Home and Community Benefits and Community Support Benefits for Members with Mental Retardation or Au

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• Section 21 and Section 29
• Home and Community Benefits and Community Support
  Benefits for Members with Mental Retardation or
  Autism Disorder Training
• December 2007

Caring..Responsive..Well-Managed..We are DHHS
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Agenda

• MaineCare Basics
• Introduction to Section 21 and Section 29
• Life Cycle of a MaineCare claim
• From Planning to Remittance
• Helpful Information to Know
• Questions and Answers

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MaineCare Basics

• Enrollment Requirements
• Providers are required to fill out enrollment
  forms and a Provider/Supplier agreement in order
  to enroll as a MaineCare provider.
• MaineCare does not reimburse providers for
  services provided to members prior to enrollment
  approval and receipt of billing numbers.
• Enrollments will be effective no earlier than the
  beginning of the month in which the enrollment is
  received.

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MaineCare Basics

• Member Records
• Member records must be kept and maintained as set
  forth in Chapter I of the MaineCare Benefits
  Manual. (1.03-M)
• In addition, Section 21 and 29 requires members
  name, dates of birth, MaineCare ID number, social
  and medical history, diagnosis, personal plan,
  summary of authorized services and written
  progress notes.
• Records must be kept for no less than 5 years.

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MaineCare Basics

• It is the Providers responsibility to check
  Member eligibility before providing services.
• Bill only for covered services and supplies
  delivered within the authorization (i.e.
  effective dates, rate, units).
• Providers have one (1) year from the date
  services are provided to bill the Department.
• When claims are rejected, providers have one (1)
  year from the date of the initial submission of
  the claim to resubmit a correct claim for
  payment, regardless of number of times submitted.

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MaineCare Basics

• Any discrepancies associated with the claim (e.g.
  member rates, classification, provider and/or
  member eligibility) must be corrected within the
  (1) one year time period.
• Exemptions for timely filing include
• Retroactive eligibility or spend-down
• Workers Compensation
• Other primary Insurance or Medicare
• MECMS issues

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Overview of Section 21

• Entire repeal and replacement of rule.
• Service definitions and clarifications were
  incorporated to align with the new methodology of
  setting detailed rates in Chapter III. Chapter
  III establishes new billing procedure codes based
  on HIPAA compliant CPT coding.
• Two services are eliminated (Personal Support and
  Residental Training)
• Three new stand alone services (Crisis
  Assessment, Work Support and Counseling)

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Overview of Section 21

• Personal Support, Residental Training
• Local MaineCare codes
• (e.g. W125 and W114)
• Hourly units of service

• Home Support Services
• HIPAA compliant CPT codes
• Per Diem (daily)
• Quarter hour units of service (15 minutes)
• Education requirements
• DSP
• CRMA/CNA-M (meds)
• High School Diploma or GED

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Overview of Section 21

• 21.05-1 Home Support (combines residential
  training and personal supports into one category)
  any 24/7 site will be a per diem daily rate.
• 21.05-2 Community Support (day habilitation), new
  definition, 2 models based on staff to consumer
  ratio, billing by ¼ hour (15 minute) increments,
  capped at 4320 quarter hours per year or 1080
  hours per year.
• Environmental Modification is now called
• 21.05-5 Home Accessibility Adaptations only
  for consumers that live in their own apartment or
  privately owned home or with parents, same cap
• Adaptive Aids is now called
• 21.05-6 Specialized Medical Equipment and
  Supplies

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Overview of Section 21

• Employment is now defined as two different
  services
• 21.05-4 Work Support primarily deals with the
  consumer and their ability and supports needed to
  do the job, billed in ¼ hour (15 minute)
  increments. Capped at 2400 quarter hours or 600
  hours per year, subtracted from community support
  capped quarter hours.
• 21.05-3 Employment Specialist Services deals
  primarily with the employer and helping the
  consumer keep the job, billed by ¼ hour (15
  minute) increments. Capped at 480 quarter hours
  or 120 hours per year, subtracted from work
  support capped quarter hours.

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Chapter 3 Section 21

• Appendices show how the rate is determined.
• Fee for service/Published Rates no longer any
  negotiated rates.
• Per Diem defines what a day is begins at
  midnight and ends 24 hours later. If a
  consumer leaves the home / facility, it is the
  place where the consumer is at the end of the day
  that can bill.
• Behavioral and Medical Add-ons

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Section 29 Why the new Section

• Due to Federal requirements the State of Maine
  has proactively preserved Community Support
  Services (Formerly known as Day Habilitation
  Services) for this population.

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Overview of Section 29

• Community Support Service (FSD or Day
  Habilitation) Max 1300 hours per year
• Work Support - Max 300 hours annually
• Employment Specialist Services Max (5) hours
  per month
• Respite Max 1,000.00 per year
• Transportation
• Home Accessibility Adaptations - 5,000.00 every
  3 years

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Overview of Section 29

• Members who receive Community Support, Work
  Support and Employment Specialist Services have
  an annual limit of 1300 hours.
• Same Provider Qualification requirements, Member
  records, and billing instructions as Section 21.
• Billing codes for these services available in
  Chapter 3 of Section 29.

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Life Cycle of a MaineCare ClaimPlanning to
Remittance
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Provider Qualifications 21.10

• Complete the DSP within (1 ) year of the rule
  being in effect OR (1) year from the date of
  hire.
• Assessment of Prior Learning
• Background checks as per 21.10-5
• Be at least 18 year old
• High school diploma or GED (if you are currently
  providing the service, and you do not have a high
  school diploma or GED, you must request for a
  written exemption within (6) months of this rule
  from DHHS).

