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NORTH EAST OHIO NETWORK
WWW.NEONCOG.ORG
DOCUMENTATION
&
BILLING
TRAINING FOR INDEPENDENT PROVIDERS
CONTENTS
EXAMPLE OF WAIVER SERVICE DELIVERY DOCUMENTATION
PROVIDER BILLING
BILLING INFORMATION AT A GLANCE
IMPORTANT TO REMEMBER FOR BILLING
NAVIGATING THE PROVIDER PAGE
IMPLEMENTATION GUIDELINES
COMPLETE SET OF FORMS
SERVICE DOCUMENTATION ODODD Administrative Rule 5123: 2-9-06
The Service Documentation rule describes the requirements for services provided to individuals receiving services funded by a Medicaid Waiver.
The following elements must be part of Service Documentation:
1. Date of Service 2. Place of Service 3. Name of Recipient 4. Recipient Medicaid number 5. Name of Provider 6. Provider contract number 7. Signature of Provider 8. Type of Service being provided 9. Number of Units delivered
10. Group Size (ratio) 11. Time-in & Time-out 12. A description of the service 13. Frequency & Duration
Reimbursements made to the Provider for services delivered that do not include the required elements may be recovered by the Ohio Department of Developmental Disabilities.
Service Documentation must be made available upon request to any agency with the authority to review such records.
Keep the Service Documentation for 7 years.
Rev. 1/14
Ohio
Department of Developmental Disabilities
Division of Medicaid Development & Administration
John R. Kaskh. Governor John l. Martin, DinKtor
To: Medicaid HCBS Waiver Providers
From: Debbie Hoffine, MDA Operations Administrator
Date: June11,2013
Subject: Serv1ce Documentation Requirements for Medicaid HCBS Waiver Providers
This memo 1s the first in a series of upcoming informational notices being sent by DODD in an effort to maintain provider awareness related to compliance with Medicaid Home and Community Based Services (HCBS) requirements. Proper service documentation is a fundamental requirement for all Medicaid services and is directly related to appropriate payment for Medicaid claims
Medicaid HCBS waiver providers are required to keep documentation to support Medicaid reimbursement Section 5123:2-9 of the Ohio Administrative Code lists the specific service documentation requirements for each HCBS waiver service. As a Medicaid HCBS waiver provider, it is your responsibility to familiarize yourself with the service documentation requirements for the service(s) that you deliver and to be fully compliant with those requirements. The rules are readily available to all providers in the Rules + Laws area of DODD's website (wwwdodd.ohio qov).
For example, under the homemaker/personal care rule (5123:2-9-30), which covers services that are not billed through the Daily Rate Application (ORA), among other documentation requirements, you must·
1. Document at the time or shortly after you deliver the service You should not be
prepanng documentation when asked for it by a surveyor or auditor. 2. Prepare the documentation yourself You should not rely on a family member or other
person to do this. 3. Write down the beginning and end t1mes of the delivered service every day you provided
services. 4. Write down the number of units of service or the continuous amount of uninterrupted time
you provided the services for every day you provided services. 5. You must keep your documentation for six years from the date you were paid or until any
initiated audit has been resolved
If you are paid for services that are not supported by proper service documentation, you may be required to repay those funds Failure to keep proper service documentation could also result in your certification to deliver serv1ces being terminated
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Service Documentation Requirements Page 2
DODD has and will continue to review provider service documentation as part of 1ts greater commitment to properly administer Medicaid HCBS waivers. Ohio relies heavily on the Federal funding that supports these waivers in order to serve the citizens of our state with developmental disabilities. We must all be diligent in our compliance responsibilities and must make a concerted effort to hold ourselves and one another accountable. Please take this opportunity to review your own service documentation and ensure that it is in full compliance with the associated rule requirements.
Thank you.
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER: ADDRESS of SERVICE:
MEDICAID #:
PROVIDER #:
RESIDENT #: SERVICE MONTH: YEAR: _
***SERVICES ARE ROUTINE HPC UNLESS OTHERWISE INDICATED AS ON-SITE/ON CALL OR LEVEL ONE EMERGENCY*** DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time In Time out # of Units
# OF INDIVIDUALS SHARING SUPPORTS , if
other than 1:1.
Supports in Plan Duration / Frequency
/
/
/
/
/
/
/
/
/
/
/
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service.
DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: INITIALS: DATE:
Prepared by AggieG 04/26/12
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER: ADDRESS of SERVICE:
MEDICAID #:
PROVIDER #:
RESIDENT #: SERVICE MONTH: YEAR: _
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Time In Time out Time In Time out Total # of Units 1:1 ratio, unless otherwise noted Supports in Plan Duration / Frequency
/
/
/
/
/
/
/
/
/
/
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: INITIALS: DATE:
Prepared by AggieG 042612
HOMEMAKER / PERSONAL CARE – SKILL DEVELOPMENT DOCUMENTATION CONSUMER NAME: PROVIDER: ADDRESS: ADDRESS:
MEDICAID #: PROVIDER #:
RESIDENT #: MONTHLY SERVICE PERIOD: / / to / /
SKILL DEVELOPMENT AREA: PROGRAM DURATION / FREQUENCY: /
PROGRAM DESCRIPTION / DESIRED OUTCOME:
DATE /
ALL SKILL DEVELOPMENT STEPS
/1
/2
/3
/4
/5
/6
/7
/8
/9
/10
/11
/12
/13
/14
/15
/16
/17
/18
/19
/20
/21
/22
/23
/24
/25
/26
/27
/28
/29
/30
/31
DOCUMENT TYPE of PROMPT NECESSARY TO PERFORM STEP: I=Independent, V=Verbal, G=Gestural, P=Physical, R=Refused, ND=Not Delivered ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION ON BACK PAGE
*SUPPORT STAFF’S INITIALS FOR DAYS SKILL DEVELOPMENT PROGRAM IS OFFERED ACCORDING TO DURATION AND FREQUENCY ON ISP
STAFF SIGNATURE: INITIALS: STAFF SIGNATURE: INITIALS:
COMMENTS (Unusual staffing & reasons, service locations if other than home, problems delivering services, reasons for refusal, etc.) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Comments on progress toward goal and recommendation for continuation, revision, or change
SIGNATURE: INITIALS: DATE:
Adult Family Living (Daily Rate) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER: ADDRESS of SERVICE:
MEDICAID #:
PROVIDER #:
RESIDENT #: SERVICE MONTH: YEAR: _
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Supports in Plan Duration / Frequency
/
/
/
/
/
/
/
/
/
/
/
/
# OF INDIVIDUALS SHARING SUPPORTS , if other than 1:1.
R= Refused ND = Not Delivered
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION BELOW.
DATE Service location, if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
PROVIDER SIGNATURE: INITIALS: DATE:
Prepared by AggieG 042612
HPC Transportation – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER: ADDRESS of SERVICE:
MEDICAID #:
PROVIDER #:
RESIDENT #: SERVICE MONTH: YEAR: _
Date Starting location address
Destination Addresses Ending location address
Miles Driven
1:1 ratio unless otherwise noted
Staff Initials
DAT E Comments, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: INITIALS: DATE:
Prepared by AggieG 01/18/13
NON MEDICAL TRANSPORTATION- MILEAGE - DOCUMENTATION – Cuyahoga County
Date of Service
License Plate #
Pick Up Time
Odometer Start
Drop Off Time
Odometer End
Total Miles Driven
Names of All Passengers & Medicaid # Staff Initials
SIGNATURE: Initials: SIGNATURE: Initials:
SIGNATURE: Initials: SIGNATURE: Initials:
SIGNATURE: Initials: SIGNATURE: Initials:
Prepared by AG 061512
WEEKLY PRE-TRIP INSPECTION REPORT
PROVIDER NAME PROVIDER # MONTH
YEAR, MAKE & MODEL LICENSE PLATE _ YEAR Date Date Date Date Date Date Date
Date
Driver Initials
Items to inspect on each trip
Windows and mirrors are clean and free of cracks/breaks? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Tie downs, if applicable, are present and function properly? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Seat belts function properly? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Wheelchair Lift, if applicable, is operating properly? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
All lights, including headlights and turn indicators, function properly? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
First Aid kit is in vehicle? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Fire extinguisher is in vehicle and indicates as "good"? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
The horn is working properly? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Windshield wipers are working correctly? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Tread on all four tires is sufficient? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Test service brakes? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
Prepared by AggieG 04/26/12
NON MEDICAL TRANSPORTATION- PER TRIP - DOCUMENTATION – Cuyahoga County
PROVIDER NAME PROVIDER # MONTH YEAR
Date
License Plate Number
Odometer Start
Start Time of Trip
Odometer End
End Time of Trip
Miles Driven
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Staff Initials
DATE Names of all other passengers/riders, including paid staff and volunteers who were in the vehicle during any portion of the trip and/or commute.
