Procedures for Completion of Third Party Billing District and Case Manager Responsibility ASEC Revision 8/24/2010 Area Special Education Coop 1505 Central Ave NW East Grand Forks, MN 56721 218-773-0315 fax: 218-773-0924 MA Biller: Lea Duckstad lea@asec.net
Why do we bill MA for IEP Health Related Services? Federal dollars available $$$ Assists schools with budgetary dilemmas Aids special education students/programs It s the Law! Since 1989, Medicaid funds have been available to pay for health related services provided by MN public schools and included in a child s IEP, IFSP or IIIP. A federal program, administered by MDHS, which provides school districts with additional funds that help support special education programs. MA reimbursement dollars can only be used exclusively for special education (MN Statute 125A.21, subd. 3). These federal funds are considered a separate pot of MA monies. They do not affect any other Medical Assistance* or MinnesotaCare* a student/family may be receiving. (MN Statutes 125A.21, 125A.74, 125A.744 and 256B.0625, subd.26). MA Payments for IEP Services Do not count against prior authorization caps for home care services; Do not affect waiver caps or the amount of services available under the waiver; Do not count against service limits or thresholds; and IEP related services are excluded for parental fee purposes. It s The Law Beginning July 1, 2000, districts shall seek reimbursement from insurers and similar third parties for the cost of services provided by the districts whenever the services provided by the district are otherwise covered by the child s health coverage. (MN Statutes 256B.0625, subd. 26, 125A.74, 125A.744) SO WHY DO WE HAVE TO DO THIS AGAIN? Since reimbursement efforts commenced in 2000 for ASEC districts: $ 2.1 Million District Responsibility Each district must establish a system for maintaining records to document billing Medical Assistance/MNCare for certain IEP/IFSP covered services. This responsibility is generally the function of the district bookkeeper or business manager. For your district specific information See Handout A-MA District Contacts and Supervisors of PCAs list Revised August 2010 Page 2
District IEP Case Manager Responsibility Check student MA eligibility list on SpEd Web periodically for MA eligible students(required at start of EACH school year) Determine if the student has a MA billable service Determine if the student has MA consent on file and if the student does NOT; Obtain MA parental consent to bill DHS Step 1-Check student eligibility list on SpEd Web To check who is eligible in your assigned student list: 1. Log on to SpEd Web at https://15.spedforms.org/0997/ and enter your user name and password. 2. Click on Work with Students 3. At the top of the list of students you will see the option to indicate MA eligible Check the MA eligible option. These are your current eligible students. Step 2-Determine if the student has MA billable service Now that you have access to the list you will need to see if any of those students receive or will receive one of the following services: Physical therapy Occupational therapy Speech Language Hearing Services Nursing Services Personal Care Assistance Services Assistive Technology Devices Special Transportation Interpreter Services IEP Evaluations Revised August 2010 Page 3
Step 3-Determine if consents are on file To check whether or not the student has current consents on file go to Work on this file Click MA forms (third yellow box on the top of forms) and go to MA billing setup Sample view of MA set up/student information If YES is checked on Signature on file then the student does have consents on file. You may see comments below in the comment box which will help clue you in if the student has an annual consent or a one-time consent. Please do NOT change any information in this section. If you see an error or an omission please email lea@asec.net to make the change. If you see that the Signature on file indicates NO then you will need to email lea@asec.net to have her either email or mail you the consents. Please indicate in your email if you would like the consent mailed or emailed to you. Consents that are emailed will be sent in an Adobe PDF format AND WILL NEED TO BE PRINTED BY THE CASE MANAGER. Revised August 2010 Page 4
Step 4-Obtain MA Parental Consent to bill DHS (IMPORTANT) When you receive/print the consents you will need to get parent s signature. This is best done at the end of an IEP meeting or if timing doesn t allow for that please obtain the parents signature however works best for that parent. SEE HANDOUT B- Third Party Cookbook -example recommendations for introducing third party billing with parents Instructions for Completing Initial MA Consent Forms When to Seek Permission for a Billable Service The procurement of health insurance information and consent to bill occurs at the conclusion of the IEP process. Therefore seeking consent from parents should not occur until after the IEP plan has been developed. It is important to explain that the services will not be increased or decreased based on the parent's decision. The staff member approaching the parent to obtain permission will generally be the case manager Step 1-Informed Consent After the IEP meeting give the