January/February 2004
No. 177
Texas Medicaid
B i m o n t h l y u p d a t e t o t h e Te x a s M e d i c a i d P r o v i d e r P r o c e d u r e s M a n u a l
Warm Up to the Articles in This Bulletin:
• • • BULLETIN • • •
•
•
•
•
2004 ICD-9-CM Implementation Postponed. See page 2.
LMSW-ACP to LCSW? See page 2.
SHARS Rates SFY04. See page 3.
Hydrophilic Intermittent Urinary Catheters article. See page 4.
Bulletin Contents, No. 177
All Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2004 ICD-9-CM Implementation Postponed ........................................................................... 2
TMHP Electronic Funds Transfer (EFT) Information ................................................................. 2
Licensed Clinical Social Worker (LCSW) ................................................................................ 2
Influenza Coding Changes .................................................................................................... 2
Medically Needy Spend Down Program Available to Adult Pregnant Women .............................. 2
Preferred Drug List (PDL) ..................................................................................................... 2
SHARS Rates SFY04 ........................................................................................................... 3
Revised Influenza Vaccine Recommendations ........................................................................ 4
DME Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Hydrophilic Intermittent Urinary Catheters ............................................................................. 4
THSteps Medical Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
TDH Laboratory Billing of THSteps Medical Providers .............................................................. 4
Excluded Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
TMHP Electronic Funds Transfer (EFT) Information ............................................................... 11
TMHP Electronic Funds Transfer (EFT) Authorization Agreement ............................................. 12
Provider Information Change Form ...................................................................................... 13
www.tmhp.com
Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for the Texas Medicaid Program
under contract with the Texas Health and Human Services Commission (HHSC)
Indicates updated information
All Providers
2004 ICD-9-CM Implementation Postponed
Implementation of the annual 2004 International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM)
diagnoses, procedures and diagnosis-related groups (DRGs) has been postponed until 2004. As a result, the implementation of Grouper 21 has also been postponed. Providers will be notified of the actual effective date and affected policies
at a future date. Continue to use 2003 ICD-9-CM and Grouper 20 information for claims and authorizations until further
notice. ■
Influenza Coding Changes
There is a change in coding related to the influenza vaccine and its administration. See the table below for appropriate
codes for claims submission for this vaccine and its administration. To determine the appropriate code(s) for submission,
the provider determines the type of service, age of the client receiving the vaccine, and whether or not the influenza vaccine
is provided by the Texas Vaccines for Children (TVFC) program. If a claim related to the influenza vaccine or its administration has been denied since September 1, 2003, submit an appeal of the claim using the appropriate codes:
THSteps
(During a THSteps medical
check-up)
Acute Care/Medical
(Outside of THSteps medical
check-up)
Client age and
vaccine source
Less than 19 years
and
Receiving vaccine from TVFC
Less 19 years
and
Receiving vaccine from TVFC
19 years or older
or
All age groups if not receiving vaccine
from TVFC
CPT code for
influenza vaccine
90749
90749
90657, 90658, or 90659
CPT code for
administration
90471 or 90472
90471 or 90472
90782 ■
Type of service
Acute Care/Medical
(Outside of THSteps medical checkup)
Licensed Clinical Social Worker (LCSW)
The Texas Medicaid Program has been informed of a recent change of licensure designation for licensed master social
worker-advanced clinical practitioner (LMSW-ACP). The Texas State Board of Social Worker Examiners announced that
effective September 1, 2003, LMSW-ACPs are now designated as licensed clinical social workers (LCSW).
The Social Work Licensing Board indicates that they understand that there will be a transition period for all licensees.
Reportedly, many licensees have stated that, in order to avoid confusion, they will not begin using the new credentials until
they are in receipt of the new license. All licensees must begin using the new titles by September 1, 2004.
At the direction of HHSC, the LMSW-ACP designation will not change until the 2005 manual revision cycle. ■
Medically Needy Spend Down Program Available to Adult Pregnant Women
The Medically Needy Spend Program is again available to adult pregnant women who are not otherwise eligible for Medicaid
because of income. The effective date of the restoration is retroactive to September 1, 2003, when the program was
discontinued for all adults. Only pregnant women are now allowed this coverage, no other adult applicants. Resume
referring pregnant women to this program. ■
Preferred Drug List (PDL)
Early next year, the Texas Health and Human Services Commission (HHSC) will begin implementing the Preferred Drug List
(PDL) for the Medicaid and Children's Health Insurance Program (CHIP) programs. In February 2004, HHSC will establish
the PDL for the 15 drug classes reviewed by the Pharmaceutical and Therapeutics (P&T) Committee at its December
meeting. HHSC will later expand the list to include additional drug classes.
