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Services Facilitation Training
Fall 2004
Individual and Family
Developmental Disabilities
Support Waiver
Today’s Training Goal
To enhance the knowledge of Service
Facilitators in areas of
– Care Plan Development
– Management Training
– Hiring Packet Paperwork
– Payroll Procedures
2
Training Goals
Service Monitoring
Responsibilities of the Employer
Responsibilities of the Facilitator
Pre Authorization
Utilization Review
Billing for Consumer Directed Service
Facilitation in the Individual and Family
Developmental Disabilities Support
(DD) Waiver and Eligibility Verification
3
DD Waiver Eligibility
Requirements
The individual must be 6 years of age
and meet the “Related Conditions”
requirements of C.F.R. § 435.1009,
including autism; and not have a
diagnosis of Mental Retardation as
defined by the American Association of
Mental Retardation (AAMR)
12 VAC 30-120-720
4
DD Waiver Eligibility
Requirements
Services must
Be approved by the Support
Coordinator; and
Be based on a current functional
assessment tool approved by DMAS
that demonstrates the need for each
specific service
5
DD Waiver Eligibility
Requirements
Individuals qualifying for IFDDS Waiver
services must meet the ICF/MR level of
care criteria; and
The individual must be eligible for
Medicaid as determined by the local
office of DSS.
6
Eligibility for the DD Waiver
Screenings are conducted by Virginia
Department of Health Child Development
Clinics
The LOF is the screening instrument used
to determine if the individual meets criteria
7
Eligibility for the DD Waiver
– Children under six years of age shall not be
screened until three months prior to the
month of their sixth birthday.
– Children under six years of age shall not be
approved for waiver services until the month
in which their sixth birthday occurs.
8
Screening Process
Referred for Screening by If found eligible based on
Request for Long Preadmission Screening Team* functional assessment, form*
Can contact either the local sent to local DSS eligibility
Term Care Department of Social Services or worker for eligibility
determination.
Services the local Health Department to
Request Screening; or DMAS for
*DMAS-96 or
Notice of Approval
DD Waiver ; or CSB for MR
Waiver
DSS completes a Medicaid
application if necessary to
determine Medicaid eligibility. If
If there is a provider, the Medicaid eligible, DSS completes
provider could initiate the DMAS- bottom half of DMAS-122 and
122 process by completing the sends to provider. DSS also
top half of the DMAS-122 and sends a Notice of Obligation of
*If expect to be eligible for sending it to DSS.
patient pay to the recipient.
Medicaid within 180 days
9
Services Facilitation
Provider
Qualifications
• Must complete a DMAS
Provider Participation Agreement
•Obtain by contacting:
First Health VMAP-PEU
P.O. Box 26803
Richmond, VA 23261-6803
804-270-5105 or 1-888-829-5373
10
Services Facilitation
Provider
Qualifications
Continued
OR From the DMAS Web Site at:
http://www.dmas.virginia.gov
click on
“Provider Enrollment”
“Consumer-Directed Services Facilitation”
11
Services Facilitation
Provider
Qualifications
Continued
Forward signed original to
First Health VMAP-PEU
P.O. Box 26803
Richmond, VA 23261-6803
804-270-5105 or 1-888-829-5373
Fax: 804-270-7027
12
Provider Enrollment
DMAS returns copy of the signed agreement
and assigns a provider number to each
approved provider.
Provider numbers must be included on all
claims and correspondence submitted to
DMAS.
Must meet the standards and requirements
set forth by the Department of Medical
Assistance Services
13
Participation Requirements
Provide services and supplies to clients
in the same quality and mode of
delivery to the general public.
Cannot exceed the provider’s usual and
customary charges to the general
public.
Accept as payment in full the amount
reimbursed by Medicaid
14
Participation Requirements
continued
Should not attempt to collect from the
client or family member any amount that
exceeds the Medicaid payment.
Hold confidential and use for authorized
DMAS purposes only all medical
information regarding the individuals
served.
15
Participation Requirements
continued
Maintain records for a period of not less
than 5 years.
Use Medicaid designated billing forms.
