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Billing Payment Training
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HCS BILLING GUIDELINES

• You can find the newest version (October 2006) of
  the Billing Guidelines on the DADS website

http//www.dads.state.tx.us/providers/HCS/hcsbilli
ngguide.pdf
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General Requirements

• 3.02 Service Claim Requirements
• All service claim requests must
• be for service authorized by IPC
• be provided in accordance with the ISP or PDP
• be supported by written documentation as
  described in 3.08 and Part 4 for the service
  (sub)component
• be based on the individuals LON authorized by an
  MR/RC assessment
• be based on billable activity

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General Requirements

• 3.02 Service Claim Requirements (cont.)
• All service claim requests must
• be based on an activity performed by a qualified
  service provider
• be for the date the service was actually provided

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General Requirements

• 3.04 Qualified Service Provider
• An adult (over 18)
• A staff member or contractor of the program
  provider
• Paid by the program provider
• Not be disqualified by this section to provide
  the particular service (sub)component being
  claimed
• Meet the minimum provider qualifications (Part 4)
• Not have been convicted of an offence listed
  under 250.006 of the Texas Health and Safety
  Code
• Not be designated in either the Employee
  Misconduct Registry or the Nurse Aid Registry
  maintained by DADS as having abused, neglected,
  or exploited a person or misappropriated a
  persons property.

3-4, 3-5 3-6
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General Requirements

• 3.05 Unit of Service
• Monthly Unit of Service applies to
• Case Management
• A program provider may include only one unit of
  service per calendar month on a service claim for
  case management except when an individual is
  transferring from one program provider to another

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General Requirements

• A Service Event
• Is a discrete period of continuous time during
  which billable activity is performed by one
  service provider
• Consists of one or more billable activities
• Ends when the service provider stops performing
  the billable activity or performs billable
  activity for a different service component

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General Requirements

• 3.06 Calculating Units of Service for Service
  Claim
• For counseling and therapies, nursing, supported
  employment and supported home living, the
  following formula must be used
• of service providers X length of service
  event of individuals served
• Service Time

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General Requirements
A written narrative (daily note) must include

• Information that identifies the individual
• A detailed, unique description of activities
  performed by the service provider
• Justification for the length of the service event

• Evidence of billable activity
• Description of the location
• Signature/title of service provider
• Description of any unusual incident or progress
  toward a service goal

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General Requirements

• A written summary (weekly note) must include
• Information that identifies the individual
• A general, unique description of activities
  performed during the calendar week
• Signature/title of service provider
• Being made within a reasonable time after the
  week being documented

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General Requirements

• Unacceptable Content for Documentation
• Ditto marks
• References to other narratives or summaries using
  words or symbols
• Non-specific statements
• Repeated statements, photocopies, otherwise
  identical narratives or summaries
• Preprinted schedules, check-off sheets, or
  fill-in-the-blank type forms

• Unacceptable as Billing Documentation
• Data collection sheets
• Medication logs

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Billing Payment Review Protocol
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• Billing and Payment Review
• Conducted by DADS staff
• Review of authorization and written documentation
  of service delivery maintained by program
  provider

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• Purpose
• To determine whether the program provider is in
  compliance with the HCS Program Billing
  Guidelines

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• Outcome
• DADS will recoup non-verified claims that were
  not supported by authorization and/or written
  documentation and may require a corrective action
  plan (CAP) by the program provider.

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• Types of Reviews
• Routine
• Once every 2 years, all services are reviewed
  for a 3-month period with the number of
  individuals reviewed determined by previous error
  rates or number of individuals served
• Special
• As determined by DADS, result of a referral

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• Routine or special review can be either
• On-site done at providers place of business
• Desk done at DADS Headquarters (documentation
  submitted by mail )

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• Samples are chosen based upon documentation error
  rate
• Error Rate non-verified dollars divided by the
  total amount billed (minus AA/MHM/DE) during the
  review period

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• Example of Error Rate
• Non-Verified Claims Total..................15,40
  0.00
• Total Claims Billed..............................
  .125,600.00
• AA/MHM/DE......................................2
  00.00
• 15,400.00 (125,600.00 - 200.00) .1228
• Error Rate 12.28

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• BPR sample size
• Error Rate Less Than Ten Percent (10)
• Provider serves more than 10 individuals 5 5
  reviewed
• Provider serves less than 10 individuals All
  reviewed

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• BPR sample size--
• Error Rate More Than Ten Percent (10)
• Provider serves more than 10 individuals 10
  10 reviewed
• Provider serves less than 10 individuals All
  reviewed

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• BPR sample size
• Never Reviewed
• Provider serves more than 10 individuals-
• 5 10
• Provider serves less than 10 individuals-
• up to 5

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• On-site Reviews
• Notification
• Routine At least seven (7) days notice by fax
  letter and phone
• Special May be done without notice

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• On-site Reviews
• List of individuals and review period identified
  at Entrance Conference.
• PROVIDERS ARE NOT PERMITTED TO CREATE ANY
  DOCUMENTATION AT ANY TIME WHILE REVIEW IS IN
  PROGRESS

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Error Codes
ADDENDUM A
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• Refuting On-site Reviews
• Refuting is conducted while on-site.
• DADS will not accept additional documentation or
  refute any unverified claims after the Exit
  Conference.

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• Demand for Payment-on-site review
• Following the Exit Conference, generally within
  30 days, DADS will send a certified letter
  (Demand for Payment) to the provider detailing
  any unverified claims. The letter includes the
  amount to be recouped, any required corrective
  action and notice of the right to request an
  Administrative Hearing.

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• On-Site Review
• Request for Administrative Hearing (appeal)
• Must be made within 15 calendar days from receipt
  of certified green card from Demand for Payment
  letter

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• Payment of unverified claims
• Recoupment is done electronically through the
  automated billing system (CARE)
• Please do not send checks.

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• Desk reviews
• Notification
• Telephone and Certified Mail

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• Timeframe to Provide Documentation-desk review
• 14 calendar days from receipt of certified green
  card from notification letter
• Documentation received after 14 days has elapsed
  will not be accepted and all services requested
  will be subject to recoupment

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• Results-desk review
• Provider notified of results in certified letter
• Refuting-desk review
• Additional documentation must be submitted
  within 14 calendar days of receipt of certified
  green card from results letter
• Late submissions are not accepted

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• Demand for Payment-desk review
• Certified letter notifies provider of final
  account of unverified claims after considering
  refuting documentation (if any submitted)

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• Desk Reviews
• Request for Administrative Hearing (appeal)
• Must be made within 15 calendar days from receipt
  of certified green card from Demand for Payment
  letter

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• Payment of unverified claims
• Recoupment is done electronically through the
  automated billing system
• Please do not send checks.