With the implementation of the PDL, HHSC will establish a prior authorization function that will allow prescribers to obtain
prior authorization for nonpreferred drugs. Nonpreferred drugs are drugs that have been reviewed by the P&T Committee,
but that were not selected by HHSC to be on the PDL. Prior authorization will not be required for drugs and drug classes
Texas Medicaid Bulletin, No. 177
2
January/February 2004
that have not been reviewed by the P&T Committee. Policies and procedures for requesting prior authorizations will be
posted on the Vendor Drug Program @eb site (www.hhsc.state.tx.us/HCF/vdp/vdpstart.html) 30 days before program
implementation. ■
SHARS Rates SFY04
This article contains an updated table of School Health and Related Services (SHARS) state fiscal year 2004 (SFY04) local
and SFY04 national code pricing changes effective during SFY04. The following table includes the local codes and pricing
effective September 1, 2003, through October 15, 2003, and the national codes and pricing effective October 16, 2003,
through August 31, 2004:
Local
Code
7007X
Description
Local Code
Pricing
(9/1/03 10/15/03)
Audiology services, each
15 minutes
$20.29 per
15 minutes
National
Code
National
Code Pricing
(10/16/03 8/31/04)
Description
92506
$20.29 per
15 minutes
or
92507
Evaluation of speech, language, voice, communication,
auditory processing, and/or aural rehabilitation status
or
Treatment of speech, language, voice, communication,
and/or auditory processing disorder (includes aural
rehabilitation); individual
7008X
Counseling services, each
15 minutes
$17.45 per
15 minutes
H0004
Behavioral health counseling and therapy, per 15 minutes
$17.45 per
15 minutes
7009X
Occupational therapy, each
15 minutes
$16.02 per
15 minutes
97003
or
97530
Occupational therapy evaluation
or
Therapeutic activities, direct (one-on-one) patient contact
by the provider (use of dynamic activities to improve
functional performance), 15 minutes each
$16.02 per
15 minutes
7010X
Physical therapy, each
15 minutes
$16.65 per
15 minutes
97001
or
97110
Physical therapy evaluation
or
Therapeutic procedure, one or more areas, 15 minutes
each, therapeutic exercises to develop strength and
endurance, range of motion, flexibility
$16.65 per
15 minutes
7011X
Psychological services,
each 15 minutes
$18.84 per
15 minutes
H0004
with
modifier
AH
Behavioral health counseling and therapy, per 15 minutes
with clinical psychologist
$18.84 per
15 minutes
7012X
Speech therapy, each
15 minutes
$15.13 per
15 minutes
92506
with
modifier
GN or
92507
with
modifier
GN
Evaluation of speech, language, voice, communication,
auditory processing, and/or aural rehabilitation status
or
$15.13 per
15 minutes
Treatment of speech, language, voice, communication,
and/or auditory processing disorder (includes aural
rehabilitation); individual with services delivered under
and outpatient speech-language pathology plan or care
7013X
Medical services, each
15 minutes
$47.61 per
15 minutes
99499
Unlisted evaluation and management service
$47.61 per
15 minutes
7014X
School health services,
each 15 minutes
$13.89 per
15 minutes
T1002
RN services, up to 15 minutes
$13.89 per
15 minutes
7015X
Assessment, each
15 minutes
$17.35 per
15 minutes
96100
Psychological testing (includes psychodiagnostic
assessment of personality, psychopathology,
emotionality, intellectual abilities, for example, WAIS-R,
Rorschach, MMPI) with interpretation and report, per hour
$69.40 per
hour, with
partial units
billable in
6-minute
increments
4738Z
SHARS special
transportation, per student
round trip
$19.76 per
student round
trip
T2003
Nonemergency transportation; encounter/trip
$19.76 per
student
round trip ■
January/February 2004
3
Texas Medicaid Bulletin, No. 177
Revised Influenza Vaccine Recommendations
The Centers for Disease Control and Prevention (CDC) has announced an expansion of the routine recommendations for
influenza vaccine during the 2003-2004 influenza season. All children eligible for the TVFC should be vaccinated in accordance with the revised Advisory Committee on Immunization Practices (ACIP) and the Federal Vaccines for Children (VFC)
Program resolution. (A copy of the resolution can be downloaded from www.cdc.gov/mmwr/PDF/rr/rr5208.pdf.) Eligible
groups are identified as:
•
•
Children age 6 months through 23 months
•
Children and adolescents age 6 months through 18 years who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal
dysfunction, hemoglolbinopathies, or immunosuppression (including immunosuppression caused by medications)
•
Children and adolescents age 6 months through 18 years who are receiving long-term aspirin therapy and may
therefore be at risk for developing Reye syndrome after influenza
•
Children and adolescents age 2 years through 18 years who are household contacts of people in high-risk groups (e.g.,
people age 65 years or older, transplant recipients, people with AIDS, and children younger than age 2 years)
•
Children and adolescents age 6 months through 18 years who are residents of nursing facilities and other chronic-care
facilities that house people at any age who have chronic medical conditions
Children and adolescents age 6 months through 18 years with chronic disorders of the pulmonary or cardiovascular
systems, including asthma
•
Adolescent females less than age 19 years who will be in the second or third trimester of pregnancy during influenza
season
Influenza vaccine orders for Medicaid children and all TVFC-eligible children should be placed following the TVFC vaccine
ordering procedures currently in place for routine childhood vaccines.
