HCBS Technology Assisted

Transcription

1 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS Technlgy Assisted

2 PART II HCBS TECHNOLOGY ASSISTED PROVIDER MANUAL Sectin BILLING INSTRUCTIONS Page 7000 HCBS Technlgy Assisted Billing Instructins Submissin f Claim HCBS Technlgy Assisted Specific Billing Infrmatin BENEFITS AND LIMITATIONS 8100 Cpayment Benefit Plan Medicaid APPENDIX Prcedure Cdes and Nmenclature FORMS CMS-1500

3 Issued 08/08 INTRODUCTION TO THE HCBS TA PROGRAM The Hme and Cmmunity Based Services (HCBS) Technlgy Assisted (TA) waiver prgram is designed t meet the needs f individuals under 22 years f age wh are chrnically ill, technlgydependent, and medically fragile. These individuals have an illness r disability that requires the level f care prvided in a hspital setting. In the absence f hme care services, they wuld require admissin and prlnged stay in a hspital r medical institutin. Additinally, the individual requires bth a medical device t cmpensate fr the lss f vital bdy functin and substantial, nging care t avert death r further disability. In rder t be eligible fr services, the individual must be Medicaid-eligible and meet the level f care eligibility criteria. The level f care eligibility will be accessed using the Medical Assistive Technlgy Level f Care (MATLOC) assessment instrument by the independent case management entity. The HCBS TA waiver prgram prvides pprtunities fr the fllwing supprts: Hme mdificatin Independent case management Lng-term cmmunity care attendant - Medical service technician (MST) - Persnal service assistance (PSA) Medical respite Specialized medical care - Licensed practical nurse (LPN) - Registered nurse (RN) Residential supprts All HCBS TA waiver services require prir authrizatin thrugh the prgram manager and electrnic plan f care prcess fr reimbursement. The prvider manual is divided int tw parts. Part I f the prvider manual cnsists f five parts: General Intrductin, General Benefits, General Billing, General Special Requirements, and General Third Party Liability (TPL). Part I cntains infrmatin that applies t all prviders, including HCBS TA prviders. This prvider specific sectin f the manual (Part II) is designed t prvide infrmatin and instructins specific t prviders f HCBS TA waiver prgram services. It is divided int fur subsectins: Billing Instructins, Benefits and Limitatins, Appendix, and Frms. The Billing Instructins subsectin prvides instructins n claim submissin. The Benefits and Limitatins subsectin utlines services included fr HCBS TA beneficiaries and limitatins n these services. It als includes qualificatins fr HCBS TA prviders, dcumentatin requirements fr reimbursement and expected service utcmes. The Appendix subsectin cntains infrmatin cncerning prcedure cdes. The appendix was develped t make finding and using prcedure cdes easier fr thse billing. The Frms subsectin includes a sample f the CMS-1500 which must be cmpleted fr reimbursement f services.

4 Issued 08/08 INTRODUCTION TO THE HCBS TA PROGRAM HCBS TA Enrllment Ptential prviders must cmplete a Kansas Medical Assistance Prgram (KMAP) prvider enrllment applicatin and submit their credentials and qualificatins with the applicatin. The fiscal agent reviews the infrmatin and frwards it t the HCBS TA prgram manager. Once the prgram manager determines the prvider meets the qualificatins, the fiscal agent ntifies the applicant f the enrllment determinatin. Once enrlled, the prvider receives a prvider number. Access prvider enrllment infrmatin at Nte: EDS supplies the prvider manual fr the HCBS TA waiver prgram when the prvider enrlls. HIPAA Cmpliance As a participant in KMAP, prviders are required t cmply with cmpliance reviews and cmplaint investigatins cnducted by the Department f Health and Human Services as part f the Health Insurance Prtability and Accuntability Act (HIPAA) in accrdance with sectin 45 f the cde f regulatins parts 160 and 164. Prviders are required t furnish the Department f Health and Human Services all infrmatin required during its review and investigatin. Access t Recrds The prvider is required t supply recrds t the Medicaid Fraud and Abuse Divisin f the Kansas attrney general's ffice upn request frm such ffice as required by the Kansas Medicaid Fraud Cntrl Act, K.S.A and , inclusive, as amended. A prvider wh receives such a request fr access t r inspectin f dcuments and recrds must prmptly and reasnably cmply with access t the recrds and facility at reasnable times and places. A prvider must nt bstruct any audit, review r investigatin, including the relevant questining f emplyees f the prvider. The prvider must nt charge a fee fr retrieving and cpying dcuments and recrds related t cmpliance reviews and cmplaint investigatins.

