7 days Group minutes record the total number of minutes this therapy was administered to the individual as part of a group of individuals in the last 7 days If the sum of individual concurrent and group minutes is zero gt skip to OO400C Physical Therapy 3A Co treatment minutes record the total number of minutes this therapy was administered to the individual in co treatment sessions in the last 7 days 4 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days 5 Therapy start date record the date the most recent 6 Therapy end date record the date the most recent therapy regimen since the last assessment started therapy regimen since the last assessment ended
41. name will be auto populated based on the information entered in field A0500 v 2014 1013 Zi LTC Community Services Waiver Programs User Guide Print Physician s Signature on Certification Statement The Print Physicians Signature feature allows a provider to generate and print a Physicians Signature page at any time Initial Assessments require a physician s signature on the certification statement The certification statement is found on the Physician s Signature page A physician s signature is optional on Annual Assessments and Significant Change in Status Assessments To print the Physician s Signature page required for an Initial Assessment 1 Complete all designated fields of the assessment on the LTC Online Portal 2 Before submitting the assessment click the Print Physician s Signature button located in the yellow Form Actions bar The diagnoses listed on the printed Physician s Signature page are pulled from the information entered in Section I and the Primary Diagnosis listed in field S3a of the LTCMI section Gave as Draft 3 Click the Save as Draft button to save the assessment until the physician s signature is obtained Form Actions Print Print Physician s Signature Save as Draft 4 Once the physician s signature is obtained retrieve the assessment from Drafts 5 Check the box labeled Physician s Signature on File found in the LTCMI section under S7e to indicate that
42. officer is DADS final administra tive decision If the appellant believes the hearing officer did not follow applicable policy and procedures the appel lant can submit a request for administrative review within 30 days of the date of the decision The appellant submits the request for administrative review to the hearing officer who will forward the request to the appropriate legal office for review Note The process for waiver managed care members and the MCOs to follow is included in the STAR PLUS handbook http www dads state tx us handbooks sph index htm v 2014 1013 51 LTC Community Services Waiver Programs User Guide Assessment Statuses Providers can monitor the status of their MN LOC Assessment by utilizing FSI or Current Activity on the LTC Online Portal The status is shown within the FSI or Current Activity results or once a specific assessment is selected the status can be located at the top of the page or at the bottom of the assessment in the History trail The following are statuses that a provider may see and their definition 52 Appealed The assessment was previously denied and the individual or their representative has requested a fair hearing Approved MN has been determined and approved Assessments that are MN approved will only stay in this status momentarily They will automatically move to the next status in the workflow This status is not search able using FSI Corrected Ihis assessment has
43. through the LTC Online Portal How to Submit a Medical Necessity and Level of Care Assessment 1 Log in to the LTC Online Portal 2 Click the Submit Form link located in the blue navigational bar 3 Type of Form Choose Waiver 3 0 Medical Necessity and Level of Care Assessment from the drop down box a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Submit Form Form Select Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessment v Recipient To prepopulate recipient information please provide one of the following combinations of information Medicaid CSHCN ID or Social Security Number AND Last Name or Social Security Number AND Date of Birth or Date of Birth AND Last Name AND First Name Medicaid Number E SSN Date of Birth First Name Last Name 4 To auto populate an individual s information in the MN LOC Assessment enter one of the following combina tions of information Medicaid Children with Special Health Care Needs CSHCN Services Program ID Or Social Security number SSN and Last Name Or SSN and Date of Birth Or Date of Birth and Last Name and First Name Note All demographic information except gender is auto populated when one of the aforementioned data items is en tered Refer to the demographic
44. 00 Date Assessment was Completed ZO500B and Medication Certification Checkbox S9 3 Click the Print button located in the yellow Form Actions bar to print the assessment in progress if you want a hard copy for your records From here you have two choices a Click the Submit Form button located at the bottom right of the screen if you are ready to submit for processing A2300 Assessment Date Observation end date COC A a CE Submit Form Form or b Click the Save as Draft button located in the yellow Form Actions bar to save an assessment as a draft until you are ready to submit MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT Version 3 0 Current Status Name DLN 0 RUG Form Actions O Print Physician s Signature ores Section A Section B Section C Section D Section E Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI v 2014 1013 29 LTC Community Services Waiver Programs User Guide Correct this form The Correct this form feature allows providers to perform corrections to the MN LOC Assessment within 14 cal endar days of the original submission i e TMHP received date However corrections are not allowed if an assess ment is set to status Form Inactivated Invalid Complete SAS Request Pending or Corrected Note A parent assessment is the original asses
45. 00 Vision Ability to see in adequate light with glasses or other visual appliances Adequate sees fine detail such as regular print in newspapers books Impaired sees large print but not regular print in newspapers books Moderately impaired limited vision not able to see newspaper headlines but can identify objects Highly impaired object identification in question but eyes appear to follow objects Severely impaired no vision or sees only light colors or shapes eyes do not appear to follow objects Corrective lenses contacts glasses or magnifying glass used in completing B1000 Vision 0 No Yes MN and LOC 3 0 V 15 3 of 32 Individual Identifier Date ST o Re Cognitive Patterns C0100 Should Brief Interview for Mental Status C0200 C0500 be Conducted Attempt to conduct interview with the individual 0 No individual is rarely never understood OR individual is less than 7 years of age skip to and complete C0700 C1000 Caregiver Assessment for Mental Status 1 Yes Continue to C0200 Repetition of Three Words Brief Interview for Mental Status BIMS C0200 Repetition of Three Words Ask individual f am going to say three words for you to remember Please repeat the words after have said all three The words are sock blue and bed Now tell me the three words Enter Dash if unable to assess Enter Number of words repeated after first attempt 0 None 1 One 2 Two 3 Thre
46. 010 To Date 5 24 2010 rE RS 1424 ZU1U wij DZ4IZU1U wij History An assessment s history can be found by scrolling down to the bottom of the screen of on an open assessment This History trail shows the different statuses the assessment has held The most recent status will appear at the bottom History Form 6 27 2014 2 28 11 PM Submitted Pending 6 27 2014 2 28 18 PM Review 6 27 2014 2 28 18 PM TMHP The Form has failed Auto MN Approval Pending 7 3 2014 8 44 38 AM Denial need more information 7 9 2014 9 42 12 AM TMHP MN LOC REVIEWED NO ADDITIONAL INFORMATION OBTAINED Pending 7 9 2014 9 42 14 AM Review 7 9 2014 9 42 14 AM TMHP Form notes have been updated Form has been re submitted for nurse review Pending 7 9 2014 10 15 28 AM Denial need more information Denied 7 10 2014 7 59 59 AM 26 v 2014 1013 LTC Community Services Waiver Programs User Guide UnLock Form Upon opening the assessment becomes automatically locked by the viewer and will remain locked for 20 minutes of no activity or until the viewer clicks the UnLock Form button The UnLock Form button will unlock the assess ment so that a different user can make changes If an assessment is locked others will not be able to make changes or add additional information You may be asked to unlock an assessment if you are seeking assistance from TMHP or DADS To unlock an asse
47. 2010 4 13 04 PM Waiver 3 0 Satter Oe Remove Open 3 From here you have two choices a Click the Open link to open the draft to edit and submit or b Click the Remove link to permanently delete the draft Note The following confirmation prompt message will appear Microsoft Internet Explorer Press OK to confirm that you would like to delete this draft From the portal Press Cancel to keep the draft Cancel Click the OK button to delete the draft Or Click the Cancel button to keep the draft Note Once a draft has been removed it cannot be retrieved 18 v 2014 1013 LTC Community Services Waiver Programs User Guide Printable Forms The Printable Forms feature allows the provider to view blank assessments print blank assessments or interactively complete assessments by saving to the provider s desktop 1 Click the Printable Forms link in the blue navigational bar J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Printable Forms MDS 3 0 Comprehensive MDS 3 0 Quarterly MDS 2 0 Correction MDS 2 0 Comprehensive MDS 2 0 Quarterl 65 BRK Pening Waiver 3 0 MN and LOC Waiver 3 0 Physician s Signature Page 2 Choose an assessment by clicking the corresponding link Adobe Reader will open in a new window and will display the blank assess
48. 410 Medications Received Enter Days i A Insulin injections Record the number of days that insulin injections were received during the last 7 days Enter Days B Orders for insulin Record the number of days the physician or authorized assistant or practitioner changed the individual s insulin orders during the last 7 days N0410 Medications Received Indicate the number of DAYS the individual received the following medications during the last 7 days Enter 0 if medication was not received by the individual during the last 7 days Enter Days A Antipsychotic Enter Days B Antianxiety Enter Days C Antidepressant Enter Days _ D Hypnotic Enter Days E Anticoagulant warfarin heparin or low molecular weight heparin F Antibiotic Enter Days G Diuretic MN and LOC 3 0 V 15 22 of 32 Individual Identifier Date Section O Special Treatments Procedures and Programs 00100 Special Treatments Procedures and Programs Check all of the following treatments procedures and programs that were performed during the last 14 days Check all that apply Cancer Treatments A Chemotherapy LIL B Radiation Respiratory Treatments C Oxygen therapy D Suctioning E Tracheostomy care F Ventilator or respirator G BiPAP CPAP H IV medications l Transfusions J Dialysis L Respite care M Isolation or quarantine for active infectious d
49. C Providers v 2014 1013 75 LTC Community Services Waiver Programs User Guide DADS Regional Nurse Contact Information Region Telephone Number 4 512 706 6018 210 438 6216 956 983 7645 DADS Utilization Review Contact Information Region Telephone Number Informational Websites Community Services Policies www dads state tx us providers index cfm Community Services Programs www dads state tx us providers index cfm Consumer Rights and Services includes information www dads state tx us services crs index html about how to make a complaint Health and Human Services Commission wwwhhecstatetus Medicaid Fraud https oig hhsc state tx us Medicaid Nursing Facility Program www dads state tx us providers NF index cfm and Instructions www txstate edu continuinged CE Online RUG Training html 76 v 2014 1013 LTC Community Services Waiver Programs User Guide Individual Service Plan ISP Table For Community Based Alternatives CBA Providers The due dates for the annual reassessment packets submitted by Home and Community Support Services Agencies HCSSAs agencies to the DADS case manager Note TMHP does not support any assessments other than the MN LOC Assessment The table below lists the reassessment due dates based on the date of the ISP expiration ISP Expiration Date To date on ISP Reassessment Packet Due to DADS Case Manager Between v 2014 1013 77 LTC Community Services Waiv
50. CC2 CC1 CB2 CB1 CA2 CA1 5 Cognitive Impairment with without Nursing Rehab IB2 IB1 A2 IA1 6 Behavior Problem with without Nursing Rehab BB2 BB1 BA2 BA1 7 Physical Function with without Nursing Rehab PE2 PEI PD2 PD1 PC2 PC1 PB2 PB1 PA2 PA1 Each RUG level has a corresponding cost limit for the MDCP CBA and STAR PLUS waiver programs The cost limit is considered when developing the individual s plan of care It is a percentage of the reimbursement rate that would have been paid for that same individual to receive nursing facility services for a year RUG training is required for registered nurses to complete MN LOC Assessments Validation of completion of RUG training occurs at the time the MN LOC is submitted on the TMHP LTC portal Texas State University in cooperation with the HHSC Office of Inspector General OIG has made this training available through univer sitys Office of Continuing Education s online course programs RUG training is valid for two years then it must be renewed by completing the online RUG training via the Texas State University online training Texas State Univer sity can take from two to seven business days to process and report completions of RUG training to TMHP depend ing on current volume of enrollments and completions To register for the RUG training or for more information visit www txstate edu continuinged CE Online RUG Training html Note Zhe MN LOC 3 0 implementation did n
51. Community Services Waiver Programs Workshop User Guide The Long Term Care LTC Community Services Waiver Programs Workshop User Guide provides step by step instructions for how to use the various features of the portal information regarding the purpose of the Medical Necessity and Level of Care MN LOC Assessment how to submit the MN LOC Assessment and managing assessments set to status Provider Action Required Medical Necessity and Level of Care Assessment 3 0 Instructions The guide is to be used in conjunction with the Medical Necessity and Level of Care 3 0 Assessment Yellow Form Actions Bar Options found in the yellow Form Actions bar may include Print Print Physician s Signature Use as template Correct this form Add Note or Inactivate Form Options will vary depending on your security level as well as the document status The yellow Form Actions bar is available when an individual document is being viewed in detail Form Actions Print Physician s Signature Use as template Correct this form Add Note Inactivate Form Print The Print feature allows the provider to print completed MN LOC Assessments Click the Print button to print completed assessments Note To only print specific sections of the assessment click the Pages radio button and enter the page range for the desired pages only When printing the MN LOC 3 0 Assessment the individuals name will appear on the top left corner of each page The
52. Individuals A person enrolled in a program Individuals are those served by Texas Medicaid Managed Care Organization MCO State contracted entity that has been given delegated authority to pro vide acute and long term services to support enrolled managed care members Program Provider An entity that provides services under a contract with the Department of Aging and Dis ability Services DADS Program provider is the preferred term for provider agency Program providers are the crucial players in a quality health care program The focus is on providing the best care possible while being reimbursed for allowed services rendered Texas Department of Aging and Disability Services DADS Texas state agency that provides long term services and supports to older persons and individuals with physical intellectual and developmental disabili ties DADS also regulates providers of long term services and supports and administers the state s guardianship program Texas Health and Human Services Commission HHSC Provides administrative oversight of Texas health and human services programs including the Medicaid acute care program Children s Health Insurance Plan CHIP State of Texas Access Reform STAR State of Texas Access Reform PLUS STAR PLUS and pro vides direct administration of some programs Texas HHSC s Office of Eligibility Services OES determines eligibility for Medicaid Texas Medicaid amp Healthca
53. N LOC Assessments are covered in the Medical Necessity and Level of Care Assessment sec tion 14 v 2014 1013 LTC Community Services Waiver Programs User Guide Form Status Inquiry FSI The FSI feature provides a query tool for monitoring the status of assessments that have been successfully submitted Providers may use FSI to search for either Type of Form Waiver 2 0 Medical Necessity and Level of Care Assess ments or Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessments The search does not have the capability to return both 2 0 and 3 0 Assessments with one search Searches must be performed separately for 2 0 and 3 0 Assessments FSI allows providers to retrieve assessments in order to e Access assessments to research and review statuses e Provide additional information to an assessment e Retrieve assessments to make corrections or perform inactivations e Resolve any assessments set to Provider Action Required 1 Click the Form Status Inquiry link in the blue navigational bar 2 Type of Form Choose Waiver 2 0 Medical Necessity and Level of Care Assessment or Waiver 3 0 Medical Necessity and Level of Care Assessment from the drop down box TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form 3 gui Current Activity My Drafts Printable Forms Help Form Status Inquiry Form Select Type of Forme Form Status Inquiry DLN Medicaid Number
54. Reproduced with permission MN and LOC 3 0 V 15 6 of 32 Individual Identifier Date SM Mood D0500 Caregiver Assessment of Individual Mood PHQ 9 OV Do not conduct if Individual Mood Interview D0200 D0300 was completed Over the last 2 weeks did the individual have any of the following problems or behaviors If symptom is present enter 1 yes in column 1 Symptom Presence Then move to column 2 Symptom Frequency and indicate symptom frequency 1 Symptom Presence 2 Symptom Frequency 1 2 0 No enter 0 in column 2 0 Never or 1 day Symptom Symptom 1 Yes enter 0 3 in column 2 2 6 days several days Presence Frequency 7 11 days half or more of the days i 12 14 days nearly every day AOE cores BaS Little interest or pleasure in doing things B Feeling or appearing down depressed or hopeless C Trouble falling or staying asleep or sleeping too much D Feeling tired or having little energy E Poor appetite or overeating Indicating that s he feels bad about self is a failure or has let self or family down G Trouble concentrating on things such as reading the newspaper or watching television H Moving or speaking so slowly that other people have noticed Or the opposite being so fidgety or restless that s he has been moving around a lot more than usual States that life isn t worth living wishes for death or attempts to harm self Being short tempered easily annoyed D0600 Total Se
