Early Intervention Provider and Billing Manual

Transcription

1 Early Intervention Provider and Billing Manual Page 1

2 Welcome to Rocky Mountain Human Services (RMHS) provider network. This manual is an extension of your contract and is a resource about RMHS s continuum of services. It will also provide you with guidelines for doing business with RMHS, including policies and procedures. Throughout this manual and the contract you receive from RMHS, individuals who provide services may also be called subcontractors. These terms should be thought of as one in the same. We use the term subcontractor in the contract because RMHS is considered by Medicaid, insurance companies and EI Colorado as the provider when we are billing for EI services. If an individual therapist is directly billing Medicaid or an insurance company for the services they provide, they are considered the provider. Rocky Mountain Human Services is a 501(c) 3 nonprofit organization that serves nearly 10,000 individuals, including more than 2,000 professionals and 7,500 Colorado and Wyoming residents through seven distinct programs. In 2012, we celebrated our 20 th anniversary and changed our name from Denver Options, Inc. to Rocky Mountain Human Services to reflect the expansion of our services throughout Colorado. Our goal is to serve vulnerable populations throughout the Rocky Mountain West. Rocky Mountain Human Services serves humanity, provides opportunity and encourages a world of compassion and hope. We utilize our human services expertise to improve the health, selfsufficiency and overall quality of life for individuals who face challenges from developmental delays, cognitive and intellectual impairments, brain injuries, aging or social conditions. Providing resources, care coordination, direct services and technical expertise for individuals, families, non-profit organizations and government agencies, we deliver unsurpassed human services to the western region of the United States. Rocky Mountain Human Services is committed to ensuring that all persons who enter the agency are provided with an experience that is found to be helpful, pleasant, meaningful, individualized, and positive. RMHS values the idea and principle that each individual be given the opportunity for choice, and decision making in an environment of individual power, authority, and autonomy. The company sees the person centered community and environment as a never ending process, where growth is always evolving for all individuals that come through the doors of RMHS. The information in this manual will provide you with a better understanding of what to expect while doing business with RMHS, but it should not be relied upon for business, financial or legal advice. If you have any questions about the information contained in this manual, our staff welcomes your call. Updates to this provider manual facilitate a better understanding of the requirements for providers. This manual is updated frequently as substantive changes are made to information, processes, etc. You can find the most current version of this manual the RMHS website at We welcome you to RMHS! Kathy Martin, Director of Stakeholder Relations & Contracts Page 2

3 Becoming a Medicaid Provider The State of Colorado requires that providers of certain services become an approved Medicaid provider if they will seek Medicaid reimbursement. This includes allowable Early Intervention services that are funded by the Medicaid State Plan and for which RMHS or the provider is going to bill Medicaid for payment (such as Physical Therapy, Occupational Therapy, Speech/Language services, and other therapy services). When you will be billing the services you provide directly to Medicaid, you should complete the Standard Provider Application. When RMHS will be billing the services you provide to Medicaid, you should complete the Rendering Provider Application. If you provide services that may be covered by Medicaid but do not wish to become a Medicaid provider, it is your right to make that choice. Providers who choose not to become Medicaid providers should just not respond to referrals for children who have Medicaid funding. If a provider provides services to a child funded by Medicaid but they are not an approved Medicaid provider they will not be reimbursed for the services provided. In order to become an approved Medicaid provider, providers should apply on the website of the Colorado Department of Health Care Policy and Financing (HCPF) at: Obtaining an NPI Number Providers of health care services are required to have a National Provider Identified (NPI) number. The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes. To apply for an NPI number, providers should access the following website: Page 3

