Medicaid accountability in the i suite
This presentation is the property of its rightful owner.
Sponsored Links
1 / 25

Medicaid Accountability in the I-Suite PowerPoint PPT Presentation


  • 93 Views
  • Uploaded on
  • Presentation posted in: General

Medicaid Accountability in the I-Suite. How to document Medicaid services in the GG Consulting I-Suite to assist with compliance with Medicaid standards. GG Consulting, LLC I-SUITE. “What criteria must a child meet in order for the district to bill Medicaid under the SHARS program?

Download Presentation

Medicaid Accountability in the I-Suite

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Medicaid accountability in the i suite

MedicaidAccountability in the I-Suite

How to document Medicaid services in the GG Consulting I-Suite to assist with compliance with Medicaid standards.

GG Consulting, LLC I-SUITE


Criteria for billing compliance

“What criteria must a child meet in order for the district to bill Medicaid under the SHARS program?

  • The child must:

    • be enrolled in a public school’s special education program;

    • be under 21 years of age;

    • Have an ARD/IEP documenting the medical necessity for services [Documentation requirements can be found in the current Texas Medicaid Provider Procedures Manual (TMPPM), in the Provider Enrollment and Responsibilities Section and in the SHARS Section];

    • Have a disability or chronic medical condition;

    • Be Medicaid eligible; and

    • Have informed parental consent to bill Medicaid for the specific services and the frequency as outlined in the child’s current IEP.”

Criteria for Billing Compliance

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Medicaid id

  • “The child’s name and Medicaid number should appear on every page of the medical records… This would include each page of the ARD/IEP document, session notes and service logs, and evaluations.” (TEA SHARS FAQ)

  • Medicaid number

    • Manually input into Student Information - General

    • (SM)2 clients – number is inserted on all forms automatically

    • Automatic label reminder can be turned on in FM – Options/Directories to print labels to stick on ARD documents

    • FM – Form Setup

      • Can indicate how many labels are needed per form.

    • Could be considered part of consent and if parent refuses number on forms then they are refusing to give consent to bill

  • Session Notes

    • (SM)2 program keeps session notes. Non-(SM)2 clients need to collect and store separately.

Medicaid ID

GG Consulting I-Suite


Parental consent

  • “Are schools required to obtain parental consent prior to billing Medicaid for SHARS services?”

    • “Yes, Section 300.154(d) of the reauthorized IDEA 2004 requires districts to obtain informed parental consent. More guidance on this issue may be found on TEA’s Division of IDEA Coordination website at: www.tea.state.tx.us/special.ed/guidance/medserv.html “

Parental Consent

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Parental consent and sem

  • Parental Consent is obtained in 2 places in SEM

    • ARD Signature page (pg. 7)

      • Should be obtained at EVERY ARD – not just the Annual

    • SHARS Letter

      • Can be given when obtaining initial consent as it also includes the Right to Provider section.

  • Both locations provide space for a Consent Expiration date.

Parental Consent and SEM

GG Consulting I-Suite


Parental consent and sm 2

(SM)2 reads PC from signature page of ARD as well as SHARS Letter

  • Will not bill TMHP if there is no consent at the time of the service

  • Reports can be run to show who has consent and who does not

Parental Consent and (SM)2

GG Consulting I-Suite


Documenting pcs

  • Personal Care Services

    • “Indication of placement in a self-contained setting [i.e., Life Skills classroom, Preschool Programs for Children with Disabilities (PPCD), etc.] is not sufficient IEP documentation to support Medicaid reimbursement for PCS.”

    • Sufficient documentation should answer:

      • Is the service provided on a one-on-one basis or group or both;

      • examples of PCS;

      • when/where are the PCS needed; and

      • the reason(s) for PCS, such as medical necessity, etc.

