Claim iming for Assistive DDevices - PaTTAN - Home€¦ · Accessit Infrared Receiver (requuires either DynaVox Maestro, Xpress, V+, Vmax+, DynaWrite, MT4, or DV4) 327 : Acrobat Electronic

Claim iming for Assistive DDevices

School Base ACCESS Program (SBAP) Public Consulting Group, Inc. V 1.0_1/2013

Assistive Device Bil lling Procedures

Under the School-Based ACCESS PProgram (SBAP), participating LEA’s are eligible too claim Medical Assistance (MA) reimbursement for procurement nt and repairs of student-specific assistive technollogy devices, provided the following criteria are met and/or form ms are completed:

1. Student has been identifieed as receiving special education serv vices. The student must have a current t Individual Education Program (IEP) that defines the student’s need for the device and any needed related s supportive services. The student’s IEP team must t have determined that an assistive device and/or service areare necessary for the student to benefit from his/herher education program.

2. Student is between 3-20 y years old.

3. Student is enrolled in the e Medical Assistance (MA) program. The student must be actively enr rolled in the MA program and eligible to receive M MA benefits.

4. The assistive device neede ded by the student is identified under SSBAP guidelines as eligible for reimbursemen nt. Only certain assistive devices qua qualify for reimbursement. Under SBAP, an assistiv ve device is defined as an item, piece of equipment, or prodproduct system that is used to increase, maintain or iimprove the functional capabilities of the student with a disability. For list of devices that qualify for reimb bursement, refer to the Assistive Device List in this pack ket.

5. Parental consent has bee en obtained. Per the Individuals with Disabilitiees Education Act (IDEA) and the Family Educatio onal Rights and Privacy Act (FERPA), the student’s parent m must sign a Parental Consent Form, authorizing th he LEA to claim MA reimbursement for the assistive ddevice. Note: If the parent has already s signed a Parental Consent Form authorizing the L LEA to claim for MA reimbursement for the current preprescribing IEP an additional form is not required fofor the assistive device.

6. Medical authorization has s been obtained. The assistive device must be dee eemed medically necessary and be ordered on eitherher:

a. physician's prescription b. Medical Practitioner Authhorization Form

If using the Medical Prac ctitioner Authorization Form, the appropriate assis stive device category must be checked and the form m must be signed and dated by one of the followining practitioners: • Medical Doctor (MD)) • Doctor of Osteopath hy (DO)

7. Transfer of ownership let tter/notice has been signed and receiveed from parent.If the LEA is submitting an eligibleligible assistive device for SBAP reimbursement, the ownership of the devicemust be transferred to student. T. The LEA must send a Transfer of Ownership lette er to notify the parent of a possible transfer.

8. Assistive Device Billing FForm has been completed and submitteded to PCG. The LEA must complete an Assisstive Device Billing Form and submit it to PCG. R Refer the Assistive Device

List for the Appropriate Y-code thhat describes the device and include it on the form orm.

• You must also include a co opy of the device invoice and a copy of the Traansfer of Ownership Letter. If claiming reimburse ement for a device repair, include a copy of the repairepair invoice as proof of payment.

School Base ACCESS Program (SBAP)Public Consulting Group, Inc.V 1.0_1/2013

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Assistive Device Bil lling Procedures

9. Billing Rejection Notice isis sent to the parent (only if claim is rejjected). In the event that MA rejects as a assistive device claim, PCG with notify the LEA. T The LEA will notify the parent via a Billing Rejection Notice thatt the device will remain the property of the LEA.

10. The LEA will make copie es of all paper documentation as neede ed to submit a claim; LEA will maintain all origi ginal documents submitted to SBAP as s part of the claim. LEA will maintain these d documents for six years for audit purpooses.

11. Assistive Device docume mentation can be sent to PCG through ththe following Methods:

Mail: Public Consulting Group Attn: Jennifer Taylor 2040 Linglestown Road Suite 201 Harrisburg, PA 17110

Email: [email protected]

Please place “Assistive Device” inin the subject.