4 Individual Family Service Plan The Individual Family Service Plan (IFSP) documents the treatment plan for the child and family. The IFSP outlines the types of services needed by the child as well as the frequency, scope and duration of those services. Services should be provided in accordance with the IFSP. Providers need to be cognizant of amount of services authorized for each child they serve; providers who are not billing through RMHS should track their utilization of units authorized in the IFSP.. If a provider believes that additional units of service or a different service is needed that is not listed on the IFSP, the provider should contact the RMHS Service Coordinator to amend the IFSP. The provider should not provide these additional services until the IFSP has been amended; doing so would put the provider at risk of non-payment of the services provided prior to the amendment of the plan. Delivery of Early Intervention Services By becoming an Early Intervention Provider with RMHS, you are agreeing to promote the Primary Service Provider Model. The designation of a primary service provider maintains the integrity of the team interaction while minimizing the number of professionals that families and child-care providers are required to interact with on a regular basis. A primary service provider model uses a trans-disciplinary process but details the role of this primary service provider team member. Primary Service Provider Model The Primary Service Provider Model is a trans-disciplinary home-based service delivery approach. One provider of the program acts as the primary service provider to the parents or other care-givers and is selected based on expertise in child development, family support, and coaching. The primary service provider has awareness of and access to other providers with a variety of knowledge, skills and experiences. The primary service provider is seen as a coach and reciprocal coaching and learning occur between the primary service provider and caregivers and between the primary service provider and other providers. The primary service provider receives coaching from other providers through ongoing interactions and promotes a parent s or other care-giver s ability to support a child s participation in everyday experiences and interactions with family members and peers across settings. Joint visits should occur at the same place and time whenever possible with/by other providers to support the primary service provider as often as deemed appropriate by the PSP. When visits occur at separate times, the primary service provider and other program staff must inform the care providers that the purpose of the visit is to gain information that will be shared with the primary service provider for his/her continued work with the family. Ongoing interaction provides opportunities for reflection and information sharing. Other providers providing coaching to the primary service provider may vary depending on the need or desire for timely ideas and feedback. It is critical for providers to promote the Primary Service Provider Model with families. All providers will have the opportunity to be on a member of a trans-disciplinary team where they are able to use their expertise to jointly evaluate, assess and plan to best meet the needs of the child and the family in a cohesive way. Teaming through regularly scheduled meetings offers a formal time for provider-to-provider information sharing and support in order to develop strategies designed to build the capacity of parents and other caregivers to meet child and family outcomes. Page 4

5 Rocky Mountain Human Services offers monthly meetings for many different trans-disciplinary teams to meet and lend their expertise to give strategies to best meet the needs of the child and family. These teams meet at various times and locations in Denver County. We can assist you in joining a trans-disciplinary team. Please contact: Llan Barkley at lbarkley@rmhumanservices.org Early Intervention Allowable Service Definitions Please see the attached link for a listing of allowable Early Intervention Services. RMHS cannot pay for services that are not on the list. 1). Allowable Services linkhttp:// 2). Then click on the PDF titled: Early Intervention Colorado State Plan under Part C of the Individuals with Disabilities Education Act (2015) 3). Go to: Section Early Intervention Services Minimum Provider Qualifications to Deliver Early Intervention Services Providers are responsible for ensuring they have the appropriate qualifications and licensure to provide Early Intervention Services. If a service requires licensure, the provider must have a valid license and provide a copy of that license to RMHS. Providers should only provide services within the scope of their license. The provider is responsible for notifying RMHS within five (5) business days if their license is revoked or suspended, or they have had a malpractice claim filed against them. The link below outlines the qualifications required to provide various allowable EI services. 1). Provider qualifications linkhttp:// then click on PDF titled- Qualified Personal Standards July 2015 Required Trainings for Early Intervention Providers All Providers are required to complete the Child Outcomes Summary for Infants and Children within 90 days of signing their contract. Page 5

