CHIP Perinatal Program Hospital Training Form H3038 Submission, Inquiry, and Processing

Texas Health and Human Services Commission

Training Objectives

• Benefit all entities, agencies, and persons involved in the completion, submission, and processing of Form H3038 for women who receive CHIP perinatal. • Obtain an understanding of how to accurately complete Form H3038.

• Know how to correctly submit Form H3038 by fax or mail for services rendered.

• Know how to perform a Medicaid-eligibility inquiry via the Texas Medicaid and Healthcare Partnership (TMHP).

• Know how and when to submit an inquiry to the Central Processing Center (CPC).

• Learn about available CHIP perinatal resources.

When To Prepare

 Prepare the Emergency Medical Services Certification Form H3038 to verify that a person not meeting citizenship requirements was treated for an emergency medical condition (i.e., provided labor with delivery-related services).  Establishing Medicaid for the newborn requires both a report of birth AND the submission of Form H3038 for the mother’s labor with delivery. The mother must establish Emergency Medicaid in order for the newborn to receive Medicaid.

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Obtaining Form H3038

Mothers who are eligible for CHIP perinatal coverage with income at or below 185% of the FPL receive in the mail:  Enrollment Confirmation Notice,  Bar-coded Emergency Medical Services Certification Form H3038 (Form H3038 has been modified to include the newborn’s name, gender and date of birth); and  Self-addressed postage paid envelope Mothers are instructed to bring Form H3038 with them to the hospital at the time of delivery.

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Bar-Coded Image

Page 5 Returning the bar coded Emergency Medical Services Certification, Form H3038 allows automated linking between Form H3038 and the CHIP perinatal case in the eligibility system.

Bar-Coded Image

Below is a sample population from 06/01/2010 to 02/23/2011 (nine months) indicating the percentage of Forms H3038 that are successfully linked.

We found:    22,018 or 36.11% successfully autolinked 298 or 0.49% had a bar-code but did not successfully autolink 38,664 or 53.40% were manually linked because they had no bar-code This information indicates that bar-coded Forms H3038 are not being successfully linked 64% of the time. This could delay the patient getting coverage and the provider receiving payment for services rendered.

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Completing the Form H3038

The physician who delivers the baby or an RN with knowledge of the patient’s care and admission and discharge dates typically completes the Emergency Medical Services Certification Form H3038, before the mother is discharged.  Bar-coded Form H3038 or  Generic (non Bar-coded) Form H3038.

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Form H3038 Requirements

• Mother’s name as it appears on the CHIP perinate card • CHIP perinate case number • Baby’s name • Baby’s date of birth • Baby’s gender Page 8

Submitting the Form H3038

• It is recommended that hospital staff send Form H3038 on the mother’s behalf, so that she does not have to mail it.

Hospital staff can return the completed form by:  Faxing to 1-877-542-5951, or  Mailing to: HHSC PO Box 14400 Midland, TX 78711-4400 Page 9

Submitting the Form H3038

• A correctly completed Form H3038 increases the success of reimbursement for services.

• An incorrect or incomplete form can delay reimbursement for services, because eligibility determination for the mother and her newborn is delayed. These forms cannot be used to determine if payment for services rendered is warranted.

• Additionally, providing only the attending physician’s or RN’s information may not be sufficient. It is beneficial to include a cover sheet with contact information (first and last name and telephone number) of the person completing the form in case there are any discrepancies. You may also write it on the bottom of the Form H3038.

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Submitting the Form H3038

• Submit each Form H3038 individually as a separate fax.

• If several Form H3038s are faxed as one document, it is possible that only the first account will be linked and processed. • Adhering to the directive above will help to ensure all accounts faxed behind the topmost document are successfully processed for payment of services rendered.

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Using an H3038 that is not bar-coded

• What if patient forgets her bar-coded Form H3038?

 The mother can request a new form by calling 1-877-KIDS-NOW.

   Hospital-based eligibility workers can use generic (non bar-coded) Form H3038 It is important to write the mom’s CHIP perinatal ID number on the top of the form.

The name on the form must match the name on the woman’s CHIP perinatal ID card.

  Include the newborns name, gender and date of birth to help HHSC link mom and newborn.

If the newborn’s name is not included the newborn will not be processed for Medicaid and will not receive 12 months of continuous Medicaid coverage.

 Consider including in hospital registration packets a reminder that women receiving CHIP perinatal coverage for prenatal care should bring their Form H3038 at delivery, if they receive one in the mail. Prenatal care providers might assist with these reminders, also.

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Verify Receipt of Form H3038

The

patient

can verify receipt of the Form H3038 by calling:  1-800-647-6558 to verify receipt  1-866-291-1258 to verify the processing status.

