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NORTH EAST OHIO NETWORK WWW.NEONCOG.ORG DOCUMENTATION & BILLING TRAINING FOR INDEPENDENT PROVIDERS
NORTH EAST OHIO NETWORK
WWW.NEONCOG.ORG
DOCUMENTATION
&
BILLING
TRAINING FOR INDEPENDENT PROVIDERS
CONTENTS__________________________________________
EXAMPLE OF WAIVER SERVICE
DELIVERY DOCUMETNATION
PROVIDER BILLING
BILLING INFORMATION AT A GLANCE
IMPORTANT TO REMEMBER FOR BILLING
NAVIGATING THE PROVIDER PAGE
IMPLEMENTATION GUIDELINES
COMPLETE SET OF FORMS
SERVICE DOCUMENTATION ODODD Administrative Rule 5123: 2-9-06 The Service Documentation rule describes the requirements for services provided to individuals receiving services funded by a Medicaid Waiver. The following elements must be part of Service Documentation:
1. Date of Service 2. Place of Service 3. Name of Recipient 4. Recipient Medicaid number 5. Name of Provider 6. Provider contract number 7. Signature of Provider 8. Type of Service being provided 9. Number of Units delivered
10. Group Size (ratio) 11. Time-in & Time-out 12. A description of the service 13. Frequency & Duration Reimbursements made to the Provider for services delivered that does not include the required elements may be recovered by the Ohio Department of Developmental Disabilities. Service Documentation must be made available upon request to any agency with the authority to review such records. Keep the Service Documentation for 7 years.
Rev. 1/14
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
***SERVICES ARE ROUTINE HPC UNLESS OTHERWISE INDICATED AS ON-SITE/ON CALL OR LEVEL ONE EMERGENCY*** DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time In
Time out
# of Units
# OF INDIVIDUALS SHARING SUPPORTS , if
other than 1:1.
Supports in Plan Duration / Frequency
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*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service.
DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: _____________ ______ INITIALS: DATE:
Prepared by AggieG 04/26/12
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time In
Time out
Time In
Time out
Total # of Units
1:1 ratio, unless otherwise noted
Supports in Plan Duration / Frequency
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*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service
DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: _____________ ______ INITIALS: DATE: Prepared by AggieG 042612
HOMEMAKER / PERSONAL CARE – SKILL DEVELOPMENT DOCUMENTATION CONSUMER NAME: PROVIDER:
ADDRESS: ADDRESS:
MEDICAID #: PROVIDER #:
RESIDENT #: MONTHLY SERVICE PERIOD: _____/_____/_____ to _____/_____/_____
SKILL DEVELOPMENT AREA: _______________________________________________________ PROGRAM DURATION / FREQUENCY: /
PROGRAM DESCRIPTION / DESIRED OUTCOME: __________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________
DATE /
ALL SKILL
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DEVELOPMENT STEPS
DOCUMENT TYPE of PROMPT NECESSARY TO PERFORM STEP: I=Independent, V=Verbal, G=Gestural, P=Physical, R=Refused, ND=Not Delivered ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION ON BACK PAGE
*SUPPORT STAFF’S INITIALS FOR DAYS SKILL DEVELOPMENT PROGRAM IS OFFERED ACCORDING TO DURATION AND FREQUENCY ON ISP
STAFF SIGNATURE: INITIALS: STAFF SIGNATURE: INITIALS:
COMMENTS (Unusual staffing & reasons, service locations if other than home, problems delivering services, reasons for refusal, etc.)
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31. Comments on progress toward goal and recommendation for continuation, revision, or change SIGNATURE: _____________ ______ INITIALS: DATE:
Adult Family Living (Daily Rate) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Supports in Plan Duration / Frequency
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# OF INDIVIDUALS SHARING SUPPORTS , if other than 1:1.
R= Refused ND = Not Delivered
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION BELOW.
