Current through Register Vol. 49, No. 9, September, 2024
Section II
Targeted Case Management
204.000
Participation Requirements for Providers of Targeted Case Management for
Beneficiaries Age Sixty (60) and Older
Providers of targeted case management who are restricted to
serving persons sixty (60) years of age and older must be certified by the
Division of Aging and Adult Services as an organization qualified to provide
targeted case management services.
In order to be certified by the Division of Aging and Adult
Services, the provider must meet the following qualifications:
A. Be located in the state of
Arkansas
B. Be licensed as a Class
A or Class B Home Health Agency by the Arkansas Division of Health or a unit of
state government or an agency
C. Be
able to demonstrate one year of experience in performing case management
services (experience must be within the past 3 years)
D. Be able to demonstrate one year of
experience in working specifically with individuals in the targeted group
(experience must be within the past 3 years)
E. Have an administrative capacity to insure
quality of services in accordance with state and federal requirements
F. Have the financial management capacity and
system that provides documentation of services and costs
G. Have the capacity to document and maintain
individual case records in accordance with state and federal
requirements
H. Be able to
demonstrate that the provider has current liability coverage
I. Employ qualified case managers who:
1. Reside in or near the area of
responsibility; and
2. Are licensed
in the state of Arkansas as a social worker (Licensed Master Social Worker or
Licensed Social Worker), a registered nurse or a licensed practical nurse;
or
3. Have a bachelor's degree from
an accredited institution in a health and human services field, plus two years'
experience in the delivery of human services to the elderly; or
4. Have performed satisfactorily as a case
manager serving the targeted population for a period of two (2) years
(experience must be within the past 3 years).
A copy of the current certification must accompany the provider
application and Medicaid contract.
212.200
Beneficiaries Age Twenty-One
(21) and Younger Eligible for Developmental Disabilities Services
This target population consists of beneficiaries who are age
twenty-one (21) and younger and who:
A.
Experience developmental delays
B.
Have a diagnosed physical or mental condition with a high probability of
resulting in developmental delay
C.
Are determined to be at risk of having substantial developmental delay if early
intervention services are not provided and
D. Are diagnosed as having a developmental
disability which is attributable to mental retardation, cerebral palsy,
epilepsy, autism or any other medical condition considered closely related to
mental retardation because it results in impairment of general intellectual
functioning or adaptive behavior similar to those of persons with mental
retardation or requires treatment and services similar to those required for
such persons.
DDS certified case managers enrolled as Medicaid targeted case
managers must obtain written verification that any beneficiary they wish to
bill for has been certified as eligible to receive services from the Division
of Developmental Disabilities Services. This documentation must be obtained
from the DDS service coordinator responsible for the beneficiary's county of
residence and must be maintained in the beneficiary's record. Providers may
request a list of DDS service coordinators and their locations from the local
DHS county office.
212.410
Regulations for ElderChoices
Program Case Management
A. A plan of
care developed by the DHS RN for the ElderChoices Program replaces any other
plan of care. The ElderChoices plan of care must include all appropriate
ElderChoices services and certain non-waiver services appropriate for the
beneficiary.
B. If services are
currently provided to an ElderChoices client, the provider must report these
services to the DHS RN. Before beginning or revising services to an
ElderChoices client, the DHS RN must be contacted to ensure that the plan of
care is revised and approved. All changes in service or client circumstances
must be reported to the DHS RN immediately. Certain services provided to an
ElderChoices client that are not included in the plan of care may be subject to
recoupment by the Medicaid Program.
C. An ElderChoices plan of care may not be
revised by anyone other than the DHS RN. All services, regardless of the
funding source, must be documented by the TCM provider in the beneficiary's TCM
case file. Non-Medicaid funded services, such as food stamps, housing, etc.,
must be included in the overall TCM assessment and on the TCM service plan.
These type services that are not required on the waiver plan of care may be
implemented without prior approval by the DHS RN.
D. If a temporary situation arises based on a
filled position becoming temporarily vacant and the hiring of the position is
in process, a case manager may exceed the maximum of 70 active cases for no
more than 60 consecutive days. The maximum number of active cases during a
temporary situation, as described above, may not exceed 90 Medicaid
beneficiaries. If the TCM agency temporarily stops accepting referrals, written
notification must be sent to the DHS RN with an effective date. Once referrals
are being accepted again, written notification must be sent to the DHS RN with
an effective date. This will ensure all TCM agencies are fairly represented and
it will avoid unnecessary referrals, which would ultimately delay services
being provided to the beneficiary.
