RI MEDICAID PROVIDER MANUAL WAIVER SERVICES
RI MEDICAID PROVIDER MANUAL WAIVER SERVICES Version 1.2 RI Medicaid Provider Manual – Waiver Services Revision History Version 1.0 1.1 Date November, 2013 March, 2014 1.2 April, 2014 PR0016 V1.2 04/30/14 Sections Revised All sections Remove CMS Interactive instructions Provider Enrollment Reason for Revisions New manual format New CMS form (02/12) NPI project – No longer assigning provider number Page 2 RI Medicaid Provider Manual – Waiver Services Table of Contents INTRODUCTION .................................................................................................................................5 Waiver Services ......................................................................................................................................... 5 Provider Participation Guidelines ............................................................................................................. 5 Provider Enrollment .................................................................................................................................. 5 Recertification ........................................................................................................................................... 5 Electronic Data Interchange Trading Partner ........................................................................................... 6 REIMBURSEMENT OF CLAIMS .............................................................................................................6 Claim Billing Guidelines ............................................................................................................................. 6 Timely Filing Requirements....................................................................................................................... 6 Eligibility Verification ................................................................................................................................ 7 Reimbursement Guidelines....................................................................................................................... 7 Co-insurance, Deductible, and Co-payments............................................................................................ 7 Patient Liability ......................................................................................................................................... 7 Definition of Terms ................................................................................................................................... 8 Homemaker .......................................................................................................................................... 8 Personal Care Aide ................................................................................................................................ 8 Combined Homemaker /Personal Care Aide ........................................................................................ 8 Case Management ................................................................................................................................ 8 LPN Services .......................................................................................................................................... 8 Day Habilitation .................................................................................................................................... 9 Supported Employment ........................................................................................................................ 9 Specialized Medical Equipment ............................................................................................................ 9 WAIVER PROGRAMS ..........................................................................................................................9 Intellectually Disabled (BHDDH) .........................................................................................................9 Core Community Services ................................................................................................................. 12 Department of Elderly Affairs Co-Pay Program.................................................................................. 12 Department of Elderly Affairs Waiver Program ................................................................................. 13 Department of Elderly Affairs Assisted Living Program ...................................................................... 13 Habilitation Community Services ...................................................................................................... 14 Habilitation Group Home ................................................................................................................. 14 PR0016 V1.2 04/30/14 Page 3 RI Medicaid Provider Manual – Waiver Services Preventive ....................................................................................................................................... 