DATE Service location, if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
PROVIDER SIGNATURE: _____________ ______ INITIALS: DATE: Prepared by AggieG 042612
HPC Transportation – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
Date Starting
location address
Destination Addresses Ending location address
Miles Driven
1:1 ratio unless otherwise noted
Staff Initials
DATE Comments, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: _____________ ______ INITIALS: DATE: Prepared by AggieG 01/18/13
NON MEDICAL TRANSPORTATION- MILEAGE - DOCUMENTATION – Cuyahoga County
Date of Service
License Plate #
Pick Up Time
Odometer Start
Drop Off Time
Odometer End
Total Miles Driven
Names of All Passengers & Medicaid # Staff Initials
SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ Prepared by AG 061512
WEEKLY PRE-TRIP INSPECTION REPORT
PROVIDER NAME __________________________________________ PROVIDER # ______________________ MONTH_____________ YEAR, MAKE & MODEL ___________________________________ LICENSE PLATE ___________________ YEAR_______________ Date Date Date Date Date Date Date
Date
Driver Initials
Items to inspect on each trip
Windows and mirrors are clean and free of cracks/breaks? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
Tie downs, if applicable, are present and function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
Seat belts function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
Wheelchair Lift, if applicable, is operating properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
All lights, including headlights and turn indicators, function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
First Aid kit is in vehicle? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
Fire extinguisher is in vehicle and indicates as "good"? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
The horn is working properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
Windshield wipers are working correctly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
Tread on all four tires is sufficient? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
Test service brakes? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ Prepared by AggieG 04/26/12
NON MEDICAL TRANSPORTATION- PER TRIP - DOCUMENTATION – Cuyahoga County
PROVIDER NAME PROVIDER # MONTH____________ YEAR__________
Date
License Plate Number
Odometer Start
Start Time of Trip
Odometer End
End Time of Trip
Miles Driven
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Staff Initials
DATE Names of all other passengers/riders, including paid staff and volunteers who were in the vehicle during any portion of the trip and/or commute. SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______
→
Third Party Liability
• Your client’s Medicaid card will show if there is TPL [insurance].• Bill as you normally would, but put an “S” in Other Source Code.• Once a year, send an invoice billing the insurance carrier for services rendered
to your client. You should get a response from the company stating that the policy does not cover your services. Keep this for your records. This is to prove to the Auditor’s that you attempted to bill all other sources before billing Medicaid. Remember, Medicaid is the “payer of last resort.”
• Do not wait to hear back from the insurance company before billing Medicaid. Billing the insurance company is done for your records. Bill as you normally would.
• ODJFS does run a random edit, so if your client has TPL, be certain you bill accordingly; otherwise, you could have errors where you previously didn’t. Also, do not automatically put “S” in Other Source Code, because if your client does not have TPL, your claims could error.
PATIENT LIABILITY CASESAs a Provider, you are responsible for checking with the County Board to see if the individual you are serving has a PL. A PL is the amount the individual has to pay for services each month. This is determined at the county level by Job and Family Services. It is similar to an insurance co-pay. ODMRDD has nothing to do with determining PL. If the individual has a PL, you must identify the amount on your billing. Bill as you normally would; however, enter "1" in the Other Source field. In the Other Source Amount field, enter the amount claimed for PL until the amount of the PL is satisfied. The County Board will advise you as to how to collect the PL.
EXAMPLE - The client has a $96.00 per month PL. You start providing services on the 11th. You would normally bill for 32 units of Homemaker/Personal Care-1 staff (APC) at $2.25 per unit for every day you worked. You would submit your billing as follows:
Day of Service Units of Other Source Other Source Service Code Service UCR Code Amount11 APC 32 225 1 72.0012 APC 32 225 1 24.0013 APC 32 22514 APC 32 225
The MBS system will automatically pay you the difference. In this case, on the second day [the 12th] you will be paid $48.00, which is what you billed for minus the $24.00 that you entered as PL. The $96.00 PL has been satisfied for the month.
Note: Patient liability must be reported through the billing process. For instance, if as in the above example the individual had a $96 PL you would not skip billing for the first day of service, enter $24.00 into other source amount the next day, and assume that the reporting was complete for the month.
Only about 9% of clients have patient liability [PL].
If a client has multiple providers, only one will be responsible for reporting the PL.
Every 18 months, a report is run to reconcile PL. If the correct amount has not been identified in the provider’s billing, the total amount will be taken out of future billings.
The client’s PL is updated 2-4 times per year. Contact your county board to ensure you are reporting the correct amount.
Note: The amount of PL reported must be equal to or less than the amount billed for that claim.
