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Consumer-Directed Services

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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

           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
      DD Waiver Eligibility
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

        DD Waiver Eligibility
  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

     DD Waiver Eligibility
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.

Eligibility for the DD Waiver

   Screenings are conducted by Virginia
    Department of Health Child Development

   The LOF is the screening instrument used
    to determine if the individual meets criteria

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.

                         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
   Services                        the local Health Department to
                                  Request Screening; or DMAS for
                                                                                     *DMAS-96 or
                                                                                   Notice of Approval
                                     DD Waiver ; or CSB for MR

                                                                           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

  Services Facilitation

• 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
 Services Facilitation
OR    From the DMAS Web Site at:
                 click on

          “Provider Enrollment”

“Consumer-Directed Services Facilitation”
   Services Facilitation
 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
            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

   Must meet the standards and requirements
    set forth by the Department of Medical
    Assistance Services
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
 Accept as payment in full the amount
  reimbursed by Medicaid

    Participation Requirements
 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

    Participation Requirements

 Maintain records for a period of not less
  than 5 years.
 Use Medicaid designated billing forms.

        Termination of Provider
   DMAS requests renewal of the
    Participation Agreement prior to its

   May terminate with Medicaid at any time
    with written 30 day notice.

        Termination of Provider
   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,

      Termination of Provider
 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

    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)

Attendant Care/Respite Activities

            Consumer Directed
Personal attendant/respite services
 provided by personal attendants in the
 home are limited to the following:

   Activities of Daily Living (ADLs)

          Consumer Directed
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.

   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

– 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
– Checking the temperature, pulse,
  respiration, and blood pressure and
  recording and reporting as required.
 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

   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


   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
Employer Responsibilities
   -Hiring(checking references,basic
   -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.

    Attending to Needs of Clients
    Who Work, Attend School, or
 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.

    Attending to Needs of Clients
    Who Work, Attend School or
 DMAS will pay the attendant to assist the
  enrolled client with functions related to the
  client completing his or her job/school
 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.
    Attending to Needs of Clients
    Who Work, Attend School or
 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.
   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.

– 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.



Service Facilitator
Service Facilitator
Is in addition to the individual’s Support
              Coordinator (SC)
 (proposed regulatory change is not in

     May be an employee of an
             agency or a
       self-employed person

Services Facilitator
MAY NOT Be . . .
    The individual
    The parent of a minor individual,
    Anyone acting as employer on
    behalf of the individual

        Service Facilitator
   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
         Service Facilitator
 MUST  have sufficient resources to
 perform required activities.

 MUST   have ability to maintain and
 retain business and professional

        Service Facilitator
 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.
     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
    Agency consent form, DMAS 122,
     LOF, 456 and 457
   Services Facilitator Duties . . .
After Being Selected by Individual
   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
Comprehensive Visit

           Comprehensive Visit
   The Service Facilitator will:
    – Assess the needs of the Individual


    – Develop the Plan of Care;

        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

       Comprehensive Visit
 The Service Facilitator is responsible for
  initiating services with the client upon
  accepting the referral from the Support
 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.

    Completing the Forms:
 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
 Sample forms in packet (99A/B)
          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.

               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
   The 99A/B records the patient pay amount
    from the DMAS 122 for the individual

           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.

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”

Completing the Forms:
    Plan of Care
   For Respite care indicate the ADL
    supports needed by the individual.

            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.

Consumer (Individual) Training

Service Facilitator Duties . . .

  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
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
 What are consumer directed services?
 What are my specific responsibilities?

    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
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
    SF Documentation

 Initial Comprehensive Visit
 DMAS 97A/B
 DMAS 99A/B
 Employee Management

     Authorization for Payment of
     Consumer Directed Services

   Medicaid will not pay for any personal
    attendant services delivered prior to the
    authorization date

Service Facilitator Duties
    Prior to attendants delivering
   Obtain pre authorization of the
   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 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

    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.


 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.

 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
Routine Visits

          Routine (Onsite) Visits
   The Service Facilitator’s documentation
    of the routine visit may be documented on
    a 99A/B.

