Private Duty Nursing (New Jersey) PRIVATE DUTY NURSING (NEW JERSEY) HS-255. Policy Number: HS-253. Original Effective Date: 6/18/2014

Size: px
Start display at page:

Download "Private Duty Nursing (New Jersey) PRIVATE DUTY NURSING (NEW JERSEY) HS-255. Policy Number: HS-253. Original Effective Date: 6/18/2014"

Transcription

1 Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc. Windsor Health Plan for Medicare Advantage Part D Windsor Rx Medicare Prescription Drug Plan Private Duty Nursing (New Jersey) Policy Number: HS-253 Original Effective Date: 6/18/2014 Revised Date(s): 6/27/2014; 5/7/2015; 6/ /2015 APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Clinical Coverage Guideline page 1

2 DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult for list of current LOBs. BACKGROUND Private-duty nursing (PDN), provided by licensed nurses, is defined as individual and continuous care, in contrast to part-time or intermittent care. Nurses can be employed by a licensed, certified home health agency or a licensed, accredited health care service firm. PDN is limited for each beneficiary to a maximum of 16 hours per day from all payment sources. It is to be provided only when there is a live-in primary caregiver (adult relative or significant other adult) who accepts 24-hour responsibility for the health and welfare of the beneficiary. PDN is also a benefit for Core Medicaid in New Jersey for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) members. For adults, Members must be considered in Managed Long Term Services and Supports (MLTSS) to receive PDN benefits. The purpose of the program is to accommodate long-term chronic or maintenance health care, as opposed to shortterm skilled care as is provided under Medicaid s home health program. PDN services provide individual and continuous nursing care, as different from part-time intermittent care, provided by licensed nurses in the home to beneficiaries under Community Resources for People with Disabilities (CRPD), Home and Community-Based Waiver for Medically Fragile Children (ABC Program), AIDS Community Care Alternatives Program Waiver (ACCAP), as well as eligible EPSDT beneficiaries. PDN services shall be provided by a licensed home health agency, voluntary non-profit homemaker agency, private employment agency and temporary-help service agency approved by the Department of Medical Assistance and Health Services (DMAHS). The voluntary nonprofit homemaker agency, private employment agency and temporary help-service agency shall be accredited, initially and on an ongoing basis, by the Commission on Accreditation for Home Care, Inc., the Community Health Accreditation Program, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the National Association for Home Care and Hospice. (New Jersey State Legislature, 2014, 10: Purpose and scope). According to New Jersey MLTSS, PDN shall be a covered service only for those beneficiaries enrolled in MLTSS. When payment for private duty nursing services is being provided or paid for by another source, the MLTSS benefit of private duty nursing hours shall supplement the other source up to a maximum of 16 hours per day, including services provided or paid for by the other sources, if medically necessary, and if cost of service provided is less than institutional care. Service Limitations Per Medical Necessity as defined in the contract. Adult PDN services are provided in the community only (the home or other community setting of the individual), and not in hospital inpatient or nursing facility settings. PDN services are a State Plan benefit for children under the age of 21. For adults over the age of 21, PDN is provided under the MLTSS benefit. Persons meeting nursing facility (NF) level of Care are eligible to receive PDN. PDN criteria are based on medical necessity and is prior approved by the MCO in a plan of care. Home and community-based services waiver / PDN is individual, continuous nursing care in the home, and is a service available to a beneficiary only after enrollment in MLTSS. Clinical Coverage Guideline page 2

3 POSITION STATEMENT Applicable To: Medicaid (Plan A) New Jersey Medicaid (MLTSS) New Jersey MLTSS Private Duty Nursing is a covered benefit when the following criteria are met: 1. Member is enrolled in Medicaid Plan A or MLTSS; AND, 2. There is a doctor's order to receive this service*; AND, 3. Live in a community based residence (e.g., private home, apartment, rooming house, or boarding home) or group home, skill development home, supervised apartment or other congregate living program where personal care is not provided as a part of the service package included in the living arrangement; AND, 4. Have a documented need for hands-on personal care. * To receive PDN services, the member does not have to be permanently disabled. Services for Children Through Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Legislature, 2014 New Jersey State To be considered for EPSDT / PDN services, the member must meet the following criteria ( 10:60-5.2): Shall be under 21 years of age; AND, Enrolled in the Medicaid / NJ FamilyCare fee-for-service program; AND, Referred by a parent, primary physician, hospital discharge planner, Special Child Health Services case manager, Division of Developmental Disabilities (DDD), Division of Disability Services (DDS), Division of Youth and Family Services (DYFS), Division of Mental Health Services (DMHS) or current PDN provider; AND, Exhibits a severity of illness that requires complex skilled nursing interventions on an ongoing basis, to be considered in need of EPSDT/PDN services. "Ongoing" means that the beneficiary needs skilled nursing intervention 24 hours per day/seven days per week. "Complexity" means the degree of difficulty and/or intensity of treatment/procedures. "Skilled nursing interventions" means procedures that require the knowledge and experience of licensed nursing personnel, or a trained primary caregiver. Requests for services shall be submitted to the using a "PDN Services" form, incorporated herein by reference. The Request shall be completed signed by the referring physician and agreed to and signed by a parent or guardian. All sections of the Request shall be completed and a current comprehensive medical history and current treatment plan, completed by the referring physician, shall be attached. The comprehensive medical history, current treatment plan and other documents submitted with the request shall reflect the current medical status of the individual and shall document the need for ongoing (not intermittent) complex skilled nursing interventions by a licensed nurse. Incomplete requests shall be returned to the referral source for completion prior to further action by. Upon receipt of the fully completed Request, a of the need for PDN services, as well as the level (LPN or RN) and amount of service required. When the is found to be eligible for EPSDT/PDN services, the number of hours approved, the level of services, and the length of time of the approval (up to a maximum of six months) shall be noted. Requests for continuation, or modification of PDN services during the treatment period, shall be submitted by the Clinical Coverage Guideline page 3

