Billing for Waiver and Alternative Care (AC) Program

Revised: February 10, 2022

· Billing

· Payer Determination

· Home and Community-Based Services (HCBS) Provider Service Documentation Requirements

· Submitting Claims

· Specialized Equipment and Supplies

· Billing Procedure Codes

· Multiple Providers Providing the Same Service at the Same Time

· Waiver Services for an Individual in an Institutional Setting

· Waiver Services for an Individual in a Residential Setting

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 (for example, 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

Home and Community-Based Services (HCBS) Provider Service Documentation Requirements

See Minnesota Statutes, 256B.4912, subdivisions 11-15 for HCBS documentation requirements.

The provider is eligible for reimbursement only if:

· The provider is delivering a service that is authorized and defined under a federally approved waiver plan.

· The provider provides the service on days and times specified on the operating license, as applicable.

· The provider has documentation that staff who provides services have reviewed the following statement: “It is a federal crime to provide materially false information on service billings for medical assistance or services provided under a federally approved waiver plan as authorized under Minnesota Statutes, sections 256B.0913, 256B.0915, 256B.092 and 256B.49.” This is required upon employment and annually thereafter.

Note: Electronic signatures are permissible. According to Minnesota Statutes, 325L.02, subdivision (h), an electronic signature is defined as “an electronic sound, symbol, or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record.”

HCBS providers must maintain the following documentation of service delivery:

· Providers must collect and maintain readable documentation in English.

· Providers may collect and maintain documentation electronically or in paper form and must produce documentation upon request by the commissioner.

· For services authorized using an hourly or minute-based unit, the provider must document:

· The date of the documentation.

· The day, month and year the service was provided.

· The start and stop times with a.m. and p.m. designations (except for case management services).

· Service name or description (for example, Individualized Home Supports).

· The name, signature and title, if any, of the person providing the service. If more than one staff member provides the service, the provider may designate one staff member responsible for verifying services and completing the documentation required.

· For services authorized using a unit other than hourly or minute-based (such as daily or per occurrence), the provider must document:

· The date of the documentation.

· The day, month and year the service was provided.

· Service name or description. (For example, 24-hour customized living).

· The name, signature and title, if any, of the person providing the service. If more than one staff member provides the service, the provider may designate one staff member responsible for verifying services and completing the documentation required.

Services with additional documentation requirements
Alongside the HCBS documentation requirements outlined above, three HCBS program services have additional documentation and billing requirements. These services are: waiver transportation, specialized equipment and supplies, and adult day services.

Waiver transportation service
A waiver transportation service is not covered if:

· The service is medical transportation under the Medicaid state plan

· It is a component of another waiver service

· Maintain odometer and other records according to Minnesota Statutes, 256B.0625, subdivision 17b(b)(3) to distinguish an individual trip with a specific vehicle and driver when the service is billed directly by the mile. Common carrier transportation as defined by Minnesota Rules, part 9505.0315, subpart 1, item B, or a publicly operated transit system provider are exempt from this clause.

· Maintain documentation demonstrating the vehicle and driver meet the transportation waiver service provider standards and qualifications according to the federally approved waiver plan.

Specialized equipment and supplies documentation requirement
A specialized equipment and supplies waivered services provider must maintain documentation that shows:

· The person’s assessed need for the equipment or supply.

· The reason why a Medicaid state plan does not cover the equipment or supply.

· The cost, quantity, type and brand of the equipment or supply delivered or purchased

· If the item is rented or purchased.

· The shipping invoice or documentation proving the date of delivery to the person, or receipt if purchased by the person.

Adult day service documentation and billing requirements
An adult day service provider must maintain documentation that shows:

· A needs assessment and current plan of care according to Minnesota Statutes, 245A.143, subdivisions 4-7 or Minnesota Rules, 9555.9700 for each person, as applicable.

· Attendance records including the date of attendance with the day, month, year and pickup and drop-off time in hours and minutes with a.m. and p.m. designations.

· Monthly and quarterly program requirements according to Minnesota Rules, 9555.9710, subpart 1 E and H, subpart 3, subpart 4 and subpart 6

· Name and qualification of each registered physical therapist, registered nurse and registered dietitian who provides services to the adult day or nonresidential program.

