Medicaid Billing Toolkit

Transcription

1 Alaska Medicaid Billing Toolkit for School-based Behavioral Health Services and Therapies Medicaid Billing Toolkit Commissioned by: State of Alaska Department of Health and Social Services Prepared by: The Pacific Health Policy Group January 30, 2009

2 Table of Contents Acknowledgement... 4 Introduction Introduction... 5 Summary of the Medicaid School-based Program (IEP Medicaid Claims Program)... 7 Parental Consent/Release of Information... 7 Staff Documentation... 7 Submission of Claims... 8 Deadline for Submitting Claims AAC Payment for school-based services (Authorizing Legislation)... 9 Provider Enrollment Provider Enrollment Overview Applying for an NPI Number Sample of NPI Application Medicaid Provider Application Alaska Medicaid Provider Application Claiming Process Release of Information (Parental Consent) Process for Obtaining Release of Information Instructions for Completing the Release of Information Form Year Old Students Frequently Asked Questions Sample of Parental Authorization Letter Eligibility for School-based Special Education Process Reviewing Of Medicaid Enrollment for Special Education Services Child Count Lists Medicaid Eligibility Checking Medicaid Eligibility Guidelines Timely Filing Billing Third Party Liabilities Claims Billing Procedures... 52

3 Claims: General Instructions Documentation of Service Delivery Student Billing Form Health Insurance Claim Form (CMS-1500) Instructions Sample CMS-1500 Form Obtaining and Submitting Paper Forms Remittance Advice Review of Denied Claims How to Read a Remittance Advice Adjustments and Recoupments Adjustments Recoupments Denied Claims Resubmission of Denied Claims Forms for Adjustments and Void Requests CPT, HCBC, and ABC Codes and Alaska Fee Schedule Confidentiality Maintaining Confidentiality of Student Health Records Overview Family Educational Rights and Privacy Act (FERPA) HIPAA and Electronic Claims Submission Day-to-Day Operations Joint Guidance on the Application of FERPA and HIPAA from HHS and DOE Recordkeeping Records for Reporting and Audits General Record Requirements Information Needed for Accurate Documentation Parent Authorization Form A Copy of the IEP Service Documentation Log Supporting Documentation Records Need to be Retained for Seven Years Training Practices Frequently Asked Questions

4 Acknowledgement PHPG would like to thank those who contributed to this project, including: Mr. Bradley Grigg; Members of the Advisory Committee; and Representatives of the Fairbanks, Juneau, Kenai, and Sitka School Districts. PHPG would like to inform the reader that this Toolkit is a compilation of PHPG s original work, materials modified by PHPG but original created by a third party, and original materials created by third parties. Third parties include, but are not limited to: officials at the Kenai School District; First Health; ACS; and the United States Departments of Health and Social Services and Education. Alaska Medicaid Billing Toolkit for School-based 4 30Jan09

5 Introduction The Medicaid program is a partnership between the federal and state governments to provide health insurance to financially-eligible Americans. While the Medicaid programs are operated independently by each state within broad federal parameters, the federal government reimburses states between 50 and 85 percent of total costs. In Alaska, the federal government contributes approximately 50 cents of each dollar spent to provide health insurance to low income Alaskans. In January 1998 an amendment as made to the federal Medicaid law allowing Medicaid claims to be made for the special education services provided by schools if they qualify as medical services. Below is the text of that amendment: Title XIX, Section 1903 c) Nothing in this title shall be construed as prohibiting or restricting, or authorizing the Secretary to prohibit or restrict, payment under subsection (a) for medical assistance for covered services furnished to a child with a disability because such services are included in the child s individualized education program established pursuant to part B of the Individuals with Disabilities Act [63] or furnished to an infant or toddler with a disability because such services are included in the child s individualized family service plan adopted pursuant to part H of such Act. This allows schools to submit Medicaid claims for services provided to students who require special education services. However, all of the usual requirements for Medicaid claims are still required. This limits the billing of Medicaid for special education services to those that are medically necessary. In order to bill Medicaid, the basic Medicaid billing requirements must be in place, including (1) service is the result of a prescription or referral by a qualified provider (2) documentation for each occurrence of service delivery; (3) staff providing services must meet licensing requirements or be supervised by appropriately licensed staff; and (4) only services covered in the State Medicaid plan may be billed to Medicaid. By electing to enroll as a Medicaid provider, school districts and tribal schools will be able to supplement current special education and therapeutic expenditures by leveraging the federal match for Medicaid-covered services. While there is some additional work involved in being a Medicaid provider e.g. verifying a student s Medicaid eligibility, preparing and submitting Medicaid claims, and maintaining the appropriate records the increased revenue should more than adequately cover the administrative costs. From a legislative and administrative perspective, Alaskan school districts are being encouraged to participate in the Medicaid program to recover a portion of the special education costs that are already being incurred by school districts to provide special education services. The Alaska Medicaid Billing Toolkit for School-based 5 30Jan09

