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HCBS Fall Quarterly HCBS News 211 IFA Website Change QA Forms for ISIS Changes Children and SCL LOC Assessment Changes Elderly Waiver Case Management Rule.

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Presentation on theme: "HCBS Fall Quarterly HCBS News 211 IFA Website Change QA Forms for ISIS Changes Children and SCL LOC Assessment Changes Elderly Waiver Case Management Rule."— Presentation transcript:

1 HCBS Fall Quarterly HCBS News 211 IFA Website Change QA Forms for ISIS Changes Children and SCL LOC Assessment Changes Elderly Waiver Case Management Rule Changes – 11/01/06 LOC Cost Changes

2 HCBS News Northeast Iowa position filled!!! Mae Hingtgen has joined the HCBS waiver staff: –Former CPC for Cherokee County –Certified trainer for personal futures planning – Phone: 563-690-0482

3 211 IOWA The state has an information and referral database of health and human resource services This system can be accessed by dialing 211 Shareholders can call the service to request assistance in finding providers and/or resources for specific services Providers can add their services to the database and can also edit the information if services change.

4 SW/CM QA Requests for ISIS Changes Common Errors: Not verifying info against My Reports in ISIS Information provided on QA is not how it appears in ISIS or is incomplete Adding services without checking what is currently on the plan in ISIS sos Ms Lezlie

5 SW/CM QA Requests for ISIS Changes Common Errors: Entering new rate info without entering end date of old rate info Requesting new end date for respite without reducing units of service to the # of hours actually used Not checking for accuracy of the QA form before submitting Ms. Lezlie

6 QA Tips When adding a new service, complete all fields of the entire correct information line. When making changes to existing services, complete the entire information currently shown on ISIS system line. Then, on the correct information line directly below, fill in only the blanks that should be different than what you just entered on the line above. If deleting a service, enter the info as it appears in ISIS on the information currently shown on ISIS system line. Leave the correct information line blank.

7 Other QA info Please email all QA requests. Do not mail or fax. At the bottom of the QA form, there is a submit button to send the info directly to HCBS via email.

8 Questions about QAs? Call or email Lezlie Tate at HCBS (515) 725-1133 OR

9 Iowa Finance Authority (for info on the HCBS rent subsidy program) NEW ADDRESS & WEBSITE: 2015 Grand Avenue Des Moines, IA 50312 Phone: (515) 725-4900 or (800) 432-7230 Fax: (515) 725-4901 Website:

10 Children and SCL SCL can not be used for child care, parenting, supervision and monitoring of a child SCL goals must relate to the childs needs and the goal must be implemented during the service provision time Example: A child has a goal to learn how to make purchases in the community. The child goes with provider staff and purchases a ticket to a movie. Only the time involving the purchase of the ticket is goal related. If the consumer and staff attend the movie and there is no goal relating to the need for staff during the movie, other than supervision, then only the ticket purchasing time can be billed as SCL

11 Elderly Waiver Case Management

12 EW and CM Services October 1, 2006, case management became a covered Elderly Waiver service. CM providers that meet one of the following qualifications may enroll as a EW CM provider: –77.33(16)a(1-6): An agency or individual that is: –Accredited by the MH, MR, DD, and BI commission as meeting standards for CM services in 441 – Chapter 24; –Or is accredited through JACHO to provide CM; –Or is accredited through CARF to provide CM; –Or is accredited through The Council to provide CM –Or is approved by the DEA as meeting CM standards in 321 – Chapter 21 –Or is approved by the DPH as meeting CM standards in 641-Chapter 80

13 Consumer Process for EW CM All individuals applying for the EW will be given a choice of EW case management providers DHS SWs will no longer be involved in EW cases IMW status will stay the same and IMWs will inform consumers of entities enrolled for EW CM Once notified, the EW CM entity will contact the consumer and assist in completing the assessment tool

14 EW CM Responsibilities IAC 44178.37(16) a (1-8) CM services shall include: –A comprehensive assessment of the consumers needs, which must be made within 30 days of referral to CM –Development/implementation of a service plan to meet those needs –Coordination, authorization, and monitoring of all services –A face-to-face meeting at least quarterly –Monitoring of the consumers health, safety, and welfare –Evaluation of outcomes –Periodic reassessment and revision of the service plan as needed, but at least annually –Assurance that consumers have a choice of providers