4 PDN agency, in writing, to on the "Prior Authorization Request Form" In an emergency, requests for modification of services may be made by telephone but shall be followed immediately by a written prior authorization (PA) request. EPSDT/PDN services are only appropriate when all of the following requirements are satisfied: There is a capable adult primary caregiver residing with the individual who accepts ongoing 24-hour responsibility for the health and welfare of the beneficiary; AND, The adult primary caregiver agrees to be trained or has been trained in the care of the individual and agrees to receive additional training for new procedures and treatments, if directed to do so by a State agency; AND, The primary caregiver agrees to provide a minimum of eight hours of hands-on care to the individual during every 24-hour period; AND, The home environment can accommodate the required equipment and licensed PDN personnel. NOTE: Individuals eligible for Medicaid services through the Medically Needy program are not eligible for EPSDT services, in accordance with N.J.A.C. 10:49-5.3(a)2. NOTE: For individuals who are enrolled in Medicaid managed care, PDN is authorized and provided by the HMO. The following requirements apply to for EPSDT/PDN services ( 10:60-5.4): PDN shall be provided for eligible beneficiaries in the community only and not in hospital inpatient or nursing facility settings. shall determine and approve the total PDN hours for reimbursement, in accordance with N.J.A.C. 10:60-5.2(b). A maximum of 16 hours of PDN services may be provided in any 24-hour period. The determination of the total EPSDT/PDN hours approved, up to the maximum 16 hours per 24-hour period, shall take into account alternative sources of PDN care available to the caregiver, such as medical day care or a school program. In emergency situations, for example, when the sole caregiver has been hospitalized, may authorize, for a limited time, additional hours beyond the 16-hour limit. Medical necessity for EPSDT/PDN services shall be based upon, but may not be limited to, one of the following: 1. A requirement for all of the following medical interventions: Dependence on mechanical ventilation; The presence of an active tracheostomy; and The need for deep suctioning; or OR, 2. A requirement for any of the following medical interventions: The need for around-the-clock nebulizer treatments, with chest physiotherapy; Gastrostomy feeding when complicated by frequent regurgitation and/or aspiration; or A seizure disorder manifested by frequent prolonged seizures, requiring emergency administration of anti-convulsants. the following situational criteria shall be considered, once medical necessity has been established in accordance with items #1 or #2 above, when determining the extent of the need for EPSDT/PDN services and the authorized hours of service: Available parental support; AND, Additional sibling care responsibilities; AND, Alternative sources of nursing care. Clinical Coverage Guideline page 4

5 Exclusions Services that shall not, in and of themselves, constitute a need for PDN services, in the absence of the skilled nursing interventions listed above, shall include, but shall not be limited to: Patient observation, monitoring, recording or assessment; Occasional suctioning; Gastrostomy feedings, unless complicated as described in (b)1 above; and Seizure disorders controlled with medication and/or seizure disorders manifested by frequent minor seizures not occurring in clusters or associated with status epilepticus. NOTE: PDN shall be a covered service only for adults those beneficiaries covered under EPSDT/PDN. While PDN is a form of respite service available under the Division of Development Disabilities - Community Care Waiver (CCW-DDD), respite services are distinct from EPSDT/PDN services and are not eligible for reimbursement as EPSDT/PDN services. Respite care is not a covered service under Medicaid/NJ FamilyCare. CODING CPT * Codes No applicable codes HCPCS * Codes T1000 Private duty/independent nursing service(s), licensed, up to 15 minutes ICD-9 Codes No applicable codes ICD-10 Codes No applicable codes *Current Procedural Terminology (CPT ) 2015 American Medical Association: Chicago, IL. REFERENCES 1. Title 10, chapter 60: home care services. New Jersey State Legislature Web site. Published Accessed May 1, MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 6/16/2015 Approved by MPC. 5/7/2015 Approved by MPC. No changes. 6/27/2014 Approved by MPC. Clarified language. 6/5/2014 Approved by MPC. Clinical Coverage Guideline page 5

Specialized Therapeutic Foster Care and Therapeutic Group Home (Florida)

Specialized Therapeutic Foster Care and Therapeutic Group Home (Florida) Care1st Health Plan Arizona, Inc. Easy Choice Health Plan Harmony Health Plan of Illinois Missouri Care Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona OneCare (Care1st Health

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: skilled_nursing_services 07/2001 2/2018 2/2019 2/2018 Description of Procedure or Service Skilled Nursing

More information

PROVIDER POLICIES & PROCEDURES

PROVIDER POLICIES & PROCEDURES PROVIDER POLICIES & PROCEDURES EXTENDED NURSING SERVICES The purpose of this document is to provide guidance to providers enrolled in the Connecticut Medical Assistance Program (CMAP) on the requirements

More information

FREQUENTLY ASKED QUESTIONS (FAQS) FOR PROVIDER INDUSTRY

FREQUENTLY ASKED QUESTIONS (FAQS) FOR PROVIDER INDUSTRY FREQUENTLY ASKED QUESTIONS (FAQS) FOR PROVIDER INDUSTRY 1. What changes are proposed for the Medicaid Program in the State Fiscal Year 2012 budget? Will clients be notified if these changes are not approved

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: private_duty_nursing_services 11/3/2005 2/2018 2/2019 2/2018 Description of Procedure or Service Private

More information

Cigna Medical Coverage Policy

Cigna Medical Coverage Policy Cigna Medical Coverage Policy Subject Observation Care Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 5 Effective Date... 10/15/2014 Next Review