5 7000. HCBS TA BILLING INSTRUCTIONS Issued 08/08 Intrductin t the CMS-1500 Claim Frm Prviders must use the CMS-1500 claim frm (unless submitting electrnically) when requesting payment fr medical services prvided under KMAP. An example f the CMS-1500 claim frm is shwn at the end f this manual. The interchange Medicaid Management Infrmatin System (MMIS) uses electrnic imaging and ptical character recgnitin (OCR) equipment. Therefre, infrmatin must be submitted in the crrect claim fields t be recgnized by the equipment. EDS des nt furnish the CMS-1500 claim frm t prviders. Refer t Sectin 1100 f the General Intrductin Prvider Manual. Cmplete, line-by-line instructins fr cmpletin f the CMS-1500 are available in the General Billing Prvider Manual. Submissin f Claim Send cmpleted first page f each claim and any necessary attachments t: Kansas Medical Assistance Prgram Office f the Fiscal Agent P.O. Bx 3571 Tpeka, Kansas BILLING INSTRUCTIONS 7-1

6 7010. HCBS TA SPECIFIC BILLING INFORMATION Issued 08/08 Enter the apprpriate prcedure cde in field 24D f the CMS-1500 claim frm. See the Appendix sectin fr an all-inclusive list f HCBS TA waiver prcedure cdes. Time Keeping Claims may be submitted fr the ttal amunt f actual minutes/hurs wrked. Claims ttal may be billed at the end f the billing cycle and runded t the nearest ne-half unit. One unit is equal t 7.5 thrugh 15 minutes; ne-half unit is equal t up t 7 minutes. Prviders are respnsible fr submitting apprpriate claims fr the amunt f services rendered. Client Obligatin The case management entity will need t assign the client bligatin t the service prvider prviding the majrity f the services. The case management entity must infrm the prvider f the client bligatin assignment, and it is the respnsibility f the service prvider t cllect this prtin f the cst f service frm the beneficiary. The prvider des nt reduce the billed amunt n the claim by the client bligatin, because the liability will autmatically be deducted as claims are prcessed. Nte: Client bligatin is assigned nly t HCBS TA services submitted n the MMIS plan f care (POC). Plan f Care Authrizatin The dates f service n the claim must match the dates apprved n the POC and cannt verlap. The electrnic POC services are prir authrized fr ne calendar mnth, beginning n the first and ending n the last day f the mnth. Fr example, services billed fr May 25-June 2 f the same year must have separate detail lines fr each mnth (May and June). Same Day Service Fr certain situatins, HCBS services apprved n a POC and prvided n the same day a beneficiary is institutinalized may be allwed. Situatins are limited t: HCBS services prvided n the date f admissin, if prvided prir t admissin. HCBS services prvided the date f discharge, if prvided fllwing discharge. HCBS targeted case management prvided 14 days prir t discharge. BILLING INSTRUCTIONS 7-2

7 8100. COPAYMENT Issued 08/08 HCBS TA prgram waiver services are exempt frm cpayment requirements. BENEFITS AND LIMITATIONS 8-1

8 8300. BENEFIT PLANS Issued 08/08 A KMAP beneficiary is assigned t ne r mre KMAP benefit plans. These benefit plans entitle the beneficiary t certain services. See Sectin 2000 f the General Benefits Prvider Manual fr cmplete infrmatin n the State f Kansas Medical Card and eligibility verificatin. 8-2

9 8400. MEDICAID Issued 08/08 HCBS TA Waiver Prgram Fr the purpse f this waiver prgram, family is defined as any persn immediately related t the beneficiary f services. Immediately-related family members are parents (including fster r adptive parents), grandparents, spuses, aunts, uncles, sisters, brthers, first cusins and any step-family relatinships. MATLOC and the Individual/Family Needs Assessment Service Delivery Plan are used t evaluate the beneficiary s medical, nursing and family needs in rder t identify the type f supprts needed. The case management entity will wrk with the beneficiary r the parent/legal guardian f the beneficiary t develp an individualized POC that identifies the fllwing: What type f supprts and services are needed Wh will prvide the service(s) Amunt f services t be prvided Cst f services The beneficiary and family can begin receiving services upn apprval f the POC. In rder t maintain eligibility, the beneficiary must cntinue t meet bth financial and level f care eligibility criteria. Reassessments are cnducted every six mnths t determine cntinued eligibility. Nte: See Cmmunity Supprts and Services (CSS) HCBS TA Waiver Plicy and Prcedure Manual fr additinal infrmatin. All HCBS TA waiver prgram services require prir authrizatin thrugh the POC prcess. Other than independent case management, services furnished t a beneficiary wh is institutinalized are nt reimbursable. 8-3

