€¦ · web viewfor va/dd-tcm the hints include: claims for clients in a ma funded facility are...

VA/DD-TCM HEALTHCARE CLAIMING

This document walks you through the generation of Vulnerable Adult/Developmental Disabilities –Targeted Case Management (VA/DD-TCM) claims that can be submitted from SSIS to MMIS for payment, possible proofing messages and related reports.

HELPFUL RESOURCES SSIS Claiming Helpful Hints and Proofing Messages is a document in the Fiscal Mentor

Manual on the SSIS Fiscal Mentor Program web page. This document includes:◦ Overview flow chart of how the claiming process flows through the different

steps.◦ Hints for each Healthcare Claim Category. For VA/DD-TCM the hints include:

Claims for clients in a MA Funded Facility are limited to 180 days for VA/DD-TCM, VA/DD-TCM and RSC-TCM combined. The beginning of the 180 days is the Service Date of the first paid claim for VA/DD-TCM, MH-TCM, or RSC-TCM. MMIS enforces this rule and no editing is done in SSIS.

VA/DD-TCM cannot be provided to a person in an institution unless it is for the purposes of transitioning/relocating from the institution to the community. Institutions are defined as hospitals, nursing facilities (including Certified Board and Care Facilities), and Intermediate Care Facilities for Persons with Developmental Disabilities (ICF/DD).

◦ Listing of Proofing Messages for each claim category that includes a possible solution to the proofing message.

Fiscal Reports and Descriptions is a link to the Fiscal Reports and Descriptions document found in the Reporting Chapter of the Fiscal Mentor Manual. This document lists all the Fiscal-related reports in SSIS a description, all the options for navigating to the report, what the report might be used for as well as a report example.

VA/DD-TCM CLAIMING REQUIREMENTSAs we think about the purpose of VA/DD-TCM it is claiming done for Time Records that meet the VA/DD-TCM criteria set by policy staff that include the following:

Social Services Information System (SSIS) Created: 12/18/17Fiscal Mentor Manual Claiming Chapter: VA/DD-TCM Healthcare Claiming of 30

http://www.dhs.state.mn.us/main/groups/county_access/documents/pub/dhs16_141216.pdf

http://www.dhs.state.mn.us/main/groups/county_access/documents/pub/dhs16_141217.pdf

ELIGIBLE STAFF ACTVITY TIME RECORDS Services

◦ 592 – Child (<21) DD Non-Waiver Case Management◦ 593 – Adult (21+) DD Non-Waiver Case Management◦ 604 – Adult Protection Assessment and Investigation◦ 607 – General Assessment◦ 693 – General Case Management

Activities◦ Client contact◦ Collateral Contact

Contact Status◦ Completed

Contact Method◦ Face to face◦ Phone

SUPPLEMENTAL HEALTHCARE ELIGIBILITYA Supplemental Healthcare Eligibility Record must exist for the claim category of VA/DD-TCM with an effective date on or before the Service Dates of the VA/DD-TCM claim.

From the Supplemental Eligibility folder we see Val Vadd has a VA/DD-TCM Supplemental Eligibility record beginning 06/01/2000. If none existed for the timeframe needed from Action


menu select New VA/DD-TCM Eligibility. Enter a Start Date, an End Date if there is one and remember to always select a WG so to see the Primary Worker name on reports.

MMIS RECIPIENT INFORMATION Must be MA Eligible

◦ Major Program – MA Eligible MA – Federally-Paid Medical Assistance

Eligibility Status must be◦ Active◦ Closed

Billable Contact Date must be within the Eligibility Start Date and Eligibility End Date The client cannot be a Waiver/AC Recipient on the Billable Contact Date

CLIENT INFORMATION Client age is determined as of the Billable Contact Date Client Age must be > = 18 on the Billable Contact Date

DIAGNOSIS CODEA billable diagnosis code is required to submit a claim. Diagnosis is determined in the following order:

Diagnosis code on a LTC or DD Screening document Diagnosis code entered in SSIS on the Disability/Diagnosis/Substance screen If there is not a billable Diagnosis, a default Diagnosis of Z60.9 is included on the claim

