Community First Choicein the HCS and TxHmL Programs

Provider TrainingPresenter: Kaliope Schmidt, Interim Manager

Billing & Payment1

B&P Presentation Sections• CFC PAS/HAB Services• CFC Qualified Service Providers• CFC Billing Guidelines• Common Errors

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What is CFC PAS/HAB?CFC is a state plan benefit that provides certain services and supports to individuals living in the community who are enrolled in the Medicaid program and meet CFC eligibility requirements.

• The CFC benefit offers:• CFC Personal Assistance Services

(PAS)/Habilitation (HAB);• CFC Emergency Response Services (ERS); and• CFC Support Management Services.

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PAS v. HABCFC PAS provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance. Such assistance is provided to an individual in performing ADLs and IADLs based on the individual's person-directed plan (PDP).

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PAS v. HAB• CFC PAS includes:• Non-skilled assistance with the performance of

ADLs and IADLs;• Household chores necessary to maintain the home

in a clean, sanitary, and safe environment;• Escort services, which consist of accompanying,

but not transporting, and assisting an individual to access PAS or activities in the community; and

• Assistance with health-related tasks.

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PAS v. HABCFC HAB is provided to allow an individual to reside successfully in a community setting by assisting the individual to acquire, retain and improve self-help, socialization, and daily living skills or assisting with and training the individual on ADLs and IADLs.

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PAS v. HABHAB Service is about teaching individuals how to do the tasks and learn how to care for themselves, which is interacting face-to-face with an individual to train the individual in activities such as:• Self-care;• Personal hygiene;• Household tasks;• Mobility;• Money management;• Community integration;• Personal decision making;• Self-administration of medication. 7

PAS v. HABPAS services provide assistance to an individual in performing the ADLs and IADLs. HAB, on the other hand, involves teaching, in addition to providing a service.

CFC HAB is about teaching individuals how to do the tasks rather than doing a task for them. Since teaching them also involves an element of doing tasks for them, a level of personal assistance services is inherent in the delivery of habilitation.

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CFC PAS/HAB Services• CFC PAS/HAB is the same in comparison with the

previous Supported Home Living (SHL) or Community Support (CS),with the exception of transportation.

• Transportation (TR) is added onto an individual’s IPC and is billed as SHL (for HCS) and CS (for TxHmL).

• A Transportation Plan must be implemented.

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CFC PAS/HAB Provider QualificationsA CFC PAS/HAB service provider must:• Be 18 years of age or older;• Have a high school degree, GED, or pass a

competency test with three references;• Not be the parent of an individual receiving

services who is under 18 years of age or the spouse of an individual receiving services; and

• MAY NOT live in the same residence as the individual receiving services.

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Residential Requirements To receive CFC services, an individual must reside in their own home or family's home (OHFH).

* Individuals receiving host home/companion care, supervised living, or residential support cannot receive CFC services.

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CFC Billing Guidelines

How to navigate our guidelines

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Section 1000 & 2000• Section 1000 contains general information, lists

the service components, statutory requirements, and B&P Review explanation.

• Section 2000 covers the definitions. • It is important to review these regularly to

reinforce what each word or phrase may mean and how that may aid in determining how to properly document service delivery.

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Section 3000 - General Requirements3100- Service Claim Requirements: • Be included on an authorized IPC;• Be identified in an individual's PDP that is provided in

accordance with the individual's implementation plan, as required by 40 TAC §9.158(r) and §9.578(c)(2);

• Be provided during a period of time for which the individual has an LOC;

• Be based on billable activity, as described in Section 3300, Billable Activity;

• Not be based on activity that is not billable, as described in Section 3400, Activity Not Billable;

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3100 (cont.)

• Be provided to only one individual;

• Be provided on only one date;

• Be for the date the CFC PAS/HAB was actually provided;

• Be for units of service determined in accordance with Section 3830, Calculating Units of Service for Service Claim;

• Be supported by written documentation, as described in Section 4000, Written Documentation; and

• Be in compliance with 40 TAC §49.311 (relating to Claims Payment).

