EPSDT SCHOOL-BASED SERVICES: AN OVERVIEW FOR PROVIDERS. Oklahoma Health Care Authority Revised May 2004

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1 EPSDT SCHOOL-BASED SERVICES: AN OVERVIEW FOR PROVIDERS Oklahoma Health Care Authority

2 Purpose of Manual This manual is intended as a reference document for schools that are enrolled as Medicaid providers. It contains requirements for participation in and reimbursement of EPSDT School-Based Services. The manual explains covered services, their limits, and who is eligible to receive and provide the services. Extensive material is included in the Appendices, including a listing of contact persons and phone numbers and other reference information. The manual will be updated as necessary. Information about the Medicaid program and eligibility policies is contained in the Medicaid State Plan and administrative rules. The State Plan Amendment for School-Based Services is on file at OHCA. A copy of the applicable administrative rules can be obtained from the OHCA website at School providers are responsible for ensuring compliance with current state/federal Medicaid policies pertaining to the services they render. This manual does not supersede Medicaid rules and is not to be used in lieu of them. Page 1

3 CHAPTER 1 MEDICAID OVERVIEW The Federal Medicaid Program Medicaid is a joint state-federal program that provides health care for low income and disabled individuals. The costs of providing health care and services to individuals that meet specific eligibility criteria established by each state are shared by the state and federal governments. The matching rates (referred to as the federal medical assistance percentage or FMAP ) are calculated annually by the federal government and are based on the state s per capita income. Oklahoma s state share is generally around 30%; the Federal share match is about 70%. Some services must be covered by each state s Medicaid plan, while other services may be provided at a state s option. One mandatory Medicaid service is the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, which provides Medicaid eligible children under age 21 with a broad array of health care screening, diagnosis and treatment services. Legal Authority Medicaid Eligibility Application For Medicaid/ SoonerCare Certified Degree Of Indian Blood Eligibility Verification The Medicaid program is authorized by Title XIX of the Social Security Act and Title 42, Code of Federal Regulations. Administrative rules pertaining to School-Based Services are found at OAC 317: to OHCA is the single State agency responsible for administering Oklahoma s Medicaid program. Eligibility for Medicaid benefits are based on need (i.e., determined by family income) and/or on categorical status (such as children eligible for Title IV-E foster care or adoption assistance or Supplemental Security Income, SSI ). In Oklahoma, children from birth through age 17 are eligible at 185% of the federal poverty level (FPL). (Although Medicaid has other eligibility requirements, such as citizenship and Social Security Number (SSN), the same income guidelines have been used for the National School Lunch Program since December 1, 1997.) The Oklahoma Department of Human Services (DHS), through its local offices, is responsible for determining eligibility for Medicaid /SoonerCare. Applications can be made in person or mailed in. Eligibility must be redetermined or recertified at least every six months. Individuals with Certified Degree of Indian Blood (CDIB) cards must apply for Medicaid benefits in the same manner as other applicants. For Medicaid reimbursement, a child must be eligible on the date of service. The following options can be used to determine a recipient s eligibility: Request Medicaid eligibility information on an individual basis, such as at school registration (e.g., ask for health insurance information, including Medicaid, on an enrollment form or health card); Query parents or guardians, or children who have reached the age of majority or emancipated youth, at the time services are initiated or at the time of an IEP or treatment team meeting; Districts with current contract status and an active PIN number may access the OHCA secured website for current eligibility information; Districts with current contract status may submit a list of students to OHCA s fiscal agent, EDS, for eligibility verification; Page 2

4 Eligibility Verification System (EVS) this is an automated system which can be accessed by phone and can be used to check up to three names at one time. The toll-free number is (800) The child s Medicaid case number or SSN and date of birth must be known. The eligibility information is very current, but the process can be time-consuming. It is more efficient to use when checking eligibility for individuals for specific months of services, rather than initial eligibility for a large number of children. Contact OHCA, Customer Services for further information; On-Line PS/2 Verification System this is an on-line eligibility verification system that can be purchased by schools that enter into a data link contract with DHS. There are minimum monthly charges to operate the system, but it is reported by schools to be efficient and accurate. Contact DHS/Family Services Division for further information; Commercial Vendors Software is available from commercial vendors for on-line eligibility verification; DHS Match -- Contact your county DHS office directly to discuss the option of establishing an initial list or match. Facilitating Medicaid Eligibility Schools can facilitate a family s application for Medicaid/SoonerCare through the provision of information on eligibility and benefits or assistance with the application process. Outreach can be provided on an individual basis, through the distribution of materials on a school-wide basis, or through more formal eligibility outreach campaigns. Parents can indicate their interest in receiving SoonerCare health benefits information for their children on the Application for Free and Reduced Price Meals and waive confidentiality so their names can be furnished by the school to the appropriate county DHS office. Contact the Child Nutrition Program at the OSDE for further information on this waiver of confidentiality. EPSDT The focus of the EPSDT program is on preventive medical care and ensuring that parents can access medical care for their eligible children in a timely manner, before a condition becomes worse and the care more costly. Comprehensive screenings are provided at periodic intervals, and where necessary, children are referred for further diagnosis and treatment services. OHCA lists the following recommendations concerning these periodic screenings. (See Appendices for a more detailed EPSDT Periodicity Schedule.) Six screenings during the first year of life; Two screenings during the second year of life; One screening each year for ages two through five; One screening every other year for ages six through 20. Components of a screen Components of a comprehensive EPSDT screen include the following: Comprehensive health and developmental history--gross and fine motor development; communication skills, language and speech development; self-help, self-care skills; social-emotional development; cognitive skills; visual-motor skills; learning disabilities; psychological/psychiatric problems; peer relations; vocational skills; nutritional assessment; Page 3

5 Comprehensive, Unclothed Physical Examination-- complete unclothed physical examination, including oral dental examination; height and weight measurements; Appropriate immunizations Appropriate Lab Test(s)--anemia, sickle cell test, tuberculin test; lead toxicity screening (a blood level assessment is mandatory where age and risk factors indicate it is medically appropriate); iron deficiency; serum cholesterol screening, if feasible; Health Education Anticipatory guidance; Vision and Hearing Screens Dental Screening Services Performing EPSDT Screens Screening SoonerCare Recipients Schools are not required to perform EPSDT screens, but may do so under limited circumstances discussed below. A school may perform the EPSDT screens and receive reimbursement under the following circumstances for children covered by SoonerCare: 1. When the Medicaid eligible child s SoonerCare provider authorizes the school to perform the screen, or 2. When the SoonerCare provider fails to schedule an appointment within three weeks of the school making and documenting a request for a screen. When a school intends to perform an EPSDT screen on a child, a copy of the EPSDT SCREENING & NOTIFICATION DOCUMENT ; Addendum of the EPSDT School-Based Services contract must be mailed to a SoonerCare member s primary care provider prior to the screen as notice of the school s intent to bill for the screen. When a school performs an EPSDT screen on a child, the original above referenced Addendum must be retained in the child s record and the screening results must be forwarded to the SoonerCare provider. Screening Fee-for-Service Recipients A referral is not needed for schools to perform EPSDT screens for children covered by fee-for-service Medicaid. This includes children in Department of Human Services (DHS) or Office of Juvenile Affairs (OJA) custody and placement. Page 4

6 CHAPTER 2 OVERVIEW OF SCHOOL BASED SERVICES Introduction The EPSDT School-Based Services program provides for reimbursement to local, regional and state educational agencies (referred to hereafter as schools ) for providing medically necessary health and related services to Medicaid eligible children. Private schools are not eligible to participate in this program. The school must enroll as a Medicaid provider to receive Medicaid reimbursement for health related services rendered to Medicaid eligible children. The school bills Medicaid for the services rendered by its qualified providers, who must be school employees or contracted staff. Services are focused on the Medicaid eligible population that is enrolled in the public school system. Services may be provided in the school setting, the home or another site in the community. Through work accomplished jointly in 1997 by the Oklahoma State Department of Education (OSDE) and the Oklahoma Health Care Authority (OHCA), the scope of EPSDT School-Based Services was expanded. New service categories were added to the existing program in an effort to make EPSDT School-Based Services both comprehensive and reflective of the types of health related activities that are already occurring in schools. Dental Screening Examination was added in the school year. OHCA operates a comprehensive health care system for Medicaid clients. Additional information on Medicaid coverage can be found on the OHCA website at Child Eligibility For EPSDT School-Based Services Parental Notification/ Permission Payment for EPSDT School-Based Services is available for all Medicaid individuals between the ages of birth and 21. Payments are subject to the conditions and limitations that apply to these services. Payment can only be made for services provided to individuals who have active enrollment status as a Medicaid recipient on the date services were actually provided. There is no Medicaid requirement that parental consent must be obtained to bill Medicaid. When a family applies for Medicaid benefits in Oklahoma, they are agreeing to the billing of Medicaid by enrolled Medicaid providers. However, schools may wish to notify parents that Medicaid or other third parties may be billed. Parents can be assured that, as an enrolled Medicaid provider, the school will not share any information with OHCA (or the State s fiscal agent) that is not specifically related to the reimbursement of EPSDT School-Based Services. The Link between Providers and Schools have historically paid for and provided health and related services to their students, through Individualized Education Programs (IEPs) that are excluded from the SoonerCare benefits package. It is the responsibility of schools to ensure there is coordination between the recipient s SoonerCare provider and the school when EPSDT School-Based services are provided to a Medicaid eligible child. Page 5

