how to implement a medicaid reimbursement program for behavioral health and therapeutic services in...
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How to Implement a Medicaid Reimbursement Program for Behavioral Health and Therapeutic Services in your
School DistrictPresented by:
Pacific Health Policy Group
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Students with Special Needs In 2007, 54 Alaskan school districts served
over 17,000 students with identified behavioral health and therapeutic needs
School districts can increase the amount of money available for these eligible services by submitting Medicaid claims
Districts will be reimbursed at the current State of Alaska Medicaid match rate (50.53%)
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About Medicaid Medicaid is operated by state governments
within a broad, federally proscribed framework
The federal government covers just over 50% of the cost of providing covered services to eligible Alaskans
Medicaid is available to Alaskans who are either financially or categorically eligible
Some services provided to students receiving behavioral health or therapies are eligible for federal reimbursement – or the federal match (currently 50.53%)
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Basic Steps to Bill for Behavioral Health and Therapeutic Services
Districts enroll as Medicaid providers Receive parental authorization Identify eligible students Bill for rendered services, while
continuing to check recipients eligibility Maintain documentation in case of audit
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Criteria for Appropriate Medicaid Billing
Eligible for Medicaid (or Denali KidCare); Recipient has a properly documented IFSP or
IEP; The type, scope, frequency & duration of the
services are documented The services are medically necessary and
covered under an existing Medicaid category; All state and federal regulations are followed; Services are provided by qualified health care
professionals working under a enrolled district
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Enrolling as a Provider For a district to qualify to enroll as a Medicaid
Provider, districts must agree to: Comply with all federal and state requirements for
billing, auditing and reporting Obtain an NPI number Reimburse DHSS for any state financial share – the
non-federal portion of the fee schedule
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Enrolling as a Provider Obtain a NPI number Complete the Alaska Medical Assistance
Program Provider Enrollment Form Forms and Instructions are included in the
Toolkit
Questions? Contact ACS at (800) 770-5650Use option 1 or 3 for enrollment assistance
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Clinicians Eligible to Bill Medicaid for Eligible Services The Alaska Administrative Code at 7 AAC 4.461
(“Payment for School-based Services”) lays out the requirements and qualifications of providers: Physician; Physician’s Assistant; Advanced Nurse Practitioner; Physical Therapist; Occupational Therapist; Speech-language Pathologist; Audiologist; Psychologist or Psychological Associate; Behavioral Health Professional; Behavioral Health Associate; or Another health care provider who is acting within the scope
of that health care provider’s license under AS 08 and is familiar with the child’s plan, health condition, and treatment history.
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Providers NOT Eligible to Bill Medicaid for Eligible Services
Individuals employed as teachers are not allowed to have eligible services billed through to Medicaid, even if the teacher is otherwise qualified to provide the service
Note: Federal regulations do not contain a provision requiring physician involvement and review of behavioral health or therapeutic services provided at the school level
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Identifying Eligible Students Districts will need parent authorization of
students to determine if a student is Medicaid eligible
A sample letter can be included with the initial IEP documentation (moving forward) and would be sent retroactively to all students that currently have an IEP
Once parent authorization is obtained, the school district can use an automated system to determine if the student is Medicaid eligible
Eligibility needs to be checked on a monthly basis
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Sample Letter
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Verification Once District is Enrolled Before providing services, the district must
verify: The age of the recipient That the recipient is eligible for Alaska Medical
Assistance and school based services Check monthly for Medicaid Check every six months for Denali KidCare
That the services are school-based and covered by Medical Assistance
Provider rendering service has the appropriate credentials
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Verification Process (continued) Eligibility can be verified by:
Checking the patient’s Medical Assistance identification card or coupon
Calling the Eligibility Verification System (EVS) at (800) 884-3223
Faxing provider inquiry at (907) 644-8126 or (907) 644-8127
When faxing, have available the student’s name, date of birth, Social Security number or Medicaid ID (available on the Identification Card or Coupon)
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Covered Behavioral Services Listed in billing manual, included in Toolkit
A shorter list of common covered behavioral services are also in Toolkit
Age restrictions may apply
Prior Authorization requirements may apply
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Covered Behavioral Services Emotional support assistant to help a child
process emotions (CDAKN) During periods of elevated stress
Behavioral management education that teaches behavior management, modification, and redirection techniques to elicit positive behaviors with Families (CDACF), Groups (CDACE), and Individuals (CDACD)
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Covered Behavioral Services Crisis response services including:
Crisis intervention (H2011) to prevent harm Build coping skills Develop mechanisms for positive self-care Stabilize a child or family in acute stress
Behavior modification assistance using counseling techniques to assist in modifying behavior To individuals (CDACI) And groups (CDACJ)