6 program in Alaska is called the School-based program. The statutory language allowing school districts to bill Medicaid for Medicaid-eligible services is provided at the end of this section. Billing Medicaid requires some merging of the medical model with special education service delivery. This Toolkit was written to serve as a guide to help those involved work out the complexities. This Toolkit has been laid out to follow the sequence of the process from the special education eligibility to submitting a Medicaid claim. It also describes what records need to be maintained by the school or school district for an audit. Alaska Medicaid Billing Toolkit for School-based 6 30Jan09

7 Summary of the Medicaid School-based Behavioral Health and Therapeutic Services Program (IEP Medicaid Claims Program) The Medicaid School-based program is used by the school district to generate Medicaid reimbursement for medically relevant services provided to eligible students. To be eligible, a student must be receiving special education services, enrolled in Medicaid (or Denali KidCare), and receiving Medicaid billable services. School districts enroll as Medicaid providers to submit claims for their member schools. Each school district can only submit claims for the students for which the district serves as the local education agency under the federal special education law (IDEA) and is fiscally responsible. Claims can only be submitted for students who are receiving special education and therapeutic services pursuant to an IEP/IFSP. Services provided through 504 plans may not be billed to Medicaid. Parental Consent/Release of Information Parental consent is required before any Medicaid claims can be processed. In order for the school to bill Medicaid, the student s legal guardian must sign a Release of Information form. If a parent refuses to provide consent, the school district may not bill Medicaid for any services provided to the student. Refusal to consent to Medicaid billing does not absolve the school district from providing legally required services. Staff Documentation In order to support a Medicaid claim, the school district must comply with certain recordkeeping requirements. A service must be determined as medically necessary and must be included in the IEP. Documentation of service delivery must also be maintained in the form of progress notes that identify the time, date, type, frequency, and intended treatment goal. Both student and staff attendance records must also be maintained. Claims for School-based School-based School districts can bill for the following services: Case management Developmental and assistive therapy Mental health counseling Rehabilitative nursing services Occupational therapy Physical therapy Speech, language & hearing services Personal Care Alaska Medicaid Billing Toolkit for School-based 7 30Jan09

8 Submission of Claims For each billing period, the Medicaid clerk collects the service authorization logs from the direct care providers. Medicaid claims may be submitted electronically or in paper format to ACS, Alaska s Medicaid fiscal agent. ACS receives the claims and processes them for payment. For districts submitting claims electronically, a weekly Remittance Advice (RA) is mailed to the district showing which claims were paid, denied, adjusted, or put into suspension (for manual review.) Deadline for Submitting Claims All claims must be submitted within twelve months from the date of service. Alaska Medicaid Billing Toolkit for School-based 8 30Jan09

9 Title 7 Health and Social Services Chapter 43 Hearings Section 461 Payment for school-based services 7 AAC Payment for school-based services (a) The department will enroll a school district as a Medicaid provider of school-based services if the school district meets the applicable requirements of AS and this chapter and enters into an agreement with the department as required by AS (b) The school district shall submit each request for payment for a school-based service using the provider code number assigned to the school district at enrollment. (c) The department will pay for school-based services in accordance with 7 AAC and established at 85 percent of the resource-based relative value scale (RBRVS) fee schedule determined under 7 AAC (b) and (c) for procedures with an established relative value unit (RVU). For services with no established RVU, the department will pay according to the department's School-Based Services Fee Schedule, dated May 2005 and adopted by reference. (d) The department will pay the cost of an evaluation, screening, or assessment of a Medicaideligible child's need for a school-based service only if the outcome indicates the child's need for services included in the individualized education plan described in (e) of this section. (e) The department will pay for school-based services for a Medicaid-eligible child if the individualized education plan developed for the child under AS specifies the services that the school district is seeking reimbursement for, each health condition to be addressed, the anticipated treatment goals, and the type, amount, frequency, and duration of each service to be offered. Any change to a plan that adds, eliminates, or alters a service, material, or supply described under this section must be documented in the Medicaid-eligible child's clinical record by or under the direction of a 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 other health care provider who is (1) acting within the scope of that health care provider's (A) license under AS 08; or (B) training and experience, if the health care provider is a psychologist or psychological associate described in (i)(7)(a)(ii) of this section, a behavioral health professional, or a behavioral health associate; and (2) familiar with the child's plan, health condition, and treatment history. Alaska Medicaid Billing Toolkit for School-based 9 30Jan09

