Department of Medical Assistance Services

Department of Medical Assistance Services PowerPoint PPT Presentation


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2. This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals Training material contains only highlights of manuals and is not meant to substitute for or take the place of the Community Mental Health Rehabilitative Services Manual. For a complete copy of manual: .

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Department of Medical Assistance Services

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1. Department of Medical Assistance Services

2. 2 This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals Training material contains only highlights of manuals and is not meant to substitute for or take the place of the Community Mental Health Rehabilitative Services Manual. For a complete copy of manual:

3. 3 Objectives of Today’s Training

4. 4 Specific Staff Qualifications

5. 5 Staff Qualifications cont.

6. 6 Human Services Fields Social Work Gerontology Psychology Psychiatric Rehabilitation Special Education Sociology Counseling Vocational Rehabilitation Human Services Counseling

7. 7 Definition of “Clinical Experience” Providing direct services to individuals with: Mental illness Mental retardation Persons receiving gerontology services Persons receiving special education services Includes supervised internships, practicums and field experience.

8. 8

9. 9

10. 10 Staff Qualifications (cont’d)

11. 11 “PARAPROFESSIONAL SUPERVISION” QMHP demonstrates supervision of “Qualified Paraprofessional” by reviewing notes, progress towards achieving ISP goals & objectives and making recommendations for change. Supervision must occur & be documented in the clinical record monthly. Individual & group supervision conducted by the QMHP are acceptable.

12. 12 Paraprofessionals who do NOT meet the experience requirement described may provide services….. if they are working directly with a Qualified Paraprofessional on site and they are supervised by a QMHP. Supervision must include on site observations of services, face -to-face consultation, review of notes, etc. and be documented in the clinical record monthly. Non-Qualified Paraprofessionals

13. 13 Intensive In-home Services to Children and Adolescents (H2012) SERVICE DEFINITION Time-limited interventions Provided Typically in the home of consumer At risk of being moved into an out-of-home placement OR Being transitioned to home from an out-of-home placement due to a documented medical need of the child.

14. 14 Scope of IIH Services: This service provides: Crisis treatment Individual and family counseling Communication counseling Case management activities Coordination with all other services child receives 24-hour emergency response

15. 15 Does the child meet the eligibility criteria for the specific service? and ….. Does the child need the service?

16. 16 Does the child meet the eligibility criteria for the service?

17. 17 Clinical necessity which arises from a condition due to a: mental behavioral OR emotional illness must be demonstrated. This condition results in significant impairments in major life activities. Eligibility Criteria for IIH:

18. 18 Two of the following must be clearly documented for the individual on a continuing or intermittent basis….. Severe problems in interpersonal relationships at risk of hospitalization or out-of-home placement because of conflicts with family or community; Eligibility Criteria (cont’d)

19. 19 Eligibility Criteria (cont’d)

20. 20 Does the child need the service?

21. 21 Eligibility Criteria (cont’d)

22. 22 At least one parent with whom the child is living must be willing to participate in In-Home treatment, with the goal of keeping the child with the family. ********************** These services may also be used to facilitate the transition to home from an out-of-home placement. Eligibility Criteria (cont’d)

23. 23 Face-to-face assessment by QMHP (approved by LMHP within 30 days): Eligibility criteria is met Service is needed Service needs can best be met through Intensive In-Home Services Required Activities for IIH:

24. 24 Billing Code for IIH Assessments As of July 1, 2008 a new billing code for IIH assessments will be implemented Assessment billing code is H0031 (no PA required) Reimbursement rate allowed is flat rate of $70 Prior authorization for billing assessment is not required Assessment code may be billed twice per treatment year (7/1-6/30) as needed for separate episodes of care

25. 25 Required Activites (cont’d) Individual Service Plan (ISP) fully completed by QMHP within 30 days of admission Document need for services Demonstrate need for 3 hour minimum of IIH treatment per week Referral should be made for well-child or EPSDT screening as needed Include a discharge plan to less intense level of service ISP must be co-signed by parent/ child Psychiatric med evaluation is recommendedPsychiatric med evaluation is recommended

26. 26 Comprehensive and regularly updated Specific to individual being treated Containing goals and measurable objectives to meet identified needs Services to be provided with recommended frequency to accomplish the measurable goals and objectives Estimated timetable for achieving the goals and objectives Maintained up to date as the needs and progress of the individual changes, ISP Critical Elements:

27. 27 Individual Service Plan (ISP) Goals (Broad, generalized statement about what is to be learned, changed) Each GOAL should have several objectives Each OBJECTIVE is 1 clearly described behavior that you wish to change in order to reach the goal: Who will do what? How often? How measured? Objective achieved by when? Each objective must have staff INTERVENTIONS

28. 28 IIH ISP DO’s INDIVIDUALIZED! Include all service needs identified in assessment Objectives = specific desired client behaviors in quantitative terms Interventions = specific planned staff actions with a specific planned frequency

29. 29 SAMPLE IIH ISP COMPONENTS 1. Goal: Medication Management Objectives: Client will take meds every morning and evening after eating, Mom will observe client taking meds and mark med compliance chart twice daily. Interventions: Staff will ask about med compliance and check chart per contact. Staff will take client to park to shoot baskets for 20 minutes every Friday as reward for 100% compliance. Staff will praise client and Mom for meeting med objectives twice weekly.

30. 30 2. Goal: Anger Management Objectives: Client will talk in a calm voice to brother every day. Client will take 10 minute time out to calm down whenever he gets angry with brother. Client will immediately log concerns with brother and go over with IIH staff ASAP. Mom will go over household rules daily & give praise when rules are obeyed. Interventions: Staff will conduct family meeting to develop House Rules. Staff will discuss, practice with, & encourage client to take time outs and log angry situations per contact. Staff will praise client & Mom for following household rules per contact. IIH ISP COMPONENTS (con’t)

31. 31 Services described in ISP are delivered primarily in the child’s home with the child present. Services MAY be provided in the community if supported by the assessment and ISP (lack of privacy, safety). Services must be provided by QMHP or LMHP Progress note documentation must be entered for all service hours that are billed.

32. 32 IIH PROGRESS NOTES DO’S & DON”TS Be sure to include ALL billable services provided to correlate with time billed--Be careful of excessive time Focus on including all staff actions that meet the service definition Address all ongoing ISP needs Describe the specific client behaviors, what staff did and clients’ responses--Client quotes are helpful Complete documentation as soon as possible after services are provided

33. 33 IIH PROGRESS NOTES DO’S & DON”TS (Con’t) Exact duplicate notes are disallowed. If service are provided in more than one location, always include time spent providing services in the home Describe ALL case management services provided Crisis intervention in the school and meeting with teachers, IEP meetings, etc. are billable Case Management services are billable and should be clearly documented Extensive telephone calls may be disallowed

34. 34 SAMPLE IIH PROGRESS NOTE Home with Mom and client April 23, 2008 3:30-6:00 PM, 2.5 hours Met client and mom at home, client was angry at loss of TV due to not completing morning chores. Discussed homework, school attendance, chores, house rules, and accepting consequences. Role played client as Mom and Mom as child who does not complete daily chores. Looked at med chart, homework assignment/completion sheet, and clients’ anger journal. Praised client for completing homework every day this week. Reminded client to take personal time outs when angry and complete daily chores. Spoke with Mom and praised her for appropriate consequence and reminded her to praise client for all compliance, set up next med appt., and call about summer camp. Candice Chavis, MA, QMHP

35. 35 Case Management Services cannot be billed separately -- IIH provider must notify case management agency when services are started (document notification efforts) -- No separate mental health case management -- No separate mental retardation case management -- No IIH for child in Treatment Foster Care- CM -- Coordination by IIH worker must occur for all services that child receives Intensive In-Home: Limitations

36. 36 Limitations (cont’d) Service is not appropriate for a family…….. while the child is not living in the home OR being kept together until an out-of-home placement can be arranged Staff travel time is excluded Tutoring or assisting with academic instruction is not a reimbursable service. Extensive observational sessions conducted in the school environment during the school day are not reimbursable. UNIT of service is one hour- fractions of hour may be accumulated up to Unit/billing period

37. 37 For reimbursement of this service, the individual must need 3 - 10 hours of therapeutic intervention per week. In exceptional circumstances, and with appropriate supporting documentation that includes medical necessity, providers may perform up to 15 hours per week, however this should not be routine. KePRO will authorize up to 50 hours per month once it is determined medical necessity has been met. Limitations (cont’d) KePRO will authorize up to 50 hours per month once it is determined medical necessity has been met. Providers may only bill for the actual services provided, and this must be well documented. KePRO will authorize up to 50 hours per month once it is determined medical necessity has been met. Providers may only bill for the actual services provided, and this must be well documented.