For more information about reporting patient liability, click here (this will open a new window) :
http://mrdd.ohio.gov/providers/billingdocs/patient-liability.ppt
For more information on Business Associate Agreements:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html Rev. 7/13 Name Address City ST Zip Contact Name Phone Email
Accusoft Billing LLC 9431 Westport Road, Suite 136 Louisville KY 40241 Sean B. Swick (614) 364-4694 [email protected]
Advanced Billing Services PO Box 26172 Columbus OH 43226 Christie Ward 866-460-2455/fax-614-890-5485
Agency Systems 7645 Production Dr./PO Box 37410 Cincinnati OH 45237 Gary Puckett 513-761-5610
All Ohio claims Michael [email protected]
Beeton Provider Services, Inc. P O Box 232 Hilliard OH 43026 Theresa Beeton 614-529-6562
BJ's I/O Waiver Billing Services 1790 McTaggart Dr Akron OH 44320 Bobbie Williams 330-869-5208 or 330-869-5887
Bout Time Medical Billing Service 23660 Miles Rd Suite 105 Bedford Hts. OH 44128 Louise Hill 216-663-1400 www.bouttimellc.com
Brenda Foster 2358 Waterfall Lane Columbus oh 43209 Brenda foster 614-235-2850 [email protected]
Carl Potter OH Carl Potter [email protected]
Clearwater COG 8200 W State Rte 163 Oak Harbor OH 43449 Michelle Thorbahn 419-898-8264
Contemporary Business Group Inc. 1147 Columbus Pike #209 Delaware OH 43015 Ken Greiner 740-369-4616 or 740-971-6933
Falcon Financial Services P O Box 465 Maumee OH 43537 Todd Frick 419-297-6577
Goodwill Data Entry Services 419 West Market St Sandusky OH 44870 Jocelyn Bisson 888-417-5576
Hattie Larlham Community Srvcs. 9772 Diagonal Road Mantua OH 44255 Donna Love 330-274-2272 or 800-233-8611
Healthcare Billing Services (HBS) 7678 Slate Ridge Blvd Reynoldsburg OH 43068 Kenneth Albert 614-866-6646
Healthcare Process Cons. (HPC) 8050 Corporate Circle, Suite #4 N. Royalton OH 44133 Frank or KarenBresky 440-884-3688
Home Financial Services 1240 Wildwood Drive Wooster OH 44691 Judy Holmes 330-345-2041
Hope Swindell 440.748.8078 [email protected]
Independence, Inc 161 East Main St Ravenna OH 44266 Teran Morrow 330-296-2851
Interactive Financial Solutions Inc. 1290 North Shoop Ave,Suite 1000 Wauseon OH 43567 Jrffrey Rutledge 419-335-1280
Internet Billing 30755 Barrington Madison Hts MI 48071 Ken Cerka 800-396-6877
Jeff Brown 3864 Snowshoe Ave. Grove City OH 43123 Jeff Brown (614) 875-9538 [email protected]
Jerry Kuhling, CPA 3865 Bach Buxton Rd Amelia OH 45102 Jerry Kuhling 513-752-0240
Katrisha Kopsch 5919 Wero Dr Hilliard OH 43026 Katrisha Kopsch 614-876-6420
Kevin Palicki Kevin Palicki 614-519-9059 [email protected]
KMS Billing Services 3821 Lockwood Ave Toledo OH 43612 Kimberly Spielman 419-269-1938/419-349-8088
LarCor 325 S. Sandusky St #303 Delaware OH 43015 Kimberley Dietsch 740-971-6933/fax-740-369-5829
Lenore Covington Cincinnati OH 513-542-0420 l.covington@ zoomtown.com
McDonald Billing & Consulting Svc. 2000 Lee Road, St 116 Cleveland OH 44118 Cassandra McDonald 216-624-8098
Medical Services Bureau, Inc. 430 Grant St Akron OH 44311 Maureena Mountcastle 330-434-1922
Nips, Andeas, Brown & Leppert Inc. 648 Taylor Rd Gahanna OH 43230 Betty Kohr 614-577-1101 / 800-336-4444
North Heights Group Home 255 N. Heights Ave Youngstown OH 44504 Diane Reviere 330-746-3636/fax-330-743-3728
Primary Solutions, Inc 1080 Kingsmill Parkway, Ste. 150 Columbus OH 43299 Anita Parsly/Tom Houser 614-430-0355
Robert Savala 1716 DuBois Dr. Piqua OH 45356 "Jay" 937-778-3780
Scarlette Streeter 18314 Windward St. Cleveland OH 44119 Scarlette Streeter 216-738-0173 fax-216-373-0319
Schrader Billing Service 155 N. Dugan Rd. Urbana OH 43078 Ticia Schrader
Stat Claims Management 3634 Mount Carmel Rd Cincinnati OH 45244 Pamela or Robert Durham 513-474-7605
Susan Loy 112911th St. NE Massillon OH 44646 Susan Loy 330.323.7211 [email protected]
The Billing Connection, Inc 11001 SW Broad Street Pataskala OH 43062 Melissa Skaggs, VP 740-964-0043/1-800-995-0043 www.billingconnection.net
Wynn-Reeth PO Box 785 Green Springs OH 44836 Jarrod Hunt 419-639-2094 ext 104
Inclusion on this list is by request of the billing agent, who retains complete and sole responsibility for ensuring the accuracy of any information on this list. Billing agents are not employed by the Department of Developmental Disabilities, and DODD does not train, certify, monitor, or endorse any billing agent, nor guarantee their performance. DODD shall not be responsible or liable directly or indirectly for any loss or dispute related to the use of a billing agent. Providers remain responsible for the accuracy and completeness of all claims, including those submitted by billing agents. In addition, providers are responsible for meeting all HIPAA requirements, including a signed Business Associate Agreement with the billing agent. This Agreement is required by federal law, and it explains the billing agent’s obligations for confidentiality.
