Appendix Automated Inquiry System (AIS) User’s B · The Automated Inquiry System (AIS) telephone number is a toll-free call (1-800-925-9126). Eligibility and claims stat us information

A p p e n d i x

B
BAutomated Inquiry System (AIS) User’s Guide
B.1 Hours of Operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-2B.2 Global Messages and Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-2

B.3 Accessing AIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-2

B.4 Welcome Message. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-2

B.5 Claim Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-3

B.6 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-5

B.7 Benefit Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-8B.8 Current Check Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-10B.9 Medically Needy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-11B.10 Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-13

B.11 Fax Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-15

B.12 Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-16

B.13 Texas Provider Identifier Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-21

B.14 Automated Inquiry System (AIS) Fax Back Forms. . . . . . . . . . . . . . . . . . . . . . . . . . . B-21

B–2

Appendix B

B.1 Hours of OperationThe Automated Inquiry System (AIS) telephone number is a toll-free call (1-800-925-9126).

Eligibility and claims status information is available 23 hours a day, with scheduled downtime between 3 a.m. and 4 a.m., Central Time, seven days a week. All other information is available 6 a.m. until 6 p.m., Central Time, Monday through Friday. TMHP call center representatives are available from 7 a.m. to 7 p.m., Central Time, Monday through Friday.

B.2 Global Messages and EventsSeveral categories of messages are used throughout the system. Rather than list these messages for each step in the call flow narrative, the messages are described in the following tables.

Global commands are simple telephone commands that callers use to navigate through the system. There is one global command programmed into AIS and it can be used at any time during a call and as often as needed. The command and description is listed below.

Enter *0 (star zero) – Returns caller to Main Menu.

The voice response software can be configured to permit the user a preset maximum number of inquiries per call session. This limit is set initially to 15 transactions. When the user enters a trans-action code, the system increments the number of transactions. After 15 transactions, AIS terminates the call.

B.3 Accessing AISTo access AIS, dial 1-800-925-9126.

B.4 Welcome MessageCaller Action AIS Response

When you call AIS and the system is available:

“Thank you for calling the Texas Medicaid & Healthcare Partnership. Our menu has recently changed, so please listen carefully. To return to the main menu at any time, press *0. Please visit our website at www.provider.tmhp.com for information regarding Medicaid programs and provider workshops. We appreciate your call.

For all automated transactions, including claim status and client eligibility, press 1.For Provider Enrollment, press 2.For Ambulance Prior Authorization, press 3.If you are a family planning agency, press 4.For all other inquiries, press 5. To hear the main menu again, press *0.If you have a rotary phone, please remain on the line.”

If you press 1: “Please enter your 9-digit Texas Provider Identifier number now. If not available, please wait on the line and you will be transferred to an agent.”

When you enter an invalid Texas Provider Identifier (TPI):

“Invalid Texas Provider Identifier number (Provider Identifier number). Please re-enter.”

If you wait on the line for 15 seconds:

“Please hold. Your call is being transferred.”

If you enter an invalid TPI two times:


When you enter a valid TPI:

“The Texas Provider Identifier number entered was (Provider Identifier number). If this is correct, press 1. If incorrect, press 2.”

Automated Inquiry System (AIS) User’s Guide

B

B.5 Claim StatusSTEP 1

STEP 2

STEP 3

STEP 4

If you press 1 for correct:

“Thank you for calling the Texas Medicaid & Healthcare Partnership Automated Inquiry System.For claim status, press 1.For eligibility, press 2.For benefit limitations, press 3.For current check amount, press 4.For Medically Needy case status, press 5.For fax-back service, press 6.For AIS appeals, press 7.To enter a new Texas Provider Identifier, press 8.To speak with a customer service representative, press 9.To repeat this menu, press 99.”

If you press 2 for incorrect:

AIS repeats its request for a TPI.

Caller Action AIS Response

For claim status inquiries:

“For claim status information, please enter the client’s nine-digit Medicaid number, followed by the # button.”

If you enter a CSHCN client number and you called the Medicaid Plan VRS telephone number:

“The client number entered (Client Number) is for the CSHCN Program. Please re-enter using the correct Medicaid client followed by the pound button; or call 1-800-568-2413 to be connected with the Automated Inquiry System for CSHCN.”


When you enter a valid client number:

“Please enter the date of service in an eight-digit month, day, and year format followed by the # button.”

If you enter an invalid date of service:

“Date entered is invalid, please re-enter. For example, February 1, 1998 should be entered as 02011998 followed by the # button.”


