MEDICAID ADMINISTRATIVE CLAIMING Training for LHD Cost Pool (rev 3/16/2011). Status of Medicaid Administrative Claiming in Oregon (3/07). Currently 20 counties participating. LHDs are claiming a range of percentages of their surveyed times as MAC claimable—between 15-45%.
…a method of identifying and accounting for the time spent by health department staff on medically related activities.
Cost Pool (provided locally)
% of allowable time (time study)
% of Medicaid eligible
= Total Claim
50% non-federal match
= Net revenue
Survey dates are randomly selected by DHS
Paid time at work is surveyed in 15-minute increments.
Staff time falls into any one of the ten activity codes.
Predominant portion of a 15-minute increment is what’s recorded.MAC SurveyHow it Works
A: Because there is no way for LHDs to know when a survey date may fall in any given quarter, the quarter prior to the one in which a trainee’s “training anniversary” date falls is the last quarter for which that training is valid. If re-training is not done before the beginning of the anniversary quarter, the individual will not be able to log onto MESD to take the survey.
A1: Outreach and Application Assistance for the Medicaid Program
A1.5 Checked a person’s OHP status
Code B-1: Referral, Coordination, Monitoring and Training of Medicaid Services
B1: Referral, Coordination, Monitoring and Training of Medicaid Services
Q: During the course of a home visit, a nurse encounters a relative of the client needing assistance; the nurse makes a referral for that person. Is the referral claimable?
A: Yes—because the referral is made for one who is not the recipient of the TCM/MCM service that was the reason for the home visit, the time given by the nurse for the referral is properly claimed as a MAC B1 activity.
A nurse conducts a pregnancy test. relative of the client needing assistance; the nurse makes a referral for that person. Is the referral claimable?It is:1) Positive. The nurse refers the client to WIC.2) Negative. The nurse refers the client to the Family Planning program for contraceptive management.
#2: Referring a client to FP is an extension of direct service in this instance. The nurse would code it E: “Direct service.”
Q: Which of these activities is claimable?
A: Neither is claimable.
#1: Referral to WIC is always coded B2: “Referral to non-Medicaid services.”
A: All these activities are considered part of the medical assessment and evaluation of clients and as such are classified as “E”, “Direct Health Care Services.”
Q: If a cost pool member delivers vaccines to staff who are providing immunizations at a field or mobile clinic, is her travel time claimable? If so, how would she code it?
A: Delivering vaccines to an immunization clinic (providing the shots are not free to the general public) is integral to setting up of such clinics—an allowable claim. As it is travel related to coordination of services, it would be coded B1.5.
Re: B1.5 “Paperwork and staff travel related to referral, coordination, monitoring and training of Medicaid services”: IF YOU ARE THINKING OF CODING AN ACTIVITY “B1.5”… TAKE NOTE!Don’t use B1.5 as a default or ‘catch-all’ for any / all paperwork!
Usually, paperwork is directly supporting another “B” activity:
When a considerable amount of staff time is coded “B1.5,” it gives the impression that employees are spending the time at their desks on paperwork instead of assisting clients.
In most cases, positive B codes involve making appointments, pulling charts, scheduling followups, etc.—these may involve entering information on paper, yet they are not activities that amount to “just paperwork.” When in doubt, ask yourself whether your activity is aimed at connecting specific clients to a service.
C1: Medicaid/OHP Transportation and Translation
Q: I am an Office Specialist 3. Today I spent 30 minutes explaining, in Spanish, the benefits of OHP to a client. The next 15 minutes I spent translating for a nurse who referred the client to an immunization clinic and answered her questions re immis for her children. Are both of these activities C1?
The first activity would be coded A1.2 by the OS3 because only one language is used in the course of serving the client.
The second activity would be coded C1.2 by the OS3 because she is translating from one language to another; the nurse could claim the same time as B1.1 because she is providing a referral.
D1: System Coordination Related to Medicaid Services
to System Coordination for
Q: Today’s meeting attended by several cost pool participants lasted all morning. Medicaid health services were discussed. What portion of their time during this AM can these staff claim?
A: Only those times during the meeting devoted to discussing system coordination related to Medicaid services.
If the total amount of claimed staff time is significant, it is requested that at least one—and preferably both—of the following documents be available on file:
surveys are accounted for. If a member of
your cost pool is being paid for that day, that
person’s survey must be completed, regardless of whether she came to work that day or not.