All About Billing Training

Transcription

1 1 NYS OPWDD All About Billing Training 2015 Training Goals Overview of Payment Structure Medicaid Billing Highlight Changes Liability Regulations Non-Medicaid Billing / Web Applications Resources to Assist Agencies Links / Rate Code Listing / Correspondence All About Billing! Billing Fee-for-Service Services Fee-for-Service services are those services that are reimbursed for each unit of service delivered Fee-for-Service services include all services billed through a price, rate or fee 1

2 Three Components of Eligibility Required for Billing The provider must be eligible to deliver the service The person must be eligible to receive the service The service to the person must be authorized by the DDSO / Regional Office Provider Eligibility Authorization by the DDSO/Regional Office OPWDD Central Office Review DOH Final Approval Billing Identifiers Services billed through emedny = provider ID and locator codes from DOH Services billed through OPWDD s Payment Processing Unit = Agency s NYS Vendor Identification Number Services billed through OPWDD s Web Based Applications = Agency s program code OPTS Sunset January 2015 for last contracts more to come on this! 2

3 Getting a Provider ID for Billing emedny For a new Medicaid service, the provider must complete & submit promptly a provider enrollment application to Computer Sciences Corporation (CSC) OPWDD will initially send the application to your agency with specific, required information unique to OPWDD (i.e., License Number) DOH sends provider a provider ID & rate code 2015 Application Fee - $553 Individual s Eligibility Medicaid Service Medicaid Client Identification Number (CIN) Non-Medicaid Fee-for-Service Services TABS ID Service Eligibility (Authorization to Provide a Service to a Particular Individual) Authorization by the DDSO/Regional Office It is essential that an agency receive authorization before providing services an agency is not entitled to payment if it provides services without authorization Service identifiers for billing = rate codes 3

4 2/19/ Bureau of Mental Hygiene Services Rate Setting Bureau of Rate Setting transitioned from OPWDD to DOH Continued responsibility for loading OPWDD rates/fees with a few exceptions (i.e. some Self-Direction rates/fees loaded by OPWDD Rate Setting) Certain initial, provider specific rates are transmitted to agencies, but most rates/fees are listed on the DOH website Office of Pool Administration (OPA) Allows for an account to be established to view agency specific rates and rate related information copy of correspondence included with training materials Contact [email protected] 2/19/ What s Needed for Billing? Once the 3 eligibility components (provider, individual, and service) are in place, the agency will be provided with the tools to bill Provider ID, service ID & individual ID To bill emedny provider ID, locator code, rate code, & Medicaid Client Identification Number (CIN) are needed To bill OPWDD NYS Vendor Identification Number, provider ID/price ID, rate code & TABS ID are needed 4

5 Critical documents & getting them to the right people DDSO/Regional Office Price Correspondence DOH Mental Hygiene Rate Setting, emedny or Computer Science Corporation (CSC) Correspondence Medicaid Remittance Statement The Remittance Statement identifies each claim submitted by your agency s billing department & specifies: If a claim was paid How much was paid The reason a claim was not paid Using the Medicaid Remittance Statement Monitoring Medicaid Revenue Early Identification of Medicaid Billing Problems 5

6 Monitoring Remittance Statements Nonprofit providers must retain remittance statements these are the official records detailing your Medicaid payments Staff must monitor to see which claims were paid, denied, or pended. They must correct problems promptly if claims were denied or pended. Remittance statements should be used to monitor actual revenue against projected revenue Early Identification of Medicaid Billing Problems: Common Error Codes Edit 0162: recipient ineligible on date of service Edit 1319: recipient exception code invalid for HCBS Waiver Early Identification of Medicaid Billing Problems: More Common Error Codes Edit 1338: recipient not on restricted recipient file Edit 1339: recipient not authorized for MSC & IRA/CR on date of service Edit 1340 claim provider not equal restriction recipient file provider 6

