Medicaid School Based Claiming Program Handbook

Program Handbook Cover

Medicaid School Based Claiming Program Handbook 6/2012

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Medicaid School Based Claiming Program Handbook

TABLE OF CONTENTS 1

INTRODUCTION

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PROGRAM OVERVIEW

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PROGRAM TERMS AND DEFINITIONS

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RANDOM MOMENT TIME STUDY 4.1 Staff Pool List 4.2 RMTS System 4.3 Participant Training 4.4 Time Study Coding

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COST REPORTING 5.1 Medicaid Administrative Claiming 5.2 Medicaid Eligibility Rate and IEP Ratio 5.3 Annual Cost Reporting, Reconciliation, and Settlement

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PREPARING AND SUBMITTING CLAIMS FOR INTERIM PAYMENTS 6.1 Determining Covered Services 6.2 Identifying Covered Services for the DSC Program 6.3 Free Care 6.4 Eligibility for AHCCCS 6.5 National Provider Identifier (NPI) 6.6 AHCCCS Registration Requirements 6.7 Linking Providers to LEAs 6.8 Submitting Claims 6.9 Time Limits 6.10 Clean Claim 6.11 Retro-Eligibility Claims 6.12 Other Insurance (TPL) 6.13 Coding for Claims and Other Billing Rules 6.14 Voids & Replacement 6.15 Special Claims Handling 6.16 Using a Biller

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6.17 6.18

Reading the Remittance Advice How Interim Payments are Calculated

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COMPLIANCE REVIEWS 7.1 Record Maintenance 7.2 Whistleblower Policy

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GENERAL PROGRAM INFORMATION 8.1 Check Cashing Policy 8.2 Claim Disputes 8.3 Fraud and Abuse 8.4 Participation Agreement 8.5 Termination of Participation

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APPENDIX: ATTACHMENTS Attachment 1: Participation Agreement Attachment 2: Guidance for Health Aide Documentation Attachment 3: Health Aide Prepayment Review Form Attachment 4: Sample Eligibility Match Instructions Attachment 5: Sample Student Eligibility Match Template Attachment 6: NPI Supplemental Registration Form Attachment 7: CMS 1500 Form (08-05) Attachment 8: Biller Authorization Template Attachment 9: Stale Check Replacement Form Attachment 10:Electronic Signature Questionnaire with Instructions

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1.

INTRODUCTION

PCG BACKGROUND PCG was founded in 1986 as a privately held consulting firm serving state and local health and human services programs. Today, with more 1000 professionals in over 30 offices around the U.S. and in 3 international locations, we offer a wide range of management consulting and technology solutions to help public sector clients achieve their performance goals and better serve populations in need. PCG continuously updates its knowledge of industry best practices and maximizes partnerships and investments to deliver the leading consulting approaches and technologies to the marketplace. The firm is committed to providing proven solutions and outstanding customer service to clients in each of our four practice areas. PCG is a national leader in school based Medicaid engagements. Since, 1992, the firm has recovered more than $1.5 billion in federal Medicaid funds for school districts clients across the U.S. – more than any other vendor in the country. PCG works with over 2,600 clients, ranging from statewide engagements and large urban to small rural districts.

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PROGRAM OVERVIEW

Arizona’s Medicaid School Based Claiming Program (MSBC) includes two complementary Medicaid reimbursement program components: the Direct Service Claiming (DSC) program, and the Medicaid Administrative Claiming (MAC). These two school-based programs assist participating school districts, referred to as Local Education Agencies (LEAs), including charter schools and the Arizona School for the Deaf and Blind (ASDB), by reimbursing them for Medicaid covered services they provide to eligible and qualified students. The purpose of the DSC Program is to allow LEAs to receive reimbursement for Medicaid covered medical services provided to Title XIX eligible students. The purpose of the MAC program is to allow LEAs to receive reimbursement for Medicaid administrative outreach activities that are done routinely within the school setting. The Centers for Medicare and Medicaid Services (CMS) is the federal agency that oversees the MSBC Program. In Arizona, the program is overseen by the Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency. AHCCCS contracts with a Third Party Administrator (TPA), PCG, to administer the MSBC Program. The requirements for both the DSC and MAC Programs are a blended result of federal laws and requirements from CMS, state laws and program requirements from AHCCCS, and administrative requirements from PCG. Significant changes in either program will typically require some level of approval from all three organizations (CMS, AHCCCS, and PCG). CMS required that an LEA participating in the MAC program must also claim in the DSC program. A LEA may, however, participate solely in the DSC program. PROGRAM METHODOLOGY CMS approved the Medicaid State Plan for Arizona to implement the Medicaid cost-based reimbursement for the DSC Program, effective July 1, 2011. Essentially, this means that the Medicaid reimbursements to LEAs are based on actual costs to provide Medicaid allowable services to students rather than a defined claims fee

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structure. This is a shift in methodology for the DSC program however; the MAC program has always been based on costs. A majority of the prior program requirements remain in place. However, with the move to a cost based reimbursement methodology, LEAs must now report actual costs and information on the provision of allowable health services and participate in a random moment time study for DSC as well as MAC. The quarterly RMTS is an integral part of the MSBC program as it is used to determine how much time is spent on Medicaid allowable activities for both DSC and MAC. Specifically for DSC, RMTS is used to determine how much time direct service and personal care providers spend doing Medicaid related services. For MAC, the RMTS is used to determine the amount of time direct service and administrative staff spends performing administrative and outreach activities that support the proper and efficient operation of the state Medicaid program. LEAs are only reimbursed for costs of those staff that are included in the RMTS. The LEA’s DSC reimbursement will be calculated annually through the annual cost report. Factors that determine the reimbursement amount for the LEA are the cost to provide health related services; percent of time spent doing allowable Medicaid direct services (RMTS results), the unrestricted indirect cost rate, IEP ratio, and FMAP. Each one of these components is explained in further detail within this Handbook and supplemental materials such as the Cost Reporting Guide and Comprehensive Cost Reporting Training Presentation. LEAs are required to continue submitting DSC claims throughout the year to demonstrate that health services continue to be delivered to students. This supports interim payments for services throughout the school year, prior to the annual cost settlement process. Once the annual cost report is completed, PCG will calculate each LEA’s allowable annual reimbursement amount. For each fiscal year, total interim payment will be deducted from the reimbursement amount. Should interim payment be less than the reimbursement amount, the LEA will receive the difference. If the reverse occurs and the interim payments are higher than the reimbursement amount, the LEA will be required to return funds to AHCCCS. Similar to the structure of RMTS serving multiple purposes, the quarterly reporting process serves dual purposes for both DSC and MAC. On a quarterly basis, LEAs report the salary, benefit, purchased professional service (PPS), and any associated federal costs for all staff included in the quarterly RMTS. The quarterly costs for direct service and administrative staff are used to calculate the quarterly MAC reimbursement. The quarterly costs reported for direct service and personal care providers will then roll up into the annual report for the cost settlement process. For all staff included in any of the quarterly RMTS’ the salary, benefit, PPS, and associated federal costs section of the annual report will be complete. Other transportation costs such as payroll, depreciation, fuel / oil, maintenance, insurance, and depreciation costs will be reported by each LEA on an annual basis. In addition to reporting allowable costs as previously stated, the LEA must identify other factors such as number of students with one or more related service on their IEP, one-way trip counts, and general versus specialized transportation vehicle costs as all of these components will be used to apportion costs during the cost settlement process. The quarterly reporting process serves multiple purposes, LEAs report costs for staff included in the RMTS and costs are used to calculate the quarterly MAC reimbursement and then also rolled up into the annual cost information for the cost settlement process.

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AHCCCS’ ROLE AHCCCS is Arizona’s Managed Care Medicaid Program that was developed as a result of Title XIX of the Social Security Act. While AHCCCS also administers other state and federal health care programs, only Title XIX members are eligible for the MSBC Program. This Handbook provides the information necessary to successfully participate in the MSBC Program. AHCCCS policies relating to the MSBC Program can be found on the AHCCCS Web site at www.azahcccs.gov under Plans, Providers, Contractors, Provider Billing Resources and Rates, AHCCCS Provider Manuals, AHCCCS Medical Policy Manual (AMPM), Chapter 700. PCG’S ROLE PCG was assigned the contract by AHCCCS to act as a third party administrator for the DSC and MAC programs in February 2009. The contract effective date was February 1, 2009. PCG provides a full spectrum of services under this contract including:     

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Training required preparing all LEAs to participate in the MSBC Programs. Technical Assistance Maintaining copies of the signed “Agreement between Participating Local Education Agency (LEA) and PCG, Inc.” for each participating LEA. Processing claims and submitting them through the AHCCCS system. Providing the Information Services (IS) system required to administer the Programs. o The PCG data processing system houses the Program membership, contracted providers and needed reference materials. o The system receives claims, edits and processes them and forwards them to AHCCCS for final approval. o The system assists with distributing payments to each LEA or their biller, providing a remittance advice that identifies the claims and the amount paid, as well as a list of any denied claims, pended claims and the reason codes. Conducting periodic compliance reviews of participating LEAs. o During the reviews, staff assesses all documentation related to the program, including provider records and student records. o PCG works closely with participants throughout this process to ensure compliance with all AHCCCS and CMS requirements.

The DSC and MAC Programs are administered by PCG in Phoenix, Arizona with staffs that are dedicated to the MSBC Programs. PCG maintains a Web site containing current information regarding the programs, forms and documents, as well as training materials that can be downloaded and related site links. Communication with PCG staff is also available online. The site may be accessed at: http://web.pcgus.com/azschools CONTRACTING WITH PCG In order to become contracted with PCG to participate in MSBC, a LEA must:

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   

Be an Arizona public school district or an Arizona charter school Have students eligible under the Individuals with Disability Education Act (IDEA) who are enrolled in Title XIX Medicaid Provide one or more of the Medicaid covered services on site Sign an agreement with PCG (Participation Agreement – Attachment 1)

The agreement details the responsibilities and rights of both PCG and the participating LEA and the services to be provided to the LEA. The completed contract allows the LEA to participate in the Medicaid School Based Claiming Program administered by PCG. On receipt of the signed contract, PCG will work with the LEA to implement Medicaid claiming processes. CONTACT INFORMATION Local Office: PCG 101 N First Ave, Suite 1800 Phoenix, AZ 85003 Phone number: (602) 324-5090 Toll Free number: 1-877-877-8011 Fax number: (602) 324-5091 E-mail: [email protected] for the DSC program [email protected] for DSC and MAC compliance reviews [email protected] for the quarterly time study [email protected] for quarterly and annual cost reporting Web site: http://web.pcgus.com/azschools Additional resources such as training materials, guides presentations and newsletters can be found on the project website.

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PROGRAM TERMS AND DEFINITIONS

Activity Codes: Categories for coding daily participant activities. Activities of Daily Living (ADL): The activities a member must perform daily for the member’s regular dayto-day necessities, including but not limited to mobility, transferring,, dressing, grooming, eating, and toileting. Administrative Claiming Program is the quarterly claim which provides reimbursement for a percentage of time LEAs spend providing administrative support for direct services, as well as efforts by LEAs to assure the Title XIX eligible children and their families are informed about the Title XIX EPSDT program, are helped to understand its importance, and are encouraged to seek EPSDT services.

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AHCCCS Medical Policy Manual (AMPM) provides information to Contractors and Providers regarding services covered within the AHCCCS program. AHCCCSA is the Arizona Health Care Cost Containment System Administration and is defined by Arizona Revised Statutes, Title 36, Chapter 29. ADOE is the Arizona Department of Education. Biller: Entity contracted with a LEA to provide assistance related to submitting claims through PCG for covered services under the DSC program. Claim refers to provider services documented on a CMS1500 form or transmitted to PCG electronically, either directly or through use of a PCG-approved clearinghouse. Clean Claim refers to a claim that may be processed without obtaining additional information from the LEA or other provider of service. This is defined in Arizona Revised Statutes 36-2904.G.1, and rules within Title 9 of the Arizona Administrative Code governing AHCCCS programs and programs administered by AHCCCS. Centers for Medicare & Medicaid Services (CMS) Federal governing entity that oversees the Medicare and Medicaid programs in the United States of America. Clinical Notes: Brief written comments in the medical record to document the student’s status or achievement in aspects of the medical treatment. They provide information needed to track progress (or lack of) toward goals, and the continued need for services. CMS 1500: Federally approved form used to claim for direct services when applicable fields are completed with appropriate claim data. Contract refers to the present and future agreements between PCG and AHCCCS that authorize PCG to provide administrative services for payment of claims for qualified children under the Medicaid school-based claiming programs through contracts/agreements between PCG and LEAs. Cost Data: The accrued salaries, benefits, and purchased professional services paid to participants listed on the staff roster. Cost Report is the report that is submitted by each LEA which contains all costs such as salaries and benefits for the use of the MAC claim and cost settlement. Cost Settlement is the process by which actual costs of providing Medicaid-covered health related services will be compared to Medicaid reimbursements received. Covered Services are all services available to qualified children pursuant to AHCCCS policies, the contract and PCG policies and procedures. Current Procedural Terminology (CPT): A series of 5-digit numeric codes that describe services rendered by a medical provider. There are a limited number of codes covered through the DSC program. Diagnosis: The term identifying the disease, illness or syndrome a person has, or is believed to have that requires a service rendered; the reason for rendering a service covered under the DSC program.

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Diagnosis Code: A 3-5-digit alphanumeric code from the ICD-9-CM code book used to identify a disease, illness or syndrome, or reason for rendering a covered service. Direct Service Claiming Payment is the amount paid by PCG to the LEA for providing covered services, calculated according to the formula detailed in the Method of Compensation section of the Medicaid Direct Service Contract Document. Direct Service Claiming Program is the program implemented by AHCCCS and ADOE to allow reimbursement for services AHCCCSA identified as being covered, are provided by the LEAs to Title XIX, Medicaid eligible children, and are part of the child’s IEP. Direct Service Claiming (DSC) Coordinator: Employee(s) of a LEA that coordinates the LEA’s involvement in the Direct Service Claiming program Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Medicaid program that allows payment for the provision of AHCCCS eligible medical services to qualified recipients age three through twenty-one. Eligible: Meeting criteria to receive reimbursement under the DSC program. A student must be covered by Medicaid Title XIX (AHCCCS) and by IDEA (in Special Education with a valid IEP) to be eligible. Federal Funding a classification (originating source) of funding used to reimburse school district personnel. Health Care Procedure Coding System (HCPCS): The HCPCS is divided into two principal subsystems, referred to as Level I and Level II of the HCPCS. 

Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system. The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.  Level II codes are also referred to as alphanumeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits. These codes represent primarily non-physician services that are not represented in the Level I codes. A common term for many codes used for the DSC program is “procedure code”. Health Insurance Portability and Accountability Act (HIPAA): A Federal regulation that requires the security and privacy of health information, and intends to simplify the health care coverage processes for providers and covered persons. ICD-9-CM: International Classification of Diseases that lists all diagnosis codes available for use to submit claims. The manual is revised and published annually with an implementation date of October 1st. Individuals with Disabilities Education Act (IDEA) was established in Federal statute and ensures children with special educational needs receive a free and appropriate public education. Individualized Education Plan (IEP) is the written plan developed and implemented to provide special education and other related services to a child with a disability that is determined eligible for such services under IDEA, Part B. The Local Education Agency (LEA) recorded within the General Provisions of this agreement is a public school district, non-affiliated charter school or the Arizona School for the Deaf and the Blind (ASDB) that desires to participate in the PCG contract network and employs or contracts with health care providers who

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registered with AHCCCS to provide covered services to qualified children and hereinafter shall be referred to as the Participating Healthcare Provider. Medicaid Administrative Claiming (MAC) Program provides a means for school districts/charter schools to receive federal reimbursement for Medicaid outreach and administrative activities that support students receiving health services, such as referrals made for health services, and the coordination of health services. Medicaid Eligibility Rate (MER): The percentage of Medicaid eligible students from the LEA total enrolled student population. Medicaid: Federal/State/Local funded state health care program for select populations, based on financial and/or medical need. Moments List: Master list of all sampled participants within a quarter, used in the Random Moment Time Study. Medically Necessary generally refers to covered services that prevent disease, disability or other adverse health conditions or progression of such, or prolong life. They must be provided by a qualified provider within the scope of his/her practice under state law. AHCCCS rules, requirements and policies determine if a particular service is medically necessary for the purposes of Direct Service Claiming compensation. National Provider Identifier (NPI): National provider identifier issued on behalf of CMS for use in standard electronic health care transactions. The identifier is either individual (provider) or organizational (LEA). Object Codes: Classification used to record the “type” of financial costs that are reported for particular functions.. Observation Form: The form utilized to capture the information obtained during the random moment time study (RMTS). Participating Provider refers to independent providers under contract with or employed by the LEA to provide specific covered services to qualified children. Participating LEA is a LEA that signed a participation agreement with PCG for the purpose of billing AHCCCSA for covered services provided to qualified children. Participating Healthcare Provider (PHP) is a health care provider duly licensed/certified in the State of Arizona, if applicable. Pended: Term used to describe a claim that has insufficient information to complete processing, but the additional information is expected to be available in less than 30 days. Position Codes: The classification of employee types, used in the RMTS program. Public Consulting Group (PCG): Arizona’s Third Party Administrator for the Medicaid School Based Claiming Program under contract with AHCCCS Qualified Child is a child at least three years old and under age 22, and who has been determined by AHCCCSA to be eligible under Title XIX of the Social Security Act, and who has been determined by the LEA to be eligible for special education services provided under IDEA and A.R.S §36-2907.

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Qualified Provider is an individual who is eligible to provide services under the Direct Service Claiming Program. Such provider must be a registered AHCCCS provider either employed or under contract with a LEA, or an employee or contractor of the LEA providing services for which the LEA is a registered provider. Related Services are the services defined by 34 CFR 300.34 that are provided to children who qualify for special education services in order to benefit from special education services under IDEA. Record is the health or medical record of a qualified child that documents the covered services that were received by a qualified child. These records include but are not limited to the student’s IEP, treatment plans, billing records, evaluations, summary of progress, treatment dates and descriptions, and signatures of the providers of service. Random Moment Time Study (RMTS) is a federally accepted method for documenting the time school district personnel spend on Medicaid direct services, outreach and administrative activities. Remittance Advice: A report that lists the status of claims processed by group biller (LEA), provider, and student. Claims may be in paid, denied, or pended status. The report is used by LEAs and their billers to confirm that submitted claims have been processed. Self-Biller: A LEA that submits claims to PCG on its own behalf for covered services under the DSC program. Service Log: A document listing the covered services ordered in an eligible student’s IEP that have been rendered by a qualified participating provider for DSC. Scope, Frequency, Duration: An IDEA requirement for services prescribed in the IEP to include the specific service to be rendered including goals (scope), how often the service is to be rendered (frequency), and the length of each session and/or the time period for which the service will be rendered (duration). This is also a DSC requirement. Special Education Services are services defined under 34 CFR 300.39 that are provided to a qualified child in order that the child may benefit from the free and appropriate education guaranteed under IDEA. Staff Roster: List of LEA participants who routinely render Medicaid outreach and administration services. Also referred to as ‘participant roster’ or ‘staff pool list’. Third Party is a person, entity or program that is or may be liable to pay all or part of the medical cost of injury, disability or disease for an AHCCCS applicant, eligible person or qualified child, as defined by Arizona Administrative Code R9-22-1001. Third Party Administrator (TPA): An organization that is contracted to provide administrative services on behalf of a separate entity. Third Party Liability refers to, as defined by Arizona Administrative Code R9-22-1001, the obligation of a person, entity or program by agreement, circumstances or otherwise to pay all or part of the medical expenses incurred by the applicant, eligible person or qualified child. Timely Filing: Regulation requires claims to be initially submitted to AHCCCS within 6 months of the date of service. A valid resubmitted claim must be received by AHCCCS within 12 months of the date of service. Title XIX of the Social Security Act means Medicaid as defined in 42 U.S.C. 7.19.

