Preschool/School Supportive Health Services Program (SSHSP)

Spring 2017

• Claiming• Parental Consent• Verifying Medicaid Eligibility• SSHSP Claiming After

April 1, 2017• Certified Public Expenditures

• Contacts & Resources

• New York State Medicaid

• SSHSP Background• Compliance

• SSHSP Provider Qualifications

• Documentation of Service

Agenda and Learning Objectives

New York State Medicaid

In New York State the CHIP is called Child Health Plus (CHP) and is available to children who are residents of NYS, under the age of 19—at little or no cost. Call toll-free: 1-800-698-4KIDS, and ask about CHP.

• Medicaid is the single largest source of health coverage in the United States. • Medicaid is a jointly funded federal/state program that, together with the

Children’s Health Insurance Program (CHIP), provides health coverage to over 72.5 million Americans including:

• Children, • Pregnant women, • Parents,• Seniors and individuals with disabilities, and • Other low-income individuals.

New York State Medicaid Program4

Refer those wishing to apply for Medicaid to the NYS Health Exchange at: http://info.nystateofhealth.ny.gov/contact

AVG JUL - SEP 2013 DEC 20160

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

5,678,4176,390,438

New York StateMedicaid/Child Health Plus Enrollment

• New York State operates a State-based Marketplace.

• As of December 2016, NYS has 6,390,438 individuals enrolled in Medicaid/CHP.

• This is a net increase of 12.54% since the first Marketplace Open Enrollment Period.

New York State Medicaid Program (Child Health Plus Enrollment)

5

• NYS Medicaid offers a full range of health services for eligible persons.

• Most Medicaid eligible persons are enrolled in a Medicaid managed care plan.

• Some services are accessed directly through Medicaid fee-for-service (FFS)

even when the eligible person is enrolled in a Medicaid managed care plan.

• SSHSP is an example of a BENEFIT that is “carved out” of managed care.

New York State Medicaid Program, cont.

bl6

eMedNY processes more than 350 million claims annually.

• Electronic Transmitter Identification Numbers (ETIN)

• ePACES (Electronic Provider Assisted Claim Entry System)

• Medicaid Eligibility Verification System (MEVS)

• Maintain eMedNY website

• Processing Medicaid claims• Provider Manuals• Remittance statements and

checks• Electronic Fund Transfer• Billing inquiries• Provider training

CSRA (formerly CSC) is NYS Medicaid’s fiscal agent.Responsibilities include:

New York State Medicaid Program

7

SSHSP Background

EPSDTFederally mandated

(every state)

C/THP NYS's version of EPSDT

SSHSP NYS Medicaid program under EPSDT (C/THP)

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), Child/Teen Health Program (C/THP), & SSHSP

• Federal - EPSDT services - § 1905(r) of the Social Security Act (SSA) • Comprehensive/preventive child health program (birth

up to 21)• Federally mandated in every state’s Medicaid program

• State - Child/Teen Health Program (C/THP)• New York State’s version of federally required EPSDT

services• Provides EPSDT services for children (birth up to 21)

• School districts & counties - SSHSP• Medicaid program included in EPSDT(C/THP) section of

the State Plan• Available to students with disabilities (ages 3 up to 21)• Provides Medicaid coverage for 10 unique services

Medicaid in Education

• A 1988 amendment to the Social Security Act provided statutory authority for Medicaid coverage of medically necessary services included in the Individualized Education Programs (IEPs) of students with disabilities.

• New York State began its SSHSP State Plan Amendment (SPA) #92-42.

• The SSHSP enables school districts and counties to obtain Medicaid reimbursement for certain diagnostic and health support services provided to students with disabilities.

• Under SPA #92-42 Medicaid claiming was done on a monthly basis.

SSHSP History

• 1998 – Whistleblower filed a lawsuit in U.S District Court• Justice Department, Office of the Inspector General and the Centers for

Medicare and Medicaid Services (CMS) audited New York State’s SSHSP.• Federal audits/findings:

• New York State’s SSHSP was found to be out of compliance with federal and State regulations and guidelines.

• School districts and counties did not maintain documentation to support Medicaid billing.

• New York State did not provide proper oversight.

SSHSP History

• 2009 - $540 million settlement - NYS paid $440 million and NYC paid $100 million.

• SPA #92-42 ended June 30, 2009

• A Compliance Agreement between the Centers for Medicare and Medicaid Services (CMS) and New York State was entered into in July 2009.

SSHSP History contd.

Compliance

For more information regarding compliance and the Confidential Disclosure Policy go to: http://www.oms.nysed.gov/medicaid/resources/

•Who is your Compliance Officer?•What is the Confidential Disclosure Policy?•Do you have a Compliance Program?

