All About Billing Training

NYS OPWDD

All About Billing

Training

1

2015

Training Goals

• Overview of Payment Structure

• Medicaid Billing

• Highlight Changes

• Liability Regulations

• Non-Medicaid Billing / Web Applications

• Resources to Assist Agencies

Links / Rate Code Listing / Correspondence

All About Billing !

• Billing “Fee-for-Service” Services

– “Fee-for-Service” services are those services that are reimbursed for each unit of service delivered

– “Fee-for-Service” services include all services billed through a price, rate or fee

Three Components of

Eligibility Required for Billing

• The provider must be eligible to deliver the service

• The person must be eligible to receive the service

• The service to the person must be authorized by the DDSO / Regional Office

Provider Eligibility

• Authorization by the

DDSO/Regional Office

• OPWDD Central Office Review

• DOH Final Approval

Billing Identifiers

• Services billed through eMedNY = provider ID and locator codes from DOH

• Services billed through OPWDD’s Payment Processing Unit = Agency’s NYS Vendor Identification Number • Services billed through OPWDD’s Web Based

Applications = Agency’s program code

• OPTS Sunset – January 2015 for last contracts – more to come on this!

Getting a Provider ID for Billing

eMedNY

• For a new Medicaid service, the provider must complete & submit promptly a provider enrollment application to Computer Sciences Corporation (CSC)

• OPWDD will initially send the application to your agency with specific, required information unique to OPWDD (i.e., License Number)

• DOH sends provider a provider ID & rate code

• 2015 Application Fee - $553

Individual’s Eligibility

• Medicaid Service

– Medicaid Client Identification Number

(CIN)

• Non-Medicaid “Fee-for-Service”

Services

– TABS ID

Service Eligibility – (Authorization

to Provide a Service to a Particular

Individual)

• It is essential that an agency receive authorization before providing services – an agency is not entitled to payment if it provides services without

authorization

Bureau of Mental Hygiene Services Rate Setting

• Bureau of Rate Setting transitioned from OPWDD to DOH

• Continued responsibility for loading OPWDD rates/fees with a few exceptions (i.e. some Self-Direction rates/fees loaded by OPWDD Rate Setting)

• Certain initial, provider specific rates are transmitted to agencies, but most rates/fees are listed on the DOH website

• Office of Pool Administration (OPA) – Allows for an account to be established to view agency specific rates and rate related information – copy of correspondence included with training materials

• Contact [email protected]

• http://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/index.htm

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What’s Needed for Billing?

• Once the 3 eligibility components (provider, individual, and service) are in place, the agency will be provided with the tools to bill

• Provider ID, service ID & individual ID

• To bill eMedNY – provider ID, locator code, rate code, & Medicaid Client Identification Number (CIN) are needed

• To bill OPWDD – NYS Vendor Identification Number, provider ID/price ID, rate code & TABS ID are needed

Critical documents & getting

them to the right people

• DDSO/Regional Office Price Correspondence

• DOH – Mental Hygiene Rate Setting, eMedNY or Computer Science Corporation (CSC) Correspondence

Medicaid Remittance Statement

• The Remittance Statement identifies each claim submitted by your agency’s billing department & specifies:

– If a claim was paid – How much was paid

– The reason a claim was not paid

Using the Medicaid

Remittance Statement

• Monitoring Medicaid Revenue

• Early Identification of Medicaid

Monitoring Remittance Statements

statements – these are the official records detailing your Medicaid payments

• Staff must monitor to see which claims were paid, denied, or pended. They must correct problems promptly if claims were denied or pended. • Remittance statements should be used to monitor

actual revenue against projected revenue

Early Identification of Medicaid Billing

Problems: Common Error Codes

• Edit 0162: recipient ineligible on date of

service

• Edit 1319: recipient exception code invalid

for HCBS Waiver

Early Identification of Medicaid

Billing Problems:

More Common Error Codes

• Edit 1338: recipient not on restricted recipient file • Edit 1339: recipient not authorized for MSC &

IRA/CR on date of service

• Edit 1340 claim provider not equal restriction recipient file provider

Early Identification of Medicaid

Billing Problems:

• Additional edit information on the eMedNY

website: www.emedny.org

• eMedNYHIPAASupport Link / Crosswalks

Link

• Provides a tool that providers can utilize to

crosswalk edit information

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New Requirement – eMedNY Payments

and Remittance Statements

• DOH announced that they will be phasing in the requirement for Electronic Fund Transfers (EFT) and Electronic Remittance Advice (ERA) or PDF Remittances