7 Early Identification of Medicaid Billing Problems: Additional edit information on the emedny website: emednyhipaasupport Link / Crosswalks Link Provides a tool that providers can utilize to crosswalk edit information 2/19/ New Requirement emedny Payments and Remittance Statements DOH announced that they will be phasing in the requirement for Electronic Fund Transfers (EFT) and Electronic Remittance Advice (ERA) or PDF Remittances Most providers are already enrolled, but if you are not, enrollment will be required when your yearly certification is due emedny will inform you of this 7

8 emedny 5010 DOH implemented changes to the HIPAA transaction standards (4010) implementation date was 6/30/12 This resulted in enhancements to claim submissions, remittance advice reports and eligibility verifications Software vendors were contacted by DOH epaces users were contacted regarding changes/updates and training was provided entation.pdf Questions regarding 5010 implementation can be directed to emedny Implementation enacted upfront billing edits for certain claim submission errors these instances are not reflected on the Remittance Statement Common Examples include Invalid Client IDs, Invalid Diagnosis Codes, Invalid Revenue Codes and ETIN not certified To view these errors, providers must view the 277CA response file that list the status of all claims submitted The NYS Medicaid Pre-Adjudication Crosswalk can be utilized to identify claims hitting up front billing edits - / emednyhipaasupport Link / Crosswalks Link / NYS Medicaid Pre-Adjudication Crosswalk for Health Care Claims 2/19/

9 Timely Claim Submissions DOH has initiated enforcement edits of the 90 day claim submission requirement Certain 90 day delay reason codes will edit against information on file with emedny (i.e., individual eligibility information, provider retro enrollment) Bill as soon as possible! 2/19/ Delay Reason Codes The list of available delay reason codes is available on the emedny website AllProviders/index.aspx#mcparty At this link see General Billing section 2/19/ Delay Reason Codes OPWDD cannot advise agencies about use of delay reason codes this is DOH Policy In general terms, eligibility delay (8) can be used when: 1) An individual has their Medicaid coverage retroactively reinstated, that prevented a provider from billing timely 2) An individual has a Restriction/Exception code retroactively updated to allow services to be billed (e.g., HCBS Waiver enrollment and the input of R/E code 46 was backdated) 9

10 2/19/ Delay Reason Codes In general terms, authorization delay (3) can be used when: 1) A provider was authorized to deliver services, but authorization was not recognized timely by emedny (e.g., provider enrollment in Medicaid) 2) A provider has not been able to bill because of a delay with loading of INITIAL RATES Providers are responsible for substantiating use of delay codes on claim submission be sure you can substantiate use if you are audited as this responsibility is with the provider 2/19/ /19/

11 2/19/ Tips for Billing emedny Ensure program staff quickly report services to billing office! Bill as quickly as possible to increase and stabilize cash flow! Be knowledgeable of Medicaid billing rules New emedny edits are in place that validate use of 90 day delay reason codes - Claims submitted with delay reason codes that cannot be substantiated will deny! Review details of all remittance statements! Follow-up immediately on DENIED claims Address these claims ASAP There are time limits! More Tips for Billing emedny Consider ELECTRONIC BILLING it is faster than paper billing! Retain a copy of ALL letters received from the Department of Health (DOH)! Route copies of DOH letters to staff in your organization who do your billing! Promptly respond to all annual certification statements for billing (electronic and paper) from DOH! When you obtain a new Provider ID, register it under your ETIN (Electronic Transmitter Identification Number)! 11

12 Changes Worth Noting OPTS Phase Out OPRA Order/Prescribe/Refer/Attend MSC Future Date Rate Rationalization ICD-10 Community Habilitation for Individuals residing in Certified Settings (IRA/CR/Family Care) Self-Direction ICF / Day Services OPTS Phase Out Initiated in August of 2012 All contracts with HCBS Waiver services ended as of January 30, 2015 Providers now billing emedny directly for services previously provided under OPTS to HCBS Waiver enrolled individuals Web service recording calendars available for initial service recording and post-processing increases for the January 2015 service month until the day prior to the first final payment run in March 2015 March 11, 2015 is the last day OPTS providers can continue to void services and/or downwardly adjust claims via the web application for 17 months from the service month. OPRA Order/Prescribe/Refer/Attend New Requirements from the Affordable Care Act mandate that services billed to Medicaid identify the practitioner who ordered/referred the service requirement went into effect on 1/1/14 Most OPWDD services are exempt from this requirement However, in order to appropriately bypass the requirement, your provider ID used for billing must be included in another component of the claim submission 12