6 Provider Database and Child Outcomes Summary All Early Intervention providers are required to complete the Child Outcomes Summary (COS) for children on their caseload at required intervals. All COS need to be entered into the EI State Provider Database. Please see EI Provider Database instructions for Providers. 1. The COS is completed within 16 weeks of a child s entry into early intervention. 2. The COS is completed when the child exits early intervention (e.g., child turns three, child has met goals early, family moves out of state, parent choice). The Service Provider will at all times maintain complete and accurate information on the State Provider Database. Early Intervention Colorado Provider Database Instructions for Providers Please login to the EI Colorado Provider Database as soon as possible at Click on "Early Intervention Providers and Staff", and then click on the link to the Provider Database on the right hand side of the screen. Requirements: All Early Intervention (EI) providers and Community Centered Board users must complete and maintain a current record in the Provider Profile section including Details, Service Areas, and Associated CCBs. Included: 1. Existing and New Provider Login 2. How to set up your Provider Profile and apply to a Community Centered Board 3. How to apply to more than one Community Centered Board 4. How to update your information in the Associated CCBs tab in your Provider Profile 5. Website: 6. EI website home page, click on: Early Intervention Providers and Staff 7. Professionals page/highlights section, click on: Provider Database 8. 3 Options; Staff Login, Provider Login, and Create an account. Existing Provider 1. Providers with an established record will use the Provider Login with your current username and password. If you have difficulty, please contact the Provider database administrator listed on the EI Colorado website under Contact Us. New Provider 1. Choose Create an account. This is where you will create your username and password in order to sign into the Provider Login. 2. Once you ve created your username and password, log in using the Provider Login on the right side of the screen. If you have difficulty, please contact the Provider database administrator listed on the EI Colorado website under Contact Us. Upon a successful login, you will be on your home page. You will see the following options in the green bar at the top; Home, Children, and My Profile. Home: Page 6

7 This page will let you know if there are comments/announcements that need to be addressed and whether you have contracts, licenses, or insurances expiring within 30 days. Children: This page will be used by the CCB to assign specific children to your caseload. You will utilize this screen to enter Entry and Exit Child Outcomes Summary (COS) information. My Profile: This page contains three tabs that should be completed from left to right: Details, Service Areas, and Associated CCBs. Details: This page contains personal, professional, and demographic information. All sections under the Detail tab with the exception of Unavailable Dates and Messages, Languages, and Comments, are required. The Unavailable Dates and Messages section is used to alert others that you are absent for a specific period of time such as vacation, medical leave, etc. Languages should be completed if you are fluent in a language other than English. The Comments section is where you can personalize your profile, including adding information about special skills or interests. Service Areas: This tab provides specific area information by Counties, Cities, and Zip Code. The area(s) you choose, will affect your CCB choices during the application phase. For instance, Rocky Mountain Human Services works within Denver County. If you choose Denver under Counties, all Denver zip codes will be revealed. You can pick and choose which zip codes you would like to work in or you can choose to Add All Areas and the entire zip code list for Denver would move from the left side of the screen to the right side. This indicates that you are willing to provide services in all of the zip codes associated with Denver County. If you change your mind and you would like to remove a zip code, you can do so by choosing the red button, Remove Area. Once this is completed, you will click on the Associated CCBs tab. Please read the entire application instruction in this section before proceeding. Completing the application process in the wrong order will result in a failed submission. Associated CCBs: First (original) Application to CCB 1. Click on the green tab on the right side of the page +Click here to select CCBs in the Service Areas you ve specified 2. Click on the Select drop down menu. This will give you a choice of CCB(s) according to the Service Areas you have selected. Click on the appropriate CCB (please choose only one if more than one is listed). See Applying to an additional CCB if applying to more than one. 3. You should now see the CCB listed with an application submission status of Not Submitted. Click on the CCB and complete the associated tabs; Credentials, Licenses and Certifications, Insurance, and Trainings. These tabs must be complete in order for the CCB to verify and approve your application. If you wish to download additional informational documents, please do so in the Documents tab. 4. Once the tabs have been completed, click on the Apply to CCB button. This will alert the CCB that you have applied and change the submission status to Submitted. Once the CCB has verified your information they will change the submission status. If you are accepted as a provider, your status will read as Active. You must be active with the CCB prior to providing services. Page 7