55. S Information Letters TMHP LTC team supports the LTC provider community in submitting claims through the Claims 5 Click the Activate my account link Al Sites 12 Advanced Search ea TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Click here to access provider applications and services Long Term Care Home would like to Program Information Click the links below to perform tasks and access provider applications DADS Information Letters Unsecured Provider Tasks Reference Material The following tasks can be performed without logging to a provider account Forms Activate my account Provider Support Services e Get user name and password e mailed e Check vendor testing status Provider Education Secure Provider Tasks 6 From here you have two choices The Texas Department of Aging and Disability Services DADS administers programs providing LTC Log In Log In to LTC Online Portal Log In to TexMedConnect TexMedConnect Get started with online claims filing Click here Log In Log In to LTC Online Portal Log In to TexMedConnect TexMedConnect Get started with online claims filing Click here a lt MDS 3 01s here Click here for forms and instructions a To create a new TMHP User Account without an existing provider vendor account click the New Username and Enroll link Ifselected go to step 8 Provider Type step b To create a
56. Should Pain Assessment Interview be Conducted Attempt to conduct interview with the individual If individual is comatose skip to J1100 Shortness of Breath dyspnea 0 No individual is rarely never understood OR individual is less than 3 years of age gt Skip to JO800 Indicators of Pain or Possible Pain 1 Yes Continue to JO300 Pain Presence Pain Assessment Interview J0300 Pain Presence Enter Ask individual Have you had pain or hurting at any time in the last 5 days 0 No gt Skip to J1100 Shortness of Breath 1 Yes Continue to J0400 Pain Frequency 9 Unable to answer Skip to JO800 Indicators of Pain or Possible Pain J0400 Pain Frequency Ask individual How much of the time have you experienced pain or hurting over the last 5 days Enter 1 Almost constantly 2 Frequently 3 Occasionally 4 Rarely 9 Unable to answer J0500 Pain Effect on Function A Ask individual Over the past 5 days has pain made it hard for you to sleep at night 0 No 1 Yes 9 Unable to answer B Ask individual Over the past 5 days have you limited your day to day activities because of pain 0 No 1 Yes 9 Unable to answer J0600 Pain Intensity Administer ONLY ONE of the following pain intensity questions A or B Numeric Rating Scale 00 10 Ask individual Please rate your worst pain over the last 5 days on a zero to ten scale with zero being no pain and ten as the worst pain yo
57. User Guide Addendum Information included in the Long Term Care LTC Community Services Waiver Programs User Guide has been expanded A new service group option has been added to field S2c Service Group of the Medical Necessity and Level of Care MN LOC Assessment 3 0 The additional service group available from the S2c drop down box is 23 CFC This new service group is for Community First Choice providers The details of this addition to the MN LOC Assessment on the LTC Online Portal are outlined in the addendum which immediately follows the User Guide and can be accessed by using the bookmarks Click the link to view the following addendum CFC Online Portal MN LOC Addendum Addendum added 6 1 2015 For more information contact the LTC Call Center Help Desk at 1 800 626 4117 Option 1 2015 0528 Long Term Care Community Services Waiver Programs Workshop USER GUIDE LTC Community Services Waiver Programs User Guide Contents Jeeta htt ODJEVENE ee EE ee ee E 1 Medicaid MAO snsase soto esce tise escent ocanaececenseceoesauneest E E E A E E N AE 2 National Provider Identifier NPI Atypical Provider Identifier API Requirements 0 ccceccceeseeeeeeee 3 The LTC Odne Tortall eeni AEAEE TEE NEO EESE E EAEE 4 Benci al U me SLIG Online Porta erisin A ee 4 UG Onine Torc SCC ena E E R 4 Fow to Greate an LIC Online Portal Administrator iC COU IG 5 tenet scenccenreeunsecsnsincesaanenecsavenneanshenessvancaxe
58. aosurs 1 800 727 5436 72 v 2014 1013 LTC Community Services Waiver Programs User Guide Additional Online Training Computer Based Training CBT of the LTC Community Services Waiver Programs Workshop material is available on the TMHP Learning Management System LMS Providers can access the above mentioned online training on the TMHP LMS as follows 1 Go to www tmhp com and click Providers in the top menu bar ta TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR clients providers TMHP Home Welcome to Texas Medicaid amp Healthcare Partnership NOL Yet a provi What is TMHP a Click here to find out how you can become a provider for Texas Medicaid and related programs Thank you for visiting the Texas Medicaid amp Healthcare Privacy HIPAA Partnership s TMHP Internet website for Texas Medicaid and other state health care programs As of January 1 2004 Reporting Fraud ACS State Healthcare LLC under contract with the Texas Health and Human Services Commission HHSC assumed l administration of claims processing for Texas Medicaid and Provider Lookup TM P other state health care programs ACS a XEROX company meets its new consolidated health care Looking fora TEXAS MEDICAID responsibilities with a team of subcontractors under the name provider HEALTHCARE PARTNERSHIP AEIR Click here to find a state A STATE MEDICAID CONTRACTOR heal
59. artnership What is TMHP _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Click here to find out how you can become a provider Thank you for visiting the Texas Medicaid amp Healthcare Privacy HIPAA Partnership s TMHP Internet website for Texas Medicaid and other state health care programs As of January 1 2004 Reporting Fraud ACS State Healthcare LLC under contract with the Texas Health and Human Services Commission HHSC assumed administration of claims processing for Texas Medicaid and Provider Lookup TM i p other state health care programs ACS a XEROX company meets its new consolidated health care Looking fora TEXAS MEDICAID responsibilities with a tearm of subcontractors under the name ORE SI Roe EAN provider HEALTHCARE PARTNERSHIP a webinar or take advantage of Click here to find a state ASTATE MEDICAID CONTRACTOR other educational offe health care provider near you for Texas Medicaid and related programs 3 Click the Log in to My Account button in the blue bar located at the top of the screen Note You may be prompted to enter your LTC Online Portal User ID and Password All Sites Advanced Search Log In Log in to My Account ea TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Want to enroll as a Medicaid pr
60. ays Record the number of calendar days that the individual received Speech Language Pathology and Audiology Services Occupational Therapy or Physical Therapy for at least 15 minutes in the past 7 days 00500 Restorative Nursing Programs Record the number of days each of the following restorative programs was performed for at least 15 minutes a dayin the last 7 calendar days enter 0 if none or less than 15 minutes daily A Range of motion passive B Range of motion active C Splint or brace assistance Training and Skill Practice In D Bed mobility G Dressing and or grooming H Eating and or swallowing I Amputation prostheses care J Communication 00600 Physician Examinations Enter Days Over the last 14 days on how many days did the physician or authorized assistant or practitioner examine the individual B 00700 Physician Orders T Over the last 14 days on how many days did the physician or authorized assistant or practitioner change the individual s orders MN and LOC 3 0 V 15 26 of 32 Individual Identifier Date Siem Restraints P0100 Physical Restraints Physical restraints are any manual method or physical or mechanical device material or equipment attached or adjacent to the individual s body that the individual cannot remove easily which restricts freedom of movement or normal access to one s body Enter Codes in Boxes Used in Bed A Bed rai
61. blue navigational bar 3 Click the View Detail link 4 Click the Inactivate Form button 5 Click the OK button when the pop up window asks Are you sure you want to Inactivate this form If so click Ok and enter a note to explain the reason for inactivation 6 When the Change Status window appears enter a note for the inactivation and click the Change Status but ton The assessment will be set to status Form Inactivated and cannot be reactivated v 2014 1013 67 LTC Community Services Waiver Programs User Guide RUG Training Requirements A Resource Utilization Group RUG level is the measure of the care needs of an individual The TMHP automated system uses a mathematical algorithm established by CMS to determine the RUG This algorithm is used in all cases to automatically generate a RUG level based on the information entered by the nurse in the RUG fields of the MN LOC Assessment The State of Texas uses this systematic approach in the waiver programs to categorize the care needs of individual establish the service plan cost limit and to identify provider reimbursement rates Ihe RUG level determination is totally objective neither DADS nor the TMHP nurse reviewing the MN LOC determines the RUG level Below are examples of RUG levels 1 Extensive Services SE3 SE2 SE1 2 Rehabilitation All Levels RAD RAC RAB RAA 3 Special Care SSC SSB SSA 4 Clinically Complex with without Depression
62. call bed 0 No could not recall 1 Yes after cueing a piece of furniture 2 Yes no cue required C0500 Summary Score it The sum of the scores for questions CO200 C0400 The sum should be a number 00 15 A score of 99 indicates that the individual was unable to complete the interview Enter Score MN and LOC 3 0 V 15 4 of 32 Individual Identifier Date Tle meme Cognitive Patterns C0600 Should the Caregiver Assessment for Mental Status C0700 C1000 be Conducted Enter 0 No Individual was able to complete interview gt Skip to C1300 Signs and Symptoms of Delirium 1 Yes Individual was unable to complete interview OR individual is less than 7 years of age Continue to Code C0700 Short term Memory OK Caregiver Assessment for Mental Status Do not conduct if Brief Interview for Mental Status CO200 C0500 was completed C0700 Short term Memory OK Enter Seems or appears to recall after 5 minutes Enter Dash if unable to assess OR individual is less than 2 years of age i 0 Memory OK Code 1 Memory problem C0800 Long term Memory OK Enter Seems or appears to recall long past Enter Dash if unable to assess OR individual is less than 2 years of age i 0 Memory OK Code 1 Memory problem C0900 Memory Recall Ability Check all that the individual was normally able to recall A Current season B Location of own room C Caregiver names and faces D That he or she is i
63. ceceaeeeeaeeeeaeeseneeeeaeeess 71 Resource Imformation 0cccsscccssccnsccascccscccscccnsccosscoscccsccasccusccesecesecencscecscesscessecuscsusecsecesecedscesscesscesscansceuss 72 Additional Online bests 9 sae eee eee ee eer ne eee ee are te eer eee ee eee ee te ee 73 DADS Regional Nurse Contact Vip Vie 10 0 aevshaseorza nsosirwoxendvacssaa ec Eaa ea ea ai 76 DADS Utilization Review Contact Information ccccccccsecccecccecccsccusccuccccuscecccseceuscuscsucccasccauscauscenseeascesnscenss 76 Informational Websites sc aius ees ccey tesshv a evactacnadcdas nab enaisnea seed aces ewobasseevieso unio das vosueace SOISSONS naon DEPONO EESE SEEE asarin 76 Individual Service Plan ISP Table cecc cece cceececcccccssssecccccceescecccccsseesecceccuuassececcueussseceeceuesseceeeaaunsseseees T7 ii v 2014 1013 LTC Community Services Waiver Programs User Guide aCe 11 11 See ee E ee ee ee E T 78 ECOL e E E E E E E 79 Appendix A LTC Online Portal Review eeeeeeeeseeeesesesssesssessressresstssrrssresssrssresstesstesstessteseresessressressreseres 81 Appendix B Word SANGIN assess crac vase es secs orien soe se ecea tab ecis seuss esa ae gieceseas et oben nexaeecsneecteceseetoceesconeeoserssieeeeceseses 83 Appendix C Medical Necessity and Level of Care Assessment Version 3 0 ccccceesceeseeeeeeeeceeeeeeneeeeneeeaes 85 v 2014 1013 ili LTC Community Services Waiver Programs User Guide Learning Objectives
64. cers with suspected deep tissue injury in evolution MN and LOC 3 0 V 15 20 of 32 Individual Identifier Date Section M Skin Conditions M0610 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar Complete only if M0300C1 MO300D1 or MO300F1 is greater than 0 If the individual has one or more unhealed Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar identify the pressure ulcer with the largest surface area length x width and record in centimeters A Pressure ulcer length Longest length from head to toe e cm B Pressure ulcer width Widest width of the same pressure ulcer side to side perpendicular 90 degree angle cm to length C Pressure ulcer depth Depth of the same pressure ulcer from the visible surface to the deepest area if depth is cm unknown enter a dash M0700 Most Severe Tissue Type for Any Pressure Ulcer Select the best description of the most severe type of tissue present in any pressure ulcer bed 1 Epithelial tissue new skin growing in superficial ulcer It can be light pink and shiny even in persons with Enter Code darkly pigmented skin 2 Granulation tissue pink or red tissue with shiny moist granular appearance 3 Slough yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous 4 Eschar black brown or tan tissue that adheres firmly to the wound bed or ulcer edg
65. correct data include e Individual is listed as a male but is actually a female e Individual s diagnosis indicates diabetes but the individual actually has hypoglycemia e If corrections to the MN LOC Assessment are needed providers must access the assessment utilizing FSI or Current Activity When to correct assessment MN LOC Assessments can only be corrected during the 14 calendar day time period following the original submis sion date Waiver 3 0 MN LOC Assessment Who may submit the correction It does not have to be the original submitter but it has to be from the same vendor contract number Regardless of the current status of an MN LOC Assessment corrections will not be allowed to assessments that have at any time been set to status Form Inactivated Invalid Complete SAS Request Pending or Corrected The Correct this form button will not be displayed in the yellow Form Actions bar on any assessment that cannot be corrected Cor rections are processed overnight and providers must wait until the following day to see changes v 2014 1013 63 LTC Community Services Waiver Programs User Guide How to Submit a Correction 64 Click the Form Status Inquiry link in the blue navigational bar TEXAS MEDICAID amp HEALTHCARE PARE Home Submit Form atus Inqui Current Activity Drafts Printable Forms Help Form Status Inquiry Type of Form Choose Waiver 3 0 Medical Necessity and Level of Care Ass
66. der will have access to the status of the assessment via FSI or Current Activity on the LTC Online Portal 8 The attending physician may respond within 14 business days of the date of the denial letter by faxing or calling TMHP with additional medical information TAC Title 40 Part 1 Chapter 19 19 2407 Or a licensed nurse familiar with the individual may provide additional information by calling and speaking with a TMHP nurse 9 Ifthe TMHP physician or nurse determines that MN has been met the assessment is approved 10 If the TMHP physician determines that MN has not been met the assessment remains in a denied status 11 If the provider does not provide additional information clarifying nursing medical needs within the 21 calendar days of Pending Denial need more information status the assessment is sent to the TMHP physician for review and steps 7 11 will apply 12 The individual may initiate the appeal process when notified by a DADS case manager via the Form 2065 C that MN has been denied by the TMHP physician If a hearing is requested additional information may be submitted at any time by the provider or by the individual s physician either via a telephone call to the TMHP nurses or via fax Note At any point providers can check the status of the assessment and the MN determination for the assessment by uti lizing the LTC Online Portal features FSI or Current Activity Request for Fair Hearing A fair h
67. dividual if known e 2 Claims Processing Information 2a DADS Vendor Site ID Number Auto Populated This field will be auto populated based on the user s logon security credentials 2b Contract Provider Number Auto Populated This field will be auto populated S2c Service Group Required Choose from the drop down box 3 CBA 11 PACE 18 MDCP 19 STAR PLUS 2d NPI Number Required This field will be auto populated This is where API would be entered if using an API number API is D two zeros then contract num ber MDCP nurses use an API v 2014 1013 35 LTC Community Services Waiver Programs User Guide S2e Region Required Choose from the drop down box 01 Lubbock 02 Abilene 03 Grand Prairie 04 Tyler 05 Beaumont 06 Houston 07 Austin 08 San Antonio 09 Midland Odessa 10 El Paso 11 Edinburg 2f Purpose Code Purpose Code is auto populated when a Utilization Review UR is submitted by a DADS RN For Initial Annual and SCSA Assessments this field is not available for data entry Purpose Code 1 is used for UR only S2f indicates DADS has submitted a UR on a previously submitted provider assessment for Service Groups SG 3 CBA and SG 18 MDCP Note DADS RNs perform Utilization Reviews A UR will override the previously submitted assessment 2g Home Health Agency HHA License
68. e After the individual s first attempt repeat the words using cues sock something to wear blue a color bed a piece of furniture You may repeat the words up to two more times C0300 Temporal Orientation orientation to year month and day Ask individual Please tell me what year it is right now Enter Dash if unable to assess A Able to report correct year Code Enter 0 Missed by gt 5 years or no answer 1 Missed by 2 5 years Code 2 Missed by 1 year 3 Correct Ask individual What month are we in right now Enter Dash if unable to assess Enter B Able to report correct month 0 Missed by gt 1 month or no answer 1 Missed by 6 days to 1 month Code 2 Accurate within 5 days Ask individual What day of the week is today Enter Dash if unable to assess Enter C Able to report correct day of the week 0 Incorrect or no answer Code 1 Correct C0400 Recall Ask individual Let s go back to an earlier question What were those three words that asked you to repeat If unable to remember a word give cue Something to wear a color a piece of furniture for that word Enter Dash if unable to assess Able to recall sock 0 No could not recall 1 Yes after cueing something to wear 2 Yes no cue required Able to recall blue 0 No could not recall 1 Yes after cueing a color 2 Yes no cue required Able to re
69. e Edits are in place to verify the validity of data entered e Provides error messages that must be resolved before submission e Providers have the ability to monitor the status of their assessments by using Form Status Inquiry FSI or Cur rent Activity e Allows providers to submit additional information LTC Online Portal Security In order to utilize the LTC Online Portal providers and Managed Care Organizations must request access to the LTC Online Portal Your agency may already have an account You may need to contact your agency s administrator for user access An administrator account is required for LTC Online Portal access but it is strongly recommended to have multiple administrator accounts in case one administrator is unavailable The administrator account is the primary user account for a provider contract number The administrator account provides the ability to add remove permissions access to LTC Online Portal features for other user accounts on the same provider contract number A user account can be created by an administrator User account permissions and limitations are set by the holder of an administrator account This allows administrators to set the level of access according to employees responsibilities Note MDCP nurses obtain LTC Online Portal access directly from DADS Claims Management http dadsview dads state tx us cms claimssupport cmlibrary requestltcportal 20access html If you already have
