Changes to the Sterilization Consent Form and Instructions, Approval Process, and Denial Letter

Transcription

1 Changes t the Sterilizatin Cnsent Frm and Instructins, Apprval Prcess, and Denial Letter Infrmatin psted July 15, 2016 Nte: This article applies t transactins submitted t TMHP fr prcessing. Fr transactins prcessed by a Medicaid managed care rganizatin (MCO), prviders must refer t the MCO fr infrmatin abut benefits, limitatins, prir authrizatin, and reimbursement. Effective September 1, 2016, the fllwing changes will be made t the Sterilizatin Cnsent Frm and crrespnding instructins, the Sterilizatin Cnsent Frm Denial Letter, and the prcess that prviders must fllw t submit the cnsent frm t TMHP. The changes include the fllwing: The Sterilizatin Cnsent Frm and instructins have been updated t include field numbers and asterisks t indicate required fields. The first submissin f the Sterilizatin Cnsent Frm received by TMHP will be prcessed, and resubmissins f the frm with crrectins will nt be prcessed. If deficiencies are fund with the submitted Sterilizatin Cnsent Frm, necessary crrectins (if applicable) can be resubmitted t TMHP using the space prvided n the Sterilizatin Cnsent Frm Denial Letter that will be faxed t prviders if deficiencies are fund. Certain crrectins t the Sterilizatin Cnsent Frm will n lnger be allwed, and the frm will nt be apprved. Fr certain crrectins, prviders may be allwed three attempts t make the necessary crrectins using the Denial Letter. If all requirements are nt met upn the third attempt, the Sterilizatin Cnsent Frm will nt be apprved. These changes will impact Texas Medicaid Title XIX family planning services, the Healthy Texas Wmen s (HTW) prgram, the Department f State Health Services (DSHS) Family Planning Prgram (DFPP), and Expanded Primary Health Care (EPHC) prviders. Imprtant: Beginning September 1, 2016, cnsent frms that have nt yet been apprved will begin t be prcessed accrding t these new requirements. Even if a cnsent frm has been submitted multiple times n r befre August 31, 2016, the first versin f the frm that is submitted n r after September 1, 2016, will be cnsidered the fficial submissin, and the prvider will be affrded three attempts t crrect any deficiencies. Required Fields The Sterilizatin Cnsent Frm has been updated t identify required fields with an asterisk (*). Fields indicated with a duble asterisk (**) are required nly under certain cnditins. Each field has been numbered fr easier identificatin. All Sterilizatin Cnsent Frms will be cnsidered based fields required fr prcessing and fields required fr apprval. Fields Required fr Prcessing

2 The fllwing fields will be required in rder t prcess the cnsent frm and ntify the prvider if deficiencies are fund and crrectins are necessary: 29. TPI: If this field is missing r invalid, the cnsent frm cannt be prcessed. This field must be crrected n the Denial Letter. 30. NPI: If this field is missing r invalid, the cnsent frm cannt be prcessed. This field must be crrected n the Denial Letter. 33. Prvider/Clinic Fax Number: If this field is missing r invalid, the prvider will nt receive ntice if the cnsent frm is denied r requires additinal infrmatin. Imprtant: Prviders must use the space indicated in the Denial Letter t submit crrectins t TMHP. Prviders must nt resubmit a crrected Sterilizatin Cnsent Frm. Only the first submissin f the frm received by TMHP will be prcessed; resubmissins f the Sterilizatin Cnsent Frm will nt be cnsidered. Fields Required fr Apprval: Crrectins Permitted Certain fields n the cnsent frm are required fr the submitted frm t be apprved. If infrmatin in the required fields is missing, invalid, r illegible, TMHP will fax the prvider a Sterilizatin Cnsent Frm Denial Letter requesting the crrected infrmatin and dcumentatin indicating the crrect infrmatin if applicable. Acceptable dcumentatin includes a cpy f the applicable pages f the perative reprt, a cpy f the client s valid state-issued ID r driver s license, r a cpy f the applicable pages f the client s medical recrd, as apprpriate. Nte: The entire perative reprt r client medical recrd is nt required. A cpy f the applicable pages f the perative reprt r client s medical recrd is acceptable. The Reference # indicated at the tp f each page f the Sterilizatin Cnsent Frm Denial Letter must be included n each page f the submitted dcumentatin t avid delays in prcessing. The fllwing fields are required in rder fr the cnsent frm t be apprved, and unless therwise indicated with an asterisk (*), acceptable dcumentatin must be submitted with prf f the crrect infrmatin: Cnsent t Sterilizatin 5. Client's birthday [mnth, day, year] 6. Client s full name The client s state-issued license is sufficient t dcument the client s name if necessary. Interpreter s Statement 14 Interpreter s Signature 15 Date f Signature The Interpreter s Statement must nly be cmpleted if a third party s services were required t ensure the client understands the prcedure in the client s primary language (ther than English). If the Interpreter s Statement sectin is cmpleted in errr, prviders will be required t prvide dcumentatin that an interpreter s services were used. If an interpreter s