10 8400. MEDICAID Issued 08/08 Independent Case Management Prcedure cde T1016 Independent case management is required fr the HCBS TA prgram waiver. Prviders f this service assist beneficiaries in gaining access t necessary waiver and ther state plan services, as well as necessary medical, scial, educatinal and ther services, regardless f the funding surce. The qualified case management prvider: Serves as the pint f access fr waiver services Cnducts preliminary screening t determine if referral is apprpriate Administers initial assessment t determine functinal eligibility and reassessments t determine cntinued eligibility Identifies required service needs, including lcating and crdinating services Develps a POC annually with clearly defined gals based n the beneficiary s level f needs Mnitrs the prvisin f services Prvides technical assistance t families and service prviders t carry ut prgram peratins Ensures beneficiary s POC is cst-effective and meets his r her medical needs as well as basic health and safety needs Ensures beneficiary s freedm cncerning prgram waiver chices, services and prviders The POC dcumentatin must include mnitring and fllw-up activities at a minimum f every six mnths with dcumentatin f prgress tward stated gals. Dcumentatin must als include whether gals are met. If a gal is nt met, the case management prvider must explain the reasn it is unattainable, reevaluate, and prpse a different apprach. The reevaluatin prcess must include the input f the beneficiary, family members, prviders, and any ther applicable entities. This shuld ccur as frequently as necessary, at a minimum f every six mnths, t determine whether: Services are being furnished in accrdance with the beneficiary s POC. Services are adequate t maintain an apprpriate level f care. Service authrizatins are adequate t supprt the delivery f needed services. Changes in the medical needs f the beneficiary r family members necessitate changes in crdinatin f services. Obstacles are impeding r limiting the delivery f services, requiring apprpriate actins t eliminate them. Dcumentatin Requirements Dcumentatin must encmpass infrmatin prvided in the level f care instrument and the Individual/Family Needs Assessment that was used t develp the beneficiary s POC. Dcumentatin must include infrmatin abut the access, apprpriateness, and crdinatin f supprts and services. Surces f infrmatin can include cntacts with the beneficiary, family members, legal representatives, service prviders and ther interested parties. Dcumentatin must prvide the necessary detail t meet federal and state requirements. Dcumentatin must be legible, accurate and timely. 8-4

11 8400. MEDICAID Issued 08/08 Nte: Beneficiary s files may be used fr supervisry reviews, hme care review audits, quality assurance reviews and issues related t client bligatins. Dcumentatin, at a minimum, must include the fllwing: Initial assessment and reassessment Assessments dated and signed by the case manager, parent/legal guardian, and physician r medical prvider Ntice f Actins Services being used and prvided Service prvider s name and signature Lcatin f service prvided Beneficiary s full name, identificatin number and demgraphic infrmatin Date f service (beginning and ending with MM/DD/YY) Signature f parent r legal guardian with the authrity t prvide cnsent t receive services Start and stp time fr each visit, including AM/PM r using 2400 clck hurs Time spent must be clearly dcumented in the ntes. Prviders are respnsible t ensure that the service was prvided prir t submitting claims. Dcumentatin must be clearly written and self-explanatry, r services billed may nt be reimbursed. Dcumentatin must be created during the time perid f the billing cycle. Dcumentatin generated after this time is nt acceptable. Limitatins Prviders f this service may nt prvide ther direct services t individuals fr whm they prvide case management. Case management des nt include the direct delivery f an underlying medical, educatinal, scial r ther service t which a beneficiary has been referred. This service may be prvided up t 14 days prir t a beneficiary s discharge frm an acute care hspital/institutin in rder t cnduct care crdinatin activities fr the beneficiary returning hme r entering a cmmunity-based setting. The case manager must assist the beneficiary in activities necessary fr the beneficiary t mve frm an institutinal setting t a cmmunity-based setting. Case management is allwed 10 hurs per mnth with the maximum allwable f 480 units per calendar year per beneficiary. One unit is equal t 15 minutes. Requests t exceed the mnthly and annual limit may be submitted fr prir authrizatin by the State f Kansas Department f Scial and Rehabilitatin Services (SRS), Disability and Behaviral Health Services (DBHS), Cmmunity Supprts and Services (CSS). The request t exceed the case management limit must meet the established criteria. The cst f transprtatin t cnduct an initial and reassessment t and frm the beneficiary s place f residence and ther service sites r places in the cmmunity is included in the reimbursement rate paid t prviders f this service. Other than independent case management, services furnished t a beneficiary wh is institutinalized are nt reimbursable. 8-5

