Provider Bulletin | May 2011

Welcome to the May edition of the Provider Bulletin. In this edition you will read about the impact of the Governor’s budget on Community Care programs, creating accurate encounters, and a reminder about authorization numbers.

THE GOVERNOR’S BUDGET: HOW IT AFFECTS CCI PROGRAMS

Many of you are aware of provisions in the Governor’s budget proposal which impact the programs we offer: Family Care, Family Care Partnership, and PACE. While we know this budget proposal may be modified before final passage, it is important to consider the issues as we know them now.

First and foremost is the proposed cap on enrollments for all programs, including the state’s IRIS self-directed supports program, that will be effective July 1 and will potentially last until June, 2013. This cap will limit enrollments in counties to the total number of people enrolled on June 20, 2011. This means that, in
counties where wait lists still exist, the Aging and Disability Resource Centers (ADRC) will not be able to continue taking people off the lists until someone leaves one of the programs. It also means that wait lists will again be formed in counties where original wait lists have been exhausted. Individuals currently enrolled in a program will still be able to go through the ADRC to move from one program to another.

What does this mean to you? Since our program enrollments will stay static, there will be few growth opportunities for providers – except in responding to members whose needs are changing over time. If you are a residential provider and you have residents who are currently paying privately, those individuals will
not automatically be able to enroll in a managed care program when funds run out. Nursing home care remains an entitlement- so it is possible people would have to go to a nursing home and then relocate back to the community using nursing home relocation dollars, which will still be available.

Another provision of the proposed budget is the delegation of authority for certification of 1 and 2 bed owner occupied adult family homes to the local managed care organization for enrollees, and to the counties for any county funded residents. Community Care has been doing those certifications for some time and will continue to do so under these provisions.

All providers are urged to keep up with changes which may occur in the proposed budget by monitoring the state’s websites and local media sources.

ELECTRONIC SUBMISSION OF CLAIMS

Community Care encourages all providers to submit claims electronically. Providers who submit claims electronically will receive payment more quickly, usually within 10 days of submission. Claims not submitted
electronically will be processed within 30 days. Currently there are two ways to submit claims electronically: Community Care’s e-forms system or through a traditional clearing house. Community Care’s payer IDs to
submit through a clearing house are:
• Family Care – 60995
• PACE & Family Care Partnership - 39126

Please note that e-forms is a special system; it does not mean submitting a claim using e-mail.

Two-hour training sessions are held for those who want to learn about e-forms. Upcoming session:
Waukesha office (1801 Dolphin Dr.) on 5/19/11 from 1:00 - 3:00pm

Call Greg Russell at 262-953-8500 for additional upcoming training dates and locations.

NEED FOR AUTHORIZATION NUMBERS

In order to process your payment accurately and efficiently, it is important to include the entire authorization number on your claim. Beginning 8/1/11, your claim may be denied if the authorization is not included on your claim. If you are currently submitting your claims via e-forms or Post N Track, you are already including the authorization number.

Why is this step important? If there is no authorization number on the invoice, the claims processor must try to find the appropriate authorization with which to link the claim. This process leaves the door open for errors.

Your assistance in this effort will ensure accurate and timely payments.

FOR TRANSPORTATION PROVIDERS

All transportation providers are likely aware that the state has entered into a contract with LogistiCare, a
transportation broker, to assume responsibility for all non-emergency medical rides for Medicaid recipients
effective July 1, 2011. Please note that the LogistiCare contract does not apply to persons who are enrolled in Family Care, Family Care Partnership, or PACE. Teams will authorize rides for non-emergency medical trips just as they authorize other transportation services for members and these trips will be paid by Community Care; your contract rates will remain in effect for these rides.

Residential providers whose rates are all inclusive and include transportation will be expected to continue providing rides to members for non-emergency medical services.

MARKETING MATERIALS

Providers are reminded that when preparing any brochures, pamphlets, or other marketing materials, the Department of Health Services prohibits mentioning or displaying logos for the Department, Community Care, Inc. or any of the programs we offer (PACE, Family Care Partnership, or Family Care) in those materials. Your adherence to this policy is appreciated.

ENCOUNTER TRANSACTIONS

Community Care, like all other Managed Care Organizations (MCOs) providing Family Care or Family Care Partnership, is required to submit to DHS encounter records, which are detailed records of services that have been provided to members. Encounter reporting requires a separate and unique record for each service.

Multiple encounters may occur for a single member on any day. For example, a member might have therapy, receive personal care services, and attend a day program on a given day. The MCO would then report three encounter records. These services may or may not be provided by the same provider, but they are three distinct encounters.

Service data must be encounter-specific (unique to a person, a provider, a service occurrence, and a service date). Service quantities must be recorded using the code unit of measure for the service, and must indicate the date of service.

Example 1: A quantity of 10 meals with a service date span from the 1st to the 31st of a month is not an
encounter-specific transaction because it cannot be determined when those 10 meals were actually provided to the member. A quantity of 10 meals with a service date span from the 1st to the 10th of a month would be determined to be 1 meal per day and is an acceptable encounter record.

Example 2: Received one hour counseling once a day every weekday. Recording as Quantity of 5 sessions with Service Date From 10/5/10 to Service Date 10/9/10 would be acceptable.

Example 2a: Received one hour counseling once a day on Monday, Wednesday and Friday. Three Encounter
records would be required as follows:
QTY 1 UNIT HR Service Date on 10/5/10
QTY 1 UNIT HR Service Date on 10/7/10
QTY 1 UNIT HR Service Date on 10/9/10

In order for Community Care to record the encounters accurately, our billing procedures require that you bill us as noted above.

Any questions can be directed to the Provider Hotline at 1-866-937-2783.

PROHIBITION ON INFLUENCING MEMBER CHOICE OF MANAGED CARE PROGRAM OR MANAGED CARE ORGANIZATION

The Aging and Disability Resource Centers (ADRCs) are the agencies charged with the responsibility to provide options counseling to individuals found eligible for any Medicaid Waiver programs (PACE, Family Care Partnership, Family Care, or IRIS) so that individuals can make a choice as to the program best suited to individual needs and to determine which Managed Care Organization (MCO), if more than one is available, is best suited to the individual. A member currently enrolled in any of these programs who wishes to explore options pertaining to other programs or other MCOs must also receive options counseling in the ADRC.

Providers are prohibited from suggesting or encouraging members to select other options; members who express an interest should always be referred to the ADRC for thorough options counseling.

BEDHOLD

Federal regulations prohibit payment to more than one provider for the same service on the same day.
Therefore, residential providers cannot receive Care and Supervision payment for any day that a member is
being served in a different location using Medicare or Medicaid dollars. This does not affect Room and Board
payments, as these payments are made using member funds. All Community Care programs (PACE, Partnership, and Family Care) use Medicaid and/or Medicare dollars to pay providers.

As an example, if a member is receiving care in a hospital or a skilled nursing facility which is paid using federal dollars, Community Care cannot also pay the provider for Care and Supervision during that time. If, however, the member is absent for other reasons and Community Care is not paying for any other services during the absence (home visits, vacations, or camp sessions being paid by the member), teams may continue payment of Care and Supervision for up to 14 consecutive days.

For those occasions where Community Care does not pay bedhold, providers are prohibited from requiring
payment from the member or the family. Admission agreements cannot specify such payment requirements.