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Billing for Waiver and Alternative Care (AC) Program

Revised: 11-14-2016

Billing

Refer to the Billing Policy section for more information about MHCP billing guidelines.

Payer Determination

All providers and lead agencies are responsible to bill available payers for services. The order of payers is as follows:

  • 1. Third party payers (e.g., large and small group health plans, private health plans, long-term care insurance, group health plans covering the beneficiary with End Stage Renal Disease for the first 18 months, workers’ compensation law or plan, no-fault or liability insurance policy or plan)
  • 2. Medicare and Medicare Advantage Plans (Medicare must always be billed unless the item is a Medicare noncovered service)
  • 3. Minnesota Health Care Programs (MHCP)
  • 4. Waiver and AC Programs
  • Submitting Claims

    When you submit claims for Waiver and AC program services:

  • • Use MN−ITS Direct Data Entry (DDE) or your own X12 compliance software (batch billing system)
  • • Use the Professional (837P) claim
  • • Bill only for services already provided
  • • Bill only for services approved on the service authorization (SA). Note: Services that require a SA cannot be billed on the same claim as services that do not require a SA
  • • Submit your usual and customary (U&C) charge for the service except for when a dollar amount is approved on the SA instead of a rate per unit:
  • • Consumer Directed Community Supports (CDCS)
  • • Specialized equipment and supplies
  • • Environmental accessibility adaptations
  • • Assistive technology services
  • • Enter a diagnosis code when submitting claims for all waiver services. Providers are required to use the most current, most specific diagnosis code when submitting their claims. MHCP will display the diagnosis code of the recipient on the SA. The diagnosis will be pulled from the primary diagnosis field on the last approved screening document or from the SA for Medical Assistance (MA) Home Care. You may use a different diagnosis code on the claim if you have a more recent or correct diagnosis code.
  • • Use the information listed on your SA when submitting claims for reimbursement through the waiver or AC program. Use Long Term Services and Supports Service Rate Limits (PDF) for a complete listing of the HCPCS codes and allocation of units for each service through each waiver or AC program.
  • • Use date spans only for monthly code(s) when you have provided services for all dates in the span; otherwise, each date must be billed on a separate line.
  • Billing for Specialized Equipment and Supplies
    To bill for specialized equipment and supplies, the lead agency, provider and MHCP must fulfill their Specialized Equipment and Supplies Authorization and Billing Responsibilities when authorizing, requesting reimbursement and paying claims.

    Billing Procedure Codes
    To bill 15 minute procedure codes for time spent providing the service, follow billing guidelines in the table below.

    Billing 15 minute unit(s)

    If the time for each service provided equals:

    Bill this number of units:

    Notes:

    8 minutes through 22 minutes

    1

    Do not bill for services for less than 8 minutes.


    If a service represented by a 15-minute code is provided for at least 8 and through 22 minutes, bill that service as one unit. If you provide the same service for at least 23 minutes, bill that service for at least two units, etc.

    Billable units are determined by time spent providing the service; not by total allowed units on the SA.


    If more than 127 minutes, continue to follow the 15 minute increments and appropriate billing units.

    23 minutes through 37 minutes

    2

    38 minutes through 52 minutes

    3

    53 minutes through 67 minutes

    4

    68 minutes through 82 minutes

    5

    83 minutes through 97 minutes

    6

    98 minutes through 112 minutes

    7

    113 minutes through 127 minutes

    8

    To bill for daily procedure code:

  • • Bill daily or per diem codes that do not have a timed component or unit assigned as one unit regardless of the time spent.
  • To bill for monthly procedure code:

  • • Bill monthly codes only after the service has been provided for the month.
  • • Bill for the dates on which services were provided. If the service is a monthly service and the recipient was absent in the middle of the month, enter one prorated unit for each span. For example, if the recipient was hospitalized from 1/15 through 1/25:
  • • Bill Jan. 1, through Jan. 14, on line one of the claim and
  • • Bill Jan. 26, through Jan. 31, on line two.
  • • In this case, if the entire month is billed, the claim will be denied.
  • • If the waiver or AC claim is paid before the hospital or long-term care facility claim is submitted, MHCP will automatically take back the waiver or AC payment when the hospital or long-term care facility claim is processed. The provider will need to resubmit the claim.
  • Multiple Providers Providing the Same Service at the Same Time
    More than one provider may be authorized to provide the same service for the same recipient. Follow these guidelines:

  • • Each provider must have a separate line item on the recipient’s SA.
  • • If the service has a daily or monthly procedure code, more than one provider cannot bill for the service.
  • • Services must be coordinated:
  • • Each provider bills for the actual dates of service.
  • • Use date spans on claims when services are provided on consecutive days.
  • • If multiple providers will bill for the same daily or monthly procedure code over the same period, the case manager must contact all providers to coordinate services to assure there is no duplication.
  • • Two facilities cannot both bill a daily code when a recipient moves from one facility to another on the same day. If both providers want to bill for the hours they actually provided services, the county would need to approve 15 minute units for that date if there is an equivalent 15 minute code for the service. If there is only a daily or per diem code, whichever location the recipient resides in at midnight is the location that is able to bill for that day.
  • For example:

  • • Recipient leaves agency A at 3:30 p.m. on June 1, 2015
  • • Recipient moves to agency B at 3:31 p.m. on June 1, 2015
  • • Agency B bills for June 1, 2015
  • Billing for Waiver Services for an Individual in an Institutional Setting

    Waiver services are not covered for dates of service when a recipient is also receiving services in an inpatient hospital, nursing facility or intermediate care facility for persons with developmental disabilities (ICF/DD) setting.