10 (f) In addition to meeting the requirements for provider records in 7 AAC and AS (b), and before the department will pay for school-based services, the school district must assure that each Medicaid-eligible child's clinical record includes (1) documentation of the relationship of the service provided to the child's achievement of individualized education plan goals and objectives; and (2) on each page of service documentation, the Medicaid recipient identification number and at least one other item of unique identification for the Medicaid-eligible child who received the service; for the purposes of this paragraph, "item of unique identification" includes the child's name, date of birth, social security number, and the student identification number assigned by the school district. (g) Nothing in this section precludes a private enrolled provider from furnishing the same service to the same child at a different time on the same day that the child was furnished a school-based service, if the applicable requirements of this chapter are otherwise met. (h) Subject to the requirements of AS (a), the department will pay a school district for the following school-based services furnished in accordance with this chapter to a Medicaideligible child with a disability, and for materials and supplies provided to the recipient in the course of performing the services, if those materials and supplies are furnished in accordance with this chapter: (1) physical therapy services furnished by or under the direction of a physical therapist licensed under AS 08.84, and practicing in accordance with 7 AAC , regardless of whether that person is enrolled under that section; (2) occupational therapy services furnished by or under the direction of an occupational therapist licensed under AS 08.84, and practicing in accordance with the provisions of 7 AAC , regardless of whether that person is enrolled under that section; (3) speech-language pathology services furnished by or under the direction of a speech-language pathologist who (A) meets the requirements of 42 C.F.R (c) or is licensed under AS 08.11; and (B) is practicing in accordance with the provisions of 7 AAC , regardless of whether that person is enrolled under that section; (4) hearing services furnished by or under the direction of an audiologist licensed under AS 08.11, and practicing in accordance with the provisions of 7 AAC , regardless of whether that person is enrolled under that section; (5) behavioral health services including Alaska Medicaid Billing Toolkit for School-based 10 30Jan09

11 (A) the following services furnished by a behavioral health associate or behavioral health professional: (i) emotional support assistance to help a child process emotions during periods of elevated stress; (ii) behavior management education that teaches behavior management, modification, and redirection techniques to elicit positive behaviors with families, groups, and individuals; (B) the following services furnished by a behavioral health professional: (i) crisis response services that include short-term interventions to prevent harm, build coping skills, develop mechanisms for positive self-care, and stabilize a child or family in acute distress; (ii) behavior modification assistance using counseling techniques to assist in modifying behavior to individuals and groups; (iii) functional behavioral assessments to assess a child's behavior; (iv) psychoeducational services designed to help a child develop or improve specific self-care skills and engage in age-appropriate social behavior; and (C) services furnished by a psychologist or psychological associate, including (i) testing a child's psychological, cognitive, and emotional functioning; and (ii) interpreting a child's psychological, cognitive, emotional, and behavioral assessment results; (6) medication services furnished by a nurse licensed under AS 08.68, including medication administration, direct observation, training, and support. ( i ) In this section, (1) "child with a disability" has the meaning given in AS ; (2) "individualized education plan" and "plan" means the plan developed for a Medicaid-eligible child with a disability through an "individualized education program" described in AS ; (3) "school-based service" means a service identified in this section that is furnished in accordance with AS and this chapter by an enrolled school district to a Medicaid-eligible child with a disability; (4) "school district" has the meaning given in AS ; Alaska Medicaid Billing Toolkit for School-based 11 30Jan09

12 (5) "behavioral health associate" means a person who has less than a master's degree in psychology, social work, counseling, or a related field with specialization or experience in working with children experiencing behavioral, physical, and emotional disabilities, and is working within the scope of the person's training and experience; "behavioral health associate" does not include a person employed as a teacher; (6) "behavioral health professional" means a person who has a master's degree in psychology, social work, counseling, or a related field with specialization or experience in working with children experiencing behavioral, physical, and emotional disabilities, and is working within the scope of the person's training and experience; "behavioral health professional" does not include a person employed as a teacher; (7) "psychologist or psychological associate" (A) means a psychologist or psychological associate (i) licensed under AS and working within the scope of the person's license; or (ii) with a special services certificate (Type C) under 4 AAC 12 endorsed in "school psychology," who is employed by the school district and working within the scope of the person's training and experience; and (B) does not include a person employed as a teacher by the school district. History: Eff. 8/19/2004, Register 171; am 9/18/2005, Register 175 Authority: AS AS AS Alaska Medicaid Billing Toolkit for School-based 12 30Jan09

