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HCS BILLING GUIDELINES
• You can find the newest version on the DADS
website:
http://www.dads.state.tx.us/handbooks/hcsbg/
1
General Information
Department of Aging and Disability Services (DADS) rules at 40 TAC §9.170 set
forth requirements for Home and Community-based Services (HCS) Program
providers to receive payment for HCS Program services. Specifically, 40 TAC
§9.170(d) requires a program provider to prepare and submit service claims in
accordance with the HCS Program Billing Guidelines. Also, Sections II. H. and II.
T. of the HCS Program Provider Agreement require program providers to
comply with the HCS Program Billing Guidelines. In addition, 40 TAC §9.170(k)
sets forth circumstances under which a program provider will not be paid or
Medicaid payments will be recouped from the program provider.
2
General Requirements
Applicable Service Components
•
Specialized Therapies
– Audiology; dietary; occupational therapy; physical therapy; behavioral support;
social work; and speech and language pathology.
•
•
Day Habilitation
Nursing
– Registered; Licensed Vocational; Specialized Registered; and Specialized Licensed
Vocational.
•
Residential Assistance
– Foster/Companion Care; Residential Support; Supervised Living; and Supported
Home Living.
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•
Respite
Supported Employment
Adaptive Aids
Minor Home Modifications
Dental Treatments
http://www.dads.state.tx.us/handbooks/hcsbg/3000/3000.htm#sec3100
3
Specific Requirements
21
Specialized Therapies
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4200
Specific Requirements
Specialized Therapies
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•
Audiology services
Dietary services
Occupational therapy services
Physical therapy services
Psychology services
Social work services
Speech and language pathology
services
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4200
Specific Requirements
Specialized Therapies Billable Activity
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•
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•
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The only billable activities for the specialized therapies service component are:
interacting face-to-face or by video conference or speaking by telephone with an
individual, based on the specialized therapies subcomponent provided, to conduct
assessments or provide services within the scope of the service provider's practice;
interacting face-to-face or by video conference or speaking by telephone with a person
regarding a specialized therapies subcomponent provided to an individual, but not
with:
– a staff person who is not a service provider; or
– a service provider of any nursing service component (registered nursing, licensed
vocational nursing, specialized registered nursing or specialized licensed
vocational nursing), or specialized therapies;
writing an individualized treatment plan for an individual's specialized therapies
which, for behavioral support services, is a behavior support plan;
reviewing documents, except for a written narrative or written summary of a service
component as described in Section 3820, to evaluate the quality and effectiveness of
an individual's specialized therapies;
24
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4220
Specific Requirements
Specialized Therapies Billable Activity
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•
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training the following persons on how to provide specialized therapies treatment,
including how to document the provision of treatment:
– a service provider of foster/companion care, residential support, supervised
living, supported home living, day habilitation, respite, supported employment
or employment assistance; or
– a person other than a service provider who is involved in serving an individual;
reviewing documents in preparation for the training described in the bullet above;
participating in a service planning team meeting;
participating in the development of an implementation plan;
participating in the development of an IPC; and
25
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4220
Specific Requirements
Specialized Therapies Billable Activity
•
for behavioral support services, in addition to the activities listed above:
– assessing the targeted behavior so that a behavior support plan may be
developed;
– training of and consulting with an individual, family member or other persons
involved in the individual's care regarding the implementation of the behavior
support plan;
– monitoring and evaluating the effectiveness of the behavior support plan;
– modifying, as necessary, the behavior support plan based on the monitoring and
evaluation of the plan's effectiveness; and
– educating an individual, family members or other persons involved in the
individual's care about the techniques to use in assisting the individual to control
maladaptive or socially unacceptable behaviors exhibited by the individual.
26
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4220
Specific Requirements
Not Billable as Specialized Therapies
The following are examples of activities that are not billable for the specialized
therapies service component:
– providing services outside the scope of the service provider's practice;
– providing services that are performed by a service coordinator or were
performed by a former case manager;
– scheduling an appointment;
– transporting an individual;
– traveling or waiting to provide a specialized therapies subcomponent;
– training or interacting about general topics unrelated to a specific individual,
such as principles of behavior management, or general use and maintenance of
an adaptive aid or equipment;
– creating written documentation as described in Section 4260;
– reviewing a written narrative or written summary of a service component as
described in Section 3820; and
27
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4230
Specific Requirements
Not Billable as Specialized Therapies
The following are examples of activities that are not billable for the specialized therapies
service component (continued):
– interacting with:
• a staff person who is not a service provider; or
• a service provider of any nursing service component (registered nursing,
licensed vocational nursing, specialized registered nursing or specialized
licensed vocational nursing) or specialized therapies, if not during a service
planning team meeting or during the development of an IPC or an
implementation plan.
Activities in Section 3300
– The activities listed in Section 3300, Activity Not Billable, are not billable for the
specialized therapies service component.
Activities Not Listed in Section 4220
– Any activity not described in Section 4220, Billable Activity, is not billable for the
specialized therapies service component.
28
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4230
Specific Requirements
Examples of Activity Not Billable
– providing services outside the scope of the service provider's practice;
– providing services that are performed by a service coordinator or were performed
by a former case manager;
– scheduling an appointment;
– transporting an individual;
– traveling or waiting to provide a specialized therapies subcomponent;
– training or interacting about general topics unrelated to a specific individual, such
as principles of behavior management, or general use and maintenance of an
adaptive aid or equipment;
– creating written documentation as described in Section 4260;
– reviewing a written narrative or written summary of a service component as
described in Section 3820; and
– interacting with:
• a staff person who is not a service provider; or
• a service provider of any nursing service component (registered nursing, licensed
vocational nursing, specialized registered nursing or specialized licensed vocational
nursing) or specialized therapies, if not during a service planning team meeting or
during the development of an IPC or an implementation plan.
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4230
29
Specific Requirements
Specialized Therapies Written Documentation
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•
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Except as provided in Section 4270, Insurance Co-payment and Deductible
(see No. 1, Item c and No. 2, Item c), a program provider must have written
documentation to support a service claim for specialized therapies that:
meets the requirements set forth in Section 3800, Written Documentation;
includes the exact time the service event began and the exact time the service
event ended documented by the service provider making the written service
log; and
for any activity performed by multiple service providers at the same time for
the same individual, includes a written justification in the individual's
implementation plan for the use of multiple service providers.
