option 1. major unusual incident reporting option 5. all...
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1.800.617.6733
• Option 1. Major Unusual Incident reporting
• Option 2. Claims
• Option 3. Certification
• Option 4. Security/IT Support
• Option 5. All others
[email protected] for security or IT support emails
Ohio Department of Developmental Disabilities
30 East Broad Street, 13th Floor
Columbus, Ohio 43215-3434
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Training Disclaimer
All trainings are intended to reflect the current policies and
procedures of Ohio Department of Developmental Disabilities and
Medicaid rules.
It is the responsibility of the provider to keep current with policy
changes.
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Ohio Business Gateway [business.ohio.gov] has information to assist
small business owners, including:
• Starting a business
• Hiring and training employees
• Filings and Payments
• Licenses and permits
• Laws and regulations
• Environment
• Financial assistance Help Center
Ohio Business Gateway is administered by the State of Ohio, and is
not affiliated with DODD.
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DODD cannot answer tax related questions. Providers with tax
questions are encouraged to contact the Internal Revenue Service.
http://www.irs.gov/ Small Business and Self-Employed Tax Center
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For more information contact:
The Ohio Department of Job and Family Services
Office of Unemployment Insurance Operations
http://jfs.ohio.gov/ouc/index.stm 877.644.6562
The Ohio Bureau or Workers’ Compensation
https://www.bwc.ohio.gov/
Liability insurance pays for your defense and any resulting damages
if your service causes damage or harm. It can also cover medical
bills if someone is injured on your premises.
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• Form SS-8, Determination of Worker Status for Purposes of
Federal Employment Taxes and Income Tax Withholding
can be filed with the IRS if it is unclear whether a worker is an
employee or a contractor.
• The form may be filed by either the business or the worker.
• The IRS will review the facts and circumstances and officially
determine the worker’s status.
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Providers are responsible for the accuracy of their claims, whether
they or a billing agent actually submits them.
Agency providers have the additional responsibility for payroll.
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Providers of services to people with developmental disabilities may
be self employed individuals or agencies.
An individual may become certified to provide non-Medicaid funded
[Supported Living] services and/or Medicaid funded [waiver] services
to individuals with developmental disabilities living in the community.
Applications are carefully reviewed on an individual basis, and must
include documentation that the applicant meets all qualifications and
standards to become certified.
An individual or agency is prohibited from providing any service until
certification is obtained from DODD.
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Medicaid is a federal program that allows eligible individuals with
low income to receive needed health-related services. Funding is
made possible with a combination of federal and state dollars.
Services are unique to each State approved under what is called a
State Plan.
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• If there is an issue with the individual’s Medicaid eligibility, a
‘Potential Loss of Medicaid’ [PLOM] letter is sent by the Ohio
Department of Medicaid to the individual and their authorized
representative, outlining the problem and what the individual
needs to do to resolve the issue.
• Depending on how the Individual Service Plan is set up, a
provider may be responsible for assisting the individual in
maintaining Medicaid eligibility. It is not the responsibility of the
provider, the county board, or DODD to maintain the individual’s
Medicaid eligibility.
• As stated on the individual’s initial enrollment letter, and on all
subsequent redetermination letters:
• You or your authorized representatives are responsible to
maintain Medicaid eligibility each month. You must be
Medicaid eligible to maintain your Waiver enrollment. You
need to have available a current Medicaid card to present to
the provider of services, if requested.
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State plan or card services
• Alcohol and drug addiction
• Dental
• Emergency
• Family Planning
• Healthchek
• Hospital
• Medical Equipment
• Mental Health
• Pregnancy
• Prescriptions
• Preventive Health
• Professional Medical Services
• Transportation
• Vision
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Third-party liability refers to any health care service(s) through any
medical insurance policy or through some other resource that covers
medical benefits.
Patient liability refers to the persons financial responsibility towards
their own cost of care.
Medicaid Buy-In is a program that provides health care coverage to
working Ohioans with disabilities. It may require a monthly premium.
