Transcript Ohio Home and Community

Ohio Home and Community-Based
Service Waivers
Ohio Home Care Waiver
Provider Education and Technical Assistance
www.pcghealth.com
Training Overview
Priorities for Ohio Home Care Waiver:
• Waiver Target Population and Services, slides 4-5
• Waiver Rules, slides 6-8
• Provider Requirements, Conditions of participation,
slides 9-30
• RN Assessment & RN Consultation Services, slides 31-36
• Criminal Records, Background Checks, slides 37-41
2
Training Overview
Priorities for Ohio Home Care Waiver continued:
• Developing your Clinical Records, slides 42-50
• Structural Review, slides 51-56
• Incident Management & Reporting, slides 57-62
• Person Centered Services Plan & Billing, slides 63-79
3
Waiver Target Population and
Services
Ohio Home Care Waiver
Serves Medicaid eligible individuals under the age of 60 with
long-term care needs that, in the absence of certain services,
would require their needs to be met in a hospital or nursing
facility.
Waiver services include:
• Nursing
• Personal Care Aide Services
• Home Care Attendant Services
• Adult Day Health Center Services
• Home-Delivered Meals
4
Waiver Target Population and
Services
Waiver services Continued:
• Supplemental Adaptive and Assistive Devices
• Supplemental Transportation
• Out-of-Home Respite
• Emergency Response Systems
5
Waiver Rules
Ohio Home Care Waiver
6
Ohio Administrative Codes (OAC)
Please note, that this is not an all inclusive list of Ohio Home Care Waiver
rules. The following rules are being highlighted as the most commonly
referenced rules for the waiver programs.
• 5160-45-01; Definitions
• 5160-45-03; Individual Choice and Control
• 5160-45-05; Incident Management, Investigation, Response System
• 5160-45-06; Structural Reviews and investigation of provider
occurrences (REVISED 2/1/2015)
• 5160-45-10; Conditions of Participation (REVISED 2/1/2015)
7
Ohio Administrative Codes (OAC)
Rules Continued:
• 5160-46-04; Covered Services, Requirements, Specifications
• 5160-46-04.1; Home Care Attendant Services
• 5160-46-06; Reimbursement Rates and Billing (REVISED 7/1/2015)
• 5160-46-06.1; Home Care Attendant Rates and Billing
• 5160-12-08; Registered nurse assessment and registered nurse
consultation services. (NEW 7/1/2015)
8
Provider Requirements
5160-45-10, 5160-46-04
Ohio Home Care Waiver
9
Provider requirements:
Conditions of Participation (COP)
Ohio Department of Medicaid (ODM) –administered waiver
providers shall:
• Maintain a professional relationship with individuals to whom they provide
services
• Furnish services in a person- centered approach that follows the
individual’s approved Person Centered Services Plan (PCSP), is attentive
to the individual’s needs and maximizes the individual’s independence
• Refrain from any behavior that may detract from the goals, objectives and
services outlined in the individual’s approved PCSP and / or may
jeopardize the individual’s health & welfare
• Maintain an active, valid Medicaid Provider Agreement (5160-1-17.2)
Ohio Administrative Code (OAC) 5160-45-10
10
Provider requirements:
Conditions of Participation (COP)
ODM –administered waiver providers shall:
• Comply with all provider requirements, including but not limited to:
• Provider service specifications
• Criminal record checks, incident reporting, provider monitoring
reviews, and oversight
OAC 5160-45-10
11
Provider requirements;
coordinating services & missed visits
Work with the individual and case manager to coordinate service
delivery, including, but not limited to:
• Agreeing to provide services in the amount, scope, location &
duration the provider has the capacity to provide, and as specified
on the individual's approved Person Centered Services Plan
• Participating in the development of a back -up plan in the event
providers are unable to furnish services on the appointed date &
time
• Contacting the individual and the case manger in the event the
provider is unable to render services on the appointed date and
time
OAC 5160-45-10
12
Provider requirements;
coordinating services & missed visits
• Work with the individual and case manager to coordinate service
delivery, including, but not limited to:
• In the case of an emergency, the provider must immediately
activate the individual’s back -up plan set forth in the
individual's approved PCSP, and contact the individual and
Case Manager and verify their receipt of information about the
absence
• In an event of a planned absence, the provider shall contact
the individual and case manager no later than 72 hours prior
to the absence & verify their receipt of information about the
absence
13
OAC 5160-45-10
Provider requirements;
notifications to the Case Manager
You need to report to the Case Management Agency within 24 hours
when you are aware of issues that may affect the individual and/or any
provider’s ability to render services as directed in the individual’s PCSP.
