Home and Community Based Services Mental Retardation/Developmental Disabilities Providers

Size: px
Start display at page:

Download "Home and Community Based Services Mental Retardation/Developmental Disabilities Providers"

Transcription

1 May 2008 Provider Bulletin Number 869 Home and Community Based Services Mental Retardation/Developmental Disabilities Providers Manual Updates and New Manuals Home and Community Based Services Mental Retardation/Developmental Disabilities (HCBS MR/DD) provider manuals have been updated with waiver service changes effective with dates of service on and after March 15, Additionally, manuals have been added for new services. The following HCBS MR/DD provider manuals have been renamed and updated: o Night Support has been renamed Sleep Cycle Support. o Residential Services has been renamed Residential Supports. o Day Services has been renamed Day Supports. Updated HCBS MR/DD provider manuals include Family Supports, Medical Alert, Supportive Home Care, and Wellness Monitoring. The new HCBS MR/DD Assistive Services Provider Manual replaces Home Modifications, Van Lifts, Wheelchair Modification, and Communication Devices. Other new HCBS MR/DD provider manuals include Personal Assistant Services and Supported Employment Services. Please reference HCBS MR/DD Bulletin 826 published in February 2008 for further information on these updates. For additional questions, contact Greg Wintle at greg.wintle@srs.ks.gov or Information about the Kansas Medical Assistance Program as well as provider manuals and other publications are on the KMAP Web site at If you have any questions, please contact Customer Service at (in-state providers) or between 7:30 a.m. and 5:30 p.m., Monday through Friday. EDS is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Health Policy Authority. Page 1 of 110

2 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Assistive Services

3 PART II HCBS MR/DD ASSISTIVE SERVICES PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Assistive Services Billing Instructions Submission of Claim HCBS MR/DD Assistive Services Specific Billing Information BENEFITS AND LIMITATIONS 8400 Medicaid FORMS CMS-1500

4 INTRODUCTION TO THE HCBS MR/DD PROGRAM The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the client's choice to participate in the HCBS program. Adult oral health services Assistive services Day supports Family/individual supports Medical alert-rental Personal assistant services Residential supports Respite care-overnight Respite care-temporary Sleep cycle support Supported employment Supportive home care Wellness monitoring All HCBS MR/DD program services (with the exception of adult oral health services) require prior authorization (PA) through the plan of care process. Oral health services are available to adults 21 years of age and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

5 7000. MR/DD ASSISTIVE SERVICES BILLING INSTRUCTIONS Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD ASSISTIVE SERVICES PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

6 7010. ASSISTIVE SERVICES SPECIFIC BILLING INFORMATION Enter procedure code S5165 (Assistive Services MR/DD) in field 24D of the CMS-1500 claim form. One unit = one service. Client Obligation If client obligation has been assigned to a particular provider and that provider has been informed that they are to collect this portion of the cost of service from the client, the provider should not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge HCBS MRDD ASSISTIVE SERVICES PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

7 8400. BENEFITS AND LIMITATIONS HCBS MR/DD program services are designed to prevent individuals from entering, or remaining, in an intermediate care facility for the mentally retarded (ICF/MR). Assistive Services Assistive services are supports or items that meet an individual s assessed need by improving and promoting the person s health, independence, productivity, or integration into the community. They are directly related to the individual s person-centered support plan (PCSP) with measurable outcomes. Examples include, but are not limited to, wheelchair modifications, ramps, lifts, modifications to bathrooms and kitchens (specifically related to accessibility), and assistive technology (items that improve communication, mobility, or assist with activities of daily living or instrumental activities of daily living in the home and workplace). The assistive service must do one of the following: Increase the beneficiary s ability to live independently Increase or enhance the beneficiary s productivity Improve the beneficiary s health and welfare Limitations General Limitations 1. HCBS MR/DD assistive services are available to Medicaid beneficiaries who: Are five years of age or older. Are mentally retarded or otherwise developmentally disabled. Meet the criteria for ICF/MR level of care as determined by ICF/MR (HCBS MR/DD) screening. Choose to receive HCBS MR/DD rather than ICF/MR services. 2. HCBS MR/DD program services are available to minor children, five to 18 years of age, who are determined eligible for the Medicaid program through requirements relating to the deeming of parental income and who meet the criteria above. 3. All assistive services must be purchased under the beneficiary s or respective guardian s written authority, must be paid to either the community developmental disability organization (CDDO) or an entity qualified by the CDDO, and must not exceed the prior authorized purchase amount. 4. Purchase or rental of used assistive technology is limited to those items not covered through regular Medicaid. 5. An outside party cannot be required to subsidize an assistive service request. The contractor must accept full payment from Medicaid. Specific Limitations for Wheelchair Modifications 1. Any wheelchair modification must be authorized by a registered physical therapist, identified as medically necessary (K.A.R ) by a physician, and identified on the beneficiary s plan of care. 2. This service can only be accessed after a beneficiary is no longer eligible for KAN Be Healthy (KBH) services through the medical card. HCBS MRDD ASSISTIVE SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS 8-1

8 8400. BENEFITS AND LIMIATIONS 3. Wheelchair modifications must be specific to the individual beneficiary s needs and not utilized as general agency equipment. Specific Limitations for Van Lifts (including repair and maintenance) 1. Van lifts purchased must meet any engineering and safety standards recognized by the secretary of the U.S. Department of Transportation. 2. Van lifts can only be installed in family vehicles or vehicles owned or leased by the beneficiary. A van lift must not be installed in an agency vehicle unless an informed exception is made by Disability and Behavioral Health Services/Community Supports and Services (DBHS/CSS). Specific Limitations for Communication Devices 1. Communication devices will only be purchased when recommended by a speech pathologist. 2. Communication devices can only be accessed after a beneficiary is no longer eligible to receive services through the local education system. 3. Communication devices are purchased for use by the individual recipient only not for use as agency equipment. Specific Limitations for Home Modifications 1. Home modifications must not increase the finished square footage of an existing structure. 2. Home modifications must not be accessed for new construction. 3. Home modifications must be used on property the recipient leases or owns, or in the family home if still living there, but not on agency owned and operated property unless an informed exception is made by DBHS/CSS. Provider Requirements All providers must be State of Kansas enrolled Medicaid providers. Beneficiaries will be permitted to purchase assistive service item(s) from any available agency in their community who is either a CDDO, an agency qualified by the CDDO or an affiliate of the CDDO. The specified item must be provided as identified in the PCSP. Agencies contracted to provide home modifications include contractors and/or agencies licensed by the county or city in which they work (if required by the county or city), and they must perform all work according to existing local building codes. Assistive services require at least two bids from companies qualified by or affiliated with the CDDO. The bids must be submitted and reviewed prior to the approval of the prior authorization. All assistive services must have prior authorization. The beneficiary or responsible party must arrange for the purchase. Work must not be initiated until approval has been obtained through prior authorization. Note: Responsible party is defined as the beneficiary s guardian or someone appointed by the beneficiary or guardian who is not a paid provider of services for the beneficiary. HCBS MRDD ASSISTIVE SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS 8-2

9 8400. BENEFITS AND LIMITATIONS Documentation Requirements Record-keeping responsibilities rest primarily with the Medicaid-enrolled provider. Written documentation is required for services provided and billed to KMAP. Documentation, at a minimum, must include the following: o Copy of the receipt identifying that the service was provided. o Name of the business or contractor. o Identification of the service being provided. o Date of service (MM/DD/YY). o Amount of purchase. o o Beneficiary s or responsible party s name and signature. Statement of inspection by provider to insure product was purchased or installed as authorized. Documentation must include a brief description of the service provided. Certain responsibilities may be passed to performing providers of the service. Documentation must be created during the time period of the billing cycle. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. HCBS MRDD ASSISTIVE SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS 8-3

10 DEFINITIONS Community Based Screening an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organization (CDDO) a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliates provides community based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by DBHS/CSS. Affiliate a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the HCBS MR/DD program manager, must include: The services to be provided The frequency of each service The provider of each service The cost of each service HCBS MRDD ASSISTIVE SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS 8-4

11 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services 1. Services are provided according to the plan of care, in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD ASSISTIVE SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS 8-5

12

13 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Day Supports

14 PART II HCBS MR/DD DAY SERVICE SUPPORTS PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 Day Service Supports Specific Billing Instructions Submission of Claim Day Service Supports Specific Billing Information BENEFITS AND LIMITATIONS 8400 Medicaid FORMS CMS-1500

15 INTRODUCTION TO THE HCBS MR/DD PROGRAM Updated 05/08 The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary s choice to participate in the HCBS program. Adult oral health services Assistive services Communication Devices Day supports Services Family/individual supports Home Modifications Medical alert-rental Night Support Personal assistant services Residential supports Services Respite care-overnight Respite care-temporary Respite Care-Emergency Screening Sleep cycle support Supported employment Supportive home care Targeted Case Management Van Lifts Wellness monitoring Wheelchair Modifications All HCBS MR/DD waiver services (with the exception of adult oral health services, Screening, and Targeted Case Management) require prior authorization through the plan of care process. Oral health services are available to adults, 21 years of age and older, who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas attorney general's office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

16 7000. DAY SERVICE SUPPORTS BILLING INSTRUCTIONS Updated 05/08 Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

17 7010. DAY SERVICES SUPPORTS SPECIFIC BILLING INFORMATION Updated 05/08 Enter procedure code T2020 in field 24D of the CMS-1500 claim. One unit = one day. Client Obligation If a case manager has assigned client obligation has been assigned to a particular provider and informed that provider has been informed that they are to collect this portion of the cost of service from the client, the provider must not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments the system is trying to read two different lines on the plan of care. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge HCBS Targeted Case Management provided within 30 days prior to discharge. HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

18 8400. BENEFITS AND LIMITATIONS Updated 05/08 HCBS MR/DD waiver services are designed to prevent individuals from entering, or remaining, in an intermediate care facility for the mentally retarded (ICF/MR). Day Supports Service These services usually, but not necessarily, take place during normal working hours. Day services supports are regularly occurring activities that provide a sense of participation, accomplishment, personal reward, personal contribution, or remuneration and thereby serve as vehicles to maintain or increase adaptive capabilities, productivity, independence or integration, and participation in the community. Day supports also include the provision of prevocational services which are aimed at preparing an individual for paid or unpaid employment but are not job-task oriented. These services include teaching such concepts as compliance, attendance, task completion, problem solving and safety. Activities must be in accordance with the lifestyle choices specified in the beneficiary s person-centered support plan (PCSP). These opportunities can include socialization, recreation, community inclusion, adult education, and skill development in the areas of employment, transportation, daily living, self-sufficiency, and resource identification and acquisition. Services will cover a wide variety of possibilities based on the person s identified interests and needs. These can include socialization activities, recreation, community inclusion, environmental awareness/stimulation, training in following directions, adapting to work routines, carrying out assigned duties, acquiring appropriate situational attitudes and habits, adjusting to the productive and social demands of the workplace, mobility training, use of public facilities and job-related facilities and, use of transportation opportunities. Any day service for whom competitive employment at or above the minimum wage is unlikely, and who, because of their disabilities, needs intensive ongoing support to perform will meet the following conditions: 1) will be conducted in a variety of settings in which persons without disabilities are employed, 2) include activities needed to sustain paid work by waiver clients, including supervision and training, 3) when provided at a work site in which persons without disabilities are employed, additional payment may be made only for the adaptations, supervision and training required by the individual as a result of their disability and will not include payment for supervisory activities rendered as a normal part of the business setting. Any paid employment services provided under the waiver which are not available under a program funded by either the Rehabilitation Act of 1973, or P.L Documentation will be maintained in the file of each individual receiving paid employment services that: the service is not otherwise available under a program funded under the Rehabilitation Act of 1973 or P.L FFP will not be claimed for incentive payments, subsidies, or unrelated employment training expenses such as the following: a) incentive payments made to an employer of beneficiaries to encourage or subsidize employer s participation in a supported employment program; b) payments that are passed through to beneficiaries of employment programs; or c) payments for training that is not directly related to a beneficiary s employment program. HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-1