ADDITIONAL RULES Maximum of one VA/DD-TCM claim can be submitted per month per client. All eligible Time Records in a month are linked to the claim. A separate claim is created for each VA/DD-TCM eligible client listed in the Regarding

section of the Time Record. For a month in which both a Phone and Face to face contact occur, the Face to face

contact is claimed even though it may occur after the Phone contact. A telephone claim is create for a month in which only a Phone contact occurred. A Face-to-face contact must occur at least once every three months. This edit ignores

Face-to-face claims that are Denied or To be denied. The first claimable contact must be Face-to-face.


CLAIM RECORDThe healthcare claim includes:

HCPCS/Modifiers◦ Contact Method = Face-to-face

T2023 U1 – VA/DD-TCM, face-to-face◦ Contact Method = Phone

T2023 U1 U4 – VA/DD-TCM, telephone Units = 1 First Service Date = Billable Contact Date Last Service Date = Billable Contact Date Diagnosis Code = Screening Diagnosis Code, SSIS Billable Diagnosis Code or Z60.9

ADDITIONAL EDITS NOT IN SSISEligibility

Client must be in need of service coordination to attain or maintain living in an integrated community setting and must be a vulnerable adult in need of adult protection as defined in statute.

County Practice Counties develop criteria for identifying who is in need of case management/service

coordination and keep a copy of those criteria on file in case of an appeal. Counties can develop a tool to determine/document eligibility.

MISC. NOTES Claims for clients in a MA Funded Facility are limited to 180 days for VA/DD-TCM, MH-

TCM and RSC-TCM combined. The beginning of the 180 days is the Service Date of the first paid claim for VA/DD-TCM, MH-TCM or RSC-TCM. MMIS enforces this rule.

VA/DD-TCM may be provided concurrently with an investigation of maltreatment of a vulnerable adult. Documentation for both must be completed.

VA/DD-TCM cannot be provided to a person in an institution unless it is for the purposes of transitioning/relocating from the institution to the community. Institutions are defined as hospitals, nursing facilities (including Certified Boarding Care Facilities), and Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD).

VA/DD-TCM expenses are included as a part of a person's spenddown for MA eligibility. MMIS does this edit.

Contact during the month can be with the adult, the adult's legal representative, family member, or primary caregiver or other relevant person identified as necessary to the development/implementation of the service plan.


CREATING A VA/DD-TCM CLAIM BATCH1. Select Claim Batch Search in the task panel.2. Search to see if a draft batch exists. Based on your claims processes, enter as much or as

little search criteria to determine if another batch exists for the time period you are working with.

3. To create a new healthcare claim batch click the Action menu and select New Claim Batch.

4. The batch entry screen displays. Select VA/DD-TCM as the Claim category. VA/DD-TCM is for Time only and the system defaults a Claim batch #. A batch may be created for one month or multiple months. Claims can be submitted for up to one year from the date of service. This edit is enforced by MMIS.


VA/DD-TCM Claim Batch

The Batch owner defaults to the user creating the batch. Only the owner of a batch or a user who has the function of Manage Claims assigned to their Role in Admin can change the Batch owner.

5. Enter a Description for your batch. Description is optional but consider having a standard naming convention in your agency.

6. The batch is in Draft Status because it has not yet been submitted it to MMIS for payment. This field is not editable. The Batch status is updates as you move through the different steps of the claims processing.

7. Once the batch has been generated the Generated date and time displays. The most recent date and time the batch was generated displays.

8. Submitted date and time displays once the batch had been submitted to MMIS.9. Claims total displays a total dollar amount of all the claims in this batch.10. # of claims display the number of claims in this batch.11. The Generate button is enabled and the batch can be regenerated at any time prior to

submitting the batch. Always Generate one last time prior to submitting a batch to be sure everything is current and accurate.


VA/DD-TCM – CLAIM TABDouble-click a batch to open it full screen to see more information without scrolling. Clicking the Claims tab of the batch provides the detail of the individual claims within the batch. Selecting a claim in the grid displays the details of the claim below. Note all the information related to the requirements that are included as a part the claim.