70. e assessments set to status Provider Action Required or Submitted to CS Providers should look for these notes in the History trail of the MN LOC Assessment History Form Submitted 6 10 2010 1 41 53 PM Approved 6 10 2010 1 41 54 PM Medicaid ID Pending 6 10 2010 1 41 56 PM ID Confirmed 6 21 2010 3 52 12 PM SAS Request Pending Required 6 21 2010 3 56 56 PM 6 21 2010 4 00 48 PM 6 10 2010 1 41 53 PM TMHP This form was submitted as a Lookback assessment for DLN 6 10 2010 1 41 54 PM TMHP The Form has passed Auto MN Approval 6 10 2010 1 41 56 PM TMHP Medicaid ID request submitted 6 21 2010 3 52 12 PM TMHP Medicaid ID seessses confirmed for this client 6 21 2010 3 52 13 PM YHP s 6 21 2010 3 56 56 PM TMHP CS 0006 The request cannot be processed because an Initial assessment for the individual cannot be found Please verify data entry or contact the case manager TMHP Please submit Initial assessment Inactivate Form The Inactivate Form feature allows providers to inactivate an MN LOC Assessment Once inactivated the assess ment will not be available for further processing Inactivations are not allowed if an assessment is set to status Cor rected Form Inactivated or SAS Request Pending Inactivated assessments may be used as templates via the Use as template feature amp MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Processed Complete Name DLN RUG PC2 Form
71. earing is an informal orderly and readily available proceeding held before an impartial health and human services enterprise hearing officer At the hearing an individual applicant appellant or their representa tive including legal counsel may present the case as they wish to show that any action inaction or agency policy affecting the case should be reviewed The individual or the individual s responsible party may request a fair hearing on behalf of the individual within 90 days from the notice of adverse action date For CBA and MDCE if the individual is currently receiving services and requests a fair hearing on or before the last day of their annual service plan period they may be able to continue receiving their current service s until the fair hearing is completed Ifa PACE participant receives a letter denying MN and giving them the right to request a fair hearing the individu al must request a fair hearing within twelve days of the date of the letter for Medicaid payment to continue until the fair hearing decision Medicaid payment will continue if the individual was already receiving services Form 4803 Acknowledgement and Notice of Fair Hearing serves as a notice of the fair hearing It is sent to the ap pellant to acknowledge the receipt of a request for a hearing and to set a time date and place for the hearing Form 4803 will be sent to all known parties and required witnesses at least ten calendar days in advance o
72. ed representative Enter the last name of the Legally Authorized Representative 12c Address Conditional This is a required field if S11a is indicated as 1 Yes Does the individual report having a legally autho rized representative Enter the street address of the Legally Authorized Representative 12d City Conditional This is a required field if S11a is indicated as 1 Yes Does the individual report having a legally autho rized representative Enter the city of the Legally Authorized Representative Ifa city has a hyphen in the city name replace the hyphen with a space Ifa city has an apostrophe in the city name enter the city name without the apostrophe v 2014 1013 LTC Community Services Waiver Programs User Guide 12e State Conditional This is a required field if S11a is indicated as 1 Yes Does the individual report having a legally autho rized representative Enter the state of the Legally Authorized Representative 12f ZIP Code Conditional This is a required field if S11a is indicated as 1 Yes Does the individual report having a legally autho rized representative Enter the ZIP Code of the Legally Authorized Representative 12g Phone Optional Enter the contact telephone number for the Legally Authorized Representative if known v 2014 1013 47 LTC Community Services Waiver Programs User Guide Medical Necessity and the
73. equired field for Service Group SG 3 CBA Enter the license number of the RN Licenses issued in Texas will be validated against the Texas BON Board of Nursing Compact licenses will be validated with the issuing state s nursing board This number is validated to ensure RUG training requirements have been met S5c HHA RN License State Conditional This is a required field for Service Group SG 3 CBA Choose the state in which the RN is licensed from the drop down box S5d DADS RN Last Name Conditional This is a required field for SG 18 MDCP Purpose code 1 UR Enter the last name of the RN completing the assessment S 5e DADS RN License Conditional This is a required field for SG 18 MDCP Purpose code 1 UR Enter the license number of the RN Licenses issued in Texas will be validated against the Texas BON Compact licenses will be validated with the issuing state s nursing board This number is validated to ensure RUG training requirements have been met S 5f DADS RN License State Conditional This is a required field for SG 18 MDCP Purpose code 1 UR Enter the state in which the RN is licensed v 2014 1013 37 LTC Community Services Waiver Programs User Guide 38 S5g DADS RN Signature Date Conditional This is a required field for SG 18 MDCP Purpose code 1 UR Enter the date the DADS RN signed the assessment as bein
74. er Programs User Guide Acronyms A2300 Assessment Reference Date on an MN LOC 3 0 Assessment Assessment Reference Date on an MN LOC 2 0 Assessment ano Assessment Reference Date BON Texas Boardof Nursing Community Based Alternatives CSHCN ID Children with Special Health Care Needs Services Program Identification number DADS Department of Aging and Disability Services DD o Developmental Disabilities Document Locator Number Do o Doctor of Osteopathy EDD Electronic Data Interchange Emergency Medical Services Form Status Inquiry HCSSA Home and Community Support Services Agency HHA Home Health Agency HHSC Health and Human Services Commission Health Insurance Portability and Account ability Act Health Maintenance Organization Note HMO has been changed to MCO ICD 9 International Classification of Diseases Ninth Revision ICD 10 International Classification of Diseases Tenth Revision Intermediate care facility facilities for individuals with an intellectual disability or related condition iD Intellectual Disabilities ID Intellectual and Developmental Disabilities Individual Service Plan 78 ICF IID m MedicalDoctor Authorization Verification mn MedicalNecessty NE Nursing Facity OOO net National Provider identifier NPPES National Plan and Provider Enumeration System Office of Eligibility Services Office of the Inspector General OOHDNR Out of Hospital Do Not Resuscitate Order PACE Program
75. er dashes if therapy is ongoing Month Day Year Month Day Year D Respiratory Therapy Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero gt skip to OO400E Psychological Therapy Enter Number of Days 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days E Psychological Therapy by any licensed mental health professional Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero gt skip to OO400F Recreational Therapy Enter Number of Days 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days F Recreational Therapy includes recreational and music therapy Enter Number of Minutes 1 Total minutes record the total number of minutes this therapy was administered to the individual in the last 7 days If zero gt skip to 00420 Distinct Calendar Days of Therapy Enter Number of Days 2 Days record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days MN and LOC 3 0 V 15 25 of 32 Individual Identifier Date Section O Special Treatments Procedures and Programs 00420 Distinct Calendar Days of Therapy Enter Number of D
76. eria are appropriately met the assessment is automatically approved If not the provider will see The Form has failed Auto MN Approval displayed in the History trail of the assessment The assessment will then be sent to a nurse for manual MN review Ihe assessment will be set to status Pending Review on the FSI search results However the last message showing in the History trail will be The Form has failed Auto MN Approval Once reviewed the assessment is either approved meeting MN or set to status Pending Denial need more information for up to 21 calendar days FSI or Current Activity will allow the provider to view the status of an assessment during the MN determination process The provider may supply additional information clarifying nursing medical needs through the Add Note fea ture on the LTC Online Portal or by calling TMHP and speaking with a TMHP nurse If the TMHP nurse determines that MN has been met the assessment is approved If the TMHP nurse still cannot determine any licensed nursing need the individual s assessment is sent to the TMHP physician for an MN determination v 2014 1013 49 LTC Community Services Waiver Programs User Guide 6 Ifthe TMHP physician determines that MN has been met the assessment is approved 7 Ifthe MN is denied by the TMHP physician notification of denied MN is sent to the individual and the physi cian of record as specified in the LT CMI via mail The provi
77. es may be softer or harder than surrounding skin 9 None of the Above M1030 Number of Venous and Arterial Ulcers Enter Number i Enter the total number of venous and arterial ulcers present M1040 Other Ulcers Wounds and Skin Problems Check all that apply Foot Problems A Infection of the foot e g cellulitis purulent drainage B Diabetic foot ulcer s C Other open lesion s on the foot Other Problems itis D Open lesion s other than ulcers rashes cuts e g cancer lesion E Surgical wound s F Burn s second or third degree G Skin tear s H Moisture Associated Skin Damage MASD i e incontinence IAD perspiration drainage None of the Above Z None of the above were present O WUUOOO OU MN and LOC 3 0 V 15 21 of 32 Individual Identifier Date SectionM Skin Conditions M1200 Skin and Ulcer Treatments 4Checkallthatapply D Nutrition or hydration intervention to manage skin problems F Surgical wound care G Application of nonsurgical dressings with or without topical medications other than to feet H Applications of ointments medications other than to feet Application of dressings to feet with or without topical medications Z None of the above were provided 0 0 0 O O O C O C L SY Yane mm Medications N0300 Injections Enter D E Record the number of days that injections of any type were received during the last 7 days If 0 gt Skip to N0
78. esenting as a shallow open ulcer with a red or pink wound bed without slough May also present as an intact or open ruptured blister Enter Number E Enter Number E Enter Number L Enter Number L Enter Number L Enter Number L Enter Number L E 1 3 Number of Stage 2 pressure ulcers If0 gt Skip to M0300C Stage 3 Date of oldest Stage 2 pressure ulcer Enter dashes if date is unknown tt Month Day Stage 3 Full thickness tissue loss Subcutaneous fat may be visible but bone tendon or muscle is not exposed Slough may be present but does not obscure the depth of tissue loss May include undermining and tunneling 1 Number of Stage 3 pressure ulcers Stage 4 Full thickness tissue loss with exposed bone tendon or muscle Slough or eschar may be present on some parts of the wound bed Often includes undermining and tunneling 1 Number of Stage 4 pressure ulcers Unstageable Non removable dressing Known but not stageable due to non removable dressing device Number of unstageable pressure ulcers due to non removable dressing device Unstageable Slough and or eschar Known but not stageable due to coverage of wound bed by slough and or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and or eschar Unstageable Deep tissue Suspected deep tissue injury in evolution Number of unstageable pressure ul
79. essment from the drop down box J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Form Status Inquiry Form Select Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessment v Yendor Number TE Form Status Inquiry DLN Medicaid Number Last Name First Name SSN Form Status From Date To Date 10 4 2010 Purpose Code Reason for Assessment Enter data for all required fields as indicated by the red dots Narrow results by entering specific criteria in the additional fields DLN Last Name First Name SSN Medicaid Number Form Status From Date and To Date Click the Search button Click the View Detail link of the requested assessment Form Status Inquiry DLN Medicaid Number Last Name First Name SSN Form Status From Date f To Date 10 5 2010 Purpose Code Reason for Assessment 27 record s returned TMHP Received Medicar Last A Purpose Contract endor Reason For Date Medicare Name Date Code Number Number Assessment 10 5 2010 Processed Complete 10 5 2010 OL Initial Det assessment ie t 10 5 2010 e be ees Invalid Complete CA2 10 5 2010
80. ext v 2014 1013 LTC Community Services Waiver Programs User Guide 11 Check the I agree to these terms box at the bottom of the screen under the General Terms and Conditions section to indicate agreement 12 Click the Create Provider Administrator button to create your User name and Password GENERAL TERMS AND CONDITIONS You have entered the secure portion of the Texas Medicaid amp Healthcare Partnership TMHP website Throughout the terms herein reference te TMHP means TMHP ACS State Healthcare LLC its parent company affiliates subsidiaries jemployees consultants and subcontractors Terms of Use By accepting the terms of use you will be allowed access to programs reports and information protected by federal and state law contained in the secure portion of this website Only authorized persons in lawful possession of a password provided by TMHP to provide such passwords may enter and access the secure portion of this website The use of this website is subject to the terms of use contained herein Once you have accepted the terms of use you will not be asked te accept such terms again when you access the site another time TMHP has the right at any time to change or modify the terms of use which will be posted on this website Any use of the website by you after modified terms have been posted will be deemed to constitute acceptance by you of the modified terms TMHP has the right at any time to change or disco
81. f the hearing The fair hearing is held at a reasonable place and time They are normally scheduled in the order in which re quests are received and are usually held via teleconference Appellants may present their own case or bring a friend relative or attorney to present their case DADS Health and Human Services enterprise does not pay attorney fees Appellants may request additional time to prepare for their case by contacting the hearing officer 50 v 2014 1013 LTC Community Services Waiver Programs User Guide Appellants may request an interpreter at no cost However appellants must notify the hearing officer at least two days before the hearing if they are going to require an interpreter Before and during the hearing appellants and their representatives have the right to examine the documents records and evidence that DADS will use To see medical evidence before the hearing the appellant must make a written request to the hearing officer The appellant may bring witnesses and present facts and details about the case The appellant may also question or disagree with any testimony or evidence that is presented by the department Appellants have the right to know all the information the hearing officer examines in making the decision The laws and policies which apply to the appellant s case and the reasons for DADS action will be explained The hearing officer will issue a final written order The decision by the hearing
82. formation for further consideration either by telephone or by using the Add Note feature on the LTC Online Portal The TMHP nurse did not find the assessment to qualify for MN Provider has 21 calendar days to submit additional information for consideration e Pending MD DO License Verification MD DO License number is pending manual verification by TMHP for licenses that are issued from states other than Texas TMHP will validate the MD DO License number entered in field S7d of the LI CMI and set assessment status to either Out of State MD DO License Valid or Out of State MD DO License Invalid If status is set to Out of State MD DO License Valid the assessment will con tinue to process through the workflow e Pending More Info DADS is waiting for more information from the provider Information required may be found within the assessment History trail e Pending Review Assessment is waiting for TMHP RN to manually review it for MN e Pending RN License Verification RN License number is pending manual verification by TMHP from the Texas BON or the licensing state from which the compact license was issued e Processed Complete Assessment has been processed and complete Please check Medicaid Eligibility and Ser vice Authorization Verification MESAV Provider Action Required Assessment must be reviewed by the provider due to the assessment being rejected by Service Authorization System SAS Refer to the assessment History t
83. g e Click the Printable Forms link in the blue navigational bar and click the Waiver 3 0 MN and LOC link 32 v 2014 1013 LTC Community Services Waiver Programs User Guide Long Term Care Medicaid Information LTCMI ne Submit Form Form Status Inquir Current Activity Drafts Printable Forms Help MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT Version 3 0 Current Status Name DLN 0 RUG Form Actions Print Physician s Signature Section A Section B Section C I Section D Section E Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI 1 Medicaid Information Sla Medicaid Client Indicator 1 Medicaid S1b Individual Address Slc City Sid State v Sle ZIP Code Sif Phone 2 Claims Processing Information 2a DADS Vendor Site ID Number 2b Contract Provider Number 2c Service Group 13 CBA 2d NPI Number 2e Region v S2f Purpose Code S2g HHA License S2h HHA License Expiration Date 3 Primary Diagnosis Primary Diagnosis ICD Code Primary Diagnosis ICD Description S3a S3b q S5 Licenses Certification To the best of my knowledge I certify to the accuracy and completeness of this information
84. g complete DADS RN Signature DADS RN must sign assessment as being complete S5h PACE RN Last Name Conditional This is a required field for SG 11 PACE Enter the last name of the RN completing the assessment S5i PACE RN License Conditional This is a required field for SG 11 PACE Enter the license number of the RN Licenses issued in Texas will be validated against the Texas BON Compact licenses will be validated with the issuing state s nursing board gt This number is validated to ensure RUG training requirements have been met S5j PACE RN License State Conditional This is a required field for SG 11 PACE Choose the state in which the RN is licensed from the drop down box S5k HMO RN Last Name Conditional This is a required field for SG 19 STAR PLUS Enter the last name of the RN completing the assessment S51 HMO RN License Conditional This is a required field for SG 19 STAR PLUS Enter the license number of the RN Licenses issued in Texas will be validated against the Texas BON Compact licenses will be validated with the issuing state s nursing board This number is validated to ensure RUG training requirements have been met S5m HMO RN License State Conditional This is a required field for SG 19 STAR PLUS Choose the state in which the RN is licensed from the drop down box v 2014 1013 LTC Community Services Waiver Programs
85. gimen 2 Yes not on physician prescribed weight loss regimen MN and LOC 3 0 V 15 18 of 32 Individual Identifier Date ST le ite aa OwWallowing Nutritional Status K0310 Weight Gain Gain o 5 or more in the last month or gain of 10 or more in last 6 months N or unknown Yes on physician prescribed weight gain regimen Yes not on physician prescribed weight gain regimen K0510 Nutritional Approaches Check all of the following nutritional approaches that were performed during the last 7 days A Parenteral IV feeding B Feeding tube nasogastric or abdominal PEG C Mechanically altered diet require change in texture of food or liquids e g pureed food thickened liquids D Therapeutic diet e g low salt diabetic low cholesterol DOOD Z None of the above K0710 Percent Intake by Artificial Route Complete K0710 only if KO510A or KO510B is checked A Proportion of total calories the individual received through parenteral or tube feeding during entire 7 days 1 25 or less 2 26 50 3 51 or more B Average fluid intake per day by IV or tube feeding during entire 7 days 1 500 cc day or less 2 501 cc day or more S a o E me Oral Dental Status L0200 Dental Check all that apply A Broken or loosely fitting full or partial denture chipped cracked uncleanable or loose B No natural teeth or tooth fragment s edentulous C Abnormal mouth tissue ulcers mas