parent the MA Parental Consent form/packet. Assure the parent that they do not need to make a decision immediately however inform them that this is a funding source for the district that will help the district pay for special education services. Emphasize that school based MA does not impact their regular MA services nor are there any cost to the parent to allow the school to access school based MA. Step 2-Obtaining Permission See Handout C-sample consent forms Student information has been entered on the MA Parental Consent form by the MA Biller. If the student has only MA the first page is all that is required. The second page is required if the student has both MA and private insurance. The MA biller will highlight and indicate where the parent needs to sign the form. Page 1-For All MA Eligible Students Page 1 of the MA Consent form is required of all MA eligible students. If the student has MA only and does not receive nursing or personal care assistant services, the parent only signs and dates the bottom of the first page. Pages 2 and 3 are not required. Page 1 cont.-medical Release Section MA and Nursing or PCA Services If the student has nursing or personal care assistant services Section 2 must be completed including the name and address of the student s doctor. The parent is required to initial and date the medical release section and then sign and date the bottom of the page. A copy could Revised August 2010 Page 5
be presented to the parent at the each annual IEP meeting for them to initial and date providing the required yearly release of information to contact the physician. A copy of the initialed form must be sent to the district bookkeeper as well as to the ASEC MA Biller. Page 2-For MA Eligible Students with Private Insurance Handout C.1 When a student has both MA and private insurance the second page of the form is required. The ASEC MA Biller will enter available information about the private insurance through the MA verification process on SpEd Web. The parents will need to complete the other information. Parents are required to initial each of the applicable services. Mental Health should always be checked and initialed as School Psychologist evaluation/service time is considered Mental Health. If the student receives or may receive any of the other services during the school year indicate with a check and initials. The ASEC MA Biller will check those services she knows the student receives, however she will not have that information unless the staff person provides it to her. The parent must initial their agreement of each service. Parents will need to complete all blanks not already filled in regarding their private insurance. It is important for the case manager or service provider seeking consent to make sure this section is complete. The parent must sign and date this page. Page 3-For both MA Only Eligible Students and those with Private Insurance Handout C.2 MA Only Students For initial consent, the third page is required only if the parent denies consent to share information with the Department of Human Services. They need to sign and date the top section of the form. MA eligible students with private insurance For initial consent, the third page is required. Typically the only box checked would be I choose to not let the district: Bill my private health plan. The parent signs and dates this section of the form. Use this section also if the parent denies consent to share information or to ask their private insurance if the service is covered. Denial If the parent indicates that they do not want to give permission, simply have the parent sign the section of the permission form that states they do not give permission (Page 3 Section 4 of the MA Parental Consent form: I choose to not let the district share information with the Minnesota Department of Human Service to get paid for covered IEP health related services ). Send the original form to the district bookkeeper, send a copy to the ASEC MA Biller and keep a copy in the working file as reference for the next year. Parents who refused to give consent should be asked every year for permission. If the parent continues to deny consent inform the ASEC MA Biller. Revised August 2010 Page 6
Instructions for Completing ANNUAL MA Consent Forms (Required if student has a PCA and/or nursing services OR MA + private health insurance) After initial consent has been given, yearly consent is only required if certain conditions are met: 1. If the student is receiving either nursing or PCA services the first page of the MA Parental Consent form must be initialed and dated each year. A copy of the initialed form should be sent/faxed to the ASEC MA Biller and the original given to the district bookkeeper. The ASEC MA Biller and PCA Supervisor will send the required communication form to the student s doctor. 