30
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4260
Common Errors
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No begin and/or end times
No location of service provided
Reviewing or creating service delivery records
Family paying for rate differential
No Progress Note
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Day Habilitation
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4300
Specific Requirements
Day Habilitation Billable Activity
•
•
The only billable activities for the day habilitation service component are:
interacting face-to-face with an individual to assist the individual in
achieving objectives to:
– acquire, retain or improve self-help skills, socialization skills or adaptive skills that are
necessary to for the individual to successfully reside, integrate and participate in the
community;
– reinforce a skill taught in school, specialized therapies; and
– develop opportunities for employment in the community (for example, completing a job
application, assessing employment skills and training on employment-related issues);
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transporting an individual between settings at which day habilitation is
provided to the individual;
assisting an individual with his or her personal care activities if the
individual cannot perform such activities without assistance;
participating in a service planning team meeting;
participating in the development of an implementation plan; and
participating in the development of an IPC.
33
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4330
Specific Requirements
Not Billable as Day Habilitation
• Travel time (except from one Day
Habilitation site to another)
• Written documentation
• Reviewing records
• Drafting Implementation Plans
• Staff Training/Conferences
• Processing service claims
• Assisting an individual for the sole
purpose of meeting vocational goals
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4340
Specific Requirements
May not submit DH service claim for:
• An individual who refuses to participate
• An individual who is sleeping
• Assisting an individual in achieving goals
not documented in their IP
• More than five units of service in a calendar
week
• More than 260 units of service per IPC year
• Day habilitation that is funded by another
source other than HCS
36
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4340
Specific Requirements
Day Habilitation Unit of Service
A unit of service for Day Habilitation is one day
• One-quarter unit of service if service is provided at
least one and one-quarter hours of consecutive day
habilitation on a calendar day
• One-half unit of service may be billed if service is
provided for at least two and one-half hours on a
calendar day. Two of the two and one-half hours
must be consecutive.
• Three-quarters unit of service may be billed if service
is provided for at least three and three-quarter hours
on a calendar day. Two of the three and threequarter hours must be consecutive.
• One unit may be billed if service is provided for at
least five hours on a calendar day. Two of the five
hours must be consecutive.
37
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4370
Common Errors
• Individual sleeping
• Not signing individual out of Day Habilitation for other services
provided (NU, SHL, etc.)
• No description of service provided (details about interactions,
activities, behaviors, successes, refusals, etc.)
• Vocational Goals – Sheltered Workshops
• No Progress Note
39
Supported Employment
40
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4700
Specific Requirements
Supported Employment
• Supported employment is a service that
assists an individual to sustain
competitive, integrated employment.
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4720
Specific Requirements
Supported Employment Billable Activity
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The only billable activities for the supported employment service
component are:
interacting face-to-face with an individual at the individual's work
site to provide training, support and intervention necessary to sustain
the individual's employment;
interacting face-to-face or by telephone with an individual's
employment supervisor as necessary to sustain the individual's
employment;
transporting an individual to and from the individual’s work site;
participating in a service planning team meeting;
participating in the development of an implementation plan; and
participating in the development of an IPC.
42
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4720
Specific Requirements
Examples of Activities Not Billable under SE
•
The following are examples of activities that are not billable for the
supported employment service component:
– interacting with an individual prior to the individual's employment;
– conducting employment interest assessments, assisting with or
arranging interviews, and completing job applications;
– interacting with an individual when the individual is not on duty; and
– transporting an individual to a job interview.
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4740
Specific Requirements
Restrictions (SE):
A program provider may not submit a service claim for
supported employment provided to an individual:
•
•
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while the individual is employed by the program provider;
in excess of 600 units of service (150 hours) per IPC year; or
if supported employment is available to the individual through
the public school system or the Department of Assistive and
Rehabilitative Services.
44
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4760
Common Errors
• Training not occurring at the job site
• Pre-vocational training
• No Progress Note
46
Nursing
47
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4400
Specific Requirements
Registered Nursing Billable Activity
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•
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The only billable activities for the registered nursing service
component are:
interacting face-to-face with an individual who has a medical need
for registered nursing, including:
– preparing and administering medication or treatment ordered by
a physician, podiatrist or dentist;
– assisting or observing administration of medication; and
– assessing the individual's health status, including conducting a
focused assessment or a comprehensive assessment;
speaking by telephone with an individual who has a medical need for
registered nursing, including assessing the individual's health status;
interacting by video conference with an individual who has a medical
need for registered nursing, including:
– observing administration of medication; and
– assessing the individual's health status, including conducting a
focused assessment or a comprehensive assessment;
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4420
48
Specific Requirements
Registered Nursing Billable Activity (cont.)
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at the time an individual receives medication from a pharmacy,
ensuring the accuracy of:
– the type and amount of medication; and
– the dosage instructions;
researching medical information for an individual who has a medical
need for registered nursing, including:
– reviewing documents, except for a written service log or written
summary log of a service component as described in Section
3820, to evaluate the quality and effectiveness of the medical
treatment the individual is receiving; and
– completing a comprehensive assessment;
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4420
Specific Requirements
Registered Nursing Billable Activity (cont.)
•
training the following persons how to perform nursing tasks:
– a service provider of foster/companion care, residential support,
supervised living, supported home living, day habilitation,
respite, supported employment or employment assistance; or
– a person other than a service provider who is involved in serving
an individual;
– reviewing documents in preparation for the training described in
the bullet above;
50
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4420
Specific Requirements
Registered Nursing Billable Activity (cont.)
•
interacting face-to-face or by video conference or speaking by
telephone with a person regarding the health status of an individual,
but not with:
– a staff person who is not a service provider; or
– a service provider of:
• registered nursing;
• licensed vocational nursing unless supervised by the
registered nurse;
• specialized registered nursing;
• specialized licensed vocational nursing unless supervised by
the registered nurse; or
• specialized therapies;
51
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4420
Specific Requirements
Registered Nursing Billable Activity (cont.)