Contact the nearest Public Health region (PHR) Immunization Program Manager with questions regarding influenza vaccine
recommendations. For influenza vaccine ordering information, contact Lisa Davis at 800-252-9152 or 512-458-7284. ■
TMHP Electronic Funds Transfer (EFT) Information
Providers currently participating in electronic funds transfer (EFT) with NHIC are not required to resubmit or change their
current EFT agreements. All current agreements will transfer to TMHP. Only providers who do not currently have an existing
agreement or newly enrolled providers will need to complete the revised EFT application.
Refer to:
TMHP Electronic Funds Transfer (EFT) Information on page 11. ■
DME Providers
Hydrophilic Intermittent Urinary Catheters
Effective for dates of service on or after October 16, 2003, all hydrophilic intermittent urinary catheters (such as, SpeediCath, Bard Interglide, and LoFric) may be considered for prior authorization and reimbursement using procedure code
A9900, Miscellaneous DME supply, accessory, and/or service component of another HCPCS code, manually priced at
manufacturer’s suggested retail price (MSRP) less 18 percent, with a maximum fee of $3.53. ■
THSteps Medical Providers
TDH Laboratory Billing of THSteps Medical Providers
All laboratory specimens, obtained as part of a THSteps medical checkup, must be submitted to the TDH Bureau of Laboratories. There is no cost to the THSteps medical provider for laboratory supplies and services that are part of a THSteps
medical checkup for THSteps-eligible clients. However, THSteps does reimburse the TDH Laboratory for the cost of these
supplies and services.
THSteps must have information sufficient to verify that the client is Medicaid-eligible on the date of the medical checkup
to reimburse the TDH Laboratory for the cost of these services. Without sufficient client information for a Medicaid eligibility
verification, THSteps cannot reimburse the laboratory. Therefore, THSteps supports the TDH Laboratory billing to any
Texas Medicaid Bulletin, No. 177
4
January/February 2004
THSteps provider for any laboratory test conducted on a specimen that is not accompanied with client information sufficient
to verify Medicaid eligibility. Sources: 2003 TMPPM-Texas Health Steps, page 22; 2004 TMPPM-Texas Health Steps,
page 23.
THSteps laboratory specimens submitted to TDH must include the client’s name and Medicaid number as they appear on
the Form 3087 on a THSteps Laboratory Request (Form NBS-3, G--1A, G-1B). Write PENDING in the Medicaid number space
if a number is not currently available but is pending (such as, a newborn or a newly certified client patient verified by a Form
1027 as eligible for Medicaid).
Important: These services and supplies are limited to THSteps medical checkup and laboratory services provided in the
course of a medical checkup to THSteps clients. Unauthorized use of services and supplies is in violation of
federal regulations. The $70 reimbursement for the complete medical checkup includes specimen collection,
shipping, and receiving test results from the TDH laboratory. Claims for tests listed in the following table
submitted by a provider or an outside laboratory for the same date of service as a THSteps medical checkup
are denied and subject to retrospective review:
Procedure Code
Tests
5-85014,
5-X7619
Total hemoglobin
5-85014,
5-X7619
Hematocrit
5-83020
Hemoglobin electrophoresis
5-83655
Lead
5-86592
Syphilis; qualitative (e.g., VDRL, RPR, ART)
5-86403
Particle agglutination; screen, each antibody
5-80061
Lipid panel
5-82465
Cholesterol, serum; total
5-83718
HDL cholesterol
5-84478
Triglycerides
5-87490
Chlamydia (direct probe)
5-87590
Gonorrhea (direct probe)
5-86701
HIV-1
5-86689
HIV confirmation (Western blot)
5-88150,
5-88142,
5-88164, 5-88147
Pap smear ■
January/February 2004
5
Texas Medicaid Bulletin, No. 177
Excluded Providers
In compliance with the Medicare and Medicaid Patient Protection Act of 1987, HHSC identifies providers or employees of
providers who have been excluded from state and federal health care programs.
Providers excluded from the Medicaid and Title XX programs must not order or prescribe services to clients after the
exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also
will be denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been
excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client.
Review the entire Exclusion List for Texas Medicaid at www.hhsc.state.tx.us/OIE/exclusionlist/exclusion.asp. Report
Medicaid providers who engage in fraud/abuse by calling 512-424-6519 or 888-752-4888, or by writing to the following
address:
Sharon E. Thompson, Director
HHSC Office of Program Integrity
PO Box 13247
Austin TX 78711-3247
Provider
License No.