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mailto:[email protected]

Assisstive Device List

Assitive Technology Proced dure Code T1999 Y Code 7 - Level Communication Builde er 315 Ablelink Connectables One Step p Communicator 184 Accessit Infrared Receiver (requuires either DynaVox Maestro, Xpress, V+, Vmax+, DynaWrite, MT4, or DV4)

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Acrobat Electronic Magnifier (m monitor required) 2 Acrobat Panel with 12 inch LCD D Monitor and Camera 1 All-Turn-It Spinner 5 Allora 6 ALT-Chat with Symbolstix 7 Amigo Portable Video Magnifier r 8 Attainment Talker Kit 9 Aumax LCD Video Magnifier 11 Bag of Sound 12 BAT USB One Hand Keyboards (Right and Left) 14 Big Keys ABC Keyboard for PC wwith Keyguard 15 Big Keys QWERTY Keyboard witth Keyguard for PC 16 BIGmack Communicator Kit (in ncludes 5 BIGmack Communicators) 17 Boardmaker Activity Pad 21 Boost Personal Video Magnifier 312 Braille Sense Plus Braille Noteta aker 22 Braille Star 40 23 Braillenote Apex BT 32 Cell 358 Braillenote Apex QT 32 Cell 359 Braillenote PK 26 Brailliant 40 Cell Refreshable Brraille Display 28 Busy Box Kit - 5 Function Activiity Center 29 Chat PC 4+ 33 ChatBox 40-XT 34 ChatBox Deluxe with Auditory S Scanning 35 ChatBox with UniChat:16 36 ChatPC Silk 341 Chattervox Voice Amplifier 313 Cheap Talk 4 - Direct / Scan wiith Jacks (in-line) 37 Cheap Talk 8 - Direct / Scan wiith Jacks 38 Clarity Deskmate Plus Video Ma agnifier 40 Clarity Deskmate Video Magnififier 41 Classmate Reader 44 Classmate Reader (For AT Spec cialists) 2 week loan period 331 Comtek ChatPack - Desktop Sou ound Field Personal FM System 326 Cordless Battery-Operated Enviironmental Control Unit 50 Deafblind Switch Kit 52 Dual Switch Kit 318 Dual-tube Video Microscopy Sysstem 56 Dynavox M3 58 Dynavox V with Wordpower 59 Dynavox Vmax with EyeMax 60 Dynavox Vmax with Wordpowe er 61


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Assitive Technology Proced dure Code T1999 Y Code DynaVox Xpress 62 Dynawrite with Keyguard 63 e-Talk 6400 64 e-Talk 8400 65 Easy Talk 332 Echovoice ev3 Voice Amplifier 66 ECO2 with Ecopoint with Word Power and Picture Word Power 68 ECO2 with Word Power and Pic ture Word Power 67 EI Adapted Toy and Switch Sta art-up Kit 319 Electronic Switch Kit 320 Evaluation Switches Kit 69 Eye-Pal 71 Eye-Pal Solo 70 Eye-Pal Solo LV 70 Eye-talk 73 Eyegaze Edge Communication SSystem 75 Falck 1001 Voice Amplifier 77 FarView Portable Video Magnifieer 78 Finger Isolation Busy Box 79 FL4SH Scanning Communicator r 81 Flip 'n Talk 334 Flipper Panel with 10 inch Moniitor 82 Focus 40 Blue Braille Display 343 Four Level Communication Buil lder 86 Franklin Speaking Language Ma aster - Special Edition 314 Frogpad Bluetooth iFrog Portab ble One-Handed Keyboard (right hand) 87 Frogpad Portable USB One-han nded Keyboard (left hand) 88 Frogpad Portable USB One-han nded Keyboard (right hand) 89 Go Talk 20+ 90 Go Talk 4+ 91 Go Talk 9+ 92 Graphing Calculator with Scree en Enlarger 94 Grasp, Squeeze, and Pull Switc ch Kit 95 Great Green Macaw with 32 Loc ocation Keyguard 96 Great Green Macaw with 8 Loca ation Keyguard 97 Half-Qwerty Keyboard for PC orr Mac 101 Head Mouse Extreme 103 Hearit Complete Auditory Tool KKit 105 Hip Talk 4 107 Hip Talk Plus (3, 6, 12 location)) 108 Index Basic-D Braille Embosser r 13 Insight Desktop Video Magnifie er (requires a monitor) 110 Intel Reader with Portable Captture Station 111 Intellikeys USB Keyboard 112 iPad with AAC apps 114 iPod Touch with Proloquo2Go 115 iSense Micro NB Wireless Perso onal FM System (Phonak) 116