COST OF DOING BUSINESS (CODB) CATEGORIES AND FACTORS
(OAC 5123:2-9-19) Factor Counties in Category
Category 1 0.9651 Adams Harrison Ross Athens Jefferson Scioto Belmont Keogs Tuscarawas Gallia Monroe Vinton Guernsey Pike Washington Category 2 0.9751 Carroll Jackson Noble Crawford Lawrence Paulding Defiance Mercer Perry Highland Morgan Van Wert Hocking Muskingum Wyandot Category 3 0.9851 Allen Fayette Putnam Auglaize Hancock Richland Brown Holmes Seneca Clinton Knox Shelby Columbiana Marion Williams Coshocton Morrow Category 4 0.9951 Ashland Henry Pickaway Darke Huron Sandusky Erie Licking Stark Fairfield Logan Trumbull Fulton Mahoning Wood Hardin Category 5 1.0051 Ashtabula Lucas Ottawa Champaign Madison Preble Clark Miami Union Delaware Montgomery Wayne Greene Category 6 1.0151 Clermont Lake Portage Franklin Lorain Summit Geauga Medina Category 7 1.0251 Butler Cuyahoga Warren
Category 8 1.0351 Hamilton
IMPORTANT TO REMEMBER FOR BILLING
LEVEL 1 WAIVER
Home Maker Personal Care (HPC) FPC Transportation FTN
Examples: HPC Unit Rate - Cuyahoga County $4.15 (15 mins.)
Transportation mileage $.45/mile (all providers and categories to access Waiver services not included under the Non-Medical Transportation category below)
Informal Respite FIN Unit Rate (per 15 minute period) $2.75
INDIVIDUAL OPTIONS WAIVER
Home Maker Personal Care (HPC) APC Transportation mileage ATN
Examples: HPC Unit Rate - Cuyahoga County $4.15 (15 mins.)
Transportation mileage $.45/mile (all providers and categories to access Waiver services not included under the Non-Medical Transportation category below)
Foster Care varies per person NON-MEDICAL TRANSPORTATION (OAC 5123:2-9-19) (For transportation to Adult Day Support, Vocational Habilitation, Supported Employment-Enclave or Supported Employment-Community) CODB Category RATE / MILE CODB Category RATE / MILE
1 $1.25 5 $1.27 2 $1.25 6 $1.29 3 $1.27 7 $1.29 4 $1.27 8 $1.29
NAVIGATING THE PROVIDER PAGE ON
THE CCBDD WEBSITE
www.cuyahogabdd.org
Click on “Are You a Provider” tab
Or Provider Resources
From this page you can access:
Provider Resources Information
Provider Certification and Renewal Information
A variety of Forms (including documentation sheets)
PROVIDER RESOURCES PAGE:
CERTIFICATION PAGE:
FORMS PAGE:
Many of these forms can be filled out on line and saved or printed for your convenience.
Take the time to look around on the Provider Page, it has a great
deal of information that will be useful to providers.
Information at your fingertips, 24 hours a day.
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It is very important that you prepare your service documentation yourself either at the
time or shortly after you deliver the service. You should not be preparing documentation
when asked for it by an auditor or other reviewer. Write down the time you begin
delivering the services, make any appropriate notes of activities performed, and then
close out by writing down the time you stopped delivering services. If you have more
than one start time and end time on the same day, these should be documented
separately. If multiple staff are delivering services, these items should be clearly
identified for each staff member.
