Title: School/Preschool Supportive Health Services Medicaid-in-Education Overview Medicaid 101
1School/Preschool Supportive Health Services
Medicaid-in-Education OverviewMedicaid 101
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2MEDICAID-101 TRAINING TOPICS
- Billing Requirements
- Student Demographics
- Documentation Requirements
- Claiming Process
- Reports
3Billing Requirements
4What are the requirements for billing?
- District/County/4201 school must have a Medicaid
provider number and a Federal NPI Number - Student must be eligible for Medicaid (have an
eligible CIN) - District/County/4201 schools must obtain
parental consent (in accordance with IDEA) prior
to billing Medicaid - District/County/4201 schools must incur a cost
for the service and/or evaluation - Evaluations student must have been officially
referred to CSE/CPSE - Student must be referred and/or classified as a
student with a disability - Delivery of services must be documented
- Services/evaluations delivered by appropriately
credentialed provider
5What services and evaluations are reimbursable?
- SPECIAL TRANSPORTATION
- - Special transportation provided
- to eligible students as listed on the
- IEP
- TARGETED CASE
- MANAGEMENT (schoolage only)
- - IEP Reviews
- - Ongoing Service Coordination
-
- SERVICES
- Speech Therapy
- Physical Therapy
- Occupational Therapy
- Psychological Counseling
- (pended)
- Nursing
- EVALUATIONS
- Psychological -basic (pended)
- Comprehensive Psychological
- with social history (pended)
- Medical
- Specialist Medical
- Audiological
6Student Demographics
7How is the demographic information processed?
- When student is referred to CSE/CPSE
- District/County/4201 schools must obtain
parental consent (in accordance with IDEA) - Enter demographics onto your local computer
software - Name (First and Last)
- Date of Birth
- Gender
8Create Electronic Demographic File
The SD/County/4201 Schools will create and
submit a Medicaid Demographic (MD) file, using
Medicaid software, to CNYRIC via the
internet/e-mail/FTP or MEDweb site.
9Matching Process
- CNYRIC processes your demographic information and
matches for Medicaid eligibility. - The eligibility information is posted on the
CNYRIC Website in your monthly Medicaid
Eligibility (ME) file (ELIGDATA). - Each month the SD/County/4201 schools would need
to update their students Medicaid eligibility
information by downloading the ELIGDATA file to
their local computer.
10Matching Process Eligibility Reports and Files
- These reports and files are now available on the
CNY-Web Report site and your RIC will provide
training on access and interpretation. -
- Medicaid Eligibility Report (ELIGREPT) lists your
students with a CIN - Medicaid Eligibility (ME) File (ELIGDATA) must be
downloaded onto your local computer - Non-Matching Reports (MATCH)
- Near-Match - possible matches
- Multiple Match must select correct CIN and
reenter - Match Not Found no CIN match identified
11Matching Process Eligibility Reports and Files
(cont)
- These reports and files are now available on the
CNY-Web Report site and your RIC will provide
training on access and interpretation. -
- Biographical Reports
- Delete Unmatched Students (BIODLTE) - students
w/o a CIN - Inactivated Students (BIOINCT) - students w/CIN
but not claimed - Transaction (BIOUPDT)
- Error Report - lists problems with the biographic
data you submitted - Update Report lists accepted adjustments
(ADD/CHG/DEL)
12DocumentationRequirements
see handout
13What EVALUATION documentation is required?
- Referral to the CSE/CPSE
- Signed/Dated copy of Evaluation
- Medical Referral (for a formal Speech,
- Specialist Medical, Audiological
Evaluation) - Professional Licenses Certifications
- When necessary, a Provider Agreement
- Statement of Reassignment are required
14Who can complete a medical referral for an
evaluation?
- Speech
- Physician, Physician Assistant, Nurse
Practitioner, NYS Licensed and Registered Speech
Language Pathologist - Specialist Medical
- Physician, Physician Assistant, Nurse
Practitioner - Audiological
- Physician, Physician Assistant, Nurse Practitioner
15When must a medical referral be completed?
- Every time a Formal Evaluation is needed.
- The medical referral must be signed/dated and can
be in a list format (can contain more than one
student) . - Note - A formal evaluation for Speech,
Specialist Medical and Audiological requires
parental permission.
16What SERVICE documentation is required?