VA/DD-TCM TIME PROOFINGThe next tab of the batch is the Time Proofing tab. The top portion of the tab displays the different categories of proofing messages. The default selections are shown below. Review as many or as few categories at one time. Perhaps one person looks at a section of messages and someone else the remaining. Again, an agency decision. You do not need to be the Batch owner to view Time Proofing.

However you do your proofing, at some point before submitting, you will want to look at all the proofing messages for the batch to make sure you haven’t missed something.

Click Search to see the proofing messages for this batch. Results display in the grid. Records listed are potentially claimable but not all the claiming requirements have been met. Search can be done multiple times. Searching again removes corrected records. Fixing one message may produce another. For example, selecting a client who does not have a PMI# proofing message. Once that client is cleared and they now have a PMI # re-search could produce a message that the client has no Supplemental Healthcare Eligibility. This is referred to as error hierarchy. Keep in mind that taking care of one proofing message does not always guarantee that a claim will generate. More work may need to be done.


Time Proofing – Time Record CategoryThe first proofing category on the Time Proofing tab is Time Record. Listed below are all the messages related to time records.

No Staff Qualification No Staff-provided Rate for the HCPCS/Modifiers County of Service not in the region First claimable contact must be “Face to face” “Face to Face” contact required every 3 months

2003 – No VA/DD-TCM Staff Qualifications for the worker on the activity date

Message 2003 displays when a Qualification has not been entered for a staff person and reads “No Staff Qualifications for the worker on the activity date.” The staff person from the Time Record is listed in the proofing message and is very helpful so you know who you need to contact without navigating to another place to see that.

Clicking on a proofing message generally takes you to where the record may be fixed. However, for this message Staff Qualifications are in the Admin application which is a separate executable so it cannot take you there from proofing.

You will need to have Admin access in order to see or change this information. In Admin:


• Search for the staff person.• From the Qualifications tab view what has been entered along with the Start and

End dates.• If a Staff Qualification needs to be entered or there was an end date create a

record from the Action menu and selecting New Qualification.• If there is already a record but it has an end date you don’t want to overwrite

the existing record. You will lose history and invalidate past claims. A new record should be created.

• It is not necessary to close Admin and Worker to apply the updates in Worker.

2004 – No Staff-provided Rate for the HCPCS/Modifiers on the activity date

Proofing message 2004 displays when no staff-provided rate has been entered for the HCPCS/Modifier that you are trying to claim.

Staff-provided rates are entered in SSIS Admin. Clicking on the message will not take you directly there. The Admin application which is a separate executable so it cannot take you there from proofing.

• Within Admin select Tools/Programs and Services. Click on the HCPCS/Modifiers folder. The grid displays all the available codes.

• Selected the HCPCS/Modifier missing a rate. For example, T2023 U1 – VA/DD-TCM, face-to-face.

• The details below show more information about the HCPCS/Modifier. For T2023 U1 the unit type is Month and this code became active 1/1/2004 and has no end date.

• Note this is for time and not for payments.


• Also there are times when additional billing information is added for detail. • The first tab, Claimable Services displays the Claimable services under this

HCPCS/Modifier and are determined by policy. • The second tab of the HCPCS/Modifier information window is the Staff-provided

Rates tab and this is where agency rates are entered. Do not just enter the maximum billable amount. Enter the rate that it actually costs your agency to provide the service.

• Do not want to overwrite existing data. If a new record is needed select the Action menu and New Staff-provided Rate. If there is an existing record without an end date you must edit that record and add an end date before a new record can be added.

• It is not necessary to exit Admin or Worker to see the change. Just be sure to save your record when you are finished.

Staff-provided Rates Tab


2014 – County of Service not in the region

The next Time Proofing message you might see is message # 2014 - County of Service not in the region. In regions, SWHHS, DVHHS, MnPrairie or F/M the county of service for the client must be a county in the region. County of Service is edited on the Workgroup setup screen. If incorrect, once corrected any Time Records must be deleted and re-entered in order for the change to be reflected on the Time Record. If there are lots of Time Records, contact the SSIS Help Desk. In general there are not many.


