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Preschool / School Supportive Health Services Program

(SSHSP)

SSHSP Fundamentals and 2013 Program Update

Revision Date: June 5, 2013

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Training Agenda

Section 1 SSHSP Compliance History SSHSP Training Recap SSHSP Audit Findings

Section 2 Review of Selected 2012-2013 Medicaid Alerts Program Review Program Updates

Section 3 Certified Public Expenditures (CPEs) Medicaid Administrative Claiming (MAC)

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Section 1

Compliance HistoryTraining RecapAudit Findings

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Three year Compliance Agreement between the federal government and NYS began in 2009

Compliance Agreement has been extended and will be in effect until NYS has met all requirements

Elements of the Compliance Agreement include: NYS SSHSP Compliance Policy NYS Confidential Disclosure Policy NYS Compliance Officer/Compliance Committee OMIG Audit Requirements Independent Audits NYS Annual Written Reports Relevant Employee Compliance Training (Phase I, II & III) Implementation of State Plan Amendment (SPA) #09-61

SSHSP Compliance History

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Social Services Law §363-d 18 NYCRR Part 521

Medicaid providers must establish checks and balances to detect and prevent inaccurate billing and inappropriate practices in the Medicaid program

Is required for all persons, providers or affiliates claiming, ordering or receiving payments in excess of $500,000 (gross) from the NYS Medicaid program

Compliance programs do not need to be approved by OMIG, but must be annually recertified by person, provider or affiliate

Do you know the elements of a compliance program? Do you know what your school district/county/affiliate

compliance program entails?

OMIG Compliance Program

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Training Recap

What was learned over the past 3 years?

How would your school district/county fare in an OMIG/CMS audit today?

What policies are in place in your school district/county to help avoid audit disallowances?

Does your school district/county have a Compliance Officer? Do your relevant employees know who your compliance

officer is and how to reach him or her? Is your school district/county only billing for services that

are included in the IEP? Are your service practitioners appropriately credentialed?

Handout 1 – Provider Qualifications and Documentation Requirements

Do you have the appropriate documentation to support your SSHSP claims?

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Training Recap

It is the school district/county responsibility to ensure their relevant employees, including contracted personnel, are aware of and adhere to SSHSP billing requirements, compliance policies and all updates.

Service(s) must be provided by a Medicaid qualified practitioner(s)

Required documentation to support Medicaid claims must be retained

Confidential disclosure policy must be displayed

Topic specific training modules will be available on the Medicaid-in-Education website at www.oms.nysed.gov/medicaid once approved and/or updated.

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OMIG Audit Findings for 2010 – 2012 Dates of Payment

OMIG initiated 152 audits in the last 3 years. Findings include lacking or inappropriate documentation to support SSHSP claims:

Written orders/referrals Missing date Dated after start of treatment

“Under the Direction of”/”Under the Supervision of” (see Handout 2) No documentation of face-to-face meetings with student No documentation of the required meetings with

practitioners Final OMIG audits can be found at:

http://www.omig.ny.gov/audit/final-audit-reports

Audit Findings

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Regional Information Center (RIC)Documentation Reviews (Site Visits)

RICs will be conducting select documentation reviews of school districts/counties in their regions

Used as a tool to assist the school district/county in maintaining proper documentation to support Medicaid billing under the SSHSP

Are NOT audits

Listing of RICs and their contact information: http://www.oms.nysed.gov/medicaid/contacts/ric_contacts.html

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Section 2

2012-2013 Medicaid AlertsProgram ReviewProgram Updates

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All Medicaid Alerts can be found at:

http://www.oms.nysed.gov/medicaid/medicaid_alerts/home.html

Medicaid Alerts

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December 2012 Medicaid Alert

Medicaid Alert #12-11 (issued 12/10/2012)

Medicaid Policy Regarding Written Orders/Referrals

All written orders/referrals completed on or after January 1, 2013 must either contain the frequency and duration of the service(s) to be furnished or must adopt - by explicit reference to the IEP - the frequency and duration of the ordered service(s) in the IEP.