8 New or Existing Provider Applying to an additional CCB: If you wish to expand to additional CCBs, please follow these steps: 1. Click on My Profile. 2. Click on Service Areas and choose the areas you wish to add. 3. Click on Associated CCBs and again on the green tab on the right side of the page, +Click here to select CCBs in the Service Areas you ve specified. 4. Click on the Select drop down menu. This will give you a choice of CCB(s) according to the new Service Areas you have selected. Click on the appropriate CCB (again choose only one). 5. The new CCB will now show up in your list of Associated CCBs with a submission status of Not Submitted. 6. Click on the original CCB and make sure all of the information contained within the tabs (Credential, Licenses, etc.) is up to date. As you check the information in each tab, you will see an option to Copy this. When you click on the copy button, it will prompt you to choose a CCB. Choose the new CCB. It is very important that the new CCB has been selected and in your list prior to completing this step. Continue to copy each tab as warranted. 7. Once you have copied the required information for each tab, click on the Assoc. CCBs tab to return to the list of CCBs. 8. Click on the new CCB to ensure that each of the tabs contain the copied records. Once confirmed, click on the Assoc. CCBs tab again and return to the list. 9. Click on the Apply to CCB button. This will alert the new CCB and change the submission status to Submitted. Once the CCB has verified your information they will change the submission status. If you are accepted as a provider, your status will read as Active. You must be active with the CCB prior to providing services. Updating your Existing Associated CCB tabs (expirations, new trainings, etc.) When updating and/or adding additional information such as licenses, insurance, etc., you will do so in My Profile, Associated CCBs. If you are active with more than 1 CCB, please update the tabs under the original CCB first. Changes made to one CCB record will not automatically be reflected in additional CCB records. Once you update and save your change(s) to the original CCB tabs, you can use the Copy this feature to copy the information to another CCB. If you experience any difficulties, please contact Connie Fixsen at or connie.fixsen@state.co.us. Page 8

9 Incident Reporting Our early intervention providers work very hard to build solid and trusting relationships with the families of children for whom they are providing therapy. It is often very difficult when a therapist, either directly or indirectly, becomes aware of the possible abuse or neglect of a child. (Abuse may be emotional, physical, sexual, or institutional). All of our RMHS contracted providers are mandated reporters and therefore have the responsibility to keep all children safe and to prevent harm. A report must be made when a reporter, in his or her official capacity, suspects or has reasons to believe that a child has been abused or neglected. Another standard frequently used is in situations in which the reporter has knowledge of, or observes a child being subjected to, conditions that would reasonably result in harm to the child. Providers should peruse the State of Colorado s website which has information about mandated reporters, definitions of abuse and neglect, and phone numbers to report abuse and neglect. The website is: As a mandated reporter, if you become aware of a situation where a child s physical and or emotional well-being is at risk you are required to call the following phone numbers for reporting abuse and neglect: CO-4-Kids or to report all concerns for a child's safety and well-being. Remember... If a child is in imminent danger, please contact the local police immediately. Suspicion of abuse is all that is necessary to report. Reports are confidential. Know where the child lives. You will be asked to describe your concerns about the child and it will be helpful if you can provide the child's name, age, address, gender, school attended (if possible), and names of parents. Immediately after you report the suspected abuse/neglect to the proper authorities, Please contact the service coordinator to inform him/her of the situation. If the service coordinator is not available, please contact his/her supervisor, or another member of the management team in the Child and Family Programs Department. If Rocky Mountain Human Services (RMHS) becomes aware of an allegation of abuse/neglect involving a child in our program and it is discovered that one of our contracted providers has knowledge of, but fails to make a report, that provider may be subject to a full investigation and the following may occur: 1. At a minimum, a hold may be placed on any new referrals to the provider. 2. Current services being provided by the therapist may be suspended. The arrangement for coverage of those services to customers will be made by the Child and Family Programs Department. 3. Termination of his/her contract with RMHS. Page 9

10 Immunity from liability person s reporting (Taken from the Colorado Code State Statute ) Any person, other than the perpetrator, conspirator, coconspirator, or accessory, participating in good faith in the making of a report, in the facilitation of the investigation of such report, or in a judicial proceeding held pursuant to this title, the taking of photographs or X-rays, or the placing in temporary custody of a child pursuant to section or otherwise performing his duties or acting pursuant to this part 3 shall be immune from liability, civil or criminal, or termination of employment that otherwise might result by reason of such acts of participation, unless a court of competent jurisdiction determines that such person s behavior was willful, wanton, and malicious. For the purpose of any proceedings, civil or criminal, the good faith of any such person reporting child abuse, any such person taking photographs or X- rays, and any such person who has legal authority to place a child in protective custody shall be presumed. Page 10

