Steps to success

Being a case management provider doesn’t just mean that you provide case management services. It also requires that you establish a well-organized business. We will focus on three primary components of running a business for case management services: Generating Referrals, Providing Services, and Billing for Services. These three areas are dependent upon one another and must move together for you to have a successful business.

Outreach and Marketing Materials

An important component of generating referrals is developing an outreach plan for marketing your business. Some questions you may consider are:

• Who am I going to educate about case management?
• How frequently am I going to perform outreach activities?
• What materials am I going to use?

HHSC CM provides useful outreach materials such as brochures and posters geared toward individuals who are potentially eligible for case management services. If you wish to develop your own materials such as business cards, brochures, posters, flyers, websites, social media or client questionnaires, the materials must be approved by HHSC CM prior to distribution and include the following information:

• 1-877-THSteps helpline
• Case management eligibility criteria (not required for business cards)
• Description of case management services (not required for business cards)
• Title of program

You can order Case Management for Children and Pregnant Women brochures and posters from the Texas Health Steps Catalog.

Outreach Activities

Outreach activities cannot impede freedom of client choice and they must comply with the Texas Administrative Code (TAC) relating to Prohibition against Solicitation of Medicaid or CHIP Recipients. Case Management for Children and Pregnant Women Rules and Policies limit how outreach can be conducted to ensure client choice.

Appropriate outreach examples include but are not limited to:

• Educating service providers such as doctors, therapists and schools in the community.
  • Example: Make presentations to school personnel about Case Management for Children and Pregnant Women.
• Increasing awareness through community networking.
  • Example: Visit with local agency staff about case management services.
  • Example: Attend coalition meetings to inform others about case management services.
• Educating potential clients.
  • Example: Set up a booth at a health fair where people can ask about services.

Providing Services

Once you have completed the enrollment process with TMHP, HHSC CM will receive notice of your approval as a Medicaid CPW provider. This signals that you are to be listed as a provider on the Case Management for Children and Pregnant Women website, which is used by Texas Health Steps Outreach, informing staff and others to make client referrals. HHSC CM will also be notified when enrollment has been completed with any managed care providers.

Billing for Services

After conducting an approved visit, you can bill for it. Case management claims are submitted to the Medicaid administrator, Texas Medicaid and Healthcare Partnership (TMHP), using TMHP’s web-based system, TexMedConnect .

To learn more about how to file claims or help with rejected or denied claims, refer to the Billing Guide located in the Appendix. It provides computer-based training links and step-by-step instructions.

You must attend to each component, generating referrals, providing services, and billing for services to ensure that the provision of case management is working smoothly. You will also need to understand who are the individuals and organizations with which you will interact and contact for additional support.

HHSC CM and DSHS Regional Office

HHSC CM provides oversight of Case Management for Children and Pregnant Women. The DSHS Regional Liaison is a source of support for quality case management and technical support. Contact HHSC CM or your DSHS Regional Liaison regarding any questions about:

• Eligibility and prior authorization
• Documentation
• Provider status
• Program compliance activities

TMHP

TMHP is the Medicaid administrator and provides a variety of support to Medicaid providers. Introducing yourself to your local TMHP representative is helpful. To find your representative, visit the TMHP website or ask your DSHS Regional Liaison.

Contact TMHP at 1-800-925-9126 regarding questions about:

• Prior Authorization
• Medicaid enrollment
• Claims and billing issues
• Account accessibility

Once you are enrolled as a Medicaid provider, TMHP must ensure you have current licensure. Please be aware of the following:

• A reminder letter will be automatically generated and sent 60 days before your license expires.
• TMHP obtains licensure information directly from the Texas Board of Nursing.
• If you are a social worker, it is recommended that you renew your licensure 4-6 weeks before it is due and provide proof to TMHP.
• Failure to renew will result in a payment denial code placed on your NPI (National Provider Identifier) and you will be unable to submit claims.
• If you have a payment denial code placed on your NPI and you submit proof of license, TMHP has 30 days to lift the payment denial code.
• If you are unable to get into your TMHP account, please contact the TMHP EDI Help Desk at 1-888-863-3638 for assistance.

TMHP provides webinars and other computer-based training through its Provider Education and Training program.

Texas Health Steps Helpline

The Texas Health Steps Helpline has designated staff in the Special Services Unit (SSU) who provide education and information about case management to clients enrolled in Medicaid.

Functions of Texas Health Steps may include:

• Referring clients for case management. Please note that the referrals may be potentially eligible for services. You will need to conduct an intake with the client, parent or guardian to confirm eligibility. Sometimes a referral may not meet eligibility criteria.
• Receiving complaints about any Medicaid provider, including case management services.
• Assisting the client, parent or guardian with locating routine medical and dental providers.

Community

It is up to you to establish networks and relationships within the community to generate case management referrals. It is also important to become familiar with the resources within your community that can appropriately meet your clients’ needs.