Introduction to SSHSP – Training Agenda

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NYS Preschool/School Supportive Health Services Program (SSHSP)

Medicaid-in-Education

Introduction to SSHSP

Revision date: May 29, 2013

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Introduction to SSHSP – Training Agenda

SSHSP Fundamentals and History Medicaid Covered (Reimbursable) Services Qualified Medicaid Practitioners Documentation Requirements Medicaid Billing and Claiming Policy Medicaid Claiming Compliance Requirements Resources Contact Information

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SSHSP Fundamentals and History

What is SSHSP?SSHSP HistoryWho may access Medicaid funds?SSHSP MissionRoles in SSHSP

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What is SSHSP?

Preschool/School Supportive Health Services Program (Collectively “SSHSP”)

A New York State program that allowsschool 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.

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SSHSP History

Social Security Act (SSA) – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services: §1905(r)

1988 – Amendment to SSA to incorporate services in schools

1988 – NYS created SSHSP (through the Medicaid State Plan Amendment (SPA) process)

2010 – State Plan Amendment #09-61 was approved for services provided 9/1/2009 and forward

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Who May Access Medicaid Funds?

School districts may access federal Medicaid funds for certain IEP services provided to school age students ages 5 - 21.

Counties may access federal Medicaid funds for certain IEP services provided to preschool students ages 3 - 5.

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SSHSP Mission

To assist school districts and counties in providing quality healthcare to students with disabilities for certain diagnostic and health support services while accessing Medicaid reimbursement for eligible services and preventing fraud, abuse, and false billing to the Preschool/School Supportive Health Services Program (SSHSP) through compliance with federal and State laws, regulations and guidelines.

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Roles in SSHSP

NYS Education Department (SED)• SSHSP Implementation (Training)• Special Education Policy• Billing Provider Support

NYS Department of Health (DOH), Office of Health Insurance Programs (OHIP)

• Medicaid Policy• Payment Methodology

NYS Office of the Medicaid Inspector General (OMIG)• Audits of school districts and counties• Compliance Plans

continued…

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Roles in SSHSP

Regional Information Centers (RICs)• Billing Provider Support

School Districts and Counties• Implement SSHSP at Local Level• Monitor Contractors• Submit SSHSP Claims for Reimbursement

Public Consulting Group, Inc. (PCG)(DOH contractor)

• Assist DOH, SED and SSHSP Billing Providers with Implementation of Certified Public Expenditures (CPE) Reimbursement Methodology

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SSHSP MedicaidCovered (Reimbursable) Services

Covered Services

SSHSP Requirements

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SSHSP Medicaid Covered (Reimbursable ) Services

Effective 9/1/2009, school districts and counties may access federal Medicaid funds for the following IEP services covered under SPA #09-61:

1. Speech Therapy (and Evaluations)

2. Physical Therapy (and Evaluations)

3. Occupational Therapy (and Evaluations)

4. Skilled Nursing

5. Psychological Counseling

6. Psychological Evaluations

7. Audiological Evaluations

8. Medical Evaluations

9. Medical Specialist Evaluations

10. Special Transportation Medicaid coverage of IEP related services is available only until the student’s 21st birthday.

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SSHSP RequirementsIn order to be Medicaid reimbursable, SSHS must be:

Medically necessary and included in a Medicaid covered service category;

Included in the State’s Medicaid plan and/or available under Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) to children from ages 3 up to age 21;

Prescribed, ordered or referred by a practitioner acting within his or her scope of practice;

Included in the child’s Individualized Education Program (IEP);

continued…

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Provided by qualified professionals under contract with or employed by a New York State school district or county;

Furnished in accordance with all requirements of the New York State Medicaid Program and other pertinent State and federal laws and regulations, including those regarding provider qualifications, comparability of services, freedom of choice and the amount, duration and scope provisions.

SSHSP Requirements

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Qualified Medicaid Practitioners

Practitioner Qualifications Practitioner Credential Verification NPI Requirements Direction/Supervision Requirements What does UDO/USO mean?

