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HCS BILLING GUIDELINES

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Presentation on theme: "HCS BILLING GUIDELINES"— Presentation transcript:

1 HCS BILLING GUIDELINES
01/24/2012 HCS BILLING GUIDELINES You can find the newest version on the DADS website:

2 01/24/2012 General Information Department of Aging and Disability Services (DADS) rules at 40 TAC §9.170 set forth requirements for Home and Community-based Services (HCS) Program providers to receive payment for HCS Program services. Specifically, 40 TAC §9.170(d) requires a program provider to prepare and submit service claims in accordance with the HCS Program Billing Guidelines. Also, Sections II. H. and II. T. of the HCS Program Provider Agreement require program providers to comply with the HCS Program Billing Guidelines. In addition, 40 TAC §9.170(k) sets forth circumstances under which a program provider will not be paid or Medicaid payments will be recouped from the program provider.

3 Applicable Service Components
01/24/2012 General Requirements Applicable Service Components Specialized Therapies Audiology; dietary; occupational therapy; physical therapy; behavioral support; social work; and speech and language pathology. Day Habilitation Nursing Registered; Licensed Vocational; Specialized Registered; and Specialized Licensed Vocational. Residential Assistance Foster/Companion Care; Residential Support; Supervised Living; and Supported Home Living. Respite Supported Employment Adaptive Aids Minor Home Modifications Dental Treatments

4 01/24/2012 General Requirements Except as provided in Items 3220 and 3230, a program provider must submit an electronic service claim that meets the following requirements. The claim must: be for a service component or subcomponent that is authorized by an IPC that meets the requirements of 40 TAC §9.159; be for an HCS service component or subcomponent identified in an individual's PDP that is provided in accordance with the individual's implementation plan, as required by 40 TAC §9.168(r); be for a service component or subcomponent provided during a period of time for which the individual has an LOC; be based on the LON that is authorized by an MR/RC assessment that meets the requirements of 40 TAC §9.163; be based on billable activity, as described in Section 4000, Specific Requirements for Service Components Based on Billable Activity, for the particular service component or subcomponent being claimed; not be based on activity that is not billable, as described in Section 3300, Activity Not Billable, and in Section 4000 for the particular service component or subcomponent being claimed;

5 01/24/2012 General Requirements Except as provided in Items 3220 and 3230, a program provider must submit an electronic service claim that meets the following requirements. The claim must: must be based on activity performed by a qualified service provider as described in Section 3400, Qualified Service Provider, and in Section 4000 for the particular service component or subcomponent being claimed; be for a service component or subcomponent provided to only one individual; be for a service component or subcomponent provided on only one date; be for the date the service component or subcomponent was actually provided; be for units of service determined in accordance with Section 3600, Calculating Units of Service for Service Claim; be supported by written documentation, as described in Section 3800, Written Documentation, and in Section 4000 for the particular service component or subcomponent being claimed; and be a clean claim and be submitted to the state Medicaid claims administrator no later than 12 months after the last day of the month in which the service component was provided.

6 General Requirements Activity Not Billable: Travel time
01/24/2012 General Requirements Activity Not Billable: Travel time Written Documentation Reviewing records Drafting Implementation Plans (IP) Staff Training/Conferences Processing service claims

7 General Requirements Qualified Service Provider
01/24/2012 General Requirements Qualified Service Provider To be a qualified service provider, a person must: be an adult; be a staff member or contractor of the program provider; be paid by the program provider to provide the particular service component or subcomponent being claimed; not be disqualified by this section to provide the particular service component or subcomponent being claimed; meet the minimum provider qualifications described in Section 4000 for the particular service component or subcomponent being claimed; not have been convicted of an offense listed under § of the Texas Health and Safety Code; and not be designated in either the Employee Misconduct Registry or the Nurse Aid Registry maintained by DADS as having abused, neglected or exploited a person or misappropriated a person's property.

8 15-Minute Unit of Service
01/24/2012 General Requirements 15-Minute Unit of Service audiology services; registered nursing; dietary services; licensed vocational nursing; occupational therapy; specialized registered nursing; physical therapy; specialized licensed vocational nursing; behavioral support services; respite; social work services; supported employment; and speech and language pathology services; supported home living. Daily Unit of Service day habilitation; foster/companion care; residential support; and supervised living.

9 General Requirements A Service Event:
01/24/2012 General Requirements A Service Event: For service components and subcomponents that have a unit of service of 15 minutes, a service event: is a discrete period of continuous time during which billable activity for one service component is performed by one service provider; consists of one or more billable activities; and ends when the service provider stops performing billable activity or performs billable activity for a different service component.

10 Calculating Units of Service for Service Claim:
01/24/2012 General Requirements Calculating Units of Service for Service Claim: For counseling and therapies, nursing, supported employment and supported home living, the following formula must be used: [# of service providers X length of service event] ÷ # of individuals served = Service Time

11 Only one method may be used on a single calendar day.
01/24/2012 General Requirements Service Time for SHL Transportation: A program provider must determine service time for the supported home living activity of transporting an individual in accordance with No. 7 in Item 4540, Supported Home Living Subcomponent. Only one method may be used on a single calendar day. Service Time for Respite: A program provider must use the length of the service event as the service time for respite. Units of Service for Service Claim : A program provider must convert a service time to a unit(s) of service for a service claim in accordance with Appendix III, Conversion Table.

12 General Requirements One Service Provider: Multiple Service Providers:
01/24/2012 General Requirements One Service Provider: One service provider may not provide different service components or subcomponents at the same time to the same individual. Multiple Service Providers: Providing Different Service Components or Subcomponents See Next Slides Multiple Service Providers of the Same Service Component or Subcomponent with a 15-Minute Unit of Service

13 Multiple Service Providers
01/24/2012 General Requirements Multiple Service Providers Service Provider of Specialized Therapies A service provider of specialized therapies may provide a service to an individual at the same time a service provider of any other service component or subcomponent is providing a service to the same individual if: the specialized therapies activity is an assessment or observation of the individual; and the assessment or observation is actually occurring at the same time the other service component or subcomponent is being provided. Service Provider of Respite, Foster/Companion Care, Residential Support or Supervised Living A service provider of respite, foster/companion care, residential support or supervised living may provide a service to an individual at the same time a service provider of specialized therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, day habilitation or supported employment provides a service to the same individual.

14 Multiple Service Providers
01/24/2012 General Requirements Multiple Service Providers Service Provider of Supported Home Living A service provider of supported home living may perform a face-to-face service for an individual at the same time a service provider of specialized therapies, registered nursing, licensed vocational nursing, specialized registered nursing and specialized licensed vocational nursing provides a service to the same individual. A service provider of supported home living may perform an activity that does not involve interacting face-to-face with an individual, as described in Item 4540, Supported Home Living Subcomponent (see third bullet), at the same time a service provider of case management, specialized therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, day habilitation or supported employment provides a service to the individual.

