REISSUE DATE: June 2, 2015 1 | P a g e Informational Packet # 028-15: REISSUE (2ND)

ODP is reissuing this communication to provide clarification in the area of billing and to announce the last day ODP will accept Approved Program Capacity change requests. See red font within the document for language changes and /or additions. AUDIENCE: Qualified Waiver Residential Habilitation Service Providers licensed under 55 Pa.

Code Chapter 6400, Administrative Entities (AE), Supports Coordination Organizations (SCO) and All Interested Parties

PURPOSE: This ODP communication is intended to inform all interested parties of the

procedures to follow to implement the changes made to the Approved Program Capacity (APC) process resulting from the provider Settlement Agreement, effective October 28, 2014.

NOTE:

The procedures detailed in this communication apply only to providers who have signed and submitted the Provider Settlement Agreement addendum. The addendum will be made available to applicable providers in the near future. Any adjustment made that results in changes to APC, pursuant to the procedures of the Settlement Agreement, will automatically be end dated on June 30, 2015 and the APC that was previously approved for the service location will be reinstated.

Please note, changes made to APC do not represent an adverse action to the participant(s). APC changes are administrative in nature, time limited and relate only to the Provider Settlement Agreement.

Informational Packet 2nd REISSUE

Changes to the Approved Program Capacity Process Resulting from the Provider Settlement Agreement

ODP Communication Number: Packet 028-15

The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives.

REISSUE DATE: June 2, 2015 2 | P a g e Informational Packet # 028-15: REISSUE (2ND)

BACKGROUND

The Department of Human Services (formerly the Department of Public Welfare) entered into a Provider Settlement Agreement effective October 28, 2014. This communication will address Paragraph #5 of the Settlement Agreement which specifies the following:

Excerpt from the Provider Settlement Agreement:

“5. The Department, for the period July 1, 2014 through June 30, 2015, will amend its policies to temporarily reclassify residential capacity related to transitional bed openings as of the date the opening occurs. The Department will process any reclassification change expeditiously but in no case later than forty-five (45) days after a request is received. The provider may bill retroactively to the date the transitional opening occurred. All residential capacity for an individual home shall be restored to the capacity level that existed prior to the application of the temporary policy effective as of the date of the policy changes. During the effective period of this policy, a provider may not act arbitrarily and capriciously in its refusal of a referral. For the period referenced above, this Agreement controls the review, approval and denial of reclassification requests.”

NOTE: For purposes of this communication and the settlement, the term “transitional bed opening”, as indicated in the above paragraph, is considered a “residential vacancy”. The term “residential vacancy” is defined in ODP Informational Packet 098-12, titled “ODP Procedure for Residential Vacancy Management”. According to the communication, a residential vacancy occurs when there is:

A change in an individual’s residential service provider OR a change in service,

Disenrollment from the waiver (death, moving out of state).

DISCUSSION

Procedures to Request a Change to Approved Program Capacity (APC)

The table on the following page details the provider action steps required to request a change to APC as a result of the provider Settlement Agreement. The table also includes the AE and ODP Regional Waiver Capacity Manager’s (WCM’s) role in this process. The deadline for an Approved Program Capacity change request is July 15, 2015.

REISSUE DATE: June 2, 2015 3 | P a g e Informational Packet # 028-15: REISSUE (2ND)

STEPS ACTION

ACTION/ROLE DESCRIPTION

PROVIDER ODP

WAIVER CAPACITY MANAGER AE

STEP 1 Complete DP 1024

In accordance with ODP Informational Packet 098-12, titled “ODP Procedure for Residential Vacancy Management”, as soon as the provider is aware of an existing or potential residential vacancy in a licensed Chapter 6400 residential setting, the provider must complete the ODP approved, Provider Vacancy Notification Form, DP 1024. A copy of the DP 1024 is attached to this communication and can be found at: http://www.odpconsulting.net/resources/odp-forms/

The completion of the DP 1024 is a required document when requesting a change to APC.

N/A N/A

STEP 2 Submit DP 1024

The provider will submit the DP 1024, via e-mail, to the AE/county of registration where the individual, who created the vacancy, was registered. The provider should copy the appropriate ODP Regional WCM on the e-mail.