More information

Authorized By: Elizabeth Connolly, Acting Commissioner, Department of Human

Authorized By: Elizabeth Connolly, Acting Commissioner, Department of Human HUMAN SERVICES 47 NJR 7(1) July 6, 2015 Filed June 10, 2015 DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES Rehabilitative Services for Children Readoption with Amendments: N.J.A.C. 10:77 Authorized

More information

Private Duty Nursing for Clinical Coverage Policy No: 3G-2. DRAFT Table of Contents

Private Duty Nursing for Clinical Coverage Policy No: 3G-2. DRAFT Table of Contents Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Skilled Nursing... 1 1.1.2 Nursing Care Activities... 1 1.1.3 Substantial... 2 1.1.4 Complex... 2

More information

Florida Downward Substitution Services

Florida Downward Substitution Services Care1st Health Plan Arizona, Inc. Easy Choice Health Plan Harmony Health Plan of Illinois Missouri Care Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona OneCare (Care1st Health

More information

Reimbursement Policy. Subject: Inpatient Readmissions Committee Approval Obtained: Effective Date: 10/01/13

Reimbursement Policy. Subject: Inpatient Readmissions Committee Approval Obtained: Effective Date: 10/01/13 Reimbursement Policy Subject: Inpatient Readmissions Committee Approval Obtained: Effective Date: 10/01/13 Section: Facilities 04/03/17 *****The most current version of the Reimbursement Policies can be

More information

1 of 32 DOCUMENTS. NEW JERSEY ADMINISTRATIVE CODE Copyright 2016 by the New Jersey Office of Administrative Law

1 of 32 DOCUMENTS. NEW JERSEY ADMINISTRATIVE CODE Copyright 2016 by the New Jersey Office of Administrative Law Page 1 Title 10, Chapter 53A -- Chapter Notes 1 of 32 DOCUMENTS N.J.A.C. 10:53A (2016) Page 2 Title 10, Chapter 53A, Subchapter 1 Notes 2 of 32 DOCUMENTS SUBCHAPTER 1. GENERAL PROVISIONS N.J.A.C. 10:53A-1

More information

Amended Date: October 1, Table of Contents

Amended Date: October 1, Table of Contents Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Private Duty Nursing... 1 1.2 Definitions... 1 1.2.1 Skilled Nursing... 1 1.2.2 Substantial... 1 1.2.3 Complex... 1 1.2.4

More information

State of California Health and Human Services Agency Department of Health Care Services

State of California Health and Human Services Agency Department of Health Care Services State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS Director EDMUND G. BROWN JR. Governor DATE: OCTOBER 28, 2013 ALL PLAN LETTER 13-014 SUPERSEDES ALL PLAN

More information

Volume 24, No. 07 July 2014

Volume 24, No. 07 July 2014 State of New Jersey Department of Human Services Division of Medical Assistance & Health Services Volume 24, No. 07 July 2014 TO: SUBJECT: All Providers For Action For Managed Care Organizations For Information

More information

1 of 39 DOCUMENTS. NEW JERSEY ADMINISTRATIVE CODE Copyright 2017 by the New Jersey Office of Administrative Law

1 of 39 DOCUMENTS. NEW JERSEY ADMINISTRATIVE CODE Copyright 2017 by the New Jersey Office of Administrative Law Page 1 Title 10, Chapter 58A -- Chapter Notes CHAPTER AUTHORITY: 1 of 39 DOCUMENTS NEW JERSEY ADMINISTRATIVE CODE Copyright 2017 by the New Jersey Office of Administrative Law *** This file includes all

More information

MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE

MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE SUBJECT BY NUMBER: ISSUE DATE: September 8, 1995 EFFECTIVE DATE: September 8, 1995 Mental Health Services Provided

More information

DIVISION CIRCULAR #8 (N.J.A.C. 10:46C) DEPARTMENT OF HUMAN SERVICES DIVISION OF DEVELOPMENTAL DISABILITIES

DIVISION CIRCULAR #8 (N.J.A.C. 10:46C) DEPARTMENT OF HUMAN SERVICES DIVISION OF DEVELOPMENTAL DISABILITIES DIVISION CIRCULAR #8 (N.J.A.C. 10:46C) DEPARTMENT OF HUMAN SERVICES DIVISION OF DEVELOPMENTAL DISABILITIES EFFECTIVE DATE: September 17, 2012 DATE ISSUED: September 17, 2012 (Rescinds DC #8 Waiting List

More information

Medicaid 201: Home and Community Based Services

Medicaid 201: Home and Community Based Services Medicaid 201: Home and Community Based Services Kathy Poisal Division of Long Term Services and Supports Disabled and Elderly Health Programs Group Center for Medicaid and CHIP Services Centers for Medicare

More information

LOUISIANA MEDICAID PROGRAM ISSUED: 04/15/12 REPLACED: CHAPTER 24: HOSPICE SECTION 24.3: COVERED SERVICES PAGE(S) 5 COVERED SERVICES

LOUISIANA MEDICAID PROGRAM ISSUED: 04/15/12 REPLACED: CHAPTER 24: HOSPICE SECTION 24.3: COVERED SERVICES PAGE(S) 5 COVERED SERVICES COVERED SERVICES Hospice care includes services necessary to meet the needs of the recipient as related to the terminal illness and related conditions. Core Services (Core services) must routinely be provided

More information

Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents

Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements...

More information

This policy describes the appropriate use of new patient evaluation and management (E/M) codes.

