EPSDT SCHOOL-BASED SERVICES: AN OVERVIEW FOR PROVIDERS

Transcription

1 EPSDT SCHOOL-BASED SERVICES: AN OVERVIEW FOR PROVIDERS Oklahoma Health Care Authority

2 Purpose of Manual This manual is intended as a reference document for schools that are enrolled as SoonerCare providers. It contains requirements for participation in and reimbursement of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) School-Based Services. The manual explains covered services, their limits, and who is eligible to receive and provide the services. The manual will be updated as necessary. Information about the SoonerCare program and eligibility policies is contained in the Medicaid State Plan and administrative rules. The State Plan Amendment for School-Based Services is on file at the Oklahoma Health Care Authority (OHCA). A copy of the applicable administrative rules can be obtained from the OHCA website at School providers are responsible for ensuring compliance with current state/federal Medicaid policies pertaining to the services they render. This manual does not supersede Medicaid rules and is not to be used in lieu of them. Page 2

3 CHAPTER 1 MEDICAID OVERVIEW Medicaid Program Medicaid is a joint state-federal program that provides health care for low income and disabled individuals. The costs of providing health care and services to individuals that meet specific eligibility criteria established by each state are shared by the state and federal governments. State Medicaid agencies receive federal matching funds each year; the matching rates (referred to as the federal medical assistance percentage FMAP ) are calculated annually and are based on the State s per capital income. Oklahoma s state share is generally around 30%; the federal share is about 70%. The FMAP is published annually by the Secretary of Health and Human Services (view current federal financial matching participation rates at Some services must be covered by each state s Medicaid program, while other services may be provided at a state s option. A mandatory Medicaid service is the EPSDT program, which provides SoonerCare eligible children under age 21 with a broad array of health care screening, diagnosis and treatment services. Legal Authority The Medicaid program is authorized by Title XIX of the Social Security Act and Title 42, Code of Federal Regulations. Administrative rules pertaining to School-Based Services are found at OAC 317: to OHCA is the single State agency responsible for administering Oklahoma s Medicaid program, otherwise known as SoonerCare. SoonerCare Eligibility Certified Degree of Indian Blood Eligibility for SoonerCare benefits is based on need (i.e., determined by family income) and/or on categorical status (such as children eligible for Title IV-E foster care or adoption assistance or Supplemental Security Income, SSI ). In Oklahoma, children from birth through age 17 are eligible at 185% of the federal poverty level (FPL). Although Medicaid has other eligibility requirements, such as citizenship and Social Security Number (SSN), the same income guidelines have been used for the National School Lunch Program since December 1, The Oklahoma Department of Human Services (OKDHS), through its local county offices, is responsible for determining eligibility for SoonerCare. Applications can be made in person or mailed in. Eligibility must be redetermined in accordance with OAC 317: Individuals with Certified Degree of Indian Blood (CDIB) cards must apply for SoonerCare benefits in the same manner as other applicants. Eligibility Verification For SoonerCare reimbursement, a child must be eligible on the date of service. The following options can be used to determine a member s eligibility: Page 3

4 Facilitating SoonerCare Eligibility Request SoonerCare eligibility information on an individual basis, such as at school registration (e.g., ask for health insurance information, including Medicaid, on an enrollment form or health card); Query parents or guardians, or children who have reached the age of majority or emancipated youth, at the time services are initiated or at the time of an INDIVIDUAL EDUCATION PLAN (IEP) or treatment team meeting; Districts with current contract status and an active PIN number may access the OHCA secured website for current eligibility information; Districts with current contract status may submit a list of students to OHCA s fiscal agent, EDS, for eligibility verification; Eligibility Verification System (EVS) this is an automated system which can be accessed by phone and can be used to check up to five names at one time. The child s SoonerCare member identification number or SSN and date of birth must be known. The eligibility information is very current, but the process can be time-consuming. It is more efficient to use when checking eligibility for individuals for specific months of services, rather than initial eligibility for a large number of children. Contact the OHCA Call Center at (800) , option 1, for further information; On-Line PS/2 Verification System this is an on-line eligibility verification system that can be purchased by schools that enter into a data link contract with OKDHS. There are minimum monthly charges to operate the system, but it is reported by schools to be efficient and accurate. Contact OKDHS/Family Support Services Division at (405) for further information; Commercial Vendors Software is available from commercial vendors for on-line eligibility verification; OKDHS Match -- Contact your county OKDHS office directly to discuss the option of establishing an initial list or match. Schools can facilitate a family s application for SoonerCare through the provision of information on eligibility and benefits or assistance with the application process. Outreach can be provided on an individual basis, through the distribution of materials on a school-wide basis, or through more formal eligibility outreach campaigns. Parents can indicate their interest in receiving SoonerCare information for their children on the Application for Free and Reduced Price Meals and waive confidentiality so their names can be furnished by the school to the appropriate county OKDHS office. Contact the Child Nutrition Program at the Oklahoma State Department of Education (405) for further information on this waiver of confidentiality. EPSDT/Child Health The focus of the EPSDT/Child Health program is on preventive medical care and ensuring that parents can access medical care for their eligible children in a timely manner, before a condition becomes worse and the care more costly. Comprehensive child health screenings are provided at periodic intervals, and where necessary, children are referred for further diagnosis and treatment Page 4

