1. Proper Billing for Services Provided
Rules for Billing
&
Distinguishing Between Billable vs. Non-Billable Activities
Tracking of Billable units
Proper Billing for Services Provided

2. The Office of Long term Living New Regulation
On May 19th, 2012, OLTL implemented regulation 55Pa Code Chapter 52. This regulation established provider qualifications and payment provisions for providers rendering services under state programs
On February 7, 2013 OLTL issued a Billing Instructions Bulletin
The new regulation and bulletin applied to all Home and Community-Based waiver providers who are enrolled in the Medical Assistance (MA) Program and receive payments for providing services as authorized in participant service plans in the following state programs:
Aging
Attendant Care
Act150
CommCare
Independence
OBRA

3. Rules for billing Units
For billing purposes for waiver and vendor services, 15 minutes equals one unit.
HCBS waiver providers are able to bill for one unit when a billable activity occurs for more than 7.5 minutes and the activity must be properly documented.
Start Time
End Time
Number of Units
8:00am
8:15am 1
8:16am
8:30am
8:31am
8:37am
8:38am
8:48am
8:49 am
8:56am
8:57am
9:07am
Total # Billable Units 4

4. Rules for billing Units
Billable units may not overlap for the same participant or across work done for multiple participants in the same day
Start Time
End Time
Number of Units
8:00am
8:15am 1
8:10am
8:30am 2
8:31am
8:37am

5. Rules for billing Units
Billable activites conducted in a consecutive time period can be billed together in one unit or more
Example: numerous phone calls were made to coordinate services and is all done in a consecutive 30 minute time period. This can be billed in 2 15 minute units
Each service billed must be billed under the correct procedure code for that specific service.
Example:
Transition Service Coordination = W7337
Accessibility Adaptations (<6000) = W7008
Accessibility Adaptations (>6000) = W7009
Service Coordination = W1011
The date a service is billed on varies with each service and either needs to be on the date the service was provided or on a date after the service was provided.

6. Rules for billing Units
Annually participants will be authorized for 144 units per year of Service Coordination
Service Coordinators have the flexibility or scheduling the hours that meet the individual needs of each participant
If a participant is unable to have their needs met with in the 144 annual units, OLTL will consider requests for additional units
Requests for additional units cannot be submitted until 75% of the original authorized units have been used
Requests for additional units must be submitted through HCSIS and SAMS
Requests must include justification of why the initial amount was not enough and how the additional units will meet the needs of the participant:
Identify the changes in the participant’s condition, circumstances, informal supports, or any other changes that warrant the request
Provide justification related to the identified changes and how additional service coordination units will meet the identified needs

7. Rules for billing Units
Home Modifications
The Final payment, Billing and Reimbursement cannot be done until the Home Modification is completed and signed off by the Participant
Example:
1st payment issued: 8/24/2013
2nd payment issued: 10/14/2013
Work completed: 12/18/13
Participant signed form stating work was completed: 12/27/13
Final payment issued: 12/28/13
Billing date for total dollar amount: on or after 12/27/13

8. Rules for billing Units
DME Billing
Billing cannot be done until the item has been delivered to the participant
Example:
Item approved in HCSIS: 10/24/2013
Item ordered: 10/25/2013
SC follow up with participant and notified item was received: 11/27/13
Billing date for total dollar amount: on or after 11/27/13

9. Distinguishing Between Billable vs. Non-Billable Activities

10. Service Coordination
Services that will assist individuals who receive OLTL services in gaining access to needed waiver services and other State Medicaid Plan services, as well as medical, social, and other services regardless of the funding source.
Service Coordination is working with the participant whenever possible to identify, coordinate, and facilitate all necessary services
Service Coordination also includes: completion of needs assessment, advocacy, arranging for services from local resources, and coordination of services so a participant can realize his/her identified goals for living independently in the community.

11. Billable Service Coordination Activities
Performing level of care re-determinations annually, or more frequently if needed
Maintaining current documentation of the participant’s eligibility for waiver services, copies of the participant’s individual service plan (ISP) and service plan addendum, financial data and related information
Providing information and assistance to participants regarding self-direction
Informing participants of rights, responsibilities and liabilities when choosing a service model
Monitoring the health and welfare of the participant and the quality of services provided to the participant through personal visits at a minimum of twice per year, telephone calls at least quarterly or as defined in the service plan – monitoring can be more frequent, but not less frequent than specific in this definition

12. Billable Service Coordination Activities
Providing notice of amount and frequency of waiver services
Working with the participant to develop a comprehensive service plan- including risk identification- that meets their needs, preferences and goals
Reviewing the service plan at least once a year or more frequently, if the needs of the participant change
Facilitating the comprehensive ISP development process
Gaining access to needed State Plan and HCBS services, as well as needed medical, social, educational and other services, regardless of the funding source
Tracking and conducting ongoing review of service delivery
Documenting and recordkeeping including contacts with individuals, families and providers
Must complete at least one telephone call or face-to-face visit per calendar quarter. At least two face-to-face visits are required per calendar year

13. Non-Billable Service Coordination Activities
Service provided while the participant is in the hospital, Rehab facility or Nursing Home
Closing out a file after a participant’s death/termination of services. *Unless it occurs on the date of death/termination and they were not in the hospital or NH
Any activities done after a participant transfers to another SC entity
General educational activities – such as training, meetings
Transportation for participants not directly related to service coordination
General information not related to specific participant services
Coordination or outreach prior to participant enrollment in the waiver

14. Non-Billable Service Coordination Activities
Payee or other financial management services
Conducting Medicaid financial eligibility determinations or redeterminations
General program outreach (such as community education programs
Coordinating any burial or funeral arrangements
Travel
Billing OLTL
Any non-program related job responsibilities (ie: completing the non-exceptional incident report, client profile, entering information onto tracking sheets

15. Documentation of Services
Whether a contact was a home visit, telephone call or contact
Whether a participant reported receiving the amount of goods and services specified in the ISP
Whether the participant reported receiving the frequency of services that are in the ISP
Whether the participant reported receiving the type of authorized services specified in the ICP
Whether the participant confirmed that and/or SC concluded that the duration of services in the ISP needs to be continued, extended or concluded

16. Documentation of Services
Whether the participant reported any change in health status or other events (hospitalization, scheduled surgery) or changes that might impact their ability to perform activities of daily living that prompt a need for a temporary or permanent change to service delivery or other follow-up to identify what discharge services are and are not being provided through the participant’s health insurance
Whether the SC had contacts with participants, families or providers
Any communication regarding service plan changes to the participant and the appropriate service provider(s)
Any reminders or prompts given to the participant of ‘next steps’ and/or their responsibilities
The amount of times a participant has utilized their individualized back-up plan and if it is effective

17. What will Occur if documentation, billable units and/or Billing time frames are not entered correctly
OLTL and/or CMS will request documentation to review any discrepancies
If a error is evident, then the following will be requested:
All monies paid for that service in the reviewed time frame that were not entered correctly will need to be paid back to the State
A Corrective Action Plan (CAP) will need to be written and implemented to prevent the error from happening again (this will be submitted to the State)

18. Daily Billing Tracking
To prevent overlaps in billing time frames we will be using a daily billing tracking sheet
This will also assist in tracking the number of billable units your draw down on a daily basis
Participant Name
Comments
Billing activity time frame
Billable time
Entered into UCP logs
Entered into HCSIS
J. Doe
11:49-11:59
.25
R. Wiseman
12:00-12:10
M. Simple
12:11-12:20
L. Love
12:21-12:30
B. Careful
12:31-12:40
A.M. Accurate
12:41-12:49
Total Daily Billable Units
1.5

19. Questions