38. 38 IIH Service Prior Authorizations (PA): Changes to the Program Effective July 1, 2008 the current authorization process will change from requiring authorization after the first 26 weeks each treatment year to requiring authorization after the first 12 weeks in the first year of treatment. The first year of service will commence July 1, 2008 for all individuals, even if they are currently receiving IIH services. Individuals that were receiving IIH services either under State Plan Option or under EPSDT that currently have an authorized period have been included in the new requirement. Any existing extension authorization period or extension request submitted before July 1, 2008 will be end dated June 30, 2008. These affected individuals will also receive the first 12 weeks of service, starting July 1, 2008, without PA. For any new IIH recipient with service dates starting on or after July 1, 2008, the first 12 weeks do not require prior authorization. All subsequent requests, regardless of the dates of services, will require PA through KePRO. The first 26 weeks of treatment are State Plan Option services. If a child under 21 years of age requires services beyond 26 weeks, coverage through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program may be requested through KePRO. After the first year of treatment, all weeks must be prior authorized. The first 26 weeks in subsequent years are State Plan services, and any additional weeks are EPSDT services. Regardless of when services start for the first treatment year, the subsequent year anniversary date is re-set to July 1. For reimbursement of this service, a minimum of 3 hours per week of therapeutic intervention must be needed by the individual, with a maximum of 10 hours per week. In exceptional circumstances only, and with appropriate supporting documentation that includes medical necessity, providers may bill for up to 15 hours per week. Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automatic letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied. Claims paid that exceed the service limits may be subject to retraction at the time of an audit. PA decisions will be made utilizing DMAS criteria identified in the Community Mental Health Rehabilitative Services Manual. Please refer to this manual for more detailed information regarding IIH services and billing requirements. The link is http://websrvr.dmas.virginia.gov/manuals/CMHS/cmhrs.htm. Changes to the Program Effective July 1, 2008 the current authorization process will change from requiring authorization after the first 26 weeks each treatment year to requiring authorization after the first 12 weeks in the first year of treatment. The first year of service will commence July 1, 2008 for all individuals, even if they are currently receiving IIH services. Individuals that were receiving IIH services either under State Plan Option or under EPSDT that currently have an authorized period have been included in the new requirement. Any existing extension authorization period or extension request submitted before July 1, 2008 will be end dated June 30, 2008. These affected individuals will also receive the first 12 weeks of service, starting July 1, 2008, without PA. For any new IIH recipient with service dates starting on or after July 1, 2008, the first 12 weeks do not require prior authorization. All subsequent requests, regardless of the dates of services, will require PA through KePRO. The first 26 weeks of treatment are State Plan Option services. If a child under 21 years of age requires services beyond 26 weeks, coverage through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program may be requested through KePRO. After the first year of treatment, all weeks must be prior authorized. The first 26 weeks in subsequent years are State Plan services, and any additional weeks are EPSDT services. Regardless of when services start for the first treatment year, the subsequent year anniversary date is re-set to July 1. For reimbursement of this service, a minimum of 3 hours per week of therapeutic intervention must be needed by the individual, with a maximum of 10 hours per week. In exceptional circumstances only, and with appropriate supporting documentation that includes medical necessity, providers may bill for up to 15 hours per week. Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automatic letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied. Claims paid that exceed the service limits may be subject to retraction at the time of an audit. PA decisions will be made utilizing DMAS criteria identified in the Community Mental Health Rehabilitative Services Manual. Please refer to this manual for more detailed information regarding IIH services and billing requirements. The link is http://websrvr.dmas.virginia.gov/manuals/CMHS/cmhrs.htm.

39. 39 The first year of service will commence July 1, 2008 for all individuals, even if they are currently receiving IIH services. Individuals that were receiving IIH services either under State Plan Option or under EPSDT that currently have an authorized period have been included in the new requirement. IIH Service PA (con’t)

40. 40 IIH Service PA (con’t) Any existing extension authorization period or extension request submitted before July 1, 2008 will be end dated June 30, 2008. These affected individuals will also receive the first 12 weeks of service, starting July 1, 2008, without PA.