This policy describes the appropriate use of new patient evaluation and management (E/M) codes. Private Property of Florida Blue. This payment policy is Copyright 2017, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission

More information

INTEGRATING TRAUMA- INFORMED SERVICES INTO MEDICAID. Lena O Rourke O Rourke Health Policy Strategies

INTEGRATING TRAUMA- INFORMED SERVICES INTO MEDICAID. Lena O Rourke O Rourke Health Policy Strategies INTEGRATING TRAUMA- INFORMED SERVICES INTO MEDICAID Lena O Rourke O Rourke Health Policy Strategies Why Medicaid? 2 Federal and State options to support community-based services/supports Coverage of services

More information

Department of Human Services Division of Aging Services Office of Community Choice Options Preadmission Screening and Resident Review (PASRR)

Department of Human Services Division of Aging Services Office of Community Choice Options Preadmission Screening and Resident Review (PASRR) Department of Human Services Division of Aging Services Office of Community Choice Options Preadmission Screening and Resident Review (PASRR) 3/18/2015 1 Objectives for Training Understand PASRR regulations

More information

MEDICARE COVERAGE SUMMARY: OUTPATIENT PSYCHIATRIC AND PSYCHOLOGICAL SERVICES

MEDICARE COVERAGE SUMMARY: OUTPATIENT PSYCHIATRIC AND PSYCHOLOGICAL SERVICES OPTUM MEDICARE COVERAGE SUMMARY: OUTPATIENT PSYCHIATRIC AND PSYCHOLOGICAL SERVICES MEDICARE COVERAGE SUMMARY: OUTPATIENT PSYCHIATRIC AND PSYCHOLOGICAL SERVICES Guideline Number: Effective Date: April,

More information

Managed Long Term Services and Supports (MLTSS)

Managed Long Term Services and Supports (MLTSS) Managed Long Term Services and Supports (MLTSS) Business Process Office of Community Choice Options Hospital and Nursing Facility MLTSS Business Process OCCO June 2014 1 Managed Long Term Services and

More information

Medicaid Fundamentals. John O Brien Senior Advisor SAMHSA

Medicaid Fundamentals. John O Brien Senior Advisor SAMHSA Medicaid Fundamentals John O Brien Senior Advisor SAMHSA Medicaid Fundamentals Provides medical benefits to groups of low-income people with no medical insurance or inadequate medical insurance. Federally

More information

2015 State Hospice Report 2013 Medicare Information 1/1/15

2015 State Hospice Report 2013 Medicare Information 1/1/15 2015 State Hospice Report 2013 Medicare Information 1/1/15 www.hospiceanalytics.com 2 2013 Demographics & Hospice Utilization National Population 316,022,508 Total Deaths 2,529,792 Medicare Beneficiaries

More information

NJ Department of Human Services. FREQUENTLY ASKED QUESTIONS (FAQs) FOR PROVIDERS NJ FamilyCare MANAGED LONG TERM SERVICES AND SUPPORTS (MLTSS)

NJ Department of Human Services. FREQUENTLY ASKED QUESTIONS (FAQs) FOR PROVIDERS NJ FamilyCare MANAGED LONG TERM SERVICES AND SUPPORTS (MLTSS) NJ Department of Human Services FREQUENTLY ASKED QUESTIONS (FAQs) FOR PROVIDERS NJ FamilyCare MANAGED LONG TERM SERVICES AND SUPPORTS (MLTSS) Assisted Living Billing Process when Member is Pending Enrollment

More information

Multiple Visit Reduction

Multiple Visit Reduction Private Property of Florida Blue. This payment policy is Copyright 2017 Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission

More information

State of New Jersey DEPARTMENT OF BANKING AND INSURANCE INDIVIDUAL HEALTH COVERAGE PROGRAM PO BOX 325 TRENTON, NJ

State of New Jersey DEPARTMENT OF BANKING AND INSURANCE INDIVIDUAL HEALTH COVERAGE PROGRAM PO BOX 325 TRENTON, NJ CHRIS CHRISTIE Governor KIM GUADAGNO Lt. Governor State of New Jersey DEPARTMENT OF BANKING AND INSURANCE INDIVIDUAL HEALTH COVERAGE PROGRAM PO BOX 325 TRENTON, NJ 08625-0325 TEL (609) 633-1882 FAX (609)

More information

HANDBOOK FOR PROVIDERS OF SCHOOL BASED/ LINKED HEALTH CENTER SERVICES

HANDBOOK FOR PROVIDERS OF SCHOOL BASED/ LINKED HEALTH CENTER SERVICES HANDBOOK FOR PROVIDERS OF SCHOOL BASED/ LINKED HEALTH CENTER SERVICES CHAPTER S-200 POLICY AND PROCEDURES FOR SCHOOL BASED/ LINKED HEALTH CENTERS Illinois Department of Healthcare and Family Services CHAPTER

More information

Care Plan Oversight Policy Annual Approval Date

Care Plan Oversight Policy Annual Approval Date Policy Number 2017R0033A Care Plan Oversight Policy Annual Approval Date 7/13/2016 Approved By REIMBURSEMENT POLICY CMS-1500 Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

More information

MEDICAL POLICY No R1 TELEMEDICINE

MEDICAL POLICY No R1 TELEMEDICINE Summary of Changes MEDICAL POLICY TELEMEDICINE Effective Date: March 1, 2016 Review Dates: 12/12, 12/13, 11/14, 11/15 Date Of Origin: December 12, 2012 Status: Current Clarifications: Deletions: Pg. 4,

More information

Community Alternatives Program 1915(c) HCBS Waiver April 26, Department of Health and Human Services Biannual Listening Session

Community Alternatives Program 1915(c) HCBS Waiver April 26, Department of Health and Human Services Biannual Listening Session Community Alternatives Program 1915(c) HCBS Waiver April 26, 2017 Department of Health and Human Services Biannual Listening Session Semiannual Listening Session 2 Statement from CAP/C beneficiary My experience

More information

Florida Medicaid. Home Health Visit Services Coverage Policy

Florida Medicaid. Home Health Visit Services Coverage Policy Florida Medicaid Home Health Visit Services Coverage Policy Agency for Health Care Administration November 2016 Table of Contents Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1 1.3 Definitions...