3 services were required and the Interpreter s Signature and Date f Signature are left blank, the cnsent frm will receive a final denial. Nte: If the date in field 15 is cmpleted but des nt meet requirements, prviders will be given the pprtunity t submit dcumentatin t crrect the date if errrs need t be crrected. If this date f signature is missing, the cnsent frm will receive a final denial and cannt be resubmitted t TMHP. Statement f Persn Obtaining Cnsent 16. Client s full name 17. Specify type f peratin 19. Date f Signature 20. Facility Name: (*dcumentatin nt required) 21. Facility Address: (*dcumentatin nt required) Physician s Statement 22. Name f individual t be sterilized 23. Date f sterilizatin 24. Specify type f peratin 25. Chse ne f the tw statements as applicable 26a. Expected date f delivery (mm/dd/yyyy) 26b. Emergency abdminal surgery; describe circumstances (perative reprt required) 28. Date f Signature Nte: If the date in fields 19 and 28 are cmpleted but d nt meet requirements, prviders will be given the pprtunity t submit dcumentatin t crrect the date if errrs need t be crrected. If these dates f signatures are missing, the cnsent frm will receive a final denial and cannt be resubmitted t TMHP. Prviders must use the space indicated in the Denial Letter t submit crrectins t TMHP. Prviders must nt resubmit a crrected Sterilizatin Cnsent Frm. Only the first submissin f the frm received by TMHP will be prcessed; resubmissins f the Sterilizatin Cnsent Frm will nt be cnsidered. Fields Required fr Apprval: Crrectins are Nt Permitted The fllwing signature and date fields must be cmpleted fr the cnsent frm t be apprved. If applicable signatures r dates f signatures are missing, the cnsent frm will receive a final denial and cannt be resubmitted t TMHP. 3. Dctr r clinic 4. Specify type f peratin 7. Dctr r clinic 8. Specify type f peratin 9. Client Signature