12 8400. MEDICAID Issued 08/08 The majrity f cntacts must ccur in custmary and usual cmmunity lcatins where the beneficiary lives, attends schl and/r childcare, and scializes. Services prvided in a hme schl setting must nt be educatinal in purpse. Reimbursement Payment fr case management services may nt duplicate payments made t public agencies r private entities under ther prgram authrities fr this same purpse. Prvider Requirements Be a KMAP-enrlled prvider fr HCBS TA waiver prgram services in rder t prvide and bill fr case management services Be an advanced registered nurse practitiner (ARNP) r registered nurse (RN) with a bachelr s degree and tw years f experience in the nursing field Participate in the TA prgram waiver and MATLOC assessment training t becme familiar with the plicies, prcedures, rules, regulatins and services available Nte: Upn cmpletin f training, a certificate f cmpletin will be issued t certify the case management entity has cmpleted the training. Maintain all standards, certificatins and licenses required fr the specific prfessinal field thrugh which service is prvided including, but nt limited t: Prfessinal license/certificatin Adherence t DBHS/CSS training and prfessinal develpment requirements Maintenance f clear backgrund as evidenced thrugh the Kansas Bureau f Investigatin (KBI), Adult Prtective Services (APS), Child Prtective Services (CPS), Kansas State Bard f Nursing (KSBN), and Department f Mtr Vehicles (DMV) Nte: Applicant must meet prvider requirements and receive apprval by SRS t prvide HCBS TA waiver prgram case management services. 8-6

13 8400. MEDICAID Updated 11/08 Specialized Medical Care Prcedure cdes: T1000 Licensed Practical Nurse (LPN) T1000 TD Registered Nurse (RN) This service prvides lng-term nursing supprt fr medically-fragile and technlgy-dependent beneficiaries. The required level f care must prvide medical supprt fr beneficiaries needing nging, daily care as in a hspital. The intensive medical needs f the beneficiary must be met t ensure that he r she can chse t live utside f a hspital r institutinal setting. Fr the purpse f this waiver, a prvider f specialized medical care must be an RN r LPN under the supervisin f an RN. Prviders must be trained t deliver skilled nursing services as identified in the POC and within the scpe f the State s Nurse Practice Act. Prviders f this service must be trained with the medical skills necessary t care fr and meet the medical needs f beneficiaries. The service may be prvided in all custmary and usual cmmunity lcatins including where the beneficiary resides and scializes. It is the respnsibility f the prvider agency t ensure that qualified nurses are emplyed and able t meet the specific medical needs f the beneficiaries. Specialized medical care des nt duplicate any ther Medicaid state plan service r ther services available t the beneficiary at n cst. The medical necessity f this service is subject t the nursing acuity assessment as identified in the MATLOC instrument and the Individual/Family Needs Assessment used in the develpment f the beneficiary s POC. Prviders f this service will be reimbursed fr medically apprpriate and necessary services relative t the level f need as identified in the POC. Dcumentatin Requirements Dcumentatin must encmpass infrmatin prvided in the MATLOC instrument and the Individual/Family Needs Assessment that was used t develp the beneficiary s POC. Dcumentatin must include infrmatin abut the access, apprpriateness, and crdinatin f supprts and services. Surces f infrmatin can include cntacts with the beneficiary, family members, legal representatives, service prviders and ther interested parties. Dcumentatin must prvide the necessary detail t meet federal and state requirements. Dcumentatin must be legible, accurate and timely. Nte: Beneficiary s files may be used fr supervisry reviews, hme care review audits, quality assurance reviews and issues related t client bligatins. Dcumentatin, at a minimum, must include the fllwing: Initial assessment and reassessment relative t the nursing POC Authrizatin f medically necessary waiver services signed by physician r medical prvider Changes in the beneficiary s medical status r care Services being used and prvided Service prvider s name and signature Lcatin f service prvided 8-7

14 8400. MEDICAID Issued 08/08 Beneficiary s full name, identificatin number and demgraphic infrmatin Date f service (beginning and ending with MM/DD/YY) Signature f parent r legal guardian with the authrity t prvide cnsent t receive services Start and stp times, including AM/PM r using 2400 clck hurs Time spent must be clearly dcumented in the ntes. Prviders are respnsible t ensure that the service was prvided prir t submitting claims. Dcumentatin must be clearly written and self-explanatry, r services billed may nt be reimbursed. Dcumentatin must be created during the time perid f the billing cycle. Dcumentatin generated after this time is nt acceptable. Limitatins Prviders f this service may nt prvide ther direct services t beneficiaries fr whm they prvide specialized medical care. Specialized medical care prvided by an entity under the Prfessinal Services Under Defined Cnditins (PSUDC) agreement cannt prvide medical respite care. Prviders f specialized medical care are limited t skilled nursing staff (RN r LPN) licensed t practice in Kansas under the emplyment and direct supervisin f a hme health agency (HHA) licensed by the Kansas Department f Health and Envirnment (KDHE). Specialized medical care is limited t 252 hurs r 1008 units per mnth per beneficiary. One unit is equal t 15 minutes. Requests t exceed the mnthly and annual limit may be submitted t the HCBS TA prgram manager at CSS fr prir authrizatin. The request t exceed the service limits must be medically necessary and meet the established criteria. The cst f transprtatin t and frm the beneficiary s place f residence and ther service sites r places in the cmmunity is included in the reimbursement rate paid t prviders f this service. The majrity f cntacts must ccur in custmary and usual cmmunity lcatins where the beneficiary lives, attends schl and/r childcare, and scializes. Services prvided in a hme schl setting must nt be educatinal in purpse. Services furnished t a beneficiary wh is an inpatient r resident f a hspital, nursing facility, ICF/MR, r IMD are nt reimbursable. This service may begin upn apprval f HCBS TA waiver prgram and services. The case management entity will crdinate and cmmunicate the effective date f service. Reimbursement Payment fr specialized medical care may nt duplicate payments made t public agencies r private entities under ther prgram authrities fr this same purpse. Specialized medical care, prcedure cde T1000, cannt be billed r reimbursed cncurrently n the same day with medical respite care, prcedure cde T