            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
    – May review the personal attendant’s record, if
    – Must discuss the individual’s satisfaction with
      the type and amount of service.                  73
Reassessment Visit

          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

   Reassessment Visit
    Transfer cases begin with a
     Reassessment visit instead of a
     Comprehensive Assessment
    When changing CD Services
    When changing SFs

Monitor the Hiring Process

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.
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).

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.
Management Training

       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.

 Services Facilitator Duties

 Completes 90 day face to face
 Required for CD Attendant Care
Review is necessary for CD
 Respite, review every six
 months or after 300 hours are
 used, whichever is first.

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
Services Facilitator Duties
   Monitors Service
Submits Plan of Care changes to SC

Attends CSP meetings, if requested
 by individual

Counsels/trains/helps resolve conflict

           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

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

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

   Fiscal Agent

            Fiscal Agent (FA)
   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

   FA Responsibilities (Cont’d)

  Assisting CD employees, employers,
  and SFs with payroll related issues

  W2-forms mailed to CD employees
  each year

   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

        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
•   FA receives DMAS-122s from SF for
    patient pay entries

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

  Example: Payroll is processed on
 Tuesday, August 24th, and mailed on
         Friday, August 27th
       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)

       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

     Example: Authorization may not be
     retroactive if the start date and the DMAS-
     122 start dates differ.
   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

           Common Obstacles
3) Hire Packets sent to FA incomplete,
and/or with forms filled out incorrectly

   •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

        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

      Completing Time Sheets

   Must be signed by employer &
   One time sheet submitted for each
    employee and one for each service
   Time sheets submitted according to the
    “Pay Schedule”

    Completing Time Sheets

   Mailed to the Fiscal Agent by the 3rd
    business day after end of each pay
   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
  Completing Time Sheets –
        Patient Pay

If the CD employee is collector of
 Patient Pay, indicate this on the time
  – The employer must pay the Patient
    Pay to the employee – the Fiscal
    Agent will not

     Helpful Hints for Forms

   Forms requesting “recipient name”
    should have the individual’s name --
    not the family member’s/guardian’s

   The Fiscal Agent will not accept copies
    or faxes

        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

      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

                                  COMMONWEALTH OF VIRGINIA
                               Personal Assistant / Companion Timesheet
                           Mail To: Fiscal Division                                                            Check One:
                                    P.O. Box 662                                                             Attendant/Assistant
                                    Richmond, VA 23218-0662                                                  Respite
                                                                                                                                   Select One
Assistant/Companion Name (Please Print):
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.
  Time In:
 Time Out:
  Time In:
 Time Out:
WEEK 2             THURS.              FRI.            SAT.            SUN.           MON.            TUES.             WED.
  Time In:
 Time Out:
  Time In:
 Time Out:
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

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.
        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
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

Utilization Review (cont’d)
    Upon Arrival, Analyst Will
   Request records be gathered
    together in a central location.

   Secure a workplace to conduct the
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.

Utilization Review (cont’d)
   Exit Conference will occur on the last
    day of the review.
   You may have any of your staff

Items to be Reviewed

 Individual   records
  – All assessments – initial &
  – CSP
  – Quarterly/Written Reviews
  – Routine visits, face-to-face contacts
  – Contact notes

Items to be Reviewed         (cont’d)

   Individual records
    – EMM and Management Training
    – KSAs confirmed
    – Documentation of dates, amount
      & type of services rendered

      Report Contents
   Technical Assistance
    – Issues not in compliance with Medicaid
      policy that should be addressed by the
   Overpayment
    – Situations in which the provider has
      failed to comply with federal and state
      regulations or policy guidelines.
   Copied to
    – Providers
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

     Other Options

 Reconsideration
  – Request will be reviewed and
    response letter sent to provider.

  – If denial is upheld, provider has the
    right to appeal.

    Other Options (cont’d)

 Appeals
  – Informal Fact Finding Conference
    • 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.
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

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
    – Signatures and dates are required on all
    – Personal attendant Registry must be available for
    – Criminal history check, TB, CPR, Flu and
      documentation that EMM manual was reviewed
      needs to be documented and available for review

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