When you enter the date in a correct format:

“The date of service entered was (Date). If this is correct, press 1; if incorrect, press 2.”


When you enter a valid date of service and press 1:

“Please enter the total billed amount in a dollars and cents format, excluding the decimal, followed by the # button.”

If you press 2: AIS returns to Step 2.

If you key an invalid total billed amount:

“Billed amount is invalid, please re-enter. For example, $1234.56 should be entered as 123456 followed by the # button.”


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Appendix B

STEP 5


When a valid total billed amount is entered:

“Please wait while the requested information is being retrieved.”

If the claim was denied: Medicaid“For Medicaid client number (PCN) on (DOS) for (Billed Amount Dollars) dollars and (Billed Amount Cents) cents, the claim was denied on (RS Date) on your Medicaid R & S report. For EOB messages, press 1. To research another claim status, press 2.If you wish to speak to a customer service representative, press 3. To complete the call, please disconnect. PCCM-Texas Health Network“For Medicaid client number (PCN) on (DOS) for (Billed Amount Dollars) dollars and (Billed Amount Cents) cents, the claim was denied on (RS Date) on your Texas State of Texas Access Reform (STAR) Program R & S report. For EOB messages, press 1. To research another claim status, press 2. If you wish to speak to a customer service representative, press 3. To complete the call, please disconnect.

If the claim was paid: Medicaid“For Medicaid client number (PCN) on (DOS) for (Billed Amount Dollars) dollars and (Billed Amount Cents) cents, the claim was paid on (RS Date) for (Paid Amount Dollars) dollars and (Paid Amount Cents) cents on your Medicaid R & S report. For EOB messages, press 1. To research another claim status, press 2. If you wish to speak to a customer service representative, press 3. To complete the call, please disconnect.”PCCM-Texas Health Network“For Medicaid client number (PCN) on (DOS) for (Billed Amount Dollars) dollars and (Billed Amount Cents) cents, the claim was paid on (RS Date) for (Paid Amount Dollars) dollars and (Paid Amount Cents) cents on your Texas STAR Program R & S report. For EOB messages, press 1. To research another claim status, press 2. If you wish to speak to a customer service representative, press 3. To complete the call, please disconnect.”

If the claim is in process:

Medicaid/PCCM-Texas Health Network“For Medicaid client number (PCN) on (DOS) for (Billed Amount Dollars) dollars and (Billed Amount Cents) cents, this claim is in process. To research another claim status, press 2. If you wish to speak to a customer service representative, press 3. To complete the call, please disconnect.”

If the claim has been adjusted with no following finalized claim:

Medicaid/PCCM-Texas Health Network“For Medicaid client number (PCN) on (DOS) for (Billed Amount Dollars) dollars and (Billed Amount Cents) cents, this claim has been appealed. The appeal is currently in process. To research another claim status, press 2. If you wish to speak to a customer service representative, press 3. To complete the call, please disconnect.”


B

STEP 6

B.6 EligibilitySTEP 1

STEP 2

If the claim has been deleted or is not on file:

Medicaid/PCCM-Texas Health Network“No claim found for Medicaid client number (PCN) on (DOS) for (Billed Amount Dollars) dollars and (Billed Amount Cents) cents. To research another claim status, press 2. If you wish to speak to a customer service representative, press 3. To complete the call, please disconnect.”

If you press 1: “(The top five priority EOBs - header and unduplicated EOBs in detail)” To repeat the EOB messages, press 1. To research another claim status, press 2. If you wish to speak to a customer service representative, press 3.”



Caller reaches 15 claim status requests

“You have now completed 15 requests. Thank you for calling Texas Medicaid & Healthcare Partnership.”


For eligibility inquiries: To enter the client’s Medicaid number, press 1. To enter the client’s 9 digit social security number, press 2.


If you enter a CSHCN client number (beginning with nine), and you called the Medicaid/Texas STAR Program VRS telephone number:

“The client number entered (client number) is for the CSHCN Program. Please re-enter using the correct Medicaid client, followed by the # button; or, call 1-800-568-2413 to be connected with the Automated Inquiry System for CSHCN.”

If you enter a CSHCN client number three times:

“Please hold. Your call is being transferred to a customer service represen-tative for assistance.”

When you enter the client's number:

AIS advances to Step 3.

When you enter the client’s Social Security number:

“Please enter the client’s date of birth in an eight-digit month/day/year format followed by the # button.”