86. heart failure CHF and pulmonary edema Hypertension 10799a Blood Pressure 10800 Orthostatic Hypotension 10900 Peripheral Vascular Disease PVD or Peripheral Arterial Disease PAD 10999 Peripheral Edema Gastrointestinal 11100 Cirrhosis 11200 Gastroesophageal Reflux Disease GERD or Ulcer e g esophageal gastric and peptic ulcers LEUS Tae Colitis Crohn s Disease or Inflammatory Bowel Disease TEA r eee L 11400 Benign Prostatic Hyperplasia BPH J 11500 Renal Insufficiency Renal Failure or End Stage Renal Disease ESRD _ 11550 Neurogenic Bladder 11650 Obstructive Uropathy HOU OOOO Multidrug Resistant Organism MDRO Pneumonia Septicemia Tuberculosis Urinary Tract Infection UTI LAST 30 DAYS Viral Hepatitis e g Hepatitis A B C D and E Wound Infection other than foot 12900 Diabetes Mellitus DM e g diabetic retinopathy nephropathy and neuropathy 12999 Blood Sugar Range Hyponatremia Hyperkalemia Hyperlipidemia e g hypercholesterolemia Thyroid Disorder e g hypothyroidism hyperthyroidism and Hashimoto s thyroiditis MN and LOC 3 0 V 15 13 of 32 Individual Identifier Date Section Active Diagnoses Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists _ Musculoskeletal Arthritis
87. help in part of bathing activity Total dependence Activity itself did not occur during the entire period Enter Code Support provided Bathing support codes are as defined in Item G0110 column 2 ADL Support Provided above G0300 Balance During Transitions and Walking After observing the individual code the following walking and transition items for most dependent Enter Codes in Boxes Coding A Moving from seated to standing position Steady at all times Not steady but able to stabilize B Walking with assistive device if used without human assistance Not steady only able to stabilize with C Turning around and facing the opposite direction while walking human assistance Activity did not occur _ D Moving on and off toilet _ E Surface to surface transfer transfer between bed and chair or wheelchair G0400 Functional Limitation in Range of Motion Code for limitation that interfered with daily functions or placed individual at risk of injury Coding 4 Enter Codes in Boxes 0 No impairment A Upper extremity shoulder elbow wrist hand 1 Impairment on one side 2 Impairment on both sides B Lower extremity hip knee ankle foot G0600 Mobility Devices Check all that were normally used C A Cane crutch C B Walker E C Wheelchair manual or electric C D Limb prosthesis C Z None of the above were used G0900 Functional Rehabilitation Potential Complete only if A0310A 01
88. i Observation end date is a required field MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Name DLN 0 RUG Form Actions Print Physician s Signature Section B Section G Section E Section C Section H Section D Section I Section K Section O Section Z Section J Section N A0310 Type of Assessment A Reason for Assessment vij A B Middle initial A0500 Legal Name of A First name Individual E lA ie Suffix a C Last name j v 2014 1013 Section L Section P Section LTCMI Section Identification Information Section M Section Q ZF LTC Community Services Waiver Programs User Guide Entering Dates To enter dates you have the option to click on the calendar icon next to any of the date fields to activate the dynam ic calendar Choose the date desired Or you may manually enter the date using the mm dd yyyy format Timeout The LTC Online Portal will timeout after 20 minutes of no activity To prevent this timeout from occurring com plete and submit the assessment within 20 minutes or click on a different tab e g Section A to reset the timer then return to the previous tab RUG Value Resource Utilization Group RUG is used to classify relative direct care resource requirements for individuals who live in a Nursing Facility NF and to establish the cost limit for
89. iaaanecedassened cons saotenesioidaanesaes EAO 27 TOT VNC a E E saree peier oe aipSenins ewan E E E E E E anaes 2 Poe MIA AG cts seen nca petites E E T E E 28 Ea a ARRE sec esse esse ONEA AEA os enlaces cence ida oc eine ves sos succeeds I AN dese 28 POG WN a5 oe eonc aac vance sncaasnencaanceasencecanedecesocciaesemenaee naasaesainasanscnesesdsnausccpanaeaesesennaaeoeae ousaueusasuenaaaesameanesawesaanceenaate 28 Medical Necessity and Level of Care 3 0 Assessment c ccccssscessseeeeeneeeesseeeseaceeseaeeceeaeeceaeeceeaueeeeaeeceeeaeeeeaaees 29 How to Submita Medical Necessity and Level or Care Asses 00600 0 cg crepecsasecaaseccesercucsyicessonaeemnerewvinsesaretaneteraatees 30 MIN TOG 3 0 Assessment Sections wesdedecosdcccsesineeteoesdecewansedsccededanwsdebsansda decease de Geneseeoaacadailaueelebeewedadelacladeleossiadeasaees 32 Lone Weimer Cac Medicaid lai woreri ae on sage aacee ct see asec sectarian see teense 33 Medical Necessity and the MN Determination Process 0 ccccceesssccesseeeesseneeeeenaeeceseaeeceseaeeceesaeesenenaeeeeeaaes 48 Dennou Or Medical Neces iy anena E E E RE E 48 General Qualifications for Medical Necessity Determinations scz sasscnasscdcesnntaiaceceossstcesstesisaeseesnelvseaensdeatecesnecciusens 48 Medical Necessity Determination ProGesSS sscsirorsinrsisindinins onaren eani arnis aE aE DES EAER Eini 49 PE E 1 AE E E A E AE E ET 50 Assessment Statuses cscs hss nsec ct activ sl socte Scns pained e
90. ic sexual acts disrobing in public throwing or smearing food or bodily wastes or verbal vocal symptoms like screaming disruptive sounds Behavior of this type occurred 4 to 6 days but less than daily Behavior of this type occurred daily E0300 Overall Presence of Behavioral Symptoms Enter Code Were any behavioral symptoms in questions E0200 coded 1 2 or 3 i 0 No Skip to E0800 Rejection of Care 1 Yes Considering all of E0200 Behavioral Symptoms answer E0500 and E0600 below E0500 Impact on Individual Did any of the identified symptom s Put the individual at significant risk for physical illness or injury 0 No 1 Significantly interfere with the individual s care 0 No 1 Significantly interfere with the individual s participation in activities or social interactions 0 No Did any of the identified symptom s Put others at significant risk for physical injury 0 No 1 Significantly intrude on the privacy or activity of others 0 No 1 Significantly disrupt care or living environment 0 No 1 Yes E0800 Rejection of Care Presence amp Frequency Did the individual reject evaluation or care e g bloodwork taking medications ADL assistance that is necessary to achieve the individual s goals for health and well being Do not include behaviors that have already been addressed e g by discussion or care planning with the individual or family and determined to be consistent wi
91. ill inactivate the assessment The status of the assessment will then set to status Form Inactivated An example of when this Inactivate Form button would be used is when the provider research indicates the assessment being submitted is a duplicate If the provider clicks the Inactivate Form button the provider will receive the following confirmation window TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help a UnLock Form MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Provider Action Required Name DLN RUG PC2 Form Actions Workflow Actions LT Print Physician s Signature Use as template Add Note L Inactivate Form Lg Resubmit Form Section B Section C Section D Section E Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI Section Identification Information A0310 Type of Assessment A Reason for Assessment Microsoft Internet Explorer A0500 Legal Name of A First name B Middle initial YD Are you sure you want to Inactivate this form Individual C Last name D Suffix To p 58 v 2014 1013 LTC Community Services Waiver Programs User Guide From here you have two choices a Click the OK button to Inactivate and the as
92. information located in Section A and section LTCMI of the MN LOC Assessment 5 Click the Enter Form button 6 Click the tabs Section A Section B etc and enter the assessment information For Initial Assessments only the following is required a Click the Print Physician s Signature button and print the signature page and obtain the MD DO signature 30 v 2014 1013 LTC Community Services Waiver Programs User Guide b Click the Save as Draft button to save the MN LOC Assessment to be recalled later Print KL print Physician s Signature LA K Save as Draft N i ai i P c Once the physician s signature has been obtained click the Drafts link in the blue navigational bar d Click the Open link gt 4a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Drafts sissi ii iaei oi 10 5 2010 5 29 35 PM Waiver 3 0 ere ero Remove 10 5 2010 4 13 04 PM Waiver 3 0 ete ume Remove a e Click the Section LTCMI tab Check the box indicating the physician s signature is on file MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Name DLN 0 RUG Form Actions Print Physician s Signature Save as Draft Section B Section C Section D Section E Section L Section M Section N Section O Section P Section Q Section Z Sectiont
93. ion 3 If you want to submit 3618s 3619s MDS MDS Quarterly MN LOC and PASARR Screenings choose NF Waiver Programs Option 4 If you are attempting to become a Texas Medicaid or CSHCN Services Program provider and currently do not have a TPI NPI choose Provider Enrollment Provider Type Select Acute Care Long Term Care NF Waiver Programs Provider Enrollment 9 Enter your provider number vendor number and vendor password 10 Click the Next button I amp TMHPe Account Activation Use the following guidelines to determine your selection from the Provider Type menu below Option 1 If you are a provider enrolled by TMHP choose Acute Care Option 2 If you are a provider enrolled by DADS and would like to view R amp S reports and submit 3071s and 3074s choose Long Term Care Option 3 If you want to submit 3618s 3619s MDS MDS Quarterly MN LOC and PASARR Screenings choose NF Waiver Programs Option 4 If you are attempting to become a Texas Medicaid or CSHCN Services Program provider and currently do not have a TPI NPI choose Provider Enrollment Provider Type NF Waiver Programs v Provide all of the following information Provider Number Format 123456789 More Info Formerly known as Contract Number Format 0123456789 More Info Vendor Number Vendor Password More Info Formerly known as MicroECS password N
94. isease does not include standard body fluid precautions N99 Psychiatric care DIU WOOO None of the Above Z None of the above MN and LOC 3 0 V 15 23 of 32 Individual Section O Identifier iss CSs S CSCSsS__ Daatt le e Special Treatments Procedures and Programs 00400 Therapies A Speech Language Pathology and Audiology Services Enter Number of Minutes Enter Number of Minutes Enter Number of Minutes Enter Number of Minutes Enter Number of Days Enter Number of Minutes Enter Number of Minutes Enter Number of Minutes Enter Number of Minutes Enter Number of Days Individual minutes record the total number of minutes this therapy was administered to the individual individually in the last 7 days Concurrent minutes record the total number of minutes this therapy was administered to the individual concurrently with one other individual in the last 7 days Group minutes record the total number of minutes this therapy was administered to the individual as part of a group of individuals in the last 7 days If the sum of individual concurrent and group minutes is zero gt skip to O0400B Occupational Therapy 3A Co treatment minutes record the total number of minutes this therapy was administered to the individual in co treatment sessions in the
95. ity My Drafts Printable Forms Help UnLock Form MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Processed Complete Name 99 gt DLN van RUG PC2 Form Actions O Print Physician s Signature Q Use as template a Correct this form Add Note Inactivate Form acai aaa ee Se Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI Section Identification Information A0310 Type of Assessment A Reason for Assessment A0500 Legal Name of Individual A First name B Middle initial EJ C Last name D Suffix L Social Security and A Social Security Number Medicare Numbers B Medicare Number or comparable railroad insurance number Medicaid Number if pending N if not a Medicaid recipient Gender Birth Date F Race Ethnicity Check all that apply A American Indian or Alaskan Native Note Modify assessment data to reflect the current status of the individual Also adjust the Reason for Assessment if necessary e g if you chose to use an Initial Assessment as a template for the Annual Assessment dont forget to change the Reason for Assessment from Initial to Annual 2 Enter data into remaining fields that are not auto populated Note Fields not auto populated in the 3 0 Assessment are Assessment Date A23
96. ity Services Waiver Programs User Guide 46 Slld Does the individual caregiver report having an Out of Hospital Do Not Resuscitate Order Required What is an Out of Hospital Do Not Resuscitate Order OQOHDNR This form is for use when an individual is not in the hospital It lets the person tell health care work ers including Emergency Medical Services EMS workers not to do some things if the person stops breathing or their heart stops If an individual does not have one of these forms filled out EMS workers will always give the person Cardiopulmonary Resuscitation CPR or advanced life support even if the advance care planning forms say not to A person should complete this form as well as the Directive to Physicians and Family or Surrogates and the Medical Power of Attorney form if they do not want CPR Choose from the drop down box 0 No 1 Yes S12 Legally Authorized Representative LAR Address Note In the future this information may be used to send MN determination letters to the LAR when indicated on the assessment 12a LAR First Name Conditional This is a required field if S11a is indicated as 1 Yes Does the individual report having a legally autho rized representative Enter the first name of the Legally Authorized Representative 12b LAR Last Name Conditional This is a required field if S11a is indicated as 1 Yes Does the individual report having a legally autho riz
97. l B Trunk restraint C Limb restraint Coding Used in Chair or Out of Bed 0 Not used 1 Used less than daily 2 Used daily E Trunk restraint F Limb restraint G Chair prevents rising Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment Enter Code A Individual participated in assessment i 0 No 1 Yes Enter Code B Family or significant other participated in assessment 0 No 1 Yes 9 No family or significant other available Enter Code C Guardian or legally authorized representative participated in assessment 0 No 1 Yes No guardian or legally authorized representative available Q0300 Individual s Overall Expectation Complete only if A0310A 01 EnterCode A Select one for individual s overall goal established during assessment process 1 Expects to be discharged to the home i e currently in ALF 2 Expects to remain in the home 3 Expects to be transferred to a facility institution 9 Unknown or uncertain Enter Code B Indicate information source for Q0300A 1 Individual If not individual then family or significant other If not individual family or significant other then guardian or legally authorized representative Unknown or uncertain CCOIL LILLI MN and LOC 3 0 V 15 27 of 32 Individual Identifier Date S a u FA Assessment Administration Z0500 Signature of RN Completing Assessment A Signature B Date Assessment Completed
98. lf sufficiency once in chair G Dressing how individual puts on fastens and takes off all items of clothing including donning removing a prosthesis or TED hose Dressing includes putting on and changing pajamas and housedresses H Eating how individual eats and drinks regardless of skill Do not include eating drinking during medication pass Includes intake of nourishment by other means e g tube feeding total parenteral nutrition IV fluids administered for nutrition or hydration I Toilet use how individual uses the toilet room commode bedpan or urinal transfers on off toilet cleanses self after elimination changes pad manages ostomy or catheter and adjusts clothes Do not include emptying of bedpan urinal bedside commode catheter bag or ostomy bag J Personal hygiene how individual maintains personal hygiene including combing hair brushing teeth shaving applying makeup washing drying face and hands excludes baths and showers O O OC O O OCC CL O O O O O OCL LIL MN and LOC 3 0 V 15 10 of 32 Individual Identifier Date Section G Functional Status G0120 Bathing How individual takes full body bath shower sponge bath and transfers in out of tub shower excludes washing of back and hair Code for most dependent in self performance and support EnterCode A Self performance Independent no help provided Supervision oversight help only Physical help limited to transfer only Physical
99. ment in Portable Document Format PDF Note To type information into an assessment click on the appropriate link Once open save the document to your desktop and begin entering information S82 amp 6 o0 9 EEO amp Aow Individual Identifier Medical Necessity and Level of Care Assessment 3 0 cYa i0 FE Identification Information A0310 Type of Assessment A Reason for Assessment 01 Initial assessment 03 Annual assessment 04 Significant change in status assessment A0500 Legal Name of Individual A First name B Middle initial Lt L C Lastname v 2014 1013 19 LTC Community Services Waiver Programs User Guide 3 Click the Print Icon 20 To print the entire document a Printer Choose the appropriate printer name from drop down box b Print Range Click the All radio button c Click the OK button To print certain pages instead of the entire document a Printer Choose the appropriate printer name from drop down box b Print Range Click the Pages radio button c Enter the pages to print Example 1 5 will print all pages 1 through 5 1 3 7 will print only pages 1 3 and 7 This is useful for printing only the LTCMI instead of the entire MN LOC Assessment d Click the OK button Printer i ane Ready Comments and Forms Type HP Laserdet 5100 PCL 6 Document and Markups Print Range Preview Composite OAl ooo Current vie
100. mitted electronically through third party software or through TexMedConnect On the LTC Online Portal NPI is used for security purposes and links providers to their assessments so that only those associated with that NPI are viewable Without an NPI providers would not be able to locate their assess ments on the LTC Online Portal Note DADS Medically Dependant Children Program MDCP nurses are not required to apply for an NPI They enter an Atypical Provider Identifier API which is assigned by the appropriate region To view a map of the DADS Commu nity Services regions go to www dads state tx us contact regional_facility Managed Care Organizations MCOs issue thier own API numbers To obtain an NPI go to https nppes cms hhs gov NPPES It is important the NPI or API be included in MN LOC Assessment submissions field S2d NPI or API is required on claims and assessment submissions using the following methods e LTC Online Portal e TexMedConnect e Third party software vendor v 2014 1013 3 LTC Community Services Waiver Programs User Guide The LIC Online Portal The LTC Online Portal is used to submit monitor and manage MN LOC Assessments Benefits of Using the LTC Online Portal e Web based application e 24 7 system availability e TMHP provides LTC Online Portal technical support by telephone at 1 800 626 4117 Option 3 from 7 00 a m 7 00 p m Central Time Monday through Friday excluding holidays
