Billing Case Management

What You Will Learn Review purpose of case management services Learn about case management activities that may be reimbursed as Medicaid Targeted Case Management (TCM) Learn about Medicaid Targeted Case Management (TCM) billing requirements Learn about financial topics you may encounter while working with families

How Learning is Measured Throughout this section, you will be given one activity and one quiz to test your knowledge of billing case management services. – The activity must be completed with 90% accuracy – The quiz must be completed with 90% accuracy

Purpose of Case Management Case management is provided to: – Assist families in accessing and receiving the services, resources, and supports that they need to support their child’s development – Assist families in understanding procedural safeguards and exercising their legal rights – Coordinate services across agencies and providers to meet the needs of the child

What activities are Case Management? Coordination of Evaluations and Assessments Facilitation and participation in development and review of IFSPs Referral and related activities to connect families with needed services Follow up with families to assist with timely access to services Monitoring and reassessment of the child’s services

What activities are Case Management? Informing families of the availability of advocacy services Coordination with medical and other health providers Facilitation of child’s transition to preschool or other appropriate services Explaining Procedural Safeguards and parental rights to the family

What types of contacts are billable? Billable case management contacts performed in the following ways: – face-to-face contact with parent or routine caregiver – telephone contact with parent or routine caregiver

Requirements for Billing TCM Activities that are billable to Medicaid must: – occur when the child is eligible for Medicaid – occur after the child is determined eligible for ECI services – be provided by a qualified service coordinator – be a direct benefit to the ECI eligible child – include face-to-face or telephone contact with the parent or other routine caregiver

Requirements for Billing TCM Documentation contains enough detail to support the time billed Service billed will be 8 minutes or more in length and rounded up or down to the nearest 15-minute increment Service billed in 15-minute increment units Correct procedure codes are used to bill contacts – Modifier (U1) is used to bill face-to-face contacts No documentation = No services occurred

How often do you provide case management services and bill TCM? The frequency and amount of case management services is determined by needs of the child and family Reimbursement of services depends on type of contact and duration of contact

Non-billable Case Management Activities NOT reimbursed by Medicaid as TCM are: Activities provided to children who are not eligible for Medicaid Activities provided to children before ECI eligibility determination Activities provided to other family members and children not eligible for ECI Activities conducted using alternative communication methods such as Skype, texting or telemedicine

Non-billable Case Management Non-billable activities included in the TCM rate: Contacts with other individuals to address the child’s needs when parent or caregiver is not present (collateral contact) Indirect case management activities (staff travel, leaving voice mails) Staff time spent documenting the provision of case management in the child’s record (when parent or routine caregiver is not present)

Billing Resource ECI Reimbursement Guide, Chapter 3.2 ECI extranet, Document Libraries, Third Party Billing

How are case management activities billed to Medicaid? The case management services that you provide that qualify as targeted case management are billed solely to the Texas Medicaid & Healthcare Partnership, referred to as TMHP.

Medicaid Administrative Claiming Case management services provided before a child is eligible for ECI are: considered Service Coordination (not TCM) covered by the Medicaid Administrative Claiming Program (MAC) or your ECI contract

Random Moment Time Study It is a poll of activities which occur at random time intervals over a given time period The results of the poll help determine the work of the entire group Participants are randomly selected to document activity at a certain time interval of one minute Service Coordination = “Pre-eligibility” Case Management, TCM = “Case management”

MAC & RMTS resource ECI Reimbursement Guide, Chapter 4.8 ECI extranet, Document Libraries, Third Party Billing

Activity The Service Coordinator will demonstrate knowledge of case management activities and Medicaid requirements for billing case management activities by completing the activity with 90% accuracy.

Case Management Supporting Activities — Supporting Activities include: Collection of insurance and financial information: Medicaid/CHIP Identification numbers Managed Care Organization phone numbers Private Insurance information – name of the insured parent – Member ID and Group number Family Cost Share Documentation Conduct periodic review of health insurance benefits Does the client still have Medicaid or CHIP? Are there any changes in health insurance?

Case Management Supporting Activities Resources to Verify Medicaid Eligibility  Log on to  Log on to TXMedConnect from the TMHP Web siteTMHP Web site  Call the TMHP Contact Center at  Use electronic card readers Medicaid clients can access their benefits and electronic health records:  Log on to  Call or

Case Management Supporting Activities Supporting activities include talking to families about health insurance coverage and financial topics such as: Texas Medicaid Buy-in for Children How to apply for CHIP Affordable Health Insurance Coverage

Talking to Families about Financial Topics Be aware of the family’s style in communicating financial topics Plan Ahead Do you know why ECI collects financial information from families? How does your program share information about Family Cost Share and insurance? Information about Family Cost Share is available on the DARS ECI website – ECI Family Cost Share ECI Family Cost Share

Talking to Families about Financial Topics Prepare the family for the conversation – What documents does the family need? – Who can provide financial information? – What is the family’s responsibility for participating in ECI? – What are the family’s rights in regards to Family Cost Share?

Talking to Families about Financial Topics What services are covered? Do you have a co-pay? Do you have a deductible? Are there annual or lifetime caps? Who pays the premium?

Talking to Families about Financial Topics Third party coverage, income information and Family Monthly Maximum Payments (FMMP) should not be collected or charged until the family has been informed of the following rights to: – receive certain ECI services at no cost to the family – refuse any ECI services they do not wish to receive – receive information about the methods used to verify income and deductions – receive information about contractor’s process for determining FMMP – request consideration of: calculated adjusted income assigned FMMP parent’s ability to pay the FMMP Refer to 40 TAC Chapter 108 Subchapter N § for more information about Family Cost Share (Texas Administrative Code) (Texas Administrative Code)

TCM Rules and Procedures Provider Requirements and Staff Qualifications – Texas Medicaid Provider Procedures Manual, Vol. 2, Children’s Services Handbook Texas Medicaid Provider Procedures Manual – DARS ECI Rules Subchapter C and D of Chapter 108 in 40 TAC, part 2 DARS Rules for Case Management

What Have You Learned Purpose of case management services Case management activities that may be reimbursed as Medicaid Targeted Case Management (TCM) and requirements for billing these activities Financial topics you may encounter while working with families

Quiz The Service Coordinator will demonstrate knowledge of ECI case management services and the requirements for reimbursement by completing a quiz with 90% accuracy

Congratulations!!! You have completed the online training of the case management module