RESA 8 

MEDICAID REIMBURSEMENT PROGRAM Terri Stewart: Medicaid Coordinator: thstewar@access.k12.wv.us

Chrissy Keller: Medicaid Secretary/Assistant: cmkeller@access.k12.wv.us

 Phone: 304-267-3595

Fax: 304-267-3599www.RESA8.org

  

MEDICAID REIMBURSEMENT PROGRAM

  WV Code 18-2 5b permits the RESA 8 school districts to participate and

submit claims for Medicaid Reimbursement via for the following services:   Physical Therapy Occupational Therapy Speech Language Therapy Psychological evaluations and counseling Audiological Services Specialized Nursing Services IEP Development Personal Care Care Coordination Specialized Tranportation/Aide   Participation in the program requires specific criteria and guidelines as

provided by the West Virginia Department of Education, Office of Special Education in coordination with the Bureau for Medical Services, Health Care Financing Agency (HCFA), and the West Virginia Department of Human Services. Reimbursements accrued through the submission of claims are used to supplement services throughout the school districts.

 

GETTING STARTED

• Each Child must have an Individualized Education Plan, (IEP), By either testing into, currently active, or testing out, with allowed billable services listed on service page(s) or addendum. (No submissions of claims should be dated past the last active day in special education).

• Each Child must be identified Medicaid eligible

At the beginning of each school year RESA will identify all students that are currently Medicaid eligible, with subsequent updates throughout the year.

• Each Child must have a completed, signed (Consent For Medicaid Billing). Consents may be requested yearly at the completion of an IEP, or when service units change. Example: next page

EXAMPLE

CONSENT TO RELEASE INFORMATION FROM EDUCATIONAL RECORDS FOR MEDICAID BILLING

Student’s Full Name: Terri Anne Stewarte The county school district wishes to periodically apply for reimbursement for certain services provided to eligible children during the year by accessing Medicaid or other publicly funded benefits. This access will not result in any decrease in available lifetime coverage or any other insured benefit; will not result in any cost to the child or the child’s family; will not increase any premium or lead to the discontinuation of the child’s benefits or insurance; and will not create any risk of loss of the child’s eligibility for West Virginia’s Title XIX MR/DD Waiver Program based on aggregate health-related expenditures. The county school system is providing the following Medicaid covered services to your child:

TYPE OF SERVICE FREQUENCY (per week/month/year)

Is the service also provided outside the

school system? Audiology Services Per need Occupational Therapy Services 60 minutes per week Physical Therapy Services 60 minutes per week Psychological Services 15 minutes per month Speech Therapy Services 45 minutes per week Nursing (RN) Specialized Procedures Medication administration Personal Care Aide (direct 1:1) Continuous adult support

across all educational settings

Specialized Transportation (vehicle) Daily to and from school Specialized Transportation (aide) Daily to and from school IEP-Development (Initial or Annual/Triennial Update)

Per need

Care Coordination One unit per month If your child is receiving audiological, occupational therapy, physical therapy, psychological and/or speech services from a provider(s) outside the school system, please list the name of the provider(s) in the box(es) provided so that the school system does not duplicate the outside provider’s Medicaid billing. Medicaid reimbursement to districts is authorized by West Virginia Code 18-2-5b, effective March 15, 1990. These funds provide additional financial resources for the county’s educational services. Regardless of the status of the consent, the school district will continue to provide your child’s IEP services with available federal, state and/or local school district dollars. I give my consent to release information from my child’s educational records for the purpose of Medicaid billing. Parent Signature: Pareent Signature Child’s Medicaid Number: 00-000000-00 Family Physician (optional): Dr. Name, 1-304-000-0000

The Medicaid Consent Form is a stand alone form. This form should be completed upon the creation of a new IEP or if there has been a change to a greater extent of services in a current IEP.

