STAR+PLUS PROGRAM
CLINICIAN MANUAL
APPENDIX
Definitions
Action also known as an adverse determination, is the denial or limited authorization of a
requested service, including the type or level of service; the reduction, suspension, or termination
of a previously authorized service; the denial in whole or in part, of payment for service; the
failure of an HMO to act within the timeframes; or, for a resident of a rural area with only one
HMO, the denial of a Medicaid members request to exercise his or her right to obtain services
outside of the network.
Behavioral Health Priority Population means those individuals served by HHSC who meet the
definition of the priority population. The priority population for behavioral health services is
defined as:
A. Children and adolescents under the age of 21 with a diagnosis of mental illness who exhibit
serious emotional, behavioral, or mental disorders and who:
1. have a serious functional impairment (GAF of 50 or less currently or in the past year); or
2. are at risk of disruption of a preferred living or child care environment due to psychiatric
symptoms; or
3. are enrolled in a school system's special education program because of a serious emotional
disturbance.
Children and adolescents do not meet the priority population criteria if they have a
single diagnosis of autism, pervasive developmental disorder, mental retardation, or
substance abuse.
B. Adults who have severe and persistent mental illnesses such as Schizophrenia, Major
Depression, Manic Depressive Disorder or other severely disabling mental disorders which
require crisis resolution or ongoing and long-term support and treatment.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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Chronic or complex condition means a physical, behavioral, or developmental condition which
may have no known cure and/or is progressive and/or can be debilitating or fatal if left untreated
or under-treated.
CMS means the Centers for Medicaid and Medicare Services formerly known as Health Care
Financing Administration (HCFA).
Community Based Alternatives (CBA) Waiver is the HHSC waiver program that provides
home and community-based services to aged and disabled adults as cost-effective alternatives to
institutional care in nursing homes.
Community Management Team (CMT) means inter-agency groups responsible for developing
and implementing the Texas Children’s Health Plan (TCHP) at the local level. A CMT consists
of local representatives from the following agencies: Department of Aging and Disability
Services (DADS); Mental Health Association of Texas (MHAT); Texas Department of Family
and Protective Services (DFPS); Health and Human Services Commission (HHSC); Texas
Juvenile Probation Commission (TJPC); Texas Youth Commission (TYC); Texas Rehabilitation
Commission (TRC); Texas Education Agency (TEA); Council on Early Childhood Intervention
(CECI). The CMT also includes parent representation. This organizational structure is
replicated in the State Management Team that sets overall policy direction for the TCHP
Community Resource Coordination Groups (CRCGs) means a statewide system of local
interagency groups, including both public and private physicians and other health care providers,
which coordinate services for “multi-problem" children and youth. CRCGs develop individual
service plans for children and adolescents whose needs can be met only through interagency
cooperation. CRCGs address complex needs in a model that promotes local decision-making and
ensures that children and adolescents receive the integrated combination of social, medical and
other services needed to address their individual problems.
Complex Need means a condition or situation that results in a need for coordination or access to
services beyond what a Primary Care Physician (PCP) would normally provide, and which
triggers the HMO's determination that a care coordinator is required.
Comprehensive Care Program (CCP or THSteps-CCP) is part of THSteps Program (known
nationally as EPSDT as mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1989.
OBRA requires all states to provide treatment for correction of physical or mental problems to
THSteps eligible clients for any medically necessary services and for which Federal Financial
Participation (FFP) is available even if the services are not covered under the state’s Medicaid
plan. This expansion of services is provided only for those clients who are younger than age 21
years and eligible to receive THSteps services.
Court-Ordered Commitment means a commitment of a STAR+PLUS Member to a psychiatric
facility for treatment that is ordered by the court of law pursuant to the Texas Health and Safety
Code, Title VII Subtitle C.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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Covered Services means health care services and health related services the HMO must provide
to Members, including all services required by this Contract and state and federal law, and all
value-added services described by the HMO or United Behavioral Health and approved by
HHSC.
Cultural Competency means the ability of individuals and systems to provide services
effectively to people of various cultures, races, ethnic backgrounds, and religions in a manner
that recognizes values, affirms and respects the worth of individuals, and protects and preserves
their dignity.
DADS means Department of Aging and Disability Services, which includes the state agency,
TDMHMR, and the Local Mental Health and Mental Retardation Authorities.
Denied Claim means a clean claim or a portion of a clean claim for which a determination is
made that the claim cannot be paid.
Disabled Person or Person with Disability means a person less than 65 years of age, including
a child, who qualifies for Medicaid services because of a disability.
Disability means a physical or mental impairment that substantially limits one or more of the
major life activities of an individual.
Disability-Related Access means that facilities are readily accessible to and usable by
individuals with disabilities, and that auxiliary aids and services are provided to ensure effective
communication, in compliance with Title III of the Americans with Disabilities Act.
ECI means Early Childhood Intervention, which is a federally mandated program for infants and
children under the age of three with, or at risk for, developmental delays and/or disabilities. The
federal ECI regulations are found at 34 C.F.R. 303.1 et seq. The state ECI rules are found at 25
TAC §621.21 et seq.
Emergency Behavioral Health Condition means any condition, without regard to the nature or
cause of the condition, which in the opinion of a prudent layperson possessing an average
knowledge of health and medicine requires immediate intervention and/or medical attention
without which Members would present an immediate danger to themselves or others or which
renders Members incapable of controlling, knowing or understanding the consequences of their
actions.
Encounter means a covered service or group of services delivered by a provider to a Member
during a visit between the Member and provider. This also includes value-added services.
Encounter Data means data elements from fee-for-service claims or capitated services proxy
claims that are submitted to HHSC by HMO in accordance with HHSC’s “HMO Encounter Data
Claims Submission Manual.”
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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EPSDT means the federally mandated Early and Periodic Screening, Diagnosis and Treatment
program contained at 42 United States Code 1396d(r). The name has been changed to Texas
Health Steps (THSteps) in the State of Texas. (See definition for THSteps.)
Evercare STAR+PLUS is an HMO selected by the State of Texas to participate in the
STAR+PLUS Medicaid Managed Care Program. Evercare STAR+PLUS is committed to special
needs populations, and has expanded its physicians and other health care providers delivery
system to serve individuals with long-term care needs in authorized service areas. Evercare
STAR+PLUS has contracted with United Behavioral Health to provide covered behavioral
health services which include mental health and substance abuse services.
Fair Hearing means the process adopted and implemented by the HHSC, 25 TAC Chapter 1, in
compliance with federal regulations and state rules relating to Medicaid Fair Hearings for Acute
Care Services, found at 42 CFR Part 431, Subpart E, and 1 TAC, Chapter 357, or a hearing
conducted under the rules set forth in 40 TAC chapter 79, Subchapters L, M and N for Long
Term Care services.
FQHC means a Federally Qualified Health Center that has been certified as such by CMS to
meet the requirements of §1861(aa)(3) of the Social Security Act and is enrolled as a physician
and other health care providers in the Texas Medicaid program.
Health and Human Service Commission Mental Health and Substance Abuse Program,
formerly Texas Commission on Alcohol and Drug Abuse (TCADA) which is responsible for
licensing chemical dependency treatment facilities as well as contracting with physicians and
other health care providers to deliver chemical abuse treatment services.
HHSC means Health and Human Services Commision, formerly known as the Texas
Department of State Health Services.