4 10. Date f Signature 18. Signature f persn Obtaining Cnsent 19. Date f Signature (left blank) 27. Physician s Signature 28. Date f Signature (left blank) Nte: If the dates in fields 19 and 28 are cmpleted but d nt meet requirements, prviders will be given the pprtunity t submit dcumentatin t crrect the dates if errrs need t be crrected. Review and Apprval Each submitted cnsent frm will be reviewed and apprved r denied as fllws: Apprved Denied pending crrectin Final denial Apprved The prvider can submit the claim fr cnsideratin f reimbursement. The prvider will nt receive ntice f an apprval. All cnsent frms will be prcessed within three business days. If the prvider has nt received a faxed Denial Letter by the fifth business day after submissin, the prvider can submit the claim fr cnsideratin f reimbursement. Denied Pending Crrectins If infrmatin is missing, invalid, r illegible n the submitted cnsent frm, prviders will receive a Denial Letter as ntificatin f the deficiencies fund with the cnsent frm. Fr required fields (ther than the signature and date f signature fields), prviders will have up t three pprtunities t make the necessary crrectins t the frm using the space prvided n the Denial Letter. Imprtant Crrectins: Prviders must use the space indicated in the Denial Letter t submit crrectins t TMHP. Prviders must nt resubmit a crrected Sterilizatin Cnsent Frm. Only the first submissin f the frm received by TMHP will be retained; resubmissins f the Sterilizatin Cnsent Frm will nt be cnsidered. Imprtant Fax Number: If the Prvider/Clinic Fax Number (field #33) is missing frm the Sterilizatin Cnsent Frm r is invalid, the prvider will nt receive ntificatin f a denied cnsent frm. If the prvider des nt receive ntice f a denied cnsent frm, and the claim is denied fr n cnsent frm: 1. The prvider can call the TMHP Cntact Center at fr infrmatin abut the denied claim and the cnsent frm. 2. The TMHP Cntact Center will fax the Sterilizatin Cnsent Frm: Request fr Fax Number frm t the prvider.

5 3. The prvider must cmplete the Sterilizatin Cnsent Frm: Request fr Fax Number frm with the apprpriate fax number, and fax the dcument t the TMHP Family Planning Unit at (512) The TMHP Family Planning Unit analyst will fax the prvider the Denial Letter with the infrmatin f each deficiency that requires crrectin. Upn receipt f the Denial Letter, the prvider can take actin as necessary and cmplete the cnsent frm apprval prcess befre appealing the claim fr cnsideratin f reimbursement. As a reminder, claims must meet all filing deadlines t be cnsidered fr reimbursement. Final Denial The submitted cnsent frm will receive a final denial fr the fllwing reasns: The prvider has exhausted 3 attempts t crrect all missing, invalid, r illegible infrmatin n the cnsent frm. The Cnsent t Sterilizatin sectin is missing ne r mre f the fllwing fields r the infrmatin prvided des nt meet requirements: 3 Dctr f clinic, 4 Specify type f peratin, 7 Dctr r clinic, 8 Specify type f peratin, 9 Client Signature, r 10 Date f Signature. The infrmatin prvided des nt meet requirements. The Sterilizatin Cnsent Frm that is submitted is the wrng versin. Prviders must use the current versin f the cnsent frm as psted t the TMHP website at One r mre signatures r dates f signature is missing r des nt meet requirements. All applicable signatures and dates must be n the cnsent frm upn submissin and must be riginal, handwritten, and unaltered. If the cnsent frm has received a final denial, crrectins will nt be cnsidered by TMHP, and all related claims will be denied. Refer t: The Texas Medicaid Prvider Prcedures Manual, Vlume 1, Sectin 7.3, Appeals t HHSC Texas Medicaid Fee-fr-Service, fr additinal infrmatin abut appeals ptins. Sterilizatin Cnsent Frm Effective September 1, 2016, the Sterilizatin Cnsent Frm has been updated as fllws: Asterisks have been added t indicate required fields. All fields have been numbered fr easier identificatin. The instructins have been updated t accmmdate the updates t the apprval prcess. The initial submissin and crrectin check bxes have been remved frm the tp f the frm. The Prgram sectin has been remved frm the bttm f the frm.

6 The infrmatin fields have been made fillable s that the infrmatin can be typed int each field befre the frm is printed and signed and dated. Imprtant: This frm is fillable. The infrmatin can be typed int the frm electrnically. This frm cannt be electrnically signed r dated. After the required fields have been cmpleted, the frm must be printed and signed and dated by all necessary parties. Only handwritten wet signatures and signature dates are accepted. Prviders can cntinue t use the previus versin (Effective Date_ /Revised Date_ ) f the Sterilizatin Cnsent Frm until March 31, Beginning April 1, 2017, prviders must use nly the new versin f the frm (Effective Date_ /Revised Date_ ). All previus versins f the frm will receive a final denial. Fr mre infrmatin, call the TMHP Cntact Center at (select Optin 2 and then Optin 3).