15 8400. MEDICAID Issued 08/08 Prvider Requirements Be an emplyee f a KMAP-enrlled prvider authrized t prvide services under the HCBS TA waiver prgram Be an RN r LPN Hld a current license granted by KSBN t practice in the capacity f a nurse in Kansas Must maintain all standards, certificatins and licenses required fr the specific prfessinal field thrugh which service is prvided including, but nt limited t: Prfessinal license/certificatin Adherence t DBHS/CSS training and prfessinal develpment requirements Maintenance f clear backgrund as evidenced thrugh KBI, APS, CPS, KSBN, and DMV Must meet the licensing standards as regulated by KDHE as specified in K.S.A thrugh K.S.A Nte: Applicant must meet prvider requirements and receive apprval by SRS t prvide HCBS TA waiver prgram specialized medical care. 8-9

16 8400. MEDICAID Issued 08/08 Lng-Term Cmmunity Care Attendant Prcedure cdes: T1004 Medical service technician agency-directed T1019 Persnal service attendant self-directed Attendant services are available t beneficiaries wh chse t remain in their hme while living with their medical limitatins. These services prvide necessary assistance fr beneficiaries bth in their hme and cmmunity. Care attendants ensure the health and welfare f the beneficiary while supprting him r her with tasks nrmally dne by a parent, legal guardian r caretaker. They assist the beneficiary in perfrming these tasks t prmte independence, prductivity, and integratin. The functins f an attendant include but are nt limited t assisting with: Activities f daily living (ADLs) Bathing Grming Tileting Transferring Health maintenance activities Extensin f therapies Feeding Mbility and exercises Scializatin Recreatin activities Nte: The attendant supprts the beneficiary in accessing medical services and nrmal daily activities by accmpanying r prviding transprtatin t accmplish tasks as listed within the scpe f service. Agency-directed attendant services will be crdinated by the independent case manager and submitted in the electrnic POC fr prir authrizatin and apprval. Self-directed attendant services will be arranged fr, and purchased under, the beneficiary s r legally respnsible party s written authrity. They will be paid thrugh an enrlled fiscal agent cnsistent with and nt t exceed the beneficiary s POC. Beneficiaries are permitted t chse qualified prvider(s) wh have passed the required backgrund checks. The beneficiary r legally respnsible individual with the authrity t direct services can at any pint determine t n lnger self-direct and can instead receive previusly apprved waiver services, withut penalty. Dcumentatin Requirements Dcumentatin must encmpass infrmatin prvided in the MATLOC instrument and the Individual/Family Needs Assessment that was used t develp the beneficiary s POC. 8-10

17 8400. MEDICAID Issued 08/08 Dcumentatin must include infrmatin abut the access, apprpriateness, and crdinatin f supprts and services. Surces f infrmatin can include cntacts with the beneficiary, family members, legal representatives, service prviders and ther interested parties. Dcumentatin must prvide the necessary detail t meet federal and state requirements. Dcumentatin must be legible, accurate and timely. Nte: Beneficiary s files may be used fr supervisry reviews, hme care review audits, quality assurance reviews and issues related t client bligatins. Dcumentatin, at a minimum, must include the fllwing: Initial assessment and reassessment relative t the nursing POC Authrizatin f medically necessary waiver services signed by physician r medical prvider Changes in the beneficiary s medical status r care Services being used and prvided Service prvider s name and signature Lcatin f service prvided Beneficiary s full name, identificatin number and demgraphic infrmatin Date f service (beginning and ending with MM/DD/YY) Signature f parent r legal guardian with the authrity t prvide cnsent t receive services Start and stp times fr each visit, including AM/PM r using 2400 clck hurs Time spent must be clearly dcumented in the ntes. Prviders are respnsible t ensure that the service was prvided prir t submitting claims. Dcumentatin must be clearly written and self-explanatry, r services billed may nt be reimbursed. Dcumentatin must be created during the time perid f the billing cycle. Dcumentatin generated after this time is nt acceptable. Limitatins An attendant may nt perfrm any duties nt delegated by the individual with the authrity t direct services r duties as apprved by the beneficiary s physician. A service r duty must be identified as a necessary task in the POC. The parent r legal guardian f the minr beneficiary may nt be his r her attendant. Attendant care is limited t 372 hurs r 1488 units per mnth per beneficiary. One unit is equal t 15 minutes. It is the expectatin that beneficiaries needing assistance with ADL tasks wh live with a parent r guardian capable f perfrming these tasks will rely n this infrmal, natural supprt fr this assistance. Otherwise, there must be extenuating r specific circumstances dcumented in the POC. As such, attendants shuld nt assist with the fllwing: Lawn care Snw remval Shpping Ordinary husekeeping (which shuld be dne alng with the husehld respnsibilities f thse living with the beneficiary) 8-11

