DADS CMS Advisory Council

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					                      Texas Department of Aging and Disability Services
                                Claims Management System
                                 Advisory Council Meeting
                                          February 11, 2009

Welcome/Introductions – Maria Garcia Montoya, Chair, DADS Claims Support

General Updates & Announcements – Maria Montoya, DADS
        Future meetings will be held at the John H. Winters Building, 701 W. 51 Street, in Austin. The
        May 2009 meeting will begin at 9:30 a.m. Details are provided at the end of these notes with the
        May 13, 2009, meeting agenda. Directions are included in the reminders emailed to DADS CMS
        Council members and stakeholders approximately 2 weeks prior to the meeting.

There was overall agreement that there have been improvements and there are still issues to be
addressed. DADS and TMHP are working closely with the Texas Health Care Association, Inc.
(THCA) and the Texas Association of Homes and Services for the Aging (TAHSA) as issues

In some instances, TMHP may conduct facility site visits to provide one-on-one assistance to
the nursing facility (NF). There was general agreement that many issues currently being
experienced involve provider education. The LTC News notice Provider Training Materials
Available was published January 22 to remind providers that information material is online at
the LTC homepage of, and that reviewing these materials can be advantageous to
help answer questions that providers may have about forms processing to expedite resolution in
lieu of calling Provider Claims Services or TMHP.

THCA is working with DADS to test the 10 most common portal messages NFs get on their
workflow. Once it is finalized, it will be posted at the website in addition to being
sent to the appropriate associations. This list is designed to provide a useful resource that can
be printed and kept handy for reference when working on the provider workflow.

Regarding recent delays affecting LTC forms processing, the bottom line is that if the
information is in Medicaid Eligibility Service Authorization Verification (MESAV), providers can
bill for services during those periods. Refer to the LTC News notice posted February 10, 2009,
on Long Term Care Program - Delays Affecting LTC Forms Processing Provider

Resource Utilization Groups (RUGs) Nursing Facilities Status – Tom Plowman,
THCA & Maria Montoya, DADS
Tom expressed thanks to DADS Provider Claims Services (PCS) and the DADS Chief Financial
Office for being so helpful in working with THCA to address issues and agreed that education
remains a key issue: most likely it is the nursing home not knowing how all the gears mesh.
Later discussion [see OFS presentation] included plans to develop high-level process flow
diagram and descriptions for providers and for clients.                                        2/11/09 CMS Advisory Council Meeting - Page 1 of 9
Maria reported that in of 1200 NF providers, 1,158 are currently receiving payments. In January
2009 DADS made $165 million in NF payments, $2 million more than in January 2008. She
was asked to report on monthly trends by the number of denied and paid claims. Maria said
that this information is available in the monthly status report and that the past 6 months of
reports would be re-sent to the requestor for trending. Reports were provided on February 12,

Tom discussed the importance of the need for save-as-draft and save-as-template capabilities.
Wanda Allen, manager of DADS Claims Support, agreed this need has been noted as a priority
for TMHP enhancements now being planned for Fall 2009 and TMHP has been asked whether
this capability could be provided sooner.

Tom said the NFs need a monthly report on managing RUG levels like the monthly report they
used to receive on managing TILE (Texas Index for Level of Effort) levels. Maria will follow up
on this request.

Medicaid Eligibility – Aurora LeBrun & Janis Ambs, HHSC Office of Family Services (OFS)

        Note:    Because HHSC determines financial eligibility for Medicaid this discussion does not
                 address additional functional eligibility and service authorization processes that DADS

Although HHSC has added 200 MEPD (Medicaid for Elderly People with Disabilities) worker
positions in the past fiscal year, demand for services is outpacing this growth, with some offices
seeing 40-50% workload increases. HHSC is requesting additional positions from the

Across the State, it takes an average of 40 days to process an application. Day 0 is the day the
application is signed and dated. LTC applications require more time because they require
verifications of all income and resources. If all required information has not been supplied,
providers are allowed until the 39th day (84th day for applications on delay in certification) to
submit additional information. While some states deny and reopen the case, in Texas MEPD
workers are encouraged to do a delay if the Medicaid Eligibility is not in place so the whole
process does not have to be started over if applicable. Presumptive eligibility is only authorized
for three categories: (1) Pregnant Women; (2) Children; (3) Medicaid for Breast and Cervical
Cancer. The State can presume eligibility for specific programs for two months at most.

