Fee-for-Service Provider Manual

Transcription

1 Fee-for-Service Provider Manual Targeted Case Management Intellectual/Developmentally Disabled Updated

2 Part II TARGETED CASE MANAGEMENT INTELLECTUAL/DEVELOPMENTALLY DISABLED FEE-FOR-SERVICE PROVIDER MANUAL Introduction Section BILLING INSTRUCTIONS Introduction to the CMS Submission of Claim... Targeted Case Management-Intellectual/Developmentally Disabled Specific Billing Information... Copayment... Benefit Plan... Medicaid Forms All forms pertaining to this provider manual can be found on the public website and on the secure website under Pricing and Limitations. DISCLAIMER: This manual and all related materials are for the traditional Medicaid fee-for-service program only. For provider resources available through the KanCare managed care organizations, reference the KanCare website. Contact the specific health plan for managed care assistance. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply. Information is available on the American Medical Association website.

3 Updated 05/16 PART II TARGETED CASE MANAGEMENT INTELLECTUAL/DEVELOPMENTALLY DISABLED This is the provider-specific section of the manual. This section (Part II) was designed to provide information and instructions specific to targeted case management (TCM) intellectual/developmentally disabled (I/DD) providers. It is divided into two sections: Billing Instructions and Benefits and Limitations, and Forms. Part I of the provider manual consists of five parts: General Information, General Benefits, General Billing, General Special Requirements, and General Third Party Liability (TPL). Part I contains information that applies to all providers, including TCM-MR/DD providers. The Billing Instructions section gives instructions on submitting a claim for completing and the billing forms applicable to TCM-MR/DD services. The Benefits and Limitations section defines specific aspects of the scope of TCM-I/DD services allowed within the Kansas Medical Assistance Program (KMAP). Forms are on the public and the secure websites, including a sample of the CMS 1500 Claim Form which must be completed for reimbursement of services. HIPAA Compliance As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. Access to Records Kansas Regulation K.A.R requires providers to maintain and furnish records to KMAP upon request. Providers must also supply records to the Department of Health and Human Services upon request. The provider is required to supply records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's office upon request from such office as required by the Kansas Medicaid Fraud Control Act, K.S.A to , inclusive, as amended. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review, or investigation, including the relevant questioning of the provider s employees. The provider shall not charge a fee to retrieve and copy documents and records related to compliance reviews and complaint investigations.

4 TARGETED CASE MANAGEMENT INTELLECTUAL/DEVELOPMENTALLY DISABLED BILLING INSTRUCTIONS Updated 05/16 Introduction to the CMS 1500 Claim Form Providers must use the CMS 1500 paper or equivalent electronic claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. Claims can be submitted on the KMAP secure website or billed through Provider Electronic Solutions (PES). When a paper form is required, it must be submitted on an original, red claim form and completed as indicated or it will be returned to the provider. The Kansas MMIS uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information is not recognized unless submitted in the correct fields as instructed. An example of the CMS 1500 Claim Form and instructions are available on the KMAP public and secure websites on the Forms page under the Claims (Sample Forms and Instructions) heading. Any of the following billing errors may cause a CMS 1500 paper claim to deny or be sent back to the provider: Sending a CMS 1500 Claim Form carbon copy. Sending a KanCare paper claim to KMAP. Using a PO Box in the Service Facility Location Information field. Staples on the claim form. EDS The fiscal agent does not furnish the CMS 1500 Claim Form to providers. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent PO Box 3571 Topeka, KS TCM I/DD FEE-FOR SERVICE PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

5 TARGETED CASE MANAGEMENT INTELLECTUAL/DEVELOPMENTALLY DISABLED SPECIFIC BILLING INFORMATION Updated 05/16 Enter procedure code T1017 in field 24D of the CMS 1500 Claim Form. One unit equals 15 minutes. TCM must be billed by units, or partial units, of service as outlined below: 0.5 units = 0.1 through 7.5 minutes of TCM service One unit = 7.51 through 15 minutes of TCM service Time spent providing TCM services beyond one unit must be recorded and billed in the same way. Start and stop times, including AM and PM or military time, must be on all documentation. TCM I/DD FEE-FOR SERVICE PROVIDER MANUAL BILLING INSTRUCTIONS 7-2

6 8100. COPAYMENT Updated 05/16 TCM-I/DD services are exempt from copayment requirements. 8-1

7 8300. BENEFIT PLANS Updated 05/16 KMAP beneficiaries are assigned to one or more KMAP benefit plans. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Fee-for-Service Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification. 8-2