41. 41 IIH Service PA (con’t) For any new IIH recipient with service dates starting on or after July 1, 2008, the first 12 weeks do not require prior authorization. All weeks after these first 12 will require PA through KePRO. After the first year of treatment, all weeks must be prior authorized. Regardless of when services start for the first treatment year, the subsequent year anniversary date is re-set to July 1.

42. 42 When PA is required and requested providers will receive authorization determinations (denials or approvals) via First Health automatic letter generation process. If approved letter from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the weeks authorized will be denied. PA decisions will be made utilizing DMAS criteria identified in the Community Mental Health Rehabilitative Services Manual.. IIH Service PA (con’t)

43. 43 Initial PA Review Criteria The provider will need to submit demographic information and include the following: • Face to Face assessment, (date completed) • A narrative description of the behaviors exhibited by the client over the past 30 days that place the child at risk of removal from the home and warrant the requested level of care (identify frequency, intensity and duration of behaviors meeting the eligibility / medical necessity for service). • DSM-IV Diagnoses: Axes I and II are required • Date the agency is initiating treatment

44. 44 Concurrent PA Criteria Concurrent Review--(same provider) required to be submitted to PA contractor no earlier than 30 days prior to end of current authorization. Must include the following information: Date of completion of fully developed Individual Service Plan (ISP) ( must be completed within 30 days of the initiation of services with dated signature of Qualified Mental Health Provider) (Identify treatment goals and progress towards identified goals) A narrative description of the behaviors exhibited by the client over the past 30 days that place the child at risk of removal from the home and warrant the requested level of care (identify frequency, intensity and duration of behaviors meeting the eligibility / medical necessity for service). DSM-IV Diagnoses: Axes I and II are required Date needing next PA Projected discharge date Please refer to this manual for more detailed information regarding IIH services and billing requirements. The link is http://websrvr.dmas.virginia.gov/manuals/CMHS/cmhrs.htm Please refer to this manual for more detailed information regarding IIH services and billing requirements. The link is http://websrvr.dmas.virginia.gov/manuals/CMHS/cmhrs.htm

45. 45 Therapeutic Day Treatment for Children & Adolescents (H0035-HA) SERVICE DEFINITION Psychotherapeutic interventions combined with education and mental health treatment Offered in programs of 2 or more hours per day with groups of children/adolescents

46. 46 Does the child meet the eligibility criteria for the service?

47. 47 TDT Eligibility Criteria: Individual demonstrates a: Mental, behavioral or emotional illness resulting in significant functional impairments in major life activities Impairment has become more disabling over time Require significant intervention services offered over a period of time that are: Supportive & Intensive Determination of significant disability should be based upon consideration of the social functioning of most children who are the same age. The disability must have become more disabling over time and must require significant intervention through services that are supportive, intensive, and offered over a protracted period of time in order to provide therapeutic intervention. Determination of significant disability should be based upon consideration of the social functioning of most children who are the same age. The disability must have become more disabling over time and must require significant intervention through services that are supportive, intensive, and offered over a protracted period of time in order to provide therapeutic intervention.

48. 48 Individuals must meet at least two: 1. Difficulty in establishing or maintaining normal interpersonal relationships at risk of hospitalization ? or out-of-home placement because of conflicts with family/community? 2. Exhibit inappropriate behavior: Repeated interventions by the community by mental health agencies by social service agencies by judicial system 3. Exhibit difficulty in cognitive ability: Unable to recognize……... personal danger OR significantly inappropriate social behavior TDT Eligibility Criteria (cont’d):

49. 49 Does the child need the service?