Documentation Maintenance:
Service documentation must be maintained for six years from the date you were paid or
until any audit initiated during that six year period has been resolved, whichever is
longer. This means that if an audit has been started before the end of the six year
period after the date a claim was paid, you must keep all of your service documentation
for that time period being reviewed - until all issues identified have been addressed and
the audit has been closed. Remember that DODD, the Ohio Department of Medicaid,
the Ohio Auditor of State, and the Federal government all have the authority to audit
your paid claims. Therefore, even if DODD has audited you and closed its audit before
the end of the six year period, you should still keep your service documentation for the
full six years because any of the other agencies could decide to audit you before the six
years are up. If an audit has not been initiated before the end of the six year period
after the date a claim was paid or all audits that were begun during that period have
been closed, then you may destroy the documentation that supports the claim. Please
be careful to destroy the records in a secure manner (shredding, for example), as the
documentation contains personal health information which is protected under the Health
Insurance Portability and Accountability Act (HIPAA).
Risk factors included in DODD’s selection process for these audits: For the first time this past year, DODD used a risk-based approach for selecting
providers for audit for state fiscal years 2010 and 2011 (July 1, 2009 through June 30,
2011). Below is a sample of some of the criteria we used to select our audits.
Providers who generated billings per individual much higher than average;
Providers who were among the highest paid in their respective peer group (i.e.
independent providers, private agencies, public agencies);
Independent providers who consistently billed for more than ninety (90) hours per
week of awake services;
Providers who had a significant number of adjustments to their claims; or
Providers who had a significant number of claims being billed but rejected for
exceeding authorized unit or dollar maximums.
Primary issues noted for Homemaker Personal Care Providers in these audits:
15 minute unit billing: Some providers have been unable to provide any service
documentation, or what they did provide was not compliant with rules. The primary
missing element and the most problematic is the lack of arrival and departure times.1
This element is a key component to proper reimbursement as it verifies that the number
of units paid equals the number of units delivered. The number of units (of service
delivered) is also a critical companion element for proper documentation. Without these
two elements, documentation is not compliant with the waiver requirements. Such
claims paid are then subject to repayment plus any accrued interest.
Daily Billing Unit: Providers using the daily billing unit for Homemaker/Personal Care
services should be using the Daily Rate Application (DRA) as part of the Medicaid
Services System (MSS) to determine the appropriate rate to bill for services delivered.
Proper documentation must be maintained to support the number of hours entered in
DRA. This documentation must include time sheets to show the number of hours
worked by each staff each day. If this documentation is not maintained, the entire
amount paid, plus any accrued interest, is subject to repayment by the provider in the
case of an audit finding.
If the documentation exists, but does not equal the hours entered into the DRA, a
revised rate may be recalculated based on the hours of service delivery that the
1 As of April 19, 2012, providers of Homemaker/Personal Care who bill in 15-minute units must document the begin and end times of the delivered service rather than arrival and departure times.
documentation reflects. In this case, the provider would be required to repay any
amount, plus any accrued interest, that is in excess of the correctly calculated amount.
DODD will continue to review provider service documentation as part of its greater
commitment to properly administer Medicaid HCBS waivers. Ohio relies heavily on the
Federal funding that supports these waivers in order to serve the citizens of our state
with developmental disabilities. We must all be diligent in our compliance
responsibilities and must make a concerted effort to hold ourselves accountable. Please
take this opportunity to review your own service documentation and ensure that it is in
full compliance with the associated rule requirements.
Thank you.
CUYAHOGA COUNTY
Board of Developmental Disabilities
April 26, 2012 Dear Provider,
The CCBDD Community and Medicaid Services Department has developed a Revision Request Form and process for changes to services authorized by a Support Administrator in an ISP or ISP addendum. A copy of the form is attached and you may also obtain a copy on the Provider Search Tool (https://providers.cuyahogabdd.org/Provider lnformation.aspx) or from the Support Administrator (SA). Please email a completed form, requesting a plan revision, to the SA, as this will also provide you with an electronic receipt. If it is not possible to submit via email, fax will be accepted.
The number of revisions received is beginning to exceed the capacity to process these, and working retroactively has become more complicated; guidelines and time limits must be established. Therefore, as of July 1, 2012, there will be a 15 calendar day limit on the time during which you may request a change.
