Mr/Dd Targeted Case Management Provider Manual

PART II MR/DD TARGETED CASE MANAGEMENT PROVIDER MANUAL

Section BILLING INSTRUCTIONS Page HCFA-1500 Claim Form Example …………………………… 7-1 7000 MR/DD Targeted Case Management Billing Instructions ……. 7-2 Submission of Claim ………………………………… 7-5 7010 MR/DD Targeted Case Management Specific Billing Information …………………………………………... 7-6

BENEFITS AND LIMITATIONS 8100 Copayment ……………………………………………………. 8-1 8300 MediKan ………………………………………………………. 8-2 8400 Medicaid ………………………………………………………. 8-3

PART II MR/DD TARGETED CASE MANAGEMENT PROVIDER MANUAL

This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to MR/DD Targeted Case Management providers. It is divided into two subsections: Billing Instructions, and Benefits and Limitations.

The Billing Instructions subsection gives an example of the billing form applicable to MR/DD Targeted Case Management services. The form is followed by directions for completing and submitting it.

The Benefits and Limitations subsection defines specific aspects of the scope of MR/DD Targeted Case Management services allowed within the Kansas Medical Assistance Program.

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7 – 1 7000. MR/DD TARGETED CASE MANAGEMENT BILLING INSTRUCTIONS

Introduction to the HCFA-1500 Claim Form

MR/DD Targeted Case Management providers must use the HCFA-1500 claim form (unless submitting electronically) when requesting payment for medical services and supplies provided under the Kansas Medical Assistance Program. An example of the HCFA-1500 claim form is shown on the previous page. Instructions for completing this claim form are included in the following pages. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed.

BCBSKS does not furnish the HCFA-1500 claim form to providers. Refer to Section 1100.

Complete The Following HCFA-1500 Claim Form Fields When Applicable

Fields not identified below should be left blank.

Field 1 Program Identification: Check appropriate box(es).

Field 1a Insured's ID Number: Enter the 11-digit beneficiary number from patient's Kansas Medical Assistance Program ID card.

Field 2 Patient's Name: Enter patient's last name, first name and middle initial exactly as it appears on the ID card.

Field 3 Patient's Date of Birth: Enter patient's date of birth as month, day and year - MM/DD/YYYY format (i.e., October 1, 1957 should be listed as 10/01/1957).

Patient's Sex: Check the appropriate box.

Field 5 Patient's Address: Enter patient's street address including city, state and zip code.

Field 9 Other Insured's Name: If patient has secondary or supplemental insurance complete fields 9 and 9a-d. (Enter the primary insurance information in field 11) ______MR/DD TARGETED CASE MANAGEMENT 09/00 BILLING INSTRUCTIONS

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Field 11 Insured's Policy Group or FECA Number: This field should be completed if the patient has insurance primary to Medicaid. If yes, complete fields 11 and 11a-d.

Field 21 Diagnosis or Nature of Illness or Injury: Enter diagnosis code Y45 (Home and Community Based Services.)

Field 22A Original Ref. No. If this is a resubmission of a claim, enter the previous ICN.

Field 23 Prior Authorization Number: Enter Prior Authorization (PA) number from PA form if procedure was prior authorized and/or precertification number, if applicable.

Field 24A Date(s) of Service: Enter date of service in MM/DD/YY format. If multiple services were performed on consecutive dates, give beginning date in "from" and give the last date of service in the "to" field and complete the units field (24G) accordingly.

Field 24B Place of Service: Enter appropriate "place of service code" for each service. Not all of the place of service codes may be appropriate for the service provided. Indicate the place of service code that most accurately reflects where the service was provided.

11-Office 34-Hospice 12-Home 41-Ambulance - Land 21-Inpatient Hospital 42-Ambulance - Air Or Water 22-Outpatient Hospital 53-CMHC 24-Ambulatory Surgical 54-ICF/MR Center 71-Local Health Department 31-Skilled Nursing 72-Rural Health Clinic Facility 81-Independent Laboratory 32-Nursing Facility 99-Other Locations

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Field 24D Procedures, Services, or Supplies: Enter the appropriate procedure code. Refer to Section 7010.

Field 24E Diagnosis Code: Enter the appropriate line number from field 21.

Field 24F Charges: Enter your usual and customary charge for each service.

Field 24G Days or Units: Enter number of visits, days or units of service rendered, as applicable to each detail line.

Field 24K Reserved for Local Use: The performing provider's 10-digit Kansas Medical Assistance Program provider number must be on each line of service he/she performed.

Field 26 Your Patient's Account Number: OPTIONAL: Any alpha/numeric character entered in this block will be referenced on the Remittance Advice. No special characters allowed, e.g., *, @, -, #, etc.

Field 27 Accept Assignment: Leave blank. All providers of Kansas Medical Assistance Program services must accept assignment in order to receive payment on a Medicare related claim.