15 01/24/2012 General Requirements Multiple Service Providers of the Same Service Component or Subcomponent with a 15-Minute Unit of Service Performance of the Same Activity Multiple service providers of the same service component or subcomponent with a 15 minute unit of service, as listed in Item 3510, 15-Minute Unit of Service, may perform an activity at the same time for the same individual if multiple service providers are needed to perform the activity. Performance of a Different Activity A service provider of supported home living may perform an activity that does not involve interacting face-to-face with an individual, as described in Item 4540 (see third bullet), at the same time another service provider of supported home living performs an activity that involves interacting face-to-face with the individual Service Coordination and Day Habilitation Provided at the Same Time A service provider of day habilitation may provide day habilitation to an individual at the same time a service coordinator is providing service coordination to the individual at the day habilitation setting. &

16 01/24/2012 General Requirements Written Documentation Legible Required content Required content for non-nursing services must include: the name of the individual who was provided the service component or subcomponent; the day, month and year the service component or subcomponent was provided; the service component or subcomponent that was provided; and a written service log, as described in Section 3820, Written Service Log and Written Summary Log, for each individual.

17 01/24/2012 General Requirements Required content for nursing services must include: The written documentation to support a service claim for the nursing service components of registered nursing, licensed vocational nursing, specialized registered nursing and specialized licensed vocation nursing must: be written after the service is provided; and include: the name of the individual who was provided the nursing service component; the day, month and year the nursing service component was provided; the nursing service component that was provided; a detailed description of activities performed by the service provider and the individual that evidences the performance of one or more of the billable activities described in Section 4000 for the particular nursing service component being claimed; a brief description of the location of the service event, as described in Section 3610, 15-Minute Unit of Service (see No. 1), such as the address or name of business; the exact time the service event began and the exact time the service event ended documented by the nurse making the written documentation; a description of the medical need for the activity performed during the service event; a description of any unusual incident that occurs such as a seizure, illness or behavioral outburst, and any action taken by the registered nurse or licensed vocational nurse in response to the incident; for any activity simultaneously performed by more than one registered nurse or more than one licensed vocational nurse, a written justification in the individual's implementation plan for the use of more than one registered nurse or licensed vocational nurse; and be supported by information that justifies the length of the service event, as described in Section 3610 (see No. 1), such as an explanation in the documentation or implementation plan of why a billable activity took more time than typically required to complete.

18 General Requirements A written service log must:
01/24/2012 General Requirements A written service log must: be written after the service is provided; for service components or subcomponents with a 15-minute unit of service, as listed in Section 3510, 15-Minute Unit of Service, include: a description or list of activities performed by the service provider and the individual that evidences the performance of one or more of the billable activities described in Section 4000 for the particular service component or subcomponent being claimed; and a brief description of the location of the service event, as described in Section 3610, 15-Minute Unit of Service (see No. 1), such as the address or name of business; be supported by information that justifies the length of the service event, as described in Section 3610 (see No. 1), such as an explanation in the written service log or implementation plan of why a billable activity took more time than typically required to complete; for service components or subcomponents with a daily unit of service, as listed in Section 3520, Daily Unit of Service, include: a description or list of activities performed by the service provider and the individual that evidences the performance of the billable activities described in Section 4000 for the particular service component or subcomponent being claimed; or for foster/companion care, residential support and supervised living, if the individual was not available to receive services, an explanation for the unavailability; be made within reasonable time after the activity being documented is provided; and include the signature and title of the service provider making the written service log.

19 General Requirements A written summary log must:
01/24/2012 General Requirements A written summary log must: be written after services have been provided; include information that identifies the individual for whom the written summary log is made; include a general description or list of activities performed during the calendar week in which the service component or subcomponent was provided; be made within a reasonable time after the week being documented; and include the signature and title of the service provider making the written summary log. Unusual Incidents or Progress Toward Objectives The description of the activities in a written service log or written summary log must include a description of any unusual incident that occurs such as a seizure, illness or behavioral outburst, and any action taken by the service provider in response to the incident.

20 General Requirements Unacceptable Content for Documentation:
01/24/2012 General Requirements Unacceptable Content for Documentation: ditto marks; references to other written service logs or written summary logs using words or symbols; non-specific statements such as "had a good day," "did ok," or "no problem today;" a statement or other information that is photocopied from other completed or partially completed written service logs or written summary logs; and a medication log. Separate Written Service Log or Written Summary Log for Service Component, Subcomponent or Service Event A program provider must have a separate written service log or separate written summary log for each service component or subcomponent, as described in Section 3810, General Requirements (see No. 2(a), fourth bullet), and for each service event as described in Section 3610, 15-Minute Unit of Service (see No. 1).

21 Specific Requirements
01/24/2012 Specific Requirements

22 Specialized Therapies
01/24/2012 Specialized Therapies

23 Specific Requirements
01/24/2012 Specific Requirements Specialized Therapies Audiology services Dietary services Occupational therapy services Physical therapy services Psychology services Social work services Speech and language pathology services

24 Specific Requirements
01/24/2012 Specific Requirements Specialized Therapies Billable Activity The only billable activities for the specialized therapies service component are: interacting face-to-face or by video conference or speaking by telephone with an individual, based on the specialized therapies subcomponent provided, to conduct assessments or provide services within the scope of the service provider's practice; interacting face-to-face or by video conference or speaking by telephone with a person regarding a specialized therapies subcomponent provided to an individual, but not with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies; writing an individualized treatment plan for an individual's specialized therapies which, for behavioral support services, is a behavior support plan; reviewing documents, except for a written narrative or written summary of a service component as described in Section 3820,  to evaluate the quality and effectiveness of an individual's specialized therapies;

25 Specific Requirements
01/24/2012 Specific Requirements Specialized Therapies Billable Activity training the following persons on how to provide specialized therapies treatment, including how to document the provision of treatment: a service provider of foster/companion care, residential support, supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or a person other than a service provider who is involved in serving an individual; reviewing documents in preparation for the training described in the bullet above; participating in a service planning team meeting; participating in the development of an implementation plan; participating in the development of an IPC; and

26 Specific Requirements
01/24/2012 Specific Requirements Specialized Therapies Billable Activity for behavioral support services, in addition to the activities listed above: assessing the targeted behavior so that a behavior support plan may be developed; training of and consulting with an individual, family member or other persons involved in the individual's care regarding the implementation of the behavior support plan; monitoring and evaluating the effectiveness of the behavior support plan; modifying, as necessary, the behavior support plan based on the monitoring and evaluation of the plan's effectiveness; and educating an individual, family members or other persons involved in the individual's care about the techniques to use in assisting the individual to control maladaptive or socially unacceptable behaviors exhibited by the individual.

27 Specific Requirements
01/24/2012 Specific Requirements Not Billable as Specialized Therapies The following are examples of activities that are not billable for the specialized therapies service component: providing services outside the scope of the service provider's practice; providing services that are performed by a service coordinator or were performed by a former case manager; scheduling an appointment; transporting an individual; traveling or waiting to provide a specialized therapies subcomponent; training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment; creating written documentation as described in Section 4260; reviewing a written narrative or written summary of a service component as described in Section 3820; and

28 Specific Requirements
01/24/2012 Specific Requirements Not Billable as Specialized Therapies The following are examples of activities that are not billable for the specialized therapies service component (continued): interacting with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan. Activities in Section 3300 The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized therapies service component. Activities Not Listed in Section 4220 Any activity not described in Section 4220, Billable Activity, is not billable for the specialized therapies service component.