7 . Provider Enrollment In order to bill Medicaid for EPSDT School-Based Services, local education services agencies (LEAs), including educational co-ops, must enter into an Intergovernmental Agreement for EPSDT School-Based Services (referred to hereafter as contract ) with OHCA. The purpose of the contract is to establish a school-based service delivery system, in accordance with the EPSDT program, whereby physical and mental health problems which adversely affect a child s development and impair educational functioning can be identified early, and needed diagnostic and treatment services can be delivered by the school. Services are reimbursed on a fee-for-service basis. Contracts submitted prior to July 31are effective for one year, from July 1 through June 30 of the following year. Any contract received August 1 December 31, will have an effective date starting the date contracts are received by the OHCA/EPSDT Unit. The deadline for submitting contracts to OHCA is December 31. Contracts must be submitted in triplicate. A Medicaid provider number is issued by OHCA with the approved contract. Additional information on provider enrollment can be obtained from OHCA. (Note: Contacts regarding the provider enrollment process are included in the Appendices.) Enrollment of Co-ops When health related services are provided and paid for by the co-op, the co-op enters into a contract with OHCA and is assigned a provider number and PIN. The co-op does not have to contract with OHCA if it is only submitting billing on behalf of its participating districts. In this instance, billing is submitted under each respective district s Medicaid provider number. If a district, as part of a co-op, provides and pays for health related services aside from the services being billed by the co-op, the district must enter into a separate contract with OHCA. Page 6

8 CHAPTER 3 CONTRACT ISSUES Matching Funds Schools expend the funds for the health and related services that are provided to their Medicaid eligible students. For schools who have entered into a contract with the OHCA to provide EPSDT School-Based Services, the school must certify, on an annual basis, the availability of non-federal (state/local) funds expended for these compensable services equal to the required state share match (See Appendices for current federal and state share match rates). Effective, July 1, 2004, schools will no longer be required to certify matching State dollars to OHCA but instead will receive the State share match from OHCA as an advanced payment. On a quarterly basis, OHCAwill then bill back all advanced payments of State share made on behalf of the school via an invoice. OCAS Coding Schools can only use state/local monies for matching Medicaid. If a federal grant has a cash match requirement, the funds used for the match cannot also be used as a match for EPSDT School-Based Services. Medicaid expenditures and reimbursements must be coded in accordance with the Oklahoma Cost Accounting System (OCAS). Proceeds from Medicaid will not be treated as program income under 34 Code of Federal Regulations (CFR) of the Individuals with Disabilities Education Act (IDEA) Amendments of Expenditures of Medicaid reimbursements for IDEA services will not be considered part of the state/local maintenance of effort (MOE) requirement under the IDEA, Amendments of Rate Maximum allowable rates have been established for each type of service. The school is reimbursed approximately 70% of this rate. Treatment encounters have both an individual and a group rate. If treatment is provided in a group setting, the group rate cannot be billed for more than five Medicaid eligible children in the group on a particular date of service. Effective July 1, 2004 OHCA shall pay schools 100% of Medicaid allowable costs pursuant to the provisions and requirements contained in their school based contract. Payments for services shall be made when properly completed claims are submitted to the OHCA fiscal agent. On a quarterly basis, OHCA will bill back all advanced payments of State share made on behalf of the school via an invoice. Provider claims for reimbursement must be based on state and local dollars expended for direct services. Providers may not bill Medicaid for amounts that exceed the district s expenditures for direct services. Providers may adjust the amount billed to Medicaid based on these expenditures (up to the maximum allowable amount). Administrative Fee Schools shall pay OHCA an administrative fee of 1% of paid claims process to cover the cost of administrative functions in the issuance of Medicaid payments during the contract period. The fee is currently based on 1% of federal dollars paid to the district within any given quarter (Note: effective July 1, 2004, the fee will be based on 1% of total claim payment). OHCA will invoice the school on a quarterly basis. Page 7

9 Procedure (Billing) Code Subcontracting The procedure code is the code used to identify EPSDT School-Based Services in the State s Medicaid billing system (refer to contract Addendum EPSDT SCHOOL HEALTH SERVICES ). Schools may choose to contract with third party agents to perform their billing functions or to furnish health services to their students. However, these functions cannot be performed simultaneously by the same third party agent. (Note: See Appendices for a compliance checklist for subcontracting with a third party agent.) Subcontracting for Health Services Schools can contract with individual State licensed providers or with provider agencies for health services in the school. The school must ensure that the individual provider meets the established provider qualifications for the EPSDT School-Based Service(s) being performed. The school retains responsibility for the accuracy of any/all service documentation/progress notes when submitted for billing to the OHCA fiscal agent. The school is also responsible to ensure that all children receive appropriate services, not just those who are Medicaid recipients. Examples of contract arrangements that can be made by schools include, but are not limited to, the following: Contract with nurses (RN or LPN under RN supervision) to provide nursing services; Contract with a licensed, independent speech language pathologist to provide speech therapy and speech language evaluations; Contract with licensed professional counselors (LPC), licensed social workers (LSW), licensed marriage and family therapists (LMFT), licensed psychologists, or licensed behavioral practitioners (LBP) or with an agency that employs these disciplines (agency must have JCAHO, CARF, COA or AOA accreditation), to provide psychotherapy counseling to children pursuant to the individuals IEP developed by the school district. Independent Practitioners A school may contract with outside providers (e.g., independent State licensed practitioners) to perform covered services. The school, as the Medicaid provider, bills Medicaid for these services. The school may want to consider including a clause in its contract with the independent practitioner to the effect that the independent practitioner will not bill Medicaid for any services covered under his/her contract with the school. Out-of-State Credentials If a Medicaid eligible child goes to a bordering state for services provided by an independent practitioner, which are not provided under contract with a school, the services are not reimbursable under the EPSDT School-Based Services program. (The independent practitioner would have to enroll as a Medicaid provider in the State of Oklahoma and meet all applicable requirements for reimbursement.) Covered services provided by an individual that has out-of-state credentials with whom a school contracts are reimbursable, if the school is an enrolled Medicaid provider in the State of Oklahoma. Page 8

10 Subcontracting for Billing Services Schools can contract with a billing agent to prepare and submit their Medicaid claims. The school is solely responsible for claims submitted by its billing agent. The school should review and approve the billing prior to claims submission to the OHCA fiscal agent. Billing agents must not have access to confidential progress/clinical notes. Third Party Liability/Free Care Under the third party liability (TPL) principle, Medicaid pays for services only after other potential third parties (e.g., private insurance, health maintenance organizations and other federal programs) have paid for such services. Medicaid is the payor of last resort. In other words, Medicaid does not pay for services that are provided free of charge to others (the free care rule). An exception to this principle relates to Medicaid eligible children receiving services under federal IDEA. Medicaid may be primary payor for covered medical services in a child s IEP. In order for schools to bill for non-iep health related services ( free care services) for Medicaid recipients, the school district must: 1) Establish a sliding fee scale; 2) Identify insurance for all children and; 3) Bill third party insurance for non-medicaid children. Parents may not be compelled to file a private insurance claim. If parents do not agree to have their insurance company billed, Medicaid cannot be billed for these services either. Private Insurance Billing Under the IDEA Amendments of 1997, children are entitled to a free and appropriate public education (FAPE). Parental consent must be obtained to access private insurance for the services required to provide FAPE to their child. Parents must also be informed that, even if they refuse to permit access to their private insurance, the required services will be provided at no cost to them. The school may pay for the required service or cost the parents would incur to use their insurance (such as a deductible or co-pay amount), including use of its Part B funds under IDEA. Public Insurance Billing Under the IDEA Amendments of 1997, parents may not be required to enroll in public insurance programs in order for their child to receive FAPE. Parents may not be required to incur an out-of-pocket expense, such as a deductible or co-pay amount, if a claim were filed for such services. The school may pay the cost that the parent would otherwise be required to pay if their public insurance were used, including use of its Part B funds under IDEA. A school may not use a child s public insurance benefits if it would decrease available lifetime coverage or any other insured benefit, result in the family paying for services provided outside of school that would otherwise be covered by the public insurance, increase premiums or lead to discontinuation of insurance, or put the child at risk of losing eligibility for home and community-based waiver services. The Page 9

11 use of Medicaid for these services will not reduce the child s Medicaid benefits. Care Coordination Linking the child to his/her medical home so that preventive health care can be furnished on a regular basis is a critical part of care coordination. Schools should inform SoonerCare providers of the children in their district who have an urgent need for an EPSDT screen within a given school year. Referrals to SoonerCare providers should be documented on the EPSDT SCREENING & NOTIFICATION STATEMENT ; Addendum of the EPSDT school contract, as well as contact with parents if the medical provider is unknown. The school should coordinate the ongoing health services that the child is receiving with the child s SoonerCare provider. Schools can obtain the name of a child s SoonerCare provider in the following ways: Ask parents/guardians or children (who have reached the age of majority or emancipated youth) to provide the name of their SoonerCare provider on registration material, at the time services are initiated, or when Medicaid eligible children are identified. Access the name of the child s SoonerCare provider by obtaining eligibility verification through OHCA s fiscal agent, EDS. Access the name of the child s SoonerCare provider through the Eligibility Verification System (EVS), an automated phone system operated by OHCA, or a dedicated line with DHS. Contract Obligations Schools are obligated, under the Intergovernmental Agreement for EPSDT School-Based Services, to do the following: Deliver Medicaid-covered services; Ensure that Individual/Group Treatment Encounters are provided pursuant to the Medicaid recipient s IEP. Ensure that services are medically indicated and necessary; Ensure that individual service providers are appropriately qualified under guidelines established by OHCA and subcontracted behavioral health service agencies are consistent with current OHCA outpatient behavioral health guidelines (JCAHO, CARF, AOA, or COA accreditation is required); Perform EPSDT screens in limited circumstances and forward the results to the child s PCP; Assist in facilitating EPSDT screens for individuals covered by fee-forservice Medicaid, or perform EPSDT screens for these individuals; Designate a school district employee, as Medicaid Coordinator, to attend the annual training provided by OHCA and to be available for all necessary EPSDT meetings, conferences or audits (Note: Medicaid Coordinator may not be district contracted staff); Designate district OCAS personnel to attend an annual training conducted by OSDE. The school must provide OHCA the name of the district contractor/representative for OCAS; Ensure that if the school district subcontracts for the provision of health services and billing, these functions are performed by separate entities; Notify OHCA of all subcontractors and the functions they perform within Page 10