• NYS Mandatory Provider Compliance Programs• Federal Deficit Reduction Act certification

Compliance14

• Set down in writing NYS’s commitment to:• Comply with all federal and State laws and regulations related to Medicaid funding;

• Ensure policies and practices are modified to achieve compliance; and

• Remedy the consequences of past practices and policies.

• Adoption of two specific policies:• NYS Policy Regarding Its Commitment to Ensure Compliance• Confidential Disclosure Policy (inappropriate billing)

Compliance – New York State

• NYS SSHSP Compliance Policy• Confidential Disclosure Policy• Compliance Officer/Compliance Committee• Audit Requirements• Independent Audits• Annual Written Reports• Training• State Plan Amendment #09-61

Compliance Agreement Elements

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• Confidential Disclosure Policy: New York State must have a confidential disclosure mechanism to enable employees to disclose anonymously any practices or billing procedures deemed by the employee to be inappropriate

• The Compliance Agreement officially ended July 21, 2014

• NYS continues to have a Compliance Officer: Robert Jake LoCicero; Esq - (518) 474-9868

• NYS will continue close oversight of the SSHSP and continue to provide Medicaid trainings to ensure continued compliance.

Compliance Agreement17

Preschool/School Supportive Health Services (SSHSP)

18

s

Educational Needs & Medical Necessity

Documentation of Service Delivery

Reimbursement

SSHSP – Start to Finish

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For additional information, See State Plan Amendment #09-61 at: http://www.oms.nysed.gov/medicaid/resources/state_plan_amendment/home.html

Preschool/School Supportive Health Services Program (SSHSP)• SSHSP is a NYS Medicaid program that allows school districts and counties to

access federal monies for medically necessary services provided to Medicaid eligible students with disabilities as long as all Medicaid requirements are met.

• SSHSP now operates under SPA #09-61 and is included in the EPSDT section of the State Plan.

• Per SPA #09-61, claiming is now encounter based.

• School districts and counties are the only billing providers under SSHSP.

What is SSHSP?

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Reference Handout #1: http://www.oms.nysed.gov/medicaid/training_materials/

Speech Therapy, Including Evaluation/Re-evaluation Physical Therapy, Including Evaluation/Re-evaluation Occupational Therapy, Including Evaluation/Re-evaluation Psychological Counseling

Psychological Evaluation Skilled Nursing Medical Evaluation

Medical Specialist Evaluation Audiological Evaluation Special Transportation

What Services are Provided under SSHSP?

21

Medical necessity means there is a written order/referral from a Medicaid enrolled provider in place prior to delivery of service.

• Service included in the student’s IEP• Medical necessity• Provided by a Medicaid qualified provider• Documentation of provision of Medicaid reimbursable service • Documentation of UDO (under the direction of)/USO (under the supervision

of) - if applicable• Medicaid eligibility

What are the requirements for Medicaid reimbursement of services under SSHSP?

22

• Documents educational needs.• Special Education requirement.• Determines what services are needed to receive free appropriate

public education (FAPE).

Individualized Education Program (IEP)

• Documents medical necessity.• NYS Medicaid requirement.• Allows for potential Medicaid reimbursement.

Written Order/Written Referral

What is the difference between medical necessity and educational needs?

23

SSHSP Provider Qualifications.

24

• Verification of Credentials• It is the responsibility of the Medicaid billing provider (school district or county) to

verify/document practitioner qualifications prior to submitting claims for Medicaid reimbursement.

• Here are some links to help: Office of Professions, OPRA, and the National Plan & Provider Enumeration System (NPPES).

• Affiliate each attending provider’s NPI in eMedNY.• Failure to complete this process could result in a lag in payment or the denial of

SSHSP claims.• Medicaid Alerts 11-03, 12-02, and 14-01 have instructions for the billing provider.

Credentials and Affiliation of Servicing Providers25

For more information see Handout #1 at: http://www.oms.nysed.gov/medicaid/training_materials/handout_1_prov_quals_and_doc_rqrmnts_may_2015.pdf

SERVICE

ORDERING/REFERRING

PROVIDER

SERVICINGPROVIDER

SPEECH THERAPY

Written order/referral signed by a Medicaid enrolled physician, physician assistant, nurse practitioner, or speech-language pathologist (SLP) who is currently licensed, registered and/or certified as required

Licensed/registered SLP, a certified teacher of the speech and hearing handicapped operating under the direction of an SLP, or a certified teacher of students with speech and language disabilities operating under the direction of an SLP

PHYSICAL THERAPY

Written order/referral signed by a Medicaid enrolled physician, physician assistant, or a nurse practitioner who is currently licensed, registered and/or certified as required

Licensed/registered physical therapist or a certified physical therapy assistant operating under the direction of a physical therapist

OCCUPATIONAL THERAPY

Written order/referral signed by a Medicaid enrolled physician, physician assistant, or a nurse practitioner who is currently licensed, registered and/or certified as required

Licensed/registered occupational therapist or a certified occupational therapy assistant operating under the direction of an occupational therapist