Issues may include, but are not limited to the following:
• The individual consistently declines services
• The individual plans to, or moves to another residential address
• There are changes in the physical, mental, and/or emotional
status of individual
OAC 5160-45-10
14
Provider requirements;
notifications to the Case Manager
Issues may include, but are not limited to the following:
• Changes in the individual’s environmental conditions
• The individual’s caregiver status has changed
• The individual no longer requires medically necessary services as
defined in rule 5160-1-01 of the Administrative Code
• The individual’s actions toward you are threatening or you feel
unsafe or threatened in the individual’s environment
OAC 5160-45-10
15
Provider requirements;
notifications to the Case Manager, continued
Issues may include, but are not limited to the following:
• The individual is consistently non-compliant with physician orders,
or is non-compliant with physician orders that may jeopardize the
individuals health and welfare
• The individual’s requests conflict with his or her Person Centered
Services Plan / or may jeopardize his or her health and welfare
• Any other situation that affects the individual’s health and welfare
OAC 5160-45-10
16
Contacting
Case Management Agencies
During normal business hours, providers must call or email the case manager
using their contact information located on the individual’s Person Centered
Services Plan.
After hours, on the weekend or holidays, call the applicable number(s) below
for further direction.
Columbus region:
• CareSource (844) 832-0159 and CareStar (800) 616-3718
Cleveland region:
• CareSource (877) 209- 3154 and CareStar (800) 616-3718
Cincinnati region:
• Council on Aging (855) 372-6176 and CareStar (800) 616-3718
Marietta region:
• CareSource (855) 288-0003 and CareStar (800) 616-3718
17
Provider requirements;
keeping contact information current, why?
• You need to make arrangements to accept all correspondence sent by ODM
or it’s designee, including but not limited to certified mail
• You need to ensure that your contact information, including but not limited to
address, telephone number, fax number & e-mail address are current. In the
event of a change in contact information, you shall notify ODM via the
Medicaid Information Technology System (MITS) & its designee, no later
than 7 calendar days after such events occurred
• You need to provide & maintain a current e-mail address to ODM and/or it’s
designee in order to receive electronic notification of any rule adoption,
amendment or rescission, & any other communication from ODM or its
designee
PCG Provider Relations (877) 908-1746
18
What is My OhioHCP?
•
This website organizes all of a provider’s important Ohio Home Care
program information onto a private, individualized page. It includes
important records including PCSP’s & structural review reports, news and
updates, contact information, and more
For log in issues contact PCG at 877-908-1746
19
Provider requirements;
discontinuing your services
You need to submit written notification to the individual and ODM or its
designee Case Management Agency at least 30 calendar days before the
anticipated last date of service if you are terminating the provision of ODMadministered waiver services to the individual.
Exceptions to the 30 day advanced notification:
You must submit verbal and written notification to the individual and ODM or it’s
designee at least ten days before the anticipated last date of service IF the
individual:
• Has been admitted to the hospital
• Has been placed in an institutional setting
• Has been incarcerated
ODM may waive advanced notification for you upon request and on a
case-by-case basis.
OAC 5160-45-10
20
Provider requirements;
while rendering services ODM –administered waiver
service providers shall
not:
• Take the individual to your home
• Bring children, animals, friends, relatives, other individuals or
anyone else to the individual's home
• Provide care to anyone other than the individual
• Smoke without the consent of the individual
• Sleep
OAC 5160-45-10
21
Provider requirements;
shall nots continued
• Engage in any activity that is not related to the services you are
providing to the extent the activity distracts, or interferes with,
service delivery.
• Including, but not limited to:
• Using electronic devices for personal or entertainment
purposes (not limited to watching television, using the computer or
playing games)
• Deliver services when you are medically, physically or
emotionally unfit
• Engaging in socialization with persons other than the individual
OAC 5160-45-10
22
Provider requirements;
shall nots continued
• Use or be under the influence of alcohol, illegal drugs, chemical
substances or controlled substances that may adversely affect
your ability to furnish services.
• Engage in any activity or conduct that may reasonably be
interpreted as sexual in nature, regardless of whether or not it is
consensual
• Engage in any behavior that my reasonably interpreted as
inappropriate involvement in the individual’s personal beliefs or
relationships
OAC 5160-45-10
23
Provider requirements;
shall nots continued
• Consume the individual’s food and/or drink without his or her offer
and consent
• Do anything that causes or may cause physical, verbal, mental,
emotional distress or abuse to the individual, or behavior that may
compromise the health & welfare of the individual.