As always, requests for changes to authorizations should be submitted prior to the change whenever possible. This includes changes to services discussed by the ISP team and authorized by the Support Administrator prior to the start of a waiver span.
After a plan has begun, if there is a change in services, the provider will have 15 calendar days to complete and submit the Revision Request Form to the CCBDD Support Administrator in order for the change to be considered. The request form should include clear explanation of what has happened with the individual, how their needs have changed and why this warrants a change in service. It should include clear information on the type of change being requested (service type, units, ratios, etc.) Failure to submit a completed request with all required information may result in a denial of the request. Approvals are not guaranteed.
Requests received more than 15 days after the change will not be approved back to the date of the change. In such an instance, and upon SA approval, the change will be made effective from the date of the notification forward.
1275 Lakeside Avenue East • Cleveland, Ohio 44114-1129 • (216) 241-8230 Fax- (216) 861-0253 • www.CuyahogaBDD.org
Richard V. Mazzola, PrP.sident ., Ara A Bagdasarian, Vice President • Andres Gonzalez, Secretary
Darnell Brown • David L. Deming • Diane Roman Fusco • Maggie Jackson
It is strongly recommended you understand the basics of MSS Cost Projection Tool (https://doddportal.dodd.ohio.gov/PRV/tools/mss/Pages/default.aspx) so that you can monitor which type(s) and amount(s) of services have been authorized and make sure it matches your understanding, otherwise you may not be paid for services you provide that are not authorized in CPT. If you have not already done so, you will need to sign a security affidavit for MSS through the Security Affidavit Wizard on the DODD website.
Also effective July 1, 2012, CCBDD will no longer mail copies of PAS/PAWS to providers. Providers must access this information via the State system (https://doddportal.dodd.ohio.gov/Pages/default.aspx) for waiver authorizations and www.ohiodd.com for local dollar authorizations.
This new procedure will be reviewed in more detail at the Quarterly Provider Meeting on May 9, 2012. If you have questions, I encourage you to attend that meeting.
Thank you for the support you provide each day.
John A. Parkowski Interim General Manager Community and Medicaid Services Department
Plan Revision Requests Consumer Name: ______________________________ Consumer Span Dates: ________________ Provider Name (please print): __________________________________________________________ Effective Requested Start Date for this Revision: ____________________ End Date for this Revision (specific date/ongoing):___________________ What is currently authorized? __________________________________________________________ __________________________________________________________________________________ Change in Service Type/Levels that is being requested :_____________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Why is this change needed for the health and safety of the individual? What has occurred in his/her life to require this change? How have the individual’s needs changed? (Please include documentation as necessary): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Provider signature: ____________________________________ Date: _______________________ Phone number: _____________________ Email address:__________________________________
CCBDD Use Only:
Action Taken: ______________________________________________________________________ __________________________________________________________________________________ SA Name (print): _______________________________________________ SA Signature: __________________________________________________ Date: ______________
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Implementation Guidelines Individual Options and Level One Waivers
Homemaker/Personal Care-On-Site/On-Call Rate Increase and Transportation Rate Increase
Effective January 1, 2014 Effective for services delivered on or after 1/1/2014:
• the base rate for Transportation services under the Individual Options (IO) and Level One (L1) waivers is increasing to $0.45 per mile
• the base rate for Homemaker/Personal Care-On-site/On-call (HPC-OSOC) under the IO and L1 waivers is increasing to $2.70* per 15-minute unit for agency providers
• the base rate for HPC-OSOC under the IO and L1 waivers is increasing to $1.90* per 15-minute unit for independent providers
*See OAC 5123:2-9-30-Appendix A for the new rates adjusted for Cost of Doing Business
• DODD is preparing a listing for each county to identify individuals who have either of these services currently authorized in PAWS and/or identified in CPT/MSS for dates of service on or after 1/1/2014.
• The Cost Projection Tool (CPT) within the Medicaid Services System (MSS) and the Payment Authorization for Waiver Services (PAWS) system will be available after December 6, 2013 for cost projecting and service authorization using the newly increased rates.
Transportation
• The Medicaid Billing System (MBS) will begin paying the new Transportation rates (service codes ATN and FTN) for dates of service on or after 1/1/2014 for claims submitted by providers indicating the new rate as the provider’s charge for the service.