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[End of Definitions]

4.

RANDOM MOMENT TIME STUDY

The Random Moment Time Study (RMTS) is a central component of the MSBC program in that it supports the cost allocation process for both the quarterly MAC claim and the annual DSC cost settlement process. The RMTS also determines the percent of time staff included on the RMTS perform Medicaid allowable activities. The RMTS methodology measures the work effort of the entire group of approved staff involved in the LEA medical and health-related services program by sampling and analyzing the work efforts of a cross-section of the group. RMTS methods employ a technique of polling employees at random moments over a given time period and tallying the results of the polling. The method provides a statistically valid means of determining what portion of the selected group of staff’s workload is spent performing activities that are reimbursable by Medicaid. The process is designed to be as quick and unobtrusive to participants as possible. Each calendar quarter, a portion of the statewide pool of selected employees and contracted staff will be identified to participate in the RMTS time study. For each participant selected, one or more RMTS e-mail notifications will be generated by PCG indicating the specific date and time that the participant is to be surveyed, or “sampled” (selected employees may be sampled more than once during a given quarter). E-mail notifications will be distributed to each LEA’s designated participant. At the specified date and time, the participant will be expected to complete the survey (referred to as Random Moment Time Study form). The RMTS coordinator is responsible for monitoring the completion of their LEA’s participant electronic responses for timely responses. One of the key factors in the success of the Medicaid School-Based Claiming program is the timely and accurate completion of the RMTS observation forms by the participant and the RMTS coordinator’s tracking of compliance. This section provides a brief overview of how the process should work, focusing on the responsibilities of the RMTS coordinator. Explanations of the RMTS process and role of the RMTS coordinator are detailed in depth in the CMS-approved Time Study Implementation Guide, Staff Pool List Guide, RMTS District Coordinator Guide, and the RMTS Participant Guide. ROLE OF THE RMTS COORDINATOR The LEA’s RMTS coordinator plays a very important part in the accurate and effective administration of the RMTS process. The RMTS coordinator is responsible for:  

Identifying the employees and contracted staff at the LEA/charter that should participate in the RMTS time study, which excludes 100% federally funded staff. Preparing and submitting staff pool lists electronically using the RMTS system on a quarterly basis and Position Classification Forms (PCFs), at a minimum once for the duration of the LEA’s participation in the program.

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All LEAs participating in RMTS must complete the certification process to have their staff roster included in the sample. Rosters that have not been certified will not be included in the sample and will not be considered as participating in RMTS during the quarter.

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Distributing training materials to the participants prior to using the RMTS system.

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    

4.1

Monitoring employees’ participation, including reviewing the RMTS Compliance Report on a regular basis. Monitoring employee participation and LEA compliance. Coordinating with the LEA’s finance personnel to ensure that the cost information (including but not limited to fund and function) of the RMTS selected personnel is reported accurately. Preparing or coordinating the preparation of the annual district wide student roster and completing the certification of student roster form for the calculation of the Medicaid Eligibility Rate. Maintaining an Audit file for a period of no less than five years from the end of the quarter in which payment was received for a participating quarter or until any form of compliance review is complete.

STAFF POOL LIST

Only certain LEA staff and contracted staff may be included in the Random Moment Time Study (RMTS). In order to optimize the effectiveness and accuracy of the time study, it is important that the LEA evaluate potential staff and only include the appropriate staff in the participant list. A careful review of the following guidelines will assist the LEA in selecting participants: 

Time study participants may be any direct employee of the LEA, contract employees, part time employees, temporary employees and any other category of individuals receiving pay from the LEA. This does not include individuals such as parents or other volunteers who receive no compensation for their work or in-kind contributions.

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The sampling methodology consists of three cost pools. The LEA must associate each individual with one of the 3 cost pools based on their role in the district and credentials.. PCG will separate the roster into three different cost pools based on the participant’s job title. The three costs pools are mutually exclusive, i.e., no staff should be included in both cost pools. AZ RMTS program consists of the following job titles: Cost Pool I (Direct Service Providers) This cost pool includes only providers that are registered with AHCCCS and billing for services for Medicaid reimbursement.             

Audiologists Certified Occupational Therapy Assistants Speech Language Pathologists Licensed Marriage and Family Therapist Licensed Professional Counselors (LPC) Occupational Therapists Physical Therapists Physical Therapy Assistants Psychiatrists Psychologists Registered Nurses and Licensed Practical Nurses Social Workers Speech Language Pathology Assistants

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Cost Pool 2 (Administrative Service Providers Only) This cost pool includes staff that provides administrative and outreach activities that support Medicaid on a routine basis. In addition, providers that do not provide direct services or bill for Medicaid reimbursement (e.g. certain psychologists, nurses) can be included in this cost pool.  Administrators for Exceptional Student Education*  Audiology Assistants  Augmentative Specialists  Bilingual Specialists  Dietitians  Interpreters  Liaisons for Exceptional Student Education*  Program and Staffing Specialists*  Special Education Teachers*  Student Services Personnel*  Guidance Counselors  School Based Psychologists *These positions require a Position Classification Form (PCF) to be included in the staff roster for the statewide sample. Cost Pool 3 (Personal Care Providers) This cost pools includes only health aides registered with AHCCCS, providing and billing for Activities of Daily Living (ADL) services prescribed in the IEP.  School Health Aides Note: All health aides in this cost pool must have a unique e-mail address and access to a computer with internet in order to complete the on-line RMTS moments if selected. 

Employees paid 100% from federal funds must not be included as time study participants. Employees partially paid from federal funds may be included. LEAs should carefully consider whether partially Federal funded staff should participate. It is the responsibility of the LEA to ensure that employees who are 100% federally funded are not included in the list of time study participants. If PCG discovers any employee(s) who are 100% federally funded, the employee’s name will be removed from future quarterly participant lists. Furthermore the LEA will be liable for reimbursement inappropriately made for employees who are 100% federally funded.

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Functions 2500, 2600 and 2840 (including all sub-functions) are utilized in the calculation of the Unrestricted Indirect Cost Rate (UICR). Since these functions codes are currently used in the calculation, they cannot be reported on the quarterly financials under salaries, benefits or purchased professional services. Therefore, staff whose costs are captured under function codes 2500, 2600, and 2840 should not be listed on the staff pool list for MSBC.

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

Only staff that routinely perform any of the following activities as part of their routine work tasks should be selected to participate: Direct Medicaid Services: Providing direct medical services as covered services delivered by school districts under the Direct Care or FFS Program. These direct medical services may be delivered to an individual and/or group in order to ameliorate a specific condition and are performed in the presence of the student(s). This includes the provision of all IDEA/IEP medical (i.e. health-related) services. It also includes functions performed pre and post of the actual direct medical services (when the student may not be present), for example, paperwork, or staff travel directly related to the direct medical services. Note: Staff who provide direct medical services and are included in the participant list must also submit direct service claims through PCG/AHCCCS. Conversely, staffs who submit claims through PCG/AHCCCS must also be on the participant list. Medicaid Outreach: Informing eligible individuals about Medicaid and EPSDT benefits and how to access the program. Information includes a combination of oral and written methods that describe the range of services available through Medicaid and EPSDT, the cost (if any), location, how to obtain services, and the benefits of preventive healthcare. Include related paperwork, clerical activities, or staff travel required to perform these activities. Facilitating Medicaid Eligibility Determination: Assisting children and families in establishing Medicaid eligibility by making referrals to the Division of Family Services for eligibility determination, assisting the applicant in the completion of the Medicaid application forms, collecting information, and assisting in reporting any required changes affecting eligibility. Include related paperwork, clerical activities, or staff travel required to perform these activities. Transportation-Related Activities in Support of Medicaid Covered Services: Assisting an individual to obtain transportation to services covered by Medicaid. This does not include the provision of the actual transportation service or the direct cost of the transportation, but rather the administrative activities involved in providing transportation. Include related paperwork, clerical activities, or staff travel required to perform these activities. Translation Related to Medicaid Services: When translation is not included and paid for as part of a medical assistance service and must be provided by separate units or separate employees performing solely translation functions for the school. The translation must facilitate access to Medicaid covered services. Please note that a LEA does not need to have a separate administrative claiming unit for translation. Include related paperwork, clerical activities, or staff travel required to perform these activities. Program Planning, Policy Development, And Interagency Coordination Related To Medicaid Services: Performing activities associated with the development of strategies to improve the coordination and delivery of Medicaid covered medical/dental/mental health services to school age children, and when performing collaborative activities with other agencies and/or providers. Only employees whose position descriptions include program planning, policy development and interagency coordination should use this code. Include related paperwork, clerical activities or staff travel required to perform these activities. Medicaid Related Training: Coordinating, conducting, or participating in training events and seminars for outreach staff regarding the benefit of medical/Medicaid related services, how to assist

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families to access such services, and how to more effectively refer students for those services. Include related paperwork, clerical activities, or staff travel required to perform these activities. Referral, Coordination, And Monitoring of Medicaid Services: Making referrals for, coordinating, and/or monitoring the delivery of medical (Medicaid covered) services. Referral, coordination and monitoring activities related to services in an IEP are reported in this code. Activities that are part of a direct service are not included in this code. Include related paperwork, clerical activities, or staff travel necessary to perform these activities.

4.2

RMTS SYSTEM

Once the LEA has identified personnel that routinely perform Medicaid allowable activities, the RMTS coordinator will update the staff roster in the RMTS system. The staff roster must be updated for all three cost pools in the online RMTS system. The RMTS coordinator must certify all rosters before it will be included in the statewide sample. Staff rosters that have not been certified will not be included in the statewide sample and will not be considered as participating in RMTS and cannot bill for direct services during the quarter. If the RMTS coordinator makes any changes before the sample is created, the coordinator must complete the certification process again. GENERAL INSTRUCTIONS To make updates to the staff roster in the RMTS system, please follow these instructions: Each employee selected by the LEA can only be included in one cost pool. (i.e., if an employee works out of more than one campus, has multiple job titles, or is paid from more than one fund / function, he/she can only be listed once.) All duplicates will be removed. RMTS coordinators will access the RMTS system using the user name and password provided by PCG. Updates made to the staff roster are made individually by participant. RMTS coordinators have the ability to:  Change / update a participant’s information (e.g. e-mail address)  Inactivate a participant  Reactivate a participant  Add a new participant After all updates have been made, the RMTS coordinator must certify all three cost pools. The staff roster will be certified for the upcoming quarter in which the LEA is participating. Once a sample is generated the staff roster can only be updated for future quarters. PCG requires that in order for individuals with certain job titles (please see section 4 for details) to remain in staff rosters that a PCF be completed and submitted to PCG. REQUIRED DATA ELEMENTS ON THE PARTICIPANT SCREEN (RMTS SYSTEM) Each of the following pieces of information must be provided for each employee selected to participate in the RMTS process: 

Participant Belongs To: This is the school name. If a school name is missing from the drop down selection, select another school and notify the PCG

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First Name: Enter the first name of the employee. Do not include titles (i.e., Dr., Ms., Mrs., Mr., etc)

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Last Name: Enter the last name of the employee. If an employee has a hyphenated name, please list the full name including the hyphen. Do not include suffixes (i.e., Jr., Mr., II or alias last names)

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Job Title: Enter each employee’s Actual job title with the LEA

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Job Code: Select the job code for the participant based on their actual job title

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E-mail Address: The e-mail address must be specific to the participant and cannot be used by more than one participant. The e-mail address must be a working e-mail address that the participant can access. User names and passwords are confidential and can only be sent to the participant



Employment Type: Enter the employees employment type of either full time, part time or contractor

POSITION CLASSIFICATION FORM Only individuals who routinely perform direct medical services as prescribed on the IEP and Medicaid administrative and outreach activities should be included in the staff rosters. However, PCG realizes that in an educational setting an individual’s job title may not always represent all of the functions he / she may routinely perform. PCG has created a Position Classification Form (PCF) that enables a LEA to identify those Medicaid allowable activities that are routinely performed by the individual with the job title in question. PCG does not require this form for all job titles as there are some positions by sheer title that are easy to recognize the Medicaid allowable activities that would be performed on a routine basis. A clinician for example (i.e., Speech Therapist) would routinely monitor a student’s progress towards speech therapy goals as well as determine whether or not a student continues to meet medical necessity for speech therapy services, in addition to providing the direct medical service (i.e., speech therapy). Other job titles are not as clearly identifiable (please see Section 2 for a detailed list of job titles that require clarification). Since all personnel included in the staff roster must routinely perform Medicaid allowable activities PCG requires that LEAs submit a PCF for individuals with job titles requiring clarification. The form is available online and can be submitted to PCG via mail or fax. Once received, PCG will review the form and make the final determination as to whether or not to accept the individual for inclusion in the staff roster. Forms that appear to be exact duplicates (e.g., every box is checked for every position) will require verification. If clarification is needed regarding the form PCG will contact you. If a RMTS coordinator is not available to provide clarification, PCG may elect not to include the questioned individual(s) on the staff roster. Please note that this does not necessarily preclude a LEA from submitting the financial data related to these individuals. Please note that the form must be received by the deadline. If a PCF is not received by the deadline for submitting staff rosters, those individuals will be automatically removed from the roster. LEAs must maintain a copy of submitted PCFs in your audit file for a period of no less than five years from the quarter in question.

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DEADLINES FOR SUBMITTING STAFF ROSTERS AND POSITION CLASSIFICATION FORMS Deadlines for submitting staff rosters for each quarterly time study will be approximately 30 days prior to the beginning of the quarter. Position Classification Forms are submitted once and will be maintained by PCG for the duration of the LEA’s participation in the program. If during any of the subsequent quarters a new job title is added to the staff roster that requires a position classification form, the new PCF must be submitted with the current quarter’s staff roster. Please note that if a LEA does not meet the deadline to update their quarterly staff roster, the LEA will not be able to participate in the corresponding time study (i.e., the next time study) or bill for direct services. The LEA will not be eligible for reimbursement for that quarter. All LEAs will receive prior written notice of exact deadlines. Please check your annual program calendar for due dates. RECEIPT OF MOMENTS LIST FROM PCG It is important to remember that not all staff listed on the LEA staff roster will be chosen for sampling in a given quarter. Furthermore, because of the random nature of the sampling process some staff may be sampled more than once within a given quarter. The RMTS coordinator will receive the moments list via e-mail prior to the start of the quarter. MOMENTS LIST This is a master list of all of the samples that occur for that particular sampling quarter for the selected LEA. The moments list will be sent electronically to the RMTS coordinator. It will include the names of the staff that have been chosen for sampling as well as the dates and times of their samples. In addition, the moments list provides the following information:  Cost Pools  LEA Name  School Name of the selected employee  Name of the selected employee  Participant’s e-mail address  Date and time of the selected moment  Job Code description (as coded by PCG)  Job Title (as coded by PCG) MOMENT NOTIFICATION PROCESS Due to the strict requirements placed on RMTS notification by CMS, RMTS coordinators may not distribute or communicate specific information regarding a participant’s moment more than five days prior to the moment. LEAs may elect to have participants receive notification of their selected moments on paper. It is strongly encouraged for LEAs to select electronic notification. 

In order for a LEA to receive paper notification for some or all of their participants the following must be completed prior to the due date established for the quarter:

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o o o

Written request to PCG requesting approval of paper notification Copy of LEA’s internal policy and process for distributing and tracking paper notifications Copy of LEA’s template for tracking the distribution of paper notifications, internal policies, processes and tracking files will be subject to audit and therefore must adhere to the record retention guideline for the program

TIME STUDY RETURN COMPLIANCE Centers for Medicare & Medicaid Services (CMS) and AHCCCS require an 85% return rate. According to CMS standards, non-responsive moments, defined as moments not returned or not accurately completed and subsequently resubmitted by the LEA, will not be included in the results unless the return rate for valid moments is less than 85%. If the return rate of valid moments falls below 85% for the quarter, then nonreturned moments must be included and coded as non-claimable. To ensure that enough moments are received to have a statistically valid sample, Arizona will over sample at a minimum of fifteen percent more moments than needed for a valid sample size. To assure that LEAs are properly returning sample moments, the LEA’s return rate percentage for each quarter will be analyzed. If the statewide compliance rate for a quarter does not achieve at least 90%, PCG will send out a non-compliance warning letter to each LEA that did not achieve an 85% return rate. For LEAs that are issued a warning letter, PCG will monitor the next consecutive quarter to ensure compliance is achieved. LEAs that continue to not meet compliance rates may be subject to suspension or termination from the school based billing program. CHANGES TO PARTICIPANT STATUS If the original participant for whom the on-line form was intended is no longer employed by the LEA , but the position that employee was in has been refilled, the RMTS coordinator must contact PCG prior to the sampled moment in time with the replacements first and last name, e-mail address and date of hire. The RMTS coordinator will be required to update the RMTS system the following quarter by inactivating the original participant and adding the replacement. If the original participant for whom the on-line form was intended is not replaced, the RMTS coordinator must contact PCG via e-mail with the participant’s termination date. Out on Leave- If the participant for whom the on-line form was intended is out sick, on medical leave, or vacation, the RMTS coordinator must contact PCG via e-mail advising of the reason the participant is not able to complete the on-line form, effective dates of leave, and if the leave is paid or unpaid. COMPLETING THE RMTS FORM ON-LINE To access the on-line RMTS form, participants will need a user name and password. PCG assigns all participants a user name and password to access the RMTS system, and provides them to the participant via email. If a participant does not have their user name and password, please contact the PCG RMTS helpline at 1-877-877-8011.

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The on-line RMTS form can be accessed after the specified moment in time has passed with the link provided in the participant e-mail notifications, or directly at https://easyrmts.pcgus.com/RMTSv2 Participants will receive the following e-mail notifications regarding his/her RMTS form prior to the specified moment:  

AZ Random Moment Time Study Notification – Pre-Participation Notice - 5 days before moment in time AZ Random Moment Time Study Notification – moment in time is in 1 Hour

If the RMTS on-line form is not completed on the day of the sampled moment, the participant will receive two follow-up e-mails. The LEA’s RMTS coordinator will be copied on the follow-up e-mail notifications. However, the user name and password will not be included in the late notification e-mails.  

