Mental Retardation or Other Developmental Disabilities ...

EDS is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Health Policy Authority.

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June 2007 Provider Bulletin Number 757b

Mental Retardation or Other Developmental Disabilities

Targeted Case Management Providers

Coverage of Targeted Case Management Effective with dates of service on and after July 1, 2007, targeted case management (TCM) will be defined as follows:

Targeted case management services are services which will assist an individual eligible under the State Plan in gaining access to needed medical, social, educational, and other services.

For a complete definition of TCM, please refer to the new Targeted Case Management-Mental Retardation or Other Developmental Disabilities (MR/DD) Provider Manual on the KMAP Web site at https://www.kmap-state-ks.us. The existing Home and Community Based Services-MR/DD TCM Provider Manual will be retained on the KMAP Web site for historical purposes only.

Effective July 1, 2007, procedure code T2023, targeted case management, per month, will no longer be used for TCM-MR/DD. Procedure code T1017, targeted case management, each 15 minutes, will be used in its place. TCM will be limited to 240 units per calendar year. The Community Developmental Disability Organization will no longer be the only enrolled Medicaid provider. Each enrolled MR/DD case management service provider shall use its own provider number when submitting claims in order to receive payment directly.

Information about the Kansas Medical Assistance Program as well as provider manuals and other publications are on the KMAP Web site at https://www.kmap-state-ks.us. For the changes resulting from this provider bulletin, please view the Targeted Case Management-Mental Retardation or Other Developmental Disabilities Provider Manual. If you have any questions, please contact Customer Service at 1-800-933-6593 (in-state providers) or (785) 274-5990 between 7:30 a.m. and 5:30 p.m., Monday through Friday.

https://www.kmap-state-ks.us/

https://www.kmap-state-ks.us/

KANSAS

MEDICAL

ASSISTANCE

PROGRAM PROVIDER MANUAL Targeted Case Management- Mental Retardation/Developmental Disabilities

Part II TARGETED CASE MANAGEMENT-

MENTAL RETARDATION/DEVELOPMENTAL DISABILITIES PROVIDER MANUAL

Introduction

Section 7000 7010

BILLING INSTRUCTIONS Introduction to the CMS-1500 Claim Form........................................................... Submission of Claim................................................................................. Targeted Case Management-Mental Retardation/Developmental Disabilities Specific Billing Information..................................................................................

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8100 8300 8400

BENEFITS AND LIMITATIONS Co-Payment…………............................................................................................ Benefit Plan…........................................................................................................ Medicaid.................................................................................................................

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Forms CMS-1500

PART II TARGETED CASE MANAGEMENT-

MENTAL RETARDATION/DEVELOPMENTAL DISABILITIES Issued 7/07

This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to targeted case management (TCM) mental retardation/developmental disabilities (MR/DD) providers. It is divided into three sections: Billing Instructions, Benefits and Limitations, and Forms. Part I of the provider manual consists of five parts: General Information, General Benefits, General Billing, General Special Requirements, and General Third Party Liability (TPL). Part I contains information that applies to all providers, including TCM-MR/DD providers. The Billing Instructions section gives instructions for completing and submitting the billing forms applicable to TCM-MR/DD services. The Benefits and Limitations section defines specific aspects of the scope of TCM-MR/DD services allowed within the Kansas Medical Assistance Program (KMAP). The Forms section includes a sample of the CMS-1500, which must be completed for reimbursement of services. HIPAA Compliance As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. Access to Records Kansas Regulation K.A.R. 30-5-59 requires providers to maintain and furnish records to KMAP upon request. Providers must also supply records to the Department of Health and Human Services upon request. The provider is required to supply records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's office upon request from such office as required by the Kansas Medicaid Fraud Control Act, K.S.A. 21-3844 to 21-3855, inclusive, as amended. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review, or investigation, including the relevant questioning of the provider’s employees. The provider shall not charge a fee to retrieve and copy documents and records related to compliance reviews and complaint investigations.

KANSAS MEDICAL ASSISTANCE PROGRAM TARGETED CASE MANAGEMENT-MENTAL RETARDATION/DEVELOPMENTAL DISABILITIES

PROVIDER MANUAL BILLING INSTRUCTIONS

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TARGETED CASE MANAGEMENT- MENTAL RETARDATION/DEVELOPMENTAL DISABILITIES

BILLING INSTRUCTIONS 7000. Issued 7/07 Introduction to the CMS-1500 Claim Form

Providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is in the Forms section at the end of this manual. The interChange Medicaid Management Information System (MMIS) uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information must be submitted in the correct claim fields to be recognized by the equipment.

EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual.

Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim

Send completed first page of each claim and any necessary attachments to:

Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, KS 66601-3571


PROVIDER MANUAL BILLING INSTRUCTIONS

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TARGETED CASE MANAGEMENT- MENTAL RETARDATION/DEVELOPMENT DISABILITIES

SPECIFIC BILLING INFORMATION

7010. Issued 7/07 Enter procedure code T1017 (Targeted Case Management, per 15 minutes) in field 24D of the CMS-1500 claim form. One unit = 15 minutes Time should be totaled by actual minutes/hours worked. Billing staff may round the total at the end of the billing cycle to the nearest one-half unit. One unit = 7.51 through 15.00 minutes; one-half unit (.5 unit) = 0.1 through 7.50 minutes. Providers are responsible to ensure the services were provided prior to submitting claims.


PROVIDER MANUAL BENEFITS AND LIMITATIONS

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BENEFITS AND LIMITATIONS 8100. CO-PAYMENT Issued 7/07 TCM-MR/DD services are exempt from co-payment requirements.