101. n and B requires licensed nurses supervision assessment planning and intervention that are avail able only in an institution 2 The individual must require medical or nursing services that A are ordered by the physician B are dependent upon the individual s documented medical conditions C require the skills of a registered nurse or licensed vocational nurse D are provided either directly by or under the supervision of a licensed nurse in an institu tional setting and E are required on a regular basis 48 v 2014 1013 LTC Community Services Waiver Programs User Guide Note MN is not the only prerequisite to qualify for LTC Medicaid Community Services Waiver programs Medical Necessity Determination Process TMHP nurse reviews MN LOC Assessment to determine MN TMHP approves MN Pending Denial Provider provides Provider does not provide additional information additional information TMHP TMHP TMHP nurse physician physician approves approves denies TMHP physician approves The individual has the right to appeal Individual s physician provides additional information MN approved MN denied This flowchart provides a high level overview of the process used for determination of MN l The TMHP nurse has five business days to review assessments and determine MN TMHP systems automatically review specific criteria on the assessments If the crit
102. n C Section D Section E Section G Section H Section I Section J Il Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI e Section A Identification Information e Section B Hearing Speech and Vision e Section C Cognitive Patterns e Section D Mood e Section E Behavior e Section G Functional Status e Section H Bladder and Bowel e Section I Active Diagnoses e Section J Health Conditions e Section K Swallowing Nutritional Status e Section L Oral Dental Status e Section M Skin Conditions e Section N Medications e Section O Special Treatments Procedures and Programs e Section P Restraints e Section Q Participation in Assessment and Goal Setting e Section Z Assessment Administration e Section LTCMI LTC Medicaid Information Detailed explanations of the MN LOC Assessment sections can be found at the following locations e Go to www tmhp com Pages LTC LTC Forms aspx and click the Medical Necessity and Level of Care 3 0 Instructions link found under the Community Waivers Programs heading e Click the Help link in the blue navigational bar and click the Medical Necessity and Level of Care 3 0 In structions link Blank MN LOC Assessments can be found at the following locations e Go to www tmhp com Pages LTC LTC Forms aspx and click the Medical Necessity and Level of Care 3 0 Assessment link found under the Community Waivers Programs headin
103. n the individual s behavior after the fall as reported by the individual caregiver Coding 0 None 1 One 2 Two or more B Injury except major skin tears abrasions lacerations superficial bruises hematomas and sprains or any fall related injury that causes the individual to complain of pain C Major injury bone fractures joint dislocations closed head injuries with altered consciousness subdural hematoma ST Ee OwWallowing Nutritional Status K0100 Swallowing Disorder Signs and symptoms of possible swallowing disorder Check all that apply A Loss of liquids solids from mouth when eating or drinking B Holding food in mouth cheeks or residual food in mouth after meals C Coughing or choking during meals or when swallowing medications D Complaints of difficulty or pain with swallowing Z None of the above K0200 Height and Weight While measuring if the number is X 1 X 4 round down X 5 or greater round up A Height in inches Record most recent height measure inches B Weight in pounds Base weight on most recent measure in last 30 days measure weight consistently according to standard facility practice e g in a m after voiding before meal with shoes off etc Enter Dash if unable to assess K0300 Weight Loss Loss of 5 or more in the last month or loss of 10 or more in last 6 months 0 Noor unknown 1 Yes on physician prescribed weight loss re
104. n their own home room Z None of the above were recalled Made decisions regarding tasks of daily life 0 Independent decisions consistent reasonable 1 Modified independence some difficulty in new situations only 2 Moderately impaired decisions poor cues supervision required 3 Severely impaired never rarely made decisions C1300 Signs and Symptoms of Delirium from CAM Code after completing Brief Interview for Mental Status or Caregiver Assessment and reviewing medical record Enter Codes in Boxes i A Inattention Did the individual have difficulty focusing attention easily distracted out of touch Coding or difficulty following what was said 0 Behavior not present Disorganized thinking Was the individual s thinking disorganized or incoherent rambling or 1 Behavior continuously i irrelevant conversation unclear or illogical flow of ideas or unpredictable switching from l subject to subject Enter Dash if unable to assess present does not fluctuate Altered level of consciousness Did the individual have altered level of consciousness 2 Behavior present e g vigilant startled easily to any sound or touch lethargic repeatedly dozed off when fluctuates comes and being asked questions but responded to voice or touch stuporous very difficult to arouse goes changes in and keep aroused for the interview comatose could not be aroused severity D P
105. name and password If you do not have an LMS account you must create one The information that you will be required to provide depends upon whether you are a provider TMHP employee state of Texas employee or other user To create an LMS account 1 Click Register under the Account Login heading to the right The registration form will appear 2 Select your user type from the drop down menu The registration screen will be refreshed with the information that your user type is required to provide Fields that are marked with an asterisk are required and must be completed All of the other fields are optional 74 v 2014 1013 LTC Community Services Waiver Programs User Guide 5 Use your cursor to hover over Provider Education in the top menu bar and click Computer Based noel peterson logout a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR TMHP EDUCATION STATE EDUCATION REVIEW HELP Workshop Materials Past Webinars Registered users can Run computer based training modules Listen to or read transcripts of past webinars Access written workshop materials need assistance please view the 6 Scroll to Long Term Care LTC Community Services Waiver Programs and click View now to start the CBT Long Term Care LTC Community Services Waiver Programs Topic How to successfully navigate and submit LTC Community Sernices Waiver assessments in the LTC Online Portal L
106. new TMHP User Account with an existing provider vendor account click the New Username and Activate Existing Provider link Ifselected go to step 7 v 2014 1013 I 2 TMHP com Account Activation LTC Community Services Waiver Programs User Guide Home TMHP com My Account Log In Welcome to the Account Activation portion of TMHP com The following instructions will help providers choose the correct option for creating TMHP User Accounts and activating Texas Medicaid or Children with Special Health Care Needs Services Program CSHCN Provider Vender Accounts online e If you do not have a TMHP User Account choose one of the following options o To create a TMHP User Account and begi Medicaid or the CSHCN Services Program fclick New Username and Enroll o To create a TMHP User Account and actifate an existing Texas Medicaid or CSHCN Services Program provider vendor account for online use click New Username and Activate Existing Provider e If you do have a TMHP User Account choose one of the following options o To make changes to an existing enrollment application for Texas Medicaid or the CSHCN Services Program click Open Existing Enrollment o To activate an existing Texas Medicaid or CSHCN Services Program Provider Yendor account under your existing TMHP User Account click Existing Username and Activate Existing Provider If you are not a Texas Medicaid Provider Vendor or you would like to return to the pre
107. nge in Status Assessment Submission Guidelines The LTC Online Portal will accept SCSA submissions only when there is a record of previously approved MN found within the past 365 calendar days for the individual If there is no approved MN within the past 365 calendar days the SCSA will not be accepted onto the LTC Online Portal and the following error message will display plete a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a i E The SCS4 cannot be accepted No previous MN on file for client within past 365 days Please submit Initial or Annual assessment I The LTC Online Portal will not accept SCSA submissions if the latest approved MN Assessment found for an indi vidual is within the 365 calendar day limit and is set to one of the following pending statuses e Pending Nurse Review e Pending Denial Denial Inventory e Pending Doctor Review In the above circumstance the following error message will display i e The SCSA cannot be accepted The final decision has not been made on your previously submitted Initial or Annual assessment for this client You may save this SCSA as a draft 1 i for submission at a later date Note Health Maintenance Organizations HMOs complete the SCSA but do not submit on the LTC Online Portal Print and keep in the individual records v 2014 1013 2 LTC Community Services Waiver Programs User Guide All assessments must be submitted
108. nner messages 12 v 2014 1013 LTC Community Services Waiver Programs User Guide Submit Form The Submit Form feature allows providers to submit Waiver 3 0 Medical Necessity and Level of Care Assess ments TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Submit Form Form Select Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessment v Recipient To prepopulate recipient information please provide one of the following combinations of information Medicaid CSHCN ID or Social Security Number AND Last Name or Social Security Number AND Date of Birth or Date of Birth AND Last Name AND First Name Medicaid Number SSN Date of Birth First Name Last Name v 2014 1013 13 LTC Community Services Waiver Programs User Guide J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Name DLN 0 RUG Form Actions Section A Section B Section C Lo Section Ee Section G Section H Section Section K Section L SectionM SectionN Section O Section P baaa Section Q ooo Section Z Section LTCMI Section Identification Information A0310
109. ntinue any aspect or feature of this website and to terminate any users access to the website TMHP has the right but not the obligation to monitor your use and access of this site HIPAA Privacy You have requested online access to confidential patient data that is protected by federal and state privacy laws We take very seriously our obligation to protect this confidential patient data from unauthorized use or disclosure Accordingly we allow only those persons with appropriate authorization te access or provide the confidential patient data through this website Any dissemination or distribution of the confidential patient data contained in this website to anyone other than the authorized recipient is unauthorized and strictly prohibited by law The privacy and security g py the Health Insurance Portability and Accountability Act of 1996 HIPAA and its iv C 1 agree to these terms Satie evga anise Note Zhe User name and Password are used for future log ins to your account Make a copy for your records My Account My Account is used to perform various maintenance activities for your account such as setting up user accounts changing passwords and other administrative tasks To access My Account 1 Go to www tmhp com 2 Click providers in the green bar located at the top of the screen TMHP ASTATE MEDICAID CONTRACTOR clients providers TMHP Home Welcome to Texas Medicaid amp Healthcare P
110. of a column the provider can choose to sort results by DLN Received Date SSN Medicaid Number Medicare Number Name or Status When the provider clicks on a column heading the first time it is sorted in ascending order By clicking on the column heading a second time the sort will change to descending order Drafts J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help v 2014 1013 Ly LTC Community Services Waiver Programs User Guide The Drafts feature allows access to all drafts saved under the vendor contract number to which the user is linked To access a saved draft 1 Click the Drafts link in the blue navigational bar 2 Click the appropriate vendor number hyperlink under Vendor Numbers A list of drafts saved for the selected vendor contract number will display a Texas MEDICAID amp HEALTHCARE PARTNERSHIP TMHEP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Drafts Long Term Care Contract Numbers Yendor Numbers for Contract Humber for Contract Humber TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home SubmitForm Form Status Inquiry Current Activity Drafts Bie A tc Drafts Date Created Form Type Description Select 10 5 2010 5 29 35 PM Waiver 3 0 oer ero Remove Open 10 5
111. of the All inclusive Care for the Elderly POF Portable Document Format PRN Provenata Latin asneeded RA Route of Administration LOC 2 0 Assessment RN Registered Nurse UR Utlizaion Review Z0500B Date Assessment was Completed on an MN LOC 3 0 Assessment v 2014 1013 LTC Community Services Waiver Programs User Guide Glossary 1915 c Medicaid Waiver The provision of the Social Security Act that authorizes the Secretary of Health and Human Services to grant waivers of certain Medicaid statutory requirements This provision allows a state to furnish home and community based services to Medicaid beneficiaries who need a level of institutional care that is provided in a hospital Nursing Facility or intermediate care facility for persons with mental retardation Appeal The formal process by which an applicant provider individual or the applicant or individual s parent guardian or legally authorized representative requests a review of an adverse action Community Based Alternatives CBA A 1915 c Medicaid waiver program that provides community based services and supports to eligible adults as an alternative to Nursing Facility care Fair Hearing An administrative procedure that affords individuals the statutory right and opportunity to appeal adverse decisions actions regarding program eligibility or termination suspension or reduction of services by the Department of Aging and Disability Services
112. onal information up to 500 characters Form Actions Print Physician s Signature Use as template Add Note Cancel 4 Click the Save button to save your note or the Cancel button to erase your note located under the text box 7 17 2014 9 33 38 AM 7 17 2014 9 33 44 AM TMHP The Form has failed Auto MN Approval 7 23 2014 12 42 52 PM TMHP Form was sent to Denial Inventory after 21 days expired TMHP Form was sent to Denial Inventory after 21 days expired 8 11 2014 11 46 55 AM _ Ltconlineuser Form notes have been updated Form has been re submitted for nurse review J 24 v 2014 1013 LTC Community Services Waiver Programs User Guide Note f unsure why an assessment is set to status Pending Denial need more information call the TMHP Help Desk 1 800 626 4117 Option 2 to speak with a nurse If Add Note is chosen for any assessment set to status Pending Denial need more information the assessment will be reviewed again for MN If the nurse is unable to approve the assessment with the additional information provided the assessment will be sent to the TMHP Medical Director for review and determination of MN Notes added in any status other than Pending Denial need more information ave added to the history of the assessment but are not reviewed by TMHP Note State staff are able to add notes to an MN LOC Assessment to assist a provider in resolving their assessment related issue s for thos
113. ong Ter Cure ay tee Oo eee ee eee Coniuunity Serviess Length Modules vary from 6 to 37 minutes Wallyer Prouriins ee ee Coupas tues Published 12 17 2011 Changes to programs policies and procedures covered in this CBT can be found on the TMHP website in LTC news articles bulletins and DADS Information Letters Click the Details button for a full description of this CBT E Details View now Long Term Care LTC Nursing Facility Hospice This CBT is under construction and is temporarily unavailable pending policy updates Please refer to the Long Term Care Nursing Facilities Hospice Workshop user guide for updated information E Details Medicaid Basics Part 1 MEDICAI Topic Introduction to the programs and services offered by Texas Medicaid and resources available through TMHP BASICS Length Approximately 60 minutes PRESENTED BY THE Published 11 1 2012 Updates to programs policies and procedures discussed in this CBT can be found on the TMHP website in the current published provider manuals web articles and banner messages _ Click the Details button for a full description 7 Registered LMS users can access computer based training past webinars and workshop materials 24 hours a day 7 days a week To supplement your learning additional online training is available 24 7 on the LMS including but not limited to e Medicaid Basics CBT e LTC Online Portal Basics CBT e TexMedConnect for LT
114. ot impact the expiration date of a providers current RUG training comple tion Providers are not required to complete MN LOC 3 0 RUG training to submit MN LOC 3 0 Assessments if the providers 2 0 completion is still valid 68 v 2014 1013 LTC Community Services Waiver Programs User Guide Reminders e LTC Online Portal has 24 7 availability to submit and track assessments e Utilize FSI and Current Activity These features will keep you informed of the status of your assessments e Print and sign the assessment prior to submission e Provide pertinent information in the Comments section e Submit additional information within 21 calendar days on the LTC Online Portal when the assessment is set to status Pending Denial need more information or call TMHP at 1 800 626 4117 Option 2 Please refer to the Add Note section of this User Guide for instructions on how to do this e All RN and MD DO licenses are validated against the appropriate licensing state board Updates are received monthly with MD licenses being updated within the first 10 days of the month and RN licenses being updated in the latter portion of the month generally between the 20th and 25th Be advised that this may result in a delay in form processing e Use the TMHP website at www tmhp com Pages LTC Itc_home aspx for recent updates and new informa tion e This User Guide can be found under the Help link located on the blue navigational bar within the LTC
115. ours 7 24 hour continuous 29 of 32 Individual LTC Medicaid Information S Number of hospitalizations in the last 90 days S6d Number of emergency room visits in the last 90 days S6e Oxygen Therapy 1 Less than once a week 2 1 to 6 times a week 3 Once a day 4 Twice a day 5 3 11 times a day 6 6 23 hours 7 24 hour continuous a S6f Special Ports Central Lines PICC Y N U 6 6 Unknown or unable to assess S6h Enter the number of times this individual has fallen in the last 90 days S6i In how many of the falls listed above was the person physically restrained prior to the fall S6g At what developmental level is the individual functioning 1 lt 1 Infant 2 1 2 Toddler 3 3 5 Pre School 4 6 10 School age 5 11 15 Young Adolescence 6 16 20 Older Adolescence In the falls listed in S6h above how many had the S6j following contributory factors More than one factor may apply to a fall Indicate the number of falls for each contributory factor Environmental debris slick or wet floors lighting etc Medication s Poor Balance Weakness Confusion Disorientation a Assault by Individual or Caregiver MN and LOC 3 0 V 15 3 Major Change in Medical Condition Myocardial Infarction MI Heart Attack Cerebrovascular Accident CVA Stroke Syncope Fainting etc Identifier Date S7 Physician s Evaluation amp Recommendation Did an MD DO certify that this indi
