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Upcoming Webinar on Writing Functional Therapy Goals

HHSC would like to make MCOs aware that TMHP will conduct a live webinar for therapy providers on writing functional goals for physical therapy (PT), occupational therapy (OT), and speech therapy (ST). Texas Medicaid requires functional goals for all PT, OT, and ST plans of care. Registration details attached here.

Neonatal Emergency Billing Address Requirements

Background: In accordance with House Bill (HB) 15 (83R) and HB 3433 (84R), HHSC established rules for inpatient hospital designations for neonatal services and maternal services. Hospitals without designation will not be reimbursed for inpatient neonatal or maternal services except emergency services required to be provided or reimbursed under state or federal law. The level of care designation for each hospital will be reviewed by HHSC every three years and updated as appropriate.

Action: Providers who submit claims for inpatient newborn care must use the billing address that matches the facility address of the neonatal designation where neonatal services are rendered. To be considered for reimbursement of neonatal claims, providers must have their neonatal billing address. Business edits will set on encounters where the provider is billing incorrectly.

ANNOUNCEMENT: Scott and White Health Plan Provider Relations Representative Contact Information

To find the Provider Relations Representative for your county, please see the Provider Relations Representative Territory Map.

For ProvidersProvider Home Page

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Here is your go-to guide for RightCare

Provider Manual

Filled with useful information, your provider handbook helps you care for your patients the way they need. It’s pretty handy to have, especially if you don’t always have Internet access. Inside you’ll find:

If you need this book in a different format such as audio, large print, braille, or in a language other than English and Spanish, call RightCare Member Services.

Provider Information

RightCare Provider Relations and Services Hotline (including claims questions) 1-855-TX-RIGHT (1-855-897-4448)

  • Provider Newsletters — All the latest information regarding Medicaid and information Provider's should know. 
  • Provider Advisory Group— RightCare will conduct quarterly Provider Advisory Groups with network providers to address any needs and concerns from the provider population. The Provider Advisory Group will include acute care, pharmacy providers, SWHP Provider Services, Medicaid Operations staff, and the RightCare Medicaid Medical Director. SWHP will review phone calls and complaint logs to determine patterns of concern that need to be addressed. SWHP will solicit providers for participation after they have completed the contracting and credentialing process. Provider feedback will be requested on the Provider Manual, newsletters, and the RightCare website. RightCare will utilize technology to engage providers across the service area. For more information on Provider Advisory Groups, please contact RightCare Provider Relations at 1-855-TX-RIGHT (1-855-897-4448).

HHSC Notifications

2017-2018 Texas Medicaid Standing Order for Mosquito Repellent

Notice to Prescribers: Mosquito Repellent Benefit

Notice to Pharmacies: Mosquito Repellent Benefit

Provider Fraud Notice

Provider Complaints

RightCare recommends that all complaints received from providers be submitted in writing to:

RightCare from Scott & White Health Plan Attn: Dispute Resolution MS-A4-144 1206 West Campus Drive Temple, TX 76502 1-855-TX-RIGHT (1-855-897-4448)

Or by e-mail to: swhpappealsandgrievances@bswhealth.org or fax to: 254-298-3086.

A provider who believes that they did not receive full due process from RightCare may file a complaint with HHSC. Providers must exhaust the complaint/appeal process with RightCare before filing a complaint with HHSC. Complaints must be in writing and received by HHSC within sixty (60) calendar days from RightCare’s notification of final action. A provider may file a complaint with the HHSC at the following address:

Texas Health and Human Services Commission Re: Provider Complaint Health Plan Operations, H-320 PO Box 85200 Austin, TX 78708

Or by e-mail to: HPM_Complaints@hhsc.state.tx.us

Provider Claim Appeals

A claim appeal is a request for reconsideration of payment for a previously adjudicated claim. Providers who are filing an appeal of a claim decision will need to submit a copy of the Explanation of Benefits (EOB) page showing the claim in question, a claim form, and other supporting documentation including the reason for the appeal. Providers should submit one copy of the EOB for each claim to be appealed and circle which claim is being appealed. The reason for the appeal or reconsideration request may be written on the EOB or described in a separate document. All information should be printed on a single side of the copy. If the original claim was denied for incorrect information, a new CMS 1500 or UB-04 with the corrected information should be submitted as a corrected claim and follow the process indicated below. Appeals must be written, and submitted within 120 days from the date of disposition, which is the date on the Remittance Advice. All appeal requests will receive an acknowledgement letter within 10 days of receipt of the appeal. RightCare will adjudicate all appeals within 30 days of receipt of the appeal. Submit all correspondence to:

RightCare from Scott and White Health Plan Attn: Claims Appeals MS-A4-144 1206 West Campus Drive Temple, Texas 76502 1-855-TX-RIGHT (1-855-897-4448)

Or by e-mail to: swhpappealsandgrievances@bswhealth.org or fax to: 254-298-3272.