If you key an invalid date of birth:

“Date of birth entered is invalid. Please re-enter. For example, February 1, 1998 should be entered as 02011998 followed by the # button.”


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B–6

Appendix B

STEP 3

STEP 4


When you enter a valid PCN or a valid Social Security number and date of birth:

Medicaid/PCCM-Texas Health Network“For current eligibility, press 1. For a prior date of service, press 2.”

If you key an invalid date of service:



If you call a Medicaid telephone line and enter the client’s Social Security number, the PCN retrieved must not have a nine as the first digit. If it does not:

“For Social Security number (SSN), the client’s Medicaid Number is (PCN). For date of service (DOS), the client is eligible for Medicaid with (For date of service repeats)(no) Medicare and with other insurance and is not locked in. The eligibility add date is (add date).To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”The Medicaid and STAR Program messages remain separate so you can identify specific program information. If you enter the client’s Medicaid number or STAR Program number, AIS advances to Step 5.

If you enter the client’s Social Security number and it is not on file:

“For Social Security number (SSN) and date of birth (DOB), there is no client number. To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”



If the client is eligible: Medicaid“For Social Security number (SSN), the client's Medicaid client number is (PCN). For date of service (DOS), the client is eligible for Medicaid with (no) Medicare and (no/with) other insurance and is (not) locked-in. The eligibility add date is (ADD DATE).To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”PCCM-Texas Health Network“For Social Security number (SSN), the client’s number is (PCN). For date of service (DOS), the client is enrolled in Managed Care, with (Plan Name) and (no) other insurance.* The enrollment date is (Date). The primary care provider’s name will be spelled (PCP NAME).* The provider’s day phone number is (PCP Day Phone number). The provider’s evening phone number is (PCP Evening Phone Number).To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”*You only will hear the provider’s name and number if a primary care provider is assigned to the client.

If the client is not eligible

Medicaid/PCCM-Texas Health Network “Client number (PCN) for date of service (DOS) is not eligible for Medicaid and is not enrolled in managed care.”


B

STEP 5

STEP 6

If the day and evening telephone numbers are missing:

“No phone numbers are available for this provider.”Otherwise, you will hear the day or evening telephone number that is on file.You will hear the correct plan name based on the client’s eligibility.

If the requested infor-mation has been successfully returned to the caller

“To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”


When you enter a valid date of service or select the # button for current eligibility:


If the client is eligible: Medicaid“Client number (PCN) for date of service (DOS) is eligible for Medicaid with (no) Medicare and (no) other insurance and is (not) locked-in and the eligi-bility add date is (ADD DATE). To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”PCCM-Texas Health Network“Client number (PCN) for date of service (DOS) is enrolled in Managed Care with (Plan Name) and (no) other insurance.* The enrollment date is (Date). The primary care provider’s name will be spelled (PCP NAME).* The provider’s day phone number is (PCP Day Phone Number). The provider’s evening phone number is (PCP Evening Phone Number). To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”*You only will hear the provider’s name and number if a primary care provider is assigned to the client.

If the day and evening telephone numbers are missing:

“No phone numbers are available for this provider.” Otherwise, you will hear the day or evening telephone number that is on file.” To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”

If the client is not eligible for either Medicaid or PCCM-Texas Health Network:

Medicaid/PCCM-Texas Health Network“Client number (PCN) for date of service (DOS) is not eligible for Medicaid and is not enrolled in the PCCM-Texas Health Network. To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”

If the PCN is not on file: “Client number (PCN) for date of service (DOS) is not on file. To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”


When the eligibility message is complete:

To research another client’s eligibility, press 1. If you wish to speak to a customer service representative, press 2. To complete the call, please disconnect.”


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B–8

Appendix B

STEP 7

B.7 Benefit LimitationsBenefit limitations are based on claims currently in the system. TMHP cannot guarantee that no other claims for limited procedures will be submitted. Therefore, benefit limitation information is not a guarantee of payment.

STEP 1

STEP 2

STEP 3

STEP 4


Caller reaches 15 claim status requests

“You have now completed 15 requests. Thank you for calling Texas Medicaid & Healthcare Partnership.”


For benefit limitation inquiries:

Medicaid/Texas STAR ProgramBenefit limitations are based on current claim information and are not a guarantee of payment.“For benefit limitation information, please enter the client's nine-digit Medicaid number followed by the # button.”



“The client number entered was (client number). If this is correct, press 1; if incorrect, press 2.”



