Why Are Outcomes Important? Outcomes must be established to move our participants towards greater independence in the community in which they live. A team consisting of supports coordinators, program specialists, house supervisors, direct care staff, family members and the participant establish these outcomes. The outcomes then must be implemented and documented by direct care staff. The implementation and documentation of these outcomes justifies NAMSC billing for residential services. In other words, this is how NAMSC receives payment for services provided to our participants.

Changes In Billing Procedures In the past agencies such as NAMSC were paid a lump sum for each participant annually by Allegheny County MH/MR. This is who NAMSC billed for services that were provided by NAMSC to our participants. The Office of Developmental Programs (ODP-State) instituted a new billing procedure; Fee-For-Service (FFS). This means NAMSC only receives payments for services that NAMSC actually provides to our participants.

Changes in Billing Procedures (cont). Fee-For-Service was implemented to assist ODP in saving funds due to increasing budgetary restraints. As Fee-For-Service becomes more prevalent, it is necessary for NAMSC to document the type of service(s) billed and the amount of service(s) utilized. This documentation must include the minimum requirements necessary to validate service provision and billing.

Changes in Billing Procedures (cont). If our participants are at camp, with their families, or in the hospital; NAMSC does not receive payment for the time that they are not in our care. Our participants must be in residence for 12 hours daily in order for NAMSC to be paid for services rendered.

What are Provider Responsibilities? To accept responsibility for the accuracy of all claims submitted. Must assure that services were rendered to each participant as written in his/her approved ISP. Are required to comply with all Federal & State auditing requirements. Will maintain records that fully describe the nature and extent of services provided. Records must separately identify waiver participants and services.

What are Provider Responsibilities (cont)? Will preserve these records until the expiration of four years after the waiver-funded service is furnished. Will restrict the use of disclosure of information concerning waiver participants to purposes directly related to the administration and implementation of the ISP. Will give full and free access to any records pertaining to waiver participants, services, and payments for services to: The Commomwealth, US Controller General and the US Dept. of Health & Human Services.

. What are Provider Responsibilities (cont)? Must maintain written policies for retention and access to records. The records retention policy must be consistent with waiver requirements. All records & progress notes must be available to the: -Supports Coordinator -Supports Coordination Entity -Administrative Entity (AE) -Office of Developmental Programs (ODP) -US Dept. of Health & Human Services

How Do Providers Maintain Information? The following information shall be maintained in electronic or paper copy in order to document that service was delivered and a valid invoice/claim was submitted to the Administrative Entity: o Date of Service o Name of Individual o Documentation that services provided are approved in the ISP.

How Do Providers Maintain Information (cont)? Information that substantiates that services listed in the ISP are the services provided & being billed for. When applicable, if multiple staff provides multiple service(s), there should be evidence of staff time to support the invoiced ratio. Staff records and/or timesheets shall provide documentation and substantiate hours worked.

Requirements of Progress Notes Progress notes are written reports in paper or electronic form that detail how the provider’s support assists the individual to achieve an approved plan outcome and/or how lack of progress in achieving the outcome will be remedied.

Requirements of Progress Notes (cont). A progress note must be maintained, at minimum, in accordance with the following frequency: Documentation must be done each time non- consecutive services are rendered. Intermittent services are periodic, non-consecutive, approved services. This includes services provided by licensed professionals such as physical therapy, occupational therapy, speech therapy, as well as habilitation and employment services.

Requirements of Progress Notes (cont). Activity for non-intermittent services can be supported by a single, monthly note if the documentation substantiates that the services were provided within the billing period. Non-intermittent services are continuous, consecutive, approved services. This includes services that are scheduled on a regular basis, such as residential habilitation, prevocational services, and licensed day services. Progress notes are required for each calendar month, at a minimum, regardless of whether services are intermittent or non-intermittent.

Requirements of Progress Notes (cont). Documentation of service activity to support each unit is not necessary unless there is a variation from the approved ISP, or the ISP critical revision. The ISP Planning Process Participant’s Signature Page for the original ISP can be utilized in lieu of a signature from the individual for each service and date of service.

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