13 OPRA Order/Prescribe/Refer/Attend When submitting the 837 Institutional (837I) claim submission to Medicaid, the provider ID used to bill for services will need to be input in the following loop/segment of your claim submission: Loop 2310F / Segment REF02 2/19/ OPRA Order/Prescribe/Refer/Attend Services that are not exempt from this requirement include: Article 16 clinic services Intensive Behavioral (IB) Services For IB Services, provision of service must be directly provided by, or supervised by a Licensed Clinical Social Worker (LCSW) or a Licensed Psychologist these staff have to enroll in Medicaid as an OPRA provider Information about these requirements is included in the IB Services ADM # Medicaid Service Coordination OPWDD expects changes to the Medicaid Service Coordination (MSC) program in 2015, including an end to the Sole Provider Sponsorship This will require MSC providers to revalidate their MSC provider IDs with the Federal Employer Taxpayer Identification (FEIN) associated with their agency currently, MSC enrollments are under the FEIN of New York State DOH is scheduled to revalidate Case Management provider enrollments in 2015, so this process would be carried out whether the MSC change were to take place or not We expect correspondence to be sent out on this in the next few weeks informing providers of the coming change You will need to complete the revalidation application timely when it is sent to your agency 13

14 2/19/ Rate Rationalization DOH s Bureau of Mental Hygiene Rate Setting initiated Rate Rationalization on July 1, 2014 for IRAs, Group Day Habilitation and ICFs Rate Rationalization for additional services is expected to go into effect on 7/1/15 Services impacted on 7/1/15 include Respite, Supported Employment (SEMP), Prevocational Services and Family Care Billing of these services will be impacted! 2/19/ Rate Rationalization - Respite Hourly Respite and Free Standing Respite will not be distinguished the reimbursement will be the same Respite will be billed with a new rate code under the Multi-Service Provider ID (not the Hourly Respite or Free Standing Respite site provider ID, as the service is currently billed) Will continue to be ¼ hour unit billing 2/19/ Rate Rationalization - SEMP SEMP will be changing from a monthly unit of service to a ¼ hour unit of service billed under the Multi- Service Provider ID, not the existing SEMP provider ID Provided in 1:1 settings and 1:group settings Provided in 2 phases Intensive and Extended Regional fee structure will be in place service billed based on where SEMP program is registered Web based billing application will be updated for payment of services provided to non-hcbs Waiver individuals Draft Regulations expected in the very near future 14

15 2/19/ Rate Rationalization Prevocational Services Service will be distinguished between Site Based and Community Based Site based will continue utilizing existing agency specific rate both variations will be billed under the Multi-Service provider ID, as Prevocational Services currently is Community Based will be billed in ¼ hour service units Provided in 1:1, 1:2 and 1:group ratios (3-8 people) Regional fee structure will be in place service billed based on provider Corp location Draft Regulations expected in the very near future 2/19/ Rate Rationalization Family Care Unit of service will continue to be a per diem under the regional fee structure based on the service provider s corporate location Fees will also take into consideration the 6 ISPM scoring levels that determine payment amounts made to the actual Family Care provider Service will be billed under the Multi-Service Provider ID 2/19/ ICD-10 International Classification of Diseases, Tenth Revision (ICD-10) Implementation date is 10/1/15 Currently, coding is utilized based on ICD-9 Claim submissions on and after 10/1/15 will need to be updated to reflect the ICD-10 primary/principal diagnosis of the individual served OPWDD has been doing outreach to providers to ensure that we have a primary diagnosis on file 15