Documenting PCS

GG Consulting I-Suite

  • Source: TEA SHARS Frequently Asked Questions


Documenting pcs1

  • SEM Options

  • ARD Physical Section (pg 2)

    • Subject on Schedule Page

      • From FM – Options/Directories

  • PCS Supplement

    • Documents time outside of the instructional day

  • Related Services

  • IEP

  • Deliberations

Documenting PCS

GG Consulting I-Suite


Documenting pcs2

  • Example of documentation in the IEP

  • Sufficient documentation

  • Assistance is required for one-on-one PCS for “Johnny”. PCS needs include observation and redirection of self-injurious behavior. PCS is required throughout the school day and during transportation to and from school on the bus. Johnny has bipolar disorder and gets angry, frustrated very easily. He often displays his anger and frustration

  • Insufficient documentation

  • Assistance is required for one-on-one PCS for “Sue”. Sue has cerebral palsy.

Documenting PCS

GG Consulting I-Suite

  • Source: TEA SHARS Frequently Asked Questions


Documenting pcs3

  • Example of documentation in the IEP

  • Sufficient documentation

  • PCS assistance is required for “Timmy” periodically throughout the day on a one-on-one basis. Timmy has mental retardation and needs periodic PCS to assist him in moving from class to class. Without PCS assistance, Timmy would wander off.

  • Insufficient documentation

  • PCS assistance is required for “Jane” periodically throughout the day on a one-on-one basis because she has visual impairment.

Documenting PCS

GG Consulting I-Suite

  • Source: TEA SHARS Frequently Asked Questions


Documenting pcs4

  • Example of documentation in the IEP

  • Sufficient documentation

  • Group PCS assistance is required for “Janice” throughout the day. Janice has ADHD. She has difficulty staying on task and is very impulsive. She requires constant cueing, prompting, and redirection.

  • Insufficient documentation

  • Group PCS assistance is required for “Janice” throughout the day because she has ADHD.

Documenting PCS

GG Consulting I-Suite

  • Source: TEA SHARS Frequently Asked Questions


Documenting pcs5

  • Example of documentation in the IEP

  • Sufficient documentation

  • Group PCS assistance is required for “Janice” throughout the day. Janice has ADHD. She has difficulty staying on task and is very impulsive. She requires constant cueing, prompting, and redirection.

  • Insufficient documentation

  • Group PCS assistance is required for “Janice” throughout the day because she has ADHD.

Documenting PCS

GG Consulting I-Suite

  • Source: TEA SHARS Frequently Asked Questions


Documenting pcs6

  • Example of documentation in the IEP for group PCS with intermittent one-on-one PCS

  • Sufficient documentation

  • Sue is in a self-contained classroom and needs group PCS throughout the day. In addition, Sue needs individual assistance with ADLs, including eating, toileting, mobility, and transfers because she is unable to transfer herself to the toilet and during transportation to and from school on the bus. Sue has cerebral palsy and cannot navigate her chair, feed or toilet herself.

  • Insufficient documentation

  • Bobby needs group and one-on-one PCS throughout the day. Bobby is wheelchair bound.

Documenting PCS

GG Consulting I-Suite

  • Source: TEA SHARS Frequently Asked Questions


Pcs provision documentation

  • What is required for documenting services for PCS?

  • Must capture the minutes of the service with start and stop times,

  • Must have notation of specific type of PCS required,

  • Must identify type of PCS (one-on-one or group),

  • If PCS is provided throughout the day, the accumulation of all the PCS minutes for the day must be totaled and converted to units of service, and

  • Must include the signature of the individual that provided the PCS. (In group settings, each caregiver does not have to provide documentation for each child. Rather one caregiver can document for 2 or 3 students while another caregiver documents on the other 2 or 3 students.

PCS Provision Documentation

GG Consulting I-Suite

  • Source: TEA SHARS Frequently Asked Questions


Documenting pcs services

Documenting PCS Services

  • Source: TEA SHARS Frequently asked questions


Documenting pcs services1

Documenting PCS Services

  • Source: TEA SHARS Frequently asked questions


Documenting related services

  • ARD Schedule Page

    • Service type, frequency, and duration need to be listed.

  • IEP

    • Goals and objectives can be sufficient documentation for billing services

  • Deliberations

    • Services can also be explained/described here.