213.000
Covered Case Management
Services
The following provides examples of case management services
that are covered by Arkansas Medicaid. The list includes but is not limited
to:
A. Assessment of the eligible
individual to determine service needs
This assessment process refers to assessing the individual's
service needs to assist in accessing services that currently may or may not be
in place. It does not refer to a medical assessment or replace any eligibility
requirement for any Medicaid program.
B. Development or assisting in the
development of an individualized care plan, specific to the beneficiary's needs
This is a service plan that meets the requirements of the TCM
program. It does not replace any required plan of care or service plan for a
Medicaid waiver program or any other Medicaid program.
C. Referral(s) to help the beneficiary obtain
needed services
D. Monitoring and
follow-up contacts
E. Scheduling
appointments related to gaining access to medical, social, educational and
other services appropriate to the beneficiary's needs
This includes, but is not limited to, medical appointments,
transportation services and appointments with DHS.
F. Face to face or telephone contacts with
the beneficiary and/or other individuals for the purpose of assisting in the
beneficiary's needs being met
1.
Communications through FAX or email are covered when the purpose of the
communication is to gather information from an individual other than the
beneficiary AND the purpose of the communication meets the TCM service
definition.
2. Billable
communication is limited to time spent sending emails and/or faxes. Receiving
faxes and/or emails is not a billable TCM service. Hard copies of emails and
faxes must be maintained in the beneficiary's file for audit purposes by the
Arkansas Medicaid Program or its representatives. Documentation must support
all claims for Medicaid reimbursement, as is currently required by the Medicaid
Program.
3. Communications through
fax or email is not billable when communication is with the
beneficiary.
G.
Assisting in or arranging for assistance in the completion of an application
for types of assistance
1. The time the case
manager spends gathering information and documents required by the application
for assistance is a covered TCM service.
2. Documentation in the case file must
support all activities for which Medicaid is billed.
H. Conferencing with others, on behalf of the
applicant, to assist in the application process for accessing services is
covered
These type contacts must be documented.
I. Referral for energy assistance
J. Referral for legal assistance
K. Referral for emergency housing
214.000
Exclusions
Services that are not appropriate for targeted case management
services and are not covered by the Arkansas Medicaid Program include, but are
not limited to:
A. Targeted case
management services provided to beneficiaries who are receiving case management
services through the DDS Alternative Community Services (DDS ACS) Waiver
Program
B. The actual
provision of services or treatment. Examples include, but are not
limited to:
1. Training in daily living
skills
2. Training in work skills,
social skills and/or exercise
3.
Grooming and other personal care services
4. Training in housekeeping, laundry,
cooking
5. Transportation services
(Arranging for transportation for a beneficiary is covered.)
6. Counseling and/or crisis intervention
services
7. Contacts made by the
TCM to vendors verifying that services or goods, such as wheelchairs, air
conditioners, canes, commodities, etc. are available or ready for
delivery
8. Delivery of services or
goods, such as wheelchairs, air conditioners, canes commodities, etc.
9. Inspection of services or goods, such as
wheelchairs, wheelchair ramps, air conditioners, installation of air
conditioners, commodities, etc.
C. Services that go beyond assisting
individuals in gaining access to needed services. Examples include, but are not
limited to:
1. Supervisory activities,
including supervisory duties required in other programs such as personal care
and home health
2. Paying bills
and/or balancing the beneficiary's checkbook
3. Delivering application forms, paper work,
evaluations and reports.
4.
Observing a beneficiary receiving a service, e.g., physical therapy, speech
therapy, classroom instruction
5.
Escorting beneficiaries to scheduled medical appointments
6. Attending meetings, conferences or court
hearings to provide information regarding the beneficiary and/or the
beneficiary's family
7. Home visits
to observe the beneficiary and family's interactions or the condition of the
home for child or adult protection purposes
8. Verifying Medicaid eligibility through
telephone calls, AEVCS, or by any other means
9. Travel and/or waiting time
10. Administrative activities associated with
Medicaid eligibility determination, application processing, and verification of
status of pending application, telephone calls requesting information regarding
steps in the application process
Follow-up calls on pending applications are not a targeted case
management function. These calls are not covered.