11 Progress Note Requirements Progress notes are required on all children enrolled in RMHS Early Intervention Program, regardless of funding source or billing method. This includes progress notes for services paid by Medicaid, Private Insurance, or the State General Fund. All documents must be submitted in a timely manner and be of high quality, i.e. they must include complete, accurate and legible information. Industry standards and best practice is that progress notes should be completed within 48 hours of service provision. Providers may use the progress note template on the following page, or may use their own program note style. Click here for a fillable copy of the RMHS progress note template. EI Provider Progress Note - fillable form.pdf If a provider is using their own progress note template, the progress note must include: The name of the provider. The full legal name of the child as written on the IFSP, The child s date of birth; The name of the Service Coordinator for the child. The service provided. The diagnosis of the child. A diagnosis is required if a provider is billing a service that has a CPT code. The funding for the service (e.g., Medicaid, Denver Health Medicaid, Kaiser, etc.) All dates of service The CPT code, if applicable, for a particular service. If the service you have provided is billed under a CPT code, a diagnosis is required on the progress note or the note is considered incomplete. Providers are responsible for knowing what services require a CPT code. If the service that was provided has a CPT code associated with it, the provider should include it on the progress notes, even if State General Fund is going to be billed. Some Early Intervention services, such as Developmental Intervention, do not have CPT codes and therefore the provider does not have to include a CPT code for this service. The duration of the service, in units. 1 unit = 15 minutes for all services. Progress notes should include any progress towards stated goals on the IFSP, as well as current techniques and activities used to help the child achieve their goals. Each progress note must be signed. For providers on Trans-disciplinary teams who bill for DI Teaming, a separate progress note documenting the activity must be submitted for each child discussed each month. Providers should note on progress notes whether translation or interpretation was used and the name of the provider that interpreted for the meeting. Progress notes should include any no-shows. After a no-show, the provider should notify the Service Coordinator before going out to the home for a second visit. Provider should also notify the service coordinator within 48 hours for each no show. Separate progress notes must be completed for each child. Progress notes must be typed or legibly printed with only one (1) child per progress note. Progress notes that are illegible will be returned to the provider for re-submission, which may delay payment. All progress notes must be sent electronically to invoices@rmhumanservices.org in an encrypted/hipaa complaint manner. Please see later in the manual for specific instructions on deadlines for submission. Page 11

12 Early Intervention Program Progress Note Child s Name: Provider Name: IFSP Service Frequency: Service Coordinator: EI Allowable Service: DOB: Provider Agency (if : IFSP Service Duration: Service Location: Diagnostic Code: Medicaid Denver Health Aetna Blue Cross / Blue Shield Cigna Kaiser United Healthcare Other Commercial Insurance Carrier State General Fund Interpretation No Show (only 1 unit may be billed for no show) Date of Service CPT Code # of Units Goals/Session Plan RMHS to bill Provider to bill No Show Observations/Progress toward IFSP Goal(s): Recommendations/Strategies: Signature of Provider: Page 12

13 Early Intervention Program Progress Note Sample Progress Note/Therapy Child s Name: Mary Jones DOB: 4/1/13 Provider Name: John Doe, P.T. Provider Agency (if : Optimal PT Associates IFSP Service Frequency: Weekly IFSP Service Duration: 60 min. Service Coordinator: Dana Harrison Service Location: In Home EI Allowable Service: Physical Therapy Diagnostic Code: Medicaid Denver Health Aetna Blue Cross / Blue Shield Cigna Kaiser United Healthcare Other Commercial Insurance Carrier State General Fund Interpretation No Show (only 1 unit may be billed for no show) Date of Service 8/1/15 CPT Code # of Units Goals/Session Plan Mary made good progress this week. She was able to bend down from a standing position to pick up objects placed on the floor around her. She was able to imitate games such as Spring like a kangaroo and Waddle like a penguin. She was able to catch a small ball when it was gently thrown to her. Interpretation for session provided by Sam Smith of Optimal Interpretation Associates. RMHS to bill Provider to bill No Show 8/8/15 1 When this therapist arrived at the family home, there was no answer to the doorbell. Notified Service Coordinator of no show. Observations/Progress toward IFSP Goal(s): Mary is making significant gains towards meeting her IFSP goal around in engaging in various gross motor activities to increase her upper body strength, balance and coordination. Recommendations/Strategies: Continue with PT therapy on a weekly basis until the IFSP team meets during October 2015 at Mary s annual review to discuss her progress and any possible changes regarding her therapy and services. Signature of Provider: John Doe Page 13

