3 3 Eligibility CHIP Perinatal covers the unborn child of low income uninsured women, including women who do not meet citizenship requirements and who do not qualify for Medicaid. Many women must obtain Emergency Medicaid to cover the cost of labor with delivery.

17 17 Verifying Coverage Prior to submitting an inquiry request, providers with accounts 40 days old or older should contact: Angela McKnight 1-512-533-2954 or Denise Townsley 1-512-533-3581

H3038-003 Summary of benefits

20 20 Failure to Return Form H3038 A new application for assistance is required if Form H3038 is not submitted within 30 days of delivery. Eligibility for Emergency Medicaid must be determined based on current household information. Eligibility for the new application is determined by either hospital based staff or staff at a local HHSC office.

13 13 Submitting the Form Hospital staff can return the completed form by: Faxing to 1-877-542-5951, or Mailing to: HHSC PO Box 14400 Midland, TX 78711-4400

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7 7 TMHP Billing The health plan identification card for women with income at or below 185% of the FPIL have contact information for the Texas Medicaid Health Partnership (TMHP) listed for hospital billing. Front Back

21 21 Resources: HHSC Websites CHIP perinatal: http://www.hhsc.state.tx.us/chip/perinatal/index.htm Billing Processes: http://www.hhsc.state.tx.us/chip/perinatal/NewbornClaimsInstruct ions.pdf http://www.hhsc.state.tx.us/chip/perinatal/NewbornClaimsInstruct ions.pdf Vital Statistics Instructions: http://www.hhsc.state.tx.us/chip/perinatal/VitalStatisticsInstructio ns_062807.pdf http://www.hhsc.state.tx.us/chip/perinatal/VitalStatisticsInstructio ns_062807.pdf Hospital Training: http://www.hhsc.state.tx.us/chip/perinatal/training.htm TMHP general inquiries hotline and website: 1-800-925-9126; http://www.tmhp.com/Medicaid/default.aspx

Printableh3038 form

FY14 Contract Training for Public Health Prenatal Program/Maternity Services Trina Miller Prenatal Program Coordinator Division of Child & Family Health.

4 4 Health Plan Pays For Delivery For women with income above 185% and at or below 200% of the federal poverty income limits (FPIL), the CHIP perinatal health plan pays: All hospital facility covered costs, and All covered professional charges. Emergency Medicaid is not required for payment of labor with delivery cost for this income group.

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H3038Medicare

15 15 Verify Receipt of Form H3038 The patient can verify receipt of the Form H3038 by calling: 1-800-647-6558 to verify receipt 1-866-291-1258 to verify the processing status.

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2 2 Objectives Hospital provider staff: Can describe the process used to cover the labor with delivery costs through Emergency Medicaid for eligible CHIP perinatal mothers. Follow established procedures to check status of H3038. Know processing timeframes from submission of H3038 to payment date.

9 9 Enrollment Confirmation Mothers who are eligible for CHIP perinatal coverage with income at or below 185% of the FPIL receive: Enrollment Confirmation Notice, Bar coded Emergency Medical Services Certification Form H3038, and Self-addressed postage paid envelope.

Medicaid Member Card July Medicaid Member Card Medicaid and PCN members received a new wallet-sized plastic Medicaid card starting July 2014 Each.

16 16 Verification of Coverage Providers can verify PCN/Medicaid number for mom and baby (185% FPL and below): On TMHP web portal: www.tmhp.com Call TMHP help line for assistance 1-800-925-9126

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11 11 Completing the Form The physician who delivers the baby typically completes the Emergency Medical Services Certification Form H3038, at the time of delivery. Bar coded Form H3038 or Regular Form H3038.

19 19 Inquiry Results Form H3038 located CPC provides Medicaid ID number Provider can bill: Facility charges to TMHP Professional charges to CHIP perinatal Health Plan Form 3038 not located Hospital asks patient to apply for Emergency Medicaid at local HHSC office Form H3038 must be completed and returned before Emergency Medicaid can be certified Patient can be billed if patient does not follow through with application process

18 18 Inquiry Request Providers email or fax inquiry requests to Melissa Rodriguez’ attention at: melissa.rodriguez.3@hhsc.state.tx.us 1-512-977-6202 or 1-866-291-1260 Inquiry lists must include the following information: CHIP perinatal case number Mom's name Dates of Service Date 3038 was faxed to MAXIMUS

Government of the District of Columbia Department of Health Care Finance ‹#› For Government Use Only 1 Pregnant Women Presumptive Eligibility Division.

H3038-001

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You can request verification for native languages by completing a simple application that takes only a couple of minutes.

14 14 Processing of 3038 Once the form is faxed, state eligibility workers have up to 45 days to process it.

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H3038 formpdf

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1 1 Refresher Training CHIP Perinatal-Labor with Delivery Changes Emergency Medical Services Certification - Form H3038

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12 12 Cover Sheet Requirements Mother’s name as it appears on the CHIP perinate card CHIP perinate case number Baby’s name Baby’s date of birth Baby’s gender

10 10 Bar Coded Image The advantage of returning the bar coded Emergency Medical Services Certification, Form H3038 is it allows automated linking between Form H3038 and the CHIP perinatal case in the eligibility system

Medicaid and CHP+ for Beginners February Medicaid and Child Health Plan Plus (CHP+) An overview for beginners who need to know the basics.

6 6 Emergency Medicaid Needed The CHIP perinatal health plan pays for all covered professional charges for women with income at or below 185% of the FPIL. Medicaid pays for all covered hospital facility charges for women with income at or below 185% of the FPIL who obtain Emergency Medicaid for labor with delivery.

formh3038, emergency medical services certification

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5 5 Health Plan Billing The health plan identification card shows billing to the health plan for both Professional/Other Services Billing and Hospital Facility Billing. Front Back

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8 8 Stream Lined Emergency Medicaid CHIP perinatal clients with income at or below 185% of the FPIL are not required to complete a new application to apply for Emergency Medicaid for labor with delivery. The initial CHIP perinatal application and supporting verification documents are used to determine eligibility for Emergency Medicaid for labor with delivery.

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