11. Attending meetings, hearings, appeals,
conferences, and/or court hearings to provide information regarding the
beneficiary and/or the beneficiary's family
This includes staffing for personal care. Information shared
between two departments of the same agency in order to best serve the
beneficiary is the responsibility of the agency providing care. This service is
not part of case management.
12. Nursing services, checking blood
pressure, post operative care, etc. Case managers must refer a beneficiary to a
home health agency or other appropriate agency for such care and monitoring.
Time spent making a referral is covered.
13. Training, accessing resource information,
any activity associated with gaining knowledge on community services available
in the area of responsibility
This is the responsibility of the TCM agency and the targeted
case manager in order to successfully provide the TCM service.
14. Staffing meetings
15. Medicaid eligibility determinations,
Medicaid intake processing, Medicaid preadmission screening for inpatient care,
and prior authorization for Medicaid services and utilization review
16. Medicaid outreach (methods to inform or
persuade beneficiaries or potential beneficiaries to enter into care through
the Medicaid system
17. Client
outreach in which a provider attempts to contact potential recipients of a
service, including TCM
The attempt to contact individuals who may or may not be
eligible for case management services or other Medicaid services is not
considered a coverable TCM service.
D. Case management services that duplicate
services provided by public agencies or private entities under other program
authorities for the same purpose.
For example, targeted case management services provided to
foster children duplicate services provided by a public agency and are
therefore not covered.
E.
Case management services that duplicate integral and inseparable parts of other
Medicaid or Medicare services, e.g., Home Health, Rehabilitative Services for
Persons with Mental Illness (RSPMI) and Children's Medical Services, when
provided on the same date of service
F. Case management services provided to
inpatients
Discharge planning is a service required of physicians, other
practitioners and inpatient facilities. Case management is not a covered
service for any date the beneficiary is an inpatient of a facility or
institution. These facilities include, but are not limited to, acute care
hospitals, rehabilitative hospitals, inpatient psychiatric facilities, nursing
homes and residential treatment facilities.
G. Case management services provided while
transporting a beneficiary
216.000
Documentation in Beneficiary
Files
The targeted case manager must develop and maintain sufficient
written documentation to support each service for which billing is made.
Written description of services provided must emphasize how the goals and
objectives of the service plan are being met or are not being met. All entries
in a beneficiary's file must be signed and dated by the targeted case manager
who provided the service, along with the individual's title. The documentation
must be kept in the beneficiary's case file.
Documentation must consist of, at a minimum, material that
includes:
A. The prescription for
targeted case management services
B. The dates of the Child Health
Services/EPSDT screens for beneficiaries under the age of twenty-one (21)
ineligible for DDS ACS waiver services
C. When applicable, a copy of the original
and all updates of the beneficiary's individualized education plan
(IEP)
D. The specific services
rendered
E. The type of service
rendered: assessment, service management and/or monitoring
F. The type of contact: face to face or
telephone
G. The date and actual
clock time for the service rendered
This must include the start time and the stop time for each TCM
service.
H. The
beneficiary's name and Medicaid number
I. The name of the provider agency, if
applicable, and person providing the service
The targeted case manager providing the service must initial
each entry in the case file. If the process is automated and all records are
computerized, no signature is required. However, there must be an agreement or
process in place showing the responsible party for each entry.
J. The place of service (Where the
service took place: e.g. office, home)
K. The number of units billed
L. Updates describing the nature and extent
of the referral for services delivered
M. For non-DDS ACS beneficiaries under the
age of twenty-one (21), a copy of the original and all updates, of the
beneficiary's service plan
N. DDS
beneficiary's certification of eligibility for DDS services
O. Description of how TCM and other in-home
services are meeting beneficiary's needs
P. Progress notes on beneficiary's
conditions, whether deteriorating or improving and the reasons for the change
1. While the targeted case manager may not be
considered a medical professional, progress notes are intended to describe a
beneficiary's overall condition, including any changes since the last contact,
the reason for the change, etc.
2.