14 Self -Direction Community Services .................................................................................................. 14 Modifiers for T1000 and S5125 ......................................................................................................... 15 Appendix ......................................................................................................................................... 16 Claim Preparation Instructions ............................................................................................................... 16 Waiver Services - Waiver/Rehab Claim Form ..................................................................................... 16 Waiver Form Filing Instructions .......................................................................................................... 16 Waiver Services - CMS 1500 Claim Form ............................................................................................ 16 CMS 1500 Form Filing Instructions ................................................................................................ 16 Error Status Codes .................................................................................................................................. 16 ESC Code List (English) ................................................................................................................... 16 Explanation of Benefits (EOB) Codes ...................................................................................................... 16 EOB Codes and Messages List (English) EOB Codes and Messages List (Spanish)......................... 16 Third Party Liability Carrier and Coverage Codes ................................................................................... 16 Third Party Liability (TPL) Carrier Codes ........................................................................................ 16 Third Party Liability (TPL) Coverage Codes ......................................................................................... 16 Connect Care Choice ............................................................................................................................... 16 Connect Care Choice Community Partners............................................................................................. 16 PR0016 V1.2 04/30/14 Page 4 RI Medicaid Provider Manual – Waiver Services INTRODUCTION HP Enterprise Services (HP), in conjunction with the Rhode Island Executive Office of Health and Human Services (EOHHS), developed provider manuals for all Medicaid Providers. The purpose of this guide is to assist Medicaid providers with general Medicaid policy, coverage information and claim reimbursement. In addition the HP Customer Service Help Desk is available to answer questions. HP ENTERPRISE SERVICES can be reached by calling: 1-401-784-8100 for local and long distance calls 1-800-964-6211 for in-state toll calls or border community calls Waiver Services The RI Global Consumer Choice Compact Waiver, or Global Waiver, was approved by the Centers for Medicare and Medicaid Services (CMS) on January 16, 2009. The Global Waiver establishes a new Federal-State compact that provides the State with greater flexibility to provide services in a more cost effective way that will better meet the needs of Rhode Islanders. This waiver combines eleven waivers into one waiver authority. Provider Participation Guidelines To participate in the Rhode Island Medicaid Program, providers must meet the following requirements: Providers must be located and be performing services in Rhode Island (except for border communities). In-state providers must be licensed or certified by the state of Rhode Island. Outof-state providers must be licensed or certified in their respective states. Provider Enrollment HP Enterprise Services is the fiscal agent for EOHHS and the Medicaid Program, and as the fiscal agent is responsible for the enrollment, claims processing and reconciliation. Providers must complete the enrollment process before claims are accepted. Information on enrollment is found on the Provider Enrollment tab of the EOHHS website. Select Provider Enrollment Application and Related forms to access the appropriate enrollment form and instructions for completion. Recertification Providers are periodically recertified by the State of Rhode Island. Providers obtain license or certification through the appropriate state department. Out of state providers must forward a copy of the renewal documentation to HP Enterprise Services. HP Enterprise Services should receive this information at least five business days prior to PR0016 V1.2 04/30/14 Page 5 RI Medicaid Provider Manual – Waiver Services the expiration date on of the license or certification. Failure to do so will result in suspension from the program. Electronic Data Interchange Trading Partner Effective October, 2003, all Medicaid providers must utilize HIPAA compliant software