Ordering/Referring Provider and Servicing Provider Requirements Speech, Physical, and Occupational Therapy:

blo26

SERVICE

ORDERING/REFERRING

PROVIDER

SERVICINGPROVIDER

PSYCHOLOGICAL

COUNSELING

Referral by an appropriate school official such as a school administrator or the chairperson of the CSE/CPSE or other licensed practitioner acting within his/her scope of practice - See Q&A #21 for more information

Licensed/registered psychiatrist, licensed/registered psychologist, licensed clinical social worker (LCSW), or a licensed master social worker (LMSW) operating under the supervision of a psychiatrist, psychologist, or an LCSW

PSYCHOLOGICAL

EVALUATION

Referral by an appropriate school official such as a school administrator or the chairperson of the CSE/CPSE or other licensed practitioner acting within his/her scope of practice – See Q&A #21 for more information

Licensed/registered psychiatrist or a licensed/registered psychologist

Ordering/Referring Provider and Servicing Provider RequirementsPsychological Counseling and Psychological Evaluations:

Block 27

SERVICE

ORDERING/REFERRING

PROVIDER

SERVICINGPROVIDER

Medical Evaluation

Referral by the CSE/CPSE documented as part of the IEP process

Physician, physician assistant, or a nurse practitioner who is currently licensed, registered and/or certified as required

Medical Specialist Evaluation

Written order signed and dated by a Medicaid enrolled physician, physician assistant, or a nurse practitioner who is currently licensed, registered and/or certified as required

Physician, physician assistant, or a nurse practitioner who is currently licensed, registered and/or certified as required

Audiological Evaluation

Written order signed and dated by a Medicaid enrolled physician, physician assistant, or a nurse practitioner who is currently licensed, registered and/or certified as required

Licensed/registered Audiologist having a Certificate of Clinical Competence (CCC) from the American Speech-Language-Hearing Association

Ordering/Referring Provider and Servicing Provider Requirements Medical Specialist, and Audiological Evaluations:

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 SERVICES

 ORDERING/REFERRING

PROVIDER

 SERVICING PROVIDER

SKILLED NURSING

Written order signed/dated by a Medicaid enrolled physician, physician assistant, or a nurse practitioner who is currently licensed, registered and/or certified as required.

Licensed/registered professional nurse or a licensed/registered practical nurse (LPN) supervised by a licensed/registered healthcare provider in accordance with the Nurse Practice Act

SPECIAL TRANSPORTATION

CSE/CPSE identifies in IEP a medical need for special transportation & how the vehicle is modified to meet the needs of the student. May only be billed on a day that a Medicaid reimbursable service (other than transportation) is delivered.

A vendor lawfully authorized to provide transportation services on the date the service is rendered

Ordering/Referring Provider and Servicing Provider Requirements Skilled Nursing and Transportation:

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• Medicaid Alert 13-07, NYS Medicaid Provider Enrollment Requirement for SSHSP Ordering/Referring Providers

• SSHSP billing providers will not be reimbursed by Medicaid for services that were ordered/referred by non-enrolled NYS Medicaid providers.

• Streamlined ordering/prescribing/referring/attending (OPRA) enrollment process can be found at: https://www.emedny.org/info/ProviderEnrollment/index.aspx.

• Medicaid enrollment status of ordering/referring providers can be found online at: https://www.emedny.org/info/opra.aspx.

Medicaid Provider Enrollment Requirement:Ordering/Prescribing/Referring/Attending (OPRA)

30

Documentation of Service Delivery to Support Medicaid Billing.

31

For more information refer to Q & A #32 at: http://www.oms.nysed.gov/medicaid/q_and_a/

• Documents medical necessity,• Must be in place prior to the provision of service,• Must be kept on file, and• The ordering/referring provider must be enrolled as a NYS Medicaid provider.

• Exception: Referrals for psychological evaluations and counseling services may be made by an appropriate school official or other voluntary health or social agency. School officials are not allowed nor required to enroll as NYS Medicaid providers.

• Must include all the required elements – See Written Order/Referral Handout

Written Order/Written Referral

32

Must include the following elements:• Name of the child for whom the order is written;• Complete date the written order was signed;• Service(s) that is being ordered; • Frequency and duration of the ordered service must either be specified on the

order itself or the order must explicitly adopt the frequency and duration of the service in the IEP by reference;

• Ordering provider’s contact information (office stamp or preprinted address and telephone number); continued

Elements of a Written Order / Written Referral

33

• Signature of a NYS licensed and registered and NYS Medicaid enrolled physician, physician assistant, or nurse practitioner acting within his or her scope of practice (for psychological counseling services this also includes an appropriate school official and for speech therapy services, a speech-language pathologist);

• Time period for which services are being ordered; • Ordering practitioner’s National Provider Identifier (NPI) or license

number; and, • Patient diagnosis and/or reason/need for ordered services.