12 Page days of entering this agreement, or within 10 days of any change in subcontractors; Submit claims according to OHCA s instructions; Certify that the estimated State Match is available and has been appropriated in the school district s budget (Addendum I of the contract). Addendum I must be completed and submitted with the contract. Effective July 1, 2004, schools will no longer be required to certify State Match dollars; Provide the non-federal match for services provided under the agreement and provide OHCA with the Certification of Match (Addendum III of the contract) by August 31of each year. The contract will not be processed and executed until OHCA has received the Addendum III for the prior contract year. Effective July 1, 2004, schools will no longer be required to certify State Match dollars; Code Medicaid expenditures and reimbursements in accordance with the Oklahoma Cost Accounting System (OCAS); Credit funds received through Medicaid reimbursement for special education and/or health related services. Pay OHCA an administrative fee of 1% of paid claims processed to cover cost of administrative functions in the issuance of federal dollar payments during the contract period. The fee will be based on 1% of federal dollars paid to the district within any given quarter. (Note: effective July 1, 2004, the fee will be based on 1% of total claim payment). OHCA will invoice school on a quarterly basis; Effective July 1, pay OHCA back the advanced state share made on behalf of the school. OHCA will invoice school on a quarterly basis. Keep required documentation on the services provided and payments claimed for a period of six years from date of service.

13 CHAPTER 4 COVERED SERVICES: GENERAL SERVICE REQUIREMENTS Introduction The general service requirements that apply to all EPSDT School-Based Services are described below. Any exceptions to this general information that apply to a specific service are noted in the service chapters that follow. Chapters 6-11 contain more detailed information on each EPSDT School-Based Service. Each service chapter includes a definition of the service, specific provider qualifications, unit of service, rate, and service authorization requirements (as specified in the Medicaid State Plan and the administrative rules.) The service chapters (and sections) have been designed as pull-outs for easy distribution to individual service providers. A district should provide all individual service providers with a copy of this chapter and the applicable service chapters or chapter sections. Medical Necessity Medicaid reimburses for services for which a child has a determined medical need. The services provided to an eligible child should be individualized and consistent with the symptoms or confirmed diagnosis of a specific disorder or delay. OHCA has adopted the following standards (OAC 317:30-3-1) concerning the establishment of medical necessity: (1) Services must be consistent with accepted health care practice standards and guidelines for the prevention, diagnosis or treatment of symptoms of illness, disease or disability; (2) Documentation submitted in order to request services or substantiate previously provided services must demonstrate through adequate objective medical records, evidence sufficient to justify the client s need for the service; (3) Treatment of the client s condition, disease or injury must be based on reasonable and predictable health outcomes; (4) Services must be necessary to alleviate a medical condition and must be required for reasons other than convenience of the client, family, or medical provider; (5) Services must be delivered in the most cost-effective manner and most appropriate setting; and (6) Services must be appropriate for the client s age and health status and developed for the client to achieve, maintain or promote functional capacity. Provider Qualifications Licensure/Certification Schools can only be reimbursed for services that are rendered by employed or contracted staff who meets the qualifications established for the EPSDT School- Based Services program at the time the service is rendered. Each service category has its own provider qualifications. Providers may only perform the service activities that are within their scope of practice. Provider qualifications requiring a State license refers to a professional license issued under State law by the applicable State licensing board (e.g., Licensed Speech Language Pathologists are licensed by the Board of Examiners under the Page 12

14 Speech Pathology and Audiology Licensing Act). Provider qualifications requiring certification refers to certification by the OSDE, unless otherwise specified. (Note: See Covered Services chapters for provider qualifications specific to each service.) Temporary Licensure Temporary licensure meets the Medicaid provider qualifications for a licensed practitioner as long as the requirements for the temporary license also meet the rules of the OSDE and OHCA for that professional type. Services Provided Under Supervision Services may not be provided under supervision, unless specifically authorized and in accordance with State laws governing professional practice. These exceptions are noted in the service chapters, as applicable. Service Authorization Services, with the exception of Child Health Encounter, Dental Screening Examination, and initial evaluations, must be authorized (i.e., specified) in the child s individualized treatment plan. The plan should identify the need for service(s); the scope, frequency and duration, the provider and a beginning and ending date. Speech Language Pathology services require a referral from a physician or licensed practitioner of the healing arts. Occupational Therapy services and Physical Therapy services require a prescription from a physician or licensed practitioner of the healing arts. In the state of Oklahoma, only persons with the designation of Doctor are practitioners of the healing arts, (59 Oklahoma Statute (2001)). Title designates 9 types of doctorates that allow a person be a practitioner of the healing arts. Those persons include a Ph.D or Ed.D regarding a person with a doctoral degree in speech and language pathology or audiology. Referral may only be made by practitioners within his/her scope of practice. Treatment Plan The individual treatment plan serves as the service authorization document. It should include a signature by the health care professional(s) authorized to determine the need for specific EPSDT School-Based Services. If the professional is a subcontractor, a school district employee s signature must also be on this document. For children with disabilities who have IEPs, IDEA federal regulations require documentation of parental notice and participation in implementing or changing related services, as well as informed written consent to conduct evaluations. IHSP There may be circumstances where a child with a disability has both an Individual Health Services Plan (IHSP) and an IEP. The IDEA requires documentation on the IEP to address all related services that are necessary for the child to benefit from their education. In such cases where there is an IHSP, in addition to the child s IEP, the IHSP is treated as secondary to the IEP. In order to bill Medicaid for services that are delivered based upon goals/objectives identified in an IHSP, the IHSP must be developed by a team inclusive of school personnel and qualified service delivery provider(s). Page 13

15 An IHSP is an individualized treatment plan for EPSDT School-Based Services. As mentioned above, the IHSP is secondary to the IEP and the IDEA requires that all related services be identified in the child s IEP. The IHSP addresses services for children with serious or chronic health-related problems for which services during the school day are needed. Examples may include children with diabetes, seizures, or asthma for which ongoing nursing intervention is required. There are also children who have an IHSP (treatment plan) for psychological and/or psychotherapy counseling services. These services must also be included in the child s IEP. An IHSP must be signed by the provider(s) that determined the need for service(s) (this may also be the provider(s) that will be performing the service(s)) and by a school employee. A parent signature on an IHSP is not a written Medicaid program requirement. However, in schools, parents must be notified (and have the opportunity to respond) prior to implementing an IHSP and must provide informed written consent to conduct intake, assessment or psychological evaluations. An IHSP should be reviewed within the timelines indicated in the plan, based on the child s particular needs. The IHSP is sometimes used as the primary treatment plan for non-iep health related services of recipients who do not have an IEP in place. However, in order for schools to bill for non-iep health related services for Medicaid recipients, the school district must: 1) Establish a sliding fee scale; 2) Identify insurance for all children and; 3) Bill third party insurance for non-medicaid children. Parents may not be compelled to file a private insurance claim. If parents do not agree to have their insurance company billed, Medicaid cannot be billed for these services either. Service Limitations Place of Service Unit of Service Daily limits have been established for all EPSDT School-Based Services. This means that a maximum number of service units will be reimbursed for a child on a given day. The Child Health Encounter has an annual limitation; however additional units for medically necessary services may be requested through the prior authorization process (if need for additional units; contact the OHCA EPSDT Unit for guidance). These service limitations are noted in the service chapters, as well as any applicable procedures for obtaining prior authorization for additional service units. For Medicaid reimbursement purposes, services may be provided at the school, at the child s home or at another site in the community. Each service has a specified unit for billing purposes. This is time spent in a direct service. Direct service should be face-to-face with the child (exceptions may be completing a child health history; or providing health education to the parent/guardian; but at all times service must be individualized to the child s needs). There is no reimbursement for time reviewing/completing paperwork/documentation related to the service or for staff travel to/from the site of service, unless otherwise specified. Most units of service are time-based, meaning that the service must be of a minimum duration in order to be billed. A unit of service that is time-based is Page 14

16 continuous minutes; the time cannot be aggregated throughout the day. Example: A physical therapist provides therapy service to a Medicaid eligible child from 9:00 a.m. to 9:20 a.m. One unit of service should be billed. (Physical therapy is billed in 15-minute increments.) The additional five minutes cannot be billed because it does not constitute a full unit of 15 continuous minutes. There are no minimum time requirements for Evaluation Services, for which the unit of service is generally a completed evaluation. The only exception is the Psychological Evaluation, which is billed in hourly increment. Page 15

17 CHAPTER 5 DOCUMENTATION Documenting Medical Necessity In order to bill Medicaid for EPSDT School-Based Services, documentation must reflect medical necessity. Medical necessity must be documented through the provider assessment/evaluation/testing of the child that clearly identifies the child s delay and/or disability and how the child s education is affected by the identified delay and/or disability (IDEA requires the same principles in determining the need for services). Documentation All EPSDT School-Based Services are subject to state and federal audit. The following documentation must be kept at the school district site when a Medicaid-reimbursable service is delivered: Child s name and Medicaid number (and person code) Date of service Description of the service performed Duration (or unit) of the service, with start and stop time Brief comment/progress note with an original signature by the service provider, including credentials No standard service logs or documentation forms are required. The documentation must be maintained onsite at the district in a manner and format that is efficient for the individuals providing the service but also accessible in the event of an audit. Progress Notes The intent of a progress note is to tie the service being performed and the outcomes achieved back to the individual treatment plan goals and objectives. At a minimum, progress notes must include a brief description of the service or treatment activity--what occurred or what was worked on with the child and, as appropriate, some indication of the child s progress (e.g., improved, no change, etc.) and need for continued treatment or follow-up, based on the observations and treatment rendered during that particular encounter with the child. No standard format for progress notes is required. SOAP (subjective, objective, assessment, plan) notes are one format for writing progress notes utilized by some health care professionals, but are not a required format. A written progress note is the supporting documentation that a service was actually provided and necessary. Consideration of the following questions will assist providers in writing a thorough progress note: Why did the child present for the service/treatment? (Why is this service necessary?) What was observed during the service/treatment encounter (i.e., ongoing assessment)? What kind of treatment did the child receive during this service/treatment encounter? What was the outcome of this service/treatment encounter? (What is necessary, if anything, for follow-up or continued treatment?) Page 16

