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1 Iowa Medicaid Enterprise Welcome to Remedial Services Provider Training.

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Presentation on theme: "1 Iowa Medicaid Enterprise Welcome to Remedial Services Provider Training."— Presentation transcript:

1 1 Iowa Medicaid Enterprise Welcome to Remedial Services Provider Training

2 2 Agenda Introduction of Remedial Services Provider program Remedial Services processes Billing services on the CMS 1500

3 3 Iowa Medicaid Enterprise Remedial Services

4 4 Remedial Services: –Enhance functional abilities –Recommended by the LPHA What are Remedial Services?

5 5 LPHAs must be Iowa Plan Providers Physicians (MD or DO) Psychologists (PhD or PsyD) Licensed Independent Social Workers Licensed Mental Health Counselors Licensed Marital & Family Therapists Licensed Master Social Worker (employed in a mental health center) Advanced Registered Nurse Practioners Each must practice within scope of licensure

6 6 Role of LPHA Completes face-to-face assessments Makes the diagnosis and treatment suggestions (which may include remedial services) Orders remedial services when indicated Assists with referral to remedial provider if requested

7 7 Remedial Service Providers (RSP): Current Adult Rehab Option providers Current RTSS providers Agencies accredited under Chapter 24 of IAC

8 8 Role of Remedial Service Providers Develop a remedial service implementation plan when requested by a member Obtain Prior Approval for Remedial Services from IME Medical Services Provide services as written in the plan, if requested by the member Document services/interventions to support remedial services and billing

9 9 RSP Codes - Children CodeDescription 96152Health and behavior intervention, 15 minute/individual H2011Crisis Intervention, 15 minute individual 96153Health and behavior intervention, 15 minute/group 96154Health and behavior intervention, 15 min-family H0037Community Psychiatric Supportive Treatment, per diem

10 10 RSP Codes – Adults CodeDescription H2014Skills Training and Development, per 15 minutes H2001Rehabilitation Program, per half day

11 11 Remedial Services May Include: Anger Management Behavior Management Relationship Skills Communication Skills Problem Solving Skills Conflict Resolution Skill Rehearsal Social Skills

12 12 Remedial Service Implementation Plan

13 13 Demographics Member name Member address Member date of birth Member Medicaid number Remedial services provider name RSP affiliation/company name RSP Provider number

14 14 RSP Provider address LPHA Name LPHA Affiliation/Company name LPHA Address Legal representative (if applicable) Legal representatives relationship to member Address of representative Demographics (cont)

15 15 Remedial Service Plan Requirements Remedial service implementation plan is consistent with LPHA order Plan addresses mental health symptoms/behaviors, IAC 441-78.42(249A) Plan is remedial and individualized Member/family strengths are incorporated into the interventions

16 16 Roles and responsibilities are identified Services/treatment are consistent with practice guidelines Plan reflects member and/or legal representative Goals and objectives are measurable and time limited Treatment outcomes are specified Plan Requirements (cont)

17 17 Remedial Services Process Medicaid members seek out or are referred to LPHA LPHA completes assessment, diagnosis LPHA orders remedial services if/ when indicated Orders for remedial services must include: –Diagnosis –Scope (remedial procedure codes) –Number of units –Duration of services (begin & end dates)

18 18 Member selects an RSP LPHA provides a copy of the order (treatment plan) to member and forwards a copy to RSP RSP develops remedial service implementation plan if requested by the member Remedial Services Process (cont)

19 19 RSP emails/faxes order complete with the diagnosis & remedial service implementation plan to IME Medical Services Medical Services will respond within 2 business days Medical Services will send Notice of Decision to member and RSP Remedial Services Process (cont)

20 20 RSP documents services and progress notes as required to support service intervention and billing Remedial services implementation plans will be authorized for up to six months Remedial Services Process (cont)

21 21 Progress Notes Member name and Medicaid ID number Date and amount of services delivered with beginning and end times Name of staff providing service & agency name Staffs signature with title Service setting

22 22 Description of the specific service and relationship to goal Description of the members response to service and progress toward goal Recommended revision in intervention/services, as appropriate Progress Notes (cont)

23 23 Continuing Services Criteria If behaviors/symptoms continue, then plans are revised to maximize treatment Member is benefiting from services New behavior/symptoms requiring remedial services are identified

24 24 Discharge Criteria Remedial goals/objectives are achieved Age appropriate functioning is achieved Member is not compliant with remedial services Member is not benefiting from services