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Covered Behavioral Services Functional behavioral assessments (CDBAW)
to assess a child’s behavior
Psycho-educational (H2027) services to help a child develop or improve specific self-care skills and engage in age-appropriate social behavior
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Covered Behavioral Services Testing (96101) a child’s psychological,
cognitive, and emotional functioning
Interpreting a child’s behavioral assessment results
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Billing Strategies Districts need to make sure they have the
appropriate personnel to process the Medicaid claim
Larger districts should hire additional FTEs For smaller districts, hiring one FTE may not be
financially viable These districts are encouraged to either hire
part-time support or collaborate with other smaller districts to “share” resources
Smaller districts can also contract with an outside vendor This would reduce the financial benefit
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Example: Kenai School District Hired a ¼ time clerical member with a
medical background
Kenai has more than 800 students with IEPs who are Medicaid eligible
Training for administrators was provided by First Health
ACS continues to hold monthly trainings in Anchorage
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Billing Options for School-based Behavioral Health Services Claims may be submitted on paper
CMS 1500 Instructions and Sample Form are available in the
Toolkit
Using the appropriate current CPT or ABC codes
Electronically PayerPath (available through ACS)
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Timely Billing and Third Party Liabilities All claims must be filed within 12 months of the
date services were provided to the recipient (Retroactive claims may be filed if documentation is proper)
Claims may either be submitted on a weekly or monthly basis
Medicaid is a payor of last resort – it only pays after other avenues have been exhausted. The State has determined that no other insurer covers school-based services, exempting school districts from this requirement
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Updating Billing Information Procedure codes can change from year to
year, but the changes are minor
Coverage (reimbursement amount) can change from year to year
Procedure codes that were covered one year may not be covered the next year
Be sure to bill with codes that are in effect for the date the service was provided
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Remittance Advice
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Remittance Advice Sample
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Adjustments and Voiding Claims Used to correct or void claims that have already been
paid Adjustments are done if there was an error in the
claim Wrong procedure code Wrong modifier Wrong number of units Wrong date of service
Recoupments are used to void a previously paid claim Claim was submitted for a student who is the responsibility
of another district Claim was submitted without the necessary documentation
Use form AK-05 – Instructions in the Provider Manual
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Records A school district documentation must include:
Recipient’s name Specific services provided Extent of service provided Date of service Name of health care provider who provided
service
A Service Documentation Sample is included in the Toolkit
A billing form is also included to maintain an overview of the student’s history
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Confidentiality Two federal statutes: FERPA and HIPAA
Family Educational Rights and Privacy Act (FERPA) Health Insurance Portability and Accountability Act
(HIPAA) School-based behavioral health and
therapeutic services are covered by FERPA, even the records used to support Medicaid billing
HIPAA defers to FERPA except as related to the electronic transmission of Medicaid claims to the fiscal agent (ACS)
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Records Needed in Case of an Audit Districts need to maintain a file for each
student that includes: A parent authorization form; A copy of the IEP; Goals and objectives; Progress notes; and Service documentation logs
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Records Needed in Case of an Audit A school district must retain the billing, clinical
and other records for a student for which services have been billed to the Medical Assistance program for at least seven years for the date the service was provided.
Districts must maintain a IFSP or IEP record with the following information: The student’s condition The health care needs for each service Each individual service provided to the student Annotated case notes, signed, dated or initialed by
the individual who provided the service, for each service delivered
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Records Needed in Case of an Audit This applies even if the student transfers Records in electronic format must be readily
accessible
The district is responsible for making sure billing services meet these requirements
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Records Needed in Case of an Audit In the event of a Medicaid audit, school
districts need to maintain the following records for seven years: Student attendance records; Employee leave records; Employee state credentials, professional licenses
or certificates; and Contracted individuals’ credentials, licenses or
certificates
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Common Mistakes Billing when child is absent or when school is
not in session Billing when qualified staff are absent and
substitute is delivering services Billing for unqualified provider No parent/guardian authorization on file Inadequate documentation for what is billed Missing documentation Services provided and billed were not part of
the IEP Expired IEP
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Support PHPG Toolkit
FHSC billing manual
Websites www.hss.state.ak.us/dhcs http://alaska.fhsc.com
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Questions?
E-mail: [email protected] Contact Jason Milstein
(847) 615-3413
Call the ACS recipient information help line: (800) 780-9972 from 8 am to 5 pm
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