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BENEFITS AND LIMITATIONS 8300. BENEFIT PLANS Issued 7/07 KMAP beneficiaries are assigned to one or more KMAP benefit plans. The assigned plan or plans are listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, contact the KMAP Customer Service Center at 1-800-933-6593 or 785-274-5990.



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BENEFITS AND LIMITATIONS

8400. MEDICAID Issued 7/07 TCM-MR/DD is the assessment and linkage of the beneficiary with services necessary to promote care outside of an institution. The goals of TCM-MR/DD are:

• To promote maximum independence and successful integration into community living for MR/DD beneficiaries

• To minimize beneficiary reliance on exclusionary MR/DD institutional services • To maintain accountability and continuity of services to beneficiaries and families as long as

services are required Targeted Case Management Targeted case management services are defined as those services which will assist the beneficiary in gaining access to medical, social, educational, and other needed services. Targeted case management includes any or all of the following services:

Assessment of a beneficiary to determine service needs by:

• Taking the beneficiary’s history • Identifying the beneficiary’s needs and completing the related documentation • Gathering information, if necessary, from other sources such as family members, medical

providers, social workers, and educators, to form a complete assessment of the beneficiary

Development of a specific support/care plan that:

• Is based on the information collected through the assessment • Specifies the goals and actions to address the medical, social, educational, and other

service needs of the beneficiary • Includes activities that ensure the active participation of the beneficiary, and working with

the beneficiary (or the beneficiary’s legal representative) and others to develop such goals and identify a course of action to respond to the assessed needs of the beneficiary

Referral and related activities:

• To help a beneficiary obtain needed services, including • Activities that help link the beneficiary with medical, social, educational providers, or

other programs and services that are capable of providing needed services, such as referrals to providers for needed services and scheduling appointments for the beneficiary



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8400. Issued 7/07

Monitoring and follow-up activities, including: • Activities and contacts that are necessary to ensure the care plan is implemented and

adequately addresses the beneficiary’s needs, and which may be with the beneficiary, family members, providers, or other entities and conducted as frequently as necessary to determine whether:

o Services are being furnished in accordance with the beneficiary’s care plan o The services in the care plan are adequate o There are changes in the needs or status of the beneficiary and, if so, making

necessary adjustments in the care plan and service arrangements with the providers

Documentation Recordkeeping responsibilities rest with the TCM provider. Medicaid requires written documentation of services provided and billed to KMAP.

Documentation at a minimum must include the following:

An Activity Log that includes: • The service being provided • Beneficiary’s first and last name • Date of service (MM/DD/YY) • Location of service provided • Case manager’s legibly-printed name and signature on each page of the case log,

verifying that every entry reflects activities performed by the signee • Detailed description of the service provided, including start and stop times that

indicate AM/PM or use 2400 hour clock Notes: Time spent should be clearly documented in the notes. Providers are responsible to ensure the services were provided prior to submitting claims.

If documentation is not clearly written and self-explanatory, the services billed may not be paid.

Services provided must be documented within the timeframe that is billed. Documentation generated after-the-fact is not acceptable.



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8400. Issued 7/07 Limitations The maximum allowable units per customer are 240 units per calendar year. This may be waived with prior authorization by Social and Rehabilitation Services (SRS) Health Care Policy, Community Supports and Services.

TCM-MR/DD may be provided up to 180 days prior to the beneficiary transitioning from an intermediate care facility for mental retardation or nursing facility to community based services. The case manager would assist the beneficiary in obtaining appropriate housing, getting utilities established and other activities necessary for the beneficiary to move from an institutional setting to a community based setting.

TCM-MR/DD is available to all KMAP beneficiaries who are mentally retarded or otherwise developmentally disabled. MR/DD case management may be limited, at the choice of the person directing and controlling the services, to reviewing the services on a regular basis to ensure the beneficiary’s needs are met, and development of the person-centered support plan and plan of care.

A HealthConnect referral is not required. Other insurance and Medicare are primary; they must be billed first.

Provider Requirements Entities licensed by SRS and enrolled for TCM-MR/DD with an affiliate agreement with the Community Developmental Disability Organization (CDDO) are the only allowable providers to be paid for TCM services through the MMIS. Licensed TCM-MR/DD providers are responsible for insuring individual case managers meet the requirements identified in Article 63.

SRS will notify EDS when a provider no longer is licensed and is no longer eligible to bill for TCM-MR/DD services.

The CDDO should notify EDS and SRS when a provider no longer has an affiliate agreement and is no longer eligible to bill for TCM-MR/DD services.



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8400. Issued 7/07 Definitions

Affiliate – a local agency that has entered into an agreement with a CDDO to provide case management to beneficiaries who are mentally retarded or developmentally disabled and has been approved by SRS Health Care Policy, Community Supports and Services.

Community Developmental Disability Organization – a local agency that directly receives county mill funds and state aid and provides community based services to beneficiaries who are mentally retarded or developmentally disabled and is formally recognized by SRS Health Care Policy, Community Supports and Services.

Mental Retardation – significantly sub-average intellectual functioning, evidenced by an IQ rating of 70 or below or a score of two standard deviations or more below the mean as measured by a generally accepted standardized individual measure of general intellectual functioning existing concurrently with deficits in adaptive behavior including related limitations in two or more applicable adaptive skill areas.

Other Developmental Disability – a condition or illness, such as cerebral palsy, epilepsy, or autism, but excluding mental illness and infirmities of aging, that:

• Manifested before age 22 • May be reasonably expected to continue to exist indefinitely • Results in substantial limitations in three or more areas of life functioning • Reflects the need for a combination and sequence of special, interdisciplinary or

generic care, treatment, or other services which are lifelong or of an extended duration, and are individually planned and coordinated

FORMS

CMS-1500

Mental Retardation or Other Developmental Disabilities ...

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