This requirement is not asking the targeted case manager to diagnose, treat, or
offer medical opinions. However, the targeted case manager must record
information provided by the beneficiary or others on behalf of the beneficiary
that pertains to the service plan goals and progress toward those
goals.
Q. Process for
tracking the date the beneficiary is due for reevaluation by the Division of
County Operations
The tracking is to avoid a beneficiary's case from being closed
unnecessarily.
1. The TCM agency may
establish a tickler system that meets the requirements of the TCM
program.
2. The Medicaid Program
has not established a specific tickler system that must be uniformly used by
all providers.
R.
Documentation, as described above, is required each time a TCM function is
provided for which Medicaid reimbursement will be requested. Time spent
recording required documentation is a billable TCM service.
217.100
Requirements for
Time Records and the Tickler System
Each TCM must maintain a tickler system for tracking
purposes.
A. The tickler system must
track and notify of the following activities:
1. Each active TCM beneficiary
2. Expiration date of any Medicaid waiver
plan of care applicable to a given beneficiary
3. Medicaid eligibility date
4. The beneficiary's case reevaluation date,
as established by DHS, Division of County Operations
B. It is the responsibility of the case
manager to maintain a tickler system, as described above, for those
beneficiaries in their specific caseload. However, the record keeping
requirements and documentation requirements must be maintained in the
beneficiary's file.
218.100
Assessment/Service Plan
Development
This component is an annual face-to-face contact with the
beneficiary and contact with other professionals, caregivers or other parties
on behalf of the beneficiary. Assessment is performed for the purpose of
collecting information about the beneficiary's situation and functioning and to
determine and identify the beneficiary's problems and needs.
The TCM assessment is a comprehensive assessment that includes
medical, social, educational, and other services. It goes beyond the assessment
process used in determining eligibility for the 1915( c) waiver program. It
addresses all facets of the individual's everyday life in determining how any
problem or need might be met and what services are available in the
individual's community.
For TCM beneficiaries age 21 and over, the maximum units
allowed for this service may not exceed twelve (12) units per
assessment/service plan visit.
This component includes activities that focus on needs
identification. Activities, at a minimum, include:
A. The assessment of an eligible beneficiary
to determine the need for any medical, educational, social and other services.
Specific assessment activities include:
1.
Taking beneficiary history
2.
Identifying the needs of the beneficiary
3. Completing related documentation
4. Gathering information from other sources,
such as family members, medical providers and educators, if necessary, to form
a complete assessment of the Medicaid eligible beneficiary
B. An assessment may be completed between
annual assessments, if the TCM deems it necessary.
1. Documentation in the beneficiary's case
file must support the assessment, such as life-changing diagnoses, major
changes in circumstances, death of a spouse, change in primary caregiver,
etc.
2. Any time an assessment is
completed, the circumstances resulting in a new assessment rather than a
monitoring visit must be documented and must support the activity billed to
Medicaid.
3.
For
beneficiaries age twenty one and older, reassessments performed between annual
assessment visits are limited to eight (8) units per reassessment.
Documentation in the beneficiary's case file must support the
reassessment, such as a life-changing diagnosis, major changes in
circumstances, death of a spouse, change in a primary caregiver, etc. Any time
an assessment is completed, the circumstances resulting in a new assessment
rather than a monitoring visit must be documented and must support the activity
billed to Medicaid.
C. Service plan development builds on the
information collected through the assessment phase and includes ensuring the
active participation of the Medicaid-eligible beneficiary or their authorized
representative. The goals and actions in the care plan must address medical,
social, education, and other services needed by the Medicaid-eligible
beneficiary. Service plans must:
1. Be
specific and explain each service needed by the beneficiary
2. Include all services, regardless of
payment source
3. Include support
services available to the beneficiary from family, community, church or other
support systems and what needs are met by these resources
4. Identify immediate, short term and long
term ongoing needs as well as how these needs/goals will be met
5. Assess the beneficiary's individualized
need for services and identify each service to be provided along with goals
NOTE: The TCM service plan is a comprehensive care plan
that includes medical, social, educational, and other services that have been
identified and included on the service plan for purposes in meeting the
identified goals. The TCM service plan goes beyond the ElderChoices waiver plan
of care developed by the DHS RN. The TCM service plan addresses all facets of
the individual's everyday life in determining how any problem or need will be
met and what services are available in the individual's
community.