If you press 1#: “Benefit limitations are based on current claim information and are not a guarantee of payment.”“For Texas Health Steps medical information, press 1.”“For Family Planning exam information, press 2.”“For Texas Health Steps, formerly EPSDT, dental, press 3.”“For vision benefits, press 4.”


If you press 1: AIS advances to Step 5.





B

STEP 5

STEP 6

STEP 7

STEP 8


If the provider enters the Texas Health Steps information selection:

Medicaid/Texas STAR Program“For client (PCN) the last Texas Health Steps screening was on (DOS).To research another client’s Texas Health Steps limitations, press 1.To speak to a customer service representative, press 2.To complete the call, please disconnect.”

If no information is available or the date is equal to zero:

Medicaid/Texas STAR Program“For client (PCN) no claims on file.To research another client’s Texas Health Steps limitations, press 2.To speak to a customer service representative, press 3.To complete the call, please disconnect.”


If you enter the family planning exam infor-mation selection:

Medicaid/Texas Star Program“For client (PCN) the last family planning exam was on (DOS).To research another client’s family planning limitations, press 1.To speak to a customer service representative, press 2.To complete the call, please disconnect.”


Medicaid/Texas Star Program“For client (PCN) no claims on file.To research another client's family planning limitations, press 1.To speak to a customer service representative, press 2.To complete the call, please disconnect.”


If you enter the Texas Health Steps dental information selection:

Medicaid/Texas STAR Program“For client (PCN) the dental screening was on (DOS).To research another client’s dental limitations, press 1.To speak to a customer service representative, press 2.To complete the call, please disconnect.”


Medicaid/Texas STAR Program“For client (PCN) no claims on file.To research another client’s dental limitations, press 1.To speak to a customer service representative, press 2.To complete the call, please disconnect.”


All requests for vision benefits:


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B–10

Appendix B

B.8 Current Check AmountBecause Medicaid and the STAR Program have two separate payment amounts, both payment amounts are spoken separately. Payment amounts can be for a check that was issued to a provider or for an electronic funds transfer. AIS determines if the TPI entered is a provider participating in both Medicaid and the STAR Program, or Medicaid only, or the STAR Program only.

Note: STAR Program Plan payment inquiries exclude monthly capitation payments.


When the TPI and selection for the payment amount have been validated:


If the payment infor-mation is found for the provider entered and if the provider is Medicaid-only (not participating in the STAR Program action reason code 53):

“For Texas Provider Identifier number (Texas Provider Identifier number), your Medicaid payment amount was (Amount) on (Date).To enter a new Texas Provider Identifier number, press 1.To complete the call, please disconnect.”

If the payment infor-mation is found for the provider entered, and if only a Medicaid payment amount is found, and the provider is eligible for Medicaid and the STAR Program Plan (no STAR Program payment was present):

“For Texas Provider Identifier number (Texas Provider Identifier number), your Medicaid payment amount was (Amount) on (Date). No record of a payment amount was found for the Texas STAR Program Plan. To enter a new Texas Provider Identifier number, press 1.To complete the call, please disconnect.”

If the payment infor-mation is found for the provider entered for Medicaid and the STAR Program:

“For Texas Provider Identifier number (Texas Provider Identifier number), your Medicaid payment amount was (Amount) on (Date), and your Texas STAR Program Plan payment amount was (Amount).To enter a new Texas Provider Identifier number, press 1.To complete the call, please disconnect.”

If the payment infor-mation is found for the provider entered, and if only a STAR Program payment amount is found:

“For Texas Provider Identifier number (Texas Provider Identifier number), your Texas STAR Program Plan payment amount was (Amount) on (Date). No record of a payment amount found for Medicaid.To enter a new Texas Provider Identifier number, press 1.To complete the call, please disconnect.”

If the payment infor-mation is not found for the provider entered:

“For Texas Provider Identifier number (Texas Provider Identifier number), no record of a payment amount found for Medicaid.To enter a new Texas Provider Identifier number, press 1.To complete the call, please disconnect.”


B

B.9 Medically NeedySTEP 1

STEP 2

STEP 3

STEP 4


When you choose the Medically Needy option:

“Currently, the Automated Inquiry Medically Needy system is limited to retrieving information for cases 1 month in length. Cases greater in span than 1 month should be retrieved from a customer service representative. To speak to a customer service representative, press 1.Please enter the client’s potential eligibility month in a six-digit month/year format now.”

If you enter an invalid eligibility month:

“Invalid entry. Please re-enter. For example, February, 1998 should be entered as 021998 followed by the # button.”