Submission of the DP 1024 should be completed within three (3) business days of becoming aware of the vacancy.

The ODP Regional WCM receives a copy of the DP 1024, via e-mail, that the provider submitted to the AE. The ODP Regional WCM will review the vacancy information found on the DP 1024, contact the AE where the individual who created the vacancy was registered and discuss with the AE of registration if they can fill the vacancy. If the vacancy cannot be filled at this the time, the ODP Regional WCM will enter the information found on the DP 1024 on the Statewide Vacancy Report.

Receives the completed DP 1024 from the provider via e-mail. The AE is contacted by the ODP Regional WCM. The AE must identify an individual who has needs that will most appropriately be addressed by the existing residential vacancy and is required to provide that information to the ODP Regional WCM within five (5) calendar days.

STEP 3 Track Referrals/ Document Decisions

The provider should track all incoming referrals and document all decisions related to the vacancy documented on the DP 1024 form. This information shall be forwarded to the ODP

As needed, request referrals and decisions that were documented by the provider. N/A

REISSUE DATE: June 2, 2015 4 | P a g e Informational Packet # 028-15: REISSUE (2ND)

STEPS ACTION

ACTION/ROLE DESCRIPTION

PROVIDER ODP

WAIVER CAPACITY MANAGER AE

Regional WCM upon request.

STEP 4 Complete and Submit APC Change Request Form

In order for a provider to request a change to their APC, a provider must have already signed and submitted the Provider Settlement Agreement addendum. To request a change to a service location APC, the provider must:

Submit the request form titled “Request for Change in Established Approved Program Capacity (APC) per the 2014 Provider Settlement Agreement”, referred to as the “APC Change” form, to the appropriate ODP Regional Waiver Capacity Manager (WCM)1.

Have a Provider Vacancy Notification Form, DP 1024, on file or submit a completed DP 1024 form with the APC change form. Approval will not be granted for a change involving a current vacancy until the DP 1024 has been submitted.

The deadline for an Approved Program Capacity change request is July 15, 2015.

WCM receives a completed APC Change Form1 from the provider. The WCM may also receive the DP 1024 from the provider if one is not on file. The ODP Regional WCM has 45 calendar days from the date they receive the APC Change Request form to respond to the provider with a determination.

N/A

STEP 5 Notification of APC Change Approval

Provider receives the APC Letter, via e-mail, from the ODP Regional WCM indicating their APC change request was approved.

The ODP Regional WCM will notify the provider that APC change has been approved using the letter template found at the end of this communication.

The AE is copied on the ODP Regional WCM’s e-mail to the provider which indicates that the provider’s APC change request has been approved.

STEP 6 Void Previously Submitted Claims

If the APC change is retroactive, the Provider must void ALL PROMISeTM billings that were submitted from the first day of the requested APC change through the last day billed for the

Available to provide technical assistance to the provider

N/A

1 The “Request for Change in Established Approved Program Capacity (APC) per the 2014 Provider Settlement Agreement” request form, also referred to as the “APC Change” form, is posted in a user friendly format on www.odpconsulting.net > Resources > ODP Forms. Providers also have the option to print out the form located on page 14 of this communication, complete the form by hand, scan it and e-mail it to your ODP Regional Waiver Capacity Manager.

REISSUE DATE: June 2, 2015 5 | P a g e Informational Packet # 028-15: REISSUE (2ND)

STEPS ACTION

ACTION/ROLE DESCRIPTION

PROVIDER ODP

WAIVER CAPACITY MANAGER AE

current APC. This is necessary because HCSIS does not allow a change to be made to the date span for a service on the ISP when billings have already been made against it. Billings for both eligible and ineligible residential procedure codes must be voided before a resubmission is done AND before a new service is authorized on the individual’s plan.

NOTE: When a claim is voided, a credit is applied to the provider’s service location in PROMISeTM. Future billings to PROMISeTM, which are approved for payment for that service location, will be reduced by the outstanding credit. Voids and credit depletions will be reflected on the provider’s remittance advice.