16 2/19/ Community Habilitation for Individuals Residing in Certified Settings Effective 10/1/14, community habilitation was expanded to allow individuals residing in IRAs/CRs and Family Care to receive the service Specific rules regarding the service put into regulation Information on correspondence dated November 7, 2014 (included with the training materials) OPWDD expects an updated ADM to be available soon until that time providers have been encouraged to delay service provision 2/19/ Self-Direction Changes Effective 10/1/14, methodology changes went into effect for Consolidated Supports and Services (CSS) the HCBS Waiver service for individuals Self-Directing their services The existing CSS reimbursement structure was broken out into separate and distinct services that could be billed directly to Medicaid as HCBS Waiver services and allow for enrollment into specific TABS program codes for service authorization purposes 2/19/ Self-Direction Changes Community Habilitation SEMP* Respite* Individual Directed Goods and Services Community Transition Services (CTS)** Support Broker Fiscal Intermediary Live in Caregiver All services billed under the Multi-Services Provider ID (* for SEMP and Respite, when provided by self-hired staff) ** CTS is billed by the FI, but the individual does not need to be Self-Directing services in order to receive 16

17 2/19/ Self-Direction Changes Services provided to individuals Self- Directing their services fall under three categories: 1) Direct Provider Purchased Services 2) Agency Supported Services 3) Services by Self-Hired Staff 2/19/ Self-Direction Changes Direct Provider Purchased Individual is attending/receiving services directly from an OPWDD service provider The service provider is billing Medicaid directly for those services provided Funds expended for these services count against an individual s Personal Resource Account (PRA) Individual is enrolled in the agency s service specific TABS program code 2/19/ Self-Direction Changes Agency Supported Services Community Habilitation, SEMP* and Respite* Individual has an MOU with the agency that describes the person s ability to make decisions about the staff Specific rate codes under the Multi-Services Provider ID are used to bill Agency Supported Services for Community Habilitation and Respite Until the unit of service changes for SEMP come into effect, the traditional monthly SEMP rate codes should be billed. Individual is enrolled in the agency s service specific TABS program code November 7, 2014 memo included as a handout with the training materials provides billing guidance * SEMP and Respite do not yet have formal guidelines for MOUs, but providers can use Community Habilitation MOU template 17

18 2/19/ Self-Direction Changes Services by Self-Hired Staff Community Habilitation, SEMP and Respite Specific rate codes under the Multi-Services Provider ID are used to bill for these services when provided by Self-Hired Staff Individual is enrolled in the FI s service specific TABS program code 2/19/ Self-Direction Changes Special billing logic was put in place to allow variable amounts to be billed to Medicaid for certain supports and services available under Self-Direction at or below the defined rate cap Services paid under special logic include Self-Hired Community Habilitation, Self- Hired SEMP, Self-Hired Respite, Live in Caregiver and Support Broker 2/19/ Self-Direction Changes For services provided by Self-Hired staff (Community Habilitation, SEMP and Respite), FI s are submitting the number of actual billable service units and the total expenses incurred not an established rate As Self-Hired staff will generate costs beyond their wages (fringe benefit costs), and additionally, may need to be paid for time that is not directly billable based on service provision (indirect time worked), this method for reimbursement allows all the service costs to be accounted for 18

19 2/19/ Self-Direction Changes On 1/12/15, an FI is submitting a Community Habilitation claim on behalf of an individual who has Self-Hired staff for 4 hours of billable service activities (Billable Hours). The FI is informed that on this date the employee, in addition to 4 hours of direct billable service time, worked an additional 3 hours (a total of 7 Work Hours). The employee is paid $13.00 an hour To calculate the Amount Charged to Medicaid, the following is taken into consideration: Work hours = 7 X $13.00 Wage Rate = $91.00 Indirect Employment Cost = 15% (Fringe) X $91.00 Wage Cost = $13.65 Total Employment Cost = $ (This amount is included as the Amount Charged to Medicaid) Billable Time to Medicaid = 4 hours (equates to 16 units submitted on the claim) Effective Reimbursement Rate = $ / 16 units ($6.54 per ¼ hour) 2/19/ Self-Direction Changes Individual Directed Goods and Services billed in $10 increments emedny allows a maximum of 99 service units to be billed to Medicaid on a given date of service This equates to $990 per date of service (99 X $10) If more than $990 has been expended for qualifying IDGS expenses, OPWDD requires submission of claims on consecutive service dates OPWDD has identified allowable IDGS expenses and the process for billing the service to Medicaid information available for providers who will become FIs 2/19/ Self-Direction Changes Community Transition Services (CTS) billed in $10 increments emedny allows a maximum of 99 service units to be billed to Medicaid on a given date of service This equates to $990 per date of service (99 x $10) If more than $990 has been expended for qualifying CTS expenses, OPWDD requires submission of claims on consecutive service dates ADM is coming soon that will detail requirements 19