DOCUMENTATION

Submitting claims for Medicaid Reimbursable Services requires specific responsibilities and accuracy for supporting documentation required by federal regulations. Specific responsibilities include but are not limited to the following:

Maintaining complete, accurate and appropriate documentation, as listed on most billing forms

Complete preparation and signing of service records/logs/forms Ensuring that supporting documentation is maintained in each child’s file in the

county Maintaining confidentiality Ensuring that duplicated claims are not submitted to Medicaid

Documentation is not a new concept to the special education system. Educational personnel are required to document student progress through a child’s IEP, lesson plans, summaries, assessments, anecdotal notes, formal progress reports and letters/memorandums to parents/guardians or other members of education. The necessity of documentation for Medicaid reimbursement runs parallel to educations requirements. The following information from the School-based Services Medicaid Operations Manual will provide teacher’s guidelines and the necessary documentation per reimbursable services.

Billing-Related Documentation 1. The first and last name, WVEIS #, and Medicaid # of the student 2. The diagnostic code(s) of the student 3. The group provider – i.e. county 4. The individual provider name, signature and credentials 5. The date(s) of service 6. Place of service 7. The type and number of service(s) provided with procedural code(s) 8. The number of units provided

WWW.RESA8.ORG

1. Select Programs2. Select Medicaid

Reimbursement3. Select Forms4. Click on the Forms Icon5. Select the form needed, (all

forms are in the Word format, you can open the form and print or save to your computer

RESA 8 UPDATED MEDICAID REIMBURSEMENT FORMS

Service Record – Initial/Triennial Treatment Plan

Medicaid Number Last Name First Name 00-0000000-00 STUDENT IDENTIFIED

Date of Birth WVEIS #

Diagnosis Code

00-00-00 000000000 79999

County School Initial Triennial Completed IEP Date

Proc. Code Units

BERKELEY MART. ELE.

X 05/11/11 H2000 1

INITIAL/TRIENNIAL (H2000)

*1. Student Assistance Team Meeting or Date of Referral to Special Education (if initial) 03/27/11

2. Reviewed previous reports /documentation 03/27/11 *3. Received parental consent to evaluate or completed a re-evaluation determination plan or completed a SLD Team Report 04/07/11

*4. Prepared notice of eligibility and parental rights to send home 04/17/11

*5. Eligibility Committee Report date 05/05/11

*6. Finalized IEP date 05/05/11

Ms. Teacher 05/05/11 IEP TEAM LEADER’S SIGNATURE _________________________ DATE ______________

Note: Documentation for Step 6 is the IEP form (all parts). Steps 1, 3, 4, 5 and 6 must be documented as having occurred, in order to bill as initial or triennial.

The following information must be documented for the Initial/Triennial (Re-evaluation) Treatment Plan.

Date Reports documenting the results of evaluations including SAT minutes Parental consent to evaluate or a completed re-evaluation determination plan, and (for triennial if

team decides no testing necessary, than a Prior Written Notice and rights to request additional testing must be sent to parent/guardian)

Notice of eligibility and parental rights Eligibility Committee meeting/report Full Individualized Education Plan (IEP) completed with the same dates on each page, signature

/attendance page, and parent permission to bill signed

Ini-Tri IEP RESA 8

There has been a change in this billing form due to the fact that a student may be found eligible for learning disability services using the RTI method rather than a psychological evaluation. Therefore language was added to #3 to accommodate the change.

Creation of an IEP is an occurrence. The submission for reimbursement includes all the activities and actions leading to the actual development of the finalized IEP.

Service Record – Annual Treatment Plan

Medicaid Number Last Name First Name 00-0000000-00 STUDENT IDENTIFIED Date of Birth WVEIS # Diagnosis Code 00-00-00 000000000 79999 County School Date of completed IEP Procedure

Code Units

BERK MH 5/17/11 H2000 TS 1

ANNUAL IEP MEETING (H2000 TS)

1. Contacted/sent notice to parent/guardian re: IEP Team meeting(s)

05/06/11 2. Finalized IEP Date 05/17/11 Ms. Teacher 5/17/11 IEP TEAM LEADER’S SIGNATURE _______________________________ DATE _______________

Note: Step 1 and 2 must be documented as having occurred, in order to bill as an Annual IEP Update. The following information must be documented for the

Annual Treatment Plan Notice of meeting to parent /guardian Review of most current testing/evaluation data and /or Review and complete Present Levels of Educational Performance (PLEPs) Full Individualized Education Plan, the date the same on all pages of IEP Current signature page and a signed parent permission

Annual IEP RESA 8

Do not submit for the development of an updated IEP when you have merely added an addendum to the current IEP.