16
Termination of Provider
Participation
DMAS requests renewal of the
Participation Agreement prior to its
expiration.
May terminate with Medicaid at any time
with written 30 day notice.
17
Termination of Provider
Participation
Provide 30 days written notification of
voluntary termination prior to the
effective date to
– the Director, Department of Medical
Assistance Services, and
– First Health Provider Enrollment Unit,
18
Termination of Provider
Participation
DMAS may terminate a provider with 30 day
written notice.
Code of Virginia mandates that “Any such
(Medicaid) agreement or contract shall
terminate upon conviction of the provider of
a felony.” Within 30 days provider must
notify DMAS of the conviction and relinquish
agreement.
19
Reconsideration of Adverse Actions
Process has 3 phases:
– Written response and reconsideration to
preliminary findings - (30 days to submit info)
– The informal conference - (30 days notice to
request informal conference)
– The formal evidentiary hearing - (30 days
notice to request formal hearing)
20
Attendant Care/Respite Activities
21
Consumer Directed
Services
Personal attendant/respite services
provided by personal attendants in the
home are limited to the following:
Activities of Daily Living (ADLs)
22
Consumer Directed
Services
Personal attendant services
– Assisting with care of the teeth and mouth
– Assisting with grooming (including care of
the hair, shaving, and ordinary nail care)
– Bathing- routine maintenance and care of
external condom catheters is considered
part of the bathing process.
23
Activities
Activities of Daily Living, cont’d.:
– Routine skin care- not to include applying
topical medications or any type of product
with an “active ingredient”
– Dressing
– Toileting
– Feeding
– Turning and changing position,
transferring, and ambulating
24
Activities
– Assisting with self-administration of
medications and assuring the client
received medications at prescribed
times (not to include in any way
determining the dosage of
medication).
– Checking the temperature, pulse,
respiration, and blood pressure and
recording and reporting as required.
25
Activities
Home Maintenance Activities- IADL’s
IADL’s may be performed when there is no
one else available or able to perform these
tasks in the home
These tasks may include:
– Preparing and serving meals
– Washing dishes and cleaning the kitchen
– Making the bed and changing linens
– Cleaning the client’s bedroom, bathroom
and rooms used primarily by the personal
care client
26
Activities
Home Maintenance Activities-
– Listing supplies for purchase that are
needed by the individual
– Shopping for necessary supplies for the
client; and
– Washing the client’s laundry
27
Activities
These services may be performed by
the personal attendant under special
training and supervision and requires
physician order:
– Bowel/Bladder Program, Range of Motion
(ROM) exercises
– Routine Wound Care
28
Employer Responsibilities
-Hiring(checking references,basic
qualifications)
-Training (Adl and IADL care)
-Supervising(arrival time and departure time,
care provided, timesheets)
-Firing the attendants
-Emergency Backup(incase attendents do not
show up or terminates employment with out
prior notice.
29
Attending to Needs of Clients
Who Work, Attend School, or
Both
Clients who wish to use CD Services may
continue to work, attend school, or both while
they receive services under this waiver.
DMAS will pay for any services that the
attendant gives to the enrolled client to assist
him or her in getting ready for work/school or
when he or she returns home.
30
Attending to Needs of Clients
Who Work, Attend School or
Both
DMAS will pay the attendant to assist the
enrolled client with functions related to the
client completing his or her job/school
functions
DMAS will review the client’s needs and
complexity of the disability when determining
the services that will be provided to the client
in the workplace/school.
31
Attending to Needs of Clients
Who Work, Attend School or
Both
The Service Facilitator must develop an
individualized plan of care which addresses
the client’s needs at home, work, and/or in
the community.
DMAS will not duplicate services that are
required as a reasonable accommodation as
a part of the Americans with Disabilities Act
(ADA) or the Rehabilitation Act of 1973.
32
Transportation
The vehicle used must be registered in the
Commonwealth of Virginia
– The vehicle owner has current automotive
insurance containing collision,
comprehensive, and liability coverage with
a minimum of 100-300-50. The insurance
must insure the individual and cover the
personal attendant as driver of the
individual’s vehicle.