18 The start/stop time of the service must be included in the progress note. Progress notes must be kept on-site of the district and accessible for review or audit purposes. The service provider must sign progress notes. Initials may be used as long as the provider s original signature with credentials and initials also appear on the documentation form. When services such as occupational or physical therapy are provided by a licensed assistant under the direction of a licensed therapist, the licensed therapist should review and sign the progress notes as part of their supervisory responsibility. Start/Stop Time Documentation must include the beginning and ending time of service delivery for all services. Electronic Documentation Electronic documentation is acceptable. However, hard copies of the documentation, with an original provider signature must be maintained on-site of the servicing district and accessible for review or audit purposes. Records Retention Original records documenting the extent of services provided to individuals under the EPSDT School-Based Services contract and payments claimed for these services must be maintained on-site of district for six years from date of service. This documentation requirement includes documentation for services provided by subcontractors. Records can be archived according to district record management policy but must be accessible for review or audit purposes. Audit Requirements All EPSDT School-Based Services are subject to state and federal audit. As the Medicaid provider, the school certifies that the services being claimed for Medicaid reimbursement were medically necessary and were furnished under the provider s direction. Both fiscal and clinical compliance will be monitored. (Note: See Appendices for quality assurance tools, including an audit preparation checklist.) The Surveillance and Utilization Review System (SURS), a unit within OHCA, is responsible for conducting audits of EPSDT School-Based Services. Generally, these are post-payment reviews as they occur after a school receives reimbursement for the services that are being reviewed. SURS will review documentation of the services provided by a school (e.g., need for services, treatment plans and case/progress notes) and compliance with Medicaid rules and regulations, including the qualifications of individual service providers. SURS uses a computerized method of statistical analysis to identify providers who are outliers or perceived over-utilizers. SURS may look into the circumstances that resulted in service utilization or payments being larger than or outside the average of those made to comparably-sized schools over a period of time. Page 17

19 CHAPTER 6 CHILD HEALTH ENCOUNTER Definition The child health encounter may include a diagnosis and treatment encounter or a home visit. A child health encounter may include a child health history, physical examination, developmental assessment, nutritional assessment and counseling, social assessment and counseling, genetic evaluation and counseling, indicated laboratory and screening tests, screening for appropriate immunizations, health counseling and treatment of childhood illness and conditions. Provider Qualifications SDE certified special education related services professionals (such as school nurses, school psychologists) or other State licensed or certified health care professionals (such as speech language pathologists, licensed professional counselors). Service Unit An encounter is in time increments up to 3 units of service, as follows: 5 10 minutes of service is 1 unit; over 10 minutes to 20 minutes is 2 units; over 20 minutes is 3 units. Rate Service Limitation $11.67 per unit 30 units per year. Additional units must be prior authorized. Daily maximum limit: 6 units Service Authorization Documented referral Clarification Types of Providers Based on the above provider qualifications, the following are providers who may perform this service for Medicaid reimbursement: (Professionals may only perform the specific service activities that are within their scope of practice.) School nurse/licensed registered nurse Licensed practical nurse (under supervision) Licensed psychologist Certified school psychologist Licensed speech language pathologist Speech pathology assistant (under supervision of a licensed independent practitioner in accordance with the Speech Pathology and Audiology Licensing Act) Licensed occupational therapist Licensed physical therapist Licensed audiologist Licensed professional counselor Licensed social worker Licensed marriage and family therapist Licensed behavioral practitioner Certified vision impairment teacher Orientation and mobility specialist Certified deaf education teacher Page 18

20 Scope The intent of a Child Health Encounter is that it is the initial assessment or screening tool that determines the need for additional evaluation or treatment services, and where appropriate, leads to the development of an individualized treatment plan. There may be circumstances when the encounter is used to provide health counseling or treatment of an incidental nature (i.e., there is no need for ongoing treatment services). The following is intended to clarify the scope of a Child Health Encounter: Service is child-specific and child-focused; most will require a face-to-face encounter with the child. (Exceptions may be completing a child health history with, or providing health education to the parent or guardian.) Service is performed based on a child s medically indicated need. Screening for immunizations must include some contact with or on behalf of the child. Health screenings, such as for vision or hearing, may be billed in the following instance: A child has an individualized medical need that warrants a screening or assessment to determine the need for further services (i.e., there is a referral for screening). IEP authorization for vision and hearing screens performed as part of an annual review fulfills the referral requirement. Documentation should reflect that the screens were done pursuant to the IEP. Self-referrals for service are not prohibited. The daily limit may not exceed a total of six units. The six units may be up to six separate medically necessary health encounters (that are each 5 10 minutes in duration) or the six units may be comprised of fewer separate health encounters that are longer in duration (e.g., three separate health encounters of two units (10 20 minutes in duration) each. Service Exclusion Medicaid reimbursement for Child Health Encounters does not include the following: Paper immunization screenings for school enrollment purposes Preventive health screenings Administering/monitoring of medication (Note: This may be appropriately billed as a Nursing Service. See Chapter 5 Section E.) Services provided on a routine or ongoing basis Classroom education on health/mental health prevention Prior Authorization When a child has received the 30 units of Child Health Encounter permitted per year, prior authorization must be obtained from OHCA to claim additional encounters. Contact OHCA for instructions on requesting additional encounters. Page 19

21 CHAPTER 7 INDIVIDUAL/GROUP TREATMENT ENCOUNTER Definition An individual/group treatment encounter may occur through the provision of individual or group treatment services to children who are identified as having specific disorders or delays in development, emotional, or behavioral problems, or disorders of speech, language or hearing. These types of encounters are initiated following the completion of a diagnostic encounter and subsequent development of a child s IEP. Includes: Hearing and Vision Services (See Section A) Speech and Language Therapy (See Section B) Occupational Therapy (See Section C) Physical Therapy (See Section D) Nursing Services (See Section E) Psychological Services (See Section F) Psychotherapeutic Counseling Services (See Section G) Assistive Technology Services (See Section H) Provider Qualifications Specific to the professional areas of services as defined under OHCA rules. (See specific provider qualifications for each service category under the Individual/ Group Treatment Encounter in Sections A - H that follow.) Service Unit Rate Service Limitation Service Authorization Completed 15-minute increments unless specified otherwise. $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: varies by service Services must be authorized in the child s IEP and, where indicated, must have a doctor referral/prescription Page 20

22 CHAPTER 7 - SECTION A HEARING AND VISION SERVICES Definition May include habilitation activities, such as auditory training, aural and visual habilitation training, including Braille, and communication management; orientation and mobility; counseling for vision and hearing losses and disorders. Provider Qualifications Service Unit Rate Service Limitation Service Authorization State licensed, master s degree audiologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. State licensed, master s degree speech language pathologist who (1) holds a certificate of clinical competence from the ASHA; or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. State certified deaf education teacher Certified orientation and mobility specialist State certified vision impairment teacher Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: 8 units Services must be authorized in child s IEP. Page 21

23 CHAPTER 7 - SECTION B SPEECH LANGUAGE THERAPY SERVICES Provider Qualifications Service Unit Rate Service Limitation Service Authorization State licensed speech language pathologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. Speech pathology assistant, authorized by the Board of Examiners, working under the direction and employment of a State licensed speech language pathologist. The supervising pathologist must be on site and may not supervise more than two speech pathology assistants. Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: 8 units Services must be authorized in child s IEP. Federal regulations require a referral from a physician or licensed practitioner of the healing arts for Speech Language Pathology services. In the state of Oklahoma, only persons with the designation of Doctor are practitioners of the healing arts, (59 Oklahoma Statute (2001)). Title designates 9 types of doctorates that allow a person be a practitioner of the healing arts. Those persons include a Ph.D or Ed.D regarding a person with a doctoral degree in speech and language pathology or audiology. Practitioner may only refer within their scope of practice. Clarification Types of Providers Speech pathologists in their clinical fellowship year (CFY) are permitted to bill for speech language therapy services. Bachelor s level speech therapists may not bill for speech therapy services under the supervision of a licensed speech language pathologist. Supervision of Speech Pathology Assistants Scope Oklahoma s Speech Pathology and Audiology Licensing Act requires that speech pathology assistants who are properly authorized under the law must perform under the direct supervision and employment of ASHA certified and State licensed speech pathologists. Speech pathology assistants cannot, therefore, be employed and supervised by school districts. The supervisor must be available for direct on-site supervision. An independent practitioner may contract with an enrolled school to provide speech and language services for which the school bills Medicaid. Speech language therapy can be provided to an eligible child in the child s classroom if it is for the benefit of that child and is provided in accordance with his/her treatment plan goals and objectives. Page 22

24 CHAPTER 7-SECTION B (continued) SPEECH LANGUAGE EVALUATION Provider Qualifications Service Unit State licensed speech language pathologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. One evaluation Rate $45.00 Service Limitation Service Authorization Daily maximum limit: 1 unit Documented doctor referral for initial evaluation. Evaluation must be authorized in child s IEP. Clarification All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan Initial evaluations are billable only if, after initial evaluation, the service is determined medically necessary, and when the service(s) are included in the the child s IEP and the initial evaluation date is noted on the IEP. Re-evaluations must be authorized in the child s treatment plan. Page 23