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interacting face-to-face or speaking by telephone with a pharmacist
or representative of a health insurance provider, including the Social
Security Administration, about an individual's insurance benefits for
medication if the registered nurse justifies, in writing, the need for the
registered nurse to perform the activity;
instructing a service provider, except a service provider of registered
nursing or specialized registered nursing, on a topic that is specific to
an individual such as choking risks for an individual who has
cerebral palsy;
supervising a licensed vocational nurse regarding an individual's
nursing services or health status;
instructing, supervising or verifying the competency of an unlicensed
person in the performance of a task delegated in accordance with
rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating
to RN Delegation to Unlicensed Personnel and Tasks not Requiring
Delegation in Independent Living Environments for Clients with
Stable and Predictable Conditions) or the Human Resources Code,
§§161.091-.093, as applicable;
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4420
52
Specific Requirements
Registered Nursing Billable Activity (cont.)
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participating in a service planning team meeting;
participating in the development of an implementation plan; and
participating in the development of an IPC.
53
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4420
Specific Requirements
Licensed Vocational Nursing Billable
Activity
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interacting face-to-face with an individual who has a medical
need for licensed vocational nursing, including:
– preparing and administering medication or treatment
ordered by a physician, podiatrist or dentist;
– assisting or observing administration of medication; and
– conducting a focused assessment of the individual's health
status;
speaking by telephone with an individual who has a medical
need for licensed vocational nursing, which may include
conducting an assessment of an individual if:
– the assessment is conducted using protocol approved by
DADS; and
– the licensed vocational nurse has been trained by a
registered nurse on using the protocol;
54
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2
Specific Requirements
Licensed Vocational Nursing Billable
Activity (cont.)
•
•
interacting by video conference with an individual who has a
medical need for licensed vocational nursing, including:
– observing administration of medication; and
– conducting a focused assessment of the individual's health
status;
at the time an individual receives medication from a pharmacy,
ensuring the accuracy of:
– the type and amount of medication; and
– the dosage instructions;
55
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2
Specific Requirements
Licensed Vocational Nursing Billable
Activity (cont.)
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•
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researching medical information for an individual who has a
medical need for licensed vocational nursing, including:
– reviewing documents, except for a written service log or
written summary log of a service component as described
in Section 3820, to evaluate the quality and effectiveness of
the medical treatment the individual is receiving; and
– completing a focused assessment;
training a service provider of residential assistance, day
habilitation, respite or supported employment, or a person
other than a service provider who is involved in serving an
individual, regarding how to perform nursing tasks;
reviewing documents in preparation for the training described
in the bullet above;
56
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2
Specific Requirements
Licensed Vocational Nursing Billable
Activity (cont.)
•
•
•
researching medical information for an individual who has a
medical need for licensed vocational nursing, including:
– reviewing documents, except for a written service log or
written summary log of a service component as described
in Section 3820, to evaluate the quality and effectiveness of
the medical treatment the individual is receiving; and
– completing a focused assessment;
training a service provider of residential assistance, day
habilitation, respite or supported employment, or a person
other than a service provider who is involved in serving an
individual, regarding how to perform nursing tasks;
reviewing documents in preparation for the training described
in the bullet above;
57
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2
Specific Requirements
Licensed Vocational Nursing Billable
Activity (cont.)
•
•
interacting face-to-face or by video conference or speaking by
telephone with a person regarding the health status of an
individual, but not with:
– a staff person who is not a service provider; or
– a service provider of any nursing service component
(registered nursing, licensed vocational nursing, specialized
registered nursing or specialized licensed vocational
nursing) or specialized therapies;
interacting face-to-face or speaking by telephone with a
pharmacist or representative of a health insurance provider,
including the Social Security Administration, about an
individual's insurance benefits for medication if the licensed
vocational nurse justifies, in writing, the need for the licensed
vocational nurse to perform the activity;
58
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2
Specific Requirements
Licensed Vocational Nursing Billable
Activity (cont.)
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•
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instructing a service provider, except a service provider of
registered nursing or specialized registered nursing, on a topic
specific to an individual such as choking risks for an individual
who has cerebral palsy;
participating in a service planning team meeting;
participating in the development of an implementation plan;
and
participating in the development of an IPC.
59
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2
Specific Requirements
Specialized Registered and Licensed
Vocational Nursing
• Follow respective sections only for an individual who has
a tracheostomy or is dependent on a ventilator.
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http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4472.2 &
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4473.2
Specific Requirements
Examples of Non-Billable Activities:
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performing or supervising an activity that does not constitute
the practice of licensed vocational nursing, including:
performing an activity that constitutes the practice of
professional nursing and must be performed by a registered
nurse;
transporting an individual;
waiting to perform a billable activity; and
waiting with an individual at a medical appointment;
making a medical appointment;
instructing on general topics unrelated to a specific individual,
such as cardiopulmonary resuscitation, or infection control;
preparing a treatment or medication for administration and not
interacting face-to-face with an individual;
storing, counting, reordering, refilling or delivering medication
except as allowed in the fourth bullet of Section 4471.2;
creating written documentation as described in Section 4471.7;
61
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.3
Specific Requirements
Examples of Non-Billable Activities:
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reviewing a written service log or written summary log of a
service component as described in Section 3820;
interacting with:
a staff person who is not a service provider; or
a service provider of any nursing service component (registered
nursing, licensed vocational nursing, specialized registered
nursing or specialized licensed vocational nursing), or
specialized therapies, if not during a service planning team
meeting or during the development of an IPC or an
implementation plan; and
performing an activity for which there is no medical need.
62
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.3
Specific Requirements
Nursing Rule of Thumb:
If it does not require a nursing license
to perform a task, it is not billable.
63
Specific Requirements
Nursing Unit of Service
• 15 Minute of Service
A service claim cannot be made for
a fraction of a unit of service
• Accumulation of Service Times
Can be accumulated for nursing
provided to one individual on a
single calendar day
64
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4450
Common Errors
• Billing for creating and reviewing service records.
