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 ServicePlan 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 ServicesProcess

• 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 ServicesProcess (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 WillEvaluate

• 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 ServicesContact Information

• IFMC (Medicaid)
• PO Box 36478
• Des Moines, IA 50315
• 800-383-1173 or 515-725-1008 local
• Fax [phone]
• 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 theClaim 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/ AdjustmentRequests

• 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