After you enter a valid eligibility month:

“Please select one of the following options:To enter the case number, press 1.To enter the client’s Social Security number, press 2.To enter the client’s Medicaid number, press 3.”


If you press 1: “Please enter the nine-digit case number, followed by the # button.”

If you enter an invalid case number:

“Case number is invalid. Please re-enter.”

When you enter the case number:

“Please enter the client’s date of birth in an eight-digit month, day, and year format, followed by the # button.”

If you enter an invalid date of birth:

“Invalid entry, please re-enter. For example, February 1, 1998 should be entered as 02011998, followed by the # button.”

If you press 2: “Please enter a * (star) and the client’s nine-digit Social Security number, followed by the # button.”

If you press 3: “Please enter the client’s nine-digit Medicaid number, followed by the # button.”

If you enter an invalid client number:

“Client number is invalid. Please re-enter.”


When you enter the last of the information:

AIS speaks one of the following:• “The client number entered was (PCN), and the potential eligibility month

entered was (potential month). If this information is correct, press 1; if incorrect, press 2.”

• “The Social Security number entered was (SSN), and the potential eligi-bility month entered was (potential month). If this information is correct press 1; if incorrect, press 2.”

• “The case number entered was (Case Number), the date of birth entered was (DOB), and the potential eligibility month entered was (potential month). If this information is correct, press 1; if incorrect, press 2.”

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B–12

Appendix B

STEP 5

STEP 6


If 2: AIS returns to Step 1.

If 1: AIS advances to Step 6.


If no information is on status:

“No spend down segment was found for the information.To check the status of another Medically Needy case, press 1.If you wish to speak to a customer service representative, press 2.To complete the call, please disconnect.”

If there is information for the requested input (for case status):

“The status of the requested spend down case is” one of the following:• “Open, this is a new case awaiting bills.”

• “Open, additional information has been requested from the client.”

• “Open, bills have been received for this case.”

• “Pending, hearing in process.”

• “The hearing has finalized. The original decision was upheld.”

• “Pending, this case is being worked.”

• “Pending, the case has been referred to the state for review.”

• “Pending, the case has an 1120 form error.”

• “Pending, the case is being reworked.”

• “Closed, this case was closed by the client.”

• “Closed, this case was closed by the state.”

• “Closed, case work was completed.”

• “Closed, this is a duplicate case.”


B

B.10 Family PlanningFrom the Main Menu, choose option 4 to check Family Planning claim status for titles V, X, and XX.

STEP 1

STEP 2

If there is information for the requested input (for segment status):

“The status for the requested spend down segment is” (one of the following):• “Approved, spend down status was met as of (Date). The spend down

amount is (spend down amount).”

• “Pending, this is a new spend down segment as of (Date). The spend down amount is (spend down amount).”

• “Pending, the spend down segment is being worked as of (Date). The spend down amount is (Spend Down Amount).”

• “Pending, the segment is on hold waiting for a client response as of (Date). The spend down amount is (Spend Down Amount).”

• “Denied, the segment was denied for a missed deadline as of (Date). The spend down amount was (Spend Down Amount).”

• “Denied, roll over request as of (Date). The spend down amount was (Spend Down Amount).”

• “Denied, spend down segment was closed by the state as of (Date). The spend down amount was (Spend Down Amount).”

• “Closed, this is a duplicate case.”

• “Closed, multiple TP30 or TP55/30 cases were created.”

To check the status of another Medically Needy case, press 1.If you wish to speak to a customer service representative, press 2.To complete the call, please disconnect.”

If more than one spend down segment matches the search criteria:

“There was more than one spend down segment found for the information entered. Please hold, your call is being transferred.”To check the status of another Medically Needy case, press 1.If you wish to speak to a customer service representative, press 2.To complete the call, please disconnect.”


When you choose the Family Planning option that covers Title V, X, and XX:

“To check Family Planning claim status, titles V, X, XX, press 1. To speak to a customer service representative, press 2.”


After completing Step 1: “Please enter the client’s Family Planning number as follows:“The letter “F” must be entered as *33, followed by the # button.”

If you enter an invalid client Family Planning number:

“Invalid client number. Please re-enter.”


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B–14

Appendix B

STEP 3

STEP 4

STEP 5

STEP 6



“Please enter the date of service in an eight-digit month/day/year format followed by the # button.”

If you enter an invalid date of service:

“Date entered is invalid. Please re-enter. For example, February 1, 1998 should be entered as 02011998 followed by the # button.”


When you enter a valid date of service:

“The date of service entered was (DOS). If correct press 1; if incorrect, press 2.”