33
Transportation
– The personal attendant has a valid Virginia
driver’s license.
– Documentation must include that it is
necessary to assist the individual with his
or her ADLs or IADLs as identified in the
individual’s Plan of Care while the
attendant accompanies the individual.
34
Consumer-Directed
Services
Service Facilitator
Service Facilitator
Is in addition to the individual’s Support
Coordinator (SC)
(proposed regulatory change is not in
effect)
May be an employee of an
agency or a
self-employed person
36
Services Facilitator
MAY NOT Be . . .
The individual
The parent of a minor individual,
Spouse
Anyone acting as employer on
behalf of the individual
37
Service Facilitator
Requirements
MUST possess required Knowledge, Skills,
and Abilities (KSAs)
If not RN, MUST have RN consulting
available as needed to consult with the
health and safety needs of the individual.
Credentials must be available for review by
Utilization Review 12VAC 30-120-770 D 2
38
Service Facilitator
Requirements
MUST have sufficient resources to
perform required activities.
MUST have ability to maintain and
retain business and professional
records.
39
Service Facilitator
Requirements
The CD services facilitator must have two
years of satisfactory experience in the
human services field working with persons
with developmental disabilities.
It is preferred the CD Service Facilitator
possess a minimum of an undergraduate
degree in a human services field or be a
registered nurse currently licensed to
practice in Virginia.
40
Services Facilitator Duties . . .
After being Selected by Individual
Confirms with SC that individual is
enrolled in DD Waiver
SC should contact the SF chosen by
individual
Agency consent form, DMAS 122,
LOF, 456 and 457
41
Services Facilitator Duties . . .
After Being Selected by Individual
(cont.)
Other supporting documentation may
include any other documents that the
provider feels necessary to develop a
Plan of Care for that individual
Any relevant evaluations, TC reports or
MD evaluations can be used
42
Comprehensive Visit
Activities
43
Comprehensive Visit
The Service Facilitator will:
– Assess the needs of the Individual
And
– Develop the Plan of Care;
44
Comprehensive Visit
The initial comprehensive visit is done
only once upon the clients entry in to
the CD Services.
If the client changes Service Facilitator,
the new provider must complete a re-
assessment in lieu of a comprehensive
visit.
45
Comprehensive Visit
The Service Facilitator is responsible for
initiating services with the client upon
accepting the referral from the Support
Coordinator.
The initial comprehensive in-home visit must
be done prior to the start of care. This must
be done before the attendant begins services.
The individual to receive services must be
present during this in home visit.
46
Completing the Forms:
99A/B
This form is a comprehensive summary of the
needs of the individual. Complete one
summary for each individual, update the
forms as changes in the care needs occur.
Use the form to record routine visit notes that
include functional status, social supports,
medical needs, lapse in services, etc.
The date the Facilitator makes the initial
comprehensive visit is the start date of CD
services
Sample forms in packet (99A/B)
47
Plan of Care
DMAS-97A/B must be completed by the
Service Facilitator prior to the start of
care for any client.
The Plan of Care indicates to the
Service Facilitator the general needs of
the client in eight areas of needs.
48
Plan of Care
Should include the specific needs of the
client according to the functional and
medical information included in the Service
Facilitator’s initial comprehensive visit, any
special considerations for service
provision, and the support available to the
client.
The 99A/B records the patient pay amount
from the DMAS 122 for the individual
49
Plan of Care
Time should be allocated for each group
of tasks on the Plan of Care in
accordance with the Personal Care
Activities of Daily Living Guide
Level of Care (LOC) is based on the ADL
score - Level A, B, or C.
The LOC will assist the Service
Facilitator by indicating the average
amount of care needed without prior
authorization. 50
Completing the Forms:
Plan of Care
One Plan of Care should be completed
per CD service.
If using split shifts, or if the amount of
services increases or decreases,
complete a separate 97A/B
Document all supports that the person
requires, with the time needed to
perform each activity.