25 CHAPTER 7 SECTION C PHYSICAL THERAPY SERVICES Provider Qualifications Service Unit Rate Service Limitation Service Authorization State licensed physical therapist Physical therapy assistant authorized by the Board of Examiners, working under the supervision of a licensed physical therapist. The licensed physical therapist may not supervise more than three physical therapy assistants. Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: 8 units Services must be authorized in child s IEP. Federal regulations require a prescription from a physician or licensed practitioner of the healing arts for Physical Therapy services. In the state of Oklahoma, only persons with the designation of Doctor are practitioners of the healing arts, (59 Oklahoma Statute (2001)). Practitioner may only prescribe within their scope of practice. PHYSICAL THERAPY EVALUATION Provider Qualifications Service Unit State licensed physical therapist One evaluation Rate $35.00 Service Limitation Service Authorization Daily maximum limit: 1 unit Documented doctor prescription. Reevaluation must be authorized in child s IEP. Clarification All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan Initial evaluations are billable only if, after initial evaluation, the service is determined medically necessary, and when the service(s) are included in the child s IEP and the initial evaluation date is noted on the IEP. Re-evaluations must be authorized in the child s IEP. Page 24

26 CHAPTER 7 SECTION D OCCUPATIONAL THERAPY SERVICES Definition Provider Qualifications Service Unit Rate Service Limitation Service Authorization Clarification May include the provision of services to improve, develop or restore impaired ability to function independently. State licensed occupational therapist Occupational therapy assistant authorized by the Board of Examiners, working under the supervision of a licensed occupational therapist Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: 8 units Services must be authorized in child s IEP. Federal regulations require a prescription from a physician or licensed practitioner of the healing arts for Occupational Therapy services. In the state of Oklahoma, only persons with the designation of Doctor are practitioners of the healing arts, (59 Oklahoma Statute (2001)). Practitioner may only prescribe within their scope of practice. If an occupational therapist provides both occupational therapy and assistive technology services to a child, both services must be included as a related service in the IEP. OCCUPATIONAL THERAPY EVALUATION Provider Qualifications State licensed occupational therapist Service Unit One evaluation Rate $35.00 Service Limitation Service Authorization Daily maximum limit: 1 unit Documented doctor referral for initial evaluation. Reevaluation must be authorized in child s IEP. Clarification All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan Initial evaluations are billable only if, after initial evaluation, the service is determined medically necessary, and when the service(s) are included in the child s IEP and the initial evaluation date is noted on the IEP. Re-evaluations must be authorized in the child s IEP. Page 25

27 CHAPTER 7 --SECTION E NURSING SERVICES Definition Provider Qualifications Service Unit May include the provision of services to protect the health status of children, correct health problems and assist in removing or modifying healthrelated barriers. Services include medically necessary procedures rendered at the school site, such as catheterization, suctioning, administration and monitoring of medication. School nurse licensed as registered nurse Licensed practical nurse (LPN) working under the supervision of a registered nurse (in accordance with OK Nurse Practice Act). Completed 5-minute increments Rate $5.83 Service Limitation Service Authorization Daily maximum limit: 24 units Services must be authorized in the child s IEP Clarification Supervision of LPNs In accordance with the Oklahoma Nurse Practice Act, LPNs must be supervised by a physician or registered nurse (RN). It is recommended that if the supervising RN is not a school employee, that the school include specific responsibilities for supervising LPNs in their contract with the RN. LPN s Scope of Practice LPNs may perform some Child Health Encounter activities under supervision and within their scope of practice, in accordance with the Oklahoma Nurse Practice Act. These activities may include vision, hearing, immunization screenings; health counseling; and triage of childhood illness and conditions. LPNs may contribute to the assessment of the health status of an individual. It is not within a LPN s scope of practice to perform a child health history or an initial (diagnostic) assessment. Medication Administration & Monitoring Medication administration and monitoring that is deemed medically necessary, can be billed only if the service took the full time increment to perform. The provider needs to document that the service shows medically necessary monitoring of the child, as well as administering medication. A progress note must be written for each medication administration and monitoring service provided.. Page 26

28 CHAPTER 7 SECTION F PSYCHOLOGICAL SERVICES Definition Provider Qualifications Service Unit Rate Service Limitation Service Authorization Planning and managing a program of psychological services, including the provision of counseling for children and parents, consulting on management of severe behavioral and emotional concerns in school and home. All services must be for the direct benefit of the child. State licensed psychologist SDE certified school psychologist Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Daily maximum limit: 8 units Individual 12 units Group Services must be authorized in the child s IEP. Clarification Psychological Services provided by schools are subject to the criteria for EPSDT School-Based Services (e.g., must be authorized in IEP) and must meet the medically necessary criteria. These services are not subject to the OFMQ approval criteria that is established for other Medicaid behavioral health services. The service in intended to be provided to the child and for the direct benefit of the child (ie. face-to-face with the child, with the exception of an occasional consult meeting with parent/guardian, teacher, etc. to discuss the child s progress or lack of progress and possible revision of care plan). The group code may only be used when providing clinical group counseling. Service Exclusions Children receiving therapeutic foster care services under the DHS contract can not also receive Psychotherapy Counseling Services under the EPSDT School-Based Services program. Page 27

29 PSYCHOLOGICAL EVALUATION & TESTING Provider Qualifications State licensed, Board certified psychologist or SDE certified school psychologist Service Unit Rate Service Limitation Service Authorization Per hour (with written report) $58.33 per hour None Documented referral for initial evaluation and when psychological service is added to the child s IEP. Re-evaluation must be authorized in the child s IEP. Clarification Report Writing All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan Initial evaluations are billable only if and when psychological/psycho-therapy services are added to the child s IEP and the initial evaluation date is noted on the IEP. Re-evaluations must be authorized in the child s IEP. The time spent writing a psychological evaluation report is not billable. The actual write-up of a report is considered to be an inherent part of the reimbursement amount. Page 28

30 CHAPTER 7 SECTION G PSYCHOTHERAPY COUNSELING SERVICES Definition Provider Qualifications Service Unit Rate Provision of counseling for children. All services must be for the direct benefit of the child. State licensed social worker State licensed professional counselor State licensed psychologist SDE certified school psychologist State licensed marriage and family therapist State licensed behavioral practitioner Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Service Limitation Service Authorization Daily maximum limit: 8 units Individual 12 units Group Services must be authorized in child s IEP. Clarification Scope Psychotherapy Counseling Services provided by schools are subject to the criteria for EPSDT School-Based Services.. They are not subject to the OFMQ approval criteria that have been established for other Medicaid behavioral health services. Psychotherapy counseling under this program is intended to be provided to the child and for the benefit of the child. In the occasional circumstances that a parent/guardian is brought into a counseling session with a child, it may be a billable service. If the family needs counseling, this needs to be provided outside of the school-based Medicaid program. A referral could be made through other programs. Service Exclusions Children receiving therapeutic foster care services under the DHS contract cannot also receive Psychotherapy Counseling Services under the EPSDT School-Based Services program. Page 29

31 CHAPTER 7 SECTION H ASSISTIVE TECHNOLOGY SERVICES Definition Provider Qualifications Service Unit Rate Provision of services that help to select a device and assist a child with a disability (ies) to use an assistive technology device, including coordination with other therapies and training of child and caregiver. State licensed speech language pathologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. State licensed physical therapist State licensed occupational therapist Completed 15-minute increments $17.50 individual rate; $7.50 group rate (group of no more than five recipients) Service Limitation Service Authorization Daily maximum limit: 8 units Services must be authorized in the child s IEP. Clarification If the child needs both a direct therapy service and assistive technology service, both services must be included as a related service in the IEP. Page 30

32 CHAPTER 8 PERSONAL CARE SERVICES Definition Provider Qualifications Service Unit Provision of personal care services allows children with a disability (ies) to safely attend school; includes but is not limited to, assistance with toileting, feeding, positioning, hygiene and riding a school bus to handle medical or physical emergencies. All services must have medical necessity. Registered paraprofessionals/assistants who have completed training approved or provided by SDE, or personal care assistants, including licensed practical nurses (LPN), who have completed on-the-job training specific to their duties. Completed 10-minute increments Rate $1.70 Service Limitation Daily maximum limit: 48 units Service Authorization Services must be identified in child s IEP Clarification Types of Providers Scope State Department of Health certified nurse aides (CNA) may provide Personal Care Services in schools under supervision of a registered nurse. It is recommended that the school district and the registered nurse jointly agree on this responsibility for supervision. CNAs are not required to complete the paraprofessional training provided by SDE. The following is intended to clarify the scope of Personal Care Services: Pursuant to an individualized treatment plan, a trained paraprofessional may ride a school bus with a child (or children) in order to provide intervention in the event of a physical or medical emergency. The amount of time the paraprofessional provides services while on the bus should be billed for the child in 10-minute increments.. If, during the course of a bus ride, Personal Care Services have to be provided to more than one child (pursuant to each child s individualized treatment plan), the time (units of service) should be allocated between those children. Bus drivers (who may have completed the paraprofessional training) cannot perform Personal Care Services while also driving a bus. Documentation Time spent providing the direct personal care service must be documented. A daily progress noted signed by the provider, is also required. A student s Personal Care Services must be documented (e.g., toileting, feeding, description of student s specific emotional/behavioral needs for which behavioral monitoring in the classroom is required, etc.) on the child s IEP. Please note: monitoring alone is not billable time; billable time may be where an outburst occurs and there is threat of harm to self or others and the paraprofessional has to contain/redirect the child. Para would need to clearly document the outburst and what she/he did to get the child under control and redirected. Page 31