29 Specific Requirements
01/24/2012 Specific Requirements Examples of Activity Not Billable providing services outside the scope of the service provider's practice; providing services that are performed by a service coordinator or were performed by a former case manager; scheduling an appointment; transporting an individual; traveling or waiting to provide a specialized therapies subcomponent; training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment; creating written documentation as described in Section 4260; reviewing a written narrative or written summary of a service component as described in Section 3820; and interacting with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan.

30 Specific Requirements
01/24/2012 Specific Requirements Specialized Therapies Written Documentation Except as provided in Section 4270, Insurance Co-payment and Deductible (see No. 1, Item c and No. 2, Item c), a program provider must have written documentation to support a service claim for specialized therapies that: meets the requirements set forth in Section 3800, Written Documentation; includes the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; and for any activity performed by multiple service providers at the same time for the same individual, includes a written justification in the individual's implementation plan for the use of multiple service providers.

31 Common Errors No begin and/or end times
01/24/2012 Common Errors No begin and/or end times No location of service provided Reviewing or creating service delivery records Family paying for rate differential No Progress Note

32 01/24/2012 Day Habilitation

33 Specific Requirements
01/24/2012 Specific Requirements Day Habilitation Billable Activity The only billable activities for the day habilitation service component are: interacting face-to-face with an individual to assist the individual in achieving objectives to: acquire, retain or improve self-help skills, socialization skills or adaptive skills that are necessary to for the individual to successfully reside, integrate and participate in the community; reinforce a skill taught in school, specialized therapies; and develop opportunities for employment in the community (for example, completing a job application, assessing employment skills and training on employment-related issues); transporting an individual between settings at which day habilitation is provided to the individual; assisting an individual with his or her personal care activities if the individual cannot perform such activities without assistance; participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC.

34 Specific Requirements
01/24/2012 Specific Requirements Day habilitation may be provided to an individual only in a setting that is not the residence of the individual, unless the provision of day habilitation in a residence is justified because of the individual's medical condition or behavioral issues or because the individual is of retirement age, and such justification is documented in the individual's record.

35 Specific Requirements
01/24/2012 Specific Requirements Not Billable as Day Habilitation Travel time (except from one Day Habilitation site to another) Written documentation Reviewing records Drafting Implementation Plans Staff Training/Conferences Processing service claims Assisting an individual for the sole purpose of meeting vocational goals

36 Specific Requirements
01/24/2012 Specific Requirements May not submit DH service claim for: An individual who refuses to participate An individual who is sleeping Assisting an individual in achieving goals not documented in their IP More than five units of service in a calendar week More than 260 units of service per IPC year Day habilitation that is funded by another source other than HCS

37 Specific Requirements
01/24/2012 Specific Requirements Day Habilitation Unit of Service A unit of service for Day Habilitation is one day One-quarter unit of service if service is provided at least one and one-quarter hours of consecutive day habilitation on a calendar day One-half unit of service may be billed if service is provided for at least two and one-half hours on a calendar day. Two of the two and one-half hours must be consecutive. Three-quarters unit of service may be billed if service is provided for at least three and three-quarter hours on a calendar day. Two of the three and three-quarter hours must be consecutive. One unit may be billed if service is provided for at least five hours on a calendar day. Two of the five hours must be consecutive.

38 Specific Requirements
01/24/2012 Specific Requirements A program provider must have written documentation to support a service claim for day habilitation that: meets the requirements set forth in Section 3800, Written Documentation; includes a description of the location of the day habilitation site; includes, for each calendar day, the exact time the day habilitation began and the exact time it ended documented by a staff person who is present at the day habilitation site during those times; includes: a written service log, as described in Section 3820, Written Service Log and Written Summary Log, of the calendar day for which the service claim is submitted; or a written summary log as described in Section 3820; and includes a description in the individual's implementation plan of objectives the program provider is assisting the individual to achieve, as described in the first bullet of Section 4330, Billable Activity

39 Common Errors Individual sleeping
01/24/2012 Common Errors Individual sleeping Not signing individual out of Day Habilitation for other services provided (NU, SHL, etc.) No description of service provided (details about interactions, activities, behaviors, successes, refusals, etc.) Vocational Goals – Sheltered Workshops No Progress Note

40 Supported Employment 01/24/2012

41 Specific Requirements
01/24/2012 Specific Requirements Supported Employment Supported employment is a service that assists an individual to sustain competitive, integrated employment.

42 Specific Requirements
01/24/2012 Specific Requirements Supported Employment Billable Activity The only billable activities for the supported employment service component are: interacting face-to-face with an individual at the individual's work site to provide training, support and intervention necessary to sustain the individual's employment; interacting face-to-face or by telephone with an individual's employment supervisor as necessary to sustain the individual's employment; transporting an individual to and from the individual’s work site; participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC.

43 Specific Requirements
01/24/2012 Specific Requirements Examples of Activities Not Billable under SE The following are examples of activities that are not billable for the supported employment service component: interacting with an individual prior to the individual's employment; conducting employment interest assessments, assisting with or arranging interviews, and completing job applications; interacting with an individual when the individual is not on duty; and transporting an individual to a job interview.

44 Specific Requirements
01/24/2012 Specific Requirements Restrictions (SE): A program provider may not submit a service claim for supported employment provided to an individual: while the individual is employed by the program provider; in excess of 600 units of service (150 hours) per IPC year; or if supported employment is available to the individual through the public school system or the Department of Assistive and Rehabilitative Services.

45 Specific Requirements
01/24/2012 Specific Requirements Supported Employment Documentation A program provider must have written documentation to support a service claim for supported employment. The written documentation must: meet the requirements set forth in Section 3800, Written Documentation; include the exact time the service event began and the exact time each service event ended documented by the service provider making the written service log; include evidence that supported employment services are not available to the individual through the public school system or the Department of Assistive and Rehabilitative Services; and for any activity simultaneously performed by more than one service provider, include a written justification in the individual's PDP for the use of more than one service provider.