• No medical necessity shown when residential staff calls nurse to
administer over the counter medication to individual
• No medical necessity for follow-up phone call
• Billing for services without Face-to-Face, Telephone or Video
conferencing contact
• Providing any activity not requiring a nursing license
• One note used for multiple service events
• No Progress Note
68
Residential Assistance
69
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4500
Specific Requirements
Residential Assistance Residential Location
• Own Home/Family Home – if no foster/companion
care, residential support or supervised living is
provided to the individual
• Foster/Companion Care – is not owned or leased by
the program provider, a service provider provides care
to the individual; and the care provider and the
individual have the same address
70
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4530
Specific Requirements
Residential Assistance Residential Location
• 3-Person Home – the individual’s
residence is a 3-person residence and a
service provider provides residential
support or supervised living to the
individual
• 4-person Home – the individual’s
residence is a 4-person residence and a
service provider provides residential
support or supervised living to the
individual (one must be RSS)
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4530
71
Supported Home
Living
72
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4540
Specific Requirements
Supported Home Living Billable Activity
Interacting face-to-face with the individual:
• to assist with activities of daily living
• to assist with ambulation and mobility
• to reinforce counseling and therapy subcomponents
• to assist with administration of medication or tasks delegated by an RN
• to conduct habilitation activities
• to secure transportation for the individual
• to supervise the individual’s safety and security
• interactions regarding an incident directly affecting the individual's health
or safety;
• performing allowable non-face-to-face activities
• participating in a service planning team meeting;
• participating in the development of an implementation plan; and
• participating in the development of an IPC.
73
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4540
Specific Requirements
Supported Home Living claims may not be
submitted for:
•
•
•
An individual whose IPC does not have a residential location of “own
home/family home”
the sole activity of supervising the individual's safety and security
Transporting an individual from one DH or SE site to another
– supporting home living provided to an individual:
• in a residence in which residential support or supervised living is
provided to another individual;
• by a service provider who is simultaneously providing residential
support, supervised living or foster/companion care to another
individual;
• if the day habilitation service component is simultaneously
provided to the individual by another service provider; or
• if the respite service component is simultaneously provided to the
individual by another service provider.
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4540
74
Specific Requirements
Supported Home Living Unit of Service
• 15 Minute of Service – may not include
fraction of service
• Calculating transportation – use Method A
or Method B (can only use one method on
a single calendar day)
75
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4540
Transportation Method A
Individual
Departure Time
Arrival Time
A. Dorothy N. Kansas
7:00am
9:00am
B. Dorothy N. Kansas
3:00pm
4:30pm
a. Transportation time of 120 minutes (7:00am-9:00am) with 6
passengers (Dorothy + 5 others) and 1 service provider for Trip A
SERVICE TIME = (1 X 120) ÷ 6 = 20 minutes
b. Transportation time of 90 minutes (3:00pm-4:30pm) with 5 passengers
(Dorothy + 4 others) and 1 service provider
SERVICE TIME = (1 X 90) ÷ 5 = 18 minutes
20 min + 18 min = 38 minutes (accumulation)
According to Attachment C:
38 minutes = 3 Units Billed (accumulation)
1 Unit (20 min) + 1 Unit (18 min)= 2 Units Billed (no accumulation)
79
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4540
Transportation Method B
Individual
Departure Time
Arrival Time
Dorothy N. Kansas
7:00am
9:00am
Little B. Blue
7:15am
9:00am
Mary Q. Contrary
7:30am
9:00am
Transportation time for Dorothy N. Kansas:
a. Transportation time of 15 minutes (7:00am-7:15am) with
one passenger (Dorothy only) and 1 service provider
SERVICE TIME = (1 X 15) ÷ 1 = 15 minutes
b. Transportation time of 15 minutes (7:15am-7:30am) with
two passengers (Dorothy and Little) and 1 service provider
SERVICE TIME = (1 X 15) ÷ 2 = 7.5 minutes
c. Transportation time of 15 minutes (7:30am-9:00am) with
three passengers (Dorothy, Little and Mary) and 1 service
provider
SERVICE TIME = (1 X 90) ÷ 3 = 30 minutes
15 min + 7.5 min + 30 min = 52.5 minutes
According to Attachment C: 52.5 minutes = 3 Units
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4540
80
Common Errors
• Overlapping times with other services
• Transportation method completed incorrectly
• Time not divided evenly between two or more individuals
receiving services at the same time
• Non-qualified Service Provider (Proof of residence, etc.)
• No justification for receiving SHL in DH facility
• No begin and/or end times on documentation
• No location of services provided on documentation
• No Progress Note
81
Foster Care
82
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Specific Requirements
Foster Care Requirements of Setting
• The program provider may not lease or own the
residence
• The individual receiving care must have a
residence in which no more than three persons
receive: foster/companion care, a non-HCS
Program service similar to foster/companion
care; and
• If the individual is a minor, the parent or stepparent may not provide this service
83
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Specific Requirements
Foster Care Requirements of Setting
• The service provider must have the
same residence as the individual; and
• Ensure that foster/companion care is
provided to an individual when
necessary
84
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Specific Requirements
Foster Care Unit of Service
• Unit of service is one day
• May not be for more than one day
• May not have a fraction of a unit of
service
85
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Specific Requirements
Foster Care Billable Activity
• Assisting the individual with activities of
daily living (bathing, dressing, personal
hygiene, eating, meal planning and
preparation and housekeeping)
• Assisting the individual with ambulation and
mobility
• Reinforcing any counseling and therapy
subcomponent provided to the individual
• Assisting with the administration of the
individual’s medication or to perform a task
delegated by an RN
86
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Specific Requirements
Foster Care Billable Activity
• Conducting habilitation activities that
train the individual to:
– Develop or improve skills that allow
the individual to live more
independently
– Develop socially valued behaviors
– Integrate into community activities
– Use natural supports and typical
community services available to the
public
– Participate in leisure activities
87
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Specific Requirements
Foster Care Service Claim for an
Individual on a Visit with Family or
Friend
A program provider may submit a service
claim for an individual who is on a visit with
a family member or friend away from their
residence if the visit is for at least a calendar
day. If the visit is for more than 14
consecutive calendar days, the program
provider may submit a service claim for only
14 calendar days of the visit.
89
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Specific Requirements
Foster Care Service Claim for an Individual on a
Visit with Family or Friend Written
Documentation
Written documentation must include the
individual’s name, the dates the
individual was visiting the family
member or friend, the location of the
visit and the date and signature of the
service provider.