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Medicaid Alert # 13-01, (issued 2/6/2013)

Medicaid Administrative Claiming

Informs school districts about the Medicaid Administrative Claiming (MAC) program for the School Supportive Health Services Program. Additional federal funds under Medicaid may be available for the cost of administrative activities that directly support efforts to identify and enroll students who are potentially eligible for Medicaid into the Medicaid program, as well as those administrative activities that directly support the provision of medical services covered under the state Medicaid plan.

February 2013 Medicaid Alert

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February 2013 Medicaid Alert

Medicaid Alert # 13-02, (issued 2/7/2013)

Psychological Evaluation and Counseling CPT Code Changes – Interim Process

The NYS Department of Health (DOH) has been notified of changes made by the American Medical Association (AMA) to the psychotherapy CPT codes as of January 1, 2013. The AMA has issued several new codes with descriptors, discontinued some codes, and maintained some existing codes for psychological evaluations and counseling services.

DOH is in the process of making the necessary system changes to accommodate these new CPT codes.

A Medicaid Alert will be issued when servicing practitioners may use the new CPT codes.

Continue using the existing CPT codes until further notice (see Handout 5)

March 2013 Medicaid Alert

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Medicaid Alert # 13-04, (Issued 4/4/2013)

Requirement to Report Ordering/Referring Provider’s National Provider Identifier (NPI) on SSHSP Medicaid Claims

School Districts and counties are required to report the NPI of the ordering/referring provider on all Medicaid claims beginning with claims submitted for dates of service on and after May 1, 2013.

Psychological evaluations or psychological counseling services referred by an appropriate school official must use the school district or county billing provider NPI in place of the ordering/referring provider NPI on claims for services rendered on and after May 1, 2013.

School districts and counties must use the school district or county billing provider NPI in place of the ordering/referring provider NPI on claims for special transportation provided on and after May 1, 2013.

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June 2013 Medicaid Alert

Medicaid Alert # 13-05, (issued 6/5/2013)

Timely Submission of SSHSP Medicaid Claims

Effective December 1, 2013, SSHSP providers must:

Submit Medicaid claims to eMedNY within 12 months after the date of service (DOS). Claims must be submitted to CNYRIC no later than 11.5

months after the date of service. This differs from the previous policy allowing the

submission of claims to CNYRIC up to 22 months from the DOS.

See the Medicaid-in-Education SSHSP revised 2013 Monthly Claiming/ Billing Calendar.

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National Provider Identifier (NPI)

eMedNY-Affiliation Process for Attending Providers’ NPI:

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

Billing providers must then affiliate the attending providers’ NPI to the school district/county SSHSP Medicaid provider number via eMedNY prior to submission of claims for dates of service on and after January 1, 2012

See Medicaid Alerts #11-03 and #12-02 for additional information

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International Classification of Diseases,9th Revision, Clinical Modification (ICD-9-CM) ICD-9-CM is a set of HIPAA translation codes used by health care

providers to indicate diagnosis for all patient (student) encounters.

Effective September 1, 2012 Medicaid claims must include a valid ICD-9 code that represents: A main condition or symptom that is the reason the service is

being provided. The diagnosis or the reason/need for a medically necessary

service included on the written order/referral for the SSHSP service can be used on claims for the ordered services.

A resulting diagnosis from an evaluation could be used on the claim for the evaluation and the claims for ongoing services that were recommended as a result of the evaluation.

See Medicaid Alert 12-04 for additional information.

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School districts and counties must report the most specific ICD-9 code available. They must report a:

three-digit code if there are no four-digit codes within the category, or

four-digit code if there are no five-digit codes within the category, or

five-digit code (fifth sub classification codes) for those categories where they are available.

