FY2018 PROVIDER MANUAL SECTION 1: SERVICE REQUIREMENTS In addition to the regulations and requirements outlined in the Michigan Medicaid Provider Manual, Behavioral Health and Intellectual and Developmental Disability Supports and Services chapter, and the Lakeshore Regional Entity Service Descriptions, the services listed below each have additional procedural information and/or requirements that Provider must comply with if contracted to provide that service. The requirements are separated out by population served and further separated out by program. If there is not anything listed for a specific program or population, there are no additional requirements separate from the Service Description for that program or population. ACT Applied Behavior Analysis Clubhouse Community Living Supports Crisis Residential Services Family Support and Training Fiscal Intermediary Services Home-Based Services Individual/Group Therapy Nursing Facility Mental Health Monitoring OBRA PAS/ARR Peer-Delivered or Peer-Operated Support Services Prevention Direct Service Models Respite Services SED Waiver Skill Building Assistance SUD Community-Based Treatment SUD Medication Assisted Treatment SUD Outpatient Treatment SUD Residential Treatment and Recovery Residences SUD Residential Withdrawal Management Support and Service Coordination Supported/Integrated Employment Services Targeted Case Management Wraparound Services Page 1 of 11
FY2018 PROVIDER MANUAL SECTION 2: FINANCIAL REQUIREMENTS In addition to the program specific financial requirements below, Provider must comply with all applicable Network180 Contracts policies. Network180 reserves the right to cap a program s budget. Network180 also reserves the right to limit referrals, authorizations, and open access should the provider not meet contract expectations. Limitations will remain in effect until Network180 and Provider agree that program expectations are being met. Refer to Section 3: Data Requirements, Allowable Services Report, for reportable service codes, unit definitions, rates, and effective dates. Monthly Rates Refer to the Allowable Services Report for programs or services paid based on a monthly rate. Provider will notify Network180 of any vacant staffing position in the program within 30 days of the position becoming open and give an update every 30 days thereafter until the position is filled. Network180 reserves the right to prorate the monthly rate for the vacant position. For programs/services paid on a monthly rate basis that require encounter (activity) reporting, prior month encounter data must be submitted before the current month claim can be paid. Residential Census Provider must complete a daily census for residential services. Leave of absence and reserve days are not eligible for payment. In addition to the census, all other service documentation requirements must also be met. If billing for child sitting services (T1009) for Women s Specialty residential services, the daily census must include the children. Attachments 1/12 th and Non-Consumer Specific Claim Payment Instructions 1/12 th Payment Encounter Info (separated by Agency and SUD or Non-SUD) Rates for 1/12 th Payments Adult Mental Illness Services Rates for 1/12 th Payments Adult Substance Use Disorder Services Rates for 1/12 th Payments Child and Family Services Rates for 1/12 th Payments Adult Intellectual/Developmental Disability Services Financial Requirements Specific to Adult Mental Illness Services Peer-Run Drop-In Center Provider will be reimbursed monthly for the actual cost to provide these services. The annual program budget for these services will be determined by the Network180. Provider s monthly financial report must reflect accrued revenue and expenditures for the month reported and shall be submitted to: ATTN: Network180 Accounts Payable 3310 Eagle Park Dr NE, Suite 100 Grand Rapids, MI 49525 Payment will be made within 30 days of receiving Provider s prior month financial report. Page 2 of 11
Financial Requirements Specific to Adult Substance Use Disorder Services Recovery Residence Provider will maintain a daily census documenting who is currently enrolled in the program. Claims submitted must be consistent with the census. Women s Specialty Services Claims or encounter data submitted for women who qualify for BSAAS Women Specialty Services under Substance Abuse Treatment Policy #12 must include the HD service code modifier. Policy #12 defines eligible women as pregnant women and women with dependent children, including women who are attempting to regain custody of their children (children who are in foster care included). Claims for child sitting services are submitted using the case number and authorization number of the mother. If services are provided to more than one dependent child of an authorized individual, the total number of days of service should be combined for all children and submitted on the same claim. Claims for child sitting services can only be submitted for days when the mother is also receiving service. Discretionary Funds Refer to the Allowable Services Report for programs with established discretionary funds and/or bus ticket funds. Network180 will reimburse Provider actual cost for discretionary