Case Management for Children and Pregnant Women (CPW) Carve-In Reminder

Date: June 29, 2023

Attention: All Providers

Call to action: The purpose of this communication is to remind providers of the Case Management for Children & Pregnant Women (CPW) carve-in to Medicaid that became effective September 1, 2022.

Background: House Bill 133, 87th Legislature, Regular Session, 2021, requires the case management for children and pregnant women benefit to be carved-in to Medicaid managed care, which means Medicaid managed care organizations like Texas Children’s Health Plan (TCHP) will contract with and reimburse providers for billable case management services.

This benefit is available for TCHP STAR and STAR Kids members:

• Children birth through age 20 with health condition or health risk; or
• Pregnant women of any age who have a high-risk condition; and
• Need assistance in gaining access to medically necessary medical, social, educational, and other services related to the health condition, health risk or high-risk condition; and
• Want case management.

How this impacts PCP and OB/GYN providers:

Providers should be aware of how the CPW benefit can help TCHP members:

• It is a Medicaid State Plan benefit and a component of the Texas Health Steps service array
• Assists eligible clients in gaining access to medically necessary medical, social, educational and other services
• Provides health related case management services to Medicaid eligible children and pregnant women
• Existing prior authorizations will be honored for 90 days to comply with current continuity of care requirements.

How is this benefit different from other types of case management?

• Home visits are conducted therefore, visits can be face-to-face
• Case manager may attend school meetings with parent to advocate for client
• The whole family is assessed, not just the client
• Services are provided only if client currently has needs related to their health condition or health risk

Next steps for PCP and OB/GYN providers:

Providers should refer eligible families to the Case Management for Children and Pregnant Women (CPW) program. In alignment with Uniform Managed Care Contract (UMCC), CPW services must be provided to Medicaid Members within 14 days. Click here to access the UMCC, Section 8.1.3.1.

The referral process is as follows:

Step 1: Referrals or requests for services can be submitted to TCHP Case Management Department via email or fax. To initiate a referral, submit a Referral and Intake Form via email to casemanagementphysicianreferral@texaschildrens.org or fax at 832-825-8745. If you have any questions, please call 832-828-1430 (toll free 844-780-1154).

Step 2: Case Management will determine eligibility of the member and identify if they are currently receiving services with a TCHP Case Manager.

• For referrals from non-CPW Providers: In cases where the member is not receiving services via TCHP, the Case Manager will identify a CPW provider based on the member’s location and complete the referral process to a CPW provider.
  
• For referrals from CPW Providers: Notification of if the member is or is not receiving services via TCHP be sent to referring CPW Provider. When TCHP members meet the CPW criteria, prior authorizations can then be submitted via Texas Children’s Link, the provider portal, as the preferred method. Authorizations may also submitted by Fax at 832-825-8760 or toll-free 1-844-473-6860 with the Standard Prior Authorization Request form fully completed, with the corresponding contact code and modifier as outlined below. If you have any questions, please call 1-800-731-8527.

Qualifications for Urgent Prior Authorization

Requests For urgent requests, Clinical reason for urgency should be listed per the prior authorization form, section II. Valid examples for an urgent request include: urgent injury, urgent procedure requested due to clinical need.

How this impacts providers of CPW services:

Eligible Provider Types to administer this benefit include:

• Registered nurses
• Licensed social workers

Eligible Provider Types may be self-employed or work for:

• Nonprofit agencies/organizations
• Health-care clinics (including FQHC’s) All Case Management for Children and Pregnant Women Medicaid providers must:
• Receive approval from Health and Human Services Commission (HHSC), enroll with Texas Medicaid and HealthCare Partnership (TMHP) as a Medicaid provider, and bill TMHP directly for each service.
• Complete HHSC’s standardized case management training.

Billable services for CPW providers include the following:

• Comprehensive visit: can be either a face to face visit or telephonic visit with the client/parent/guardian, which includes completing the Family Needs Assessment and developing a Service Plan
• Follow-up visit is a face to face or telephone contact in which the case manager reviewed the complete Service Plan with the client/parent/guardian
• Procedure and Contact Code information
  • Procedure code G9012 is for all Case Management for Children and Pregnant Women services. Modifiers are used to identify which service component is provided.

• Case Management for Children and Pregnant Women (CPW) services are limited to one contact per day per person.
• Case Management for Children and Pregnant Women (CPW) services are not billable when a person is an inpatient at a hospital or other treatment facility.

Source: https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2023/2023-06-june/2_11_Inpatient_Outpatient_Hosp_Srvs.pdf

Claim payment timelines

• A provider must file a claim with Texas Children’s Health Plan within ninety-five (95) days from the date of service.
• Texas Children’s Health Plan will adjudicate the claim for payment or denial within the thirty (30) day claim processing timeframe. If denied in whole or in part, Texas Children’s Health Plan will notify the provider of why the claim will not be paid via the Electronic Remittance Advice (ERA) or Explanation of Payment (EOP).

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.