• Most providers are already enrolled, but if you are not, enrollment will be required when your yearly certification is due – eMedNY will inform you of this

eMedNY 5010

• DOH implemented changes to the HIPAA transaction standards (4010) – implementation date was 6/30/12 • This resulted in enhancements to claim submissions,

remittance advice reports and eligibility verifications • Software vendors were contacted by DOH • ePACES users were contacted regarding

changes/updates and training was provided

• http://www.emedny.org/HIPAA/5010/Webinar/5010_Pres

entation.pdf

• Questions regarding 5010 implementation can be directed to [email protected]

eMedNY 5010

• 5010 Implementation enacted upfront billing edits for certain claim submission errors – these instances are not reflected on the Remittance Statement

• Common Examples include Invalid Client IDs, Invalid Diagnosis Codes, Invalid Revenue Codes and ETIN not certified

• To view these errors, providers must view the 277CA response file that list the status of all claims submitted • The NYS Medicaid Pre-Adjudication Crosswalk can be utilized

to identify claims hitting up front billing edits

-www.emedny.org / eMedNYHIPAASupport Link / Crosswalks Link / NYS Medicaid Pre-Adjudication Crosswalk for Health Care Claims

Timely Claim Submissions

• DOH has initiated enforcement edits of the 90 day claim submission requirement

• Certain 90 day delay reason codes will edit against information on file with eMedNY (i.e., individual eligibility information, provider retro enrollment)

• Bill as soon as possible!

Delay Reason Codes

• The list of available delay reason codes is

available on the eMedNY website

•

https://www.emedny.org/ProviderManuals/

AllProviders/index.aspx#mcparty

• At this link see “General Billing” section

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Delay Reason Codes

• OPWDD cannot advise agencies about use of delay reason codes – this is DOH Policy

• In general terms, eligibility delay (8) can be used when:

• 1) An individual has their Medicaid coverage retroactively reinstated, that prevented a provider from billing timely

• 2) An individual has a Restriction/Exception code retroactively updated to allow services to be billed (e.g., HCBS Waiver enrollment and the input of R/E code 46 was backdated)

Delay Reason Codes

• In general terms, authorization delay (3) can be used when:

• 1) A provider was authorized to deliver services, but authorization was not recognized timely by eMedNY (e.g., provider enrollment in Medicaid)

• 2) A provider has not been able to bill because of a delay with loading of INITIAL RATES

• Providers are responsible for substantiating use of delay codes on claim submission – be sure you can substantiate use if you are audited as this

responsibility is with the provider

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Tips for Billing eMedNY

• Ensure program staff quickly report services to billing office! • Bill as quickly as possible to increase and stabilize cash flow! • Be knowledgeable of Medicaid billing rules – New eMedNY edits

are in place that validate use of 90 day delay reason codes -Claims submitted with delay reason codes that cannot be substantiated will deny!

• Review details of all remittance statements!

• Follow-up immediately on DENIED claims – Address these claims ASAP – There are time limits!

More Tips for Billing eMedNY

billing!

• Retain a copy of ALL letters received from the Department of Health (DOH)!

• Route copies of DOH letters to staff in your organization who do your billing!

• Promptly respond to all annual certification statements for billing (electronic and paper) from DOH!

• When you obtain a new Provider ID, register it under your ETIN (Electronic Transmitter Identification Number)!

Changes Worth Noting

• OPTS Phase Out

• OPRA – Order/Prescribe/Refer/Attend • MSC – Future Date

• Rate Rationalization • ICD-10

• Community Habilitation for Individuals residing in Certified Settings (IRA/CR/Family Care)

• Self-Direction • ICF / Day Services

OPTS Phase Out

• Initiated in August of 2012

• All contracts with HCBS Waiver services ended as of January 30, 2015

• Providers now billing eMedNY directly for services previously provided under OPTS to HCBS Waiver enrolled individuals • Web service recording calendars available for initial service

recording and post-processing increases for the January 2015 service month until the day prior to the first final payment run in March 2015 – March 11, 2015 is the last day

• OPTS providers can continue to void services and/or downwardly adjust claims via the web application for 17 months from the service month.