13 Provider Enrollment Overview The State of Alaska has contracted with an independent entity - ACS Healthcare to act as its Medicaid fiscal agent. ACS is responsible for enrolling providers, verifying recipient eligibility, and processing claims. ACS was recently awarded this contract and is replacing First Health Services Corporation, Alaska s previous fiscal agent. During the transition you will continue to see documents and materials bearing the First Health name. In addition, providers can continue to use the website to access enrollment materials, procedure manuals, and other information. In order to bill Medicaid for school-based behavioral health services and therapies, each school district is required to enroll for an NPI number. An NPI number is a National Provider Identifier and its use is mandated by the Health Insurance Portability Accountability Act of 1996 (HIPAA). This form can be completed either online or in paper version. Instructions for both methods are contained in this section of the Toolkit. Only school districts are required to obtain NPI numbers; individual practitioners employed by the school are not required to obtain a unique number. Upon receipt of an NPI number, a school district must then enroll with ACS as an Alaska Medicaid provider. Instructions and a paper copy of the application are included in this toolkit. Upon receipt of a State Provider Identification Number (SPIN), a provider is then eligible to bill Medicaid for eligible services. Alaska Medicaid Billing Toolkit for School-based 13 30Jan09

14 Applying for an NPI Number This section needs to be completed prior to applying for a Medicaid number Online 1. Navigate to: 2. Click on the blue link that says National Provider Identifier (NPI) which is located in the third paragraph 3. Click on Apply Online for an NPI Paper Application A paper application has also been included in the toolkit. The following are instructions to assist in completing the paper application (and can serve as a basis for completing the online application as well.) Section 1 Basic Information A. Reason for submittal of this form check the box next to Item 1 ( Initial Application ) B. Entity Type check the box next to Item 2 ( An organization that renders health care); next to the first bullet ( Is the organization a subpart? ) check the No box Section 2, Part B Organizations Complete Items 1-4 Section 3 Business Addresses and Other Information Section C - should not be applicable to any school district Section D - Part 1: Primary Taxonomy Code is: X This is the taxonomy code for a Local Education Agency Skip License Number and State where issued (N/A for LEAs) Skip Items 4-9 Section 4 Certification Statement Section A Skip this section Section B Complete this section Section 5 Contact Person Complete as applicable The completed form can be sent to: NPI Enumerator P.O. Box 6059 Fargo, ND Alaska Medicaid Billing Toolkit for School-based 14 30Jan09

15 Sample of NPI Application Alaska Medicaid Billing Toolkit for School-based 15 30Jan09

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21 Medicaid Provider Application A copy of the application is included in the toolkit. It can also be obtained through: You will need to download the Standard Provider Enrollment form and the School Based Services Provider Addendum. Section A Item 1 Today s date Item 2 School-based Services Item 3a Not Applicable Item 3b Not Applicable Item 3c Complete using the School District Administrative Office Item 3d to 4f complete with appropriate information Item 5a Check box next to other Item 5b Check box next to Public Federal, State or Municipal Item 6 Check the box next to No and Skip #1 in Section B Section B Item 1 Skip Item 2a Fill in the NPI number obtained prior to completing this application Item 2b X Items 2c, 2d, 2e, 3a, 3b, 3c Not Applicable Section C Skip Section D Skip Section E Items 1, 2, and 3 Answer appropriately Section F Items 1 & 2 Answer appropriately Alaska Medicaid Billing Toolkit for School-based 21 30Jan09

22 Section G Check the No box associated with Do you perform clinical laboratory services? Section H Skip Section I Item 1 Initial and Date Item 2 Initial and Date Item 3 Initial and Date Item 4 Initial and Date Section J Sign and date School-based Services Addendum Sign and date Upon completion, these forms can be sent to the following address for processing: First Health Services Corporation Provider Enrollment Unit P.O. Box Anchorage, Alaska Alaska Medicaid Billing Toolkit for School-based 22 30Jan09

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41 Release of Information (Parental Consent) Before any Medicaid claims can be submitted under the Program, the legal guardian must sign a Release of Information. The Release of Information form gives the school district consent to release the child s confidential records. The Release of Information is needed so that the school district can submit records of the students services to ACS as part of the claiming process. Process for Obtaining Release of Information For the special education students enrolled in Medicaid, the school district needs to request consent to release the individual student s information needed for the rest of the billing process. The consent is requested of the student s legal guardian. The student s legal guardian(s) is usually the student s parent(s). For the special education evaluation, IEP process and school enrollment information, the school district should be aware of who the student s legal guardian is. School districts have different processes for requesting Release of Information (parental consent). One of the most expeditious methods for obtaining the consent is to include the form for all students as part of the special education evaluation and initiation process. A sample letter has been included at the end of this section and a pamphlet is available for distribution to the parents. Instructions for Completing the Release of Information Form The information requested on the form is self-explanatory. The name(s) of the student(s) for whom parental consent is being requested can be added before requesting the legal guardian s signature. When the form is returned, the Medicaid clerk should check to see if the legal guardian signed the form. If the form is not dated, the date received should be noted on the form. Once the signed Release of Information form is received, it must be kept in the student s Medicaid file. No Medicaid claims can be submitted for a student until this form is received. If no consent has been obtained, no claims can be submitted to Medicaid for this student. This form only needs to be signed one time while the child is in the educational system unless the student s legal guardian changes. If the child transfer to a different school district, copies of the student s Release of Information can be sent to the new school district as part of the special education file. 18 Year Old Students Unless a student over the age of 18 is under legal guardianship, consent to the release of information must be signed by the student. Claims cannot be submitted for students 18 or Alaska Medicaid Billing Toolkit for School-based 41 30Jan09

