Date: March 4, 2025
Attention: Independent School Districts
Call to action: The purpose of this communication is to provide information on SHARS, mainly how to route claims to Texas Medicaid Healthcare Partnership (TMHP) for payment consideration. All SHARS claims must be sent to TMHP for processing and not Texas Children’s Health Plan (TCHP).
New information on claims submissions: TMHP has determined that some claims submitted for SHARS with dates of receipt from January 17, 2025, through February 7, 2025, were inadvertently forwarded to the client's managed care organization (MCO) like TCHP instead of TMHP. Affected providers should resubmit their claims to TMHP for processing if they received an explanation of benefit (EOB) message on their claim response (277CA) indicating that the claim was forwarded to an MCO like TCHP for the dates of receipt listed previously.
Background information: SHARS services are available to clients regardless of Medicaid service delivery mechanism (traditional Medicaid or Medicaid Managed Care). SHARS services are carved-out of the Medicaid Managed Care Program. Carved-out services are those that are rendered to Medicaid Managed Care clients but are administered by TMHP and not the client’s Managed Care Organization (MCO) like TCHP.
Source:Texas Medicaid Provider Procedure Manual February 2025 Provider Handbooks School Health and Related Services (SHARS) Handbook Section 2.5
How this impacts providers: Claims Filing and Reimbursement
- Mechanism: SHARS claims are accepted by way of an electronic claims format or a CMS-1500 claim form.
- Deadline: SHARS Claims must be submitted within 365 days from the date of service, or no later than 95 days after the end of the federal fiscal year (FFY) (i.e., January 3), whichever comes first.
Source: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.
Source: https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2025/2025-02-february/1_03_electronic_data_interchange.pdf
“Section 6: Claims Filing” (Vol. 1, General Information) for instructions on completing paper claims and additional general information about claims filing.
Source: https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2025/2025-02-february/1_06_claims_filing.pdf
- Reimbursement:
- During the cost report period, local education agencies (LEAs) participating in SHARS are reimbursed on an interim basis using SHARS interim rates.
- In order to accommodate participating SHARS districts that require interim cash flow to offset the financial burden of providing for students.
- An interim fee-for-service claiming system still exists for SHARS.
- Providers are reimbursed for direct medical services and transportation services provided under the SHARS Program on a cost basis using federally mandated allocation methodologies in accordance with 1 TAC §355.8443
- Required information on claims:
- At least one interim claim for each direct medical service that an eligible student receives within the cost-reporting period.
- Interim claims for all personal care services that an eligible student receives within the cost reporting period
- Interim claims for all eligible specialized transportation trips provided within the cost reporting period
- Timed Units:
- For timed procedure codes, providers must only report billable time when the midpoint of the total duration for the procedure code has been passed.
- All claims for reimbursement of timed procedure codes are based on the actual amount of billable time associated with the SHARS service.
- For those services for which the unit of service is 15 minutes based on code description for SHARS services (i.e., 1 unit = 15 minutes), partial units must be rounded up or down to the nearest quarter hour for 15-minute units.
- Cost Reporting
- The total allowable costs for providing services for SHARS must be documented by submitting the required annual cost report.
- The provider’s final reimbursement amount is arrived at by a cost report, cost reconciliation, and cost settlement process.
- Submittal of a SHARS cost report is required for each provider that requests and receives interim payments.
- Failure to file a SHARS cost report will result in sanctions, which includes recoupment of all interim payments for the cost report period in which the default occurs.
For more information on this information presented here: Texas Medicaid Provider Procedure Manual February 2025 Provider Handbooks School Health and Related Services (SHARS) Handbook Section 2.7
Coverage information: There is no lifetime benefit max for SHARS services provided so long as the services are medically necessary and documented in the student’s individualized education program. The services provided to the student at the school do not affect the type or amount of Medicaid services the student receives outside of the school setting.
Next step for Providers: LEAs/school districts are strongly encouraged to follow the guidance provided here in the document when rendering SHARS services.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts: https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts.