Aurora pointed out that when a case can be touched once, it is better for everyone than cases
which must be worked two, three and four times to verify additional information before the
eligibility determination is made. She was asked whether it would be possible to provide any
information for providers on how to facilitate earlier determinations; e.g., the 10 most common
problems or the10 steps for success to get your application processed. Aurora said they see
documentation coming on the 39th day or the 40th day. It was noted that it takes additional time
to get a match in MESAV, that Forms 3618s and 3619s still have to process even if the client
has medical eligibility [see introductory note to this section regarding the dual HHSC & DADS
processes involved].

Flowcharts summarizing this process are available in the LTC Workshop materials at the
following links; especially see the NF Quick Reference Guide, pages 23-26:
        1. LTC MDS RUG Workbook, Slide 47                                          2/11/09 CMS Advisory Council Meeting - Page 2 of 9

2. 2008 Nursing Facilities and Hospice Quick Reference Guide, Pages 23-26

A Council representative said they need an Information Letter showing the steps of an
application. Aurora said her organization would do their part to help with that request.
However, they have found that when a letter is provided, many times a focus group was
confused. HHSC Information Letters are reviewed by their communications director to facilitate
clarity. A Council member requested that the diagram for providers show how the process
works for all entities involved: HHSC, DADS, TMHP and the providers. A simplified version
could be developed for clients to show:
 how it flows through both departments and systems; and
 what they have to do when.

DADS will work with HHSC and TMHP to develop this. This process may take time to develop
because of the amount of coordination between the three entities.

Aurora agreed that this would be useful, along with the top 5-10 reasons LTC applications take
longer. HHSC will provide these reasons at the May Council meeting.

The Council representative also requested that NF resident data be extracted to determine what
the average processing time is for NFs, since NFs take longer than 40 days. This information is
needed to establish more realistic expectation for NFs in planning for how long it will take, on
average, for Medicaid eligibility to be established.

Trish Risley pointed out that nothing prevents a facility from completing the Minimum Data Set
(MDS) assessment with a + sign in the Medicaid ID field, and at that point DADS begins the
verification process: if everything is good, it goes through, although it is not as though there are
not other significant steps that also have to be completed after HHSC determines Medicaid

Aurora was asked to provide application processing averages by program type. Although
HHSC does not have averages for NFs, they will look at averages for facilities on a "go forward"

A Council representative asked what a nursing facility can do to track the status of an
application when services are being provided and the facility is not getting paid for a patient
after a long period of time, months or even over a year. Aurora said there are issues with how
much information the State can give the provider without violating the client's privacy. The State
is limited on how much information it can tell the provider, especially if the guardian and
authorized representative are not cooperating. There is a very limited form for HHSC staff to
give providers to allow information for release in certain circumstances. Aurora said perhaps
Sherry Nichols, HHSC Attorney, could attend the next meeting.                                        2/11/09 CMS Advisory Council Meeting - Page 3 of 9
Janis recently sent a letter to facilities with contact information for use in the event a worker
does not return calls or resolve issues. Attendees noted it has been useful to have this contact
information. While overall the more than 1,000 MEPD workers are very busy and their
timeliness is very good, LTC cases take longer and it cannot be guaranteed that every worker
will do it right all the time. Aurora emphasized that her office needs to know if a provider has
issues with worker performance for their facility because if OFS is not aware there is a problem
they cannot address it. Providers were encouraged to use the contact information provided in
Janis's letter. If needed, facilities also can contact Janis or her staff as follows:
      David Pfleeger 927-337-6773
      Gloria Robinson 903-723-1905 ext. 248
      Janis Ambs 972-337-6193

In some cases OES has found that the issue resides with new facility staff that did not quite
know the process. Aurora stated that OES is willing to go into the facility and work with the
process to identify the reasons cases are being delayed or are not being processed: if OES is
the cause, they will fix it and if it is something else OES will help with that, too. OES is willing to
send a program management team if providers are having issues getting paid, not only to assist
NFs but also for someone providing services in the community.

In discussion regarding outstationed workers, OES confirmed outstationed workers are State
staff who may be assigned other work, although work for their assigned facility gets priority.
Facilities have been understanding especially when there are special needs, such as occurred
in response to Hurricane Ike. OES is amenable to having smaller facilities share a worker
although so far this has not been done.