· Location of the service (if alternate location, must document: address, length of time with a.m. and p.m. designations and list of people who went to the alternative location).

· For adult day services, if a provider exceeds its licensed capacity, DHS must recover all Minnesota Health Care Program payments (including Medical Assistance) for that date of service.

Submitting Claims

Bill only for services already provided and approved on the service authorization (SA).

When you submit claims for Waiver and Alternative Care (AC) program services:

· Use MN−ITS Direct Data Entry (DDE) 837P Professional or your own X12 compliance software (batch billing system)

· Enter a diagnosis code when submitting claims for all waiver services. Use the most current, most specific diagnosis code when submitting claims. MHCP will display the diagnosis code 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.

· Enter the approved SA number in the claim. Note: Services that require an SA cannot be billed on the same claim as services that do not require an SA

· Use date spans only for monthly codes when you have provided services for all dates in the span; otherwise, bill each date on a separate line.

· Submit your usual and customary charge for the service.

· An exception to this would be when a dollar amount is approved on the SA instead of a rate per unit for the following services:

· Consumer Directed Community Supports (CDCS),

· Specialized Equipment and Supplies,

· Environmental Accessibility Adaptations, or

· Assistive Technology Services.

· 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 (DHS-3945) (PDF) for a complete listing of the Health Care Common Procedural Coding System (HCPCS) codes and allocation of units for each service through each waiver or AC program.

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 the billing guidelines in the table.

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 lasting less than 8 minutes. Bill services in 15-minute units. If you provide a service 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 hourly procedure codes for time spent providing the service, a unit of time is attained when the length of time providing the service passes the hour mid-point. For example, an hour of billable time is attained when 31 minutes have elapsed. A second hour is attained when a total of 91 minutes have elapsed.

To bill for daily procedure codes, use daily or per diem codes found on your service authorization that do not have a timed component or unit assigned regardless of the time spent.

To bill for monthly procedure codes, only use the codes after the service has been provided for the month.

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 person. Follow these guidelines:

· Each provider must have a separate line item on the service authorization (SA).

· If the service has a daily or monthly procedure code, more than one provider cannot bill for the same 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 person 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 person resides in at midnight is the location that is able to bill for that day.

For example:

· Person leaves agency A at 3:30 p.m. on June 1

· Person moves to agency B at 3:31 p.m. on June 1

· Agency B bills for June 1

Waiver Services for an Individual in an Institutional Setting

Waiver services are not covered when an MHCP member is 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 an institutional setting if they provided services before the time of admission or after the time of discharge with the appropriate 15-minute code. If the person 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 daily or per diem code for a waiver service, providers may not bill for the date of admission to an institutional setting. MHCP will deny the claim or take back a previously paid claim. Providers may bill for the date of discharge from an institutional setting.

Exceptions:

· Waivers and AC allow payment for respite care services provided in a hospital or long-term care facility using respite care procedure codes. See the respite care description.

· Up to 180 days of AC conversion case management may be provided during the nursing facility stay and billed against the AC service agreement for a person receiving AC services.

Waiver Services for an Individual in a Residential Setting

MHCP covers the following waiver services in a residential setting:

· Customized living

· Adult foster care

· Community residential services

· Family residential services

· Integrated community supports

Waivers do not pay for room and board with the exception of respite and caregiver living expenses. Other income sources such as Social Security Disability Insurance (SSDI), General Assistance (GA), Supplemental Security Income (SSI) and Housing Support may cover room and board. See DHS’ Housing Support webpage for more information. The county worker determines all appropriate payment sources for room and board.

Absences from a residential setting not related to an admission to an institutional setting

The following applies to residential services provided under Brain Injury (BI), Community Alternative Care (CAC), Community Access for Disability Inclusion (CADI), Developmental Disabilities (DD), and Elderly Waiver (EW).

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

The Centers for Medicare & Medicaid Services (CMS) policy states Medicaid will pay for services actually provided to an eligible member. Providers may not bill for full days when MHCP members are absent from the residential setting 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 following examples for a person 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)