OPRA –

Order/Prescribe/Refer/Attend

• New Requirements from the Affordable Care Act mandate that services billed to Medicaid identify the practitioner who ordered/referred the service – requirement went into effect on 1/1/14

• Most OPWDD services are exempt from this requirement – However, in order to appropriately bypass the requirement, your provider ID used for billing must be included in another component of the claim submission

OPRA –

Order/Prescribe/Refer/Attend

• When submitting the 837 Institutional

(837I) claim submission to Medicaid, the

provider ID used to bill for services will

need to be input in the following

loop/segment of your claim submission:

• Loop 2310F / Segment REF02

OPRA –

Order/Prescribe/Refer/Attend

• Services that are not exempt from this requirement include:

• Article 16 clinic services • Intensive Behavioral (IB) Services

• For IB Services, provision of service must be directly provided by, or supervised by a Licensed Clinical Social Worker (LCSW) or a Licensed Psychologist – these staff have to enroll in Medicaid as an OPRA provider

• Information about these requirements is included in the IB Services ADM – #2013-03

• http://www.opwdd.ny.gov/node/4788

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Medicaid Service Coordination

• OPWDD expects changes to the Medicaid Service Coordination (MSC) program in 2015,

including an end to the Sole Provider Sponsorship

• This will require MSC providers to “revalidate” their MSC provider IDs with the Federal Employer Taxpayer Identification (FEIN) associated with their agency – currently, MSC enrollments are under the FEIN of New York State

• DOH is scheduled to revalidate Case Management provider enrollments in 2015, so this process would be carried out whether the MSC change were to take place or not • We expect correspondence to be sent out on this in the next few weeks informing providers

of the coming change

Rate Rationalization

• DOH’s Bureau of Mental Hygiene Rate

Setting initiated Rate Rationalization on July

1, 2014 for IRAs, Group Day Habilitation and

ICFs

• Rate Rationalization for additional services is

expected to go into effect on 7/1/15

• Services impacted on 7/1/15 include Respite,

Supported Employment (SEMP),

Prevocational Services and Family Care

• Billing of these services will be impacted!

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Rate Rationalization - Respite

• Hourly Respite and Free Standing Respite

will not be distinguished – the

reimbursement will be the same

• Respite will be billed with a new rate code

under the Multi-Service Provider ID (not

the Hourly Respite or Free Standing

Respite site provider ID, as the service is

currently billed)

• Will continue to be ¼ hour unit billing

2/19/2015 41

Rate Rationalization - SEMP

• SEMP will be changing from a monthly unit of service to a ¼ hour unit of service – billed under the Multi-Service Provider ID, not the existing SEMP provider ID • Provided in 1:1 settings and 1:group settings

• Provided in 2 phases – Intensive and Extended • Regional fee structure will be in place – service billed

based on where SEMP program is registered • Web based billing application will be updated for

payment of services provided to non-HCBS Waiver individuals

• Draft Regulations expected in the very near future

Rate Rationalization –

Prevocational Services

• Service will be distinguished between “Site Based” and “Community Based”

• Site based will continue utilizing existing agency specific rate – both variations will be billed under the Multi-Service provider ID, as Prevocational Services currently is

• Community Based will be billed in ¼ hour service units • Provided in 1:1, 1:2 and 1:group ratios (3-8 people) • Regional fee structure will be in place – service billed

based on provider Corp location

• Draft Regulations expected in the very near future

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Rate Rationalization – Family

Care

• Unit of service will continue to be a per diem

under the regional fee structure based on the

service provider’s corporate location

• Fees will also take into consideration the 6

ISPM scoring levels that determine payment

amounts made to the actual Family Care

provider

• Service will be billed under the Multi-Service

Provider ID

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ICD-10

• International Classification of Diseases, Tenth Revision (ICD-10)

• Implementation date is 10/1/15

• Currently, coding is utilized based on ICD-9 • Claim submissions on and after 10/1/15 will need

to be updated to reflect the ICD-10

primary/principal diagnosis of the individual served • OPWDD has been doing outreach to providers to

ensure that we have a primary diagnosis on file • https://www.emedny.org/icd/index.aspx

Community Habilitation for Individuals

Residing in Certified Settings

• Effective 10/1/14, community habilitation was expanded to allow individuals residing in IRAs/CRs and Family Care to receive the service • Specific rules regarding the service put into

regulation

• http://www.opwdd.ny.gov/regulations_guidance/opwdd_regulations/community-habilitiation-oct1-final

• Information on correspondence dated November 7, 2014 (included with the training materials) • OPWDD expects an updated ADM to be available

soon – until that time providers have been encouraged to delay service provision

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Self-Direction Changes

• Effective 10/1/14, methodology changes went into effect for Consolidated Supports and Services (CSS) – the HCBS Waiver service for individuals Self-Directing their services

