Volume XXX, Number 11
THCA Managed Care Helpful Tips
THCA offers the following helpful tips in order to provide THCA members with the most up to date information and to assist with issues that have been identified regarding the Managed Care Process.
The only codes for Place of Service that should be entered on a nursing facility claim are 21, 22 and/or 28. MCO’s have reported that other place of service codes such as 18, 66 and 86 are sometimes being used by a nursing facilities on claim forms which is resulting in denied/rejected claims.
The MCOs have reported the following top 4 reasons that claims are being denied/rejected:
Below is suggested information facilities may want to include in a request for prior authorization. At a minimum the following information may be included for consideration to support medical necessity for services being requested.
If you are experiencing a MCO taking more than 3 days to provide a decision on a prior authorization HHSC has suggested that you submit an email to their complaints mailbox:
Superior is developing a webinar that will provide information on prior authorizations for add on services, therapy and documentation. Dates have not been announced at this time but THCA will keep you informed.
Commitment to Care
If you have any questions about the THCA C to C Initiative or would like to share your facilities successes please contact Gloria Bean-Williams at email@example.com or call (512) 458-1257.
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Ron Payne, THCAPAC Co-Chair