- An IEP (that covers the service period)
- Medical recommendation (order) for Services
- - (for Speech, OT, PT, Nursing before
- beginning services)
- Provider Service Sheets (date specific,
signed/dated) - Progress Notes (that cover the billed period)
- must be signed and dated by service provider
- electronic or paper format is acceptable
17What SERVICE documentation is required (cont)?
- Professional Licenses and Certifications
- Speech-Under the Direction Of (UDO) proof
- The Nature of Special Transportation on IEP
- When necessary, a Provider Agreement Statement
of Reassignment is required - TCM-Ongoing Service Coordination contact sheets
18Who can complete a medical recommendation (order)
for services?
- Speech
- Physician, Physician Assistant, Nurse
Practitioner, NYS Licensed and Registered Speech
Language Pathologist - Physical Therapy
- Physician, Physician Assistant, Nurse
Practitioner - Occupational Therapy
- Physician, Physician Assistant, Nurse
Practitioner - Skilled Nursing Service
- Physician, Physician Assistant, Nurse Practitioner
19A Medical Recommendation (Order) for Services
- Must be signed/dated by an appropriate
professional. - Must be child specific
- Must either include frequency and duration
- or include the phrase as indicated on
IEP - Is good for the life of the referenced IEP
20Why is Under the Direction of for Speech
Services necessary?
- SED requires that speech services must be
provided by teacher of speech and hearing
handicapped (TSHH) or teacher of students with
speech and language disabilities (TSSLD) - Medicaid regulations require that speech
services must be provided by NYS Licensed and
Registered Speech Language Pathologist -
21What is the responsibility of the speech
pathologist?
- Assures services scheduled as indicated on IEP
- Assures services are medically appropriate
- see handout-365A
- Accessible to TSHH and TSSLD
- Reviews progress notes
- (see handout-May 23, 2003 SED ltr)
22What documentation is needed for Under the
Direction of?
- Certification for UDO and accessibility
- - A list of TSHHs and TSSLDs
- - How accessibility will be provided
- - Dated signature of Speech Language Pathologist
(SLP), w/title - Note This sheet must be updated when there is a
change in personnel (see handout)
23Documentation Needed for Under the Direction Of
(cont)
- Documentation must exist that would support the
IEP, Student Service schedule, and Progress Notes
have been reviewed by the SLP - February 6, 2007 Theresa Savo Letter (see
handout) - Face to face contact (SLP and student)
- - at the beginning of treatment and
periodically thereafter - (If TSHH/TSSLD is also an SLP, see handout-6/03
SED ltr)
24Documentation Needed for Under the Direction Of
(cont)
- SLP must be familiar with students treatment
plan - SLP assumes responsibility for services
- SLP must provide adequate supervisory direction
to teacher - Regularly scheduled meetings and phone contacts
must be documented - Accessibility must be documented per occurrence
- All documentation must be signed/initialed and
dated
25Who must have a copy of the certification for
Under the Direction of and accessibility?
School District
TSHH/TSSLD
NYS Licensed and Registered Speech Pathologist
26Psychological Counseling Service
- Billing for Psychological Counseling Services is
pended until further notice. - Documentation required for psychological
counseling services - Must be on the IEP.
- Quarterly Progress Notes, signed and dated.
- Monthly Service Report, signed and dated.
- Service must be provided by licensed professional
(certification alone is not sufficient) - - Professional titles will be determined at a
later date
27PHYSICAL THERAPY OCCUPATIONAL THERAPY
- Documentation required
- Must be on the IEP with Frequency Duration.
- Appropriate Credential of the Licensed and
Registered Therapist. - Medical Recommendation (Order) for service,
Signed and Dated. - Quarterly Progress Notes Signed and Dated.
- Monthly Service Report indicating Attendance,
Signed and Dated by the Therapist. - All of the above required when supervising a PTA
or OTA.
28Additional Supervision Requirements for Physical
Therapy Assistant
- Documentation required for Supervision
- Licensed PT sets all Goals and establishes a plan
of care determines whether the student is
appropriate to receive care from a PTA. - Initial joint visit between the student, the Lic.
PT and the PTA. - Periodic Treatment of the Student by the Lic. PT
as indicated in the Plan of Care. Must occur
every sixth visit or every 30 days, whichever
occurs first. - The performance appraisals and evaluations of the
PTAs. - All documents must be signed and dated by the
Lic. PT. -
-
see Article 136
29Additional Supervision Requirements for
Occupational Therapist Assistants
- The Licensed Occupational Therapist must sign and
Date - The Treatment Plan
- The evaluations and assessment documents that are
used to determine the method of treatment. - The weekly service notes after reviewing
- The performance appraisals and evaluations of the
OTAs, -
see Article 156
30Nursing Services
- Documentation Requirements
- Must be on the IEP
- Medical Recommendation for the Service.