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Assitive Technology Proced dure Code T1999 Y Code iTalk2 Communication Aid 117 Jot a Dot Pocket Brailler 120 Juliet Brailler 121 Jumbo Universal Remote Contr rol 122 Large Target Area Switch Kit 126 LCD Touch Screen 17 inch Mon onitor (Serial and USB) 353 Light Pressure Switch Kit 133 Lightspeed Desktop Soundpak System 322 Lightwriter SL35/C Cherry withh Full Size Keyboard 138 Lightwriter SL40 337 Lingo Wearable Communication n Aid 140 Linkswitch with Taction Pads 141 Logan Proxtalker 142 Low Tech Communicators Kit 347 Low Vision Switch Kit 143 Lynx Portable Video Magnifier 144 Maestro by Dynavox 338 Magic Arm Mount Kit 146 Magnicam Electronic Portable V Video Magnifier (connects to a TV) 149 Magnilink S Portable Video Mag gnifier with Reading and Distance Camera 150 Magnisight Explorer Custom Fo ocus CCTV with 17 inch CRT Color Monitor 349 Magnisight Explorer Custom Fo ocus CCTV with 17 inch LCD Monitor - PC Ed dition 151 Magnisight Explorer Custom Fo ocus CCTV with 19 inch LCD Monitor 152 Maltron Ergonomic One-handed d Keyboard (left handed) for PC 153 Maltron Ergonomic One-handed d Keyboard (right handed) for PC 154 Maxport Color Portable Magnifieer 157 McCaw 5 158 Medium Visually Impaired Com ommunicator 160 Merlin Desktop Electronic Magn nifier with 19 inch LCD 161 Message Mate 20 Message Mate 40 163 Message Mate 40 with Multi-lev vel 40/600 164 Microlink with Naida SuperPoweer Hearing System (for moderately-severe to severe hearing loss)

166

Microlink with Naida UltraPowerr Hearing System (for severe to profound h hearing loss)

167

Microlink with Nios Micro III Junnior Hearing System (for mild to moderatetely severe hearing loss)

168

Mimio XI Wireless Digital White eboard Recorder 169 Mini Light Box Mini Message Mate 172 Mobi 175 Motiva Personal FM System (W Williams Sound) 176 Mountbatten Brailler - MB Pro 317 My Tobii P10 Eye Control Syste em with Viking Software 180 myReader Desktop Video Magn nifier/Auto Reader 179 myReader2 Desktop Video Mag gnifier/Auto Reader 351