5 services. The required components of a child health screen are listed in the OHCA rules at OAC 317: Performing Comprehensive Child Health Checkups (Screens) Schools are not required to perform comprehensive child health checkups (screens), but may do so under limited circumstances discussed below. When performing a comprehensive child health checkup, providers must assure that the checkup meets the minimum standards established by OHCA as outlined at OAC 317: A school may perform a comprehensive child health screen and receive reimbursement for children covered by SoonerCare under the following circumstances and when performed by a qualified provider (see Chapter 11): 1. When the SoonerCare Choice member s primary care provider (PCP) authorizes the school to perform the screen, or 2. When the SoonerCare PCP fails to schedule an appointment within three weeks of the school making and documenting a request for a screen. When a school intends to perform a child health screen on a child, a copy of the EPSDT SCREENING & NOTIFICATION DOCUMENT (Addendum of the EPSDT School-Based Services contract) must be mailed to the SoonerCare member s PCP prior to the screen as notice of the school s intent to bill for the screen. When a school performs a screen on a child, the original above referenced Addendum must be retained in the child s record and a copy of the screening results must be forwarded to the SoonerCare PCP. Screening Fee-for-Service Recipients A referral is not required for schools to perform comprehensive child health screens for children who receive their benefits under the SoonerCare Traditional benefit package. This includes children in Department of Human Services (OKDHS) or Office of Juvenile Affairs (OJA) custody and placement. Page 5

6 CHAPTER 2 OVERVIEW OF SCHOOL BASED SERVICES Introduction Through work accomplished jointly in 1997 by the Oklahoma State Department of Education (OSDE) and the OHCA, the scope of EPSDT School-Based Services was expanded. New service categories were added in an effort to make EPSDT School-Based Services both comprehensive and reflective of the types of health related activities that are already occurring in the public school system. Local educational agencies and/or interlocal cooperatives (referred to hereafter as schools ) may seek reimbursement for providing medically necessary health related services to SoonerCare eligible children enrolled in the public school system. Private schools are not eligible to participate. The Link between Providers and EPSDT The school must enroll as a SoonerCare provider to receive reimbursement for IDEA health related services rendered to SoonerCare members. The school bills OHCA for the services rendered by its qualified providers, who must be employed by or contracted with the school district. Services may be provided in the school setting, the home or another site in the community. Payment for EPSDT services is available for all SoonerCare members between the ages of birth and 21. Payments are subject to the conditions and limitations that apply to these services. Payment can only be made for services provided to individuals who have active SoonerCare enrollment status on the date services were actually provided. Schools have historically paid for and provided health related services to their students through IEPs that are excluded from the SoonerCare benefit package.. Provider Enrollment It is the responsibility of schools to ensure there is coordination between the SoonerCare member s PCP and the school when EPSDT School-Based services are provided to a SoonerCare member. Schools must enter into a Intergovernmental Agreement for EPSDT School- Based Services (referred to hereafter as contract ) with OHCA. The purpose of the contract is to establish a school-based service delivery system, in accordance with the EPSDT program, whereby physical and mental health problems which adversely affect a child s development and impair educational functioning can be identified early, and needed diagnostic and treatment services can be delivered by the school. Services are reimbursed on a fee-for-service basis. When health related services are provided and paid for by the interlocal co-op, the co-op enters into a contract with OHCA and is assigned a provider number and PIN. If the co-op is only submitting billing on behalf of its participating school district, a contract with OHCA is not required for the co-op. In this Page 6

7 instance, billing is submitted under each respective district s SoonerCare provider number. Additionally, schools/co-ops seeking SoonerCare reimbursement must apply for a National Provider Identifier (NPI) number. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare and Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers. Providers can apply for an NPI online at or can call the NPI enumerator to request a paper application at Health care providers should know that getting an NPI is free; it is not necessary to pay an outside source to obtain your NPI. The contract period is July 1 through June 30 of the following year. Districts must submit their contracts July 1 December 31 for each contract year. Contracts received after the December 31 deadline will not be processed for the current contract period. If a district is submitting a contract for renewal, the contracts must reach the OHCA no later than July 31 to maintain current contract status; otherwise, the renewal effective date will be the date received by the OHCA Provider Enrollment Unit. The contract may be downloaded from the OHCA website at Page 7