116. ovider eae M here Miatalc in ematic ana ty Glick here for more information and te lick her Click here to access provider P An ae applications and services v 2014 1013 9 LTC Community Services Waiver Programs User Guide 4 The My Account page will appear 3 QIMHP com Welcome to My Account This section allows a user to perform various maintenance activities for their TMHP account Click the appropriate link for access to the maintenance options My Account LTC Online Portal Submit Form Inquire about a form status Manage Provider Accounts Administer a Provider Identifier Become a Provider Administrator for a Provider Identifier authorization required Administer a Provider Enrollment Transaction Open the provider enrollment application Account Settings My Profile Modify your profile information Change Password Change your account password It is recommended that you do this every 30 days Log In to the LTC Online Portal 1 Go to www tmhp com 2 Click providers in the green bar located at the top of the screen TMHP ASTATE MEDICAID CONTRACTOR clients providers Wi TMHP Home Welcome to Texas Medicaid amp Healthcare Partnership What is TMHP TO OO en On eset Click here to find out how you can Thank you for visiting the Texas Medicaid amp Healthcare Privacy HIPAA Partnership s TMHP Internet website for Texas Medicaid and other state health care programs As of Januar
117. r 3 0 0310a 01 Inactivate Form 61 LTC Community Services Waiver Programs User Guide 62 Reject Message Description Message Number GN 9248 System Message Associated Displayed in History with Reason for Assessment GN 9248 This form cannot be processed MN LOC due to one or more invalid Diagnosis Codes Correct the Diagnosis Codes and resubmit Suggested Action The submitted Diagnosis International Classification of Diseases ICD Code is not valid e Correct the Diagnosis Codes on the Long Term Care Medicaid Information LTCMI section or Section as needed using the Correct this form button If the Diagnosis Codes are valid e Contact the DADS regional Claims Management System CMS Coordi nator Select the appropriate region per website link provided to locate the CMS Coordinator contact informa tion PACE Excluded www dads state tx us contact region al_facility index html If PACE Contact DADS per website link provided www dads state tx us provid ers PACE contacts html v 2014 1013 LTC Community Services Waiver Programs User Guide Corrections If incorrect data is submitted on the MN LOC Assessment the provider can submit a correction within 14 calendar days of the original submission by clicking the Correct this form button However not all fields are correctable see list of fields unable to be corrected in the Provider Workflow section Examples of in
118. r and manage System processing errors including rejection messages are found within the History trail of the assessment and the assessment is set to status Provider Action Required Once an assessment is set to status Provider Action Required the assessment will re quire provider action before processing on that particular assessment continues If a system error occurs the error will display in the History trail of the assessment The assessment is set to status Provider Action Required Finding Assessments with Provider Action Required Status To find the items in your provider workflow i e those items with system processing errors to be resolved by the provider 1 Click the Form Status Inquiry link in the blue navigational bar 54 v 2014 1013 LTC Community Services Waiver Programs User Guide 2 Choose Type of Form Waiver 3 0 Medical Necessity and Level of Care Assessment from the drop down box J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRA Home Submit Form I atus Inquil Current Activity My Drafts Printable Forms Help Form Status Inquiry Form Select Type of Form e Waiver 3 0 Medical Necessity and Level of Care Assessment Form Status Inquiry DLN Medicaid Number Last Name First Name SSN H Form Status Li From Date To Date sono 3 Enter the From Date and To Date range in the fields allocated 4 Form Status Choose
119. r finding Wavier 3 0 Medical Necessity and Level of Care Assessments set to status Provider Action Required until there are no results found Provider Workflow Rejection Messages Below are the rejection messages providers will receive as a result of an error occurring during the nightly batch processing The messages are in order of message number The table contains four columns 1 Message Number This is the specific error message that will be displayed in the portal 2 System Message Further clarification of the portal error message including basic example of the situation 3 Associated with Reason for Assessment What type of assessment can result in the error Waiver 3 0 MN LOC Assessment A0310a 01 Initial Assessment A0310a 03 Annual Assessment A0310a 04 Significant change in status assessment SCSA 4 Suggested Action Most likely the Workflow Action Button to be used Reject Message Description Message System Message Associated Suggested Action Number Displayed in History with Reason for Assessment CS 0001 CS 0001 The request cannot be pro The request cannot be processed be cessed because an existing Initial Assess cause an existing Initial Assessment has ment has already been processed Please already been processed Please contact contact the DADS case manager or the DADS case manager or inactivate submit an Annual Assessment or SCSA the Initial Assessment and submit an as appropriate Annual A
120. rail for the specific error message The error message must be resolved before further processing of assessment will occur e SAS Request Pending Assessment has passed all TMHP validations and will be sent from TMHP to DADS for SAS processing Please allow two to four business days for the next status change Submitted to manual workflow Assessment has been submitted to DADS due to the assessment being re jected by SAS Refer to the assessment History trail for additional information DADS will review this assess ment within ten business days While the assessment is being reviewed no action is required on the part of the provider v 2014 1013 53 LTC Community Services Waiver Programs User Guide Provider Workflow Process Provider workflow allows providers to independently manage their assessments when errors in the Medicaid sys tem processing occur The assessments going into the provider workflow are those situations where the provider is required to take action for resolution of the problem The benefit to the provider is shorter time in resolution since providers can resolve their own errors In summary assessments are sent to the provider workflow when the assessment is set to status Provider Action Required Assessments reach this status if e The assessment was not successfully processed e An error occurred during the nightly batch processing The provider workflow is the responsibility of the provider to monito
121. rded It just for you Click here tor more information about the webinar recording Workshop Materials Radio TMHP Provider Lookup Provider Education Home Page This is the home page for all of the provider education opportunities offered by TMHP Using the Looking fora buttons to the left providers can run computer based training modules register for workshops and e Dardin Thai narin l ttnr DLEE Te Ts N a E a 4 Log in to your LMS user account or create a new user account New visitors to the LMS must create a user ac count to access the CBT Welcome to the TMHP LMS Account Login This is the home page for the education opportunities that are offered by TMHP Registered users can User Name e Run computer based training modules O Passwort m Listen to or read transcripts of past webinars m Access written workshop materials If this is your first visit follow the instructions below to create a user account C Remember Login If you are a returning user you can skip the instructions for registering and click on one of the buttons below to view materials you will be required to log in a Forgot Password 7 If you need technical assistance with the TMHP Learning Management System please email TMVIHF Training Support Please note that policy and or terminology questions cannot be answered at this email address First Time Login Instructions person that accesses the LMS must have an LMS account user
122. re Partnership TMHP Contracted by the state as the claims administrator to process claims for providers under traditional Medicaid TMHP processes and approves claims for traditional Long Term Care LTC TMHP does not pay LTC claims this is done by the comptroller Responsibilities also include the following Determination of MN Provider Education Provide timely processing of claims except for services covered by the STAR PLUS premium and repre sents DADS at Fair Hearings Provide yearly program manuals quarterly LTC Provider Bulletins and Remittance and Status R amp S Reports Maintain the TMHP Call Center Help Desk Monday through Friday 7 00 a m 7 00 p m Central Time excluding holidays Conduct training sessions for providers which includes technical assistance on the TexMedConnect online application Texas State Legislature The state legislature allocates budgetary dollars for Texas Medicaid v 2014 1013 LTC Community Services Waiver Programs User Guide National Provider Identifier NPI Atypical Provider Identifier API Requirements The Health Insurance Portability and Accountability Act HIPAA established the National Provider Identifier NPI as the 10 digit standard unique identifier for health care providers and requires covered health care providers clear inghouses and health plans to use this identifier in HIPAA covered transactions NPI is required on all claims sub
123. red absence of useful hearing B0300 Hearing Aid Enter Hearing aid or other hearing appliance used in completing B0200 Hearing P 0 No Code 1 Yes B0600 Speech Clarity Enter Select best description of speech pattern 0 Clear speech distinct intelligible words 1 Unclear speech slurred or mumbled words 2 No speech absence of spoken words Ability to express ideas and wants consider both verbal and non verbal expression Enter Dash if unable to assess 0 Understood 1 Usually understood difficulty communicating some words or finishing thoughts but is able if prompted or given time 2 Sometimes understood ability is limited to making concrete requests 3 Rarely never understood B0799 Modes of Expression Check all used by individual to make needs known Speech Writing messages to express or clarify needs American sign language or Braille Signs Gestures Sounds Communication Board Voice Modulator Other None of the above B0800 Ability To Understand Others Understanding verbal content however able with hearing aid or device if used Enter Dash if unable to assess E 0 Understands clear comprehension Code LL 1 Usually understands misses some part intent of message but comprehends most conversation 2 Sometimes understands responds adequately to simple direct communication only 3 Rarely never understands B10
124. remr O 7 Click the Submit Form button a Ifthe assessment is submitted successfully a DLN will be assigned and the following message will be dis played TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHFP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Your form was submitted successfully You can track this form using the DLN b Ifan assessment is not successfully submitted an error message will appear at the top of the screen The provider must resolve the error s to ensure the assessment will be submitted successfully The error message will prompt the provider as to how to resolve the error or save to draft for research and correction at a later date If the provider is unable to resolve the error they may contact TMHP for assistance The following errors must be fixed before the form will submit Reason for Assessment is a required field First Name is 3 required field ast Name is 3 required field Medicaid Number is 3 required field Gender is a required field Birth Date is 3 required field Does the individual need or want an interpreter is a required field Observation end date is 3 required field 1 1 1 eo 1 e I 1 1 9 pi KA ioe a Ka 1 1 a q v 2014 1013 31 LTC Community Services Waiver Programs User Guide MN LOC 3 0 Assessment Sections Form Actions Print Physician s Signature Section A Section B Sectio
125. rintable Forms Help UnLock Form MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 wW Name pE DLN Gaya RUG CA2 Note Waiver corrections are allowed within 14 days from the original submission Form Actions Print Physician s Signature Use as template Correct this form Add Note Inactivate Form Section A Section B Section C Section D v 2014 1013 65 LTC Community Services Waiver Programs User Guide Inactivations Assessments may need to be inactivated when fields cannot be corrected as needed e g Medicaid Individual Name MN LOC Assessments can be inactivated through the LTC Online Portal by first retrieving the assessment using FSI or Current Activity Once the assessment is inactivated it will be set to status Form Inactivated The as sessment cannot be reactivated however it can still be used as a template When to inactivate There are no time limitations on performing an inactivation Providers may perform an inactivation when an assess ment needs to stop processing in the workflow if an assessment needs to be canceled that has already processed to completion or when fields cannot be corrected as needed e g Medicaid Individual Name Who may inactivate Inactivations may be performed based on the vendor contract who submitted the assessment originally None of the DADS or TMHP teams Community Services CS Workers CS Team Leads and TMHP Operations may submit an inactivation on an MN LOC A
126. rm Status Inquiry DLN Medicaid Number Last Name First Name i SSN H Form Status From Date To Date v 2014 1013 1 LTC Community Services Waiver Programs User Guide LIC Online Portal Basics Blue Navigational Bar Links All portal features based on your security level will be found in the blue navigational bar located at the top of the portal screen Options found in the blue navigational bar may include Home Submit Form Form Status Inquiry Current Activ ity Drafts Printable Forms and Help Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Home When the blue navigational bar above is displayed the Home feature at the far left will take you to My Account From the My Account page providers can perform various maintenance activities for an account such as setting up user accounts changing passwords and other administrative tasks Providers may click the TMHP com link located on the far left side of the My Account page to go back to the www tmhp com home page gt a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP A STATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Using the TMHP home page providers may e Access the LTC Online Portal e Access TexMedConnect e Submit a prior authorization e Access provider manuals and guides e Access bulletins and ba
127. rtal The Long Term Care LTC Nursing Facility Hospice Workshop User Guide provides step by step instructions for how to use the various features of the portal each form type when to submit the various forms and assessments and managing forms and assessments set to status Provider Action Required LTCMI Nursing Facility 2 0 Instructions The entry of 2 0 LTCMI Long Term Care Medicaid Information can ONLY occur after the submission of the Federal MDS 2 0 Assessments and retrieval on TMHP s LTC Online Portal This document covers only the LTCMI portion of the MDS 2 0 Assessments All other 2 0 Assessment field information can be found on the Federal CMS website http www cms hhs gov LTCMI Nursing Facility 3 0 Instructions The entry of 3 0 LTCMI Long Term Care Medicaid Information can ONLY occur after the submission of the Federal MDS 3 0 Assessments and retrieval on TMHP s LTC Online Portal This document covers only the LTCMI portion of the MDS 3 0 Assessments All other 3 0 Assessment field information can be found on the Federal CMS website http www cms hhs gov PASARR Screening Instructions The PASARR level 1 screening is designed to identify persons who may have indicators of mental illness mental retardation or a related condition to determine if a more in depth evaluation is required The PASARR Screening must be completed and submitted via the TMHP Long Term Care Portal prior to a NF admission Long Term Care
128. s Below are links to the current news for Texas Medicaid providers Click here to view past news articles Information of interest to 4 Click the Log In to LIC Online Portal button All Sites A Advanced Search ea TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Log In to LTC Online Portal Click here to access provider Log In to TexMedConnect applications and services Long Term Care Home TexMedConnect oe Long Term Care Homepage Sana Program Information The Texas Department of Aging and Disability Services DADS administers programs providing LTC elie Galina m Services and Institutional Care to eligible clients The Texas Medicaid amp Healthcare Partnership DADS Information Letters TMHP LTC team supports the LTC provider community in submitting claims through the Claims Bic Management System CMS TMHP also supports providers as they submit forms via the LTC Online a d s Reference Material Portal Forms Below are links to the current news for Long Term Care providers Click here to view past news articles 5 Enter your User name and Password 6 Click the OK button After log in Form Status Inquiry FSI will display by default TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Form Status Inquiry Form Select Type of Form Fo
129. savesssardecesaee 5 DO IES MIO a as E eee usec ease E E E E E E ceeeanseeeeeaea eae 9 Loc Cig con avd Ok Oe Online Portilor cence ree ene mer rn er eee er Cre ee ee eee ere 10 MC Onlie Pori 0 cy e lt gee ne eee ee eee eee 12 Diae Novi raniona Da EIO eae E E E E E E E E E N 12 FO e E A EE E A EE A E E E E ates 12 SU OLE Ot ca dered ab eather E E E NENS 13 Po a a e e E E EE A E E 15 TING PACU e a E nade san E E E E E T alivoxe duateaseameats 16 D e E E E E E EEE A E E E E 17 Pone bie T e E E R N 19 i o EE EEA E E T AE SANE O E ANEA A eee E AAE 21 De UE Ct OIS TANG cata sey deta sessacssacuonsevanctcecaracuinccsneae ectors on cteuncok seve E 2 DP gest fe sce decent psc terest E Pans ate oe eae ged oeeadanen A tere saisiadids ames eau eeete acess 2l Pont Physicians Sie 0 tiie oi Ces Cal 5 eee seier ean ranh Ee EA E 22 USS E E T EE O E E T OE E epee eee 22 Co E E E E E 24 Add PE E E E A E E E ceeiaaaesasecdashenens 24 PAC CIV AGS TO e E E E E 23 ea D E E E E E E E A EEE 25 v 2014 1013 i LTC Community Services Waiver Programs User Guide Other Basic Tir AE Go 55cscassccaivacacaeduzecoctavoscinsnaasenadlaaudeanealeoiacowivwhescuaremosexawaaisedaatesisadautn odiedealonelseikaloawasuatiedasiedetaaiinubaneene 26 PRG CG TN eas eee a cn cpa seen a aes ea E E nsec RSE pate nap E E E E E ER 26 FNS i acters E E cents sees Pe E ese ee eerste carpe pager eee eee 26 MRO Cie PO ii tgeacg ssa sasesancasacsacaaasesecensaeseconesacaaaesawadacsananaasaa
130. ses oral lesions including under denture or partial if one is worn F Mouth or facial pain discomfort or difficulty with chewing MN and LOC 3 0 V 15 19 of 32 Individual Section M Identifier Date Skin Conditions Report based on highest stage of existing ulcer s at its worst do not reverse stage M0100 Determination of Pressure Ulcer Risk Check all that apply L O O L A Individual has a stage 1 or greater a scar over bony prominence or a non removable dressing device B Formal assessment instrument tool e g Braden Norton or other C Clinical assessment Z None of the above M0150 Risk of Pressure Ulcers Enter Code Is this individual at risk of developing pressure ulcers 0 1 No Yes M0210 Unhealed Pressure Ulcer s Does this individual have one or more unhealed pressure ulcer s at Stage 1 or higher No gt skip to M1030 Number of Venous and Arterial Ulcers Yes Continue to M0300 Current Number of Unhealed Pressure Ulcers at Each Stage Enter Code 1 M0300 Current Number of Unhealed Pressure Ulcers at Each Stage A Number of Stage 1 pressure ulcers Stage 1 Intact skin with non blanchable redness of a localized area usually over a bony prominence Darkly pigmented skin may not have a visible blanching in dark skin tones only it may appear with persistent blue or purple hues Stage 2 Partial thickness loss of dermis pr