AZ Random Moment Time Study Notification – 24 Hour Late Notice AZ Random Moment Time Study Notification – 3 Day Late Notice

Participants log in to the RMTS system by entering their user name and password assigned by PCG. First, participants will read the on-line training material, which provides an overview of the Medicaid School-Based Claiming program as well as training material on how to complete an on-line RMTS form. While reading the on-line training material, participants will click the Next button to advance through the training screens and to reach their RMTS on-line form. The moment list will only display current participant selected moments in time. Participants will not be able to complete an on-line RMTS form appearing on the moment list prior to the sampled moment in time. Once a sampled moment in time has occurred, the participant will click on the Respond button to complete the RMTS form. If the participant selects that they were Not working, the RMTS form will automatically populate with the reason the participant was not working. By clicking the Next button, the participant will be able to view the completed form. If the participant wants to change the reason he or she was not working, click the Edit button and the participant will be taken to the previous screen. After reading the on-line training material, participants will document the activity by answering the four following questions:    

Who were you with? What were you doing? Describe why you were doing this activity Is the service provided listed on the child’s IEP? (Response is limited to four drop down options) o Yes, the service is listed on the child’s IEP o No, the service is not listed on the child’s IEP o No, the student does not have an IEP o N/A

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The participant must click on the check box indicating that they have read the materials, understand their role in the Medicaid School-Based Claiming program and how to accurately complete the form, then click “Submit” to submit the form for coding. The form must be completed within five school days of the moment to be valid. A detailed explanation of how to complete a RMTS form can be found in the “AZ RMTS Participant’s Guide.” FOLLOW-UP PROCESS PCG uses an electronic follow-up process in the RMTS system for notifying participants of additional information / follow-up that is needed to accurately code the submitted moment. If additional information is needed, the participant will receive an e-mail notification from the RMTS system. The e-mail will contain a link to the RMTS system along with the participant’s user name and password. The participant will log into the RMTS system and provide the additional information. PCG will send three follow-up e-mail notifications in an attempt to obtain the additional information that is needed. The participant will have seven days between e-mails to provide the information. The LEA’s RMTS coordinator is copied on the third and final e-mail. The third e-mail does not contain the participant’s user name and password. Follow-up moments that are not responded to after the three follow-up attempts will be coded conservatively based on the initial response. VALIDATION PROCESS PCG uses centralized coders to select the appropriate RMTS activity code based on the participant’s answers to the four questions on the RMTS form. Once the participant submits the RMTS form an activity code is selected based on the participant’s responses. PCG then conducts a quality review process on a quarterly basis. In addition, AHCCCS performs an internal validation process on a quarterly basis. MONITORING EMPLOYEE PARTICIPATION RMTS coordinators must monitor employee participation to ensure that every RMTS form for their LEA is completed. PCG generates a weekly RMTS Statewide Compliance Report and distributes it to all participating LEAs on a weekly basis via e-mail. The report displays which moments have been completed for each individual LEA. In addition, all RMTS coordinators have access to their LEAs individual RMTS Compliance Report through the RMTS system. Reimbursement is directly related to the percentage of time spent on Medicaid allowable activities such as direct medical services and administrative and outreach activities performed. The percentage of time that is identified using RMTS forms is applied to each LEAs allowable expense, which directly impacts the LEAs reimbursement. Remember, the time study results are applied to all LEAs in a statewide methodology. A reduction in the percentage of time spent of reimbursable activities, will adversely affect the reimbursement of all participating LEAs. Every Moment Counts!

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4.3

PARTICIPANT TRAINING

Training is essential to the success of the Medicaid School-Based Claiming Program. Therefore, PCG recommends that individuals receive training periodically. To assist school LEAs / charter schools, PCG has created training modules for the various school staff responsible for the Medicaid School-Based Claiming program including:  

RMTS coordinators Time study participants

PCG has created training materials, handouts, and Power Point presentations that are available on-line, in addition to regularly scheduled Webinars. TRAINING RMTS COORDINATORS PCG provides Regional Information Sessions approximately two times per year throughout Arizona. These sessions allow RMTS coordinators to hear the latest information about the Medicaid School-Based Claiming Program, and provide an opportunity to meet other Arizona RMTS coordinators. PCG is also available to provide individual or small group RMTS coordinator training sessions for new LEAs as well as those wanting refresher courses.

TRAINING TIME STUDY PARTICIPANTS The RMTS system requires each participant, upon logging in to the system, to read a series of screens providing information about the Medicaid School-Based Claiming program, the role of the participant, and how to complete the time survey. The participant must select the “Next” button to progress through the screens to obtain access to their sampled moment. The standardized training ensures that all participants are appropriately trained prior to their scheduled moment. RMTS coordinators should distribute the AZ RMTS Participant’s Guide to the participants prior to completing the on-line RMTS form. The guide provides information on how to navigate through the RMTS system. The AZ RMTS Participant’s Guide can also be found on PCG project website.

4.4

TIME STUDY CODING

The time study coding process supports the assessment of what percentage of time staff spend on allowable Medicaid direct service, administrative and outreach activities. The RMTS process is a time reporting technique that produces statistically valid results, identifying the percentage of staff time that is spent on these Medicaid allowable activities. The time study coding process is conducted using a centralized coding methodology. PCG centralized coders determine the appropriate activity code based on the participant’s answers to the questions on the RMTS on-line form. The results of the RMTS are then used to determine the percentage of time spent on medical direct services, which is then used as one of the factors in the annual cost settlement process. The RMTS results also determine the percent of time spent on allowable administrative and outreach activities

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which is then used as a factor in the calculation in the quarterly Medicaid Administrative Claim (MAC) The following section provides a description and examples of each activity code used for coding in the MSBC program. Please note that not all activity codes are reimbursable. Code 1A: Non-Medicaid Outreach This code is used when staff performs activities that inform eligible or potentially eligible individuals about non-Medicaid social (Food Stamps and Title IV-E), vocational, general health and educational programs (including special education) and how to access them; describing the range of benefits covered under these non-Medicaid social, vocational and educational programs and how to obtain them. Both written and oral methods may be used. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples:   

Scheduling and promoting activities, which educate individuals about the benefits of healthy life-styles and practices. Conducting general health education programs or campaigns that address life-style changes in the general population (e.g., dental hygiene, anti-smoking, alcohol reduction, etc.). Conducting outreach campaigns directed toward encouraging persons to access social, educational, legal or other services not covered by Medicaid.



Assisting in early identification of children with special medical/dental/mental health needs through various Child Find activities.

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Outreach activities in support of programs that are 100 percent funded by State general revenue. Developing and/or distributing outreach materials such as brochures or handbooks for these programs.

Code 1B: Medicaid Outreach This code is used when staff performs specific activities to inform eligible individuals about Medicaid and EPSDT benefits and how to access the program. Information includes a combination of oral and written methods that describe the range of services available through Medicaid and EPSDT, the cost (if any), location, how to obtain services, and the benefits of preventive healthcare. Such activities also include informing potential eligible students and their parents about the Medicaid Programs for the purpose of determining eligibility. Outreach may only be conducted for the populations served by the school districts, i.e., students and their parents or guardians. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples:    

Informing Medicaid eligible and potential Medicaid eligible children and families about the benefits and availability of services provided by Medicaid, including services provided through the EPSDT program. Distributing literature about the benefits, eligibility requirements, and availability of the Medicaid program, including EPSDT. Informing foster care providers of foster children residing within school district boundaries about Medicaid and the EPSDT program. Interpreting materials about Medicaid to person with children with in the school district boundaries who are illiterate, blind, deaf, or who cannot understand the English language.

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    

Contacting pregnant and parenting teenagers about the availability of Medicaid prenatal and well baby care programs and services. Utilizing brochures approved by the Division of Medical Services, designed to effectively inform eligible individuals about the benefits Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and services, and about how and where to obtain services. Providing information about the Medicaid EPSDT screening (e.g., dental, vision) in the schools that will help identify medical conditions that can be corrected or ameliorated by services covered through Medicaid. Providing information regarding Medicaid managed care programs and health plans to individuals and families and how to access that system. Encouraging families to access medical/dental/mental health services provided by the Medicaid program.

Code 2A: Facilitating an Application to Non-Medicaid Programs This code is used when staff assists an individual or family to make application for programs such as Temporary Assistance for Needy Families (TANF), Food Stamps, Women, Infants, and Children (WIC), day care, legal aid, and other social or educational programs and referring them to the appropriate agency to make application. Both written and oral methods may be used. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples:  

Explaining the eligibility process for non-Medicaid programs, including IDEA. Assisting the individual or family in collecting/gathering information and documents for the nonMedicaid program application.

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Assisting the individual or family in completing the application.

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Developing and verifying initial and continuing eligibility for the Free and Reduced Lunch Program. When a school district employee is verifying a student’s eligibility or continuing eligibility for Medicaid for the purpose of eligibility under the Free and Reduced Lunch program, report that activity under this code. Developing and verifying initial and continuing eligibility for non-Medicaid programs.

 

Providing necessary forms and packaging all forms in preparation for the Non-Medicaid eligibility determination.

Code 2B: Facilitating Medicaid Eligibility Determination This code is used when staff assists an individual in the Medicaid eligibility process, by making referrals to the Division of Family Services, assisting the applicant in the completion of the Medicaid application forms, collecting information, and assisting in reporting any required changes affecting eligibility. Include related paperwork, clerical activities, or staff travel required to perform these activities. This activity does not include the actual determination of Medicaid eligibility. Examples:

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   

Referring an individual or family to the local assistance office to make an application for Medicaid benefits. Explaining the Medicaid eligibility rules and the Medicaid eligibility process to prospective applicants. Providing assistance to the individual or family in collecting/gathering required information and documents for the Medicaid application. Assisting individuals or a family in completing the Medicaid eligibility application.

Code 3: School Related and Educational Activities This code is used when staff performs school-related activities that are not Medicaid related, such as social services, educational services, teaching services; employment and job training. These activities include the development, coordination, and monitoring of a student’s education plan. Include related paperwork, clerical activities, or staff travel required to perform these activities. Examples:                  

Providing classroom instruction (including lesson planning) or 504 educational activities/services. Testing, correcting papers. Developing, coordinating, and monitoring the Individualized Education Program (IEP) for a student, which includes ensuring annual reviews of the IEP are conducted, parental sign-offs are obtained, and the actual IEP meetings with the parents. Compiling attendance reports. Performing activities that are specific to instructional, curriculum, and student-focused areas. Reviewing the education record for students who are new to the school district. Providing general supervision of students (e.g., playground, lunchroom). Monitoring student academic achievement. Providing individualized instruction (e.g., math concepts) to a special education student. Conducting external relations related to school educational issues/matters. Compiling report cards. Carrying out discipline. Performing clerical activities specific to instructional or curriculum areas. Activities related to the educational aspects of meeting immunization requirements for school attendance. Enrolling new students or obtaining registration information. Conferring with students or parents about discipline, academic matters or other school related issues. Participating in or presenting training related to curriculum or instruction (e.g., language arts workshop, computer instruction). Providing Individuals with Disabilities Education Act (IDEA) mandated child find activities.

Code 4A: Direct Medical Services – Not Covered as IDEA/IEP Services This code is used when the participant is providing direct client care services that are not IDEA and/or not IEP services. This code includes the provision of all no IDEA/IEP medical services reimbursed through Early and Periodic Screening, Diagnosis,

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and Treatment (EPSDT) services. This code includes pre and post activities associated with the actual delivery of the direct client care services, e.g., paperwork or staff travel required to perform these services. Examples:  Providing medical/mental health services.  Conducting medical/mental health assessment and evaluation as part of the development of an IEP.  Conducting medical/mental health assessments/evaluations and diagnostic testing and preparing related reports.  Providing personal aide services.  Providing speech, occupational, physical and other therapies.  Administering first aid, or a prescribed injection or medication to a student.  Providing direct clinical/treatment services.  Performing developmental assessments.  Providing counseling services to treat health, mental health, or substance abuse conditions.  Developing a treatment plan (medical plan of care) for a student if provided as a medical service.  Performing routine or mandated child health screening, including but not limited to vision, hearing, dental, scoliosis, and EPSDT screens;  Providing immunizations.  Activities which are services or components of services, listed in the state’s Medicaid plan.  Making referrals for and/or coordinating medical or physical examinations and necessary medical evaluations as a result of a direct medical service.  Immunizations and performance of routine or education agency mandated child health screens to the student enrollment, such as vision, hearing and scoliosis screens.

Code 4B: Direct Medicaid Services – Covered as IDEA/IEP Services Nursing services and evaluation including skilled nursing services and time spent administering/monitoring medication when the service is not included on the student’s IEP. For example, medication for a short-term illness or recent injury would not normally be included in an IEP. Time spent administering/monitoring medication that is not included as part of the IEP and not documented in the IEP such as administration/monitoring of maintenance drugs (example 1: insulin for a diabetic if the insulin administration/monitoring is not in the IEP; example 2: anti-seizure medication for a child if the anti-seizure medication is not in the IEP) and administration/monitoring of non-routine medications for acute conditions when the administering/monitoring of the medication is not included as part of the IEP and not documented in the IEP. All IDEA and/or IEP direct client care services when the student is present:  Providing health/mental health services as covered in the student’s IEP.  Conducting medical/health assessments/evaluations and diagnostic testing and preparing reports as covered in the students IEP Examples:  Audiologist services including evaluation and therapy services (only if included in the student’s IEP)  Physical Therapy services and evaluations (only if included in the student’s IEP)  Occupational Therapy services and evaluations (only if included in the student’s IEP)  Speech Language Therapy and evaluations (only if included in the student’s IEP)

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

  

Psychological service, including evaluations and assessment (only if included in the student’s IEP) o [Assessment services are not in the client’s IEP because assessments are performed before the students IEP is developed] Counseling services, including therapy service (only if included in the student’s IEP) Providing personal aide services (only if include in the student’s IEP Nursing services and evaluations (only if included in the student’s IEP), including skilled nursing services on the IEP and time spent administering/monitoring medication only if it is included as part of an IEP and documented in the IEP. [For example, administration of a medication such as Ritalin would only be included as an IEP-Related Service if the student IEP’s actually contained a requirement or its provision; administration/monitoring of anti-spasmotic drugs for children with cerebral palsy, such as baclofen, that is included as part of an IEP and documented dint he IEP; insulin for a diabetic if the insulin administration/monitoring is in the IEP]

This code also includes pre and post time directly related to providing direct client care services when the student is not present. Examples of pre and post time activities when the student is not present include: time to complete all paperwork related to the specific direct client care service, such as preparation of progress notes, translation of session notes, review of evaluation testing/observation, planning activities for the therapy session, travel to/from the therapy session, or completion of billing activities. Examples:  Pre and post activities associated with physical therapy services, for example, time to build a customized standing frame for a student or time to modify a student’s wheelchair desk for improved freedom of movement of for the client.  Pre and post activities associated with speech language pathology service, for example, preparing lessons for a student to use with an augmentative communicative device or preparing worksheets for use I group therapy sessions.  Updating the medical/health-related service goals and objective of the IEP.  Travel to the direct service/therapy.  Paperwork associated with the delivery of the direct care service, as long as the student/client is not present. Such paperwork could include the preparation of progress notes, translation of session notes, or completion of billing activities.  Interpretation of the evaluation results and/or preparation of written evaluations, when student/client is not present. (Assessment services are billed for testing time when the student is present, for interpretation time when the student is not present, and for report writing when the student is not present.

Code 5A: Transportation for Non-Medicaid Services This code is used when staff assists an individual to obtain transportation to services not covered by Medicaid, or accompanying the individual to services not covered by Medicaid. Include related paperwork, clerical activities or staff travel required to perform these activities. Example:

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

Scheduling or arranging transportation to social, vocational, and/or educational programs and activities.

Code 5B: Transportation-Related Activities in Support of Medicaid Covered Services This code is used when staff assists an individual to obtain transportation to services covered by Medicaid. This does not include the provision of the actual transportation service or the direct cost of the transportation, but rather the administrative activities involved in providing transportation. Include related paperwork, clerical activities or staff travel required to perform these activities. Example: 

Scheduling or arranging transportation to Medicaid covered services.

Code 6A: Non-Medicaid Translation This code is used when staff provides translation service for non-Medicaid activities. Include related paperwork, clerical activities or staff travel required to perform the activities. Examples:   

Arranging for or providing translation services (oral or signing services) that assist the individual to access and understand social, educational, and vocational services. Arranging for or providing translation services (oral or signing services) that assist the individual to access and understand state education or state-mandated health screenings (e.g., vision, hearing, and scoliosis) and general health education outreach campaigns intended for the student population. Developing translation materials that assist individuals to access and understand social, educational, and vocational services.

Code 6B: Translation Related to Medicaid Services This code is used when it is not included and paid for as part of a medical assistance service. However, translation must be provided either by separate units or separate employees performing solely translation functions for the school and it must facilitate access to Medicaid covered services. Please note that a school district does not need to have a separate administrative claiming unit for translation. School employees who provide Medicaid translation services should use this code. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples:  

Arranging for or providing translation services (oral or signing) that assist the individual to access and understand necessary care or treatment covered by Medicaid. Developing translation materials that assist individuals to access and understand necessary care or treatment covered by Medicaid.

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Code 7A: Program Planning, Policy Development, and Interagency Coordination Related To NonMedical / Non-Medicaid Services This code is used when staff performs activities associated with the development of strategies to improve the coordination and delivery of non-medical services to school age children. Non-medical services may include social services, educational services, and state or state education mandated child health screenings provided to the general school population. Employees whose position descriptions include program planning, policy development and interagency coordination may use this code. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples:           

Identifying gaps or duplication of non-medical services (e.g., social, vocational educational and state mandated general health care programs) to school age children and developing strategies to improve the delivery and coordination of these services. Developing strategies to assess or increase the capacity of non-medical school programs. Monitoring the non-medical delivery systems in schools. Developing procedures for tracking families’ requests for assistance with non-medical services and the providers of such services. Evaluating the need for non-medical services in relation to specific populations or geographic areas. Analyzing non-medical data related to a specific program, population, or geographic area. Working with other agencies providing non-medical services to improve the coordination and delivery of services and to improve collaboration around the early identification of non-medical problems. Defining the relationship of each agency’s non-medical service to one another. Developing advisory or work groups of professionals to provide consultation and advice regarding the delivery of non-medical services and state mandated health screening to the school populations. Developing medical referral sources. Coordinating with interagency committees to identify, promote and develop non-medical services in the school system.

