Provider Manual

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2009 STAR Provider Manual 2-13-09

Exhibit 01 - Request for Continuity Transition Care

Exhibit 02 - Category Codes and Type Programs

Exhibit 03 - STAR Form 3087

Exhibit 04 - Plain ID Card

Exhibit 05 - Provider Request for Transfer

Exhibit 06 - Request for Increase in 1500 Capacity

Exhibit 07 - Texas Referral-Authorization Form

Exhibit 08 - Complex Neonate Acuity of Service Matrix

Exhibit 09 - Turberculosis Report of Case and Patient Services

Exhibit 10 - Periodicity Schedule (2010)

Exhibit 11 - Sterilization Consent

Exhibit 12 - BH Request Additional Visits

Exhibit 13 - Psychological Testing Request Form

Exhibit 14 - Member Education Request Form

Exhibit 15A - PCP: 14.1 PCP Documentation Guidelines 2010 14.2 PCP Medical Record Review Tool 2010

Exhibit 15B - OB/Gyn: 18.4 OB-GYN Documentation Guidelines 2010 18.5 OB-GYN Medical Record Review Tool 2010

Exhibit 15C - Behavior Health: 07.1 Behavioral Health Documentation Guidelines 2010 07.2 Behavioral Health Medical Record Review Tool 2010

Exhibit 15D - Specialist: 14.3 Specialist Documentation Guidelines 2010 14.4 Specialist Medical Record Review Tool 2010

Exhibit 16 - Member-Client Acknowledgement Statement

Exhibit 17 - Adult Preventative Care

Exhibit 18 - PA-NP Waiver

Exhibit 19 - Clean Claim CMS-1500

Exhibit 20 - Clean Claim UB-04

Exhibit 21 - Private Pay Agreement

Exhibit 22 - EOP

Exhibit 23 - Provider Complaint Form

Exhibit 24 - Provider Appeal Form

Exhibit 25 - Care Plan for Children with Complex Needs

Exhibit 26 - Medicaid Eligibility Verification Form (H1027 - A)

Exhibit 27 - 2010 Immunization Schedule: Exhibit 27A - Recommended Immunization Schedule 0-6 years of age Exhibit 27B - Recommended Immunization Schedule 7-18 years of age Exhibit 27C - Recommended Immunization Schedule 4 months - 18 years Exhibit 27D - 2010 Recommended Adult Immunization Schedule

Exhibit 28 - Infectious Disease Report

Exhibit 29 - Blood Lead Screening and Testing Guidelines