D. The assessment and the service plan may be
accomplished at the same time, during the same visit, or separately.
1. However, for the assessment and the
service plan for beneficiaries age 21 and over,
the total time in completing the assessment and
developing the service plan may not exceed 12 units per beneficiary, regardless
of whether the two are completed on the same date of service or different dates
of service.
2.
For beneficiaries age 21 and over, the total time spent on the assessment
and service plan development process may not exceed 12 units.
NOTE: Annual reassessments and service plan development
are allowed, in fact, encouraged. This policy does not prohibit annual
reassessments and service plan development. Reassessments may be conducted any
time the case manager deems it appropriate, however, when reassessments are
performed more frequently than annually, justification for conducting a full
reassessment, rather than a monitoring visit, must be included in the
documentation contained in the case record.
TCM service plans must be renewed, at least,
annually.
218.200
Service Management/Referral and
Linkage
This component includes activities that help link Medicaid
eligible beneficiaries with medical, social, educational providers and/or other
programs and services that are capable of addressing identified needs and
achieving goals specified in the service plan. For example, making referrals to
providers for needed services and scheduling appointments may be considered
case management. This component details:
A. Functions and processes that include
contacting service providers selected by the beneficiary and negotiation for
the delivery of services identified in the service plan. Contacts with the
beneficiary and/or professionals, caregivers or other parties on behalf of the
beneficiary may be a part of service management.
B. For beneficiaries participating in an HCBS
waiver program, the transfer of information to the DHS RN via the AAS-9511,
AAS-9510, or other communication form is not a covered service.
This activity is required but it is considered administrative
paperwork and is not a billable TCM activity.
See Section 262.100 for the appropriate procedure code.
218.300
Service
Monitoring/Service Plan Updating
This component includes activities and contacts that are
necessary to ensure the TCM care plan is effectively implemented and adequately
addressing the needs of the Medicaid-eligible beneficiary.
The maximum units allowed for this service may not exceed
four (4) units per monitoring visit when providers are dealing with
beneficiaries age 21 and over.
A. The activities and contacts may be with
the Medicaid-eligible beneficiary, family members, providers or other
entities.
B. They may be as
frequent as necessary, within established Medicaid maximum allowable
limitations, to help determine such things as:
1. Whether services are being furnished in
accordance with a Medicaid eligible beneficiary's plan of care
2. The adequacy of the services in the plan
of care
3. Changes in the needs or
status of the Medicaid-eligible beneficiary
C. Monitoring is allowed through regular
contacts with service providers at least every other month to verify that
appropriate services are provided in a manner that is in accordance with the
service plan and assuring through contacts with the beneficiary, at least
monthly, that the beneficiary continues to participate in the service plan and
is satisfied with services.
1. A face to face
monitoring contact with the beneficiary must be completed once every three
months. Required contacts with the service providers may be conducted through
face to face contact or by telephone. Communication with service providers by
email or fax are allowed as described in Section 213.000, F.1.
2. A face to face contact is not considered a
covered monitoring contact unless the required monitoring form is completed
according to instructions, dated, signed by the targeted case manager, and
filed in the beneficiary's case record.
D. Updating includes:
1. Reexamining the beneficiary's
needs
2. Identifying changes that
have occurred since the previous assessment
3. Identifying hospitalizations or other
extended absences from the home
4.
Altering the TCM service plan
5.
Measuring the beneficiary's progress toward service plan goals. Service plans
should not be updated more than quarterly unless there is a significant change
in the beneficiary's needs.
Monitoring and follow-up activities include making necessary
adjustments in the TCM care plan and service arrangements with providers,
according to established program guidelines.
Face to face monitoring contacts must be completed as often as
deemed necessary, based on the professional judgment of the TCM, but no less
frequent than established in Medicaid TCM program policy.
E. Non-Covered Services include:
1. The updating of a tickler system
2. A case management agency is not allowed to
monitor or update an activity when the service being monitored or updated is
provided to the beneficiary by the same agency.
3. However, the same agency is allowed to be
both the TCM agency and the agency providing a direct service, such as personal
care, home delivered meals, or PERS.
