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Kansas
Medical Assistance
Program
Perspective
KANSAS
MEDICAL
ASSISTANCE
PROGRAM
PROVIDER MANUAL
HCBS MR/DD Targeted Case
Management
PART II
MR/DD TARGETED CASE MANAGEMENT PROVIDER MANUAL
Section
7000
7010
BILLING INSTRUCTIONS
MR/DD Targeted Case Management Billing Instructions ....... ........
Submission of Claim .. ......... ........ ......... ......... ........
MR/DD Targeted Case Management Specific
Billing Information ... ......... ........ ......... ......... ........
BENEFITS AND LIMITATIONS
8100
Co-Payment .... ........ ......... ......... ........ ......... ......... ........
8300
Benefit Plans... ........ ......... ......... ........ ......... ......... ........
8400
Medicaid
HCFA-1500 CMS-1500 Form
KANSAS MEDICAL ASSISTANCE PROGRAM
HCBS MR/DD TARGETED CASE MANAGEMENT PROVIDER MANUAL
INTRODUCTION
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PART II
MR/DD TARGETED CASE MANAGEMENT PROVIDER MANUAL
This is the provider specific section of the manual. This section (Part II) was designed to provide
information and instructions specific to MR/DD Targeted Case Management providers. It is divided
into two subsections: Billing Instructions, and Benefits and Limitations.
The Billing Instructions subsection gives an example of the billing form applicable to MR/DD
Targeted Case Management services. The form is followed by directions for completing and
submitting it.
The Benefits and Limitations subsection defines specific aspects of the scope of MR/DD Targeted
Case Management services allowed within the Kansas Medical Assistance Program (KMAP).
HIPAA Compliance
As a KMAP participant, providers are required to comply with compliance reviews and complaint
investigations conducted by the Secretary of the Department of Health and Human Services as part of
the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the
code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and
Human Services all information required by the Department during its review and investigation. The
provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse
Division of the Kansas Attorney General's Office upon request from such office as required by
K.S.A. 21-3853 and amendments thereto.
A provider who receives such a request for access to or inspection of documents and records must
promptly and reasonably comply with access to the records and facility at reasonable times and
places. A provider must not obstruct any audit, review, or investigation, including the relevant
questioning of employees of the provider. The provider shall not charge a fee for retrieving and
copying documents and records related to compliance reviews and complaint investigations.
KANSAS MEDICAL ASSISTANCE PROGRAM
HCBS MR/DD TARGETED CASE MANAGEMENT PROVIDER MANUAL
INTRODUCTION
7000. MR/DD TARGETED CASE MANAGEMENT BILLING INSTRUCTIONS
Introduction to the HCFA-1500 CMS-1500 Claim Form Updated 05/07
Providers must use the HCFA-1500 CMS-1500 claim form (unless submitting electronically)
when requesting payment for medical services provided under the Kansas Medical Assistance
Program (KMAP). An example of the HCFA-1500 CMS-1500 claim form is shown at the end
of this manual. The Kansas MMIS will be using electronic imaging and optical character
recognition (OCR) equipment. Therefore, information will not be recognized if not submitted
in the correct fields as instructed.
EDS does not furnish the HCFA-1500 CMS-1500 claim form to providers. Refer to Section
1100 of the General Introduction Provider Manual.
Complete, line by line instructions for completion of the HCFA 1500 CMS-1500 are available in
the General Billing Provider Manual., pages 5-14 through 5-19.
SUBMISSION OF CLAIM:
Send completed first page of each claim and any necessary attachments to:
Kansas Medical Assistance Program
Office of the Fiscal Agent
P.O. Box 3571
Topeka, KS 66601-3571
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HCBS MR/DD TARGETED CASE MANAGEMENT PROVIDER MANUAL
BILLING INSTRUCTIONS
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7010. MR/DD TARGETED CASE MANAGEMENT SPECIFIC BILLING INFORMATION
Updated 05/07
Enter procedure code T2023 (Targeted Case Management MR/DD) in field 24D of the HCFA-1500
CMS-1500 claim form.