International Classification of Diseases,9th Revision, Clinical Modification (ICD-9-CM)

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EXAMPLE:

314 Hyperkinetic syndrome of childhood 314.0 Attention deficit disorder

314.00 Without mention of hyperactivity 314.01 With hyperactivity

314.1 Hyperkinesis with developmental delay 314.2 Hyperkinetic conduct disorder 314.8 Other specified manifestations of hyperkinetic

syndrome 314.9 Unspecified hyperkinetic syndrome

4-digit code

5-digit code

3-digit code

International Classification of Diseases,9th Revision, Clinical Modification (ICD-9-CM)

International Classification of Diseases,9th Revision, Clinical Modification (ICD-9-CM)

Claims are being denied because the most specific ICD-9 code is not being used on the electronic Medicaid claim.

See your CNYRIC “Pre-adjudication” web report – Reason 254 invalid ICD-9 code.

Example: 299.0 Autism Disorder (not a billable code) 299.00 and 299.01 (are both billable and more specific)

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Q. What if the coding professional cannot assign a 4-digit or 5-digit code from the reason/need on the written order because the reason/need is not that specific?

A. Suggest that the ordering/referring provider be contacted for clarification. Create and maintain detailed documentation of correspondence with ordering practitioner for the record (this documentation will be proof of the reason why the diagnosis on the order may not exactly match the diagnosis code used on claims).

International Classification of Diseases,9th Revision, Clinical Modification (ICD-9-CM)

International Classification of Diseases,9th Revision, Clinical Modification (ICD-9-CM)

American Physical Therapy Association (APTA) http://www.apta.org/

American Occupational Therapy Association (AOTA) http://www.aota.org/

American Speech-Language-Hearing Association (ASHA) http://www.asha.org/

American Psychological Association (APA)http://www.apa.org/

American Medical Association (AMA)

http://www.ama-assn.org/ama

The Centers for Medicare and Medicaid Services (CMS)

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html

The Centers for Disease Control and Prevention (CDC)http://www.cdc.gov/nchs/icd.htm

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Coding guidance for professionals:

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Business Office Reminder

Electronic Transmitter Identification Number (ETIN)

Involves the SSHSP billing provider giving approval to the Central New York Regional Information Center (CNYRIC) to receive their electronic remittance (payment) files for posting to the billing provider’s web reports and MedWeb system for downloading.

ETIN certification statements must be renewed annually. Failure to renew will result in the inability to submit claims and receive payments (claims pended at CNYRIC).

Renewal notices are sent to billing providers by Computer Science Corporation (CSC). Pre-printed forms must be signed and notarized.

A copy of the recertification statement should be sent to your local Regional Information Center (RIC).

Medicaid SSHSP Update

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Edit Code #22 ‘Covered by Another Payer’ – Past Denials

Business Office Reminder

The implementation of HIPAA 5010 system changes caused many SSHSP claims to be denied by Computer Sciences Corporation (CSC) with the edit code #22, “Covered by Another Payer”.

This issue was corrected as of 10/20/2012 processing. Resulting Action for SSHSP edit #22 - past denials:

The edit #22 denied claims with a date of service (DOS) of 1/1/12 forward were reprocessed by CSC and paid in Cycle 1838 (DOH Check Date 11/12/2012).

The edit #22 denied claims with a DOS 12/1/10-12/31/11 were reprocessed by CSC and paid in Cycle 1854 (DOH Check Date 3/4/2013) and Cycle 1855 (DOH Check Date 3/11/2013).

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Medicaid SSHSP Update

Parental Consent

On February 14, 2013, the Federal Department of Education published in the Federal Register IDEA Part B final regulations that the requirements in 34 CFR 300.154(d) related to parental consent to access public benefits or insurance (e.g., Medicaid) be amended. These final regulations, which take effect on March 18, 2013, will make it easier for school districts and counties to access public benefits while still protecting family rights.

Specifically, these final regulations require that public agencies (school districts and counties): obtain a one-time written consent from the parent, after

providing written notification . . . before accessing the child’s or the parent’s benefits or insurance for the first time . . .

provide written notification to child’s parents before accessing the child’s or the parent’s public benefits or insurance for the first time and prior to obtaining the one-time parental consent and annually thereafter . . .

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Medicaid SSHSP Update

Parental Consent

The written notice must explain all the of the protections available to parents under Part B of IDEA to ensure parents are fully informed of their rights

The written notice must be written in language understandable to the general public and in the native language of the parent . . . unless it is clearly not feasible to do so.