STEP 7 Notify AE, Via E-mail, That Claims Have Been Voided

The Provider must e-mail the affected AE(s) and communicate to them that all of the participant’s claims have been voided. The ODP Regional WCM should be copied on the e-mail to the AE(s).

Receive notification from the provider that the applicable claims have been voided in the claims processing system and the AE(s) has been informed.

AE is informed that applicable claims have been voided.

STEP 8 Update the SSD/Revise ISP

After the provider voids the applicable claims in PROMISeTM, the provider should update the Services and Supports Directory (SSD) in HCSIS by adding the new services (W codes for eligible and ineligible) to the service location using the start date AND end date found in the APC letter.

Available to provide technical assistance to the provider

AE notified by provider that their SSD has been updated to reflect the services and timeframe found on the APC Determination Letter. 1. End date both the current eligible

and ineligible residential service authorizations for the day prior to the new APC start date. For partial year adjustments, units will need to be adjusted accordingly.

2. Enter the new eligible and ineligible residential services with the new start date and the new

REISSUE DATE: June 2, 2015 6 | P a g e Informational Packet # 028-15: REISSUE (2ND)

STEPS ACTION

ACTION/ROLE DESCRIPTION

PROVIDER ODP

WAIVER CAPACITY MANAGER AE

end date identified in the APC Determination letter from ODP. Do the same for partial year adjustments but also add units.

3. Upon completion of the revision to the authorized services, add language to the Plan Comments section of the ISP. This is accessed by clicking on the Add/New Comments link at the bottom left of ISP submission page. The hyperlink opens up a text box to enter comments. The AE should enter the following language: “This is a time limited administrative action related to a Provider Settlement Agreement and does not represent an adverse action to the participant”. After entering the comments, the plan can be submitted.

4. AE must approve and authorize the ISP(s).

STEP 9 Notification Plan Updated

Provider notified by AE that the ISP has been updated and claims can now be billed.

ODP Regional WCM notified by the AE that the ISP has been updated.

Notify the ODP Regional WCM, SC and provider that the ISP has been updated and changed.

STEP 10 Validate plan updates

Obtain new service authorization notice from HCSIS and confirm accuracy prior to billing.

N/A N/A

STEP 11 Submit Claims Bill for services per the new service authorizations found in HCSIS.

N/A N/A

STEP 12 Reestablish Provider APC Levels

In order to reestablish APC to the level it was prior to the reduction, based on the Settlement Agreement, the Provider must follow the

N/A N/A

REISSUE DATE: June 2, 2015 7 | P a g e Informational Packet # 028-15: REISSUE (2ND)

STEPS ACTION

ACTION/ROLE DESCRIPTION

PROVIDER ODP

WAIVER CAPACITY MANAGER AE

procedures in the ODP Approval of Residential Service Locations and Approved Program Capacity, Informational Packet 055-12, to increase the APC when accepting a new referral.

NOTE Impact when no other changes requested to APC During FY 2014-2015

If the provider does not request another change in APC during fiscal year 2014-2015, the APC is automatically restored to the original APC on July 1, 2015.

N/A N/A

On the following page is an example of a partial year APC change request and the process to follow from a provider’s perspective.

APC CHANGE EXAMPLE: Provider’s Perspective

REISSUE DATE: June 2, 2015 8 | P a g e Informational Packet # 028-15: REISSUE (2ND)

In this scenario, a licensed community home has an approved program capacity for a Four Individual Home from 7/1/2014 – 6/30/2015. The provider had a DP 1024 on file that documented the home had a vacancy during the period 9/1/2014 – 12/1/2014. The provider requested a change to the approved program capacity, per the settlement agreement, and the ODP Regional WCM sent the provider an APC Determination Letter approving the APC change request. The shaded columns, on the table below, display the changes that will need to be made to the services (procedure codes – eligible and ineligible W codes), begin and end dates and units, in both PROMISeTM and HCSIS, to accurately reflect the change to APC. To summarize, the provider will need to do the following in sequential order:

Identify and void all eligible and ineligible W code claims that were originally billed to PROMISeTM from the first day of the requested APC change through the last day billed for the current APC;

Add the new approved services (procedure codes – eligible and ineligible W codes), associated with the APC change, to the SSD and ensure the APC change period is reflected in the SSD;

Add the new approved services (procedure codes – eligible and ineligible W codes), associated with the APC change, to the consumer’s individual support plan (ISP) for the APC change period and authorized by the AE.