33 CHAPTER 9 IMMUNIZATION (ADMINISTRATION ONLY) Definition Immunizations must be coordinated with the primary care provider (PCP) for those Medicaid eligible children enrolled in SoonerCare. An administration fee, only, can be paid for immunizations provided by the schools. Because immunizations are a component of the EPSDT child health screening examination, schools must use the same guidelines that apply to the EPSDT exam. However, immunizations may be given to a child after an attempt is made for the child to receive the service from the HMO or PCP (e.g., the parent failed to keep an appointment and further delay will result in the child not being able to attend school.) Provider Qualifications School nurses licensed as registered nurses or LPNs working under their supervision. Service Unit Immunization, one administration Rate $13.33 Service Limitation None Service Authorization SoonerCare provider, unless appointment cannot be scheduled, or circumstances will result in the child not being able to attend school. Clarification Documentation When a school intends to provide immunizations to a child, a copy of the EPSDT SCREENING & NOTIFICATION STATEMENT ; Addendum of the EPSDT School-Based Services contract must be mailed to a SoonerCare member s primary care provider prior to the immunizations being provided as notice of the school s intent to bill for immunizations. When a school provides immunizations, the original Addendum must be retained in the child s record. If immunizations are provided, results must be forwarded to the SoonerCare provider. (This does not apply to children covered by fee-for-service Medicaid.) Page 32

34 CHAPTER 10 SECTION A HEARING EVALUATION & HEARING AID EVALUATION, BINAURAL Definition Includes pure tone air, bone and speech audiometry. Provider Qualifications State licensed audiologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. Service Unit Completed evaluation Rate Hearing evaluation: $40.00 Hearing aid evaluation, binaural: $52.50 Service Limitation Daily maximum limit: 1 unit each Service Authorization Documented referral for initial evaluation. Re-evaluation must be authorized in IEP. Clarification All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan Initial evaluations are billable only if the initial evaluation date is noted on the IEP. Re-evaluations must be authorized in the child s treatment plan.. Page 33

35 CHAPTER 10 SECTION B EAR IMPRESSION (FOR EARMOLD) Definition Provider Qualifications Service Unit Rate Service Limitation Includes taking impression of a client s ear and providing a finished earmold which is used with the client s hearing aid. State licensed audiologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. Two molds (one per ear) $25.00 per ear Daily maximum limit: 2 units Service Authorization Documented referral for initial evaluation. Re-evaluation must be authorized in IEP.. Clarification Scope All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan. Reevaluations must be authorized in the child s treatment plan. Page 34

36 CHAPTER 10 SECTION C AUDIOMETRY TEST (IMMITTANCE IMPEDANCE AUDIOMETRY OR TYMPANOMETRY) Definition Provider Qualifications Service Unit Includes bilateral assessment of middle ear status and reflex studies (when appropriate). State licensed audiologist who (1) holds a certificate of clinical competence from the American Speech and Hearing Association (ASHA); or (2) has completed the equivalent educational requirements and work experience necessary for the certificate of clinical competence from the ASHA; or (3) has completed the academic program and is acquiring supervised work experience to qualify for the certificate of clinical competence from the ASHA. Audiometric Test: Completed test (both ears) Tympanometry and Acoustic Reflexes: Completed test Rate $15.00 Service Limitation Daily maximum limit: 1 unit of each test Service Authorization Documented referral for initial evaluation. Reevaluation must be authorized in IEP. Clarification All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan Initial evaluations are billable only if the initial evaluation date is noted on the IEP. Re-evaluations must be authorized in the child s treatment plan.. Page 35

37 CHAPTER 10 SECTION D VISION SCREENING EXAMINATION Definition Provider Qualification Service Unit At a minimum, includes diagnosis and treatment for defects in vision. State licensed Doctor of Optometry (O.D.), or licensed physician specializing in ophthalmology (M.D. or D.O.). One exam Rate $25.36 Service Limitation Daily maximum limit: 1 unit Service Authorization Documented referral for initial evaluation. Re-evaluation must be authorized in IEP. Clarification All evaluations are billed under this code, including the initial evaluation activity performed prior to the development of a treatment plan Initial evaluations are billable only if and when speech services are added to the child s IEP and the initial evaluation date is noted on the IEP. Re-evaluations must be authorized in the child s treatment plan. Page 36

38 CHAPTER 10 SECTION E DENTAL SCREENING EXAMINATION Definition Provider Qualifications Service Unit Screening for dental disease by an Oklahoma licensed dentist. Child may be referred directly to a dentist for further screening and/or treatment. State licensed Doctor of Dentistry (D.D.S.) One screening Rate $16.48 Service Limitation Daily maximum limit: 1 unit Service Authorization Documented referral Clarification Referral Procedure If a need is identified, a written referral is made to a State licensed dentist (D.D.S.) contracted with the school district to perform a dental screening examination of a child. The school may then bill this screening examination. If it is determined during this dental screening examination that further dental treatment/services are needed, the child must be referred to a Medicaid dental provider. For example, if the child is covered by a health plan (HMO), the dentist would have to contact the HMO to provide the dental care. If the child is a non-managed care recipient (e.g., covered by fee-for-service Medicaid), the child may be referred to a Medicaid-enrolled dentist for any additional treatment. Page 37

39 CHAPTER 11 SECTION A CHILD HEALTH SCREENING EXAMINATION Definition Provider Qualifications Service Unit An initial screening that includes all necessary components of the screening examination as defined under Child Health Centers at OAC 317: May be requested by an eligible individual at any time and must be provided without regard to whether the individual s age coincides with the established periodicity schedule. Coordination referral is made to the SoonerCare provider to assure at a minimum that periodic screens are scheduled and provided in accordance with the periodicity schedule following the initial screening. Medicaid eligible children enrolled in SoonerCare are referred to their SoonerCare provider for these services. In cases where the SoonerCare provider authorizes the school to perform this screen or fails to schedule an appointment within three weeks and a request has been made and documented by the school, the school may then furnish the EPSDT child health screening and bill it as a fee-for-service activity. Results of this screening for forwarded to the child s SoonerCare provider. State licensed physician (M.D. or D. O.) State licensed nurse practitioner with prescriptive authority State licensed physician assistant Completed comprehensive screening Rate $68.20 Service Limitation Service Authorization Maximum daily limit: 1 unit Referral from SoonerCare provider, unless appointment cannot be scheduled; then qualified school personnel may perform screen. Place of Service School Clarification Documentation When a school intends to perform an EPSDT screen on a child, a copy of the EPSDT SCREENING & NOTIFICATION STATEMENT ; Addendum of the EPSDT School-Based Services contract must be mailed to the SoonerCare provider prior to the screen as notice of the school s intent to bill for the screen. When a school performs an EPSDT screen on a child, the original Addendum must be retained in the child s record. If the school performs the screen, results must be forwarded to the child s PCP/SoonerCare provider. (This does not apply to children covered by fee-forservice Medicaid.) Page 38

40 CHAPTER 11 SECTION B INTERPERIODIC CHILD HEALTH SCREENING EXAMINATION Definition Provider Qualifications Service Unit Must be provided when medically necessary to determine the existence of suspected physical or mental illness or conditions. May include physical, mental or dental conditions. The determination of whether an interperiodic screen is medically necessary may be made by a health, developmental or educational professional who comes into contact with the child outside of the formal health care system. Medicaid eligible children enrolled in SoonerCare are referred to their SoonerCare provider for these services. In cases where the SoonerCare provider fails to schedule an appointment within three weeks and a request has been made and documented by the school, the school may then furnish the EPSDT child health screening and bill it as a fee-for-service activity. Results of this screening are forwarded to the child s SoonerCare provider. State licensed physician (M.D. or D. O.) State licensed nurse practitioner with prescriptive authority State licensed physician assistant Completed interperiodic screening Rate $25.00 Service Limitation Service Authorization Maximum daily limit: 1 unit SoonerCare provider, unless appointment cannot be scheduled; then qualified school personnel may perform screen. Place of Service School Clarification Documentation When a school intends to perform an EPSDT screen on a child, a copy of the EPSDT SCREENING & NOTIFICATION STATEMENT ; Addendumof the EPSDT School-Based Services contract must be mailed to the SoonerCare provider prior to the screen as notice of the school s intent to bill for the screen. When a school performs an EPSDT screen on a child, the original Addendum must be retained in the child s record. If the school performs the screen, results must be forwarded to the SoonerCare provider. (This does not apply to children covered by fee-for-service Medicaid.) Page 39

41 CHAPTER 12 BILLING FOR EPSDT SCHOOL-BASED SERVICES Authority Types of Claims EMC More detailed information about billing for EPSDT School-Based Services can be found in Subsection 7 of Section 30-7 of OHCA s administrative rules. Schools can file claims for reimbursement either manually or electronically. Instructions on filling out Medicaid claim forms can be obtained from OHCA. Further information can also be obtained from the OHCA website at Electronic media claims (EMC) are the most efficient way to file Medicaid claims. Electronic media claims help reduce billing errors, lower the district s operating costs, increase cash flow and result in an average turnaround time of seven to 10 days. There is no charge to providers for EMC submission. The school must have an agreement with the OHCA fiscal agent prior to submitting electronic claims. The OHCA's secure website is intended for providers, clerks and billing agents. This site gives you the opportunity to file claims, view claim status inquiry, claim summary, prior authorization inquiry and claim payment summary. Also, you may receive messages from the OHCA that apply specifically to you. Manual Billing (Paper Claims) Schools also have the option of billing manually. The HCFA-1500 form is used for billing of school-based services. Information should be entered legibly on the claim form, using a typewriter or a ballpoint pen with black ink. The following fields must be completed on a paper HCFA-1500 claim: 1, 1a, 2, 5 (optional), 24A, 24B, 24D, 24F, 24G, 28, 30, 31, and 33 (optional, except PIN # is required). The HCFA-1500 must be purchased from a business forms company. (Note: See Appendices for sample HCFA-1500 claim form.) Use of a Billing Agent Billing Limit Schools that do not wish to do their own electronic claim preparation can use the services of a billing agent approved by OHCA. Prior to submitting electronic claims, an agreement between the OHCA fiscal agent and the school s billing agent or subcontractor must be in place. The school is solely responsible for claims submitted by its billing agent and for the accuracy of any billing submitted by a billing agent. The school must maintain documentation showing that billing was reviewed and approved prior to its submission to the OHCA fiscal agent. Claims must be received by the OHCA fiscal agent (the entity that processes the State s Medicaid claims) within 12 months from the date of service. Page 40

