CHIP Perinatal Program
Hospital Training
Form H3038 Submission, Inquiry, and
Processing
Texas Health and Human Services Commission
Training Objectives
• Benefit all entities, agencies, and persons involved in
the completion, submission, and processing of Form
H3038 for women who receive CHIP perinatal.
• Obtain an understanding of how to accurately
complete Form H3038.
• Know how to correctly submit Form H3038 by fax or
mail for services rendered.
• Know how to perform a Medicaid-eligibility inquiry via
the Texas Medicaid and Healthcare Partnership
(TMHP).
• Know how and when to submit an inquiry to the
Central Processing Center (CPC).
• Learn about available CHIP perinatal resources.
Page 2
When To Prepare
 Prepare the Emergency Medical Services
Certification Form H3038 to verify that a person not
meeting citizenship requirements was treated for an
emergency medical condition (i.e., provided labor
with delivery-related services).
 Establishing Medicaid for the newborn requires both
a report of birth AND the submission of Form H3038
for the mother’s labor with delivery. The mother must
establish Emergency Medicaid in order for the
newborn to receive Medicaid.
Page 3
Obtaining Form H3038
Mothers who are eligible for CHIP perinatal
coverage with income at or below 185% of the
FPL receive in the mail:
 Enrollment Confirmation Notice,
 Bar-coded Emergency Medical Services
Certification Form H3038 (Form H3038 has been
modified to include the newborn’s name, gender
and date of birth); and
 Self-addressed postage paid envelope
Mothers are instructed to bring Form H3038
with them to the hospital at the time of delivery.
Page 4
Bar-Coded Image
Returning the barcoded Emergency
Medical Services
Certification, Form
H3038 allows
automated linking
between Form H3038
and the CHIP perinatal
case in the eligibility
system.
Page 5
Bar-Coded Image
Below is a sample population from 06/01/2010 to 02/23/2011 (nine
months) indicating the percentage of Forms H3038 that are
successfully linked.
We found:
 22,018 or 36.11% successfully autolinked
 298 or 0.49% had a bar-code but did not successfully autolink
 38,664 or 53.40% were manually linked because they had no
bar-code
This information indicates that bar-coded Forms H3038 are not
being successfully linked 64% of the time. This could delay the
patient getting coverage and the provider receiving payment for
services rendered.
Page 6
Completing the Form H3038
The physician who delivers the baby or an RN
with knowledge of the patient’s care and
admission and discharge dates typically
completes the Emergency Medical Services
Certification Form H3038, before the mother is
discharged.
 Bar-coded Form H3038 or
 Generic (non Bar-coded) Form H3038.
Page 7
Form H3038 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
Page 8
Submitting the Form H3038
• It is recommended that hospital staff send
Form H3038 on the mother’s behalf, so that
she does not have to mail it.
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
Page 9
Submitting the Form H3038
• A correctly completed Form H3038 increases the success of
reimbursement for services.
• An incorrect or incomplete form can delay reimbursement for
services, because eligibility determination for the mother and
her newborn is delayed. These forms cannot be used to
determine if payment for services rendered is warranted.
• Additionally, providing only the attending physician’s or RN’s
information may not be sufficient. It is beneficial to include a
cover sheet with contact information (first and last name and
telephone number) of the person completing the form in case
there are any discrepancies. You may also write it on the bottom
of the Form H3038.
Page 10
Submitting the Form H3038
• Submit each Form H3038 individually as a
separate fax.
• If several Form H3038s are faxed as one
document, it is possible that only the first
account will be linked and processed.
• Adhering to the directive above will help to
ensure all accounts faxed behind the topmost
document are successfully processed for
payment of services rendered.
Page 11
Using an H3038 that is not
bar-coded
•
What if patient forgets her bar-coded Form H3038?
 The mother can request a new form by calling 1-877-KIDS-NOW.
 Hospital-based eligibility workers can use generic (non bar-coded)
Form H3038
 It is important to write the mom’s CHIP perinatal ID number on the
top of the form.
 The name on the form must match the name on the woman’s CHIP
perinatal ID card.
 Include the newborns name, gender and date of birth to help HHSC
link mom and newborn.
 If the newborn’s name is not included the newborn will not be
processed for Medicaid and will not receive 12 months of
continuous Medicaid coverage.
 Consider including in hospital registration packets a reminder that
women receiving CHIP perinatal coverage for prenatal care should
bring their Form H3038 at delivery, if they receive one in the mail.
Prenatal care providers might assist with these reminders, also.
Page 12
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.
 There is no provider hotline to determine the
status of an application at this time.
