School/Preschool Supportive Health Services Medicaid-in-Education Overview Medicaid 101

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School/Preschool Supportive Health Services
Medicaid-in-Education OverviewMedicaid 101

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MEDICAID-101 TRAINING TOPICS

• Billing Requirements
• Student Demographics
• Documentation Requirements
• Claiming Process
• Reports

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Billing Requirements
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What 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

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What 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

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Student Demographics
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How 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

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Create 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.
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Matching 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.

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Matching 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

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Matching 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)

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DocumentationRequirements
see handout
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What 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

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Who 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

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When 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.

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What 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

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What 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

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Who 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

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A 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

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Why 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

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What 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)

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What 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)

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Documentation 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)

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Documentation 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

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Who must have a copy of the certification for
Under the Direction of and accessibility?
School District
TSHH/TSSLD
NYS Licensed and Registered Speech Pathologist
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Psychological 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

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PHYSICAL 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.

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Additional 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

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Additional 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

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Nursing 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.

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Special 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

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What 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

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Ongoing 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.

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Retention 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.

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Claiming Process
(see handout)
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Claiming 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

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Processing of Claim Data

• SD/County/4201 Schools submit claiming files to
  CNYRIC

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2010 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

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Review 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)

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Management 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

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Medicaid 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.
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Websites

• 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/

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SED Contact Listing

• SED
• Harold Matott hmatott_at_mail.nysed.gov 518-486-197
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• Steven Wright swright2_at_mail.nysed.gov 518-486-488
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• Kelly Gicobbi kgicobbi_at_mail.nysed.gov 518-486-782
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• http//www.oms.nysed.gov/medicaid/contacts/State_M
  edicaid_Contacts.htm