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Services common to all three waivers include adult day support,
vocational habilitation, non-medical transportation, community and
residential respite, and remote monitoring.
I/O and LV1 have homemaker/personal care, while SELF has a similar
service-community respite. The transportation service is also similar
among all three waivers.
SELF has a budget cap of $25,000 per year for children, and $40,000
for adults.
LV1 has a budget cap of $5,325 for homemaker/personal care
services. The budget cap for adult day services is the same as the I/O
waiver.
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COG’s are created under the authority of Chapter 167 of the Ohio
Revised code. There are 8 COGS in Ohio representing 74 out of the
88 counties.
Services to the county board can include:
• MUI Services
• Quality Assurance
• Medication
• QA administration
• Provider Compliance
• Waiver Administration
• Supported Living Administration
• Provider Billing
• Training and Technical Assistance for CB’s and Providers
• Financial Management
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• Previously an office within the Ohio Department of Job and
Family Services.
• Launched in July 2013, the Ohio Department of Medicaid (ODM)
is Ohio’s first Executive-level Medicaid agency.
• With a network of more than 83,000 active providers, ODM
delivers health care coverage to 2.9 million residents of Ohio on
a daily basis.
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To Contact OSS:
Ohio Shared Services
4310 E. Fifth Ave.
Columbus, OH 43219
614.338.4781 -or- 877.644.6771
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• Federal agency within the United States Department of Health and Human Services [DHHS] that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children’s Health Insurance Program [SCHIP] and the Health Insurance Portability and Accountability Act [HIPAA]
• Reimburses DODD, through ODM, for part of the costs of waiver services
Ohio is in Region 5, which includes Illinois, Indiana, Michigan,
Minnesota, and Wisconsin
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https://sites.google.com/site/doddworkspace/home/tools
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With the active participation of the individual and members of the
individual’s team, the service and support administrator at the county
board shall coordinate an assessment of the individual that takes into
consideration:
• What is important to the individual and for the individual;
• Known and likely risks;
• The individual’s place on the path to community employment;
• What is and is not working in the individual’s life
The assessment shall identify supports that promote the individual’s:
• Rights;
• Self-determination;
• Physical, emotional, and material well-being;
• Personal development;
• Interpersonal relationships;
• Social inclusion
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Using person-centered planning, the SSA shall develop, review, and
revise the individual service plan and ensure that the individual
service plan:
• Reflects the results of the assessment;
• Includes appropriate services and supports;
• Integrates all sources of services and supports, including natural
supports;
• Reflects services and supports that are consistent with efficiency,
economy, and quality of care;
• Is updated throughout the year as needed.
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• The Cost Projection Tool [CPT] which is housed within the Medicaid
Services System [MSS] is used state wide by county boards as the
single common system to project the total costs of services for an
individual based on assessed need to assure health and safety.
• MSS provides a core DODD system to integrate other Department
applications and improve data flow, integrity, and streamline the
payment authorization process.
• The MSS Process is comprised of the following steps:
• Project costs;
• Finalize costs;
• Authorize costs;
• Recommend authorization of payment in PAWS;
• Generate site costs [if needed] in the Daily Rate Application
• MSS is not a billing system. Providers will submit claims through
the Medicaid Billing System [eMBS]. Providers have ‘read’ access
to MSS, which allows them to view cost projections and Payment
Authorization for Waiver Services [PAWS] plans.
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Information on the Medicaid Services System, including the Cost
Projection Tool, the Payment Authorization for Waiver Services
system, and the Daily Rate Application are available online.
http://dodd.ohio.gov/Providers/Resources/Pages/MedicaidServi
cesSystem.aspx
The MSS Process is comprised of the following steps:
(1) Project Costs,
(2) Finalize Costs,
(3) Authorize Costs,
(4) Recommend authorization of payment in PAWS, and
(5) Generate site costs (if needed) in DRA.