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3300 - Billable ActivityBillable activities are an all-inclusive list. If an activity is not listed as billable, then it does not constitute billable activity.

The only billable activities for CFC PAS/HAB are:

• Interacting face-to-face with an individual to:• Assist the individual with activities of daily living;• Assist the individual with ambulation and mobility;• Reinforce any professional therapies

subcomponent provided to the individual; 16

3300 - Billable Activity• Assist with the administration of the individual's

medication or to perform a task delegated by a registered nurse;

• Conduct habilitation activities;• Escort services*• Incidents concerning health and safety of individual

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3300 - Billable Activity• Performing one of the following activities that does not

involve interacting face-to-face with an individual:• Shopping for the individual;• Planning or preparing meals for the individual;• Housekeeping for the individual;• Procuring or preparing the individual's medication;• Securing transportation for the individual;• Participating in a service planning team meeting;• Participating in the development of an implementation

plan; and• Participating in the development of an IPC. 18

3400 - Activity Not Billable• The following activities by a service provider for CFC

PAS/HAB do not constitute billable activity: • Transporting the individual;• Traveling by a service provider if the service provider

is not accompanied by an individual, except as allowed by Section 3300 (escort services);

• Documenting the delivery of CFC PAS/HAB (for example, writing written narratives, completing forms and entering data);

• Reviewing an individual’s written record;

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3400 - Activity Not Billable• Drafting an implementation plan;• Performing an activity regarding a staff member’s

employment or contractor’s association with the program provider (for example, attending conferences and participating in the performance evaluation of a staff member or contractor);

• Performing an activity regarding the preparation, submission, correction or verification of service claims;

• Any activities not described in Section 3300.

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3600 - Restrictions on ClaimsA program provider may NOT submit a service claim for: • CFC PAS/HAB provided to an individual whose IPC does

not have a residential location of "own/family home;"• Transporting an individual; or

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3600 - Restrictions on ClaimsA program provider may NOT submit a service claim for: • CFC PAS/HAB provided to an individual:

• In a residence in which HCS residential support or supervised living is provided to another individual;

• By a service provider who is simultaneously providing residential support, supervised living or host home/companion care to another individual;

• If the day habilitation service component is simultaneously provided to the individual by another service provider except as described in Section 3920, Multiple Service Providers,(See No.1); or

• If the respite service component is simultaneously provided to the individual by another service provider.

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3710 - Service Provider RequirementsA qualified service provider of CFC PAS/HAB must: • Meet the following minimum qualifications:

• Not have the same residence as the individual; • Be an adult; • Have:

• A high school diploma or a certificate; or• Documentation of a proficiency evaluation of

experience and competence to perform the job tasks• Be the program provider or a staff member or contractor

of the program provider; • Be paid by the program provider to provide CFC PAS/HAB

being claimed; 23

3720 - Service Provider Not Qualified• Service Coordinator - On Duty

• Service Coordinator - Off Duty (individual’s SC)

• Parent, Spouse of Parent or Contractor (minor)

• Contractor (adult Individual)

* Contractor= a person contracted with DFPS to provide residential childcare to the individual.

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3800 - Unit of Service• This section covers the unit breakdown and

calculations for CFC PAS/HAB services. • A unit of service for CFC PAS/HAB is 15 minutes.• A service event is a discrete period of continuous

time during which billable activity for CFC PAS/HAB is:• Performed by one service provider• Consists of one or more billable activities• Ends when the service provider stops

performing the billable activity.

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Calculation of Service TimeA program provider must use the following formula for calculating the service time for CFC PAS/HAB:

Number of service providers x length of service event divided by the number of persons served = service time.

* Person=individual served.

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Examples

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Note: Service time less than 15 minutes (one unit) is notbillable. Service log should be completed; however, less than 15 minutes is not billable.