46 Common Errors Training not occurring at the job site
01/24/2012 Common Errors Training not occurring at the job site Pre-vocational training No Progress Note

47 01/24/2012 Nursing

48 Specific Requirements
01/24/2012 Specific Requirements Registered Nursing Billable Activity The only billable activities for the registered nursing service component are: interacting face-to-face with an individual who has a medical need for registered nursing, including: preparing and administering medication or treatment ordered by a physician, podiatrist or dentist; assisting or observing administration of medication; and assessing the individual's health status, including conducting a focused assessment or a comprehensive assessment; speaking by telephone with an individual who has a medical need for registered nursing, including assessing the individual's health status; interacting by video conference with an individual who has a medical need for registered nursing, including: observing administration of medication; and

49 Specific Requirements
01/24/2012 Specific Requirements Registered Nursing Billable Activity (cont.) at the time an individual receives medication from a pharmacy, ensuring the accuracy of: the type and amount of medication; and the dosage instructions; researching medical information for an individual who has a medical need for registered nursing, including: reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and completing a comprehensive assessment;

50 Specific Requirements
01/24/2012 Specific Requirements Registered Nursing Billable Activity (cont.) training the following persons how to perform nursing tasks: a service provider of foster/companion care, residential support, supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or a person other than a service provider who is involved in serving an individual; reviewing documents in preparation for the training described in the bullet above;

51 Specific Requirements
01/24/2012 Specific Requirements Registered Nursing Billable Activity (cont.) interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with: a staff person who is not a service provider; or a service provider of: registered nursing; licensed vocational nursing unless supervised by the registered nurse; specialized registered nursing; specialized licensed vocational nursing unless supervised by the registered nurse; or specialized therapies;

52 Specific Requirements
01/24/2012 Specific Requirements Registered Nursing Billable Activity (cont.) interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the registered nurse justifies, in writing, the need for the registered nurse to perform the activity; instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic that is specific to an individual such as choking risks for an individual who has cerebral palsy; supervising a licensed vocational nurse regarding an individual's nursing services or health status; instructing, supervising or verifying the competency of an unlicensed person in the performance of a task delegated in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §§ , as applicable;

53 Specific Requirements
01/24/2012 Specific Requirements Registered Nursing Billable Activity (cont.) participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC.

54 Specific Requirements
01/24/2012 Specific Requirements Licensed Vocational Nursing Billable Activity interacting face-to-face with an individual who has a medical need for licensed vocational nursing, including: preparing and administering medication or treatment ordered by a physician, podiatrist or dentist; assisting or observing administration of medication; and conducting a focused assessment of the individual's health status; speaking by telephone with an individual who has a medical need for licensed vocational nursing, which may include conducting an assessment of an individual if: the assessment is conducted using protocol approved by DADS; and the licensed vocational nurse has been trained by a registered nurse on using the protocol;

55 Specific Requirements
01/24/2012 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) interacting by video conference with an individual who has a medical need for licensed vocational nursing, including: observing administration of medication; and conducting a focused assessment of the individual's health status; at the time an individual receives medication from a pharmacy, ensuring the accuracy of: the type and amount of medication; and the dosage instructions;

56 Specific Requirements
01/24/2012 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) researching medical information for an individual who has a medical need for licensed vocational nursing, including: reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and completing a focused assessment; training a service provider of residential assistance, day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks; reviewing documents in preparation for the training described in the bullet above;

57 Specific Requirements
01/24/2012 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) researching medical information for an individual who has a medical need for licensed vocational nursing, including: reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and completing a focused assessment; training a service provider of residential assistance, day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks; reviewing documents in preparation for the training described in the bullet above;

58 Specific Requirements
01/24/2012 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies; interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the licensed vocational nurse justifies, in writing, the need for the licensed vocational nurse to perform the activity;

59 Specific Requirements
01/24/2012 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy; participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC.

60 Specific Requirements
01/24/2012 Specific Requirements Specialized Registered and Licensed Vocational Nursing Follow respective sections only for an individual who has a tracheostomy or is dependent on a ventilator. &

61 Specific Requirements
01/24/2012 Specific Requirements Examples of Non-Billable Activities: performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including: performing an activity that constitutes the practice of professional nursing and must be performed by a registered nurse; transporting an individual; waiting to perform a billable activity; and waiting with an individual at a medical appointment; making a medical appointment; instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation, or infection control; preparing a treatment or medication for administration and not interacting face-to-face with an individual; storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section ; creating written documentation as described in Section ;

62 Specific Requirements
01/24/2012 Specific Requirements Examples of Non-Billable Activities: reviewing a written service log or written summary log of a service component as described in Section 3820; interacting with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and performing an activity for which there is no medical need.

63 Specific Requirements
01/24/2012 Specific Requirements Nursing Rule of Thumb: If it does not require a nursing license to perform a task, it is not billable.

64 Specific Requirements
01/24/2012 Specific Requirements Nursing Unit of Service 15 Minute of Service A service claim cannot be made for a fraction of a unit of service Accumulation of Service Times Can be accumulated for nursing provided to one individual on a single calendar day

65 Specific Requirements
01/24/2012 Specific Requirements Nursing Services Written Documentation be written after the service is provided; and include: the name of the individual the day, month and year the service was provided; the nursing service that was provided; a detailed description of activities performed by the service provider and the individual that evidences the performance of one or more of the billable activities described in Section 4000 for the particular nursing service component being claimed; a brief description of the location of the service event, as described in Section 3610, 15-Minute Unit of Service (see No. 1), such as the address or name of business;

66 Specific Requirements
01/24/2012 Specific Requirements Nursing Services Written Documentation be written after the service is provided; and include: the exact time the service event began and the exact time the service event ended documented by the nurse making the written documentation; a description of the medical need for the activity performed during the service event; a description of any unusual incident that occurs such as a seizure, illness or behavioral outburst, and any action taken by the registered nurse or licensed vocational nurse in response to the incident;

67 Specific Requirements
01/24/2012 Specific Requirements Nursing Services Written Documentation be written after the service is provided; and include: for any activity simultaneously performed by more than one registered nurse or more than one licensed vocational nurse, a written justification in the individual's implementation plan for the use of more than one registered nurse or licensed vocational nurse; and be supported by information that justifies the length of the service event, as described in Section 3610 (see No. 1), such as an explanation in the documentation or implementation plan of why a billable activity took more time than typically required to complete.

68 Common Errors Billing for creating and reviewing service records.
01/24/2012 Common Errors Billing for creating and reviewing service records. No medical necessity shown when residential staff calls nurse to administer over the counter medication to individual No medical necessity for follow-up phone call Billing for services without Face-to-Face, Telephone or Video conferencing contact Providing any activity not requiring a nursing license One note used for multiple service events No Progress Note

69 Residential Assistance
01/24/2012 Residential Assistance

70 Specific Requirements
01/24/2012 Specific Requirements Residential Assistance Residential Location Own Home/Family Home – if no foster/companion care, residential support or supervised living is provided to the individual Foster/Companion Care – is not owned or leased by the program provider, a service provider provides care to the individual; and the care provider and the individual have the same address

71 Specific Requirements
01/24/2012 Specific Requirements Residential Assistance Residential Location 3-Person Home – the individual’s residence is a 3-person residence and a service provider provides residential support or supervised living to the individual 4-person Home – the individual’s residence is a 4-person residence and a service provider provides residential support or supervised living to the individual (one must be RSS)

72 Supported Home Living 01/24/2012

73 Specific Requirements
01/24/2012 Specific Requirements Supported Home Living Billable Activity Interacting face-to-face with the individual: to assist with activities of daily living to assist with ambulation and mobility to reinforce counseling and therapy subcomponents to assist with administration of medication or tasks delegated by an RN to conduct habilitation activities to secure transportation for the individual to supervise the individual’s safety and security interactions regarding an incident directly affecting the individual's health or safety; performing allowable non-face-to-face activities participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC.