Individualized Care Plan (ICP) means an individualized plan of care developed with and for
STAR+PLUS Members that have chronic or complex conditions. An ICP includes, but is not
limited to, the following:
a) a Member’s history
b) a summary of current medical and social needs and concerns
c) short and long term needs and goals
d) a list of services required, their frequency and a description of who will provide the
services
Linguistic Access means translation and interpreter services, for written and spoken language to
ensure effective communication. Linguistic access includes sign language interpretation, and the
provision of other auxiliary aids and services to persons with disabilities.
Local Health Department means a local health department established pursuant to Health and
Safety Code, Title 2, Local Public Health Reorganization Act §121.031.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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Local Mental Health Authority (LMHA) means an entity within a specified region responsible
for planning, policy development, coordination, and resource development and allocation and for
supervising and ensuring the provision of behavioral health care services to persons with mental
illness in one or more local service area
Medical Assistance Only (MAO) means one of the three primary classes of Texas Medicaid
clients. The other two are Public Assistance and Supplemental Security Income (SSI). Medical
Assistance Only (MAO) clients receive no cash assistance but receive "Medical Assistance
Only." MAO clients are related to the financial assistance programs in that, except for some
eligibility criteria, they would be eligible for money payments. This means that they are in one of
the categories of aged, blind, disabled or families with dependent children.
Medicare is a health insurance program for people 65 and older and some people under age 65
who are disabled. It is a federal government program authorized under Title XVIII of the Social
Security Act and is administered by CMS. For people with very low incomes, state Medicaid
programs may pay the amounts Medicare does not pay, and may pay some health care expenses
not covered by Medicare if the individual is also eligible for Medicaid.
Member means a person who is entitled to benefits under Title XIX of the Social Security Act
and Medicaid and is in a Medicaid eligibility category included in the STAR+PLUS Program
and who is enrolled in the STAR+PLUS Program and the HMO’s STAR+PLUS HMO;
Member Complaint or Grievance means an expression of dissatisfaction about any matter
other than an action, as defined above. As provided by 42 C.F.R. §438.400, possible subjects for
complaints include, but are not limited to, the quality of care of services provided,
and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure
to respect a Member’s rights.
Provider means any physician or other health care provider or facility contracted with UBH to
provide mental health or substance abuse services.
Qualified Disabled and Working Individual (QDWI) is one whose only Medicaid benefit is
payment of the Medicare Part A premium. The Omnibus Budget Reconciliation Act of 1989
requires the state to pay the Medicare Part A premiums for certain disabled and working
individuals who are enrolled in Medicare Part A, who are not otherwise eligible for Medicaid,
who have countable income of no more than 200% of the Federal poverty level, and whose
countable resources do not exceed twice the resource limit of the SSI program.
Qualified Medicare Beneficiary (QMB) is an individual who does not receive Medicaid
benefits other than Medicare premiums, deductible and coinsurance liabilities. The Medicare
Catastrophic Coverage Act of 1988 requires HHSC to pay Medicare premiums, deductibles, and
coinsurance for individuals who are entitled to Medicare Part A, whose income does not exceed
100% of the federal poverty level, and whose resources do not exceed twice the resource limit of
the SSI program.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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Representative means a person who can make care-related decisions for a Member who is not
able to make such decisions alone. A representative may, in the following order of priority, be a
person who is:
a court-appointed guardian of the person;
a spouse or other family member (parent) as designated by the Member or the State's
surrogate decision maker statute; or
designated as the Member’s health care Representative
SED means severe emotional disturbance as defined by a Local Mental Health Authority
Service Area the counties included in any HHSC-defined Core and Optional Service Area as
applicable to each HMO program.
Significant Traditional Physicians (STP). Primary Care Providers and long-term care
Providers, identified by HHSC as having provided a significant level of care to Fee-for-Service
clients. Disproportionate ShareHospitals (DSH) are also Medicaid STPs. For acute care services,
STP means all hospitals receiving disproportionate share hospital funds (HHSC) in Fiscal Year
‘97 (FY ‘97) and all other physicians and other health care providers in a county that, when listed
by physicians and other health care providers type in descending order by the number of
recipient encounters, provided the top 80% of recipient encounters for each physicians and other
health care providers type in FY’97. For Long Term Care services, STP means a physician and
other health care provider with whom Medicaid recipients have well-established or longstanding
health care providers/client relationships, or to whom the recipients have typically or
traditionally gone for health care, emergency care or family planning advice. A physician and/or
other health care provider falling within this definition shall be determined by criteria established
by the state.
Special Health Care Needs means a Member with an increased risk of disability, including but
not limited to: chronic physical or developmental condition; severe and persistent mental illness;
behavioral or emotional condition that accompanies the Member’s physical or developmental
condition.
Special Hospital means an establishment that:
a) offers services, facilities, and beds for use for more than 24 hours for two or more
unrelated individuals who are regularly admitted, treated, and discharged and who
require services more intensive than room, board, personal services, and general
nursing care;
b) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities, or
other definitive medical treatment;
c) has a medical staff in regular attendance; and
d) maintains records of the clinical work performed for each patient.
Specified Low-Income Medicare Beneficiary (SLMB) is an individual who’s only Medicaid
benefit is payment of the Medicare Part B premium. The Omnibus Budget Reconciliation Act of
1990 requires the state to pay the Medicare Part B premiums for individuals who are enrolled in
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Medicare Part A, whose income is more than 100% of the Federal Poverty Level (FPL) but less
than 120% of the FPL, and whose resources do not exceed twice the resource limit of the SSI
program. SLMB is considered an extension of QMB.
Special Needs mean an increased prevalence of risk of disability.
SPMI means severe and persistent mental illness.
STAR+PLUS is the name of the State of Texas Medicaid managed care program that provides
and coordinates preventive, primary, acute and long-term care services to persons of all ages
with
disabilities and elderly persons 65 and over who qualify for Medicaid through SSI/MAO.
Supplemental Security Income (SSI) is a federal cash assistance program of direct financial
payments to the aged, blind, and disabled. It is federally administered by the Social Security
Administration under Title XVI of the Social Security Act and funded through general federal
tax
revenues. All persons who are certified as eligible for SSI in Texas are eligible for Medicaid.
Local Social Security Administration (SSA) claims representatives make SSI eligibility
determinations. The transactions are forwarded to SSA in Baltimore, who then notifies the states
through the State Data Exchange (SDX).
SSI beneficiary is a person that receives supplemental security income cash assistance as cited
in 42 USCA § 1320 a-6.
TAA: Texas Access Alliance (TAA) (f/k/a) MAXIMUS is the Enrollment Broker for the State of
Texas Access Reform (STAR) program, and Children’s Health Insurance Program (CHIP), and
manages the THSteps program. TAA serves as an intermediary between the Health Maintenance
Organizations (HMOs), the Primary Care Case Management (PCCM) Administrator, the
Recipients, and the State. They provide newly certified clients packets of information about the
plan choices available in their county of residence.
TAC means Texas Administration Code.
TCADA means Texas Commission on Alcohol and Drug Abuse, the state agency responsible for
licensing chemical dependency treatment facilities. TCADA also contracts with physicians and
other health care providers to deliver chemical dependency treatment services.
TCHP stands for Texas Children’s Health Plan and means an inter-agency, state-funded
initiative
that plans, coordinates, provides and evaluates service systems for children and adolescents with
behavioral health needs. The Plan is operated at a state and local level by Community
Management Teams representing the major child-serving state agencies.
TDD means telecommunication device for the deaf. It is interchangeable with the term teletype
United Behavioral Health
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machine or TTY.
