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Arizona Medicaid School Based Claiming Regional Information Sessions February 2010

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Arizona Medicaid School Based Claiming Regional Information Sessions February 2010

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    1. Arizona Medicaid School Based Claiming Regional Information Sessions February 2010

    2. Agenda General Updates Compliance Review MAC Compliance Speech Language Pathology Assistant (SLPA) Update Health Aides PCG Claim Processing System

    3. General Updates Electronic Signature Questionnaire LEAs using software approved by PCG are not required to print their medical records and have their providers sign and date them LEAs may submit the electronic signature questionnaire to PCG for review and approval The Electronic questionnaire and instructions can be downloaded from PCGs website at - http://web.pcgus.com/azschools/downloads.html

    4. General Updates Remittance Advice (RA) Remits are provided weekly to the LEA or biller, which provides the LEA or biller with the payment status of the claim batch Sorted by the rendering provider, then student Contains claim status (paid, denied, pending or suspended claims) Provides denial reason and description, applicable Reimbursement total should match the check amount As of January 2010, billers can now access remits from a FTP server LEAs can request RAs from their biller or PCG account manager

    5. General Updates

    6. Compliance Reviews Program Compliance Enhancing the process to improve results!

    7. Compliance Reviews 70 Compliance Reviews were completed for Q4-09 (October December) DSC time frame: 9/1/2008 - 5/31/2009 MAC time frame: Q1-2009 (Jan-March) 39 Compliance Reviews are in process for Q1-10 (January March) DSC time frame: 9/1/2008 - 5/31/2009 MAC time frame: Q2-2009 (April -June)

    8. Compliance Reviews Areas identified that need improvement.Areas identified that need improvement.

    9. Compliance Reviews Corrective Action Plan (CAP) If your LEA requires a CAP as a result of the compliance review, a qualified representative such as the Special Education Director should complete and manage implementation of the CAP Superintendents will be required to sign the CAP LEAs are responsible for monitoring the development and implementation of the corrective action plan approved by PCG to ensure effective resolution of the specific finding

    10. Compliance Reviews Corrective Action Plan (CAP) LEAs should not bill until processes have been developed and implemented to ensure adequate documentation of claims Only claims that can be fully supported should be submitted for payment by Medicaid LEAs should conduct internal compliance reviews to ensure the district has proper supporting documentation to back-up each claim submitted for payment and meet standards of clean claims

    11. Compliance Review Sanctions AHCCCS and PCG are developing sanctions for non-compliance; an average compliance percentage for components not above the 90% passing threshold Possible sanctions include Claiming restricted for failed components until corrections are demonstrated or for a set period of time based on the compliance percentage Back billing restrictions for suspension periods Suspension of claiming by procedure code, provider type or LEA provider number Suspension from the programs (DSC and MAC) for LEAs that cannot demonstrate compliance by the third (1 Year) compliance review

    12. MAC Compliance AHCCCS and PCG have communicated, through several forms of communication (i.e., memos, newsletters, RIS sessions, webinars, and account manager follow-up), the state-wide time study must meet a minimum 85% compliance rate and thus each LEA must also maintain a minimum compliance rate of 85% All participating LEAs are required to monitor and follow-up with participants throughout the quarter Weekly compliance report sent by PCG RMTS reports PCG will notify LEAs that are not meeting the quarterly 85% compliance rate, however each LEA should already know based on the reports available in the RMTS system

    13. MAC Compliance All LEAs should strive for 100% compliance and complete all moments selected for participants in their district or charter AHCCCS and PCG are currently monitoring the LEAs not meeting the minimum 85% compliance rate LEAs who have not met the compliance rate for two consecutive quarters should expect penalties for failure to comply Every Moment Counts!

    14. MAC Compliance Statewide RMTS Compliance History Every Moment Counts!

    15. MAC Compliance LEA RMTS Compliance History 3 LEAs did not meet the minimum 85% compliance rate for both the Q3-09 and Q4-09 quarters Effective Q4-09, number of total moments increased from 1,200 to 6,000

    16. MAC Compliance Q2-09 Time Study Analysis - 79.75% RMTS compliance rate If the 85% compliance rate was met, LEAs could have received an increase in reimbursement for the Q2-09 MAC quarter Every Moment Counts!

    17. MAC Compliance Q1-10 Time Study Compliance as of Friday, February 19, 2010 Every Moment Counts!

    18. MAC Compliance Helpful tools for monitoring LEA and participant compliance Weekly RMTS Statewide Compliance Report - displays all sampled moments for the quarter by LEA and which moments have been submitted Individual Master Sample File Report - displays the sampled moments for the district by calendar week within the quarter. The moments displayed in this report will be moments that have already occurred and moments that are within five days of the sampled moment Compliance Report - displays sampled moments that have been submitted / completed and those moments that are within 5 days of the sampled moment. 24 Hour Late Notice & 3 Day Late Notice E-Mail The LEA coordinator is copied on the late notices that are sent to the participant when the moment has not been completed