Elements of a Written Order / Written Referral - continued

34

•Evaluation - Evaluation Report

•Ongoing service - Session Note

•Medication administration - Medication Administration Record (MAR) or Session note

•Special Transportation - Transportation Log for each one-way trip

Documentation of Each Encounter

35

An evaluation report is used to identify a child’s health-related needs as part of the IEP processMedicaid reimbursement is available for evaluations that identify a student’s health-related needs as part of the IEP process. • Documentation of an evaluation is the written report.• The evaluation report must be completed at the end of each evaluation. • An evaluation may take more than one session to complete, but only one unit

is submitted on the claim and billed to Medicaid.• Evaluation report must be dated• Evaluation report must be signed

Evaluation Report

36

• Ongoing service…• Speech;• Physical therapy;• Occupational therapy; or• Psychological counseling.

• A group session includes two or more students.• A session is a block of time (e.g., 30 minutes) specifically set aside to devote

to the provision of that specific service.• Documentation—session note must be completed for the session to be

Medicaid reimbursable.

Session (Individual or Group )

37

For more information see Question and Answer #25 at: http://www.oms.nysed.gov/medicaid/q_and_a/q_and_a_combined_revised_12_9_16.pdf

• Date and time the service was rendered (length of session — record session start time and end time)

• Brief description of the student’s progress made by receiving the service during the session

• Name, title, signature and credentials of the person furnishing the service

• Dated signature and / credentials of supervising clinician as appropriate (signature date must be within 45 days of the date of service).

• Student’s name• Specific type of service provided• Whether the service was provided

individually or in a group (specify actual group size)

• The setting in which the service was rendered (school, clinic, other)

Session NoteSession notes specifically document that the servicing provider delivered a service to a student on a particular date. Session notes must include:

38

Under the Direction of (UDO) for the PTA, OTA, TSHH, or TSSLD means that the supervising therapist (SLP/PT/OT):• Sees the student at the beginning of and periodically during treatment; • Is familiar with the treatment plan as recommended by the referring physician

or other licensed practitioner of the healing arts practicing under State law;• Has input into the type of care provided; • Has continued involvement in the care provided, and reviews the need for

continued services throughout treatment; • Assumes professional responsibility for the services provided under his or her

direction and monitors the need for continued services;

Under the Direction of (UDO)39

See Handout 2 for additional information.

Under the Direction of (UDO) for the PTA, OTA, TSHH, or TSSLD means that the supervising therapist (SLP/PT/OT):• Spends as much time as necessary directly supervising services to ensure students are

receiving services in a safe and efficient manner in accordance with accepted standards of practice;

• Ensures that providers working under his or her direction have contact information to permit them direct contact with the supervising therapist as necessary during the course of treatment; and

• Keeps documentation supporting the supervision of services and ongoing involvement in the treatment of each student.

Note: For occupational therapy, UDO of an OTA/COTA there must be a written OT supervision plan in place, per the updated Article 156.

Under the Direction of (UDO) — continued 40

See Handout 2 for additional information.

Under the Supervision of (USO) for the LMSW means:• The LMSW apprises the supervisor of the diagnosis and treatment of each client; • The LMSW’s cases are discussed; • The supervisor provides the LMSW with oversight and guidance in diagnosing and

treating clients; • The supervisor regularly reviews and evaluates the professional work of the LMSW; and • The supervisor provides at least two hours per month of in-person individual or group

clinical supervision.

The supervising therapist must be a licensed/registered psychiatrist, psychologist, or licensed clinical social worker (LCSW).

Under the Supervision of (USO)41

See Medicaid Alert 15-04 for additional support.

• Documentation of the provision of “UDO” or “USO” must be on file prior to claim submission. This documentation includes the attending provider signing and dating each session note that the servicing provider has completed.

• The servicing provider (clinician that provides the service) must complete and sign a session note as close to the end of the session as practicable.

• The attending provider (practitioner that has overall responsibility for the provided service) must: co-sign and date each session note not more than 45 days following the date of service. (This constitutes one component of documentation of UDO/USO.)

Timely Signatures/Co-signatures for UDO and USO42

School nursing personnel should maintain accurate records of the medication administered, any special circumstances related to the procedure, and the student’s reactions/responses. Sample form is in Handbook 8.

The Medication Administration Record (MAR) must include: • Student’s name and date of birth;• Grade/school; • Medication name, dosage, and route of administration; • Order start date; • Order expiration date; • Prescribers name/telephone number; • Parent’s name/telephone number; • Date, time, and dosage of medication administered; and • Signature and title of the person administering medication.

Medication Administration Record (MAR)43

See Medicaid Alert #13-10 for additional information, including specific exceptions at: http://www.oms.nysed.gov/medicaid/medicaid_alerts/alerts_2013/13_10_clarification_of_federal_guidelines_for_transport_8_28_13.pdf

• The Individualized Education Program (IEP) must include the specific medical need for special transportation to accommodate the student’s disability.

