Private Duty Nursing. May 2017

Transcription

1 Private Duty Nursing May 2017

2 Overview Provider Enrollment Member Eligibility Private Duty Nursing Services Specialized Private Duty Nursing Services Billing Additional Information 2

3 Provider Enrollment 3

4 Agency Enrollment Requirements To be eligible for payment for providing private duty nursing services, a provider must: Be enrolled as a private duty nursing agency, and Be enrolled as either a hospice service provider or a home health service provider who employs: A registered nurse (RN) A licensed practical nurse (LPN), or An advanced nurse practitioner (ANP) Provider Enrollment Fee In compliance with 42 CFR , group providers (but not individual members of groups) and facilities are required to submit an enrollment fee at the time of enrollment, revalidation and upon adding a new service location. If you have already paid the fee to Medicare or another state s Medicaid or CHIP program you do not need to pay the enrollment fee to Alaska Medicaid. You will need to provide evidence of having paid the enrollment fee to Medicare or another state Medicaid or CHIP program. 4

5 Employee Enrollment Requirements The employee of a private duty nursing agency who furnishes services directly to a member must: Be separately enrolled as: A rendering provider if the employee is an LPN or RN or An ANP Have an active license to practice as an RN, an LPN, or an ANP issued by the jurisdiction in which the nurse provides services In addition to enrolling with Alaska Medicaid, out-of-state providers must be licensed in the jurisdiction in which they are providing services, and be enrolled as a provider in their own state s Medicaid program 5

6 Update Provider Information Request Form 6

7 Member Eligibility 7

8 Member Eligibility Always verify member eligibility by using one of the following options: Request to see the member's eligibility coupon or card that shows the current month of eligibility; photocopy for your records Call Automated Voice Response System (AVR): (toll-free) Verify via Alaska Medicaid Health Enterprise website Fax complete Recipient Eligibility Inquiry Form - General Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction Call Provider Inquiry , option 1 or , option 1, 1 (toll-free) 8

9 Member Eligibility Private Duty Nursing Services Eligibility Code 11 Medicaid for pregnant women Category 20 Family Medicaid or APA related Medicaid 50 Medicaid for children under age 21 who are not in state custody 51 Medicaid for children under age 21 who are in state custody, including Title IV-E foster care 52 4 months of Medicaid for recipients otherwise ineligible due to earned income 54 Medicaid only for disabled child received SSI 69 APA/QMB full Medicaid plus QMB 80/81 Medically Complex Children - waiver 9

10 Member Eligibility Specialized Private Duty Nursing Waiver Services Eligibility Code Category 30/31 Waiver for adults with physical & developmental disabilities 34 Adults with physical & developmental disabilities waiver APA/QMB 40/41 Older or disabled adult with waiver and Medicaid 44 Older or disabled adult with waiver and Medicaid APA/QMB 70/71 Intellectual & developmental disability (IDD) - waiver 74 Intellectual & developmental disability (IDD) waiver APA and receives Medicare 10

11 Private Duty Nursing Services 11

12 Covered Services The goal of regular private duty nursing services is to maintain a child under the age of 21 in a family setting and to prevent admission to an acute care or long-term care (LTC) facility. Private duty nursing services may be covered if: The member: Is under 21 years of age Has recently been discharged from a general acute care hospital or LTC facility or has a physical health status that would justify admission to a hospital or LTC facility With services, will be able to live in a family setting Services will prevent admission to, or will promote early discharge from, a general acute care hospital or LTC facility and Requires more individual and continuous care than is available from a visiting nurse or routinely provided by nursing staff of a hospital, SNF or ICF 12

13 Covered Services Private duty nursing may only be reimbursed if the services are: provided by a registered nurse or a licensed practical nurse under the direction of the member s physician or provided by an advanced nurse practitioner for a life-threatening condition and the provider can safely provide the services outside of an institution provided under an approved plan of care required less than 24 hours a day A competent individual residing with the member must agree to participate in care for the member in accordance with the established plan of care Private duty nursing services include: Assessment Administration of treatment related to technological dependence Monitoring and maintaining parameters, machinery, and interventions 13

14 Non-Covered Services Private duty nursing services may not be provided by: A personal care assistant A home health aide A member of the immediate family Other members of the member s household Private duty nursing services do not include housekeeping, laundry, shopping, meal preparation, or transportation 14

15 Non-Covered Services (cont.) Alaska Medicaid will not pay for private duty nursing services: If intended to enable the member to attend school or other activities outside the home, but not necessary to live successfully in the home, hospital or nursing facility During the hours the member attends a childcare facility For a member that is homeschooled In excess of the private duty nursing services already authorized by the department That are considered nurse supervision That are provided to other individuals living in the member s household For which the department has not given prior authorization 15

16 Service Authorization Private duty nursing services must be authorized before they are provided. Services are authorized for up to 60 days at a time Service authorizations are requested by the private duty nursing agency provider, and must include the following information: Plan of care Nursing assessment Any supporting documentation, where applicable Identify the day of actual or planned hospital or nursing facility discharge, where applicable Any planned surgical interventions Number of days services are needed Identify the exact number of hours requested per day 16

17 Plan of Care All private duty nursing authorization requests must include a plan of care. Generally, a plan of care is submitted on a CMS 485 form and includes: Pertinent diagnoses, including mental status, and prognosis Types of services and equipment required Orders for therapy services must include the specific procedures and modalities to be used and their amount, frequency, and duration Frequency of visits Analysis of the member s rehabilitation potential Description of the member s functional limitations Member s permitted activities, nutritional requirements, medications, and treatments Any safety measures to protect the member against injury Instructions for a timely discharge and referral 17