19 8400. BENEFITS AND LIMITATIONS Updated 05/08 Limitations 1. HCBS MR/DD day supports Service are available to Medicaid program beneficiaries who: Are 18 years of age or older. Note: In rare circumstances, a person who is under 18 years of age with extenuating circumstances may receive services if specifically approved in writing by Disability and Behavioral Health Services/Community Supports and Services (DBHS/CSS). Are mentally retarded or otherwise developmentally disabled determined eligible for MR/DD services. Meet the criteria for ICF/MR level of care as determined by ICF/MR (HCBS MR/DD screening). Choose to receive HCBS MR/DD rather than ICF/MR services. 2. HCBS MR/DD cannot be provided to anyone who is an inpatient of a hospital, a nursing facility, or an ICF/MR. 3. Transportation costs are not covered by this service included. 4. Persons eligible for services through the local education authority do not have access for reimbursement unless they are at least 18 years of age, are graduating from high school before 22 years of age, and a transition plan is developed by a transition team that includes the community developmental disability organization (CDDO) representative or the CDDO s designee. To receive the daily rate for this service, agencies must provide day services for a minimum of five hours per weekday (excluding meal time). OR. Day services may be billed in tenths of a unit (1/10 unit = 30 minutes) when a person participates less than 5 hours per day. Hours less than 5 per day may be combined until enough are accrued to bill the full daily rate. Beneficiaries age who are receiving a like service supported by an Individual Education Plan (IEP) cannot access this service. 5. Supported employment must be provided away from the beneficiary s place of residence. 6. Supported employment activities cannot be provided until the beneficiary has applied to the local Rehabilitation Services office. The HCBS MR/DD program will fund supported employment activities until the point in time when Rehabilitation Services funding for the supported employment begins. Coverage under the waiver will be suspended until the case is closed by Rehabilitation Services. HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-2

20 8400. BENEFITS AND LIMITATIONS Updated 05/08 7. If the beneficiary is determined ineligible for vocational training through Rehabilitation Services under Section 110 of the Rehabilitation Act of 1973, then this service can be provided as a waiver service. Documentation of this determination must be maintained in the beneficiary s file. 8. Case managers are responsible for insuring that vocational rehabilitation services are NOT being duplicated for waiver beneficiaries. To Receive Reimbursement (Five of Seven Days a Week): a) Individuals must be out of their home a minimum five hours per day, or a total 25 hours per week unless they are either medically fragile or frail and elderly (any of these conditions must be verified in writing by a physician). b) The time for which reimbursement for day service is requested is spent doing those things chosen by individuals, their guardians or family, and those who know and care about them which will lead to a lifestyle typical of peers with developmental disabilities of the same chronological age. c) The activities, and the ways in which the provider supports persons in participating in the activities, respond to needs related to identified substantial limitations in order to accomplish more easily or with fewer public funds. It is the desired outcome of DBHS/CSS that individuals receiving day supports have the opportunity to receive such services consistent with their preferred lifestyle a minimum of 25 hours per week. DBHS/CSS understands each individual is unique, and this outcome can be met in a variety of ways. Individuals must be out of their home a minimum of five hours per day or a total of 25 hours per week unless one of the following applies: o A person operates a home-based business. o A person is unable to be out of their home due to medical necessity or significant physical limitations related to frailty which a physician has provided current, written verification for the necessity to remain in the house. Note: Current is within the past 90 days and must be reviewed at least every 90 days thereafter. Those eligible to receive services while they remain in the home must participate in activities consistent with their PCSPs. These activities must replicate those which would normally occur outside the home. For those who prefer not to receive day supports five days a week, supporting documentation consistent with this preference must be available in their PCSPs. HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-3

21 8400. BENEFITS AND LIMITATIONS Updated 05/08 To receive reimbursement for five of seven days a week, the provider must document that services were provided at least 25 hours during the community service providers defined seven-day week. This may be accomplished through documentation indicating the person received more than five hours of services on some days and less than five hours per day on other days. For those receiving less than 25 hours of supports within the community service providers defined seven-day week, time may be accumulated and then billed for the appropriate number of full and/or partial units (which may be as small as.10 unit, equal to 30 minutes). Time may not be carried over from one defined seven-day week to the next defined seven-day week. Provider Requirements A provider of HCBS MR/DD day Service supports must be a recognized CDDO or an affiliate, as well as licensed by the State of Kansas Department of Social and Rehabilitation Services (SRS) to provide this service. Documentation Requirements Written documentation is required for services provided and billed to KMAP. Documentation, at a minimum, must consist of an attendance record. Minimum components of an attendance record include: o Name of the service. o Beneficiary s first and last name. o Date of service (MM/DD/YY). o Check mark to indicate the beneficiary received the service as defined. o Signature of a responsible staff person verifying the information is correct. If the beneficiary did not receive a full day of service, then some alternate mark must be used to indicate what portion of the service was provided on that date. A key to define all coding should be present on the attendance form. This record must be created and maintained during the timeframe covered by the document. Creating documentation after that time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-4

22 DEFINITIONS Updated 05/08 Community Based Screening - an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organization (CDDO) - a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliate provides community-based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by DBHS/CSS Mental Health and Developmental Disabilities (MH&DD). Affiliate - a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care - a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the HCBS MR/DD program manager, must include: The services to be provided Service The frequency of each service The provider for each service The cost of each service HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-5

23 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services Updated 05/08 1. Services are provided according to the plan of care, and in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, and in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD DAY SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-6

24

25 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Family/Individual Supports

26 PART II HCBS MR/DD FAMILY/INDIVIDUAL SUPPORTS PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Family/Individual Supports Specific Billing Instructions 7-1 Submission of Claim HCBS MR/DD Family/Individual Supports Specific Billing Information 7-2 BENEFITS AND LIMITATIONS 8400 Medicaid FORMS CMS-1500

27 INTRODUCTION TO THE HCBS MR/DD PROGRAM Updated 05/08 The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary's choice to participate in the HCBS program. Adult oral health services Assistive services Communication Devices Day supports Services Family/individual supports Home Modifications Medical alert-rental Night Support Personal assistant services Residential supports Services Respite care-overnight Respite care-temporary Respite Care-Emergency Screening Sleep cycle support Supported employment Supportive home care Targeted Case Management Van Lifts Wellness monitoring Wheelchair Modifications All HCBS MR/DD program services (with the exception of adult oral health services Screening, and Targeted Case Management) require prior authorization through the plan of care process. Oral health services are available to adults 21 years of age and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

28 7000. MR/DD FAMILY/INDIVIDUAL SUPPORTS BILLING INSTRUCTIONS Updated 05/08 Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under the KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line by line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD FAMILY / INDIVIDUAL SUPPORTS PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

29 7010. MR/DD FAMILY/INDIVIDUAL SUPPORTS SPECIFIC BILLING INFORMATION Updated 05/08 Enter procedure code S5126 (Family/Individual Supports MR/DD) in field 24D of the CMS-1500 claim form. One unit = one day. Client Obligation If a case manager has assigned client obligation has been assigned to a particular provider and informed that provider has been informed that they are to collect this portion of the cost of service from the client, the provider should not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments the system is trying to read two different lines on the plan of care. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge HCBS Targeted Case Management provided within 30 days prior to discharge. HCBS MRDD FAMILY / INDIVIDUAL SUPPORTS PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

30 8400. BENEFITS AND LIMITATIONS Updated 05/08 HCBS MR/DD program services are designed to prevent individuals from entering, or remaining, in an intermediate care facility for the mentally retarded (ICF/MR). Family/Individual Supports Family/individual supports are available to beneficiaries who live in the family home or in settings that do not provide residential services. This service provides necessary support for individuals to meet their daily living needs and to insure their residence in family homes. A beneficiary receiving these supports cannot also receive residential services, live in a setting with more than two others receiving family/individual supports, or reside with others who receive residential services. This service provides for paid staff to perform in-home assistance any hour of the night or day, in the absence or presence of nonpaid caregivers, as determined to meet the beneficiary s needs. Supportive Home Care These supports provide direct assistance or training in daily living and personal adjustment, attendant care, assistance with medications that are ordinarily self-administered, supervision, reporting changes in the beneficiary s condition and needs, extension of therapy services, ambulating and exercise, household services essential to health care at home or performed in conjunction with assistance in daily living (such as meal preparation, clean up after meals, bathing, using appliances, dressing, feeding, bed making and cleaning) and household maintenance related to the beneficiary. Night Sleep Cycle Support Overnight assistance in the individual s home in case of emergencies or to assist with repositioning is also an allowable use of this service. The staff would need to be able to contact a doctor, hospital or provide other assistance if an emergency occurs. If staff are paid an hourly wage, only those periods of time when staff are actually providing support will be considered as providing this service. Sleep-time or on-call is not considered providing this service. These in-home supports can be in the form of regularly scheduled assistance provided at the hours of the day or night when needed or respite when the primary non-paid care givers are not available. Respite Respite would be provided on a short-term basis because of the absence or need for relief of those persons who normally provide non-paid care. Room and board is not part of the cost of service unless provided as part of respite care in a facility approved by the State that is not a private residence. Overnight respite care will be provided in the following location(s): 1) Individual s home or place of residence, 2) Foster home, 3) Facility approved by the State which is not a private residence, and 4) Licensed respite care facility/home. HCBS MRDD FAMILY / INDIVIDUAL SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-1

31 8400. BENEFITS AND LIMITATIONS Updated 05/08 Provider Requirements To enroll as a provider for this service, written approval from the Medicaid waiver manager for Developmental Disabilities will have to be obtained and submitted with enrollment forms as part of the enrollment procedure. Providers of family/individual supports must be affiliated with the community developmental disability organization (CDDO) for the area where they operate. Providers of overnight facility-based respite care for minor children must be licensed by KDHE. Adult respite care providers must be licensed by SRS-SAMHDD. As indicated in K.A.R , any individual providing services must be at least 16 years of age or at least 18 years of age if a sibling of the recipient of service. All individuals providing services must receive at least 15 hours of prescribed training, or the person directing and controlling the services has must provided written certification to the CDDO that sufficient training to meet the beneficiary s needs has been provided. Documentation Requirements 1. Written documentation is required for services provided and billed to KMAP. 2. Documentation, at a minimum, must consist of a daily record indicating: Name of the service being provided. Beneficiary s (or responsible party s) name and signature if self directing. Caregiver s name and signature. Date of service (MM/DD/YY). Start time for each visit, include AM/PM or use 2400 clock hours. Stop time for each visit, include AM/PM or use 2400 clock hours. Brief description of duties performed. 3. Time should be totaled by actual minutes/hours worked. Billing staff may round the total to the quarter hour at the end of the billing cycle. 4. This record must be created and maintained during the timeframe covered by the document. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. 5. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. In addition, a record must be maintained that reflects that the persons performing the work, meets all provider requirements. HCBS MRDD FAMILY / INDIVIDUAL SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-2

32 DEFINITIONS Updated 05/08 Community Based Screening - an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organizations (CDDO) - a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliates provides community-based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by Disability and Behavioral Health Services/Community Supports and Services (DBHS/CSS) Mental Health and Developmental Disabilities (MH&DD). Affiliate - a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care - a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the HCBS MR/DD program manager Administrator MR/DD Program Services, must include: The services to be provided The frequency of each service The provider for each service The cost of each service HCBS MRDD FAMILY / INDIVIDUAL SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-3

33 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services Updated 05/08 1. Services are provided according to the plan of care, and in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, and in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD FAMILY / INDIVIDUAL SUPPORTS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-4

34

35 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Medical Alert

36 PART II HCBS MR/DD MEDICAL ALERT PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Medical Alert Billing Instructions Submission of Claim HCBS MR/DD Medical Alert Specific Billing Information BENEFITS AND LIMITATIONS 8400 Medicaid FORMS CMS-1500 Form

37 INTRODUCTION TO THE HCBS MR/DD PROGRAM Updated 05/08 The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary's choice to participate in the HCBS program. Adult oral health services Assistive services Communication Devices Day supports Services Family/individual supports Home Modifications Medical alert-rental Night Support Personal assistant services Residential supports Services Respite care-overnight Respite care-temporary Respite Care-Emergency Screening Sleep cycle support Supported employment Supportive home care Targeted Case Management Van Lifts Wellness monitoring Wheelchair Modifications All HCBS MR/DD program services (with the exception of adult oral health services Screening, and Targeted Case Management) require prior authorization through the plan of care process. Oral health services are available to adults 21 years of age and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

38 7000. MR/DD MEDICAL ALERT BILLING INSTRUCTIONS Updated 05/08 Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD MEDICAL ALERT PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

39 7010. MEDICAL ALERT SPECIFIC BILLING INFORMATION Updated 05/08 Enter procedure code S5161 (Rental of the adult failure alarm) in field 24D of the CMS-1500 claim form. One unit = one month. Client Obligation If a case manager has assigned client obligation has been assigned to a particular provider and informed that provider has been informed that they are to collect this portion of the cost of service from the client, the provider should not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments the system is trying to read two different lines on the plan of care. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge HCBS Targeted Case Management provided within 30 days prior to discharge. HCBS MRDD MEDICAL ALERT PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