to submit claims electronically. Providers in Rhode Island may use HP Enterprise Services’ free software, Provider Electronic Solutions (PES), or software that has completed HIPAA compliance testing with HP Enterprise Services. To submit claims electronically, providers must complete an Electronic Data Interchange (EDI) Trading Partner Agreement (TPA). A Trading Partner Agreement is also required to access the secured portion of the EOHHS website. This portion of the website allows you to check eligibility, claim status, Remittance Advice, and other necessary information. New providers should submit a Trading Partner Agreement with their enrollment application. This agreement is found on the EOHHS website (www.eohhs.ri.gov) on the Forms and Application Tab, under Business Process Forms, titled Trading Partner Agreement. This completed form will generate an identification number and a password to access the EOHHS portal. For questions about completing the TPA, contact the EDI coordinator at (401) 784-8014. REIMBURSEMENT OF CLAIMS Claim Billing Guidelines Claims should be billed electronically. If a paper claim must be submitted, it should be billed on the appropriate form: Waiver /Rehab or CMS 1500. Instructions for completing the Waiver/Rehab and CMS 1500 claim form are located in Claims Processing. Links can also be found in the appendix. Timely Filing Requirements A claim for services provided to a Medicaid client, with no other health insurance, has to be received by the States’ fiscal agent, HP Enterprise Services within twelve months of the date of service or if the claim is over a year old then 90 days from the date of denial by HP Enterprise Services in order to be processed for adjudication. Any claim that does not meet these criteria will be denied for timely filing. A claim, over a year old that involve a third party payer must be submitted within 90 days from the date payment was made by the other payer. The other insurance Explanation of Benefits (EOB) will verify this. The other insurance actual Explanation of Benefits must be attached to the claim. Any claim received with a date greater than the 90 days from payment of the third party will be denied for timely filing. PR0016 V1.2 04/30/14 Page 6 RI Medicaid Provider Manual – Waiver Services Adjustments to a paid claim, over a year old, will be accepted up to 90 days from the remittance advice date that the original claim payment was posted. Criteria for overriding the timely filing edit are; retroactive client or provider eligibility (within the year), previous denial (other than timely filing), HP Enterprise Services processing error or recoupment, within 90 days. Computer printouts are not considered acceptable proofs of timely filing. Eligibility Verification Recipient eligibility can be verified on the EOHHS web portal. To access the portal, providers need to have completed a Trading Partner Agreement and will use their assigned identification number and password. Providers must have the recipient’s Medicaid ID number (MID), usually a social security number. The web portal is found at https://www.eohhs.ri.gov/secure/logon.do. Reimbursement Guidelines A list of procedure codes is located in each of the individual Waiver programs located on the following pages. Providers must bill the Medicaid Program at the same usual and customary rate as charged to the general public and not at the published fee schedule rate. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to Medicaid. Payment to providers will not exceed the maximum reimbursement rate of the Medicaid Program. Co-insurance, Deductible, and Co-payments Medicaid Program recipients who have other insurance and co-payments for insurance coverage may have a co-insurance, deductible, and/or co-payment liability amount that must be met. The other insurance carrier must be billed first, then the provider must submit the other carrier’s EOB with the claim. If the other insurance has paid for the service, the Medicaid Program will pay any co-insurance, deductible, and/or co-payment as long as the total amount paid by the other insurance does not exceed the Medicaid Program allowed amount(s) for the service(s). Patient Liability Unless otherwise stipulated, the Medicaid Program reimbursement is considered payment in full. The provider is not permitted to seek further payment from the recipient in excess of the Medicaid Program rate. When it is stipulated that a recipient must “spend down” or contribute a portion of their personal income towards the cost of care, the amount of the recipient share will be indicated on the notice sent to the recipient. PR0016 V1.2 04/30/14 Page 7 RI Medicaid Provider Manual – Waiver Services Definition of Terms Homemaker Homemaker Services include household duties, such as cleaning, meal preparation and laundry. These services are performed and covered when the regular provider of these services, usually a relative with whom the recipient lives, is unavailable. Personal Care Aide Hands-on care, of