90
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4550
Common Errors
• Failure to discharge individual while in the
hospital
• Weekly summary exceeds seven days
• Not documenting location information
• No Progress Note
91
Residential Support
Services
92
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4560
Specific Requirements
Residential Support Requirements of Setting
• The residence must be a Three or Four person
residence
• The program provider may not have the same
residence as the individual
• The service provider must be available to provide
residential support to an individual as needed; and
• The service provider must be present and awake in the
residence when the individual is present in the
residence
93
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4560
Specific Requirements
Residential Support Billable Activity
– assisting the individual with activities of daily living;
– assisting the individual with ambulation and mobility;
– reinforcing any specialized therapies subcomponent provided to
the individual;
– assisting with the administration of the individual's medication or
to perform a task delegated by a registered nurse in accordance
with rules of the Texas Board of Nursing at 22 TAC, Chapter 225
(relating to RN Delegation to Unlicensed Personnel and Tasks not
Requiring Delegation in Independent Living Environments for
Clients with Stable and Predictable Conditions) or the Human
Resources Code, §161.091-.093, as applicable;
– conducting habilitation activities that train the individual;
– securing transportation for or transporting the individual; and
– supervising the individual's safety and security.
94
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4560
Specific Requirements
Residential Support Unit of Service
• Unit of service is one day
• A service claim may not be for more
than one day
• A service claim may not include a
fraction of a unit of service
95
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4560
Specific Requirements
Residential Support Service Claim for an
Individual on a Visit with Family or Friend
A program provider may submit a service claim for
an individual who is on a visit with a family
member or friend away from their residence if
the visit is for at least a calendar day. If the visit
is for more than 14 consecutive calendar days,
the program provider may submit a service
claim for only 14 calendar days of the visit.
97
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4560
Specific Requirements
Service Claim for an Individual on a Visit
with Family or Friend Written
Documentation
Written documentation must include
the individual’s name, the dates the
individual was visiting the family
member or friend, the location of the
visit and the date and signature of the
service provider.
98
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4560
Common Errors
•
•
•
•
Failure to discharge individual while in the hospital
Not providing location codes
Not providing staff signatures
Not showing night shift coverage activities
99
Supervised Living
100
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4570
Specific Requirements
Supervised Living Requirements of Setting
• The residence must be a 3 or 4-person
residence
• The service provider must be available to
provide residential support to an
individual as needed; and
• The service provider must be present in
the residence when the individual is
present in the residence
101
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4570
Specific Requirements
Supervised Living Billable Activity
– assisting the individual with activities of daily living;
– assisting the individual with ambulation and mobility;
– reinforcing any specialized therapies subcomponent provided to
the individual;
– assisting with the administration of the individual's medication or
to perform a task delegated by a registered nurse in accordance
with rules of the Texas Board of Nursing at 22 TAC, Chapter 225
(relating to RN Delegation to Unlicensed Personnel and Tasks not
Requiring Delegation in Independent Living Environments for
Clients with Stable and Predictable Conditions) or the Human
Resources Code, §161.091-.093, as applicable;
– conducting habilitation activities that train the individual;
– securing transportation for or transporting the individual; and
– supervising the individual's safety and security.
102
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4570
Specific Requirements
Supervised Living Unit of Service
• Unit of service is one day
• A service claim may not be for more
than one day
• A service claim may not include a
fraction of a unit of service
103
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4570
Specific Requirements
Supervised Living Service Claim for an
Individual on a Visit with Family or
Friend
A program provider may submit a service claim
for an individual who is on a visit with a family
member or friend away from their residence if
the visit is for at least a calendar day. If the visit
is for more than 14 consecutive calendar days,
the program provider may submit a service
claim for only 14 calendar days of the visit.
105
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4570
Specific Requirements
Service Claim for an Individual on a
Visit with Family or Friend Written
Documentation
Written documentation must include
the individual’s name, the dates the
individual was visiting the family
member or friend, the location of the
visit and the date and signature of the
service provider.
106
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4570
Common Errors
• Failure to discharge consumer while in the
hospital
• Not providing location
• No Progress Note
107
Respite
108
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4600
Specific Requirements
Respite
– is the temporary provision of assistance and support necessary
for an individual to perform personal care, health maintenance
and independent living tasks, participate in community activities,
and develop, retain and improve community living skills; and
– provides relief for a caregiver of the individual who:
• has the same residence as the individual;
• routinely provides assistance and support necessary for an
individual to perform personal care, health maintenance and
independent living tasks, participate in community activities,
and develop, retain and improve community living skills;
• is temporarily unavailable to provide such assistance and
support; and
• is not a service provider of foster/companion care,
residential support or supervised living to the individual.
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4610
109
4.06-1
Specific Requirements
Respite
Room and BoardIf respite is provided in a setting other
than the individual's residence, the
program provider must provide room
and board to the individual free of
charge.
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4600
110
4.06-1
Specific Requirements
Respite Billable Activity
•
interacting face-to-face with an individual to:
– assist the individual with activities of daily living;
– assist the individual with ambulation and mobility;
– reinforce any specialized therapies subcomponent provided to the
individual;
– assist with the administration of the individual's medication or to perform a
task delegated by a registered nurse in accordance with rules of the Texas
Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to
Unlicensed Personnel and Tasks not Requiring Delegation in Independent
Living Environments for Clients with Stable and Predictable Conditions) or
the Human Resources Code, §161.091-.093, as applicable;
– conduct habilitation activities that teach the individual;
– secure transportation for the individual;
– supervise the individual's safety and security; and
– transport the individual, except from one day habilitation site to another;
111
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4620
Specific Requirements
Respite Billable Activity
•
•
interacting face-to-face or by telephone with an individual or an
involved person regarding an incident that directly affects the
individual's health or safety; and
performing activities that does not involve interacting face-to-face
with an individual described in Section 4620.
112
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4620
Specific Requirements
Respite must be provided:
Residence
•
If an individual receives respite in a residence, the residence must be:
– the individual's residence;
– a three-person residence;
– a four-person residence; or
– the residence of another person (other than a three-person residence or a
four-person residence) in which no more than three persons are receiving
HCS Program services or a non-HCS program service similar to HCS Program
services.
Non-residence
•
If an individual is receiving respite during an overnight stay in a setting that is
not the residence of any person, no more than six persons receiving HCS Program
services or a non-HCS Program service similar to HCS Program services may be in
the setting.
113
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4630
Specific Requirements
Submitting a Service Claim for Respite
Respite Provided in an Individual's Residence
• If a program provider provides respite in an individual's
residence, the program provider may submit a service
claim for no more than 96 units of service (24 hours) in
one calendar day.
