Partners for Children (PFC) Waiver Services, Procedure Codes, Rates and Billing

1. Partners for Children(PFC) Waiver Services, Procedure Codes, Rates and Billing Jill Abramson, MD MPH February14, 2013

2. PFC Provider Training • Overview • Care Coordination/CCSNL/Communication • Family-Centered Action Plan • Services/Billing • Federal Assurances/ Health & Welfare • Agency Responsibilities/Summary

3. What Happens Before Submitting Claim • Services identified on F-CAP • Services authorized by CCSNL • SAR received by agency • Service(s) provided

4. PFC Services, Procedure Codes, Rates and Billing Objectives: • Understand PFC services • Understand the use of the procedure codes and billing limits • Know the rates for each service • Understand claims processing procedure

5. PFC Services Care Coordination: Will provide child/family with Care Coordinator to: • Assume a majority of the responsibility, otherwise placed on parents, of coordinating all medically necessary care in the community • Work with the child/family to develop the Family-Centered Action Plan (F-CAP) • Provide ongoing monitoring of health and safety of the child, including home visits

6. PFC Services • Regularly communicate with the CCSNL, child, family, treating physician and other providers • Accompany child/family to appointments as necessary such as; physician, school or hospital Service Provider: RN, MSW Care Coordination (cont):

7. PFC Services Expressive Therapies: Will allow children to express their understanding and reaction to their illness by utilizing play, art, music and massage therapy to improve the capacity of the body and mind to heal. Service Provider: certified therapist

8. PFC Services Family Training: Allows an RN to instruct caregivers about end of life care, palliative care principles, care needs, medical treatment regimen, use of medical equipment and how to provide in-home medical care to meet the needs of the child. Service Provider: RN

9. PFC Services Respite Care: Provides relief for family members either in the home or in an approved facility. This benefit may be intermittent or regularly scheduled. Service Provider: RN, LVN, HHA

10. PFC Services Family Counseling: Provides child/family with emotional support and grief counseling. Includes visits before and after the death of the child. Service Provider: LCSW, Licensed Psychologist, MFT, ACSW

12. PFC Procedure Codes and Rates Care Coordination Services:

13. PFC Procedure Codes and Rates Care Coordination Services (cont):

14. PFC Procedure Codes and Rates Expressive Therapies:

15. PFC Procedure Codes and Rates Family Training:

16. PFC Procedure Codes and Rates Respite Care:

17. PFC Procedure Codes and Rates Respite Care (cont):

18. PFC Procedure Codes and Rates Family Counseling: *At least one visit must be provided, and the whole 22 units billed, before the child’s death.

19. Billing PFC Services • PFC services are Fee for Service • PFC services must be authorized for the correct dates of service • Service Authorization Request (SAR) = auth. • Agency requests service on F-CAP, sends to CCSNL for authorization • County CCS will share completed authorization with Agency • Very different from traditional hospice per diem

21. Billing PFC Services Billing: • SARs (authorization) • Initial SAR to begin Care Coordination • Additional SARs for requested PFC services once F-CAP is completed • Separate SARs for other non-PFC services covered by the state plan • Check Medi-Cal eligibility prior to providing services

22. Billing PFC Services - Claim Completion UB-04 Field Descriptions:

23. Billing PFC Services- Claim Completion UB-04 Field Descriptions (cont):

24. Billing PFC Services- Claim Completion UB-04 Field Descriptions (cont):

25. Billing PFC Services- Claim Completion UB-04 Field Descriptions (cont):

26. Billing PFC Services- Claim Completion UB-04 Field Descriptions (cont):

27. 60. CIN or 14-digit ID # Claim Completion Sample UB-04 CCS/Medi-Calclaim authorized with a SAR 63. PFC SAR #

28. Billing PFC Services - Claim Completion and Submission For help completing UB04 and submission instructions: Contact Xerox Regional Representative. Xerox Telephone Service Center: 1-800-541-5555

29. Billing Troubleshooting • Denied Claims: • Check AEVS, CIN, SAR, correct dates (eligibility, date on SAR corresponds to service), # units • If no clear reason for denial, send to PPC mailbox: • Name, CCS#, CIN, service, date of service, CCN, RAD, notes, provider NPI

30. Billing: Troubleshooting • Underpaid claims • Verify $ in provider manual vs. $ paid. • If incorrect, send to PPC mailbox: • Name, CCS#, CIN, service, date of service, CCN, units paid, $ paid, $ expected

31. Billing: Troubleshooting • Claims neither paid nor denied >2 months after submission • Send to PPC mailbox: • Name, CCS#, CIN, service, date of service, CCN (if available), whether client has OHC

32. Questions?

33. PFC Provider Training • Overview • Care Coordination/CCSNL/Communication • Family-Centered Action Plan • Services/Billing • Federal Assurances/ • Health & Welfare • Agency Responsibilities/Summary

34. CCSPPC@dhcs.ca.gov