• An explanation as to how the transporting vehicle has been specially modified to serve the needs of that student with a disability must be documented in the IEP.

• The bus/transportation log must include:• The student’s name;• Both the origination of the trip and time of pickup;• Both the destination of the trip and time of drop off;• Bus number or the vehicle license plate number; • The full printed name of the driver providing the transportation; and• Signature of the driver for contracted entities only.

Special Transportation44

These documents are in conjunction with any new/renewed contracts.

Provider Agreement

Contracted provider keeps

any record necessary to disclose the

extent of services the practitioner furnishes to recipients.

Contracted provider

complies with all School

Supportive Health Services

Program (SSHSP)

documentation and program requirements.

Statement of Reassignment

Contracted provider

reassigns all Medicaid

reimbursements to the school district/county

that the practitioner

contracted with for providing

medical services billed under

SSHSP.

Contracted provider accepts

as payment in full, the

contracted reimbursement

rates for covered services.

Contracted provider

complies with all the rules and policies as

described in the contract with the

school district/county.

Contracted provider agrees

not to bill Medicaid directly for any services that the school

district will bill for under the SSHSP.

Must be completed by all outside agencies/contractors (other than BOCES) with whom a school district or county contracts for the provision of SSHSP services.

Provider Agreement & Statement of Reassignment

45

Claiming

46

Information on parental consent can be found online at: http://www.oms.nysed.gov/medicaid/parental_consent/

• Parental consent is a New York State Education/federal Individuals with Disabilities Education Act (IDEA) requirement.

• School districts and counties must obtain a one-time written consent from the parent, and annually provide parents with a written notification of their rights and the opportunity to withdraw consent.

• Medicaid may not be billed for school supportive health services furnished to a student without a signed parental consent that meets IDEA and Family Educational Rights and Privacy Act (FERPA) requirements.

Parental Consent47

Verifying Medicaid Eligibility

48

What are some steps a school district/county should take to obtain a student’s client identification number (CIN)?

School districts/counties have several opportunities to obtain a student’s CIN once parental consent to bill Medicaid has been granted, including but not limited to the following:• Request the student’s CIN when the Parental Consent Form is signed; record the CIN on the

Parental Consent Form.• Request that Medicaid cards are brought to CSE/CPSE meetings.• Request that the ordering practitioner include the student’s CIN on written orders/referrals for

SSHSP services when they have that information in their patient records.• If the school district/county billed in the past, pull CIN from previous billing records or web reports.• Explore opportunities to work with local Social Services or Medicaid Offices to identify students’

CINs.

Verifying Medicaid Eligibility

49

• How can school districts/counties verify a student’s Medicaid eligibility?• To verify a student’s Medicaid eligibility a provider must have either a CIN or a

social security number.• There are three ways to verify Medicaid eligibility (using a CIN or social

security number):• ePACES: Free Internet-based application• Audio Response Unit: (touch-tone telephone method) 1-800-997-1111• Alternate access: Batch and Real-time 270/271 Eligibility Inquiry & Response

Verifying Medicaid Eligibility

50

• The DOH and SED are pursuing a systems project that will result in a limited matching process for situations where parental consent has been obtained and the school district or county has been unable to obtain student’s CIN after using strategies outlined on the previous slide.

• This limited matching process (exact matches) is intended to supplement, not supplant, the steps SSHSP providers will take to obtain CINs and to ensure they have current eligibility information for students receiving SSHSP services.

• Additional information on this process will be forthcoming in 2017.

Limited Eligibility Matching Process

51

• Submit claims for reimbursement as soon as all supporting documentation has been met/obtained.

• Best practice = initial submission should be within 6 months of the date of service.

• SSHSP claims must be submitted to Medicaid no later than 12 months after the date of service.

• Review Medicaid Remittance Reports • Identify and take corrective action to resubmit claims within allowed time

frame.• Resubmissions can not go past the 12-month deadline.

Achieving Maximum Reimbursement52

These are examples only.

Can a billing provider submit a claim that is over 12 months old?If claim submission is delayed due to certain circumstances outside the control of the provider, a formal request (in writing) may be made to DOH to file the claim(s) late. DOH will review each case to determine if claiming is permissible.• Potentially valid reasons could include:

• Delay in Medicaid eligibility determinations;• eMedNY system errors; or• State directed delays.

• Potentially non-valid reasons could include:• Third party billing vendor software deficiencies;• Billing provider not affiliating the clinician; or• Resubmission of denials past the 12-month deadline.

Achieving Maximum Reimbursement53

All Medicaid providers switched from ICD-9 to ICD-10 diagnosis codes for dates of service on or after 10/1/2015.