2203 – First claimable contact must be “Face to face”

Message 2203 - First Claimable contact must be Face to Face displays when the first claimable contact Method is Phone. For all the TCM claim categories the first claimable Time Record must be Face to face. This message displays when a Phone contact exists where no prior Face-to-face contacts has been submitted during the Supplemental Healthcare Eligibility Span.

Clicking on the message in proofing displays the Time Record in question. Follow agency practice for who should edit the record. There are times reading the Note section will help identify if this really was a Phone contact or selected in error. If changes are made to the Time Record be sure to save your changes.Best practice is to generate the batch before doing proofing to reduce the number of Phone proofing messages that display.


2204 – “Face to face” contact required at least once every 3 months

Message 2204 - Face to Face contact is required at least once every 3 months displays when two consecutive monthly phone contacts have been made without a face to face contact.

Clicking on the proofing message displays the Time Record. Check if changes are needed.In a month where both a Phone and Face-to-face contact occur the Face to face contact is always billed first to be sure as many months of Face to face are billed that can be. In the instance where the previous two claims were phone, another claim for a phone contact cannot be submitted.


Time Proofing – Attempted Contact CategoryThe next Time Proofing category is Attempted Contact. There is only one message.

Attempted Contact is not claimable

2202 – “Contact Status” (Attempted) is not claimable

Message 2202 – “Contact Status” Attempted is not claimable. The Status of the contact must be Completed in order to claim.

Clicking on the proofing message navigates to the Time Record. Claims generation looks at the Status of the contact. If Attempted is selected the record is not claimable. Reading the Notes can also give you an idea if it was completed. The contact Status must be ‘Completed” to claim. Follow your agency policy for editing records.

Best practice is to generate your batches first to reduce the number of "Attempted" messages that display and picks up the claimable Face to face contacts. If a claim is generated for a


Completed contact and Time Records for this same client in this month for VA/DD-TCM that were Attempted will not display in proofing.

Time Proofing – Client Age CategoryThe next proofing category is Client Age. One message is available.

Client must be 18 or over

2201 – Age (17) on the service date must be 18 or over

Message 2301 – Age on the service date must be 18 or over. The client must be 18 years of age or older on the date of service to generate a claim.

Clicking on the proofing message displays the Client demographics screen. Claims generation looks at the Date of birth for the client and the corresponding Age at the time of the contact. If the client is under the age of 18 on the date of service the record is not claimable.


Time Proofing – Duplicate Claim CategoryNext in the list of proofing categories is Client Age. One message applies to this category.

Claim would be a duplicate

2017 – One or more claims already exist during the service dates

Message 2017 – One or more claims already exist during the service dates. Only one VA/DD-TCM claim can be submitted per month per client.

Clicking on the proofing message displays a grid listing all the claims with the same service dates. Clicking on the record in the grid displays the submitted claim below. As the long message states, only one claim can be submitted for a HCPCS/Modifier for a given date range. The existing claims would need to be Voided and Resubmitted in order for this time record to be included in the claim.


Time Proofing – MA Eligibility Category Client must be MA Eligible to claim Invalid Major Program Client cannot be on a waiver No MMIS Eligibility Information

2010 – No Eligibility Span exists for the service dates

Message 2010 – No Eligibility Span exists for the service dates.

Clicking on the message navigates to the Eligibility Spans folder for the client. In the example the program eligibility ended on November 30, 2006 and no claims will be generated after that date. In order for a claim to generate the Status must be “Active” or “Closed” for the date of the time record.

2011 – The Major Program is not valid for VA/DD-TCM

Message 2011 – The Major Program is not valid for VA/DD-TCM.

Clicking on the Invalid Major Program message navigates to the Eligibility Spans folder for the client. Here the Major Program for the client is NM. Although the Status is Active and currently


open because Major Program NM is not eligible, and a claim is not generated. Note for VA/DD-TCM the Major Program must be MA – Federally-Paid Medical Assistance.