• The existing CSS reimbursement structure was broken out into separate and distinct services that could be billed directly to Medicaid as HCBS Waiver services and allow for enrollment into specific TABS program codes for service authorization purposes 2/19/2015 47

Self-Direction Changes

• Individual Directed Goods and Services • Community Transition Services (CTS)** • Support Broker

• Fiscal Intermediary • Live in Caregiver

• All services billed under the Multi-Services Provider ID (* for SEMP and Respite, when provided by self-hired staff) • ** CTS is billed by the FI, but the individual does not need to

be Self-Directing services in order to receive

Self-Direction Changes

• Services provided to individuals

Self-Directing their services fall under three

categories:

• 1) Direct Provider Purchased Services

• 2) Agency Supported Services

• 3) Services by Self-Hired Staff

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Self-Direction Changes

• Direct Provider Purchased

• Individual is attending/receiving services

directly from an OPWDD service provider

• The service provider is billing Medicaid

directly for those services provided

• Funds expended for these services count

against an individual’s Personal Resource

Account (PRA)

• Individual is enrolled in the agency’s service

specific TABS program code

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Self-Direction Changes

• Community Habilitation, SEMP* and Respite*

• Individual has an MOU with the agency that describes the person’s ability to make decisions about the staff

• Specific rate codes under the Multi-Services Provider ID are used to bill Agency Supported Services for Community Habilitation and Respite

• Until the unit of service changes for SEMP come into effect, the traditional monthly SEMP rate codes should be billed.

• Individual is enrolled in the agency’s service specific TABS program code

• November 7, 2014 memo included as a handout with the training materials provides billing guidance

• * SEMP and Respite do not yet have formal guidelines for MOUs, but providers can use Community Habilitation MOU template

Self-Direction Changes

• Services by Self-Hired Staff

• Community Habilitation, SEMP and Respite

• Specific rate codes under the Multi-Services

Provider ID are used to bill for these services

when provided by Self-Hired Staff

• Individual is enrolled in the FI’s

service

specific

TABS program code

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Self-Direction Changes

• Special billing logic was put in place to

allow variable amounts to be billed to

Medicaid for certain supports and services

available under Self-Direction at or below

the defined rate cap

• Services paid under special logic include

Hired Community Habilitation,

Self-Hired SEMP, Self-Self-Hired Respite, Live in

Caregiver and Support Broker

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Self-Direction Changes

• For services provided by Self-Hired staff

(Community Habilitation, SEMP and Respite), FI’s are submitting the number of actual billable service units and the total expenses incurred – not an established rate

• As Self-Hired staff will generate costs beyond their wages (fringe benefit costs), and additionally, may need to be paid for time that is not directly billable based on service provision (indirect time worked), this method for reimbursement allows all the service costs to be accounted for

Self-Direction Changes

• On 1/12/15, an FI is submitting a Community Habilitation claim on behalf of

an individual who has Self-Hired staff for 4 hours of billable service activities (Billable Hours). The FI is informed that on this date the employee, in addition to 4 hours of direct billable service time, worked an additional 3 hours (a total of 7 Work Hours). The employee is paid $13.00 an hour

• To calculate the Amount Charged to Medicaid, the following is taken into

consideration:

• Work hours = 7 X $13.00 Wage Rate = $91.00

• Indirect Employment Cost = 15% (Fringe) X $91.00 Wage Cost = $13.65

• Total Employment Cost = $104.65 (This amount is included as the Amount

Charged to Medicaid)

• Billable Time to Medicaid = 4 hours (equates to 16 units submitted on the

claim)

• Effective Reimbursement Rate = $104.65 / 16 units ($6.54 per ¼ hour)

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Self-Direction Changes

• Individual Directed Goods and Services – billed in $10 increments

• eMedNY allows a maximum of 99 service units to be billed to Medicaid on a given date of service • This equates to $990 per date of service (99 X $10) • If more than $990 has been expended for qualifying

IDGS expenses, OPWDD requires submission of claims on consecutive service dates

• OPWDD has identified allowable IDGS expenses and the process for billing the service to Medicaid – information available for providers who will become FIs

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Self-Direction Changes

• Community Transition Services (CTS) – billed in $10 increments

• eMedNY allows a maximum of 99 service units to be billed to Medicaid on a given date of service • This equates to $990 per date of service (99 x