8 CHAPTER 3 CONTRACT ISSUES Matching Funds School districts who have entered into a contract with the OHCA to provide EPSDT School-Based Services must certify the availability of non-federal (state/local) funds expended for these compensable services equal to the required state share match (view current federal financial matching participation rates at Schools expend the funds for the health related services that are provided to SoonerCare members. Schools can only use state/local monies for matching Medicaid. If a federal grant has a cash match requirement, the funds used for the match cannot also be used as a match for Medicaid. Schools can make budget revisions to their Individuals with Disabilities Education Act (IDEA) federal funding (flow-through) applications in order to move staff who provide health related services from federally-funded to statefunded positions. The usual process for submitting IDEA budget revisions to Special Education Services of the OSDE must be followed. Medicaid expenditures and reimbursements must be coded in accordance with the Oklahoma Cost Accounting System (OCAS). Proceeds from Medicaid will not be treated as program income under 34 Code of Federal Regulations (CFR) of the IDEA Amendments of Expenditures of Medicaid reimbursements for IDEA services will not be considered part of the state/local maintenance of effort (MOE) requirement under the IDEA, Amendments of Rate Maximum allowable rates have been established for each type of service. The school is reimbursed 100% of this rate for allowable claims. Payments for services are made when properly completed claims are submitted to the OHCA fiscal agent. On a quarterly basis, OHCA will bill back, via an invoice, all advanced payments of State share made on behalf of the school. Treatment encounters may have both an individual and a group rate. Two or more individuals in one setting constitute a group session. If treatment is provided in a group setting, the group size cannot be more than five children in the group on a particular date of service. Procedure (Billing) Code The procedure code is the code used to identify the service rendered in the State s SoonerCare billing system (refer to EPSDT School-based Fee All procedure codes must be linked to an identified ICD-9-CM diagnosis. When billing, the ICD-9-CM code must be used in conjunction with the procedure code. Page 8

9 Provider Qualifications Schools can only be reimbursed for services that are rendered by employed or contracted providers who meet the qualifications established for the EPSDT School-Based Services program. Each service category has its own provider qualifications. Providers may only perform the service activities that are within their scope of practice. Licensure/Certification Provider qualifications requiring a State license refers to a professional license issued under State law by the applicable State licensing board (e.g., Licensed Speech Language Pathologists are licensed by the Board of Examiners under the Speech Pathology and Audiology Licensing Act). Provider qualifications requiring certification refers to certification by the OSDE, unless otherwise specified. (Note: See Covered Services chapters for provider qualifications specific to each service.) Temporary Licensure Services Provided Under Supervision Out-of-State Credentials Temporary licensure from practitioners governing board meets the provider qualifications for a licensed practitioner as long as the requirements for the temporary license also meet the rules of the OSDE and OHCA for that professional type. Services may not be provided under supervision, unless specifically authorized and in accordance with State laws governing professional practice. These exceptions are noted in the service chapters, as applicable. When a SoonerCare member receives services at the school site, services are billable only when the direct service provider holds an Oklahoma State license or has reciprocity. In order to bill for services rendered by an out-of-state practitioner, the services must be rendered in the State in which the practitioner holds a license. Subcontracting Schools may choose to contract with third party agents to perform their billing functions or to furnish health services to their students. However, these functions cannot be performed simultaneously by the same third party agent. Schools can contract with a billing agent to prepare and submit their SoonerCare claims. The school is solely responsible for claims submitted by its billing agent. Billing agents must not have access to confidential progress/clinical notes. Schools may contract directly with individual State licensed providers or with a provider agency that employs qualified direct service providers to provide health related services in the school. However, if contracting with an outside provider who is also a contracted SoonerCare provider, the school must include a clause in its contract to the effect that the contracted provider will not directly bill OHCA for any services which are being covered under his/her contract with the school. Page 9