SSHSP claims must contain the following information: • Student’s Medicaid client identification number (CIN) and other pertinent

demographics;• NPI numbers for: Ordering/referring, attending and billing providers;• A valid appropriate ICD-10 code(s); • An appropriate Current Procedural Terminology (CPT) code(s) and an appropriate

rate code; • Procedure code modifier for PT, OT, and ST claims only; and• Number of unit(s).

Claiming54

• Documentation of service:• Evaluation report; • Session note;• Medication Administration Record

(MAR); or• Special transportation logs.

• Verification of current certification, licensure, and/or registration, of servicing clinician (Medicaid qualified provider);

• Provider Agreement and Statement of Reassignment completed by outside contractors, if applicable;

• Written Order/Referral; and• “UDO” or “USO” documentation, if

applicable.

Documentation that supports Medicaid claiming must be in place prior to submission of the claim and includes:

Summary of Documentation for Claiming

55

• All Medicaid providers are required to report the NPI of the ordering/referring provider on all claims submitted for reimbursement.

• The NPI for the LEA is reported for Psychological Counseling referrals from an appropriate school official.

• Attending providers (employed and contracted) must report their NPI to the appropriate SSHSP billing providers (school districts and counties).

• Billing providers must affiliate the attending providers’ NPI to the school district/county SSHSP Medicaid provider number via eMedNY prior to submission of claims.

National Provider Identifier (NPI) - Medicaid Requirements

56

• In compliance with Health Insurance Portability and Accountability Act (HIPAA) 5010 transaction requirements, the inclusion of an appropriate diagnosis code on Medicaid claims is required.

• An appropriate diagnosis code is one that most closely matches the reason for the service.

• The diagnosis code(s) create a source of data that can be used:• To show why services were rendered;• For resource allocation, such as appropriate staffing and scheduling; and• To track utilization of services.

• Claims for dates of service on and after October 1, 2015 must contain an appropriate ICD-10 code.

ICD-10: Coding and HIPAA Requirements

57

PT and OT evaluation/reevaluation CPT codes were updated by the AMA effective January 1, 2017. See Medicaid Alert #16-08 for interim guidance.

• CPT® is a registered trademark of the American Medical Association (AMA).

• The CPT coding system offers practitioners a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency.

• A CPT code shows what service(s) were rendered. • Appropriate CPT codes must be included on claims. • For CPT codes available for SSHSP claims refer to Handout 5.

Current Procedural Terminology (CPT) Codes58

Medicaid Alert 14-06 provides additional guidance.

Physical, occupational, and speech therapy claims require modifiers.• All Medicaid claims submitted for PT, OT, and ST services (evaluations and

ongoing services) must include the two-digit procedure code modifier to identify the type of service or the claim will deny.

• Each therapy type has a unique procedure code modifier that must be included on the claim.

• GP – Physical therapy GO – Occupational Therapy GN – Speech Therapy

• The procedure code modifier should match the service provider.• Example: CPT Code 97530 group therapy—therapy service provided by PT, a GP

modifier code would be used. If an OT uses this CPT code, a GO modifier would be used.

Procedure Code Modifiers59

If an IEP is developed and ongoing services are recommended, the initial evaluation must be reflected in that IEP to be Medicaid reimbursable. Refer to Medicaid Alert 12-03 for more information.

Physical, Occupational, Speech Therapy or Psychological Counseling• An initial evaluation is the evaluation that is done

• Prior to the development of a student’s first Individualized Education Program (IEP), or• Prior to the inclusion of that therapy (PT, OT, ST, or psychological counseling) in the

student’s existing or next IEP.

• An initial evaluation is not Medicaid reimbursable if it is determined that ongoing services in that same therapy type are not needed.

• See Initial Evaluation Handout.

Initial Evaluations60

Physical, Occupational, and Speech Therapy or Psychological Counseling• A re-evaluation is the evaluation that is done after the student has been

receiving ongoing services in that same therapy type.• Re-evaluations are Medicaid reimbursable even when it is determined that the

ongoing service is no longer needed.Example:

• If a student with an IEP which included speech therapy is re-evaluated for speech therapy, and it is determined the student no longer needs speech therapy, that re-evaluation is billable to Medicaid.

Re-evaluations61

See Q+A 77 for make-up; and Q+As 148 -149 for cycle calendar.

Definition: A make-up session is one that was scheduled, subsequently missed, rescheduled, and then made-up. • Medicaid reimbursement is available for a make-up session only when it is made up

within the same week or cycle that it was missed. • A make-up session is the only time 2 services of the same type may be billed for the

same date of service.

Claiming: To bill Medicaid for multiple sessions on the same date of service, submit one claim with all services provided and increase the units, as appropriate.

Claiming for Make-up Session

62

SSHSP Claiming AfterApril 1, 2017

63

• Final submission of SSHSP claims to eMedNY by CNYRIC was March 30, 2017.