Page 13
Processing of Form H3038
CPC staff receives a referral task from MAXe CHIP perinatal system with
an image of Form H3038. Staff must:
 Perform inquiry to determine which system of record (TIERS or SAVERR)
to use when processing the Emergency Medicaid case.
 Use the supporting verification documents provided with the original CHIP
perinatal application to determine eligibility for Emergency Medicaid
coverage for the labor and delivery. The mother’s emergency medical
services certification must be completed before the newborn can be
certified for Medicaid for Newborn Children (TP 45). This is because the
baby must be linked with a Medicaid-eligible mother to receive the 12
months continuous coverage from birth.
 Determine eligibility for Medicaid for Newborn Children if birth information is
provided along with Form H3038. Newborn coverage processing is a three
step process. CPC has up to 45 calendar days to complete the entire
process.
NOTE: Effective February 1, 2011, hospital based advisors process TP 45
coverage for newborns in the Neonatal Intensive Care unit.
Page 14
Verifying Coverage
Verifying PCN/Medicaid number for mom and baby (185% FPL and below):
 Look on TMHP web portal: www.tmhp.com
 Call TMHP help line for assistance: 1-800-925-9126. TMHP can verify a maximum of
10 at a time. This number also provides access to the Automated Inquiry System
(AIS).
 The newborn’s number (TP 45) will now be available through AIS. These numbers can
be found through the TMHP web portal.
 Note that TMHP cannot verify CHIP perinatal eligibility.
Options for verifying CHIP perinatal eligibility:

Have the mother contact 1-877-KIDS-NOW. The hotline representative should be able
to provide her ID number, as well as FPL level. This is a client only phone number.
 Call CHIP provider number: 1-800-645-7164. This hotline cannot provide a client ID
number, but it can provide verification of CHIP enrollment and coverage days, as well
as the health plan and plan phone number.
 Contracted health plan providers who have an online account may be able to verify
eligibility by using the health plan’s website.
 Contact health plan by calling plan’s provider hotline.
Page 15
Inquiry Request
•
Perform inquiry via TMHP to determine if a Medicaid number has been issued
prior to submitting an inquiry request to CPC. Only submit inquiry forms to CPC
containing accounts that are more than 45 days old. Email or fax inquiry
requests to the locations below after performing inquiry via TMHP:
 Cpc@hhsc.state.tx.us
 Fax 1-866-291-1260
 Inquiry lists must be faxed only once and must only include accounts that are more
than 45 days old.
 Inquiry lists must include the following information:
 CHIP perinatal case number
 Mom's name as it appears on her CHIP perinatal card
 Dates of Service
 Date Form H3038 was faxed to MAXIMUS
 Baby’s First and Last name
 Baby’s Date of Birth
 Contact information of the person completing the request
 CPC will research inquiries and respond to the provider within 10 business days. This
time frame is an approximation and may only apply if all information including
complete contact information is provided and the list is not overly extensive.
Page 16
Inquiry Results
•
•
Form H3038 located
 CPC provides Medicaid ID number
 Provider can bill:
• Newborn facility and professional charges to TMHP
• Consult the TMHP website at http://www.tmhp.com for the Bulletin
article dated July 9, 2010 entitled “Changes to Claim Submission and
Payment for Newborns Formerly Enrolled in the CHIP Perinatal
Program” for more details on billing. Click on Providers at the top of the
TMHP home page, and then use the search feature at the top of the
page.
Form H3038 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 for both mom and the newborn.
 Patient can be billed if patient does not follow through with application
process
Page 17
Failure to Return Form H3038
• A new application for assistance is required
if Form H3038 is not submitted accurately
within 90 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.
Page 18
Recap
• Obtain the bar-coded Form H3038 from the patient with CHIP
perinatal coverage information or use a blank Form H3038.
• Accurately complete all required information.
• Fax each Form H3038 individually or mail the forms to HHSC at
the address provided in this presentation.
• Have the patient verify receipt of the Form H3038 and
processing status.
• Perform inquiry via TMHP to verify coverage.
• Send an inquiry request via fax or secure email to the CPC
locations in this presentation if an account is more than 45 days
old.
• CPC will research each inquiry and respond to the provider
within 10 business days. This time frame is an approximation
and only applies if all information including complete contact
information is provided and the list is not overly extensive.
Page 19
Additional Resources
TMHP general inquiries hotline and website:
1-800-925-9126;
http://www.tmhp.com/Medicaid/default.aspx
Form H3038 completion and submission:
Sheree Coleman 512-533-3791
sheree.coleman@hhsc.state.tx.us
Page 20