FAQ - PHC07

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Clinical/Services

Billing/Eligibility

Administrative

Clinical/Services

A question has come up recently about our forms we use for documentation on our PHC physicals. One of our docs in particular, prefers to dictate, rather than use a form. If the dictation covers all areas listed on the PHC physical form, can we use it? (4/2007)
Yes. We do not require any specific form. We only require that all of the information be in the chart.

I am looking into reimbursement fees for our PHC subcontracted physicians for influenza vaccine. As I understand we can use code 90658 for anyone over the age of three AND a code for the administration. I called TMHP and they confirmed my understanding but I did not get to confirm which code to use for the administration fee. The TMHP website gives procedure codes but I am unsure of what each one is and was not successful in researching at the TMHP website. Do you have a link that would help me information or know the vaccine administration fee code?
Amy Schlabach, DSHS Immunization Branch, says: "The number to TMHP general information is 800-925-9126. I believe there are 8 CPT codes for vaccine administration. The best place to find the admin CPT codes is in the current CPT code book in the section labeled 'Immunization Administration for Vacine/Toxiods'." If you have additional questions, you may call Amy at 800-925-9152 or 512-458-7111, ext. 6496.

If the agency is not funded by PHC, do they still have to screen for PHC on the eligibility form and refer out? Do they need to circle that on the form?
If an agency does not have PHC funds, they do not have to screen the client or family members PHC eligible. The screening and eligibility form is for the agency to screen for the eligibility of the funding sources they have and to rule out Medicaid eligibility. Mark "Not Eligible" if not screening for PHC or on blank line write "NA for PHC or PHC not screened". The same instructions would be true if an agency does not have Title V funding but do have PHC.

Billing/Eligibility

Regarding Completion of the Presumptive Eligibility Form. - Sometimes patients seen on a presumptive eligibility basis cannot schedule a return appointment to complete the eligibility process until they are able to check their calendar, childcare arrangements, etc. Instead of an exact time and date, can the provider staff write in something like "within 30 days" in the "Date & Time" block at the bottom of the page?
If unable to document an exact date and time to return to complete the eligibility process, it is allowable to write in something like "within 30 days" in the "Date & Time" block. However, remember that the process has to be completed within 90 days or the client becomes self-pay.

The Screening and Eligibility Form, income section questions 4 asks if anyone in the household is receiving TANF, Food Stamps, etc., the policy has Food Stamps listed as income which is not counted. The instructions list Food Stamps as unearned income to be counted. (10/2006)
Each numbered item on page one is an item of its own. Number 1 is family information. Number 2 is list of the household's income. Number 3 is inquiring about health care coverage. Number 5 is inquiring whether anyone in the household is pregnant.

Number 4 is inquiring whether any household members are on TANF, Food Stamps, Workers Compensation, and/or disability benefits. This information can be used by the clinic to make appropriate referrals and is not necessarily used in determining eligibility.

Income Section, page 3, instructions, "Food Stamps" will be removed because it is not a form of earned or unearned income.

The signature block states the applicants spouse may also sign and date the form. The policy states each PHC eligible client who is a legal adult is required to sign and date the form. PHC policy, Section II-3, states: "Each PHC eligible client, who is a legal adult, is required to sign and date the form. If confidentiality of services is a concern, separate forms for spouses may be completed." (10/2006)
Signature area of page 1 on the form will have the signature instructions removed and "If applicable", will appear next to "Signature-Spouse". Clinics shall defer to funding source policy manual for spousal signature policy.

In the Eligibility Determination Section to be completed by staff, clients who are screened potentially eligible for Medicaid would they be checked as not eligible or pending determination. Wouldn't they be checked as pending determination with comment "pending Medicaid?"(10/2006)
Yes, they would be checked as pending determination with comment "pending Medicaid". "Not eligible" is only used when an individual is not eligible for any funding source.

Does the agency place a copy in the client file of the Screening and Eligibility Determination Instructions, (FPL table)? The table that is updated every April? How will we know if the QA review if they used a current table? (10/2006)
It is not necessary to require the FPL table in each chart. The table is in the instructions for the eligibility clerk to use. The QA staff will have their own FPL table to refer to if necessary. This table is updated every April and sent out to the contractors and DSHS staff.

Will we no longer collect ss#? There is no place for this? (10/2006)
We no longer require collection of the social security number. Clinics may collect if required by agency policy.

Page 2 Document any special circumstances. What would be an example of a "special circumstance". (10/2006) Screening and Eligibility Determination Form for Medical Services Assistance, page 2, "Special Circumstances" area is for the provider staff to document any special circumstances not already noted in this section if applicable per page 3 of the form instructions. PHC policy manual, Section II Chapter 1 page II-1 states "Special circumstances may occur in the disclosure of information, documentation of pertinent facts, or events surrounding the client's application for services that make decisions and judgments by the contractor staff necessary. These circumstances should be documented in the case record on the Screening and Eligibility Determination Form for Medical Services Assistance."

Type of Title V/PHC service and who is eligible. What does "Full" mean?(10/2006)
PHC clients may be eligible for full, presumptive, or supplemental services. PHC policy manual, Introduction, page v and Section II Chapter 1 page II-9 defines presumptive eligibility. PHC policy manual, Section II Chapter 1 page II-11 explains supplemental benefits. Full eligibility means the client is eligible for ALL PHC benefits.


If a person is presumptive and they will need to come back to bring back their information do they still need to give them slip with an appointment?(10/2006)
In the past they gave them the bottom portion of the presumptive eligibility form. Yes, the client is to receive a slip with an appointment to complete the eligibility process. The new Presumptive Eligibility Form is still designed to cut the bottom portion to give to the client.

Please clarify the difference between signatures for "Person who helped complete this application" and "Applicant's representative" on pg. 1 of the form and when to use each of them.(10/2006)
There is no difference between "Person who helped complete this application" and "Applicant's Representative". With this said, in the near future the form will be revised with "Applicant's Representative and 2nd Date" removed and "Relationship to client" added.

Regarding the "Type of Title V/PCH service and who is eligible box" on pg. 2 of the form, please provide clarification on completion of this box. For example, how would you complete this box if you have a family of 3 people, the mother eligible for Title V Family Planning and PHC as a supplemental, the father if eligible for full PHC; and the child is eligible for Title V MCH and PHC supplemental?
Use the letter of the appropriate family member for full, presumptive, or supplemental to save space. Can also designate if it is Title V or PHC with each letter.

Regarding the "Determined Eligible For" box on pg 2 of the form: If a mother applies for PHC and her child is on Chip, would you check the "not eligible" box or check the blank box in the "Determined Eligible" box and write in CHIP on the blank line?(10/2006)
Check the blank box in the "Determined Eligible" box and write in CHIP on the blank line. The "Not Eligible" box is only for not eligible for any funding sources.

If an applicant applies for a program, has all the verifying documentation, and is determined eligible, does the staff have to check the "Potentially Eligible" box as well as the "Determined Eligible" box. Or can they put NA in the "Potentially Eligible" box and just check the "Determined Eligible" box?(10/2006)
Just check the "Determined Eligible" box. It is acceptable to also mark NA in the "Potentially Eligible" box, however, it is not necessary.

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Last updated May 07, 2010