Medicaid Billing Module Transportation Billing Form.
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Medicaid Billing Module Transportation Billing Form
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Transcript of Medicaid Billing Module Transportation Billing Form.
Medicaid Billing Module
Transportation Billing Form
Transportation Billing Form Demographics Section
Medicaid Number Last Name First Name County School
WVEIS # Diagnosis Code Date of Birth Month/Year Vehicle Type
Modified
Demographics Section
• Complete the top row of demographic information using the county and school codes.
• On the bottom row fill in the full WVEIS #, Diagnosis Code should be left blank until further notice, date of birth and the Month and Year for billing.
• The billing form cannot have data from multiple months.
Transportation Billing Form Demographics Section EXAMPLE
Medicaid Number Last Name First Name County School
00000000001 Doe Jane 058 301
WVEIS # Diagnosis Code Date of Birth Month/Year Vehicle Type
999999999 01-01-1900 August 2015 Modified
Procedure Code and Instruction
__T2001 SE – Non-Emergency Medical Transportation – with Bus Aide. List start and end times per trip.
T2002 SE – Non-Emergency Medical Transportation (NO AIDE). List mileage of each trip.
(Up to 4 one-way trips per instructional day.) Locations would be school, home, or another specific location such as RESA or doctor office. The last column will be completed at a later date by staff responsible for Medicaid. Purpose is completed only for students who are receiving a Medicaid billable service that day.
Procedure Code Section
• Check the line next to T2001 SE for modified bus with an aide. This is used for a bus with a lift only.
• This procedure is for a one way trip. (We no longer need round trips to bill.)
• Typically you can bill two trips per instructional day. • If a student is taken to a billable service during the
instructional day you could bill up to four trips in a day.
Procedure Code Section
• Procedure Code T2002 SE is only used for a modified bus (with a lift) that doesn’t have an aide.
• Unlikely you will have any billable trips for this code.
• If using this code complete the mileage column instead of start and stop times.
Data Entry Section
Date Departure Location
Arrival Location
Start Time
Stop Time Mileage Purpose: To provide access to the following billable service(s).
Data Entry Section
• For Procedure T2001 SE the aide or driver will complete the first five columns per one-way trip.
• Mileage is not needed and should be left blank
• The last column will be completed by staff at the school, county or RESA level.
Data Entry Section• Date: Enter the date of the trip• Departure Location: Enter home or school • Arrival Location: Enter home or school• Start Time: Document the time the student boarded the
bus. • Stop Time: Document the time the student exited the
bus. • Start and stop times must be actual times each day not
the regularly scheduled times. Actual times will vary based upon weather, traffic, and other factors.
Data Entry Section
Date Departure Location
Arrival Location
Start Time
Stop Time Mileage Purpose: To provide access to the following billable service(s).
8-17-15 Home School 7:32 7:50
8-17-15 School Home 2:55 3:18
Data Entry Section
• If a student was transported to RESA for an Audiology Evaluation during the school day with a modified bus and aide you could document this as follows.
Data Entry Section
Date Departure Location
Arrival Location
Start Time
Stop Time Mileage Purpose: To provide access to the following billable service(s).
8-17-15 Home School 7:32 7:50
8-17-15 School Home 2:55 3:18
8-18-15 Home School 7:30 7:50
8-18-15 School RESA 8 9:30 10:15
8-18-15 RESA 8 School 11:30 12:15
8-18-15 School Home 2:55 3:25
Data Section Purpose Column
• This section will be completed by an employee who has access to the student’s completed billing forms for the month.
• Enter the billable service provided for trips that match the date of service
• If there was not a billable service for a trip date enter NA
• Only one billable service needs to be entered per trip.
Data Entry Section
• Billable services include: Speech, Occupational Therapy, Physical Therapy, Audiological, Nursing, Personal Care, Psychological (testing or psychotherapy) and Targeted Case Management (TCM).
Data Entry Section
Date Departure Location
Arrival Location
Start Time
Stop Time Mileage Purpose: To provide access to the following billable service(s).
8-17-15 Home School 7:32 7:50 NA
8-17-15 School Home 2:55 3:18 NA
8-18-15 Home School 7:30 7:50 Speech
8-18-15 School Home 2:55 3:25 Speech
8-19-15 Home School 7:32 7:50 TCM
8-19-15 School Home 2:55 3:22 TCM
Data Entry Section
• After completing the purpose column fill in the number of total trips, total billable trips, and total non-billable trips.
• This information will be used by the financial department for year end calculations.
Data Entry Section
Date Departure Location
Arrival Location
Start Time
Stop Time
Mileage Purpose: To provide access to the following billable service(s).
8-17-15 Home School 7:32 7:50 NA 8-17-15 School Home 2:55 3:18 NA 8-18-15 Home School 7:30 7:50 Speech 8-18-15 School Home 2:55 3:25 Speech 8-19-15 Home School 7:32 7:50 TCM 8-19-15 School Home 2:55 3:22 TCM
Total Trips 6 Total Billable Trips 4 Total Non-Billable Trips 2
Signatures and Credentials
• Driver is required to sign this form. • Driver credential is Bus Driver• Aide is required to sign this form.• Aide credential is the classification of
employment such as Aide I, Aide II, Aide III.
Attendance Verification
• It is important to verify that the student was present in school on the day that billable trips were listed.
• Compare attendance logs to ensure accuracy.
• A student could have a tardy, early departure, or a half-day absence and still have one billable trip.
Terry Riley – CoordinatorOffice of Special Education
[email protected] ext 53223
WVDE Medicaid Website:http://wvde.state.wv.us/osp/medicaid.html