One unit = one month.
Client Obligation:
If a case manager has assigned client obligation to a particular provider and informed that provider
that they are to collect this portion of the cost of service from the client, the provider will not reduce
the billed amount on the claim by the client obligation because the liability will automatically be
deducted as claims are processed.
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BILLING INSTRUCTIONS
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BENEFITS AND LIMITATIONS
8100.
CO-PAYMENT
Updated 11/03
MR/DD targeted case management is exempt from the co-payment requirement.
KANSAS MEDICAL ASSISTANCE PROGRAM
HCBS MRDD TARGETED CASE MANAGEMENT PROVIDER MANUAL
BENEFITS & LIMITATONS
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BENEFITS AND LIMITATIONS
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Benefit Plan
Updated 11/03
Kansas Medical Assistance Program beneficiaries are assigned to one or more medical assistance
benefit plans. The assigned plan or plans are listed on the beneficiary ID card. These benefit plans
entitle the beneficiary to certain services. If there are questions about service coverage for a given
benefit plan, contact the Medical Assistance Customer Service Center at 1-800-933-6593 or (785)
274-5990.
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HCBS MRDD TARGETED CASE MANAGEMENT PROVIDER MANUAL
BENEFITS & LIMITATONS
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BENEFITS AND LIMITATIONS
8400. MEDICAID
Updated 04/07
Mental retardation or other developmental disabilities (MR/DD) targeted case management (TCM) is
the assessment and linkage of an individual with services necessary to promote care outside of an
institution.
The goals of MR/DD TCM are:
• To promote maximum independence and successful integration into
community living for MR/DD individuals
• To
minimize
individual
reliance
on
exclusionary
MR/DD
institutional services
• To maintain accountability and continuity of services to
individuals and families as long as services are required
MR/DD TCM services include the following (as identified in K.A.R. 30-64-24):
• Assessment, including an ongoing process to identify the person’s needs and preferred
lifestyle, and the resources that are available to the person through both formal and informal
evaluation methods
• Support planning, with the participation of the person and the person’s support network,
including
o Developing (or assistance in developing), updating, and reviewing of the person’s
person-centered support plan and any related service or support plan
o Building upon assessment information to assist the person in meeting his or her needs
and achieving the person’s preferred lifestyle
o Providing the following assistance to the person:
Becoming knowledgeable about the types and availability of community services
and support options
Receiving information regarding the rights of persons served pursuant to the
developmental disabilities reform act
Implementing regulations, the content of which shall be approved by the
commission
Obtaining the community services and supports of the person’s choice
• Support coordination, including the following:
o Arranging for and securing supports outlined in the person’s person-centered support
plan
o Developing and accessing of natural supports and generic community support systems
o Providing advocacy, including pursuing means for gaining access to needed services
and entitlements
o Seeking modification of service systems when necessary to increase the accessibility to
those systems by the person
• Monitor and follow-up, including ongoing activities that are necessary to ensure that the
person-centered support plan and related supports and services are effectively implemented
and adequately address the person’s needs
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HCBS MRDD TARGETED CASE MANAGEMENT PROVIDER MANUAL
BENEFITS & LIMITATONS
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BENEFITS AND LIMITATIONS
8400. MEDICAID
Updated 04/07
•
Transition assistance and portability, including the planning of and arranging for services to
follow the person when the person moves between any of the following:
o From school to the adult world
o From an institution to community alternatives (180 days)
o From one kind of service setting to another kind of service setting
o From one provider to another provider
o From one service area to another service area
Effective with dates of service on and after April 1, 2007, oral health services are available to adults
age 21 and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and
Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for
services available for HCBS MR/DD, TBI, and PD adult beneficiaries.
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BENEFITS & LIMITATONS
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Updated 09/05
Limitations:
MR/DD targeted case management is available to all Medicaid beneficiaries who are mentally
retarded or otherwise developmentally disabled.
