How to Implement a Medicaid Reimbursement Program for Behavioral Health and Therapeutic Services in your

School DistrictPresented by:

Pacific Health Policy Group

Students with Special Needs In 2007, 54 Alaskan school districts served

over 17,000 students with identified behavioral health and therapeutic needs

School districts can increase the amount of money available for these eligible services by submitting Medicaid claims

Districts will be reimbursed at the current State of Alaska Medicaid match rate (50.53%)

2

About Medicaid Medicaid is operated by state governments

within a broad, federally proscribed framework

The federal government covers just over 50% of the cost of providing covered services to eligible Alaskans

Medicaid is available to Alaskans who are either financially or categorically eligible

Some services provided to students receiving behavioral health or therapies are eligible for federal reimbursement – or the federal match (currently 50.53%)

3

Basic Steps to Bill for Behavioral Health and Therapeutic Services

Districts enroll as Medicaid providers Receive parental authorization Identify eligible students Bill for rendered services, while

continuing to check recipients eligibility Maintain documentation in case of audit

4

Criteria for Appropriate Medicaid Billing

Eligible for Medicaid (or Denali KidCare); Recipient has a properly documented IFSP or

IEP; The type, scope, frequency & duration of the

services are documented The services are medically necessary and

covered under an existing Medicaid category; All state and federal regulations are followed; Services are provided by qualified health care

professionals working under a enrolled district

5

Enrolling as a Provider For a district to qualify to enroll as a Medicaid

Provider, districts must agree to: Comply with all federal and state requirements for

billing, auditing and reporting Obtain an NPI number Reimburse DHSS for any state financial share – the

non-federal portion of the fee schedule

6

Enrolling as a Provider Obtain a NPI number Complete the Alaska Medical Assistance

Program Provider Enrollment Form Forms and Instructions are included in the

Toolkit

Questions? Contact ACS at (800) 770-5650Use option 1 or 3 for enrollment assistance

7

8

Clinicians Eligible to Bill Medicaid for Eligible Services The Alaska Administrative Code at 7 AAC 4.461

(“Payment for School-based Services”) lays out the requirements and qualifications of providers: Physician; Physician’s Assistant; Advanced Nurse Practitioner; Physical Therapist; Occupational Therapist; Speech-language Pathologist; Audiologist; Psychologist or Psychological Associate; Behavioral Health Professional; Behavioral Health Associate; or Another health care provider who is acting within the scope

of that health care provider’s license under AS 08 and is familiar with the child’s plan, health condition, and treatment history.

9

Providers NOT Eligible to Bill Medicaid for Eligible Services

Individuals employed as teachers are not allowed to have eligible services billed through to Medicaid, even if the teacher is otherwise qualified to provide the service

Note: Federal regulations do not contain a provision requiring physician involvement and review of behavioral health or therapeutic services provided at the school level

10

Identifying Eligible Students Districts will need parent authorization of

students to determine if a student is Medicaid eligible

A sample letter can be included with the initial IEP documentation (moving forward) and would be sent retroactively to all students that currently have an IEP

Once parent authorization is obtained, the school district can use an automated system to determine if the student is Medicaid eligible

Eligibility needs to be checked on a monthly basis

11

Sample Letter

12

Verification Once District is Enrolled Before providing services, the district must

verify: The age of the recipient That the recipient is eligible for Alaska Medical

Assistance and school based services Check monthly for Medicaid Check every six months for Denali KidCare

That the services are school-based and covered by Medical Assistance

Provider rendering service has the appropriate credentials

13

Verification Process (continued) Eligibility can be verified by:

Checking the patient’s Medical Assistance identification card or coupon

Calling the Eligibility Verification System (EVS) at (800) 884-3223

Faxing provider inquiry at (907) 644-8126 or (907) 644-8127

When faxing, have available the student’s name, date of birth, Social Security number or Medicaid ID (available on the Identification Card or Coupon)

14

Covered Behavioral Services Listed in billing manual, included in Toolkit

A shorter list of common covered behavioral services are also in Toolkit

Age restrictions may apply

Prior Authorization requirements may apply

15

Covered Behavioral Services Emotional support assistant to help a child

process emotions (CDAKN) During periods of elevated stress

Behavioral management education that teaches behavior management, modification, and redirection techniques to elicit positive behaviors with Families (CDACF), Groups (CDACE), and Individuals (CDACD)

16

Covered Behavioral Services Crisis response services including:

Crisis intervention (H2011) to prevent harm Build coping skills Develop mechanisms for positive self-care Stabilize a child or family in acute stress

