KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Targeted Case Management- Frail Elderly
Part II TARGETED CASE MANAGEMENT-FRAIL ELDERLY PROVIDER MANUAL Introduction Section 7000 7010 8100 8300 8400 Forms BILLING INSTRUCTIONS Introduction to the CMS-1500 Claim Form... Submission of Claim. Targeted Case Management-Frail Elderly Specific Billing Information.. BENEFITS AND LIMITATIONS Co-Payment Benefit Plans.. Medicaid. CMS-1500 7-1 7-1 7-2 8-1 8-2 8-3
INTRODUCTION TO TARGETED CASE MANAGEMENT-FRAIL ELDERLY Issued 07/07 Targeted case management (TCM) frail elderly (FE) is provided to beneficiaries qualifying for home and community based services (HCBS) for the FE waiver program, ensuring assistance in access and coordination of information and services to older beneficiaries and/or their caregivers to support the beneficiaries in the living environment of their choice. Individuals qualifying for this service must be Medicaid eligible and 65 years of age or older. This manual is designed to provide information specific to providers of TCM-FE services and is divided into three sections: Billing Instructions, Benefits and Limitations, and Forms. The Billing Instructions section provides instructions on submitting a claim. The Benefits and Limitations section outlines services included in TCM-FE for HCBS-FE waiver beneficiaries and limitations on these services. It also includes qualifications for TCM-FE providers, documentation required for reimbursement, and expected service outcomes. The Forms section includes a sample of the CMS-1500, which must be completed for reimbursement of services. HIPAA Compliance As a Kansas Medical Assistance Program (KMAP) participant, providers are required to comply with compliance reviews and complaint investigations conducted by 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 by the Department during its review and investigation. Access to Records Kansas Regulation K.A.R. 30-5-59 requires providers to maintain and furnish records to KMAP upon request. Providers must also supply records to the Department of Health and Human Services upon request. The provider is required to supply records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's office upon request from such office as required by the Kansas Medicaid Fraud Control Act, K.S.A. 21-3844 to 21-3855, inclusive, as amended. 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 the provider s employees. The provider shall not charge a fee to retrieve and copy documents and records related to compliance reviews and complaint investigations.
TARGETED CASE MANAGEMENT-FRAIL ELDERLY BILLING INSTRUCTIONS 7000. Issued 7/07 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 in the Forms section at the end of this manual. The interchange Medicaid Management Information System (MMIS) uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information must be submitted in the correct claim fields to be recognized by the equipment. 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, KS 66601-3571 BILLING INSTRUCTIONS 7-1
TARGETED CASE MANAGEMENT-FRAIL ELDERLY SPECIFIC BILLING INFORMATION 7010. Issued 7/07 Enter procedure code T1017 (Targeted Case Management, per 15 minutes) in field 24D of the CMS- 1500 claim form. One unit = 15 minutes TCM must be billed by units, or partial units, of service as outlined below: 0.5 unit = 0.1 through 7.50 minutes of targeted case management service 1.0 unit = 7.51 through 15.00 minutes of targeted case management service Time spent providing TCM services beyond one unit must be recorded and billed in the same way. BILLING INSTRUCTIONS 7-2
BENEFITS AND LIMITATIONS 8100. CO-PAYMENT Issued 7/07 TCM-FE services are exempt from co-payment requirements. BENEFITS AND LIMITATIONS 8-1
BENEFITS AND LIMITATIONS 8300. BENEFIT PLANS Issued 7/07 KMAP beneficiaries are assigned to one or more KMAP benefit plans. The assigned plan or plans are listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, contact the KMAP Customer Service Center at 1-800-933-6593 or 785-274-5990. BENEFITS AND LIMITATIONS 8-2
BENEFITS AND LIMITATIONS 8400. MEDICAID Issued 7/07 Targeted Case Management Targeted case management services are defined as those services which will assist the beneficiary in gaining access to medical, social, educational, and other needed services. TCM-FE consists of two billable components, the first, referral and related activities; the second, monitoring and follow-up activities. Senior case managers may complete all activities under both components. Junior I and junior II case managers may only provide services specifically indicated. TCM-FE includes any or all of the following services: I. Referral and Related Activities: A. To help the beneficiary obtain needed services including, 1. Activities that help link the beneficiary with medical, social, and educational providers, or 2. Other programs and services that are capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the beneficiary, including but not limited to: a. Reporting to Adult Protective Services and/or law enforcement any suspected abuse, neglect, or exploitation of the beneficiary b. Assisting the beneficiary with acquiring needed supplies in an emergency when informal or formal supports are not available B. Finalizing prior authorization of the beneficiary s plan of care (POC) prior to its implementation. Prior authorization includes entering the POC into the prior authorization system and notifying the beneficiary of services and the levels to be provided (Note: Function may be performed by junior I and junior II case