Information from MSS is used to populate the enhanced Daily Rate
Application (DRA), Payment Authorization of Waiver Services (PAWS),
and indirectly the enhanced Medicaid Billing System (eMBS).
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You can search by the MSS site name, by individual, or by your
contract number.
If you search for an individual by their first and last name, you must
also include their county of residence.
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Click on ‘Select Site’ to go into the MSS site.
Click on ‘Individual No.’ to view the individual’s PAWS.
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You can go to ‘Manage Cost Projections’ to find out exactly how the
county board has developed your client’s budget.
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The County board can add Homemaker/Personal Care services to a
calendar for routine services. Click on the staffing pattern to view the
details. For instance:
Staffing Pattern: Mon-Fri
Time: # Units: Service: Provider:
12:00 AM-06:00 AM 24 OSOC (S:1 O:1)
06:00 AM-07:30 AM 6 HPC (S:1 H:1)
01:30 PM-11:59 PM 42 HPC (S:1 H:1)
This individual receives a total of 72 units of service throughout the
week. 24 units are on-site/on-call, and 48 units are regular
homemaker/personal care.
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County boards can also project for unscheduled services. In this
case, an additional 40 units of HPC per month has been authorized
for those days that the individual does not attend day programing.
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• PAWS is the system used by county boards to
authorize DODD to reimburse providers for services
• Like the Cost Projection Tool, PAWS is housed within
the Medicaid Services System
• County boards have complete and sole authority to
enter or modify a PAWS plan
• It may take several weeks for a county board to enter
a PAWS plan
• Providers have ‘read-only’ access to PAWS, but
providers do not enter anything into PAWS
• PAWS is not a billing system. All claims are
submitted through the Medicaid Billing System
[eMBS]
• PAWS plans are based on the individual, and not the
provider. Providers do not have PAWS plans
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You will have ‘read-access’ to any PAWS plan that you are
associated.
Click on one of the blue links to continue to the plan details.
PAWS is integrated with the Medicaid Services System and is based
on what is entered in the Cost Projection Tool [CPT] portion of MSS.
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County boards may offer service documentation forms. The provider remains
responsible for ensuring that the forms meet the requirements for
documentation in service-specific rules.
Not all county board forms comply with current requirements.
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• Common issues:• No documentation• Insufficient documentation/documentation not supporting current ISP• Billing a daily rate for HPC & not utilizing the DRA• Non-medical transportation billed on a day the individual did not
receive day services• Not reporting patient liability
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Neither the State of Ohio nor the Department of DD accepts any liability should you,
as an independent business owner, choose to contract with a billing agent.
DODD will not be party to any disputes between providers and billing agents.
You remain complete responsibility for the accuracy and completeness of all claims,
including those submitted by billing agents
You can only be paid for services if:
The services are identified on an approved ISP and recommended
for payment through PAWS.
You are certified to provide the service.
You or your agency supplied the service. All claims are for
services that have already been provided.
You submit claims within 350 days of service.
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• This is the claims processing cycle. You can submit claims at any
time; however, to be processed with a given week we must receive
the claims by noon on Wednesday. It is advisable to submit your
claims before Wednesday to avoid missing the deadline.
• Claims that are submitted after noon Wednesday might not be
picked up for processing.
• Claims that are submitted after the deadline, and that are not
processed until the following week, are still subject to the 350 day
limit for submission.
Effective January 1, 2016, when billing as an independent provider, the State of Ohio has defined a work week as Sunday, 12:00 a.m. to Saturday, 11:59 p.m.
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Check the user guides if you have questions.
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• Single claim entry is where you will submit claims for
reimbursement.
• You will submit a claim for every service you provided to an
individual on a given date. For example:
• Jane Doe is an independent provider who has one client.
• She provides both homemaker/personal care [HPC] and
transportation. On January 5 she provided six hours of HPC
as well as driving her client 12 miles to and from a doctor’s
appointment.
• Jane would submit two claims. One claim would be for 24
units of HPC, and the other would be for 12 units of
transportation.