40 8400. BENEFITS AND LIMITATIONS Updated 05/08 Medical Alert Medical alert and other monitoring systems provide support to the beneficiary having a medical need that could become critical at any time and who is alone a large portion of the time, to avoid placement in an adult care home. The following are examples of medical needs that might require this service: Quadriplegia Severe heart conditions Diabetes which is difficult to control Severe convulsive disorders Severe chronic obstructive pulmonary disease Head injury Medical alert providers dispense adult failure alarm systems which are small pieces of electronic equipment linked to the beneficiary's phone which can automatically dial three phone numbers when buttons on the instrument are pushed. The first call is placed to a predetermined responder who answers the call for help. Ideally, the responder is a relative or friend who volunteers his or her services. However, it may be considered part of the case manager's duties. The second call should be to a physician, and the third to a medical emergency unit or center. The adult failure system (e.g., medical alert) can be maintained for a 30-day period if a beneficiary is placed in a nursing home or a hospital for a short stay. This avoids the need to discontinue and reinstall the service which is both disruptive and costly to the patient. Limitations 1. HCBS MR/DD medical alert rental is available to Medicaid program participants who both: Meet the criteria for the intermediate care facility for the mentally retarded (ICF/MR) level of care as determined by ICF/MR (HCBS MR/DD) screening. Are determined eligible for MR/DD services. 2. HCBS MR/DD program services are available to minor children, five to 18 years of age, who are determined eligible for the Medicaid program through a waiver of requirements relating to the deeming of parental income and who meet the criteria above. 3. Rental, but not purchase, of this unit is covered. NOTE: Under the old guidelines, purchase was permitted; any previously purchased equipment will be the property of SRS and should be returned to the local/area office when the unit is no longer needed. 4. This service must be billed at a monthly rate. HCBS MRDD MEDICAL ALERT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-1

41 8400. BENEFITS AND LIMITATIONS Updated 05/08 Enrollment Home health agencies do not have to complete a separate provider enrollment application when providing this service. Examples of qualified providers of this service include, but are not limited to, agencies, hospitals, and emergency transportation service companies. Documentation Requirements 1. Documentation, at a minimum, must include the following: Service provider s name. Service being provided. Date of invoice or statement (MM/DD/YY). Beneficiary s name. Month of coverage (MM/YY). Cost of service. 2. Documentation must be created during the timeframe of the billing cycle. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. 3. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. HCBS MRDD MEDICAL ALERT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-2

42 DEFINITIONS Updated 05/08 Community Based Screening - an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organizations (CDDO) - a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliates provides community-based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by Disability and Behavioral Health Services/Community Supports and Services (DBHS/CSS) Mental Health and Developmental Disabilities (MH&DD). Affiliate - a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care - a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the HCBS MR/DD program manager Administrator MR/DD Program Services, must include: The services to be provided The frequency of each service The provider for each service The cost of each service HCBS MRDD MEDICAL ALERT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-3

43 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services Updated 05/08 1. Services are provided according to the plan of care, and in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, and in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD MEDICAL ALERT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-4

44

45 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Personal Assistant Services

46 PART II HCBS MR/DD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Personal Assistant Services Billing Instructions Submission of Claim HCBS MR/DD Personal Assistant Services Billing Information BENEFITS AND LIMITATIONS 8400 Medicaid/MediKan FORMS CMS-1500

47 INTRODUCTION TO THE HCBS MR/DD PROGRAM The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary's choice to participate in the HCBS program. Adult oral health services Assistive services Day supports Family/individual supports Medical alert-rental Personal assistant services Residential supports Respite care-overnight Respite care-temporary Sleep cycle support Supported employment Supportive home care Wellness monitoring All HCBS MR/DD program services (with the exception of adult oral health services) require prior authorization (PA) through the plan of care process. Oral health services are available to adults 21 years of age and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

48 7000. MR/DD PERSONAL ASSISTANT SERVICES BILLING INSTRUCTIONS Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

49 7010. MR/DD PERSONAL ASSISTANT SERVICES BILLING INFORMATION Enter procedure code T1019 (Personal Assistant Services - MR/DD) in field 24D of the CMS-1500 claim form. One unit = 15 minutes. Client Obligation If client obligation has been assigned to a particular provider and that provider has been informed that they are to collect this portion of the cost of service from the client, the provider should not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge HCBS MRDD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

50 8400. BENEFITS AND LIMITATIONS HCBS MR/DD program services are designed to prevent individuals from entering, or remaining in, an intermediate care facility for the mentally retarded (ICF/MR). Personal Assistant Services Personal assistant services are available to individuals who choose to receive services in a setting that would normally be provided by an entity licensed by Disability and Behavioral Health Services/Community Supports and Services (DBHS/CSS). These services provide necessary one-on-one assistance for individuals both in their home and community. Personal assistant services involve one or more personal assistants ensuring the health and welfare of an individual. The individual receives assistance with tasks typically done independently to promote productivity, integration, and inclusion. Personal assistant services include assisting with activities of daily living (ADLs) such as bathing, grooming, toileting, and transferring, and independent activities of daily living (IADLs) such as shopping, housecleaning, seasonal chores, meal preparation, laundry, and financial management (directly related to the recipient). Services also include health maintenance activities such as extension of therapies, feeding, mobility and exercises. Support services (SS) available provide socialization and recreation activities. Assistance may also include obtaining necessary medical services and reporting changes in the individual s condition and needs. The personal assistant may accompany or provide transportation to accomplish any of the tasks listed above. Limitations General Limitations HCBS MR/DD personal assistant services are available to Medicaid beneficiaries who: Are mentally retarded or otherwise developmentally disabled Meet the criteria for ICF/MR level of care as determined by the ICF/MR (HCBS MR/DD) screening instrument Choose to receive HCBS MR/DD rather than ICF/MR services Receive services in a setting that would otherwise require that the services be provided by an entity licensed by DBHS/CSS Agree to self direct their services Note: HCBS MR/DD cannot be provided to anyone who is an inpatient of a hospital, a nursing facility or an ICF/MR. Specific Limitations and Restrictions 1. Waiver beneficiaries who require assistance with IADL tasks and who live with a capable spouse or guardian should rely on him or her for this type of informal and natural support. The only exception is if there are extenuating or specific circumstances that are documented in the person-centered support plan (PCSP). For example, the PCSP defines the role of the personal assistant as a person who is teaching the beneficiary how to perform a certain skill. In accordance with this expectation, personal assistant services should not be used for the following: Lawn care HCBS MRDD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-1

51 8400. BENEFITS AND LIMITATIONS Snow removal Shopping Ordinary housekeeping (which should be done by the individual with whom the recipient lives) Meal preparation (during the times when the person with whom the recipient lives would normally prepare a meal) 2. All personal assistant services must be arranged and purchased under the written authority of the individual or the individual s responsible party. Fees must be paid through an enrolled fiscal agent and must not exceed the individual s plan of care. Individuals are permitted to choose qualified providers who have passed background checks that comply with KAR (f) and the DBHS/CSS background check policy. 3. If an individual no longer wants to continue self directing personal assistant services, he or she has the opportunity to receive their previously approved waiver services without penalty. 4. A personal assistant may not perform any duties for the individual that would otherwise be consistent with the Supported Employment definition, Sections 1. a & b. 5. Personal assistant services cannot be provided to an individual who is an inpatient of a hospital, a nursing facility or an ICF/MR when the inpatient facility is billing Medicaid, Medicare and/or private insurance. Note: The only exception is that personal assistant retainer services may be billed and the personal assistant may be paid up to a maximum of 14 days per calendar year at a level consistent with the approved plan of care. These services may be provided during a time when the individual is an inpatient of a hospital, a nursing facility, or an ICF/MR when the facility is billing Medicaid, Medicare and/or private insurance and the individual self directs their care while retaining their current care provider(s). 6. Individuals in residential supports cannot also receive personal assistant services for the same residential supports or any of the family/individual supports. (This does not prevent the conversion of day supports to personal assistant services.) Provider Requirements As indicated in K.A.R , any personal assistant providing services must be at least 16 years of age or at least 18 years of age if a sibling of the individual. Personal assistant services cannot be provided by the legal guardian of the beneficiary. Providers must be either a Community Developmental Disability Organization (CDDO) or an affiliate of the CDDO who functions as a payroll agent. Consistent with K.A.R , the beneficiary or the beneficiary s responsible party must maintain documentation showing that the individual personal assistant provider has received sufficient training to meet the participant s needs. Written certification must be provided to the CDDO. Providers are required to pass background checks consistent with the State of Kansas Department of Social and Rehabilitation Services (SRS) background check policy and comply with all regulations related to abuse, neglect and exploitation. HCBS MRDD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-2

52 8400. BENEFITS AND LIMITATIONS Documentation Requirements Record-keeping responsibilities rest primarily with the Medicaid-enrolled provider. Written documentation is required for services provided and billed to KMAP. Documentation at a minimum must include the following: o Beneficiary s (or responsible party s) name and signature. o Personal assistant s name and signature. o Complete date of service (MM/DD/YY). o Start time for each visit, include AM/PM or use 2400 clock hours. o Stop time for each visit, include AM/PM or use 2400 clock hours. o Brief description of duties performed. o Each entry dated and initialed by the personal assistant. Note: Responsible party is defined as the beneficiary s guardian or someone appointed by the beneficiary or guardian who is not also a paid provider of services for the beneficiary. Time should be totaled by actual minutes/hours worked. Billing staff may round the total to the nearest quarter hour at the end of the billing cycle. Documentation must be created at the time of the visit. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. Signature Limitations When choosing the self-directed option, the expectation is that the beneficiary provides oversight and accountability for those providing services. Signature options are provided knowing the beneficiary may have limitations. A designated signatory can be anyone aware of the services provided. The individual providing the service cannot sign the timesheet on behalf of the beneficiary. Each timesheet must contain the signature of the beneficiary or designated signatory verifying the services received and the time recorded. Approved signing options include: Beneficiary s signature Beneficiary making a distinct mark representing their signature Beneficiary using their signature stamp Designated signatory In situations where there is no one to serve as designated signatory, the billing provider must establish, document and monitor a plan based on the situation. If a beneficiary refuses to sign accurate timesheets without a legitimate reason, he or she must be advised that the attendant s time may not be paid or money may be taken back. Timesheets not reflecting accurate times and services must not be signed. Unsigned timesheets are the responsibility of the billing provider. HCBS MRDD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-3

53 DEFINITIONS Community Based Screening an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organization (CDDO) a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliates provides community-based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by DBHS/CSS. Affiliate a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the HCBS-MR/DD program manager, must include: The services to be provided The frequency of each service The provider of each service The cost of each service HCBS MRDD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-4

54 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services 1. Services are provided according to the plan of care, in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD PERSONAL ASSISTANT SERVICES PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-5

55

56 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Residential Services Supports

57 PART II HCBS MR/DD RESIDENTIAL SERVICE SUPPORTS PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Residential Service Supports Specific Billing Instructions 7-1 Submission of Claim HCBS MR/DD Residential Service Supports Specific Billing Information 7-2 BENEFITS AND LIMITATIONS 8400 Medicaid/MediKan FORMS CMS-1500

58 INTRODUCTION TO THE HCBS MR/DD PROGRAM Updated 05/08 The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary s choice to participate in the HCBS program. Adult oral health services Assistive services Communication Devices Day supports Services Family/individual supports Home Modifications Medical alert-rental Night Support Personal assistant services Residential supports Services Respite care-overnight Respite care-temporary Respite Care-Emergency Screening Sleep cycle support Supported employment Supportive home care Targeted Case Management Van Lifts Wellness monitoring Wheelchair Modifications All HCBS MR/DD waiver services (with the exception of adult oral health services, Screening, and Targeted Case Management) require prior authorization through the plan of care process. Oral health services are available to adults, 21 years of age and older, who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

59 7000. MR/DD RESIDENTIAL SERVICE SUPPORTS BILLING INSTRUCTIONS Updated 05/08 Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas KANSAS MEDICAL ASSISTANCE HCBS MRDD RESIDENTIAL SUPPORTS BILLING INSTRUCTIONS 7-1

60 7010. RESIDENTIAL SERVICE SUPPORTS SPECIFIC BILLING INFORMATION Updated 05/08 Enter procedure code T2016 (Residential Supports MR/DD) in field 24D of the CMS-1500 claim. One unit = one day. Client Obligation If a case manager has assigned client obligation has been assigned to a particular provider and informed that provider has been informed that they are to collect this portion of the cost of service from the client, the provider should not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments the system is trying to read two different lines on the plan of care. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge. HCBS Targeted Case Management provided within 30 days prior to discharge. KANSAS MEDICAL ASSISTANCE HCBS MRDD RESIDENTIAL SUPPORTS BILLING INSTRUCTIONS 7-2