When you enter a valid date of service and press 1:

“Please enter the total billed amount in a dollars and cents format, excluding the decimal, followed by the # button.”


When you enter an invalid total billed amount:

“Billed amount is invalid. Please re-enter. For example, $1234.56 should be entered as 123456 followed by the # button.”


When you enter a valid total billed amount:


If the claim was denied: “For Family Planning client number (Client Number) on date of service (DOS) for (Billed Amount Dollars) and (Billed Amount Cents), the claim was denied on (Date) on your family planning Remittance and Status report. To end EOB messages at anytime, press #. For EOB messages, press 1. To check on the status of another Family Planning claim, press 2. To speak to a family planning representative regarding Titles V, X, and XX program-specific information, press 3.”

If the claim was paid: “For Family Planning client number (Client Number) on date of service (DOS) for (Billed Amount Dollars) and (Billed Amount Cents), the claim was paid on (Date) for (Amount) on your family planning Remittance and Status report. To end EOB messages at anytime, press #. For EOB messages, press 1. To check on the status of another family planning claim, press 2. To speak to a family planning representative regarding Titles V, X, and XX, press 3.”


B

B.11 Fax BackSTEP 1

STEP 2

STEP 3

STEP 4

If the claim has finalized with “Funds Gone” status:

“For Family Planning Client number (client number) on date of service (DOS) for (Billed Amount Dollars) and (Billed Amount Cents), the claim number was designated to be funds gone on (date) on your Family Planning Remit-tance and Status report. To end EOB messages at anytime, press #. To check the status of another Family Planning claim, press 2. To speak to a family planning representative regarding Titles V, X, and XX program-specific information, press 3.”

If the claim is in process:

“For Family Planning client number (Client Number) on (DOS) for (Billed Amount Dollars) and (Billed Amount Cents), the claim is in process. To check on the status of another Family Planning claim, press 2. To speak to a family planning representative regarding Titles V, X, and XX, press 3.”


When you choose the fax-back option:

“To obtain a faxed list of instructions and available documents, press 1.”If you know the document number, press 2.”



If you press 2: “Enter the document you would like faxed, followed by the # button. You will be limited to a selection of four documents.”


When you enter a document number:

“The document number entered was (document number). If this is correct, press 1. If incorrect, press 2.”


If you press 2: AIS returns to Step 2 and asks you to re-enter the document code.


After you enter your first choice:

“To request additional documents, press 1. If no other documents are needed, press 2.”

If you press 1: AIS returns to Step 2 up to four times.

If you press 2: AIS advances to Step 5. AIS repeats this loop as many as four times. On the fifth attempt, AIS advances to Step 5.


B–15

B–16

Appendix B

STEP 5

STEP 6

Refer to: “Hours of Operation” on page B-2 for a list of AIS fax back forms.

B.12 AppealsSTEP 1

STEP 2


When you enter a valid document number:

“Please enter your 10-digit fax number, beginning with the area code, followed by the # button.”“The fax number entered was (fax number). If this is correct, press 1. If incorrect, press 2.”

If you enter a fax number that is either too long or short:

“The fax number entered (fax number) is invalid. Please re-enter your fax number beginning with the area code, followed by the # button.”



If you press 1: “Thank you for using the fax-back service. Your fax will be sent shortly.”

If the fax server is unavailable due to technical errors:

AIS terminates the call after it informs you:“The fax server is not available at this time, please try again later.”


Select option 7: “Thank you for choosing Automated Appeals. Some limitations apply to performing automated appeals as follows:You may bypass this message by selecting 1.• Only three fields may be changed per claim.

• Only the fields announced on the options menu can be appealed.

• You are allowed 15 transactions per call.

• The billing TPI on the ICN entered must match the TPI you entered into AIS.

• Automated Appeals instructions can be obtained by selecting 2 from the fax back option. The document number is (101).

Please enter the 24-digit claim number that you wish to appeal followed by the # button. The claim number can be found on your R&S report.”


Enter the internal control number (ICN) of the claim you wish to appeal followed by the pound # button.

If the ICN entered is valid:

“The Claim Number entered was (ICN number). If this is correct, press 1. If incorrect, press 2.”

If you press 1: AIS relays one of the comments below or advances to Step 3.


If the ICN is invalid: “The claim number entered is invalid. Re-enter the 15- or 24-digit claim number, followed by the pound # button.”