$10)

• If more than $990 has been expended for qualifying CTS expenses, OPWDD requires submission of claims on consecutive service dates • ADM is coming soon that will detail requirements

Self-Direction Changes

• Training sessions were held for FI’s and

for providers interested in becoming FI’s

• If you would like more information about

the Self-Direction changes, we can share

the training materials

• Email [email protected]

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OPWDD Day Service billing for

ICF Residents

• Effective 1/1/15 certain day services provided to ICF enrolled individuals can be billed directly to eMedNY

• Day Services (comparable to Day Habilitation), Vocational Services, Day Services Downstate Template Highly Complex, Day Services Upstate Template Highly Complex, Vocational Services Downstate Template Highly Complex and Vocational Services Upstate Template Highly Complex

• For those providers that are authorized to deliver In Home Day Service, rates will be loaded in the near future • While these services are billed for ICF residents, providers

are submitting these claims using the Multi-Services Provider ID for reimbursement

• Providers no longer need to bill ICF provider for these services!!!!

OPWDD’s Liability for Services

Regulations

14 NYCRR 635-12

Kristina Cunningham

Revenue Support Field Operations

Topics

• Definitions

• Covered Services

• Responsibilities

• Limited Exception

• Resources

Definitions

• “Preexisting” – services an individual was

receiving on a regular basis from the same

provider at the time the regulations were

implemented for that service

• “Other than preexisting” – services that

commence on or after the date the

regulations were implemented for that service

• “Full Medicaid coverage” – the type of

coverage that will pay for the services

someone is receiving or wants to receive

635-12 Liability for Services

• Original Regulation – effective 2/15/2009

• Day Habilitation • ICF Residential Services

• Residential Habilitation (IRAs, CRs, FC)

• Liability notice issued by 3/15/2009

• Individual liability began 4/15/2009

• Bills issued no later than 30 days beyond

635-12 Liability for Services

• Amended Regulation – effective 3/15/2010

– MSC – Day Treatment

– At-Home Residential Habilitation (Community Habilitation) – Prevocational Services

– Supported Employment Services – Respite

– Blended and Comprehensive Services (OPTS)

• Liability notice issued by 5/15/2010 • Individual liability began 6/15/2010

• Bills issued no later than 30 days beyond last day of month of service

Individuals Responsibilities

• Individuals who want specified OPWDD

Medicaid service(s) must file and be

approved for “Full Medicaid Coverage” or

else pay for their services

• Individuals who want OPWDD HCBS

Waiver service(s) must take all necessary

steps to enroll in the HCBS Waiver

Service Provider Responsibilities

• Issue Liability Notice(s)

– Preexisting Services - should have been issued by 3/15/2009 or 5/15/2010

– Other than Preexisting Services - relevant notices must be issued prior to service delivery

– Liability notices must be issued to everyone receiving or applying for any covered service(s), regardless of their Medicaid/HCBS Waiver status

– If the provider does not provide any covered services, no liability notices are required

Service Provider Responsibilities

• Verifying Medicaid and HCBS Waiver Status

– Local Revenue Support Field Offices (RSFOs) can verify Medicaid enrollment and type of coverage, review a Medicaid denial notice and advise if an appeal is warranted

– Service provider must be given any Medicaid denial notice within 5 days of receipt. RSFO can advise if an appeal is warranted

– Contact DDSO to verify HCBS Waiver status – State-funded service coordination available for up

to 3 months to assist with Medicaid and Waiver enrollment

Service Provider Responsibilities

• Calculating Charges for Services

– Liability amount is the full Medicaid rate or fee for the service

– For individuals without Medicaid, use the Benefit Eligibility Questionnaire (located in the Benefit Development Resource Guide on OPWDD’s website) to gather financial and other information – Reductions or waivers MAY be available for

individuals who fully cooperate in the benefit development process

Service Provider Responsibilities

• Billing the individual

– All individuals are liable for the full cost of their services unless Medicaid is paying for their services

– The provider must bill the individual and/or liable party for the full cost of the services if the individual does not Medicaid/HCBS Waiver enrollment to pay for the services they are receiving or requesting,

• Bills must be issued monthly, no later than 30 days beyond the last day of the month of service

• Provider has to issue viable bills (expecting payment)

• Provider has to actively pursue collection of unpaid amounts from the individual/liable party

• Providers receiving State funding for an individual’s preexisting services will continue to be paid by OPWDD, subject to fund availability, if the service provider complies with all regulatory requirements