both a medical and non-medical supportive nature, specific to the needs of a medically stable, developmentally disabled, and/or physically handicapped individual. This service may include skilled medical care to the extent permitted by State law. Housekeeping activities which are incidental to the performance of the client-based care may also be furnished as part of this activity. Combined Homemaker /Personal Care Aide Consists of any combination of Homemaker and Personal Care Services as defined by the Case Manager in the case plan. Case Management The array of home and community-based services available under this Waiver are coordinated by Case Managers from the Division of Developmental Disabilities (DDD). The Case Manager is responsible for the following: Identifying individuals who qualify for the Waiver program. This includes the completion of a CP-1 / Eligibility Assessment form, which is reviewed by the Long Term Care (LTC) Unit at the Department of Human Services (DHS). (A sample CP-1 form is located at the end of this policy section.) Establishing and updating an individual plan of care Arranging and authorizing services Evaluating the cost-effectiveness of the Waiver services Monitoring and adjusting the service mix Reassessing the recipient’s need for services and ICF/MR level of care LPN Services Licensed Practical Nurses provide nursing care to include promotion, maintenance, and restoration of health. The LPN utilizes standard nursing procedures leading to predetermined outcomes which are in accord with the professional nurse regimen under the supervisor or registered nurse. Homemaker/LPN services require prior authorization. Before prior authorization is granted, administrative approval is needed. Approval must be granted by a PR0016 V1.2 04/30/14 Page 8 RI Medicaid Provider Manual – Waiver Services Long Term Care (LTC) supervisor or an administrator equal to or above the Coordinator of Community Planning and Development at the Division of Developmental Disabilities (DDD). The Case Worker will obtain the necessary approval at DDD and forward it to the provider. Prior authorization guidelines can found on the Prior Authorization page. Day Habilitation Assistance with acquisition, retention or improvement in self-help, socialization and adaptive skills which take place in a non-residential setting, separate from the home or facility in which the individual resides. Supported Employment Paid employment services for persons for whom competitive employment at or above minimum wage is unlikely, and who need intensive ongoing support to perform in a work setting. Specialized Medical Equipment Specialized medical equipment and supplies include items which enable members to increase their ability to perform activities of daily living. WAIVER PROGRAMS Intellectually Disabled (BHDDH) The Division of Developmental Disabilities is responsible for planning, providing and administering a community system of services and supports for adults with developmental disabilities (DD). While safeguarding the health and safety of people with DD, the Division promotes human rights and ensures equitable access to and allocation of available resources in order to be responsive to the needs of each individual. The Division funds a statewide network of community services and supports for this population through a variety of community provider agencies. Support is available in categories such as Residential Services, Day/Employment Services and Communitybased Supports. Case Management Procedure Code T2022 T2022 T2022 T2022 T2022 T2022 T2022 T2022 T2022 Modifier Modifier L6 U5 U6 U7 UA YG U5 U6 U7 U2 U2 U2 PR0016 V1.2 04/30/14 Description Case Management, per month (participants with FI/Day agency combo) Case Management, per month Case Management, per month Case Management, per month Case Management, per month Case Management, per month Case Management, per month Case Management, per month Case Management, per month Page 9 RI Medicaid Provider Manual – Waiver Services T2022 T2022 UA TG U2 U2 Case Management, per month Case Management, per month Intellectually Disabled (BHDDH) -Residential Habilitation Procedure Code Modifier T2033 U5 T2033 U6 T2033 U7 T2033 UA T2033 TG T2016 T2016 T2016 T2016 T2016 T2033 T2033 T2033 T2033 T2033 U5 U6 U7 UA TG U5 U6 U7 UA TG Modifier U1 U1 U1 U1 U1 Description Residential care not otherwise specified, per diem, community residence supports Residential care not otherwise specified, per diem, community residence supports Residential care not otherwise specified, per diem, community residence supports Residential care not otherwise specified, per diem, community residence supports Residential care not otherwise specified, per diem, community residence supports Habilitation, residential, per diem, non-congregant residential supports Habilitation, residential, per diem, non-congregant residential supports Habilitation, residential, per diem, non-congregant residential supports Habilitation, residential, per diem, non-congregant