131. sessment will set to status Form Inactivated or b Click the Cancel button to cancel the Inactivation request keeping the assessment set to status Pro vider Action Required J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help UnLock Form MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Provider Action Required Name eS DLN 3 RUG PC2 Form Actions Print Physician s Signature Use as template Add Note Inactivate Form a Resubmit Form e Section B Section C Section D Section E Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI Resubmit Form Resubmit Form will set assessment to status SAS Request Pending Ihe assessment will process during the nightly system processing Check the status of the assessment the next day to determine if the assessment processed successfully The assessment will be set to status Processed Complete if success fully processed The Resubmit Form button will only be used after a provider has been instructed to do so by DADS If the provider clicks the Resubmit Form button the following screen will appear allowing the provider to add any comments J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form S
132. sment that is being corrected and will be set to status Corrected The child assessment is the new assessment that will be processed through the LTC Online Portal UnLock Form MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Medicaid ID Pending Name DLN n RUG PC2 Parent DLN sisi Note Waiver corrections are allowed within 14 days from the original submission Form Actions a Print Physician s Signature Use as template Correct this form ami Add Note Inactivate Form Note The steps to correct an assessment are covered in the Corrections section Add Note The Add Note feature located in the yellow Form Actions bar is always available unless the assessment is locked by another user It may be used to add additional MN information that was not captured upon original submission Information is added to the History trail of the assessment not to the assessment itself i e not added to Comments in the LTCMI section of the assessment If the status is set to Pending Denial need more information and a note is added the assessment will be set to status Pending Review the additional information entered will then be reviewed by a TMHP nurse To add a note to a submitted assessment 1 Locate the assessment using FSI or Current Activity 2 Click the Add Note button a text box will open Form Actions Print Physician s Signature Use as template Add Note J 3 Enter additi
133. ssessment TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help i MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Processed Complete Name 8 DLN RUG PC2 Form Actions Print Physician s Signature __Use astemplate_ Add Note KI inactivate Form Section B Section C Section D Section E Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI Section A Identification Information A0310 Type of A Reason for Assessment Assessment E aaa Microsoft Internet Explorer Are you sure you want to Inactivate this Form A0500 Legal Name of e A First name B Middle initial Individual lon C Last name D Suffix L l L A0600 Social Security A Social Security Number and Medicare Numbers B Medicare Number or comparable railroad insurance number Note When inactivating MN LOC 3 0 Assessments a note must be entered identifying why the form or screening was inactivated This note will be added to the History trail 66 v 2014 1013 LTC Community Services Waiver Programs User Guide How to Inactivate an Assessment 1 Log in to the LTC Online Portal 2 Click the Form Status Inquiry or Current Activity link in the
134. ssessment SCSA as appropri ate CS 0003 CS 0003 The request cannot be pro Inactivate Form and submit Annual As cessed because the Annual Assessment sessment when within the 90 days is being submitted more than 90 days prior to the Service Plan end date Please resubmit the assessment at the appro priate time 60 v 2014 1013 LTC Community Services Waiver Programs User Guide Reject Message Description Message Number CS 0004 CS 0005 CS 0006 CS 0011 CS 0012 CS 0020 CS 0021 CS 0023 v 2014 1013 System Message Associated Displayed in History Assessment CS 0004 The request cannot be pro cessed because the Annual Assessment has been submitted more than 132 days after the end of the last Service Plan Please submit an Initial Assessment CS 0005 The request cannot be pro cessed because a previous Service Plan cannot be found Please submit an Initial Assessment CS 0006 The request cannot be pro cessed because an Initial Assessment for the individual cannot be found Please verify data entry or contact the DAD case manager Significant Change in Sta tus Assessment CS 0011 The request cannot be pro cessed because there is not an open Service Plan for the individual Please verify data entry or contact the DADS case manager CS 0012 The request cannot be processed because the SCSA assessment is being submitted more than 30 days after the Service Plan end date
135. ssment This field is optional for Annual and SCSA Assess ments Choose from the drop down box 1 No 2 Yes S7b Did a military physician providing health care according to requirements stipulated in 10 US Code 1094 provide the evaluation and recommendation for this individual Required If the licensed physician providing health care to this individual is practicing in a health care facility of the Department of Defense DOD a civilian facility affiliated with the DOD or any other location authorized by the Secretary of Defense and is not licensed by the State of Texas answer Yes to this item Choose from the drop down box 1 No 2 Yes S7c MD DO Last Name Required Enter the last name of the MD DO Note The physician listed in sections S7c S7d and S7e is the physician on record that receives the MN determi nation letter S7d MD DO License Required Enter the license number of the MD DO This number is validated against the appropriate State Medical Board file Physicians are not required to complete the RUG training Note The physicians licensing information is a vital piece of information Therefore the physicians license num ber is required on all MN LOC submissions regardless of the Reason for Assessment A0310A S7e MD DO License State Required Choose the state in which the MD DO is licensed from the drop down box Indicate Physician Signature on file by checking bo
136. ssment click the UnLock Form button located at the top right corner of the screen UnLock Form MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Processed Complete Name 9 e DLNA E RUG PC2 Form Actions Print Physician s Signature Use as template Add Note Inactivate Form Section B Section C Section D Section E Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI Error Messages If required information is missing or information is invalid an error message s will display and you will not be able to continue to the next step until the error is resolved You may need to scroll to the top of the screen to find the error message s since the error message s will be displayed at the top If you click an error message hyperlink you will automatically go to the field containing the error J a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help The following errors must be fixed before the form will submit Reason for Assessment is a required field First Name is a required field i Last Name is a required field Medicaid Number is a required field Gender is a required field i Birth Date is a required field Does the individual need or want an interpreter is a required field
137. ste cores Giloateiv aio eins eecerdd pected eased Scat dat poet abled Shen ka nctaddwaieecee 52 Provider Workflow Process 0 cccccscccssccscccccccsccoscccscccnccccccascccsccessccscecasecasscassecaccsascsascccscceaccesccesccasscansceass 54 Finding Assessments with Provider Action Required Stats i acceszepxscntcasiccese te naianei ann Eaa aa EAN RESE aat 54 Provider Workhow Rejection MESsanes cass cca ote sansa ceca tanedec caseeeeu teetecanestaceaascasa ini ne o iapa piniis 60 Corrections csssssisisisusrisisrsbstd indicts tuod vi iross rar PSUS NENN SGSNISESE NES OSENE NEES N S NASENEA SISENE EIENEN E ENSEN EO NAS NOSUN O ENISI E TENANE SESE SETER 63 FowtoSabmitrai Con 6 ee EEN N 64 Inactivations oe ccc ons donate eects edi tress case cscio bs acs bes wee rn treneren evere bsp es tag DESE nntaemnadivseihcesnahputhee nsaciscts na aeunenciaddosecaiiouees 66 How to Inactivate an PASS OSS CEN Eocene se scvicccs bese an dctsnaccat ce saiiecade cand davencieiyeedaaaoseeaneicweuscacaotesehocaycblansesieuceseuctedeuasaes 67 RUG Training Reqairements sige cinerea ranse rete ao ees eeoen 68 LE A t EAA E carn ET rrsteng ie E A E baleen chanacateaiaa cattnian AE 69 Reporting Medicaid Waste Abuse and Fraud oneeeeeeeeeeeeeesererersressrsssressresstssressressressressressresressressreesressres 70 FAOW TO Repot N eA ua AU eaaa e E SE TEES E 70 HIPAA Guidelines and Provider Responsibilities 20 00 0000 cece ceecceseeesseeeeeeeeeseeeeaeeceanecea
138. sychomotor retardation Did the individual have an unusually decreased level of activity such as sluggishness staring into space staying in one position moving very slowly C1600 Acute Onset Mental Status Change Enter Is there evidence of an acute change in mental status from the individual s baseline 0 No Code 1 Yes No information not assessed Copyright 1990 Annals of Internal Medicine All rights reserved Adapted with permission MN and LOC 3 0 V 15 5 of 32 Individual Identifier Date SE Mood D0100 Should Individual Mood Interview be Conducted Attempt to conduct interview with the individual 0 No Individual is rarely never understood OR individual is less than 7 years of age gt Skip to and complete D0500 D0600 Caregiver Assessment of Individual Mood PHQ 9 OV 1 Yes Continue to D0200 Individual Mood Interview PHQ 9 D0200 Individual Mood Interview PHQ 9 Say to individual Over the last 2 weeks have you been bothered by any of the following problems If symptom is present enter 1 yes in column 1 Symptom Presence If yes in column 1 then ask the individual About how often have you been bothered by this Read and show the individual a card with the symptom frequency choices Indicate response in column 2 Symptom Frequency 1 Symptom Presence 2 Symptom Frequency 1 2 0 No enter 0 in column 2 0 Never or 1 day Symptom Symptom 1 Yes enter 0 3 in col
139. t The new assessment replaces the original assessment a TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help amp MEDICAL NECESSITY AND LEVEL OF CARE ASSESSMENT 3 0 Current Status Provider Action Required Name eee DLN Sree RUG PC2 Note Waiver corrections are allowed within 14 days from the original submission Form Actions Workflow Actions se as template ff correct this form TA Section A Section B Section C Section D Section E Section G Section H Section I Section J Section K Section L Section M Section N Section O Section P Section Q Section Z Section LTCMI Section Identification Information A0310 Type of A Reason for Assessment Assessment z a A0500 Legal Name of e A First name B Middle initial Individual v 2014 1013 3 LTC Community Services Waiver Programs User Guide All fields are correctable except for the following Waiver 3 0 MN LOC Assessment A0500c A0600a A0600b A0700 A0310a Z0500b S5a S5m Licenses section 2a DADS Vendor Site ID S2b Contract Provider Number S2c Service Group S2d Individual Name does not allow changes to last name Social Security Number Medicare or comparable railroad insurance number Medicaid Number Type of Assessment Tracking Date Assessment Completed Inactivate Form Inactivate Form w
140. t 90 days Required Record number of times the individual has fallen in the last 90 days Enter 0 zero if no falls Each fall should be counted separately So if the individual has fallen multiple times in one day count each fall individually Valid range includes 0 999 v 2014 1013 LTC Community Services Waiver Programs User Guide S6i In how many of the falls listed in S6h above was the individual physically restrained prior to the fall Conditional This is a required field only if S6h indicates the individual has fallen Valid range includes 0 with a maximum being the number entered in Soh Enter 0 if no falls when the individual was physically restrained prior to the fall S6j In the falls listed in S6h above how many had the following contributory factors Required gt More than one factor may apply to a fall Indicate the number of falls for each contributory factor v 2014 1013 S6j1 Environmental debris slick or wet floors lighting etc Conditional This field is required only if S6h indicates the individual has fallen Valid range includes 0 with a maximum being the number entered in Soh S6j2 Medication s Conditional This field is required only if S6h indicates the individual has fallen Valid range includes 0 with a maximum being the number entered in Soh S6j3 Major Change in Medical Condition Myocardial Infarction MI Heart Attack
141. t Provider Number Auto Populated This field will be auto populated S2c Service Group Required Choose from the drop down box 3 CBA 11 PACE 18 MDCP 19 STAR PLUS 23 CFC 2d NPI Number Required This field will be auto populated This is where API would be entered if using an API number API is D two zeros then contract number MDCP nurses use an API 2 v 2015 0528
142. t are used regularly but less than weekly V Medication Certification I certify this individual is taking no medications OR the medications listed below are correct Medication Name and Dose Ordered Route of Administration Frequency PRN n of doses 1 by mouth PO w 3D TID three times daily Delete 1 by mouth PO w 3D TID three times daily Delete 1 by mouth PO w 1D QD or HS once daily Delete 1 by mouth PO w 1D QD or HS once daily Delete amp inhalation w 1D QD or HS once daily Delete Add Meds e S10 Comments Optional The comments field allows up to 500 characters to be entered It is essential to include signs and symptoms that present an accurate picture of the individual s condition The Comments section can be used for additional qualifying data that indicates the need for skilled nursing care such as Pertinent medical history Ability to understand medications Ability to understand changes in condition Abnormal vital signs Previous attempts at outpatient management of medical condition Results of abnormal lab work 44 v 2014 1013 LTC Community Services Waiver Programs User Guide e 11 Advanced Care Planning What is Advance Care Planning Advance care planning means planning ahead for how the individual wants to be treated if ill or near death Sometimes when people are in an accident or have an illness that will cause them to die they are not able
143. tatus Inquiry Current Activity Drafts Printable Forms Help Change Status for form HER ms to Submit to SAS Enter the notes below If you would like the provider to see the note please select the provider facing option from the list below 1 ProviderFacing v 2 System 1 ProviderFacing There is an option to select 2 System or 1 ProviderFacing e 2 System will allow comments entered by the provider to be seen only by internal state staff The com ments will not be seen by the provider e 1 ProviderFacing will allow comments entered to be seen by both state staff and the provider In either case the comments will be seen in the History trail of the assessment and are for informational pur poses only These comments will not be used in the system processing of the assessments v 2014 1013 59 LTC Community Services Waiver Programs User Guide The provider may choose to enter comments Entering comments is optional a Click the Cancel button to cancel the request keeping the assessment set to status Provider Action Re quired or b Click the Change Status button to move the assessment out of the Provider Action Required 13 Once one of the actions have been completed Correct this form Inactivate form or Resubmit Form the sta tus of the form or assessment will no longer be set to status Provider Action Required Processing will continue based upon action chosen 14 Repeat all of the steps fo
144. th care provider near you T 2 Click Provider Education in the left side menu on any provider web page on this website The Provider Educa tion homepage displays TMHP ASTATE MEDICAID CONTRACTOR Ee F 1 Fa a a o s Want to enroll as a Medicaid provider Tr A Oh N tag 72 SS Click here for more information and to i Aa enroll today a u S L Lan e a a La 7 Medicaid Home Texas Medicaid Provider Home Page Program Information This is the provider home page for Texas Medicaid The information on these pages help Medicaid providers succeed with their Medicaid practice For information specific to a related program click on Reference Material the program s button above Provider Education Below are links to the current news for Texas Medicaid providers Click here to view past r articles News for Medicaid Providers Claims Reprocessing Reimbursement Rates Reminder 2013 HCPCS Dental Fluoride Procedure Code 01208 Claims ta Be g Reprocessed 6 18 7013 NEW 2013 ty Ads Pa Code Updates Reimbursement Rate Change v 2014 1013 73 LTC Community Services Waiver Programs User Guide 3 Click Computer Based Training in the left side menu The LMS displays in a new window B Texas MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Provider Education Home _ Computer Based Training A 3 Mn Missed the ACA webinar on March 20 Workshop Registration No worrles Maw a We reco
145. th individual values preferences or goals Enter Code 0 Behavior not exhibited i 1 Behavior of this type occurred 1 to 3 days 2 3 Behavior of this type occurred 4 to 6 days but less than daily Behavior of this type occurred daily MN and LOC 3 0 V 15 8 of 32 Individual Identifier Date Section E E0900 Wandering Presence amp Frequency Has the individual wandered 0 Behavior not exhibited Skip to E1100 Change in Behavioral or Other Symptoms 1 Behavior of this type occurred 1 to 3 days 2 Behavior of this type occurred 4 to 6 days but less than daily 3 Behavior of this type occurred daily E1000 Wandering Impact Does the wandering place the individual at significant risk of getting to a potentially dangerous place e g stairs outside of the residence facility 0 No 1 Yes Does the wandering significantly intrude on the privacy or activities of others 0 No 1 Yes E1100 Change in Behavior or Other Symptoms Consider all of the symptoms assessed in items E0100 through E1000 How does individual s current behavior status care rejection or wandering compare to prior assessment 0 Same 1 Improved 2 Worse 3 N A because no prior assessment MN and LOC 3 0 V 15 9 of 32 Individual Identifier Date Section G Functional Status G0110 Activities of Daily Living ADL Assistance Instructions for Rule of 3 E When an activity occurs three times at any one given le
146. the assessment was completed as identified in field R2b for 2 0 Assessments and field Z 0500B for 3 0 Assessments e Purpose Code Utilization Review Assessment submitted by DADS e Contract Number The nine digit provider number e Vendor Number The four digit site identification number e Reason for Assessment 2 0 AA8a 3 0 A0310A Waiver 2 0 MN LOC Assessment Waiver 3 0 MN LOC Assessment AA8a 01 Initial Assessment A0310A 01 Initial Assessment AA8a 02 Annual Assessment A0310A 03 Annual Assessment AA8a 03 Significant change in status assess A0310A 04 Significant change in status as ment SCSA sessment SCSA Current Activity The Current Activity feature allows providers to view assessment submissions or status changes that have occurred within the last 14 calendar days After 14 days providers must utilize the FSI query tool to locate an assessment 1 Click the Current Activity link in the blue navigational bar 16 v 2014 1013 LTC Community Services Waiver Programs User Guide 2 Click the appropriate vendor number if applicable TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Current Activity The user name is associated with the following Vendor Contract numbers Select the YVendor Contract number to configure a administrator account Yendor Numbers for Contract