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Assitive Technology Proced dure Code T1999 Y Code NEO with Co:Writer Applet 182 Olympia Portable Magnifier 183 ONYX Swing-arm Portable Magnnification Camera 185 Optelec Clearview+ Desktop Vi ideo Magnifier 188 Oticon Amigo Personal FM Syst tem 190 Pacmate BX 400 195 Pacmate BX 400 with Portable BBraille Display 195 Pacmate QX 400 (Qwerty with h Portable Braille Display) 197 Page Turner 198 Partner/Plus Four 199 Pearl Portable Reading Camera a 345 Perkins Brailler 210 Perkins Brailler (electric) 211 Personal FM System (Comtek) 328 Personal FM System (Lightspee ed) 212 Pico Pocket Video Magnifier 213 Pocket Viewer 220 Powerlink 3 with Airlink Cordles ss Switch 221 Quicklook Full Color Portable M Magnifier 224 Radium Sound Field System 323 Reading Pen 226 RedCat Classroom Audio Systemm 342 Rio Video Magnifier 227 SAM (Switch Adapted Mouse) J Joystick for Mac/Windows SAM (Switch Adapted Mouse) J Joystick for Windows (USB) Sapphire Portable Video Magniffier 230 SARA - Scanning and Reading Appliance 231 Say-it! SAM Communicator v.3 3 344 SAY-IT! SAM Tablet 232 School DAF Anti-Stuttering Dev vice 234 Sci-Plus 200 Scientific Calculato or 324 Sensview Duo Portable Magnifieer 237 Sensview P 430 Portable Magniifier 238 Small Target Area Switch Kit 240 Smart 128 242 Smart Speak (32 location) 243 Smart Talk (8 location) 244 Smartview Graduate Portable V Video Magnifier 245 Smartview Nano Handheld Vide eo Magnifier 246 SPOK 21 Communication Devic ce 249 Springboard Lite 250 Step By Step Communicator 251 Super Talker Progressive Comm municator 255 Switch Click USB 256 Switch-activated Tape Recorderr with Latch / Timer 257 Symbol Communicator for the BBlind 258 T-3 Talking Tactile Tablet 259


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Assitive Technology Proced dure Code T1999 Y Code Tactile Image Enhancer 260 Talk 4 (with 12 Levels and Optiional Vibration) 261 Talk 8 (with 12 Levels and Scannning and Vibration Option) 262 Talking Magic Roller 355 Tango 264 Tech Scan 32 Plus 266 Tech Scan 8 Plus (auditory scannning) 267 Tech Speak - 32 location 268 Tech Talk - 8 Location 325 Tech Touch 269 The View Portable Desktop Vide eo Magnifier 273 The Writer Fusion 274 The Writer Plus 275 Tiger Cub Braille Embosser 278 Tobii C12 339 Tobii C8 340 Topaz Desktop Video Magnifier 19 inch LCD Model 280 Topaz Space Saver Desktop Vid deo Magnifier with 17 inch Monitor 281 Tracker Pro 284 Transformer USB Portable Electtronic Magnifier 357 Traxsys Joystick Plus -- Mac/PC C (USB) 208 Traxsys Rollerball 2 Trackball (UUSB and PS/2) 209 Traxsys Trackball and Joystick Assessment Kit (PC) 207 Tufftalker with Gus - Communiccator Software 287 UBI DUO - Face to Face Commuunicator 290 USB Switch Interface (Mac or P PC) 293 Vanguard II with Headpointing Access 295 Vantage Lite with Word Power aand Picture Word Power 296 Vantage with Integrated Headp pointing 297 Victor Reader Stream - Digital TTalking Book Player 300 Vocaflex 356 Voice Pal Max (90 seconds rec cording time) + Scanning 302 Voice Pal Plus with Scanning 303 Zoomview Screen Magnifier for or 14 inch to 33 inch Monitors 310


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Assistive Device Parenta al Consent Form

Local Education Agencies (LEAs)) are eligible to receive federal Medicaid reim mbursement for student-specific assistive technology deices ces and their repairs when the device meets tthe requirements of the state’s Medicaid program and is n necessary for the students to benefit from his s or her education program.

The Individual with Disabilities Ed Education Improvement Act of 2004 (IDEA) andd the Family Educational Rights and Privacy Act (FERPA) rrequire schools to obtain written parental con nsent to share students’ education and health-related reco ords such as IEPs and Evaluation Reports. W We are requesting your permission to share this informatiion with the PA Department of Education, the e PA Department of Public Welfare, and a physician in order to bill Medical Assistance.

In addition to the Medicaid-covereded services your child may receive as part of his/her IEP, MA will continue to pay for medically necessacessary, Medicaid-covered services that are p provided to your child outside of school.

I understand that: • if I give permission, I may withdraw it for future services at any time. H However, it does not

negate an action that has occurred after consent was given and before e the consent was revoked.

• my refusal to give consentt will not change the services my child receiv ved under his/her IEP.

• whether I consent or refus se, I will not have to pay for these services.