Respite Provided in Location Other Than the Individual's
Residence
• If a program provider provides 10 hours or more of
respite to an individual in one calendar day in a location
other than the individual's residence, the program
provider may submit a service claim for no more than 40
units of service.
114
http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4600
Common Errors
• Location of service not on documentation
• Billing more than 10 hours for respite occurring out of the
individuals home
• Individual lives alone without a live-in caregiver
• No begin and/or end times
• Non Qualified Service Provider (Proof of residence, etc.)
• Not providing location information
• No Progress Note
116
Billing & Payment
Review Protocol
117
Billing and Payment Review
•Conducted by DADS Billing and
Payment staff
•Review of authorization and written
documentation of service delivery
maintained by program provider
118
Purpose:
To determine whether the program provider is in
compliance with the HCS Program Billing Guidelines
Outcome:
DADS will recoup non-verified claims that were not
supported by authorization and/or written
documentation and may require a corrective action
plan (CAP) by the program provider.
119
Types of Reviews:
• Routine
Once every 2 years, all services are reviewed with the
number of individuals reviewed and review period
determined by previous error rates or number of individuals
served
• Special
As determined by DADS, result of a complaint, referral or
billing anomalies
120
Routine or special review can be either:
• On-site – conducted at provider’s place
of business
• Desk – conducted at DADS Headquarters
(documentation submitted by mail )
121
Samples are chosen based upon documentation error rate:
Error Rate = non-verified dollars divided by
the total amount billed during the review
period
122
Example of Error Rate:
Non-Verified Claims Total..................$15,400.00
Total Claims Billed...............................$125,600.00
$15,400.00 ÷ $125,600.00 = .1226
Error Rate: 12.26%
123
BPR sample size:
Error Rate Less Than Ten Percent (10%):
• Provider serves more than 10 individuals – 5 + 5% reviewed
• Provider serves less than 10 individuals – All reviewed
124
BPR sample size-Error Rate More Than Ten Percent (10%):
• Provider serves more than 10 individuals – 10 + 10%
reviewed
• Provider serves less than 10 individuals – All reviewed
125
BPR sample size
Never Reviewed:
• Provider serves more than 10 individuals5 + 10%
• Provider serves less than 10 individualsup to 5
126
On-site Reviews:
Notification:
•Routine:
• At least fourteen(14) days notice by phone and followed by a
faxed letter.
• Individual sample list from outside of Waiver Contract Area
(WCA) of review location provided two business days prior to
Entrance Conference.
•Special:
• Will be conducted without notice.
127
On-site Reviews:
List of individuals within the review location’s WCA are
identified at Entrance Conference.
PROVIDERS ARE NOT PERMITTED TO CREATE ANY
DOCUMENTATION AT ANY TIME WHILE REVIEW IS IN
PROGRESS
128
Error Sheet Forms
129
Refuting – On-site Reviews
•Refuting is conducted while on-site.
•DADS will not accept additional
documentation or refute any unverified
claims after the Exit Conference.
130
Demand for Payment-on-site review:
Following the Exit Conference, generally within
30 days, DADS will send a certified letter
(Demand for Payment) to the provider
detailing any unverified claims. The letter
includes the amount to be recouped, any
required corrective action and notice of the
right to request an Administrative Hearing.
131
On-Site Review:
Request for Administrative Hearing (appeal)
Must be made within 15 calendar days from
receipt of certified green card from
Demand for Payment letter
132
Payment of unverified claims:
Recoupment is done electronically through the automated
billing system (CARE)
Please do not send checks.
133
Desk reviews:
Notification:
•Telephone and Certified Mail
134
Timeframe to Provide Documentation-desk review
14 calendar days from receipt of certified
green card from notification letter.
Documentation received after 14 days has
elapsed will not be accepted and all
services requested will be subject to
recoupment.
135
Results-desk review:
Provider notified of results in certified letter
Refuting-desk review:
Additional documentation must be submitted within 14
calendar days of receipt of certified green card from
results letter
Late submissions are not accepted
136
Demand for Payment-desk review:
Certified letter notifies provider of final account of unverified
claims after considering refuting documentation (if any
submitted)
137
Desk Reviews:
Request for Administrative Hearing
(appeal):
Must be made within 15 calendar days
from receipt of certified green card
from Demand for Payment letter
138
Payment of unverified claims:
Recoupment is done electronically through the automated
billing system.
Please do not send checks.
139
Misti J. Ackermann, Billing & Payment Manager
2011 Billing Guidelines
Guidelines:
 http://www.dads.state.tx.us/handbooks/h
csbg/index.htm
Guideline Changes:
 http://www.dads.state.tx.us/handbooks/h
csbg/rmemo/11-1.htm
Section
2000
Title
Definitions
Change
Adds definitions for competitive employment, comprehensive assessment, focused assessment,
integrated employment, service coordination and service coordinator.
3210
3230
General Requirements
Service Claim for Day Habilitation for
Individual Receiving Supported
Employment
Updated references.
Deleted.
3230
Service Claim for Foster/Companion
Section 3240 is renumbered to 3230.
Care, Residential Support or Supervised
Living for Individual on a Visit with Family
or Friend
3430
Relative, Guardian or Managing
Conservator Qualified as Service
Provider
15-Minute Unit of Service
Daily Unit of Service
Billing Service Components Provided at
the Same Time and Billing Day
Habilitation Provided at the Same Time
as Service Coordination
Updates information in the first paragraph and deletes outdated information.
3730
Service Coordination and Day
Habilitation Provided at the Same Time
Adds new section.
3810
3820
General Requirements
Written Service Log and Written
Summary
Example Forms
General Description of Service
Component
Adds new information and deletes outdated material.
Updates section title; adds new information; deletes outdated material.
4220
4230
4250
4260
4320
Billable Activity
Activity Not Billable
Unit of Service
Written Documentation
Requirements of Setting
Updates billable activities for the specialized therapies.
Updates examples of non-billable activities.
Adds service time information.
Updates documentation required to support a service claim for specialized therapies.
Adds retirement age as justification for providing day habilitation at the individual’s residence.
4370
4380
Unit of Service
Written Documentation
Updates billable units of service.
Deletes outdated information and clarifies required documentation to support a service claim for day
habilitation.
3610
3620
3700
3850
4210
Defines “person” under No. 2, Service Time.