More information

Home Health, Hospice, and Nursing Facility. Indiana Health Coverage Programs DXC Technology October 2017

Home Health, Hospice, and Nursing Facility. Indiana Health Coverage Programs DXC Technology October 2017 Home Health, Hospice, and Nursing Facility Indiana Health Coverage Programs DXC Technology October 2017 Agenda Billing Tips Home Health Hospice Nursing Facility Claim Form Update Helpful Tools Questions

More information

Page 1 of 7 Medicaid Benefits Services Covered, Limits, Copayments and Reimbursement Methodologies For 50 States, District of Columbia and the Territories (as of January 2003) CHOOSE SERVICE Go CHOOSE

More information

Managed Long Term Services and Supports (MLTSS) A Forum for Consumers, their Families and Caregivers, Advocates and Community-Based Agencies

Managed Long Term Services and Supports (MLTSS) A Forum for Consumers, their Families and Caregivers, Advocates and Community-Based Agencies Managed Long Term Services and Supports (MLTSS) A Forum for Consumers, their Families and Caregivers, Advocates and Community-Based Agencies 1 Background To give you an update on the implementation of

More information

Providing and Billing Medicare for Chronic Care Management Services

Providing and Billing Medicare for Chronic Care Management Services Providing and Billing Medicare for Chronic Care Management Services (and Other Fee-For-Service Population Health Management Services) No portion of this white paper may be used or duplicated by any person

More information

Opportunities to Advance Lifespan Respite: Managed Long-Term Services and Supports and Affordable Care Act Options

Opportunities to Advance Lifespan Respite: Managed Long-Term Services and Supports and Affordable Care Act Options Opportunities to Advance Lifespan Respite: Managed Long-Term Services and Supports and Affordable Care Act Options October 18, 2013 Joe Caldwell Director of Long-Term Services and Supports Policy 1 Overview

More information

Page 1 of 5 Health Reform Medicaid/CHIP Medicare Costs/Insurance Uninsured/Coverage State Policy Prescription Drugs HIV/AIDS Medicaid Benefits Services Covered, Limits, Copayments and Reimbursement Methodologies

More information

Subject: Skilled Nursing Facilities (Page 1 of 6)

Subject: Skilled Nursing Facilities (Page 1 of 6) Subject: Skilled Nursing Facilities (Page 1 of 6) Objective: I. To ensure that Tuality Health Alliance (THA) and delegated Providence Health Plan Medicare members are appropriately placed in skilled nursing

More information

While receiving hospice care services, non-hospice services may still be covered under other portions of the benefit plan.

While receiving hospice care services, non-hospice services may still be covered under other portions of the benefit plan. Medical Coverage Policy Effective Date... 3/15/2018 Next Review Date... 3/15/2019 Coverage Policy Number... 0462 Hospice Care Table of Contents Coverage Policy... 1 Overview... 2 General Background...

More information

Mississippi Medicaid Autism Spectrum Disorder Services for EPSDT Eligible Beneficiaries Provider Manual

Mississippi Medicaid Autism Spectrum Disorder Services for EPSDT Eligible Beneficiaries Provider Manual Mississippi Medicaid Services for EPSDT Eligible Beneficiaries Provider Manual Effective Date: July 1, 2017 Services for Introduction: eqhealth Solutions Services (ASD) Utilization Management Program includes

More information

Statewide Medicaid Managed Care Long-term Care Program Coverage Policy

Statewide Medicaid Managed Care Long-term Care Program Coverage Policy Statewide Medicaid Managed Care Long-term Care Program Coverage Policy Coverage Policy Review June 16, 2017 Today s Presenters D.D. Pickle, AHC Administrator 2 Objectives Provide an overview of the changes

More information

MEDICAL POLICY EFFECTIVE DATE: 08/25/11 REVISED DATE: 08/23/12, 08/22/13

MEDICAL POLICY EFFECTIVE DATE: 08/25/11 REVISED DATE: 08/23/12, 08/22/13 MEDICAL POLICY SUBJECT: PERSONAL CARE AIDE (PCA) AND PAGE: 1 OF: 7 If the member's subscriber contract excludes coverage for a specific service it is not covered under that contract. In such cases, medical

More information

Personal Care Services (PCS): An Overview of PCS and The Request for Independent Assessment for PCS Attestation of Medical Need Form (DMA 3051)

Personal Care Services (PCS): An Overview of PCS and The Request for Independent Assessment for PCS Attestation of Medical Need Form (DMA 3051) Personal Care Services (PCS): An Overview of PCS and The Request for Independent Assessment for PCS Attestation of Medical Need Form (DMA 3051) January 2018 OBJECTIVES At the conclusion of this training,

More information

#14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT)

#14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT) COUNTY OF SANTA BARBARA ALCOHOL, DRUG AND MENTAL HEAL TH SERVICES Section - Policy- QUALITY ASSURANCE #14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT) Director's /{A A.. \

More information

DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK. Chapter 3. Description of DOEA Coordination With Other State and Federal Programs

DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK. Chapter 3. Description of DOEA Coordination With Other State and Federal Programs Chapter 3 Description of DOEA Coordination With Other State and Federal Programs TABLE OF CONTENTS Section: Topic Page I. Overview and Specific Legal Authority 3-3 II. 3-5 A. Adult Care Food Program 3-5

More information

Diabetes Outpatient Clinical Coverage Policy No: 1A-24 Self-Management Education Amended Date: October 1, Table of Contents

Diabetes Outpatient Clinical Coverage Policy No: 1A-24 Self-Management Education Amended Date: October 1, Table of Contents Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 2 2.2 Special

