medicaid administrative claiming training for lhd cost pool rev 3 16 2011
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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\%.

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status of medicaid administrative claiming in oregon 3 07
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%.
  • Most LHDs are claiming in range of 20-25%.
  • Average claim for a given quarter (latest average for the last four quarters) is $24,988.
medicaid administrative claiming is
Medicaid Administrative Claiming Is:

…a method of identifying and accounting for the time spent by health department staff on medically related activities.

  • Reimbursement is then claimed for the time spent doing those activities; many are already being done by health department staff.
  • Staff do not need to know who is Medicaid/OHP eligible, nor do they need to become Medicaid experts.
mac and maternity case management and targeted case management
MAC and Maternity Case Management and Targeted Case Management
  • MAC is population based; MCM/TCM is individual, Medicaid-eligible based
  • MAC is total time accounting; TCM is billing for unit of time; MCM is an OHP benefit
  • MAC provided to all by all staff in cost pool; MCM/TCM are billed only when provided to Medicaid eligibles by appropriate staff
  • MAC not dependent on MCM/TCM plan; MCM/TCM is plan dependent
developing the claim formula for reimbursement
Developing The Claim Formula for Reimbursement

Cost Pool (provided locally)


% of allowable time (time study)


% of Medicaid eligible

= Total Claim


50% non-federal match

= Net revenue

developing the cost pool
Developing the Cost Pool
  • Identify appropriate staff: routine contact with children and families
    • Nurses, community health workers, interpreters, eligibility specialists, health educators / promotoras, supervisors
    • Do not include federally funded WIC staff, sanitarians, janitorial, or volunteers
  • Identify actual salary, benefits and other personnel expenses
  • Remove federal funds from the cost pool
training requirements
Training Requirements
  • Trainers must receive DHS training at least once a year
  • All staff who are to be surveyed must be trained prior to taking the survey
  • All staff in cost pool must be trained at a minimum of once per year
  • Staff must sign in at training, or have trainer/coordinator sign
  • Trainers ensure adequate time for training and are the first line for technical assistance for staff
the time study percent of allowable time
The Time StudyPercent of Allowable Time
  • Strategy of random moment sampling using time study done quarterly
  • Random day selection
    • 4 days selected by DHS using random number table
    • Individual staff surveyed on all of the 4 days
    • All 4 days are used by each LHD
  • All public health staff in cost pool are surveyed
mac survey how it works
Individual employee does on-line survey four days per survey period

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
q i was last trained on sept 2 2010 can i participate in surveys in summer qtr 2011
Q: I was last trained on Sept. 2, 2010. Can I participate in surveys in Summer Qtr 2011?

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.

ten activity codes
Ten Activity Codes
  • A1. Outreach and application assistance for Medicaid/OHP Program
  • A2. Outreach and Application assistance for non- Medicaid/OHP Outreach
  • B1. Referral, Coordination, Monitoring and Training of Medicaid services
  • B2. Referral, Coordination, Monitoring and Training of Non-Medicaid Services
  • C1. Medicaid/OHP Transportation and Translation
  • C2. Non-Medicaid/OHP Transportation and Translation
  • D1. System Coordination related to OHP services.
  • D2. System Coordination related to Non-OHP services.
  • E. Direct Health Care Services.
  • F. Other work activities
code a1 outreach and application assistance for ohp program
Code A1: Outreach and Application Assistance for OHP Program
  • This code should be used for:
  • Informing individuals on how to access, use and maintain OHP
  • Assisting in early identification of individuals who could benefit from OHP health services
  • Explaining OHP eligibility rules and process
  • Assisting individuals to complete OHP application including translation and comprehension activities
documentation for positive mac codes
Documentation for Positive MAC codes

A1: Outreach and Application Assistance for the Medicaid Program

  • A1.1 Conducted individual or group session to inform potentially Medicaid eligible individuals about the benefits and availablility of services provided by the Medicaid program.
  • A1.2 Informed a person on how to effectively access, use, and maintain participation in Medicaid/OHP-covered health care resources . (Includes describing the range of services, and distributing OHP literature)
  • A1.3 Created and/or disseminated materials to inform individuals or families about Medicaid
  • A1.4 Assisted a person on how to access, apply for and/or complete the Medicaid/OHP application (includes transportation and translation related to the application and gathering appropriate information)

A1.5 Checked a person’s OHP status

  • A1.6 Contacted a pregnant woman or parent about the availability of Medicaid/OHP for prenatal and well baby care programs
  • A1.7 Staff travel or paperwork related to outreach and application assistance for the Medicaid program.
Code B-1: Referral, Coordination, Monitoring and Training of Medicaid Services
  • This code should be used for:
  • Making referrals / appointments for medical, mental, dental health or substance abuse services covered by Medicaid/OHP
  • Coordinating supportive documentation / tasks to help connect clients to services covered by Medicaid/OHP
  • MAC trainings
documentation for positive mac codes1
Documentation for Positive MAC codes

B1: Referral, Coordination, Monitoring and Training of Medicaid Services

  • B1.1 Referred a person for medical, mental health, dental health and substance abuse evaluations and services covered by Medicaid/OHP.
  • B1.2 Coordinated the delivery of medical health, mental health, dental health and substance abuse services covered by Medicaid/OHP. (Includes participation in multidisciplinary team meetings, conferencing on health, developmental issues, consultations, and preparing or presenting materials for case review)
  • B1.3 Monitored the delivery of medical (Medicaid/OHP) covered services.
  • B1.4 Participated in, coordinated or conducted a training on Medicaid Administrative Claiming.
  • B1.5 Staff travel or paperwork related to Referral, Coordination, Monitoring and Training of Medicaid Services.
code b 2 referral coordination monitoring and training of non medicaid services
Code B-2: Referral, Coordination, Monitoring and Training of Non-Medicaid Services
  • This code should be used if not TCM/MCM for:
  • Case planning for non-Medicaid/OHP services
  • Coordinating and monitoring educational, vocational, and social services of family plan
  • General health, weight loss
  • Training on these type programs
  • Referral to WIC, food banks, TANF, energy assistance
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.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.”

