Medicaid Billing Module

Transportation Billing Form

Transportation Billing Form Demographics Section

Medicaid Number Last Name First Name County School

         

WVEIS # Diagnosis Code Date of Birth Month/Year Vehicle Type

        Modified

Demographics Section

• Complete the top row of demographic information using the county and school codes.

• On the bottom row fill in the full WVEIS #, Diagnosis Code should be left blank until further notice, date of birth and the Month and Year for billing.

• The billing form cannot have data from multiple months.

Transportation Billing Form Demographics Section EXAMPLE

Medicaid Number Last Name First Name County School

 00000000001 Doe Jane 058 301

WVEIS # Diagnosis Code Date of Birth Month/Year Vehicle Type

999999999   01-01-1900  August 2015 Modified

Procedure Code and Instruction

__T2001 SE – Non-Emergency Medical Transportation – with Bus Aide. List start and end times per trip.

T2002 SE – Non-Emergency Medical Transportation (NO AIDE). List mileage of each trip.

(Up to 4 one-way trips per instructional day.) Locations would be school, home, or another specific location such as RESA or doctor office. The last column will be completed at a later date by staff responsible for Medicaid. Purpose is completed only for students who are receiving a Medicaid billable service that day.

Procedure Code Section

• Check the line next to T2001 SE for modified bus with an aide. This is used for a bus with a lift only.

• This procedure is for a one way trip. (We no longer need round trips to bill.)

• Typically you can bill two trips per instructional day. • If a student is taken to a billable service during the

instructional day you could bill up to four trips in a day.

Procedure Code Section

• Procedure Code T2002 SE is only used for a modified bus (with a lift) that doesn’t have an aide.

• Unlikely you will have any billable trips for this code.

• If using this code complete the mileage column instead of start and stop times.

Data Entry Section

Date Departure Location

Arrival Location

Start Time

Stop Time Mileage Purpose: To provide access to the following billable service(s).

Data Entry Section

• For Procedure T2001 SE the aide or driver will complete the first five columns per one-way trip.

• Mileage is not needed and should be left blank

• The last column will be completed by staff at the school, county or RESA level.

Data Entry Section• Date: Enter the date of the trip• Departure Location: Enter home or school • Arrival Location: Enter home or school• Start Time: Document the time the student boarded the

bus. • Stop Time: Document the time the student exited the

bus. • Start and stop times must be actual times each day not

the regularly scheduled times. Actual times will vary based upon weather, traffic, and other factors.

Data Entry Section

Date Departure Location

Arrival Location

Start Time

Stop Time Mileage Purpose: To provide access to the following billable service(s).

8-17-15 Home School 7:32 7:50

8-17-15 School Home 2:55 3:18

Data Entry Section

• If a student was transported to RESA for an Audiology Evaluation during the school day with a modified bus and aide you could document this as follows.

Data Entry Section

Date Departure Location

Arrival Location

Start Time

Stop Time Mileage Purpose: To provide access to the following billable service(s).

8-17-15 Home School 7:32 7:50

8-17-15 School Home 2:55 3:18

8-18-15 Home School 7:30 7:50

8-18-15 School RESA 8 9:30 10:15

8-18-15 RESA 8 School 11:30 12:15

8-18-15 School Home 2:55 3:25

Data Section Purpose Column

• This section will be completed by an employee who has access to the student’s completed billing forms for the month.

• Enter the billable service provided for trips that match the date of service

• If there was not a billable service for a trip date enter NA

• Only one billable service needs to be entered per trip.

Data Entry Section

• Billable services include: Speech, Occupational Therapy, Physical Therapy, Audiological, Nursing, Personal Care, Psychological (testing or psychotherapy) and Targeted Case Management (TCM).

Data Entry Section

Date Departure Location

Arrival Location

Start Time

Stop Time Mileage Purpose: To provide access to the following billable service(s).

8-17-15 Home School 7:32 7:50 NA

8-17-15 School Home 2:55 3:18 NA

8-18-15 Home School 7:30 7:50 Speech

8-18-15 School Home 2:55 3:25 Speech

8-19-15 Home School 7:32 7:50 TCM

8-19-15 School Home 2:55 3:22 TCM

Data Entry Section

• After completing the purpose column fill in the number of total trips, total billable trips, and total non-billable trips.

• This information will be used by the financial department for year end calculations.

Data Entry Section

Date Departure Location

Arrival Location

Start Time

Stop Time

Mileage Purpose: To provide access to the following billable service(s).

8-17-15 Home School 7:32 7:50 NA 8-17-15 School Home 2:55 3:18 NA 8-18-15 Home School 7:30 7:50 Speech 8-18-15 School Home 2:55 3:25 Speech 8-19-15 Home School 7:32 7:50 TCM 8-19-15 School Home 2:55 3:22 TCM

Total Trips 6 Total Billable Trips 4 Total Non-Billable Trips 2

Signatures and Credentials

• Driver is required to sign this form. • Driver credential is Bus Driver• Aide is required to sign this form.• Aide credential is the classification of

employment such as Aide I, Aide II, Aide III.

Attendance Verification

• It is important to verify that the student was present in school on the day that billable trips were listed.

• Compare attendance logs to ensure accuracy.

• A student could have a tardy, early departure, or a half-day absence and still have one billable trip.

Terry Riley – CoordinatorOffice of Special Education

tjriley@k12.wv.us304-957-9833 ext 53223

WVDE Medicaid Website:http://wvde.state.wv.us/osp/medicaid.html