10 Billing Private/Public Insurance Practitioners who are contracted as a SoonerCare provider and rendering health related services that are pursuant to a child s IEP, can not directly bill OHCA for the IEP health related services rendered. Health related services identified in accordance with IDEA and that are pursuant to an IEP are the responsibility of the school district. The independent provider must contract with the school district and invoice the district for services rendered. Therefore, in order to seek SoonerCare reimbursement for medically necessary IEP health related services rendered to a SoonerCare member, the school district must contract with OHCA and bill using the district s provider number. The school retains responsibility for the accuracy of all service documentation when submitted for billing to the OHCA fiscal agent. The school is also responsible for ensuring that all children receive appropriate services, not just those who are enrolled in SoonerCare. Examples of contract arrangements that can be made by schools include, but are not limited to, the following: Contract with nurses (Registered Nurses (RN) or Licensed Practical Nurse (LPN) under RN supervision) to provide nursing services; Contract with a licensed, independent speech language pathologist to provide speech therapy and speech language evaluations; Contract with licensed professional counselors (LPC), licensed social workers (LSW), licensed marriage and family therapists (LMFT), licensed psychologists, or licensed behavioral practitioners (LBP) or with an agency that employs these disciplines (agency must have accreditation through one of the following : Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Commission on Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation (COA) or American Osteopathic Association (AOA)), to provide psychotherapy counseling to children pursuant to the individuals IEP/IHSP developed by the school district. When a family applies for SoonerCare benefits they are also providing parental consent for the billing of SoonerCare by enrolled SoonerCare providers. Obtaining parental consent is a federal requirement under the Individuals with Disabilities Education Act (IDEA) and school districts may be subject to state/federal audits to ensure compliance of IDEA. The definition of parental consent under IDEA may be narrower than that under Medicaid; schools are encouraged to examine their own practices to ensure compliance with all federal programs. Additionally, under IDEA children are entitled to a free and appropriate public education (FAPE). Parental consent must be obtained to access private/public insurance for the services required to provide FAPE to their child. Parents must also be informed that, even if they refuse to permit access to their private/public insurance, the required services will be provided at no cost to them. The school may pay for the required service or cost the parents would incur to use their insurance (such as a deductible or co-pay amount), including use of its Part B funds under IDEA. Page 10

11 Parents may not be required to enroll in public insurance programs in order for their child to receive FAPE. Parents may not be required to incur an out-ofpocket expense, such as a deductible or co-pay amount, if a claim were filed for such services. The school may pay the cost that the parent would otherwise be required to pay if their public insurance were used, including use of its Part B funds under IDEA. A school may not use a child s public insurance benefits if it would decrease available lifetime coverage or any other insured benefit, result in the family paying for services provided outside of school that would otherwise be covered by the public insurance, increase premiums or lead to discontinuation of insurance, or put the child at risk of losing eligibility for home and communitybased waiver services. Billing SoonerCare for these services will not reduce the child s SoonerCare benefits. Care Coordination Linking the child to his/her medical home so that preventive health care can be furnished on a regular basis is a critical part of care coordination. Schools must inform SoonerCare PCPs of the children in their district who have an urgent need for an EPSDT/Child Health screen within a given school year. Referrals to SoonerCare PCPs must be documented on the EPSDT SCREENING & NOTIFICATION STATEMENT (Addendum of the EPSDT school-base contract), as well as contact with parents if the medical provider is unknown. The school must coordinate the ongoing health services that the child is receiving with the child s SoonerCare PCP. Schools can obtain the name of a child s SoonerCare PCP in the following ways: Ask parents/guardians or children (who have reached the age of majority or emancipated youth) to provide the name of their SoonerCare provider on registration material, at the time services are initiated, or when SoonerCare eligible children are identified. Access the name of the child s SoonerCare provider by obtaining eligibility verification through OHCA s fiscal agent, EDS. Access the name of the child s SoonerCare provider through the Eligibility Verification System (EVS), an automated phone system operated by OHCA, or a dedicated line with OKDHS. Page 11

12 Contract Obligations The school is obligated, under the Intergovernmental Agreement for EPSDT School-Based Services, to do the following: Deliver SoonerCare-covered services; Ensure that Individual/Group Treatment Encounters are provided pursuant to the child s IEP/IHSP. Ensure that services are medically indicated and necessary; Ensure that individual service providers are appropriately qualified under guidelines established by OHCA and subcontracted behavioral health service agencies are consistent with current OHCA outpatient behavioral health guidelines (JCAHO, CARF, AOA, or COA accreditation is required); Assist in facilitating EPSDT/Child Health exams for individuals covered by SoonerCare, or perform child health exams for these individuals, in limited circumstances and forward the results to the child s PCP; Designate a school district employee, as Medicaid Coordinator, to attend the annual training provided by OHCA and to be available for all necessary meetings, conferences or audits related to SoonerCare billing (Note: Medicaid Coordinator must be an employ of the district; not a contracted provider); Designate district OCAS personnel to attend an annual training conducted by OSDE. The school must provide OHCA the name of the district contractor/representative for OCAS; Ensure that if the school district subcontracts for the provision of health services and billing, these functions are performed by separate entities; Notify OHCA of all subcontractors and the functions they perform within 30 days of entering this agreement, or within 10 days of any change in subcontractors; Submit claims according to OHCA s instructions; Code SoonerCare expenditures and reimbursements in accordance with OCAS; Credit funds received through SoonerCare reimbursement for special education and/or health related services; Pay OHCA back the advanced state share made on behalf of the school. OHCA will invoice school on a quarterly basis; The Contractor shall keep such records as are necessary to disclose fully the extent of service provided to SoonerCare recipients and, upon request, shall furnish records and information regarding any claim for providing such service to OHCA, the Oklahoma Attorney General s Medicaid Fraud Control Unit (MFCU hereafter), and the U.S. Secretary of Health and Human services (Secretary hereafter) for six years from the date of provision. The Contractor shall not destroy or dispose of records, which are under audit, review or investigation when the six-year limitation is met. The Contractor shall maintain such records until informed in writing by the auditing, reviewing or investigating agency that the audit, review or investigation is complete. Page 12