20 2/19/ Self-Direction Changes Training sessions were held for FI s and for providers interested in becoming FI s If you would like more information about the Self-Direction changes, we can share the training materials [email protected] OPWDD Day Service billing for ICF Residents Effective 1/1/15 certain day services provided to ICF enrolled individuals can be billed directly to emedny Day Services (comparable to Day Habilitation), Vocational Services, Day Services Downstate Template Highly Complex, Day Services Upstate Template Highly Complex, Vocational Services Downstate Template Highly Complex and Vocational Services Upstate Template Highly Complex For those providers that are authorized to deliver In Home Day Service, rates will be loaded in the near future While these services are billed for ICF residents, providers are submitting these claims using the Multi-Services Provider ID for reimbursement Providers no longer need to bill ICF provider for these services!!!! OPWDD s Liability for Services Regulations 14 NYCRR Kristina Cunningham Revenue Support Field Operations 20

21 Definitions Covered Services Responsibilities Limited Exception Resources Topics Definitions Preexisting services an individual was receiving on a regular basis from the same provider at the time the regulations were implemented for that service Other than preexisting services that commence on or after the date the regulations were implemented for that service Full Medicaid coverage the type of coverage that will pay for the services someone is receiving or wants to receive Liability for Services Original Regulation effective 2/15/2009 Day Habilitation ICF Residential Services Residential Habilitation (IRAs, CRs, FC) Liability notice issued by 3/15/2009 Individual liability began 4/15/2009 Bills issued no later than 30 days beyond last day of the month of service 21

22 Liability for Services Amended Regulation effective 3/15/2010 MSC Day Treatment At-Home Residential Habilitation (Community Habilitation) Prevocational Services Supported Employment Services Respite Blended and Comprehensive Services (OPTS) Liability notice issued by 5/15/2010 Individual liability began 6/15/2010 Bills issued no later than 30 days beyond last day of month of service Individuals Responsibilities Individuals who want specified OPWDD Medicaid service(s) must file and be approved for Full Medicaid Coverage or else pay for their services Individuals who want OPWDD HCBS Waiver service(s) must take all necessary steps to enroll in the HCBS Waiver Service Provider Responsibilities Issue Liability Notice(s) Preexisting Services - should have been issued by 3/15/2009 or 5/15/2010 Other than Preexisting Services - relevant notices must be issued prior to service delivery Liability notices must be issued to everyone receiving or applying for any covered service(s), regardless of their Medicaid/HCBS Waiver status If the provider does not provide any covered services, no liability notices are required 22

23 Service Provider Responsibilities Verifying Medicaid and HCBS Waiver Status Local Revenue Support Field Offices (RSFOs) can verify Medicaid enrollment and type of coverage, review a Medicaid denial notice and advise if an appeal is warranted Service provider must be given any Medicaid denial notice within 5 days of receipt. RSFO can advise if an appeal is warranted Contact DDSO to verify HCBS Waiver status State-funded service coordination available for up to 3 months to assist with Medicaid and Waiver enrollment Service Provider Responsibilities Calculating Charges for Services Liability amount is the full Medicaid rate or fee for the service For individuals without Medicaid, use the Benefit Eligibility Questionnaire (located in the Benefit Development Resource Guide on OPWDD s website) to gather financial and other information Reductions or waivers MAY be available for individuals who fully cooperate in the benefit development process Service Provider Responsibilities Billing the individual All individuals are liable for the full cost of their services unless Medicaid is paying for their services The provider must bill the individual and/or liable party for the full cost of the services if the individual does not Medicaid/HCBS Waiver enrollment to pay for the services they are receiving or requesting, Bills must be issued monthly, no later than 30 days beyond the last day of the month of service Provider has to issue viable bills (expecting payment) Provider has to actively pursue collection of unpaid amounts from the individual/liable party Providers receiving State funding for an individual s preexisting services will continue to be paid by OPWDD, subject to fund availability, if the service provider complies with all regulatory requirements 23