Exclusion Date
City
State
LA
Abdullahi, Shadia
683211
12-Aug-03
New Orleans
Adams, Kathy Lynn
130145
10-Jun-03
Corpus Christi
De Soto
TX
Provider Type
Add Date
RN
04-Dec-03
LVN
13-Oct-03
Adelman, Harold F
H3965
6-Jun-03
MD
23-Oct-03
Amstutz, John F
90145
10-Jun-03
Seguin
LVN
13-Oct-03
Anderson, Christy D F
217626
11-Feb-03
Arlington
RN
8-Oct-03
Bache-Russell, Amanda B
532596
4-Oct-02
Dallas
RN
6-Oct-03
Bailey, George A
L0009
28-Mar-03
Houston
DO
Baker, Michele A
132810
10-Jun-03
Abbott
LVN
27-Oct-03
Baluch, Abdul
F7693
15-Aug-03
Lubbock
MD
25-Nov-03
Bauer, John
12539
1-Sep-03
Mansfield
DDS
15-Oct-03
Bazazzadegan, Julia E
1-Oct-03
09-Sep-03
Elmo
Beals, Lee E
181229
10-Jun-03
Dallas
04-Dec-03
Betros, Arnold
133522
10-Jun-03
Killeen
Boling, Louis A
118339
4-Mar-03
Brownsville
Brende, Marti A
583416
6-May-03
Bastrop
TX
RN
Broadnax, Terri L
158610
4-Mar-03
El Paso
TX
LVN
RN
3-Oct-03
TX
RN
22-Oct-03
TX
LVN
29-Oct-03
LVN
23-Oct-03
LVN
1-Oct-03
15-Oct-03
3-Oct-03
Brock, Cathleen
603398
28-Apr-03
Rockport
Brown, Janet
634487
29-May-03
Texas City
Brown, John D
40159
Houston
MD
23-Oct-03
Brown, Linda
152916
10-Jun-03
Austin
LVN
23-Oct-03
Broyles, Sarah E
256719
28-Apr-03
Houston
6-Aug-03
Houston
TX
Houston
TX
Bryant, Yolanda K
Callaway, Angelia D
168477
Campbell, Monte C
8511
4-Jun-03
4-Mar-03
20-Jun-03
Nederland
RN
1-Oct-03
LPC
6-Oct-03
BVNE
13-Oct-03
DDS
24-Nov-03
Cantu, M Sylvia
563331
11-Feb-03
San Marcos
RN
25-Sep-03
Cantu, Randolf G
H7709
15-Aug-03
Humble
TX
DO
21-Oct-03
Carlock, Brenda J
433452
11-Feb-03
Bay City
TX
RN
Carson, Royce L
172033
10-Jun-03
Lubbock
TX
LVN
Carter, Kimberly S
116021
Cash, Lenny
4-Mar-03
20-Oct-03
MD City
San Antonio
LVN
TX
2-Oct-03
23-Oct-03
7-Oct-03
04-Dec-03
Chan, Richard J
615203
13-May-03
Slidell
LA
RN
13-Oct-03
Chennault, Elizabeth G
250356
28-Apr-03
Austin
TX
RN
13-Oct-03
Clark, Beverly
G0588
6-Jun-03
Clark, Jacob D
153337
10-Jun-03
Texas Medicaid Bulletin, No. 177
6
Amarillo
TX
MD
27-Oct-03
Port Aransas
TX
LVN
3-Nov-03
January/February 2004
Provider
License No.
Exclusion Date
City
State
Provider Type
Add Date
Claypool, Patricia T
98640
10-Jun-03
Austin
LVN
4-Nov-03
Collier, Terri L
82867
10-Jun-03
Gladewater
TX
LVN
27-Oct-03
Cooke, Janice A
592864
10-Sep-02
Oklahoma City
OK
RN
25-Sep-03
Courson, Linda D
562198
09-Sep-03
Chino Valley
AZ
RN
24-Nov-03
29-Sep-03
Cuellar, Evangelina M
83394
4-Mar-03
Daniel, Richard Jay
21180
17-Dec-01
TX
LVN
TX
Pharm
Henderson
TX
92484
Daulton, Ellen S
510206
Davidson, Mysti D
180072
4-Mar-03
Davis, Kimberly R
143865
09-Sep-03
Day, Rebecca S
237145
11-Feb-03
Front Royal
Dietze, Beth A
464672
28-Apr-03
Corpus Christi
Dinh, Quan A
J8516
Dotson, Jennifer
662391
16-Apr-03
Dressendorfer, April
674331
13-May-03
Dumit, Sandra L
549285
10-Jun-03
19-Sep-03
Eckenroth, Rhonda R
48242
16-May-03
Edokpa, Andrew A
28174
20-Jul-03
Houston
PH
10-Oct-03
Ellis, Michael
D1205
15-Aug-03
Marshall
MD
15-Oct-03
Emerson, Timothy Joe
G8831
15-Aug-03
San Angelo
MD
24-Nov-03
Etemadi, Anthony S
169157
10-Jun-03
Brookeland
LVN
13-Oct-03
31-Mar-03
6-Jun-03
LVN
2-Oct-03
Daniels, Arlene
Durrence, Terri M
4-Mar-03
McAllen
Dallas
25-Sep-03
Abilene
RN
Roamoke
LVN
3-Oct-03
Houston
LVN
24-Nov-03
BNE
3-Oct-03
RN
1-Oct-03
VA
6-Oct-03
San Antonio
MD
29-Oct-03
Lake Jackson
RN
23-Oct-03
Lake Mary
FL
RN
27-Oct-03
Toledo
OH
RN
27-Oct-03
McGregor
LPN
4-Nov-03
Manvel
BVNE
8-Oct-03
Evans, Kimberly D
174147
10-Jun-03
Blooming Grove
LVN
22-Oct-03
Evans, Vicky L
176992
10-Jun-03
Port Arthur
LVN
27-Oct-03
Ezeude, Christopher
25864
16-Jun-99
Houston
R.Ph.