50. 50 This service is designed for youth who meet one of the following: Require year-round treatment in order to sustain behavioral or emotional gains, or TDT Eligibility Criteria (cont’d):

51. 51 Have behavior/emotional problems so severe they cannot be handled in self-contained or special classrooms (ED) without this programming during the school day or as a supplement to the school day/year, or Would otherwise be placed on homebound instruction because of behavior, or TDT Eligibility Criteria (cont’d):

52. 52 or Have deficits in: social skills peer relations dealing with authority are hyperactive have poor impulse control are extremely depressed marginally connected with reality or TDT Eligibility Criteria (con’t)

53. 53 or Preschool child in an enrichment & early intervention program & cannot function in this program (due to the severity of their emotional/behavioral problems) without these additional services. TDT Eligibility Criteria (con’t)

54. 54

55. 55 TDT ISP Requirements Comprehensive and regularly updated Specific to individual being treated Containing goals and measurable objectives to meet identified needs Services to be provided with recommended frequency to accomplish the measurable goals and objectives Estimated timetable for achieving the goals and objectives Maintained up to date as the needs and progress of the individual changes,

56. 56 TDT ISP DO’s INDIVIDUALIZED! Include all service needs identified in assessment Objectives = specific desired client behaviors in quantitative terms Interventions = specific planned staff actions with a specific planned frequency Services must be provided according to the ISP (minimally by QPPs under the supervision of a QMHP) A psychiatric med eval is recommended Referrals to the student’s primary care provider (PCP) for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening examinations are to be made and documented in the recordA psychiatric med eval is recommended Referrals to the student’s primary care provider (PCP) for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening examinations are to be made and documented in the record

57. 57 SAMPLE TDT ISP COMPONENTS 1. Goal: Medication Management/Education Objectives: Client will take meds every morning. Mom will observe client taking meds and let TDT staff know whenever he has not taken his meds. Mom agrees to bring meds to school if meds are forgotten. Interventions: Staff will ask about med compliance per contact and give individual medication education weekly. Staff will praise client and Mom for meeting med objectives twice weekly. Staff will provide group Medication Education twice a month.

58. 58 SAMPLE IIH ISP COMPONENTS 2. Goal: Decrease Fighting with Peers Objectives: Client will talk in a calm voice every day. Client will keep two feet away from peers whenever possible to avoid physical contact. Client will take 10 minute time out to calm down whenever he gets angry with peers. Client will take ten slow deep breaths when he becomes irritated or annoyed with a peer and contact teacher or TDT staff, if he isn’t able to calm down. Interventions: Staff will conduct weekly Anger Management and Peer Relations Groups. Staff will discuss, practice with, & encourage client to take time outs and deal calmly when angry each day. Staff will praise client for not fighting with school peers per contact.

59. 59 TDT Required Activities (con’t) Child must participate in a program of therapeutic activities in addition to being monitored in the classroom. Time spent directly monitoring the youth in the classroom or being onsite & available to respond to classroom behaviors may be billed to Medicaid, provided the following conditions are also met: If services are billed for time that staff is not in classroom, specific objectives regarding classroom behavior must be identified and included in Individual Service Plan (ISP). Child must participate in a program of therapeutic activities in addition to being monitored in the classroom. Time spent directly monitoring the youth in the classroom or being onsite & available to respond to classroom behaviors may be billed to Medicaid, provided the following conditions are also met: If services are billed for time that staff is not in classroom, specific objectives regarding classroom behavior must be identified and included in Individual Service Plan (ISP).

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61. 61 Minimum billing is 2 hrs per day (1 Unit). One hour must be direct face-to-face, the other hour may be indirect; A minimum of 2 therapeutic activities must occur per day; Family counseling (in person or telephone) must occur at least weekly; TDT Required Activities (con’t)

62. 62 Progress notes are completed on a weekly basis at a minimum Daily written summary of service provided. Summary must include description of child’s behavior, staff interventions & child’s response to interventions. Summary must support time billed; TDT: Required Activities

63. 63 Progress note documentation must include: Name of service rendered Date service rendered The setting Signature/credentials of person rendering service Amount of time/units delivered TDT: Required Activities

64. 64 TDT Progress Note DO’S Be sure to include ALL billable services provided to correlate with time billed Address all ongoing needs from the ISP Describe the specific client behaviors, what staff did, and clients’ responses Document weekly communication/counseling with parents Academic instruction, tutoring, and functioning as a school aide are not billable Duplicate notes are not billable When in doubt focus on staff actions Client quotes are helpful Remember this is a Day Treatment Program where intensive mental health services are provided Complete documentation as soon as possible after services are provided When in doubt focus on including all staff actions that meet the service definition When in doubt focus on staff actions Client quotes are helpful Remember this is a Day Treatment Program where intensive mental health services are provided Complete documentation as soon as possible after services are provided When in doubt focus on including all staff actions that meet the service definition