Creation of an IEP is an occurrence. The submission for reimbursement includes all the activities and actions leading to the actual development of the finalized IEP.

Service Record – Care Coordination Medicaid Number Last Name First Name School 00-0000000-00 STUDENT IDENTIFIED MH

Date of Birth WVEIS # Provider # Diagnosis Code

00-00-00 00000000 00000000000 79999

County Beginning Date(mo/dy/yr) Ending Date(mo/dy/yr) Procedure Code

Units

BERKELEY 08/01/11 08/31/11 T2022 1

Care Coordination. T2022 = 1 unit per month. List dates of activities completed this calendar month (This does not include activities in the development of IEP) Care Coordination Activities Date(s) A. Met with Special Ed. or Reg. Ed. teacher regarding child’s service needs/progress (Name:) Ms. Teacher

8/25/11

B. Met with Therapist regarding service needs/progress (Name) C. Met with Psychologist regarding service needs/progress (Name) D. Met with Social Worker (Name) E. Met with Counselor regarding service needs/progress (Name) F. Met with Personal Care Aide regarding needs/progress (Name) G. Met with other health care provider regarding child’s service needs/progress (Name)

H. Issued letter/memorandum regarding child’s service needs/progress (attached copy required)

I. Contacted provider(s) to schedule testing/consultation J. Met with parent(s)/guardian(s) regarding child’s treatment needs/progress K. Met with parent(s)/guardian(s) on testing results L. Issued letter/memorandum to parent(s)/guardian(s) (attached copy required) M. Contacted parent(s)/guardian(s) to schedule consultation N. Met with child to discuss progress O. Met with child to discuss service needs P. Met with child to discuss social/behavioral issues Q. Reviewed provider assessment/testing results R. Reviewed provider notes/memoranda regarding child’s service needs/progress 8/23/11 S. Prepared progress notes (attached copy required) T. Prepared summary of provider consultation (attached copy required) U. Prepared summary of parent/guardian consultation (attached copy required) V. Prepared summary of child consultation (attached copy required) W. Prepared other documentation of service treatment/progress (attached copy required)

X. Other: (Explain) Completed agenda for parent 8/25/11 Outcome: (Circle one) A. Progress Satisfactory - Continue IEP until completion date B. Reconvene IEP Team to address change Ms. Teacher 8/31/11 ________________________________________ __________________ Signature Date The following information must be documented for Care Coordination.

Section A completed with name and Medicaid number of student The month and year of service The LEA The specific activity or activities should be dated Circle Outcome Signature of person providing the coordination of the IEP

Care Coordination Form RESA 8

NOTES:________________

_______________________

_______________________

_______________________

_______________________

This form is completed for activities and services provided concerning the implementation of the services from the IEP, Not the development of the IEP

Service Record – Personal Care (Partial day student) Medicaid Number Last Name First Name

00-0000000-00 STUDENT IDENTIFIED Date of Birth Diagnosis Code WVEIS #

00-00-00 79999 000000000 County School Beginning of Month

(mo/dy/yr) End of Month

(mo/dy/yr) Procedure Code Units

BERK MH 08/01/11 08/31/11 T1020 U5 5

PERSONAL CARE – PARTIAL DAY STUDENT T1020 U5 (Attach attendance record) SERVICE UNIT: Once per day DESCRIPTION: Services related to a child’s physical and behavioral health requirements,

including assistance with eating, dressing, personal hygiene, activities of daily living, bladder and bowel requirements, use of adaptive equipment, ambulation and exercise, behavior modification, and/or other remedial services necessary to promote a child’s ability to participate in, and benefit from, the educational setting.