Code 7B: Program Planning, Policy Development, and Interagency Coordination Related To Medicaid Approved Medical Services This code is used when staff performs activities associated with the development of strategies to improve the coordination and delivery of medical/dental/mental health services to school age children, and when performing collaborative activities with other agencies and/or providers. Employees whose position descriptions include program planning, policy development and interagency coordination may use this code. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples:    

Identifying gaps or duplication of medical/dental/mental health services to school age children and developing strategies to improve the delivery and coordination of these services. Developing strategies to assess or increase the capacity of school medical/dental/mental health programs. Monitoring the medical/dental/mental health delivery systems in schools. Developing procedures for tracking families’ requests for assistance with medical/dental/ mental

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health services and providers, including Medicaid. (This does not include the actual tracking of requests for Medicaid services). Evaluating the need for medical/dental/mental health services in relation to specific populations or geographic areas. Analyzing Medicaid data related to a specific program, population, or geographic area. Working with other agencies and/or providers that provide medical/dental/mental health services to improve the coordination and delivery of services, to expand access to specific populations of Medicaid eligible, and to increase provider participation and improve provider relations. Working with other agencies and/or providers to improve collaboration around the early identification of medical/dental/mental health problems. Developing strategies to assess or increase the cost effectiveness of school medical/dental/mental health programs. Working with Medicaid resources, such as the Medicaid agency and Medicaid managed care plans, to make good faith efforts to locate and develop EPSDT health services referral relationships. Developing advisory or work groups of health professionals to provide consultation and advice regarding the delivery of health care services to the school populations. Working with the Medicaid agency to identify, recruit and promote the enrollment of potential Medicaid providers. Developing medical referral sources such as directories of Medicaid providers and managed care plans that will provide services to targeted population groups, (e.g., EPSDT children). Coordinating with interagency committees to identify, promote and develop EPSDT services in the school system.

Code 8A: Non-Medical/Non-Medicaid Related Training This code is used when staff coordinates, conducts, or participates in training events and seminars for outreach staff regarding the benefit of the programs other than the Medicaid program. For example, training may include how to assist families with accessing the services of education programs, and how to more effectively refer students for those services. Include related paperwork, clerical activities, or staff travel required to perform these activities. Examples:  

Participating in or coordinating training that improves the delivery of services for programs other than Medicaid. Participating in or coordinating training that enhances IDEA Child Find programs.

Code 8B: Medical/Medicaid Related Training This code is used when staff coordinates, conducts, or participates in training events and seminars for outreach staff regarding the benefit of medical/Medicaid related services, how to assist families to access such services, and how to more effectively refer students for services. Include related paperwork, clerical activities, or staff travel required to perform these activities. Examples: 

Participating in or coordinating training that improves the delivery of medical/Medicaid related

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services. Participating in or coordinating training that enhances early identification, intervention, screening and referral of students with special health needs to such services (e.g., Medicaid EPSDT services). Participating in training on administrative requirements related to medical/Medicaid services.

Code 9A: Referral, Coordination, and Monitoring of Non-Medicaid Services This code is used when staff makes referrals for coordinate, and/or monitor the delivery of non-medical services, such as educational services. Include related paperwork, clerical activities, or staff travel necessary to perform these activities. Examples: 

Making referrals for and coordinating access to social and educational services such as childcare, employment, job training, and housing.

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Making referrals for, coordinating, and/or monitoring the delivery of state education agency mandated child health screening (e.g., vision, hearing, scoliosis).

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Making referrals for, coordinating, and/or monitoring the delivery of scholastic, vocational, and other non-health related examinations. Gathering any information that may be required in advance of these non-Medicaid related referrals. Participating in a meeting/discussion to coordinate or review a student’s needs for scholastic, vocational, and non-health related services not covered by Medicaid. Monitoring and evaluating the components of a 504 plan. Monitoring and evaluating the non-medical components of the IEP as appropriate.

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Code 9B: Referral, Coordination, and Monitoring of Medicaid Services Use this code when making referrals for, coordinating, and/or monitoring the delivery of medical (Medicaid covered) services. Referral, coordination of and monitoring activities related to services in an IEP are reported in this code. Activities that are part of a direct service are not claimable as an administrative activity and are not included in this code. Include related paperwork, clerical activities, or staff travel necessary to perform these activities. Examples:  

Identifying and referring adolescents who may be in need of Medicaid family planning services. Making referrals for and/or coordinating medical or physical examinations and necessary medical/dental/mental health evaluations.

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Making referrals for and/or scheduling EPSDT screens, interperiodic screens, and appropriate immunization, but not to include the state-mandated health services. Referring students for necessary medical health, mental health, or substance abuse services covered by Medicaid. Arranging for any Medicaid covered medical/dental/mental health diagnostic or treatment services that may be required as the result of a specifically identified medical/dental/mental health condition. Gathering any information that may be required in advance of medical/dental/mental health referrals. Participating in a meeting/discussion to coordinate or review a student’s needs for health-related

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services covered by Medicaid (This is not the IEP meeting). Providing follow-up contact to ensure that a child has received the prescribed medical/dental/mental health services covered by Medicaid. Coordinating the completion of the prescribed services, termination of services, and the referral of the child to other Medicaid service providers as may be required for continuity of care. Providing information to other staff on the child’s related medical/dental/mental health services and plans. Monitoring and evaluating the Medicaid service components of the IEP as appropriate. Coordinating medical/dental/mental health services provision with managed care plans as appropriate. Coordinating the delivery of community based medical/dental/mental health services for children with special/severe health care needs. Please note that this is not the IEP meeting.

Code 10: General Administration This code is used when performing activities that are not directly assignable to program activities. Include related paperwork, clerical activities or staff travel required to perform these activities. Examples:        

Taking lunch, breaks, leave, or other paid time not at work. Establishing goals and objectives of health related programs as part of the school’s annual or multiyear plan. Reviewing school or district procedures and rules. Attending or facilitating school or unit staff meetings, training, or board meetings. Performing administrative or clerical activities related to general building or district functions or operations. Providing general supervision of staff, including supervision of student teachers or classroom volunteers, and evaluation of employee performance. Reviewing technical literature and research articles. Other general administrative activities of a similar nature as listed above that cannot be specifically identified under other activity codes.

Code 11: Not Scheduled to Work This code is used when the RMTS moment occurs at a time when an employee is not scheduled to be at work (e.g., the moment in time occurs before or after the typical work day or part-time employee not scheduled to work on that day).

5.

COST REPORTING

ROLE OF THE FINANCE CONTACT The finance contact is the individual at a school LEA/charter school responsible for the accuracy and submission of information to PCG for calculation of the reimbursement amount. Costs submitted by the finance contact are certified by a CFO, Business Manager, etc..The finance contact works in collaboration with the RMTS coordinator. The Finance contact is responsible for:

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Reporting the salaries, benefits and purchased professional services (PPS) costs expended each quarter for all staff included on the staff roster on a cash basis quarterly Ensuring that costs do not include federal funds and/or funds that are included in the calculation of the UICR Reporting transportation information and costs for the annual cost report Reviewing annual salary, benefits, and PPS entered from prior quarters by the LEAs finance liaison and if needed, adjusted report costs for accuracy Certifying the accuracy of financial information reported to PCG Providing the RMTS coordinator with a copy, for the purpose of the audit file, any relevant documentation to support costs reported for the claim, including but not limited to: o Any computations or allocation used in reimbursement calculation o A detailed list of all revenues offset from the claim, by source o A completed quarterly invoice o A copy of the certification of financial information reported o A copy of the certification of student roster information reported o Data used to calculate transportation ratios and transportation costs

Note: The LEA will designate an employee(s) to act as liaison with PCG for reporting financial information. The LEA may choose to designate more than one person based on roles and responsibilities. If the designated employee(s) changes roles or leaves the district the LEA must provide notice to PCG within twenty business days. REQUIRED DOCUMENTATION FOR REPORTING COST DATA In order to calculate the reimbursement amount for each participating LEA, PCG requires that quarterly financial data be submitted and certified electronically using the Arizona Cost Reporting System. Additional information is reported annually in the Cost Reporting System such as transportation related costs and information. The system can be accessed on the internet by going to https://costreporting.pcgus.com/az. Effective July 1, 2011, all quarterly costs are reported on a cash accounting method. Cash-based accounting is when costs are reported when payments are made, regardless of when the services were rendered. Cost Data Salaries and Benefits Purchased Professional Services

Accrual Accounting Based on start and end dates of the pay period Based on dates of service

SECTIONS OF THE COST REPORTING SYSTEM    

Dashboard Quarterly Financial Submission Manage Contacts Annual Financial Submission

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DASHBOARD The dashboard contains important dates and training information. It also has links to important resources including user guides, training presentations, and partner Web sites. The dashboard is updated regularly so users should check for updated information each time they log into the site. The Dashboard contains important dates and training information. QUARTERLY FINANCIAL SUBMISSION Each quarterly financial submission includes the reporting of payroll information (i.e., paid hours, salaries and benefits for employees and paid hours and contracted compensation for contracted staff) for staff listed on the quarterly RMTS staff roster for that cost report period. All cost must be reported using the accrual account method. The system requires cost data to be entered sequentially; for example, the July-September quarterly financial submission must be completed and certified before the user can enter data into the October-December quarterly financial submission. The Cost Reporting System is accessible to the LEA throughout the school year. Quarterly financial periods will be available for input of data after the close of each quarter and in general financial reports are due 30-45 days after the quarter closes. LEAs should utilize the dashboard to stay informed of relevant reporting dates.

Quarterly Payroll Information This section is pre-populated with the name and position of each staff person (employee and contracted staff) on the LEA’s quarterly RMTS staff roster. No additional staff may be added to the list. The only staff for which the LEA can report costs are those who were included on the LEA’s staff pool roster at the beginning of the quarter. The user can enter payroll information directly into the web-based system or download the staff roster as a comma delimited file (.csv), which can be viewed in a program such as Microsoft Excel, enter payroll information into the file, and then upload the information into the web-based cost reporting system. The Quarterly Payroll Information page includes the following data elements, which are discussed in detail within the Cost Reporting System Guide available on the dashboard:           

Last Name First Name Job Category Staff Employment Status LEA Job Title LEA Employee ID Paid Hours (optional) Salaries Employer Benefits Contracted Staff Costs Compensation Federal Revenues

Cost Data 

Salary - The total gross earnings for the individual as paid by the LEA for the quarter, including regular wages plus any amounts paid for paid time off (i.e., sick or annual leave), overtime, bonuses, longevity,

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stipends, cash bonuses, and/or cash incentives. Salaries are those payments from which payroll taxes are (or should be) deducted. Reimbursements for expenses such as mileage or other travel reimbursements should not be included. 

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Employee Benefits - Report the total of all employee benefits and taxes including employer-paid health/medical, life, disability, or dental insurance premiums, employer-paid child day care, retirement contributions, and worker’s compensation costs in the Employer Benefits field. Taxes such as employer-paid 401K contributions, employer-paid Medicare contributions, employer-paid state unemployment taxes, and employer-paid federal unemployment taxes can also be reported into this field. Amounts paid by the LEA which are directly associated with each staff member (full or part time) should be reported. o Worker’s compensation costs are the actual costs paid by the LEA during the reporting period related to employee on-the-job injuries (such as commercial insurance premiums or the medical bills paid on behalf of an injured employee). Costs must be reported with amounts accrued for premiums, modifiers, and surcharges. Costs must be reported net of any refunds and discounts actually received or settlements paid during the same cost reporting period. The premiums are accrued, while the refunds, discounts, or settlements are reported on a cash basis. Litigation expenses related to workers' compensation lawsuits are not allowable costs. Costs related to self-insurance are allowable on a claims paid basis and are to be reported on an accrual basis. Self-insurance is a means whereby a LEA undertakes the risk to protect itself against anticipated liabilities by providing funds in an amount equivalent to liquidate those liabilities. Self--insurance can also be described as being uninsured. Contributions to selfinsurance funds that do not represent payments based on current liabilities are unallowable costs. Purchased Professional Services (Contracted Staff Costs) – Report compensation paid for all services contracted by the LEA for the individual. Compensation-Federal Revenues - All costs should be reported in total. The Web-based financial cost reporting system allows the entry of any federal portion of cost data. The cost reporting system will automatically offset the federal portion to determine the net allowable costs. If any of the reported payroll costs for an individual were paid with federal revenues, then the amount paid with federal funds must be entered in the Compensation-Federal Revenues field. The amount reported cannot exceed the total payroll costs reported for the individual. o Examples of federal revenues are IDEA funds, Title 1 payments, etc. o Reimbursements through the Arizona Medicaid School-Based Claiming program are not considered federal revenues and therefore should not be reported under CompensationFederal Revenues.

All costs reported for staff should be 100% of the LEA costs regardless of funding. Portions of costs covered through federal revenues will be reported in the Compensation Federal Revenues field and will thus allow for reporting of net allowable costs. Costs should be reported using the accrual accounting method. Cost reporting should be consistent with generally accepted accounting principles (GAAP), which are principles approved by the American Institute of

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Certified Public Accountants (AICPA). Employee payroll taxes and benefits/insurance costs must be directly associated to the individual employee and cannot be allocated. Reported costs should be formatted with two decimal places and not rounded to the nearest whole dollar. If using reported paid hours field, then format data with two decimal places and not rounded to the nearest whole hour. Quarterly Edits Once the information has been entered or uploaded into the system, the web-based cost reporting system analyzes the reported payroll information and reviews it for common errors. Audits also include reported salaries exceeding a quarterly threshold amount, such as $25,000, benefits-to-salaries ratio exceeding 50%, and not reporting costs for a staff person listed. If one of these common errors is identified, the LEA either must make necessary revisions or provide a written explanation as to support the reported information and its accuracy. Once the edits/reviews have been resolved or explained, the LEA can proceed to the quarterly certification. Quarterly Certification Financial information entered into the Cost Reporting System is not finalized until the LEA “certifies” the cost. The designated LEA Level Administrator (LevelAdmin) individual must review the information entered for accuracy and then select the ‘certify’ button within the cost reporting system. LEAs may be requested to answer desk review questions and/or provide copies of documentation to support the information reported on the quarterly financials. Upon certification, PCG will proceed with reviewing the information and then utilizing in the calculation of the quarterly MAC claim and annual cost settlement to determine the LEA’s DSC reimbursement. The four quarterly certified submissions will be aggregated in the annual cost report eliminating the need for the LEA to re-enter salary/benefit information. MANAGE CONTACTS The first time a user successfully logs in and changes their password, they should update their contact information under the Manage Contacts tab on the navigation menu. The user should also verify the accuracy of the reported information and make any necessary changes. The user should fill in the blank areas such as job title, telephone number, fax number, and other requested information. This information is necessary in case an issue arises and the user needs to be contacted regarding costs submitted through the system. ROLES: LevelAdmin A LevelAdmin can view and edit all information for a LEA and can also add new users to the LEA’s Manage Contacts section of the application. ReportEditor A ReportEditor can view and edit all information for a LEA, but cannot add new users to the LEA’s Manage Contacts section of the application. ReportViewer

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A ReportViewer can view all information for a LEA, but cannot edit the information or add new users to the LEA’s Manage Contacts section of the application. The school LEA Level Administrator (LevelAdmin) and PCG are the only ones that have the capability to add users to the system that require access to submit data, review data or receive related correspondence. In order to do that, the Level Administrator will use the ―Add User link located at the top of the Manage Contacts section of the application.

5.1

MEDICAID ADMINISTRATIVE CLAIMING

Medicaid Administrative Claiming (MAC) is a federal program that allows Arizona school districts/charter schools to receive reimbursement for costs associated with employing individuals who routinely perform Medicaid Administrative and Outreach Activities through a quarterly claiming process. HOW REIMBURSEMENT IS CALCULATED The MAC claim calculation consists of six components combined to determine the final reimbursement to the LEAs: cost data, percent (%) of time (RMTS results) spent on allowable Medicaid administration and outreach, Medicaid Enrollment Rate (MER), Federal Financial Participation (FFP) rate, Unrestricted Indirect Cost Rate (UICR), and the administrative fees. Costs are reported using the accrual accounting method. Cost reporting should be consistent with generally accepted accounting principles (GAAP), which are principles approved by the American Institute of Certified Public Accountants (AICPA). Percent (%) of time claimable to Medicaid Administration and Outreach (Statewide Component) The Random Moment Time Study (RMTS) results are used to identify the amount or percent of time employees are participating in Medicaid administrative and outreach activities. The direct service providers and administrative service providers only cost pools will have separate and different percentages. A MAC claim is calculated for each cost pool using their relevant cost and RMTS %. See Section 5. Medicaid Enrollment Rate (MER) (LEA-Specific Component) The percentage of students in a district/charter that are AHCCCS eligible out of the total number of students in a district/charter. The MER is applied to the total claimable percentage. See Section 5. Federal Financial Participation (FFP) (Statewide Component) The results of the time study are multiplied by the cost pool expenditures, they are then multiplied by the 50% FFP rate. Unrestricted Indirect Cost Rate (UICR) (LEA-Specific Component) Indirect costs included in the MAC claim are calculated by multiplying the costs by the LEAs approved unrestricted indirect cost rate. The indirect rates are developed by the Arizona Department of Education and are updated annually. Administrative Fees (Statewide Component) LEA reimbursement is reduced by the 20% administrative fee for TPA services and AHCCCS’s 1.5% fee per quarterly MAC claim.

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QUARTERLY FILING MAC claims are filed on a quarterly basis. The quarters follow the state fiscal year structure is as follows:    

July – September October – December January - March April - June

All quarters utilize the like RMTS staff roster with the exception of the July – September, which utilizes the April – June RMTS staff roster.

5.2

MEDICAID ELIGIBILITY RATE and IEP RATIO

There are two Medicaid eligibility factors utilized in the MSBC program. The Medicaid Eligibility Rate (MER) is used in the quarterly MAC calculation. The MER reflects the percent of students in the entire LEA that are AHCCCS eligible (Title XIX) on a specific date. Please note that this percent reflects the entire student body versus the special education population, as a student does not have to have a disability in order to qualify for Medicaid services. The MER is one of the four variables that directly influence a LEA’s MAC reimbursement amount. The MER can influence a LEA’s MAC reimbursement by approximately 60%. Given the statistical significance of this variable, it is important that the data submitted to PCG accurately reflect the entire student population. The IEP ratio is used in the annual cost settlement process. The IEP ratio is the total number of Medicaid eligible special education students with an IEP prescribed reimbursable related services divided by the total number of ALL special education students with an IEP-prescribed reimbursable related service in their IEP. The LEA is responsible for providing the relevant student data to PCG. PCG conducts the match to determine the relevant Medicaid eligible populations. In order to support the determination of both the MER and the IEP ratio, LEAs annually submit a district wide student roster for all students reflecting directory information for all students (not including those who have declined inclusion in the dissemination of directory information) including:  Name of LEA  Student’s First Name  Student’s Middle Name  Student’s Last Name  Student’s Date of Birth  Student’s Gender  Enrolled in Special Education (Yes/No)  IEP-Prescribed Reimbursable Related Service (Yes/No)

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FREQUENCY OF COLLECTION PCG will collect district wide/charter wide student rosters (directory information only) as of October 1st for every participating LEA on an annual basis during the fourth calendar quarter. The MER ratio calculated will be applied to all MAC quarterly claims within the related fiscal year. The IEP ratio will be used for the related annual cost settlement year. For example the ratios utilized an October 1, snapshot date will be used for MAC claims beginning with Quarter July-September 2011 through April – June 2012. The IEP ratio will be applied to the cost settlement calculation for the fiscal year of July 2011 – June 2012. LEAs that fail to submit student data for the calculation of the MER and IEP ratio will be required to return all DSC interim payments received and quarterly MAC payments to AHCCCS for relevant the related fiscal year. It is critical for LEAs to submit their data by the deadline, as information received afterward the deadline will not be accepted. VALIDATION OF DIRECTORY INFORMATION Since the MER and IEP ratio are a significant reimbursement component of the MSBC Program and subsequently the reimbursement to participating LEAs, it is important to ensure accuracy of the information as any findings related to this in an audit will likely result in a recoupment of funds. PCG will receive district wide student rosters from participating LEAs along with a Certification of Student Roster form. The certification form verifies that:   

The student file submitted contains the names of all students enrolled with the LEA as of the October 1st date; It is unduplicated (doesn’t contain the same student more than once); It accounts for students whose parents (or if applicable themselves) have declined the release of Directory information the name and gender fields are replaced with the word “undisclosed” and the date of birth field is replaced with “99999999”

Furthermore, the LEA representative who is responsible for compiling the district wide student roster will complete the Certification of Student Roster form. SUBMISSION OF DATA Student rosters must be submitted using the PCG approved template. The template will be available on the project web site or by contacting PCG directly. Utilize the following naming scheme for the data file name: Full LEA Name – student data – as of MMYYDD (e.g., example: Cloverdale Unified School District - student data – as of 110809.xls) Electronic files containing student data should be e-mailed to: [email protected]. The subject line of the e-mail should include:

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The Name of the LEA The phrase “district wide student data”

A CD containing the file and the original copy of the certification form can be mailed to the PCG Phoenix office.

