Welcome!

The Webinar will begin shortly. We will be recording today’s webinar. Everyone has been muted

to reduce background noise.

Your presenters today are:

Dawn Pearson, 1915(i) Administrator

Medical Services Division, NDDHS

Laura Holzworth, Provider Relations Supervisor

Medical Services Division, NDDHS

Part 1 - 1915(i) Provider Billing & Claims

1915(i) Home and Community-Based Behavioral Health Services

Policy & Procedures Training for 1915(i) Providers

Presentation Overview

Billings & Claims Training

Part 1 - 1915(i) Policy and

Procedural components of

Provider Billing & Claims.

Part 2 – MMIS Web Portal

– Claims Submission

MMIS Billing & Claims

Today’s 1915(i) Billing & Claims Training will:

Identify the steps for billing Medicaid.

Provide resources and support for the billing process.

Answer questions about the billing process.

Todays Participants are…

Agencies enrolled as 1915(i) Medicaid Providers and staff responsible for agency billing.

2/1/2021 4

Traditional vs. Expansion

The 1915(i) is available to both Traditional Medicaid and

Medicaid Expansion members.

Today’s trainings are applicable to only Traditional Medicaid

members.

The Managed Care Organization (MCO), currently Sanford

Health Plan, will provide training applicable to Medicaid

Expansion Members.

MCO – Expansion Members

Further information on 1915(i) for Expansion members is available from the Manage Care Organization:

Website: https://www.sanfordhealthplan.com/providers/medicaid-expansion

Telephone Number: (855) 305-5060 | TTY: 711

What is MMIS?

MMIS is short for Medicaid Management Information System.

It is the billing system used by ND Medicaid for submitting

claims for Traditional Medicaid members.

Service Authorization requests are submitted and approved

through MMIS.

All 1915(i) provider claims for reimbursement for Traditional

Medicaid members must be submitted through MMIS on a

Professional Claim form.

Scenario - Jessica

Scenario

The Zone 1915(i) Eligibility Worker has recently determined Jessica eligible for the 1915(i). Jessica has chosen Lutheran Social Services (LSS), an enrolled 1915(i) provider, as her Care Coordination provider.

Jessica and the Care Coordinator develop the Person-Centered Plan of Care (POC). The POC is built around Jessica’s WHODAS domain scores which identify her needs. Peer Support and Employment Supports are identified as services to address her needs and assist her with meeting the goals she has identified.

Scenario (Cont.) The POC identifies how much of each services is needed, as well

as the frequency and duration. Jessica choses Path as her Peer Support Provider and Community Options as her Employment Supports Provider. The Care Coordinator submits a Service Authorization for the Care Coordination Service in MMIS and uploads the POC.

The State Medicaid Office approves the Service Authorization in MMIS. MMIS generates a letter to Jessica and to LSS. Upon notification of approval, the Care Coordinator completes and emails a referral form and the POC to the member’s choice of service providers, PATH and Community Options.

Scenario (cont.)

Path and Community Options each complete a Service Authorization, making certain it matches what is contained in the POC. Each submit the SA in MMIS and upload the POC. The Sate Medicaid Office confirms the request matches the POC, approves the request in MMIS, and MMIS generates letters to Jessica and each of the providers.

Care Coordination, Peer Support, and Employment Support Services are delivered to Jessica. All providers keep documentation/notes. Each provider submits a claim in MMIS to bill for the services provided. NDDHS issues payments.

Service Limits, Rates, Codes

Service Limits, Rates, Codes, etc.

Service Description Age Rate

Type Code & Modifier

Medicaid

Fee/Rate

Service

Limits

Remote Support/Tele-

Communication Limits (Use

Service Code 02)

Provider

Type

Specialty

Code

Group

Taxonomy

Individual

Taxonomy

Care Coordination - Coordinates

participant care, develops

Person-centered Plan of Care

and assists individuals with

gaining access to needed

1915(i) and other services. 0+

per 15

minutes H2015 $20.40

8 hours

per day

25% of Total Service in a

Calendar Month.