Liability Notices

– 2009 Preexisting Services Liability Notice (LIAB 02) – 2010 Preexisting Services Liability Notice (LIAB 06) – Liability Notice for Persons Applying for Services (LIAB 05) – Limited Exception Notice for Persons Meeting Exception

(LIAB 07)

– Limited Exception Notice for Persons Applying for Other Services (used by SEMP/Respite Provider) (LIAB 08) – Limited Exception Notice for Persons Applying for Other

Services (used by provider of other requested services) (LIAB 09)

– Information About the Limited Exception for Persons Receiving Supported Employment or Respite Services (LIAB 10)

Liability Notices

• Use the instructions

• They tell the provider

– Which notice to use – How to fill out the notices – Who gets the notices – When to give the notices

• Do not alter notices

• Copies may be requested by OPWDD

Who Gets Liability Notices?

• See instructions

• All people who fit situations described in chart in instructions • Could be more than one person

• Possibilities

– the person receiving or requesting services – anyone accompanying the person – parent(s)

– legal guardian – trustee

– representative payee or other payee for benefits – person holding money or assets for the person – conservator or committee

Limited Exception

• Individuals receiving only SEMP or only Respite services

• If not funded by Medicaid/HCBS Waiver on or after 3/15/2010

• Not required to enroll in Medicaid and HCBS Waiver

• Can drop other services to qualify • Limited exception NOT available for:

– Individuals receiving any other covered service – Services funded by Medicaid (Medicaid and HCBS

Waiver enrolled) at any time on or after 3/15/2010

Limited Exception

• Service providers must issue a specific Liability Notice to the individual/liable party

• Individual must notify the SEMP/Respite provider if applying for any other covered services

• Providers of other covered services must ask an individual if he or she is receiving SEMP or Respite services and notify the SEMP/Respite service provider that individual is applying for other services

LIAB 07 (limited exception)

• Tells the person they are eligible for the

limited exception

• Issued by 5/15/2010 for persons receiving

supported employment or respite as of

3/15/2010

• Issue prior to service delivery if person

applies for supported employment or respite

after 3/15/2010

• Only supported employment and respite

providers give this notice

LIAB 08 (limited exception)

• Given by supported employment or respite

provider

• Given if a person who is eligible for the

limited exception applies for another

service that would disqualify him or her for

the limited exception

LIAB 09 (limited exception)

• Given by provider of any other covered

service(s) for which the individual applies

while under the limited exception

• Provider of other covered service(s) will

also need to give the Liability Notice for

Persons Applying for Services (OPWDD

LIAB 05)

LIAB 10 (limited exception)

• Informational only

• Give to anyone who asks for more

information about the limited exception

Fee Reductions & Waivers

• Individuals who have fully cooperated in the Medicaid application and HCBS Waiver enrollment processes may be eligible for a fee waiver or reduction based on the individual’s income, resources, and living situation

– Releases provider from responsibility for billing the individual or lowers the amount the individual must be billed monthly

– Provider continues to be paid by OPWDD during fee waiver/reduction period

– Provider must bill individual for any period for which they do not have a current approved fee waiver in place.

Fee Reductions & Waivers

• See “Liability for OPWDD Medicaid and

Home and Community Based Waiver

Services, Addendum 1 - Rules for

Determining Waived or Reduced Fees for

OPWDD Services” (available on the

OPWDD website) for the guidelines for

calculating fees to be billed to individuals

without Medicaid

Fee Reductions & Waivers

• Submit Form OPWDD LIAB 04, “Fee

Reduction/Waiver for Preexisting Services Request for Approval” to Revenue Support Field Office

– Include supporting documentation - individual’s/liable party’s financial information, Medicaid denial notice, HCBS Waiver Notice of Decision, etc.

• If a fee waiver has been approved by OPWDD, OPWDD will pay the provider and the provider does not have to bill the individual for the period of the fee waiver

• Fees for services can be reduced or waived without approval by OPWDD only if the service provider is not seeking state funding

Fee Reductions & Waivers

– Use when

– Individual with Medicaid Coverage does not meet the level of care for HCBS Waiver

– Undocumented immigrant has limited or no income or assets

– Do not use when

– Medicaid or HCBS Waiver application is pending – Individual is not meeting a spenddown

– Individual is not cooperating with benefit development process

Resources

• OPWDD website:

(www.opwdd.ny.gov/opwdd_resources/benefits_information)

