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Partners for Children (PFC) Waiver Services, Procedure Codes, Rates and Billing. Jill Abramson, MD MPH February14, 2013. PFC Provider Training. Overview Care Coordination/CCSNL/Communication Family-Centered Action Plan Services/Billing Federal Assurances/ Health & Welfare

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Partners for children pfc waiver services procedure codes rates and billing

Partners for Children(PFC) Waiver Services, Procedure Codes, Rates and Billing

Jill Abramson, MD MPH February14, 2013


Pfc provider training
PFC Provider Training

  • Overview

  • Care Coordination/CCSNL/Communication

  • Family-Centered Action Plan

  • Services/Billing

  • Federal Assurances/ Health & Welfare

  • Agency Responsibilities/Summary


What h appens before s ubmitting claim
What Happens Before Submitting Claim

  • Services identified on F-CAP

  • Services authorized by CCSNL

  • SAR received by agency

  • Service(s) provided


Pfc services procedure codes rates and billing
PFC Services, Procedure Codes, Rates and Billing

Objectives:

  • Understand PFC services

  • Understand the use of the procedure codes and billing limits

  • Know the rates for each service

  • Understand claims processing procedure


Pfc services
PFC Services

Care Coordination:

Will provide child/family with Care Coordinator to:

  • Assume a majority of the responsibility, otherwise placed on parents, of coordinating all medically necessary care in the community

  • Work with the child/family to develop the Family-Centered Action Plan (F-CAP)

  • Provide ongoing monitoring of health and safety of the child, including home visits


Pfc services1
PFC Services

  • Regularly communicate with the CCSNL, child, family, treating physician and other providers

  • Accompany child/family to appointments as necessary such as; physician, school or hospital

    Service Provider: RN, MSW

Care Coordination (cont):


Pfc services2
PFC Services

Expressive Therapies:

Will allow children to express their understanding and reaction to their illness by utilizing play, art, music and massage therapy to improve the capacity of the body and mind to heal.

Service Provider: certified therapist


Pfc services3
PFC Services

Family Training:

Allows an RN to instruct caregivers about end of life care, palliative care principles, care needs, medical treatment regimen, use of medical equipment and how to provide in-home medical care to meet the needs of the child.

Service Provider: RN


Pfc services4
PFC Services

Respite Care:

Provides relief for family members either in the home or in an approved facility. This benefit may be intermittent or regularly scheduled.

Service Provider: RN, LVN, HHA


Pfc services5
PFC Services

Family Counseling:

Provides child/family with emotional support and grief counseling. Includes visits before and after the death of the child.

Service Provider: LCSW, Licensed Psychologist, MFT, ACSW


Pfc procedure codes and rates
PFC Procedure Codes and Rates

Care Coordination Services:


Pfc procedure codes and rates1
PFC Procedure Codes and Rates

Care Coordination Services (cont):


Pfc procedure codes and rates2
PFC Procedure Codes and Rates

Expressive Therapies:




Pfc procedure codes and rates5
PFC Procedure Codes and Rates

Respite Care (cont):


Pfc procedure codes and rates6
PFC Procedure Codes and Rates

Family Counseling:

*At least one visit must be provided, and the whole 22 units billed, before the child’s death.


Billing pfc services
Billing PFC Services

  • PFC services are Fee for Service

  • PFC services must be authorized for the correct dates of service

  • Service Authorization Request (SAR) = auth.

  • Agency requests service on F-CAP, sends to CCSNL for authorization

  • County CCS will share completed authorization with Agency

  • Very different from traditional hospice per diem


Billing pfc services1
Billing PFC Services

Billing:

  • SARs (authorization)

    • Initial SAR to begin Care Coordination

    • Additional SARs for requested PFC services once F-CAP is completed

    • Separate SARs for other non-PFC services covered by the state plan

  • Check Medi-Cal eligibility prior to providing services


Billing pfc services claim completion
Billing PFC Services - Claim Completion

UB-04 Field Descriptions:


Billing pfc services claim completion1
Billing PFC Services- Claim Completion

UB-04 Field Descriptions (cont):


Billing pfc services claim completion2
Billing PFC Services- Claim Completion

UB-04 Field Descriptions (cont):


Billing pfc services claim completion3
Billing PFC Services- Claim Completion

UB-04 Field Descriptions (cont):


Billing pfc services claim completion4
Billing PFC Services- Claim Completion

UB-04 Field Descriptions (cont):


60.

CIN or 14-digit ID #

Claim Completion

Sample UB-04

CCS/Medi-Calclaim authorized with a SAR

63.

PFC

SAR #


Billing pfc services claim completion and submission
Billing PFC Services - Claim Completion and Submission

For help completing UB04 and submission instructions:

Contact Xerox Regional Representative.

Xerox Telephone Service Center: 1-800-541-5555


Billing troubleshooting
Billing Troubleshooting

  • Denied Claims:

    • Check AEVS, CIN, SAR, correct dates (eligibility, date on SAR corresponds to service), # units

    • If no clear reason for denial, send to PPC mailbox:

      • Name, CCS#, CIN, service, date of service, CCN, RAD, notes, provider NPI


Billing troubleshooting1
Billing: Troubleshooting

  • Underpaid claims

    • Verify $ in provider manual vs. $ paid.

    • If incorrect, send to PPC mailbox:

      • Name, CCS#, CIN, service, date of service, CCN, units paid, $ paid,

        $ expected


Billing troubleshooting2
Billing: Troubleshooting

  • Claims neither paid nor denied >2 months after submission

  • Send to PPC mailbox:

    • Name, CCS#, CIN, service, date of service, CCN (if available), whether client has OHC



Pfc provider training1
PFC Provider Training

  • Overview

  • Care Coordination/CCSNL/Communication

  • Family-Centered Action Plan

  • Services/Billing

  • Federal Assurances/

  • Health & Welfare

  • Agency Responsibilities/Summary



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