• PAWS plans that do not have enough total dollars available to cover the cost of the higher rate will need to be revised at some point prior to the end of the service span. It is important to note, however, that MBS does not look to PAWS for rate information as PAWS does not house rate information, so it is not necessary to revise every PAWS plan that has Transportation on it prior to 1/1/2014. This can be done over time, as needed.
• As cost projections are done in CPT/MSS, Transportation services entries that are authorized using Span as the Frequency Period (not using Day, Week or Month) will need to be split into entries that do not cross the 1/1/2014 effective date of the rate increase. This will allow entries for dates of service through 12/31/2013 to be projected at the current rate and entries for dates of service on or after 1/1/2014 to be projected at the increased rate. Upon completion of the updated cost projection, the PAWS plan will be to be revised to reflect the newly authorized amounts.
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HPC-OSOC not billed as part of a Daily Billing Unit
• MBS will begin paying the new HPC-OSOC rates (service codes AOC, AOW, AOX, AOY, AOZ, FOC, FOW, FOX, FOY, FOZ, EOC, EOW, EOX, EOY, EOZ) for dates of service on or after 1/1/2014 for claims submitted by providers indicating the new rates as the provider’s charge for the service.
• PAWS plans that do not have enough total dollars available to cover the cost of the higher rate will need to be revised at some point prior to the end of the service span. It is important to note, however, that MBS does not look to PAWS for rate information as PAWS does not house rate information, so it is not necessary to revise every PAWS plan that has HPC-OSOC (PAWS roll-up codes A44, F44 and E44) on it prior to 1/1/2014. This can be done over time, as needed.
• As cost projections are done in CPT/MSS, HPC-OSOC entries that are not identified on the HPC Calendar and are authorized using Span as the Frequency Period (not using Day, Week or Month), will need to be split into entries that do not cross the 1/1/2014 effective date of the rate increase. This will allow entries for dates of service through 12/31/2013 to be projected at the current rate and entries for dates of service on or after 1/1/2014 to be projected at the increased rate. Upon completion of the updated cost projection, the PAWS plan will be to be revised to reflect the newly authorized amounts.
HPC-OSOC billed as part of a Daily Billing Unit
• If HPC-OSOC incorporated into a Daily Billing Unit (service codes ADL and ADP), MSS/CPT will need to be updated as close to 1/1/2014 as possible to allow the Daily Rate Application (DRA) to correctly calculate the daily amounts to be billed by providers for dates of service on or after 1/1/2014.
• If the implementation of the increased rates for HPC-OSOC causes the projected daily rate for one or more individuals in a site to exceed $403.98 on a regular basis, the county may have to consider contacting the Department for assistance with a DRA exemption. This can be done via email to [email protected].
Level One Enrollees
• If the implementation of the increased rates causes the cost of services for an individual enrolled on the Level One waiver to exceed the $5,000 annual cost cap, it is acceptable to utilize a portion of the Emergency Benefit ($8,000 over each three year period of enrollment) within the waiver to prevent a reduction in Medicaid services. If the utilization of the Emergency Benefit is insufficient to accommodate the increase cost of services as a result of the rate increase, services will need to be revised to fit within existing budget limitations.
• The county may have to consider contacting the Department for assistance with a DRA exemption in the rare cases where a person enrolled on a Level One
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Waiver is residing in an MSS site that uses the DRA and the person receives HPC-OSOC. This can be done via email to [email protected].
ODDP Ranges and Prior Authorization
• If the implementation of the increased rates causes the cost of services for an individual enrolled on the Individual Options (IO) waiver to exceed the top of the ODDP range, it is acceptable to request a Prior Authorization (PA) for the additional funds needed.
• If the implementation of the increased rates causes the cost of services for an individual enrolled on the Individual Options (IO) waiver to exceed the previously approved PA funding level, it is acceptable to request a budget adjustment to the previously approved PA for the additional funds needed.
• In order to allow these budget adjustment requests to be handled as expeditiously as possible, please follow the steps below:
o Name your CPT version “rate increase” o Page 2 of IRF :
Check all boxes “yes” Enter “Rate Increase” into both “rationale” boxes Under PA Criteria, select Medical Condition, and copy and paste
“Rate Increase” o No uploads of ISP or other documents are necessary
Please contact the DODD Support Center at 1-800-617-6733 with specific questions or concerns.
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
***SERVICES ARE ROUTINE HPC UNLESS OTHERWISE INDICATED AS ON-SITE/ON CALL OR LEVEL ONE EMERGENCY*** DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time In
Time out
# of Units
# OF INDIVIDUALS SHARING SUPPORTS , if
other than 1:1.