18 8400. MEDICAID Issued 08/08 Meal preparatin (during the times when nrmal meal preparatin ccurs in the husehld) The majrity f cntacts must ccur in custmary and usual cmmunity lcatins where the beneficiary lives, attends schl and/r childcare, and scializes. Services prvided in a hme schl setting must nt be educatinal in purpse. Services furnished t a beneficiary wh is an inpatient r resident f a hspital, nursing facility, ICF/MR, r IMD are nt reimbursable. The cst f transprtatin t and frm the beneficiary s place f residence and ther service sites r places in the cmmunity is included in the reimbursement rate paid t prviders f these services. Reimbursement Payment fr lng-term cmmunity care attendant may nt duplicate payments made t public agencies r private entities under ther prgram authrities fr this same purpse. Prvider Requirements Prviders must maintain all standards, certificatins and licenses required fr the specific prfessinal field thrugh which service is prvided including, but nt limited t: Prfessinal license/certificatin Adherence t DBHS/CSS training and prfessinal develpment requirements Maintenance f clear backgrund as evidenced thrugh KBI, APS, CPS, KSBN, and DMV Medical Service Technician (MST) Agency-directed Have a high schl diplma r equivalent Be 18 years f age r lder Meet the agency s qualificatins Reside utside f the beneficiary s hme Cmplete training and pass certificatin as regulated under K.A.R r by the State f Kansas licensing agency Be emplyed by and under the direct supervisin f a HHA licensed by KDHE, enrlled as a KMAP prvider authrized t prvide services under the HCBS TA waiver prgram Meet the skill training dcumentatin required by SRS Persnal Service Attendant (PSA) Self-directed Have a high schl diplma r equivalent Be 18 years f age r lder Meet the family s qualificatins Reside utside f the beneficiary s hme Cmplete the necessary skill training needed in rder t care fr the beneficiary as recmmended by the parent r legal representative and qualified medical prvider Be a KMAP-enrlled prvider authrized t prvide HCBS TA waiver prgram services Meet the skill training dcumentatin required by SRS 8-12

19 8400. MEDICAID Updated 11/08 Payrll Agent Requirements KMAP prviders wh chse t prvide payrll agent services t self-directed beneficiaries must cmply with the fllwing: Have a federal emplyment identificatin number and receive KMAP payments under this number Withhld and depsit all applicable taxes fr each attendant wrking with a self-directed beneficiary, including federal, state and FICA withhlding Prvide unemplyment insurance fr each attendant wrking with a self-directed beneficiary Prvide wrker s cmpensatin insurance in accrdance with K.S.A Nte: This cverage can be prvided as a benefit, if nt required by law. Issue an annual W-2 t each attendant wrking with a self-directed beneficiary Maintain recrds in accrdance with all federal and state requirements Cmplete backgrund checks n the self-directed attendants wrking with the beneficiary Prvide t each self-directed beneficiary, in writing, a descriptin f the services that will be prvided t the attendant, including any benefits the attendant will receive All payments fr persnal service attendant (self-directed) care will be arranged by a payrll agent with the beneficiary s r parent/legal guardian s written authrizatin f the purchase. The beneficiary will have cmplete access t chse any qualified prvider (agency r individual). The prvider must meet the qualificatin as specified under the TA waiver prvider requirement. Each individual qualified prvider will nt be given a separate prvider agreement but may chse t cntract with any qualified prvider agency r thrugh a payrll agency. Prviders f these services must meet all standards, certificatins and licenses that are required fr the specific field thrugh which service is prvided including but nt limited t: Prfessinal license/certificatin Adherence t DBHS/CSS training and prfessinal develpment requirements Maintenance f clear backgrund as evidenced thrugh KBI, APS, CPS, KSBN and DMV 8-13