When asked about TIERS, Aurora noted they are not in a hurry to move LTC clients to TIERS
until all LTC functionality is working in the system. This weekend TIERS installed the last build
to prevent some of the issues that have been seen in the past. HHSC is keeping the links to the
legacy system until they are confident all issues are resolved.

One continuing problem involves undeliverable Medicaid ID cards being returned by the U.S.
Postal Service. This is problem more for clients who do not receive their MedID cards. OES is
working with the health plans to capture address changes. In discussing whether facilities can
assist in reducing the volume of returned MedID mailings, HHSC offered to include a
presentation at the May meeting regarding the possibility of using the form (mentioned above)
for this; HHSC Legal staff will need to be involved to address confidentiality release issues.

In addition, a project is underway so that the HHSC Data Integrity Unit would no longer put
Supplemental Security Income (SSI) clients on hold. Aurora also said they are on target to
implement the Medicaid access card at the end of the year.

RUGS Enhancements & MDS 3.0 – Trish Risley, DADS & Tabatha Harbers, TMHP

Enhancements are underway to make the LTC Online Portal and the process more efficient.
Trish discussed the information in the following handout [light yellow highlights indicate
clarifying text inserted as a result of meeting discussion]. She noted that as a result of this
release, providers may see a notation in the history of some forms indicating that the DLN
(document locator number) has been automatically processed by DADS. DADS also will run a                                       2/11/09 CMS Advisory Council Meeting - Page 4 of 9
process to identify any duplicate forms sitting in any workflow so the remaining duplicates can
be cleaned out; this will probably be effective the week of February 25, 2009.

Maria said DADS will post an LTC News notice on the LTC homepage of about the
inventory clean up. An LTC News item titled Nursing Facility Forms Inventory Cleanup Notice
was posted February 16, 2009, at


        MDS 2.0 SAS Releases
        1. February 2, 2009 MDS 2.0 Release
                 a. Nursing Facility Changes to 3619 Medicare Coinsurance
                         o Corrected MDSAS to recognize that a client has 20 days of Qualifying
                           Stay, even if the forms 3619 are submitted out of Dates of Qualifying
                           Stay order, and to create the SAS records.
                         o Corrected MDSAS to create no more than 80 days of Coinsurance.
                         o Modified MDSAS to accept provider corrections to the 3619 Dates of
                           Qualifying Stay. Note: This should eliminate the need to submit
                           duplicate forms.
                 b. Community Services Changes:
                         o Process a Significant Change in Status Assessment (SCSA) as long as a
                           RUG or TILE has been established for the client.
                         o Process a Community Services (CS) Enrollment with Denied MN;
                           rather than sending it back to the CS Workflow.
        2. Upcoming MDS 2.0 Releases
                 a. Late February Nursing Facility Changes to 3619 Processing:
                         o Eliminate the errors in identifying and correctly counting days within
                           a Spell of Illness. These changes will also lay the foundation for pair
                           and retro 3619 processing.
                 b. Late March Nursing Facility Changes to 3619 Pair Processing:
                         o This functionality will “match up” 3619 admissions and discharges so
                           that they will process automatically into SAS, and not be rejected back
                           to the PCS or Provider workflows.

When asked whether this meant there was no longer a need to call about residents and wait 3-4
weeks for a PCS response, Trish noted that there's a good chance nursing facilities will not
have to call. The goal is to address the oldest forms to get them cleared out as much as
possible, although this does not guarantee you will never need to call again.

If MESAV indicates facilities can bill, then they should bill. If a previously submitted claim
rejected, facilities need to resubmit the claim.                                      2/11/09 CMS Advisory Council Meeting - Page 5 of 9
Hold Harmless - Trish
HHSC Rate Analysis is looking at data that is based on September to February for the first of
the Hold Harmless payment calculations. Please see the payment schedule below. The
payments will be a lump sum not processed through the DADS Claims Management System,
rather than a per-claim payment. Information Letter 2008-151, Texas Index for Level of Effort
(TILE) to Resource Utilization Groups (RUGs) Hold Harmless Feature, located at, further
explains the Hold Harmless Feature. The following handout was distributed:


        MDS 2.0 Hold Harmless Payments
        1. Automation
                 a. On schedule for providing payments to Providers
        2. Payment schedule:
                 a. First payment is April to be based on September to February analysis
                 b. Second payment is October 2009
                 c. Third & Final payment is January 2010

TMHP Enhancements - Tabatha
Providers will begin to see communications regarding what changes will be implemented in
upcoming MDS enhancements. TMHP is planning enhancements such as save as draft/save
as template for the 2.0 version of the form. Wanda noted that DADS is asking TMHP to
expedite the save as draft/template functionality. Tabatha said TMHP is planning a late
summer/fall implementation of the next TexMedConnect release, and batch MESAV reporting is
the #1 priority on the list of enhancements. Providers should submit any enhancement
suggestions to:

MDS 3.0 - Trish
The change from MDS 2.0, which DADS implemented in September 2009, to MDS 3.0 will be
done in two phases. The federal Centers for Medicare and Medicaid Services (CMS) requires
NFs to move to a new Resident Assessment Instrument (RAI) based on MDS 3.0 by October
10, 2009:
   DADS is not changing any of the business process for using the new MDS for Medicaid
   There will be new federal assessment instruments; new LTC Online Portal screens will be
    added to reflect the new assessments.

For Community Services, implementation is set for March 1, 2010: six months after the NF
implementation. If the federal CMS slips the NF date, DADS will slip the CS date so that CS
would still implement six months after the NF implementation.

Recently, our federal contacts have stated they would not meet their published March 20, 2009,
milestone with the final data specification for MDS 3.0 but gave no revised date for when the
final specification will be made available. DADS has been working since September 2008 with                                     2/11/09 CMS Advisory Council Meeting - Page 6 of 9
internal workgroups which include some Council representatives. Providers can send questions
to DADS regarding the MDS 3.0 project to the following email address:

Trish provided the handout below and requested that providers look at the following assessment
drafts on the new MDS 3.0 website,
       Draft Business User Requirements (PDF) Note: as this is a 130-page draft document

        that describes the requirements for the LTC Online Portal changes, it would be useful to
        scan the table of contents for areas of particular interest to you as a Provider.
       Draft MDS 3.0 Assessment (PDF) this is a link to the Federal CMS Nursing Facility
        Resident Assessment Instrument (RAI) draft based on the new MDS 3.0 to be used for a
        Comprehensive assessment of a resident. This assessment will replace the current MDS
        2.0 RAI instruments in use in the Nursing Facilities as of the Federal CMS Implementation
        date of October 1, 2009. All current software in use in the facilities must be updated to
        comply with this new version as of that date. NOTE: Please notify your software
        vendors of this Federal CMS mandated upgrade so you are able to submit the
        MDS 3.0 assessments to CMS in October. The ability to retrieve assessments for the
        Medicaid payment process in the LTC Online Portal depends upon your ability to submit to
        Federal CMS.

       Draft MN and LOC 3.0 Assessment (PDF) – this is a draft of the new MNLOC based on the
        MDS 3.0 specification for use in the Community Services Waiver programs including CBA;
        CWP; PACE; MDCP; STAR+PLUS; and ICM. This assessment will replace the current
        MNLOC Assessment based on MDS 2.0 as of the Phase II (currently March 1, 2010)
        Implementation date.

       Draft PASARR Screening 3.0 (PDF) – this is a draft of the new PASARR Screening
        assessment based on the MDS 3.0 specification to be used in the Texas Nursing Facilities
        with the implementation of Phase II (currently March 1, 2010) of the MDS 3.0 project.
        This will replace the current PASARR Screening based on MDS 2.0 as of the
        implementation date.


        MDS 3.0 Project Status
        1. Implementation for Texas to be done in two phases:
              a. Nursing Facilities: 10/1/2009 (per Federal CMS mandated date)
              b. Community Services Waivers: 3/1/2010

        2. Federal CMS Deliverables Delayed - no new dates at this time                                      2/11/09 CMS Advisory Council Meeting - Page 7 of 9
                    a. MDS 3.0 Specifications originally scheduled for 3/20/2009
                    b. Train the Trainer originally scheduled for 5/20/2009

           3. DADS activities in progress
                a. September to November 2008
                          o Scope of Work document prepared by DADS staff and delivered to TMHP
                            for Change Order Request (COR).
                b. October to present
                          o Workgroups for Nursing Facilities; Waivers; PASARR; Medical Necessity
                            and Pediatrics have been in progress to define requirements.
                c. February 2 to present
                          o Business User and Requirements document (including draft Assessments) in
                            review by Project Management staff & staff participating in the workgroups.