Updates billable units of service.
Revises section heading.
Updates title and adds new information.
Defines specialized therapies subcomponents.
4390
4420
4430
4450
4470
4471.2
4471.3
4471.5
4471.7
4472.2
4472.3
4472.5
4472.7
4473.2
4473.3
4473.5
4473.7
4540
4550
Submitting a Service Claim for
Individuals Receiving Supported
Employment
Billable Activity
Activity Not Billable
Unit of Service
Written Documentation
Billable Activity
Activity Not Billable
Unit of Service
Written Documentation
Billable Activity
Activity Not Billable
Unit of Service
Written Documentation
Billable Activity
Activity Not Billable
Unit of Service
Written Documentation
Supported Home Living Subcomponent
Foster/Companion Care Subcomponent
4560
Residential Support Subcomponent
4570
Supervised Living Subcomponent
4610
4730
General Description of Service
Component
Billable Activity
Restrictions Regarding Submission of
Claims for Respite
Written Documentation
General Description of Service
Component
Billable Activity
4740
Activity Not Billable
4620
4651
4690
4710
Deleted.
Updates billable activities for the licensed registered nursing service component.
Updates text.
Adds No. 3, Service Time.
Deletes outdated information.
Updates billable activities for the licensed vocational nursing service component.
Updates examples of non-billable activities.
Adds No. 3, Service Time.
Deletes outdated information.
Updates billable activities for the specialized registered nursing service component.
Updates text.
Adds No. 3, Service Time.
Deletes outdated information.
Updates bill activities for the specialized licensed vocational nursing service component.
Updates text.
Adds No. 3, Service Time.
Deletes outdated information.
Updates rule citations; adds new requirements; deletes outdated information.
Updates rule citations; clarifies requirements for service provider; updates text in No. 5, Restrictions
Regarding Submission of Claims for Foster/Companion Care; and clarifies required documentation in
No. 8, Written Documentation.
Deletes text under No. 1(d), Service Provider Shifts; updates rule citations under No. 2, Billable
Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Residential
Support; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to
No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend.
Updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions
Regarding Submission of Claims for Supervised Living; adds new bullet under No. 8, Written
Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an
Individual on a Visit with Family or Friend.
Updates information in No. 1, Temporary Provision of Assistance, and No. 2, Room and Board.
Updates rule citations.
Adds reasons for which a program provider may not submit a service claim.
Deletes a bulleted item and makes minor wording changes.
Updates definition of supported employment.
Adds transporting individual to and from the individual’s work site as a billable activity for the
supported employment service component.
Adds transporting an individual to a job interview as a non-billable activity.
4760
Restrictions Regarding Submission of
Claims for Supported Employment
4770
Unit of Service
4780
Written Documentation
4790
Submitting a Service Claim for Day
Habilitation
6160
Required Documentation for an Adaptive
Aid
6170
Prior Approval
6170
Authorization for Payment
6240
Payment Limit
6250
Required Documentation for a Minor
Home Modification
6260
Prior Approval
6260
Authorization for Payment
Appendix IBilling and Payment Review Protocol
Appendix Example of Service Delivery Log with
IV
Written Narrative
Appendix Billable Adaptive Aids
VII
Appendix Instructions for AA/MHM Request for
VIII
Prior Approval
Appendix Billable Minor Home Modifications
X
Form
Home and Community-based
4116Services/Texas Home Living Dental
Dental,
Summary Sheet
Instruction
s
Form
Home and Community-Based
4116Services/Texas Home Living Minor
MHM-AA, Home Modification/Adaptive Aids
Instruction Summary Sheet
s
Deletes outdated information.
Adds No. 3, Service Time
Updates information.
Deleted.
Updates section reference and removes prior approval requirement.
Deleted.
Updates section number; adds new information and deletes outdated text.
Deletes outdated information.
Removes prior approval requirement.
Deleted.
Updates section number; adds new information and deletes outdated material.
Updates information.
Deletes appendix and reserves it for future use.
Updates abbreviations and number codes.
Deletes appendix and reserves it for future use.
Updates abbreviations.
Deletes outdated information and adds instruction for signature/date line.
Deletes outdated information, updates references and adds instruction for signature/date line.
Changes to Billing Guidelines
Section 2000 - Definition Additions

Competitive employment — Employment that pays an individual
at or above the greater of:



(A) the applicable minimum wage; or
(B) the prevailing wage paid to individuals without disabilities performing the same
or similar work.
Comprehensive Assessment: An extensive evaluation of an
individual's health status that:







(A) addresses anticipated changes in the conditions of the individual as well as
emergent changes in the individual's health status;
(B) recognizes changes to previous conditions of the individual;
(C) synthesizes the biological, psychological, spiritual and social aspects of the
individual's condition;
(D) collects information regarding the individual's health status;
(E) analyzes information collected about the individual's health status to make
nursing diagnoses and independent decisions regarding nursing services provided
to the individual;
(F) plans nursing interventions and evaluates the need for different interventions;
and
(G) determines the need to communicate and consult with other service providers or
other persons who provide supports to the individual.
Changes to Billing Guidelines
Section 2000 - Definition Addition

Focused Assessment: An appraisal of an individual's current health
status that:




(A) contributes to a comprehensive assessment conducted by a registered nurse;
(B) collects information regarding the individual's health status; and
(C) determines the appropriate health care professionals or other persons who
need the information and when the information should be provided.
Integrated employment — Employment at a work site at which an
individual routinely interacts with people without disabilities other
than the individual's work site supervisor or service providers.