residential supports Habilitation, residential, per diem, non-congregant residential supports Residential Code not otherwise specified, per diem, shared living arrangements Residential Code not otherwise specified, per diem, shared living arrangements Residential Code not otherwise specified, per diem, shared living arrangements Residential Code not otherwise specified, per diem, shared living arrangements Residential Code not otherwise specified, per diem, shared living arrangements Intellectually Disabled (BHDDH) Independent Living or Family Supports Procedure Code Modifier Modifier T2017 T2017 T2013 T2013 T1005 T1005 S9125 UD UD NS Description Habilitation, educational, waiver, per 15 min, community based supports standard Habilitation, educational, waiver, per 15 min, community based supports, Professional staff Habilitation, education, per hour, natural supports training (standard) Habilitation, education, per hour, natural supports training, professional staff Respite services – 15 minutes Respite services (overnight) Respite care in the home, per diem Intellectually Disabled (BHDDH) Independent Living T2016 U8 Habilitation, residential, per diem, access to overnight shared supports Intellectually Disabled (BHDDH) Transportation T2003 T2003 T2003 UA TG PR0016 V1.2 04/30/14 Non-emergency transportation; encounter/Trip, day activity Non-emergency transportation; encounter/Trip, day activity Non-emergency transportation; encounter/Trip, day activity Page 10 RI Medicaid Provider Manual – Waiver Services Intellectually Disabled (BHDDH) Prevocational Training Procedure Code T2015 T2015 T2015 T2015 T2015 T2015 Modifier US UR UQ UP UN Modifier Description Habilitation, prevocational, per hour, prevocational training Habilitation, prevocational, per hour, prevocational training Habilitation, prevocational, per hour, prevocational training Habilitation, prevocational, per hour, prevocational training Habilitation, prevocational, per hour, prevocational training Habilitation, prevocational, per hour, prevocational training Intellectually Disabled (BHDDH) Employment Based T2025 T2019 UD Waiver services, not otherwise specified, job development or assessment Habilitation, supported employment, per 15 minutes, job coaching Intellectually Disabled (BHDDH) Day Program Procedure Code Modifier Modifier T2021 T2021 T2021 T2021 T2021 T2021 T2021 T2021 T2021 T2021 T2020 T2020 T2020 T2020 T2020 U5 U6 U7 UA TG U5 U6 U7 UA TG U5 U6 U7 UA TG U1 U1 U1 U1 U1 Description Day habilitation, per 15 minutes, day program (center based) Day habilitation, per 15 minutes, day program (center based) Day habilitation, per 15 minutes, day program (center based) Day habilitation, per 15 minutes, day program (center based) Day habilitation, per 15 minutes, day program (center based) Day habilitation, per 15 minutes, day program (community based) Day habilitation, per 15 minutes, day program (community based) Day habilitation, per 15 minutes, day program (community based) Day habilitation, per 15 minutes, day program (community based) Day habilitation, per 15 minutes, day program (community based) Day habilitation, per diem, day program (home based) Day habilitation, per diem, day program (home based) Day habilitation, per diem, day program (home based) Day habilitation, per diem, day program (home based) Day habilitation, per diem, day program (home based) Intellectually Disabled (BHDDH) Home Health Provider Services Procedure Code Modifier Modifier S5125 S5130 Description Attendant care services for 15 minutes Homemaker services, not otherwise specified, per 15 minutes Intellectually Disabled (BHDDH) Self-Directed Services Procedure Code Modifier T2041 T2025 U2 Modifier PR0016 V1.2 04/30/14 Description Supports brokerage, self-directed, per 15 minutes Waiver services, not otherwise specified, per 15 minutes, self-directed goods or services Page 11 RI Medicaid Provider Manual – Waiver Services Intellectually Disabled (BHDDH) Other Procedure Code Modifier S5160 S5161 S5162 S5165 T5999 Note: Modifier Description Emergency response system, installation and testing, PERS Emergency response system, service fee, per month (excludes installation or testing, PERS Emergency response system, purchase only, PERS Home modifications, per service (PA required) Supply, not otherwise specified, assistive technology Must have Medicaid eligibility Must have an active BHDDH waiver segment Recipient may have a share BHDDH must authorize the services Core Community Services Core Community Services Procedure Code S5125 S5125 S5130 S5130 S5165 S5160 S5161 T2028 T2029 S5170 S5170 S5170 T1028 T1017 Note: Modifier U1 TE U1 U2 UF Description (15 min) Personal Care Only Combined Personal Care and Homemaker Homemaker Only Homemaker LPN Major home modification per service Emergency response Emergency response – monthly Specialized supply, NOS (PA required) Specialized medical equipment, NOS (PA Required) Frozen meal Shelf staple Service provided in the morning Medical needs assessment Targeted case management