KANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. Psychiatric Residential Treatment Facility

Transcription

1 Provider Manual Psychiatric Residential Treatment Facility Updated 11/2011

2 PART II Introduction Section BILLING INSTRUCTIONS Introduction to the CMS-1500 Claim Form Submission of Claim PRTF Specific Billing Information MS-2126 Billing Instructions BENEFITS AND LIMITATIONS Copayment Benefit Plans Medicaid Appendix PRTF Codes A-1 Forms All forms pertaining to this provider manual can be found on the public website at and on the secure website at under Pricing and Limitations.

3 PART II Updated 11/11 This is the provider specific section of the manual. This section (Part II) provides instructions, limitations, and requirements specific to Psychiatric Residential Treatment Facility (PRTF) providers. It is divided into the following subsections: Billing Instructions, Benefits and Limitations, and Appendix. Part I of the provider manual consists of five parts: General Information, General Benefits, General Billing, General Special Requirements, and General Third Party Liability Payment. Part I contains information that applies to all providers, including PRTFs. The Billing Instructions subsection gives instructions for completing and submitting the billing forms applicable to PRTF services. The Benefits and Limitations subsection defines specific aspects of the scope of PRTF services allowed within KMAP. The Appendix subsection contains information concerning codes. The appendix was developed to make finding and using codes easier for the biller. HIPAA Compliance As a participant in KMAP, providers are required to comply with compliance reviews and complaint investigations conducted by the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. Access to Records Kansas Regulation K.A.R requires providers to maintain and furnish records to KMAP upon request. Providers must also provide records to the Department of Health and Human Services upon request. The provider is required to supply records to the Medicaid Fraud and Abuse Division of the Kansas attorney general's office upon request from such office as required by the Kansas Medicaid Fraud Control Act, K.S.A to , inclusive, as amended. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review, or investigation, including the relevant questioning of the provider s employees. The provider shall not charge a fee to retrieve and copy documents and records related to compliance reviews and complaint investigations. i

4 7000. PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY BILLING INSTRUCTIONS Updated 11/11 Introduction to the CMS-1500 Claim Form PRTF providers must use the CMS-1500 red claim form (unless submitting electronically) when requesting payment for medical services provided under the KMAP. Any CMS-1500 claim form not submitted on the red claim form will be returned to the provider. An example of the CMS-1500 claim form is on the public website at and on the secure website at The Kansas MMIS uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information must be submitted in the correct claim fields to be recognized by the equipment. The fiscal agent does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in Section 5800 of the General Billing Provider Manual. Send completed first page of each claim and any necessary attachments to: Submission of Claim Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas BILLING INSTRUCTIONS 7-1

5 7010. PRTF SPECIFIC BILLING INFORMATION Updated 05/10 Place of Service Code The only place of service code accepted on a PRTF claim is 56. Prior Authorization Dates of Service Dates of service billed must be within the dates of service approved by the prior authorization. Dates of service billed are not allowed to span two approved prior authorization periods. If procedure codes are authorized under different prior authorizations, separate detail lines on the claim form must be completed. Client Obligation For beneficiaries residing in a PRTF who have a client obligation, providers are responsible for collecting the client obligation. Providers should submit claims for the full amount. Client obligation is deducted automatically from payment during claims processing. BILLING INSTRUCTIONS 7-2

6 7020. MS-2126 BILLING INSTRUCTIONS Updated 11/11 Introduction to the Notification of Facility Admission/Discharge MS-2126 Providers must complete the MS-2126 (Notification of Facility Admission/Discharge) and send a copy to the PRTF contact staff at the local Kansas Department of Social and Rehabilitation Services (SRS) office. Providers must retain the MS-2126 in their records. Providers do not have to complete the MS-2126 for payment of a visitation day. Note: This form must be copied or duplicated by providers since the fiscal agent does not furnish the form to providers. The form and instructions are located on the KMAP website at under the Publications heading and then Forms. When to Use the MS-2126 Sections I, II, and III Facility placement/discharge, shall be initiated by the facility when: An eligible KMAP beneficiary is admitted to or discharged from the facility A resident of a PRTF becomes eligible for KMAP An eligible KMAP beneficiary transfers from one facility to another facility A resident's KMAP eligibility is reinstated after suspension Section IV This section is not used by the PRTF. Completion of this section is not required for approved leave days. Return to the Facility Whether Section III or IV is being completed, the Economic and Employment Support (EES) retains a copy of this form for their files. The original MS-2126, completed by the facility, and the Notice of Action must be retained by the facility. BILLING INSTRUCTIONS 7-3