61 8400. BENEFITS AND LIMITATIONS Updated 05/08 HCBS MR/DD waiver services are designed to prevent individuals from entering, or remaining in, an intermediate care facility for the mentally retarded (ICF/MR). Residential Supports This service is provided in the to individuals who live in a residential setting (outside the individual s family home) and do not live with someone meeting the definition of family. Family is defined as any person immediately related to the beneficiary of services. Immediately-related family members are parents (including adoptive parents), grandparents, spouses, aunts, uncles, sisters, brothers, first cousins and any step-family relationships. This service provides providing assistance, acquisition, retention and/or improvement in skills related to activities of daily living, such as, personal grooming and cleanliness, bed making and household chores, food preparation, and the social and adaptive skills necessary to enable the individual to reside in a noninstitutional setting. Payments for residential services supports are not made for room and board, the cost of facility maintenance, upkeep, and improvement, other than costs for modifications or adaptations to the facility as required to assure the health and safety of individuals or to meet the requirements of the applicable life safety code. Payment for residential services supports does not include payments made, directly or indirectly, to members of the beneficiary s immediate family. Payments will not be made for routine care and supervision which is expected to be provided by immediate family members or for which payment is made by a source other than Medicaid. In order to optimize community integration, This service will not be offered in residential settings which are within 1000 feet of an ICF/MR, or in a setting with nine or more beds or larger in size. Residential Services supports for adults are authorized for persons 18 years of age of older and are provided by entities licensed by Mental Health & Developmental Disabilities Disability and Behavioral Health Services/Community Supports and Services (DBHS/CSS). Residential Services supports for children are provided for children five through 21 years of age. These services for children are designed to serve children who are not in the custody of the State of Kansas Department of Social and Rehabilitation Services (SRS) in order to avoid placement in an institution or other congregate residential setting when they cannot, for whatever reason, remain in their natural families. Residential Services supports for children must occur outside the child s family home in a setting licensed by child placing agencies applying the regulations of the Kansas Department of Health and Environment. No more than two children, unrelated by blood or marriage to the surrogate family, can be living in a residential service supports setting for children. Residential services supports for children also must: 1. Cooperate with case management, the school district, and any consultants in designing and implementing specialized training procedures 2. Actively participate in individual education plan development and the public school education program 3. Be located in or near the community where the child s family lives KANSAS MEDICAL ASSISTANCE HCBS MRDD RESIDENTIAL SUPPORTS BENEFITS & LIMITATIONS 8-1

62 8400. BENEFITS AND LIMITATIONS Updated 05/08 Limitations 1. HCBS MR/DD Residential Services supports are available to Medicaid beneficiaries who: Are five years of age or older. Are mentally retarded or otherwise developmentally disabled. Meet the criteria for ICF/MR level of care as determined by ICF/MR (HCBS MR/DD) screening. Choose to receive HCBS MR/DD rather than ICF/MR services. 2. HCBS MR/DD is available to minor children, five through 18 years of age, who are determined eligible for the Medicaid program through a waiver of requirements relating to the deeming of parental income and who meet the criteria outlined above. 3. HCBS MR/DD cannot be provided to anyone who is an inpatient of a hospital, a nursing facility, or an ICF/MR. 4. Room, board, and transportation costs are excluded in the cost of any HCBS MR/DD services except overnight facility-based respite. 5. Beneficiaries of residential Services supports cannot also receive family/individual supports (supportive home care, respite care or night sleep cycle support). 6. Residential Services supports cannot be provided in the beneficiary s family home. However, they may be provided to a beneficiary in his or her own home or apartment as long as the community service provider is licensed by SRS to provide this service. 7. Residential Services supports for children cannot be provided in a home where more than two beneficiaries funded with State or Medicaid money reside. 8. Children who receive residential Services supports with a surrogate nonrelated family must be at least five but no older than 21 years of age (eligibility ends on the 22 nd birthday). 9. Residential Services supports are paid on a daily rate where one unit equals one day. The beneficiary must have been present for a meal served during normal dining times in order for the provider to bill for the daily rate. 10. This service is billed on daily tiered rates. 11. No more than 20 percent of the aggregated tiered reimbursement for all recipients of residential supports can be retained by the child placing agency to defray administrative costs. KANSAS MEDICAL ASSISTANCE HCBS MRDD RESIDENTIAL SUPPORTS BENEFITS & LIMITATIONS 8-2

63 8400. BENEFITS AND LIMITATIONS Updated 05/08 Provider Requirements Providers of residential Services supports for children must be affiliated with the community developmental disability organization (CDDO) for the area where they operate and be licensed by the Kansas Department of Health and Environment as a child-placing agency (K.A.R ). Providers of residential Services supports for adults must be a CDDO or affiliate that is licensed by SRS to provide residential services supports. Residential Service supports for adults can serve no more than eight individuals in one home. All providers of residential supports must be in compliance with K.A.R. Article through Documentation Requirements Written documentation is required for services provided and billed to KMAP. Documentation at a minimum must consist of an attendance record. Minimum components of an attendance record include: o Name of the service. o Beneficiary s first and last name. o Date of service (MM/DD/YY). o Check mark to indicate the beneficiary received the service as defined. o Signature of a responsible staff person verifying the information is correct. If the beneficiary did not receive a full day of service, then some alternate mark should be used to indicate what portion of the service was provided on that date. A key to define all coding should be present on the attendance form. This record must be created and maintained during the timeperiod covered by the document. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. KANSAS MEDICAL ASSISTANCE HCBS MRDD RESIDENTIAL SUPPORTS BENEFITS & LIMITATIONS 8-3

64 DEFINITIONS Updated 05/08 Community Based Screening an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organizations (CDDO) - a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliates provides community based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by DBHS/CSS Mental Health and Developmental Disabilities (MH&DD). Affiliate - a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care - a document completed following the determination of ICF/MR eligibility, after the individual elects home and community-based services (HCBS MR/DD) instead of ICF/MR services. This document, subject to the approval of the Administrator MR/DD Program Services HCBS-MR/DD Program Manager, must include: The services to be provided The frequency of each service The provider of each service The cost of each service KANSAS MEDICAL ASSISTANCE HCBS MRDD RESIDENTIAL SUPPORTS BENEFITS & LIMITATIONS 8-4

65 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services Updated 05/08 1. Services are provided according to the plan of care, and in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, and in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. KANSAS MEDICAL ASSISTANCE HCBS MRDD RESIDENTIAL SUPPORTS BENEFITS & LIMITATIONS 8-5

66

67 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Night Sleep Cycle Support

68 PART II HCBS MR/DD NIGHT SLEEP CYCLE SUPPORT PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Night Sleep Cycle Support Billing Instructions Submission of Claim HCBS MR/DD Night Sleep Cycle Support Specific Billing Information 7-2 BENEFITS AND LIMITATIONS 8400 Medicaid FORMS CMS-1500

69 INTRODUCTION TO THE HCBS MR/DD PROGRAM Updated 05/08 The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described within this manual are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary s choice to participate in the HCBS program. Adult oral health services Assistive services Communication Devices Day supports Services Family/individual supports Home Modifications Medical alert-rental Night Support Personal assistant services Residential supports Services Respite care-overnight Respite care-temporary Respite Care-Emergency Screening Sleep cycle support Supported employment Supportive home care Targeted Case Management Van Lifts Wellness monitoring Wheelchair Modifications All HCBS MR/DD waiver services (with the exception of adult oral health services, Screening, and Targeted Case Management) require prior authorization through the plan of care process. Oral health services are available to adults, 21 years of age and older, who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

70 7000. MR/DD NIGHT SLEEP CYCLE SUPPORT BILLING INSTRUCTIONS Updated 05/08 Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD SLEEP CYCLE SUPPORT PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

71 7010. MR/DD NIGHT SLEEP CYCLE SUPPORT SPECIFIC BILLING INFORMATION Updated 05/08 Enter procedure code T2025 (Night Sleep Cycle Support for MR/DD Waiver Participants) in field 24D of the CMS-1500 claim form. One unit = Up to A minimum of eight hours and maximum of 12 hours. Client Obligation If a case manager has assigned client obligation has been assigned to a particular provider and informed that provider has been informed that they are to collect this portion of the cost of service from the client, the provider must not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments the system is trying to read two different lines on the plan of care. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge HCBS Targeted Case Management provided within 30 days prior to discharge. HCBS MRDD SLEEP CYCLE SUPPORT PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

72 8400. BENEFITS AND LIMITATIONS Updated 05/08 HCBS MR/DD waiver services are designed to prevent individuals from entering, or remaining, in an intermediate care facility for the mentally retarded (ICF/MR). Night Sleep Cycle Support The primary purpose of night sleep cycle support is to give overnight assistance to beneficiaries living with a person who meets the definition of family in their home. The attendant must be immediately available but can sleep when not needed. The duties of a night support attendant include: Calling a doctor or hospital Providing assistance if an emergency occurs Turning and repositioning the beneficiary Assisting with peri-care and/or toileting Reminding the beneficiary of nighttime medication Administering medication when necessary The attendant does not perform any other personal care, training, or homemaker tasks. Individuals affiliated with or hired by SRS-licensed agencies will provide this service. Limitations 1. HCBS MR/DD night support is available to Medicaid program beneficiaries who: Are five years of age or older. Meet the criteria for ICF/MR level of care as determined by the HCBS MR/DD screening. Choose to receive HCBS MR/DD rather than ICF/MR services. 2. HCBS MR/DD is available to children, five to 18 years of age, who are determined eligible for the Medicaid program through a waiver of requirements relating to the deeming of parental income and who meet the criteria outlined above. 3. Night Sleep cycle support cannot be provided to anyone who is an inpatient of a hospital, a nursing facility, or an ICF/MR. 4. Night Sleep cycle support cannot be provided by the beneficiary's spouse or by a parent of a beneficiary less than eighteen years of age. 5. Night Sleep cycle support cannot be provided to beneficiaries of residential services. 6. Night Sleep cycle support is limited to individuals unable to be alone at night due to anticipated medical problems. 7. Sleep cycle support services must be provided a minimum of eight and maximum of 12 hours. HCBS MRDD SLEEP CYCLE SUPPORT PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-1

73 8400. BENEFITS AND LIMITATIONS Updated 05/08 A written justification, signed by the beneficiary's physician, must be submitted along with the Plan of Care indicating the medical necessity for the service to: Administrator MR/DD Program Services MH&DD, 5th Floor Docking State Office Building Topeka, Kansas This service is not to exceed 12 hours, per night, per individual. 8. The self-direct option may be chosen for night sleep cycle support by the beneficiary. If the beneficiary is incapable of providing self-direction, his or her guardian, parent, or other person acting on his or her behalf may choose. 9. Beneficiaries receiving night support cannot additionally receive residential services or family/individual supports. 10. A statement of medical necessity, signed by a physician, must be on record. Provider Requirements Night Sleep cycle support must be provided by a community developmental disability organization (CDDO) or an agency affiliated with a CDDO, who may or may not be licensed by the State of Kansas Department of Social and Rehabilitation Services (SRS) for other purposes, who is enrolled in KMAP. Documentation Requirements Written documentation is required for services provided and billed to KMAP. Documentation, at a minimum, must include the following: o Service being provided. o Beneficiary s (or responsible party s) name and signature if self-directed. o Caregiver s name and signature. o Date of service (MM/DD/YY). o Start time for each visit, include AM/PM or use 2400 clock hours. o Stop time for each visit, include AM/PM or use 2400 clock hours. o Brief description of the duties performed and including any changes in the beneficiary s status. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. Documentation must be created at the time of the visit. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. HCBS MRDD SLEEP CYCLE SUPPORT PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-2

74 8400. BENEFITS AND LIMITATIONS Updated 05/08 Signature Limitations When choosing the self-directed option, the expectation is that the beneficiary provides oversight and accountability for those providing services. Signature options are provided knowing the beneficiary may have limitations. A designated signatory can be anyone aware of the services provided. The individual providing the service cannot sign the timesheet on behalf of the beneficiary. Each timesheet must contain the signature of the beneficiary or designated signatory verifying the services received and the time recorded. Approved signing options include: Beneficiary s signature Beneficiary making a distinct mark representing their signature Beneficiary using their signature stamp Designated signatory In situations where there is no one to serve as designated signatory, the billing provider must establish, document and monitor a plan based on the situation. If a beneficiary refuses to sign accurate timesheets without a legitimate reason, he or she must be advised that the attendant s time may not be paid or money may be taken back. Timesheets not reflecting accurate times and services must not be signed. Unsigned timesheets are the responsibility of the billing provider. HCBS MRDD SLEEP CYCLE SUPPORT PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-3

75 DEFINITIONS Updated 05/08 Community Based Screening an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organizations (CDDO) - a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliates provides community-based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by Disability and Behavioral Health Services/Community Supports and Services Mental Health and Developmental Disabilities (MH&DD). Affiliate - a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care - a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the Administrator MR/DD Program Services HCBS-MR/DD Program Manager, must include: The services to be provided The frequency of each service The provider of each service The cost of each service HCBS MRDD SLEEP CYCLE SUPPORT PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-4

76 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services Updated 05/08 1. Services are provided according to the plan of care, and in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, and in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD SLEEP CYCLE SUPPORT PROVIDER MANUAL BENEFITS AND LIMITATIONS 8-5

77

78 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Supported Employment

79 PART II HCBS MR/DD SUPPORTED EMPLOYMENT PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Supported Employment Specific Billing Instructions Submission of Claim HCBS MR/DD Supported Employment Specific Billing Information BENEFITS AND LIMITATIONS 8400 Medicaid FORMS CMS-1500