25 25 Quality Review Process Quality review will evaluate documentation as follows: –Member demographics; emergency and crisis information, releases –LPHA diagnosis and order (treatment plan) –Member functional assessment information sufficient to support remedial service implementation plan

26 26 Quality Review Process (cont) Evidence of collaboration with other community resources Documentation of member/members guardian participation in treatment planning Remedial services implementation plan is individualized Plan goals and objectives are measurable and time limited

27 27 Quality Review Process (cont) Roles and responsibilities for services are identified Plan is implemented as written Documentation of referrals for further evaluation if needed Ancillary services identified Billing matches progress notes

28 28 Quality Review Will Evaluate: Time from member referral to remedial treatment plan development Continuity of treatment Affiliation of LPHA to RSP Gaps in service

29 29 Quality Review will Evaluate: Achieved treatment results Member satisfaction with services Results of quality review will be compiled with copies submitted to providers and IME Policy Medical Services will offer RSP quality improvement training and education

30 30 Remedial Services Contact Information IFMC (Medicaid) PO Box 36478 Des Moines, IA 50315 800-383-1173 or 515-725-1008 local Fax 515-725-0931

31 31 Iowa Medicaid Enterprise Billing Services to the IME

32 32 (Eligibility Verification System) Eligibility Verification System (ELVS) Verify member eligibility for todays date or past date of service. Verify member enrollment with the Iowa Plan. Member eligibility can be verified by date of birth – ddmmyyyy and social security number or the State ID number. Access your last payment amount and date. 800-338-7752 515-323-9639 (Local)

33 33 Electronic Claim Submission Electronic Date Interchange Support Services (EDISS) –800-967-7902 9 AM-5 PM EDI paperwork must be completed and forwarded to EDI for enrollment Find forms at, follow directions in the Tool Box PC-ACE Pro: free software

34 34 Billing Information Mailing address for all claims from RSP: Iowa Medicaid Enterprise (IME) PO Box 150001 Des Moines, IA 50315 Provider Services phone numbers: 800-338-7909 515-725-1004 Monday – Friday 7:30 AM -4:30 PM

35 35 IME Contacts for Claims Medicaid Claims P. O. Box 150001 Des Moines, Iowa 50315 Provider Correspondence P. O. Box 36450 Des Moines, Iowa 50315 E-mail:

36 36 IME Phone Numbers PROVIDER SERVICES 7:30 AM – 4:30 PM 800-338-7909 515-725-1004 (Local) MEMBER SERVICES 8:00 AM – 5:00 PM 800-338-8366 515-725-1003 (Local) ELVS (Eligibility Verification System) 24 Hours a Day/7 Days a Week 800-338-7752 515-323-9639 (Local) PROVIDER AUDITS AND RATE SETTING 8:00 AM – 5:00 PM 866-863-8610 515-725-1108 (Local)

37 37 Billing Tips IME suggests that claims should be billed no more often than once per month CMS 1500 claim forms must be used and correctly completed IME payment cycles are weekly

38 38 Completing the Claim Form Discussion of each required box –Detailed instructions are included in the handout –Many boxes are not required or are optional –Ensure all required boxed are correctly completed or the claim will not pay

39 39 Claim Submission Issues Use original claim forms, do not make copies Do not use red or light colored ink Do not use highlighter of any color Position data in the center of each box, not touching any red line

40 40 Submission Issues (cont) Diagnosis codes (ICD-9) and CPT codes cannot include description on the form Column E Diagnosis Code must have the corresponding number from box 21, not the actual diagnosis code Indicate both dollars and cents for sub-charge and total charge. Limit the use of handwritten information

41 41 Timely Filing Guidelines Original claim submissions must be filed within 12 months of the through date of service. If the claim was filed timely but denied, then it can be resubmitted up to 12 months from the remit denial date. Claims after 12 months must be filed on paper with resubmission and the original filing date in the signature box. Adjustments can be filed within 12 months of the payment date.

42 42 Credit/ Adjustment Requests Used to change information on a paid claim: –Paid amount needs to be changed –Number of units needs to be changed –Dates of service need to be changed Complete form correctly and entirely Form #470-0040 found on the IME Website Must be filed within 12 months of payment

43 43 Reimbursement Interim rates on DHS web site –By agency –By service Based on current information Cost report- due 3 months after agency fiscal year end Cost settlement Interim rates recalculated

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