January 1: Morphine Equivalent Dose Limitations for RightCare to Decrease in January
2019 News January 1: Peer Specialist
Background: This policy is a result of House Bill (H.B.) 1486, 85th Legislature, Regular Session, 2017, which requires HHSC to establish a Medicaid reimbursable peer service benefit and adopt rules establishing training and certification requirements for peer specialists to provide Medicaid-reimbursable peer specialist "services to persons with mental illness or services to persons
The attached Peer Specialist notification outlines the new benefit, requirements for eligibility and service delivery, as well as claims filing/reimbursement details effective Jan. 1, 2019.
RightCare from Scott and White Health Plan will decrease the daily morphine equivalent dose limit for people enrolled in Medicaid Managed Care on January 1, 2019. The new limit will be set at 90, and apply to all opioid prescriptions with exceptions for those people diagnosed with cancer or those receiving palliative or hospice care. Prescribing providers and pharmacies should contact the Navitus Provider Hotline 1-877-908-6023 for dosage limitation override assistance. SUD Policy
Background: The attached SUD Policy notification outlines the finalized Substance Use Disorder Services policy update to be effective Jan. 1, 2019.
This policy update includes:
- Updated statement of benefits section
- Addressed Mental Health Parity and Addiction Equity Act requirements by allowing limits to be exceeded for adults with prior authorization
- Made Medication Assisted Treatment payable on same day as withdrawal management and treatment services
- Made Vivitrol payable to Chemical Dependency Treatment Facilities
- Made buprenorphine payable to Physician Assistants and Nurse Practitioners as allowed under the Comprehensive Addiction and Recovery Act of 2016
- Updated Prior Authorization forms for Fee for Service Medicaid recipients: Qualified Credentialed Counselor signature now permissible consistently across all forms, and supporting documentation now required with all forms consistently
2. Referring provider number (NPI) is missing when billing provider is a non-person entity for Encounter FDOS < 01/01/3999. This edit will set under the following conditions.
October 31: Paper Claims Update Please note the RightCare mailroom has currently moved to 300 S. Riverside Plaza Suite 700, Chicago, IL 60606. All mail sent to P.O. Box 3757 Corpus Christi, Texas 78463 will be forwarded to Chicago. Providers whose mail cannot be forwarded will have mail returned. For more information, please contact RightCare customer service at 855 897-4448 (855-TX-Right). October 1: Ordering and Referring Providers NPI Requirements Implementation Date
Background: As an update to the MCO notification sent June 18, 2018 about the ordering and referring provider’s (ORP) National Provider Identifier (NPI) requirement, the implementation date has been postponed. Previously set to be implemented on September 1, 2018, the new implementation date is October 1, 2018. Beginning October 1, 2018, HHSC will implement the requirement for the submission of the ORP NPI on all managed care encounters.
Additional Information: The edits to be implemented are: 1. Ordering Provider Number (NPI) cannot be identified for Encounter FDOS < 01/01/3999. This edit will set under the following conditions:
- No provider match found
- Detail Ordering Provider NPI is NOT NULL
- Detail Ordering Provider API is NOT Present OR present but first letter is not F/S/A
- Detail Ordering Provider API is present and first letter is F/S/A but is not equal to 10 characters
- OON Exception Code 3 or 4 is not submitted
- OON Exception Code 3 or 4 is submitted but the submitted ordering provider NPI is not found on the NPPES table for the submitted FDOS
- Submitted billing provider taxonomy requires a referring provider and the submitted referring NPI is not submitted.
September 19: Retroactive APR DRG Relative Weight Change and 2019 Relative Weight Table Background: HHSC has determined that an adjustment is needed for some All Patient Refined Diagnosis Related Group (APR DRG) relative weights and related factors. The relative weights that are being adjusted were for new APR DRGs in Grouper 35. The relative weights that were originally assigned were not proper for HHSCs reimbursement system. Key Details: The changes will require an adjustment in payment to some inpatient claims and encounters with discharge dates on or after October 1, 2017. See below for links to the following information: • Changes – a list of the impacted APR DRGs with revised and original details • 2018 Revised Grouper Table – effective 10/1/2017 • 2019 Grouper Table – effective for discharges occurring on or after 9/1/2018 Note: There are no changes in the weight tables from 2018 to 2019. Any potential changes will be made effective 10/1/2018 when 3M release their APR DRG grouper updates.
Provider Education: Lead Exposure Screening and Treatment
RightCare would like you to be aware of the following course from Texas Health Steps. This short course covers what you need to know to screen, test, and retest children; properly collect blood specimens; use the mandatory reporting system; and protect Texas children from being exposed to lead in the first place.
Preventing Lead Exposure September 7: Wraparound Training Webpage Update for MH TCM/Rehab Providers. Wraparound training is a requirement for mental health (MH) targeted case management (TCM) providers to provide intensive targeted case management. In response to concerns brought by providers and health plans about accessing information on Wraparound training, HHSC is sharing that the Texas Center of the National Wraparound Implementation Center has updated its website to include more detailed information about the training .
August 1: Anti-psychotics Clinic Prior Authorization Changes Begin September 1. RightCare from Scott and White Health Plan will revise the anti-psychotics clinical prior authorization for people enrolled in Managed Medicaid beginning 9/1/18. To learn more please review the antipsychotics clinical prior authorization guide (PDF).
July 12: HHSC recently released an Op-Ed piece that features resources for women experiencing postpartum depression. This information was published in The Daily News and the Tyler Morning Telegraph. July 1: Mental Health Screenings to Change for Texas Health Steps
Effective for dates of service on or after July 1, 2018, mental health screening benefits will change for Texas Health Steps. Mental health screening for behavioral, social and emotional development is required at each Texas Health Steps checkup birth through age 20. Major changes to this medical benefit policy include the following: Changes to limitation for initial health screening for clients 12 through 18 years of age; Update to mental health screening tools recognized by Texas Health Steps
View the changes to Mental Health Screenings for Texas Health Steps . July 1: Postpartum Depression Screening During an Infant’s Texas Health Steps Checkup to Become a Benefit of Texas Medicaid
Effective for dates of service on or after July 1, 2018, postpartum depression screening will be a benefit of Texas Medicaid.
See information on benefits, guidelines, documentation requirements, and submitting claims here.