Volume XXX, Number 11
 November 2015

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.

Claim Denials

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.

Code 21
SNF Inpatient (Including Medicare Part A)

Code 22
SNF Inpatient (Medicare Part B)

Code 28
Swing Bed – Nursing Facility

The MCOs have reported the following top 4 reasons that claims are being denied/rejected:

  1. Duplicate submission of claims – 37%
  2. Provider omitted or input incorrect data on claims form – 34%
  3. Service authorization data not matching claims providers are submitting – 28%
  4. Providers on vendor hold submitting claims – 14%

Prior Authorizations

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.

  1. Office and hospital records
  2. MD Signed Order as appropriate
  3. A history of the presenting problem
  4. Clinical exam
  5. Diagnostic testing results
  6. Treatment plans and progress notes
  7. Patient psychosocial history
  8. Information on consultations with the treating practitioner
  9. Evaluations from other healthcare practitioners and providers
  10. Operative and pathological reports
  11. Rehabilitative evaluations (notes and goals)
  12. Patient information
  13. Information from responsible family members
  14. Accurate ICD-10 code(s)

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:
HPM_Complaints@hhsc.state.tx.us Please also send a copy to mcopacomplaints@txhca.org By sending this email, HHSC will be able to follow up with the MCO.

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.

President’s Report


 Legislative Update


 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 gbwilliams@txhca.org or call (512) 458-1257.


State / THCA News

  • THCA Managed Care Helpful Tips


National / AHCA News


Announcements & Recognitions



  • Mark your Calendar with our 2016 Summer “Golf Fore PAC” Golf Tournament scheduled for Monday, July 11, 2016 at the Wolfdancer Golf Club @ Hyatt Lost Pines-Bastrop. More information will be forthcoming!
?’s About THCAPAC…Contact Us
Ron Payne, THCAPAC Co-Chair
Mark McKenzie, THCAPAC Co-Chair
Gina Muniz, THCAPAC Liaison


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