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Iowa Medicaid Enterprise

Welcome to

Remedial Services Provider Training

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Agenda

• Introduction of Remedial Services Provider program

• Remedial Services processes

• Billing services on the CMS 1500

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Iowa Medicaid Enterprise

Remedial Services

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Remedial Services:

– Enhance functional abilities

– Recommended by the LPHA

What are Remedial Services?

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LPHAs must be Iowa Plan Providers

• Physicians (MD or DO)• Psychologists (PhD or PsyD)• Licensed Independent Social Workers • Licensed Mental Health Counselors • Licensed Marital & Family Therapists• Licensed Master Social Worker (employed in a mental health

center)• Advanced Registered Nurse Practioners • Each must practice within scope of licensure

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Role of LPHA

• Completes face-to-face assessments• Makes the diagnosis and treatment

suggestions (which may include remedial services)

• Orders remedial services when indicated• Assists with referral to remedial provider if

requested

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Remedial Service Providers (RSP):

• Current Adult Rehab Option providers • Current RTSS providers

• Agencies accredited under Chapter 24 of IAC

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Role of Remedial Service Providers

• Develop a remedial service implementation plan when requested by a member

• Obtain Prior Approval for Remedial Services from IME Medical Services

• Provide services as written in the plan, if requested by the member

• Document services/interventions to support remedial services and billing

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RSP Codes - Children

Code Description

96152 Health and behavior intervention, 15 minute/individual

H2011 Crisis Intervention, 15 minute individual

96153 Health and behavior intervention, 15 minute/group

96154 Health and behavior intervention, 15 min-family

H0037 Community Psychiatric Supportive Treatment, per diem

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RSP Codes – Adults

Code Description

H2014 Skills Training and Development, per 15 minutes

H2001 Rehabilitation Program, per half day

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Remedial Services May Include:

• Anger Management

• Behavior Management

• Relationship Skills

• Communication Skills

• Problem Solving Skills

• Conflict Resolution

• Skill Rehearsal

• Social Skills

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Remedial Service Implementation Plan

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Demographics

• Member name • Member address • Member date of birth • Member Medicaid number • Remedial services provider name • RSP affiliation/company name • RSP Provider number

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• RSP Provider address • LPHA Name • LPHA Affiliation/Company name • LPHA Address • Legal representative (if applicable) • Legal representative’s relationship to member

• Address of representative

Demographics (cont)

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Remedial ServicePlan Requirements

• Remedial service implementation plan is consistent with LPHA order

• Plan addresses mental health symptoms/behaviors, IAC 441-78.42(249A)

• Plan is remedial and individualized • Member/family strengths are incorporated

into the interventions

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• Roles and responsibilities are identified • Services/treatment are consistent with practice

guidelines • Plan reflects member and/or legal representative• Goals and objectives are measurable and time limited • Treatment outcomes are specified

Plan Requirements (cont)

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Remedial ServicesProcess

• Medicaid members seek out or are referred to LPHA • LPHA completes assessment, diagnosis • LPHA orders remedial services if/ when indicated • Orders for remedial services must include:

– Diagnosis – Scope (remedial procedure codes) – Number of units – Duration of services (begin & end dates)

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• Member selects an RSP • LPHA provides a copy of the order

(treatment plan) to member and forwards a copy to RSP

• RSP develops remedial service implementation plan if requested by the member

Remedial Services Process (cont)

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• RSP emails/faxes order complete with the diagnosis & remedial service implementation plan to IME Medical Services

• Medical Services will respond within 2 business days

• Medical Services will send Notice of Decision to member and RSP

Remedial ServicesProcess (cont)

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• RSP documents services and progress notes as required to support service intervention and billing

• Remedial services implementation plans will be authorized for up to six months

Remedial Services Process (cont)

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Progress Notes

• Member name and Medicaid ID number

• Date and amount of services delivered with beginning and end times

• Name of staff providing service & agency name

• Staff’s signature with title

• Service setting

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• Description of the specific service and relationship to goal

• Description of the member’s response to service and progress toward goal

• Recommended revision in intervention/services, as appropriate

Progress Notes (cont)

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Continuing Services Criteria

• If behaviors/symptoms continue, then plans are revised to maximize treatment

• Member is benefiting from services

• New behavior/symptoms requiring remedial services are identified

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Discharge Criteria

• Remedial goals/objectives are achieved

• Age appropriate functioning is achieved

• Member is not compliant with remedial services

• Member is not benefiting from services

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Quality Review Process

Quality review will evaluate documentation as follows: – Member demographics; emergency and crisis

information, releases – LPHA diagnosis and order (treatment plan)– Member functional assessment information

sufficient to support remedial service implementation plan

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Quality Review Process(cont)