More information

CHAPTER 74 MEDICAID AND NJ FAMILYCARE MANAGED CARE. Division of Medical Assistance and Health Services MEDICAID AND NJ FAMILYCARE MANAGED CARE

CHAPTER 74 MEDICAID AND NJ FAMILYCARE MANAGED CARE. Division of Medical Assistance and Health Services MEDICAID AND NJ FAMILYCARE MANAGED CARE CHAPTER 74 1 TABLE OF CONTENTS SUBCHAPTER 1. GENERAL PROVISIONS 10:74-1.1 Purpose 10:74-1.2 Authority 10:74-1.3 Scope 10:74-1.4 Definitions 10:74-1.5 Pharmacy lock-in program under managed care SUBCHAPTER

More information

1.2.4(a) PURCHASE OF SERVICE POLICY TABLE OF CONTENTS. General Guidelines 2. Consumer Services 3

1.2.4(a) PURCHASE OF SERVICE POLICY TABLE OF CONTENTS. General Guidelines 2. Consumer Services 3 TABLE OF CONTENTS General Guidelines 2 Consumer Services 3 Services for Children Ages 0-36 months 3 Infant Education Programs 4 Occupational/Physical Therapy 4 Speech Therapy 5 Services Available to All

More information

Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL

Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL Effective Date: 6/2017 Last Review Date: See Important Reminder at the end of this policy for important

More information

The New NJ FamilyCare

The New NJ FamilyCare The New NJ FamilyCare 1 October 1, 2013 Changes 2 Newly eligible populations: Parents and Caretaker Relatives up to 133% FPL Single Adults and Couples without dependent children aged 19 64 up to 133% FPL

More information

CARE PLAN OVERSIGHT POLICY

CARE PLAN OVERSIGHT POLICY CARE PLAN OVERSIGHT POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 171.12 T0 Effective Date: June 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE

More information

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY Global Surgery Policy Number GLS03272013RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 04/09/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare

More information

Preventive Medicine and Screening Policy

Preventive Medicine and Screening Policy Reimbursement Policy CMS 1500 Preventive Medicine and Screening Policy Policy Number 2018R0013C Annual Approval Date 3/14/2018 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT

More information

Partnering with Public Health Departments in Managed Care. THIS AREA CAN BE LEFT BLANK or ADD A PICTURE

Partnering with Public Health Departments in Managed Care. THIS AREA CAN BE LEFT BLANK or ADD A PICTURE Partnering with Public Health Departments in Managed Care THIS AREA CAN BE LEFT BLANK or ADD A PICTURE 2/3/2017 The Value of Medicaid Managed Care States Have Seen the Value of Medicaid Managed Care 75

More information

Table of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness...

Table of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness... Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Hospice... 1 1.1.2 Terminal illness... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1

More information

MEDICAL POLICY No R5 PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS

MEDICAL POLICY No R5 PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS Effective Date: September 8, 2014 Review Dates: 10/07, 10/08, 10/09, 6/10, 6/11, 6/12, 6/13, 8/14, 8/15, 8/16, 8/17 Date Of Origin:

More information

MEDICAL POLICY No R2 TELEMEDICINE

MEDICAL POLICY No R2 TELEMEDICINE Summary of Changes Clarifications: Page 1, Section I. A 6, additional language added for clarification. Deletions: Additions Page 4, Section IV, Description, additional language added in regards to telemedicine.

More information

2015 National Training Program. History of Modern Hospice. Hospice Legislative History. Medicare s Coverage of Hospice Services

2015 National Training Program. History of Modern Hospice. Hospice Legislative History. Medicare s Coverage of Hospice Services 2015 National Training Program Medicare s Coverage of Hospice Services For Those Who Counsel People With Medicare July 2015 History of Modern Hospice 1948 English physician Dame Cicely Saunders works with

More information

Improving Systems of Care for Children and Youth with Special Health Care Needs

Improving Systems of Care for Children and Youth with Special Health Care Needs Improving Systems of Care for Children and Youth with Special Health Care Needs May 23, 2017 Treeby Brown Chief, Integrated Services Branch Division of Services for Children with Special Health Needs (DSCSHN)

More information

Corporate Reimbursement Policy

Corporate Reimbursement Policy Corporate Reimbursement Policy Code Bundling Rules Not Addressed in ClaimCheck or Correct File Name: code_bundling_rules_not_addressed_in_claim_check Origination: 6/2004 Last Review: 12/2017 Next Review:

More information

Heather Leschinsky Administrator II, Managed Care and HCBS Nebraska Department of Health and Human Services Medicaid and Long-Term Care

Heather Leschinsky Administrator II, Managed Care and HCBS Nebraska Department of Health and Human Services Medicaid and Long-Term Care Heather Leschinsky Administrator II, Managed Care and HCBS Nebraska Department of Health and Human Services Medicaid and Long-Term Care 1 2 Total Medicaid and CHIP population- 235,000 Currently approximately

More information

Hospital Transitions: A Guide for Professionals.