13 CHAPTER 4 COVERED SERVICES: GENERAL SERVICE REQUIREMENTS Introduction The general service requirements that apply to all EPSDT School-Based Services are described below. Any exceptions to this general information that apply to a specific service are noted in the service chapters that follow. Chapters 6-11 contain more detailed information on each category of service. Each service chapter includes a definition of the service, specific provider qualifications, and service authorization requirements (as specified in the Medicaid State Plan and the administrative rules.) The service chapters (and sections) have been designed as pull-outs for easy distribution to individual service providers. Medical Necessity Reimbursement can be made for services for which a child has a determined medical need. The services provided to an eligible child must be individualized and consistent with the symptoms or confirmed diagnosis of a specific disorder and/or delay. Prior to treatment plan development, direct service providers must perform the appropriate evaluations/assessments (within their scope of practice) to determine the SoonerCare member s need for services. Annual re-evaluations are required to determine the need for continued services. OHCA has adopted the following standards (OAC 317:30-3-1(f)) concerning the establishment of medical necessity: (1) Services must be consistent with accepted health care practice standards and guidelines for the prevention, diagnosis or treatment of symptoms of illness, disease or disability; (2) Documentation submitted in order to request services or substantiate previously provided services must demonstrate through adequate objective medical records, evidence sufficient to justify the client s need for the service; (3) Treatment of the client s condition, disease or injury must be based on reasonable and predictable health outcomes; (4) Services must be necessary to alleviate a medical condition and must be required for reasons other than convenience of the client, family, or medical provider; (5) Services must be delivered in the most cost-effective manner and most appropriate setting; and; (6) Services must be appropriate for the client s age and health status and developed for the client to achieve, maintain or promote functional capacity. Service Authorization Services, with the exception of the Child Health Encounter, Nursing Assessment, Dental Screening Examination, and evaluations, must be authorized (i.e., specified) in the child s individualized treatment plan. The treatment plan must identify the need for service(s); the scope, frequency and duration of service Page 13

14 to be provided with beginning and ending date and; the provider. Physician orders must be obtained, where applicable, prior to providing the service. The only exception to this rule is noted in Oklahoma Senate Bill 1280, signed by Governor Brad Henry with an effective date of July 1, This bill amended the Oklahoma Statute of Healing Arts allowing State licensed Speech Language Pathologist, Audiologist, Occupational Therapist, and Physical Therapist to be practitioners of the healing arts when providing services to a child under the Individuals with Disability Education Act (IDEA) and pursuant to a recipient s Individual Education Plan (IEP). Thus, in the case that these practitioners perform the appropriate testing/evaluations that clearly identifies medical necessity and creates a plan of care for a child under the IDEA may render services without a physician s order. Please note; if providing a non-iep health related service, SB 1280 does not apply; therefore, physician orders, where applicable, must be obtained. Treatment Plan The individual treatment plan serves as the service authorizing document. It must include a signature by the health care professional(s) authorized to determine the need for the specific health related service. If the practitioner is a subcontractor, a school district employee s signature must also be on this document. For children with disabilities who have IEPs, IDEA federal regulations require documentation of parental notice and participation in implementing or changing related services, as well as informed written consent to conduct evaluations. IHSP The Individual Health Services Plan (IHSP) is used as the primary treatment plan for health related services of recipients who do not have an IEP. In order to bill for services that are delivered based upon medical goals/objectives identified in an IHSP, the IHSP must be developed by a team inclusive of school personnel and qualified service delivery provider(s). An IHSP must be signed by the provider(s) that determined the need for service(s) (this may also be the provider(s) that will be performing the service(s)) and by a school employee designated by the district who is familiar with the child s needs. An IHSP must be reviewed within the timelines indicated in the plan, based on the child s particular needs. A parent signature on an IHSP is not a written Medicaid program requirement, however, in schools, parents must be notified (and have the opportunity to respond) prior to implementing a treatment plan and must provide informed written consent to conduct intake, assessment or psychological evaluations. There may be circumstances where a child with a disability has both an IEP and an IHSP. In such cases where there is an IHSP in addition to the child s IEP, the IHSP is treated as secondary service plan to the IEP. The IDEA requires documentation on the IEP to address all related services that are necessary for the child to benefit from their education. Page 14