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SSHSP Provider Definitions Billing provider

• School district or county

Ordering/referring provider • Licensed practitioner who has ordered/referred

services

Attending provider• Clinician who has the overall responsibility for the

student’s medical care and treatment. In cases where the servicing provider works “under the direction of” or “under the supervision of” a licensed clinician, the directing/supervising clinician is considered the “attending” clinician

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Practitioner Credential Verification

Verification of current New York State certification/licensure/registration of the servicing/attending practitioner

• It is the responsibility of the Medicaid billing provider (school district or county) to verify practitioner qualifications prior to submitting claims for Medicaid reimbursement

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NPI Requirements

National Provider Identifier (NPI)• National standard for identifying health care providers• Federal requirement per the Health Insurance Portability and

Accountability Act (HIPAA)

Each SSHSP billing provider must have an NPI

Each attending provider must have an NPI registered with billing provider’s eMedNY file

• Attending providers can apply for a NPI at the following website: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions

• See Medicaid Alert 12-02

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Direction/Supervision Requirements

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What Does UDO/USO Mean?

Under the Direction of (UDO) for the TSHH, TSSLD, PTA, OTA:

Sees the student at beginning of and periodically during treatment;

Is familiar with the treatment plan and has continued involvement and directly supervises services;

Assumes professional responsibility; and

Keeps documentation supporting the supervision of services.

Under the Supervision of (USO)for the LMSW:

Apprises the supervisor of the diagnosis and treatment;

Cases are discussed; and supervisor provides oversight and guidance;

The supervisor provides at least two hours per month of in-person individual or group clinical supervision.

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SSHSP - What Does UDO Mean for the Licensed Practical Nurse (LPN)?

LPNs may only work under the direction of a registered professional nurse or licensed physician, or other licensed health care provider legally authorized under Education Law - Article 139 Nursing, and in accordance with the commissioner's regulations.

LPN’s scope of practice:• Performing tasks and responsibilities within the framework of

case finding• Health teaching and health counseling• Providing supportive and restorative care

For further information, refer to the NYSED website at: http://www.op.nysed.gov/prof/nurse/article139.htm

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SSHSP DocumentationRequirements

Parental Consent to Bill Medicaid * Individualized Education Program (IEP) Provider Agreement/Statement of Reassignment Service Documentation

* Although not a Medicaid documentation requirement, IDEA requires parental consent to

share student specific information to access federal Medicaid funds in this program.

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Parental Consent to Bill MedicaidParental Consent to Bill Medicaid (per IDEA)

School districts and counties must obtain parental consent to claim for SSHSP Medicaid reimbursable services that are on the student’s IEP

The consent form must include the specific IEP time period

Must be informed consent - the parent must be made aware that this is a voluntary consent and it can be withdrawn at any time without affecting IEP services

Note: There were changes in federal parental consent regulations on 3/18/13. Additional guidance will be posted on the SED website when available.

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Individualized Education Program (IEP)

The IEP is a strategic plan documenting special needs related to a student, his/her disability and how the special needs will be met. All related services and evaluations must be reflected in the student’s IEP to be Medicaid reimbursable.

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Provider Agreement and Statement of Reassignment

Provider Agreement and Statement of Reassignment are to be completed by all outside agencies/contractors (other than a BOCES) with whom a school district or county contracts for the provision of SSHSP reimbursable services.

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Service Documentation: Written Order/Referral

Documents medical necessity Must be in place prior to service delivery in order

to bill Medicaid Must be completed by a Medicaid qualified practitioner Must include the following elements:

• The name of the child for whom the order is written;• The complete date the written order was signed;• The service type that is being ordered;*

*Effective January 1, 2013 the frequency and duration of the ordered service must be either specified on the order itself or the order can adopt the frequency and duration of the service by explicit reference to the IEP.

(See Medicaid Alert 12-11.) continued…

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• Ordering/referring provider’s contact information (office stamp or preprinted address with telephone number)*;

• Original signature of a NYS licensed and registered physician, physician assistant or nurse practitioner** acting within his or her scope of practice;

• The time period for which services are being ordered;

• The ordering practitioner’s National Provider Identifier (NPI) or license number; and

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

*A Medicaid alert is forthcoming that will establish a future date that the ordering/referring provider must be an enrolled NYS Medicaid provider.

**For purposes of the SSHSP, where written referrals are permitted (e.g., speech therapy services, psychological counseling services), the written referral must include the information as listed above.