2. The student that has both MA and private health insurance and is receiving speech therapy, OT, PT, mental health, nursing, audiology, assistive technology devices or oral language interpreter services. The second and third pages of the MA Parental Consent form must be completed and signed by the parent and a copy sent/faxed to the ASEC MA Biller with the original given to the district bookkeeper. The ASEC MA Biller will seek denial from the private insurance company. Generally the ASEC MA Biller will notify the case manager or service provider prior to the end of the consent and inform the person what forms should be completed for annual consent. Step 5-Distribution of Form IMPORTANT-After the necessary Consent forms have been signed, send the original to the district bookkeeper and mail/fax a copy to the ASEC MA Biller. Once the consent form is complete you need to COPY the consent and give the original to the MA district contact that is listed in Handout A. She will keep the original in the district MA files. You then need to mail the COPY to the MA biller at the ASEC office. Please also complete the Checklist of billable services (HANDOUT E-Checklist of billable services) neon colored form that was mailed with the consents. This is important so the biller can inform all the correct service providers to begin logging their service times. Again mail back a copy of the consents and the Checklist of billable services to: ASEC, Attn: Lea Duckstad, 1505 Central Ave NW, East Grand Forks, MN 56721 or fax to 218-773-0924 Revised August 2010 Page 7
Some common questions a parent may ask: 1. My child doesn t receive mental health services. Why is mental health services checked? Answer: Schools can bill for school psychologist assessment hours and school psychological services are considered mental health services. This box is generally always checked. 2. I don t want the school to bill my private insurance. How can I be sure the school will not do so? Answer: Double check that the second page of the form does not have a check by Bill my insurance for the Individualized Education Program (IEP) health related services and assessments initialed below. Point out the statement on the second page that states If I give permission only to ask my insurance/hmo and they do cover the service, the district will not bill my insurance/hmo and will not be able to bill MA or MNC. Also, on the third page the parent should check the box at the top section that states I choose to not let the district: Bill my private health plan (third choice) and sign and date that section. Revised August 2010 Page 8
PCA services Paraprofessional services (PCA-Personal Care Assistant) may be billable under certain conditions. PCA services are provided to a student who is unable, because of his/her medical diagnosis or condition to manage the activities him/herself. However if most children the age of the child need assistance with an activity, the activity is not covered. For example, assisting a two year old child with toileting activities would not be covered because most two year old children require assistance with toileting. Assisting a ten year old child with toileting would be a covered activity. TO QUALIFY OR GET IN THE DOOR FOR MA BILLABLE PCA SERVICES THE STUDENT NEEDS TO HAVE AT LEAST ONE ASSISTIVE DAILY LIVING ACTIVITY OR LEVEL 1 BEHAVIOR. And MUST HAVE A MEDICAL DIAGNOSIS AND BE IN NEED OF SUPPORT FOR ANY OR ALL OF THE FOLLOWING ACTIVITIES: Toileting: bowel/bladder elimination and care including transfers, mobility, positioning, feminine hygiene, using toileting equipment and supplies, cleansing, inspection of the skin and adjusting clothing. Mobility: the process of ambulation including using a wheelchair and assisting a person with ambulation. Transferring: the process of moving or assisting a child/student with moving from one seating/reclining area to another including standing by to assist if needed, pivoting the person, two people assisting or using a Hoyer lift. Positioning: The process of moving the person for necessary care and comfort or to relieve pressure areas including positioning the child/student in a bed using pillows, wedges or bolsters and repositioning him/her in a wheelchair, bed, chair or sofa. Grooming: the process of personal hygiene including hair care, oral care, nail care, applying cosmetics and deodorant, and the care of eyeglasses, contact lenses and hearing aids. Dressing: The process of being clothed appropriately for the day including applying or changing clothing for the child/student, applying TED hose, orthotics and prosthetics.(remember if typical children need assistance it is not covered) Eating: the process of getting food into the body including transfers, mobility, positioning, hand washing, application of required orthotics for eating, food preparation and feeding or assistance with feeding. Bathing: the process of starting and completing a bath or shower including transfers, mobility, positioning, using soap, rinsing, drying, skin inspections, and applying lotion. Providing activities listed above during off-campus activities such as field trips. Assisting and supporting a child/student with schoolwork is not covered. Revised August 2010 Page 9