15 Other EW CM Guidelines Case management does not include the provision of direct services by the CM Payment for CM will not be made until the consumer is enrolled in the waiver – payment for CM activities for the consumer shall only be made during a month when the consumer is enrolled in EW A unit of service is one month A unit of service is reimbursed at $70 per mo The $70 is not part of the LOC dollars

16 EW CM Requirements EW CMs will develop the comprehensive service plan which contains the following: –Observable or measurable individual goals –Interventions and supports needed to meet goals –Incremental action steps, as appropriate –The names of staff, people, businesses, or organizations responsible for carrying out the goals –The desired individual outcomes –The identified activities to encourage the consumer to make choices, experience achievement, to modify to continue participation in the treatment process –Description of any rights restrictions, including the need for the restriction and the plan to restore the rights

17 EW CM Service Plan Requirements EW CMs will develop the comprehensive service plan which contains the following: –A list of all Medicaid and non-Medicaid services the consumer received at the time of the waiver program enrollment that includes: The name of the service provider for the service The funding source for the service The amount of service that the consumer is to receive –Indication of whether the consumer has elected the consumer choice option and, if so, identification of ISB and FMS –The determination that the service authorized in the plan are the least costly

18 EW CM Service Plan Requirements The service plan must contain a plan for emergencies. This plan shall identify supports available to the consumer in situations for which no approved service plan exists and which, if not addressed, may result in injury or harm to the consumer or other persons or in significant amounts of property damage. The emergency plan shall include: –The consumers risk assessment and health and safety issues identified by the IDT –The emergency backup support and crisis response system identified by the IDT –Emergency, backup staff designated by the providers for applicable services

19 NOD Requirements Guidelines for Notice of Decisions are defined in XVI K Manual for DHS. Go to Click on Manuals – click on Social Services – then click on Health Related Services – scroll down to XVI K – Medicaid Waiver Services and click. Page 30-31 contains the requirements for NODs Pages 37 – 38 defines adverse actions for NODS. The right to appeal an adverse action should be included with the NOD.

20 Level of Care Assessments

21 Effective September 1, 2006, LOC determination for the AIDS/HIV, I&H, EW, and PD waivers have been redeployed to SW/CMs –SW/CMs coordinates the completion of LOC form for HCBS (form 470-4392) by the medical profession with the consumer and/or family –The Medical professional will fax the form to IME Medical Services Unit at (515) 725-1355 –An electronic template of the form is available at: –The IME Medical Services nurse reviews will determine the LOC and notify the SW/CM through ISIS LOC responsibilities for the MR & BI, Waivers stay the same.

22 LOC Assessments for EW, A/H, PD, and I&H Completing LOCs is now the responsibility of a medical professional working with the consumer Medical professional is defined as: –Physician (MD) –Doctor of Osteopathic Medicine (DO) –Physicians assistant (PA) –Advanced registered nurse practitioner (ARNP) The SW/CM coordinates the completion of the LOC form with the consumer and family members

23 LOC Increases (effective12/1/06) Ill and Handicapped: Skilled NursingICF/MR Old $2480 $852 $3019 New $2554 $878 $3110 Elderly: SkilledNursing Old $2480$1052 New $2554$1084

24 Monthly Cost Increases Brain Injury : Old $2650 New $2730 AIDS/HIV: Old $1650 New $1700 Physical Disability Old $621 New $640 Children's Mental Health Old $1765 New $1818

25 Fiscal and Clinical Records HCBS

26 New Rules for Financial and Clinical Records – 11/1/06 Effective November 1, 2006, rules have changed under IAC 441-79.3(249A). This code section clarifies rules regarding financial and clinical records Provider accountability for these records is tightened These rules will be used to determine recoupment $$$ for waivers

27 Provider Service Documentation Financial (fiscal) records Medical (clinical) records Maintaining records Availability of records

28 Financial Records 79.3(1) Financial (fiscal) records: –A provider of service shall maintain records as necessary to: Support the determination of the providers reimbursement rate under the medical assistance program and; Support each item of service for which a charge is made to the medical assistance program. These records include financial records and other records as may be necessary for reporting and accountability. –A financial record does not constitute a medical record.

