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Iowa Medicaid Enterprise

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Licensed Master Social Worker (employed in a mental health center) Advanced Registered Nurse Practioners. Each must practice within scope of licensure ... – PowerPoint PPT presentation

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Title: Iowa Medicaid Enterprise


1
Iowa Medicaid Enterprise
  • Welcome to
  • Remedial Services Provider Training

2
Agenda
  • Introduction of Remedial Services Provider
    program
  • Remedial Services processes
  • Billing services on the CMS 1500

3
Iowa Medicaid Enterprise
Remedial Services
4
What are Remedial Services?
  • Remedial Services
  • Enhance functional abilities
  • Recommended by the LPHA

5
LPHAs must be Iowa Plan Providers
  • Physicians (MD or DO)
  • Psychologists (PhD or PsyD)
  • Licensed Independent Social Workers
  • Licensed Mental Health Counselors
  • Licensed Marital Family Therapists
  • Licensed Master Social Worker (employed in a
    mental health center)
  • Advanced Registered Nurse Practioners
  • Each must practice within scope of licensure

6
Role of LPHA
  • Completes face-to-face assessments
  • Makes the diagnosis and treatment suggestions
    (which may include remedial services)
  • Orders remedial services when indicated
  • Assists with referral to remedial provider if
    requested

7
Remedial Service Providers (RSP)
  • Current Adult Rehab Option providers
  • Current RTSS providers
  • Agencies accredited under Chapter 24 of IAC

8
Role of Remedial Service Providers
  • Develop a remedial service implementation plan
    when requested by a member
  • Obtain Prior Approval for Remedial Services from
    IME Medical Services
  • Provide services as written in the plan, if
    requested by the member
  • Document services/interventions to support
    remedial services and billing

9
RSP Codes - Children
10
RSP Codes Adults
11
Remedial Services May Include
  • Anger Management
  • Behavior Management
  • Relationship Skills
  • Communication Skills
  • Problem Solving Skills
  • Conflict Resolution
  • Skill Rehearsal
  • Social Skills

12
Remedial Service Implementation Plan
13
Demographics
  • Member name
  • Member address
  • Member date of birth
  • Member Medicaid number
  • Remedial services provider name
  • RSP affiliation/company name
  • RSP Provider number

14
Demographics (cont)
  • RSP Provider address
  • LPHA Name
  • LPHA Affiliation/Company name
  • LPHA Address
  • Legal representative (if applicable)
  • Legal representatives relationship to member
  • Address of representative

15
Remedial Service Plan Requirements
  • Remedial service implementation plan is
    consistent with LPHA order
  • Plan addresses mental health symptoms/behaviors,
    IAC 441-78.42(249A)
  • Plan is remedial and individualized
  • Member/family strengths are incorporated into the
    interventions

16
Plan Requirements (cont)
  • Roles and responsibilities are identified
  • Services/treatment are consistent with practice
    guidelines
  • Plan reflects member and/or legal representative
  • Goals and objectives are measurable and time
    limited
  • Treatment outcomes are specified

17
Remedial Services Process
  • Medicaid members seek out or are referred to LPHA
  • LPHA completes assessment, diagnosis
  • LPHA orders remedial services if/ when indicated
  • Orders for remedial services must include
  • Diagnosis
  • Scope (remedial procedure codes)
  • Number of units
  • Duration of services (begin end dates)

18
Remedial Services Process (cont)
  • Member selects an RSP
  • LPHA provides a copy of the order (treatment
    plan) to member and forwards a copy to RSP
  • RSP develops remedial service implementation plan
    if requested by the member

19
Remedial Services Process (cont)
  • RSP emails/faxes order complete with the
    diagnosis remedial service implementation plan
    to IME Medical Services
  • Medical Services will respond within 2 business
    days
  • Medical Services will send Notice of Decision to
    member and RSP

20
Remedial Services Process (cont)
  • RSP documents services and progress notes as
    required to support service intervention and
    billing
  • Remedial services implementation plans will be
    authorized for up to six months

21
Progress Notes
  • Member name and Medicaid ID number
  • Date and amount of services delivered with
    beginning and end times
  • Name of staff providing service agency name
  • Staffs signature with title
  • Service setting

22
Progress Notes (cont)
  • Description of the specific service and
    relationship to goal
  • Description of the members response to service
    and progress toward goal
  • Recommended revision in intervention/services, as
    appropriate

23
Continuing Services Criteria
  • If behaviors/symptoms continue, then plans are
    revised to maximize treatment
  • Member is benefiting from services
  • New behavior/symptoms requiring remedial services
    are identified

24
Discharge Criteria
  • Remedial goals/objectives are achieved
  • Age appropriate functioning is achieved
  • Member is not compliant with remedial services
  • Member is not benefiting from services

25
Quality Review Process
  • Quality review will evaluate documentation as
    follows
  • Member demographics emergency and crisis
    information, releases
  • LPHA diagnosis and order (treatment plan)
  • Member functional assessment information
    sufficient to support remedial service
    implementation plan

