SPECIALIZED FAMILY CARE Provider Training

Category: Pre-Service Training Title: Personal Care Billing for Specialized Family Care Providers

Materials: Fact Sheet – Medicaid Personal Care Program, Diagnosis Code for Personal Care, Medicaid Personal Care Billing Instructions, Form 1500, WV-BMS-PC-Plan of Care for Specialized Family Care

Goal: Specialized Family Care Provider to learn how to bill for Personal Care Credit Hours: 2 Hours

Date Developed: September 2016 Developed by: Carol Brewster, SFC Program

This skill-building instruction has been approved for Specialized Family Care Provider training by:

Specialized Family Program Manager Date

Content Developed by: Carol Brewster, FBCS Date

Training Objectives:

Specialized Family Care Provider knows how to bill for personal care thru Molina

Medicaid

Specialized Family Care Provider learns about plan of care and how to complete the

billing forms

Training Procedures: Specialized Family Care Provider initiated self-study Test completed by Specialized Family Care Provider Review of test responses by Family Based Care Specialist and Specialized Family Care

Provider

I certify that I have completed all the materials associated with this training module. I feel that I have a basic understanding of the material completed.

Specialized Family Care Provider Start Time End Time Date Reviewed by: _____________________________________________________________________________________ Family Based Care Specialist Date This Program is funded by the WV Department of Health & Human Resources, Bureau for Children & Families and administered by the Center for Excellence in Disabilities, West Virginia University. WVDHHR/CED/SFC/Personal Care Billing for Specialized Family Care Providers, September 2016

01-19-2017

1/19/2017

PERSONAL CARE BILLING FOR SPECIALIZED FAMILY CARE PROVIDERS FACT SHEET MEDICAID PERSONAL CARE PROGRAM

The Specialized Family Care Program (SFCP) is in place to help link adults and children who have intellectual or developmental disabilities with families that are willing to open their homes to them and offer loving family environments. SFC allows a person to continue living in the community in safe, loving family units, rather than being confined to an institutional setting or left unattended without care in the community. SFC also gives help to families who care for their loved ones at home by providing part-time care for their family member over short periods of time, and then have their loved one returned to their own homes.

Persons qualified for this program live in a foster care setting with individuals and families who are specially screened, trained, and state certified to provide care in their home, 24 hours a day, offering the person care, support, training, and supervision. The person is welcomed into that home as a family member

The Medicaid Personal Care Program is administered by the Department of Health and Human Resources, Bureau of Administration and Finance, Office of Medical Services. The Specialized Family Care Provider (SFCP) is an individual who operates a foster care home which has received certification through the WVDHHR Specialized Family Care Program. Both the home and the individual providing services must be certified by a Specialized Family Care Family Based Care Specialist. WVDHHR contracts with West Virginia University’s Center for Excellence in Disabilities to oversee this program.

Specialized Family Care Providers are certified annually by the West Virginia Bureau of Children and Families (BCF) and must maintain their certification at all times in order to provide Personal Care (PC) services. Personal Care Services are medically oriented activities of tasks ordered by a physician, implemented according to a NURSING PLAN OF CARE (POC) and completed under the supervision of a REGISTERED NURSE. The RN will submit the Pre-Admission Screening form and submit it to the Utilization Management Contractor (UMC). UMC reviews requests for Personal Care services and make authorization determinations. The Specialized Family Care Provider will receive an authorization notice which will include provider ID number and billing information to be used for services. Personal Care Services for the person with an intellectual/developmental disability generally involves a “HANDS ON” approach. Personal Care Services must meet the recipient’s needs. Some Personal Care Services include:

Personal Hygiene

Dressing

Feeding

Nutrition

Health Related Tasks The Personal Care Provider is responsible for documentation, using their daily log. (See: Form WV-BMS-PC-Plan of Care for Specialized Family Care). Documentation should refer back to the Plan of Care and relate to the 4 major categories of Personal Care.

Each specific task on the Plan of Care will have a time planned by the RN. This planned time will be transcribed to the daily log. Provider’s initials on the daily log will indicate that a service was provided on a particular day. The Specialized Family Care Provider may bill for time according to the minutes/units on the daily log (see copy of daily log – WV-BMS-PC-Plan of Care for Specialized Family Care) as they are specified in the Plan of Care.

A. Supervision for sleep times is not allowable as a routine aspect of Personal Care.

B. If the member receiving Personal Care Services is out of the home for respite or any other reason, i.e. in the hospital, the Specialized Family Care Provider with whom the individual/s lives may not bill during this time.

C. If the Specialized Family Care Provider travels out of state with the member, services cannot be billed. The only exception is for those who live in a West Virginia county bordering another state. In those instances, the provider may bill up to 30 miles beyond the state border.

D. Under no circumstance is it appropriate for the Specialized Family Care Provider to access respite services for the individual(s) placed in their home, so that the Specialized Family Care Provider may provide respite services to any other individuals.

The Plan of Care for Personal Care Services will be completed by a Registered Nurse who is currently licensed by the State of West Virginia. The Specialized Family Care Provider of Personal Care Services Eligibility: Any individual or agency with the exception of immediate relatives who meet the following criteria, may serve as a Personal Care Provider in accordance with the State Plan. An agency/corporation that contracts with the State of West Virginia for the provision of direct services to specific target population, or employees of the provider agency; or an agency that subcontracts with the provider agency for the provision of Personal Care Services; or an individual of the recipient’s choice who contracts with the provider agency for the provision of Personal Care Services.

Persons who have been approved and are currently Medicaid-eligible as determined by the Department of Human Services may receive personal care services when prescribed by a physician. The level of services will be determined based on the person’s health care needs. The initial physician’s order for Personal Care Services is good for six months. If the person continues to need Personal Care Services beyond the first six months, the physician must renew the order. Reauthorization is required every six month/yearly. If the person’s condition has not changed, a new plan is not required. The Plan of Care is to be changed as needed.

