1. (a) Texas Index for Level of Effort (TILE) Assessment and Client Assessment Review and Evaluation (CARE) form completion. TILE assessments are primarily based on the nursing facility nurse assessor's (FNA) evaluation of the recipient. This evaluation may also be supplemented by staff interviews and documentation in the medical record. TILE assessments are documented on the CARE form, and must be signed by the FNA that completed the assessment. These assessments establish TILE classifications as described in paragraphs (1)-(9) of this subsection.

   1. (1) If the nursing facility recipient is also a hospice recipient, the following must be completed before the Texas Department of Human Services (DHS) will reimburse nursing facility room and board to the hospice provider:

      1. (A) The hospice nurse assessor must also evaluate the hospice recipient and either:

         1. (i) sign the CARE form completed by the nursing facility assessor to indicate complete agreement with the assessment; or
         2. (ii) request the nursing facility assessor to complete a new CARE form based on a joint assessment, and then sign to indicate complete agreement with the assessment.
      2. (B) The hospice provider must submit the Texas Medicaid Hospice Program Recipient Election/Cancellation/Discharge Notice (Form 3071), and the TDHS Medicaid/Medicare Hospice Program Physician Certification of Terminal Illness (Form 3074) forms to the DHS, Provider Claims Services Department.
   2. (2) Preadmission assessments do not establish a TILE classification.

   3. (3) Admissions assessments establish TILE classifications as follows:

      1. (A) If the nursing facility recipient has not previously attained permanent medical necessity or if an individual is simultaneously admitted to a nursing facility as a hospice recipient, the nurse assessor submits an admission assessment within 20 calendar days of admission, as provided in the Texas Administrative Code (TAC), Title 40, Part 1, Chapter 19, Subchapter Y, §19.2403 (relating to Utilization Review Process). The admission assessment begins the medical necessity (MN) process, and TILE classification for 180 days.
      2. (B) If the nursing facility recipient has previously attained permanent MN, an assessment with a purpose code 4 is completed, which sets TILE only.
   4. (4) Medical necessity review (MNR) is required 180 days after the effective date of the admission assessment. Nursing facilities can submit the renewal form up to 45 days prior to the expiration date of the current form. MN is established by completing an assessment with a purpose code 3. If the MNR indicates MN for nursing facility care, DHS will notify the facility of the permanent MN. The MNR may also establish a new TILE classification. The permanent MN will be lost if a recipient is discharged to home over 30 days.
   5. (5) After the establishment of permanent MN, recipients with a 211 TILE require no further assessment unless there is a change in their condition. All other TILE levels require a review every 180 days.
   6. (6) If a recipient's medical condition changes to the extent that he qualifies for a different TILE, an off-cycle assessment may be submitted. If a nursing facility recipient becomes a hospice recipient or terminates hospice services, an off-cycle assessment must be submitted. Only two off-cycle assessments for any one nursing facility recipient or hospice recipient residing in a nursing facility are permitted per calendar year, one from January through June and one from July through December. The off-cycle assessment for a nursing facility recipient that becomes a hospice recipient or terminates hospice services is not included in the two allowable off-cycle assessments. The assessment sets a new schedule for submission of forms if permanent MN has been achieved. Before permanent MN, the assessment will not set a new schedule for submission of forms.

   7. (7) A new corrected CARE form and supportive documentation may be submitted for the purpose of correcting errors previously made in the assessment portion of the form (Items 30, 31, and 50-99). The submission of the correction does not change the schedule for submission of forms or necessarily change the TILE group. The new corrected CARE form and the supportive documentation must be submitted within 60 days from the date of the assessment that contained error(s). The Commission will not accept requests for changes submitted:

      1. (A) over 60 days from the date of the assessment that contained the error(s); or
      2. (B) on previously submitted forms with the same assessment date.
   8. (8) If a recipient experiences a significant change related to mental illness, mental retardation, and/or a related condition that indicates the recipient might benefit from specialized services, a request for a recipient Preadmission Screening and Recipient Review (PASARR) must be submitted to the local DHS' PASARR office using a CARE form.