24 Liability Notices 2009 Preexisting Services Liability Notice (LIAB 02) 2010 Preexisting Services Liability Notice (LIAB 06) Liability Notice for Persons Applying for Services (LIAB 05) Limited Exception Notice for Persons Meeting Exception (LIAB 07) Limited Exception Notice for Persons Applying for Other Services (used by SEMP/Respite Provider) (LIAB 08) Limited Exception Notice for Persons Applying for Other Services (used by provider of other requested services) (LIAB 09) Information About the Limited Exception for Persons Receiving Supported Employment or Respite Services (LIAB 10) Liability Notices Use the instructions They tell the provider Which notice to use How to fill out the notices Who gets the notices When to give the notices Do not alter notices Copies may be requested by OPWDD Who Gets Liability Notices? See instructions All people who fit situations described in chart in instructions Could be more than one person Possibilities the person receiving or requesting services anyone accompanying the person parent(s) legal guardian trustee representative payee or other payee for benefits person holding money or assets for the person conservator or committee spouse 24

25 Limited Exception Individuals receiving only SEMP or only Respite services If not funded by Medicaid/HCBS Waiver on or after 3/15/2010 Not required to enroll in Medicaid and HCBS Waiver Can drop other services to qualify Limited exception NOT available for: Individuals receiving any other covered service Services funded by Medicaid (Medicaid and HCBS Waiver enrolled) at any time on or after 3/15/2010 Limited Exception Service providers must issue a specific Liability Notice to the individual/liable party Individual must notify the SEMP/Respite provider if applying for any other covered services Providers of other covered services must ask an individual if he or she is receiving SEMP or Respite services and notify the SEMP/Respite service provider that individual is applying for other services LIAB 07 (limited exception) Tells the person they are eligible for the limited exception Issued by 5/15/2010 for persons receiving supported employment or respite as of 3/15/2010 Issue prior to service delivery if person applies for supported employment or respite after 3/15/2010 Only supported employment and respite providers give this notice 25

26 LIAB 08 (limited exception) Given by supported employment or respite provider Given if a person who is eligible for the limited exception applies for another service that would disqualify him or her for the limited exception LIAB 09 (limited exception) Given by provider of any other covered service(s) for which the individual applies while under the limited exception Provider of other covered service(s) will also need to give the Liability Notice for Persons Applying for Services (OPWDD LIAB 05) LIAB 10 (limited exception) Informational only Give to anyone who asks for more information about the limited exception 26

27 Fee Reductions & Waivers Individuals who have fully cooperated in the Medicaid application and HCBS Waiver enrollment processes may be eligible for a fee waiver or reduction based on the individual s income, resources, and living situation Releases provider from responsibility for billing the individual or lowers the amount the individual must be billed monthly Provider continues to be paid by OPWDD during fee waiver/reduction period Provider must bill individual for any period for which they do not have a current approved fee waiver in place. Fee Reductions & Waivers See Liability for OPWDD Medicaid and Home and Community Based Waiver Services, Addendum 1 - Rules for Determining Waived or Reduced Fees for OPWDD Services (available on the OPWDD website) for the guidelines for calculating fees to be billed to individuals without Medicaid Fee Reductions & Waivers Submit Form OPWDD LIAB 04, Fee Reduction/Waiver for Preexisting Services Request for Approval to Revenue Support Field Office Include supporting documentation - individual s/liable party s financial information, Medicaid denial notice, HCBS Waiver Notice of Decision, etc. If a fee waiver has been approved by OPWDD, OPWDD will pay the provider and the provider does not have to bill the individual for the period of the fee waiver Fees for services can be reduced or waived without approval by OPWDD only if the service provider is not seeking state funding 27