B
STEP 3
STEP 4

If the ICN is for a claim in process:

“This claim is currently in process and cannot be appealed. To appeal another claim, press 1. To speak to a customer service representative, press 2. To complete the call, please disconnect.”

If the ICN entered was denied with an EOB that cannot be appealed:

“This claim denied and cannot be appealed through the Automated Inquiry System. To appeal another claim, press 1. To speak to a customer service representative, press 2. To complete the call, please disconnect.”

If the ICN entered is past the 180-day appeal deadline:

“This claim is past the 180-day appeal deadline and cannot be appealed through the Automated Inquiry System. Submit a paper claim with appro-priate documentation to show previous submission. To appeal another claim, press 1. To speak to a customer service representative, press 2. To complete the call, please disconnect.”

If the ICN entered is a CSHCN claim number:

“The claim number entered is for the Children with Special Health Care Needs program. Please re-enter using the correct Medicaid claim number followed by # or for CSHCN information. Please hang up and dial 1-800-568-2413 to be connected with the Automated Inquiry System for CSHCN.”


If you press 2: AIS returns you to Step 1 to enter a valid ICN.

If you press 1: “Please choose one of the following options. If you know your menu option:• To change a place of service, press 11, followed by the # button.

• To change a Type of Service, press 22, followed by the # button.

• To change an Authorization Number, press 33, followed the # button.

• To change a Quantity Billed, press 44, followed by the # button.

• To change a Medicaid Number, press 55, followed by the # button.

• To change a Beginning Date of Service, press 66, followed by the # button.

• To change an Ending Date of Service, press 77, followed by the # button.

• To change an X-ray Date, press 88, followed by the the # button.

• To change a Date of Onset, press 99, followed by the # button.

• To change a Date of Birth, press 00, followed by the # button.

• To repeat the Appeals Menu, press 0, followed by the # button.”


Enter the transaction code for the information you wish to appeal.

If you enter an invalid selection from the Appeals Menu:

“Invalid selection. Please re-enter.”


B–17

B–18

Appendix B

STEP 4.1

STEP 4.2

STEP 4.2.1

STEP 4.2.2

STEP 5

STEP 6After you have chosen the field and line number to be changed, AIS instructs you to do the following:

STEP 6.1


If you press 33, 55, 88, 99, or 00:

AIS transfers the caller to the appeal menu option selected to be changed (Step 6).


If you press 11, 22, 44, 66, or 77:

“If your claim has multiple line items, and you wish to correct the same information on all lines, press 1; or, if you wish to change one line item, press 2.”


If you press 1. Call transfers to Step 6.


If you press 2. “Please enter the line number, as shown on your submitted claim, which is to be changed, followed by the # button.”

If an invalid line number:Note: An invalid line number indicates no information is available on the line chosen and, therefore, cannot be appealed.

“Invalid line number (Line Number). Please re-enter.”

If a valid line number: “Line number entered was (Line Number). If this is correct, press 1. If incorrect, press 2.”


If you press 1: Call advances to Step 6.

If you press 2: Call returns to Step 4.2.2.


To change a place of service code (option 11):

“Enter the correct place of service code, followed by the # button.”

If an invalid place of service:

“Place of service code is invalid. Please re-enter.”


B

STEP 6.2

STEP 6.3

STEP 6.4

STEP 6.5

STEP 6.6

STEP 6.7


To change a type of service code (option 22):

“Enter the correct type of service code, followed by the # button.”

If an invalid type of service:

“Type of service code is invalid. Please re-enter.”


To change an authori-zation number (option 33):

“Enter the correct authorization number, followed by the # button.”

If an invalid authori-zation number:

“Authorization number entered (Authorization Number) is invalid. Please reenter.”


To change a quantity billed (option 44):

“Enter the correct quantity billed, followed by the # button.”

If an invalid quantity billed:

“Quantity billed (Quantity Billed) is invalid. Please re-enter.”


To change a Medicaid number (option 55):

“Enter the correct nine-digit numeric patient account number, followed by the # button.”

If an invalid PCN: “Patient number entered (PCN) is invalid. Please re-enter.”


To change a beginning date of service (option 66):

“Enter the correct beginning date of service in a month, day, and year format followed by the # button.”

If an invalid beginning date of service:

“Beginning date of service is invalid. Please re-enter. For example, February 1, 1998, should be entered as 02011998 followed by the # button.”


To change an ending date of service (option 77):

“Enter the correct ending date of service in a month, day, year format followed by the # button.”

If an invalid ending date of service:

“Ending date of service is invalid. Please re-enter. For example, February 1, 1998 should be entered as 02011998 followed by the # button.”