– Liability for Services Regulations

– Liability for OPWDD Medicaid and Home and Community Based Waiver Services

– Liability Notices – Medicaid Coverage Chart – Benefit Development Resource Guide – List of Revenue Support Field Offices

• Revenue Support Field Offices • Kristina Cunningham

– E-mail: [email protected] – Phone: 518-402-4339

Non-Medicaid Payments

• Voucher Billing - state paid services, assistive supports, state paid component of Self-Direction

• Web Based Billing – respite & SEMP (to persons not in the HCBS Waiver) and OPTS for a very limited time • Non-billed Payments – property for freestanding respite,

IRA room & board supplements & IRA land costs • For Supervised IRAs/CRs, agencies receive 1/12 of the

supplement regardless of billing (effective 7/1/14) • For Supportive IRAs/CRs, the supplement payment is

based on the paid residential habilitation claim

Non-Medicaid Funded Payments

Policy Clarification

• For new recipients of Non-Medicaid funded services, a State Funding Authorization Request (SFAR) is required • DDSO/Regional Office staff will complete the SFAR form • Revenue Support Field Office (RSFO) Staff can provide

guidance regarding the policy

OPWDD Payment Processing

Unit Rules

• Effective 10/1/13, agencies have 3 months

from the conclusion of a service month to

submit claims

• The received date of the claim by OPWDD

determines if the claim was submitted timely,

not the date the voucher was signed, or when

the agency staff mailed the voucher

• A claim for January 2015 services must be

submitted and received by 4/30/15

Tips for Billing OPWDD’s Payment

Processing Unit

• Claims should be submitted on the 1st of the month (or later) following the month of Service delivery

• All services claimed on a billing form must be for the same month and year

• Only one service type (rate code) should be submitted on a billing form except for Supervised IRA/CR Residential Habilitation (July 2014 service or later)

• Multiple billing forms can be submitted with a single voucher, unless directions state otherwise

• Individuals served should be listed in ALPHABETIC order, in the format: LAST NAME, FIRST NAME

More Tips for Billing OPWDD’s

Payment Processing Unit

• TABS ID must be included for each individual • All billing forms must be signed and dated

• Instead of entering data on a billing form, a computer printout can be submitted with the signed and dated billing form, but the computer printout must contain all required data identified on the billing form

• If the service date is more than 3 months old, a letter explaining the delay must accompany the claim submission – OPWDD Central Office will consider these claims on a case by case basis

• A completed Claim for Payment form (AC-3253s) or Standard Voucher (AC-92) must be included with each submission of billing forms. Form AC-3253s may be obtained by visiting the following link:

• https://www.osc.state.ny.us/agencies/forms/ac3253s_f.pdf

2/19/2015 89

• Ensure that you are using up to date billing

forms

• www.opwdd.ny.gov

• Resources

• Forms

• Payment Processing Unit Billing Forms

and Instructions

Even More Tips for Billing OPWDD’s

Payment Processing Unit

Questions?

OPWDD Web Based Applications

• Utilized for Respite and Supported Employment (SEMP) and for a short time period, OPTS

• Users request access via User ID and System Access Request Form

www.opwdd.ny.gov / Resources / Forms

• Completed forms submitted to appropriate contact at the DDSO/Regional Office or the OPWDD Help Desk

• Form Available at the OPWDD Website

(www.opwdd.ny.gov)

• Resources Link / Forms Link

2/19/2015 95

USER ID AND SYSTEM ACCESS REQUEST FORM

• Choices from the dropdown include SEMP,

SV OPTS and SV Respite

USER ID AND SYSTEM ACCESS REQUEST FORM

2/19/2015 97

USER ID AND SYSTEM ACCESS REQUEST FORM

• SV Respite access requires sign off by the DDSO/Regional Office FSS Coordinator or designee

• Sign off not required for SEMP

• Web-Based Payment Application utilized for all individuals enrolled in your program

• Individuals enrolled via the DDP-1 submitted to your DDSO/Regional Office

• Once the DDSO/Regional Office processes the DDP-1 to complete TABS enrollment, web roster will be updated to include enrolled individual

• For SEMP/Respite individuals not enrolledin the HCBS waiver, service entry results in payment from OSC

OPWDD Web Based Applications

• For SEMP/Respite individuals enrolledin the HCBS waiver,

providers must separately submit claims to eMedNY • Until Rate Rationalization, recording of SEMP services

through the Web Based Application for HCBS enrolled individuals informs providers of the appropriate rate code to use for billing eMedNY