5.3

ANNUAL COST REPORTING, RECONCILIATION, AND SETTLEMENT

ANNUAL COST REPORT PROCESS Each participating LEA must complete and certify an annual cost report for staff on the RMTS who provided direct services and health aide services during the state fiscal year covering July 1 through June 30. The cost report is due five months after the fiscal year reporting period. The primary purposes of the cost report are to: 1) Document the LEA provider's total CMS approved Medicaid-allowable costs of delivering Medicaid coverable services using a CMS approved cost allocation methodology. 2) Reconcile the annual interim payments, described in the Section 6, to the LEA provider’s total CMS approved, Medicaid-allowable costs using a CMS approved cost allocation methodology. The cost report includes the following:  Payroll information for Direct Service and Personal Care providers (health aide) staff listed on each of the quarterly RMTS staff cost pool lists  Medicaid-allowable costs associated with medically-related supplies and materials and other specialized transportation services  Statistical information for IEP student counts and clients who receive specialized transportation as required in the IEP. In addition, the following fields will be populated within the cost report: RMTS annual percentage for each cost pool, LEA assigned indirect cost rate, specialized transportation trip count and the total interim payments made to the LEA (gross Medicaid claims amount). Detailed instructions on how to complete the Annual Cost Report can be found in the Web-Based Cost Reporting System Guide. COST RECONCILIATION PROCESS The annual cost report process (Section 13.1) is the first step in the cost reconciliation process. This process includes discretely identifying, totaling, and discounting all Medicaid-allowable costs for an entire reporting period. This total Medicaid allowable cost, as identified in the LEA’s cost report, is then compared to the Medicaid interim payments (Section 9) paid to the LEA during the reporting period as documented in the MMIS. Any difference between these two totals will result in reconciliation, i.e. the LEA will either receive additional funds or pay back a portion of funds received through interim payments.

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For the purposes of the cost reconciliation, the federally approved scope of costs, cost allocation methodology procedures, or the RMTS results or processes cannot be modified by AHCCCS or its vendor. Any modifications to these processes require approval from CMS prior to implementation. COST SETTLEMENT PROCESS If a LEA’s interim payments exceed the total certified costs, as identified in the LEAs cost report, the LEA is required to return an amount equal to the overpayment. If the total, certified costs, as identified in the LEAs cost report, exceed the interim payments AHCCCS will pay the federal share of the difference to the LEA. Once the reconciliation amount has been finalized the LEA will receive a cost reconciliation and settlement letter that denotes the final amount due to or from the LEA. DESK REVIEWS Prior to the finalization of the cost reconciliation and settlement process, the annual cost report will be desk reviewed by PCG. LEAs may be requested to answer desk review questions and/or provide copies of documentation to support the information reported on the quarterly cost report.

6. PREPARING AND SUBMITTING CLAIMS FOR INTERIM PAYMENT Direct service claims must continue to be submitted by the LEA to demonstrate that services are being provided to AHCCCS eligible students. LEAs will receive interim payments for approved claims submitted. As previously stated, the interim payment does not equate to direct service reimbursement. The direct service reimbursement is calculated during the annual cost settlement process and interim payments are then factored in to determine if additional monies are due to the LEA or if the LEA was over paid and must reimburse AHCCCS the difference. All qualified direct service staff that are included in the direct service cost pool for the RMTS should also bill for direct medical services that they provide to Medicaid eligible students. It is important that the LEA only submit claims for those qualified staff that are included in the RMTS direct service cost pool. The LEA is at risk for a pay-back during the cost settlement process if interim payments are received for staff that are not part of the RMTS, as the LEA can only submit salary and benefit costs for those providers that are on the RMTS.

6.1

DETERMINING COVERED SERVICES

Covered services for school-based Medicaid claiming are determined by Centers for Medicare and Medicaid Services (CMS) and Arizona Health Care Cost Containment System (AHCCCS). Through the Direct Service Claiming (DSC) program, Local Education Agencies (LEAs) are paid for services determined to be Medicaid covered services. For a service to be considered covered, the service must be:

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Medically necessary Provided on site unless stated otherwise in the IEP Approved by AHCCCS as a Medicaid covered service Rendered by a qualified provider Provided to an eligible child

MEDICALLY NECESSARY For purposes of the DSC program, “medically necessary” means: Medicaid covered services provided through the DSC program by a licensed practitioner, or qualified provider of the healing arts within the scope of their practice under state law to: 1. Allow the student to obtain an education through the public school system 2. Prevent death, treat/cure disease and ameliorate disabilities or other adverse health conditions 3. Prolong life The documentation in the student’s record is important when evaluating the medical necessity of services. Key components include:     

Evaluations completed and signed by qualified providers that specifically identify the reason for the service and treatment recommendations An Individualized Education Plan (IEP) that specifies scope, frequency, and duration that correlate with the professional recommendations Signed and dated progress notes or treatment summaries completed at least quarterly that specifically address the progress being made toward the identified goals and why continued treatment is required Description of the services in the IEP to be rendered by all DSC-eligible providers, including scope, frequency, and duration Signed and dated clinical notes for individual dates of service showing what treatment was provided, observations and comments

ON SITE SERVICES Only Medicaid covered services provided on site at the school will be reimbursed, except when the IEP requires that an eligible student must be treated in an alternative setting other than at the school. Examples of other locations include students receiving educational services in a private special education program (e.g., tuition based or private placement facilities). In these cases, covered services provided to the students in these alternative settings may be reimbursed. For additional information regarding covered services, please refer to the AHCCCS Medical Policies Manual (AMPM), Chapter 700, General Requirements.

6.2

IDENTIFYING COVERED SERVICES FOR THE DSC PROGRAM

Covered services for school-based Medicaid claiming are identified by CMS and AHCCCS. Services must be within the Medicaid scope of services and included in the State Plan. Covered services for Arizona include:     

Behavioral Health Services Occupational and Physical Therapies Speech Therapy Audiology Nursing Services

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 

School-based Health Aides Transportation

RESTRICTIONS Evaluations and assessments can be submitted for Medicaid reimbursement when it is conducted by the appropriate qualified medical provider. The evaluation and assessment documentation or reports must also be signed and dated by each qualified medical provider. In addition, the evaluation must lead to an appropriate covered DSC service in the IEP. AHCCCS may cover the following behavioral health services provided under the DSC program for Medicaid eligible students when provided by a registered AHCCCS provider within the scope of their practice and determine by a limited code set and provider discipline: BEHAVIORAL HEALTH SERVICES     

Assessments Individual, group and family therapy and counseling Psychological and developmental testing Neurobehavioral status examinations and neuropsychological testing Cognitive skills training

Providers must be registered with AHCCCS and be licensed or certified as follows:   

Psychiatrists must be licensed per requirements in Arizona Revised Statute (A.R.S.) Title 32, or the regulatory body of the State where the psychiatrist resides Psychologists must be licensed per requirements in A.R.S. Title 32, Chapter 19.1, or the regulatory body of the State where the psychologist resides Licensed Clinical Social Workers (LCSW), Licensed Professional Counselors (LPC) and Licensed Marriage and Family Therapists (LMFT) must have current licensure by the Arizona Board of Behavioral Health Examiners as a LCSW, LPC or LMFT, or if outside Arizona, be licensed or certified to practice independently by the local regulatory authority

OCCUPATIONAL THERAPY AND PHYSICAL THERAPY         

Therapy evaluations and re-evaluations (must result in an appropriate covered DSC in the IEP) Therapeutic procedures, exercises and activities to develop strength, endurance, range of motion and/or flexibility, and to improve functional performance. Services may be provided on an individual or group basis Neuromuscular re-education to develop, improve or maintain movement, balance, coordination, kinesthetic sense, posture, and proprioception Gait training and stair climbing Massage necessary to effect change or improve function (e.g., effleurage, petrissage, or tapotement) Manual therapy techniques (e.g. mobilization/manipulation) Orthotic fittings and training for upper or lower extremities Prosthetic training for upper or lower extremities Wheelchair management and propulsion training

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

Physical performance test or measurement (e.g. musculoskeletal, functional capacity), along with a written report  Therapeutic activities for development of cognitive skills, including compensatory training and/or sensory integrative activities to improve attention, memory, problem solving  Application of a modality manual electrical stimulation Providers of Occupational and Physical therapy services must be registered with AHCCCS and be licensed as follows: 



Occupational Therapists must be licensed by the Arizona Board of Occupational Therapy Examiners, or the governing Board of the State where the therapist practices, or a certified OT Assistant (under the supervision of the occupational therapist, according to 4 A.A.C. 43, Article 4) licensed by the Arizona Board of Occupational Therapy Examiners Physical Therapists must be licensed by the Arizona Board of Physical Therapy or the governing Board of the State where the therapist practices or a Physical Therapy Assistant (under the supervision of the PT, according to 4 A.A.C. 24, Article 3) certified by the Arizona Physical Therapy Board of Examiners NOTE: A Certified OT Assistant (COTA) or Physical Therapy Assistant (PTA) providing DSC covered services must do so under the supervision of their affiliated therapist in accordance to State law. Claims shall be submitted for reimbursement using the qualified medical provider’s individual NPI number who is responsible for supervision, as appropriate. COTAs and PTAs cannot replace the qualified medical provider for an evaluation or prescription of service in an IEP.

SPEECH THERAPY     

Evaluation of speech, language, voice, communication, auditory processing and/or aural rehabilitation status (only covered if a resulting IEP recommends speech services) Treatment of speech, language, voice, communication, and/or auditory processing disorders, including aural rehabilitation. These services may be provided on an individual or group basis Laryngeal function studies Evaluations or treatment of swallowing or swallowing dysfunction and oral function for feeding Aural rehabilitation following cochlear implant including evaluation or aural rehabilitation status and hearing, therapeutic services, with or without speech processor programming

Providers of Speech therapy services must be registered with AHCCCS and be licensed as follows: Speech therapy qualified providers must meet the Federal requirements of 42 CFR 440.110, and services may be provided by the following professionals within their scope of practice:  



A qualified Speech-Language Pathologist (SLP) licensed by the Arizona Department of Health Services (ADHS), or A Speech-Language Pathologist who has a temporary license from ADHS and is completing a clinical fellowship year. He/she must be under the direct supervision of an ASHA certified speech-language pathologist. AHCCCS registration will be terminated at the end of two years if the fellowship is not completed at that time. A qualified SLP Assistant (under the supervision of the speech-language pathologist and according to A.R.S. §36-1940.04 and R9-16-501 et seq) licensed by the Arizona Department of Health Services. The SLPA must be identified as the treating provider and bill for services under his or her individual NPI

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number (a group ID number may be utilized to direct payment). SLPAs may only perform services under the supervision of a SLP and within their scope of service as defined by regulations NOTE: The SLPA providing services must do so under the supervision of a Speech Language Pathologist, and have their clinical notes signed off by their supervising SLP. To bill for covered DSC services, the SLPA must obtain their own NPI number, register with AHCCCS, and obtain an AHCCCS Provider ID. AUDIOLOGY Audiology services may be covered under the DSC program, with certain limitations. Included services must be:  

Medically necessary services regarding the diagnosis or treatment of eligible students, and Individual and group instruction/treatment, which may include auditory training, speech, reading and audiometry

Examples of covered services include:  

Evaluation of hearing loss Rehabilitation of eligible students by individual and group instruction in auditory training, speech, reading, and audiometry  Those that result in the development of a “Hearing Impaired Plan” or another type of audiology service on a student’s IEP For additional covered services please reference the Medicaid School Based Claims fee schedule. Specifically excluded services are:    

General screening exams for all students Annual hearing screening for all Special Education students Screening and evaluations that do not result in an audiology/hearing impaired plan Exams or evaluations for hearing aids, cochlear implants, speech-generating and non-speechgenerating augmentative and alternative communicating devices, and therapeutic services regarding their use. These excluded services may be available to the student through their AHCCCS Health Plan, ALTCS Contractor, or AHCCCS Fee for Service Administration. Providers of Audiology services must be registered with AHCCCS and be licensed as follows: The audiologist must have a master’s or doctoral degree in audiology and meet one of the following conditions:  Have a Certificate of Clinical Competence (CCC) in audiology granted by the American SpeechLanguage-Hearing Association, or  Have successfully completed a minimum of 350 clock-hours of supervised clinical practicum (or be in the process of accumulating such supervised clinical experience under the supervision of a qualified master or doctoral-level audiologist), performed not less than nine months of supervised full-time audiology, or a related field, and successfully completed a national examination in audiology approved by the Secretary of the U.S. Department of Health and Human Services.

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AHCCCS will require all audiologists registered with AHCCCS to provide documentation of State licensure and one of the criteria noted above. NURSING SERVICES (RN’S AND LPN’S ONLY) AHCCCS covers nursing services provided to Medicaid eligible students when the provider is registered with AHCCCS and performing within the scope of his/her practice. In addition, Nursing services provided are in accordance with the student’s IEP and are medically necessary to enable the student to begin and/or continue receiving education in the public setting. Services may include but are not limited to:  Administering medication  Suctioning  G-tube feeding  Ventilator care  Catheter care Qualified providers who can bill for these services:  School-Based Registered Nurses must be licensed by the regulatory body of the State where the nurse resides  School-Based Licensed Practical Nurses must be licensed by the regulatory body of the State where the nurse resides SCHOOL-BASED HEALTH AIDES School-based health aides are also referred to as paraprofessionals, teacher aides, one-on-one assistants, personal care aides and instructional aides. Services typically provided by health aides that are covered by DSC are limited to the following: Assistance with Activities of Daily Living (ADL)  Eating/Feeding  Dressing  Toileting  Transfers  Positioning  Mobility  Grooming  Use of Assistive Devices (Guidance for Health Aide Documentation - Attachment 2) School-Based health aides are specially trained and approved by the schools in general care. School-Based health aides must follow the IEP for each student. They are supervised by a nurse or other appropriate licensed personnel employed by, or contracted with, the LEA. Health aide services must be identified in the IEP. Scope, frequency, and duration must be clearly addressed and written in the IEP as prescribed by a qualified medical provider. A qualified medical provider may include providers such as: Physician, Psychologist, Registered Nurse, Physical Therapist, Licensed Clinical Social

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Workers, Occupational Therapist or Speech Language Pathologist. Refer to the AMPM for a comprehensive list of qualified medical providers. Training received by the health aide(s) related to the specific needs of the student should be documented by the LEA. School-Based health aides must have current certification in first aid and cardiopulmonary resuscitation (CPR). Certification in first aid and CPR must meet the following standards:  Training in first aid and CPR must be provided or sponsored by a nationally recognized organization (e.g., American Heart Association, American Red Cross, etc.), using an established training curriculum.  Training sessions must be in person, in order for the participant to return demonstrate learned skills such as mouth-to-mouth resuscitation and chest compressions. Web-based training without the benefit of on-site return demonstration of skills is not acceptable.  Certificates of completion of first aid and CPR training must be provided to the LEA and to AHCCCS upon requesting provider registration as an AHCCCS provider. NOTE: Health aide services are not DSC-eligible when a student’s IEP reflects only academic assistance, the service must be medically necessary. Only time spent actually providing a covered medical service may be billed. A health aide may not log, record or bill more hours than the time worked in a day, regardless of the number of children in the classroom. Qualified providers who can bill for these services:  School-Based health aides must possess current certification in first aid and CPR, and receive training as specified by the LEA. All health aide services are subject to a pre-payment review. For reimbursement of these services, the LEA must submit a Health Aide Prepayment Review Form for each student along with the student’s IEP prior to submitting claims for reimbursements. Claims received prior to an approval will be denied. The most current version of the Health Aide Prepayment Review Form must be used. The form can be found on the Arizona program Web site under the Health Aide Prepayment Review Template section at: http://web.pcgus.com/azschools/downloads.html. (Health Aide Prepayment Review Form - Attachment 3) TRANSPORTATION Transportation services are reimbursable for students who have been determined by the LEA to be eligible for specialized transportation when all of the following criteria are met:  Student is Medicaid eligible  Student qualifies for special education and related services  Student’s need for non-regular school transportation (i.e., curb-to-curb and limited to IDEA eligible students) is identified in the student’s IEP  Student requires transportation in an adaptive vehicle (i.e., special needs school bus that is designed to transport disabled passengers) and is constructed with a special service entrance; (or) the student can be transported in a regular school bus but due to behavioral health problems or mental disability, must be transported separately from other students that are not eligible for special education

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

 

Student must receive another DSC reimbursable service at school that same day, or receive a reimbursable service that is provided at an approved alternative setting that same day (as identified in the student’s IEP) There must be a clear audit trail to verify that another DSC-billable service was provided on that same day Detailed transportation logs are maintained and signed by the bus drivers

In order for transportation services to be billed, the student must require the specialized equipment or supervision available on the bus, or individual transport due to a behavioral problem or mental disability requiring door-to-door transport. For example, if a DSC enrolled student is being transported in a bus that is equipped with a wheelchair lift but is ambulatory and does not require the use of the wheelchair lift; the LEA cannot bill the wheelchair code. The ambulatory code would be applicable in this case. It is not the fact that the bus has special equipment, but whether the student needs the specialized equipment that determines how the service should be billed. Please note that CMS guidelines specify that a maximum of two trips (i.e., home to school, and a return trip from school to home; or school to a secondary site, and secondary site back to school) are allowed per day. NOTE: Use of a health aide to provide door-to-door services are included in the transportation reimbursement and may not be billed separately.