Changes to Billing Guidelines
Section 3000
 Supported Employment/Day Habilitation
 Division of Time Between Individuals
 Service Coordination & Day Habilitation
 Written Documentation for non-nursing
services
 Other Changes to Section 3000
Changes to Billing Guidelines
Section 4000

Specialized Therapies
 Definitions
 Video Conference

Day Habilitation
 In-Home Exception
 Time Change
 Supported Employment Dual Billing Removal
Nursing (See Next Slides)
 Residential Services (See Next Slides)
 Respite

 Clarification

Supported Employment
 Transportation included
Changes to Billing Guidelines
Section 4400 – Nursing Services
 Registered Nursing





Assessments & Comprehensive Assessments
Medication Review
Insurance Provider Communication
Supervising LVN (RN can only bill)
Licensed Vocational Nursing
 Focused Assessments
 Medication Review
 Insurance Provider Communication
Changes to Billing Guidelines
Section 4500 – Residential Services
 Foster Care & Supervised Living
 No Significant Changes

Residential Support Services
 Service Provider Shifts
 Off Duty Requirement
 No Shifts of More than 24 Hours

Supported Home Living
 Safety & Supervision
 No Volunteer Hour Limit
Changes to Billing Guidelines
Section 6000
 Adaptive Aids
 Prior Approval Removal
 Authorization for Payment Requirements

Minor Home Modifications
 Prior Approval Removal
 Authorization for Payment Requirements
Changes to Billing Guidelines
Other Changes
 Guideline Format
 Billing and Payment Review Process
 Form Updates
○
○
○
○
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○
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○
○
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2122 Service Delivery Log with Written Narrative/Written Summary
2124 Community Support Transportation Log
4116-Dental Dental Summary Sheet
4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet
4117 HCS Supported Employment Service Delivery Log
4118 HCS Respite Service Delivery Log
4119 HCS Residential Support Services (RSS) and Supervised Living (SL)
4120 HCS Day Habilitation (DH)
4121 HCS Supported Home Living
4122 Foster/Companion Service Delivery Log
Vivian Griffor, Billing and Payment Team Leader
153
Documentation required before purchasing any
AA/MHM:
 Written assessment
Not required for AA under $500 or MHM under $1000
 Individual and Program Provider Agreement
 Three Bids
 3 bids are required no matter the cost
 need an explanation if 3 bids have not been obtained
 Proof of non-coverage by private insurance, Medicare,
and Medicaid (AA only-as applicable)
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
154
The Written Assessment must:
•
be based on a face-to-face evaluation
•
be done in the home if a MHM is being requested
•
be done by a qualified medical professional-
See Appendix VII for Adaptive Aids & Appendix X for Minor Home
Modifications
•
include a description of AND a recommendation
for the specific AA/MHM being requested
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
155






Assuming that a recommended item is a covered
item
**Obtaining an assessment that is not current
**Obtaining an assessment that does not
contain sufficient medical justification
Assuming that a doctor’s prescription is
sufficient
**Obtaining an assessment that is not legible
**Obtaining an assessment done by an
unauthorized professional
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
156
Individual and Program Provider Agreement Must
• consider the written assessment
• document any discussion about the
recommended item(s)
• agree that the recommended item is necessary
and should be purchased
• document their agreement in writing
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
157
 Failure to include signatures
 Team meeting/Staffing/Individual and Program
Provider Agreement
 Failure to document discussion of need for item
requested
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
158
Bids :
•
Three (3) bids are required, regardless of cost
•
Bids must be comparable (for like or very similar items)
•
Bids must state the total cost of the requested AA/MHM
and, if it includes more than one AA/MHM, state the
itemized cost of each AA/MHM listed by service code
•
Bids must include the name, address and telephone
number of the vendor/contractor
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
159
Exceptions to bid requirements
:
 Less than three bids for an AA/MHM may be acceptable IF
there is written justification stating the AA/MHM is
available from only a limited number of vendors/contractors
 A single bid from the custom fitting vendor is acceptable for
eyeglasses (220), hearing aids, batteries and repairs (260)
and orthotic devices, orthopedic shoes, and braces (107)
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
160
Annual Vendor:
Will there still be an Annual Vendor?
 Yes.
A Program Provider:
 May be exempted from bid requirement for frequently
purchased consumable items with an approval for
Annual Vendor status
 Will submit application for Annual Vendor by January 31
for current calendar year
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
161
 Failure to obtain three bids (no justification)*
 Obtaining bids that contain items not
recommended in the assessment**
 Obtaining bids that contain items not covered on
the waiver**
 Obtaining bids that are not for the same item or
list of items**
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
162
Pursuing alternate funding sources:
Written proof of non-coverage from
Medicare/Medicaid must be obtained for any AA
denoted with a (1) or (2) on the “List of Billable
(Reimbursable) Adaptive Aids”
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
163
 Obtaining a statement by a DME vendor that an item
is not covered**
 Obtaining a denial letter that indicates that
insufficient documentation was submitted with
claim**
 Obtaining a Medicaid denial letter that indicates that
consumer is eligible for Medicare (primary)**
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
164
Texas Department of Aging
and Disability Services
Form 4116-MHM-AA
September 2011
Home and Community-Based Services/Texas Home Living
Minor Home Modification/Adaptive Aids Summary Sheet
Service Month and Year
Component Code
Contract No.
Contact Person
Area Code and Telephone No.
September 2011
000
00100XXXX
Ima Provider
512-555-5555
Client
Prior
Service Date
Care ID
Approval
(MM,DD,YY)
No.
Tracking No.
Name (Last, First, Initial)
1.
Anita N. Item
12345
09/01/11
Service Description
Minor Home
Modification
Service
Code
N/A
Service Description
Dollars
Spent
Req. Fee
Adaptive Aids
Leg Brace
Dollars
Service
Code
107
Req. Fee
Spent
$180.00
$18.00
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Total
I certify by submission of this form that it meets all requirements set forth in the Home and Community-Based Services/Texas Home Living Billing Guidelines.
Ima Provider
9/22/11
Signature
Date
165
Submit reimbursement claims (4116) to:
DADS
Provider Claims Services
PO BOX 149030 MC W-400
Austin, TX 78714-9030
For questions contact Provider Claims Services at
512-438-2200 option 5
http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm
166
Manager
Misti J. Ackermann
[email protected]
HCS Team Leaders
Vivian Griffor -Adaptive Aids Contact
Willie Mae Jones
D. Sam Montgomery
Virginia Sifuentes
Julia Solis – Cost Report Contact
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Program Specialists
Karri Henager
Jeff Rehagen
Stephanie Santos-Vela
Nikolaos Vekris– Cost Report Contact
[email protected]
[email protected]
[email protected]
[email protected]
Additional Information
Billing and Payment Email & Hotline
Fax
[email protected] [512-438-5359]
512-438-2695
Mailing Address
Department of Aging and Disability Services
Community Services, Billing and Payment
PO BOX 149030, Mail Code W-200
Austin, Texas 78714-9030