80 INTRODUCTION TO THE HCBS MR/DD PROGRAM The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary's choice to participate in the HCBS program. Adult oral health services Assistive services Day supports Family/individual supports Medical alert-rental Personal assistant services Residential supports Respite care-overnight Respite care-temporary Sleep cycle support Supported employment Supportive home care Wellness monitoring All HCBS MR/DD program services (with the exception of adult oral health services) require prior authorization (PA) through the plan of care process. Oral health services are available to adults 21 years of age and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

81 7000. MR/DD SUPPORTED EMPLOYMENT BILLING INSTRUCTIONS Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD SUPPORTED EMPLOYMENT PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

82 7010. MR/DD SUPPORTED EMPLOYMENT SPECIFIC BILLING INFORMATION Enter procedure code H2023 (Supported Employment MR/DD) in field 24D of the CMS-1500 claim form. One unit = 15 minutes. Client Obligation If client obligation has been assigned to a particular provider and that provider has been informed that they are to collect this portion of the cost of service from the client, the provider must not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge HCBS MRDD SUPPORTED EMPLOYMENT PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

83 8400. BENEFITS AND LIMITATIONS HCBS MR/DD program services are designed to prevent individuals from entering, or remaining in, an intermediate care facility for the mentally retarded (ICF/MR). Supported Employment Supported employment is competitive work in an integrated setting with on-going support services for individuals who have MR/DD. Competitive work is defined as compensated work in accordance with the Fair Labor Standards Act. An integrated work setting is a job site that is similar to that of the general work force. Such work is supported by any activity needed to sustain paid employment by persons with disabilities. The following supported employment activities are designed to assist individuals in acquiring and maintaining employment. Individualized assessment Individualized job development and placement services to create an appropriate job match for the individual and the employer On-the-job training in skills required to perform the necessary functions of the job Ongoing monitoring of the individual s performance on the job Ongoing support services necessary to ensure job retention as identified in the personcentered support plan (PCSP) Training in related skills essential to secure and retain employment Limitations 1. HCBS MR/DD assistive services are available to Medicaid beneficiaries who: Are 18 years of age or older. Are determined eligible for MR/DD services. Meet the criteria for ICF/MR level of care as determined by ICF/MR (HCBS MR/DD) screening. Choose to receive HCBS MR/DD rather than ICF/MR services. 2. HCBS MR/DD cannot be provided to anyone who is an inpatient of a hospital, a nursing facility, or an ICF/MR. 3. Transportation costs are not covered by this service. 4. Beneficiaries 18 to 21 years of age who are receiving a similar service supported by an individual education plan (IEP) cannot access this service. 5. Supported employment must be provided away from the beneficiary s place of residence. 6. Supported employment services must not be provided until the beneficiary has applied to the local Rehabilitation Services office. HCBS MR/DD waiver will fund supported employment activities until Rehabilitation Service s funding for the supported employment begins. Coverage under the waiver will be suspended until the case is closed by Rehabilitation Services. HCBS MRDD SUPPORTED EMPLOYMENT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-1

84 8400. BENEFITS AND LIMITATIONS 7. If the beneficiary is determined ineligible for vocational training through Rehabilitation Services under Section 110 of the Rehabilitation Act of 1973, then this service can be provided as a waiver service. Documentation of this determination must be maintained in the beneficiary s file. 8. Case managers are responsible for insuring that vocational rehabilitation services are NOT being duplicated for waiver beneficiaries. Provider Requirements A provider of MR/DD supported employment services must be a recognized community developmental disability organization (CDDO) or an affiliate, as well as licensed by the State of Kansas Department of Social and Rehabilitation Services (SRS) to provide this service. Documentation Requirements Written documentation is required for services provided and billed to KMAP. Documentation, at a minimum, must include the following: o Name of the service. o Beneficiary s first and last name. o Date of the service (MM/DD/YY). o Check mark to indicate the beneficiary received the service as defined. o Signature of a responsible staff person verifying the information is correct. Documentation must be created during the timeframe of the billing cycle. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. HCBS MRDD SUPPORTED EMPLOYMENT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-2

85 DEFINITIONS Community Based Screening an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organization (CDDO) a local agency, specified by county government, which directly receives county mill funds and state aid, and either directly and/or through a network of affiliates, provides community-based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by Disability and Behavioral Health Services/Community Supports and Services. Affiliate a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the HCBS-MR/DD program manager, must include: The services to be provided The frequency of each service The provider of each service The cost of each service HCBS MRDD SUPPORTED EMPLOYMENT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-3

86 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services 1. Services are provided according to the plan of care, in a quality manner, and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD SUPPORTED EMPLOYMENT PROVIDER MANUAL BENEFITS & LIMITATIONS 8-4

87

88 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MR/DD Supportive Home Care

89 PART II HCBS MR/DD SUPPORTIVE HOME CARE PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS MR/DD Supportive Home Care Specific Billing Instructions Submission of Claim HCBS MR/DD Supportive Home Care Specific Billing Information BENEFITS AND LIMITATIONS 8400 Medicaid FORMS CMS-1500

90 INTRODUCTION TO THE HCBS MR/DD PROGRAM Updated 05/08 The Home and Community Based Services (HCBS) Mental Retardation/Developmental Disabilities (MR/DD) program is designed to meet the needs of individuals who would be institutionalized without these services. The variety of services described below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the beneficiary s choice to participate in the HCBS program. Adult oral health services Assistive services Communication Devices Day supports Services Family/individual supports Home Modifications Medical alert-rental Night Support Personal assistant services Residential supports Services Respite care-overnight Respite care-temporary Respite Care-Emergency Screening Sleep cycle support Supported employment Supportive home care Targeted Case Management Van Lifts Wellness monitoring Wheelchair Modifications All HCBS MR/DD program services (with the exception of adult oral health services Screening, and Targeted Case Management) require prior authorization through the plan of care process. Oral health services are available to adults 21 years of age and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. HCBS MR/DD Enrollment HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program (KMAP) and receive a provider number for HCBS MR/DD program services. Access provider enrollment information at Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required during its review and investigation. The provider is required to provide access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider must not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

91 7000. MR/DD SUPPORTIVE HOME CARE BILLING INSTRUCTIONS Updated 05/08 Introduction to the CMS-1500 Claim Form Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under the KMAP. An example of the CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

92 7010. MR/DD SUPPORTIVE HOME CARE SPECIFIC BILLING INFORMATION Updated 05/08 Enter procedure code S5125 (Supportive Home Care - MR/DD) in field 24D of the CMS-1500 claim form. One unit = 15 minutes. Client Obligation If a case manager has assigned client obligation has been assigned to a particular provider and informed that provider has been informed that they are to collect this portion of the cost of service from the client, the provider must not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. One Plan of Care per Month Prior authorizations through the plan of care process are approved for one month only. Dates of service that span two months must be billed on two separate claims. Example Services for July 28 - August 3 must be billed with July on one claim and August 1-3 on a second claim. Overlapping Dates of Service The dates of service on the claim must match the dates approved on the plan of care and cannot overlap. For example, there are two lines on the plan of care with the following dates of service, July 1-15 and July If billing service dates of July 8-16, the claim would deny because the billed dates cross plan of care segments the system is trying to read two different lines on the plan of care. For the first service line, any date that falls between July 1-15 will prevent the claim from denying for date of service. Same Day Service For certain situations, HCBS MR/DD program services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to: Services provided the date of admission, if provided prior to admission Services provided the date of discharge, if provided following discharge. HCBS Targeted Case Management provided within 30 days prior to discharge. HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

93 8400. BENEFITS AND LIMITATIONS Updated 05/08 HCBS MR/DD program services are designed to prevent individuals from entering, or remaining in, an intermediate care facility for the mentally retarded (ICF/MR). Supportive Home Care Supportive home care (SHC) services are available to an HCBS MR/DD beneficiary who meets one of the following requirements: Lives with a person meeting the definition of family Is a child, five to 21 years of age, who is in the custody of the State of Kansas Department of Social and Rehabilitation Services (SRS) but not living with someone meeting the definition of family Is a child, 15 years of age or older, who resides in a setting with persons who do not meet the definition of family and have not been appointed the legal guardian or custodian Note: Family is defined as any person immediately related to the beneficiary. Immediaterelated family members are parents (including adoptive parents), grandparents, a spouse, aunts, uncles, sisters, brothers, first cousins and any step-family relationships. live in the birth or adoptive family home. These services provide necessary assistance for eligible persons in order to meet their daily living situations. SHC services provide individualized (one-on-one) direct assistance to HCBS MR/DD beneficiaries with: Daily living and personal adjustment Attendant care Assistance with medications that are ordinarily self-administered Accessing medical care Supervision Reporting changes in the beneficiaries condition and needs Extension of therapy services Ambulation and exercise Household services essential to health care at home or performed in conjunction with assistance in daily living (shopping, meal preparation, clean-up after meals, bathing, using appliances, dressing, feeding, bed making, laundry, and cleaning the bathroom and kitchen) Household maintenance related to the beneficiary Note: The SHC worker can accompany or transport the beneficiary to accomplish any of the tasks listed above or to provide supervision or support for community activities. Limitations 1. HCBS MR/DD supportive home care is available to Medicaid program beneficiaries who: Are five years of age or older. Are mentally retarded or otherwise developmentally disabled. Meet the criteria for ICF/MR level of care as determined by ICF/MR (HCBS MR/DD) screening. Choose to receive HCBS MR/DD rather than ICF/MR services. HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BENEFITS & LIMITATIONS 8-1

94 8400. BENEFITS AND LIMITATIONS Updated 05/08 2. HCBS MR/DD is available to minor children, five to 18 years of age, who are determined eligible for the Medicaid program through a waiver of requirements relating to the deeming of parental income and who meet the criteria outlined above. HCBS MR/DD cannot be provided to anyone who is an inpatient of a hospital, a nursing facility, or an ICF/MR. Supportive home care will only be approved when a schedule of tasks or detailed explanation is attached to the plan of care. Room and board costs are excluded in the cost of any HCBS MR/DD services except overnight facility-based respite. Supportive home care shall not be provided in settings in which three or more unrelated people reside (unless it is the beneficiary's natural, adoptive, or foster home). Supportive home care beneficiaries may not also receive residential services. Supportive home care may not be provided in a school setting and may not be used for education or as a substitute for educationally related services. A description of expectations for supportive home care workers must be maintained and available for review. The descriptions are subject to audit. If services fluctuate based on school hours, two descriptions (one for when school is in session and one for when not in session) may be appropriate and must also be available for review. These descriptions are also subject to audit. A self-directed option may be chosen for supportive home care by the consumer or, if the consumer is incapable of providing self-direction, by the consumer s guardian or parent acting on their behalf. Supportive home care services are limited to a maximum of eight hours on any given date, and to only the activities described above unless sufficient rationale is provided for hours in excess of eight a day. The absolute maximum allowable billing is twelve hours on any given date and to the service component only of these activities. Supportive home care hours are provided ONLY when the primary care givers are present OR regularly scheduled to be absent; otherwise, respite hours should be utilized. A consumer can receive supportive home care services from more than one worker, but no more than one worker can be paid for services at any given time of the day. Exceptions will be allowed when the Targeted Case Manager approves with documented rationale. 3. SHC services cannot be provided by a beneficiary s spouse or by a parent of a beneficiary who is a minor child under 18 years of age. HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BENEFITS & LIMITATIONS 8-2

95 8400. BENEFITS AND LIMITATIONS Updated 05/08 4. SHC recipients cannot receive residential supports in addition to supportive home care or personal assistant services as an alternative to residential supports. 5. SHC services cannot be provided in an educational setting, used for education, used as a substitute for educationally-related services, or used for transition services as outlined in the beneficiary s individual education plan. In order to verify that SHC services are not used as a substitute, an SHC Services Schedule (MR-10) or an In-Home Supports Needs Assessment must clearly define the division of educational services and SHC services. Educational services must be equal to or greater than the seven hours per day of a regularly scheduled school day. These hours do not have to be consecutive hours. The minimum number of hours required for kindergarten students is seven hours per day for those eligible for full-day and three-and-a-half hours per day for those eligible for half-day. 6. SHC services are limited to a maximum of an average of eight hours per day in any given month. The services are only for the activities described above unless sufficient rationale is provided for hours in excess of an average of eight hours per day in any given month. 7. SHC hours are provided only when the primary care giver is present or regularly scheduled to be absent. Otherwise, respite hours should be utilized. 8. A beneficiary can receive SHC services from more than one worker, but no more than one worker can be paid for services at any given time of the day. 9. Waiver beneficiaries who require assistance with independent activities of daily living (IADL) tasks and who live with a capable spouse or guardian should rely on him or her for this type of informal and natural support. The only exception is if there are extenuating or specific circumstances documented in the person-centered support plan (PCSP). For example, the PCSP defines the role of the SHC provider as a person who is teaching the beneficiary how to perform a certain skill. In accordance with this expectation, SHC services should not be used for the following: Lawn care. Snow removal. Shopping. Ordinary housekeeping (which should be done by the individual with whom the recipient lives). Meal preparation (during the times when the person with whom the recipient lives would normally prepare a meal). 10. SHC services cannot be provided to a beneficiary who is an inpatient of a hospital, a nursing facility, or an ICF/MR when the inpatient facility is billing Medicaid, Medicare and/or private insurance except as described below in SHC retainer services. HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BENEFITS & LIMITATIONS 8-3

