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GUIDELINES, DOCUMENTATION, AND BILLING PRESENTED BY: THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING AND THE DIVISION FOR DEVELOPMENTAL DISABILITIES.

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Presentation on theme: "GUIDELINES, DOCUMENTATION, AND BILLING PRESENTED BY: THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING AND THE DIVISION FOR DEVELOPMENTAL DISABILITIES."— Presentation transcript:

1 GUIDELINES, DOCUMENTATION, AND BILLING PRESENTED BY: THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING AND THE DIVISION FOR DEVELOPMENTAL DISABILITIES Targeted Case Management

2 Background Case Management in Colorado Administrative Case Management Case Management as a Waiver Service Targeted Case Management Designated by Waiver

3 Overview State Plan Benefit Entitlement Benefit Targeted Population Persons with Developmental Disabilities; and Enrolled HCBS-DD, SLS, or CES; or Enrolled in Early Intervention Services; and Medicaid Eligible

4 CMS Assurances The State Assures that: Clients will have free choice of providers Case management services will be provided in a manner consistent with the clients best interest Case management services will not be used to restrict a clients access to other services Clients will not be compelled to receive case management services Case managers cannot authorize or deny other State Plan services

5 Qualified Providers Community Centered Boards Only legally authorized agencies to provide TCM to individuals with DD in community settings Case Managers Appropriate qualifications to provide TCM Bachelors Degree, Five years experience in the field of developmental disabilities, OR Some combination of education and experience

6 Purpose Facilitate Enrollment Service Plan Development Service Monitoring Effective Efficient Coordination of Services/Benefits Educational Mental Health Emotional Social Medical Ensure Non Duplication of Services

7 Reimbursement 15 Minute Increments CMS Compliant HSRI Findings Audits Billing Codes

8 Reimbursement Specifically Defined Activity and Purposeful Outcome Example: Telephone contact to schedule IDT Meeting Bill in 15 minute increments 1-15 minutes = 15 minutes Continuous Activity with Separate tasks Example: Record Review, Telephone Contact, Service Plan Revision Bill Total Time Spent State of Colorado

9 Reimbursement Multiple Client Contact Example: Monitoring Visit with 4 Clients at the same Group Home Estimate time/unit per individual Multiple Contacts – One Day Example: Client calls 10 times in one day Professional Judgment Number of units billed should not exceed total amount of time worked. State of Colorado

10 General Contacts Direct Contacts Face-to-Face Correspondence Indirect Contacts Consultation with supervisor for the purpose to plan or coordinate need services Documentation of TCM Activities Documentation and Review of Documentation for the purpose of the individual record Review and distribution of records for planning, coordinating, assessing, and referral to services.

11 Billable Activities Comprehensive Assessment and Periodic Reassessment Determine need for: Medical, Educational, Social, Other Services Examples: Client History Assist in accessing benefits e.g., Social Security and/or Medicaid re-determination Obtain and review any relevant and/or required assessments needed for service planning

12 Billable Activities Service Plan Development Based on information collected through assessment Specifies goals for meeting all service needs Medical Social Educational Other Services Activities to ensure client participation Work with individual and others to develop goals Identifies course of action

13 Billable Activities Service and Support Coordination Coordination of the services being provided in the Service Plan to ensure continuity of service provision Referral and Related Activities Help individual obtain needed services and activities and link them to the appropriate provider: Medical Social Educational Other Programs

14 Billable Activities Monitoring and Follow Up Activities Services are: Implemented and delivered according to Service Plan Adequately meeting the individuals need Monitor changes in need Make necessary changes/revisions Provide Notification

15 Billable Activities Monitoring and Follow Up Activities cont. Health & safety needs are met Rights are respected Client Satisfaction

16 Administrative Activities Intake and Eligibility Determination Reporting and Aggregating Data Critical Incidents Complaints Agency Meetings Case Management/Staff Training Professional Developmental Utilization Review ULTC SIS

17 Documentation Benefits Utilization System If it didnt happen on the BUS, it didnt happen...

18 Documentation Reimbursement based on BUS Documentation Log notes document units Reports generated by the BUS Support claims paid Benefits Utilization System If it didnt happen on the BUS, it didnt happen...

19 Documentation Date The BUS will generate a date and time of entry CM should reflect within the log note the date/time of the activity noted Time Record when appropriate Pertinent to the activity Units Drop Down Menu 15 Minute Increments Record Units up to 32 Units (8 Hours)

20 Documentation Activity TCM activity that is being performed Multiple related activities or activities performed within a single day may be entered into a single log note Must be a billable activity Type of contact Direct Indirect

21 Documentation Finding The observations, assessments, or outcomes of the activity. Follow Up Action The actions to be taken with the information obtained from the activity When appropriate

22 Considerations Ethical and Professional Reporting Appropriation Budget Neutrality

23 Questions?


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