Service Documentation: Written Order/Referral

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Service Documentation: Evaluations/Services

Encounter Documentation Requirements: For Ongoing Treatment – a contemporaneous

session note For Evaluations – the evaluation report For Medication Administration – Medication

Administration Record (MAR) or session note For Special Transportation – a daily

transportation log

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Service Documentation: Session Notes

A contemporaneous session note documents the service that was rendered by a practitioner and must include:

Student’s name; Specific type of service provided; Whether the service was provided individually or in a group (specify the actual group size serviced during the session); The setting in which the service was rendered (school, clinic, other); Date and time the service was rendered (length of session – record session start and end time); Brief description of the student’s progress made by receiving the service during the session; and Name, title, signature and credentials of the person furnishing the service and signature/credentials of the directing/supervising clinician as appropriate.

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SSHSP Medicaid Documentation Retention Policy

Billing providers must retain SSHSP supporting documentation for a period of six years from the date the services were furnished or billed, whichever is later

All records necessary to support the nature and extent of services/evaluations furnished and the medical necessity therefore, including any prescription (written order or written referral) for services/evaluations

Note that individual professions may have other record retention requirements in addition to the Medicaid program requirements

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MedicaidBilling and ClaimingPolicy Fundamental Medicaid Billing Requirements NPI Requirements CPT Codes ICD-9 Codes

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Fundamental Medicaid Billing Requirements

The student must be eligible for Medicaid (have an eligible CIN) for the date the service was delivered.

Billing provider must maintain the documentation to support a claim billed to the SSHSP.

Billing provider must obtain parental consent to bill Medicaid (in accordance with IDEA).

Billing provider must incur a cost for providing the service or evaluation.

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Prior to submitting claims to Medicaid for reimbursement, the billing provider is responsible for ensuring that each service or evaluation is:

Medically necessary (written order/referral); Included in the IEP; Provided by a Medicaid qualified practitioner; and Documented (evaluation report, session note,

MAR or transportation log).

Fundamental Medicaid Billing Requirements

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NPI Requirements

Effective January 1, 2012, SSHSP Medicaid claims must include:

Billing provider NPI• School district or county

Attending provider NPI• Clinician who has the overall responsibility for the student’s

medical care and treatment. In cases where the servicing provider works “under the direction of” or “under the supervision of” a licensed clinician, the directing/supervising clinician is considered the “attending” clinician.

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NPI Requirements

SSHSP Medicaid claims must also include:

Ordering/referring provider NPI*• Licensed practitioner who has ordered/referred

services


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Current Procedural Terminology (CPT) Codes

CPT code(s) must be reported on each SSHSP Medicaid claim.

The SSHSP Medicaid qualified attending practitioner will need to:

• Assign a CPT code(s) that accurately describes the type of service rendered during the session, and

• Report the units of service rendered during the session

CPT codes are either timed/untimed and individual/group.

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International Classification of Diseases, 9th Revision, Clinical

Modifications (ICD-9)

Effective September 1, 2012, SSHSP Medicaid claims must include:

An appropriate ICD-9 code(s) that represents a main condition or disability of the student receiving the service

• Billing providers must report the most specific diagnosis code available (3, 4 or 5 digit code)

• See Medicaid Alert 12-04

MedicaidClaiming Medicaid Claiming Process Current SSHSP Funding & Reimbursement Anticipated SSHSP Funding & Reimbursement

Certified Public Expenditures (CPEs)

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SSHSP Claiming Process

Billing providers, except the New York City Department of Education, submit claims for services to the SSHSP clearinghouse – the Central New York Regional Information Center (CNYRIC)

When a student is referred to the Committee on Special Education (CSE) or the Committee on Preschool Special Education (CPSE), the billing provider enters the student’s biographical data into billing software

CNYRIC will run the biographical data against the New York State Medicaid eligibility list to create a monthly Medicaid Eligible Match Report (ELIGREPT) and a Near Match/Multiple Match Report (MATCH) for each billing provider

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SSHSP Claiming ProcessThe billing provider must transmit the following information for each SSHSP Medicaid claim:

Student demographics, Dates of service, CPT code(s), Number of units, Attending provider and billing provider NPI Ordering/referring provider NPI* Diagnosis code(s) (effective 9/1/12)

This data is entered into billing software to create a billing data file (BILLSUM) to be submitted to CNYRIC for processing based on the Medicaid Monthly Claiming/Billing Calendar.


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SSHSP Claiming Process

Medicaid reimbursement from NYS/eMedNY will be sent to the billing provider when processing is completed.

Web reports are available at the CNYRIC website to assist the billing provider in understanding the claiming process.