Hospital Transitions: A Guide for Professionals. Hospital Transitions: A Guide for Professionals 2017 www.medicarerights.org Medicare Rights Center The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure

More information

MEDICARE COVERAGE SUMMARY: HOME HEALTH PSYCHIATRIC CARE MEDICARE COVERAGE SUMMARY

MEDICARE COVERAGE SUMMARY: HOME HEALTH PSYCHIATRIC CARE MEDICARE COVERAGE SUMMARY OPTUM MEDICARE COVERAGE SUMMARY: HOME HEALTH PSYCHIATRIC CARE MEDICARE COVERAGE SUMMARY: HOME HEALTH PSYCHIATRIC CARE MEDICARE COVERAGE SUMMARY Guideline Number: Effective Date: June, 2017 INTRODUCTION

More information

Documentation Requirements for Timed Therapeutic Procedures Reimbursement Policy Annual Approval Date. Approved By

Documentation Requirements for Timed Therapeutic Procedures Reimbursement Policy Annual Approval Date. Approved By Policy Number 0049 Documentation Requirements for Timed Therapeutic Procedures Reimbursement Policy Annual Approval Date 04/2017 Approved By Optum Reimbursement and Technology Committee Optum Quality and

More information

STATE OF NEW JERSEY. Statewide Transition Plan. Addendum

STATE OF NEW JERSEY. Statewide Transition Plan. Addendum STATE OF NEW JERSEY Statewide Transition Plan Addendum The Statewide Transition Plan outlines to the Centers for Medicare & Medicaid Services (CMS) how New Jersey will meet compliance with federal Home

More information

Assistant Surgeon Policy

Assistant Surgeon Policy Assistant Surgeon Policy Policy Number Annual Approval Date 11/08/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate claims.

More information

Private Duty Nursing (PDN) Eligibility Determination Workshop. A refresher course for current PIHP Nurses and initial training for new PIHP Nurses

Private Duty Nursing (PDN) Eligibility Determination Workshop. A refresher course for current PIHP Nurses and initial training for new PIHP Nurses Private Duty Nursing (PDN) Eligibility Determination Workshop A refresher course for current PIHP Nurses and initial training for new PIHP Nurses Presenters: Linda Fletcher, RN, MS, CPNP Deb Ziegler, HSW

More information

Global Surgery Package

Global Surgery Package Private Property of Florida Blue. This payment policy is Copyright 2017 Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission

More information

OBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY

OBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY OBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 232.10 T0 Effective Date: March 1, 2017 Table of Contents Page INSTRUCTIONS

More information

IMPORTANT PROVIDER UPDATES

IMPORTANT PROVIDER UPDATES December 28, 2015 IMPORTANT PROVIDER UPDATES Dear Provider, Please find attached important updates, reminders and policy changes for Coordinated Care providers regarding: Page Title Number 2 Notice 1:

More information

Reimbursement Policy. Subject: Consultations Effective Date: 05/01/05

Reimbursement Policy. Subject: Consultations Effective Date: 05/01/05 Reimbursement Policy Subject: Consultations Effective Date: 05/01/05 Committee Approval Obtained: 06/06/16 Section: Evaluation and Management *****The most current version of the Reimbursement Policies

More information

Shift Nursing, Personal Care, and Medical Daycare. Coding... 6 Benefit Application... 7 Description of Services... 7 Clinical Evidence...

Shift Nursing, Personal Care, and Medical Daycare. Coding... 6 Benefit Application... 7 Description of Services... 7 Clinical Evidence... Title: TABLE OF CONTENTS Product Variations.... 1 Policy Statement.... 2 Related Policies.... 3 Policy Guidelines..... 4 Coding.... 6 Benefit Application........ 7 Description of Services..... 7 Clinical

More information

Assistant Surgeon Policy

Assistant Surgeon Policy Policy Number 2017R5000J Annual Approval Date Assistant Surgeon Policy 11/09/2016 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate

More information

KENTUCKY DECEMBER 7, Cabinet for Health and Family Services HOME AND COMMUNITY BASED SERVICES (HCBS) WAIVER REDESIGN

KENTUCKY DECEMBER 7, Cabinet for Health and Family Services HOME AND COMMUNITY BASED SERVICES (HCBS) WAIVER REDESIGN KENTUCKY Cabinet for Health and Family HOME AND COMMUNITY BASED SERVICES (HCBS) WAIVER REDESIGN DECEMBER 7, 2016 Session Timeline Time Topic 9:30 9:45 AM Welcome: Introductions & Agenda Review 9:45 10:15

More information

Cognitive Emotional Social Behavioral functioning

Cognitive Emotional Social Behavioral functioning TIP SHEET Health and Behavior Assessment and Intervention (HBAI) Services Coverage of Chronic Disease Self-Management Education Medicare and Medicare Advantage Purpose: The HBAI services are used to identify

More information

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services

More information

Introduction. Introduction 9/14/2010. ALABAMA NURSING HOME ASSOCIATION ANNUAL CONVENTION & TRADE SHOW Birmingham, Alabama September 20 23, 2010

Introduction. Introduction 9/14/2010. ALABAMA NURSING HOME ASSOCIATION ANNUAL CONVENTION & TRADE SHOW Birmingham, Alabama September 20 23, 2010 ALABAMA NURSING HOME ASSOCIATION ANNUAL CONVENTION & TRADE SHOW Birmingham, Alabama September 20 23, 2010 1 Introduction CMS defines state long term care rebalancing as achieving a more equitable balance

More information

Payment Policy: Problem Oriented Visits Billed with Preventative Visits

Payment Policy: Problem Oriented Visits Billed with Preventative Visits Payment Policy: Problem Oriented Visits Billed with Preventative Visits Reference Number: CC.PP.052 Product Types: ALL Effective Date: 11/1/2017 Last Review Date: Coding Implications Revision Log See Important

More information

Prolonged Services Policy, Professional

Prolonged Services Policy, Professional REIMBURSEMENT POLICY CMS-1500 Prolonged Services Policy, Professional Policy Number 2018R0003D Annual Approval Date 11/8/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS

More information

Medical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14

More information

NEW MEXICO DEPARTMENT OF HEALTH DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION MEDICALLY FRAGILE WAIVER (MFW)

NEW MEXICO DEPARTMENT OF HEALTH DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION MEDICALLY FRAGILE WAIVER (MFW) NEW MEXICO DEPARTMENT OF HEALTH DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION MEDICALLY FRAGILE WAIVER (MFW) CASE MANAGEMENT Effective January 1, 2011 MFW case management is a collaborative process of assessment,

More information

MEDICALLY COMPLEX CHILDREN S WAIVER

MEDICALLY COMPLEX CHILDREN S WAIVER MEDICALLY COMPLEX CHILDREN S WAIVER About Us Who is South Carolina Solutions? We are a part of a Family of Companies. Our corporate office, Community Health Solutions, is located in St. Petersburg, FL.