TDI means the Texas Department of Insurance.
TDMHMR means the Texas Department of Mental Health and Mental Retardation.
THSteps means Texas Health Steps, which is the name adopted by the State of Texas for the
federally mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.
It includes the state’s Comprehensive Care Program extension to EPSDT, which adds benefits to
the federal EPSDT requirements contained in 42 United States Code §1396d(r), and defined and
codified at 42 Code of Federal Regulations §440.40 and §§441.56-62. HHSC rules relating to
EPSDT are contained in TAC, Title 25, Part 1, Chapter 33.
TMHP means Texas Medicaid Healthcare Partnership.
Texas Medicaid Provider Procedures Manual means the policy and procedures manual
published by or on behalf of the State, which contains policies and procedures required of all
health care physicians and other health care providers who participate in the Texas Medicaid
program. The manual is published annually and provides bi-monthly updates called “Medicaid
Bulletins”. These bulletins can be found at the Texas Medicaid and Healthcare Partnership’s
(TMHP) website at www.tmhp.com.
Texas Medicaid Service Delivery Guide means an attachment to the Texas Medicaid
Physicians
Procedures Manual.
United Behavioral Health (UBH) is a managed behavioral health organization, contracted with
Evercare to manage the behavioral health benefits of the Evercare STAR+PLUS Membership.
Urgent Behavioral Health Situations: behavioral health condition that requires attention and
assessment within twenty-four (24) hours, but which does not place the Member in immediate
danger to himself, herself, or others, and the Member is able to cooperate with treatment.
Urgent Condition: a health condition, including an Urgent Behavioral Health Situation, which is
not an emergency, but is severe or painful enough to cause a prudent layperson, possessing the
average knowledge of medicine, to believe that his or her condition requires medical treatment,
evaluation, or treatment within twenty-four (24) hours, by the Member’s PCP or PCP designee,
to prevent serious deterioration of the Member’s condition or health.
Value-Added Services means an extra service to Evercare STAR+PLUS Members that the state
has approved to be included in the Evercare STAR+PLUS contract for which Evercare
STAR+PLUS does not receive capitation.
Introduction
United Behavioral Health
Evercare STAR+PLUS
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ppendix
United Behavioral Health welcomes you as a member of our growing network of high-quality
clinicians providing care to Evercare STAR+PLUS Medicare enrollees in Texas. You play a key
role as we pursue our commitment to improve the health and well-being of all UBH members.
United Behavioral Health has contracted with Evercare STAR+PLUS to provide covered
behavioral and substance abuse services. As part of this agreement, UBH has developed this
appendix to the UBH Clinician Manual to serve as a resource and reference guide to the
Evercare STAR+PLUS product as it relates to behavioral health clinicians.
Background
STAR+PLUS is a Texas Medicaid program designed to integrate delivery of acute and long-term
care services through a managed care delivery system. The STAR+PLUS project is aimed at
Medicaid recipients with chronic and complex conditions who need more than typical acute care
services. These recipients usually need personal care services to assist with their activities of
daily living. The HMO networks include acute and long-term care physicians and other health
care providers and are able to offer the continuum of care required to meet these recipient’s
needs. Texas Health and Human Services Commission (HHSC) is the operating agency for
STAR+PLUS.
Participants may select one of the HMOs contracted with HHSC to provide STAR+PLUS
services. Evercare STAR+PLUS is one of the HMOs selected by the State of Texas to
participate in the STAR+PLUS Medicaid Managed Care Program. United Behavioral Health
under agreement with Evercare STAR+PLUS administers mental health and substance abuse
benefits for Evercare STAR+PLUS Members.
As a participating health care delegate within the STAR+PLUS program, our commitment is to
provide all Texans, regardless of age or health status, with access to quality behavioral health
care services. United Behavioral Health is committed to special needs populations, and has
expanded its clinical network delivery system to serve individuals with long-term care needs in
state designated service areas.
Objectives of Program
The objectives of the STAR+PLUS program are to:
Improve the access to care for Members
Increase quality and continuity of care for Medicaid clients
Decrease inappropriate usage of the health care delivery system, e.g. Emergency rooms
for nonemergencies
Achieve cost-effectiveness and efficiency for the state
Promote physicians and other health care providers and client satisfaction
Integrate acute and long-term care
Coordinate Medicare services for clients who are dually eligible
United Behavioral Health contracted clinicians will be trained in relevant areas of United
Behavioral Health operations, including cultural and linguistic sensitivity, confidentiality, quality
improvement, and utilization management. Additionally, United Behavioral Health will offer
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Evercare STAR+PLUS
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ongoing in-service training on topics of importance to clinicians who serve the STAR+PLUS
Member population.
How to Reach Us
State Agency Contacts
TAA/MAXIMUS 1-800-964-2777 (For state eligibility issues & enrollment)
STARLINE 713-767-3919 or 1-800-411-9929 (Medicaid questions, eligibility)
Texas Medicaid & Healthcare Partnership (TMHP)
(Automated eligibility, Texas Medicaid Claims Payment, Obtain TPI/Medicaid #s) 1-800-925-9126
Medical Transportation Program (MTP) 1-877-MED-TRIP (1-877-633-8747)
United Behavioral Health Contacts
Customer Service Center 1-866-302-3996
TTY 1-888-331-5674
(For Claims Issues, Clinician Questions Mon.-Fri., 7:30 AM to 6:00 PM (CST) Eligibility,
member services)
Authorizations 1 - 866-302-3996
Claims Submission Address:
SCS/UBH
P O Box 30757
Salt Lake City, Utah 84130-0757
Clinician Updates and Other United Behavioral Health Information www.ubhonline.com
Online Claims Submissions, Check Claim Status, Check Patient Eligibility
www.ubhonline.com
STAR+PLUS Member Identification
The Evercare STAR+PLUS Member will receive an identification card and letter that will have
the Member’s name and Evercare STAR+PLUS ID number and the Primary Care
Physician’s (PCP’s) name and number. This card identifies the individual as an Evercare
STAR+PLUS Member. To determine eligibility if the Member does not have an identification
card, you may call the Customer Service number listed in the “How To Reach Us” section of this
manual for verification. Members may have a copy of their enrollment form as interim proof of
membership until a card is sent.
Benefits
Covered Services
STAR+PLUS Members receive all the benefits of the traditional Texas Medicaid program.
Members that are eligible only for Medicaid will receive unlimited medically necessary
prescription drugs through the Vendor Drug Program. Members that are dually eligible must
select the same Medicare and Medicaid HMO to receive unlimited prescription drug benefits.
Children (under 21 years of age), residents of a nursing facility and clients in the Community
Based Alternatives (CBA) program also receive unlimited medically necessary prescriptions
through the Vendor Drug Program, regardless of Medicare coverage.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
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All covered services under the STAR+PLUS program are available regardless of pre-existing
conditions, prior diagnoses, or receipt of any prior health care services.