51
Completing the Forms:
Plan of Care
For Attendant Care indicate the
amount of times that are needed for
each support. If a separate time of day
is needed for the service, use a
separate care plan for “split shifts”
52
Completing the Forms:
Plan of Care
For Respite care indicate the ADL
supports needed by the individual.
53
Plan of Care
The Level of Care score does not
restrict the Attendant to the designated
number of hours per week, it functions
as a guide for plan development. It acts
as a “norm”
The Plan of Care must be developed to
meet the ADL/IADL needs of the client.
54
Consumer (Individual) Training
55
Service Facilitator Duties . . .
Provides
Consumer(Individual)Training,
using Employee Management
Manual, within 7 Days of
performing the comprehensive visit
Documents in individual’s record
that the training was provided 56
Consumer Training
– Provide and review a copy of the
– Employee Management Manual, and
– Ensure that the client understands his or
her rights and responsibilities in the
program and sign all of the participation
agreements found in the Employee
Management Manual, (including those
related to the Selection of Service, Fiscal
Agent, and the consumer-directed services
facilitator).
57
Consumer (Individual) Training
The individual should demonstrate an
understanding of the expectations as
an employer
Screening process for personal
attendant applicants
Interviewing techniques
Record keeping (personal attendant
duties checklist)
How to complete personal attendant
evaluations and guidelines for
hiring/firing personal attendants 58
Consumer (Individual) Training
Upon receiving the Employee
Management Manual training, the
individual should be able to answer the
following:
What are consumer directed services?
What are my specific responsibilities?
59
Services Facilitator Duties
All CD forms must be signed before the
client can begin employing personal
attendants in the program.
The facilitator shall send the original
Fiscal Agent Contract to DMAS and
keep a copy for the individual’s file.
All employment forms must be signed
and dated by the attendant and the
employer prior to attendant services
beginning. 60
Service Facilitator
Duties
Ensure that the start date,
which is the date of the Initial
Comprehensive Visit, is
recorded on the supporting
documentation and reflected in
the Pre authorization date
61
SF Documentation
Initial Comprehensive Visit
DMAS 97A/B
DMAS 99A/B
Employee Management
Training
62
Authorization for Payment of
Consumer Directed Services
Medicaid will not pay for any personal
attendant services delivered prior to the
authorization date
63
Service Facilitator Duties
Prior to attendants delivering
care:
Obtain pre authorization of the
services
forward the 97A/B and 99A/B to the
Support Coordinator, confirm patient
pay amount
Do not allow attendants to begin
prior to pre authorization 64
Responsibilities of The
Services Facilitator for
Monitoring of Individual
Services
65
Services Facilitator Responsibilities
The provider is responsible for monitoring
the ongoing provision of services to each
Medicaid client. Monitoring includes:
– The quality of care received by the client;
– The functional and medical needs of the
client and any modification necessary to the
Plan of Care due to a change in needs
– Appropriate management of patient pay with
attendant reimbursement as appropriate
66
Services Facilitator Responsibilities
The provider is responsible for monitoring
the ongoing provision of services to each
Medicaid client. Monitoring includes:
– The client’s need for support in addition to
the care provided by personal attendant
services. This includes an overall
assessment of the client’s safety and welfare
in the home with personal attendant services.
67
Responsibilities
The Service Facilitator must follow the
checklist for Consumer-Directed
Recipient Comprehensive Training form,
to assure that the training content meets
the minimum acceptable requirements.
The services facilitator must check each
subject on the form after it has been
covered, and have the required
signatures and dates.
68
Responsibilities
The training check list must be
maintained in the individual’s file and
available for review by DMAS staff.
Regardless of the method of training,
documentation must indicate that
training was received prior to the
individual’s employment of a personal
attendant.
69
Routine Visits
70
Routine (Onsite) Visits
The Service Facilitator’s documentation
of the routine visit may be documented on
a 99A/B.
71
Routine (Onsite) Visits
After the comprehensive visit, the Service
Facilitator must conduct 2 routine onsite
visits within 60 days of the initiation of care
(once per month) to monitor the client’s Plan
of Care and ensure both the quality and
appropriateness of services being provided.