• Evidence of collaboration with other community resources

• Documentation of member/member’s guardian participation in treatment planning

• Remedial services implementation plan is individualized

• Plan goals and objectives are measurable and time limited

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Quality Review Process (cont)

• Roles and responsibilities for services are identified

• Plan is implemented as written • Documentation of referrals for further

evaluation if needed • Ancillary services identified • Billing matches progress notes

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Quality Review WillEvaluate:

• Time from member referral to remedial treatment plan development

• Continuity of treatment • Affiliation of LPHA to RSP

• Gaps in service

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Quality Review will Evaluate:

• Achieved treatment results • Member satisfaction with services• Results of quality review will be compiled with

copies submitted to providers and IME Policy • Medical Services will offer RSP quality

improvement training and education

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Remedial ServicesContact Information

IFMC (Medicaid)• PO Box 36478

• Des Moines, IA 50315

• 800-383-1173 or 515-725-1008 local

• Fax 515-725-0931

• www.remedialservices@dhs.state.ia.us 

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Iowa Medicaid Enterprise

Billing Services

to the IME

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(Eligibility Verification System) 

Eligibility VerificationSystem (ELVS)

•Verify member eligibility for today’s date or past date of service. • Verify member enrollment with the Iowa Plan. • Member eligibility can be verified by date of birth – ddmmyyyy and social security number or

the State ID number.• Access your last payment amount and date.• 800-338-7752• 515-323-9639 (Local)

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Electronic Claim Submission

• Electronic Date Interchange Support Services (EDISS) – 800-967-7902 9 AM-5 PM

• EDI paperwork must be completed and forwarded to EDI for enrollment

• Find forms at www.ime.state.ia.us, follow directions in the Tool Box

• PC-ACE Pro: free software

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Billing Information

• Mailing address for all claims from RSP:Iowa Medicaid Enterprise (IME)PO Box 150001Des Moines, IA 50315

• Provider Services phone numbers:• 800-338-7909• 515-725-1004• Monday – Friday 7:30 AM -4:30 PM

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IME Contacts for Claims

Medicaid ClaimsP. O. Box 150001

Des Moines, Iowa 50315 

Provider CorrespondenceP. O. Box 36450

Des Moines, Iowa 50315

E-mail: imeproviderservices@dhs.state.ia.us

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IME Phone Numbers

PROVIDER SERVICES

7:30 AM – 4:30 PM

800-338-7909

515-725-1004 (Local)

MEMBER SERVICES

8:00 AM – 5:00 PM

800-338-8366

515-725-1003 (Local)

ELVS(Eligibility Verification System)24 Hours a Day/7 Days a Week800-338-7752515-323-9639 (Local)

PROVIDER AUDITS AND RATE SETTING

8:00 AM – 5:00 PM866-863-8610515-725-1108 (Local)

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Billing Tips

• IME suggests that claims should be billed no more often than once per month

• CMS 1500 claim forms must be used and correctly completed

• IME payment cycles are weekly

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Completing theClaim Form

• Discussion of each required box– Detailed instructions are included in the

handout– Many boxes are not required or are optional– Ensure all required boxed are correctly

completed or the claim will not pay

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Claim Submission Issues

• Use original claim forms, do not make copies

• Do not use red or light colored ink

• Do not use highlighter of any color

• Position data in the center of each box, not touching any red line

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Submission Issues(cont)

• Diagnosis codes (ICD-9) and CPT codes cannot include description on the form

• Column E Diagnosis Code must have the corresponding number from box 21, not the actual diagnosis code

• Indicate both dollars and cents for sub-charge and total charge.

• Limit the use of handwritten information

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Timely Filing Guidelines

• Original claim submissions must be filed within 12 months of the through date of service.

• If the claim was filed timely but denied, then it can be resubmitted up to 12 months from the remit denial date.

• Claims after 12 months must be filed on paper with “resubmission” and the original filing date in the signature box.

• Adjustments can be filed within 12 months of the payment date.

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Credit/ AdjustmentRequests

• Used to change information on a paid claim:– Paid amount needs to be changed

– Number of units needs to be changed

– Dates of service need to be changed

• Complete form correctly and entirely• Form #470-0040 found on the IME Website• Must be filed within 12 months of payment

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Reimbursement

• Interim rates on DHS web site– By agency– By service

• Based on current information• Cost report- due 3 months after agency fiscal

year end• Cost settlement• Interim rates recalculated