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......... 7-1 Submission of Claim................ 7-1 7010 MR/DD Home Modifications Specific Billing Information....................... 7-2 BENEFITS AND LIMITATIONS 8400 Medicaid........................ 8-1 HCFA-1500 CMS-1500 Form
INTRODUCTION TO THE HCBS MR/DD PROGRAM Updated 04/07 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 Communication Devices Day Services Family/Individual Supports Home Modifications Medical Alert-Rental Night Support Residential Services Respite Care-Overnight Respite Care-Temporary Respite Care-Emergency Screening 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. Effective with dates of service on and after April 1, 2007, oral health services are available to adults age 21 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. Enrollment: HCBS MR/DD All HCBS MR/DD providers must enroll in the Kansas Medical Assistance Program and receive a provider number for HCBS MR/DD services. Contact EDS for enrollment. Note: EDS supplies manuals for each HCBS MR/DD program in which the provider is enrolled. HIPAA Compliance As a participant in the Kansas Medical Assistance Program (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 by the Department during its review and investigation. The provider is required to provide the same forms of 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. 21-3853 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.
7000. MR/DD HOME MODIFICATIONS BILLING INSTRUCTIONS Introduction to the HCFA-1500 CMS-1500 Claim Form Updated 05/07 Providers must use the HCFA-1500 CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under the Kansas Medical Assistance Program (KMAP). An example of the HCFA-1500 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 HCFA-1500 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 HCFA 1500 CMS-1500 are available in the General Billing Provider Manual., pages 5-14 through 5-19. 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 66601-3571 BILLING INSTRUCTIONS 7-1
7010. MR/DD HOME MODIFICATIONS SPECIFIC BILLING INFORMATION Updated 05/07 Enter procedure code S5165 in field 24D of the HCFA-1500 CMS-1500 claim form. One unit = 1 service. Client Obligation: If a case manager has assigned client obligation to a particular provider and informed that provider that they are to collect this portion of the cost of service from the client, the provider will 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 28-31 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 16-31. If you were to bill service dates of July 8-16, the claim would deny because 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 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: HCBS services provided the date of admission, if provided prior to consumer being admitted HCBS services provided the date of discharge, if provided following the consumer s discharge HCBS Targeted Case Management provided within 30 days prior to discharge. BILLING INSTRUCTIONS 7-2
8400. BENEFITS AND LIMITATIONS Updated 11/03 Home and community based waiver services for persons with mental retardation or other developmental disabilities (MR/DD) are designed to prevent individuals from entering, or remaining, in an intermediate care facility for the mentally retarded (ICF/MR). Home Modifications (including repair and maintenance): Home modifications are those services which assess the need for, arrange for and provide modifications or improvements to a recipient's living quarters to permit an individual to remain with his/her natural, adoptive, or foster family or in an inclusive setting and ensure safety, security, and accessibility. Housing modification services consist of the following: Ramps Lifts - porch or stair lifts - hydraulic, manual, or other electronic lifts* o *these are portable lifts or lift systems which could be removed and taken to a new location Modifications/additions of bathroom facilities - roll-in showers - sink modifications - bathtub modifications - toilet modifications - water faucet controls - floor urinal and bidet adaptations - plumbing modifications - turnaround space adaptations Specialized accessibility/safety adaptations/additions - door-widening - electrical wiring - grab bars and handrails - automatic door openers/doorbells - voice activated, light activated, motion activated, and electronic devices - fire safety adaptations - medically necessary air filtering devices - medically necessary heating/cooling adaptations - medically necessary modifications as identified by recipient's physician (medically necessary as defined in K.A.R. 30-5-58) BENEFITS & LIMITATIONS 8-1
8400. Updated 11/03 General house repairs are not included but repairs to housing modifications will be allowed as necessary if identified in the individual Plan of Care. Such modifications are essential to provide safe access to and within the home while at the same time facilitating independence and self-reliance. Housing modifications are cost effective since greater individual access and hence greater overall independence allow the individual to perform more activities of daily living with less assistance. This decreases family stress and reliance on paid staff. For persons who, due to mental and physical impairments, require these adaptations in their environment, the modifications are critical in the avoidance of institutional placement. Also, by having available and utilizing such supports as ramps, handrails, and grab bars, the risk of injury is decreased, thus saving costly hospital and other medical bills. Alarm and fire safety systems allow individuals with severe impairments to reside at home while assuring their safety. No home modification should increase the square footage of an existing structure. Home modifications should not be accessed for new construction. Limitations: HCBS MR/DD Home Modifications are available to Medicaid Program beneficiaries who:. Are 5 years old 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, and. Choose to receive HCBS MR/DD rather than ICF/MR services. Home modifications will only be performed by licensed contractors; and/or all work will be done according to existing codes and inspected by CDDO personnel prior to reimbursement. No work should be initiated until approval has been obtained through prior authorization. HCBS MR/DD Home Modifications are available to minor children, ages 5-18, 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. Room and board costs are excluded in the cost of any HCBS MR/DD services except overnight facility-based respite. BENEFITS & LIMITATIONS 8-2
8400. Updated 11/03 No outside party can subsidize a home modification request. The contractor must accept full payment from Medicaid. Home modifications should be utilized on property where the consumer leases or owns, in the family home if still living there, but not on agency owned and operated property unless an informed exception is made by MH/DD. Home modifications should be billed only upon completion of all work and only after personnel from the CDDO have inspected to assure work was completed as requested. Provider Requirements: Providers of Home Modifications must be a Community Developmental Disability Organization (CDDO) or an affiliate that is a licensed contractor. Recordkeeping: Documentation at a minimum must include the following: o Provider must maintain a copy of the receipt identifying that the service was provided: at a minimum the receipt must include: o Name of the business or contractor o Identify technology/service being provided o Date of service (MM/DD/YY) o Amount of purchase o Consumer or Responsible party s name and signature o Statement of inspection by provider to insure product was purchased/installed as authorized Documentation must be created at the time of purchase. Creating documentation after-thefact 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 s may be subject to recoupment. 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. BENEFITS & LIMITATIONS 8-3
8400 Updated 11/03 Community Developmental Disability Organization (CDDO) - a local agency specified by county government which directly receives county mill funds and state aid and provides community based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by 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, must include:. The services to be provided,. The frequency of each service,. Who will provide each service, and. The cost of each service. BENEFITS & LIMITATIONS 8-4
Updated 11/03 Expected Service Outcomes For Individuals or Agencies Providing HCBS MR/DD Services 1. Services are provided according to the plan of care and in a quality manner and as authorized on the notice of action. 2. Coordinate provision of services in a cost-effective and quality manner. 3. Maintain consumers' independence and health where possible, and in a safe and dignified manner. 4. Communicate consumer concerns/needs, changes in health status, etc., to the Case Manager or Independent Living Counselor within 48 hours including any ongoing reporting as required by the Medicaid program. 5. Any failure or inability to provide services as scheduled in accordance with the plan of care must be reported immediately, but not to exceed 48 hours, to the Case Manager or the Independent Living Counselor. BENEFITS & LIMITATIONS 8-5