28 Fee Reductions & Waivers Use when Individual with Medicaid Coverage does not meet the level of care for HCBS Waiver Undocumented immigrant has limited or no income or assets Do not use when Medicaid or HCBS Waiver application is pending Individual is not meeting a spenddown Individual is not cooperating with benefit development process Resources OPWDD website: ( Liability for Services Regulations Liability for OPWDD Medicaid and Home and Community Based Waiver Services Liability Notices Medicaid Coverage Chart Benefit Development Resource Guide List of Revenue Support Field Offices Revenue Support Field Offices Kristina Cunningham [email protected] Phone: Questions? 28

29 Non-Medicaid Payments Voucher Billing - state paid services, assistive supports, state paid component of Self-Direction Web Based Billing respite & SEMP (to persons not in the HCBS Waiver) and OPTS for a very limited time Non-billed Payments property for freestanding respite, IRA room & board supplements & IRA land costs For Supervised IRAs/CRs, agencies receive 1/12 of the supplement regardless of billing (effective 7/1/14) For Supportive IRAs/CRs, the supplement payment is based on the paid residential habilitation claim Non-Medicaid Funded Payments Policy Clarification For new recipients of Non-Medicaid funded services, a State Funding Authorization Request (SFAR) is required DDSO/Regional Office staff will complete the SFAR form Revenue Support Field Office (RSFO) Staff can provide guidance regarding the policy OPWDD Payment Processing Unit Rules Effective 10/1/13, agencies have 3 months from the conclusion of a service month to submit claims The received date of the claim by OPWDD determines if the claim was submitted timely, not the date the voucher was signed, or when the agency staff mailed the voucher A claim for January 2015 services must be submitted and received by 4/30/15 29

30 Tips for Billing OPWDD s Payment Processing Unit Claims should be submitted on the 1st of the month (or later) following the month of Service delivery All services claimed on a billing form must be for the same month and year Only one service type (rate code) should be submitted on a billing form except for Supervised IRA/CR Residential Habilitation (July 2014 service or later) Multiple billing forms can be submitted with a single voucher, unless directions state otherwise Individuals served should be listed in ALPHABETIC order, in the format: LAST NAME, FIRST NAME 2/19/ More Tips for Billing OPWDD s Payment Processing Unit TABS ID must be included for each individual All billing forms must be signed and dated Instead of entering data on a billing form, a computer printout can be submitted with the signed and dated billing form, but the computer printout must contain all required data identified on the billing form If the service date is more than 3 months old, a letter explaining the delay must accompany the claim submission OPWDD Central Office will consider these claims on a case by case basis A completed Claim for Payment form (AC-3253s) or Standard Voucher (AC-92) must be included with each submission of billing forms. Form AC-3253s may be obtained by visiting the following link: Even More Tips for Billing OPWDD s Payment Processing Unit Ensure that you are using up to date billing forms Resources Forms Payment Processing Unit Billing Forms and Instructions 30

31 Questions? OPWDD Web Based Applications Utilized for Respite and Supported Employment (SEMP) and for a short time period, OPTS Users request access via User ID and System Access Request Form / Resources / Forms Completed forms submitted to appropriate contact at the DDSO/Regional Office or the OPWDD Help Desk USER ID AND SYSTEM ACCESS REQUEST FORM Form Available at the OPWDD Website ( Resources Link / Forms Link 31

32 2/19/ USER ID AND SYSTEM ACCESS REQUEST FORM Choices from the dropdown include SEMP, SV OPTS and SV Respite 32

33 2/19/ USER ID AND SYSTEM ACCESS REQUEST FORM USER ID AND SYSTEM ACCESS REQUEST FORM SV Respite access requires sign off by the DDSO/Regional Office FSS Coordinator or designee Sign off not required for SEMP OPWDD Web Based Applications Web-Based Payment Application utilized for all individuals enrolled in your program Individuals enrolled via the DDP-1 submitted to your DDSO/Regional Office Once the DDSO/Regional Office processes the DDP-1 to complete TABS enrollment, web roster will be updated to include enrolled individual For SEMP/Respite individuals not enrolled in the HCBS waiver, service entry results in payment from OSC 33