96 8400. BENEFITS AND LIMITATIONS Updated 05/ SHC retainer services may be billed up to a maximum of 14 days per calendar year, at a level consistent with the approved plan of care. These services are provided during the period of time when the individual is an inpatient of a hospital, a nursing facility, or an ICF/MR when the facility is billing Medicaid, Medicare and/or private insurance. They are provided to assist individuals who self-direct their care in retaining their current care provider(s). Provider Requirements SHC providers must be affiliated with the community developmental disability organizations (CDDO) for the area where they operate. As indicated in K.A.R , any individual providing services must be at least 16 years of age or at least 18 years of age if a sibling of the beneficiary. All individuals providing services must receive at least 15 hours of prescribed training or the person directing and controlling the services must provide written certification to the CDDO that sufficient training to meet the beneficiary s needs has been provided. The beneficiary may choose the self-direct option for SHC. If the person is incapable of providing self-direction, the beneficiary s guardian, family member or person acting on his or her behalf may choose. Documentation Requirements Recordkeeping responsibilities rest primarily with the Medicaid-enrolled provider. Written documentation is required for services provided and billed to KMAP. Documentation, at a minimum, must include the following: o Beneficiary s (or responsible party s) name and signature if self-directed. o Caregiver s name and signature. o Complete date of service (MM/DD/YY). o Start time for each visit, include AM/PM or use 2400 clock hours. o Stop time for each visit, include AM/PM or use 2400 clock hours. o Brief description of duties performed. Note: Responsible party is defined as the person s guardian or someone appointed by the person or guardian who is not the paid provider of services for the person. Time should be totaled by actual minutes/hours worked. Billing staff may round the total to the quarter hour at the end of the billing cycle. Documentation must be created at the time of the visit. Creating documentation after this time is not acceptable. Providers are responsible to insure the service was provided prior to submitting claims. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BENEFITS & LIMITATIONS 8-4

97 8400. BENEFITS AND LIMITATIONS Updated 05/08 Signature Limitations When choosing the self-directed option, the expectation is that the beneficiary provides oversight and accountability for those providing services. Signature options are provided knowing the beneficiary may have limitations. A designated signatory can be anyone aware of the services provided. However, the individual providing the services cannot sign the timesheet on behalf of the beneficiary. Each timesheet must contain the signature of the beneficiary or designated signatory verifying the services received and the time recorded. Approved signing options include: Beneficiary s signature Beneficiary making a distinct mark representing their signature Beneficiary using their signature stamp Designated signatory In situations where there is no one to serve as designated signatory, the billing provider must establish, document and monitor a plan based on the situation. If a beneficiary refuses to sign accurate timesheets without a legitimate reason, he or she must be advised that the attendant s time may not be paid or money may be taken back. Timesheets not reflecting accurate times and services must not be signed. Unsigned timesheets are the responsibility of the billing provider. HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BENEFITS & LIMITATIONS 8-5

98 DEFINITIONS Updated 05/08 Community Based Screening an assessment of the adaptive needs, maladaptive behaviors, and health needs of individuals who are mentally retarded or developmentally disabled to determine their eligibility for ICF/MR level of care. Community Developmental Disability Organizations (CDDO) - a local agency, specified by county government, which directly receives county mill funds and state aid and either directly and/or through a network of affiliates provides community-based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by Disability and Behavioral Health Services/Community Supports and Services Mental Health and Developmental Disabilities (MH&DD). Affiliate - a local agency which provides at least one service to individuals who are mentally retarded or developmentally disabled and has entered into an affiliation agreement with the recognized CDDO. Plan of Care - a document completed following the determination of ICF/MR eligibility, after the individual elects HCBS MR/DD instead of ICF/MR services. This document, subject to the approval of the Administrator MR/DD Program Services HCBS-MR/DD program manager, must include: The services to be provided The frequency of each service The provider of each service The cost of each service HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BENEFITS & LIMITATIONS 8-6

99 Expected Service Outcomes for Individuals or Agencies Providing HCBS MR/DD Services Updated 05/08 1. Services are provided according to the plan of care, and in a quality manner and as authorized on the notice of action. 2. Provision of services is coordinated in a cost-effective manner. 3. Beneficiary s independence and health are maintained, when possible, and in a safe and dignified manner. 4. Beneficiary s concerns and needs, such as changes in health status, are communicated to the case manager or independent living counselor within 48 hours. This includes any ongoing reporting required by the Medicaid program. 5. Failure or inability to provide services as scheduled in accordance with the plan of care are reported immediately, but not to exceed 48 hours, to the case manager or the independent living counselor. HCBS MRDD SUPPORTIVE HOME CARE PROVIDER MANUAL BENEFITS & LIMITATIONS 8-7

100

HCBS MRDD Home Modifications

HCBS MRDD Home Modifications KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS MRDD Home Modifications PART II MR/DD HOME MODIFICATIONS PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 MR/DD Home Modifications Billing Instructions.........

More information

KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. HCBS TBI Cognitive Therapy

KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. HCBS TBI Cognitive Therapy KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS TBI Cognitive Therapy PART II TBI COGNITIVE THERAPY PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 TBI Cognitive Therapy Billing Instructions............

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Intellectual/Developmentally Disabled

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Intellectual/Developmentally Disabled Fee-for-Service Provider Manual HCBS Intellectual/Developmentally Disabled Updated 07.2017 PART II HCBS INTELLECTUAL/DEVELOPMENTALLY DISABLED FEE-FOR-SERVICE PROVIDER MANUAL Section BILLING INSTRUCTIONS

More information

KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. HCBS Autism Waiver

KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. HCBS Autism Waiver KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS Autism Waiver Introduction Section 7000 7010 8100 8300 8400 BILLING INSTRUCTIONS HCBS Autism Waiver Billing Instructions... Submission of Claim...

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Frail Elderly

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Frail Elderly Fee-for-Service Provider Manual HCBS Frail Elderly Updated 02.2016 PART II Section BILLING INSTRUCTIONS Page 7000 HCBS FE Billing Instructions................. 7-1 7010 HCBS FE Specific Billing Information.............

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. Podiatry

KANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. Podiatry Provider Manual Podiatry Updated 07/2012 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Podiatry Billing Instructions.................. 7-1 Submission of Claim.................. 7-1 7010 Podiatry

More information

Targeted Case Management- Mental Health

Targeted Case Management- Mental Health KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Targeted Case Management- Mental Health Part II TARGETED CASE MANAGEMENT-MENTAL HEALTH PROVIDER MANUAL Introduction Section 7000 7010 8100 8300 8400 Forms

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Podiatry

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Podiatry Fee-for-Service Provider Manual Podiatry Updated 03.2014 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Podiatry Billing Instructions.................. 7-1 Submission of Claim..................

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. HCBS Traumatic Brain Injury

KANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. HCBS Traumatic Brain Injury Provider Manual HCBS Traumatic Brain Injury Updated 07/2012 PART II Section BILLING INSTRUCTIONS Page 7000 HCBS TBI Billing Instructions................ 7-1 Submission of Claim.................. 7-1 7010

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Physical Disability

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Physical Disability Fee-for-Service Provider Manual HCBS Physical Disability Updated 03.2017 PART II Section BILLING INSTRUCTIONS Page 7000 HCBS PD Billing Instructions................. 7-1 7010 HCBS PD Specific Billing Information.............

More information

NEW YORK STATE MEDICAID PROGRAM OFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED SERVICES WAIVER MANUAL

NEW YORK STATE MEDICAID PROGRAM OFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED SERVICES WAIVER MANUAL NEW YORK STATE MEDICAID PROGRAM OFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED SERVICES WAIVER MANUAL POLICY GUIDELINES Table of Contents SECTION I - DESCRIPTION OF

More information

May 2007 Provider Bulletin Number 753. Hospice Providers. Changes to ICF/MR Room and Board Charges for Hospice Beneficiaries

May 2007 Provider Bulletin Number 753. Hospice Providers. Changes to ICF/MR Room and Board Charges for Hospice Beneficiaries May 2007 Provider Bulletin Number 753 Hospice Providers Changes to ICF/MR Room and Board Charges for Hospice Beneficiaries This is an update to bulletin 743. A correction has been made regarding how to

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Non-PIHP Alcohol and Substance Abuse Community Based Services

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Non-PIHP Alcohol and Substance Abuse Community Based Services Fee-for-Service Provider Manual Non-PIHP Alcohol and Substance Abuse Community Based Services Updated 08.2015 PART II Introduction Section 7000 7010 8100 8200 8300 8400 Appendix BILLING INSTRUCTIONS Alcohol

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Traumatic Brain Injury

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Traumatic Brain Injury Fee-for-Service Provider Manual HCBS Traumatic Brain Injury Updated 03.2017 PART II HCBS TRAUMATIC BRAIN INJURY FEE-FOR-SERVICE PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 HCBS TBI Billing Instructions................

More information

UnitedHealthcare Community Plan. Intellectually/Developmentally Disabled Benefits Supplement (TTY: 711) myuhc.com/communityplan KANSAS

UnitedHealthcare Community Plan. Intellectually/Developmentally Disabled Benefits Supplement (TTY: 711) myuhc.com/communityplan KANSAS KANSAS UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Benefits Supplement 1-877-542-9238 (TTY: 711) myuhc.com/communityplan 953-CST4074 2/14 2014 United HealthCare Services, Inc.

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Local Education Agency

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Local Education Agency Fee-for-Service Provider Manual Local Education Agency Updated 07.2018 Introduction PART II Section Page 7000 Local Education Agency Billing Instructions............ 7-1 7010 Local Education Agency Billing

More information

Waiver Covered Services Billing Manual

Waiver Covered Services Billing Manual Covered Services Waiver Covered Services Billing Manual Section 1 - Long Term Care Home and Community Based Waiver Services....2 Section 2 - Assisted Living Facility Waiver Services... 6 Section 3 - Children

More information

This draft of service definitions and provider qualifications for the Community Care Waiver are pending approval from the Centers for Medicare and

This draft of service definitions and provider qualifications for the Community Care Waiver are pending approval from the Centers for Medicare and This draft of service definitions and provider qualifications for the Community Care Waiver are pending approval from the Centers for Medicare and Medicaid Services (CMS) and thus, are not final. Assistive

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

Connecticut interchange MMIS

Connecticut interchange MMIS Connecticut interchange MMIS Provider Manual Chapter 7 Hospice August 10, 2009 Connecticut Department of Social Services (DSS) 55 Farmington Ave Hartford, CT 06105 DXC Technology 195 Scott Swamp Road Farmington,

More information

Effective July 1, 2010 Draft Issued January 14, 2010

Effective July 1, 2010 Draft Issued January 14, 2010 Attachment 1 Service Definitions Narrative for Consolidated Waiver, Person/Family Directed Support Waiver, Administrative Services, and Base/Waiver Ineligible Services INDEX Title Page Administrative Services

More information

OPWDD Region Family Support Services Family Reimbursement Program Guidelines

OPWDD Region Family Support Services Family Reimbursement Program Guidelines OPWDD Region 1 2018 Support Services Reimbursement Program Guidelines PURPOSE: The Reimbursement Program is intended to assist the family caring for their family member with a developmental disability.

More information

Individual and Family Guide

Individual and Family Guide 0 0 C A R D I N A L I N N O V A T I O N S H E A L T H C A R E Individual and Family Guide Version 9 revised November 1, 2016 2016 Cardinal Innovations Healthcare 4855 Milestone Avenue Kannapolis, NC 28081

More information

Office of Long-Term Living Waiver Programs - Service Descriptions

Office of Long-Term Living Waiver Programs - Service Descriptions Adult Daily Living Office of Long-Term Living Waiver Programs - Descriptions *The service descriptions below do not represent the comprehensive Definition as listed in each of the Waivers. Please refer

More information

Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER II

Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER II TABLE OF CONTENTS PAGE 20.01... INTRODUCTION... 1 20.02... DEFINITIONS... 1 20.02-1 Abuse... 1 20.02-2 Assessing Services Agency (ASA)... 1 20.02-3 Authorized Agent... 1 20.02-4 BMS99... 1 20.02-5 Care

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Non- PAPH Outpatient Mental Health

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Non- PAPH Outpatient Mental Health Fee-for-Service Provider Manual Non- PAPH Outpatient Mental Health Updated 05.2014 PART II Introduction Section 7000 7010 8100 8200 8300 8400 8410 Appendix BILLING INSTRUCTIONS Non-PAHP Outpatient Mental

More information

5101: Home health services: provision requirements, coverage and service specification.