2021 – The client has no Healthcare Eligibility from MMIS

Message 2021 - The client has no Healthcare Eligibility from MMIS.

The client must have Healthcare Eligibility from MMIS in SSIS to verify eligibility. No eligibility information has been received from MMIS as a part of the nightly load to SSIS. Since MMIS eligibility does not exist clicking on the proofing message brings you to the Time Record. If the date of the time record is correct check with your MMIS staff to see if the person was eligible. If not, the time record cannot be claimed.


Time Proofing – Supplemental Eligibility CategoryNext in the list of proofing messages is the Supplemental Eligibility category which has one message.

No Supplemental Eligibility

2015 – No VA/DD-TCM Supplemental Eligibility Exists for the service dates

Message 2015 – No VA/DD-TCM Supplemental Eligibility Exists for the service dates. A VA/DD-TCM Supplemental Eligibility record must exist in order to claim.

Clicking on the proofing messages displays the Supplemental Healthcare Eligibility folder. The grid displays empty because no records have been entered for the client. To enter a new Supplemental Eligibility click on the Action menu and select New VA/DD-TCM Eligibility.


VA/DD-TCM Supplemental Eligibility Entry Screen

The VA/DD-TCM Supplemental Eligibility Entry screen displays. Enter the Start Date, and End date if you have one. Remember to always select a workgroup so the Primary Worker can be added to reports based on the workgroup selected here.

Time Proofing – Client CategoryWe move through the list to the Client Category which has two proofing messages.

Missing PMI# Estimated DOB

1018 – No PMI #

Message 1018 – No PMI #. The client must have a valid PMI # in order to claim.

Clicking on the No PMI # messages navigates to the Client node. In the example the PMI # is blank. The PMI # for a client displays when a client has been cleared. The PMI # is the link between SSIS and MMIS for the eligibility information. If a client is known to have a PMI but it


does not display here, change something on this screen to send them back to your clearing log again. Be sure to change that information back before clearing them. You cannot manually add in a PMI, it must be done through the clearing process. If you are not the person who does the clearing in your agency speak to that person about your agency process to reclear the client to include the PMI #.

107 – Est. date of birth

Message 107 – Estimated date of birth. A client must have an actual DOB in order to claim.

Clicking on the Estimated DOB message navigates to the client node. The client has an estimated DOB, and not an actual DOB. If an actual DOB is known, enter it for the client. Until you have an actual DOB claims will not generate for the client. Once the actual DOB has been entered follow your agency process for clearing clients to include the PMI and MMIS Eligiblity information for the client in SSIS.


Time Proofing – Do Not Claim CategoryNext in the list is the Do Not Claim category. There is one message in this category.

Client marked “Do Not Claim”

2008 – A Do Not Claim Determination is in effect on the service dates

Message 2008 – A Do Not Claim Determination is in effect on the service dates.

Clicking on message 2008 navigates to the Do Not Claim record in effect for the date of the time record. Review the dates of the record to be sure this remains accurate. Make changes as needed, be sure to save your changes. If the dates are accurate the Time Record cannot be claimed.


Time Proofing – Staff Not Qualified CategoryThe Staff Not Qualified Category has only one message.

Staff Claim Qualifications, Qualified = No

2018 – “Qualified” = “No” on the VA/DD-TCM Staff Qualifications for the worker on the activity date

Message 2018- "Qualified" = "No" on the VA/DD-TCM Staff Qualifications for the worker on the activity date.

Clicking on message 2018 navigates to the Time Record. Staff Qualifications are entered in the SSIS Admin application. Proofing cannot take you directly to the Admin application. The proofing message lists the worker on the time record. Review the dates of the time record to be sure they are accurate. If the Time Record looks correct go to the Admin application and look at the Staff Qualifications entered for the worker. In order to do this, you must have SSIS Admin rights.


Staff Qualifications Entry

In the example the worker name is Paulina Party. 1. Within the User Search of SSIS Admin enter the first and/or last name of the staff person

you’re looking for and click Search.2. Click on the Qualifications tab. We can see that a Staff Qualification has been entered

stating this user is not qualified to claim for VA/DD-TCM beginning 01/01/2000. If this remains true, do nothing and the time record cannot be claimed.