The Texas Medicaid Providers Procedures Manual outlines covered services and
limitations such as:
 Behavioral Health Hospital Inpatient Services
 Hospital Outpatient Services
 Professional Services
 Professional Lab and Radiology Services
 Vision Services
 Ambulance Services
 Home Health Services
 Rural Health Services
 Ambulatory Surgical Centers
 Certified Nurse Midwife Services
 Birthing Center
 Maternity Clinic Services
 Transplant Services
 Federally Qualified Health Centers
 Adult Well Check
 Family Planning
 Genetics
 Renal Dialysis
 EPSDT Medical Check-ups
 EPSDT CCP Program
 Total Parenteral Hyperalimentation (TPN)
 Physical Therapy
 Occupational Therapy
 Speech/language Therapy
 Screening and Stabilization

Evercare STAR+PLUS will be responsible for all covered services under the STAR+PLUS
program for the period in which Evercare STAR+PLUS has received payment, except: Services
provided by non-approved physicians and other health care providers Services provided without
HMO authorization, unless emergent Dually eligible members, those with Medicare coverage,
should file Medicaid covered services
outlined in the Texas Medicaid Provider Procedures Manual with Medicare as primary and
TMHP will remain the secondary payer. Examples: eyeglasses, hearing aids, ambulance, and
some home health Hospital charges for admissions prior to enrollment in Evercare STAR+PLUS
remain the responsibility of the previous payer, if any. In certain service areas, hospital charges
are the responsibility of TMHP until further notice.*
Durable Medical Equipment ordered prior to Member enrollment is the responsibility of the
previous payer, if any
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
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*Medicaid HMO Contractors are responsible for providing a benefit package to Members that
includes all medically necessary services covered under the traditional, fee-for-service Medicaid
programs except for Non-capitated Services provided to Medicaid Members outside of the HMO
capitation. In addition to the non-capitated services, Hospital Inpatient Stays are excluded from
the capitation payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative
Contractor (TMHP) responsible for payment of Traditional Medicaid fee-for-service claims.
Medicaid HMO Contractors must coordinate care for Members for these Non-capitated Services
so that Members have access to a full range of medically necessary Medicaid services, both
capitated and non-capitated. A Medicaid HMO Contractor may elect to offer additional acute
care Value-added Services.
.
Evercare STAR+PLUS and/or United Behavioral Health coordinates Member care between its
clinical network and local community programs and/or physicians and other health care
providers, such as:
 Women, Infants, and Children (WIC)
 Early Childhood Intervention (ECI)
 Family Planning Programs
 Local Mental Health Authority (LMHA)
 Local Health Department

Physician and health care providers are contractually bound to provide appropriate assistance to
Members that may have limited English proficiency or reading skills. If the physician or health
care
provider is unable to accommodate the Member, the physician or health care provider must
contact
United Behavioral Health for assistance by calling the UBH Intake Department at 866-302-3996.
A
translation service using Language Line Services or visiting www.languageline.com is available
at
the request of the Member, the physician or health care provider.
Transportation
Evercare STAR+PLUS is responsible for ambulance transportation for Members eligible for
Medicaid only, as outlined in the Texas Medicaid Provider Procedures Manual. This includes
emergent and non-emergent ambulance transportation for the severely disabled.
Behavioral Health Care
United Behavioral Health is the administrator of behavioral health and chemical dependency
services for Evercare STAR+PLUS Medicaid Members only. United Behavioral Health will
work closely with Evercare STAR+PLUS care coordinators and will develop an integrated Care
Management program with the medical physicians and other health care providers of the health
plan. There are dedicated care coordinators at the health plan as well as Care Managers at UBH
to assist Members and physicians and other health care providers in accessing and receiving
services under STAR+ PLUS.
The benefits available for STAR+PLUS Members who need behavioral health or chemical
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dependency services are outlined below. All must be pre-authorized by UBH.
Foreign Language Translation Services
Children and Adolescents
Emergency hospitalization and treatment of acute psychiatric episodes, or medically
necessary detoxification
Inpatient treatment under the direction of a psychiatrist, in an accredited inpatient
hospital
Individual, group and/or family therapy provided by a behavioral health clinician
Immediate crisis intervention services 24 hours/day to provide support in situations
where the Member’s decision making and coping patterns are temporarily impaired
Evaluation and diagnostic services (to include a diagnostic interview and, as
indicated, psychological testing) by a behavioral health clinician to determine the
presence or absence of a psychiatric disorder
Evaluation and monitoring of psychotropic medication
Laboratory and radiology services for diagnosis and medication regulation
Individual, group and/or family therapy
Adults
Emergency hospitalization and treatment of acute psychiatric episodes, or medically
necessary detoxification
Inpatient treatment under the direction of a psychiatrist, in an accredited inpatient
hospital*
Individual, group and/or family therapy provided by a psychiatrist
Immediate crisis intervention services 24 hours/day to provide support in situations
where the Member’s decision making and coping patterns are temporarily impaired
Evaluation and diagnostic services (to include a diagnostic interview and, as
indicated, psychological testing) by a behavioral health clinician to determine the
presence or absence of a psychiatric disorder
Evaluation and monitoring of psychotropic medication
Laboratory and radiology services for diagnosis and medication regulation
Outpatient behavioral health services are limited to 30 visits per Member per calendar year.
Please contact UBH for authorization of an extension to outpatient sessions beyond the 30 visits.
Additional outpatient services will be authorized in 10 visit increments.
*Medicaid HMO Contractors are responsible for providing a benefit package to Members that
includes all medically necessary services covered under the traditional, fee-for-service Medicaid
programs except for Non-capitated Services provided to Medicaid Members outside of the HMO
capitation. In addition to the non-capitated services, Hospital Inpatient Stays are excluded from
the capitation payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative
Contractor (TMHP) responsible for payment of Traditional Medicaid fee-for-service claims.
Medicaid HMO Contractors must coordinate care for Members for these Non-capitated Services
so that Members have access to a full range of medically necessary Medicaid services, both
capitated and non-capitated. A Medicaid HMO Contractor may elect to offer additional acute
care Value-added Services.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 13 -
NOTE: “Court-Ordered Commitment” means a commitment of a Member to a
psychiatric facility for treatment that is ordered by a court of law pursuant to the Texas Health
and Safety Code, Title VII, Subtitle C. The HMO must provide inpatient psychiatric services to
Members under the age of 21, up to the annual limit, who have been ordered to receive the
services by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the
Texas Health and Safety Code, relating to Court-Ordered Commitments to psychiatric facilities.
The HMO is not obligated to cover placements as a condition of probation, authorized by the
Texas Family Code. The HMO cannot deny, reduce or controvert the Medical Necessity of
inpatient psychiatric services provided pursuant to a Court-ordered Commitment for Members
under age 21. Any modification or termination of services must be presented to the court with
jurisdiction over the matter for determination. A Member who has been ordered to receive
treatment under the provisions of Chapter 573 or 574 of the Texas Health and Safety Code can
only Appeal the commitment through the court system.
Value Added Behavioral Health Services
United Behavioral Health is committed to providing innovative services to the Evercare
STAR+PLUS Member. These innovative services are designed to create a continuum of care,
which allows for flexibility in service delivery at all levels of care. This reduces the need for the
more restrictive treatment modalities (such as inpatient admission), when clinically appropriate.
These innovative programs may be coordinated with publicly funded, non-STAR+PLUS
treatment programs (such as residential treatment, ongoing specialty group counseling programs
for sexual abuse victims and “first offender” programs). All value added services must be prior
authorized.
Some Value Added Services include:
Children and Adolescents
 Partial Hospitalization Program/Extended Day Treatment
 Intensive Outpatient Treatment/Day Treatment
 Residential
 Forensic Services related to a person’s involvement with the legal system
 Individual, group and/or family therapy provided by a psychologist or behavioral health
 Clinician (e.g. UBH network Masters level clinician).
 Off-site Services: home based services, school based services, mobile crisis services,
Intensive case management.