• April 1, 2017 - The claiming window for SSHSP has returned to 12 months.• SSHSP claims date must now be submitted to NYS Medicaid directly by the

school district or county, or via a contracted Medicaid Service Bureau.

• CNYRIC will accept demographic data files for creation of matching and eligibility Web Reports for two additional months through June 1, 2017.

.

TAKE ADVANTAGE: The final submission for demographic data files will be June 1, 2017.

SSHSP Billing

• Effective April 1, 2017 school districts and counties are either:

• Submitting claims for Medicaid reimbursement directly to eMedNY or • Submitting claims for Medicaid reimbursement to eMedNY via a Medicaid Service

Bureau.

• Whether the SSHSP provider or the Medicaid Service Bureau submits the claims, the SSHSP provider is has ultimate responsibility for the integrity of the claim.

SSHSP Billing

By April 1, 2017 SSHSP providers should have:

• Determined if they will be using a Medicaid Service Bureau;• Determined if they need an ETIN (Electronic Transmission Identification

Number);• Obtained an ePACES login and ePACES training if they will be checking

Medicaid eligibility and or submitting claims; and • Completed a Trading Partner Agreement

SSHSP Billing

Who needs to have an ETIN?• SSHSP providers must apply for their own ETIN if they will be

submitting claims directly to eMedNY.

• SSHSP providers that have chosen to use a Medicaid Service Bureau must complete a Certification Statement to link their MMIS billing provider number to the Service Bureau’s ETIN.

• SSHSP providers are strongly encouraged to apply for their own ETIN.

SSHSP Billing - ETIN

Who needs to complete a Trading Partner Agreement?• The Trading Partner Agreement addresses certain requirements applicable to the electronic exchange

of information and data associated with health care transactions. All trading partners who will be submitting claims or other electronic transactions to NYSDOH need to have a Trading Partner Agreement (TPA) on file. The TPA form must include the Electronic Transmitter Identification Number (ETIN) as assigned by NYS DOH and other identifying information as noted on the form.

• School districts and counties must complete and submit a Trading Partner Agreement for each ETIN the provider uses for electronic transactions.

• The NYS Medicaid Trading Partner Agreement is available at eMedNY.org:a. Select Provider Enrollment tabb. Click on Provider Maintenance Formsc. Under Miscellaneous Maintenance Forms, Click on Trading Partner Agreement.

Trading Partner Agreement Information

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Certified Public Expenditures (CPEs)

69

• The CPE reimbursement methodology is an annual cost reconciled and settled reimbursement methodology.

• CPE cost settlements are based on the school year (July 1st to June 30th).• Allows NYS to request additional federal funding for costs not completely

covered by current fee-for-service Medicaid reimbursement.• Public Consulting Group (PCG) is the Department of Health’s contractor who

assists with the implementation of the CPE reimbursement methodology.

Certified Public Expenditures (CPEs)70

• The major components of the CPE reimbursement methodology are… • Time spent by practitioners delivering Medicaid reimbursable services

(Random Moment Time Study – RMTS);• Actual costs including employee salaries, fringe benefits, contract costs, and

equipment purchases and maintenance (reflected in annual cost reports); and • Interim Medicaid reimbursement received from encounter-based billing.

Certified Public Expenditures (CPEs)71

The Random Moment Time Study (RMTS) identifies the statewide proportion of allowable and reimbursable direct service time, and the results are used as a statistic in the cost reimbursement process.

Certified Public Expenditures (CPEs) - RMTS72

Who participates in the RMTS? • Included in RMTS Process:

• School district staff providing direct medical services• Excluded from RMTS Process:

• School district/county contracted providers of SSHSP services (cost included in cost report process)

• County staff providing direct medical services (staff included in separate 100% time-tracking process)

Certified Public Expenditures (CPEs) - RMTS Overview 73

• Participants do not receive advance notification of moments. The first notification will be delivered shortly after the moment occurs.

• Participants have two (2) school days from the time of the moment to submit the moment. After two school days, the moment expires and can no longer be accessed or submitted by the participant.

The RMTS includes the distribution of 2,827 moments to participants within each cost pool on a quarterly basis.

All moment notifications are sent to participants via e-mail from nysshsp@pcgus.com.