20 8400. MEDICAID Updated 11/08 Medical Respite Prcedure cde: T1005 Medical respite is a temprary service prvided n an intermittent basis t prvide the beneficiary s family shrt, specified perids f relief. Medical respite must be prvided in the beneficiary s place f residence. It serves the family by: Meeting nnemergency r emergency family needs Restring r maintaining the physical and mental well-being f the beneficiary and/r his r her family Prviding supervisin, cmpaninship and persnal care t the beneficiary Dcumentatin Requirements Dcumentatin must encmpass infrmatin prvided in the MATLOC instrument and the Individual/Family Needs Assessment that was used t develp the beneficiary s POC. Dcumentatin must include infrmatin abut the access, apprpriateness, and crdinatin f supprts and services. Surces f infrmatin can include cntacts with the beneficiary, family members, legal representatives, service prviders and ther interested parties. Dcumentatin must prvide the necessary detail t meet federal and state requirements. Dcumentatin must be legible, accurate and timely. Nte: Beneficiary s files may be used fr supervisry reviews, hme care review audits, quality assurance reviews and issues related t client bligatins. Dcumentatin, at a minimum, must include the fllwing: Initial assessment and reassessment relative t the nursing POC Authrizatin f medically necessary waiver services signed by physician r medical prvider Changes in the beneficiary s medical status r care Services being used and prvided Service prvider s name and signature Lcatin f service prvided Beneficiary s full name, identificatin number and demgraphic infrmatin Date f service (beginning and ending with MM/DD/YY) Signature f parent r legal guardian with the authrity t prvide cnsent t receive services Start and stp times fr each visit, including AM/PM r using 2400 clck hurs Time spent must be clearly dcumented in the ntes. Prviders are respnsible t ensure that the service was prvided prir t submitting claims. Dcumentatin must be clearly written and self-explanatry, r services billed may nt be reimbursed. Dcumentatin must be created during the time perid f the billing cycle. Dcumentatin generated after this time is nt acceptable. 8-14

21 8400. MEDICAID Updated 11/08 Limitatins 1. Prviders f medical respite are limited t skilled nursing staff (RN r LPN) licensed t practice in Kansas under the emplyment and direct supervisin f a HHA licensed by KDHE. 2. Medical respite is limited t 168 hurs r 672 units per calendar year. 3. The cst f transprtatin t and frm the beneficiary s place f residence and ther service sites r places in the cmmunity is included in the reimbursement rate paid t the prviders f this service. 4. The majrity f cntacts must ccur in custmary and usual cmmunity lcatins where the beneficiary lives, attends schl and/r childcare, and scializes. Services prvided in a hme schl setting must nt be educatinal in purpse. 5. Services furnished t a beneficiary wh is an inpatient r resident f a hspital, nursing facility, ICF/MR, r IMD are nt cvered. Reimbursement Payment fr medical respite may nt duplicate payments made t public agencies r private entities under ther prgram authrities fr this same purpse. Medical respite, prcedure cde T1005, cannt be billed r reimbursed cncurrently n the same day with specialized medical care service, prcedure T1000 r T1000(TD). Medical respites services prvided by an entity under the PSUDC agreement are nt reimbursable. Prvider Requirements Be an emplyee f a KMAP-enrlled prvider authrized t prvide services under the HCBS TA waiver prgram Be an RN r LPN Hld a current license granted by KSBN t practice in the capacity f a nurse in Kansas Maintain all standards, certificatins and licenses required fr the specific prfessinal field thrugh which service is prvided including, but nt limited t: Prfessinal license/certificatin Adherence t DBHS/CSS training and prfessinal develpment requirements Maintenance f clear backgrund as evidenced thrugh KBI, APS, CPS, KSBN and DMV Meet the licensing standards as regulated by KDHE as specified in K.S.A thrugh K.S.A

22 8400. MEDICAID Updated 11/08 Hme Mdificatin Prcedure cde: S5165 Fr the purpse f the HCBS TA waiver prgram, hme mdificatin services are defined as mdificatins r adaptatins t the beneficiary's hme thrugh tangible equipment r hardware, such as adaptive equipment r envirnmental mdificatins. The need fr a hme mdificatin must be identified as necessary t assist the beneficiary in day-t-day functins as indicated in the individualized POC. The gal is t supprt beneficiaries in maintaining their independence, mbility and prductivity in the cmmunity. Dcumentatin Requirements Dcumentatin must be cmpleted at the time the service is prvided and encmpass infrmatin prvided in the MATLOC instrument and the Individual/Family Needs Assessment that was used t develp the beneficiary s POC. Dcumentatin must include infrmatin abut the access, apprpriateness, and crdinatin f supprts and services. Surces f infrmatin can include cntacts with the beneficiary, family members, legal representatives, service prviders and ther interested parties. Dcumentatin must prvide the necessary detail t meet federal and state requirements. Dcumentatin must be legible, accurate and timely. Nte: Beneficiary s files may be used fr supervisry reviews, hme care review audits, quality assurance reviews and issues related t client bligatins. Dcumentatin, at a minimum, must include the fllwing: Name f business r cntractr Beneficiary s full name Signature f parent, legal guardian r designated signatry Identificatin f the technlgy r service being prvided Date f service (beginning and ending with MM/DD/YY) Amunt f purchase Statement f inspectin by prvider t ensure that the prduct was purchased and/r installed as authrized Time spent must be clearly dcumented in the ntes. Prviders are respnsible t ensure that the service was prvided prir t submitting claims. Dcumentatin must be clearly written and self-explanatry, r services billed may nt be reimbursed. Dcumentatin must be created during the time perid f the billing cycle. Dcumentatin generated after this time is nt acceptable. Cvered Services Purchase r rental f new r used beneficiary transfer lift Purchase f r installatin f ramp nt cvered by any ther resurces Widening f drways 8-16