Once the first two visits have been
completed, the services facilitator and the
client can decide how frequent the routine
onsite visits will be. 72
Routine (Onsite) Visits
During visits, the Service Facilitator –
– Must observe, evaluate, and document the
adequacy and appropriateness of the
attendant services, with regard to the
individual’s current functioning status, medical
and social needs, and the established plan of
care.
– May review the personal attendant’s record, if
available
– Must discuss the individual’s satisfaction with
the type and amount of service. 73
Reassessment Visit
74
Reassessment Visit
Required once every six months
Documentation must include a complete
review of the client's needs and
available supports, and a review of the
Plan of Care.
Visit should be documented on either a
DMAS-99A/B or a case note
The Service Facilitator shall observe,
evaluate and document the adequacy
and appropriateness of the attendant’s
services. 75
Transfers
Reassessment Visit
Transfer cases begin with a
Reassessment visit instead of a
Comprehensive Assessment
When changing CD Services
When changing SFs
76
Monitor the Hiring Process
77
Monitor the Hiring Process
Have the individual notify you when they have
hired an attendant.
Offer support with completing the hiring
packet as needed. (Get a copy for phone
based troubleshooting)
Ensure that the employee is aware of the job
requirements. Ensure that they receive the
TB tests, CPR training, flu shots, and criminal
background checks.
78
Service Facilitator Duties
Assures that attendant has received
training in the SPECIAL CARE
DELIVERY Procedures (Bowel &
Bladder, Range of Motion, Routine
Wound Care, Catheter care,
Monitoring Vitals).
79
Personal Attendant Registry
The consumer-directed services facilitator
shall maintain a personal attendant registry.
The registry shall contain the names of
persons who have experience with providing
personal attendant services.
The registry shall be maintained as a
supportive source for the individual who may
use the registry to obtain names of potential
personal attendants.
80
Management Training
81
Management Training
This may be additional management
training for the client or special training
for the personal attendant at the request
of the client.
Service Facilitators can provide up to
four hours of management training to a
client within any six-month period.
82
Services Facilitator Duties
Completes 90 day face to face
visits
Required for CD Attendant Care
Review is necessary for CD
Respite, review every six
months or after 300 hours are
used, whichever is first.
83
Services Facilitator Duties
Monitors Service – to ensure
adequate and appropriate CD Services
Contacts SC to discuss services,
health and safety issues, etc.
Hiring Packets for new attendants
Discusses need for any changes in
CD services with individual
84
Services Facilitator Duties
Monitors Service
Submits Plan of Care changes to SC
Attends CSP meetings, if requested
by individual
Counsels/trains/helps resolve conflict
85
Billing Codes for
Attendant Care and Respite Care
S5126- Attendant Care (paid to personal
attendant by fiscal agent) - $7.80/hour in
Rest of State, $10.10 NOVA
S5150 - CD Respite (paid to personal
attendant by fiscal agent) - $7.80/hour in
Rest of State, $10.10 NOVA
86
Billing Codes for Service Facilitators
H2000- Initial Comprehensive Visit -
$161.56 Rest of State, $209.73 NOVA
S5109- Consumer Training - $160.56
Rest of State, $208.73 NOVA
99509– Routine Visit - $50.18 Rest of
State, $65.00 NOVA
99199 U1- Criminal History Record
Check - $15.00
87
Billing Codes for Service Facilitators
T1028– Reassessment Visit - $80.28
Rest of State, $105.37 NOVA
S5116– Management Training - $20.07
Rest of State, $26.09 NOVA
99199- CPS Registry Check - $5.00
88
Fiscal Agent
for
Consumer-Directed
Services
2004
89
Fiscal Agent (FA)
Responsibilities
In a nutshell:
– to handle employment, payroll, and tax
responsibilities on behalf of the recipient who is
receiving consumer-directed services
This includes:
– receiving & processing time sheets
– verifying the authorization of employment for
assistants/companions
90
FA Responsibilities (Cont’d)
Includes:
Assisting CD employees, employers,
