ODP Communication Number: Memo

Transcription

1 Informational Memo CLARIFICATION ON INFORMATIONAL PACKET MONEY FOLLOWS THE PERSON (MFP) INITIATIVE BILLING FOR START-UP AND SUPPORTS COORDINATION TRANSITION SUPPORT ODP Communication Number: Memo The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives. AUDIENCE: Unlicensed and Licensed Waiver Funded Residential Habilitation Providers, Direct Vendors, Organized Health Care Delivery System (OHCDS) providers, Supports Coordination Organizations (SCOs) and Administrative Entities (AEs). PURPOSE: This Office of Developmental Programs (ODP) communication is intended to clarify the claims submission and billing requirements for providers to use when billing PROMISe TM for approved Money Follows the Person (MFP) funding requests. BACKGROUND ODP Informational Packet announced that the Centers for Medicare and Medicaid Services (CMS) approved the Department of Human Services (DHS s) MFP proposal. The proposal provides enhanced federal matching funds to support the movement of people to community settings. Informational Packet also explained how providers may request start-up funding or payment for supports coordination transition activities provided to a person moving from a private or public intermediate care facility (ICF)/intellectual disability (ID) setting to a waiver funded setting serving four or fewer people. Refer to Informational Packet , page 2, for additional conditions that must be met in order to obtain MFP reimbursement. DISCUSSION: In order to receive payment for procedure codes W0400, MFP provider start-up, and procedure code W0401, MFP supports coordination (SC) transition services; providers must adhere to specific billing rules. Any deviation from these billing rules will cause your claim submission to deny. ISSUE DATE: 03/23/15 ODP COMMUNICATION NUMBER: Memo Page 1

2 RULE 1: RULE 2: For procedure codes W0400, MFP provider start-up, and W0401, MFP supports coordination transition services, only one claim submission per service per consumer is permitted to be submitted for payment. The date of service fields on the claim should reflect one day only and must either be the same date or a greater date than the consumer s effective date of waiver enrollment. PROMISe TM Internet and Provider Electronic Solutions Software (PES): The dates of service fields on these two claim submission methods are called the From DOS field and the To DOS field. These two fields are both required fields on the transaction and must contain the exact same date. The date entered must be the consumer s effective date of waiver enrollment or a later date. CMS 1500 paper claim: There is a From and To field in the Date(s) of Service block, which is Block 24a. ONLY complete either the From or the To field NOT BOTH. Whichever field you choose to use, enter a date that is either greater than or equal to the consumer s effective date of waiver enrollment. RULE 3: The number 1 is required in the unit(s) field on the claim. For both procedure codes W0400, MFP provider start-up and W0401, SC transition services, enter the number 1 in the unit(s) field found on the claim submission. ODP recognizes that SC transition services has a 15 minute unit of service, however, due to billing system restrictions, providers must enter the number 1 in the unit field on the claim in order to be paid for these services. NOTE: Units rendered for MFP provider start-up and MFP SC transition services, are eligible for payment up to a maximum of 180 days prior to the person s waiver enrollment start date. Only waiver eligible SC activities are reimbursable. The number of units billed must be substantiated by service notes in the Home and Community Services Information System (HCSIS) and marked as non-billable. RULE 4: For procedure code W0401 only, MFP SC transition services, providers are required to enter the accumulated units delivered for this service and the SC ISSUED DATE 03/23/15 Page 2

3 services rate per unit in a specific field on the claim. This field is referred to by a different name for each of the following claim submission methods: PROMISe TM Internet: Patient Account # field. This field has a 38 character limitation. Provider Electronic Solutions Software (PES): Account Number field. CMS 1500 paper claim: Patient s Account Number, Block no. 26. This field has a 10 character limitation. NOTE: The units entered in this field should be based on 15 minute units of service increments. For example, if the SC rendered MFP SC transition services to the individual for a two week period and the accumulated units of service delivered is 50 hours, 200 units would be entered in this field on the claim. The data entered in this field will appear on the remittance advice (RA). RULE 5: Correct calculation of the dollar amount requested/billed amount on the claim. The dollar amount requested, also referred to as the billed amount, for services rendered is entered in a specific place on the claim depending on the claim submission method: - PROMISe TM Internet and Provider Electronic Solutions Software (PES): For these two claim submission methods the dollar amount the provider is requesting for service(s) rendered is called the Billed Amount field. - CMS 1500 paper claim: Enter the requested amount/billed amount for services rendered in the field called $Charges, which is found in Block 24F on the CMS 1500 paper claim form. For procedure code W0400, MFP provider start-up: For this particular service, enter the actual costs incurred up to the amount approved by ODP on the claim. This dollar amount should not exceed $5,000. If a dollar amount is submitted on the claim in excess of $5,000, the claim will deny. If a dollar amount is submitted and it exceeds the amount approved by ODP, the claim will deny. NOTE: If you submit the incorrect dollar amount on your claim for this service, you will not be able to adjust the claim or void it. Any adjustments ISSUED DATE 03/23/15 Page 3

4 or voids submitted after the original claim was submitted will be denied. Therefore, it is very important that you review your claim prior to submission and ensure the dollar amount/billed amount is accurate. For procedure code W0401, MFP supports coordination transition services: To calculate the dollar amount to enter in the Billed Amount or $Charges field on the claim for this service, multiply your SCO (unit of service) rate by the number of units of transition planning support/activities provided to the individual. Depending on which claim submission method you use, the units rendered to the individual should be entered/found in the Patient Account #, Account Number or Patient s Account Number fields on the claim. POST CLAIM SUBMISSION PROCESS PERFORMED BY ODP Claims submitted to PROMISe TM for procedure codes W0400, MFP provider start-up, and W0401, MFP supports coordination transition services, will be suspended for review by ODP Claims Resolution staff. ODP Claims Resolution staff will make a payment determination based on: Whether there is an ODP Regional Fiscal Office (RFO) approval on file; The individual is enrolled in the Consolidated waiver; and The provider requesting payment is authorized to provide waiver funded services NOTE: All compensable expenses and services should be included on the initial invoice. Claim adjustments and voids will be denied. RESOURCES The PROMISe TM Internet User Manual is available to assist providers with program specific billing rules. Click on the following hyperlink to view this manual: The Provider Electronic Solutions User Manual is available as a billing resource: The instructions provided in the CMS 1500 Billing Guide for ODP services are available at: ISSUED DATE 03/23/15 Page 4

5 INQUIRIES Questions regarding MFP may be directed to your Regional Fiscal Officer or Regional Program Manager. Billing questions should be addressed to ISSUED DATE 03/23/15 Page 5