Medicaid Accountability in the I-Suite

MedicaidAccountability in the I-

Suite

How to document Medicaid services in the GG Consulting I-Suite to assist with

compliance with Medicaid standards.

GG Consulting, LLC I-SUITE

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Criteria for Billing Compliance

“What criteria must a child meet in order for the district to bill Medicaid under the SHARS program?

The child must: be enrolled in a public school’s special education

program; be under 21 years of age; Have an ARD/IEP documenting the medical

necessity for services [Documentation requirements can be found in the current Texas Medicaid Provider Procedures Manual (TMPPM), in the Provider Enrollment and Responsibilities Section and in the SHARS Section];

Have a disability or chronic medical condition; Be Medicaid eligible; and Have informed parental consent to bill Medicaid for the

specific services and the frequency as outlined in the child’s current IEP.”Source: TEA SHARS Frequently asked questions

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Medicaid ID

“The child’s name and Medicaid number should appear on every page of the medical records… This would include each page of the ARD/IEP document, session notes and service logs, and evaluations.” (TEA SHARS FAQ)

Medicaid number Manually input into Student Information - General (SM)2 clients – number is inserted on all forms automatically Automatic label reminder can be turned on in FM –

Options/Directories to print labels to stick on ARD documents FM – Form Setup

Can indicate how many labels are needed per form. Could be considered part of consent and if parent refuses number

on forms then they are refusing to give consent to bill Session Notes

(SM)2 program keeps session notes. Non-(SM)2 clients need to collect and store separately. GG

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Parental Consent

“Are schools required to obtain parental consent prior to billing Medicaid for SHARS services?” “Yes, Section 300.154(d) of the reauthorized

IDEA 2004 requires districts to obtain informed parental consent. More guidance on this issue may be found on TEA’s Division of IDEA Coordination website at: www.tea.state.tx.us/special.ed/guidance/medserv.html “

Source: TEA SHARS Frequently asked questions

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http://www.tea.state.tx.us/special.ed/guidance/medserv.html

http://www.tea.state.tx.us/special.ed/guidance/medserv.html

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Parental Consent and SEM

Parental Consent is obtained in 2 places in SEM ARD Signature page (pg. 7)

Should be obtained at EVERY ARD – not just the Annual

SHARS Letter Can be given when obtaining initial consent

as it also includes the Right to Provider section.

Both locations provide space for a Consent Expiration date.

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Parental Consent and (SM)2

(SM)2 reads PC from signature page of ARD as well as SHARS Letter Will not bill TMHP if there is no consent at the

time of the service Reports can be run to show who has consent

and who does not

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Documenting PCS

Personal Care Services “Indication of placement in a self-contained setting

[i.e., Life Skills classroom, Preschool Programs for Children with Disabilities (PPCD), etc.] is not sufficient IEP documentation to support Medicaid reimbursement for PCS.”

Sufficient documentation should answer:(1) Is the service provided on a one-on-one basis

or group or both; (2) examples of PCS; (3) when/where are the PCS needed; and (4) the reason(s) for PCS, such as medical

necessity, etc.

Source: TEA SHARS Frequently Asked Questions

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Documenting PCS

SEM Options ARD Physical Section (pg 2)

Subject on Schedule Page From FM – Options/Directories

PCS Supplement Documents time outside of the instructional

day Related Services IEP DeliberationsGG

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Documenting PCS

Example of documentation in the IEP

Sufficient documentationAssistance is required for one-on-one PCS for “Johnny”. PCS needs include observation and redirection of self-injurious behavior. PCS is required throughout the school day and during transportation to and from school on the bus. Johnny has bipolar disorder and gets angry, frustrated very easily. He often displays his anger and frustration

Insufficient documentationAssistance is required for one-on-one PCS for “Sue”. Sue has cerebral palsy.

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Documenting PCS


Sufficient documentationPCS assistance is required for “Timmy” periodically throughout the day on a one-on-one basis. Timmy has mental retardation and needs periodic PCS to assist him in moving from class to class. Without PCS assistance, Timmy would wander off.

Insufficient documentationPCS assistance is required for “Jane” periodically throughout the day on a one-on-one basis because she has visual impairment. GG

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Documenting PCS


Sufficient documentationGroup PCS assistance is required for “Janice” throughout the day. Janice has ADHD. She has difficulty staying on task and is very impulsive. She requires constant cueing, prompting, and redirection.

Insufficient documentationGroup PCS assistance is required for “Janice” throughout the day because she has ADHD.

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Documenting PCS


Sufficient documentationGroup PCS assistance is required for “Janice” throughout the day. Janice has ADHD. She has difficulty staying on task and is very impulsive. She requires constant cueing, prompting, and redirection.

Insufficient documentationGroup PCS assistance is required for “Janice” throughout the day because she has ADHD.