B–19

B–20

Appendix B

STEP 6.8

STEP 6.9

STEP 6.10

STEP 7

STEP 8

STEP 9


To change an X-ray date (option 88):

“Enter the correct eight-digit X-ray date in a month, day, year format, followed by the # button.”

If an invalid X-ray date: “X-ray date entered is invalid. Please re-enter. For example, February 1, 1998, should be entered as 02011998.”


To change a date of onset (option 99):

“Enter the correct date of onset in an eight-digit month, day, year format, followed by the # button.”

If an invalid date of onset:



To change a date of birth (option 00):

“Enter the correct eight-digit date of birth in a month, day, year format, followed by the # button.”

If an invalid date of birth: “Date of birth entered is invalid. Please re-enter. For example, February 1, 1998, should be entered as 02011998 followed by the # button.”


When you enter valid information:

“The information entered was (XXXXXXXXX). If this is correct, press 1. If incorrect, press 2.”


If you press 1: If only one or two fields have been appealed:“To change another field, press 1. To complete this appeal, press 2.”



If you have completed changing three fields on a claim:

“Three fields have been corrected on this claim. No other fields can be changed. Press 2 to receive the NEW claim number.”



If you press 2: “Please record the following NEW claim number for your records. The claim number is (ICN).To appeal another claim, press 1. To speak to a customer service representative, press 2. To complete the call, please disconnect.”


B

STEP 10

B.13 Texas Provider Identifier Number

B.14 Automated Inquiry System (AIS) Fax Back Forms


If you press 1: AIS returns to Step 1.Note: This advance can be performed up to 14 times, depending on the number of transactions the caller enters before coming to the appeals option.

When you exceed the limit:Note: You have 20 seconds to respond to a transaction request. If you do not make a selection when prompted by the system, it repeats the message.

AIS terminates the call after it informs you:“You have completed 15 transactions. Thank you for calling the Medicaid Automated Inquiry System (AIS).”

If you do not choose an option:

“Please hold; your call is being transferred.”


If you choose the Texas Provider Identifier number option (back to B.4):

“Please enter your 9-digit Texas Provider Identifier number now. If not available, please wait on the line and you will be transferred to an agent.”

If you enter an invalid Provider Identifier number:

“Invalid Texas Provider Identifier number (TPI). Please re-enter.”

Form Description

TMHP Contact Center

100 Instruction for Using the Fax Back Server

101 Instruction for Appealing a Claim on the Automated Inquiry System

102 Active Provider list request form

103 Acknowledgement form

104 Bulletins Medicaid (current issue)

105 Check request form

106 Sterilization consent form

107 Electronic Funds Transfer (EFT)

108 Electronic Remittance & Status (ER&S)

109 Fee Schedule request form

110 Manual Request form

111 Texas Medicaid Provider Enrollment Application

112 Quick codes Texas Health Steps

113 Quick Reference Guide

114 Quick Territory Guide

115 Refund Information

116 TDHconnect Applications

B–21

B–22

Appendix B

Home Health Services/CCP Medical/CCP Customer

119 CCP Prior Authorization Request

120 Addendum to Title XIX

130 Title XIX form

131 Plan of Care

Dental

119 Dental Authorization

Ambulance

N/A Ambulance Authorization

CCIP

124 Psychiatric Inpatient Admission

125 Extended Psychiatric Inpatient Request

TPR/Tort

126 Tort Response

127 Other Insurance Maintenance

CSHCN

202 CSHCN Bulletin (current issue)

203 Remittance and Status (R&S) report

204 CSHCN Provider Enrollment Application

205 Provider Address Change Request

206 CSHCN Surgery Authorization Request

207 CSHCN Quick Reference Guide

208 CSHCN Ambulance Authorization

209 CSHCN Inpatient Admission Authorization Request

211 Refund Information Form

212 CSHCN Inpatient Rehabilitation Admission Authorization request

213 CSHCN DME Authorization request

214 CSHCN Dental Authorization request

215 Authorization form for Diapers and Medical Nutrition Products & Services

216 Home Health Services Plan of Care

217 CSHCN Documentation of Receipt for DME equipment

218 Outpatient Surgery Authorization

Family Planning

400 Family Planning 2017 Claim

Form Description

Documents

Appendix Automated Inquiry System (AIS) User’s B · The Automated Inquiry System (AIS) telephone number is a toll-free call (1-800-925-9126). Eligibility and claims stat us information