42 Submitting Claims Claim Inquiries Original, corrected and refiled claims (HCFA-1500 forms) are submitted to the OHCA fiscal agent EDS, EDS, at the following address: EDS P.O. Box Oklahoma City, OK Inquiries about the status of a claim may be made to OHCA using procedures described in Section of OHCA s policies and procedures. The OHCA operates a customer service line. Remittance Advice Statements Remittance statements are sent to providers to explain the disposition of claims. The statements will list paid, denied and suspended claims. Remittance statements are mailed weekly and will include payment checks or a Notice of Deposit if payment was due. Error messages or adjustments appear on each remittance statement that contains a claim that has been denied or adjusted. Denied Claims Suspended Claims Adjusted Claims If payment is denied because incorrect information has been entered on the claim form, a corrected claim must be submitted in order to be properly adjudicated. The final disposition of a denied claim will be listed on the remittance document. A suspended claim will be listed as in process for the provider s information only. Generally, a suspended claim requires no action on the part of the provider. It has been suspended for internal processing reasons. The claim will appear on a subsequent remittance advice document as either paid or denied. An adjusted claim can be filed if an original claim has been filed in error. Contact the Adjustments Unit at OHCA for information on filing an adjusted claim. Page 41

43 APPENDICES

44 APPENDIX A EPSDT SCHOOL-BASED SERVICES: AN IMPLEMENTATION PRIMER FOR LOCAL EDUCATION AGENCIES Step 1: Readiness Identify (estimate) the percentage of Medicaid eligible students in the school district, interlocal or district cooperative. One rule of thumb is that the special education population has a Medicaid eligibility rate up to 10% higher than the Medicaid eligibility rate of students served in regular education. A local educational agency with at least 20% of its students on Medicaid should seriously consider becoming a provider of EPSDT School-Based Services. However, other factors, such as district size and the presence of pockets of poverty within a district, should be considered. For example, in a very large district (such as one with 30,000+ students), even 10% Medicaid means a large number of students for which billing can potentially be done. Similarly, there may be schools within a district with a very high free and reduced lunch rate. Such specific sites or programs could be identified to participate in the Medicaid program, while others located in higher income neighborhoods would not. Small districts should also seriously consider enrolling as providers of EPSDT School-Based Services. Even with a relatively small number of Medicaid eligible students, the reimbursements received from Medicaid may support funding for health and related services to at-risk students or for prevention services to a larger population. The following are two possible ways of arriving at the estimated percentage of Medicaid eligible students. 1. Identify the percentage of students participating in the free and reduced lunch program. Medicaid and the free and reduced lunch program have the same income standards (as of December 1, 1997). However, because Medicaid has some additional eligibility requirements, the actual rate of individuals who receive benefits might be lower. Subtract 5-10% from the free and reduced lunch program percentage for a conservative estimate of Medicaid eligible students (although this formula may not hold true in all localities or between schools within a district). 2. If Medicaid information is available (e.g., routinely requested at enrollment or on health forms), do an actual count or look at a sample of students across the district. Gather support for the project from the following significant groups: Administrators--a high level administrator, such as the superintendent; the director of special education; the budget director or finance officer; and someone with the authority to make decisions in the district s management information systems (MIS) department; Providers--a program supervisor or lead staff person in each program; Support staff--data and clerical services; Community providers and consumer constituents; School board. Determine whether the district will participate on its own or through an arrangement with an interlocal or multi-district cooperative.

45 Secure a commitment from the district, the interlocal or multi-district cooperative to front-end either the time or the cost of someone to coordinate this project at the beginning. Depending on the size of the district, the interlocal or multi-district cooperative, a professional staff person and an administrative assistant will be needed to some degree. Designate at least one person to act as the Medicaid coordinator for the district, the interlocal or multi-district cooperative. It is beneficial to have a contact person on the fiscal side, as well as the program side, if the coordinator is not experienced in both. Decide whether to bring up the program all at once (all providers, all services) or in phases. Establish phase-in plan, if appropriate. Identify which personnel are qualified providers and whether they are funded with State/local monies, instead of federal funds. Medicaid cannot reimburse services provided by staff whose salaries are paid with other federal funds. Step 2: Launching the Program Attend an annual training session provided by the Oklahoma Health Care Authority (OHCA). It is required that the district s designated Medicaid Coordinator attend an in-service training at least once each year. Review and complete the contract needed to enroll as a Medicaid provider; submit three original copies with signatures to OHCA. The contract must be submitted in its original version and cannot be altered or reformatted. Establish a system for distributing and receiving information (service logs, etc.) between staff who will be documenting the provision of services and the district Medicaid coordinator. Decide whether to use a billing entity or to prepare claims internally. Determine whether the district has adequate computer hardware and software capacity to perform the necessary billing functions and electronic transfers, or if upgrades are needed. Develop a method for identifying students who are Medicaid eligible. There are various options available. 1. Use the Eligibility Verification System (EVS). This is a phone verification system. The tollfree number is (800) For additional information on this system, contact OHCA Customer Services at (800) Purchase the on-line PS/2 Verification System from the Department of Human Services (DHS). For information on purchasing this system, contact Dan Yeager at (405) Establish an initial list or match of Medicaid eligible students with your county DHS office. Contact the county DHS office directly to discuss this option. 4. Establish an initial list or match of Medicaid eligible students with OHCA. To establish the procedure and schedule for obtaining this match, contact EDS at (405) (reference to Medicaid eligibility inquiry data match). Assist staff providing EPSDT School-Based Services to identify students who are eligible for Medicaid by creating files to build provider-specific lists of Medicaid eligible students; these lists would help ensure providers are documenting service logs for their Medicaid students.

46 Step 3: Implementing Fee-for-Service Billing Conduct initial orientation for administrators and/or staff. These sessions should be organized based on the size and complexity of the district. Discuss range of services, provider qualifications, design of service logs/forms for the collection of data for billing purposes, information flow, individual treatment plan (e.g., IEP) and documentation requirements. Establish procedures for care coordination for students who are receiving ongoing services from SoonerCare providers. Determine how, or if, parents will be notified that the school is going to seek reimbursement for EPSDT School-Based Services from Medicaid for eligible students. The following are possible ways to notify parents: printing a notice in a school newsletter or paper, including an announcement in a school handbook or enrollment packet, or by sharing information at a parent meeting. Distribute forms and any necessary information on the Medicaid eligibility of students receiving EPSDT School-Based Services to the provider; begin documenting the provision of services for billing; collect forms. Transfer billing data to standard claim forms (the HCFA-1500). Submit claims to the State s fiscal agent for payment. Identify problems that have been encountered, correct misinformation, and streamline billing process. Update provider staff on any changes in billing, forms or documentation requirements. Have school district Medicaid coordinator conduct periodic program reviews to ensure that billing and documentation meet all federal and state Medicaid requirements. Step 4: Coordination of EPSDT Screens Develop system for identifying Medicaid eligible students in district or cooperative who have an urgent need to receive an EPSDT screen sometime during the school year. Identify each student s SoonerCare Primary Care Physician (PCP/CM).

47 Determine whether or not the district or cooperative will perform EPSDT screens if the SoonerCare PCP/CM fails to schedule an appointment within three weeks. If the district or cooperative chooses to perform EPSDT screens, establish a procedure for ensuring that, the intent to bill for EPSDT screening is documented on the EPSDT SCREENING & NOTIFICATION DOCUMENT (Addendum of the OHCA contract), and that copies of the Addendum are sent to the SoonerCare PCP/CM. This procedure should also include a step for ensuring that the screening results are sent to the SoonerCare PCP/CM. Step 5: Reinvestment Establish procedure and decision-making process for reinvesting Medicaid reimbursements into special education and health related services. Conduct needs assessment to establish priorities for reinvestment and anticipated outcomes. Disperse new revenues. Monitor results. Code Medicaid expenditures and reimbursements in accordance with the Oklahoma Cost Accounting System (OCAS). Contact Lu Norman, OSDE, at (405) , for information about OCAS coding requirements for expenditures and reimbursements. Proceeds from Medicaid will not be treated as program income under 34 CFR of the IDEA, Amendments of Expenditures of Medicaid reimbursements for IDEA services will not be considered part of the state/local maintenance of effort requirement under the IDEA, Amendments of 1997.