Adults
 Partial Hospitalization Program/Extended Day Treatment
 Intensive Outpatient Treatment/Day Treatment
 Residential
 Forensic Services related to a person’s involvement with the legal system
 Individual, group and/or family therapy provided by a psychologist or behavioral health
 clinician (e.g. UBH network Masters level clinician).
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 14 -

Off-site Services: home based services, school based services, mobile crisis services,
intensive case management.
Member Access to Services
Members are able to self-refer for routine behavioral health care appointments without a referral
from their (Primary Care Physician) PCP. However, certification of benefits from United
Behavioral Health is required for all non-emergent services. To ensure continuity and
coordination of behavioral health care, behavioral health clinicians will communicate closely
regarding diagnosis and treatment planning. The Member or the clinician must call United
Behavioral Health’s toll-free number at 1-866-302-3996 to certify services. UBH provides for
24-hour, telephonic availability. Emergency services, care management and crisis services will
be centralized and available 24 hours per day/ 7 days per week via 1-866-302-3996. In this way
United Behavioral Health assists Members and referral sources in facilitating crisis response
continuously. Face-to-face assessment for acute and crisis situations are available 24 hour per
day, 7 days per week including holidays.
Behavioral Health Needs Identification
In non-emergent situations, initial certification of benefits for assessment is obtained by a
telephone conversation between the Member or family member and a UBH staff member. In
addition, the clinician may also request initial certification. When a Member calls seeking
referrals UBH staff will assess the Member’s safety, collect demographic information, explain
the services available under their benefit plan, and obtain a brief description of the presenting
problem. A referral is then made to a UBH network clinician based on the clinical, cultural and
geographic needs of the Member.
In emergent situations, a medical professional in an emergency setting will identify the need for
behavioral health services.
Coordination with Local Mental Health Authority
Assessment to determine eligibility for rehabilitative and targeted Mental Health Mental
Retardation (MHMR) case management services is a function of the LMHA. United Behavioral
Health will coordinate services for Members with Severe and Persistent Mental Illness (SPMI) or
Severe Emotional Disturbance (SED) with the LMHA.
In addition, United Behavioral Health will coordinate with the LMHA and the state psychiatric
facilities regarding admission and discharge planning, treatment objectives and projected length
of stay for Members committed to care by a court order.
Quality Management for Behavioral Health Services
United Behavioral Health’s Quality Improvement (QI) Department monitors performance in the
following areas:
Access to Care
Member Satisfaction
Physician and Other Health Care Provider Satisfaction
Utilization Management
Quality Improvement/Management
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 15 -
PCP and BH practitioner coordination
The QI Department monitors the quality of care delivered to Members and the outcomes of
treatment through several clinical studies. Examples of studies completed are Major Depression,
Bipolar Disorder, and Reasons for Rehospitalization, Chronic Pain and Continuity of Care/PCP
Notification Study.
Another way to monitor the quality of care delivered to Members is through direct review of
medical records. The QI and Clinical Network Services departments review a sample of medical
records at least annually. Physicians and other health care providers are notified of the results of
the audits with strengths and weaknesses being identified. Corrective Action Plans are required
of physicians and other health care providers when performance falls below expected thresholds.
Quality of care issues are forwarded to the Regional Peer Review Committee. This committee
meets on an as needed basis. The committee reviews cases, determines an action, and notifies
the physician and the health plan of all corrective actions. The Peer Review process is strictly
confidential.
Coordination with Non-STAR+PLUS Covered Services
Certain Texas Medical Assistance Program components will be excluded from the services
covered under the STAR+PLUS program. United Behavioral Health is not responsible for
providing these services but is responsible for appropriate referrals for these services. These
services include:
Texas Agency Administered Programs and Case Management Services
Department of Family and Protective Services (DFPS): United Behavioral Health
STAR+PLUS works with DFPS to ensure that the at-risk population, both children in
custody and not in custody of DFPS, receive the services they need. Children who are
served by DFPS may transition into and out of United Behavioral Health STAR+PLUS
more rapidly and unpredictably than the general population, experiencing placements and
reunification inside and outside of the Evercare Star+Plus service area. During the
transition period and beyond, physicians and other health care providers must:
Refer suspected cases of abuse or neglect to DFPS
Contact DFPS for assistance with Members
Vendor Drug
The state administered Texas Medicaid Vendor Drug Program makes payment for prescriptions
of covered outpatient drugs only to pharmacy physicians and other health care providers
contracted with the Texas Vendor Drug Program. The only drugs eligible for Vendor Drug
reimbursement are listed in the current Texas listing of National Drug Codes. United Behavioral
Health is, however, responsible for assisting its Members with medication management through
its PCPs and/or specialists.
Preferred Drug List and Prior Authorization Program
To Request a Prior Authorization for a non-preferred agent:
The physician, another authorized prescriber or one of their staff representatives may
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 16 -
call Prior Authorization requests in to the Texas Prior Authorization Call Center
Hotline Monday – Friday 7:30 AM – 6:30 PM (CST) at: 1-877-PA-TEXAS (1-877- 728-3927)
**Prior authorization requests will not be handled via the Pharmacy Resolution Call Center.
**To obtain criteria requirements or more information on the Prior Authorization Program:
http://www.hhsc.state.tx.us/HCF/vdp/PT/PA_Program.html
Submitting Claims for a preferred drug at Point-of-Sale (POS)
If the claim is for a preferred agent the POS transaction will be approved. Fill the script per
standard store/facility procedures.
Submitting Claims for a non-preferred drug at the Point-of-Sale (POS)
If a prior authorization is not on file, expired or the claim does not meet the PDL prior
authorization criteria, the claim will be denied at the POS. The pharmacy or recipient should
contact the prescriber’s office. The prescriber has the option of switching the patient to a
preferred drug or requesting prior authorization if there is a clinical reason why the patient needs
to receive the non-preferred drug. Additional information may be required for evaluation of the
prior authorization before an approval can be issued. The pharmacy may provide the patient with
a 72-hour emergency supply after hours, on weekends, or in other situations when the physician
cannot be reached and the patient needs the drug right away.
Requesting a Prior Authorization for a non-preferred drug
Only the prescribing physician, another prescriber or one of their staff representatives can
request a prior authorization. Requests submitted with missing information will not be assessed
until that information can be provided. The following information will be required by the call
center in order to quickly assess the PA request:
Recipient-specific information:
Texas Medicaid assigned recipient ID number
Recipient Name and Date of Birth
Reason for requesting prior authorization for a non-preferred drug
Prescriber-specific information:
Texas Medicaid assigned provider ID number (5-character Texas license number)
Physician (or Delegating Physician) Name, Phone Number and Address
Claim-specific information:
Requested drug and strength
Day’s supply and number of refills
Request is Approved at the Call Center
If the Texas Prior Authorization Call Center approves the PA, the patient can to return to their
pharmacy to obtain the prescription. The drug claim will pay and no further action will be
required. The PA applies to a specific drug and all respective strengths. For example, another PA
will not be required when switching strengths.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 17 -
Request is Denied at the Call Center
If the Texas Prior Authorization Call Center denies the request, the physician’s office will be
notified immediately. The prescriber has the option of prescribing a preferred drug that does not
require PA or mailing in a Request for Reconsideration. If the Request for Reconsideration is
denied, within 7 to 10 business days, the patient will receive information in the mail outlining the
Texas Vendor Drug Program appeal process.
Early Childhood Intervention (ECI) Case Management/Service Coordination
Case management/service coordination services provided to children from birth to 2 years with a
developmental disability and/or developmental delay, as defined by ECI criteria. Members must
be referred within two working days of identification.