74 Specific Requirements
01/24/2012 Specific Requirements Supported Home Living claims may not be submitted for: An individual whose IPC does not have a residential location of “own home/family home” the sole activity of supervising the individual's safety and security Transporting an individual from one DH or SE site to another supporting home living provided to an individual: in a residence in which residential support or supervised living is provided to another individual; by a service provider who is simultaneously providing residential support, supervised living or foster/companion care to another individual; if the day habilitation service component is simultaneously provided to the individual by another service provider; or if the respite service component is simultaneously provided to the individual by another service provider.

75 Specific Requirements
01/24/2012 Specific Requirements Supported Home Living Unit of Service 15 Minute of Service – may not include fraction of service Calculating transportation – use Method A or Method B (can only use one method on a single calendar day)

76 Specific Requirements
01/24/2012 Specific Requirements Supported Home Living Written Documentation meets the requirements set forth in Section 3800, Written Documentation; includes the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; for any activity that does not involve interacting face-to-face with an individual, as permitted by the third bullet in No. 1, includes: a written justification in the individual's implementation plan for such activity; and a statement or description of such activity in the written service log; and for any activity simultaneously performed by more than one service provider, includes a written justification in the individual's implementation plan for the use of more than one service provider.

77 Specific Requirements
01/24/2012 Specific Requirements SHL Transportation Written Documentation the name of the individual who was being transported; the day, month and year the transportation was provided; the place of departure and destination for the individual being transported; a notation of whether the program provider is using Method A or Method B to calculate transportation time, as required by (7)(b)(II) above; a begin and end time for each transportation time, as described in (7)(b) above; the total minutes of each transportation time;

78 Specific Requirements
01/24/2012 Specific Requirements SHL Transportation Written Documentation for each "trip" if using Method A (see (7)(b)(III) and (IV)) or, for each "segment" if using Method B (see (7)(b)(V)): the number of passengers; the number of service providers; the resulting service time; and the signature of the service provider transporting the individual; the unit of service for a service claim resulting from each service time; and any service times accumulated to make a unit of service for a service claim

79 Transportation Method A
01/24/2012 Transportation Method A Individual Departure Time Arrival Time A. Dorothy N. Kansas 7:00am 9:00am B. Dorothy N. Kansas 3:00pm 4:30pm a. Transportation time of 120 minutes (7:00am-9:00am) with 6 passengers (Dorothy + 5 others) and 1 service provider for Trip A SERVICE TIME = (1 X 120) ÷ 6 = 20 minutes b. Transportation time of 90 minutes (3:00pm-4:30pm) with 5 passengers (Dorothy + 4 others) and 1 service provider SERVICE TIME = (1 X 90) ÷ 5 = 18 minutes 20 min + 18 min = 38 minutes (accumulation) According to Attachment C: 38 minutes = 3 Units Billed (accumulation) 1 Unit (20 min) + 1 Unit (18 min)= 2 Units Billed (no accumulation)

80 Transportation Method B
01/24/2012 Transportation Method B Individual Departure Time Arrival Time Dorothy N. Kansas 7:00am 9:00am Little B. Blue 7:15am Mary Q. Contrary 7:30am Transportation time for Dorothy N. Kansas: a. Transportation time of 15 minutes (7:00am-7:15am) with one passenger (Dorothy only) and 1 service provider SERVICE TIME = (1 X 15) ÷ 1 = 15 minutes b. Transportation time of 15 minutes (7:15am-7:30am) with two passengers (Dorothy and Little) and 1 service provider SERVICE TIME = (1 X 15) ÷ 2 = 7.5 minutes c. Transportation time of 15 minutes (7:30am-9:00am) with three passengers (Dorothy, Little and Mary) and 1 service provider SERVICE TIME = (1 X 90) ÷ 3 = 30 minutes 15 min min + 30 min = 52.5 minutes According to Attachment C: 52.5 minutes = 3 Units

81 Common Errors Overlapping times with other services
01/24/2012 Common Errors Overlapping times with other services Transportation method completed incorrectly Time not divided evenly between two or more individuals receiving services at the same time Non-qualified Service Provider (Proof of residence, etc.) No justification for receiving SHL in DH facility No begin and/or end times on documentation No location of services provided on documentation No Progress Note

82 01/24/2012 Foster Care

83 Specific Requirements
01/24/2012 Specific Requirements Foster Care Requirements of Setting The program provider may not lease or own the residence The individual receiving care must have a residence in which no more than three persons receive: foster/companion care, a non-HCS Program service similar to foster/companion care; and If the individual is a minor, the parent or step-parent may not provide this service

84 Specific Requirements
01/24/2012 Specific Requirements Foster Care Requirements of Setting The service provider must have the same residence as the individual; and Ensure that foster/companion care is provided to an individual when necessary

85 Specific Requirements
01/24/2012 Specific Requirements Foster Care Unit of Service Unit of service is one day May not be for more than one day May not have a fraction of a unit of service

86 Specific Requirements
01/24/2012 Specific Requirements Foster Care Billable Activity Assisting the individual with activities of daily living (bathing, dressing, personal hygiene, eating, meal planning and preparation and housekeeping) Assisting the individual with ambulation and mobility Reinforcing any counseling and therapy subcomponent provided to the individual Assisting with the administration of the individual’s medication or to perform a task delegated by an RN

87 Specific Requirements
01/24/2012 Specific Requirements Foster Care Billable Activity Conducting habilitation activities that train the individual to: Develop or improve skills that allow the individual to live more independently Develop socially valued behaviors Integrate into community activities Use natural supports and typical community services available to the public Participate in leisure activities

88 Specific Requirements
01/24/2012 Specific Requirements Foster Care Written Documentation meet the requirements set forth in Section 3800, Written Documentation; include a description of the location of the individual's residence (by address or location code); and include: a written service log, as described in Section 3820, Written Service Log and Written Summary Log, of the calendar day for which the service claim is submitted; or a written summary log as described in Section 3820.

89 Specific Requirements
01/24/2012 Specific Requirements Foster Care Service Claim for an Individual on a Visit with Family or Friend A program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

90 Specific Requirements
01/24/2012 Specific Requirements Foster Care Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.

91 Common Errors Failure to discharge individual while in the hospital
01/24/2012 Common Errors Failure to discharge individual while in the hospital Weekly summary exceeds seven days Not documenting location information No Progress Note

92 Residential Support Services
01/24/2012 Residential Support Services

93 Specific Requirements
01/24/2012 Specific Requirements Residential Support Requirements of Setting The residence must be a Three or Four person residence The program provider may not have the same residence as the individual The service provider must be available to provide residential support to an individual as needed; and The service provider must be present and awake in the residence when the individual is present in the residence

94 Specific Requirements
01/24/2012 Specific Requirements Residential Support Billable Activity assisting the individual with activities of daily living; assisting the individual with ambulation and mobility; reinforcing any specialized therapies subcomponent provided to the individual; assisting with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, § , as applicable; conducting habilitation activities that train the individual; securing transportation for or transporting the individual; and supervising the individual's safety and security.