fund and/or bus ticket expenditures, limited to a capped budget. Claims must be submitted monthly for prior month actual expenditures. Prior month corrections can be made with the current month claim except at fiscal year-end expenditures must be reported during the Network180 fiscal year expended. Final claim must be submitted within 30 days of Network180 fiscal year end. Intensive Stabilization Service code H0018 (TF) may only be billed for the first day of care reported when a client is admitted to the program after normal business hours or on the weekend. Service code H0018 with no service code modifier must be billed for all subsequent days of care. Detoxification Services Service code H0010 (TF) may only be billed for the first day of care reported when a client is admitted to the program after normal business hours or on the weekend. Service code H0010 with no service code modifier must be billed for all subsequent days of care. Financial Requirements Specific to Child and Family Services Discretionary Funds Wraparound Service Providers can be reimbursed for actual cost for Discretionary Funds in adherence with the Flex Fund requirements established within this program. The Discretionary Funds reimbursement is limited to a separate, capped budget. Supporting documentation for claims submitted, including paid receipts and flex fund approval form must be faxed to Network180. Prior month corrections can be made with the current month claim except at fiscal year-end, September 29 th expenditures must be reported during the Network180 fiscal year expended. Final claim must be submitted prior to October 5 th. Page 3 of 11
Family Member(s) Billable Contacts Providers delivering the following services can bill direct, face-to-face contact time with the child or family. Encounter data can be submitted even if the authorized child is not present during activity when family member(s) are present. Services include: H0036 Community Psychiatric Supportive Treatment (Home-Based Services) H2021 Wraparound Services H2022 Community Wraparound H2033 Multi-Systemic Therapy S5111 Home Care Training-Family Training S9482 Behavioral Health Prevention Education (Infant Mental Health) Child Community Placement The rate is based on the actual cost paid to the community placement vendor delivering the service plus an administrative overhead of 10%, up to but not to exceed $150.00 per month, per individual. Respite Services The rate for out-of-home respite services H0045, T2036 and T2037 will be based on the actual cost paid to vendor delivering the service plus an administrative overhead of 10%, up to but not to exceed $75.00 per month, per individual. SED Waiver Provider must adhere to all applicable program and billing regulations and requirements set forth in the Michigan Department of Health and Human Services SED Waiver Technical Assistance Manual. Network180 will make payment in advance of collection of the fee screen from the State and reserves the right to recover payment from Provider should the State refuse to reimburse Network180 for services. Financial Requirements Specific to Adult Intellectual/Developmental Disability Services Residential Rates The rates include medical supplies such as nutritional supplements, ostomy supplies, over the counter medications, prescription co-pays, and adaptive/sensory equipment (including but not limited to mats, bolsters, positioning devices, wheelchairs when not covered by Medicaid). Residential Treatment-Short Term Cost Settlement Payment for services will be on a cost settlement basis, combining payment through submission of client specific fee-for service claims and a twice annual cost settlement amount. See attached Residential Treatment-Short Term Cost Settlement Process. Supported Employment (SE) Incentives Service code H2023 for supported employment incentives has two service code modifiers and four levels of incentive payments. Under no circumstance can the provider bill more than four incentives during a one-year authorization period. Following are the requirements for submitting claims for each level: Level 1 H2023: The SE provider can submit a claim after the first face-to-face contact is made with the individual within the authorization period. This payment is intended for new referrals to the SE provider. Providers cannot submit a claim for repeated authorizations from year to year. Level 2: A claim can only be submitted if the SE provider assisted the individual in obtaining the job and the job was maintained by the individual for 60 days. Submit one claim using the appropriate service code/modifier below: Page 4 of 11
o H2023 TF: Competitive employment for 5-19 hours per week. OR o H2023 TG: Competitive employment for 20 hours or more per week. Note: If the individual s hours were adjusted during the first 60 days of employment, the provider shall submit the appropriate service code/modifier based on the average number of hours worked per week. Level 3 H2023 TG: A claim can only be submitted if the SE provider assisted the individual in obtaining or maintaining a job for 120 days for competitive employment of 5-40 hours per week. Note: The 120 days is counted from the first day of employment or if the individual was already employed and referred to the SE provider for assistance with retaining employment the 120 days is counted from the first face-to-face contact with the individual by the SE provider. Level 4 H2023 TG: The SE provider can submit a claim when the individual is successfully discharged from supported employment (i.e., job coach no longer required because job placement has been successful and it has been determined the individual can maintain employment without job coaching support). Page 5 of 11