6.3

FREE CARE

The reimbursement section of this guide explains how states determine reimbursement rates for covered services and how LEAs can claim reimbursement for school based health services. This section explains the exclusion of “Free Care” from the DSC program and the billing requirements for third party liability as it pertains to school-based services. The fact that Medicaid does not reimburse for items identified in the “Free Care” policy, and that payment must be sought from any liable third party before Medicaid can make payment (third party liability) are two separate and distinct principles for Medicaid billing, but are often confused. From the outset of the Medicaid program, a principle basic to public assistance has applied to Title XIX: Medicaid funds may not be used to pay for services that are available without charge to everyone in the community. “Free Care,” services provided without charge, are services for which there is no beneficiary liability and for which there is no Medicaid liability. In applying the “Free Care” principle to determine whether medical services are provided free of charge and, therefore, result in no Medicaid payment liability, a determination must be made whether both Medicaid and non-Medicaid beneficiaries are charged for the service. Providers of Medicaid services must have the authority to charge for their services and utilize this authority, before Medicaid will make payment. If only Medicaid recipients or their third parties are charged for the service, the care is free and Medicaid will not reimburse for the service. Schools should determine independently whether or not the service is provided for free, and whether or not Medicaid allows the service to be billed.

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EXCEPTIONS TO FREE CARE There are two exceptions to the Free Care rule for the provision of school-based health services. IDEA: Section 1903(c) of the Act prohibits the Secretary from refusing to pay or otherwise limiting payment for services provided to children with disabilities that are funded by IDEA under an IEP or IFSP (Individual Family Service Plan). Under these circumstances, Medicaid is the primary payer to the Department of Education. Medicaid-covered services mandated in a student’s IEP or IFSP are exempt from the Free Care rule. This means that school providers may bill Medicaid for Medicaid-covered services provided to children under IDEA even though they may be provided to non-Medicaid eligible children for free, as long as the IEP requires the service. However, as discussed in more detail below, the requirement to bill all liable third parties for services still applies. Although the services would be exempt from the Free Care rule, the school would still have to pursue any liable third party insurers for reimbursement. Title V: Another exception to the Free Care policy which relates to school-based health services includes services provided by Title V of the Social Security Act. Title V of the Act is the Maternal and Child Health Services Block Grant. It provides a lump sum of funds to states for the provision of health services and related activities to mothers, children, and adolescents for the reduction of infant mortality, preventable diseases, and access to necessary health services. Federal Medicaid regulations (42 CFR 431.615) define Title V grantees as agencies, institutions, or organizations that receive federal funding for part or all of the cost of providing maternal and child health services, services to children with special health care needs, maternal and infant care projects, children and youth projects, and projects for the dental health of children. Schools may be able to qualify for funding under Title V as grantees, whether they contract with health providers or are a provider themselves. Medicaid regulations specify that requirements for cooperative agreements and arrangements between Title V grantees and state Medicaid agencies are exempt from both the Free Care rule and the policy of Medicaid as the payer of last resort. Therefore, Medicaid will pay before Title V for Medicaid-covered services. Although the services would be exempt from the Free Care rule, the school would still have to pursue any other liable third party insurers for reimbursement before billing Medicaid. IMPACT OF FREE CARE ON SCHOOL-BASED HEALTH SERVICES The Free Care policy limits the ability of schools to bill Medicaid for services provided to Medicaid eligible students, unless the school charges all students for the provided services or meets one of the exceptions above. For example, many schools have a school nurse on staff to provide necessary health services to all students without charging them for the care provided. The school cannot charge the Medicaid program for the services of the school nurse if she furnishes the same services to all students for free. While there are exceptions to this Free Care requirement for Title V and Medicaid-covered services provided under the scope of an IEP or IFSP under IDEA, many schools provide a wide range of health services which would not fall under either exception. For additional information on claims submission for students with Third Party Liability Insurance, reference section 6.19 Other Insurance (TPL) of the Handbook.

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6.4

ELIGIBILITY FOR AHCCCS

The LEA will be reimbursed only for specified Medicaid covered services provided to an eligible child. A child is considered eligible when s/he meets these requirements:  The student is Medicaid /Title XIX eligible and enrolled (AHCCCS or Arizona Long Term Care (ALTCS))  The student is eligible under the Individuals with Disabilities Education Act (IDEA), Part B and has an active, valid IEP  Services are covered only for AHCCCS Title XIX members who are from 3 through 21 years of age, and who have been determined by the LEA to be eligible for special education and related services under the Individuals with Disabilities Education Act (IDEA), Part B Those members age 3 through ages 20 are eligible for services covered under EPSDT. Those members age 21 to age 22 who are eligible for Medicaid services provided under IDEA are covered within the same service limitations that apply to all eligible AHCCCS acute care members age 21 and older. NOTE: AHCCCS recipients eligible under the KidsCare, SOBRA Family Planning, and the Emergency Services program are not eligible for the DSC school based claiming program. There are a variety of ways in which the LEA may obtain student eligibility information:   

Submit an eligibility file at scheduled intervals throughout the year through PCG Use the AHCCCS Interactive Voice Response (IVR) system Online verification through the AHCCCS Web site

PCG runs an electronic student match of Special Education students against the AHCCCS eligibility system on a periodic basis:   



The DSC coordinator for each LEA is notified with instructions and a blank Excel template. The instructions must be followed exactly, using the LEA’s Group Biller AHCCCS ID, name, and the specific formatting required for the Special Education student’s name and date of birth The list of Special Education students is created by the LEA, or their representative/biller, after obtaining parental consent from the students’ parents to release the information. (This permission ensures compliance with FERPA requirements for disclosing student records by the school.) The correctly formatted list of Special Education students is submitted in a password protected file format by the LEA or their biller to PCG at [email protected] for the student match. This protection ensures compliance with HIPAA regulations to secure protected health information (PHI) by PCG and AHCCCS Information is then used by PCG to verify eligibility



The student matches are returned to the submitter with the students’ AHCCCS IDs, whether they had other insurance (TPL) on a specific date, and whether the students were eligible in the months submitted for match (T = yes, F = no) (Sample Eligibility Match Instructions - Attachment 4; Sample Student Eligibility Match Template Attachment 5) Remember that the student must be Title XIX eligible.

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HOW TO VERIFY MEDICAID ELIGIBILITY WITH AHCCCS The LEA may contact AHCCCS directly to determine if a student is eligible. The LEA must have a Group Biller ID number in order to obtain eligibility information about a student. The LEA should have ready the student’s name, date of birth, AHCCCS ID number, or Social Security Number, plus the dates of service to be verified. Verification of Medicaid eligibility is not a guarantee of payment. Once the relevant information is gathered, the LEA may use one of the following methods: 

The AHCCCS Interactive Voice Response system (IVR) allows a LEA to obtain eligibility verifications by entering information using a touch-tone phone and following the recorded instructions. There is no charge for this service. Call IVR at: Phoenix: (602) 417-7200 All others: 1-800-331-5090



The AHCCCS Verification Unit is staffed from 7:00 am to 6:00 pm daily, except Sunday. The call is limited to five names per call. There is no charge for this service. Call the AHCCCS Verification Unit at: Phoenix: (602) 417-7000 All others: 1-800-962-6690



6.5

AHCCCS also provides verification on-line. A registered provider is able to obtain eligibility information on-line by signing up at AHCCCS’ Web site: https://azweb.statemedicaid.us/Home.asp

NATIONAL PROVIDER IDENTIFIER (NPI)

The Centers for Medicare and Medicaid Services (CMS) require that all typical health care providers must have a 10-digit National Provider Identifier (NPI) to comply with the Health Insurance Portability and Accountability Act (HIPAA). This single, unique ID is used for billing purposes by the provider to all third party payers, including billing for reimbursement under the DSC program. Certain providers must obtain their NPI number prior to registering with AHCCCS. All claims submitted for the DSC program must be billed with each provider’s NPI. (Health aides and transportation are atypical providers and do not require NPI.) Use the following website to obtain a NPI: https://nppes.cms.hhs.gov/NPPES Forward the e-mail confirmation received from NPPES to: [email protected]

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If the confirmation does not clearly state the name of the provider or the LEA, and the provider’s or LEA’s AHCCCS ID, those items must be added to the e-mail sent to AHCCCS. Fax a copy of the NPI confirmation, including the LEA/Provider name and AHCCCS ID to: Attn: AHCCCS Provider Registration 602-256-1474 Mail a copy of the NPI confirmation, including the LEA/Provider name and AHCCCS ID to: AHCCCS Provider Registration P.O. Box 25520, M/D 8100 Phoenix, AZ 85002 Send the NPI Supplemental Registration Form to the above address, signed by the Provider or an authorized signer at the LEA. (NPI Supplemental Registration Form - Attachment 6)

6.6

AHCCCS REGISTRATION REQUIREMENTS

LEAs should refer to the AHCCCS website periodically to stay abreast of any changes to provider registration. Effective January 1, 2012, AHCCCS implemented several program integrity changed related to provider registration. Details regarding these requirements can be found in the attached link: http://www.azahcccs.gov/commercial/Downloads/ProviderRegistration/ACAProgramIntegrityChangeStak eholdermemo.pdf The following documents must be on file with the AHCCCS Provider Registration Unit before a Provider or Group Biller ID can be issued: PROVIDER REGISTRATION FORM OR GROUP BILLER REGISTRATION FORM Use these forms to obtain an individual AHCCCS Provider ID number and to obtain the LEA’s Group Biller ID number. Note that each request for an ID number must be on AHCCCS’ own forms, which can be completed online and printed, or downloaded from the AHCCCS Web site: www.azahcccs.gov/commercial/ProviderRegistration/registration.aspx No reproductions, re-typing or re-formatting will be accepted by AHCCCS’ Provider Registration Unit. Please be aware that updates to the provider registration form do occur. Be sure to obtain the most current version of the form from the Web site.   

The Provider or LEA must obtain their NPI first (see above). When obtaining a LEA Group Billing ID, the LEA must list all authorized signers For an individual AHCCCS Provider ID, the form must be completed and signed by the provider. It allows the provider to designate a LEA employee (e.g., Superintendent, Business Manager, or Special

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Education Director) to act as the provider’s authorized representative with regard to AHCCCS claims and correspondence GROUP BILLING AUTHORIZATION FORM  

A Group Billing Authorization Form is included in the registration application packet. This form must be completed when a provider has an active AHCCCS provider ID number and wants to designate a LEA (or additional LEAs) as a group billing entity on their behalf. The LEA’s NPI and Group Billing ID number must be identified on this form, along with the provider’s NPI and AHCCCS ID.

PROVIDER PARTICIPATION AGREEMENT AND GROUP BILLER PARTICIPATION AGREEMENT 

 

The Provider and Group Biller Participation Agreements are contractual arrangements between the AHCCCS Administration and the LEA on behalf of the provider of DSC services. The agreement forms and content are consistent with Medicaid regulations and no changes may be made to the language of either agreement The AHCCCS administration may impose penalties and sanctions for any violations of the terms of the agreement. The agreement remains in effect until terminated by either AHCCCS or the LEA/Provider The Provider Participation Agreement should reflect the LEA Tax ID number and may be signed by the provider or a LEA designee. An original signature is required

FORM W-9: REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION  

The form W-9 should reflect the LEA Tax ID number, not the provider’s Social Security Number. It should be signed by a LEA designee, rather than the provider



It must be submitted with the Group Billing Authorization Form when linking the provider to another LEA. It may be copied for submission to Provider Registration at AHCCCS.



PROOF OF LICENSURE OR CERTIFICATION 

Current license or certificate must be attached to the AHCCCS Provider Registration Form



The name on the certificate(s) should match the legal name on the AHCCCS Provider Registration Form, with any discrepancies explained

Forms, templates, and instructions are available from AHCCCS Provider Registration, or on AHCCCS’ Web site noted above. REGISTERING WITH AHCCCS All providers must have an AHCCCS ID number. The AHCCCS Provider Registration Unit issues all ID numbers. In the DSC program, there are three types of AHCCCS ID numbers:

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  

Group Biller ID number (LEA ID number) Individual Provider ID number (required for all providers except transportation) Group (Transportation) ID number (provider type 92)

GROUP BILLER ID NUMBERS Each school district and charter school not sponsored by a LEA, participating in the DSC program, must obtain a Group Biller ID number. Note: If a charter school is not sponsored by a LEA, the charter school may register as its own group biller in order to bill on behalf of its providers. If a charter school is sponsored by a LEA, the LEA must register as a group biller in order to bill on behalf of providers employed by, or working under, contract with the charter school. LEAs can obtain a Group Biller ID by completing the Group Biller Registration Form and the Group Biller Participation Agreement found on the AHCCCS Web site: www.azahcccs.gov/commercial/ProviderRegistration/registration.aspx The LEA must have already obtained their Organizational NPI before registering with AHCCCS or sending in the Group Biller Participation Agreement. The NPI must be entered on the Group Biller Registration Form when registering. INDIVIDUAL PROVIDER ID NUMBERS All providers except transportation must obtain their own, individual ID number, which is then linked to the LEA’s Group ID number. Providers must obtain their individual NPI (except health aides and transportation) before registering with AHCCCS. Each provider is categorized into a Provider Type. The requirements for registration depend on the Provider Type. For your reference, the AHCCCS Provider Type follows each provider title. Providers who obtain their own ID number include:            

Audiologists (type 62) Licensed Clinical Social Worker (85) Licensed Marriage and Family Therapists (type 86) Licensed Professional Counselors (type 87) Occupational Therapists (type 13) Physical Therapists (type 14) Psychiatrists (type 08 (M.D.), 31 (D.O.)) Psychologists (type 11) School Based Attendants/Health Aides (type 93) School Based Nurses (RN/LPN) (type 94) Speech/Hearing Therapists (type 15) Speech Language Pathology Assistants (type SA)

Note: Any eligible provider employed by, or working under, contract with an LEA may participate as an AHCCCS provider for the DSC program, if the provider complies with AHCCCS’ Provider Registration

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criteria. This includes providers working in a tuition based or private school placement setting. These providers need to be linked to the LEA and the IEP must reflect the place of service. The table below outlines the licensure/certification requirements for eligible providers: Provider Provider Title Type

AHCCCS requires proof of licensure or certification from:

62

Audiologists

American Speech-Language-Hearing Association

85

Licensed Clinical Social Workers

Arizona Board of Behavioral Health Examiners

86

Licensed Marriage and Family Therapists Arizona Board of Behavioral Health Examiners

87

Licensed Professional Counselors

Arizona Board of Behavioral Health Examiners

94

Licensed Practical Nurses

Arizona Board of Nursing

08, 31

Licensed Psychiatrists

Arizona Medical Board

11

Licensed Psychologists

Arizona Board of Psychologist Examiners

13

Occupational Therapists

Arizona Board of Occupational Therapy Examiners

14

Physical Therapists

Arizona Board of Physical Therapy Examiners

94

Registered Nurses

Arizona Board of Nursing

15

Speech and Hearing Therapists

Arizona Department of Health Services

SA

Speech Language Pathology Assistants

Arizona Department of Health Services

93

Health Aides

(see details below)

92

Transportation

(see details below)

Health Aides Health aides are required to be both CPR and First Aid certified. In addition, any health aide training for additional specific medical duties at the school must also be on file. Health aides must be individually registered with AHCCCS as any other provider. However, health aides do not require NPI. To register, the health aide must submit a copy (front and back) of their CPR and First Aid Certificate(s) from an organization offering a recognized training curriculum, such as the American Red Cross, the American Heart Association, the American Safety and Health Institute or the National Safety Council.

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(Internet/online certifications are not acceptable, unless they include a method for demonstrating technique that can be directly evaluated.) The certificate(s) must be current, and be in the name of the health aide. AHCCCS will issue an individual provider ID in the health aide’s name. Health aide claims must be billed with the health aide’s individual AHCCCS ID. GROUP ID NUMBERS It is the LEA’s responsibility to ensure that transportation services meet the program requirements before billing for their services. AHCCCS issues group ID numbers for transportation services. The Transportation ID number allows all transportation services for a specific LEA to be billed as one provider. Transportation The LEAs must register as transportation providers with AHCCCS, and in doing so, must submit proof of insurance and maintain:  

Copies of the driver’s licenses for all school bus drivers The LEA’s proof of insurance

Please contact AHCCCS Provider Registration for further details on registration requirements.  

In Maricopa County: (602) 417-7670 and select option 5 Outside Maricopa County: 1-800-794-6862

UPDATES TO LICENSURE OR CERTIFICATION Completed and signed registration packets should be sent to: Arizona Health Care Cost Containment System (AHCCCS) ATTN: Provider Registration Unit PO Box 25520, MD-8100 Phoenix, AZ 85002 The provider is notified in writing when their application is approved. A unique AHCCCS provider ID number is assigned at that time. Once the provider’s ID number is assigned, the LEA may begin billing for covered services rendered by that provider. AHCCCS automatically sends a letter to a provider’s license/certification board or agency upon expiration of the provider’s license/certificate requesting a copy of the renewed license/certificate. If the renewed license/certificate is not returned to AHCCCS prior to the expiration date, AHCCCS will terminate the provider’s ID number and the provider’s claims will be denied by PCG.

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If a response is not received from the board or agency within 45 days, then a request for a copy of the renewed license/certificate is sent directly to the provider. If the provider does not submit a copy of the current license/certificate within 21 days of the notification, then the provider’s status will remain terminated and subsequent claims will continue to be denied. MAKING CHANGES TO INFORMATION ON FILE The registered provider or the LEA must notify AHCCCS Provider Registration in writing of any changes to the information on file. Failure to report changes may result in misdirected payments and correspondence, and/or could result in the termination of a provider’s AHCCCS ID number or recoupment of payment. Changes that must be reported include, but are not limited to, the following: LICENSURE/CERTIFICATION  

Notification must be in writing and signed by the provider or authorized designee A copy of the changed license/certificate should accompany notification

CHANGE OF ADDRESS  

When a Provider Address Update form signed by the provider is submitted to AHCCCS, a verification letter will be sent to the LEA. If any information is incorrect, the LEA should make the necessary changes on the verification letter and return it to AHCCCS. If the change of address is due to the provider’s working for a new LEA, a Group Billing Authorization Form and W-9 must also be submitted so that the provider can be properly linked to the LEA.

CHANGE OF NAME  

6.7

Notification must be in writing and signed by the provider or authorized designee A copy of the documentation showing the name change is required (either the updated license/certificate bearing the new name, or the marriage license, divorce decree, etc.).

LINKING PROVIDERS TO LEAS

In order to participate in the DSC program, each provider must register with AHCCCS and authorize the LEA to bill on his/her behalf. This is accomplished through the initial registration process. If the provider wants to authorize another LEA to bill for their services, this link is created by submitting a Group Billing Authorization form to AHCCCS, along with a W-9 form showing the new LEA’s Tax ID number and an address update form. AHCCCS will link the provider to the LEA. If the link between provider and LEA is not in place at AHCCCS, claims for that provider will be denied. IMPORTANT! When the LEA hires a new provider, please confirm with AHCCCS to identify whether the provider is currently registered. If they are not, all the provider registration forms must be completed as usual. If the provider already has an AHCCCS ID number, the LEA must link the provider to the LEA. To do this, the Group Billing Authorization form must be submitted to reflect the LEA’s AHCCCS ID number

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and the provider’s AHCCCS ID number, with a W-9 form showing the LEA’s Tax ID number. An address update will also be required. The provider remains affiliated with the LEA’s group biller number until the provider or the LEA notifies the AHCCCS Provider Registration Unit in writing of the termination of their employment or contractual relationship with the LEA. It is important for the LEA to notify AHCCCS when a provider is no longer part of the LEA. Forms for this purpose are included in the AHCCCS Registration packet.