and SFs with payroll related issues
W2-forms mailed to CD employees
each year
91
FA Responsibilities (Cont’d)
Does NOT include:
obtaining waiver service authorizations
determining the type or amount of
services for recipients
determining patient pay amounts
discharges or admissions into the waiver
92
The Payroll Process
• FA receives Authorizations from WVMI
and DMHMRSAS on Mondays
• FA receives time sheet in the mail and
enters them into a database every 2
weeks
• FA receives DMAS-122s from SF for
patient pay entries
93
The Payroll Process (Cont’d)
Tuesday evening data is sent to
Access Independence, Inc. for data
entry, printing & mailing of checks
Checks are mailed on the following
Friday
Example: Payroll is processed on
Tuesday, August 24th, and mailed on
Friday, August 27th
94
Hire Packet Forms
Forms that need to be sent to the FA
Personal Attendant Provider form
Recipient Notification form
Employee Agreement
Signatory Authority form
Employment Verification form (I-9)
Policies for Employees
Have the employer use the Hire Packet Check
List (new)
95
Common Obstacles
1) The assistant/companion should not
start services until after the SF receives
service authorization
•We receive time sheets before authorization of
waiver services. The employee cannot be paid
until after authorization is received by the FA
•If the authorization is not retroactive, the
employer will be responsible to pay the personal
attendant
Example: Authorization may not be
retroactive if the start date and the DMAS-
122 start dates differ.
96
Common Obstacles (cont)
2) Hire Packets sent to FA incomplete,
and/or with forms filled out incorrectly
•The Signatory Authority form must be filled
out for each employee
•Photocopies of the two IDs used on the I-9
(Employment Verification form) must be
included
97
Common Obstacles
3) Hire Packets sent to FA incomplete,
and/or with forms filled out incorrectly
(cont’d)
•The FA must have the original copies of the
forms in the Hire Packet
•“Recipient’s Name” = the Medicaid recipient’s
name vs. the family member/caregiver acting
as employer
98
Common Obstacles
3) Issues need to be resolved prior to the
Monday and Tuesday of a pay cycle
4) The employee cannot also be the caregiver
that directs/manages the waiver recipient’s plan
of care.
5) Time Sheets
•Time crosses over pay periods
•Name are not legible
•Hours are not added up correctly
99
Completing Time Sheets
Must be signed by employer &
employee
One time sheet submitted for each
employee and one for each service
Time sheets submitted according to the
“Pay Schedule”
100
Completing Time Sheets
Mailed to the Fiscal Agent by the 3rd
business day after end of each pay
period
Time sheets must be copied from the
blank one in the EMM
Ensure individual is making a copy of
each time sheet for SF review
101
Completing Time Sheets –
Patient Pay
If the CD employee is collector of
Patient Pay, indicate this on the time
sheet
– The employer must pay the Patient
Pay to the employee – the Fiscal
Agent will not
102
Helpful Hints for Forms
Completion
Forms requesting “recipient name”
should have the individual’s name --
not the family member’s/guardian’s
name
The Fiscal Agent will not accept copies
or faxes
103
Helpful Hints (cont’d)
Direct deposit for employee
paychecks is an option.
One “Signatory Authority” form for
each employee, even though signing
for the same individual
104
Helpful Hints (cont’d)
Make sure that the FA has the
employee’s current mailing address
If an employee is terminated, the FA
needs to be notified
Send updated DMAS-122s to the FA
105
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Personal Assistant / Companion Timesheet
Mail To: Fiscal Division Check One:
P.O. Box 662 Attendant/Assistant
Richmond, VA 23218-0662 Respite
Companion
Select One
Assistant/Companion Name (Please Print):
Service
Please check the appropriate program:
Consumer-Directed Personal Attendant Services Waiver (CD-PAS):
Individual and Family Developmental Disabilities Support Waiver (IFDDS):
Mental Retardation Waiver (MR):
AIDS Waiver:
(A Separate Time Sheet Must Be Completed For Each Service, i.e. Respite, Personal Assistant, or Companion)
WEEK 1 THURS. FRI. SAT. SUN. MON. TUES. WED.