Intervention for seizure disorders, including monitoring and observation if the child has had a seizure that requires intervention within the past three months. Redirection and intervention for behavior, including observation and monitoring: Level 1 behavior is defined as (level one can only be used to QUALIFY a billable PCA service: Self-injurious behavior-causes injury to one s own body; examples: hitting, biting, head-banging, burning, poking or stabling, ingesting foreign substances or objects, pulling out hair, and suicide threats. Physical injury to others-causes physical injury or has the potential for causing physical injury to other people; examples: hitting, biting, pinching, scratching, kicking, stabbing, and pulling out hair. Destruction of property-causes damage or has the potential to cause damage to things; examples: breaking desks or chairs, tearing clothes, setting fires, and using tools or objects to damage property. Level 2 behaviors are defined as: Behaviors occur on a daily basis, interfere with completing the ADLs and include one or more of the following: unusual or repetitive habits; withdrawn behavior; offensive behavior. The intervention and redirection must be medically necessary and related to the child/student s diagnosis. Redirecting and intervening with a child/student to stay on task to complete schoolwork is not covered. The PCA supervisor and MA biller must notify the doctor listed in the consent of the IEP PCA Service each year. Procedure if initial permission is sought for a Personal Care Assistant (PCA) See Handout D for Sample IEP Language 1. If the team anticipates or knows that the student has a medical diagnosis, and may or does need support for the above services, please contact Gary, Colleen or Julie to review the IEP and verify possible eligibility for billing. a. Remember that the duties need to be clearly spelled out on the IEP. If you have any question about the services that are billable review the guideline descriptions above or call Gary, Colleen or Julie. b. If the PCA is for redirection and intervention for behavior, the requirement is rather specific as to what may be billed. Please document on the IEP that the time being billed is for Level 1 and specifically describe the behavior. If there are questions on how the need is documented contact Gary, Colleen or Julie for Revised August 2010 Page 10
guidance. You also need to note in your Services and Modifications section of the IEP that the PCA will be supervised by a qualified professional. 2. The case manager will then provide SpEd Web access to the PCA for that student. If the PCA is new or has not been given previous MA PCA access the case manager should contact the SpEd Web coordinator, Lea Duckstad @lea@asec.net to add the individual to the MA PCA access list. 3. Notify the supervision person (either the MA billable speech therapist in the district or OT) so that required supervision of the PCA occurs at the specified intervals. The supervisor will in-service the PCA on how to complete the log. If the PCA has questions, refer the PCA to Lea at the ASEC office for further clarification. 4. Each year the student s doctor needs to be notified that the child is receiving an IEP PCA Service. The ASEC MA Biller will email the case manger prior to the expiration of the medical release so that a current release to the doctor is obtained from the parent. Monthly Activity Logs Each month the service provider (i.e. billable speech therapist or PCA) will complete and finalize the activity log on SpEd Web, print and sign the form and send the monthly Activity Log to the district bookkeeper. It is important to finalize the log at the end of the month so that the ASEC biller knows that log is completed. Whoever has been identified within the district to document transportation miles for authorized students must also complete the Trip log. At the end of the month the trip log should be printed and turned into the district bookkeeper. The trip log must match the student s attendance report for that month and have received a billable MA service for each day transported (i.e. either PCA or billable MA speech service). The district must maintain the following original records on each student for at least five years for auditing purposes. Specific records include: Consent Form to Seek Reimbursement for IEP Health Related Services Communication from School or School District to Primary Care Provider Regarding Personal Care Assistance Services Instructions for the school/school district: Annually, after obtaining consent from a parent or legal representative, IEP/IFSP Services Activity Logs IEP/IFSP Service Trip Logs, SIGNED and DATED Payments School districts will receive a monthly check for the federal share of the health related services provided. Minnesota's federal share changes yearly, however it is generally around 50-53%. School districts are responsible for the non-federal share and this amount will be deducted from the payment and appear as part of the gross adjustment on the Remittance Advice (RA). Revised August 2010 Page 11
The percentage of expenses for Medical Assistance covered services for which federal funds are used as payment or reimbursement to the district is reviewed and adjusted annually. At the end of the fiscal year the data on the IEP/IFSP Activity Logs will be compiled for each billable staff person by the ASEC biller and submitted to the state. This data will establish the district's reimbursement rates for each billable service for the following year. Further Information For further information or clarification contact Lea Duckstad at lea@asec.net or for additional information go to www.asec.net and click the Third Party Billing tab. Revised August 2010 Page 12