___________________________________ ____________________________________

Signature Signature

Family Based Care Provider Family Based Care Specialist

___________________________________ _____________________________________

Date Date

PERSONAL CARE BILLING FOR SPECIALIZED FAMILY CARE PROVIDERS SPECIALIZED FAMILY CARE PROVIDERS will complete billing (monthly) for the person in placement. They will turn the billing in by the 1th of each month to their:

A. Their Family Based Care Specialist for Personal Care This billing will be submitted to Molina – Medicaid by the Family Base Care Specialist and the Specialized Family Care Provider must complete the forms accurately. The Specialized Family Care Provider will read the attached Medicaid Personal Care Program Fact Sheet and sign the acknowledgement. The Specialized Family Care Provider may bill for time according to the minutes/units on the daily log as they are specified in the Plan of Care. (This form is included and labeled at the top “Personal Care Specialized Family Care Plan of Care” and labeled at the bottom as the “WV-BMS-PC-Plan of Care for Specialized Family Care.”) This form will be completed for: Day 1 thru 15 for the days provided Day 16 thru 31 for the days provided The Specialized Family Care Provider will mail to the Family Base Care Specialist by the 1th of the month the following:

A. Health Insurance Claim Form(red) Referred to as Form 1500 (1 page) Example Attached with instructions on how to complete

B. WV-BMS-PC-Plan of Care for Specialized Family Care for 1st thru 15th of month (be sure to sign and date for the 15th of the month or the last date

worked during this period). (2 pages) Example attached C. WV-BMS-PC-Plan of Care for Specialized Family Care for 15th to end of

the month (be sure to sign and date it for the last day of the month worked during this period). (2 pages) Example Attached

See Examples attached and instructions for completion of these forms. The diagnosis codes for personal care are attached. Use the ICD 10 code. This code goes in block 21 on the Health Insurance Claim form. (On Form 1500 –red form) Diagnosis Code for Personal Care

ICD 10 DSM 5

F70 317 Mild Mental Retardation IQ 50-55 to 70

F71 318.0 Moderate Mental Retardation IQ 35-40-50-55

F72 318.1 Severe Mental Retardation IQ 20-25 to 35-40

F73 318.2 Profound Mental Retardation IQ below 20

F79 319 (individual is too impaired or uncooperative or with infants)

C71.6 191.6 Brain tumor Cerebellum

F20.5 295.60 Schizophrenia (Residual Type)

F33.9 296.30 Major Depressive Disorder Unspecified

F33.9 296.32 Major Depressive Affective Disorder, recurrent episode moderate

F84.0 299.00 Autistic Disorder

F90.0 314.00 Attention Deficit Disorder

F90.8 314.1 Attention Deficit Hyperactivity Disorder

F80 315.39 Phonological Disorder (errors in sound production)

F89 315.9 Learning Disorder not otherwise specified

G80.0 343.2 Cerebral Palsy, Quadriplegic, Tetraplegic

G71.0 359.1 Dystrophy

J45.909 493.90 Asthma

721.1

F40.10 746.1 Social Phobia

Z60.0 995.52 Neglect of child Problems of adjustment to life-cycle transitions

V62.89 Phase of Life Problem

MEDICAID Personal Care Billing Instruction for the Health Insurance Claim Form

Form 1500 that is in RED

Example Attached

Fill out entire document in blue ink!

Block 1: The Medicaid block is always marked (this is the second block).

Block 1a: Insured’s I.D. Number: This is the client’s Medicaid number. It is always 11 digits,

Block 2: Patient’s name: Last name, First name, Middle initial

Block 3: Patient’s birthday and mark the correct gender:

Block 4: Insured’s Name, Last Name, Middle Name, and First Name

Block 5: Patient’s address and phone number:

Block 6: Patient Relationship to insured: This is usually “Self”.

Block 21: Diagnosis: See the attachment. One thing to remember about the

diagnosis code is that it has to be complete. Example: F71 no dashes or decimals. There are

diagnosis codes that have decimals. Example F84.0 please make sure to add the decimal and the

following number.

Block 21: A 0 must go between the parallel lines labeled ICD ind.

Block 23: Prior Authorization Number: The prior authorization number is ten (10) digits. This number is

listed on your Prior Authorization Notice that you receive in the mail.

The authorization numbers no longer has WXUTH before the digits.

Block 24a: Dates of Service: Unless the client has left the home and will not

be returning to that home – the dates ALWAYS reflects the whole

month. The exception to this is if a client is placed in the home

in the middle of the month. You list the first day the client is placed

and the last day of the month. This is called a “rolling month”, and has to be handled differently

with Molina with the next billing month.

Example: 09.21.10 – 09.30.10. This 1500 will pay for only the days on the 1500 Form. However,

in October the billing will reflect the whole month (this is the billing that is called the “rolling

month”).

Block 24b: Place of Service: This is always 12

Block 24d: CPT/HCPCS: This is always T1019

Block 24e: Diagnosis Pointer: This is always A

Block 24f: Charges: This dollar amount reflects the number of units being

billed.

Block 24g: Days or Units: This is the units that are authorized for billing.

Block 25: Federal Tax I.D. Number: The provider’s social security number.

Make sure the SSN Block is marked.

Block 28: Total Charges: Bring down the billed dollar amount.

Block 31: Signature: Provider signs his/her name and the correct date in blue ink

Block 33: Billing provider info & phone #: Complete address and phone number.

Block 33b: Provider ID Number: Must begin with the code G2 followed by the provider number, which is 10

Digits. The ten digit number is mailed to you and listed in your Prior Authorization Notice.