More information

State of California Health and Human Services Agency Department of Health Care Services

State of California Health and Human Services Agency Department of Health Care Services State of California Health and Human Services Agency Department of Health Care Services JENNIFER KENT DIRECTOR EDMUND G. BROWN JR. GOVERNOR DATE: December 3, 2015 ALL PLAN LETTER 15-025 (SUPERSEDES ALL

More information

HOUSING AND SERVICES PARTNERSHIP ACADEMY MEDICAID 101

HOUSING AND SERVICES PARTNERSHIP ACADEMY MEDICAID 101 HOUSING AND SERVICES PARTNERSHIP ACADEMY MEDICAID 101 Medicaid Background Federal and State Roles Whom Does Medicaid Serve? What Does Medicaid Cover? Medicaid Waiver Programs and Services In 1965, Medicare

More information

SMMC: LTC and MMA. Linda R. Chamberlain, P.A. Member Firm Florida Elder Lawyers PLLC

SMMC: LTC and MMA. Linda R. Chamberlain, P.A. Member Firm Florida Elder Lawyers PLLC SMMC: LTC and MMA Linda R. Chamberlain, P.A. Member Firm Florida Elder Lawyers PLLC 727.443.7898 Why should you care about SMMC Florida has 7M+ people 50 y/o + 4M+ Social Security beneficiaries 3.5M+ Medicare

More information

Notice of Instruction 5905 Breckenridge Parkway, Suite F Tampa, Florida (813) Fax (813)

Notice of Instruction 5905 Breckenridge Parkway, Suite F Tampa, Florida (813) Fax (813) Notice of Instruction 5905 Breckenridge Parkway, Suite F Tampa, Florida 33610 (813) 740-3888 Fax (813) 623-1342 Notice of Instruction Number: 071610 Revised Aged and Disabled Adult Waiver Services Coverage

More information

TCS FAQ s. How will the implementation of national standard code sets reduce burden on the health care industry?

TCS FAQ s. How will the implementation of national standard code sets reduce burden on the health care industry? TCS FAQ s What is a code set? Under HIPAA, a code set is any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes.

More information

Medicaid Managed Care. Long-term Services and Supports Trends

Medicaid Managed Care. Long-term Services and Supports Trends Medicaid Managed Care Long-term Services and Supports Trends Medicaid Managed Care Statistics As of 2011, 74.2% of Medicaid Enrollees were enrolled in a Medicaid Managed Care system As of 2011, California,

More information

Moderate Sedation PAYMENT POLICY ID NUMBER: Original Effective Date: 12/22/2009. Revised: 03/15/2018 DESCRIPTION:

Moderate Sedation PAYMENT POLICY ID NUMBER: Original Effective Date: 12/22/2009. Revised: 03/15/2018 DESCRIPTION: Private Property of Florida Blue. This payment policy is Copyright 2018, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission

More information

Use of Medicaid MCO Capitation by State Projections for 2016

Use of Medicaid MCO Capitation by State Projections for 2016 Use of Medicaid MCO Capitation by State Projections for 5 Slide Series September, 2015 Summary of Findings This edition projects Medicaid spending in each state and the percentage of spending paid via

More information

Illinois Health Care Coverage Options Conference AgeOptions All rights reserved.

Illinois Health Care Coverage Options Conference AgeOptions All rights reserved. Illinois Health Care Coverage Options Conference AgeOptions 2017. All rights reserved. MMW work is supported by grants from local and regional foundations: Retirement Research Foundation Michael Reese

More information

Florida Medicaid. Private Duty Nursing Services Coverage Policy

Florida Medicaid. Private Duty Nursing Services Coverage Policy Florida Medicaid Agency for Health Care Administration November 2016 Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1 1.3 Definitions... 1 2.0 Eligible

More information

Primary Care Provider Access and Reimbursement Rates: What We Know

Primary Care Provider Access and Reimbursement Rates: What We Know Primary Care Provider Access and Reimbursement Rates: What We Know Stu Dubin DMAHS Performance Evaluation & Presentations Coordinator Medical Assistance Advisory Council Meeting June, 11 2014 1 Review

More information

Innovations Waiver Update. (effective November 1, 2016)

Innovations Waiver Update. (effective November 1, 2016) Innovations Waiver Update (effective November 1, 2016) Training Overview Disclaimer How we arrived here Supports Intensity Scale (SIS) Resource Allocation Information on services-new and changed Stakeholder

More information

Bulletin. DHS Provides Policy for Certified Community Behavioral Health Clinics TOPIC PURPOSE CONTACT SIGNED TERMINOLOGY NOTICE NUMBER DATE

Bulletin. DHS Provides Policy for Certified Community Behavioral Health Clinics TOPIC PURPOSE CONTACT SIGNED TERMINOLOGY NOTICE NUMBER DATE Bulletin NUMBER 17-51-01 DATE February 27, 2017 OF INTEREST TO County Directors Social Services Supervisors and Staff Case Managers and Care Coordinators Managed Care Organizations Mental Health Providers

More information

The Balancing Incentive Program and Caregivers

The Balancing Incentive Program and Caregivers The Balancing Incentive Program and Caregivers Balancing Incentive The Affordable Care Act created the Balancing Incentive Program (BIP), which helps states provide quality care in the most appropriate,

More information