• Engage in an activity that may take advantage of or manipulate
the individual or his or her authorized representative, family or
household members or may result in a conflict of interest
exploitation, or any other advantage for personal gain.
OAC 5160-45-10
24
Provider requirements;
shall nots continued
• This includes but, is not limited to:
• Misrepresentation: deliberate intention to deceive, either for
profit or advantage
• Accepting, obtaining, attempting to obtain, borrowing, or
receiving money or anything of value including, but not limited
to gifts, tips, credit cards or other items
• Being designated on any financial account including, but not
limited to bank accounts and credit cards
OAC 5160-45-10
25
Provider requirements;
shall nots continued
• This includes but, is not limited to continued:
• Using the Individual’s real or personal property
• Lending or giving money or anything of value
• Engaging in the sale or purchase of products, services or
personal items
• Engaging in any activity that takes advantage of or manipulates
ODM-administered waiver program rules
OAC 5160-45-10
26
Non-Agency Personal Care Aide
(PCA) requirements
• PCAs must complete twelve hours of in-service continuing
education annually that must occur on or before the anniversary
date of their enrollment as a medicaid personal care aide provider.
•
Examples of continuing education include, but are not limited to the following:
consumer health & welfare, cardiopulmonary resuscitation (CPR), patient rights,
aging sensitivity, developmental stages, transfer techniques, disease specific
trainings, and mental health issues.
• PCAs must obtain and maintain first aid certification from a class
that is not solely internet-based and includes hands-on training by a
certified instructor.
• PCAs must comply with the individual’s specific service instructions
on the PCSP & provide a return demonstration upon request of the
individual or Case Manager.
OAC 5160-46-04
27
Agency Personal Care Aide
(PCA) requirements
• PCAs must obtain and maintain first aid certification from a class
that is not solely internet-based and includes hands-on training by a
certified instructor.
• PCAs must maintain evidence of the completion of twelve hours of
in-service continuing education within a twelve month period,
excluding agency and program specific orientation. Continuing
education must be implemented immediately, and must be
completed annually thereafter.
• PCAs must receive supervision from an Ohio Licensed Registered
Nurse (RN), or an Ohio Licensed Practical Nurse (LPN), at the
direction of a RN at least every 60 days. These face-to-face
consumer home visits must be documented in the individual’s
record.
OAC 5160-46-04
28
Registered Nurse (RN)
Requirements
Registered Nurses must do the following:
• Maintain a valid Ohio nursing license
• Follow the Nurse Practice Act
• Obtain physician orders and be listed on physician’s orders to
provide the service, as well as the PCSP prior to delivering services
to any individual
• Ensure physician’s order (plan of care) is updated at least once
every 60 days
• Ensure all verbal orders are documented including date, time, and
physician. Verbal orders need to be signed by the physician, or the
order is not valid & the nurses do not have the authorization to
deliver services
OAC 5160-46-04
29
Licensed Practical Nurse (LPN)
Requirements
•
Have a face-to-face visit at least every 60 days with the directing RN to
evaluate the provision of waiver nursing services, LPN performance, and to
assure services are being delivered in accordance with approved Person
Centered Services Plan.
•
Have a face-to-face visit at least every 120 days with directing RN, LPN,
and individual/guardian to evaluate all of the above in addition to the
individual’s satisfaction with care delivery.
•
The LPN must provide clinical notes, signed and dated by the LPN,
documenting the face-to-face visits between the LPN and the directing RN.
• Maintain documentation of plan of care review and physician orders by
directing RN.
OAC 5160-46-04
30
RN assessment & RN consultation
services (NEW 7/1/2015)
5160-12-08
Ohio Home Care Waiver
31
Registered nurse assessment and
registered nurse consultation service
An RN assessment shall be performed on an individual
participating in the following medicaid programs prior to the
individual receiving the services:
• State plan home health services
• Private duty nursing
• Waiver nursing
• Personal care aide services furnished by a medicare- certified home
health agency or other accredited agency
• HOME choice nursing services
OAC 5160-12-08
32
RN - Assessment Service, continued
An RN assessment shall be performed also:
• Prior to any change being made to an individual's current services
• Any time the RN is informed that the individual has experienced a
significant change, including an improvement or a decline in
condition
An RN performing an RN assessment service shall:
• Possess a current, valid and unrestricted license with the Ohio
Board of Nursing
• Only provide services within the RN's scope of practice
OAC 5160-12-08
33
RN - Assessment Service, continued
An RN performing an RN assessment service shall :
•
Provide the basis for the RN to make independent decisions and nursing
diagnoses, plan nursing interventions and evaluate the need for other
interventions, develop the plan of care and assess the need to
communicate and as applicable, consult with other team members
•
Include a face-to-face interview with, and observation of the individual in
his or her place of residence
•
Serve as the guide for the directing RN
OAC 5160-12-08
34
The RN Assessment Service, continued
Reimbursement for an RN assessment service is now billable to
Medicaid.