20-Nov-03
Beaumont
Cs Mn
7-Oct-03
Family Nursing Care Inc
2-Sep-03
Faulkenberry, Judy
225603
2-May-03
Houston
TX
RN
4-Nov-03
Feddersen, Janie L
582341
19-Feb-03
Springton
TX
RN
7-Oct-03
Fitzpatrick, Bobbie R
51381
10-Jun-03
Denison
LVN
22-Oct-03
Flower, Christopher
657556
11-Feb-03
Abernathy
RN
8-Oct-03
Foster, Sue A
149099
4-Mar-03
Jacksboro
LVN
5-Nov-03
Fowler, Patricia A
606312
10-Jun-03
Cedar Hill
RN
14-Oct-03
Franklin, Cheryl
629967
05-Sep-03
Frisco
RN
25-Nov-03
Gaddy, Coulter
600934
1-Apr-03
San Antonio
RN
10-Oct-03
Gallawa, Heather N
149789
9-Sep-03
Sacramento
Garcia, Amanda R
161314
4-Mar-03
League City
Garcia, Mary E
100063
09-Sep-03
Gardner, Nan F
86714
4-Mar-03
CA
Leander
Santa Fe
NM
LVN
13-Nov-03
LVN
8-Oct-03
LVN
25-Nov-03
LVN
7-Oct-03
Garrett, Kelley G
174147
10-Jun-03
Childress
LVN
27-Oct-03
Garza, Kim
646693
29-Apr-03
San Antonio
RN
10-Oct-03
Gass, Tracey
643143
13-May-03
Amarillo
Gilbreath, Flora A
585359
28-Mar-03
Jacksonville
Gill, Melanie B
582518
20-Dec-02
Tyler
Gloria, Meinrad D
635133
31-Jan-03
Indianopolis
Gonzales, Wendi R
165953
10-Jun-03
San Angelo
Goodge, David R
582570
1-Apr-02
Grissom, Lenore L
516872
20-Mar-03
January/February 2004
7
Hoquiam
Katy
RN
27-Oct-03
FL
RN
1-Oct-03
RN
6-Oct-03
IN
RN
13-Oct-03
LVN
23-Oct-03
WA
RN
25-Sep-03
RN
10-Oct-03
Texas Medicaid Bulletin, No. 177
Provider
License No.
Exclusion Date
Griswold, Jody M
K9204
6-Jun-03
Guajardo, Frank
K4072
15-Aug-03
Haley, April A
137336
4-Mar-03
Haliburton, Patricia L
127919
10-Jun-03
City
State
Provider Type
Add Date
Harlingen
DO
21-Oct-03
Uvalde
MD
15-Oct-03
Whitehouse
LVN
2-Oct-03
Waco
LVN
04-Dec-03
Haney, Nicolle D
571534
14-Apr-03
Dallas
TX
RN
Hardeman, Juanita
17036
09-Sep-03
Ft.Worth
TX
LVN
2-Oct-03
Hardin, Jennifer
641015
13-May-03
San Antonio
RN
3-Nov-03
Hargrove, Nora M
215364
11-Feb-03
Houston
RN
6-Oct-03
24-Nov-03
Harris, Victoria
223791
30-Jun-03
Fort Worth
RN
25-Nov-03
Harrison, Nancy R
562832
11-Feb-03
Sherman
RN
30-Sep-03
13-Oct-03
Harvey, Patricia
71977
10-Jun-03
San Antonio
LVN
Haskell, David D
650035
12-Dec-02
Midland
RN
Hill, John
164752
10-Jun-03
Jessup
Hill, Linda M
582852
21-Apr-03
Denton
RN
1-Oct-03
Hood, Michael W
127624
10-Jun-03
Rosharon
LVN
4-Nov-03
Hughes, Linda G
78529
Gorman
LVN
6-Oct-03
4-Mar-03
MD
6-Oct-03
LVN
23-Oct-03
Huie, Elizabeth M
547675
13-May-03
Rotan
RN
27-Oct-03
Hurst, Ylando M
127370
10-Jun-03
San Antonio
LVN
27-Oct-03
Hutcheson, Melanie M
164784
10-Jun-03
Levelland
LVN
13-Oct-03
Jones, Carolyn S
242123
25-Apr-03
Midland
RN
4-Nov-03
Julius, Lisa M
160164
10-Jun-03
Brownwood
LVN
27-Oct-03
Kahn, Beatrice M
558897
12-Aug-03
Houston
RN
24-Nov-03
Kelso, Adrienne
160153
4-Mar-03
Kennison, Victoria
647597
26-Apr-02
30-Jun-03
Aspermont
King, Sandra K
88277
09-Sep-03
Paris
Lentis, Nancy G
578715
11-Mar-03
Houston
RN
6-Oct-03
Lingner, John D
589364
20-Oct-03
Houston
RN
04-Dec-03
Mansfield, Nancy L
501981
11-Feb-03
Arlington
RN
Maples, Toni A
143512
10-Jun-03
Andrews
LVN
Marriott, Thomas F
667606
2-Jan-03
Marshall, Kathryn T
679426
20-Aug-03
Mathis, John D
673613
12-Aug-03
Arlington
McCormack, Ann M
673817
11-Feb-03
Sumter
McDaniel, Laurie
8741
31-Jul-01