• upon request, I may receiveve copies of my child’s records that are discloosed as a result of this authorization.

I give my child’s school perm mission to share my child’s education and heaalth-related information and bill Medical Al Assistance.

I do not give my child’s scho ool permission to share my child’s educationa al and health-related information and bill Medical A l Assistance.

Name of School

Student’s Full Name (last, first, middlle initial) DaDate of Birth

IEP Meeting Date IEP Start Date IEP End Date

Parent/Guardian Name (print)

Parent/Guardian Signature DaDate


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AsAssistive Device Medical Practitioner Autthorization Form

LEA Name: __________________ _____________________________

Student’s Name: __________ __________________________________

Date of Current IEP: __________ _________________

I have reviewed the student’s Indiividual Education Program (IEP) and agree t hat the following assistive device and services recommended ed by the IEP team are both appropriate and medically necessary for the proper treatment and manage ement of the student’s illness or disability.

Type of Assistive Device

Augmentative/alternative ccommunication device

Vision device

Assistive listening amplific cation device

Supportive Services Needed

Authorized Signature: _________ _______________________________ DaDate: ______________

Record Review Timme: ______________


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Assistive Device Transf fer of Ownership

Student’s Name:

Transfer of Ownership Date:

Dear Parent/Guardian:

Your child’s LEA (Local Educationn Agency) is a participant of the School Base ed ACCESS Program (SBAP). Through SBAP, they can can submit a claim for reimbursement from Med dical Assistance (MA) for the cost of providing your child wiith this assistive device.

A claim for this device, which was as purchased specifically for your child, is being ng processed. Once MAapproves and reimburses the LEAA for the federal portion of the cost, the owne ership of this device must transfer to your child.

Please note that if MA rejects the e claim, your child will continue to have full acce ccess to this device as partof his/her Individual Education Proogram (IEP); however, the device will remainn the property of the LEA.

The LEA, through the Assistive Te Technology Team, will provide the necessary training and support in the use of the device. It is importa ant to collaborate with the school personnel wwho are assisting in the training process for the proper us use of the device.

If the device is not working and neeeds to be repaired, please contact us at _____________________ for assistance. The LEA is responsibble for any costs related to the repair of the devdevice; however, the school district does not cover any ny repairs once the student graduates.

If you have any questions, please e contact your LEA for assistance.

Sincerely,

cc: School District Representative ve


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Assistive Dev vice Billing Form

LEA Name Transfer of Ownership Date

Student Name (last, first, middle initial) Date of Birth Medical Assistance ID Number

LEA Contact Name and Title LEA Contact Phone

Assistive Device “Y” Code Assistive Device Description Cost

Attach a copy of the Transfer of Ownership Le etter and copy of the device invoice. Total Cost $

Assistive Device Repair

Equipment owned by: Student

Date Paid Vendor Name Cost

Attach a copy of the repair invoice Tota al repair cost

Signature

LEA Contact Signature: _________________ ____________________________________________________ Date:

Note: If billing for equipment, atta tach a copy of the Transfer of Ownership Lette er. If billing for repairs, a Transfer of Ownership Letter is noot required.


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Assistive Device Billing RRejection Notice

Date: ____ __________________

Dear Parent:

This letter is to inform you that Meedical Assistance has denied our Local Educat cation Agency’s (LEA) claim for cost reimbursement for yoyour child’s assistive device.

Therefore, the device will remain the property of our LEA. However, your child d will continue to have full access to the device as part of hiss/her Individual Education Program (IEP) unttil your child graduates.

If the device should malfunction a an need repair, please call

___________________________ __________________ at ____________________for assistance. The LEA is responsible for any costs rrelated to the repair of the device.

Please do not hesitate to contact me if you have questions.

Sincerely,

cc:


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Documents

Claim iming for Assistive DDevices - PaTTAN - Home€¦ · Accessit Infrared Receiver (requuires either DynaVox Maestro, Xpress, V+, Vmax+, DynaWrite, MT4, or DV4) 327 : Acrobat Electronic