4. However, the agency is not allowed to bill
for a TCM monitoring contact when monitoring the quality of care or the
quality of the service provided by the same agency or when the purpose
of the contact is to monitor the progress of a service being in place,
delivered, having started, effective date, etc.
5. In addition, TCM is not allowed when
monitoring is required through the direct service policy, such as with PERS
providers.
6. Monitoring the PERS
service is a part of the certification policy for all PERS providers.
Additional monitoring of the PERS service by a TCM is not a covered TCM
service.
F. Examples of
case monitoring and service plan updating are shown below:
1. Example # 1
Provider "A" has been chosen by the beneficiary to provide home
delivered meals. The beneficiary has also chosen provider "A" for case
management services. Case management by provider "A" may not be billed for any
activity associated with the provision of home delivered meals. It is the
responsibility of the direct service provider to ensure quality services are
provided. In this example, the home delivered meal provider is responsible for
ensuring meals are delivered timely and to the beneficiary's satisfaction. Case
management activity does not include monitoring the provision of home delivered
meals by the same agency.
This same policy applies to any service where the case
management agency is the same agency providing the in-home
service.
2. Example #
2
Provider "B" has been chosen by the beneficiary to provide
personal care. The beneficiary has also chosen provider "B" for targeted case
management services. Case management by provider "B" may not be billed for any
activity associated with the quality of the personal care services being
provided by the same agency. It is the responsibility of the direct service
provider to ensure quality services are provided.
In this example, the personal care provider is responsible for
ensuring personal care services are provided to the satisfaction of the
beneficiary and according to the plan of care (POC) that includes the personal
care service. This includes whether or not the aide performs the duties
assigned, arrives timely, stays the assigned period of time, is courteous and
meets the requirements established for the Personal Care Program by the
Arkansas Medicaid Program.
G. A TCM provider is allowed to bill a
monitoring contact when the monitoring is for the purpose of verifying the
services included on the POC are sufficient based on the beneficiary's current
condition. This is also true when the case manager is contacted by the
beneficiary.
1. If the monitoring contact is
billed, based on this purpose, documentation must support the reason for the
contact, the results of the contact and any changes requested to the POC.
a.
NOTE:This type activity, when
based on the beneficiary's condition and the sufficiency of the services in
place, may be billed regardless of whether or not the case manager and the
direct service provider are the same agency.
b. If the monitoring contact, whether
initiated by the case manager or the beneficiary, is not addressing
quality of care, the monitoring contact is billable, if it meets
the definition described in this manual.
2. The same policy applies to the personal
emergency response system (PERS) service. The TCM provider may test the PERS
unit when completing a monitoring visit, if the PERS unit is not provided by
the same agency as the TCM service.
a. Since
the PERS providers are required to test their units monthly, if they choose to
meet that requirement by having their targeted case managers test the units
while in the home, this is not considered a covered TCM service.
b. It does, however, meet the requirement
established for the PERS providers, if results of the testing are documented by
the PERS provider and available for audit.
H. All requests from case managers to
increase or decrease services or change service providers will be verified by
the DHS RN and justified by the DHS RN prior to any changes being made to the
waiver plan of care. This applies when the beneficiary is a participant in a
home and community based waiver program.
See Section 262.100 for the appropriate procedure code and
modifier.
220.000
Benefit Limits
Based on the state fiscal year (SFY) July through June,
beneficiaries age twenty-one (21) and older are limited to fifty (50) hours
(200 units) of targeted case management services per year.
Regardless of the overall SFY benefit limit, each waiver plan
of care must specify the number of units being authorized and documentation
must reflect how those units are utilized. Utilization must be reasonable,
documented, and justified in the case record, based on the beneficiary's
overall medical condition, support services available to the beneficiary, and
in-home services currently in place.
If a TCM beneficiary is also a home and community based waiver
beneficiary, such as ElderChoices, the waiver plan of care supersedes any other
plan of care. Therefore, the number of units authorized on the waiver plan of
care may not be exceeded unless prior approved by the DHS RN. Approval
will not be granted after the services are already provided.
For audit purposes, the authorization must be in writing,
placed in the beneficiary's file, and available for auditors.
250.100
Method of Reimbursement
Reimbursement is based on the lesser of the billed amount or
the Title XIX (Medicaid) maximum allowable for each procedure.