42 older unless the student has given consent for the release of information or the student has a legal guardian who has given consent. Frequently Asked Questions Q: Can the educational surrogate sign for a student? A: The signature on the Release of Information must be from a legal guardian. The surrogate parent is appointed only to represent the student as the parent for the special education evaluation and IEP process. Foster parents, educational surrogate parents, stepparents, grandparents or a legal guardian ad litem cannot sign the Release of Information unless they are the legal guardian. Q: When is a Release of Information form needed from a foster parent who is adopting the student? A. Once the student is legally adopted, the adoptive parents must sign a Release of Information form in order for the school district to submit Medicaid claims. Q. What if the parent refuses to release the child s records/information? A: If a parent refuses to release the child s records, then no Medicaid claims can be submitted for the student. In the event the parent refuses to sign the form, a note stating their objection with the date must be kept in the file. Q: If the student, who previously had a signed Release of Information form, dropped out of school and then returns to school, is a new signed Release of Information needed? A: No, the original Release of Information form is valid. Q: What signatures are required for a student who is in joint parental custody? A: Both parent s signatures are required. If one parent refuses to sign the Release of Information form, no billing may be done. Q: If a student, at the age of 16, is considered an emancipated minor, can that student then sign the Release of Information form? A: If a student has been appointed as an emancipated minor through the courts, the student must sign a Release of Information form. Alaska Medicaid Billing Toolkit for School-based 42 30Jan09

43 Sample of Parental Authorization Letter Month Day, Year To the Parent/Guardian of: Address 1 Address 2 City, AK ZIP ON SCHOOL DISTRICT LETTER HEAD The NAME OF SCHOOL DISTRICT is able to be reimbursed by Medicaid for providing certain health-related services to student enrolled in Medicaid and/or Denali Kid Care and eligible for certain special education services. However, before the reimbursement process can begin, the District needs your permission to submit claims to the Division of Health Care Services, Alaska s Medicaid agency, for health related services provided to your child through the district s special education program. Please be assured that you will not incur any out-of-pocket cost for the provisions of these services, nor will this affect your child s current or future eligibility for Medicaid, Medicaid Services, Denali KidCare, or any Medicaid related programs. All information concerning your child is strictly confidential. Whether your child is/is not eligible for Medicaid or Denali Kid Care, please fill out the attached form and return it in the enclosed envelope. This authorization will expire when the child is not longer receiving Medicaid billable health related services, unless you revoke your authorization. If you have any questions or concerns regarding special education, please contact FIRST LAST NAME at (907) XXX-XXXX. If you have questions or concerns about Medicaid reimbursement, please contact FIRST LAST NAME at (907) XXX-XXXX. Thank you in advance for your cooperation and participation; it will greatly benefit our schools and our students! Sincerely, Alaska Medicaid Billing Toolkit for School-based 43 30Jan09

44 NAME OF SCHOOL DISTRICT RETURN ADDRESS CITY, AK ZIP Name of Student: Date of Birth: School: Name of Parent/Guardian: Is this student currently eligible for Medicaid or Denali Kid Care Benefits? [ ] YES [ ] NO Has this student ever been eligible for Medicaid or Denali Kid Care Benefits? [ ] YES [ ] NO Parent/Guardian Authorization for Release of Information I,, parent/guardian of Please print your name Please print student s full name give permission to the SCHOOL DISTRICT NAME HERE to release information to the Department of Health and Social Services, the Alaska Medicaid agency, regarding services my child receives through the District s special education program. This information is for the sole purpose of obtaining federal reimbursement to our district for the cost of eligible health-related special education services your child receives. I hereby authorize the use or disclosure of health care and/or information as described above. I understand that this authorization is voluntary. I understand that these records may contain sensitive information. I understand that I may revoke this authorization at any time by notifying the individual(s) or district releasing this information in writing, but if I do, it won t have any affect on actions taken on this authorization before my revocation was received. I understand that the individual(s) or district releasing this information will not condition my treatment, payment, enrollment in a health plan (if applicable) or eligibility for benefits on whether I provide this authorization. I understand that if the person(s) or district authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. To the extent that this information is required to remain confidential by federal or state law, the recipient of this information must continue to keep this information confidential. I understand that I may request a copy of this signed authorization. This authorization will expire when the child is not longer receiving Medicaid billable health related services, unless you revoke your authorization. Parent/Guardian signature Student s Medicaid Number Date Student s Social Security Number This release may be revoked at anytime: Please contact FIRST LAST (907) XXX-XXXX for appropriate paperwork. A PHOTOCOPY OF THIS AUTHORIZATION IS AS VAILID AS THE ORIGNIAL. Alaska Medicaid Billing Toolkit for School-based 44 30Jan09