    Providers may bill DHS for waiver services provided on the date of admission or the date of discharge from a hospital, if they provided services before the time of admission or after the time of discharge with the appropriate 15 minute code. If the recipient had been previously approved for a procedure code that is a per diem or daily code, the provider will need to contact the case manager for authorization of the 15 minute code on the SA. If there is only a per diem code, MHCP will deny the claim.

    Exceptions:

  • • Elderly waiver (EW) and AC allows payment for respite care services provided in a hospital or long-term care facility using respite care procedure codes. See the respite service description.
  • • Up to 180 days, AC case management conversion may be provided during the nursing facility stay and billed against the AC service agreement for AC recipients.
  • Waiver Services in a Residential Setting
    The following waiver services are covered in a residential setting:

  • • Customized living
  • • Residential care
  • • Foster care
  • Waivers do not pay for room and board. Other income sources of the recipient such as Social Security Disability Insurance (SSDI), General Assistance (GA), Supplemental Security Income (SSI) and Group Residential Housing (GRH) may cover room and board. See DHS’ Group Residential Housing website for more information about GRH. The county financial worker determines all appropriate payment sources for room and board.

    Billing and Absences from a Residential Setting for Brain Injury (BI), Community Alternative Care (CAC), Community Access for Disability Inclusion (CADI) and Developmental Disabilities (DD) waivers

    Definition: Days when a recipient is not receiving residential services are days a recipient is not in the residential setting.

    Providers may not bill for full days when recipients are absent from the residential service settings regardless of the reason for the absence. If an individual receives service for any portion of a day, providers may bill for that day.

    See the examples below for a recipient on the BI, CAC, CADI, or DD waiver that leaves the residential service setting and returns at a later date.

    Leave

    Return

    Number of Days Absent

    4:30 p.m. Friday

    5:00 p.m. Saturday

    0 (More than 23 hours)

    4:30 p.m. Friday

    8:00 p.m. Sunday

    1 (Did not receive service on Saturday)

    4:30 p.m. Friday

    7:30 a.m. Monday

    2 (Did not receive service on Saturday or Sunday)

    Billing and Absences from a Residential Setting for AC and EW

    Definition: Days when a recipient is not receiving residential services are days a recipient is not in the residential setting.

    Providers may not bill for full days when recipients are absent from the residential service settings regardless of the reason for the absence. An overnight absence of more than 23 hours is a noncovered day. An absence of less than 23 hours on the first day is covered if the day does not overlap with a long-term care facility admission date. After the first 23 hours, each time the clock passes midnight counts as another noncovered day. Providers must pro-rate billing to reflect noncovered days during the month.

    See the examples below for a recipient on the AC or EW waivers that leaves the residential service setting and returns at a later date.

    Leave

    Return

    Number of Days Absent

    4:30 p.m. Friday

    11:30 a.m. Saturday

    0 (Less than 23 hours)

    4:30 p.m. Friday

    5:00 p.m. Saturday

    1 (More than 23 hours)

    4:30 p.m. Friday

    8:00 p.m. Sunday

    2 (More than 23 hours; past midnight once)

    4:30 p.m. Friday

    7:30 a.m. Monday

    3 (More than 23 hours; past midnight twice)

    Regardless of calculating absence, a residential service provider may not bill for dates of service that overlap with a long-term care facility admission date.

    This policy affects the following Home and Community Based Services (HCBS):

  • • Customized living
  • • Foster care
  • • Residential care
  • The Centers for Medicare & Medicaid Services (CMS) policy states Medicaid will pay for services actually provided to an eligible recipient. For additional information review Reimbursement for Overhead Expenses due to Residential Absence.

    Process and Procedure
    Consider a variety of overhead expenses when the rate is established using the approved rate tools. A portion of the cost of absences may be considered an overhead expense. The authorized individual monthly limits and case mix caps for the individual still apply.

    Rates for Elderly Waiver (EW)

  • • The EW Residential Services Tool (RS Tool) has predictable absent days built into the tool formula.
  • • Using the procedure code, enter the authorized service rate (unit) on the line item of the service agreement.
  • Claims for the above mentioned community services cannot include periods that overlap with a period of hospital admission, nursing facility stay or other periods defined as “residential absence days”.

    Claims must be adjusted to account for days absent. The period is a time span that does not overlap with any residential absence days.

  • • The total amount field is the total number of days in the setting for that month multiplied by the daily rate noted in the Residential Services Tool Rate Guide.
  • • A notation on the claim form must identify the period of time, minus the residential absence days, that the claim represents.
  • Waiver Recipients Enrolled in Prepaid Health Plans (PPHPs)
    Bill all regular MA-covered services through the health plan. Contact the health plan for coverage information. For more information review MCOs and PPHP’s.

    Some services are “carved-out” services of managed care organization (MCO) coverage and are covered through MHCP fee-for-service (FFS). The BI, CAC, CADI and DD waivered services are carved out services.

    Recipients Enrolled in Minnesota Senior Health Option (MSHO) and Minnesota Senior Care Plus (MSC+)
    Bill all EW services through the health plan except for those recipients enrolled with South Country Health Alliance (SCHA). Recipients enrolled with this health plan will have an EW service agreement entered in MMIS for payment processing. No service agreement will be entered for recipients enrolled in MSHO or MSC+ under any other health plan organization. Contact the health plan directly for the process.

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