147. to talk or to let others know how they feel Advance care planning is a five step process that should be discussed with the individual 1 Thinking about what you would want to happen if you could not talk or communicate with anyone 2 Finding out about what kind of choices you will need to make if you become very ill at home in a nursing home or in a hospital Talking with your family and doctor about how you want to be treated Filling out papers that spell out what you want if you are in an accident or become sick Telling people what you have decided Slla Does the individual caregiver report having a legally authorized representative Required Legally Authorized Representative is a person authorized by law to act on behalf of a person and may include a parent guardian or managing conservator of a minor or the guardian of an adult Choose from the drop down box 0 No 1 Yes Sl11b Does the individual caregiver report having a Directive to Physicians and Family or Surrogates Required Directive to Physician is a document that communicates an individual s wishes about medical treatment at some time in the future when he or she is unable to make their wishes known because of illness or injury Choose from the drop down box 0 No 1 Yes Sllc Does the individual caregiver report having a Medical Power of Attorney Required Choose from the drop down box 0 No 1 Yes v 2014 1013 45 LTC Commun
148. to use the MN LOC to determine medical necessity for Social Security Income SSI children The MN LOC Assessment will be completed on the LTC Online Portal in the exact same manner as it is completed today for the other program providers however the MN LOC Assessment informa tion will not be transmitted to the Department of Aging and Disability Services DADS The Portable Document Format PDF of the MN LOC Assessment 3 0 has also been updated to reflect the addition of 23 CFC For more information contact the LTC Help Desk at 1 800 626 4117 Option 1 Sid State Sle ZIP Code Sif Phone 2 Claims Processing Information S 2a DADS Vendor Site ID Number S2b Contract Provider Number 2c Service Group S2d NPI Number S2e Region S2f Purpose Code 2g HHA License S2h HHA License Expiration Date M S3 Primary Diagnosis Primary Diagnosis ICD Code Primary Diagnosis ICD Description S3a S3b v 2015 0528 l LTC Community Services Waiver Programs User Guide Addendum The following instructions on page 35 of the LTC Community Services Waiver Programs User Guide which also apply to non waiver CFC providers have been updated e 2 Claims Processing Information 2a DADS Vendor Site ID Number Auto Populated This field will be auto populated based on the user s logon security credentials 2b Contrac
149. u can imagine Show individual 00 10 pain scale Enter two digit response Enter 99 if unable to answer Verbal Descriptor Scale Code Code Ask individual Please rate the intensity of your worst pain over the last 5 days Show individual verbal scale 1 Mild 2 Moderate 3 Severe 4 Very severe horrible 9 Unable to answer MN and LOC 3 0 V 15 16 of 32 Individual Identifier Date Section J Health Conditions J0700 Should the Caregiver Assessment for Pain be Conducted Enter Cod SUSSAL EXTEN No J0400 1 thru 4 gt Skip to J1100 Shortness of Breath dyspnea Yes J0400 9 Continue to JO800 Indicators of Pain or Possible Pain Caregiver Assessment for Pain J0800 Indicators of Pain or Possible Pain in the last 5 days Check all that apply Lh A Non verbal sounds e g crying whining gasping moaning or groaning L B Vocal complaints of pain e g that hurts ouch stop C C Facial expressions e g grimaces winces wrinkled forehead furrowed brow clenched teeth or jaw gO D Protective body movements or postures e g bracing guarding rubbing or massaging a body part area clutching or LI holding a body part during movement Z None of these signs observed or documented If checked skip to J1100 Shortness of Breath dyspnea J0850 Frequency of Indicator of Pain or Possible Pain in the last 5 days Enter Code Frequency with which indi
150. umn 2 1 2 6 days several days Presence Frequency 9 No response leave column 2 blank 2 7 11 days half or more of the days 3 12 14 days nearly every day Enter Scores in Boxes A Little interest or pleasure in doing things B Feeling down depressed or hopeless C Trouble falling or staying asleep or sleeping too much D Feeling tired or having little energy E Poor appetite or overeating F Feeling bad about yourself or that you are a failure or have let yourself or your family down G A Trouble concentrating on things such as reading the newspaper or watching television H Moving or speaking so slowly that other people could have noticed Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way WWIII WILLIE D0300 Total Severity Score P The sum of the scores for all frequency responses in Column 2 Symptom Frequency The sum should be a number 00 27 A score of 99 indicates that the individual was unable to complete interview i e Symptom Frequency is blank for 3 or more HARCA items D0350 Safety Notification Complete only if D020011 1 indicating possibility of individual self harm Enter Was responsible caregiver provider or appropriate entity informed that there is a potential for individual self harm Pp No Copyright Pfizer Inc All rights reserved
151. urce Information TMHP Call Center Help Desk WNC HOTA eme e E AEE E E E E E E 1 800 727 5436 1 800 626 4117 General Inquiries Press 1 Medical Necessity Press 2 Technical Support Press 3 1E se E EE es as A E ERA N AEI AE AEEA N A 512 514 4223 Neea FON rE E EA 1 800 252 8263 PUG Tia n a a O e a aai RO A E E EE E E E R 512 245 7118 EDLA Deske A E E E E E E EE E E A 1 888 863 3638 ALO AD E E A A A E A IE NE E E A esas 1 800 626 4117 TMHP General iS CO SS eo aah ess ccctcm rca ceenceenosacs eulecevteasdearecedcenteudscaubnsevacteuscussausceastas 1 800 925 9126 Mend tA a S E A O sacmessectwevseceerosaevcean 1 800 436 6184 Community Based Alternatives MN LOC Assessment Contacts Completing the MN LOC Assessment Contact your DADS Regional Nurse www dads state tx us providers CBA contacts html Community Services Regional Contacts www dads state tx us contact regional facility index html Medically Dependent Children Program Contacts Completing the MN LOC Assessment Contact the Access and Intake Stare Office Nurse sescosiussisadiccdicondoninwcudorasnskonnasiubesicbudebiaiecd neies 512 438 5837 EC TPG IT ON Se etched eine E E E ce area et erase A E E 512 438 2013 STAR PLUS Contacts Dasncss Rule Ours tions serrr srira an een anne ae an ne nC aera Contact allison moss hhsc state tx us Questions regarding MN Determinations Conr ENUT ioe rence saat E E da crase oe ctase sansa eesgnbaseeacenseec onases aise seaeseun ses soseesuance
152. vel code that level E When an activity occurs three times at multiple levels code the most dependent exceptions are total dependence 4 activity must require full assist every time and activity did not occur 8 activity must not have occurred at all Example three times extensive assistance 3 and three times limited assistance 2 code extensive assistance 3 m When an activity occurs at various levels but not three times at any given level apply the following O When there is a combination of full caregiver performance and extensive assistance code extensive assistance O When there is a combination of full caregiver performance weight bearing assistance and or non weight bearing assistance code limited assistance 2 If none of the above are met code supervision 2 ADL Support Provided 1 ADL Self Performance Code for individual s performance not including setup If the ADL activity Code for most support provided occurred 3 or more times at various levels of assistance code the most dependent except for code regardless of individual s self total dependence which requires full caregiver performance every time performance classification Coding Coding Activity Occurred 3 or More Times 0 No setup or physical help from caregiver 0 Independent no help or caregiver oversight at any time 1 Setup help only 1 Supervision oversight encouragement or cueing 2 One person physical assist 2
153. verity Score Enter Score D0650 Safety Notification Complete only if D050011 1 indicating possibility of individual self harm WWIII MILLI The sum of the scores for all frequency responses in Column 2 Symptom Frequency The sum should be a number 00 30 Was responsible caregiver provider or appropriate entity informed that there is a potential for individual self harm 0 No 1 Yes Copyright Pfizer Inc All rights reserved MN and LOC 3 0 V 15 7 of 32 Individual Identifier Date SOG Ecravior SS E0100 Potential Indicators of Psychosis Check all that apply A Hallucinations perceptual experiences in the absence of real external sensory stimuli B Delusions misconceptions or beliefs that are firmly held contrary to reality E Z None of the above Behavioral Symptoms E0200 Behavioral Symptom Presence amp Frequency Note presence of symptoms and their frequency Enter Codes in Boxes Physical behavioral symptoms directed toward others e g hitting kicking pushing scratching grabbing abusing others sexually Coding Behavior not exhibited Verbal behavioral symptoms directed toward others e g threatening Behavi f this t d 1to3 CNAVION Or UNS YPE OCCUITE i others screaming at others cursing at others days Other behavioral symptoms not directed toward others e g physical symptoms such as hitting or scratching self pacing rummaging publ
154. vices Waiver Programs User Guide 8 Scroll to the bottom of the page to view the History trail 42300 Assessment Date Observation end date History 5 10 2010 2 11 32 PM 5 12 2010 4 54 43 PM 5 12 2010 5 18 10 PM ID Confirmed 5 17 2010 11 00 43 AM History Form Submitted Approved 5 10 2010 2 11 31 PM Medicaid ID Pending 5 10 2010 2 11 32 PM 5 12 2010 4 54 43 PM 5 12 2010 5 18 10 PM bree Bee ID Confirmed E ETE ath me gem 5 17 2010 11 00 43 AM ee d ki SAS Request th E a E gee 5 17 2010 11 14 55 AM 17 2010 11 14 55 AM TMHP CS 0005 The request cannot be processed because a previous Service Plan cannot be found Please submit an Initial assessment 01 10 Find the rejection message in the white line just below Provider Action Required 11 Perform the necessary research to resolve the error For more information on the error messages see the Pro vider Workflow Rejection Messages section of this User Guide 12 Depending on the provider research a provider has one of three options to move the assessment out of the pro vider worksflow These are Correct this form Inactivate form or Resubmit form Correct this form Correct this form allows provider to submit a correction within 14 calendar days of the original submission date The original assessment with a status of Provider Action Required will be set to status Corrected and will have a parent relationship DLN to the new child assessmen
155. vidual complains or shows evidence of pain or possible pain 1 Indicators of pain or possible pain observed 1 to 2 days 2 Indicators of pain or possible pain observed 3 to 4 days 3 Indicators of pain or possible pain observed daily Other Health Conditions J1100 Shortness of Breath dyspnea Check all that apply L A Shortness of breath or trouble breathing with exertion e g walking bathing transferring B Shortness of breath or trouble breathing when sitting at rest C Shortness of breath or trouble breathing when lying flat Z None of the above J1400 Prognosis Does the individual have a condition or chronic disease that may result in a life expectancy of less than 6 months J1550 Problem Conditions Check all that apply A Fever B Vomiting C Dehydrated D Internal bleeding E99 Syncope Z None of the above 17 of 32 MN and LOC 3 0 V 15 Individual Identifier Date Section J Health Conditions Did the individual have a fall any time in the last month 0 No 1 Yes 9 Unable to determine Did the individual have a fall any time in the last 2 6 months 0 No 1 Yes 9 Unable to determine Did the individual have any fracture related to a fall in the last 6 months 0 No 1 Yes 9 Unable to determine J1900 Number of Falls in the last 6 months with or without injury Complete only if J1700A or J1700B 1 Enter Codes in Boxes A No injury no evidence of any pain injury or change i
156. vidual requires nursing facility services or alternative community based services under the supervision of an MD DO Y N Did a military physician providing healthcare according to requirements stipulated in 10 US Code 1094 provide the evaluation and recommendation for this individual Y N Indicate Physician Signature on file by checking box Required for Initial Assessments L The following MD DO information is required if MD DO is not licensed in Texas S7f MD DO First Name S7g MD DO Address 30 of 32 Individual Identifier Date LTC Medicaid Information S9 Medications List all medications that the individual received during the last 30 days Include scheduled medications that are used regularly but less than weekly L Medication Certification certify this individual is taking no medications OR the medications listed below are correct 1 Medication Name and Dose Ordered MN and LOC 3 0 V 15 31 of 32 Individual Identifier Date LTC Medicaid Information S10 Comments S11 Advance Care Planning S11a Does the individual caregiver report having a legally authorized representative Does the individual caregiver report having a Directive to Physicians and Family or Surrogates Y N S11c Does the individual caregiver report having a Medical Power of Attorney Y N S11d Does the individual caregiver report having an Out of Hospital Do Not Resuscitate Order Y N S12 LAR Address
157. vious page click here Return to TMHP com If you have difficulty with the account activation process contact the TMHP EDI Helpdesk at 1 888 863 3638 between the business hours of 7 00 am to 7 00 pm CST 7 The following page will appear Follow the instructions listed at the top of the page and click the Create a Provider Vendor Administrator Account link at the bottom of the page S 2 TMHP com s Account Activation v 2014 1013 Home TMHP com My Account Log In A What happens when I activate a Provider Yendor Account 1 A TMHP User Account is created 2 Texas Medicaid or CSHCN Services Program Provider Vendor Account is activated for online use 3 The TMHP User Account is given administrative rights to the Provider YVendor Account What is a TMHP User Account TMHP User Account includes a username and password which are required to log into TMHP Applications 4 User Account can be linked to one or more Provider Yendor Accounts What do administrative rights allow a User to do When a TMHP User Account is given administrative rights to a Texas Medicaid or CSHCN Services Program Provider Yendor Account the User is allowed to control account activity and access protected data pertaining to a particular Provider Facility or Vendor Within the secure portion of TMHP com Provider Yendor administrators have the ability to Submit Claims Appeal Claims Inquire about claim status Verify client eligibility
158. w M Current page A e Soston a ise niticstion wtormatics dd Subset ll pages in range v C Reverse pages Page Handling age Page Scaling Shrink to Printable Area oo00 Auto Rotate and Center C Choose Paper Source by PDF page size C Print to file C Print color as black Units Inches 1 5 1 Q ox D canca Rit a ell v 2014 1013 LTC Community Services Waiver Programs User Guide Help The Help feature at the far right in the blue navigational bar will display a Help page consisting of links to online guides that will assist with questions you may have about the LIC Online Portal The Medical Necessity and Level of Care Assessment 3 0 Instructions link provides section by section instructions to guide the registered nurses RNs in completing the MN LOC Assessment Note Providers may access an electronic version of the LTC User Guide by clicking the Long Term Care Community Services Waiver Programs Workshop User Guide link within the Help page TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Home Submit Form Form Status Inquiry Current Activity Drafts Printable Forms Help Information regarding claims submissions via TexMedConnect can be found in the TexMedConnect User Guide All user guides and manuals can be found on the TMHP website http www tmhp com The following are links to online guides to be used in conjunction with TMHP s LTC Online Po
159. x The box under the License State is required to be checked for Initial Assessments it is optional for Annual and SCSA Assessments Fields S7f through S7j is required information if the MD DO is not licensed in Texas v 2014 1013 LTC Community Services Waiver Programs User Guide Enter the address and telephone number of the facility in which the physician providing the evaluation and recommendation practices in S7g S7k This information will be used to mail MN determination letters 7f MD DO First Name Conditional This field is required if the MD DO is not licensed in Texas Enter the first name of the individual s MD DO This information is used to mail MN determination letters 7g MD DO Address Conditional This field is required if the MD DO is not licensed in Texas Enter the street address of the individuals MD DO This information is used to mail MN determination letters 7h MD DO City Conditional This field is required if the MD DO is not licensed in Texas Enter the city of the individuals MD DO mailing address gt This information is used to mail MN determination letters Ifa city has a hyphen in the city name replace the hyphen with a space Ifa city has an apostrophe in the city name enter the city name without the apostrophe 7i MD DO State Conditional This field is required if the MD DO is not licensed in Texas Choose the state of the individual
160. y 1 2004 Reporting Fraud ACS State Healthcare LLC under contract with the Texas Health and Human Services Commission HHSC assumed l administration of claims processing for Texas Medicaid and Provider Lookup TM i P other state health care programs ACS a XEROX company meets its new consolidated health care Looking fora TEXAS MEDICAID responsibilities with a team of subcontractors under the name i m of TMHP become a provider for Texas Medicaid and related programs provider HEALTHCARE PARTNERSHIP Click here to find a state ASTATE MEDICAID CONTRACTOR health care provider near you 10 v 2014 1013 LTC Community Services Waiver Programs User Guide 3 Click Long Term Care in the yellow bar All Sites 2 Advanced Search ta TEXAS MEDICAID amp HEALTHCARE PARTNERSHIP TMHP ASTATE MEDICAID CONTRACTOR Log in to My Account Go to TexMedConnect Want to enroll as a Medicaid provider Click here for more information and to d Click here to access provider anro day ad A je enroll today applications and services Texas Medicaid Provider Homepage This is the provider homepage for Texas Medicaid The information on these pages help Medicaid providers succeed with their Medicaid practice For information specific to a related program click on HCPCS and ICD 9 codes Reference Material the program s button above se ee ee Medicaid Home Recent changes to procedure and diagnosis codes including Form
161. you see the yellow Form Actions bar When an individual assessment is being viewed in detail How can you tell if a field is required When it is marked with a red dot v 2014 1013 LTC Community Services Waiver Programs User Guide Appendix B Word Search Long Term Care Community Services Waiver Programs Workshop Word Search Use this activity to reinforce the terminology learned throughout this workshop MDEINEDWEETIPETTIMEAL GEVTIROCTODETCEHRROCRP HGDGMLWALACMNBSSMS UJ OTNIFHVFALDIOPRUFEFWGR ZCZKCIPPDEAATQUWTVQW OMRQTATIQPIPLTIWIMZAAP PORCZHTFHEACADHVNITG WQOASDPXIGCXCNIYTVTODS YNUTGMTLOSWPTIUGERTTK IHGRSLUMENAOMODRES LS QZ ASSES SMENTSRREEKQAZZ YFBWFUXVONNTECCMJISIMTI XK MDS RNDGEUODEATMEODTICAL LGTILZACJI PECLEXIPIJMHEHY NI TJOLNKPVECODISWFEFQHA GYCDYNNKTIOS HTLEFUCODCH INCEHEJV HIXQRSPAEXPWE FP JQOFNVLUNFPIJSOKJSJXKODITQ QYATRSATJDPTNQGROQGRPL LSCLKDEEOAYDADSFIWTZ NECESSITY PORTAL RUG DETERMINATION HIPAA APPROVED ASSESSMENT GLALM INACTIVATE LICENSE SLA Us IMHP COMMUNITY MEDICAID MEDICAL CORRECTED DADS WAIVER WORKFLOW MEDICATION DENIED 83 v 2014 1013 LTC Community Services Waiver Programs User Guide Hah MNN MIAH ATA ON LEROS KANN AER OnE m e AON pK HH MAIO SZAQhH MSE o YnNOHh HH amp OEAUH H e z gt Aa zpDax Of H A MOH gw a MHnNnmh x he Miaj o oa OoFAHD ols x HAW MO id gy CREE CW ks HIRSH Me HYOMOMAKHAOTAH

2013 Long Term Care Community Services Waiver

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