(Use Place of Service Code

02) 049 641 251B00000X 171M00000X

View the entire chart at https://www.behavioralhealth.nd.gov/1915i

Service Description

Care Coordination - Coordinates

participant care, develops Person-

centered Plan of Care and assists

individuals with gaining access to

needed 1915(i) and other services.

Age

Care Coordination is

available to members of any

age.

Rate Type

per 15 minutes

The Rate Type for the Care

Coordination Service is “per

15 minutes”

Code & Modifier

The code for the Care

Coordination service is H2015.

There is no modifier for this

service.

Medicaid Fee/Rate

$20.40

The Medicaid Fee/Rate for Care

Coordination is $20.40 per 15

minute unit.

1 hour of service = $81.60 ($20.40 x

four 15 minute units)

Service Limits

The maximum limit for Care

Coordination is

32 Units/8 hours per day

Remote Support/Tele-

Communications Limits

Use Service Code 02

Care Coordination Service may be

delivered remotely up to 25% of the

total services delivered in a calendar

month.

Provider Type

The Provider Type for the

1915(i) is 049

Specialty Code

The Specialty Code for Care

Coordination is 641

Group Taxonomy

The Group Taxonomy Code

for the Care Coordination

Provider Group is 251B00000X

Individual Taxonomy

The Individual Taxonomy for

the Care Coordination

Individual Provider is

171M00000X

NPI Number

All 1915(i) Providers will obtain

a National Provider ID (NPI)

Key Points

The Care Coordinator, in collaboration with the individual, determine the

services, and amounts, frequency and duration that each provider will

request.

The service amount, frequency, and duration requested by the provider in

the Service Authorization request must match the POC.

Provider Claims must be within the limits of the previously approved

service authorization.

Electronic Visit Verification (EVV)

The 21st Century Cures Act mandates that

states implement EVV for all Medicaid

personal care services (PCS) and home

health services (HHCS) that require an in-

home visit by a providers, by January 1,

2020.

1915(i) Respite Subject to EVV

Requirements

The 1915(i) Respite Service is subject to Federal EVV Regulations. The individual provider is required to check in and out to confirm their presence in the home.

The service authorization process will be different for the Respite Service as the Therap system is used.

Therap will provide training to all 1915(i) Respite providers in the use of EVV.

Place of Service Codes

Place of Service Codes (POS)

Medicaid requires 1915(i) Providers to use POS

Codes.

The POS Codes identify the location a provider

delivers a service to a member.

Place of Service Codes

When submitting a Service Authorization

Request, 1915(i) providers are required to

identify the one POS code you expect to

deliver the majority of the services at.

Later, when submitting the claim, the provider

is required to list the correct POS codes for

each of services they provided and are billing

the department for reimbursement.

Place of Service Codes

Code Name Description

02 Telehealth Services are provided or received through a

telecommunication system.

03 School A facility whose primary purpose is education.

04 Homeless

Shelter

Location whose primary purpose is to provide temporary

housing to homeless individuals.

12 Home Location, other than a hospital or facility, where the

member receives services in a private residence.

18 Place of

Employment-

Worksite

Location where the patient is employed.

11 Office The provider’s office.

For a complete list of codes visit:

https://www.cms.gov/Medicare/Coding

/place-of-service-

codes/Place_of_Service_Code_Set

Confirmation of Member Eligibility

It is the provider’s responsibility to confirm 1915(i)

eligibility prior to providing each service.

If 1915(i) eligibility ends, no services can be provided,

and the service authorization is no longer valid.

Why Check for the Member’s

Eligibility?

If you provide a service to someone

who isn’t eligible, you won’t be

reimbursed.

Providers are to call the AVRS 1-877-

328-7098 line to check individual

member eligibility. AVRS is for

Traditional Medicaid only.

Traditional or Expansion?

It is also the providers responsibility to know if the

member is a Traditional or Expansion member prior to

providing each service.

If you submit a claim for an Expansion member

into MMIS, it will be rejected.

Contact the Manage Care Organization for

instructions on checking member eligibility for

Expansion clients.

Members Medicaid Status Change

If a member’s Medicaid status changes from

Traditional Medicaid to Expansion, the current

service authorization is no longer valid. The care

coordinator will submit the POC to the MCO, and the

MCO’s Service Authorization process will be

implemented.