14 Early Intervention Program Progress Note Sample Progress Note - ECSE Child s Name: Mary Jones DOB: 4/1/13 Provider Name: John Doe, ECSE Provider Agency (if : Best ECSE Ever IFSP Service Frequency: Weekly IFSP Service Duration: 60 min. Service Coordinator: Dana Harrison Service Location: In Home EI Allowable Service: Developmental Intervention (DI) Diagnostic Code: Medicaid Denver Health Aetna Blue Cross / Blue Shield Cigna Kaiser United Healthcare Other Commercial Insurance Carrier State General Fund Interpretation No Show (only 1 unit may be billed for no show) Date of Service 8/1/15 CPT Code # of Units 4 Goals/Session Plan Mary made good progress this week. She was able to imitate games such as Spring like a kangaroo and Waddle like a penguin. She was able to catch a small ball when it was gently thrown to her. RMHS to bill X Provider to bill No Show 8/8/15 1 When this therapist arrived at the family home, there was no answer to the doorbell. Notified Service Coordinator of no show. X X Observations/Progress toward IFSP Goal(s): Mary is making significant gains towards meeting her IFSP goal around in engaging in various social play activities to increase her social interactions and play skills. Recommendations/Strategies: Continue with DI on a weekly basis until the IFSP team meets during October 2015 at Mary s annual review to discuss her progress and any possible changes regarding her therapy and services. Signature of Provider: John Doe Page 14

15 Early Intervention Program Progress Note Sample Progress Note DI Teaming Child s Name: Mary Jones DOB: 4/1/13 Provider Name: John Doe, P.T. Provider Agency (if : Optimal PT Associates IFSP Service Frequency: Monthly IFSP Service Duration: 60 min. Service Coordinator: Dana Harrison Service Location: Transteam meeting EI Allowable Service: DI Teaming Diagnostic Code: Medicaid Denver Health Aetna Blue Cross / Blue Shield Cigna Kaiser United Healthcare Other Commercial Insurance Carrier State General Fund Interpretation No Show (only 1 unit may be billed for no show) Date of Service CPT Code # of Units Goals/Session Plan 8/1/15 8 Discussed Mary s progress in weekly PT and requested feedback and strategies related to her IFSP goal of increasing her engagement during social interactions and play. Received feedback and strategies such as incorporating interactive games such as Ring around the Rosie, use of bubbles, specific positive labeled praise around interacting, and supporting mom with positive feedback when she and Mary have positive interactions during play and therapy. RMHS to bill X Provider to bill No Show Observations/Progress toward IFSP Goal(s): Mary is making significant gains towards meeting her IFSP goal around in engaging in various gross motor activities to increase her upper body strength, balance and coordination. Mary can benefit from strategies that address her IFSP goal of increasing her engagement during social interactions and play during weekly PT sessions. Recommendations/Strategies: Continue with PT therapy on a weekly basis and incorporate the above strategies from TransTeam; bring in transteam member for direct observation and consultation if needed. Discuss goals and therapy priorities with family and SC at October 2015 at Mary s annual review to discuss her progress and any possible changes regarding her therapy and services. Signature of Provider: John Doe Page 15

16 Early Intervention Program Progress Note Sample Progress Note Trans Team Attendance Child s Name: N/A DOB: N/A Provider Name: John Doe, P.T. Provider Agency (if : Optimal PT Associates IFSP Service Frequency: Monthly IFSP Service Duration: Service Coordinator: Service Location: Trans team meeting EI Allowable Service: DI Teaming Diagnostic Code: Medicaid Denver Health Aetna Blue Cross / Blue Shield Cigna Kaiser United Healthcare Other Commercial Insurance Carrier State General Fund Interpretation No Show (only 1 unit may be billed for no show) Date of Service CPT Code # of Units Goals/Session Plan RMHS to bill 8/1/15 4 Attended 2 hour trans team meeting X Provider to bill No Show Observations/Progress toward IFSP Goal(s): NA Recommendations/Strategies: NA Signature of Provider: John Doe Page 16