Once the provider has confirmed all of the aforementioned steps have been completed, the provider should bill the new approved services (procedure codes – eligible and ineligible W codes), associated with the APC change, to PROMISeTM.

For this scenario, the provider must bill three (3) separate claims because each claim can only contain date spanning for a calendar month. The provider will be billing W6094 and W6095 on three (3) separate claims with each claim containing two separate claim detail lines. One claim detail line will be for the Three Individual Home, Eligible and the second claim detail line will be for the Three Individual Home, Ineligible. Units and the “From” and “To” date on the claim should reflect no more than a calendar month. The provider will also be required to enter an identifier in the patient account number field on the claim. The identifier will be furnished to the provider in their APC Determination Letter. Providers should ensure they enter the entire identifier on the claim including any letters. See the next page to view where the patient account number field is located on both a PROMISeTM internet claim and a Provider Electronic Solutions Software (PES) claim.

Procedure Code/ Service

Description

W6096 - Four Individual Home,

Eligible

W6097 - Four Individual Home,

Ineligible

W6094 - Three Individual Home,

Eligible

W6095 - Three Individual Home,

Ineligible

W6096 – Four Individual Home,

Eligible

W6097 – Four Individual Home,

Ineligible

Begin Date of Service

7/1/2014 7/1/2014 9/1/2014 9/1/2014 12/2/2014 12/2/2014

End Date of Service

8/31/2014 8/31/2014 12/1/2014 12/1/2014 6/30/2015 6/30/2015

Units Billed (Day Units)

62 62 92 92 211 211

PROMISeTM Internet Claim: Patient Account # field

REISSUE DATE: June 2, 2015 9 | P a g e Informational Packet # 028-15: REISSUE (2ND)

Your APC approval letter will contain the identifier to enter in this field when submitting a PROMISe

TM

internet claim.

Provider Electronic Solutions (PES) Software: Account # field

REISSUE DATE: June 2, 2015 10 | P a g e Informational Packet # 028-15: REISSUE (2ND)

ODP Regional Waiver Capacity Managers (WCMs)

Name e-mail Region

Bill Bruaw wbruaw@pa.gov Central

Mary Citko mcitko@pa.gov Southeast

Marie Craven mcraven@pa.gov Northeast

Dan Goclano dgoclano@pa.gov Western

Your APC approval letter will contain the identifier to enter in this field when submitting a claim using PES software.

DP 1024 Form – For Reference Only [get form at www.odpconsulting.net > Resources > ODP Forms > DP 1024 UF]

REISSUE DATE: June 2, 2015 11 | P a g e Informational Packet # 028-15: REISSUE (2ND)

DP 1024 Form – For Reference Only [get form at www.odpconsulting.net > Resources > ODP Forms > DP 1024 UF]

REISSUE DATE: June 2, 2015 12 | P a g e Informational Packet # 028-15: REISSUE (2ND)

APC CHANGE REQUEST FORM

REISSUE DATE: June 2, 2015 13 | P a g e Informational Packet # 028-15: REISSUE (2ND)

Request for Change in Established Approved Program Capacity (APC) PER the 2014 Provider Settlement Agreement

Name of Provider:

MPI#: ProviderContact Person:

Name:

Phone number:

Requested Start Date:

Service location Code:

Service location address:

End Date (no later than 6/30/15)

Vacancy Notification Submitted?

Current APC: Requested APC:

Individual(s) remaining at service location:

MCI# Individual Name Administrative Entity

(Registration) SC Name and address

Individual(s) who created the vacancy:

MCI# Individual Name Administrative Entity

(Registration) SC Name and address

APC LETTER – FOR REFERENCE ONLY

REISSUE DATE: June 2, 2015 14 | P a g e Informational Packet # 028-15: REISSUE (2ND)