managers.) C. Expanding the service options available by encouraging the informal supports and formal service providers to be more flexible, and also seeking new or nontraditional resources and services D. Promoting the enrollment of new providers on behalf of beneficiaries E. Documenting all pertinent information related to this component II. Monitoring and Follow-up Activities: A. Activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the beneficiary s needs, and which may be with the beneficiary, family members, providers, or other entities (Note: Function may be performed by junior I case managers.) and conducted as frequently as necessary to determine whether: 1. Services are being furnished in accordance with the beneficiary s care plan 2. The services in the care plan are adequate 3. There are changes in the needs or status of the beneficiary, and if so, making necessary adjustments in the care plan and service arrangements with the providers B. Ensuring public and private resources are used efficiently to meet the health and welfare needs of the beneficiary as set forth in the POC C. Documenting all pertinent information related to this component BENEFITS AND LIMITATIONS 8-3
8400. Issued 7/07 Limitations TCM (T1017) shall not be provided in conjunction with any other case management service. The maximum allowable units per beneficiary are 800 units per calendar year. TCM does not include the direct delivery of an underlying medical, educational, social, or other service to which a beneficiary has been referred. Enrollment All TCM-FE providers must enroll in the Kansas Medical Assistance Program and receive a provider number for TCM-FE services. Contact EDS Provider Enrollment by phone at 785-274-5914 for more information. Note: EDS supplies manuals for each service in which the provider is enrolled. Individuals providing TCM for HCBS-FE beneficiaries must meet TCM-FE provider qualifications and be either a contractor or employee of the Area Agency on Aging for the service area in which they serve. Enrollment criteria has been established to ensure: The case manager is knowledgeable about the array of services available to seniors in the service area There is a single point of entry for access to these services There is no conflict of interest between the case manager and direct service provider(s) Provider Qualifications Senior Case Manager An individual with a four-year degree from an accredited college or university with a major in gerontology, nursing, health, social work, counseling, human development, family studies, or a related area defined by the Area Agency on Aging and at least one year experience in the human service field; or A registered professional nurse licensed to practice in the State of Kansas with at least one year experience in the human service field; or An individual with at least one year experience on or before January 1, 1997, as an SRS Long Term Care case manager that is in good standing Junior I Case Manager An individual with a high school or general education diploma and four years work experience in the human services field; or An individual with a combination of work experience in the human services field and post-secondary education, with one year of work experience substituting for one year of education as defined by the Area Agency on Aging Note: A senior case manager must supervise a junior I case manager Junior II Case Manager An individual with a high school or general education diploma and one year work experience as defined by the Area Agency on Aging Note: A senior case manager must supervise a junior II case manager. BENEFITS AND LIMITATIONS 8-4
8400. Issued 7/07 Documentation Requirements Written documentation is required for services provided and billed to KMAP. Documentation at a minimum must include the following: An Activity Log that includes: Beneficiary s first and last name Date of service (MM/DD/YY) Name of the provider agency Case manager s name and signature (individual entries may be initialed, but the signature must be on each page of the case log) Senior case manager s signature on case log entries made by junior I and junior II case managers, indicating the review of these entries Amount of time spent in units or partial units, on each contact or activity The component of TCM-FE being provided Location of service provided Client obligation as changes occur Detailed description of the contact or activity The case management service must be a component of TCM-FE services. Services provided must be documented within the timeframe that is billed. Documentation generated after-the-fact is not acceptable. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. Expected Service Outcomes Beneficiaries receive services in a timely manner Beneficiaries make informed choices regarding their services Beneficiaries receive services they expect as outlined on their POC Beneficiaries report satisfaction with the case management services they receive Case management services are provided in an efficient manner Case managers provide quality services to their beneficiaries Case managers receive appropriate notification of financial KMAP eligibility from SRS and/or receive appropriate Kansas Department On Aging (KDOA) authorization of the POC prior to sending the Notice of Action Note: When the TCM provider authorizes services without appropriate notification from SRS and/or the appropriate authorization from KDOA, the TCM provider is responsible for payment to the provider(s) for services rendered prior to the approval date. BENEFITS AND LIMITATIONS 8-5
FORMS CMS-1500