95 Specific Requirements
01/24/2012 Specific Requirements Residential Support Unit of Service Unit of service is one day A service claim may not be for more than one day A service claim may not include a fraction of a unit of service

96 Specific Requirements
01/24/2012 Specific Requirements Residential Support Written Documentation meet the requirements set forth in Section 3800, Written Documentation; include a description of the location of the individual's residence (by address or location code); and demonstrate that a service provider is present and awake in the residence during the time an individual is present in the residence.

97 Specific Requirements
01/24/2012 Specific Requirements Residential Support Service Claim for an Individual on a Visit with Family or Friend A program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

98 Specific Requirements
01/24/2012 Specific Requirements Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.

99 Common Errors Failure to discharge individual while in the hospital
01/24/2012 Common Errors Failure to discharge individual while in the hospital Not providing location codes Not providing staff signatures Not showing night shift coverage activities

100 01/24/2012 Supervised Living

101 Specific Requirements
01/24/2012 Specific Requirements Supervised Living Requirements of Setting The residence must be a 3 or 4-person residence The service provider must be available to provide residential support to an individual as needed; and The service provider must be present in the residence when the individual is present in the residence

102 Specific Requirements
01/24/2012 Specific Requirements Supervised Living Billable Activity assisting the individual with activities of daily living; assisting the individual with ambulation and mobility; reinforcing any specialized therapies subcomponent provided to the individual; assisting with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, § , as applicable; conducting habilitation activities that train the individual; securing transportation for or transporting the individual; and supervising the individual's safety and security.

103 Specific Requirements
01/24/2012 Specific Requirements Supervised Living Unit of Service Unit of service is one day A service claim may not be for more than one day A service claim may not include a fraction of a unit of service

104 Specific Requirements
01/24/2012 Specific Requirements Supervised Living Written Documentation meet the requirements set forth in Section 3800, Written Documentation; include a description of the location of the individual's residence (by address or location code); and demonstrate that a service provider is present in the residence during normal sleeping hours.

105 Specific Requirements
01/24/2012 Specific Requirements Supervised Living Service Claim for an Individual on a Visit with Family or Friend A program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

106 Specific Requirements
01/24/2012 Specific Requirements Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.

107 Common Errors Failure to discharge consumer while in the hospital
01/24/2012 Common Errors Failure to discharge consumer while in the hospital Not providing location No Progress Note

108 01/24/2012 Respite

109 Specific Requirements
01/24/2012 Specific Requirements Respite is the temporary provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; and provides relief for a caregiver of the individual who: has the same residence as the individual; routinely provides assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; is temporarily unavailable to provide such assistance and support; and is not a service provider of foster/companion care, residential support or supervised living to the individual. 4.06-1

110 Specific Requirements
01/24/2012 Specific Requirements Respite Room and Board- If respite is provided in a setting other than the individual's residence, the program provider must provide room and board to the individual free of charge. 4.06-1

111 Specific Requirements
01/24/2012 Specific Requirements Respite Billable Activity interacting face-to-face with an individual to: assist the individual with activities of daily living; assist the individual with ambulation and mobility; reinforce any specialized therapies subcomponent provided to the individual; assist with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, § , as applicable; conduct habilitation activities that teach the individual; secure transportation for the individual; supervise the individual's safety and security; and transport the individual, except from one day habilitation site to another;

112 Specific Requirements
01/24/2012 Specific Requirements Respite Billable Activity interacting face-to-face or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and performing activities that does not involve interacting face-to-face with an individual described in Section 4620.

113 Specific Requirements
01/24/2012 Specific Requirements Respite must be provided: Residence If an individual receives respite in a residence, the residence must be: the individual's residence; a three-person residence; a four-person residence; or the residence of another person (other than a three-person residence or a four-person residence) in which no more than three persons are receiving HCS Program services or a non-HCS program service similar to HCS Program services. Non-residence If an individual is receiving respite during an overnight stay in a setting that is not the residence of any person, no more than six persons receiving HCS Program services or a non-HCS Program service similar to HCS Program services may be in the setting.

114 Specific Requirements
01/24/2012 Specific Requirements Submitting a Service Claim for Respite Respite Provided in an Individual's Residence If a program provider provides respite in an individual's residence, the program provider may submit a service claim for no more than 96 units of service (24 hours) in one calendar day. Respite Provided in Location Other Than the Individual's Residence If a program provider provides 10 hours or more of respite to an individual in one calendar day in a location other than the individual's residence, the program provider may submit a service claim for no more than 40 units of service.

115 Specific Requirements
01/24/2012 Specific Requirements Respite Written Documentation meet the requirements set forth in Section 3800, Written Service Log and Written Summary Log; include the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; and include a written justification in the individual's PDP for the use of more than one service provider for any activity simultaneously performed by more than one service provider.

116 Common Errors Location of service not on documentation
01/24/2012 Common Errors Location of service not on documentation Billing more than 10 hours for respite occurring out of the individuals home Individual lives alone without a live-in caregiver No begin and/or end times Non Qualified Service Provider (Proof of residence, etc.) Not providing location information No Progress Note

117 Billing & Payment Review Protocol
01/24/2012 Billing & Payment Review Protocol

118 Billing and Payment Review
01/24/2012 Billing and Payment Review Conducted by DADS Billing and Payment staff Review of authorization and written documentation of service delivery maintained by program provider

119 01/24/2012 Purpose: To determine whether the program provider is in compliance with the HCS Program Billing Guidelines Outcome: DADS will recoup non-verified claims that were not supported by authorization and/or written documentation and may require a corrective action plan (CAP) by the program provider.

120 Types of Reviews: Routine Special
01/24/2012 Types of Reviews: Routine Once every 2 years, all services are reviewed with the number of individuals reviewed and review period determined by previous error rates or number of individuals served Special As determined by DADS, result of a complaint, referral or billing anomalies

121 Routine or special review can be either:
01/24/2012 Routine or special review can be either: On-site – conducted at provider’s place of business Desk – conducted at DADS Headquarters (documentation submitted by mail )

122 01/24/2012 Samples are chosen based upon documentation error rate: Error Rate = non-verified dollars divided by the total amount billed during the review period

123 Non-Verified Claims Total..................$15,400.00
01/24/2012 Example of Error Rate: Non-Verified Claims Total $15,400.00 Total Claims Billed $125,600.00 $15, ÷ $125, = .1226 Error Rate: 12.26%

124 Error Rate Less Than Ten Percent (10%):
01/24/2012 BPR sample size: Error Rate Less Than Ten Percent (10%): Provider serves more than 10 individuals – 5 + 5% reviewed Provider serves less than 10 individuals – All reviewed

125 Error Rate More Than Ten Percent (10%):
01/24/2012 BPR sample size-- Error Rate More Than Ten Percent (10%): Provider serves more than 10 individuals – % reviewed Provider serves less than 10 individuals – All reviewed

126 Provider serves more than 10 individuals- 5 + 10%
01/24/2012 BPR sample size Never Reviewed: Provider serves more than 10 individuals- 5 + 10% Provider serves less than 10 individuals- up to 5

127 Routine: Special: On-site Reviews: Notification:
01/24/2012 On-site Reviews: Notification: Routine: At least fourteen(14) days notice by phone and followed by a faxed letter. Individual sample list from outside of Waiver Contract Area (WCA) of review location provided two business days prior to Entrance Conference. Special: Will be conducted without notice.