• The red asterisks indicate fields that you must fill in for all claims.
Some claims need additional information. Check the service codes
in the user guides if you aren’t certain what information you need to
submit.
• In eMBS, you can hover your cursor over the red ‘Help’ to find out
more about that field.
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• You will enter the individual’s 12-digit Medicaid number, the first
initial of their first name, and the first five letters of their last name.
• If the individual’s last name is short, like ‘Doe’, you would enter
‘DOE’.
• If their name was ‘William Doe, Jr’, you would enter ‘DOEJR’.
• If they had a long last name, like ‘Johnson’, you would enter
‘JOHNS’.
• Do not use hyphens or spaces. If the individual’s last name was
‘Doe-Johnson’, you would enter ‘DOEJO’.
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• Pay careful attention to this field.
• For example, if you are entering claims for the last week of
December and the first week of January, make certain you
remember to change the month and the year when going
from December to January.
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• Service codes indicate the type of service you provided.
• A complete list of service codes is available in the user guides of
eMBS, as well as service-specific rules available on our website at
dodd.ohio.gov.
• Service codes are specific to a particular waiver.
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A complete list of service codes is available in the user guides of
eMBS, as well as service-specific rules available on our website at
dodd.ohio.gov.
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Some service codes require that you indicate the group size with
each claim. "Group size“ means the number of individuals who are
sharing services, regardless of the funding source for those services.
Below are two scenarios to illustrate the meaning of group size.
1. You are providing homemaker/personal care to two individuals.
One individual is on a Level 1 waiver and the other is on an
Individual Options waiver. You would submit a separate claim for
each individual, using group size two on both claims.
2. You are providing non-medical transportation to three individuals.
A volunteer is riding along with you. You would submit a separate
claim for each individual using group size three on each claim. You
are not providing services to the volunteer.
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• For agency providers, staff size is the number of staff you provided
for the service that you are submitting a claim.
• Staff size must match your service code.
• For example, if you use service code AMW, which is for
HPC-2 staff, but put a ‘1’ in the staff size, the claim will error
at production.
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• The service county for homemaker/personal care is usually where
the individual lives, unless the Individual Service Plan specifies
otherwise.
• For adult day services, the service county is where the service
actually took place.
• You probably noticed that some of the service codes on the
previous slides indicated a service county was not needed, but the
single claim entry feature in eMBS will require you to enter a
service county for every claim.
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• DODD is required to have a mechanism through which providers
report their usual and customary rate. This is the purpose of the
UCR field in eMBS. You report your usual customary rate with
every claim.
• You can choose to submit the Medicaid rate as your UCR. What
you charge for a service is a decision that only you can make.
• Your UCR must be consistent. You cannot charge a different rate
for different individuals if they live in the same service county.
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• The state of Ohio is divided into 8 cost-of-doing-business
categories.
• The Medicaid rate for a given service is the same for all counties in
the same category.
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Medicaid maximum ratesCost-of-doing-business categories
In this example, we will look for the Medicaid rate for an independent
provider providing homemaker/personal care services in Franklin
county.
• The cost category is 6.
• The group size is 1.
• The Medicaid rate is $4.40. The provider will be paid either
their UCR, or the Medicaid rate, depending on which is
lower.
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Medicaid maximum rates
You would enter an ‘S’ in Other Source Code if the individual has
third party liability [TPL], or ‘1’ if you are reporting patient liability
[PL]. Other Source Amount is only used to report patient liability.
Consult the user guide understanding other source code for more
information.
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This field is optional. If you decide to use it, enter only letters and
numbers. Do not use special characters [ “ “, , ( ), // ] in this field.
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• After entering all of your information, click on ‘Submit Claim’. You
should receive a notice:
• Claim Successfully Submitted. Please note the File Reference
Number :
• Make a note of the reference number for your records. At this
point, your claim has been successfully submitted and will be
processed in the next billing cycle. Successfully submitting a
claim does not mean that the claim will not error. You will need to
view your provider weekly reports, available in eMBS, to see the
status of your claim.