SHARS
Texas School Health and Related Services (SHARS) for children under age 21 with disabilities
who need audiology services, medical services, occupational therapy, physical therapy,
psychological services, speech therapy, school health services, assessment and counseling.
MHMR Targeted Case Management
Services provided to assist individuals who meet the Texas MHMR priority population definition
for Mental Illness or Mental Retardation in gaining access to needed services such as social,
educational and other services.
Behavioral Health Rehabilitation
Rehabilitative services provided to persons, regardless of age, who have a single severe mental
disorder, excluding mental retardation.
Texas Commission for the Blind Case Management
Case management services and visually impaired Medicaid eligible clients under 16 years of age.
This is limited to one contact per client, per month.
Medical Transportation
The Medical Transportation Program (MTP) provides transportation services to Medicaid
eligible clients that have no other means of transportation by the most cost-effective means.
MTP may also pay for an attendant if a physician and/or other health care providers document
the need, the Member is a minor, or there is a language barrier. MTP can reimburse gas money if
the member has an automobile but no funds for gas.
DADS Hospice Services
DADS Long Term Care Policy Section manages the Hospice Program through physicians and
other health care providers’ enrollment contracts with hospice agencies. Coverage of services
follows the amount, duration, and scope of services specified in the Medicare Hospice Program.
TMHP pays for services related to the treatment of the client’s terminal illness and for certain
physician services (not the treatments). Hospice care includes medical and support services
designed to keep clients comfortable and without pain during the last weeks and months before
death.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 18 -
i
All United Behavioral Health clinicians treating STAR+PLUS Members have the responsibility
to:
Verify STAR+PLUS Member eligibility prior to performing services.
Refer to in-network physicians and other health care providers.
Adhere to the United Behavioral Health certification of benefits policies.
Provide appropriate health education and instructions to the Member or, if the
Member is a child, to family members or primary caregivers.
Adhere to the United Behavioral Health appointment and accessibility standards for
Evercare STAR+PLUS Members.
Adhere to the United Behavioral Health medical record keeping and chart review
standards.
Provide services in compliance with generally accepted medical and behavioral health
standards for the community in which the services are rendered.
Provide services to Members in a non-discriminatory manner. Physicians and other
health care providers/clinicians must provide and/or arrange for delivery of services
and/or products in the same manner and quality as services that are provided to all
other patients. Physicians and other health care providers/clinicians will not
discriminate against any Member on the basis of race, color, creed, religion, sex,
sexual preference, national origin, health status, income level, or on the basis that
they are Members of Evercare STAR+PLUS.
Determine if Members have medical benefits through other insurance coverage.
Advocate for the Member as needed.
Notify UBH of any patient capacity changes. Panel limitations are non-restricted by
HHSC.
Notify UBH whenever you encounter changes to your office location, billing address,
phone number, Tax ID number, close your business, change your entity name, or
retire.
Behavioral Health Specific Responsibilities
Coordinate the Member’s care with the PCP, and provide consultation reports to the
Member’s PCP, with findings and recommendations, as indicated
Clinicians must refer Members with known or suspected and untreated physical
health problems or disorders to their PCP for examination and treatment, with the
Member’s or the Member’s legal guardian’s consent
Clinicians must send initial and quarterly (or more frequently if clinically indicated)
summary reports of a Members’ behavioral health status to their identified PCP, with
the Member’s or the Member’s legal guardian’s consent
Behavioral health clinicians may only provide physical health care services if they are
licensed and authorized to do so through UBH.
Clinicians and inpatient facilities must coordinate outpatient follow-up and/or
continuing treatment prior to discharge. The outpatient treatment must occur within
seven (7) days from the date of discharge. Clinicians must contact Members who
have missed outpatient follow-up appointments following an inpatient stay within 24
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 19 -
hours to reschedule appointments
Department of Family and Protective Services
All physicians and other health care providers must cooperate and coordinate with the
Department of Family and Protective Services (DFPS) for the care of a child who is receiving
services from or has been placed in the conservatorship of DFPS.
Physicians and other health care providers must be compliant with all provisions of the DFPS
service plan. Any modification or termination of ordered services must be presented and
approved by the court with jurisdiction over the matter for decision. A Member, or the parent or
guardian, whose rights are subject to an Order or Service Plan, cannot appeal the necessity of the
services ordered through United Behavioral Health Complaint and Appeals process or to HHSC.
Physicians and other health care providers must schedule medical and behavioral health
appointments within 14 day unless requested earlier by DFPS. Physicians and other health care
providers should report all recognized abuse and neglect with a referral to DFPS and abide by
United Behavioral Health policies related to Medical Records.
Access to Care Standards
Evercare STAR+PLUS is offered in a defined service area. Within the service area, Evercare
STAR+PLUS must offer a uniform benefit package and maintain a network of contracted
clinicians to meet access standards. Evercare STAR+PLUS must ensure that all covered services
are available and accessible through Evercare STAR+PLUS or United Behavioral Health, and all
medically necessary services are available 24 hours per day, seven days per week. To
accomplish this, STAR+PLUS has established access standards.
Evercare STAR+PLUS and United Behavioral Health monitors compliance with these standards
and takes appropriate corrective actions as necessary. United Behavioral Health and/or Evercare
STAR+PLUS also ensures that the hours of operation of contracted physicians and other health
care providers do not discriminate against the Member, and that services are provided in a
culturally competent manner to all Members, including those with limited English proficiency or
reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities.
Physicians and other health care providers are contractually bound to provide appropriate
assistance to Members that may have limited English proficiency or reading skills.
If the physicians and other health care providers are unable to accommodate the Member, they
must contact United Behavioral Health for assistance by calling the Customer Service number in
the “How to Reach Us” section in this manual.
Appointment and Accessibility Standards
United Behavioral Health has established standards to ensure the accessibility of
primary care services and specialist services. The United Behavioral Health Clinical
Network Services Department monitors physicians and other health care providers’
performance against the standards, and reports its findings to the Regional Quality
Improvement Committee (RQIC). The RQIC or designee takes corrective actions for
non-compliance when necessary.
Behavioral Health Services Appointment Standards
Emergency Care: Members should be seen immediately
Urgent Care: Members should be seen within 48 hours
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 20 -
Initial Outpatient Behavioral Health Care: Members should be seen within 10
business days
Accessibility Standards
Physicians and other health care providers are to be accessible by telephone to
STAR+PLUS Members 24 hours per day and 7 days per week. This standard may be
met through the use of a covering (on-call) physicians and other health care providers
rotation, an answering service, or a telephone pager system. An answering service
may be used after hours only if the physicians and other health care providers can
return the call within 30 minutes.
Physicians and other health care providers must be available to provide, or arrange for
the provision of, emergency medical services to STAR+PLUS Members 24 hours per
day and 7 days per week.
Physicians and other health care providers must maintain reasonable normal business
hours and take reasonable steps to respond to Member service needs after normal
business hours.
PCPs must maintain an office practice schedule of at least 20 hours per week.
Chemical Dependency Treatment
In compliance with the Texas Administrative Code regarding the utilization review of
chemical dependency treatment, United Behavioral Health follows the Level of Care
Guidelines set forth in 28 TAC, Part 1, Chapter 3, Subchapter HH, Rules 3.8001 through
3.8009. These rules cover utilization review criteria for admission, continued stay and
discharge. The Texas Commission on Alcohol and Drug Abuse Level of Care Guidelines
are available at www.ubhonline.com on the Guidelines/Policies page.