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Documenting PCS

Example of documentation in the IEP for group PCS with intermittent one-on-one PCS

Sufficient documentationSue is in a self-contained classroom and needs group PCS throughout the day. In addition, Sue needs individual assistance with ADLs, including eating, toileting, mobility, and transfers because she is unable to transfer herself to the toilet and during transportation to and from school on the bus. Sue has cerebral palsy and cannot navigate her chair, feed or toilet herself.Insufficient documentationBobby needs group and one-on-one PCS throughout the day. Bobby is wheelchair bound.

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PCS Provision Documentation

What is required for documenting services for PCS? Must capture the minutes of the service with start and stop times,Must have notation of specific type of PCS required,Must identify type of PCS (one-on-one or group),If PCS is provided throughout the day, the accumulation of all the PCS minutes for the day must be totaled and converted to units of service, andMust include the signature of the individual that provided the PCS. (In group settings, each caregiver does not have to provide documentation for each child. Rather one caregiver can document for 2 or 3 students while another caregiver documents on the other 2 or 3 students.GG

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Documenting PCS Services


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Documenting PCS Services


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Documenting Related Services

ARD Schedule Page Service type, frequency, and duration need to be listed.

IEP Goals and objectives can be sufficient documentation for

billing services Deliberations

Services can also be explained/described here. Counseling as a Related Service

ARD Schedule Page “Counseling” is billed by LCSW or LPC “Psychological Services” is billed by LSSP

“BIP is needed to bill for emergency services and should list the need for emergency counseling”


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Documenting Related Services

Nursing Services ARD Physical Section (pg 2)

Adds service to Related Service section on Schedule Page

“The ARD minutes should include recommendations derived from the RN/APN or physician’s evaluation of the student’s nursing services needs. Nursing services need to be stated with the same level of detail as is provided for the other related services. But, due to the type of services, it may be appropriate to add language such as “as needed”.


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Transportation Criteria


“When can specialized transportation be billed for SHARS?

Specialized transportation service may be Medicaid reimbursable if: it is being provided to and from a Medicaid covered

(SHARS) service(s) for the day the claim is made; the Medicaid covered service(s) is included in the

student's IEP; the specialized transportation needs are included in the

IEP, and the child requires transportation in a school bus adapted

to serve the needs of a student with a disability, which includes the need for personnel on the bus due to a student’s disability (i.e., constant monitoring, suctioning).”GG

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Transportation Criteria


“What type of documentation is required for billing specialized transportation services?”

“Another billable SHARS service must be provided that same day the specialized transportation service is provided.” (SM)2 will not bill the service that day if no other service was

provided. “A transportation log must be maintained recording one-way

trips.” (SM)2 has a log for tracking each ride to and from school.

“IEP documentation must support the medical necessity as to why the student requires the specialized transportation adaptation. “ A blank is provided for the ARD facilitator to record this

information on the Transportation Eligibility form in the ARD in SEM.GG

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Transportation Eligibility Form Records medical necessity for the service

Transportation Information Transportation Special Needs Report

New report in RU

Transportation CriteriaGG

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Common questions

Can a SHARS provider provide services beyond the IEP requirements? No, the IEP authorizes the maximum services

that can be provided and billed. Under the Individuals with Disabilities Education Act (IDEA), districts are required to follow the IEP requirements. Any services billed to Medicaid in excess of those stated in the IEP could be subject to recoupment.


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Common questions

If a student needs constant monitoring all day, even during instructional time, is the entire day billable as personal care services?

The IEP should clearly justify the need for constant supervision or monitoring and any other PCS (such as toileting, feeding, etc.) required during the school day. The documentation needs to answer the following questions or provide the requested documentation: (1) examples of PCS; (2) when/where are the personal care services are needed; (3) reason(s) for PCS (such as medical necessity, etc.); and (4) why can’t the student perform the age appropriate

task?


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Record Maintenance


Minimum records to keep (7 years):ARD/IEP documentsAttendance recordsAssessment/evaluationsProvider qualifications (current licenses and certifications)Written agreements (contract) for contracted service providersRequired prescriptions or referrals for servicesSupervision logs Session notes or service logsTransportation documentation (daily trip logs; maintenance logs/records; bus documentation; documentation for cost report)Claims Submittal and Payment Histories (R&S Reports and General Ledger)Copies of signed/notarized quarterly Certification of Funds (COF) letters and supporting documentation, including quarterly COF ReportsNonschool SHARS provider affiliation letter and attachments (if applicable)Cost Report and supporting documentationGG

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Resources

TEA SHARS site http://

ritter.tea.state.tx.us/interagency/shars.html Frequently Asked Questions Billing Guidelines Join Listserv

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http://ritter.tea.state.tx.us/interagency/shars.html