18 Service Authorization Submission Private duty nursing service authorizations can be requested through Xerox using the following options: By fax to or By mail to: Service Authorization PO Box Anchorage, AK All services must be requested on the Service Authorization Request Form available at Always follow the instructions for completion and submission given on the form 18

19 Additional Hours Requests To request additional hours within a 60-day period, the private duty nursing agency must submit a new request including: Daily nursing notes Updated plan of care signed by the member s attending physician Attending physician s order for services dated no more than seven days from the date of the request Recent significant clinical findings from the member s attending physician Recent clinical summaries 19

20 Additional Hours Requests The department will approve a request for additional hours if: The individual who has agreed to participate in caring for the member needs additional training, has become ill, is temporarily unable to assist in providing care, is unable to provide care because of a family emergency involving the caregiver An acute episode has occurred that would otherwise require hospitalization and the attending physician has determined that the member can still be safely be cared for outside an institution Additional hours are medically necessary Provider Note: The department may increase or decrease the number of hours authorized for the member at any time based on evidence from the attending physician that the member s condition, need or situation has changed. 20

21 Specialized Private Duty Nursing Services 21

22 Specialized Private Duty Nursing Specialized private duty nursing allows an eligible individual to avoid being institutionalized and remain in the home setting by providing individual and continuous care specific to the member s needs. Authorized for members who are 21 years of age and older and in one of the following member categories Alaskans Living Independently Adults with Physical and Developmental Disabilities Intellectual and Developmental Disabilities Provided by a licensed or registered nurse or advanced nurse practitioner Prescribed, in writing, and included in the member s plan of care Should describe the scope including type, frequency, and duration of care Reimbursed under the Home and Community-Based Waiver Services program 22

23 Specialized Private Duty Nursing Specialized private duty nursing services are authorized through the care coordination process Services must be included in the member s plan of care and are authorized by the Division of Senior and Disabilities Services Specialized private duty nursing services will not be paid by Alaska Medicaid if: The service does not fall under the definition of private duty nursing It is not provided by an employee of a home and community-based waiver service provider who is enrolled individually and separately 23

24 Billing 24

25 Recordkeeping Recordkeeping requirements are documented in the Individual Provider Agreement and Tax Certification and Group Provider Agreement and Tax Certification Providers must comply with general and provider-specific recordkeeping requirements Providers must maintain complete and accurate clinical, financial, and other relevant records to support the care and services for which they bill Alaska Medical Assistance for a minimum of 7 years from the date of service Providers are subject to audits, reviews and investigations Providers must ensure their staff, billing agents, and any other entities responsible for any aspect of records maintenance meet the same requirements. 25

26 Timely Filing All claims must be filed within 12 months of the date services are provided to a member. 12-month timely filing limit applies to all claims, including those that must first be filed for TPL or Medicare crossover Claims denied for timely filing cannot be corrected and resubmitted; you may only appeal the decision A claim denied for timely filing may be appealed within 180 days from the initial denial date Member Retroactive Eligibility There are times when a member is granted retroactive or backdated eligibility. If this occurs, the member should forward all appropriate documentation to their provider. Providers have the ability to file claims for the retroactive timeframe if this documentation is attached to the claim. Even with this documentation, there is still a time limit to file, so don t delay. 26

27 Claims Submission Methods There are several billing options for Alaska Medicaid vision providers. Alaska Medicaid Health Enterprise 837P Transaction (electronic claim using billing software) Companion Guide: Implementation Guide (referred to as TR3): Payerpath (electronic claim) CMS-1500, Professional Health Insurance Claim Form (paper claim) 27

28 Overpayments & Repayment of Payment Errors Providers should closely review each remittance advice (RA) to ensure it reflects accurate payment for all billed services, including correct member details and services provided. In accordance with 7 AAC (e), Alaska Medical Assistance providers have 30 days from the time of payment to notify the department in writing of a payment error. Federal law (42 U.S.C. 1320(d)) requires repayment of overpayments to the department within 60 days of identifying the overpayment. Mail the written overpayment notification and a copy of the RA page detailing the overpayment to the address below: Conduent State Healthcare, LLC P.O. Box Anchorage, Alaska

29 Compliance and Ethics CBT Alaska Medicaid Compliance and Ethics101 includes an interactive video presentation and a supplemental handbook Familiarizes providers with the responsibilities and requirements associated with being a Medicaid provider Guides providers through the laws and regulations Medicaid providers must follow The training is available at Click on Enroll or Attend Training and log in* Under Training Catalog, select Provider Compliance and Ethics Training Click Enroll, then View Upon completion of the training, the attendee will see a certificate that can be personalized and printed for your records Please direct any questions to the Provider Training department at or *Requires account setup this is a different login than Health Enterprise 29

30 Additional Resources Alaska Medicaid Health Enterprise website at Information necessary for successful billing Includes provider-specific Medicaid billing manuals and fee schedules You may also call: Provider Inquiry Eligibility only , option 1,2 or (toll-free), option 1,1,2 Claim status and other inquiries , option 1,1 or (toll-free), option 1,1,1 EDI Coordinator Electronic transaction assistance , option 3 or (toll-free), option 1, 4 30

31 Disclaimer The information contained in this presentation was current at the time it was written. It was prepared as a tool to assist providers and is not intended to be all inclusive, grant rights, impose obligations, or function as a stand-alone document. Although every reasonable effort has been made to assure the accuracy of the information within the presentation, the ultimate responsibility for understanding Medicaid program regulations lies with the provider of services. The State of Alaska Department of Health and Social Services and Xerox, Incorporated employees and staff make no representation, warranty or guarantee that this compilation of information is error-free and/or comprehensive and will bear no responsibility or liability for the results or consequences of the use of this guide. 31

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