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Provider Qualifications 21.10

• Medication training (CRMA or CNA-M) within 1 year
  of the rule being in effect OR 1 year from the
  date of hire.
• Employment Specialist must have completed Maines
  Employment Curriculum for Employment Support
  Personnel.

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Plan Requirements 21.04-2 (pg 10-11)

• Need planning meeting before services start
• All services determined medically necessary are
  discussed in the plan
• -Frequency of provision of services
• -List who by name will be responsible to
  complete the services needed
• -List all goals / trainings / support needed
• All services listed in the plan will have a
  corresponding authorization on the SAS (formerly
  known as the checklist)

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(No Transcript)
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Documentation Requirements

• Provider must document each service provided
• Date of the service
• Type of Service
• The activity
• Need or goal to which the service relates
• Services requiring a 21 ratio staffing may be
  documented by (1) staff member, but must be
  signed by both staff members.
• Services provided by (2) or more staff members
  working different shifts, each shift must be
  documented separately.

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Documentation Example

• A member receives twenty four (24) coverage from
  (3) staff members working Monday through Friday
  in (8) hour shifts, and one (1) that covers the
  weekend. The provider must have documentation for
  each (8) hour shift per day and one (1) progress
  note to cover the weekend shift.

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Crisis Intervention

• Requires separate progress notes to be included
  in the members chart
• Date the service
• Length of time
• Describe the crisis service provided
• Signature of the individual performing the crisis
  service

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Filling out the claim See your billing
Instructions for more detail

• Box 24A Enter both From and To dates of service
• Box 24B Enter place of service
• Find these codes in the billing instructions
• Box 24D enter procedure code
• Procedures must be authorized and can be found on
  your SAS form
• Box 24E Diagnosis indicator 1 through 4
  depending on what was entered in box 21
• Box 24F Enter your charges
• Box 24G Enter number of days or units of
  services provided.

• Box 1A MaineCare ID
• Box 2 Member Name
• This must be written as it is shown on the
  MaineCare ID Card
• Box 3 Date of Birth and Sex code
• This must be in an 8 digit format MM/DD/YYYY
• Box 21 ICD 9 Diagnosis
• At least one but no more than 4, do not use
  punctuation
• Box 22 use for VOID functionality only

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• Box 25 SSN or FEIN
• Box 26 Your patient account
• Box 28 Total of charges in Box 24F lines 1
  through 6
• Box 29 Amount Paid
• e.g. spend-down responsibility
• Box 30 Total of Box 28 and 29
• Box 31 Signature of provider or authorized
  person and Date
• must be on or after the last date of service on
  the claim

• Box 32 Location services were provided
• Only required if different then billing address
• Box 33 Billing name, address and phone
• Box 33B Billing provider
• (CMS 1500) enter 1D (space) Billing provider
  number (1D 100090000)
• in 33B.
• (HCFA 1500) enter Billing provider number in PIN

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The processing of the Claim

• Paper and electronic claims submitted to
  MaineCare, once received, are loaded into the
  system within 24 to 48 hours.
• Once in the system, the claim goes through the
  MECMS validation process.
• The adjudication process can take between two to
  four weeks.

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Validation Process
Starts Here
Ends Here
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Reading a Remittance Advise (RA)

• The RA consists of three sections
• Summary Page
• Total paid, denied, adjusted, denied adjusted by
  provider number
• Detail Page
• All TCNs detailed by line. Listed in
  alphabetical order by member by group (paid,
  denied, ect.).
• Legend Page
• All codes and descriptions listed on the
  remittance advise

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Provider Name Provider Address Provider
Address
This reference number is useful when you have
questions.
This is your state accounting ID.
RA Number 40589 Vendor E010XXXXX
Check/Trace XXXXXXXXXX Check Date
07/25/2005
Check Amount 106,977.63 Payment Method
Electronic Fund Transfer Claims Summary
Or Check
Summary of paid/denied claims by billing number
Number of units or covered days
Maine Care maximum allowed
Paid by Primary Insurers
Total Paid by MaineCare
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MaineCare Remittance Statement
Prepared Date will be a day later than RA date
Prepared Date 07/26/2005 RA Date
07/25/2005 Provider Adjustments
When inquiring about an adjustment have this OFIN
Invoice number available, as it identifies the
source.
Previous, Current, and remaining adjustment
amounts
Tells you where the adjustment was initiated
Check Amount 106,977.63

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Provider Name
MaineCare

Remittance Statement Provider
Address
Prepared Date 07/26/2008 Provider Address


RA
Date 07/25/2008 RA Number 40589
Check/Trace 1111111111 Check Date
07/25/2008

Category Paid Billing
Provider 123456700 VendorE123456789
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MaineCare Provider Name Remittance
Statement address Prepared Date
07/26/2005 RA Date 07/25/2005 RA Number
40589 Vendor E0104899239 Check/Trace
Check Date 07/25/2005
Summary of Remark Codes and Adjustments is
available on our web-site
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Helpful Information to know

• Department Names and Phone numbers
• Who to call
• Useful Websites
• Office of MaineCare Services http//www.maine.gov
  /dhhs/bms/
• Office of Adults with Cognitive and Physical
  Disabilities
• http//www.maine.gov/dhhs/OACPD/DS/
• Behavorial Health Sciences Institute (DSP
  training)
• http//www.bhsi.net/index.html
• Using the temporary claims status portal

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• Questions and Answers
• Thank you for coming!

Caring..Responsive..Well-Managed..We are DHHS