6.8

SUBMITTING CLAIMS

Claims are accepted in two formats: electronic and paper. PCG will provide the appropriate training materials and system access. ELECTRONIC CLAIMS The 837 claim files are uploaded by the user (LEA or Biller). The PCG claims system will provide a report upon completion of the upload file. The confirmation report will identify if the file was successfully uploaded or not. LEAs must verify the information and if successful, move to the next step of processing the claim file. If the file does not upload successfully, the LEA must make corrections to the claim file and re-upload. Once the 837 claim file is uploaded successfully, the next step is for the claims to be processed. Only clean claims will be processed. Claims are not considered ‘submitted’ to AHCCCS until the status of the file is listed as ‘Processing Complete’ in the system. The user has the opportunity to correct claim errors after upload. If the LEA does not have the ability to submit claim files in an 837 file format, the option to enter claims through the single claims entry within the web-based claiming system is available. LEAs should refer to the Claims Processing System Training Guide and the PCG Companion Guide located on the project Web site. The HIPAA companion guide may be utilized as a reference: http://www.azahcccs.gov/edidocs/EDI%20Companion%20Documents/AZ_837_Claim_Companion_Doc. pdf PAPER CLAIMS Paper claims must be submitted on an original CMS1500 claim form. These forms can be ordered on the Internet through various companies, or ordered through office supply stores. Copies or faxes will not be accepted. Original forms must be mailed directly to PCG. Because correct medical coding is necessary, the LEA must use a current set of coding books: ICD-9, CPT and HCPCS. Each of these books is updated annually. Coding information used to submit claims for this program must be current. The following information is required on the form. The box number refers to the field on the CMS1500 Form where the information is located (CMS1500 Form - Attachment 7):

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Medicaid box

Box 1

Student’s AHCCCS ID number

Box 1a

Student’s full name

Box 2

Student’s date of birth

Box 3

Student’s gender

Box 3

Name of other insured, and company information, if applicable

Box 9a, b, c, d

Diagnosis code, up to 4

Box 21

Resubmission code, if applicable

Box 22

Original PCG ICN, if applicable

Box 22

Date of service

Box 24A

Place of service (03 / 99)

Box 24B

Procedure code

Box 24D

Modifier, if applicable Diagnosis pointer

Box 24D Box 26E

Billed charges

Box 24F

Units

Box 24G

Rendering provider AHCCCS ID

Box 24J

Federal Tax ID of LEA

Box 25

Total charges Balance Due

Box 28 Box 30

Name of the Rendering Provider (must be legible) whose ID is in Box 24J if other than a transportation claim

Box 31

School name

Box 32

LEA name

Box 33

LEA Group Biller AHCCCS ID number

Box 33a

LEA NPI

Box 33b

Retain a copy of the claim form and mail the original to the PCG Phoenix office. Fax copies are not permissible.

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6.9

TIME LIMITS

Regardless of the LEA’s billing method, all claims must be received by PCG within the timely filing limit in order to be considered for reimbursement. If the LEA is going to utilize the paper option, claims are considered “received” when the paper forms arrive at PCG. If claims are submitted through the web-based claiming system, “received” means the date the clean claim is uploaded and processed in the system. In accordance with ARS 36-2904 (G), Arizona Administrative Code R9-22-703, and the AHCCCS Provider Manual, an initial clean claim must be received by PCG no later than six months from the date of service. Clean claims initially received beyond the six-month time frame will be denied. If the clean claim is originally received within the six-month time frame and denied, the claim can be resubmitted up to 12 months from the date of service.

6.10 CLEAN CLAIM As defined by ARS 36-2904 (G), a “clean claim” is: A claim that may be processed without obtaining additional information from the provider of service or from a third party, but does not include claims under investigation for fraud or abuse, or claims under review for medical necessity. PCG is the Administrator of the DSC program, and therefore cannot alter the claims once they have been received. Therefore, all proper claims preparation must be done before the submission of the claim. The LEA is responsible for submitting clean claims. PCG will pend transportation claims up to 45 days from submission until a corresponding covered service has been paid, OR has been denied due to TPL. Pended claims will automatically be recycled weekly to check against the claims database for a paid service or TPL denial. If an appropriate corresponding service is found, PCG will automatically submit the pended claim to AHCCCS for reimbursement. It is the LEAs responsibility to provide the proper documentation either electronically or on paper validating another DSC service was provided on the same day. All transportation claims not submitted for reimbursement will be denied after 45 days. Transportation claims with a corresponding service that denies due to TPL will still be submitted to AHCCCS for proper adjudication.

6.11

RETRO-ELIGIBILITY CLAIMS

A Retro-Eligibility Claim is defined as a claim where no Medicaid eligibility for the student was posted on the AHCCCS system for the date(s) of service, but at later date eligibility for the student was posted retroactively, to cover the date(s) of service. Retro-Eligibility Claims must be received by PCG no later than six months from the AHCCCS date of eligibility posting and attain a clean claim status no later than 12 months from the AHCCCS date of eligibility posting. EXAMPLE:

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Event

Date

A Medicaid application is submitted to the Department of Economic Security (DES) by the recipient

April 20

A LEA renders service to the recipient

April 28

The LEA’s biller submits a claim for the service

May 15

The claim is denied by AHCCCS and PCG

May 20

DES sends an eligibility tape to AHCCCS

June 10

AHCCCS posts eligibility retroactive to April 20

June 11

The LEA has six months from the eligibility posting date (June 11) rather than the date of service (April 28) to submit the initial claim and now has 12 months from the eligibility posting date to resubmit a clean claim.

6.12 OTHER INSURANCE (TPL) TPL means third party liability. Generally this means that the child has medical coverage under a policy through a parent or other source. Under Medicaid law and regulations, Medicaid is generally the payer of last resort (42 CFR 433.136). There is an exception, however, when it comes to Medicaid-covered services listed on a Medicaid-eligible student’s IEP. This means that Medicaid will pay prior to the federal Department of Education for those Medicaid-covered services listed in a student’s IEP. (See Section 1.1.9) This does not provide an exemption to LEAs from pursuing other third party payers such as private insurance. Medicaid is still secondary to all other sources of payment. As a result of this secondary position, it is the responsibility of each LEA or their designated biller to bill all third party payers prior to billing the DSC program. AHCCCS indicates on the student’s Medicaid file whether the child is covered by another payer. That indicator or “TPL flag” is sent to PCG in the student eligibility file that is provided to PCG for the purpose of editing claims. Therefore, claims for children with the TPL flag will be denied unless the third party’s denial is submitted with the claim. Exceptions to the claims denial rule are services for nursing, health aides and transportation, which do not have to be billed to a third party prior to being billed to the DSC program. In order to be eligible for payment by PCG, the service requiring third party billing must be submitted to PCG on a CMS1500 Form with a copy of the Explanation of Benefits (EOB) from the student’s primary carrier indicating the service was denied. If the six-month filing deadline is approaching and the EOB from the primary carrier has not yet been received, the LEA is advised to submit the claim to PCG without the EOB. PCG will then deny the claim because the EOB was not attached. The LEA may later re-bill the claim to PCG after the EOB has been received, as long as it is no more than 12 months from the date of service.

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6.13 CODING FOR CLAIMS AND OTHER BILLING RULES ICD-9CM CODING (DIAGNOSIS) The ICD-9 (International Classification of Diseases, 9th Revision) code is a medical code that represents the diagnosis indicating the medical necessity, or reason, for the child to be receiving covered services. In DSC medical claiming, all claims must have at least one valid ICD-9CM code. The diagnosis code must be appropriate for the billed service (procedure code). The ICD-9CM code is alphanumeric and consists of three digits followed by a decimal point with up to two digits after the decimal adding specificity. The claim can contain as many as four ICD-9CM codes, but at least one is required. All ICD-9CM codes should be used at their highest level of applicable specificity. For additional information on ICD-9CM coding consult a current ICD-9CM coding manual. These are national codes; therefore, any changes to the codes nationally will affect the codes for this program. Reference books can be found in bookstores and on the Internet. If the LEA uses a biller, a certified biller may be able to assist with selecting the appropriate ICD-9CM code for each claim, based on information the qualified provider provides to the biller. CPT/HCPCS CODING (PROCEDURE) The Healthcare Common Procedure Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS.



Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system. The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.



Level II codes are also referred to as alphanumeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits. These codes represent primarily non-physician services that are not represented in the Level I codes.

A common term for many codes used for the DSC program is “procedure code”. Revised manuals are published annually with a January 1st implementation date. In the DSC program, there is a limited set of procedures that can be billed. A complete Fee Schedule list can be found on the project Web site: http://web.pcgus.com/azschools/downloads.html MODIFIERS A modifier is an extension to the procedure code. There are billing rules with modifiers, just as there are with the CPT and HCPCS codes. In this program, only certain modifiers are allowed, and only certain procedure codes require a modifier: Transportation codes: A0120, A0130, S0209 and S0215 Modifier:

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

Add “TN” as the modifier, if the service took place in a rural area or outside the LEA’s customary service area

Behavioral Health code: H0004 Modifier:   

Add “HR” if the service is family counseling with the student present Add “HS” if the service is family counseling without the student present Add “HQ” if the service is group therapy

 

Use no modifier, if the service is individual counseling or therapy This is a “timed” code and is billed at one unit per 15 minutes

PLACE OF SERVICE On the CMS 1500 claim form, this is Box 24B. This program requires all services be performed at the school site unless clearly identified in the IEP. In medical coding, the code for school site is “03”. Transportation can be coded “03” or “99”. However, transportation is the only allowable service coded to “99” for this program. All other related services coded to “99” will be denied. If a student is receiving services outside of the normal school setting, the placement code must appropriately reflect the outside setting and must be clearly defined in the IEP. However, the claim (if submitted via 837 file) may be denied initially due to place of service system edits and require resubmission on a CMS 1500 form with supporting documentation. Supporting information includes the student’s IEP and clinical note. To avoid delay in potential reimbursement of these claims, the LEA/biller may choose to submit the claim initially on the CMS 1500 with all supporting documentation and forego the electronic submission and resubmission process. UNITS The procedure codes used in this program are either “event” driven or “time” driven. Refer to the procedure description in CPT or HCPCS to determine which the procedure is. If the procedure is event driven, it is billed once per day, per session or provider. Exceptions, such as make-up sessions should be clearly defined and should be clearly documented. If the procedure is time driven, such as health aide services, then the units or quantity will represent the amount of time the service was provided. For example, health aide time is billed in 15 minute increments. If one hour of health aide time is provided, then the number of units is “4” (4 x 15 minutes = 60 minutes). DO NOT bill four lines of health aide services with “1” unit each because the first line will be paid, but the succeeding three lines will be denied as duplicate claims. If the LEA is billing for more than one unit for a date of service, it must be on one claim line. The billed charge must also indicate the number of units. For example, if one unit of a service is $15, then a claim line for four units of that service would have a billed charge of $60 (4 x $15 = $60).

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6.14 VOIDS AND REPLACEMENTS After a claim has been submitted to PCG, a remittance advice (“RA” or “remit”) is returned to the submitter. If after review of the remit it is determined that the claim should be corrected and billed again, a re-bill should be prepared. Important things to remember about a re-bill:      

Must be submitted on a CMS 1500 Form Do not resubmit the claim until the reason for the denial has been corrected The only data that can be changed on a re-bill are the procedure code, the number of units, the billed charges, and the diagnosis The re-bill must be received within 12 months from the date of service If the initial claim was denied for timeliness (after six months), then a re-bill will not be considered The Individual Claim Number (ICN), found on the remit MUST be included on the re-bill; otherwise a re-bill over six months from the date of service will be denied

Depending on the reason of the resubmission, additional documentation may need to be provided to PCG along with the CMS 1500 Form. Additional documentation may include a Health Aide Prepayment Review Form, the student’s IEP, clinical notes, bus logs, etc. For all resubmission claims, identify the original claim information and original ICN (Individual Claim Number) from the electronic remittance advice or PDF report. Only submit relevant records and do not send PCG the entire remittance advice file. This information can be submitted to PCG via FTP or a password protected CD with the CMS 1500 Forms. ADJUSTMENTS OR VOIDS An adjustment is a type of re-bill for situations when the amount or quantity of a previously paid claim was incorrect. For example, a health aide provided four units of service, but the claim only indicated one unit. If a LEA were to bill the remaining three units, the claiming system will consider the second claim a “duplicate” of the first and deny the claim. Therefore, an adjustment must be requested. All adjustments must be submitted to PCG on a CMS 1500 Form along with a cover letter on LEA letterhead indicating the field element that has been changed and reason for resubmission. The ICN of the original claim must be entered on the CMS 1500 Form in box 22. The received date of the mailed CMS 1500 Form is recorded and becomes part of the file for timeliness determination and reporting purposes. A void is a type of re-bill, but its purpose is to request that the claim be reduced to $0/0 units. For example, after the claim has been paid, the LEA realizes that the claim was submitted for the wrong student. In order to tell PCG that an error has been made, the LEA can request the claim be voided. All voids must be submitted to PCG on a CMS 1500 Form along with a cover letter on LEA letterhead indicating why the claim should be voided. The ICN of the original claim must be noted on the CMS 1500 Form in box 22. The received date of the mailed CMS 1500 Form is recorded and becomes part of the file for timeliness determination and reporting purposes.

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If applicable, once the claim is voided, the corrected claim may be resubmitted to PCG on a CMS 1500 Form with appropriate documentation referencing that the claim was previously voided so that timeliness can be overridden and the claim paid correctly.

6.15 SPECIAL CLAIMS HANDLING Special claims handling may require the LEA to provide additional documentation to PCG along with a CMS1500 Form. Additional documentation may include Explanation of Benefits, the student’s IEP, clinical notes, bus logs, etc. See sections 6.12 Other Insurance (TPL), and 6.14 Voids and Replacement

6.16 USING A BILLER The LEA may choose to hire an outside (or contracted) biller to prepare and submit claims. Hiring a biller will likely require some type of contract between the LEA and the biller. The LEA also needs to notify PCG that they are using a biller, so that PCG has the LEA’s permission to exchange confidential claim information with that biller on the LEA’s behalf using the Biller Authorization Form. The form must be completed and signed by the LEA’s authorized signer on the LEA’s letterhead and then mailed to the local PCG office. Many of the PCG processes are set up to include the biller, so it is important that LEAs keep PCG informed as to their current biller. (Sample Biller Authorization Form - Attachment 8) If a LEA changes billers, they must notify PCG in writing of the change. A new Biller Authorization Form showing the new biller and the effective date must be submitted. The effective date is the date the LEA will begin sending their claim information to the new biller. The LEA is fully responsible for all claims submitted for reimbursement, regardless of the involvement of a biller. LEAs should have processes in place to monitor biller activity and appropriate claiming. Using a contracted biller is not a DSC program requirement. CHANGES IN BILLING METHODS If a LEA changes from one of these billing methods to another, they notify PCG as soon as possible to support transition. PCG will help to determine if new user access and additional forms must be completed such a biller authorization form. The LEA should have a contingency backup plan on submitting claims if their current biller is no longer able to provide the service. The LEA should know:    

Timeline for their new biller to start submitting claims If claims will be submitted within the 6 month timely filing window How to follow up on outstanding claims from the previous biller Which claims have been recently submitted and rejected

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Remits are provided weekly to the LEA, or their biller/consultant, for any claims batch submitted that week for payment. The remit provides the LEA with the payment status of the claims batch. REMIT BASICS      

Remits are prepared in two formats: paper copy (PDF) and electronic (Excel) Remits are created one per LEA Remits are sorted by the rendering provider, then by student Each provider is sub-totaled Each student under each provider is sub-totaled Remit total matches the check amount

Below is a detailed list of the information provided on a remit: Fields: RA Date: PCG LEA ID: LEA Name: Check Number: Render Provider: Render FN: Render LN: AHCCCS ID#: Name: AHCCCS Remit Date: Claim Number: Service Date: Proc/Mod code: Qty: Billed Amount: Non Covered Amount: Status:

Denial: Paid Qty: Admin Fee:

Final adjudication date by LEA Tax ID is not listed on the remit LEA for which the claim was filed The claim check number The provider’s AHCCCS ID number The provider’s first name The provider’s last name The student’s AHCCCS ID number Name of the student who received the service Final adjudication date by AHCCCS Internal Claim Number (ICN), original claim number Date the service was given to the child The CPT or HCPCS code identifying the service provided and modifier for the procedure code The number of units billed Dollar amount billed The total dollar amount of the State match and any amount that was billed more than the AHCCCS fee schedule P = Paid: the claim was paid D = Denied: the claim was denied; refer to the denial code S = Suspend: the claim is being pended internally This key is at the bottom of every page Codes that indicate the reason(s) for the claim being denied. The description of these codes are listed at the end of every remit The number of units paid Fees for PCG and AHCCCS

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Paid Amount:

Net payment for that claim

6.18 INTERIM PAYMENT AND CLAIM PROCEDURE CODES HOW INTERIM PAYMENTS ARE CALCULATED There are three figures used to calculate interim payments to the LEAs: the billed amount, the Federal Medical Assistance Percentage (FMAP) and the administrative fees. Billed Amount The approved procedure codes for the DSC program are listed in the Fee Schedule posted on the project Web site. The list includes the CPT or HCPCS code, and the national description of the procedure. It also includes the AHCCCS Fee Schedule amount assigned to that procedure code. The billed amount for each claim should reflect the amount the LEA paid to provide that service or the Fee Schedule amount. The lesser of the billed amount or the AHCCCS Fee Schedule will be used to calculate payment. Each LEA should work to develop their own fee schedule that is more closely aligned to their individual costs. LEA specific rates will be more reflective to the individual LEA’s actual cost of providing related direct services. LEAs should not base billing on AHCCCS’ fee schedule. Even if the LEA costs are more than the AHCCCS fee schedule the LEA should be billing based on the actual cost of providing the direct service. The LEA will still be reimbursed the lesser of the AHCCCS fee-for service rate or the amount billed. Example: Individual Speech Therapy Service Scenario 1 LEA rate < AHCCCS rate

Scenario 2 LEA rate > AHCCCS rate

LEA Rate

$35.75

$52.12

Billed Rate

$35.75

$52.12

AHCCCS Rate

$39.10

$39.10

Reimbursement Rate

$35.75

$39.10

Rate Type

FMAP The Federal Medical Assistance Percentage (FMAP) represents the federal share of the payment. The state share is the amount that the LEA must match using state and/or local funding. When the payment is calculated, the state portion is not paid. The rate used is the rate in effect when the claim is processed for payment. The rate is set at the federal level and is usually in effect for one year. The most recent FMAP rates are available at US Department of Health and Human Service’s Web site at: http://aspe.hhs.gov/health/fmap.htm

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ADMINISTRATIVE FEES Based on a per unit charge, the LEA pays PCG half the administrative fee and the other half is paid by AHCCCS. The LEA fee to AHCCCS for claims paid is based on a fixed percentage of the adjusted paid amount. The PCG fee is a separate per unit fixed price applied to claim transactions. For purposes of how a payment is calculated, as of July 1 2011, the AHCCCS fee is 1.5% and the PCG per unit charge is 64¢. For example, a speech service is provided and procedure code 92508 is billed for one unit. The claim is billed at $11.69. Payment is calculated as follows: $ 11.69 x .6575 $ 7.69 - 1.5% $ 7.57 __- .64 $ 6.93

AHCCCS reimbursement to provide the service FMAP State Administrative Fee PCG Fee Paid to LEA

Note: The fees listed in the Fee Schedule do not represent the final amount of reimbursement to the LEA. (See calculation in section 9.1). For the most current Fee Schedule, refer to the project Web site (http://web.pcgus.com/azschools/downloads.html), or the AHCCCS Web site (https://www.azahcccs.gov).