   9. (9) A facility may submit a request for retroactive payment in the following instances:

      1. (A) when a facility provides care for a recipient for a period of time not covered by an effective MN determination at admission or by assessment CARE forms as provided in TAC, Title 40, Part 1, Chapter 19, Subchapter Y, §19.2413 (relating to Reconsideration of Medical Necessity Determination and Effective Dates); or
      2. (B) if a recipient is found to be otherwise eligible for Medicaid for the three months prior to the month of his date of application for Medicaid assistance as provided in TAC, Title 40, Part 1, Chapter 19, Subchapter Y, §19.2408 (relating to Retroactive Medical Necessity Determinations).
2. (b) TILE training. Nursing facility directors of nursing and nurse assessors must complete and pass the Texas Health and Human Services Commission (Commission) approved TILE training course with a minimum score of 70% in order for the nurse's license number to be registered with the Medicaid Claims Administrator (MCA). The TILE training certification will be effective for a two-year period. Currently certified TILE nurses will be granted a one-year grace period from the effective date of the rule. Nursing facilities with new directors of nurses or nurse assessors may request a one time 60-day waiver to complete the TILE assessments. At the end of the 60-day waiver period, the nursing facility director of nurses, or nurse assessor must have completed and passed the Commission's approved TILE training course with a minimum score of 70%. The hospice nurse assessors may complete the Commission's approved TILE training course, either on-line or by correspondence. Providers are required to pay $30.00 each time they register to take the on-line TILE training course. The correspondence course will continue to be available for a $30.00 fee plus an additional $10.00 handling fee.

3. (c) Review and appeal of case-mix assessments. Commission nurse reviewers conduct desk reviews and in-depth, on-site reviews of CARE forms completed by nursing facility and hospice staff to verify TILE and medical necessity information.

   1. (1) Commission nurse reviewers will conduct unannounced on-site visits. The decisions regarding the validation of a claimed TILE, will be based on documentation that is presented to the nurse reviewers during the on-site visit. Forms expired over 12 months will not be routinely reviewed. For all on-site visits, nurse reviewers must be given prompt access to information and resources necessary to conduct the TILE review.

   2. (2) When a Commission nurse reviewer determines that the TILE classification is not substantiated and/or does not accurately reflect the recipient's status, the reviewer will discuss the error and give the provider an opportunity to submit additional information for the assessment period to support the item claimed. An exit conference is held with the nursing facility staff following the review. Hospice staff are encouraged to attend if hospice recipients are reviewed. The nursing facility and hospice staff may submit for consideration, additional information for the assessment period, at any time during the review process or the exit conference. The Commission gives the nursing facility administrator and hospice provider formal written notification of all TILE changes within 15 days of the exit conference.

      1. (A) At the direction of the Commission, DHS recovers funds paid to the nursing facility and/or hospice provider under incorrect TILE classification. At the direction of the Commission, DHS reimburses the nursing facility and/or the hospice provider any increase due to a change in TILE classification.
      2. (B) The changes in TILE classification and per diem rate are retroactive to the "effective date" of the assessment reviewed.

   3. (3) If the nursing facility and/or hospice provider disagrees with the Commission's TILE classification, either, or both, provider(s) may submit a reconsideration request to the Commission.

      1. (A) The request for reconsideration and all documentation supporting the requested changes must be received by the Commission within 15 days of the facility's receipt of formal notification of TILE changes.
      2. (B) Commission staff will review material submitted by the provider.
      3. (C) The TILE classification and associated per diem rate specified by the Commission nurse reviewer remain in effect during the reconsideration period.
      4. (D) If the reconsideration establishes that the Commission has changed a TILE classification in error, the Commission will direct DHS to correct the error retroactively.

   4. (4) If the provider disagrees with the reconsideration determination, the provider may request a formal appeal, as stated in Title 40, Chapter 79, Subchapter Q (relating to Contract Appeals Process) by submitting a request to the Director, Hearings Department, Mail Code W-613, Texas Department of Human Services, P.O. Box 149030, Austin, Texas 78714-9030 within 15 days of the facility's receipt of notification of the results of the reconsideration.

      1. (A) The TILE classification and associated per diem rate specified in the reconsideration determination remains in effect during the formal appeal.
      2. (B) If the formal appeal process establishes that the Commission has changed a TILE classification in error, the Commission will direct DHS to correct the error retroactively.

4. (d) Error rate. The error rate for a TILE review is determined by dividing the number of forms with an identified TILE decrease by the total number of forms reviewed.

   1. (1) Frequency of on-site TILE reviews may be determined by the accuracy of the assessment and error rate history. Nursing facilities whose TILE error rates are below 25% may be visited less frequently, but within 16-month intervals. TILE error rates of 25% or higher, may require a return visit within 7 months.
   2. (2) If the TILE error rate is 20% or higher on the return visit, the Commission may direct DHS to hold vendor payment to the facility, including pass through funds to hospice providers until the facility's error rate is below 20%. During a vendor payment hold, facilities may not submit CARE forms to the MCA either electronically or by mail. All CARE forms and supportive documentation, which includes both NF recipients and hospice recipients, must be submitted to HHSC.
   3. (3) Corrective action plan. For hospice providers, deficient practice in documentation may result in a corrective action plan.

Source Note:The provisions of this §371.214 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective January 15, 1997, 21 TexReg 11970; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308; amended to be effective July 15, 2001, 26 TexReg 4989; amended to be effective May 12, 2004, 29 TexReg 4454.