Reimbursement is contingent upon eligibility of both the
beneficiary and provider at the time the service is provided and upon accurate
completeness of the claim filed for the service. The provider is responsible
for verifying the beneficiary is eligible for Medicaid prior to rendering
services.
Targeted case management services must be billed on a per unit
basis, as reflected in a daily total, per beneficiary, per TCM service. One
unit equals 15 minutes.
One (1) unit = 5 - 15 minutes Two (2) units = 16 - 30 minutes
Three (3) units = 31 - 45 minutes Four (4) units = 46 - 60 minutes
Providers must accumulatively bill for a single
date of service. Providers are not allowed accumulatively bill for
spanning dates of service. For example, a targeted case manager may make
several referrals on behalf of a beneficiary on Monday and then again on
Tuesday. The targeted case manager is allowed to bill for the total amount of
time spent on Monday and the total amount of time spent on Tuesday, but is not
allowed to bill for the total amount of time spent both days as a single date
of service.
All billing must reflect a daily total, per TCM service, based
on the established procedure codes. No rounding is allowed.
A.
Example 1:
Case management documents reflect:
10:00 a.m. to 10:02 a.m.: Scheduled food stamp appointment and
reviewed list of required information with the county eligibility worker.
(Referral and Linkage)
11:00 a.m. to 11:06 a.m.: Contacted beneficiary's daughter and
verified hospitalization dates of service and discussed any change in
beneficiary's condition and any additional services needed. (Service
Monitoring)
1:30 p.m. to 1:36 p.m.: Called DHS RN and reported
hospitalization of client and conversation with client's daughter (also sent
9511).
TOTAL BILLING: 6 minutes (1 unit) (CALL TO DHS RN AND
ADMINISTRATIVE PAPERWORK IS NOT BILLABLE. Two minute Referral and Linkage does
not equal a unit, therefore, is not billable.)
B.
Example 2:
Case management documentation reflects:
8:30 a.m. to 8:36 a.m.: Contacted beneficiary and discussed
need for diapers and durable medical equipment, as requested by DHS RN. Also
scheduled home visit. (Referral and Linkage)
10:00 a.m. to 10:02 a.m.: Scheduled transportation for eligible
client. (Referral and Linkage)
10:30 a.m. to 11:00 a.m.: Delivered diapers and 3 pronged cane
to eligible client.
TOTAL BILLING: 8 minutes (1 unit). (DELIVERY OF DIAPERS AND
CANE IS NOT BILLABLE.)
C.
Example 3:
8:15 a.m. to 8:20 a.m.: Telephone call to DHS County Office to
verify status of pending food stamp application.
9:00 a.m. to 9:15 a.m.: Telephone call to applicant to report
information regarding pending application. Client has no food and asks case
manager about local Food Pantry. Case Manager contacts food pantry and arranges
for food to be delivered to client's home. (Referral and Linkage)
9:15 a.m. to 9:16 a.m.: Telephone call to city staff to see if
commodities were in and ready for distribution.
TOTAL BILLING: 15 minutes for Referral and Linkage.
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19. Case
Management Services A. Pregnant Women Reimbursement is a fee for
service.
19. Case
Management Services
B. Persons Sixty years of
Age and Older
TCM services, when prescribed by a physician or other medical
professional designated by the Division of Medical Services, are available to
beneficiaries age 60 and older, including individuals participating in the
ElderChoices 1915 (c) waiver, who:
* have limited functional capabilities in two or more ADLs or
IADLs, resulting in a need for coordination of multiple services and/or other
resources; OR
* are in a situation or condition which poses imminent risk of
death or serious bodily harm and one who demonstrates the lack of mental
capacity to comprehend the nature and consequences of remaining in that
situation or condition.
Reimbursement is based on the lesser of the billed amount
or the Title XIX (Medicaid) maximum allowable for each procedure. Case
management services are billed on a per unit basis. One unit equals 15
minutes.
The agency's targeted case management fee schedule rates
were set as of October 1, 2012 and are effective for services on or after that
date. All targeted case management fee schedule rates are published on the
agency's website
(www.medicaid.state.ar.us).
A uniform rate for these services is paid to all governmental and
non-governmental providers unless otherwise indicated in the state
plan.
Cost per 15 minute unit = $7.50