48 APPENDIX B RESOURCE LIST Phone Fax OHCA RESOURCES General program and Medicaid/EPSDT information Provider enrollment and contract information EPSDT Contacts Sue Robertson (405) (405) [email protected] Shelly Patterson (405) (405) [email protected] Kjulonda Ogles (405) [email protected] Janet Byas (405) [email protected] Felicia Lewis (405) [email protected] LaQueda McDonald (405) [email protected] Canielle Preston (405) [email protected] Audit information Paula Lane, SURS (405) OHCA Customer Service (800) OHCA website ohca.state.ok.us OSDE RESOURCES OCAS coding Lu Norman, Exec. Dir., Financial Accounting (405) Waiver of confidentiality/free and reduced meals Child Nutrition Program (405) OTHER RESOURCES Medicaid eligibility verification systems information On-line PS/2 verification system Dan Yeager, DHS Data Services (405) EVS (toll free eligibility verification systeim) Eligibility verification line (800) OHCA Customer Services (800) or (405) Electronic Data Match Electronic Data Systems (405) Medicaid/SoonerCare eligibility guidelines Local DHS county office Claims or billing procedures, EMC (electronic billing) EDS/EDI Call Center (405) Assistive Technology consultation and assistance Oklahoma ABLE Tech (800) (V/TDD) or (405) Oklahoma Assistive Technology Center (OATC) (800) 700-OATC or (405) (TDD)

49 APPENDIX C Revised by OHCA Draft Revised 05/2004 QUALITY ASSURANCE CHECKLIST FOR MEDICAID PROVIDERS Quality assurance efforts should be built into districts EPSDT School-Based Services program. Records may be subject to both State and Federal audit. MEDICAL NECESSITY AND SERVICE AUTHORIZATION Appropriate doctor referral/prescription on file for Speech, Occupational and Physical Therapy Appropriate medical evaluation performed by direct service provider (ie. PT, OT, Speech) All treatment encounters and re-evaluations are authorized in IEP; frequency, duration and scope of services must be specified. Documentation of a referral for Child Health Encounters, initial evaluations, and Dental Screening Examinations. Documentation of prior approval (from OHCA) for Child Health Encounters performed in excess of the annual limitation. PERFORMANCE OF EPSDT SCREENS Documentation of attempts to contact SoonerCare PCPs for EPSDT screens (using the Addendum of the EPSDT School-Based Services contract). Documentation that screening results are sent to the PCP, if the school performs EPSDT screens. DOCUMENTATION FOR ALL EPSDT SCHOOL-BASED SERVICES All supporting documentation must be kept for up to six years form date of service; on-site of district and accessible for review/audit purposes; Documentation maintained at the school site for all Medicaid-reimbursable services, that includes: Child s name and Medicaid number (and person code) Date of service Description of service performed Duration (or unit) of service, with start and stop time Progress note with an original signature by the service provider, including credentials (and documentation of qualified supervisors for service providers such as PTAs and COTAs); Maintain original/copy of doctor referrals/prescriptions; Maintain original/copy of provider evaluation(s)/assessments; Maintain IEP authorizing the related service; Maintain individual service provider billing logs completed at the time the service is rendered. The logs must be signed and dated for each date of service; Maintain service provider(s) written daily documentation of the nature of the service encounters and progress notes. Progress notes must be signed by the provider with credentials. PROVIDER QUALIFICATIONS Maintain records (copies) of current State credentials, professional licenses, registrations or certificates for all employed or contracted individual service providers. Documentation of supervision that is provided to licensed practical nurses, licensed physical therapy assistants, licensed occupational therapy assistants, and providers of personal care services, as required. 1

50 APPENDIX C Revised by OHCA Draft Revised 05/2004 RECORD/DOCUMENTATION RETENTION Records supporting EPSDT School-Based Services are retained for six years from date of service; must be kept on-site of district and accessible for review/audit purposes; Records that disclose the type and extent of services provided to individuals under the EPSDT School- Based Services contract (e.g., provider service/billing logs, progress notes, etc.); Pertinent financial books and records concerning payments claimed for EPSDT School-Based Services are maintained (e.g., eligibility printouts or match disks; paper claims, if used; remittance documents, financial summaries, OCAS financial reports, etc.). ONGOING PROVIDER ENROLLMENT Documentation of state/local match for Medicaid eligible services expenditures. (Expenditures and reimbursements are documented according to OCAS requirements.) Name, title and phone number of the school district employee(s), designated as the Medicaid Coordinator/OCAS contact, to attend annual training provided by OHCA, and to be available at necessary program meetings, conferences or review/audits. 2

51 APPENDIX C Revised by OHCA Draft Revised 05/2004 PREPARATION FOR A CMS MEDICAID AUDIT The following information may be required during an audit by the Centers for Medicare and Medicaid Services (CMS), the federal Medicaid agency formerly known as the Health Care Financing Administration (HCFA). This list may not be all-inclusive. Note that some items are also required as part of the district s contract with OHCA to participate in the EPSDT School-Based Services program. Other items contribute to the logistics of an audit. PROVIDERS Names of all service providers (including those providers who are contracting with the district), by job title, their job descriptions, and indication of the relationship between the district and the provider. Copy of each provider s license/credentials and original signature (for all district providers, including those who are supervised and/or inactive). School location of each provider (e.g., a weekly schedule). Copy of the professional practice act and relevant documents for each related service provided and for any services that are contracted (e.g., Nurse Practice Act, Licensed Professional Counselor Practice Act, Speech Pathology and Audiology Licensing Act, etc.). STUDENTS Student attendance reports for the students being audited. School location of students being audited. PHYSICIAN ORDERS/REFERRALS Physician orders for physical, occupational & speech services. Physician orders for medications. PROGRESS NOTES/OTHER DOCUMENTATION Medication logs and provider progress notes are maintained for billing administration/monitoring of medication or nursing treatments. Progress notes from each service provider must be kept at a central location, accessible by the school district in case of a review/audit. TREATMENT PLANS Individualized Education Programs (IEP) for the students being audited. CONTRACTS Copies of contracts and subcontracts that the district has with all agencies and personnel providing a direct service and/or billing service in the district. OTHER Map of school sites and telephone numbers. 3

52 APPENDIX D Revised by OHCA Draft Revised 05/2004 SCHOOL-BASED MEDICAID EPSDT SERVICES SUBCONTRACTING WITH A THIRD PARTY BILLING OR SERVICE AGENT: A COMPLIANCE CHECKLIST FOR SCHOOLS Pursuant to its contract with the Oklahoma Health Care Authority (OHCA) for Medicaid Early Periodic Screening Diagnosis and Treatment (EPSDT) School-Based Services, school districts or cooperatives (referred to hereafter as schools ) retain responsibility for ensuring that program requirements are met, regardless of whether the services are provided by employees or subcontractors. It is recommended that a school considers the following questions when entering into a subcontract with a third party agent for billing services or to perform school-based health related services. These third party agents are referred to hereafter as subcontractors. (Note: A school may not be in compliance if any statement below is checked NO. ) Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Do all individual service providers meet the established provider qualifications for the EPSDT school-based service being performed? If contracting with a behavioral health service agency for the provision of behavioral health services (e.g., psychotherapy counseling), is that agency in compliance with current OHCA outpatient behavioral health guidelines? (JCAHO, COA, AOA or CARF accreditation is required.) Is the billing documentation accurate for services performed by a subcontracted provider? Does the school review and approve (district employee signs) all billing by a subcontracted third party billing agent, prior to its submission to the OHCA s fiscal agent? If the school subcontracts for services and billing, are these functions performed by separate entities? Does the school document sufficient expenditures of non-federal (State and local) dollars to use as the 30% match for all services, including those performed by subcontractors in accordance with the Oklahoma Cost Accounting System (OCAS)? Is the school documenting all expenditures and reimbursements (including services provided by subcontractors) in accordance with the Oklahoma Cost Accounting System (OCAS)? Does the school ensure that all children (not just Medicaid eligible recipients) receive appropriate services? Has the school notified OHCA of all subcontractors and of the functions the subcontractors perform within 30 days of entering into the annual contract (Intergovernmental Agreement for EPSDT School-Based Services) with OHCA? Has the school notified OHCA of any change in subcontractors within 10 days of the change? 1

53 APPENDIX D Revised by OHCA Draft Revised 05/2004 Yes No Yes No Yes No Yes No Yes No Yes No Are all treatment plans (IEP and where appropriate IHSPs) developed by a team that includes school personnel and qualified providers of the service? Are parents notified and given the opportunity to respond prior to the implementation of an IHSP? Does the school obtain informed written consent from parents before intake, assessment, or psychological evaluations are conducted? Does the subcontractor document services as required by the EPSDT School- Based Services manual and OHCA directives? Are the subcontractor s records maintained onsite for the district? Are the subcontractor s records available at a central district location during an audit? 2

54 APPENDIX D Revised by OHCA Draft Revised 05/2004 SUGGESTED QUESTIONS TO ASK PROSPECTIVE THIRD PARTY AGENTS 1. What is the extent of the third party agent s knowledge of special education and school practices? 2. What is the extent of the third party agent s knowledge of the Federal and State Medicaid programs, the law and regulations, and of EPSDT School-Based Services, in particular? 3. How long has the third party agent been in business in Oklahoma? In other states? 4. Ask for references and contact them. 5. Is there a clause in the proposed contract for mutual or unilateral discontinuance? 6. What are the respective responsibilities of the district and the third party agent? 7. What does the subcontracting process involve? Subcontracting for Billing Services 8. Will the third party billing agent require district providers to submit documentation on all students or just Medicaid recipients? 9. Does the third party agent allow a reasonable amount of time for the submission of service data? For payment? 10. What kind of feedback will it provide to the district on the reasons for claim denials? 11. What kind of feedback will it provide to the district on the adequacy of the documentation prepared by its providers? 12. What kind of reports will it provide to the district? Subcontracting for Service Providers 13. What are the qualifications of the third party agent s providers? 14. Where will the documentation and records be kept? 15. Is the third party agent open to random quality assurance audits by the district? 16. Are any of the third party agent s providers paid with federal funds? 17. Who writes the treatment plans? What are their qualifications? 18. Who completes the documentation forms for billing? 19. Can the third party agent comply with the schedule for turning in billing data that has been established by the district? (The district should make clear if there are any penalties for not complying.) 20. How will the third party agent reimburse the district if any claims are disallowed and result in a payback to OHCA? 21. Does the third party service agent understand the Federal/State matching for reimbursement of Medicaid services, and that the district has to certify the non-federal share of the match? 3