A HealthConnect referral is not required.
Other insurance and Medicare are primary; they must be billed first.
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BENEFITS & LIMITATONS
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Updated 05/07
To receive Medicaid reimbursement, persons must meet the following qualifications to
provide case management, whether or not they work for an agency:
•
•
•
•
Six months full-time experience (etc.) and either (1) a bachelors degree; (2) eight
years of additional full-time experience (etc.) that will substitute for a college
degree; or (3) a combination of college credit and additional full-time experience
(etc.) that substitutes six months of full-time experience (etc.) for one full-time
college semester that adds up to the equivalent of a four year bachelors degree.
The "etc." is the related work with DD populations.
Complete the SRS registration process within the designated timeframe
Be employed by an enrolled community service provider licensed to provide
MR/DD targeted case management
Abide by the TCM Rules of Conduct
Refer to K.A.R. 30-64-24(b)(1)(F)for the standard for case management training.
Provider Requirements:
Community Developmental Disabilities Organizations (CDDOs) are the only allowable billing
provider to be paid for TCM services through the MMIS fiscal agent. Performing providers
may bill for TCM; however Medicaid reimbursement will be sent to the CDDO.
Billing Provider: A CDDO organized pursuant to K.S.A. 19-4001 through 19-4015 and
amendments thereto.
Performing Provider: A community service provider that meets all of the following criteria:
• Employs registered targeted case managers
• Is licensed for TCM
• Is enrolled as TCM performing provider
• Maintains an affiliate agreement with the CDDO
The affiliate must submit claims using his or her 10-digit KMAP provider ID or taxonomy
code as the performing provider in Field 24K Field 24J, Rendering Provider ID #, on the
HCFA 1500 CMS-1500 claim form. In the bottom field, enter the rendering provider’s NPI.
Enter the CDDO’s provider number and contact information as the billing provider in Field
33, Billing Provider Info & Ph #. Field 33A is the billing provider’s NPI. Field 33B is the
billing provider’s KMAP Provider ID or Taxonomy Code. Enter the 10-digit KMAP
provider ID or taxonomy code on the HCFA-1500 CMS-1500 claim form. If the affiliate is
associated with more than one CDDO, it is the affiliate’s responsibility to use the correct
CDDO’s number on a given claim.
The CDDO should notify EDS when a performing provider no longer has an affiliate
agreement and is no longer eligible to bill under the CDDO’s provider number.
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BENEFITS & LIMITATONS
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Updated 2/04
Documentation:
Recordkeeping responsibilities rest with the provider. Medicaid requires written
documentation of services provided and billed to the Kansas Medical Assistance Program.
Documentation at a minimum must include the following:
• Detailed description of the service provided
• Service provider’s signature
• Complete date (MM/DD/YYYY)
• Location where the service was provided (e.g beneficiary’s home,beneficiary’s
workplace, TCM’s office)
• Beneficiary’s name
If documentation is not clearly written and self-explanatory, the services billed will not be
paid.
Definitions:
Affiliate - a local agency that has entered into an agreement with a CDDO to provide case
management to individuals who are mentally retarded or developmentally disabled and has
been approved by Mental Health and Developmental Disabilities (MH&DD).
Community Developmental Disability Organization (CDDO) - a local agency that directly
receives county mill funds and state aid and provides community based services to individuals
who are mentally retarded or developmentally disabled and is formally recognized by Mental
Health and Developmental Disabilities (MH&DD).
Mental Retardation - significantly subaverage intellectual functioning, evidenced by an IQ
rating of 70 or below or a score of two standard deviations or more below the mean as
measured by a generally accepted standardized individual measure of general intellectual
functioning existing concurrently with deficits in adaptive behavior including related
limitations in two or more applicable adaptive skill areas.