FY2018 PROVIDER MANUAL SECTION 3: DATA REQUIREMENTS Network180 collects QI data, including demographics, functional assessment/outcome measures, discharge data, claims records, and service activity data. The following grid indicates, in general, which data is submitted by each population. This chart indicates all data types except for claims and encounters. DATA TYPES I/DD MISUD CF Demographics DD Functional Assessment CAFAS Discharge PECFAS OBRA PAS/ARR Claims and Demographics Treatment Admission Treatment Discharge Providers will update QI data at least annually if the consumer is receiving a service for more than a year with the provider. All other providers will update QI data if there is a change or if the Network180 EHR has not been updated in over a year. Discharge dates will be updated by all providers, as appropriate. I/DD functional assessments (proxy measures) will be updated at the time of admission and annually by I/DD Supports Coordinators. QI data can be updated using the Network180 EHR or by faxing the QI form to Network180 during the authorization/reauthorization process. Network180 reserves the right to request a fax submission of the QI form during the authorization/reauthorization process, even if an electronic submission is made. Please verify with your Network180 contact for authorization/reauthorization for further clarification on your specific program. PECFAS is a required assessment tool for young children in Individual/Group Therapy, Home-Based Services, and Targeted Case Management, including Specialized Family Case Management. This tool will only be used when children are between the ages of 4 and 6 and are not involved in preschool or a formal daycare setting. If the child is involved in preschool or a formal daycare setting, the CAFAS tool will be used instead. CAFAS is also a required tool for children between the age of 7-17 in Outpatient Therapy, Home-Based Services, and Targeted Case Management, including Specialized Family Case Management. Trading Partner Agreements only clarify the 837 Implementation guide and do not in any way supersede the Federal 45 CFR defined 837 Implementation Guide. Providers must submit all electronic files using the Network180 Data Upload process. All providers submitting claims/encounters electronically in HIPAA compliant format must pass a Network180 testing process and agree to the Trading Partner Agreement terms. All non-billing transfers must be received by the 10 th of the month following the month in which services Page 6 of 11
are provided. Please see the Agency Data Rules policy referenced in the Network180 contract boilerplate to ensure compliance with data submission stipulations. Monthly service activity data may also be required in addition to claims. Individuals receiving only OBRA PAS/ARR services are not entered into the Network180 authorization system, but have a minimum set of demographic data entered via the OBRA PAS/ARR data and claim form. Attachments Network180 837 Companion Guide Standardized File Naming Convention for Claims and Service Activity Using Modifiers with Service Codes Page 7 of 11
FY2018 PROVIDER MANUAL SECTION 4: FORMS Network180 forms that are required for use by providers are listed below, arranged alphabetically by population. Child and Family Services ABA Parent Handbook ABA Supplemental Testing Information for State of Michigan Autism Benefit Closure Form Autism Benefit Reauthorization Request Form Child Health and Developmental Screening-Ages 0-9 Child Health and Developmental Screening-Ages 0-9 (Spanish) Child Health and Developmental Screening-Ages 10-17 Child Health and Developmental Screening-Ages 10-17 (Spanish) CLS Needs Assessment CLS Tracking Sheet DBT Authorization Request Fax Cover Sheet DD Proxy Measures Worksheet DD Supports Coordination Change in Authorization Form Early Childhood Continued Authorization Request Form Enhanced Mental Health Services Request Form Family Empowerment Program Guidelines Family Status Report Ages 0-6 Family Status Report Ages 7-18 FASD Pre-Screen Foster Care Addendum Foster Care-Therapist Coordination Form Infant Mental Health Home-Based Fax Cover Sheet In-Home Services-Additional Units Request Form In-Home Services-Continued Authorization and Change Request Form In-Home Services-Sibling Services Request Form Inpatient Hospital Denial Tracking Form KSSN Ancillary Services Fax Authorization Form KSSN Authorization Fax Cover Sheet KSSN Behavioral Health Care Plan KSSN Behavioral Health Care Plan (Spanish) KSSN Screen Fax Cover Sheet Notice of Termination Fax Cover Sheet Notification/Coordination with Primary Care Physician Form Notification/Coordination with Primary Care Physician Form (Spanish) Notification/Coordination with School Outpatient Reauthorization Request Form Parent Guide to Re-accessing Network180 Services Parent Guide to Re-accessing Network180 Services (Spanish) Parent Support Partner Progress Summary Parent Support Partner Reauthorization Request Form Page 8 of 11