Kerrville
LCDC
McLarty, Richard W
663133
14-Apr-03
Longview
RN
1-Oct-03
Meeks, Victoria A
151456
4-Mar-03
Merriman, Tracie L
563010
11-Mar-03
Sherman
Micker, Louise R
435025
11-Mar-03
Poughkeepsie
Miller, Doris L
250077
12-Aug-03
Lubbock
Kilgore, Erica
Houston
Arlington
Plano
680498
11-Apr-03
Greenfield
Moer, Deborah L
145666
10-Jun-03
Wichita Falls
Morriston, Frances A
166203
09-Sep-03
Rush Springs
Murphy, Michael P
645644
20-Aug-03
Waco
Neece, Stephen
E1910
15-Aug-03
Nicotre, Kristen R
170821
Norris, Darrell D
36547
Texas Medicaid Bulletin, No. 177
13-May-03
8
LVN
7-Oct-03
RN
25-Sep-03
LVN
04-Dec-03
4-Nov-03
TX
Austin
Miraglia, Maria C
4-Mar-03
TX
San Antonio
TX
SC
TX
NY
RN
3-Oct-03
RN
13-Nov-03
RN
24-Nov-03
RN
6-Oct-03
25-Sep-03
LVN
6-Oct-03
RN
8-Oct-03
RN
30-Sep-03
RN
25-Nov-03
RN
25-Nov-03
LVN
13-Oct-03
OK
LVN
04-Dec-03
TX
RN
24-Nov-03
Wichita Falls
MD
10-Oct-03
Woodville
LVN
8-Oct-03
Houston
OH
7-Oct-03
23-Oct-03
TX
PH
13-Oct-03
January/February 2004
Provider
License No.
Nunn, Ted A
170043
O'Brien, Robert J
J2712
Exclusion Date
10-Jun-03
6-Jun-03
City
Provider Type
Add Date
Burleson
LVN
23-Oct-03
Austin
MD
14-Oct-03
Ochoa, Yolanda
144018
10-Jun-03
El Paso
Ollison, Tommy G
78978
10-Jun-03
Gonzales
Omoile, Dada J
164534
09-Sep-03
Lewisville
25-Jan-00
Lewisville
Operation New Future
Otis, Shawn M
174361
8-Oct-03
Palmer, Regina K
245331
1-May-03
Parker, Rhonda S
160514
30-Sep-03
San Angelo
Perry, Eddie L
177057
10-Jun-03
Kansas City
Pierce, Paul Jr
Points, Jennifer K
178650
State
TX
LVN
13-Oct-03
LVN
22-Oct-03
LVN
24-Nov-03
27-Oct-03
Edinburg
TX
LVN
North Richland Hills
TX
RN
22-Oct-03
8-Oct-03
TX
LVN
30-Sep-03
MO
LVN
13-Oct-03
27-Oct-03
Garland
4-Mar-03
Kilgore
LVN
29-Sep-03
5-Nov-03
Porter, Terry S
177526
10-Jun-03
Gilmer
LVN
13-Oct-03
Pritchett, Tommy R
180981
10-Jun-03
Grand Saline
LVN
27-Oct-03
Quincy, John J
12052
1-Sep-03
Fort Worth
Quintana, Oscar F
K5672
6-Jun-03
Atlanta
GA
CO
DDS
23-Oct-03
MD
14-Oct-03
Radcliffe, Lorne J
639017
11-Mar-03
Colorado Springs
RN
2-Oct-03
Ray, Anthony C
502122
25-Apr-03
El Paso
RN
27-Oct-03
Redmond-Brown, Teresa
657677
24-Mar-03
Emory
RN
22-Oct-03
Renner, Helen L
601907
10-May-03
Converse
RN
27-Oct-03
Reyes, Knyvett J
126919
4-Mar-03
Arlington
LVN
6-Oct-03
Reynolds, Trudy W
618716
11-Feb-03
Huffman
RN
8-Oct-03
Rivera, Esperanza L
83669
Roberts, Kara
664379
11-Feb-03
4-Mar-03
San Antonio
LVN
Spring
RN
25-Sep-03
Roberts, Shana L
175740
09-Sep-03
Robinson, Jane C
437488
11-Mar-03
Robinson, Judith
599961
11-Feb-03
Las Cruces
Rome, Lisa J
112394
10-Jun-03
Baytown
Moran
LVN
25-Nov-03
Montgomery
RN
3-Oct-03
RN
13-Oct-03
LVN
4-Nov-03
Row, Brenda J
526691
13-May-03
Ruiz, Cheryl A
655407
10-May-03
Snyder
RN
23-Oct-03
Pflugerville
RN
27-Oct-03
NM
6-Oct-03
Ruiz, Tammy L
100692
10-Jun-03
San Angelo
LVN
22-Oct-03
Rutledge, Brian
F1958
15-Aug-03
Fort Worth
MD
15-Oct-03
Santibanez, Alfredo L
E-8234
11-Aug-03
Sarvis, Lucy Dorsey
518094
5-Apr-02
Houston
TX
MD
12-Nov-03
Dallas
TX
RN
3-Oct-03
TX
MD
14-Oct-03
LVN
25-Nov-03
MD
22-Oct-03
Scheffey, Eric H
E6607
29-Aug-03
Houston
Sewell, Beverly A
126147
09-Sep-03
Trinity
Shah, Sureshchandra
G0538
Shalchi, Alhareth A