3900 - Billing CFC and HCS or TxHmL at same time3910- One Service ProviderCFC service provider may not provide CFC PAS/HAB to one individual who is simultaneously receiving a HCS or TxHmL service from the same service provider. • Issues:

• Calculation of service event.• Conflicting information. • Suspicion of fraud.

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3900 - Billing CFC and HCS or TxHmL at same time3920 - Multiple Service ProvidersCFC provided face to face:• Professional therapies• RN• LVN• Specialized RN• Specialized LVN • Transportation as a supported home living or community

support provides a service to the same individual

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3900 - Billing CFC and HCS or TxHmL at same time3920 - Multiple Service ProvidersCFC provided non face to face:• Professional therapies• RN• LVN• Specialized RN• Specialized LVN• Day habilitation • Employment assistance • Supported employment• Transportation as a supported home living or community

support activity provides a service to the individual30

3900 - Billing CFC and HCS or TxHmL at same time3920 - Multiple Service Providers• Multiple service providers of CFC PAS/HAB may

perform an activity at the same time for the same individual if multiple service providers are needed to perform the activity.

Note: This should be documented in individual’s PDP/IP with explanation of reason for multiple service providers.

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3900 - Billing CFC and HCS or TxHmL at same time3920 - Multiple Service Providers

A service provider of CFC PAS/HAB may perform an activity that does not involve interacting face to face with an individual, as described in Section 3300, at the same time another service provider of CFC PAS/HAB performs an activity that involves interacting face-to-face with the individual.

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4000 - Written Documentation4010 - General Requirements:• Legible• Name of individual• Day, month, year service was provided• A written service log for each individual

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4000 - Written Documentation4020 - Required Content and Timeliness of log:• Be written AFTER the service is provided• Include description of activities (narrative or codes)• Include the location of service • Begin and end times - justified length of service• Be made after reasonable time after the activity is

provided• Include the signature of the service provider

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4000 - Written Documentation4020 - Unacceptable Content• Ditto marks• References to other logs or symbols• Non-specific statements• Photocopied/pre-filled logs• Medication log (MARS)

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4040 - Example Forms• Form 4121- Supported Home Living/Community

Supports/Community First Choice Personal Assistance Services/Habilitation may be used to document CFC PAS/HAB in accordance with this section.

• These documents are only examples.

• A program provider may document CFC PAS/HAB in any way that meets the requirements of this section.

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5000 - CFC ERS5200 - Service Claim Requirements:• Be included on an authorized IPC;• Be identified in an individual's PDP that is provided

in accordance with the individual's implementation plan, as required by 40 TAC §9.158(r) and §9.578(c)(2);

• Be provided during a period of time for which the individual has an LOC;

• Be provided to only one individual;

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5000 - CFC ERS5200 - Service Claim Requirements (cont.):• Only be provided to an individual who has a

residential location of "own/family home" on the individual's IPC;

• Be for the month the CFC ERS was actually provided; and

• Be in compliance with 40 TAC §49.311 (relating to Claims Payment).

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5000 - CFC ERS5300 - A unit of service for CFC ERS is one month.

5400 - CFC ERS Billing Amount- whichever is less:

• The actual cost of the CFC ERS

• The monthly reimbursement rate of $29.76.

Note: If the program provider contracts for the provision of CFC ERS, the actual monthly cost is the amount the program provider paid the contractor for CFC ERS.

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Common Errors, Helpful Tips/Ideas

Knowing is half the battle

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Common Errors• Missing documentation• Billing more units than documented• Photocopied service documents• Billing for transportation• Overlapping services and times• Missing location information• Service provider not qualified

• Lives in same residence as individual.

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Helpful Tips/Ideas (cont.)

• Develop a quality assurance program• Ongoing service provider training related to billing

guidelines and documentation requirements• Review and understand your program provider

agreement (contract)• Subcontractors must be bound to same terms as

provider agreement• Never create, change, alter, or destroy

documentation related to a B&P review• Self report errors

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Thank You

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