26
Quality Review Process (cont)
  • Evidence of collaboration with other community
    resources
  • Documentation of member/members guardian
    participation in treatment planning
  • Remedial services implementation plan is
    individualized
  • Plan goals and objectives are measurable and time
    limited

27
Quality Review Process (cont)
  • Roles and responsibilities for services are
    identified
  • Plan is implemented as written
  • Documentation of referrals for further evaluation
    if needed
  • Ancillary services identified
  • Billing matches progress notes

28
Quality Review Will Evaluate
  • Time from member referral to remedial treatment
    plan development
  • Continuity of treatment
  • Affiliation of LPHA to RSP
  • Gaps in service

29
Quality Review will Evaluate
  • Achieved treatment results
  • Member satisfaction with services
  • Results of quality review will be compiled with
    copies submitted to providers and IME Policy
  • Medical Services will offer RSP quality
    improvement training and education

30
Remedial Services Contact Information
  • IFMC (Medicaid)
  • PO Box 36478
  • Des Moines, IA 50315
  • 800-383-1173 or 515-725-1008 local
  • Fax 515-725-0931
  • www.remedialservices_at_dhs.state.ia.us 

31
Iowa Medicaid Enterprise
  • Billing Services
  • to the IME

32
(Eligibility Verification System)  
Eligibility Verification System (ELVS)
  • Verify member eligibility for todays date or
    past date of service.
  • Verify member enrollment with the Iowa Plan.
  • Member eligibility can be verified by date of
    birth ddmmyyyy and social security number or
  • the State ID number.
  • Access your last payment amount and date.
  • 800-338-7752
  • 515-323-9639 (Local)

33
Electronic Claim Submission
  • Electronic Date Interchange Support Services
    (EDISS)
  • 800-967-7902 9 AM-5 PM
  • EDI paperwork must be completed and forwarded to
    EDI for enrollment
  • Find forms at www.ime.state.ia.us, follow
    directions in the Tool Box
  • PC-ACE Pro free software

34
Billing Information
  • Mailing address for all claims from RSP
  • Iowa Medicaid Enterprise (IME)
  • PO Box 150001
  • Des Moines, IA 50315
  • Provider Services phone numbers
  • 800-338-7909
  • 515-725-1004
  • Monday Friday 730 AM -430 PM

35
IME Contacts for Claims
Medicaid Claims P. O. Box 150001 Des Moines, Iowa
50315   Provider Correspondence P. O. Box
36450 Des Moines, Iowa 50315 E-mail
imeproviderservices_at_dhs.state.ia.us
36
IME Phone Numbers
  • ELVS
  • (Eligibility Verification System)
  • 24 Hours a Day/7 Days a Week
  • 800-338-7752
  • 515-323-9639 (Local)
  • PROVIDER AUDITS AND RATE SETTING
  • 800 AM 500 PM
  • 866-863-8610
  • 515-725-1108 (Local)
  • PROVIDER SERVICES
  • 730 AM 430 PM
  • 800-338-7909
  • 515-725-1004 (Local)
  • MEMBER SERVICES
  • 800 AM 500 PM
  • 800-338-8366
  • 515-725-1003 (Local)

37
Billing Tips
  • IME suggests that claims should be billed no more
    often than once per month
  • CMS 1500 claim forms must be used and correctly
    completed
  • IME payment cycles are weekly

38
Completing the Claim Form
  • Discussion of each required box
  • Detailed instructions are included in the handout
  • Many boxes are not required or are optional
  • Ensure all required boxed are correctly completed
    or the claim will not pay

39
Claim Submission Issues
  • Use original claim forms, do not make copies
  • Do not use red or light colored ink
  • Do not use highlighter of any color
  • Position data in the center of each box, not
    touching any red line

40
Submission Issues (cont)
  • Diagnosis codes (ICD-9) and CPT codes cannot
    include description on the form
  • Column E Diagnosis Code must have the
    corresponding number from box 21, not the actual
    diagnosis code
  • Indicate both dollars and cents for sub-charge
    and total charge.
  • Limit the use of handwritten information

41
Timely Filing Guidelines
  • Original claim submissions must be filed within
    12 months of the through date of service.
  • If the claim was filed timely but denied, then it
    can be resubmitted up to 12 months from the remit
    denial date.
  • Claims after 12 months must be filed on paper
    with resubmission and the original filing date
    in the signature box.
  • Adjustments can be filed within 12 months of the
    payment date.

42
Credit/ Adjustment Requests
  • Used to change information on a paid claim
  • Paid amount needs to be changed
  • Number of units needs to be changed
  • Dates of service need to be changed
  • Complete form correctly and entirely
  • Form 470-0040 found on the IME Website
  • Must be filed within 12 months of payment

43
Reimbursement
  • Interim rates on DHS web site
  • By agency
  • By service
  • Based on current information
  • Cost report- due 3 months after agency fiscal
    year end
  • Cost settlement
  • Interim rates recalculated
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