128 01/24/2012 On-site Reviews: List of individuals within the review location’s WCA are identified at Entrance Conference. PROVIDERS ARE NOT PERMITTED TO CREATE ANY DOCUMENTATION AT ANY TIME WHILE REVIEW IS IN PROGRESS

129 Error Sheet Forms 01/24/2012

130 Refuting is conducted while on-site.
01/24/2012 Refuting – On-site Reviews Refuting is conducted while on-site. DADS will not accept additional documentation or refute any unverified claims after the Exit Conference.

131 Demand for Payment-on-site review:
01/24/2012 Demand for Payment-on-site review: Following the Exit Conference, generally within 30 days, DADS will send a certified letter (Demand for Payment) to the provider detailing any unverified claims. The letter includes the amount to be recouped, any required corrective action and notice of the right to request an Administrative Hearing.

132 01/24/2012 On-Site Review: Request for Administrative Hearing (appeal) Must be made within 15 calendar days from receipt of certified green card from Demand for Payment letter

133 01/24/2012 Payment of unverified claims: Recoupment is done electronically through the automated billing system (CARE) Please do not send checks.

134 Telephone and Certified Mail
01/24/2012 Desk reviews: Notification: Telephone and Certified Mail

135 01/24/2012 Timeframe to Provide Documentation-desk review 14 calendar days from receipt of certified green card from notification letter. Documentation received after 14 days has elapsed will not be accepted and all services requested will be subject to recoupment.

136 Provider notified of results in certified letter
01/24/2012 Results-desk review: Provider notified of results in certified letter Refuting-desk review: Additional documentation must be submitted within 14 calendar days of receipt of certified green card from results letter Late submissions are not accepted

137 Demand for Payment-desk review:
01/24/2012 Demand for Payment-desk review: Certified letter notifies provider of final account of unverified claims after considering refuting documentation (if any submitted)

138 Desk Reviews: Request for Administrative Hearing (appeal):
01/24/2012 Desk Reviews: Request for Administrative Hearing (appeal): Must be made within 15 calendar days from receipt of certified green card from Demand for Payment letter

139 Payment of unverified claims:
01/24/2012 Payment of unverified claims: Recoupment is done electronically through the automated billing system. Please do not send checks.

140 HCS Billing Guideline Revision
Misti J. Ackermann, Billing & Payment Manager

141 2011 Billing Guidelines Guidelines:
Guideline Changes:

142 Section Title Change 2000 Definitions Adds definitions for competitive employment, comprehensive assessment, focused assessment, integrated employment, service coordination and service coordinator. 3210 General Requirements Updated references. 3230 Service Claim for Day Habilitation for Individual Receiving Supported Employment Deleted. Service Claim for Foster/Companion Care, Residential Support or Supervised Living for Individual on a Visit with Family or Friend Section 3240 is renumbered to 3230. 3430 Relative, Guardian or Managing Conservator Qualified as Service Provider Updates information in the first paragraph and deletes outdated information. 3610 15-Minute Unit of Service Defines “person” under No. 2, Service Time. 3620 Daily Unit of Service Updates billable units of service. 3700 Billing Service Components Provided at the Same Time and Billing Day Habilitation Provided at the Same Time as Service Coordination Revises section heading. 3730 Service Coordination and Day Habilitation Provided at the Same Time Adds new section. 3810 Adds new information and deletes outdated material. 3820 Written Service Log and Written Summary Updates section title; adds new information; deletes outdated material. 3850 Example Forms Updates title and adds new information. 4210 General Description of Service Component Defines specialized therapies subcomponents. 4220 Billable Activity Updates billable activities for the specialized therapies. 4230 Activity Not Billable           Updates examples of non-billable activities. 4250 Unit of Service Adds service time information. 4260 Written Documentation Updates documentation required to support a service claim for specialized therapies. 4320 Requirements of Setting Adds retirement age as justification for providing day habilitation at the individual’s residence. 4370 4380 Deletes outdated information and clarifies required documentation to support a service claim for day habilitation.

143 4390 Submitting a Service Claim for Individuals Receiving Supported Employment Deleted. 4420 Billable Activity Updates billable activities for the licensed registered nursing service component. 4430 Activity Not Billable Updates text. 4450 Unit of Service Adds No. 3, Service Time. 4470 Written Documentation Deletes outdated information. 4471.2 Updates billable activities for the licensed vocational nursing service component. 4471.3 Updates examples of non-billable activities. 4471.5 4471.7 4472.2 Updates billable activities for the specialized registered nursing service component. 4472.3 4472.5 4472.7 4473.2 Updates bill activities for the specialized licensed vocational nursing service component. 4473.3 4473.5 4473.7 4540 Supported Home Living Subcomponent Updates rule citations; adds new requirements; deletes outdated information. 4550 Foster/Companion Care Subcomponent Updates rule citations; clarifies requirements for service provider; updates text in No. 5, Restrictions Regarding Submission of Claims for Foster/Companion Care; and clarifies required documentation in No. 8, Written Documentation. 4560 Residential Support Subcomponent Deletes text under No. 1(d), Service Provider Shifts; updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Residential Support; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend. 4570 Supervised Living Subcomponent Updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Supervised Living; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend. 4610 General Description of Service Component Updates information in No. 1, Temporary Provision of Assistance, and No. 2, Room and Board. 4620 Updates rule citations. 4651 Restrictions Regarding Submission of Claims for Respite Adds reasons for which a program provider may not submit a service claim. 4690 Deletes a bulleted item and makes minor wording changes. 4710 Updates definition of supported employment. 4730 Adds transporting individual to and from the individual’s work site as a billable activity for the supported employment service component. 4740 Adds transporting an individual to a job interview as a non-billable activity.

144 4760 Restrictions Regarding Submission of Claims for Supported Employment Deletes outdated information. 4770 Unit of Service Adds No. 3, Service Time 4780 Written Documentation Updates information. 4790 Submitting a Service Claim for Day Habilitation Deleted. 6160 Required Documentation for an Adaptive Aid Updates section reference and removes prior approval requirement. 6170 Prior Approval Authorization for Payment Updates section number; adds new information and deletes outdated text. 6240 Payment Limit 6250 Required Documentation for a Minor Home Modification Removes prior approval requirement. 6260 Updates section number; adds new information and deletes outdated material. Appendix I Billing and Payment Review Protocol Appendix IV Example of Service Delivery Log with Written Narrative Deletes appendix and reserves it for future use. Appendix VII Billable Adaptive Aids Updates abbreviations and number codes. Appendix VIII Instructions for AA/MHM Request for Prior Approval Appendix X Billable Minor Home Modifications Updates abbreviations. Form 4116-Dental, Instructions Home and Community-based Services/Texas Home Living Dental Summary Sheet Deletes outdated information and adds instruction for signature/date line. Form 4116-MHM-AA, Instructions Home and Community-Based Services/Texas Home Living Minor Home Modification/Adaptive Aids Summary Sheet Deletes outdated information, updates references and adds instruction for signature/date line.