           4. TMHP activities in progress
                a. Change Order Request (COR) is in progress
                         o Operations staff and business analyst have been attending DADS workgroups
                            when available.

ICDs and EDI (Electronic Data Interchange) Format for 5010s - Tabatha
As was done when NPI was implemented, TMHP is conducting extensive analysis of needed
changes and the impacts. This project is now in analysis.

LTCMI Timer - Tabatha
In earlier discussion regarding the LTCMI Timer, Tom Plowman indicated that extending the
timer from 20 minutes would not be helpful because facilities still cannot save the document.
Upon further discussion, it was agreed that the save-as functionality will have more bearing on
issues providers are experiencing than a longer timeout period or a display alerting providers
how much time will elapse before the LTCMI (Long Term Care Medicaid Information) will time
out. The technical team will continue to perform analysis on the timeout period to determine
where improvements can be made.

Integrated Care Management – Lena Brown-Owens and Rhonda Pratt, DADS

February 1, 2009, is the one-year anniversary of the ICM program. Recently DADS has seen
greater HHSC involvement, including holding EverCare accountable to contract requirements,
and making sure EverCare completes assessments on a timely basis and uses proper phone
escalation protocol. It is our understanding EverCare hired an additional 100 staff to address
HHSC review findings.

Lena mentioned two pending DADS Information Letters:
 No. 2009-01, ICM Providers (New and Existing) Must Help Ensure Their Contracts are
   Linked to Evercare, will provide instructions about the importance of linking contract
   numbers to EverCare ICM contract numbers
 No. 2009-19 (formerly No. 2008-119), ICM 1915(c) Waiver Rules, Adaptive Aids, Minor
   Home Modification and Medical Supplies Processes, will replace No. 2008-47. This letter
   currently is on route for review/comment.
    International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM)                                                2/11/09 CMS Advisory Council Meeting - Page 8 of 9
STAR+PLUS – Not presented; HHSC representative unable to attend as planned

Because Star+PLUS staff were not available, Star+PLUS has been asked to contact Rose
Dunaway, TAHC, to discuss proposed items that could not be discussed. Rose will continue to
work with HHSC.

LTC Provider Bulletin - The February issue was sent to Council members February 6 and
published online at the LTC homepage of on February 9; paper copies are
scheduled to be mailed by February 13.
Workshop invitations will be mailed separately to provide Spring 2009 Workshop schedules.

Pending / Action Items
1. NF Portal Messages. DADS will post an LTC News item on listing the 10 most
   common portal messages NFs get on their workflow.
2. Save-as-draft/template functionality. DADS has included this as a priority enhancement
   TMHP is scheduled to implement by Fall 2009
3. Steps in Application Processing. HHSC and DADS will collaborate on an Information Letter
   including application averages by program type, particularly the average NF application
   processing time, and a flowchart diagram providers can use to show clients and their
   representatives how the application process works and what they have to do when.
4. Reasons for delays in processing LTC applications. Top reasons LTC applications take
   longer than the average processing time.

Tentative Agenda for May 13, 2009, Advisory Council Meeting
     General Updates           STAR+PLUS Update
     RUGs Status               ICM
     MDS 3.0                   HHSC Presentation
Contact to add any other items to this agenda.

Planned Council Meetings -            10:00 – 12:00 unless otherwise announced: May 2009
                                      meeting will begin half an hour earlier

▪   Dates:        Wednesday, May 13, 2009: 9:30 a.m. – 12:00 noon, Winters Bldg, Austin
                  Wednesday, August 12, 2009
                  Wednesday, November 18, 2009: note change to third week of the month in
                                                observance of Veteran’s Day
▪   Location: John H. Winters (JHW) Human services Complex, West Tower
              Conference Room 651-W
              701 W. 51st Street, Austin, Texas 78714
                 Note: Check in with Security in the main JHW lobby; the DADS contact for
                       these meetings is Maria Garcia Montoya                                    2/11/09 CMS Advisory Council Meeting - Page 9 of 9