1. Medicaid Billing Module Transportation Billing Form

2. Transportation Billing Form Demographics Section Medicaid NumberLast NameFirst NameCountySchool WVEIS #Diagnosis CodeDate of BirthMonth/YearVehicle Type Modified

3. Demographics Section Complete the top row of demographic information using the county and school codes. On the bottom row fill in the full WVEIS #, Diagnosis Code should be left blank until further notice, date of birth and the Month and Year for billing. The billing form cannot have data from multiple months.

4. Transportation Billing Form Demographics Section EXAMPLE Medicaid NumberLast NameFirst NameCountySchool 00000000001DoeJane058301 WVEIS #Diagnosis CodeDate of BirthMonth/YearVehicle Type 999999999 01-01-1900 August 2015 Modified

5. Procedure Code and Instruction

6. Procedure Code Section Check the line next to T2001 SE for modified bus with an aide. This is used for a bus with a lift only. This procedure is for a one way trip. (We no longer need round trips to bill.) Typically you can bill two trips per instructional day. If a student is taken to a billable service during the instructional day you could bill up to four trips in a day.

7. Procedure Code Section Procedure Code T2002 SE is only used for a modified bus (with a lift) that doesn’t have an aide. Unlikely you will have any billable trips for this code. If using this code complete the mileage column instead of start and stop times.

8. Data Entry Section Date Departure Location Arrival Location Start Time Stop TimeMileage Purpose: To provide access to the following billable service(s).

9. Data Entry Section For Procedure T2001 SE the aide or driver will complete the first five columns per one-way trip. Mileage is not needed and should be left blank The last column will be completed by staff at the school, county or RESA level.

10. Data Entry Section Date: Enter the date of the trip Departure Location: Enter home or school Arrival Location: Enter home or school Start Time: Document the time the student boarded the bus. Stop Time: Document the time the student exited the bus. Start and stop times must be actual times each day not the regularly scheduled times. Actual times will vary based upon weather, traffic, and other factors.

11. Data Entry Section Date Departure Location Arrival Location Start Time Stop TimeMileage Purpose: To provide access to the following billable service(s). 8-17-15HomeSchool7:327:50 8-17-15SchoolHome2:553:18

12. Data Entry Section If a student was transported to RESA for an Audiology Evaluation during the school day with a modified bus and aide you could document this as follows.

13. Data Entry Section Date Departure Location Arrival Location Start Time Stop TimeMileage Purpose: To provide access to the following billable service(s). 8-17-15HomeSchool7:327:50 8-17-15SchoolHome2:553:18 8-18-15 HomeSchool7:307:50 8-18-15SchoolRESA 89:3010:15 8-18-15RESA 8School11:3012:15 8-18-15 SchoolHome2:553:25

14. Data Section Purpose Column This section will be completed by an employee who has access to the student’s completed billing forms for the month. Enter the billable service provided for trips that match the date of service If there was not a billable service for a trip date enter NA Only one billable service needs to be entered per trip.

15. Data Entry Section Billable services include: Speech, Occupational Therapy, Physical Therapy, Audiological, Nursing, Personal Care, Psychological (testing or psychotherapy) and Targeted Case Management (TCM).

16. Data Entry Section Date Departure Location Arrival Location Start Time Stop TimeMileage Purpose: To provide access to the following billable service(s). 8-17-15HomeSchool7:327:50 NA 8-17-15SchoolHome2:553:18 NA 8-18-15 HomeSchool7:307:50 Speech 8-18-15SchoolHome2:553:25 Speech 8-19-15HomeSchool7:327:50 TCM 8-19-15 SchoolHome2:553:22 TCM

17. Data Entry Section After completing the purpose column fill in the number of total trips, total billable trips, and total non-billable trips. This information will be used by the financial department for year end calculations.

18. Data Entry Section Date Departure Location Arrival Location Start Time Stop Time Mileage Purpose: To provide access to the following billable service(s). 8-17-15HomeSchool7:327:50 NA 8-17-15SchoolHome 2:553:18 NA 8-18-15HomeSchool7:30 7:50 Speech 8-18-15SchoolHome2:553:25 Speech 8-19-15HomeSchool7:327:50 TCM 8-19-15SchoolHome2:553:22 TCM Total Trips 6Total Billable Trips 4Total Non-Billable Trips 2

19. Signatures and Credentials Driver is required to sign this form. Driver credential is Bus Driver Aide is required to sign this form. Aide credential is the classification of employment such as Aide I, Aide II, Aide III.

20. Attendance Verification It is important to verify that the student was present in school on the day that billable trips were listed. Compare attendance logs to ensure accuracy. A student could have a tardy, early departure, or a half-day absence and still have one billable trip.

21. Terry Riley – Coordinator Office of Special Education tjriley@k12.wv.us 304-957-9833 ext 53223 WVDE Medicaid Website: http://wvde.state.wv.us/osp/medicaid.html tjriley@k12.wv.us http://wvde.state.wv.us/osp/medicaid.html