7.

COMPLIANCE REVIEWS

PCG conducts compliance reviews on all contracted LEAs. All participating LEAs will be reviewed at least once every three years. Some circumstances that may result in a compliance review include:    

If the LEA scored less than 90% on a previous review, a focus review may be conducted. If through interactions with the LEA, the biller, AHCCCS and/or PCG identifies the need for review If the LEA demonstrates unusual claim billing patterns, or If notification of potential quality of care or service issues have been received

Documentation that will be reviewed during a compliance review for the DSC program includes, but is not limited to:      

Student IEPs Service Logs Clinical notes Progress Reports Student attendance records Licensure of qualified providers

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Note: refer to the “Required Records” section for details on the above stated documentation. Prior to the compliance review, PCG will call the LEA to schedule the date of the compliance review. A confirmation letter via email will follow along with a sample of claims to be reviewed, and a copy of the compliance review tool. All documents requested must be available for PCG review. The compliance review may occur onsite at a LEA specified location or as a desk review as determined by PCG. Desk reviews entail that copies of required documentation are mailed to PCG one business day prior to the review. A LEA contact should be available for an entrance and exit meeting as well as throughout the review for reviewer questions or requests for additional documentation. A preliminary report outlining any findings or recommendations will be provided to the LEA contact during an exit meeting after the review of documentation is completed. PCG will have twenty (20) working days from the date of the compliance review to provide a draft compliance review report to the LEA. The LEA will have twenty (20) working days from the receipt of the draft compliance review report to refute the initial findings or provide any additional documentation for areas of non-compliance. If no additional documentation is submitted to PCG refuting the findings identified during the initial compliance review, the findings will become final and the draft compliance review report will be the LEAs final compliance review report. A Corrective Action Plan (CAP) may be required to demonstrate the steps the LEA will undertake to resolve any areas of non-compliance. The CAP must be signed by an LEA contact, and submitted to PCG for approval. PCG will provide a final compliance report to the LEA within 15 days after the receipt of the CAP and/or refuting evidence. If the LEA’s final compliance score falls within the substantial compliance or partial compliance category, the LEA will be required to perform a “self review” within six months of the initial review. Based on a sample selection supplied by PCG to the LEA, the LEA will conduct a review using the Compliance Review Tool as a guide and will provide the results to PCG. If the self review does not indicate full compliance, PCG will conduct a focus review on all partial and non compliant standards from the original review. If the focus review falls below a final score of 79%, PCG will conduct another full compliance review. If a LEA’s final compliance score from their initial review falls within the non-compliant category, PCG will conduct another full compliance review that addresses all standards in the tool. However, the number of claims reviewed will be reduced to half of the original number of claims. Note: Because this is a federal program, the LEA may also be required to produce additional documentation, or to allow an onsite visit from AHCCCS, CMS, or their authorized auditors. LEA’s may request a copy of the compliance review at any time. PCG strongly encourages LEAs to conduct self reviews regularly to evaluate the appropriateness of their claiming program, and to identify any areas in need of improvement. PCG conducts compliance reviews of the Medicaid Administrative Claiming (MAC) program as well. Each LEA that has received MAC reimbursement will be reviewed at least once every three years. An additional review may be conducted if PCG suspects non-compliance or if there is a request from a LEA, AHCCCS or CMS.

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The following documentation may be reviewed:      

Documentation of the quarterly salaries paid for participants on the staff roster for the quarter outlining amounts and account codes Documentation of the quarterly employer paid benefits paid for participants on the staff roster for the quarter including amount and account codes Documentation of quarterly purchased professional services paid for participants on the staff roster for the quarter including amounts and account codes Copy of the MAC check, quarterly invoice received, and any summary documentation Copy of the latest financial audit from the LEA’s CPA firm

An explanation for any variance in the documentation provided and the amount shown on the Cost Data reported to PCG. If an explanation is not provided, the claim is subject to recoupment

Prior to a PCG MAC compliance review, PCG will contact the program coordinator or financial director to schedule the date of the compliance review as well as provide the quarter being reviewed. An engagement letter will follow via e-mail. All documents requested must be available one business day prior to the date of the review. An exit report outlining any findings or recommendations will be provided to the LEA during the exit interview. PCG will have twenty (20) working days from the date of the compliance review to provide a draft compliance review report to the LEA. The LEA will have twenty (20) working days from the date of the draft compliance review report to provide any additional documentation for any areas of non-compliance identified during the compliance review. If no additional documentation is submitted to PCG refuting the findings identified during the initial compliance review, the findings will be final and the draft compliance review report will be the LEAs final compliance review report.

7.1

RECORD MAINTENANCE

Participating LEAs must comply with record keeping requirements as outlined in AHCCCS policy. Documentation must be maintained for the LEA, its providers, and student records for a period of five years from the payment date. Medical records must be accessible and available to PCG, the AHCCCS Administration, CMS, and any health care provider serving the student. All documentation included in the LEA audit file must be kept for a period of no less than five years from the date of payment. Exceptions include compliance reviews, audits, grievances, and litigations which may require documentation to be kept longer. If additional information is deemed necessary for inclusion in an audit file, PCG will notify participating LEAs. PCG recommends that the items listed above be placed in a file clearly marked as “Audit File for quarter (insert number) and year (insert year)”. By keeping the information in a central location, you will be able to quickly identify any missing documentation. Also in the event that the MAC coordinator is not available to the LEA at the time of a compliance review, the LEA will know exactly where the required documents are located. DISTRICT RECORDS

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LEA records must include:   

A written agreement with PCG Group Billing registration form Attendance records

CERTIFICATION OF MATCH/FINANCIAL RECORDS The federal government provides only a portion of the Medicaid reimbursement amount for covered services or the costs necessary to provide the services, whichever is less. The remainder must be provided by the LEA through a combination of state/local funds paid for the salaries, benefits, and overhead of those providing covered services. All LEAs that receive DSC payments must expend at least the amount of reimbursement using NON-FEDERAL MONEY. The Federal Office of Management and Budget (OMB) Circular A-87 contains information on allowable expenses to meet state/local match requirements and is the best resource for information (www.whitehouse.gov/omb/circulars/). PROVIDER RECORDS Each provider, with the exception of school bus drivers, must be individually registered with AHCCCS. On request, the LEA must be able to produce the following documents for all providers:     



Copies of their AHCCCS registration Any licenses or certifications applicable to the specific provider type Documentation of supervisory relationship when applicable Proof of insurance for all providers For bus drivers, a copy of Arizona commercial driver’s license, as it relates with Arizona Revised Statutes, Title 28, Chapter 7, Article 5 and Arizona Administrative Code requirements regarding school bus transportation and bus drivers o Note: according to ADOT a commercial driver’s license is not required when the vehicle seats 15 or less passengers including the driver For health aides, copies (front and back) of CPR and first aid certification cards

Any other specific health-related training provided to these employees should also be documented. Examples would include health aide training on implementing activities of daily living. STUDENT RECORDS The following requirements for student medical records have been adopted by AHCCCS as the minimum acceptable requirements for the DSC program. PCG recognizes that much of this documentation may already be collected on the IEP. It is not the intent to require that this information be re-created on another record. The requirements will be met if the information is included in the IEP and supporting documentation. PCG will conduct periodic compliance reviews of all participating LEAs to verify the appropriate claiming for services under the DSC program. Documentation by LEAs is critical in those reviews.

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All records must be well organized and comprehensive with enough detail to support a valid service and payment by Medicaid. All records must be legible to someone other than the writer. Paper records must be typed or written in blue or black ink, signed and dated. Each student medical record must be kept up-to-date and include the following:        

The current student IEP signed and dated by the appropriate qualified medical provider A plan of treatment with outcome oriented goals Scope, frequency and duration of services to be provided to the student Signed and dated periodic summary reports and progress towards goals Date, description of service performed, and number of service units provided Dated signature of the provider for each service type Sufficient documentation to properly identify the student as DSC eligible and as the child for whom the service was billed Signed and dated service logs or clinical notes for all DSC covered services

REVISIONS AND CHANGES TO RECORDS If a paper record is physically changed, the stricken information must be identified as an error by the qualified person who is changing the record. Corrections can be made by drawing a single line through the incorrect information, signing, and then dating the change. White out or correction tape is not allowed. A process must be in place to track when and who makes revisions to records. A late entry may be recorded in the member’s record but must be noted as such. The late entry should show the date of the late entry and must be signed. Records may also be documented in an approved electronic format that tracks when and who makes changes and ensures that information cannot be altered inadvertently. Accessibility to and transmission of electronic medical records must be compliant with HIPAA standards and AHCCCS policies. If the LEA will rely on electronic information during a compliance review, the LEA must submit an electronic signature certification questionnaire for authorization by PCG. Approval for an electronic format must be obtained before LEAs submit claims. (Electronic Signature Certification Questionnaire - Attachment 10) CONFIDENTIALITY Student records must be stored in a secure location and protected from unauthorized access. Records can be released to a third party only with an appropriate release from the student’s parent or guardian. All information about the student and the services he/she receives that is documented in a “medical” record (a record of DSC covered services provided and progress toward IEP goals and objectives related to DSC) must be kept confidential. This information includes, but is not limited to:     

Identifying information such as the student’s name, AHCCCS ID number, address, telephone number, and the name of the parent or guardian Diagnosis and/or diagnostic evaluations/reports Pertinent medical history Plan of treatment and/or changes in treatment plan Services provided

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    

Dates of service Notations on progress or lack of progress Consultation reports Information obtained from the student’s primary care physician, attending physician or other service provider Changes in physical or mental status

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) CMS has rules and regulations regarding the requirements for electronic medical data transmission, as well as to ensure that Protected Health Information (PHI) is kept confidential. These rules are contained in the Health Insurance Portability and Accountability Act (HIPAA). LEAs can do many things to maintain confidentiality of information and enhance the privacy of students with special needs and their families, such as:       

7.2

Maintain an individual health care record for each student enrolled in the DSC program Exclude any other classmate’s name from a student’s record Discuss a student’s medical or behavioral condition only in conference with other healthcare professionals, the student’s special education teacher, or his/her parents or guardian, and only in a setting where an unintended listener cannot hear PHI Never leave PHI on a desk unattended or overnight; always keep such information in a locked secure place when not actively working on it Provide outside parties such as billers, lawyers, etc. with the minimum amount of information as necessary for them to do their job Shred all PHI before disposing of it At the time of enrollment, discuss the LEA’s current privacy policies with the student’s parent(s) or guardian(s) regarding his/her PHI and request consents and/or authorizations if necessary

WHISTLEBLOWER POLICY

LEA’s that receive $5,000,000 (five million dollars) in direct service reimbursement annually (July – June) must have a Whistleblower Policy (Section 1902(a) (68) of the Social Security Act) in place. The policy must:   

Be approved by the Board Educate and communicate the Whistleblower policy through written means that is disseminated to all staff, contractors, and agents Be included in the employee handbook if the LEA is required to provide one

The Whistleblower Policy is subject for review as part of the compliance review process if the LEA meets or exceeds the annual threshold. Documentation regarding the policy, approval, and education must be provided.

8.

GENERAL PROGRAM INFORMATION

8.1

CHECK CASHING POLICY

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If a check has not been cashed within 60 days from the date of issuance, PCG staff will follow up to inquire on the status of the check. If a check needs to be reissued, a Stale Check Replacement Form along with a $35 reprocessing fee must be mailed to PCG. The reprocessing fee is subject to change and is determined by the bank. (Stale Check Replacement Form - Attachment 9) PCG complies with 42 CFR 433.40 in that payments issued for the DSC program must be cashed within 180 days of its initial issue date, including replacement checks issued for lost or un-cashed checks. It is important that program checks are cashed promptly. After 180 days, a stop payment is placed on the un-cashed check, associated claims will be voided, and funds will be returned to AHCCCS.

8.2

CLAIM DISPUTES

The LEA has several forums to address questions and issues regarding the payment of claims. Questions regarding the payment of individual claims such as the amount paid, denials or recoupment should be addressed to PCG. If the claim has been denied, PCG will provide information to assist the LEA in understanding the reason for denial and assist with a resubmission or resolution as necessary. As a last resort, if the claim or recoupment issue cannot be resolved using the informal methods described above, the issue may be reviewed as a formal Claim Dispute. Claim Disputes of denied claims must be filed with PCG within twelve months from the date of service, twelve months from the eligibility posting date, or within sixty days from the adjudication of a timely submitted claim, whichever is later. A formal Claim Dispute must be submitted in writing, provide the factual basis for the dispute, document the steps that were taken to resolve the issue, and specify the requested resolution or relief. A formal Claim Dispute must be submitted to the PCG Phoenix office. PCG will acknowledge receipt of a Claim Dispute in writing within five days of receipt and will handle the dispute in accordance with A.A.C. Title 9 Chapter 34 Article 4). Adverse Claim Dispute decisions by PCG can be appealed to the AHCCCS Administration, where they will be reviewed.

8.3

FRAUD AND ABUSE

AHCCCS adheres to the program integrity rules mandated by the ACA and those are monitored by the AHCCCS OIG. As outlined in the “Provider Integrity Changes Mandated By The Affordable Care Act Of 2010” memo issued by AHCCCS on December 16, 2011 (link below), suspension of provider payment requires AHCCCS to suspend payments to a provider if AHCCCS determines that there is a “credible allegation of fraud” against the Medicaid Program. A “credible allegation of fraud” is defined as an allegation which has been verified by the State from any source, including but not limited to: (1) fraud hotline complaints (2) claims data mining and (3) patterns identified through provider audits, civil false claims cases and law enforcement investigations. Allegations are considered credible when they have indicia of reliability and the State Medicaid Agency has reviewed all allegations, facts and evidence carefully and acts judiciously on a case-by-case basis.

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Previously, the State Medicaid Agency could suspend a provider’s payment only if “reliable evidence of fraud” was found. Now, the State Medicaid Agency must suspend payment if a “credible allegation of fraud” is found. This regulation also requires AHCCCS to refer every provider whose payments have been suspended to the Medicaid Fraud Control Unit (MFCU) at the Arizona Attorney General’s Office. The referral must occur within 24 hours of the suspension and the MFCU will provide a quarterly report to AHCCCS that their investigation is either ongoing and the suspension should continue, or that MFCU is declining the investigation and the suspension may be lifted absent another law enforcement agency’s acceptance of the case. Additional detail regarding these program integrity changes can be found in the attached link: http://www.azahcccs.gov/commercial/Downloads/ProviderRegistration/ACAProgramIntegrityChangeStak eholdermemo.pdf It is everyone’s responsibility to identify and eliminate fraud, abuse, and waste occurring in the Medicaid program. Medicaid fraud costs taxpayers millions of dollars every year. Arizona Revised Statutes 36-2918.01 states, “All contractors, providers, and non-providers shall advise the director or the director’s designee immediately in a written report of any cases of suspected fraud or abuse.” The AHCCCS Office of Program Integrity is the director’s designee for the purposes of reporting fraud. AHCCCS maintains a Web site (www.azahcccs.gov) that can be used for reporting fraud directly to the State Office of the Inspector General. On the right side of the home page in the “Common Resources” section is a link for reporting fraud or abuse. Per ARS 36-2918.01, “Any person making a complaint or furnishing a report, information or records in good faith pursuant to this section is immune from any civil liability by reason of that action unless that person has been charged with or is suspected of the fraud or abuse reported.” PCG is the agent of the State for the Medicaid School-Based Claiming programs, therefore, PCG should be notified of any suspected fraud or abuse. PCG educates all program participants regarding program compliance requirements, and needs to be made aware of any issues that arise. By knowing the issues within the program, PCG can address them, by resolving them and preventing them from occurring in the future.

8.4

PARTICIPATION AGREEMENT

The Participation Agreement (PA) is a legal document between the LEA and PCG. The PA must be signed and in place before a LEA can begin participating in the MSBC program. The PA outlines if the LEA will be participating in the DSC Program or the DSC and MAC Programs. Please note that LEAs cannot choose to solely participate in MAC. In order for a LEA to receive reimbursement under the MAC Program they must also participate in DSC. In addition, the PA defines the roles and requirements of PCG, the LEA and AHCCCS. Generally, the PA is approved by the LEA’s school board. (Reference Attachment 1 – Participation Agreement)

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8.5

TERMINATION OF PARTICIPATION

A provider’s participation as a registered AHCCCS provider may be terminated for several reasons: GENERAL TERMINATION REASONS   



A provider may voluntarily terminate participation in the program by providing 30 days written notice to the AHCCCS Provider Registration Unit. AHCCCS may terminate a provider’s participation for “loss of contact” (i.e., if mail is returned as undeliverable). Provider participation may be terminated if the provider does not submit a claim within a 24-month period. (The 24-month period is calculated from the last date of payment by AHCCCS to the current date.) Providers terminated for this reason must complete and submit a new Provider registration packet to AHCCCS. If a provider does not supply AHCCCS with a current copy of his/her license/certification, AHCCCS will terminate their provider ID number effective with the termination date of the license/certification.

TERMINATION FOR CAUSE AHCCCS may terminate a provider’s participation when it is determined that:   

The health or welfare of a recipient is endangered by the provider The provider fails to comply with federal and state laws and regulations There is a cancellation, termination, or material modification in the provider’s qualifications to provide services

AHCCCS may terminate a LEA’s participation when:    

The LEA fails to meet program requirements as stated in the Participation Agreement The LEA consistently does not meet the RMTS compliance rate of 85% The LEA does not submit financial or student data necessary for the calculation of the MAC claim or the DSC annual cost settlement The LEA does not submit DSC claims

Any provider determined to have committed fraud or abuse related to AHCCCS or Medicaid may be terminated. This provision is also extended to providers terminated from Medicare participation. Providers who are determined to be rendering substandard care may be terminated, suspended, or placed on restrictions or review. If the provider’s license or certification is revoked, suspended, or lapses, the provider’s participation may be terminated or suspended.

9.

APPENDIX: ATTACHMENTS Attachment 1: Attachment 2: Attachment 3: Attachment 4:

Participation Agreement Guidance for Health Aide Documentation Health Aide Prepayment Review Form Sample Eligibility Match Instructions

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Attachment 5: Sample Student Eligibility Match Template Attachment 6: NPI Supplemental Registration Form Attachment 7: CMS 1500 Form (08-05) Attachment 8: Biller Authorization Template Attachment 9: Stale Check Replacement Form Attachment 10:Electronic Signature Questionnaire with Instructions

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