The NYS Office of Special Education Services has issued guidance on the implementation of these regulations: http://www.p12.nysed.gov/specialed/publications/parentconsent-publicbenefits.htm

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Medicaid SSHSP Update

Parental Consent

Link to memorandum from the NYSED P-12 Office of Special Education:

http://www.p12.nysed.gov/specialed/publications/parentconsent-publicbenefits.htm

Link to the federal Office of Special Education & Rehabilitative Services (OSERS): 

http://www2.ed.gov/policy/speced/reg/idea/part-b/part-b-parental-consent.html

The federal link includes: An unofficial copy of the revised regulations A one-page summary of what the changes mean A Q&A to explain what the revisions mean to schools

across the United States.

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Medicaid billing providers are required to check the following exclusion lists: NYS Exclusion Listhttp://www.omig.ny.gov/index.php/fraud/medicaid-terminations-and-exclusions

Federal Exclusion Listhttp://oig.hhs.gov/exclusions/index.asp

School districts/counties are no longer required to check the www.epls.com website (which is inactive) or the SAM website (which is where users are being directed to register)

NYS/Federal Exclusion Lists UPDATE

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Section 3

Certified Public Expenditures (CPEs)

Medicaid Administrative Claiming (MAC)

CPEs and MAC

Public Consulting Group, Inc. (PCG)

Is a contractor of the New York State Department of Health and is assisting with the implementation of both CPEs and MAC. http://www.oms.nysed.gov/medicaid/CPEs/home.html

Certified Public Expenditures (CPEs) Quarterly Random Moment Time Study (RMTS) Annual Cost Report Fee-for-Service, Cost Settlement

Medicaid Administrative Claiming (MAC) Quarterly Random Moment Time Study (RMTS) Quarterly MAC Claim No Fee-for-Service, No Cost Settlement

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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. The CPE methodology will allow additional federal funding for SSHSP direct service costs that are not covered by fee-for-service Medicaid reimbursement.

The components of CPEs include: Random Moment Time Study (RMTS) Annual Cost Report Cost Settlement Process

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Certified Public Expenditures (CPEs)

Random Moment Time Study (RMTS)

For a school district or county to participate in the SSHSP (fee-for-service), they must participate in the RMTS

Measures the work effort of a group of providers involved in the SSHSP by sampling and analyzing the work efforts of a randomly selected cross-section of the group

RMTS coordinators provide rosters, on a quarterly basis, of eligible employees (do not include contracted practitioners)

Determines the percentage of time participants spend on direct medical services, administrative, and other activities

Used in both the CPE process and Medicaid Administrative Claiming (MAC)

RMTS user guide: http://www.oms.nysed.gov/medicaid/CPEs/rmts_training_MarApr12.ppt

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Certified Public Expenditures (CPEs)

Random Moment Time Study (RMTS)

New York State must meet a 90% response rate Participants are contacted via e-mail If a participant is randomly selected, a response is required in the

web-based RMTS system Participants are notified 5 days in advance of moment and then

again 24 hours prior to moment Participants and Coordinators receive reminder notifications for

moments without a response at 24 and 72 hours after the moment

Each moment needs to be completed within 5 days Potential negative statewide impact if moments are not

responded to

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Certified Public Expenditures (CPEs)

Annual Cost Report – due December 31 of each year

Cost based reconciliation process for direct medical services delivered by school districts and counties

The annual cost report will be used in conjunction with the quarterly random moment time study process to determine the school district/county cost basis

The annual cost report is completed electronically via the Medicaid Cost Reporting and Claiming System (MCRCS)

School districts and counties billing Medicaid under SSHSP (fee-for-service) are required to participate in the annual direct service cost reporting process.

Certified Public Expenditures (CPEs)

Annual Cost Report – due December 31 of each year (continued)

Can only include salaries of those school district/county employed practitioners on the RMTS rosters.

Include contracted practitioners (non-tuition-based) on Supplemental Form.