Must have Medicaid eligibility. Must have an active Core Community Service eligibility segment. Recipient may have a share. Department of Elderly Affairs Co-Pay Program The Home and Community Care Co-Pay Program pays a portion of the cost of personal care and adult day services. An individual must be unable to leave home without considerable assistance and must need help with personal care. The income limit is approximately $21,600 annually for an individual. There is no asset limit like there is in Medicaid Long Term Care programs. PR0016 V1.2 04/30/14 Page 12 RI Medicaid Provider Manual – Waiver Services Department of Elderly Affairs Co-Pay Program Procedure Code S5125 Note: Modifier U1 Description (15 min) Combined Personal Care and Homemaker Must not be eligible for Medicaid Must have Prior Authorization, approved by DEA Recipient will have an hourly co pay Department of Elderly Affairs Waiver Program The DEA Home and Community Care Programs provides eligible seniors with innovative options to help them remain in the community and avoid premature institutionalization. These options are designed to assist the functionally impaired senior meet a wide variety of medical, environmental, and social needs. For most Home and Community Care Programs, a person must be 65 or older, a resident of Rhode Island, and be basically homebound (unable to leave home without considerable assistance). Department of Elderly Affairs Waiver Program Procedure Code S5125 S5125 S5130 Note: Modifier U1 Description (15 min) Personal Care Only Combined Personal Care and Homemaker Homemaker Only Must have Medicaid eligibility. Must have an active DEA Waiver segment. Recipient may have a share. Department of Elderly Affairs Assisted Living Program Live in apartment-like housing with 24-hour support services, supervision, meals, housekeeping services and personal care. Department of Elderly Affairs Assisted Living Program Procedure Code T2031 T1016 T2029 T2028 S5102 PR0016 V1.2 04/30/14 Description Assisted Living – per diem Case Management Specialized medical equipment Specialized supply, NOS (PA required) Day Care – per diem Page 13 RI Medicaid Provider Manual – Waiver Services Habilitation Community Services Procedure Code Modifier Description T2021 Day Habilitation – 15 minutes T2019 Habilitation supported employment - 15 minutes T2038 Community Transition T1028 Medical Needs assessment S5170 U1 Frozen meal S5170 U2 Shelf staple S5170 UF Service provided in the morning S5165 Major home modification, per service (PA required) S5160 Emergency response- Installation S5161 Emergency response – monthly T2028 Specialized supply, NOS ( PA required) T2029 Specialized medical equipment, NOS (PA required) T1000 Private duty nursing S5130 Homemaker S5125 Personal care S5125 U1 Combined homemaker and personal care Note: Must have Medicaid eligibility Must have an active “habilitation community service” segment Habilitation Group Home Procedure Code T2016 T2029 T2028 T1028 Description Day habilitation – per diem Specialized medical equipment, NOS (PA required) Specialized supply, NOS (PA required) Medical needs assessment Preventive Procedure Code Modifier Description S5130 Homemaker S5125 U1 Combined homemaker and Personal care aid T2028 Specialized supply,NOS (PA required) Note: Must have Medicaid eligibility Must have an active preventive community services segment Self -Direction Community Services Procedure Code T2025 T1019 Modifier PR0016 V1.2 04/30/14 Description Fiscal Management Personal Care Services Page 14 RI Medicaid Provider Manual – Waiver Services T2022 S5170 S5170 S5170 T1999 T2028 T2029 S5160 S5161 S5165 U1 U2 UF Case Management – per month Frozen meal Shelf staple Service provided in the morning Miscellaneous therapeutic items Specialized supply, NOS (PA required) Specialized medical equipment, NOS (PA required) Emergency response - Installation Emergency response – monthly Major home modification per service (PA required) Modifiers for T1000 and S5125 Note: T1000 requires Prior Authorization Modifiers for S5125 and T1000 (CNA) Modifier Description UH Evening shift UJ Night shift TV Weekend shift TV Holiday shift U9 High Acuity Modifiers for T1000 (LPN) Modifier Description TE Day shift LPN UH TE Evening shift LPN UJ TE Night shift LPN TV TE Weekend shift LPN TU TV Holiday shift LPN PR0016 V1.2 04/30/14 Page 15 RI Medicaid Provider Manual – Waiver Services Appendix Claim Preparation Instructions Waiver Services - Waiver/Rehab Claim Form Waiver Form Filing Instructions Waiver Services - CMS 1500 Claim Form CMS 1500 Form Filing Instructions Error Status Codes ESC Code List (English) Explanation of Benefits (EOB) Codes EOB Codes and Messages List (English) EOB Codes and Messages List (Spanish) Third Party Liability Carrier and Coverage Codes Third Party Liability (TPL) Carrier Codes Third Party Liability (TPL) Coverage Codes Connect Care Choice Connect Care Choice Community Partners PR0016 V1.2 04/30/14 Page 16
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