145 Changes to Billing Guidelines
Section Definition Additions Competitive employment — Employment that pays an individual at or above the greater of: (A) the applicable minimum wage; or (B) the prevailing wage paid to individuals without disabilities performing the same or similar work. Comprehensive Assessment: An extensive evaluation of an individual's health status that: (A) addresses anticipated changes in the conditions of the individual as well as emergent changes in the individual's health status; (B) recognizes changes to previous conditions of the individual; (C) synthesizes the biological, psychological, spiritual and social aspects of the individual's condition; (D) collects information regarding the individual's health status; (E) analyzes information collected about the individual's health status to make nursing diagnoses and independent decisions regarding nursing services provided to the individual; (F) plans nursing interventions and evaluates the need for different interventions; and (G) determines the need to communicate and consult with other service providers or other persons who provide supports to the individual.

146 Changes to Billing Guidelines
Section Definition Addition Focused Assessment: An appraisal of an individual's current health status that: (A) contributes to a comprehensive assessment conducted by a registered nurse; (B) collects information regarding the individual's health status; and (C) determines the appropriate health care professionals or other persons who need the information and when the information should be provided. Integrated employment — Employment at a work site at which an individual routinely interacts with people without disabilities other than the individual's work site supervisor or service providers.

147 Changes to Billing Guidelines
Section 3000 Supported Employment/Day Habilitation Division of Time Between Individuals Service Coordination & Day Habilitation Written Documentation for non-nursing services Other Changes to Section 3000

148 Changes to Billing Guidelines
Section 4000 Specialized Therapies Definitions Video Conference Day Habilitation In-Home Exception Time Change Supported Employment Dual Billing Removal Nursing (See Next Slides) Residential Services (See Next Slides) Respite Clarification Supported Employment Transportation included

149 Changes to Billing Guidelines
Section 4400 – Nursing Services Registered Nursing Assessments & Comprehensive Assessments Medication Review Insurance Provider Communication Supervising LVN (RN can only bill) Licensed Vocational Nursing Focused Assessments

150 Changes to Billing Guidelines
Section 4500 – Residential Services Foster Care & Supervised Living No Significant Changes Residential Support Services Service Provider Shifts Off Duty Requirement No Shifts of More than 24 Hours Supported Home Living Safety & Supervision No Volunteer Hour Limit

151 Changes to Billing Guidelines
Section 6000 Adaptive Aids Prior Approval Removal Authorization for Payment Requirements Minor Home Modifications

152 Changes to Billing Guidelines
Other Changes Guideline Format Billing and Payment Review Process Form Updates 2122 Service Delivery Log with Written Narrative/Written Summary 2124 Community Support Transportation Log 4116-Dental Dental Summary Sheet 4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet 4117 HCS Supported Employment Service Delivery Log 4118 HCS Respite Service Delivery Log 4119 HCS Residential Support Services (RSS) and Supervised Living (SL) 4120 HCS Day Habilitation (DH) 4121 HCS Supported Home Living 4122 Foster/Companion Service Delivery Log

153 Guide to Purchasing Adaptive Aids & Minor Home Modifications
Vivian Griffor, Billing and Payment Team Leader

154 Adaptive Aids & Minor Home Modifications
Documentation required before purchasing any AA/MHM: Written assessment Not required for AA under $500 or MHM under $1000 Individual and Program Provider Agreement Three Bids 3 bids are required no matter the cost need an explanation if 3 bids have not been obtained Proof of non-coverage by private insurance, Medicare, and Medicaid (AA only-as applicable)

155 Adaptive Aids & Minor Home Modifications
The Written Assessment must: be based on a face-to-face evaluation be done in the home if a MHM is being requested be done by a qualified medical professional- See Appendix VII for Adaptive Aids & Appendix X for Minor Home Modifications include a description of AND a recommendation for the specific AA/MHM being requested

156 Avoid These Common Errors
Assuming that a recommended item is a covered item **Obtaining an assessment that is not current **Obtaining an assessment that does not contain sufficient medical justification Assuming that a doctor’s prescription is sufficient **Obtaining an assessment that is not legible **Obtaining an assessment done by an unauthorized professional

157 Adaptive Aids & Minor Home Modifications
Individual and Program Provider Agreement Must consider the written assessment document any discussion about the recommended item(s) agree that the recommended item is necessary and should be purchased document their agreement in writing

158 Avoid These Common Errors
Failure to include signatures Team meeting/Staffing/Individual and Program Provider Agreement Failure to document discussion of need for item requested

159 Adaptive Aids & Minor Home Modifications
Bids : Three (3) bids are required, regardless of cost Bids must be comparable (for like or very similar items) Bids must state the total cost of the requested AA/MHM and, if it includes more than one AA/MHM, state the itemized cost of each AA/MHM listed by service code Bids must include the name, address and telephone number of the vendor/contractor

160 Adaptive Aids & Minor Home Modifications
Exceptions to bid requirements: Less than three bids for an AA/MHM may be acceptable IF there is written justification stating the AA/MHM is available from only a limited number of vendors/contractors A single bid from the custom fitting vendor is acceptable for eyeglasses (220), hearing aids, batteries and repairs (260) and orthotic devices, orthopedic shoes, and braces (107)

161 Adaptive Aids & Minor Home Modifications
Annual Vendor: Will there still be an Annual Vendor? Yes. A Program Provider: May be exempted from bid requirement for frequently purchased consumable items with an approval for Annual Vendor status Will submit application for Annual Vendor by January 31 for current calendar year

162 Avoid These Common Errors
Failure to obtain three bids (no justification)* Obtaining bids that contain items not recommended in the assessment** Obtaining bids that contain items not covered on the waiver** Obtaining bids that are not for the same item or list of items**

163 Adaptive Aids & Minor Home Modifications
Pursuing alternate funding sources: Written proof of non-coverage from Medicare/Medicaid must be obtained for any AA denoted with a (1) or (2) on the “List of Billable (Reimbursable) Adaptive Aids”

164 Avoid These Common Errors
Obtaining a statement by a DME vendor that an item is not covered** Obtaining a denial letter that indicates that insufficient documentation was submitted with claim** Obtaining a Medicaid denial letter that indicates that consumer is eligible for Medicare (primary)**

165

166 Adaptive Aids & Minor Home Modifications
Submit reimbursement claims (4116) to: DADS Provider Claims Services PO BOX MC W-400 Austin, TX For questions contact Provider Claims Services at option 5

167 Additional Information
Manager Misti J. Ackermann HCS Team Leaders Vivian Griffor -Adaptive Aids Contact Willie Mae Jones D. Sam Montgomery Virginia Sifuentes Julia Solis – Cost Report Contact Program Specialists Karri Henager Jeff Rehagen Stephanie Santos-Vela Nikolaos Vekris– Cost Report Contact Additional Information Billing and Payment & Hotline  [ ] Fax   Mailing Address Department of Aging and Disability Services Community Services, Billing and Payment PO BOX , Mail Code W-200 Austin, Texas


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