17 Early Intervention Program Progress Note Sample Progress Note - Interpretation Child s Name: Mary Jones DOB: 4/1/13 Provider Name: Sam Smith, Interpreter Interpretation Associates Provider Agency (if : Optimal IFSP Service Frequency: Weekly IFSP Service Duration: 60 min. Service Coordinator: Dana Harrison Service Location: In Home EI Allowable Service: Physical Therapy Diagnostic Code: Medicaid Denver Health Aetna Blue Cross / Blue Shield Cigna Kaiser United Healthcare Other Commercial Insurance Carrier State General Fund Interpretation No Show (only 1 unit may be billed for no show) Date of Service 8/1/15 CPT Code # of Units 4 Goals/Session Plan Interpretation services for physical therapy session RMHS to bill X Provider to bill No Show 8/8/15 1 No Show X X Observations/Progress toward IFSP Goal(s): NA Recommendations/Strategies: NA Signature of Provider: Sam Smith Page 17

18 Guidelines for Medical Record Documentation RMHS suggests following the guidelines for medical record documentation as recommended by the National Committee of Quality Assurance (NCQA). Consistent, current and complete documentation in the medical record is an essential component of quality patient care. To access the guidelines for NCQA suggested medical record documentation, click here: Appointment Cancellations and No-Shows A no-show is when the provider makes a good faith attempt to provide services (i.e., the provider is in route to the family s home) and the family is unavailable for a scheduled therapy session when the provider arrives to the place of the visit. The provider will be reimbursed for their time at one (1) unit per no show. This payment is contingent upon the provider notifying the service coordinator immediately after the service provider is aware of the missed appointment. The service provider must document the missed appointment on the progress note. No CPT code should be included on the documentation for the no show (for example, the service provider should not be billing OT for the service date it should be billed as a no show) A provider will only be reimbursed for two (2) no-shows in a 6 month period per child. After the first no-show the service coordinator will contact the family. After the second no-show, the service coordinator will set up a meeting with the family to review the IFSP services and ensure all needs are being met. Page 18

19 Billing and Payment Funding Hierarchy RMHS is required through Early Intervention Colorado to use the funding hierarchy. This means we must have providers in our network who accept reimbursement from private health insurance and Medicaid. We must always access these funding sources prior to using EI State or Federal Funding. RMHS will send referrals with information about the child s funding source, and if you agree to take the referral, we will expect that you are prepared to either bill that funding source yourself, or to submit billing through RMHS for that funding source. If you are billing your own services for a child with commercial insurance or Medicaid, you may only submit that child s billing for reimbursement by State General Fund (SGF) if it is accompanied by an Explanation of Benefit (EOB) that addresses the payment status from the funding source on the referral. Some private health insurance companies have contracted with RMHS to provide therapeutic services to their members. EI providers may opt-in to the RMHS network and RMHS will bill the insurance company and pay the provider for services rendered. Providers may also opt-out of the RMHS network in this case the provider should have a contract directly with the private health insurance company. If a provider bills the insurance company directly, and receives a denial of payment EOB for non-contracted provider, RMHS will not reimburse the provider for the services provided because the provider was responsible for ensure they had a contract in place to provide services. Page 19

20 Progress Note Submission Requirements If you are billing any services through RMHS, your progress notes serve as your invoice for payment. Progress notes must be received prior to or on the 3 rd business day following the month in which service was provided. If progress notes are not received by the billing deadline, payment will occur the following month. Progress notes should be submitted electronically to invoices@rmhumanservices.org. Progress notes should be submitted in an encrypted or HIPAA compliant manner. If progress notes are incomplete, have inaccuracies, or are attempting to bill for unallowable services, the progress note will be returned to the provider and payment could be delayed until the following month. An example of an incomplete progress note is if a CPT code is listed but there is no diagnosis listed. We encourage you to submit your billing/progress notes on a weekly basis throughout the month; this will allow us to review and let you know if anything is missing with enough time for you to fix and Page 20