QUALIFIED PROVIDERS: Services are furnished by providers who have satisfactorily completed a

program for home health aides/nursing assistants, or other equivalent training, or who have appropriate background and experience in the provision of personal care or related services for individuals with a need for assistance due to physical or behavioral conditions.

MUST BE IDENTIFIED ON IEP: Yes, example language: (“Child requires adult supervision on a direct and a

continuous basis”), or equivalent) PHYSICIAN AUTHORIZATION: Not required. OTHER/MISC: Service must be provided on a full-time basis to partial day student. Partial day student means a student who attends for no more than one-

half of a normal school day. Full-time service means at least 2.75 hours per day.

Check dates if the part-time student had a personal care aide for the full time in school (2.75 hours). Provide a time in for dates tardy or time out for early dismissal.

Date 1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25 26 27

28

29 30 31 Total

Partial-day Student

5

Ms. Teacher 8/31/11 ___________________________________________ ______________________________ Signature Date Documentation for Personal Care:

Section A completed with name, Medicaid number of student, month, year, LEA The specific dates of attendance checked on paper form and attendance register to coincide with the claim dates for each

student ex. (WVEIS report AOS.760) Signature of authorized LEA personnel Personal Care-Partial-Day RESA 8

NOTES:________________

_______________________

_______________________

_______________________

_______________________

Service Record – Personal Care (Full-day student) Medicaid Number Last Name First Name

00-0000000-00 STUDENT IDENTIFIED Date of Birth Diagnosis Code WVEIS #

00-00-00 79999 000000000 County School Beginning Month

Date (mo/dy/yr) Ending Month Date

(mo/dy/yr) Procedure Code Units

BERK MH 08/01/11 08/31/11 T1020 5

PERSONAL CARE – FULL DAY STUDENT T1020 (Attach attendance for each month) SERVICE UNIT: Once per day DESCRIPTION: Services related to a child’s physical and behavioral health requirements, including assistance with eating, dressing, personal hygiene, activities of

daily living, bladder and bowel requirements, use of adaptive equipment, ambulation and exercise, behavior modification, and/or other remedial

services necessary to promote a child’s ability to participate in, and benefit from, the educational setting.

QUALIFIED PROVIDERS: Services are furnished by providers who have satisfactorily completed a

program for home health aides/nursing assistants, or other equivalent training, or who have appropriate background and experience in the provision of personal care or related services for individuals with a need for assistance due to physical or behavioral conditions.

MUST BE IDENTIFIED ON IEP: Yes, example language: (“Child requires adult supervision and direct care on a

continuous basis”), or equivalent) PHYSICIAN AUTHORIZATION: Not required OTHER/MISC: Service must be provided on a full-time basis to full day student. Full-time service means at least 5.5 hours per day. “Check dates if aide provided care (5.5 hours). (Tardy dates should include a time in.) Early dismissal or early leave should include time out) Date 1 2 3 4 5 6 7 8 9 1

0 11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Total

Fulll-day Student

5 \\student went home sick at 9.05 am Ms. Teacher 8/31/11  ___________________________________________ ______________________________ Signature Date Documentation for Personal Care:

Section A completed with name, Medicaid number of student, month, year, LEA The specific dates of attendance checked on paper form and attendance register to coincide with

the dates submitted for each student, ex. (AOS.760 Report from WVEIS) Signature of authorized LEA personnel or electronic signature o WVEIS

Personal Care Full Day MSWord table RESA 8

NOTES:________________

_______________________

_______________________

_______________________

_______________________

Service Record – Specialized Transportation Berkeley County X 08 08 Specialized Transport:___ Modified Bus:____ AM Bus #______PM Bus #______

Medicaid Number Last Name First Name

00-0000000-00 STUDENT IDENTIFIED

Date of Birth WVEIS Diagnosis Code Provider #

00-00-00 00000000 79999 0000000000

County School Beginning of Month (m/d/y)

End of Month (m/d/y)

Proc. Code Units

BERK MH 08/01/11 08/31/11 T2002 5

Beginning of Month (m/d/y)

End of Month (m/d/y)