• RN assessment services performed must be prior-approved by
the Ohio Department of Medicaid and be specified on the
individual’s PCSP.
• An RN may be reimbursed for an RN assessment service no
more than once every sixty days per individual receiving services
unless the RN is informed that the individual receiving services
experienced a significant change, including an improvement or a
decline in condition, and therefore a subsequent RN assessment
is required.
• RN assessments are reimbursable when sequentially, but not
concurrently, performed with any other service during a visit.
OAC 5160-12-08
35
RN Consultation Services
•
•
•
An LPN shall seek the guidance of the directing RN when the individual
receiving services from the LPN experiences a significant change in
condition that may necessitate a change in the individuals plan of care and
the interventions being provided by the LPN
An RN consultation service must be conducted between the directing RN
and LPN either face-to-face or over the telephone
If an individual selects multiple non-agency LPNs to furnish PDN services,
waiver nursing, or HOME choice nursing services, the individual may
designate a single RN to provide RN assessment and/or RN consultation
services. Such designation shall be identified on the individual’s PCSP, as
applicable, or the case manager, if one is assigned to the individual, shall
develop a plan for the coordination of non-agency nursing services
• See rule for complete details of the content of the RN
assessment and RN Consultation Services. OAC 5160-12-08
36
Criminal Records Background Checks
5160-45-10, 5160-45-07, 5160-45-08
Ohio Home Care Waiver
37
Criminal Record Checks:
Non-Agency Providers
Each enrolled non-agency waiver provider, before the anniversary date of their
Medicaid provider agreement, shall be informed of the requirement to:
• Provide a set of fingerprint impressions
• Complete a criminal records check
NOTE: This is a requirement for continued approval as a provider.
Provider background check(s) must be conducted by the Ohio Bureau of
Criminal Identification and Investigation (BCI&I), following the receipt of
fingerprint impressions and required document(s).
• If BCI&I does not receive the report within the required timeframe, ODM
will move forward with revoking the provider’s agreement with the
department
• Failure to submit the annual background check will lead to termination
of provider number
OAC 5160-45-08
38
Criminal Record Checks:
Non-Agency Providers, continued
To obtain a background check, you must go to a location that performs
electronic Web Check.
A listing of Web Check agencies can be found on the Ohio Attorney General’s
website at the following link, Web Check Community Listing:
http://www.ohioattorneygeneral.gov/Business/Services-forBusiness/WebCheck/Webcheck-Community-Listing
Contact BCI&I by telephone at (877) 224-0043 for additional information.
Background checks from BCI&I must be sent directly to this ODM address:
The Ohio Department of Medicaid
Attention: BCI Coordinator
P.O. Box 183017
Columbus, Ohio 43218
OAC 5160-45-08
39
Criminal Records Checks:
Agency Providers
Agency providers may not employ or continue to employ an employee if:
• An employee is included on the databases listed in OAC
• System for Award Management (SAM)
• Ohio Department of Developmental Disabilities (DODD) online abuser
registry
• Internet- based sex offender & child- victim offender database
• Internet-based database of inmates
• State nurse aide registry & there is a statement detailing findings
• An employee fails to submit a records check conducted by BCI&I, including
failure to access and complete fingerprint impression sheet
As a condition of continued employment, agencies shall conduct a criminal
records check of employees at least once every five years.
OAC 5160-45-07
40
Federal Bureau of Investigation (FBI)
background checks, do I need one?
•
•
Any applicant or provider found to have been convicted of, or pleaded guilty
to, a disqualifying offense, regardless of the date of the conviction or date
entry of the guilty plea cannot work with any of the waiver individuals.
New and existing providers are also required to submit a Federal Bureau
of Investigation (FBI) background check in addition to the Ohio
background check if any of the following applies:
•
•
•
•
You do not currently live in the State of Ohio.