Provider Screen for Crisis Service Authorization Residential Placement Committee Process Residential Placement Initial Assessment Residential Placement IPOS Requirements Residential Placement Parent Fact Sheet Residential Placement Referral Form Residential Placement Review Outline Residential Placement Role Clarifications Respite Request Fax Form-Out of Home Respite Sibling Services Brief Screening Form SUD Change in Level of Care Request Form SUD Reauthorization Request Form TFCBT Authorization Fax Cover Sheet Wraparound Addendum Wraparound Plan of Service Wraparound Quarterly Review Youth Engagement Program Authorization Fax Cover Sheet Youth Enhancement Program Authorization Fax Cover Sheet Youth Enhancement Program Reauthorization Request Form **Please note: All CFP and Wraparound Best Practices-Kent County forms can be accessed online at: http://www.cfpsystemofcare.org/services/tools-and-resources Adult Intellectual/Developmental Disability Services Adult Respite Services Allocation Form Adult Respite Services Allocation Levels and Standard Unit Allocation Adult Respite Services Worksheet Authorization Cover Sheet/Change Request Form Case Consultation Form Crisis Stabilization Requests Enhanced Mental Health Services Request Form Housing Assistance Reference Sheet Housing Assistance Request Form Housing Assistance Request Procedure Housing Assistance Request Requirements Individual CLS Daily Log Individual CLS Daily Log-Multiple Individual Supports Respite Log and Cover Sheet Inpatient Hospital Denial Tracking Form Interagency Clinical Team (ICT) Presentation Form Interagency Supports Coordination Referral Packet Cover Sheet Life Skills CLS 15-Minute Daily Log Notification/Coordination with Primary Care Physician Outpatient Group Authorization Request Form Peer Mentor Certification Process Peer Mentoring Brochure Purpose of Interagency Clinical Team (ICT) Staff Note Instructions for Individual CLS Staff Note Instructions for Life Skills CLS Transportation Eligibility Form Page 9 of 11
Adult Mental Illness and Substance Use Disorder Services CLS Authorization Request Form CLS Guidelines for Completing Authorization Requests CLS Process Flow Chart Concurrent Services Authorization Grid Crisis Residential Services Reconsideration Request Form Enhanced Mental Health Services Request Form FASD Pre-Screen Financial Status Report Form Housing Assistance Reference Sheet Housing Assistance Request Form Housing Assistance Request Procedure Housing Assistance Request Requirements Inpatient Hospital Denial Tracking Form Inpatient Rapid Readmission Form Provider Initial Reconsideration Request Form Reauthorization Form Short-Term Therapy Case Note Short-Term Therapy Open and Closing Forms Specialized Residential Discharge Verification Form Specialized Residential SharePoint Site Training Form Specialized Residential Transfer Verification Form StreetReach Reauthorization Form SUD Change in Level of Care Request Form SUD Evaluation Referral Form Targeted Case Management Interagency Transfer Request Form Targeted Case Management Reauthorization Request Form Transportation Eligibility Form Self-Determination (SD) Forms General SD Forms 42 CFR Attachment A, B and C Attachment A-CLS, SBA, Respite and SE Attachment A-RN and OT Definition of Self-Determination Eligibility-ISB Review Process Guide to Employment Agreement and AWC Contract Guide to Self-Determination LRE Guide to Self-Determination LRE (Spanish) Guide to Self-Determination Network180 Supplement Guidelines for Insufficient Documentation I/DD and MI ISB Rates for FI Cases Individual Service Budget Form Instructions for Rate Sheet for Individual Budgets and ISB Form IPOS Training Documentation Form Self-Determination Background Check for Rights Self-Determination Brochure Self-Determination Brochure (Spanish) Page 10 of 11
Self-Determination Provider Agreement Self-Direction Arrangement Agreement-DE or AWC Self-Direction Life Quality Survey Direct Employment (DE) CLS Log Multiple-DE CLS Log-DE Employer Orientation Checklist Employment Agreement FI Readiness Report-DE for BHT&D GUSCO FI Readiness Report-OT FI Readiness Report-RN Guidelines for Allowable Expenses in DE SD Arrangements Hiring Workers for a DE SD Arrangement Kent Blank Expense Reimbursement Form Kent Blank Mileage Reimbursement Form Mileage Expense Report-Multiple Payroll Practices Policy PDN Cover Sheet RCS and CLS Cover Sheet RCS Log-DE RCS Log Multiple-DE SBA Log-DE SE Log-DE Self-Audit-DE Staff Note Instructions for Individual CLS Training Process for Direct Employment Agency with Choice (AWC) Agency with Choice Contract Choosing an Agency for an AWC Arrangement CLS Daily Log-AWC CLS Daily Log Multiple-AWC FI Readiness Report-AWC GUSCO RCS and CLS Cover Sheet RCS Log-AWC RCS Log Multiple-AWC SBA Log-AWC SBA Log Multiple-AWC SE Log-AWC Service Provider Requirements for Self-Directed Agency with Choice Staff Note Instructions for Individual CLS Page 11 of 11