15 Service Limitations Place of Service Unit of Service Daily limits have been established for all EPSDT School-Based Services. This means that a maximum number of service units may be reimbursed for a child on a given day. There are some services that have an annual limitation. Service limitations are noted in the school-base fee schedule. Services may be provided at the school, at the child s home or at another site in the community. Each service has a specified unit for billing purposes. This is time spent in a direct service. Direct service must be face-to-face with the child (exceptions may be completing a child health history; or providing health education to the parent/guardian; but at all times service must be individualized to the child s needs). There is no reimbursement for time reviewing/completing paperwork and/or documentation related to the service or for staff travel to/from the site of service, unless otherwise specified. Most units of service are time-based, meaning that the service must be of a minimum duration in order to be billed. A unit of service that is time-based is continuous minutes; the time cannot be aggregated throughout the day. There are no minimum time requirements for evaluation services, for which the unit of service is generally a completed evaluation. The only exception is the Psychological Evaluation, which is billed in hourly increments. Page 15

16 CHAPTER 5 DOCUMENTATION Documenting Medical Necessity In order to bill for EPSDT School-Based Services, documentation must reflect medical necessity. Medical necessity must be documented through the provider s written comprehensive evaluation/assessment of the child that clearly identifies the child s deficit/delay and/or disability and how the child s education is affected by the identified delay and/or disability. A re-evaluation/ assessment must be performed annually and prior to development of treatment plan. Initial evaluation/assessment must include a written report that consists, at a minimum, of the following components: Date of evaluation/assessment Age of child Diagnostic testing to determine deficit/delay; Area specific test results/percentage of delay; Effects of deficit/delay on child s learning; Potential benefit/effects on child s learning if treated; Expected/anticipated outcome (measurable medical goals & objectives); Specific planned interventions to include time, duration & frequency of sessions Signature/credentials of service provider Annual re-evaluation/assessment must include a written report that consists of the following components: Date of evaluation/assessment Age of child Testing/re-testing (if informal testing; must show how level of functioning was determined) Prior level of delay; Present level of delay; Expected/anticipated outcome Measurable medical goals/objectives; Specific planned interventions to include time, duration and frequency of sessions Signature/credentials of service provider Documentation/Progess Notes All documentation that supports the district s billing must be maintained onsite at the district in a manner and format that is efficient for the individuals providing the service but also accessible in the event of an audit. The intent of a progress note is to tie the service being performed and the outcomes achieved back to the individual treatment plan goals and objectives. At a minimum, progress notes must include: Child s name and DOB or Name & SSN Date of service (MMDDYY) Page 16

17 Electronic Documentation Start and stop time of service Diagnosis (primary and/or functional) Demonstrate the relationship of service with the medical goals/objectives What was worked on with the recipient Participation level of recipient (how did the child respond) Identify any plans for the next session or change in treatment Each entry to be legible and signed by service provider w/credentials No standard format for progress notes is required. SOAP (subjective, objective, assessment, plan) notes are one format for writing progress notes utilized by some health care professionals, but are not a required format. A written progress note is the supporting documentation that a service was actually provided and necessary. The service provider must sign daily progress notes. Initials may be used as long as the provider s original signature with credentials and initials also appear on the documentation form. When services such as occupational or physical therapy are provided by a licensed assistant under the direction of a licensed therapist, the licensed therapist must review and sign the progress notes as part of their supervisory responsibility. Electronic signatures are acceptable however; the use of electronic signature must be in compliance with OAC 317: Computer generated logs are acceptable. However; if use of electronic signature is not compliant with OAC 317: , then multiple entry logs would not be acceptable. Instead, a printed copy of each entry with original servicing provider signature and credential is required. Records Retention Audit Requirements Original records documenting the extent of services provided to individuals under the EPSDT School-Based Services contract and payments claimed for these services must be maintained on-site of district for six years from date of service. This documentation requirement includes documentation for services provided by subcontractors. Records can be archived according to district record management policy but must be accessible for review or audit purposes. All EPSDT School-Based Services are subject to state and federal audit. As the SoonerCare provider, the school certifies that the services being claimed for reimbursement were medically necessary and were furnished under the provider s direction. Both fiscal and clinical compliance will be monitored. The Surveillance and Utilization Review System (SURS), a unit within OHCA, is responsible for conducting audits. Generally, these are post-payment reviews as they occur after a school receives reimbursement for the services that are being reviewed. SURS will review documentation of the services provided by a school (e.g., need for services, treatment plans and case/progress notes) and compliance with Medicaid rules and regulations, including the qualifications of Page 17