You have not lived in Ohio for the last five consecutive years.
You have been arrested and/or convicted of a crime in another state.
ODM instructed you to obtain an FBI background check.
Background checks from either BCI&I and FBI must be sent directly to
this ODM address:
The Ohio Department of Medicaid
Attention: BCI Coordinator
P.O. Box 183017
41
Columbus, Ohio 43218
Developing your Clinical Records
5160-45-10, 5160-46-04
Ohio Home Care Waiver
42
Developing your Clinical Records,
what is required?
Non-agency waiver nursing & personal care aide service providers:
• Must leave a legible copy of complete clinical record including
the daily visit note & a copy of the PCSP in the individual’s home
• Must keep the original in your place of business.
• Your place of business must be a location other than the
individual’s residence.
Agencies, including Medicare- certified, or otherwise accredited
agencies:
• Must maintain the clinical records at their place of business.
ALL clinical records are to be maintained in a confidential
manner & maintained for a period of 6 years
OAC 5160-46-04
43
Clinical Records,
individual’s identifying information
• Name, address, age, date of birth, sex, race, marital status,
significant phone numbers, and health insurance identification
numbers
• The individual’s medical history
• The name of individual's treating physician (now also needed for
billing)
• A copy of the initial and all subsequent Person Centered Services
Plan (PCSP)
OAC 5160-46-04
44
Clinical Records,
individual’s identifying information continued
• Documentation of all drug & food interactions, allergies &
dietary restrictions
• Copy of any advance directives including, but not limited
to:
• Do Not Resituate (DNR)
• Medical Power of Attorney (POA)
OAC 5160-46-04
45
Clinical Records,
Service/ visit records
Service documentation is required for each visit and must contain all of
the following:
• Your arrival & departure times
• Tasks performed or not performed during the visit
• The dated signatures of both the provider & the individual verifying
the service delivery upon completion of service delivery
OAC 5160-45-10, 5160-46-04
46
Clinical Records,
Service/ visit records continued
Service documentation is required for each visit and must contain all of
the following:
• Progress notes signed by the provider documenting:
• All communications with the case manager, treating physician,
or other members of the multidisciplinary team
• Documentation of any unusual events occurring during the visit
• Documentation of the general condition of the individual
OAC 5160-45-10, 5160-46-04
47
Clinical Records,
additional documentation for nurses
• A copy of all the initial and all subsequent plans of care specifying
type, frequency, and duration of the nursing services being
performed
• Documentation that the RN supervisor has reviewed the plans of
care with the LPN
• Plans of care must be recertified by the treating physician every
60 days, or more frequently when there is a significant change
OAC 5160-46-04
48
Clinical Records,
additional documentation for nurses cont’d
• When the treating physician gives verbal orders to the
nurse, the nurse must document in writing, the
physician’s orders, the date & time the orders were given,
and sign the entry in the clinical record. The treating
physician must sign and date the verbal orders.
OAC 5160-46-04
49
Clinical Records,
discharge summary
Home Health Aide
•
Signed & dated by the departing non-agency PCA or the RN supervisor of
an agency PCA, at the point that personal care is no longer going to be
provided, or when the individual no longer needs the personal care services
• Summary to include documentation regarding progress made toward
achievement of goals as specified on the individual’s PCSP
Nursing
•
Signed and dated by the departing nurse at the point the nurse is no longer
going to provide services to the individual, or when the individual no longer
needs nursing services
• The summary should include documentation regarding progress made
toward goal achievement and indicate any recommended follow-ups or
referrals
OAC 5160-46-04
50
Structural Review
5160-45-06
Ohio Home Care Waiver
51
Structural Reviews of Providers
Waiver providers are subject to Structural Reviews to evaluate provider
compliance with all applicable Ohio Administrative Codes.
Medicare-certified/ or otherwise accredited agencies are subject to reviews in
accordance with their certification & accreditation bodies, and therefore shall be
exempt from a regularly scheduled structural review.
 If requested to do so by the Ohio Department of Medicaid (ODM) or its
designee (PCG), agencies shall submit a copy of their updated certification
and/or accreditation, and shall make available to ODM or its designee within
10 business days, all review reports and accepted plans of correction from
the certification and/or accreditation.
Note: All ODM-administered waiver providers may be subject to an announced
or unannounced Structural Review at any time as determined by ODM or its
designee.
OAC 5160-45-06
52
All other ODM-administered waiver providers shall be subject to
Structural Reviews by ODM or its designee during each of the first
three years after a provider begins furnishing billable services.