  • Counseling as a Related Service

    • ARD Schedule Page

      • “Counseling” is billed by LCSW or LPC

      • “Psychological Services” is billed by LSSP

    • “BIP is needed to bill for emergency services and should list the need for emergency counseling”

Documenting Related Services

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Documenting related services1

  • Nursing Services

    • ARD Physical Section (pg 2)

      • Adds service to Related Service section on Schedule Page

    • “The ARD minutes should include recommendations derived from the RN/APN or physician’s evaluation of the student’s nursing services needs. Nursing services need to be stated with the same level of detail as is provided for the other related services. But, due to the type of services, it may be appropriate to add language such as “as needed”.

Documenting Related Services

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Transportation criteria

“When can specialized transportation be billed for SHARS?

  • Specialized transportation service may be Medicaid reimbursable if:

    • it is being provided to and from a Medicaid covered (SHARS) service(s) for the day the claim is made;

    • the Medicaid covered service(s) is included in the student's IEP;

    • the specialized transportation needs are included in the IEP, and

    • the child requires transportation in a school bus adapted to serve the needs of a student with a disability, which includes the need for personnel on the bus due to a student’s disability (i.e., constant monitoring, suctioning).”

Transportation Criteria

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Transportation criteria1

“What type of documentation is required for billing specialized transportation services?”

  • “Another billable SHARS service must be provided that same day the specialized transportation service is provided.”

    • (SM)2 will not bill the service that day if no other service was provided.

  • “A transportation log must be maintained recording one-way trips.”

    • (SM)2 has a log for tracking each ride to and from school.

  • “IEP documentation must support the medical necessity as to why the student requires the specialized transportation adaptation. “

    • A blank is provided for the ARD facilitator to record this information on the Transportation Eligibility form in the ARD in SEM.

Transportation Criteria

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Gg consulting i suite

Transportation Criteria

  • Transportation Eligibility Form

    • Records medical necessity for the service

  • Transportation Information

  • Transportation Special Needs Report

    • New report in RU

GG Consulting I-Suite


Common questions

  • Can a SHARS provider provide services beyond the IEP requirements?

    • No, the IEP authorizes the maximum services that can be provided and billed. Under the Individuals with Disabilities Education Act (IDEA), districts are required to follow the IEP requirements. Any services billed to Medicaid in excess of those stated in the IEP could be subject to recoupment.

Common questions

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Common questions1

If a student needs constant monitoring all day, even during instructional time, is the entire day billable as personal care services?

The IEP should clearly justify the need for constant supervision or monitoring and any other PCS (such as toileting, feeding, etc.) required during the school day. The documentation needs to answer the following questions or provide the requested documentation:

(1) examples of PCS;

(2) when/where are the personal care services are needed;

(3) reason(s) for PCS (such as medical necessity, etc.); and

(4) why can’t the student perform the age appropriate task?

Common questions

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Record maintenance

  • Minimum records to keep (7 years):

    • ARD/IEP documents

    • Attendance records

    • Assessment/evaluations

    • Provider qualifications (current licenses and certifications)

    • Written agreements (contract) for contracted service providers

    • Required prescriptions or referrals for services

    • Supervision logs

    • Session notes or service logs

    • Transportation documentation (daily trip logs; maintenance logs/records; bus documentation; documentation for cost report)

    • Claims Submittal and Payment Histories (R&S Reports and General Ledger)

    • Copies of signed/notarized quarterly Certification of Funds (COF) letters and supporting documentation, including quarterly COF Reports

    • Nonschool SHARS provider affiliation letter and attachments (if applicable)

    • Cost Report and supporting documentation

Record Maintenance

GG Consulting I-Suite

  • Source: TEA SHARS Frequently asked questions


Resources

  • TEA SHARS site

  • http://ritter.tea.state.tx.us/interagency/shars.html

    • Frequently Asked Questions

    • Billing Guidelines

    • Join Listserv

Resources

GG Consulting I-Suite


  • Login