45 Revocation I hereby request that the authorization to release information to the Department of Health and Social Services, the Alaska Medicaid agency, for Student s name be rescinded, effective. I understand that any action taken on this Date authorization prior to the rescinded date is legal and binding. Parent/Guardian signature Date Printed Name of Parent/Guardian Alaska Medicaid Billing Toolkit for School-based 45 30Jan09

46 Eligibility for School-based In order to submit Medicaid claims, a school district must determine which of its students are eligible for Medicaid and received Medicaid-covered services. For a student to be eligible, the student must be a special education student receiving services in accordance with his/her Individualized Education Program (IEP) and be enrolled in Medicaid. In addition, a portion of the student s special education services must be determined to be medically necessary. Students Billed by School Districts Acting as a Local Education Agency (LEA) A school district can only bill for those students for whom it is legally responsible or for whom it acts as the local education agency under the Individuals with Disabilities Education Act (IDEA). This includes students who reside in a school district whether they are legal residents or placed by an Alaska state agency. Special Education Process School districts are responsible for providing special education to children who meet the eligibility requirements. The eligibility criteria are established by State Board rules and are amended from time to time. Some changes in eligibility are due to changes in the federal special education law known as the Individuals with Disabilities Education Act. For a child to be eligible for special education, the child must meet the three gates of special education eligibility: 1. Has a disability (i.e., meets the criteria for one of the categories of disabilities established for special education); 2. The disability results in an adverse effect on the child s educational performance; and 3. Needs special education services to benefit from his or her education program. A special education evaluation may include observations, tests, and other diagnostic measures. The special education evaluation is also the name of the process used to determine special education eligibility for a student. An evaluation and planning team (EPT) is the team that is responsible for making the eligibility determination. The team consists of one of the child s regular education teachers, a special educator, the child s parents, and a local education agency representative. The determination of eligibility must be reviewed at least once every three years. Reevaluations can be conducted sooner at the request of a parent or teacher. Within 30 days of being determined eligible for special education, an Individualized Education Program (IEP) must be developed for a student. The IEP must be reviewed and revised at least annually. The IEP is required to include: 1. Statement of the child s present level of performance; 2. Measurable annual goals related to the child s educational performance; Alaska Medicaid Billing Toolkit for School-based 46 30Jan09

47 3. Special education and related services, supplementary aides and services to be provide to the child, and a statement of program modifications or supports that will be provided by school personnel; 4. Beginning date of the IEP and the anticipated frequency, location, and duration of the services and modifications; 5. General characteristics of the child s placement; 6. A statement of any individual accommodations for state or district-wide assessments; 7. A description of any extended school year services (ESY); 8. A description of transition services if appropriate for the student; 9. A statement, when appropriate, that parental rights transfer to the student age 18; 10. A multi-year plan when appropriate. The important pieces of information for the School-based Behavioral Health and Therapeutic Services program are numbers 3, 4 and 7 above that describe the services to be provided to the student. These are important as they describe the services that can potentially be billed to Medicaid. The IEP for Medicaid eligible students must also include the type of personnel (professional or paraprofessional) and group size for each service. Reviewing Of Medicaid Enrollment for Special Education Services Each school district needs to have a process in place to determine which special education students are enrolled in Medicaid and can potentially have claims submitted under the Schoolbased program. It is important to know of new special education students soon after they start receiving services due to the 12-month deadline for filing claims. This process needs to be developed locally and should tie into the information process for new IEP students. If the school district keeps their special education child count database continually updated, the information about new IEP students should be available from the child count clerk. As part of the IEP initiation process, the school district should include a Release of Information form that the parents can sign which specifies that they will allow the school district to determine Medicaid eligibility and submit claims for Medicaid-eligible services that are identified in the IEP. A new release needs to be obtained each time the IEP is changed or if service levels differ from those specified in the IEP. This release should be kept in the student s file. A template has been included in the Toolkit. Child Count Lists Child count is a federally required count of students who are eligible for and are receiving special education services as of December 1 of each year. This data collection provides the Department of Education with information on the students receiving special education services in each school district. The child count data collection requires specific information for each of Alaska Medicaid Billing Toolkit for School-based 47 30Jan09