Member Rights and Responsibilities
Member Rights
United Behavioral Health will not prohibit a physician or other health care provider, acting
within the scope of his or her lawful practice, from advising, acting or advocating on behalf of
the Member about the Member’s condition, risks and treatment options. We are committed to
promoting the dignity, quality of life and appropriate standards of care for all of our members.
Members have the right to:
Respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:
Be treated fairly and with respect; and
Know that their medical records and discussions with their physicians and other health
care providers will be kept private and confidential.
Reasonable opportunity to choose a health care plan and primary care provider (the doctor or
health care provider they will see most of the time and who will coordinate their care) and to
change to another plan or provider in a reasonably easy manner. That includes the right to:
Be informed of how to choose and change health plans and primary care providers;
Choose any health plan that is available in their area and choose a primary care provider
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 21 -
from that plan;
Change their primary care provider;
Change health plans without penalty; and
Be educated about how to change their health plan or their primary care provider.
Ask questions and get answers about anything they don’t understand. That includes the right
to:
Have their provider explain their health care needs to them and talk to them about the
different ways their health care problems can be treated; and
Be told why services were not certified under the Member’s benefit plan.
Consent to or refuse treatment and actively participate in treatment decisions. That includes
the right to:
Work as part of a team with their provider in deciding what health care is best for them;
and
Say yes or no to the care recommended by their provider.
Utilize each available complaint process through the managed care organization and/or
through Medicaid. That includes the right to:
Make a complaint to their health plan or to the state Medicaid program about their health
care, provider or health plan;
Get a timely answer to their complaint
Access the plan’s appeal process and the procedures for doing so; and
Request a fair hearing from the state Medicaid program about their complaint.
Timely access to care that does not have any communication or physical access barriers.
That includes the right to:
Have telephone access to a medical professional 24 hours per day, 7 days per week in
order to obtain any needed emergency or urgent care;
Get medical care in a timely manner;
Be able to get in and out of a health care provider’s office, including barrier-free access
for persons with disabilities or other conditions limiting mobility, in accordance with the
Americans with Disabilities Act;
Have interpreters, if needed, during appointments with their provider and when talking to
their health plan. Interpreters include people who can speak in their native language,
assist with a disability, or help them understand the information; and
Be given an explanation they can understand about their health plan rules, including the
health care services they can get and how to get them.
STAR+PLUS Members receive a complete list of their Member rights and responsibilities in
their Member handbook. The Member handbook is included in their new Member packet.
Member Responsibilities
Learn and understand each right they have under the Medicaid program. That includes the
responsibility to:
 Learn and understand their rights under the Medicaid program;
 Ask questions if they do not understand their rights; and
 Learn what choices of health plans are available in their area.
 Abide by the health plan and Medicaid policies and procedures. That includes the
 responsibility to:
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 22 -
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Learn and follow their health plan rules and Medicaid rules;
Choose their health plan and a primary care provider quickly;
Make any changes in their health plan and primary care provider in the ways established
by Medicaid and by the health plan;
Keep their scheduled appointments;
Cancel appointments in advance when they cannot keep them;
Always contact their primary care provider first for non-emergency medical needs;
Be sure they have approval from their primary care provider before going to a medical
specialist; and
Understand when they should and should not go to the emergency room.
Share information relating to their health status with their primary care provider and
become
fully informed about service and treatment options. That includes the responsibility to:
Tell their primary care provider about their health;
Talk to their providers about their health care needs and ask questions about the different
ways their health care problems can be treated; and
Help their providers get their medical records.
Actively participate in decisions relating to service and treatment options, make personal
choices, and take action to maintain their health. That includes the following
responsibilities:
Work as a team with their provider in deciding what health care is best for them;
Understand how the things they do can affect their health;
Do the best they can to stay healthy; and
Treat providers and staff with respect.
Clinician and STAR+PLUS Member Grievance Process
Clinician and Member Appeals and Complaints
Resolution of Evercare Clinician, Facility and Member appeals and complaints are delegated to
UBH as of June 1, 2011. UBH is responsible for resolution of all Clinician, Facility and Member
Complaints and Appeals. The Member will be provided with the following UBH Complaint &
Appeal address:
United Behavioral Health
Attention: Appeals Department
4212 San Felipe PMB 448
Houston, TX 77027
The member will also receive the UBH Appeals and Complaints Customer Service number:
(Toll free) 877-447-5989
Providers should use the same contact information as provided to Evercare Members for appeals
and complaints.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 23 -
State Medicaid Fair Hearing Process:
A Member has the right to access the Texas Fair Hearing process at any time during the Appeal
process. However, if the Member requests an expedited Texas Fair Hearing process, the Member
will be notified that he/she must exhaust the UBH internal expedited Appeal process prior to
filing an expedited Fair Hearing request.
Members will be notified in writing of their rights to Access Fair Hearing Proceedings including
that they can be represented by an authorized representative.
You can request a Fair Hearing by contacting HHSC at 1-800-252-8263 or by mailing to:
Health Plan Operations – H-320
Health and Human Services Commission
ATTN: Resolution Consultant
P.O. Box 85200
Austin, TX 78708-5200
Marketing/Enrollment Standards and Guidelines
Marketing Standards & Guidelines
In order to ensure that all STAR+PLUS eligible Members are given freedom of choice when
participating in the state’s Medicaid managed care program, the Texas Health and Human
Services Commission has issued specific guidelines for educating Members about Medicaid
managed care. Any violation of these guidelines by Evercare STAR+PLUS/United Behavioral
Health physicians and other health care providers will result in swift and immediate action,
including contract termination.
As a physician or other health care provider you are able to educate Members, enabling them to
make the best choice for themselves and their care needs. Physicians and other health care
providers cannot, however, enroll members, or influence members to enroll with a specific health
plan. The following state enrollment guidelines apply to all Evercare STAR+PLUS/United
Behavioral Health physicians and other health care providers:
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In general, a clinician may not influence a Member to choose one health plan over
another, clinicians may merely educate.
Clinicians must inform Members of all health plans in which they may participate.
A Clinician may inform their patients of the benefits, services, and specialty care services
offered through the plans they participate in.
Clinicians may inform the Member of particular hospital services, specialists, or specialty
care available in a particular plan.
Clinicians may assist a Member by contacting a plan (or plans) to determine if a
particular specialist or service is available.
Clinicians may not influence Members based upon reimbursement rates or methodology
used by a particular plan.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
- 24 -
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Clinicians may distribute or display written health educational materials (as defined in the
Glossary of Terms) or health related posters (no larger than 16" x 24"), developed by the
health plan or third party. Distribution and/or display of all materials submitted by all
contracted health plans are required. These materials may have the health plan’s name,
logo, and phone number.
Providers may distribute or display written health educational materials (as defined in the
Glossary of Terms) or health related posters (no larger than 16" x 24"), developed by the
health plan or third party. Distribution and/or display of all materials submitted by all
contracted health plans are required. These materials may have the health plan’s name,
logo, and phone number.
Providers may display plan stickers (no larger than 5" x 7") indicating they participate
with a particular Health Plan as long as they do not indicate anything more than ”health
plan is accepted or welcomed here.” Stickers must have the Medicaid logo affixed.
Prohibitions:
 Providers are not allowed to stock, reproduce or handle enrollment forms.
 Providers or their staff may not assist recipients in filling out enrollment forms or making
a decision on selecting a health plan.