23 8400. MEDICAID Updated 11/08 Mdificatins t bathrm facilities wned by the beneficiary, parent r legally respnsible party where the beneficiary resides Mdificatins related t the apprved installatin f mdified ramps, drways r bathrm facilities Limitatins Services must be prvided within specified lcal and state building cdes. Mdificatins are made within the existing structures and must nt result in additin f square ftage t the existing structure. Hme mdificatin services are reimbursed at ne unit equal t ne purchase, limited t a lifetime maximum f $7,500. All services prvided must meet the lcal city and state building cdes. The prperty must be wned by the beneficiary r his r her parent/legal guardian and ccupied by the beneficiary. Hme mdificatin needs are assessed by the independent case manager, using the MATLOC instrument. The independent case manager and the beneficiary r parent/legal guardian must btain and submit t SRS tw bids fr the equipment r mdificatin accrding t plicy guidelines. The cst f transprtatin t and frm the beneficiary s place f residence and ther service sites r places in the cmmunity is included in the reimbursement rate paid t the prviders f this service. The majrity f cntacts must ccur in custmary and usual cmmunity lcatins where the beneficiary lives, attends schl and/r childcare, and scializes. Services prvided in a hme schl setting must nt be educatinal in purpse. Services furnished t a beneficiary wh is an inpatient r resident f a hspital, nursing facility, ICF/MR, r IMD are nt cvered. Reimbursement T avid any verlap f services, hme mdificatin is limited t thse services nt cvered thrugh the regular state plan. Prvider Requirements Prvider must be a licensed cntractr/dme prvider eligible t prvide hme mdificatin r adaptatin services. Services will be arranged by the independent case manager and reimbursed thrugh Medicaid with the written authrizatin f the beneficiary r parent/legal guardian fr the purchase. The beneficiary has the pprtunity t chse any qualified prvider (agency r individual). In rder t prvide services, the individual qualified prvider can cntract directly with Medicaid r chse t cntract with any qualified prvider agency. Prviders must maintain all standards, certificatins and licenses required fr the specific prfessinal field thrugh which service is prvided including, but nt limited t: Prfessinal license/certificatin Adherence t DBHS/CSS training and prfessinal develpment requirement 8-17

24 8400. MEDICAID Updated 11/08 Maintenance f clear backgrund as evidenced thrugh KBI, APS, CPS, KSBN and DMV Nte: An exceptin f certificatin r licensure requirement can be granted with a letter frm the city r cunty f the beneficiary s residence declaring certificatin r licensure is nt required. 8-18

25 APPENDIX Updated 11/08 Prcedure Cdes and Nmenclature The fllwing prcedure cdes represent an all-inclusive list f HCBS TA waiver prgram services billable t KMAP fr HCBS TA beneficiaries. Prcedures nt listed here are nt reimbursable. PROCEDURE CODE T1016 T1000 T1000 TD T1004 T1019 T1005 S5165 NOMENCLATURE INDEPENDENT CASE MANAGEMENT Case management, each 15 minutes SPECIALIZED MEDICAL CARE LPN Private duty/independent LPN nursing services, licensed, up t 15 minutes SPECIALIZED MEDICAL CARE RN Private duty/independent RN nursing services, licensed, up t 15 minutes LONG-TERM COMMUNITY CARE ATTENDANT MEDICAL SERVICE TECNICIAN (AGENCY-DIRECTED) Services f a qualified nursing aide, up t 15 minutes LONG-TERM COMMUNITY CARE ATTENDANT PERSONAL SERVICE ATTENDANT (SELF-DIRECTED) Persnal care services, nt fr an inpatient r resident f a hspital, nursing facility, ICF/MR r IMD, part f the individualized plan f treatment, per 15 minutes MEDICAL RESPITE SERVICES RN/LPN Respite care services, up t 15 minutes HOME MODIFICATION Hme mdificatins, per service APPENDIX I A-1

26 FORMS CMS-1500

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