Supports in Plan Duration / Frequency
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/
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service.
DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: _____________ ______ INITIALS: DATE:
Prepared by AggieG 04/26/12
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time In
Time out
Time In
Time out
Total # of Units 1:1 ratio, unless otherwise noted
Supports in Plan Duration / Frequency
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*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service
DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: _____________ ______ INITIALS: DATE: Prepared by AggieG 042612
HOMEMAKER / PERSONAL CARE – SKILL DEVELOPMENT DOCUMENTATION CONSUMER NAME: PROVIDER:
ADDRESS: ADDRESS:
MEDICAID #: PROVIDER #:
RESIDENT #: MONTHLY SERVICE PERIOD: _____/_____/_____ to _____/_____/_____
SKILL DEVELOPMENT AREA: _______________________________________________________ PROGRAM DURATION / FREQUENCY: /
PROGRAM DESCRIPTION / DESIRED OUTCOME: __________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________
DATE / SKILL
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DEVELOPMENT STEPS
DOCUMENT TYPE of PROMPT NECESSARY TO PERFORM STEP: I=Independent, V=Verbal, G=Gestural, P=Physical, R=Refused, ND=Not Delivered ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION ON BACK PAGE
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*SUPPORT STAFF’S INITIALS FOR DAYS SKILL DEVELOPMENT PROGRAM IS OFFERED ACCORDING TO DURATION AND FREQUENCY ON ISP
STAFF SIGNATURE: INITIALS: STAFF SIGNATURE: INITIALS:
COMMENTS (Unusual staffing & reasons, service locations if other than home, problems delivering services, reasons for refusal, etc.)
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31. Comments on progress toward goal and recommendation for continuation, revision, or change SIGNATURE: _____________ ______ INITIALS: DATE:
Adult Family Living (Daily Rate) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Supports in Plan Duration / Frequency
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# OF INDIVIDUALS SHARING SUPPORTS , if other than 1:1.
R= Refused ND = Not Delivered
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION BELOW.
DATE Service location, if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
PROVIDER SIGNATURE: _____________ ______ INITIALS: DATE: Prepared by AggieG 042612
HPC Transportation – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH: __________ YEAR: _ ____
Date Starting location
address Destination Addresses Ending
location address
Miles Driven
1:1 ratio unless
otherwise noted
Staff Initials
DATE Comments, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: _____________ ______ INITIALS: DATE: Prepared by AggieG 01/18/13
NON MEDICAL TRANSPORTATION- MILEAGE - DOCUMENTATION – Cuyahoga County Date of Service
License Plate #
Pick Up Time
Odometer Start
Drop Off Time
Odometer End
Total Miles Driven
Names of All Passengers & Medicaid # Staff Initials
SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ SIGNATURE: _____________ Initials: ______ Prepared by AG 061512
WEEKLY PRE-TRIP INSPECTION REPORT
PROVIDER NAME __________________________________________ PROVIDER # ______________________ MONTH_____________ YEAR, MAKE & MODEL ___________________________________ LICENSE PLATE ___________________ YEAR_______________ Date Date Date Date Date Date Date
Date Driver Initials
Items to inspect on each trip Windows and mirrors are clean and free of cracks/breaks? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Tie downs, if applicable, are present and function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Seat belts function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Wheelchair Lift, if applicable, is operating properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO All lights, including headlights and turn indicators, function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO First Aid kit is in vehicle? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Fire extinguisher is in vehicle and indicates as "good"? YES NO YES NO YES NO YES NO YES NO YES NO YES NO The horn is working properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Windshield wipers are working correctly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Tread on all four tires is sufficient? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Test service brakes? YES NO YES NO YES NO YES NO YES NO YES NO YES NO SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ Prepared by AggieG 04/26/12
NON MEDICAL TRANSPORTATION- PER TRIP - DOCUMENTATION – Cuyahoga County
PROVIDER NAME PROVIDER # MONTH____________ YEAR__________
Date
License Plate Number
Odometer Start
Start Time of Trip
Odometer End
End Time of Trip
Miles Driven
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Staff Initials
DATE Names of all other passengers/riders, including paid staff and volunteers who were in the vehicle during any portion of the trip and/or commute. SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ SIGNATURE: _____________ ______ Prepared by AggieG 12/28/12