 There is no provider hotline to determine the status of an application at this time.

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Processing of Form H3038

CPC staff receives a referral task from MAXe CHIP perinatal system with an image of Form H3038. Staff must:    Perform inquiry to determine which system of record (TIERS or SAVERR) to use when processing the Emergency Medicaid case.

Use the supporting verification documents provided with the original CHIP perinatal application to determine eligibility for Emergency Medicaid coverage for the labor and delivery.

The mother’s emergency medical services certification must be completed before the newborn can be certified for Medicaid for Newborn Children (TP 45). This is because the baby must be linked with a Medicaid-eligible mother to receive the 12 months continuous coverage from birth.

Determine eligibility for Medicaid for Newborn Children if birth information is provided along with Form H3038. Newborn coverage processing is a three step process. CPC has up to 45 calendar days to complete the entire process.

NOTE

: Effective February 1, 2011, hospital based advisors process TP 45 coverage for newborns in the Neonatal Intensive Care unit. Page 14

Verifying Coverage

Verifying PCN/Medicaid number for mom and baby (185% FPL and below):  Look on TMHP web portal: www.tmhp.com

 Call TMHP help line for assistance: 1-800-925-9126. TMHP can verify a maximum of 10 at a time. This number also provides access to the Automated Inquiry System (AIS).

 The newborn’s number (TP 45) will now be available through AIS. These numbers can be found through the TMHP web portal.

 Note that TMHP cannot verify

CHIP perinatal

eligibility.

Options for verifying CHIP perinatal eligibility:  Have the mother contact 1-877-KIDS-NOW. The hotline representative should be able to provide her ID number, as well as FPL level. This is a client only phone number.

 Call CHIP provider number: 1-800-645-7164. This hotline cannot provide a client ID number, but it can provide verification of CHIP enrollment and coverage days, as well as the health plan and plan phone number.   Contracted health plan providers who have an online account may be able to verify eligibility by using the health plan’s website. Contact health plan by calling plan’s provider hotline.

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Inquiry Request

•          Perform inquiry via TMHP to determine if a Medicaid number has been issued prior to submitting an inquiry request to CPC. Only submit inquiry forms to CPC containing accounts that are more than 45 days old. Email or fax inquiry requests to the locations below after performing inquiry via TMHP:  [email protected]

  Fax 1-866-291-1260 Inquiry lists must be faxed only once and must only include accounts that are

more than 45 days old.

Inquiry lists

must

CHIP perinatal case number Mom's name as it appears on her CHIP perinatal card Dates of Service include the following information: Date Form H3038 was faxed to MAXIMUS Baby’s First and Last name Baby’s Date of Birth Contact information of the person completing the request CPC will research inquiries and respond to the provider within 10 business days. This time frame is an approximation and may only apply if all information including complete contact information is provided and the list is not overly extensive.

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Inquiry Results

• • Form H3038 located  CPC provides Medicaid ID number  Provider can bill: • Newborn facility and professional charges to TMHP • Consult the TMHP website at http://www.tmhp.com

for the Bulletin article dated July 9, 2010 entitled “Changes to Claim Submission and Payment for Newborns Formerly Enrolled in the CHIP Perinatal Program” for more details on billing. Click on Providers at the top of the TMHP home page, and then use the search feature at the top of the page.

Form H3038 not located  Hospital asks patient to apply for Emergency Medicaid at local HHSC office  Form H3038 must be completed and returned before Emergency Medicaid can be certified for both mom and the newborn.

 Patient can be billed if patient does not follow through with application process Page 17

Failure to Return Form H3038

• A new application for assistance is required if Form H3038 is not submitted accurately within 90 days of delivery. Eligibility for Emergency Medicaid must be determined based on current household information. • Eligibility for the new application is determined by either hospital based staff or staff at a local HHSC office.

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Recap

• Obtain the bar-coded Form H3038 from the patient with CHIP perinatal coverage information or use a blank Form H3038.

• Accurately complete all required information.

• Fax each Form H3038 individually or mail the forms to HHSC at the address provided in this presentation.

• Have the patient verify receipt of the Form H3038 and processing status.

• Perform inquiry via TMHP to verify coverage.

• Send an inquiry request via fax or secure email to the CPC locations in this presentation if an account is more than 45 days old.

• CPC will research each inquiry and respond to the provider within 10 business days. This time frame is an approximation and only applies if all information including complete contact information is provided and the list is not overly extensive.

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Additional Resources

TMHP general inquiries hotline and website:

1-800-925-9126; http://www.tmhp.com/Medicaid/default.aspx

Form H3038 completion and submission: Sheree Coleman 512-533-3791 [email protected]