Include contract practitioner costs and tuition costs on respective schedules of cost report

Contracted practitioners for whom costs are included on contractor page must be identified on Supplemental form

Cost reporting user guide: http://www.oms.nysed.gov/medicaid/CPEs/cost_reporting_guide.pdf

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Certified Public Expenditures (CPEs)

Cost Settlement (Direct Medical Services)

Annual cost report of SSHSP related direct services expenditures

Each school district’s/county’s cost report will be compared to their fee-for-service SSHSP billing

The resulting difference is the cost settlement Three quarterly random moment time studies used in the

cost settlement process

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Medicaid Administrative Claiming (MAC) Federal reimbursement for administrative costs associated with

the implementation of the SSHSP

Facilitating Medicaid Outreach Facilitating Medicaid Eligibility Determination Translation Related to Medicaid Services Program Planning, Policy Development, and Interagency

Coordination Medicaid Related Training Referral, Coordination and Monitoring of Medicaid Services

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Medicaid Administrative Claiming (MAC)

Two ways Medicaid Administration is claimed: Quarterly Cost Reports and Quarterly Administrative

RMTS Via the Direct Cost Report and Quarterly Direct Service

RMTS MAC is available to school districts participating in cost

settlement process At this time, MAC is not being implemented for counties School districts may choose to participate at the beginning

of any quarter MAC costs do not include the costs of developing an IEP See Medicaid Alert #13-01 MAC User Guide:

http://www.oms.nysed.gov/medicaid/CPEs/MAC_Presentation_0213.ppt

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Contact Information and Resources

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Local Regional Information Center (RIC) Contacts

<RIC – please enter your contact information as appropriate>

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NYS SSHSP Contacts - SED

Name Telephone E-mail RegionSteven Wright 518-486-4887 swright2@mail.nysed.gov

NYCKelly Gicobbi 518-486-7828 kgicobbi@mail.nysed.gov

Broome/MohawkJeff Foley 518-402-5121 jfoley@mail.nysed.gov

Nassau/Suffolk/Northeast

Paula Cooper 518-402-5218 pcooper@mail.nysed.gov Mid Hudson/ Westchester/

NortheastSheila Costa 518-474-4178 scosta@mail.nysed.gov

Western/Southern TierKelly Mason 518-486-2287 kmason2@mail.nysed.gov

Monroe/ Central/Finger Lakes

Mailbox: medined@mail.nysed.gov

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Name Telephone E-mail

Connie Donohue 518-473-2160 cld03@health.state.ny.us

Cristin Carter 518-473-2160 cmc10@health.state.ny.us

Melissa Kinnicutt 518-473-2160 mak16@health.state.ny.us

NYS SSHSP Contacts - DOH

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Listserv

Medicaid Listserv

To subscribe, please send an e-mail message to:

LISTSERV@LISTSERV.NYSED.GOV Subject = Subscribe The body of the message must read: SUBSCRIBE

MEDINED firstname lastname

Complete instructions for subscribing/unsubscribing athttp://www.oms.nysed.gov/medicaid/listserv_registration.html

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NYSED Medicaid-in-Education Websitehttp://www.oms.nysed.gov/medicaid/

Medicaid-in-Education Handbook Medicaid-in-Education Questions & Answers Medicaid Alerts Claiming and Billing Calendar Training Calendar

NYSED Office of Professionshttp://www.op.nysed.gov

NYS Department of Healthhttp://www.health.state.ny.us/health_care/medicaid

National Alliance for Medicaid in Education (NAME) http://www.medicaidforeducation.org/

Medicaid Resources

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Public Consulting Group, Inc.

Hotline: 866-912-2974

E-mail: NYSSHSP@pcgus.com

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OMIG Contact Information

E-mail for compliance questions: compliance@omig.ny.gov

Website: www.omig.ny.gov

OMIG ListServ Subscriptions:http://www.omig.ny.gov/omig-email-list-subscriptions

Compliance Exclusion ListsDedicated Line Sean ParkerBureau of Compliance 518-402-1816 518-408-0401

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Thank you!