18 individual service providers. SURS uses a computerized method of statistical analysis to identify providers who are outliers or perceived over-utilizers. SURS may look into the circumstances that resulted in service utilization or payments being larger than or outside the average of those made to comparably-sized schools over a period of time. Page 18

19 CHAPTER 6 CHILD HEALTH ENCOUNTER Definition The child health encounter may include a diagnosis and treatment encounter. A child health encounter may include a child health history, physical examination, developmental assessment, nutritional assessment and counseling, social assessment and counseling, genetic evaluation and counseling, indicated laboratory and screening tests, screening for appropriate immunizations, health counseling and treatment of childhood illness and conditions (OAC 317: (b) (2)). Provider Qualifications SDE certified special education related services professionals or other State licensed or certified health care professionals. Unit of Service Service limitation: Per encounter 3 encounters per day Service Authorization Documented written referral Clarification The following are providers who may perform this service for SoonerCare reimbursement: (Professionals may only perform service activities that are within their scope of practice.) School nurse/licensed registered nurse Licensed practical nurse (under supervision) Licensed psychologist Certified school psychologist Licensed speech language pathologist Speech pathology assistant (under supervision of a licensed independent practitioner in accordance with the Speech Pathology and Audiology Licensing Act) Licensed occupational therapist Licensed physical therapist Licensed audiologist Licensed professional counselor Licensed social worker Licensed marriage and family therapist Licensed behavioral practitioner Certified vision impairment teacher Orientation and mobility specialist Certified deaf education teacher Scope The intent of a Child Health Encounter is that it is the initial assessment or screening that determines the need for additional evaluation or treatment Page 19

20 service, and where appropriate, leads to the development of an individualized treatment plan. The following is intended to clarify the scope of a Child Health Encounter: Service is child-specific and child-focused; most will require a face-to-face encounter with the child. (Exceptions may be completing a child health history with, or providing health education to the parent or guardian.) Service is performed based on a child s medically indicated need. Self-referrals for service are not prohibited. The daily limit may not exceed a total of three encounters. There is no time increment on an encounter. Service Exclusion Reimbursement for Child Health Encounters DOES NOT include: Paper immunization screenings for school enrollment purposes Preventive health screenings Mass screenings Administering of routine medications Services provided on a routine or ongoing basis Classroom education on health/mental health prevention Vision/hearing screenings performed as a requirement of IDEA (considered child-find activity) Page 20

21 CHAPTER 7 INDIVIDUAL/GROUP TREATMENT ENCOUNTER Definition An individual/group treatment encounter may occur through the provision of individual or group treatment services to children who are identified as having specific disorders or delays in development, emotional, or behavioral problems, or disorders of speech, language or hearing. These types of encounters are initiated following the completion of a diagnostic encounter and subsequent development of a child s IEP/IHSP. Includes: Hearing and Vision Services (See Section A) Speech and Language Therapy (See Section B) Physical Therapy (See Section C) Occupational Therapy (See Section D) Nursing Services (See Section E) Vision and Hearing Screens (See Section F) Behavorial Health Services (See Section G) - Psychological Evaluation and Testing - Psychotherapeutic Counseling Services Assistive Technology Services (See Section H) Provider Qualifications See specific provider qualifications for each service category under the individual/group Treatment Encounter in Sections A - H that follow. Service Limitation Daily maximum limit varies by service as noted on fee schedule. Page 21

22 CHAPTER 7 - SECTION A HEARING AND VISION SERVICES Definition May include habilitation activities, such as auditory training, aural and visual habilitation training, including Braille, and communication management; orientation and mobility; counseling for vision and hearing losses and disorders. Provider Qualifications State licensed, master s degree audiologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA (317: (b) (12) (A)). State licensed, master s degree speech language pathologist who (1) holds a certificate of clinical competence from the ASHA; or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA (317: (12) (B)). State certified deaf education teacher Certified orientation and mobility specialist State certified vision impairment teacher Page 22