Thereafter, reviews shall be conducted annually unless, at the
discretion of ODM, biennial reviews may be conducted, when all of the
following apply:
• You had no findings during the provider’s most recent Structural Review
• You were not substantiated to be the violator in an incident described in
rule 5160-45-05
• You were not the subject of more than one provider occurrence during
the previous 12 months
• You do not live with an individual receiving ODM-administered waiver
services
OAC 5160-45-06
53
Structural Reviews,
what should you bring to the review?
•
Structural reviews must be conducted in person between the provider &
ODM or its designee with an ODM approved structural review tool.
•
The Structural Review shall not occur while you are providing services to an
individual
•
The Structural Review process consists of the following activities:
• Except for unannounced reviews, you shall be notified in advance of the
review to arrange a mutually agreeable time, date & location for the
review
• You shall be notified of the time period for which the review is being
conducted
OAC 5160-45-06
54
Structural Reviews,
what should you bring to the review cont’d?
• The Structural Review process consists of the following activities
continued:
• You shall be provided with a list of the type of documents required for
the review
• You shall ensure the availability of the required documents & maintain
the confidentiality of information about the individual enrolled in the
ODM-administered waiver
• The Structural Review shall include an evaluation of your compliance
with Chapters 5160-45 and 5160-46 of the Ohio Administrative Code
OAC 5160-45-06
55
Structural Reviews, what should you expect?
• A unit of service verification shall be conducted to assure that
all waiver services are authorized, delivered, & reimbursed in
accordance with the approved PCSP for the individual receiving
services
• At the conclusion of the review you shall receive: an exit
conference containing preliminary findings, any individual
remediation, & other required follow-up
• You will receive written findings report summarizing the overall
outcome of the Structural Review, specifying the Administrative
Code rules that are the basis for which non-compliance has
been determined, and outline the specific findings of
noncompliance that you must address in a plan of correction,
including any individual remediation
OAC 5160-45-06
56
Incident Management & Reporting
5160-45-05
Ohio Home Care Waiver
57
Incident Management,
what is an incident?
An incident is an alleged, suspected, or actual event that is not
consistent with routine care of and/or delivery to an individual.
Incidents include, but are not limited to, all of the following:
• Abuse
• Neglect
• Exploitation
• Misappropriation
OAC 5160-45-05
58
Incident Management,
what is an incident?
Incidents include, but are not limited to, all of the following
continued:
• Death of an individual
• Hospitalization or emergency department visit (including
observation) as a result of an accident , injury or fall; injury or
illness of an unknown cause or origin; or a reoccurrence of an
illness or medical condition within 7 calendar days of the of the
individual’s discharge from the hospital
OAC 5160-45-05
59
Incidents include, but are not limited to:
• Unauthorized use of restraint, seclusion and /or restrictive
intervention that does not result in, or cannot reasonably be
expected to result in, injury to the individual
• An unexpected crisis in the individual’s environment that results in
the inability to assure the individual’s health & welfare in his or her
primary place of residence
• Inappropriate service delivery including, but not limited to:
• Violations of the conditions of participation
• Services provided to an individual that are beyond your scope of
practice
• Services delivered to the individual without, or not in accordance
with the physician’s orders
• Medication administration errors
60
OAC 5160-45-05
Incidents include, but are not limited to
continued:
• Action on the part of the individual that place health & welfare of the
individual at risk including, but not limited to:
• The individual cannot be located
• Activities that involve law enforcement
• Misuse of medications; and the use of illegal substances
OAC 5160-45-05
61
Incident reporting,
notification, & response requirements
• When you learn of a reportable incident, you must report the incident
to the Case Management Agency within twenty-four hours unless
bound by federal, state or local law or professional licensure or
certification requirements to report sooner
All waiver providers are required to complete an online Incident
Management training by ODM. Attendance is reported to ODM.
Required annual training can be found at the link provided below.
• http://ohiohcbs.pcgus.com/TrainingMaterials/verify.html
OAC 5160-45-05
62
Provider Billing & Person Centered
Services Plan
5160-46-04, 5160-1-17.9
Ohio Home Care Waiver
63
Person Centered Services Plan
(PCSP)
The Person Centered Services Plan is the document which identifies
person-centered goals, objectives, and interventions including any
authorized medically necessary services.