Behavior modification assistance using counseling techniques to assist in modifying behavior To individuals (CDACI) And groups (CDACJ)

17

Covered Behavioral Services Functional behavioral assessments (CDBAW)

to assess a child’s behavior

Psycho-educational (H2027) services to help a child develop or improve specific self-care skills and engage in age-appropriate social behavior

18

Covered Behavioral Services Testing (96101) a child’s psychological,

cognitive, and emotional functioning

Interpreting a child’s behavioral assessment results

19

Billing Strategies Districts need to make sure they have the

appropriate personnel to process the Medicaid claim

Larger districts should hire additional FTEs For smaller districts, hiring one FTE may not be

financially viable These districts are encouraged to either hire

part-time support or collaborate with other smaller districts to “share” resources

Smaller districts can also contract with an outside vendor This would reduce the financial benefit

20

Example: Kenai School District Hired a ¼ time clerical member with a

medical background

Kenai has more than 800 students with IEPs who are Medicaid eligible

Training for administrators was provided by First Health

ACS continues to hold monthly trainings in Anchorage

21

Billing Options for School-based Behavioral Health Services Claims may be submitted on paper

CMS 1500 Instructions and Sample Form are available in the

Toolkit

Using the appropriate current CPT or ABC codes

Electronically PayerPath (available through ACS)

22

Timely Billing and Third Party Liabilities All claims must be filed within 12 months of the

date services were provided to the recipient (Retroactive claims may be filed if documentation is proper)

Claims may either be submitted on a weekly or monthly basis

Medicaid is a payor of last resort – it only pays after other avenues have been exhausted. The State has determined that no other insurer covers school-based services, exempting school districts from this requirement

23

Updating Billing Information Procedure codes can change from year to

year, but the changes are minor

Coverage (reimbursement amount) can change from year to year

Procedure codes that were covered one year may not be covered the next year

Be sure to bill with codes that are in effect for the date the service was provided

24

Remittance Advice

25

Remittance Advice Sample

26

Adjustments and Voiding Claims Used to correct or void claims that have already been

paid Adjustments are done if there was an error in the

claim Wrong procedure code Wrong modifier Wrong number of units Wrong date of service

Recoupments are used to void a previously paid claim Claim was submitted for a student who is the responsibility

of another district Claim was submitted without the necessary documentation

Use form AK-05 – Instructions in the Provider Manual

27

Records A school district documentation must include:

Recipient’s name Specific services provided Extent of service provided Date of service Name of health care provider who provided

service

A Service Documentation Sample is included in the Toolkit

A billing form is also included to maintain an overview of the student’s history

28

29

Confidentiality Two federal statutes: FERPA and HIPAA

Family Educational Rights and Privacy Act (FERPA) Health Insurance Portability and Accountability Act

(HIPAA) School-based behavioral health and

therapeutic services are covered by FERPA, even the records used to support Medicaid billing

HIPAA defers to FERPA except as related to the electronic transmission of Medicaid claims to the fiscal agent (ACS)

30

Records Needed in Case of an Audit Districts need to maintain a file for each

student that includes: A parent authorization form; A copy of the IEP; Goals and objectives; Progress notes; and Service documentation logs

31

Records Needed in Case of an Audit A school district must retain the billing, clinical

and other records for a student for which services have been billed to the Medical Assistance program for at least seven years for the date the service was provided.

Districts must maintain a IFSP or IEP record with the following information: The student’s condition The health care needs for each service Each individual service provided to the student Annotated case notes, signed, dated or initialed by

the individual who provided the service, for each service delivered

32

Records Needed in Case of an Audit This applies even if the student transfers Records in electronic format must be readily

accessible

The district is responsible for making sure billing services meet these requirements

33

Records Needed in Case of an Audit In the event of a Medicaid audit, school

districts need to maintain the following records for seven years:  Student attendance records; Employee leave records; Employee state credentials, professional licenses

or certificates; and Contracted individuals’ credentials, licenses or

certificates

34

Common Mistakes Billing when child is absent or when school is

not in session Billing when qualified staff are absent and

substitute is delivering services Billing for unqualified provider No parent/guardian authorization on file Inadequate documentation for what is billed Missing documentation Services provided and billed were not part of

the IEP Expired IEP

35

Support PHPG Toolkit

FHSC billing manual

Websites www.hss.state.ak.us/dhcs http://alaska.fhsc.com

36

Questions?

E-mail: toolkit@phpg.com Contact Jason Milstein

(847) 615-3413

Call the ACS recipient information help line: (800) 780-9972 from 8 am to 5 pm

37