Each provider on the POC will need to submit a new

service authorization request to the MCO, using the

MCO’s process for Expansion members.

Members Medicaid Status Change

1915(i) service limit maximums start over

on the effective date of the individual’s

change from Traditional Medicaid to

Expansion, and from Expansion to

Traditional Medicaid.

Traditional a.k.a. Fee for Service vs.

Expansion

Providers will submit claims in MMIS for

Traditional Medicaid members.

Claims for Expansion members must be

submitted to the MCO.

1915(i) Claims Submission Process

1. An enrolled 1915(i) Provider prepares to submit a reimbursement claim to the department for services provided.

2. The provider confirms the required documentation has been completed, and there is a valid service authorization in MMIS for the service(s) they are about to bill.

3. The provider creates and submits a professional claim in MMIS.

4. The department reimburses the provider for valid claims.

Documentation Requirements ND Medicaid providers are required to keep records that

thoroughly document the services rendered to members and billed to ND Medicaid.

Records are used by ND Medicaid to determine the service was necessary and to verify that services were billed correctly.

Medical records must be in their original or legally reproduced form, which may be electronic. Documentation must support the time spent rendering a service for all time-based codes.

Documentation Requirements

Records must be retained for a minimum of six years from the date of its creation or the date when it was last in effect, whichever is later. State law may require a longer retention period for some provider types.

Medicaid Provider Manual: http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/general-information-medicaid-provider-manual.pdf

Case File Documentation Must Be

Maintained:

In a secure setting

On each individual in separate case files

Medical Record

Valid Signature Requirements

For a signature to be valid, the following criteria is needed:

Services that are provided must be authenticated by the

author

Signatures shall be handwritten or an electronic signature

Signatures are legible

Signature is dated and timed

Confidentiality and Access to

Expansion Member Records

All Medicaid member and applicant information

and related medical records are confidential.

Providers are responsible for maintaining

confidentiality of protected health information

subject to applicable laws.

Confidentiality

Providers are required to permit ND Medicaid personnel, or

authorized agents, access to all information concerning any

services that may be covered by Medicaid. This access does

not require an authorization from the member because the

purpose for the disclosure is to carry out treatment, payment

or healthcare operations permitted under the HIPAA Privacy

rule under 45 CFR §164.506.

Health plans contracting with ND Medicaid must be permitted

access to all information relating to Medicaid services

reimbursed by the health plan.

Medical Record

Valid Signature Requirements

In order for a signature to be valid, the following criteria are

used:

Services that are provided must be authenticated by the

author

Signatures shall be handwritten or an electronic signature

Signatures are legible

Signature is dated and timed

Resources 1915(i) Billing & Claims policy will soon be located on the department’s

website on our policy bookshelf: https://www.nd.gov/dhs/policymanuals/home/#financialhelp.htm

Today’s video recording and materials located on the 1915(i) website at https://www.behavioralhealth.nd.gov/1915i

Further information is available in the General Provider Manual located at this link: http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/general-information-medicaid-provider-manual.pdf

DHS Provider Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/provider.html

ND Medicaid Call Center

Noridian Healthcare Solutions

Contact Information

Telephone: 877-328-7098

Email: mmisinfo@nd.gov

Provider Appeals

SFN 168 Medicaid Provider Appeals

https://apps.nd.gov/itd/recmgmt/rm/stFrm/eforms/Doc

/sfn00168.pdf

Medicaid Provider Appeals Summary

http://www.nd.gov/dhs/services/medicalserv/medicaid

/docs/provider-appeals-info.pdf

Wrapping Up

Stay Connected!HTTPS://WWW.BEHAVIORALHEALTHND.GOV/1915i

1915(i) HOME AND COMMUNITY-BASED BEHAVIORAL HEALTH SERVICES: AN ORIENTATION TO SERVICE DELIVERY & Services2/1/2021 52

Thank You!

QUESTIONS?

Dawn Pearson, 1915(i) Administrator

Medical Services Division, NDDHS

drpearson@nd.gov

Go to Part 2 – MMIS Claims Submission Training now