As a provider of the Medicaid Waiver Program you are responsible to assure
the following:
• Prior to delivery of any service(s), you must verify the Individual’s
Medicaid eligibility and that their PCSP is accurate and contains the
following:
• The Individual’s PCSP must list your name, the correct type of
service(s) you agreed to provide, a correct procedure code for those
services, and an approved start of care date
• You need to assure that the authorized hours listed on the goals page
matches the authorization on the units page.
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Person Centered Services Plan
(PCSP)
Make sure to keep a copy of the Individual’s PCSP for your records.
If the PCSP information is unavailable or incorrect,
you are to notify the Individual’s Case Manager. You
should not provide the service or bill for the service if
the authorization is not listed on the Individual’s
PCSP. You will be in jeopardy of non-payment or an
overpayment if you do provide unauthorized
services.
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Person Centered Services Plan (PCSP)
Service authorizations are listed under “Goals” and “Units” sections of the
Individual’s PCSP.
The “Goals” page of the PCSP identifies what the Individual hopes to achieve
through implementation of interventions such as medically necessary services.
The Goals page also will detail the days, hours, and times you are expected to
work.
The “Units” page of the PCSP identifies how many shifts are authorized, the
services billing code, and the monthly cost of the service (if all of the services are
delivered that month as authorized).
• Any changes to an Individual’s care or services must be updated on the
Individual’s PCSP and distributed to all service providers by the case manager.
You can accept verbal approval from the Case Manager. You may not
bill for these services until the PCSP has been updated with this
written authorization.
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Person Centered Services Plan (PCSP)
Providers should
always verify that
the information
contained on
PCSP is accurate
on both the
Goals page and
Units page.
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Reimbursement Rates & Billing
Procedures (REVISED 7/1/2015)
Providers must bill in accordance to the Ohio Home Care Waiver
rules as it pertains to the base and unit rates outlined in
Ohio Administrative Code 5160-46-06
Base Rate means the amount reimbursed by Ohio Medicaid for the first
35 to 60 minutes of service delivered time.
Unit Rate means the amount reimbursed by Ohio Medicaid for each 15
minutes of service delivered when the visit is:
• Greater than 60 minutes in length
• Ohio Medicaid will reimburse a maximum of one unit of service when the
service delivery is equal to or less than 15 minutes in length
• Ohio Medicaid will reimburse a maximum of 2 units if the service delivery is 16
through 34 minutes in length
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Reimbursement Rates & Billing
Procedures (REVISED 7/1/2015)
When the initial visit is greater than sixty minutes
For a visit in length beyond the initial hour of service, the base rate plus the
rate amount for each 15‐minute unit over the initial one hour may be claimed
for services performed which does not exceed the prescribed OAC limits
(e.g., visits not more than 4 hours for home health; more than 4 hours for
Private Duty Nursing; or the individual’s PCSP).
Length of visit
1 - 15 minutes
16 - 34 minutes
35 - 60 minutes
1 hour and 15 minutes
1 hour and 30 minutes
Your billing should reflect:
One Unit
Two Units
One Base Unit
One Base Unit + One Unit
One Base Unit + Two Units
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Reimbursement Rates: OAC 5160-46-06
Billing
Code
T1002
Service
Waiver nursing services
provided by an agency RN
Waiver nursing services
T1002 provided by a non-agency
RN
Base
rate
Modifier
Description
Requirement
U1
Infusion
Therapy
Must be used with code G0154 for the purpose of
identifying home infusion therapy provided in
accordance with OAC rule 5160-12-01.
Unit
rate
$45.40 $8.32
U2
Must be used to identify the second visit for the
same type of service made by a provider on a
Second Visit
date of service per individual in accordance to
OAC rule 5160-12-04.
U3
Third Visit
Must be used to identify the third or more visit
for the same type of service made by a provider
on a date of service per individual in accordance
to OAC rule 5160-12-04.
U5
Healthchek
Must be used to identify the individual receiving
services due to Healthchek in accordance to OAC
rule 5160-12-01.
HQ
Group Visit
Must be used to identify individual receiving
services in accordance to OAC rule 5160-12-04.
RN Visit
Must be used to identify a visit conducted by a
registered nurse (RN) for home health nursing
service billed to Ohio Medicaid.
LPN Visit
Must be used to identify a visit conducted by a
licensed practical nurse (LPN) for home health
nursing service billed to Ohio Medicaid.