65. 65 Sample TDT Progress Note Holly Grove School, 8:00- 2:15 PM, 6.25 hours, 3 units Client on time this morning, remembered homework, bathed, and dressed in clean clothes. Looks like he took meds this AM and he confirmed this. Provided redirection to keep him on task five times, had 1-1 in hallway when he became very annoyed with peer where I reminded him to focus on his own project, move as far away from this peer as possible, and let his teacher know if it continues to send for TDT staff. Conducted Peer Issue Group and reminded client to discuss this issue and praised client for participation as group role played situation and appropriate responses. Role modeled appropriate peer interactions for client in lunchroom. Candice Chavis, MA, QMHP Date: April 1, 2008

66. 66 TDT Limitations: Time for academic instruction when no treatment activity is going on cannot be included in the billing unit A maximum of 780 units per year may be billed Staff travel time is excluded

67. 67 One Unit of service is defined as a minimum of two hours on a given day. TDT Service Units:

68. 68 Utilization Review

69. 69 Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program…………… Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program. Under the Participation Agreement with DMAS, the provider also agrees to give access to records and facilities to Virginia Medical Assistance Program representatives Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program. Under the Participation Agreement with DMAS, the provider also agrees to give access to records and facilities to Virginia Medical Assistance Program representatives

70. 70 Purpose of Utilization Review Ensure clinical necessity and that an appropriate provider delivers the services Purpose of Utilization Review: Ensure the provision of quality health care DMAS routinely conducts utilization reviews of community mental health, case management, and substance abuse services to ensure that services provided to Medicaid recipients are medically necessary and appropriate and are provided by the appropriate provider. Ensure the appropriate provision of services These reviews may be unannounced. During each review, an appropriate sample of the provider's total Medicaid billing will be selected for review. Ensure clinical necessity and that an appropriate provider delivers the services An expanded review shall be conducted if an excessive number of exceptions or problems are identified. Purpose of Utilization Review: Ensure the provision of quality health care DMAS routinely conducts utilization reviews of community mental health, case management, and substance abuse services to ensure that services provided to Medicaid recipients are medically necessary and appropriate and are provided by the appropriate provider. Ensure the appropriate provision of services These reviews may be unannounced. During each review, an appropriate sample of the provider's total Medicaid billing will be selected for review. Ensure clinical necessity and that an appropriate provider delivers the services An expanded review shall be conducted if an excessive number of exceptions or problems are identified.

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72. 72 Your UR Site Visit Record Review will include: Request to review program and billing records in a central location The Review may include: Observation of service delivery Face-to-face/telephone interviews with the consumer and/or family Review of staff qualifications On Site Reviews Record Review will include: Request to review program and billing records in a central location We try not to be intrusive with the UR process. We will offer time to complete any needed filing. If we cain’t locate information we will ask program staff to assist. The Review may include: Observation of service delivery Face-to-face or telephone interviews with the consumer and/or family We may request to look at staff qualifications On Site Reviews Record Review will include: Request to review program and billing records in a central location We try not to be intrusive with the UR process. We will offer time to complete any needed filing. If we cain’t locate information we will ask program staff to assist. The Review may include: Observation of service delivery Face-to-face or telephone interviews with the consumer and/or family We may request to look at staff qualifications

73. 73 Reviewers check that: Services provided meet all requirements defined and described in the DMAS Service manual Services billed match documented delivered care Services do not exceed specific service limitations

74. 74 Delivered services as documented are consistent with the recipient’s Individual Service Plan, submitted invoices and specified service limitations . “The UR “Golden Rule” Delivered services as documented are consistent with the recipient’s plan of care, submitted invoices and specified service limitations. “The UR “Golden Rule” Delivered services as documented are consistent with the recipient’s plan of care, submitted invoices and specified service limitations.

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76. 76 Process has 3 phases- Written response and reconsideration to preliminary findings (30 days to submit information) The informal conference (30 days to request informal conference) The formal evidentiary hearing (30 days to request formal hearing) Reconsideration of the findings:

77. 77 Overpayments required when: Medicaid billed contrary to regulation or statute Provider fails to maintain any record or adequate documentation to support the claim Provider bills for an unnecessary service Error found in computing billing amounts

78. 78 You may email any specific questions to the following email address: [email protected]

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