Certified Public Expenditures (CPEs) - RMTS Overview

74

s

Educational Needs & Medical Necessity

Documentation of Service Delivery

Reimbursement

SSHSP – Start to Finish

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Contacts & Resources

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Public Consulting Group: RMTS and CPE• Hotline: (866) 912-2974• NYSSHSP@pcgus.com

Compliance Officer, SSHSPRobert Jake LoCicero, Esq.Director, Bureau of Vital Records Division of Administration Department of Health800 North Pearl Street Menands NY 12204• (518) 474-5245• robert.locicero@health.ny.gov

NYS DOH: SSHSP Medicaid Policy and Medicaid Claiming Questions

• (518) 473-2160• SSHSP@health.ny.gov

NYSED: Medicaid in Education –Provider Support and Training

• (518) 474-7116• Medined@nysed.gov • RIC Contacts

OMIG: Compliance Program and Audit• (518) 473-3782 (main office)

Contacts77

Computer Science Corporation (eMedNY): https://www.emedny.org/• Enrollment, Affiliation, and Revalidation

NYS Office of Medicaid Inspector General (OMIG): http://www.omig.ny.gov/• Compliance Program and Audit

Medicaid-In-Education: http://www.oms.nysed.gov/medicaid/

• Questions & Answers • Medicaid Alerts • Handbook 8• Handouts 1 – 7

• DOH: SSHSP Policy and Claiming, and

• SED: Provider Support and Training

Public Consulting Group (PCG): • Random Moment Time Study (RMTS) and Certified

Public Expenditures (CPEs)

Resources78

• Medicaid Alert 13-09, Update to SSHSP CPT Codes

• Medicaid Alert 14-02, International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)

Handbook 8• http://www.oms.nysed.gov/medicaid/

handbook/Questions & Answers• http://www.oms.nysed.gov/medicaid/

q_and_a/Medicaid Alerts• http://www.oms.nysed.gov/medicaid/

medicaid_alerts/

Resources for Psychological Evaluations79

• Medicaid Alert 13-07, NYS Medicaid Provider Enrollment Requirement for Providers who Order/Refer in the SSHS Program

• Medicaid Alert 13-16, Speech Evaluation CPT Code Changes – Interim Process

• Medicaid Alert 14-02, International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)

• Medicaid Alert 14-03, SSHSP Billing Codes for Speech Evaluations (Update to Medicaid Alert 13-16)

• Medicaid Alert 14-06, Effective Immediately - Physical, Occupational, and Speech Therapy Claims Now Require Modifiers

Handbook 8• http://www.oms.nysed.gov/medicaid

/handbook/Questions & Answers• http://www.oms.nysed.gov/medicaid

/q_and_a/Medicaid Alerts• http://www.oms.nysed.gov/medicaid

/medicaid_alerts/

• Medicaid Alert 10-03, Clarification of Credential Requirements for Speech-Language Pathologist

Resources for Speech Therapy

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• Medicaid Alert 13-08, Update on Physical Therapist Qualifications for the Preschool/School Supportive Health Services Program (SSHSP)

• Medicaid Alert 14-02, International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)

• Medicaid Alert 14-06, Effective Immediately - Physical, Occupational, and Speech Therapy Claims Now Require Modifiers

Handbook 8• http://www.oms.nysed.gov/medicaid/

handbook/Questions & Answers• http://www.oms.nysed.gov/medicaid/

q_and_a/Medicaid Alerts• http://www.oms.nysed.gov/medicaid/

medicaid_alerts/

Resources for Physical Therapy81

• Medicaid Alert 10-02, Clarification of Credential Requirements for Occupational Therapy Assistants

• Medicaid Alert 13-09, Update to SSHSP CPT Codes

• Medicaid Alert 14-02, International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)

• Medicaid Alert 14-06, Effective Immediately - Physical, Occupational, and Speech Therapy Claims Now Require Modifiers

Handbook 8• http://www.oms.nysed.gov/medicaid/

handbook/Questions & Answers• http://www.oms.nysed.gov/medicaid/

q_and_a/Medicaid Alerts• http://www.oms.nysed.gov/medicaid/

medicaid_alerts/

Resource for Occupational Therapy82

• Medicaid Alert 13-09, Update to SSHSP CPT Codes

• Medicaid Alert 14-02, International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)

Handbook 8• http://www.oms.nysed.gov/medicaid/

handbook/Questions & Answers• http://www.oms.nysed.gov/medicaid/

q_and_a/Medicaid Alerts• http://www.oms.nysed.gov/medicaid/

medicaid_alerts/

Resources for Psychological Counseling83

• Medicaid Alert 14-02, International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)

• Medicaid Alert 15-02, Clarification on Medicaid Reimbursement for Nursing Services

Handbook 8• http://www.oms.nysed.gov/medicaid/

handbook/Questions & Answers• http://www.oms.nysed.gov/medicaid/

q_and_a/Medicaid Alerts• http://www.oms.nysed.gov/medicaid/

medicaid_alerts/

Resources for Skilled Nursing84

Do you know who your Compliance Officer is?

• NYS Commitment to Compliance• NYS agrees to be in compliance with federal and State laws, rules and regulations.• NYS requires those participating in SSHSP to also be in compliance. • http://www.oms.nysed.gov/medicaid/Training/A_Commitment_to_Compliance_Final.pdf

• Confidential Disclosure Policy• How to anonymously report fraud, waste and abuse.• Should be posted conspicuously in the school district/county locations.

Resources for Compliance Policies85

Thank you.

Questions?

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