$38.60 $6.96
Waiver nursing services
T1003
$37.90 $6.82
provided by an agency LPN
Waiver nursing services
T1003 provided by a non-agency
LPN
$31.65 $5.57
Personal care aide services
T1019 provided by an agency
$22.45 $3.73
personal care aide
Personal care aide services
T1019 provided by a non-agency $18.10 $2.86
personal care aide
TD
TE
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Ordering, Referring, Prescribing Numbers
(ORP)
Reference OAC 5160-1-17.9
As of April 1, 2015, all provider types are required to include
the Ordering, Referring, Prescribing (ORP) number on billing
claims.
“Ordering or referring providers” has been created in order to
comply with new program integrity regulations contained in
the Patient Protection and Affordable Care Act (ACA). As a
result, Ohio Medicaid is implementing new requirements for
the “Enrollment and Screening of Providers.”
The physician or other health care professional who is an
ordering or referring only provider MUST also be enrolled as
a participating provider with Medicaid.
Billing claims will be denied if they do not include the National
Provider Number (NPI) or the legal name of the physician or
health care professional that ordered/prescribed the service
or referred the client for the service.
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Billing Accuracy / Remittance
Advice- what should you look for?
• Ensure your claims have the correct code, date of service, and
individual
• Ensure that the clinical documentation matches the appropriate
individual, length of visit, date billed, and PAID amount
• Review your billing claims after each submission to assure all
claims are submitted accurately, including the amount PAID
• If an overpayment is found or a claim was billed incorrectly, you
have 60 days to resubmit a correction to the claim
Remittance advice statements for claims prior to 08/02/2011 are
available on the Medicaid portal at:
https://Medicaidremit.ohio.gov/default/home.jsf
All other remittance advice statements for claims submitted on or
after 08/02/2011 are available through the MITS system.
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Service & Billing Overview
• Providers shall only bill for services when those services
were delivered face-to-face with an Individual
• Providers shall not act as a “contract agent” or pay
someone else to provide care to the Individual
• Providers shall not bill for services while the individual
receives care at another healthcare setting, physician’s
office, hospital, or extended care facility
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Service & Billing Overview Cont’d
• Providers must submit billing claims to the individual’s insurance prior to
billing Medicaid. If the cost of service is covered by insurance, the
provider shall not submit any billing claims to Medicaid.
• Providers should review billing after each submission to assure
accuracy of claims which includes service delivery dates, units billed
reflects time on timesheets, and bank deposit is the same as what was
billed.
• ODM has 30 days to make a payment from the date of a clean
submission
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Billing References for Agencies, Nurses, & PCA’s
Reference Information:
•
MITS Website:
https://portal.ohmits.com/public/Providers/tabid/43/Default.aspx
•
Web Portal Eligibility Verification:
http://Medicaid.ohio.gov/Portals/0/Providers/Training/MITS_Eligibility_Verify_
Quick_Guide.pdf
•
Provider Billing:
http://Medicaid.ohio.gov/PROVIDERS/Training/BasicBilling.aspx
•
Website contains training on how to adjust for overpayments.
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Billing References for Agencies, Nurses, & PCA’s
Reference Information continued:
•
Provider Training: http://ohiohcbs.pcgus.com/
•
Website contains a wealth of information and online training
opportunities.
•
Ordering, Referring, Prescribing Numbers (ORP) Info:
http://Medicaid.ohio.gov/PROVIDERS/EnrollmentandSupport/Provider
Enrollment/ORP.aspx
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ICD-10 Transition
What service providers are affected?
• All providers that are currently required to include
ICD-9 codes on claims will be required to use ICD-10
codes beginning with the date of service or date of
discharge of October 1, 2015
• Ancillary service providers are included, such as
transportation and waiver providers
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ICD-10 Transition
What ICD-10 codes should I use?
• Research the codes that will apply to your business
• If another provider supplies your ICD-10 codes, you
must ensure those providers are ICD-10 compliant
• If you utilize a clearinghouse/ billing service, you must
ensure the vendor will be ready to accommodate the
ICD-10 transition. (Send test claims)
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ICD-10 Resources
• Public Consulting Group (PCG):
http://ohiohcbs.pcgus.com/
• Centers for Medicare and Medicaid Services (CMS):
www.cms.gov/ICD10
• Ohio Department of Medicaid (ODM):
http://www.Medicaid.ohio.gov/PROVIDERS/Billing/ICD10.aspx
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QUESTIONS
Please email all waiver provider
inquiries to:
[email protected]
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Public Consulting Group, Inc.
155 E. Broad St. 8th Floor Columbus, Ohio 43215
(877) 908-1746, [email protected]
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