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• You can click on the ‘Upload Flat File’ link to view the file you just
created through Single Claim Entry.
• You have the option of downloading the file, viewing the contents
of the file, or deleting the file.
• There is no ‘edit’ capability in eMBS. If you see a claim you do
not wish to be processed on the file, you will need to delete the
file.
• When you create a file using Single Claim Entry, there is no need
to upload the file. The upload flat file feature is for providers who
create a file off-line, and then upload the file to eMBS.
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• If you see a claim on the file that should not be processed,
the entire file will need to be deleted.
• Example: lines 10 and 11 are both for 2014.
• The most likely reason is that the provider forgot to change the
year when entering the service date.
•
• This would cause eMBS to process the claim as an adjustment-if
the service date had already been entered- or to process a claim
for a date where no service had been provided.
• In this case, the provider should delete the file, and start over.
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You have reached the Ohio Department of Developmental
Disabilities (DODD) Medicaid Billing System (MBS) website.
1) In 'File Status' you can check the status of your file, either by
entering your 7-digit contract number or the 10-digit file
reference number. This will tell you if the file has been picked
up for processing. 'File Status' will NOT tell you the status of the
claims on the file.
2) To view the status of the claims contained within a file please
utilize this Provider Weekly Reports link. Another option (and
available from anywhere within eMBS) to access Provider Weekly
Reports is to navigate under the menu option 'REPORTS' on the left-
hand side of your screen, select 'Provider Weekly Reports', and select
the appropriate weekly billing cycle to find out the status of your
claims.
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• Individual claims without errors that will be submitted to Ohio
Department of Medicaid for adjudication, by billing program and
month billed.
• The input rate is the rate the provider entered into eMBS as their
Usual and Customary Rate. The billed rate is the rate the
amount billed is based on, taking into account the Medicaid
maximum rate for the service being delivered.
• ‘C’ indicates a claim that is being processed for the first time.
• ‘R’ indicates a previous claim that is being adjusted. The original
claim would have been paid on a previous billing cycle, which is
why it does not show up on the current billed report.
• ‘A’ indicates what the claim is being adjusted to.
An adjustment is a change to the number of units, or the input rate,
of a previously paid claim.
Claims are never voided out before making an adjustment. If a claim
is voided out, then anything submitted after that is a new claim, NOT
an adjustment.
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WILLIAMSON, WILLIAM 112233445566 12/15/2014 APC 1
1 WARREN $4.15 $4.15 16 C
The error 28 on the error summed report is a duplicate of the above
claim. Notice that the number of units is different. You cannot enter
two claims for the same date of service with the same service code,
service county, and group size. MBS will error the second claim.
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A complete list of errors is available in eMBS user guides.
A complete list of error codes is available in eMBS User Guides
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Listing of claims that cannot be processed until a matching claim
submitted in a previous billing cycle is approved/denied by the Ohio
Department of Medicaid
Claims will be resubmitted automatically in the next billing cycle
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For assistance with denied claims,
contact Provider Support at
1.800.617.6733.
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• Check your reimbursed approved report against your service
documentation to make certain you have billed correctly.
• If you see where you need to make adjustments to a claim, now
is the time.
• Check to see if you have a reimbursed denied report, and if you
do call DODD to see if the situation is resolved and if you can
resubmit claims.
• Check to see if you have an error report from the prior week, and
if so resubmit the claims correctly.
• Call the county board if you see there is an issue involving
PAWS.
• Use your service documentation from the prior week to submit
your current claims.
• Document your services daily.
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This is the amount that will be deposited into your account, or sent
out as a check.
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1.800.617.6733
• Option 1. Major Unusual Incident reporting
• Option 2. Claims
• Option 3. Certification
• Option 4. Security/IT Support
• Option 5. All others
[email protected] for security or IT support emails
Ohio Department of Developmental Disabilities
30 East Broad Street, 13th Floor
Columbus, Ohio 43215-3434
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