23 CHAPTER 7 - SECTION B SPEECH LANGUAGE EVALUATION & THERAPY SERVICES Provider Qualifications State licensed speech language pathologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate. Speech pathology assistant, authorized by the Board of Examiners, working under the direction and employment of a State licensed speech language pathologist. The supervising pathologist must be on site and may not supervise more than two speech pathology assistants (317: (b) (12) (B)). Professionals may only perform activities that are within their scope of practice. Service Authorization: Initial evaluation requires a documented referral. Re-evaluation must be performed annually to determine need for ongoing services. Therapy services must be authorized in child s IEP/IHSP. Non-IEP services require a doctor prescription. Clarification Speech pathologists in their clinical fellowship year (CFY) are permitted to bill for speech language therapy services. Supervision of Speech Pathology Assistants Bachelor s level speech therapists may not bill for speech therapy services under the supervision of a licensed speech language pathologist. Oklahoma s Speech Pathology and Audiologist Licensing Act requires that Speech Pathology Assistants who are properly authorized under the law must perform under the direct supervision and employment of ASHA certified and State licensed speech pathologists. Speech pathology assistants cannot, therefore, be employed and supervised by school districts. The supervisor must be available for direct on-site supervision. An independent practitioner may contract with an enrolled school to provide speech and language services for which the school bills Medicaid. The initial evaluation activity performed as part of the IEP development process is billable when the appropriate documented referral is in place. Annual reevaluations must be performed to determine the need for ongoing services. Page 23

24 CHAPTER 7 SECTION C PHYSICAL THERAPY EVALUATION & SERVICES Provider Qualifications State licensed physical therapist Physical therapy assistant authorized by the Board of Examiners, working under the supervision of a licensed physical therapist. The licensed physical therapist may not supervise more than three physical therapy assistants. (OAC 317: (b) (12) (C)) Professionals may only perform service activities that are within their scope of practice. Service Authorization: Initial evaluation requires a documented referral. Re-evaluation must be performed annually to determine need for ongoing services. Therapy services must be authorized in child s IEP/IHSP. Non-IEP services require a doctor prescription. Clarification The initial evaluation activity performed as part of the IEP development process is billable when the appropriate documented referral is in place. Annual reevaluations must be performed to determine the need for ongoing services. NOTE: *Code Therapeutic Group Therapy; this code is used for both PT and OT group sessions. It is important to collect claims from both provider types when both services are provided on same date of service. If submitted separately, subsequent claim will deny as duplicate. Page 24

25 CHAPTER 7 SECTION D OCCUPATIONAL THERAPY EVALUATION & SERVICES Definition May include the provision of services to improve, develop or restore impaired ability to function independently. Provider Qualifications State licensed occupational therapist Occupational therapy assistant authorized by the Board of Examiners, working under the supervision of a licensed occupational therapist (OAC 317: (b) (12) (D)) Professionals may only perform service activities that are within their scope of practice. Service Authorization: Initial evaluation requires a documented referral. Re-evaluation must be performed annually to determine need for ongoing services. Therapy services must be authorized in child s IEP/IHSP. Non-IEP services require a physician/doctor prescription Clarification The initial evaluation activity performed as part of the IEP development process is billable when the appropriate documented referral is in place. Annual reevaluations must be performed to determine the need for ongoing services. NOTE: *Code Therapeutic Group Therapy; this code is used for both PT and OT group sessions. It is important to collect claims from both provider types when both services are provided on same date of service. If submitted separately, subsequent claim will deny as duplicate. Page 25

26 CHAPTER 7 --SECTION E NURSING SERVICES (Includes Assessment/Treatment) Definition May include the provision of services to protect the health status of children, correct health problems and assist in removing or modifying health-related barriers. Services include medically necessary procedures rendered at the school site, such as catheterization and suctioning, (OAC 317: (b) (12) (E)). Provider Qualifications Registered nurse (RN) Licensed practical nurse (LPN) working under the supervision of an RN (in accordance with OK Nurse Practice Act). Service Unit Nursing Assessment per assessment (1 daily 18 yearly maximum) Nursing Treatment Service: Up to 15 minutes Service Authorization Nursing treatment services requires doctor s orders and must be authorized in the child s IEP/IHSP. Clarification Nursing assessment can be billed when performing medically necessary acute episodic interventions/treatments that do not require a treatment plan. Nursing Treatment Services may be billed when treating chronic conditions pursuant to a treatment plan. Supervision of LPNs In accordance with the Oklahoma Nurse Practice Act, LPNs must be supervised by a physician or registered nurse (RN). It is recommended that, if the supervising RN is not a school employee, the school include specific responsibilities for supervising LPNs in their contract with the RN. LPN s Scope of Practice LPNs may perform some Child Health Encounter activities under supervision and within their scope of practice, in accordance with the Oklahoma Nurse Practice Act. These activities may include vision, hearing, immunization screenings; health counseling; and triage of childhood illness and conditions. LPNs may contribute to the assessment of the health status of an individual. It is not within a LPN s scope of practice to perform a child health history or an initial (diagnostic) assessment. Medication Administration & Monitoring Administration and monitoring of routine medications is not a billable service, Page 26