21 resubmit and still be reimbursed for each service within the appropriate time frame. If you wait to submit your notes on the 3 rd business day, you may not be paid in a timely fashion. Timely filing all services must be billed within 45 days of the services rendered or the provider will not be reimbursed by RMHS Submitting Billing to RMHS Progress notes (which are your invoice) should be sent electronically to invoices@rmhumanservices.org. s must be sent as protected documents per HIPAA regulations. Progress notes are due no later than 5:00 p.m. on the third working day of each month following the month in which services were provided. Progress notes for services provided during the month of June 2016 are due no later than 5:00 p.m. on July 6, 2016 Progress notes sent in after the 3 rd business day of the month will be processed in the next month s billing cycle Progress notes that are sent in an incorrect, unsecured format or not through the invoices@rmhumanservices.org site will be denied and sent back to the service provider. Progress notes must be charged correctly. If a progress note contains incorrect hours, charges for an unallowable service or a service that has not been approved on the child s IFSP, or is missing information, providers will be notified that their progress note has been declined. A corrected progress note will need to be submitted before 5:00 p.m. on the 3 rd working day of the month. Payment will be based only upon receipt of the corrected progress note prior to the deadline. If a corrected progress note is received after the deadline, payment may not be paid in a timely fashion, even if the original progress note was submitted prior to the deadline. Security All documents sent to RMHS must comply with the HIPAA standards (please see the HIPAA agreement in the EI contract). Documents must be sent to RMHS through a secured service. RMHS sends all HIPAA sensitive documents through Fuse Mail and all providers must have a personal Fuse Mail account to retrieve these documents. Providers may also send documents to RMHS through this secured service. Prior Authorizations for Service Delivery If a provider is billing directly to Medicaid or another insurance company, the provider is responsible for obtaining any needed Medicaid or insurance prior authorizations. If a provider is billing through RMHS, RMHS will obtain the prior authorizations. Submitting Medicaid or Insurance Denials to RMHS Denials from Medicaid or other insurance companies may be sent to RMHS for reimbursement through the State General fund. Providers are responsible for researching and resubmitting Medicaid denied claims. Denial codes that will be accepted by RMHS include code 271 (child is no longer Medicaid eligible) and 0308 (child is eligible for Denver Health Medicaid). Page 21

22 1. Denials can be included on the following month after a denial is received. Denials must include: for each child noting each date of service, CPT code, and amount of services rendered, and the child s diagnosis code. Please see Sample Progress note. Proof of the Medicaid or insurance denial (e.g., an Explanation of Benefits or EOB) must be included with the progress note. RMHS will not submit the denial to be paid by the State fund without proof of the denial from Medicaid or the child s private insurance carrier. Only denials with the rejection codes of 271 (child is no longer Medicaid eligible) and 0308 (child is eligible for Denver Health Medicaid) will be accepted by RMHS. 2. Progress notes that include the EOB should be sent to invoices@rmhumanservices.org 3. Payment for all services rendered within the timely filing period will be sent to providers within thirty (30) days of the submission of the appropriate documentation. Payment For providers billing through RMHS, clean claims (complete progress notes) will be paid within thirty (30) days of the billing deadline. RMHS reserves the right to process progress notes and pay providers prior to the 30 day deadline. For example, if a provider bills weekly, RMHS may choose (but is not contractually required) to process the billing and pay the provider on a weekly or bi-weekly basis. In these situations, checks remitted to providers may appear to be short. Providers need to be aware that the payment for complete progress notes may be variable, but will not exceed 30 days after the established billing date. If RMHS issues checks on a bi-weekly basis for 3 months, providers should not expect that this has suddenly become the payment policy and RMHS will continue to do this every month. Providers should not count on checks coming before the contractually agreed upon timeframe of 30 days after the billing deadline. Providers will receive a remittance statement along with their check. Trans-Disciplinary questions Llan Barkley lbarkley@rmhumanservices.org COS questions: Ann Howell` AHowell@rmhumanservices.org Contact Information Progress Notes Send secured to invoices@rmhumanservices.org Page 22