5101: Home health services: provision requirements, coverage and service specification. Page 1 of 8 5101:3-12-01 Home health services: provision requirements, coverage and service specification. (A) Home health services includes home health nursing, home health aide and skilled therapies

More information

OHIO DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES NEW FUTURES WAIVER

OHIO DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES NEW FUTURES WAIVER OHIO DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES NEW FUTURES WAIVER CONCEPT PAPER SUBMITTED TO CMS Brief Waiver Description Ohio intends to create a 1915c Home and Community-Based Services

More information

Request for an Amendment to a 1915(c) Home and Community-Based Services Waiver

Request for an Amendment to a 1915(c) Home and Community-Based Services Waiver Page 1 of 11 Request for an Amendment to a 1915(c) Home and Community-Based Services Waiver 1. Request Information A. The State of North Carolina requests approval for an amendment to the following Medicaid

More information

C. The individual must be capable of assisting in the selection, training, and supervision of the attendant s scheduled activities.

C. The individual must be capable of assisting in the selection, training, and supervision of the attendant s scheduled activities. 4200 ATTENDANT CARE SERVICES. 4201 General. This section addresses two types of attendant care services: A. Supportive attendant care services required to enable an individual to participate in one or

More information

CHILD HEALTH SERVICES TARGETED CASE MANAGEMENT COVERAGE AND LIMITATIONS HANDBOOK

CHILD HEALTH SERVICES TARGETED CASE MANAGEMENT COVERAGE AND LIMITATIONS HANDBOOK Florida Medicaid CHILD HEALTH SERVICES TARGETED CASE MANAGEMENT COVERAGE AND LIMITATIONS HANDBOOK Agency for Health Care Administration June 2012 UPDATE LOG CHILD HEALTH SERVICES TARGETED CASE MANAGEMENT

More information

Type & Specialty pages Mark the specialty(s) you wish to enroll in. Attach required documents including license as specified.

Type & Specialty pages Mark the specialty(s) you wish to enroll in. Attach required documents including license as specified. P O Box 3571 Below is a checklist for your convenience to help ensure that all forms are completed in their entirety. If any of the following items are not complete, do not contain original signatures,

More information

Administrative Guide. KanCare Program Chapter 11: Hospice. Physician, Health Care Professional, Facility and Ancillary. UHCCommunityPlan.

Administrative Guide. KanCare Program Chapter 11: Hospice. Physician, Health Care Professional, Facility and Ancillary. UHCCommunityPlan. KanCare Program Physician, Health Care Professional, Facility and Ancillary Administrative Guide Doc#: PCA-1-003044_06202016 UHCCommunityPlan.com Welcome to UnitedHealthcare This administrative guide is

More information

ODP Communication Questions and Answers Regarding the Consolidated and P/FDS Waiver Amendments Approved July 2016

ODP Communication Questions and Answers Regarding the Consolidated and P/FDS Waiver Amendments Approved July 2016 ODP Communication Questions and Answers Regarding the Consolidated and P/FDS Waiver Amendments Approved July 2016 ODP Announcement 084-16 The mission of the Office of Developmental Programs is to support

More information

Long-Term Care Glossary

Long-Term Care Glossary Long-Term Care Glossary Adjudicated Claim Activities of Daily Living (ADL) A claim that has reached final disposition such that it is either paid or denied. Basic tasks individuals perform in the course

More information

NC INNOVATIONS WAIVER HANDBOOK

NC INNOVATIONS WAIVER HANDBOOK A Managed Care Organization of the NC Department of Health & Human Services NC INNOVATIONS WAIVER HANDBOOK Revised April 01, 2013 Sandhills Center provides access to services for mental health, intellectual

More information

DOCUMENTATION REQUIREMENTS

DOCUMENTATION REQUIREMENTS DOCUMENTATION REQUIREMENTS Service All documentation requirements listed below are identified in Rule 65G- Adult Dental Services An invoice listing each procedure and negotiated cost. Copy of treatment

More information

8.500 HOME AND COMMUNITY BASED SERVICES FOR THE DEVELOPMENTALLY DISABLED (HCB-DD) WAIVER

8.500 HOME AND COMMUNITY BASED SERVICES FOR THE DEVELOPMENTALLY DISABLED (HCB-DD) WAIVER 8.500 HOME AND COMMUNITY BASED SERVICES FOR THE DEVELOPMENTALLY DISABLED (HCB-DD) WAIVER 8.500.1 DEFINITION Home and Community Based Services for the Developmentally Disabled (HCB-DD) waiver services shall

More information

Michelle P Waiver Training

Michelle P Waiver Training Michelle P Waiver Training Presented by Department for Medicaid Services and Department for Mental Health, Developmental Disabilities and Addiction Services 1 Workshop Outline I. History and Overview of

More information

NEW YORK STATE MEDICAID PROGRAM HOME AND COMMUNITY-BASED SERVICES MEDICAID WAIVER FOR INDIVIDUALS WITH TRAUMATIC BRAIN INJURY MANUAL

NEW YORK STATE MEDICAID PROGRAM HOME AND COMMUNITY-BASED SERVICES MEDICAID WAIVER FOR INDIVIDUALS WITH TRAUMATIC BRAIN INJURY MANUAL NEW YORK STATE MEDICAID PROGRAM HOME AND COMMUNITY-BASED SERVICES MEDICAID WAIVER FOR INDIVIDUALS WITH TRAUMATIC BRAIN INJURY MANUAL POLICY GUIDELINES Table of Contents SECTION I - REQUIREMENTS FOR PARTICIPATION

More information

HOME AND COMMUNITY BASED SERVICES INTELLECTUAL DISABILITY WAIVER INFORMATION PACKET

HOME AND COMMUNITY BASED SERVICES INTELLECTUAL DISABILITY WAIVER INFORMATION PACKET HOME AND COMMUNITY BASED SERVICES INTELLECTUAL DISABILITY WAIVER INFORMATION PACKET The Medicaid Home and Community Based Intellectual Disability Waiver (HCBS ID) provides service funding and individualized

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

pennsylvania D E P A R T M E N T O F P U B L I C W E L F A R E D E P A R T M E N T O F A G I N G

pennsylvania D E P A R T M E N T O F P U B L I C W E L F A R E D E P A R T M E N T O F A G I N G ISSUE DATE 7/6/10 pennsylvania D E P A R T M E N T O F P U B L I C W E L F A R E D E P A R T M E N T O F A G I N G www.dpw.state.pa.us/about/oltl/ EFFECTIVE DATE 7/1/10 OFFICE OF LONG-TERM LIVING BULLETIN

More information

How to Affiliate with The Shawnee County Community Developmental Disabilities Organization (CDDO)

How to Affiliate with The Shawnee County Community Developmental Disabilities Organization (CDDO) How to Affiliate with The Shawnee County Community Developmental Disabilities Organization (CDDO) 1 Table of Contents Introduction 3 Licensed Provider/Financial Management Provider 4 Step 1 License Process

More information

MEMBER HANDBOOK. My Choice Family Care. Phone: Fax: Toll Free: TTY: 711

MEMBER HANDBOOK. My Choice Family Care. Phone: Fax: Toll Free: TTY: 711 M MEMBER HANDBOOK My Choice Family Care Template provided by the WI Department of Health Services Phone: 414-287-7600 Fax: 414-287-7704 Toll Free: 1-877-489-3814 TTY: 711 www.mychoicefamilycare.com APPENDICES

More information

HOME AND COMMUNITY BASED SERVICES BRAIN INJURY WAIVER INFORMATION PACKET GENERAL PARAMETERS

HOME AND COMMUNITY BASED SERVICES BRAIN INJURY WAIVER INFORMATION PACKET GENERAL PARAMETERS HOME AND COMMUNITY BASED SERVICES BRAIN INJURY WAIVER INFORMATION PACKET The Medicaid Home and Community Based Services Brain Injury Waiver (HCBS BI) provides service funding and individualized supports

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

PAGE R1 REVISOR S FULL-TEXT SIDE-BY-SIDE

PAGE R1 REVISOR S FULL-TEXT SIDE-BY-SIDE 69.11 ARTICLE 4 69.12 CONTINUING CARE 50.15 ARTICLE 4 50.16 CONTINUING CARE 69.13 Section 1. Minnesota Statutes 2010, section 62J.496, subdivision 2, is amended to read: 50.17 Section 1. Minnesota Statutes

More information

Georgia Department of Behavioral Health & Developmental Disabilities FOR. Effective Date: January 1, 2018 (Posted: December 1, 2017)

Georgia Department of Behavioral Health & Developmental Disabilities FOR. Effective Date: January 1, 2018 (Posted: December 1, 2017) Georgia Department of Behavioral Health & Developmental Disabilities PROVIDER MANUAL FOR COMMUNITY DEVELOPMENTAL DISABILITY PROVIDERS OF STATE-FUNDED DEVELOPMENTAL DISABILITY SERVICES FISCAL YEAR 2018

More information

NORTH CAROLINA DEPARTMENT OF HEALTH & HUMAN SERVICES

NORTH CAROLINA DEPARTMENT OF HEALTH & HUMAN SERVICES NORTH CAROLINA DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Mental Health, Developmental Disabilities and Substance Abuse Services State-Funded MH/DD/SA SERVICE DEFINITIONS Revision Date: September

More information

Florida Medicaid. Intermediate Care Facility for Individuals with Intellectual Disabilities Services Coverage Policy

Florida Medicaid. Intermediate Care Facility for Individuals with Intellectual Disabilities Services Coverage Policy Florida Medicaid Intermediate Care Facility for Individuals with Intellectual Disabilities Services Coverage Policy Agency for Health Care Administration July 2016 Florida Medicaid Table of Contents 1.0

More information

QUEST Expanded Access (QExA) Provider Guidelines and Service Definitions

QUEST Expanded Access (QExA) Provider Guidelines and Service Definitions QUEST Expanded Access (QExA) Provider Guidelines and Service Definitions The following are the provider guidelines and service definitions for 1915(c) waiver services that will be provided in the QExA

More information

Medicare and Medicaid

Medicare and Medicaid Medicare and Medicaid Medicare Medicare is a multi-part federal health insurance program managed by the federal government. A person applies for Medicare through the Social Security Administration, but

More information

Provider Certification Standards Adult Day Care

Provider Certification Standards Adult Day Care Provider Certification Standards Adult Day Care December 2015 1 Definitions: Activities of Daily Living (ADL s)- Includes but is not limited to the following personal care activities: bathing, dressing,

More information

CDDO HANDBOOK MISSION STATEMENT

CDDO HANDBOOK MISSION STATEMENT Adopted 6-19-09 Revised 11-1-10 Revised 4-30-13 Revised 2-27-17 CDDO HANDBOOK MISSION STATEMENT Arrowhead West, Inc. is the Community Developmental Disabilities Organization (CDDO) for initial contact

More information

907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services.