Field 28 Total Charge: Enter total of all itemized charges on this page of the claim. If filing more than one claim page for the same beneficiary, total each claim page separately.

Field 29 Amount Paid: Enter any amount paid by insurance or other third party sources known at the time claim is submitted. If the amount shown in this field is the result of other insurance, documentation of the payment must be attached. (Field 11 must identify other insurance source.) Refer to Sections 3200 and 3300 for more specific information. Do not enter copayment or spenddown payment amounts. They are deducted automatically. ______MR/DD TARGETED CASE MANAGEMENT 02/97 BILLING INSTRUCTIONS

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Field 30 Balance Due: Subtract block 29 from 28 and enter balance here.

Field 31 Signature of Physician or Supplier: Read statement on back of claim form, sign and date.  Phrase "signature on file" is acceptable.  Provider’s name typed/stamped is acceptable.

Field 33 Physician's or Supplier's Name, Address, Zip Code and Telephone Number: Enter provider name, address, zip code, and telephone number.

Grp #: Enter Medicaid provider number.

SUBMISSION OF CLAIM:

Send completed first page of each claim and any necessary attachments to:

Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas 66601-3571

7 - 5 7010. MR/DD TARGETED CASE MANAGEMENT SPECIFIC BILLING INFORMATION

Enter procedure code Y9560 (Targeted Case Management MR/DD) in field 24D of the HCFA- 1500 claim form.

One unit = one month.

If a case manager has assigned client obligation to a particular provider and informed that provider that they are to collect this portion of the cost of service from the client, the provider must reduce the billed amount on the claim by the client obligation. Do not reduce the units billed on the claim although you are reducing the billed amount due to client obligation.

BENEFITS AND LIMITATIONS

8100. COPAYMENT

MR/DD targeted case management is exempt from the copayment requirement.

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8300. MEDIKAN

MR/DD targeted case management services are currently non-covered under the MediKan Program.

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8400. MEDICAID

MR/DD (mental retardation or other developmental disabilities) targeted case management is the assessment and linkage of an individual with services necessary to promote care outside of an institution.

The goals of MR/DD targeted case management are:  To promote maximum independence and successful integration into community living for MR/DD individuals,  Minimize individual reliance on exclusionary MR/DD institutional services,  Maintain accountability and continuity of services to individuals and families as long as services are required.

MR/DD targeted case management services include the following:  Assessment - The determination of an individual's current and potential strengths, resources, and basic needs through formal and informal evaluation.  Service Planning - The development and ongoing monitoring and updating of the Individual Service Plan, based upon assessment information, with the participation of the client, and other pertinent parties.  Service Coordination - Facilitation of the provision of services outlined in the Individual Service Plan, and developing natural community support systems.  Community Inclusion - Responsibility for developing increased opportunities for community access and involvement, including, but not limited to, community living skills vocational training, civic and recreational services, and crisis intervention services.  Advocacy - Activities with the client/family and providers for the purpose of gaining access to needed services and entitlements and modifying service systems to increase accessibility and appropriateness.  Transition to the Community - The discharge planning for an individual leaving an institution (ICF/MR, NF or NF/MH) 30 days prior to discharge which is not normally provided by the institution.

Limitations: MR/DD targeted case management is available to all Medicaid beneficiaries who are mentally retarded or otherwise developmentally disabled.

A HealthConnect referral is not required.

Other insurance and Medicare are primary; they must be billed first.

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In order to receive Medicaid reimbursement, persons must have the following qualifications to provide case management, whether or not they work for an agency:  A minimum of six months of experience in the field of services to individuals who have developmental disabilities and  A Bachelor’s degree OR  Additional relevant experience in the field of service to individuals with mental retardation or a developmental disability which may substitute for any portion of a Bachelor’s degree at a rate of six months of experience for each semester.

Refer to K.A.R. 30-64-24(b)(2) for the standard for case management training.

Provider Requirements: Community Developmental Disabilities Organizations (CDDO) are the only allowable Medicaid provider. Entities who have an affiliate agreement with a CDDO will still be allowed to bill for the service, however, Medicaid reimbursement will be sent to the CDDO instead of the affiliate.

The affiliate must submit claims using their provider number as the performing provider in Field 24K and the CDDO’s provider number as the billing provider in Field 33 on the HCFA-1500 claim form. If the affiliate is associated with more than one CDDO, it is the affiliate’s responsibility to use the correct CDDO’s number on a given claim.

Documentation: Recordkeeping responsibilities rest with the provider. Medicaid requires written documentation of services provided and billed to the Kansas Medical Assistance Program. Documentation at a minimum must include the following:  A detailed description of the service provided  Start/stop time spent with or on behalf of the consumer, including AM/PM or utilizing 2400 clock hours  Service provider’s signature  Complete date (MM/DD/YYYY)  Location the service was provided (i.e., home, office, etc.)