Other Developmental Disability - a condition or illness, such as cerebral palsy, epilepsy, or
autism, but excluding mental illness and infirmities of aging, that:
• Manifested before age 22
• May be reasonably expected to continue to exist indefinitely
• Results in substantial limitations in three or more areas of life functioning
• Reflects the need for a combination and sequence of special, interdisciplinary or
generic care, treatment, or other services which are lifelong or of an extended
duration, and are individually planned and coordinated
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BENEFITS & LIMITATONS
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Updated 11/03
Positive Behavioral Support Services
Effective January 1, 2002, three Positive Behavior Support (PBS) services were created for KAN Be
Healthy (KBH) beneficiaries. These services are listed below.
PBS Environmental Assessment - An assessment of environmental events, antecedents, and
consequences that are associated with or maintain the behaviors of interest, including physiological
responses. This service should be billed as 90885 (22).
PBS Treatment - Procedures that include environmental manipulation of one or more of the following:
antecedent events, setting events, consequent events, and teaching new skills. This service should be
billed as 90806 (22).
PBS Person-Centered Planning - The use of person-centered planning approaches that integrate a
person’s desired quality of life, taking into account barriers to achievement. This service should be
billed as 90882 (22).
Effective with dates of service on and after May 1, 2003, the following conditions apply with respect to
these services:
1
The Community Developmental Disabilities Organizations (CDDOs) are the only provider
type allowed for reimbursement of these services.
2. Individuals providing PBS services must have, at a minimum, a bachelor’s degree and have
completed the Kansas Institute for Positive Behavior Support (KIPBS) Training Program.
3
To receive PBS services, the beneficiary must be a KAN Be Healthy participant with a
current screen who has obtained prior authorization through the process developed and
implemented by KIPBS staff, University of Kansas.
Typically, the delivery of services will be limited to one billing cycle per beneficiary
(the allowable hours of assessment, treatment, and person-centered planning that can
be used during a one-year billing cycle).
• There may be occasions when a case is determined to be so severe that a subsequent
year of service is required. If this occurs, an exception may be considered. All
exceptions must receive prior authorization using the process noted above.
•
Note: If the limitation of allowable hours of assessment, treatment, and person-centered planning
has not been used during the first year of service, the remaining allotment of billable hours cannot
be carried over into the second year as part of any new prior authorized service for an exception.
All services approved by the KIPBS prior authorization system as part of an exception will
constitute a new service arrangement for a beneficiary with specific limitations and conditions.
Once prior authorization is approved for an exception and the one year billing cycle expires,
further exceptions will not be considered.
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BENEFITS & LIMITATONS
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Updated 11/03
All PBS services must be authorized through the KIPBS prior authorization system. The following
conditions apply:
•
Only persons who have successfully completed the KIPBS training system and are
currently recognized by that system as approved for reimbursement may make application
to the KIPBS prior authorization system.
•
The KIPBS prior authorization application is available on the Internet at
www.kipbs.lsi.ku.edu. Or, prior authorization may be obtained by calling the KIPBS
project coordinator at 785-864-4096.
•
The KIPBS Prior Authorization team takes action on each application within 48 hours
whenever possible.
•
If the KIPBS Prior Authorization team approves an application, it is faxed immediately to the
appropriate fiscal agent contact person for appropriate action. Approval letters are sent to the
approved provider, beneficiary, and KIPBS team.
•
All approved applications constitute an agreement on the part of the service provider to
deliver all PBS services in a comprehensive and integrated fashion; for example, person
centered planning, assessment, and intervention should not be separated whenever possible to
specialized personnel.
•
Service providers maintain internal documentation systems that comply with all necessary
regulations and laws pertaining to confidentiality and privacy protection. For all PBS
services, documentation for billing should be in quarter of an hour increments. The PBS
service provider must maintain a record of the individuals to whom he or she provides
services that shows:
-
Name of the individual receiving the service
Date the service was provided
Name of the provider agency
Name of the individual providing the service
Location at which the service was provided
Type of PBS treatment provided
Amount of time it was provided to the nearest quarter hour
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HCBS MRDD TARGETED CASE MANAGEMENT PROVIDER MANUAL
BENEFITS & LIMITATONS
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