907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services. 907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services. RELATES TO: KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 1396a(a)(23) STATUTORY AUTHORITY:

More information

Office of Developmental Programs Service Descriptions

Office of Developmental Programs Service Descriptions 1 Office of Developmental Programs Descriptions *The service descriptions below do not represent the comprehensive Definition as listed in each of the Waivers. Please refer to the appropriate Waiver Program

More information

Application for a 1915(c) Home and Community-Based Services Waiver

Application for a 1915(c) Home and Community-Based Services Waiver Application for a 1915(c) Home and Community-Based Services Waiver PURPOSE OF THE HCBS WAIVER PROGRAM Page 1 of 117 The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in

More information

Home Health & HP Provider Relations

Home Health & HP Provider Relations Home Health & Hospice HP Provider Relations October 2010 Agenda Session Objectives Home Health Benefit Coverage Billing Overhead Multiple Visits Most Common Denials Hospice Benefit Coverage Election/Revocation/Discharge

More information

ALABAMA CARES SCOPE OF SERVICES IN-HOME RESPITE CARE

ALABAMA CARES SCOPE OF SERVICES IN-HOME RESPITE CARE ALABAMA CARES SCOPE OF SERVICES IN-HOME RESPITE CARE Operating Agency-SARCOA RC-Respite Care PC-Personal Care RCW-Respite Care Worker PCW-Personal Care Worker POC-Plan of Care DSP-Direct Service Provider-(In

More information

STATE OF IOWA DEPARTMENT OF HUMAN SERVICES MEDICAID

STATE OF IOWA DEPARTMENT OF HUMAN SERVICES MEDICAID STATE OF IOWA DEPARTMENT OF HUMAN SERVICES MEDICAID Provider Manual HCBS Mental Retardation Waiver TABLE OF CONTENTS PAGE 4 July 1, 2003 CHAPTER E. Page I. THE HOME- AND COMMUNITY-BASED MR WAIVER PROGRAM...1

More information

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF LONG TERM CARE. Traumatic Brain Injury Initiatives

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF LONG TERM CARE. Traumatic Brain Injury Initiatives NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF LONG TERM CARE Traumatic Brain Injury Initiatives Home and Community-Based Services Medicaid Waiver for Individuals with Traumatic Brain Injury The Home and

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Rural Health Clinic/ Federally Qualified Health Center

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Rural Health Clinic/ Federally Qualified Health Center Fee-for-Service Provider Manual Rural Health Clinic/ Federally Qualified Health Center Updated 08.2013 PART II RURAL HEALTH CLINIC AND FEDERALLY QUALIFIED HEALTH CENTER FEE-FOR-SERVICE PROVIDER MANUAL

More information

March 31, 2006 APD OP SUPPORTED LIVING PROVISION OF IN-HOME SUBSIDIES FOR PERSONS IN SUPPORTED LIVING ARRANGEMENTS

March 31, 2006 APD OP SUPPORTED LIVING PROVISION OF IN-HOME SUBSIDIES FOR PERSONS IN SUPPORTED LIVING ARRANGEMENTS March 31, 2006 APD OP 17-002 OPERATING PROCEDURE APD OP 17-002 STATE OF FLORIDA AGENCY FOR PERSONS WITH DISABILITIES TALLAHASSEE, March 31, 2006 SUPPORTED LIVING PROVISION OF IN-HOME SUBSIDIES FOR PERSONS

More information

907 KAR 1:044. Coverage provisions and requirements regarding community mental health center behavioral health services.

907 KAR 1:044. Coverage provisions and requirements regarding community mental health center behavioral health services. 907 KAR 1:044. Coverage provisions and requirements regarding community mental health center behavioral health services. RELATES TO: KRS 194A.060, 205.520(3), 205.8451(9), 422.317, 434.840-434.860, 42

More information

SUPPORTED LIVING PROVISION OF IN-HOME SUBSIDIES FOR PERSONS IN SUPPORTED LIVING ARRANGEMENTS

SUPPORTED LIVING PROVISION OF IN-HOME SUBSIDIES FOR PERSONS IN SUPPORTED LIVING ARRANGEMENTS March 31, 2006 APD OP 17-002 OPERATING PROCEDURE APD OP 17-002 STATE OF FLORIDA AGENCY FOR PERSONS WITH DISABILITIES TALLAHASSEE, March 31, 2006 SUPPORTED LIVING PROVISION OF IN-HOME SUBSIDIES FOR PERSONS

More information

UPDATED Nursing/Intermediate Care Facility Providers

UPDATED Nursing/Intermediate Care Facility Providers December 2008 Provider Bulletin Number 8160 UPDATED Nursing/Intermediate Care Facility Providers Revenue Codes The revenue codes listed under field 42 for the UB-04 form were inadvertently deleted with

More information

Home and Community-Based Waivers: Opportunities for Community Living for ABI Survivors

Home and Community-Based Waivers: Opportunities for Community Living for ABI Survivors Home and Community-Based Waivers: Opportunities for Community Living for ABI Survivors BIA-MA Brain Injury Conference March 30, 2017 Amy Bernstein Director, Community Based Waivers MassHealth Dorothée

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

HOSPICE POLICY UPDATE

HOSPICE POLICY UPDATE #02-56-13 Bulletin June 24, 2002 Minnesota Department of Human Services # 444 Lafayette Rd. # St. Paul, MN 55155 OF INTEREST TO County Directors Administrative contacts AC, EW, CAC, CADI, TBI DD Waiver

More information

term does not include services provided by a religious organization for the purpose of providing services exclusively to clergymen or consumers in a

term does not include services provided by a religious organization for the purpose of providing services exclusively to clergymen or consumers in a HEALTH CARE FACILITIES ACT - LICENSURE OF HOME CARE AGENCIES AND HOME CARE REGISTRIES, CONSUMER PROTECTIONS, INSPECTIONS AND PLANS OF CORRECTION AND APPLICABILITY OF ACT Act of Jul. 7, 2006, P.L. 334,

More information

Iowa Medicaid Habilitation Services Criteria Utilization Management Guidelines

Iowa Medicaid Habilitation Services Criteria Utilization Management Guidelines https://providers.amerigroup.com Iowa Medicaid Habilitation Services Criteria Utilization Management Guidelines Description State plan home- and community- based habilitation services are intended to meet

More information

Office of Developmental Programs Bureau of Autism Services. Service Definitions, Rates, Procedure Codes & Qualifications

Office of Developmental Programs Bureau of Autism Services. Service Definitions, Rates, Procedure Codes & Qualifications Office of Developmental Programs Bureau of Autism Services Service Definitions, Rates, Procedure Codes & Qualifications Fiscal Year 2016-2017 Waiver Service Page Number Assistive Technology 3 Career Planning:

More information

Guidelines for the Provision of Services Under the Community First Choice Option (CFCO) Benefit Within Managed Long Term Care

Guidelines for the Provision of Services Under the Community First Choice Option (CFCO) Benefit Within Managed Long Term Care NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS Division of Long Term Care December 6, 2016 Guidelines for the Provision of Services Under the Community First Choice Option (CFCO)

More information

Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note:

Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note: Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note: If you are a Medicaid beneficiary and have a serious mental illness, or serious emotional disturbance, or developmental

More information

1. Non-Emergent Transportation Providers

1. Non-Emergent Transportation Providers Table of Contents 1.... 1 1.1. Introduction... 1 1.1.1. Non-Emergency Record Keeping Requirements... 1 1.2. Commercial Transportation... 1 1.2.1. Freedom of Choice... 2 1.2.2. Member Eligibility... 2 1.2.3.

More information

All Waiver Providers, Extended Care ICF/MRs, and Rehabilitation Facilities. Traumatic Brain Injury Waiver Program

All Waiver Providers, Extended Care ICF/MRs, and Rehabilitation Facilities. Traumatic Brain Injury Waiver Program P R O V I D E R B U L L E T I N B T 2 0 0 0 1 2 M A R C H 1 0, 2 0 0 0 To: Subject: All Waiver Providers, Extended Care ICF/MRs, and Rehabilitation Facilities Overview Beginning January 1, 2000, the Health

More information

Application for a 1915 (c) HCBS Waiver

Application for a 1915 (c) HCBS Waiver Application for a 1915 (c) HCBS Waiver HCBS Waiver Application Version 3.5 Submitted by: Department of Human Services, Commonwealth of Pennsylvania Submission Date: March 29, 2011 CMS Receipt Date (CMS

More information

The Alliance Health Plan. NC Innovations Individual and Family Guide

The Alliance Health Plan. NC Innovations Individual and Family Guide The Alliance Health Plan NC Innovations Individual and Family Guide Corporate Office 4600 Emperor Boulevard Durham, NC 27703 24 Hour Toll-Free Access and Information Line: (800) 510-9132 This handbook

More information

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 33

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 33 DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 33 IN-HOME CARE AGENCIES PROVIDING MEDICAID IN-HOME SERVICES 411-033-0000 Purpose and Scope

More information

PROVIDER REQUIREMENTS. Providers must meet the following requirements in order to participate in the program:

PROVIDER REQUIREMENTS. Providers must meet the following requirements in order to participate in the program: Standards of Participation PROVIDER REQUIREMENTS Providers must meet the following requirements in order to participate in the program: Possess a current license for Personal Care Attendant Services issued

More information

Application for a 1915(c) Home and Community- Based Services Waiver PROPOSED

Application for a 1915(c) Home and Community- Based Services Waiver PROPOSED Page 1 of 165 Application for a 1915(c) Home and Community- Based Services Waiver PURPOSE OF THE HCBS WAIVER PROGRAM The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in

More information

Medicaid Covered Services Not Provided by Managed Medical Assistance Plans

Medicaid Covered Services Not Provided by Managed Medical Assistance Plans Medicaid Covered Services Not Provided by Managed Medical Assistance Plans This document outlines services not provided by MMA plans, but are available to Medicaid recipients through Medicaid fee-for-service.

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

KanCare Implementation Meeting: January 4, 2013 Questions & Answers. 9:00am-12pm

KanCare Implementation Meeting: January 4, 2013 Questions & Answers. 9:00am-12pm Page 1 of 10 KanCare Implementation Meeting: January 4, 2013 Questions & Answers 9:00am-12pm 1. Does it matter what position the PRAP coding is in? It should not. It is noted that there are concerns regarding

More information

Long-Term Services and Support (LTSS) Handbook. Blue Cross Community ICPSM

Long-Term Services and Support (LTSS) Handbook. Blue Cross Community ICPSM Blue Cross Community ICPSM Long-Term Services and Support (LTSS) Handbook Effective March 2014 www.bcbsilcommunityicp.com Call Toll Free: 1-888-657-1211 TTY/TDD 711. We are open between 8 a.m. to 8 p.m.

More information

Revised: November 2005 Regulation of Health and Human Services Facilities

Revised: November 2005 Regulation of Health and Human Services Facilities Revised: November 2005 Regulation of Health and Human Services Facilities This guidebook provides an overview of state regulation of residential facilities that provide support services for their residents.

More information

COMMUNITY-BASED LONG TERM CARE PROGRAMS IN WISCONSIN. Attorney Mitchell Hagopian Disability Rights Wisconsin July 2013

COMMUNITY-BASED LONG TERM CARE PROGRAMS IN WISCONSIN. Attorney Mitchell Hagopian Disability Rights Wisconsin July 2013 COMMUNITY-BASED LONG TERM CARE PROGRAMS IN WISCONSIN I. INTRODUCTION Attorney Mitchell Hagopian Disability Rights Wisconsin July 2013 In 1981, with the creation of the Community Options Program, the state

More information

1. Section Modifications

1. Section Modifications Table of Contents 1. Section Modifications... 1 2.... 2 2.1. Overview... 2 2.2. Regional Medicaid Services... 2 2.3. General Information... 2 2.3.1. Provider Qualifications... 2 2.3.2. Record Keeping...

More information

Basic Covered Benefits and Services

Basic Covered Benefits and Services Basic Covered Benefits and A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Bed Liners Coverage Covered for members age 4 and up; Prior

More information

Initial Needs Determination Report for Disability Waiver Residential and Support Services. Disability Services Division

Initial Needs Determination Report for Disability Waiver Residential and Support Services. Disability Services Division DHS-6674-ENG This document is made available electronically by the Minnesota Legislative Reference Library as part of an ongoing digital archiving project. http://www.leg.state.mn.us/lrl/lrl.asp Initial

More information

65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically

65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically 65G-4.0213 Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically validated relationships between individual characteristics

More information

Addendum SPC: Supportive Home Care

Addendum SPC: Supportive Home Care Addendum SPC: The provision of contracted, authorized, and provided services shall be in compliance with the provisions of this agreement, the service description and requirements of this section; and

More information

DEVELOPING A MEDICAID SUPPORTIVE HOUSING SERVICES BENEFIT

DEVELOPING A MEDICAID SUPPORTIVE HOUSING SERVICES BENEFIT DEVELOPING A MEDICAID SUPPORTIVE HOUSING SERVICES BENEFIT CONSIDERATIONS AND DECISION POINTS EXECUTIVE SUMMARY This tool is designed to assist States in the development of a Medicaid benefit to pay for

More information

For Review and Comment Purposes Only Not for Implementation DEVELOPMENTAL PROGRAMS BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE

For Review and Comment Purposes Only Not for Implementation DEVELOPMENTAL PROGRAMS BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE DEVELOPMENTAL PROGRAMS BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE DATE OF ISSUE DRAFT EFFECTIVE DATE DRAFT NUMBER DRAFT SUBJECT: Lifesharing Safeguards BY: Kevin T. Casey Deputy

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

Integrated Licensure Background and Recommendations

Integrated Licensure Background and Recommendations Integrated Licensure Background and Recommendations Minnesota Department of Health and Minnesota Department of Human Services Report to the Minnesota Legislature 2014 February 2014 Minnesota Department

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

Mental Retardation/Intellectual Disability Community Services Manual Chapter Subject. Provider Participation Requirements 2/8/2012 CHAPTER II

Mental Retardation/Intellectual Disability Community Services Manual Chapter Subject. Provider Participation Requirements 2/8/2012 CHAPTER II Subject Revision Date i CHAPTER PROVIDER PARTICIPATION REQUIREMENTS Subject Revision Date ii CHAPTER TABLE OF CONTENTS Participating Provider 1 Provider Enrollment 1 Requests for Participation 2 Participation

More information

OFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BULLETIN

OFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BULLETIN OFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BULLETIN ISSUE DATE EFFECTIVE DATE: NUMBER: SUBJECT: Clarification of Policies Regarding the Authorization and Delivery of Behavioral Health Rehabilitation

More information