8 8400. MEDICAID Updated 05/16 TCM-I/DD is the assessment and linkage of the beneficiary with services necessary to promote care outside of an institution. The goals of TCM-I/DD are: To promote maximum independence and successful integration into community living for I/DD beneficiaries To minimize beneficiary reliance on exclusionary I/DD institutional services To maintain accountability and continuity of services to beneficiaries and families as long as services are required Targeted Case Management Targeted case management services are defined as those services which will assist the beneficiary in gaining access to medical, social, educational, and other needed services. Targeted case management includes any or all of the following services: Assessment of a beneficiary to determine service needs by: Taking the beneficiary s history Identifying the beneficiary s needs and completing the related documentation Gathering information, if necessary, from other sources such as family members, medical providers, social workers, and educators, to form a complete assessment of the beneficiary Development of a specific support/care plan that: Is based on the information collected through the assessment Specifies the goals and actions to address the medical, social, educational, and other service needs of the beneficiary Includes activities that ensure the active participation of the beneficiary, and working with the beneficiary (or the beneficiary s legal representative) and others to develop such goals and identify a course of action to respond to the assessed needs of the beneficiary Referral and related activities: To help a beneficiary obtain needed services, including Activities that help link the beneficiary with medical, social, educational providers, or other programs and services that are capable of providing needed services, such as referrals to providers for needed services and scheduling appointments for the beneficiary 8-3

9 8400. Updated 05/16 Monitoring and follow-up activities, including: Activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the beneficiary s needs, which may be with the beneficiary, family members, providers, or other entities and conducted as frequently as necessary to determine whether: o Services are being furnished in accordance with the beneficiary s care plan. o The services in the care plan are adequate. o There are changes in the needs or status of the beneficiary and, if so, making necessary adjustments in the care plan and service arrangements with the providers. For dates of service on and after July 1, 2008, rrefer to the Money Follows the Person Fee-for-Service Provider Manual for claims specific to TCM-Money Follows the Person (MFP). All existing TCM requirements apply to MFP. Documentation Recordkeeping responsibilities rest with the TCM provider. Medicaid requires written documentation of services provided and billed to KMAP. Documentation at a minimum must include an activity log that includes: The service being provided Beneficiary s first and last name Date of service (MM/DD/YY) Location of service provided Case manager s legibly-printed name and signature on each page of the case log, verifying that every entry reflects activities performed by the signee Detailed description of the service provided, including start and stop times that indicate AM/PM or use 2400 hour clock Notes: Time spent should be clearly documented in the notes. Providers are responsible to ensure the services were provided prior to submitting claims. If documentation is not clearly written and self-explanatory, the services billed may not be paid. Services provided must be documented within the timeframe that is billed. Documentation generated after-the-fact is not acceptable. 8-4

10 8400. Updated 05/16 Limitations The maximum allowable units per beneficiary are 240 units per calendar year. This may be waived with prior authorization by the Kansas Department for Aging and Disability Services Community Services and Programs (KDADS-CSP) Social and Rehabilitation Services (SRS) Health Care Policy, Community Supports and Services. TCM-I/DD may be provided up to 180 days prior to the beneficiary transitioning from an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) mental retardation or nursing facility to community-based services. The case manager would assist the beneficiary in obtaining appropriate housing, getting utilities established, and other activities necessary for the beneficiary to move from an institutional setting to a community-based setting. TCM-I/DD is available to all KMAP beneficiaries who are intellectually mentally retarded or otherwise developmentally disabled. I/DD case management may be limited, at the choice of the person directing and controlling the services, to reviewing the services on a regular basis to ensure the beneficiary s needs are met, and development of the person-centered support plan and plan of care. A HealthConnect referral is not required. Other insurance and Medicare are primary; they must be billed first. Provider Requirements Entities licensed by KDADS SRS and enrolled for TCM-I/DD with an affiliate agreement with the Community Developmental Disability Organization (CDDO) are the only allowable providers to be paid for TCM services through the MMIS. Licensed TCM-I/DD providers are responsible for insuring individual case managers meet the requirements identified in Article 63. KDADS SRS will notify the fiscal agent EDS when a provider no longer is licensed and is no longer eligible to bill for TCM-I/DD services. The CDDO should notify the fiscal agent EDS and KDADS SRS when a provider no longer has an affiliate agreement and is no longer eligible to bill for TCM-I/DD services. 8-5

11 8400. Updated 05/16 Definitions Affiliate a local agency that has entered into an agreement with a CDDO to provide case management to beneficiaries who are intellectually mentally retarded or developmentally disabled and has been approved by KDADS-CSP SRS Health Care Policy, Community Supports and Services. Community Developmental Disability Organization a local agency that directly receives county mill funds and state aid and provides community-based services to beneficiaries who are intellectually mentally retarded or developmentally disabled and is formally recognized by KDADS-CSP SRS Health Care Policy, Community Supports and Services. Intellectual Disability 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, that: 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 8-6