7 BENEFITS AND LIMITATIONS COPAYMENT Issued 07/07 PRTF services are exempt from copayment requirements. BENEFITS & LIMITATIONS 8-1

8 8300. BENEFIT PLANS Updated 11/11 KMAP beneficiaries are assigned to one or more KMAP benefit plans. The benefit plan entitles the beneficiary to certain services. If providers have questions regarding service coverage for a particular benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification. PRTF services are noncovered under the current MediKan and Title XXI program. BENEFITS & LIMITATIONS 8-2

9 8400. MEDICAID Updated 05/10 PRTF services must provide active treatment in a structured therapeutic environment for children and youth with significant functional impairments resulting from an identified mental health diagnosis, substance abuse diagnosis, or a mental health diagnosis with a co-occurring disorder (for example, substance related disorders, mental retardation/developmental disabilities, head injury, sexual misuse disorders, or other disabilities which may require stabilization of mental health issues). Such services are provided in consideration of a child's developmental stage. Criteria Providers must provide services in accordance with an individualized treatment plan under the direction of a physician. The activities included in the service must be intended to achieve identified treatment plan goals and objectives and be designed to achieve the beneficiary s discharge from inpatient status at the earliest possible time. Services to be provided must be in accordance with 42 C.F.R. Secs through Beneficiaries receiving these services must be assessed by a licensed mental health practitioner (LMHP) or physician independent of the treating facility, using an assessment consistent with state law, regulation, and policy. Using this assessment, a community based services team (CBST), which complies with the requirement of 42 C.F.R. Sec , must certify in writing their determination of the medical necessity of this level of care in accordance with the criteria and requirements outlined in 42 C.F.R. Sec Also, the need for this level of care must be shown by meeting all of the following circumstances: A substantial risk of harm to self or others, or a child or youth who is so unable to care for his or her own physical health and safety as to create a danger to his or her life. The services can reasonably be expected to improve the beneficiary s condition or prevent further regression so that the services will no longer be needed. All other ambulatory care resources available in the community have been identified, and if not accessed, determined not to meet the immediate treatment needs of the child or youth. Proper treatment of the beneficiary s psychiatric condition requires services on an inpatient basis under the direction of a physician. After the initial admission, the beneficiary must be recertified in writing as described in the Recertification Process section. Note: The only place of service code accepted on a PRTF claim is 56. BENEFITS & LIMITATIONS 8-3

10 8400. MEDICAID Updated 05/10 Provider Requirements KMAP grants a provider of PRTF services approval for enrollment as an active PRTF provider in KMAP following the receipt of a letter from SRS Central Office, Mental Health Division, PRTF Program Manager, DSOB 9 th Floor, 915 SW. Harrison, Topeka, KS, 66612, stating that the provider has met the qualifications or licensing requirements to deliver such services. Providers are required to meet the PRTF service standards as described in the SRS PRTF Service Standards Manual. To enroll as a KMAP provider, download enrollment material from the KMAP website ( or contact Provider Enrollment at This process consists of applying for licensure approval from SRS and submitting a provider enrollment application to KMAP. You may contact either entity at the following addresses: SRS Mental Health Division Attn: PRTF Program Manager DSOB 9 th Floor 915 SW Harrison Topeka, KS Provider Enrollment Office of the Fiscal Agent P.O. Box 3571 Topeka, KS Preadmission Assessments The preadmission assessment must follow the PRTF service standards as described in the SRS PRTF Service Standards Manual. When appropriate, Kansas Health Solutions (KHS), the mental health state contractor, will call and arrange the assessment. KHS must ensure the assessment is completed within seven business days. SRS social workers, Juvenile Justice Authority (JJA) case managers, child welfare contractors, and any interested person can contact KHS at If KHS approves admission, a prior authorization number will be assigned by KHS. The PRTF will use the assigned prior authorization number when billing for PRTF services. Recertification Process The LMHP or physician recertifying the need for services must be independent of the facility. The recertification of services is the responsibility of the LMHP or physician in conjunction with the CBST. This must include a face-to-face assessment by an independent LMHP or physician. Recertification must occur within 90 days of admission and every 60 days thereafter. BENEFITS & LIMITATIONS 8-4