48 the students reported in the collection. The child count is due to the Department of Education by mid-december of each school year. The information is submitted by each school district from the Special Education Director s office. Each school district has a system for collecting and submitting the information to the Department and employs someone to act as a child count clerk. After the child count is submitted to the Department, a copy will be given to the School-based staff and the students will be checked to see If they are currently enrolled in Medicaid (assuming a release has been obtained from the parents.) A list of special education students enrolled in Medicaid will be generated for each school district. The information that is collected as part of the child count data collection includes a number of fields that are useful in the School-based program billing process. Relevant Child Count Data Fields: Child s Name Date of Birth (DOB) Grade Town of Residence Case Manager Primary Disability Initial Evaluation (Date of) Most Recent Evaluation (Date of) IEP Meeting Date (Most recent as of December 1) Exit Date The primary disability is used to help determine the diagnosis code. (See 50 for Medicaid diagnosis codes). Dates of initial evaluations, most recent evaluation and IEP meeting are used to check the student files. Exit date is used to check the date that the student exited from special education services for that district. Medicaid Eligibility The second requirement for billing the School-based Behavioral Health and Therapeutic Services program for a student s special education services is that the student is enrolled in Medicaid. There are different factors that may make a student eligible for Medicaid. The criteria include: Family income The severity of a student s disability Alaska Medicaid Billing Toolkit for School-based 48 30Jan09

49 Being in state custody Checking Medicaid Eligibility Before rendering services, the school district is responsible for verifying the following: the age of the recipient that the recipient is Alaska Medical Assistance-eligible and is also eligible for the schoolbased services that the services are school-based services covered by Medical Assistance The provider can verify the patient s age and eligibility through use of the Eligibility Verification System (EVS) at (800) Upon enrollment, each provider will be provided with a unique user identification number to access the EVS. The EVS is available 24 hours a day, seven days a week. Eligibility on as many as 30 enrollees can be obtained per call. In order to verify eligibility, the school district s Medicaid billing clerk needs either the student s Medical Assistance Identification number or Social Security number. You will also need the recipient s name and date of birth. Each month s updated information is available on the first day of the month. System access may be unavailable during the last two days of the month for updates. In addition the phone-based verification system, the Medicaid clerk can also elect to send a fax to the Provider Inquiry Unit at (907) Alaska Medicaid Billing Toolkit for School-based 49 30Jan09

50 Common Medicaid Diagnostic Codes Category ICD-9 Code Description Learning Impaired Moderate Mental Retardation 319 Unspecified Mental Retardation Hearing Impaired Unspecified Hearing Loss Deaf Congenital Deafness (Deaf and Dumb) Speech/Language Developmental Speech or Language Disorder Impaired Visually Impaired Unspecified Visual Loss Emotional Disorder/Upset Anorexia Nervosa Emotional-Behavioral Separation Anxiety Disorder Disturbance Behavior Bulimia Orthopedically Other Specified Delays in Development Impaired Other Health Unspecified Delay in Development Impairments Asthma with Chronic Obstructive Pulmonary Disease Specific Learning Disability Deaf-Blind Multi-Handicapped Developmentally Delayed Other Specific Learning Disability Attention Deficit Disorder ADHD/Hyperactivity Unspecified Hyperkinetic Syndrome Reading Disorder, Unspecified Alexia Developmental Dyslexia Dyslexia Emotional/Function Unspecified Visual Loss Unspecified Hearing Loss Lyme Disease Other Specified Delays in Development Cerebral Palsy Spina Bifida Down s Syndrome Other Specified Anomalies Chronic Fatigue Invalid Mixed Development Disorder Unspecified Delay in Development Lack of Expected Normal Physiological Development Unspecified Drug Inducted Mental Disorder Traumatic Brain Injury Unspecified Non-Psychotic Mental Disorder Epilepsy, Unspecified Autism Infantile Autism (Childhood) Alaska Medicaid Billing Toolkit for School-based 50 30Jan09

51 Guidelines Timely Filing All claims must be filed within 12 months of the date services were provided to the recipient. The 12-month timely filing limit applies to all claims. Billing All providers are required to bill Medicaid the provider s lowest charge, with few exceptions. The exceptions are not applicable to school districts since school districts do not typically establish fee schedules for services provided. At this time, school districts are instructed to bill Medicaid based on the established fee schedule included in this manual. In the future, schools may be required to reconcile charges to actual expenses to provide services Third Party Liabilities The State of Alaska has determined that all school-based behavioral health services are not covered by commercial insurers and no third party liabilities will exist. 1 1 Medicaid is considered a payor of last resort, meaning that it only covers medical expenses that are not covered by other health insurers. Providers are required to bill all other insurers prior to billing Medicaid. School districts are exempt from this requirement in Alaska because the State has determined that commercial insurers will not cover school-based services. Alaska Medicaid Billing Toolkit for School-based 51 30Jan09