34 OPWDD Web Based Applications For SEMP/Respite individuals enrolled in the HCBS waiver, providers must separately submit claims to emedny Until Rate Rationalization, recording of SEMP services through the Web Based Application for HCBS enrolled individuals informs providers of the appropriate rate code to use for billing emedny Until Rate Rationalization, recording of Respite services through the Web Based Application for HCBS enrolled individuals informs providers of the appropriate rate code and units used for billing emedny OPWDD Web Based Applications Calendar Roster Availability There are timeframes in place that must be adhered to for recording services through the Web based payment applications At the start of a month until the day prior to the first final payment run of the month, rosters for the (2) months prior, plus the roster for the current month will be available for service recording BEST PRACTICE: Record service of prior month in current month OPWDD Web Based Applications Calendar Roster Availability Once the first final SEMP/Respite payment run occurs in a month, only rosters for the current and prior month will be available for service recording At the start of the next month until the day prior to first final payment run in that month, providers again have rosters for the two prior months and current month available for service recording. Payment run dates and data entry deadline dates are available in the web applications 34

35 OPWDD Web Based Applications Calendar Roster Availability To address reduced timeframes, submit DDP-1 add to program forms ASAP Record services as close to the date(s) of service provision as possible Inform others at your agency of these timeframes, especially those that are responsible for service documentation Read notices posted on the Web Application Best Practice Record service from prior month (September) this month (October) Accessing Web Based Applications / Login / Secure Site Applications Services Recording for Respite Supported Employment System for SEMP 35

36 36

37 Respite, Inc. Respite, Inc. 37

38 RESPITE, INC. October 2012 JONES,JOHN KIM,JUDY MILLER,MARY ROSE,JAMES UPTON,MARY WELLS,TIM NYS Office For People With Developmental Disabilities KIM,JUDY RESPITE INC. Program 44 Holland Ave NYS Office For People With Developmental Disabilities RESPITE, INC. 38

39 July 2012 RESPITE, INC. Month of Service RESPITE, INC. KIM,JUDY KIM,JUDY RESPITE, INC. PROGRAM: 44 HOLLAND AVE September 11, 2012 December 10,

40 RESPITE, INC. RESPITE, INC. RESPITE, INC RESPITE, INC P.O. BOX 9999 WHEREVER, NY SFS VENDOR ID: MMIS PROVIDER ID #; KIM,JUDY **NOTE: Do not claim the services listed on this report to MMIS for Medicaid Reimbursement. These services have been forwarded to OSC for payment** 40

41 RESPITE INC. RESPITE, INC RESPITE, INC FEDERAL PAYEE ID: MMIS PROVIDER #: Locator Code: 03 Rate Code : 4486 WELLS, TIM XX11111X 41

42 21 MAY 12 SEMP, INC. 25 MAY 12 April 2012 WALSH, JACK /18/1958 XXX XX XXXX WARD, MIKE /29/1982 XXX XX XXXX WEBB, JOE /14/1981 XXX XX XXXX YARD, JED /13/1981 XXX XX XXXX YOUNG, JAY /25/1963 XXX XX XXXX 42

43 5/26/2012 5/25/2012 OPWDD SEMP, INC SEMP PROGRAM P.O. BOX 9999 WHEREVER, NY FEDERAL PAYEE ID: WALSH, JACK WARD, MIKE WEBB, JOE YARD, JED YOUNG, JAY XXX XX XXXX XXX XX XXXX XXX XX XXXX XXX XX XXXX XXX XX XXXX April April April April April VOUCHER TOTALS: /26/2012 OPWDD 5/25/ BROOME SEMP, INC SEMP PROGRAM P.O. BOX 9999 WHEREVER, NY FEDERAL PAYEE ID: JONES, GEORGE /20/ YY00000Y JUL emedny Billing CONTACTS - Earl Jefferson [email protected] - Matt Breslin [email protected] - Shaun Scanlon [email protected] (518) CSC Call Center (800)

44 2/19/ CONTACTS Payment Processing Unit Brenda Salsburg State Paid Self-Direction Lori Adams (518)