11 8400. MEDICAID Issued 07/07 Prior Authorization Prior authorization is required for all PRTF services. KHS enters the prior authorization and is responsible for answering any questions regarding the prior authorization. The child does not need to be in state custody for Medicaid to reimburse PRTF services, but the child must be an eligible Medicaid beneficiary. Payment for PRTF services (billed using T2048) shall be made consistent with the SRS PRTF Service Standards Manual. This includes certification and subsequent recertification. PRTF services are not reimbursed with either Medicaid or any state funding unless the medical necessity for the service has been determined consistent with these standards. Emergency Exception Screening Process A beneficiary can be admitted to a PRTF upon acceptance by the facility using the emergency exception screening process. The admission screen must be completed by the KHS designated LMHP or physician certifying the need within 48 hours of admission. The LMHP or physician will certify this is an exception screen and that the CBST plan has not yet been completed. The CBST will convene within seven days of admission to determine whether the beneficiary s needs can be met by the PRTF or if the beneficiary should be diverted to community based services. Admissions using the emergency admission procedure must be authorized through the certification of need. If the certification determines that the beneficiary s needs can best be served in the community, the beneficiary must be moved from the PRTF. After such a determination, KMAP funding is not available to the PRTF, and if applicable, the placing entity becomes responsible for payment. Unconditional Discharge An individual who is younger than age 22 and has been receiving inpatient psychiatric services in a PRTF is considered to be a patient in the facility until the facility unconditionally releases the individual, or the date the individual turns age 22, whichever is earlier. Upon discharge, billing must cease. The provider must notify KHS to end-date the prior authorization. The provider must send an updated MS-2126 to the local SRS PRTF contact staff. Discharge Discharge planning must be consistent with the PRTF service standards as described in the SRS PRTF Service Standards Manual. Upon discharge, billing must cease. The provider must notify KHS to end-date the prior authorization. The provider must send an updated MS-2126 to the local SRS PRTF contact staff. BENEFITS & LIMITATIONS 8-5

12 8400. MEDICAID Issued 07/07 Payment of Absent Days A beneficiary is considered present at the facility for an entire day if the beneficiary is at the facility at 11:59 p.m. The facility should take a beneficiary specific census at this time and ensure the facility s business manager has a record of which beneficiaries are present in the facility on any given day and can accurately track absentee days for each beneficiary. The PRTF is reimbursed for absent days as follows: Visitation days When indicated in the child s treatment plan (within the total number of days approved for the child's stay), a maximum of seven days per visit is paid at the contracted per diem rate. The frequency, duration, and location of the visits must be a part of the child's individual case plan developed by the facility before the visitation. An approved visitation plan must be documented in the child s official record at the facility. Other covered absences If a beneficiary is absent from the facility for a short time due to circumstances needing the beneficiary s immediate attention (deaths, weddings, personal business), or the beneficiary leaves the facility without permission, the facility can be reimbursed for up to five days per year at the contracted per diem rate unless the beneficiary s placement is terminated sooner by the beneficiary s guardian in conjunction with the PRTF. Hospital Leave Hospital leave is an absence from the facility for more than 24 consecutive hours due to the resident receiving acute inpatient treatment in a hospital, excluding treatment in a psychiatric unit of a hospital and excluding treatment in a state psychiatric hospital. If the PRTF is unable to plan for return of the resident and continue continuity of care planning because it is unsure when the resident may return from the hospital, the resident should be discharged. Under no circumstances shall the PRTF bill for more than five resident days when the resident is in the hospital. Mental health services received during leave time are the PRTF s responsibility. KMAP does not pay for beneficiaries while they are in a correctional institution. All other absences not defined above are not covered by KMAP. Documentation To verify services provided in the course of a postpayment review, documentation in the beneficiary s medical record must support the service(s) billed. Ancillary Providers KMAP does not make any payment to ancillary providers for services included in the content of service list for a PRTF. For a listing of procedure codes included in the content of service list, refer to the Non- PAHP Outpatient Mental Health Provider Manual and the Non-PIHP Alcohol and Drug Abuse Community Based Services Provider Manual. BENEFITS & LIMITATIONS 8-6

13 APPENDIX Updated 05/10 CODES The following procedure code represents an all-inclusive list of PRTF services billable to KMAP. Procedure codes not listed here are noncovered by KMAP. Procedure code T2048 is covered with prior authorization. APPENDIX A-1