Note: The CNYRIC will post available web reports athttp://www.cnyric.org/ (click Web Application, Web Reports). Please contact your local RIC for password authorization, web access and web reports training.

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Current SSHSP Funding & Reimbursement

SSHSP billing, under SPA #09-61, began in April 2011 for appropriately documented services provided on or after 9/1/2009.

The SSHSP is a jointly funded program (50% federal share, 50% non-federal share)

The federal share represents new monies to the billing providers

The non-federal share represents an advance of state aid reimbursement

The NYS Department of Health issues an electronic transfer to the billing provider representing both the federal and non-federal shares.

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Anticipated SSHSP Funding & Reimbursement

Certified Public Expenditures (CPEs)

Federal Medicaid law and regulation authorize the use of Certified Public Expenditures (CPEs), an annual cost reconciled and settled reimbursement methodology.

DOH intends to utilize CPEs in an effort to increase federal funding of the SSHSP. The CPE methodology allows NYS to request additional federal funding for SSHSP costs that are not completely covered by current Medicaid reimbursement.

DOH has contracted with Public Consulting Group, Inc. (PCG) to implement and support the CPE reimbursement methodology.

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Components of CPEs

Random Moment Time Study (RMTS)• The time study determines the percentage of time that

direct medical services staff spend on direct medical services. The percentage is used to determine the billing provider’s Medicaid reimbursable costs.

Cost Based Settlement Process• The billing provider’s Medicaid reimbursable costs are

compared to the billing provider’s interim SSHSP billing to determine excess/deficit in reimbursement.

Anticipated SSHSP Funding & Reimbursement

ComplianceRequirements

NYS Compliance Agreement NYS Compliance Policy/Confidential

Disclosure Policy

OMIG Compliance Program

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Compliance Agreement

SSHSP Compliance Officer/SSHSP Compliance Committee

State Plan Amendment Audit Requirements Independent Audits Annual Written Reports NYS P/SSHSP Compliance Policy Confidential Disclosure Program Training

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Adoption of two specific policies:

• NYS Compliance Policy NYS Policy Regarding Its Commitment to

Ensure Compliance

• Confidential Disclosure Policy Confidential Disclosure Policy (inappropriate

billing)

Compliance Requirements

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Compliance RequirementsOMIG Compliance Program

Effective October 1, 2009, all persons, providers and affiliates (including school districts and counties) claiming, ordering or receiving payments in excess of $500,000(gross) from the Medical Assistance Program are requiredto have a written Compliance Program.

Ensures Medicaid providers establish systemic checksand balances to detect and prevent inaccurate billing and inappropriate practices in the Medicaid Program.


Prevents, detects and remedies inappropriate billing and protects whistleblowers:

1. Written policies and procedures, including how to report

2. Designated compliance officer (best practice)

3. Training for employees, administrators and board members

4. Reporting line to compliance officer (including anonymous and confidential)

continued… 50

5. Discipline failing to report, permitting suspected non-compliance

6. Routine identification of risk areas – internal/external audit

7. Procedures to respond to, correct, and report compliance issues

8. Policy of non-intimidation and non-retaliation for making a report of suspected non-compliance

For more information go to the OMIG website at www.omig.state.ny.us 51


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Lists of individuals or entities excluded, restricted, terminated or censured from participating in the Medicaid Program

Will help providers avoid submitting claims for services provided by excluded individuals/agencies

Includes ordering practitioners

Lists should be checked on a monthly basis

Exclusion Lists

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Exclusion ListsNYS Exclusion List

http://www.omig.ny.gov/index.php/fraud/medicaid-terminations-and-exclusions

Federal Exclusion List

http://oig.hhs.gov/exclusions/index.asp

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Resources

Informational websites Contact information

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SSHSP – Informational Websites

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

• Medicaid Handbook #7• Frequently Asked Questions• Billing and Claiming Calendar• Online Training• Medicaid Alerts

Office of Professions Website: http://www.op.nysed.gov

National Alliance for Medicaid in Education (NAME) Website

http://medicaidforeducation.org/

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SSHS Program Contacts:Medicaid in Education

Please direct SSHSP questions to:

<add local RIC contact information here>

or e-mail

[email protected]

Introduction to SSHSP – Training Agenda

Documents

Transcript of Introduction to SSHSP – Training Agenda