 Health Plan specific, non-health related materials or banners are NOT allowed in
 Provider offices.
 Providers shall not make false, misleading or inaccurate statements relating to services,
benefits, Providers or potential Providers.
 Providers may not recommend one plan over another. • Providers are prohibited from
marketing and participating in Medicaid Program enrollment activities. All Medicaid
recipients are to be enrolled in the Medicaid Program by the HHSC Administrative
 Services Contractor via the official State enrollment form or by calling the Medicaid
 Program help line at 1-800-964-2777.
Members needing to enroll in a STAR health plan should be instructed to call TAA/Maximus at
1-800-964-2777.
Member Billing
Billing Members
Clinicians may not require a down payment before providing Medicaid-allowable services to
eligible Members and may not bill or take recourse against eligible Members for denied or
reduced claims for services that are within the amount, duration, and scope of benefits of the
Texas Medicaid Program. There are no co-payments for acute services under STAR+PLUS.
Member Acknowledgment Statement.
United Behavioral Health or Evercare STAR+PLUS, as appropriate, reimburses only services
that are medically necessary. Services are subject to non-certification of benefits based upon
medical review. Physicians and other health care providers may bill a Member for services after
an adverse benefit determination based on medical review only if:
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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A specific service or item is provided at the request of the Member
Providers have obtained and kept a written Member Acknowledgment Statement signed
by the Member that states:
“I understand that, in the opinion of (provider’s name), the services or items that I have
requested to be provided to me on (dates of service) may not be covered under the Texas
Medical Assistance Program as being reasonable and medically necessary for my care. I
understand that Evercare/UBH determines the medical necessity of the services or items that I
request and receive. I also understand that I am responsible for payment of the services or items I
request and receive if these services or items are determined not to be
reasonable and medically necessary for my care.”
“Comprendo que, según la opinión del (nombre del proveedor), es posible que Medicaid no
cubra los servicios o las provisiones que solicité (fecha del servicio) por no considerarlos
razonables ni médicamente necesarios para mi salud. Comprendo que Evercare/UBH determina
la necesidad médica de los servicios o de las provisiones que el cliente solicite o reciba. También
comprendo que tengo la responsibilidad de pagar los servicios o provisiones que solicité y que
reciba si después se determina que esos servicios y provisiones no son razonables ni
médicamente necesarios para mi salud.”
Providers may bill the following to a Member without obtaining a signed Member
Acknowledgment Statement when:
The Member is accepted as a private pay patient pending Medicaid eligibility
determination and does not become eligible for Medicaid retroactively.
Physicians and other health care providers are allowed to bill the client as a private pay patient if
retroactive eligibility is not granted. If the client becomes eligible retroactively, the client
notifies the clinician of the change in status. Ultimately, the physician or other health care
provider is responsible for filing timely Medicaid claims. If the client becomes an eligible
Member, the physician or other health care provider must refund any money paid by the client
and file Medicaid claims for all services rendered.
Billing and Payment
Billing and Claims
UBH providers are paid primarily on a fee-for-service basis. The fees are based on a
contractual rate that will vary depending on the type of physician and other health care
provider and the type of contract signed. For acute inpatient care, TMHP is the payer of
the claim and UBH will only provide certification and case management services.
Each physician or other health care provider should apply for a National Provider Identity
(NPI) number. This number must be included on all claims to identify the provider that
rendered the service. Only the NPI number of the provider rendering the service should be
used. Claims should not be submitted using another provider’s NPI Number. In order to
apply for an NPI number:
Web-based application process https://nppes.cms.hhs.gov
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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Phone: 1-800-465-3203 or TYY 1-800-692-2326
Mailing address:
NPI Enumerator
PO Box 6059
Fargo, ND 58108-6059
Email address
[email protected]
The Member’s complete Medicaid ID number must always be legible
Providers must submit claims for services rendered to Member’s and work directly with
UBH for reimbursement. Members should not be asked to submit claims for services
rendered.
Prompt Payment
UBH. Providers should submit claims for health services to UBH using the appropriate claim
form (example: a CMS 1500 Claim Form for outpatient services; a UB92 Claim Form for
inpatient services). UBH must receive all information necessary to process the claims no more
than 95 days from the date of discharge from a facility or 95 days from the date the health
services are rendered to the United Behavioral Health member. Any claims received after this
time period may be rejected for payment, at UBH discretion.
UBH will pay claims for health services provided to a Member in accordance to its contractual
agreement with Evercare. Payment to providers will be generated within 30 days of receipt of all
information necessary to process the claim. For acute inpatient care, TMHP is the payer of the
claim and UBH will only provide certification and case management services.
The physicians and other health care providers cannot bill the Member for health services
provided if the physicians and other health care providers fail to submit a claim. The
Member cannot be balance billed for services covered under the contractual agreement at a
predetermined contracted rate.
Texas Medicaid Healthcare Partnership (TMHP)
Beginning January 1, 2004, the Texas Medicaid & Healthcare Partnership (TMHP) assumed
Medicaid Claims Administrator responsibilities for the state of Texas, under contract with the
Texas Health and Human Services Commission (HHSC). This new contract transitions
functions such as claims processing, the automated inquiry system (AIS), HHSC connect, and
other services previously handled by National Heritage Insurance Company (NHIC) to TMHP.
Claims Payment Deadlines
Effective January 1, 2004, new payment deadlines, as defined by HHSC, were implemented as a
result of the fiscal agent arrangement. Payment deadlines refer to the maximum time afforded to
pay a claim. The payment deadlines ensure that both state and federal financial requirements are
met.
Claims Payment- All clean claims must be adjudicated within thirty (30) days. For acute
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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inpatient care, TMHP is the payer of the claim and UBH will only provide certification and case
management services. A clean claim shall mean a claim submitted by network clinician or
facility for medical care or health care services rendered to a Member, with documentation
reasonably necessary for UBH to process the claim. Except for Capitation Compensation or as
otherwise provided in the program, UBH shall pay to network clinician or facility all clean
claims within thirty (30) days after receipt by UBH. UBH shall pay network clinician or facility
interest on all clean claims which are not paid within such thirty (30) day period in accordance
with applicable State and/or federal law for each month the clean claim remains unpaid.
Claims Appeals and Adjustment Filing Deadline
Beginning August 1, 2004, providers must file appeals or adjustment requests within 120 days
from the date of disposition. This change applies to both paper and electronic submissions. The
date of disposition refers to the date of the Remittance and Status (R&S) report on which the last
action on the claim appears. HHSC and TMHP will no longer process appeals or adjustment
requests received more than 120 days after the date of disposition. For example, a request for an
appeal received on August 2, 2004, will be processed only if the date of disposition is between
April 2, 2004 and August 2, 2004. If the date of disposition was more than 120 days, or in this
example, before April 2, 2004, the request will deny for late filing.
Coordination of Benefits. – When a Medicaid client has other health insurance (primary), the
health care provider must bill the other insurance before billing United Behavioral Health. A
copy of the other insurance company’s payment statement must be attached to the claim in order
for the claim to be adjudicated correctly as the secondary insurance.
For more information about eligibility, claim information, provider enrollment, Medicaid
Bulletins etc., visit the TMHP website at www.tmhp.com or call their General Inquiries line at
1-800-925-9126 or contact UBH Customer Service at 1-866-302-3996.
United Behavioral Health
Evercare STAR+PLUS
Program 2005_Updated Nov 2006_Updated Jan 2007_Updated May 2011
Source: Evercare Provider Administrative Manual 2004
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