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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


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.

  • * Submitted billing provider taxonomy requires a referring provider and the submitted referring NPI is not submitted.

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

Mental Health Screenings to Change for Texas Health Steps Effective July 1, 2018

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 .

Postpartum Depression Screening During an Infant’s Texas Health Steps Checkup to Become a Benefit of Texas Medicaid July 1, 2018

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.

 

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.