6-Jun-03
21-Oct-02
Palm Desert
CA
Helotes
Clerk
2-Oct-03
Sharman, Ralph S
D7300
15-Aug-03
Houston
MD
21-Oct-03
Shaw, Jessica L
148062
10-Jun-03
Lubbock
LVN
27-Oct-03
Sill, Rani
111900
4-Mar-03
Pipe Creek
Silver, Patty L
612106
10-Jun-03
Las Cruces
NM
RN
22-Oct-03
Smith, Detra L
662260
19-Sep-03
Tishomingo
OK
RN
24-Nov-03
Staffel, Misty J
18158
20-Jun-03
Keller
DDS
13-Nov-03
Steingrube, Christina M
504380
11-Mar-03
Big Snady
RN
30-Sep-03
24-Sep-03
Corpus Christi
CNA
2-Oct-03
LVN
15-Oct-03
Tamez, Andrew
Taylor, Susan E
January/February 2004
123081
4-Mar-03
9
Rowlett
LVN
TX
6-Oct-03
Texas Medicaid Bulletin, No. 177
Provider
License No.
Exclusion Date
City
State
Teel, Becky A
149787
3-Dec-02
Lometa
Thomason, Noel D
555870
6-May-03
Fort Worth
TX
Thompson, Geraldine F
139673
9-Sep-03
Baytown
TX
Thompson, Karyl L
28701
3-Dec-02
Houston
NV
LVN
25-Sep-03
RN
13-Oct-03
LVN
13-Nov-03
LVN
25-Sep-03
510206
RN
15-Oct-03
Tidmore, Suzanne B
42879
09-Sep-03
Trinidad
LVN
24-Nov-03
Tiffie, Marylon L
555886
28-Feb-03
DeKalb
RN
25-Sep-03
Trader, Joanne R
162172
4-Mar-03
New Boston
LVN
25-Sep-03
17-Dec-01
Carrollton
650733
13-May-03
Houston
Truesdell, Shelley K
139836
4-Mar-03
Gainesville
LVN
Tungpalan, Erwin E
559494
5-Jun-03
Sugarland
RN
Trudo, Matthew
Las Vegas
Add Date
Thompson, Shannon Lea
Trinity Pharmacy
3-Mar-03
Provider Type
Pharm
TX
RN
2-Oct-03
25-Nov-03
6-Oct-03
22-Oct-03
Vela, Shelley Colene
554344
16-Apr-03
Big Springs
TX
RN
1-Oct-03
Vernon, Carol J
657802
10-Jun-03
Broken Arrow
OK
RN
23-Oct-03
27-Oct-03
Villareal, David
3924
17-Oct-00
Austin
LCDC
Waldon, Ramona L
548660
14-Feb-03
Gatesville
RN
Wallace, Marde E
150556
4-Mar-03
Dallas
BVNE
Walton, Kimberly L
160083
4-Mar-03
Joaquin
LVN
3-Oct-03
6-Oct-03
29-Sep-03
Wang (Thomas), Tien-Shih
14139
25-Nov-02
Houston
TX
DDS
Watson, Deidre D
535021
25-Apr-03
Houston
TX
RN
Watson, Lesa L
152410
4-Mar-03
Shreveport
LA
LVN
6-Oct-03
2-Sep-03
Beaumont
Owner
7-Oct-03
Webb, Oveta Darby
TX
5-Nov-03
13-Oct-03
Webb, Patricia R
257162
11-Feb-03
Texas City
RN
6-Oct-03
Welch, Linda S
BNE
23-Jan-03
Shoreaues
RN
3-Oct-03
Wells, Beverly Jean
1137808
4-Mar-03
Houston
LVN
8-Oct-03
Wendel, Dodie J
138398
3-Dec-02
Gonzales
LVN
8-Oct-03
Wickware, Cathy G
104106
09-Sep-03
Tyler
LVN
24-Nov-03
Williams, Betty R
22108
09-Sep-03
Nederland
LVN
24-Nov-03
Williams, Leona J
1106508
10-Jun-03
Katy
LVN
22-Oct-03
Williams, Stacy
637495
21-Apr-03
Houston
RN
6-Oct-03
Williams, William H
614232
27-Aug-03
Little Rock
RN
24-Nov-03
Winningham, Roy R
148643
4-Mar-03
San Antonio
LVN
Woodard, Lisa S
635714
11-Feb-03
Dallas
RN
30-Sep-03
Woodruff, Irma L
233896
24-Mar-03
Paris
RN
5-Nov-03
Wright, Robert W
659094
20-Jun-03
Tyrone
OK
RN
22-Oct-03
Zima, Robert
527329
11-Feb-03
Westport
MD
RN
25-Sep-03 ■
Texas Medicaid Bulletin, No. 177
10
8-Oct-03
January/February 2004
Forms
TMHP Electronic Funds Transfer (EFT) Information
Texas Medicaid Bulletin, No. 177
11
January/February 2004
TMHP Electronic Funds Transfer (EFT) Authorization Agreement
January/February 2004
12
Texas Medicaid Bulletin, No. 177
Provider Information Change Form
To update your provider files, complete this form and mail or fax it to the appropriate entity.