Q: If flow staff take blood pressure, measure height and weight, and assist with lab work, is it considered direct service?

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 writing down an appointment and/or entering it into a schedule, it is a referral of a client to a specific service: Code it “B1.1: Referred a person…”
  • When taking notes from a meeting with a nurse that is under your supervision re her case load: Code it “B1.2: Coordinated the delivery of…”
  • When entering the results of a followup call in the file of a patient that has been treated by someone else (i.e. the service provider): Code it “B1:3 Monitored the delivery…”
When taking notes during a MAC training: Code it “B1.4: Participated in…a training on MAC.”
  • Bottom line: “B1.5” should generally be used rarely, for activities that don’t quite qualify as directly supportive of the ones noted above, yet still related.
  • Example: writing a required report on one or more of these activities.
  • If you are not sure how to code an activity, don’t guess-- ask your MAC Trainer.
q why is it important to make a distinction between b1 5 and the other b1 codes
Q: Why is it important to make a distinction between B1.5 and the other B1 codes?

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.

documentation for positive mac codes2
Documentation for Positive MAC codes

C1: Medicaid/OHP Transportation and Translation

  • C1.1 Scheduled, arranged or provided transportation to OHP covered services (not as part of the direct services billing for transportation)
  • C1.2 Scheduled, arranged or provided translation for OHP covered services (translation for access to or understanding necessary care and treatment)
  • C1.3 Staff travel or paperwork related to Medicaid/OHP transportation and translation
c 1 medicaid ohp transportation and translation
C-1: Medicaid/OHP Transportation and Translation
  • This code should be used for:
  • Scheduling, arranging or providing transportation to Medicaid/OHP covered service
  • Arranging for or providing translation services that assist the individual to access and understand necessary care and treatment
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.

code d 1 system coordination related to ohp services
Code D-1: System Coordination Related to OHP Services
  • This code should be used for:
  • Working internally and with other agencies to improve OHP services
  • Identifying gaps, duplications, overlaps of medical services
  • Developing strategies to access or increase the capacity of medical, developmental, dental, mental health programs
  • Interagency coordination to improve delivery of OHP services
documentation for positive mac codes3
Documentation for Positive MAC codes

D1: System Coordination Related to Medicaid Services

  • D1.1Developed strategies and policies to assess or increase the capacity, access and utilization of community medical/dental/mental health programs (Includes workgroups)
  • D1.2 Worked internally or with other agencies and/or providers to improve the coordination and collaboration and delivery of medical, mental health and substance abuse services.
  • D1.3 Staff travel or paperwork related

to System Coordination for

Medicaid Services.

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:

  • A written agenda for the mtg clearly outlining Medicaid-related topics;
  • Official notes kept of the mtg that would document the claimable portion(s).
code d2 system coordination related to non ohp services
Code D2: System Coordination Related to Non-OHP Services
  • This code should be used for:
  • working collaboratively with other agencies to identify gaps, overlaps or duplication of non-medical/health services, such as vocational, social or educational services
  • improving coordination and expanding access or delivery of non-Medicaid/OHP services
  • developing strategies to assess or increase the capacity of non-medical, dental and mental health programs
code e direct medical services
Code E: Direct Medical Services
  • This code should be used for:
  • Targeted Case Management or Maternity Case Management Services
  • providing direct health/dental/mental health care services
  • conducting health/dental/mental health assessments/evaluations and diagnostic testing
  • administering first aid or prescribed injection or medication to an individual
code f other work activities
Code F: Other Work Activities
  • This code should be used for:
  • All other job related activities that do not fall under one of the above categories
  • Paid time off; vacation leave, sick leave; or any other paid time away from work
survey documentation protocols
Survey Documentation Protocols
  • In most cases, it is not necessary for staff to provide a written narrative account of an activity; documentation is in the form of a numeric system that associates an activity narrative with a number.
  • MESD web survey system has the method for documenting built in to the survey
  • Exceptions:
  • When an employee claims 50%+ of time worked as MAC, the Coordinator should note the reason for this and keep in a file.
  • When employees attend meetings or trainings lasting for several hours, a record of the session should be on file.
coding details and guidelines
Coding Details and Guidelines
  • Code only paid time and actual work hours
  • Paid leave including absences, vacation, etc. are Code F (supervisor may need to complete survey)
  • Blank increments on survey are only used for unpaid time—otherwise will default to Code F: other
  • Part-time employees survey only paid time worked on the day of survey
attention local coordinators
Attention Local Coordinators!
  • On every survey day, make sure that all

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.

  • If a survey day falls on a day that a cost pool member regularly has off (i.e. she is not paid for that day), then no survey will be logged for that employee on that day.
  • Cost pool members who have little or no MAC-claimable time for more than five surveys over the course of two quarters should be dropped from the next quarter’s cost pool.
  • On the day of a cost pool member’s MAC training, make a note of the day when that training will expire. (Hint: it will always be on the last day of the third full quarter from the training date.)
health services mac coordinator
Health Services MAC Coordinator
  • Dave Anderson