• Until Rate Rationalization, recording of Respite services through the Web Based Application for HCBS enrolled individuals informs providers of the appropriate rate code and units used for billing eMedNY

OPWDD Web Based Applications

Calendar Roster Availability

• There are timeframes in place that must be adhered to for recording services through the Web based payment applications

• At the start of a month until the day prior to the first final payment run of the month, rosters for the (2) months prior, plus the roster for the current month will be available for service recording • BEST PRACTICE: Record service of prior month in current month

OPWDD Web Based Applications

Calendar Roster Availability

• Once the first final SEMP/Respite payment run occurs in a month, only rosters for the current and prior month will be available for service recording

• At the start of the next month until the day prior to first final payment run in that month, providers again have rosters for the two prior months and current month available for service recording.

• Payment run dates and data entry deadline dates are available in the web applications

OPWDD Web Based Applications

Calendar Roster Availability

program forms ASAP

• Record services as close to the date(s) of service provision as possible

• Inform others at your agency of these timeframes, especially those that are responsible for service documentation

• Read notices posted on the Web Application • Best Practice – Record service from prior month

(September) this month (October)

Accessing Web Based Applications

• www.opwdd.ny.gov / Login / Secure Site Applications

• Services Recording for Respite

Respite, Inc.

JONES,JOHN KIM,JUDY MILLER,MARY ROSE,JAMES UPTON,MARY WELLS,TIM RESPITE, INC. October 2012

KIM,JUDY RESPITE INC.

Program  44 Holland Ave

NYS Office For People With Developmental Disabilities

RESPITE, INC. NYS Office For People With Developmental Disabilities

RESPITE, INC. July 2012 KIM,JUDY RESPITE, INC. Month of Service RESPITE, INC. PROGRAM: 44 HOLLAND AVE

KIM,JUDY

December 10, 2014 September 11, 2012

RESPITE, INC.

RESPITE, INC.

**NOTE: Do not claim the services listed on this report to MMIS for Medicaid Reimbursement.  These services have been  forwarded to OSC for payment**

99999999 – RESPITE, INC P.O. BOX 9999 WHEREVER, NY 99999 SFS VENDOR ID: 9999999999 MMIS PROVIDER ID #; 99999999 RESPITE, INC. KIM,JUDY 999999

RESPITE INC.

RESPITE, INC. 99999999 – RESPITE, INC

FEDERAL PAYEE ID: 999999999 MMIS PROVIDER #: 99999999 Locator Code: 03 Rate Code : 4486 WELLS, TIM 888888 XX11111X

SEMP, INC. WALSH, JACK WARD, MIKE WEBB, JOE YARD, JED YOUNG, JAY 1111111 2222222 3333333 4444444 5555555 XXX‐XX‐XXXX XXX‐XX‐XXXX XXX‐XX‐XXXX XXX‐XX‐XXXX XXX‐XX‐XXXX April 2012 08/18/1958 08/29/1982 07/14/1981 11/13/1981 04/25/1963 21 – MAY ‐12 25 – MAY ‐12

VOUCHER TOTALS: 5 2238.00 SEMP, INC.

12345678 – SEMP PROGRAM P.O. BOX 9999 WHEREVER, NY 99999 FEDERAL PAYEE ID: 999999999

WALSH, JACK WARD, MIKE WEBB, JOE YARD, JED YOUNG, JAY 1111111 2222222 3333333 4444444 5555555 XXX‐XX‐XXXX XXX‐XX‐XXXX XXX‐XX‐XXXX XXX‐XX‐XXXX XXX‐XX‐XXXX OPWDD 5/26/2012 5/25/2012 April 2012       3 April 2012     1 April 2012    2 April 2012    1 April 2012     3 SEMP, INC. 12345678 – SEMP PROGRAM P.O. BOX 9999 WHEREVER, NY 99999 FEDERAL PAYEE ID: 999999999

0233 ‐BROOME

JONES, GEORGE 000‐00‐0000 09/20/1973 66666 YY00000Y JUL 2009 1 4471 353.00

OPWDD 5/26/2012 5/25/2012 353.00 

CONTACTS

- Earl Jefferson –[email protected]

- Matt Breslin –[email protected]

- Shaun Scanlon –[email protected]

(518) 402-4333 • CSC Call Center

CONTACTS

• Payment Processing Unit

• Brenda Salsburg

• State Paid Self-Direction

• Lori Adams

• (518) 402-4333