- Monthly service report in 15 minute segments.
- Health Care Plan if appropriate.
- Health Care Protocols if appropriate.
- All services must be provided in accordance with
the Nurse Practice Act. - Only acceptable credential is Registered
NurseRN or a Licensed Practical Nurse LPN
under the supervision of an RN.
31Special Transportation
- As defined in the SED March, 2005 Rebecca Cort
memo (see handout) - Must be included in the IEP
- The Nature of Spec. Trans. must be
- documented on the IEP
- Can only be claimed for a round trip on a day of
Medicaid reimbursable service - - School bus rosters (schedules)
- - Bus logs (attendance)
- - Service delivery documents
32What Targeted Case Management (TCM) documentation
is required?
- Referral to the CSE
- The IEP and/or CSE meeting notes
- (with the meeting type clearly labeled)
- Initial Review
- Annual Review
- Triennial Review (Reevaluation)
- Amended/Requested Review
- Ongoing Service Coordination (OSC) -
contact notes - Note TCM is not billable for preschool students
33Ongoing Service Coordination
- Must be discussed at CSE meeting.
- The service coordinator or case manager must
document at least two contacts per month relating
to service coordination or case management in
order to bill Medicaid - The contact notes (see handout) will serve as
documentation for billing Medicaid. - District must be preapproved to bill for OSC
- Must identify who was contacted, when and
include issue, action, summary of the contact
then the sheet must be signed/dated by the
coordinator.
34Retention of Documentation
- Per January, 2002 Richard Cate letter (see
handout) - All documentation must be retained
- until further notice!
-
- The School District/County/4201 School officials
are responsible for and should have formal
written policy regarding compliance of all
documentation requirements.
35Claiming Process
(see handout)
36Claiming Services and Evaluations
- SD/County/4201 Schools collect
- Monthly/Annual Service Provider Sheets
- School-age documentation for Targeted Case
Management - SD/County/4201 Schools enter service
dates/evaluation completion dates and completed
Targeted Case Management review dates (SD/4201
Schools only) onto their Medicaid billing software
37Processing of Claim Data
- SD/County/4201 Schools submit claiming files to
CNYRIC
382010 Claiming Calendar (see handout)
- To determine when claims should be submitted to
CNYRIC and when checks should arrive - Your Business Office should be notified as to
when a claim has been submitted, the amount of
the claim and when to expect the (SED DOH)
checks
39Review Service Reports/Files
- Service Update Report (SRVUPDT)
- Accepted claims
- Rejected claims
- Held Claims
- Billing Summary Report
- Claims forwarded to CSC for processing
(BILLSUM) - Non-Billed Report-lists rejected billing
(NONBILL) - Remittance Report (REMIT)
- Paid
- Denied
- Pended
- Remittance File (MR File) (RMITDATA)
40Management Reports
- CNYRIC SERVNOS Report (SRVNDIST)
- Generated quarterly by CNYRIC
- (March, June, September, December)
- A two year listing of claims submitted for each
individual student, by month/service - DOH - Summary of Paid Claims
- For all SD within a designated RIC
- Individual, for each SD/County/4201 School
41Medicaid in EducationCNYRIC-Web Report Internet
Access
You will now be able to access your
SD/County/4201 School reports at anytime
via the internet on the CNYRIC Website
at http//www.cnyric.org under
Web Applications, in the Web
Reports Please contact your RIC for password
authorization procedures and Web access training.
42Websites
- Medicaid-in-Education homepage
- http//www.oms.nysed.gov/medicaid/
- Office of Professions homepage
- http//www.op.nysed.gov
- National Alliance for Medicaid in Education
- http//medicaidforeducation.org/
- LEAnet
- http//www.theleanet.com/
43SED Contact Listing
- SED
- Harold Matott hmatott_at_mail.nysed.gov 518-486-197
9 - Steven Wright swright2_at_mail.nysed.gov 518-486-488
7 - Kelly Gicobbi kgicobbi_at_mail.nysed.gov 518-486-782
8 - http//www.oms.nysed.gov/medicaid/contacts/State_M
edicaid_Contacts.htm