If documentation is not clearly written and self-explanatory, the services billed will not be paid.

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Definitions: Affiliate - a local agency which has entered into an agreement with a CDDO to provide case management to individuals who are mentally retarded or developmentally disabled and has been approved by Mental Health and Developmental Disabilities (MH&DD).

Community Developmental Disability Organization (CDDO) - a local agency which directly receives county mill funds and state aid and provides community based services to individuals who are mentally retarded or developmentally disabled and is formally recognized by Mental Health and Developmental Disabilities (MH&DD).

Mental Retardation - significantly sub-average intellectual functioning, evidenced by an IQ rating of 70 or below or a score of two standard deviations or more below the mean as measured by a generally accepted standardized individual measure of general intellectual functioning existing concurrently with deficits in adaptive behavior including related limitations in two or more applicable adaptive skill areas.

Other Developmental Disability - a condition or illness, such as cerebral palsy, epilepsy, or autism, but excluding mental illness and infirmities of aging, which:  Manifested before age 22,  May be reasonably expected to continue to exist indefinitely,  Results in substantial limitations in three or more areas of life functioning,  Reflects the need for a combination and sequence of special, interdisciplinary or generic care, treatment, or other services which are lifelong, or of an extended duration, and are individually planned and coordinated.

Positive Behavioral Support Services

Effective January 1, 2002, three new Positive Behavior Support (PBS) services were created for KBH consumers. These services are listed below:

PBS Environmental Assessment - An assessment of environmental events, antecedents, and/or consequences that are associated with or maintain the behaviors of interest, including physiological responses. This service should be billed as 90885 (22).

PBS Treatment - Procedures that include environmental manipulation of one or more of the following: antecedent events, setting events, consequent events, and teaching new skills. This service should be billed as 90806 (22).

PBS Person-Centered Planning - The use of person-centered planning approaches that integrate a person’s desired quality of life, taking into account barriers to achievement. This service should be billed as 90882 (22).

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Effective with dates of service on and after May 1, 2003, the following conditions will apply with respect to these services:

1. The Community Developmental Disabilities Organizations (CDDOs) will be the only provider type allowed for reimbursement of these services.

2. Individuals providing PBS services must have, at a minimum, a Bachelor’s degree and have completed the Kansas Institute for Positive Behavior Support (KIPBS) Training Program.

3. In order to receive PBS services, the beneficiary must be a KAN-Be- Healthy participant with a current screen who has obtained prior authorization through the process developed and implemented by Kansas Institute for Positive Behavior Support (KIPBS) staff, University of Kansas.

 Typically, the delivery of services will be limited to one billing cycle per recipient (i.e., the allowable hours of assessment, treatment, and person-centered planning that can be utilized during a one year billing cycle).  There may be occasions when a case is determined to be so severe that a subsequent year of service is required. If this occurs, an exception may be considered. All exceptions must be prior authorized using the process noted above.

Note: If the limitation of allowable hours of assessment, treatment, and person-centered planning has not been utilized during the first year of service, the remaining allotment of billable hours cannot be carried over into the second year as part of any new prior authorized service for an exception. All services approved by the KIPBS prior authorization system as part of an exception will constitute a new service arrangement for a consumer with specific limitations and conditions. Once an exception has been prior authorized and the one year billing cycle expires, further exceptions will not be considered.

All PBS services must be authorized through the KIPBS Prior Authorization system. The following conditions apply:

 Only persons who have successfully completed the KIPBS training system and are currently recognized by that system as approved for reimbursement may make application to the KIPBS prior authorization system.  The KIPBS Prior Authorization application is available on the Internet at www.kipbs.lsi.ku.edu, or may be obtained by calling, KIPBS Project Coordinator at 785- 864-4096.

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 The KIPBS Prior Authorization team will take action on each application within 48 hours whenever possible.  If the KIPBS Prior Authorization team approves an application, it will be faxed immediately to the appropriate fiscal agent contact person for appropriate action. Approval letters will be sent to the approved provider, the consumer, and to the KIPBS team.  All approved applications will constitute an agreement on the part of the service provider to deliver all PBS services in a comprehensive and integrated fashion, i.e., person centered planning, assessment, and intervention should not be separated whenever possible to specialized personnel.  Service providers will maintain internal documentation systems that comply with all necessary regulations and laws pertaining to confidentiality and privacy protection. For all PBS services, documentation for billing should be in quarter of an hour increments. The PBS service provider must maintain a record of the individuals to whom he/she provides services that shows:

 The name of the individual receiving the service  The date the service was provided  The name of the provider agency  The name of the individual providing the service  The location at which the service was provided  The type of PBS treatment provided  The amount of time it was provided to the nearest quarter hour