Date:
Time In:
Time Out:
Time In:
Time Out:
TOTAL:
WEEK 2 THURS. FRI. SAT. SUN. MON. TUES. WED.
Date:
Time In:
Time Out:
Time In:
Time Out:
TOTAL:
TOTAL WEEKLY HOURS: WEEK 1: + WEEK 2: = TOTAL HOURS:
HOURLY RATE: $ GROSS PAY TOTAL (Total Hours x Hourly Rate):
(If Applicable, Minus) PATIENT PAY:
ADJUSTED GROSS PAY TOTAL:
My signature certifies that I have provided a service on the dates listed above. I understand that payment for this service will
be from federal and state funds, and that any false claims, statements, documents, or concealment of material facts may be
prosecuted under applicable federal and state laws. I also understand that, if applicable, I will receive as part of payment for
my services the individual’s patient pay amount.
Assistant/Companion’s Signature: Date:
My signature certifies that I received a service on the dates listed above. I understand that, if applicable, I must pay the
personal assistant/companion my patient pay amount, which goes toward the cost of services provided.
Recipient/Authorized Signator: Name signing for recipient's name Date:
Print Recipient’s Name: 106
DMAS-91 (02/04)
What to Expect During a
Utilization Review
Department of Medical
Assistance Services
(DMAS)
107
What Generates a Review
Statewide Sample
– A computer generated list is created
and reviews are scheduled randomly.
Complaints
– DMAS receives a concern regarding
services from a constituent.
108
Utilization Review
• Unannounced
• May be on-site or desk review
• Usually 1 – 3 days in length
• depends on size of review sample
• An average of 4 months’ services
will be reviewed
109
Utilization Review (cont’d)
Upon Arrival, Analyst Will
show ID
give business card
explain the purpose of the review
present a list of individuals to be
reviewed
110
Utilization Review (cont’d)
Upon Arrival, Analyst Will
Request records be gathered
together in a central location.
Secure a workplace to conduct the
review.
111
Utilization Review (cont’d)
During the review:
Analyst may ask questions regarding
your documentation.
Analyst will let you know how long the
review will last and when to set up the
Exit Conference.
112
Utilization Review (cont’d)
Exit Conference will occur on the last
day of the review.
You may have any of your staff
attend.
113
Items to be Reviewed
Individual records
– All assessments – initial &
reassessments
– CSP
– Quarterly/Written Reviews
– Routine visits, face-to-face contacts
– Contact notes
114
Items to be Reviewed (cont’d)
Individual records
– EMM and Management Training
– KSAs confirmed
– Documentation of dates, amount
& type of services rendered
115
Report Contents
Technical Assistance
– Issues not in compliance with Medicaid
policy that should be addressed by the
provider
Overpayment
– Situations in which the provider has
failed to comply with federal and state
regulations or policy guidelines.
Copied to
– Providers
116
Possible Overpayment Reasons
Absence of adequate documentation
to support services billed or the need
for service. Ex: Monthly notes, routine
visits and assessments
Unqualified staff delivering the service
Ex. RN has License
117
Other Options
Reconsideration
– Request will be reviewed and
response letter sent to provider.
– If denial is upheld, provider has the
right to appeal.
118
Other Options (cont’d)
Appeals
– Informal Fact Finding Conference
(IFFC)
• Provider may request within 30 days of
receipt of reconsideration decision.
– Formal Evidentiary Hearing
• Request must be made within 30 days of
receipt of IFFC decision.
119
Recent Findings-Trends
CSP needs to:
– Reflect assessed needs and
individual’s desires and input
– Reflect goals on the CSP
– Be modified as needed, based upon
changing needs of individual
120
Recent Findings Trends (cont’d)
Quarterly/Written Reviews
– Should accurately reflect the individual’s response
for that quarter
– Routine visits documented
– Documents signed by the individual or individual
family that acknowledge the responsibilities of the
services
– Signatures and dates are required on all
documents
– Personal attendant Registry must be available for
review
– Criminal history check, TB, CPR, Flu and
documentation that EMM manual was reviewed
needs to be documented and available for review
121