Proc. Code Units

08/01/11 08/31/11 T2001 5

SPECIALIZED TRANSPORTATION – VEHICLE T2002 Once per day (round-trip) AIDE T2001 Once per day (round-trip) DESCRIPTION: Services include transportation to and from necessary medical care, education, if child’s medical or behavioral needs require use of specialized transportation services, including specially-equipped (i.e. short bus; multi-passenger van; wheelchair equipped). A regular bus that is modified (i.e. seatbelt/harness) must also have a Specialized Transportation Aide. QUALIFIED Services are furnished by providers who meet the qualifications established by the PROVIDERS: Medicaid agency and Department of Education or the Local Education Agency. *MUST BE IDENTIFIED

ON IEP: Yes, example: (“Specialized Transportation or Specialized Transportation with aide”) REQUIRES PHYSICIAN AUTHORIZATION: Not required

Check dates for specialized transportation (vehicle). Date 1 2 3 4 5 6 7 8 9 1

0 11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Total

Transportation Vehicle AM

5 Transportation Vehicle PM

5

Check dates for specialized transportation (aide).

Date 1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Total

Transportation Aide AM

5 Transportation Aide PM

5

Ms. Teacher 8/31/11 ____________________________________________ ________________________________ Signature Date

Make sure that the service of specialized transportation is listed on the child’s IEP. Attach attendance record to coincide with dates submitted for reimbursement, ex. WVEIS Report AOS.760. Sp.Trans.Vehicle Aide RESA 8

NOTES:________________

_______________________

_______________________

_______________________

_______________________

ASSISTIVE DIAGNOSIS CODES PER ELIGIBILITY

AUTISM

EMOTIONAL/ BEHAVIORAL DISORDERS

BLINDNESS/ LOW VISION

DEAF/ BLINDNESS

29900 31281-Conduct 3699-Impaired 3897-Combined29901-Residual 3129-BD29980-Pervasive Dev 3130-Overanxious29990-Unspecified psychoses 31321-Avoidant

31381-Oppositional3139-Disorder NOS

DEAFNESS HARD OF HEARINGEXCEPTIONAL GIFTED

MENTAL IMPAIRMENT

38910-Hearing loss, unspec. 3899-Impaired Gifted **plus 317-Mild38911-Sensory loss 3884-Abnormal Auditory additional diag. 3180-Moderate38912-Neural 3181-Severe38914-Cental 3182-Profound38918-Combined loss 319-Unspecified

ORTHOPEDIC IMPAIRMENT

OTHER HEALTH IMPAIRMENT

DEVELOPMENTAL DELAY

SPECIFIC LEARNING DISABILITY

*See other 31400-ADD 783.40-lack of normal dev 31500-Reading Dis31401-ADHD 315.9-Unspecified 3151-Arithmetic

78342-Delayed milestones 3152-Specific78341-Failure to thrive 31502- Dyslexia

SPEECH LANGUAGE IMPAIRMENT Preschool

TRAMATIC BRAIN INJURY Other*

3070-Fluency, Stammering/Stuttering 3139-Disorder NOS 85400-Tramatic 299.00 Autism31531-Dev. Exp. Lang. Dis, 783.40 lack of normal dev 95901-Head Injury, unspecified 296.60 Bipolar31532-Rec./Exp. Dis (Mixed) 7670-Brain Hemor/Birth Trauma 741.00-Spina Bifida315.34-Speech Dis. Due to hearing loss 7679-Birth Injury NOS 3430-Diplegic (CP)31539-Articulation 343.1-Hemiplegic (CP)78440- Voice disturbance (unspec.) 758.0 Downs78441-Alphonia-Loss of voice 3450 Epilepsy78449-Other changes in voice, hypernasility-hyponasality 76071 Fetal Alcohol7845-Dysarthria, Dysphasia 714.30-Juvenile Arthritis

7597-Congenital Anomalies (multiple)

This list is meant as an assistive device. It provides a small number of the most widely used diagnosis. If you find you need additional assistance please call Terri Stewart --304-267-3595 or e-mail thstewar@access.k12.wv.us