29 Medical Records 79.3(2) Medical (clinical) records –A provider of service shall maintain complete and legible medical records for each service for which a charge is made to the medical assistance program, except as provided in paragraph 79.3(2) d –Medical record = a tangible history that provides evidence of: The provision of each service and each activity billed to the program; and First and last of the member receiving service

30 Medical Records The purpose of the medical record shall provide evidence that the service provided is: –Medically necessary; –Consistent with the diagnosis of the members condition; and –Consistent with professionally recognized standards of care

31 Medical Records The medical records shall consist of the following components: –Identification. The medical record shall contain demographic information about the member receiving services. Each page of the medical record shall contain: The members full name. The members date of birth. The members medical assistance identification number.

32 Medical Records Basis for service. The medical record shall reflect the reason for performing the service or the activity. Documentation may include one or more of the following, as applicable to the service being provided: –The members complaint or symptoms. –The members history. –Examination findings. –Diagnostic test results. –Goals or needs identified in the members plan of care. –The observers assessment, clinical impression, or diagnosis, including the date of the observation and the identify of the observer.

33 Medical Records Service Documentation. The record for each service encounter shall include information necessary to support each item of service reported on the medical assistance claim form (billing form). The documentation shall identify the following: –The specific procedures or treatments performed. –The date and the beginning and ending time when the service was provided. –The location where the service was provided. –The name, dosage, and route of administration of any medication administered. –The first and last name and title of the person providing the service. –The signature of the person providing the service.

34 Medical Records The medical record shall contain the outcome of service. The medical record shall indicate the members progress in response to the services rendered, including any changes in treatment, alteration of the plan of care, or revision of diagnosis.

35 Medical Records Exceptions. A provider of products, goods, or ancillary services is required to maintain limited medical records that include a prescription or service plan notice of decision for the provision of goods and services. –Ancillary services means the following home and community-based waiver services: Chore service. Financial management. Transportation. Home and vehicle modifications. Personal emergency response systems. Home-delivered meals.

36 Medical Records – Ancillary Services Ancillary services – Providers of products, goods, or ancillary services shall maintain a financial record for each service encounter that includes the information necessary to support that each item reported on the medical assistance claim form (billing form) was properly authorized and delivered. At a minimum, the record shall include: –Date and time of service. –The specific product, good or service provided.

37 Medical Records – CDAC Forms – a provider of home-and community- based consumer directed attendant care service may meet the requirements by completing the following forms: –Form 470-4388 – Skilled Consumer-Directed Care Services, for skilled care; –Form 470-4389 – Unskilled Consumer-Directed Care Services, for unskilled services; and –Form 470-4390 - Consumer-Directed Attendant Care Addendum, as necessary.

38 Records Maintenance IAC 44179.3(3) Maintenance requirement for records. The provider shall maintain records as required by this rule: –During the time the member is receiving services from the provider. –For a minimum of five years from the date when a claim for the service was submitted to the medical assistance program for payment. –As may be required by any licensing authority or accrediting body associated with determining the providers qualifications.

39 Records Availability IAC 44179.3(4) Availability. The provider shall make supporting fiscal and clinical records available to the department or its authorized representative upon request. –Submission of records for review or audit. Upon written request for records, the provider must submit all responsive records to the department or its authorized agent within 30 days of the mailing date of the request – except when an extension is granted.

40 Records Availability - Extensions IAC 44179.3(4) b – Extension of time limit for submission. The department may grant an extension to the required submission of up to 15 days upon written request from the provider or the providers designee. The request must: –Establish good cause for the delay in submitting the records; and –Be received by the department before the date the records are due to be submitted.

41 Extensions – Exceptional Circumstances 79.3(4)b(2-4) – Under exceptional circumstances, a provider may request on additional 15-day extension. The provider or the providers designee shall submit a written request that: –Establishes exceptional circumstances for the delay in submitting records; and –Is received by the department before the expiration of the initial 15 – day extension period. The department may grant a request for an extension of the time for submitting records at its discretion. The department shall issue a written notice of its decision. Providers may appeal the departments denial of an extension in accord with 441Chapter 7.

42 Fiscal and Clinical Records Failure to provide records – 441-79.3(4)c-d –Records that are not received within the initial 30-day period or within an extension granted pursuant to 79.3(4)b shall not be accepted or considered in any decision by the department regarding claim denial or recoupment. –Access to records during a site review – the department may elect to conduct an announced ( as little as 1 day notice) or unannounced on-site review or audit. There is no notice requirement for an unannounced audit. Records must be provided on request and before the end of the on-site review. The conclusion of the review or the audit shall be considered the end of the period to produce records.

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