52 Claims Billing Procedures Claims: General Instructions Claim forms are designed for computer processing. When completed, the forms contain information necessary to process claims for services rendered to Medical Assistance recipients. Adhere to the following instructions for claims to be processed efficiently. Accuracy, completeness, and clarity are important. 1. Do not fold or crease claims. 2. Fill in handwritten claims neatly and accurately. 3. Keep names, numbers, codes, etc., within the designated boxes and lines 4. Make corrections carefully. Do not strike or write over errors to correct. Correction fluid or tape may be used as long as the correct information is readable. 5. Include a return address on all claims and mailing envelopes. 6. Send only required attachments. Documentation of Service Delivery After the Medicaid clerk determines which students receiving special education services are Medicaid eligible each month, a list should be sent to the Special Education Program Manager. The manager can then let each practitioner know which students on that provider s caseload are eligible for Medicaid claiming and that the Service Delivery log should be completed. A service delivery log should be completed each week for each student who is Medicaid-eligible during the month. At the end of the week, the logs should be submitted to the Medicaid clerk so that she or he can complete the claim. A copy should be kept in the student s case file. A sample form is included on the next page. Alaska Medicaid Billing Toolkit for School-based 52 30Jan09

53 ALASKA SCHOOL DISTRICT SERVICES DOCUMENTATION LOG Provider s Name School School ID Student ID DOB Grade Student Name Medicaid ID Please complete the table below. If you did not perform a service on that day, leave it blank. Monday Tuesday Wednesday Thursday Friday Date of Service CPT Code IEP AK Standard and Goal Description of Service (use codes below or describe) Length Progress (Y/N) # in Group Explanation of Treatment Session Description of Service Codes: Child Health Encounter OR Child Treatment Encounter SO - Student Observation IT - Individual Therapy PI - Parent Interview (may include home visit) GT - Group Therapy IET - Initial Evaluation and Testing RE - Re-Evaluation Signature Date Alaska Medicaid Billing Toolkit for School-based 53 30Jan09

54 Student Billing Form The Medicaid billing clerk should maintain a Medicaid file for each student that contains all required information and previous documentation (see Recordkeeping.) The form on the following page can be used to provide an overview of the student s history. Alaska Medicaid Billing Toolkit for School-based 54 30Jan09

55 Student Billing Form Student Information Student Name Sex Date of Birth Grade Student ID # Location Student Address: Parent/Guardian Name and Phone Number: Billing File Checklist Parent Authorization on File Date Signed Services Frequency (per week) Duration (min/day) OT PT SP/LA Other Medicaid Number Eligibility Verification Date Verified Month/Year Code Alaska Medicaid Billing Toolkit for School-based 55 30Jan09

56 Health Insurance Claim Form (CMS-1500) Instructions Each number listed below refers to the field on the sample CMS-1500 form (see page 59). Required fields when submitting a paper claim are bolded; additional fields may be necessary for providers billing electronically in a HIPAA-compliant format. Field # Claim Field Identification Explanations and Instructions 1 Medicare/Medicaid/CHAMPUS/etc Select Medicaid 1a Insured s I.D. Number Enter the student s 10-digit Medical Assistance identification number as it appears on the eligibility coupon/label. 2 Patient s Name Enter the following information as it appears on the eligibility coupon: patient s first name, middle initial, and last name in full. 3 Patient s Date of Birth/Sex Optional. If used, enter patient s date of birth in MM/DD/YY format. 4 Insured s Name No entry needed skip 5 Patient s address Optional. If used, enter the following information: patient s full street address, city, state, and ZIP code. 6 Patient s Relationship to Insured Select Self 7 Insured s Address No entry needed skip 8 Patient Status Select the appropriate box 9-9d Other Insured s Name No entry needed skip 10 Is Patient s Condition Related to: No entry needed skip a. Employment b. Auto Accident c. Other Accident 10d Reserved for local use No entry needed skip 11-11c Insured s Policy Group or FECA Number No entry needed skip 11d Is There Another Health Benefit Plan Select No Signature Have the formed signed by the appropriate individuals or indicate if the signature is on file. 14 Date of Current Illness or Injury or Pregnancy Optional skip If Patient Has Had Same or Similar Illness, No entry needed skip Give First Date/Dates Patient Unable to Work in Current Occupation 17 Name of Referring Physical or Other Source Optional skip 17a ID Number of Referring Physician Optional skip 18 Hospitalization Dates Related to Current No entry needed skip Services 19 Reserved for Local Use Not applicable skip 20 Outside Lab? No entry needed skip Alaska Medicaid Billing Toolkit for School-based 56 30Jan09