3. If the staff person is now qualified enter an end date that they were not qualified and then create an new VA/DD-TCM Staff Qualification selecting Yes for Qualified and the date they became qualified.

4. Click the Action menu and select New Qualification. 5. The options for Type are Healthcare claiming and Child safety/permanency

professional. We are working with Healthcare claiming so that would be the appropriate selection.

6. Enter Yes/No if they are qualified. 7. Select the claim category for which they are qualified. In this example select VA/DD-

TCM. Enter the Start Date and End Date if there is one. 8. Save your record when finished.

Remember, do not want to just change this record unless it was incorrect. You want that history of when they were not qualified as well as when they became qualified. SSIS does not edit to be sure a staff person is qualified. Verification is a manual process done outside of SSIS and documented here.


Time Proofing – Exclusions CategoryThe last proofing category is Exclusions and there is one message here as well.

Exclusions Exist – Time Records

2051 – An Exclusion for Healthcare Claiming exists

Message 2051 – An Exclusion for Healthcare Claiming exists displays when an Exclusion has been entered for a time record so a claim is never generated.

Clicking on the proofing message navigates to the time record. Clicking on the Exclusion tab displays the entered Exclusion and details. More than one exclusion can be entered for each time record. To enter additional exclusion click the Action menu and select New exclusion – Healthcare claiming.

Edit the existing record if errors were made. The date the record was created, the reason the record is being excluded and any additional comments displays. It is helpful for future reference to enter additional details as to why you do not want to claim for this record.


Submitting the batch

Once satisfied with cleaning up your proofing messages the batch can be submitted to MMIS for payment. Always remember to generate your batch one last time before submitting to pull in anything from proofing that has been corrected.

To submit the batch, click the Action menu and select Submit batch.


Updates to the Submitted Batch

Once submitted the Batch status updates to Submitted.The Submitted date updates to the date and time the batch was submitted. Both of these fields are system generated and cannot be changed.

The Claims tab of the submitted batch displays the claims within the batch and the Claims Status of each of the claims within this batch also display the status of Submitted.

Overnight processing by MMIS and the interface between MMIS and SSIS will update the Claim status to “To be paid” or “To be denied”.

MMIS processes Remittance Advices every two weeks. At that time the Claim Status will update to Paid, Partially Paid or Denied.

Paid units display in the Allowed Units column and the dollar amount displays in the Paid Amount column.

Research any Partially Paid or Denied claims to determine if further action is needed.


If additional payment is being sought for a Partially Paid claim Void and Resubmit the Open claim. To return paid money to MMIS and resubmit a replacement claim by generating a new VA/DD-TCM claim once the Void claim has been processed by MMIS.If the claim was Denied, make the necessary corrections and Resubmit the Open claim.

VA/DD-TCM Reports

In addition to the general Healthcare Claim Reports that cover all claim categories there is one General Reports specific to VA/DD-TCM, the VA/DD-TCM Eligibility Report. This report is available from:

Tools>General Reports> Healthcare Eligibility Searches/Logs>Healthcare Claiming>Healthcare Eligibility Reporting (Treeview) Healthcare Claiming> Healthcare Eligibility Reporting

This grid report lists the VA/DD-TCM Eligibility dates for clients in SSIS. Use this report to review all the VA/DD-TCM Supplemental Eligibility records entered. Records display on this report sorted by Current Primary Worker. Review the report for needed additions or changes. Selecting the report in the list displays the Setup tab for the report.

On the Setup tab of the report enter the desired date parameters. Filter the report for the desired detail by using the Report on options of Department, Unit, Worker or All. The following is an example of the report results. Current Primary Worker is determined by the Workgroup selected on the VA/DD-TCM Supplemental Eligibility record. If no Workgroup is selected the record displays under Current Primary Worker: (blank).


VA/DD-TCM Eligibility Report Example


€¦ · web viewfor va/dd-tcm the hints include: claims for clients in a ma funded facility are...

Documents