    19. MAC Compliance RMTS Reminders Participants may only be listed once in the staff roster. Participants cannot be listed in both cost pools Each participant must have their own unique email address Contact your PCG account manager when a sampled participant is on leave and will not be returning during the 5 days to complete the moment, or when the participant has terminated or replaced When providing your PCG account manager with the participants leave status you must indicate whether the leave is paid or unpaid and the effective date. If the participant has termed, provide the termination date

    20. MAC Compliance RMTS Reminders The participant must complete 14 training screens prior to being able to select their moment for completion and to progress through the screens they must select Next Participants cannot be notified more than five (5) days before their sampled moment. Notification includes emails, calls, letters, conversations or any other form of communication LEAs must be approved for paper notification by PCG For lost user names and passwords, contact the PCG RMTS hotline at 1-877-877-8011

    21. MAC Compliance Remember: Time study results are applied to all LEAs in a State-wide methodology. A reduction in the percentage of time spent on reimbursable activities, will adversely affect the reimbursement of all participating LEAs. Every Moment Counts!

    22. Speech Language Pathology Assistant (SLPA) Update July 20, 2009 - Arizona Department of Health Services (ADHS) announced the approval of the Governors Office to proceed with rule making regarding Speech Language Pathology Assistants (SLPAs) ADHS starts licensing SLPAs December 25, 2009 - The final rule (R9-16-501 et seq) was published in the Arizona Administrative Register (http://www.azsos.gov/aar/2009/52/final.pdf), to become effective February 1, 2010 January 4, 2010 - AHCCCS began accepting and processing licensed SLPA provider registration applications January 27, 2010 - PCG e-mailed LEAs the AHCCCS updated FFS rates and codes to reflect the SLPA change effective February 1, 2010

    25. Health Aides With support provided to LEAs through health aide guidance document, newsletters and multiple trainings sessions regarding appropriate billing for Activities of Daily Living (ADLs), PCG has found that many LEAs continue to be out of compliance when billing ADLs Problem Areas Missing the IEP language that clearly defines scope, frequency and duration Using the parental consent form for scope, frequency and duration Using ranges which are not allowed

    26. Health Aides Health Aide Claims Reimbursement February 2009 January 2010 = $6,677,262.19 Health Aide % of total claims paid = 32.34% If LEAs continue to fail to meet compliance, Health Aide claiming could potentially be eliminated

    27. Health Aides Range of Time Request should specify amount of time or additional units being sought for approval Only time/units associated with allowable activities of daily living (ADLs) will be approved PCG will deny requests for additional units that are provided in a range. e.g. 4 6 hours per day Scope, frequency, and duration must be clearly addressed and written in the IEP as prescribed by a qualified provider through the appropriate IEP documentation and supporting medical records

    28. PCG Claim Processing System Overview PCG is migrating to a new claim processing system to comply with HIPAA compliant 837 file format Secure web based portal used for claim submission allows users easy access System will provide updated functionality including online claim correction Process LEA/biller will create the claim file in the 837 file format and upload into web portal Claim file will be checked for 837 compliance before it is uploaded into the claim submission program Once the file passes the initial edit, user will process the claims and they will pass through another audit designed to check the validity of the claim data (Member ID, Member DOB, Provider number, etc.)

    29. PCG Claim Processing System Claims passing edits will be forwarded to AHCCCS for adjudication, claims failing the edits will be separated allowing the user to make corrections and reprocess Once adjudicated by AHCCCS, the payment information will be sent to PCG and the payment and remittance advice will be generated in the same format they are currently provided Features and Benefits HIPAA compliant 837 claim files can be uploaded directly into the web portal without the need to revert the file into the NSF format Online provider file provides access to AHCCCS Provider ID and contract effective date

    30. PCG Claim Processing System Claim submission process identifies data errors (invalid member ID, invalid DOB, etc.) and allows for immediate online corrections by providing links to the member eligibility file. Once errors are corrected the claim can be submitted again immediately without having to create and upload another claim file LEAs using a biller can be provided with view only access to check the status of claims Implementation Process and Timeline Communication/Registration Training Testing Transition to live claim submission

    31. PCG Claim Processing System Communication / Registration LEAs and billers sent initial notification the week of February 22, 2010 LEAs and billers will be required to complete a user registration form identifying individuals requesting user access LEAs must have a Biller Authorization form on file with PCG to allow linkage of biller to claims processing system Identification/review of key dates Training Two (2) training sessions will be conducted in March; biller and self-biller trainings will be conducted separately Prior to training, users will be provided with the companion guide and other relevant materials Users will be given access to the system after completing a training certification form demonstrating their understanding of the system

    32. PCG Claim Processing System Testing Process Billers and self-billers will be required to submit test claims to ensure claim files are uploaded correctly in the 837 file format LEAs can continue to submit claim files in the current format until they are approved so there is no interruption of claiming Testing must be completed by April 23, 2010 Live claim data submission Total system changeover scheduled for May 3, 2010 at which time claims will no longer be accepted in current format

    33. Questions

    34. Thank you for joining us have a wonderful day!

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