PRINT OR TYPE THE INFORMATION SUBMITTED ON THIS FORM.
Date: __________________
Nine-Character Texas Provider Identifier (TPI):_____________________________________
If you have more than one TPI that uses this same information, list the other TPIs: _______________________________
_______________________________________________________________________________________________________
Physical Address
(Cannot be a PO Box)
Accounting/Mailing Address
(W-9 Form Required)
Secondary Address
(Plan Use Only)
______________________________
______________________________
_____________________________
______________________________
______________________________
_____________________________
______________________________
______________________________
_____________________________
______________________________
______________________________
___________________________
Telephone
Telephone
Telephone
______________________________
Fax
______________________________
______________________________
Fax
______________________________
____________________________
Fax
______________________________
Type of Change: (check the appropriate box below)
r
Change of Physical Address, telephone and/or fax number
r
Change of Billing/Mailing Address, telephone and/or fax number
r
Change/Add Secondary Address, telephone and/or fax number
r
Change of Provider Status (i.e., termination from plan, moved out of area, specialist, etc.), Explain Below:
r
Other (i.e., panel closing, capacity changes, age acceptance, etc.)
Explanation Required:
___________________________________________________________________________________
___________________________________________________________________________________
Tax Information: IRS ID Number (attach W-9)______________________________ Effective Date __________________________
List the exact name reported to the IRS for the above Tax ID number: _______________________________________________
Must be signed and dated or changes cannot be completed:
Provider Signature: ___________________________________________
Date: ______________________________
E-mail Address: _____________________________________________
Send your completed change form to:
TMHP
ATTN: Provider Enrollment
PO Box 200795
Austin TX 78720-0795
FAX: 512-514-4214
If Managed Care, send this form via mail or fax to TMHP c/o your respective plan.
Name_________________________________________
January/February 2004
TPI___________________
13
Texas Medicaid Bulletin, No. 177
Notes
Texas Medicaid Bulletin, No. 177
14
January/February 2004
Notes
January/February 2004
15
Texas Medicaid Bulletin, No. 177
Visit the TMHP Web site at www.tmhp.com for the following provider
information:
•
HIPAA Information and Updates
•
2003-2004 Publications—includes the Texas Medicaid Provider Procedures Manual, Texas Medicaid Provider Procedures Manual - Texas
Health Steps, and Texas Medicaid Bulletins
•
78th Legislature Session Policy Changes
•
TDHconnect 3.0 Information
•
Regional Support—lists TMHP Provider Representatives
PRESORTED STANDARD
US POSTAGE PAID
AUSTIN TX
PERMIT NO 156
ATTENTION: BUSINESS OFFICE