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Iowa Medicaid Enterprise

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Presentation on theme: "Iowa Medicaid Enterprise"— Presentation transcript:

1 Iowa Medicaid Enterprise
Welcome to Remedial Services Provider Training

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

3 Iowa Medicaid Enterprise
Remedial Services

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

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

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 RSP Codes - Children Code Description 96152
Health and behavior intervention, 15 minute/individual H2011 Crisis Intervention, 15 minute individual 96153 Health and behavior intervention, 15 minute/group 96154 Health and behavior intervention, 15 min-family H0037 Community Psychiatric Supportive Treatment, per diem

10 RSP Codes – Adults Code Description H2014
Skills Training and Development, per 15 minutes H2001 Rehabilitation Program, per half day

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

12 Remedial Service Implementation Plan

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

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

16 Plan Requirements (cont)
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

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 Remedial Services Process (cont)
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

19 Remedial Services Process (cont)
RSP s/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

20 Remedial Services Process (cont)
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

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 Staff’s signature with title Service setting

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

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

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 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 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 Remedial Services Contact Information IFMC (Medicaid) PO Box 36478 Des Moines, IA or local Fax

31 Iowa Medicaid Enterprise
Billing Services to the IME

32 (Eligibility Verification System)
Eligibility Verification System (ELVS) Verify member eligibility for today’s 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. (Local)

33 Electronic Claim Submission
Electronic Date Interchange Support Services (EDISS) 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 Billing Information Mailing address for all claims from RSP:
Iowa Medicaid Enterprise (IME) PO Box Des Moines, IA Provider Services phone numbers: Monday – Friday 7:30 AM -4:30 PM

35 IME Contacts for Claims
Medicaid Claims P. O. Box Des Moines, Iowa Provider Correspondence P. O. Box 36450

36 IME Phone Numbers ELVS (Eligibility Verification System)
24 Hours a Day/7 Days a Week (Local) PROVIDER AUDITS AND RATE SETTING 8:00 AM – 5:00 PM (Local) PROVIDER SERVICES 7:30 AM – 4:30 PM (Local) MEMBER SERVICES 8:00 AM – 5:00 PM (Local)

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 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 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 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 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 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 # found on the IME Website Must be filed within 12 months of payment

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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