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
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Print Screen! Fiscal Year End Attention Providers: The Office of Budget and Management's fiscal year end will be the last week of June. Claims submitted for the June 8 production date [Junl lC] will pay out around June 24 as normal. Claims submitted for the June 15 production date [JunllD] will pay out around July 8, along with any claims submitted for the June 22 production date [JunllE]. There will be no payment made the week of June 27th. Please continue to submit claims as normal. SINGLE CLAIM ENTRY : • indocates ruired field
Today's Date :156/2011 Help Contract Number (7 Numbers) : 500000 Help
. .d R . . b 1123456789123 Help d1c 1 e 1p1e e :
Recipient First Initial :b Help Recipient Last Name {First sc:
' ..1 ADMINISTRATION Letters) l"ase : Help
Date Of Service (mm dd yyyy) :r-IaJn--u-ary--::J...,
Service Code :lapc Help
Units Of Service Delivered :j24' Help
Group Size :r Help
Staff Size :r Help
I f1'i] I !2011::J Help
Service County :Fr-_1 R_AKN_LI_N-25--::J..., Help
Usual Customary Rate $ :r-. Help
Other Source Code : iS
Other source Amount $ : .1 Help
Contractor Reference Number.--------- {Optional) : Help
'S' in Other Source Code
indicates third party liability
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DEPARTMENT OF DEVELOPMENTAL DISABILITIES 091: 1Fr day, August ll, 1010 8405
DIVISOIN Of NFORMATION SY STEMS
MEDCIAID BILLIN:; SYSTEM TOTAL NET I/>IOONT BILLED TO THE DEPARTMENT OF JOB AND FAMLYI SERVICES
DURI N:; THE CURRENT B LLIN:; CYCLE Of ALQOC BY CONTRACTOR, PROGRAM, AND NTH/YEAR BILUD
•••••••••••••••••••••••••• CONTRACT NUMBER•2500000 NAME• TAMMY PROVIDER PROGRAM•INDIV OPTION WAIVH NTH/YEAR BILLED•2010/08 •••••••••••••••••••••••••••
RECIPIENT UNITS CNTY OF OTHER NET CWM BLILIN:; SERV Of GROUP STAFF SERVICE DATE OF AMOUNT SOURCE INPUT BILLED AMOUNT REFERENCE
RECIPIENT NAME NUMBER CODE SERY sm sm DELIVERY SERVICE BLI LED I/>IOONT RATE RATE BILLED NUMBER
CASE, JUSTIN 102200000000 AOC 14 FRANKLIN 01A001010 144.40 !1.85 11.85 144.40 000000000 CASE, JUSTIN 102200000000 APC 36 FRANKLIN 02A001010 1147.96 ! 4 .11 14.11 1147.96 000000000 CASE, JUSTIN 102200000000 ATH 3 FRANKLIN 02A11020l0 !1.20 ! 0.40 ! 0.40 !1.20 000000000 CASE, JUSTIN 102200000000 AP C 36 FRANKLIN 03A001010 1147.96 !4.11 !4.11 1147.96 000000000 CASE, JUSTIN 102200000000 ATN 3 FRANKLIN 03A001010 !1.20 ! 0.40 ! 0.40 !1.20 000000000 C ASE , JUSTIN 101200000000 MX. 14 FRANKLIN 04A001010 144.40 !1.85 11.85 144.40 000000000 CASE, JUSTIN 102200000000 APC 36 FRANKLIN 04A001010 S147.96 ! 4.11 S4.11 1147.96 000000000 CASE, JUSTIN 102200000000 ATN 4 FRANKLIN 04A001010 Sl.60 !D.40 SD.40 Sl.60 000000000 CASE, JUSTIN 102200000000 APC 36 FRANKLIN 05A001010 1147.96 !4.11 S41. 1 1147.96 000000000 CASE, JUSTIN 101100000000 ATN 3 FRANKLIN 05A001010 suo ! 0.40 S 0.40 s uo 000000000 CASE, JUSTIN 102200000000 MX. 14 FRANKLIN 06A001010 144.40 !1.85 Sl.85 144.40 000000000 CASE, JUSTIN 102200000000 APC 36 FRANKLIN 06A001010 S147.96 !4.11 S4.11 1147.96 000000000 CASE, JUSTIN 102200000000 ATN 4 FRANKLIN 06A001010 Sl.60 ! 0.40 S 0.40 Sl.60 000000000 C A SE I JUSTIN 102200000000 APC 36 FRANKLIN 07A001010 S147.96 !4.11 S4.11 1147.96 000000000 CASE, JUSTIN 102100000000 ATN 3 FRANKLIN 07A001010 11.10 ! 0.40 S 0.40 s uo 000000000 CASE, JUSTIN 102200000000 MX. 14 FRANKLIN 08A001010 144.40 !1.85 Sl.85 144.40 000000000 CASE, JUSTIN 102200000000 APC 72 FRANKLIN 08A002010 S 295.92 !4.11 S4.11 S295.92 000000000 CASE, JUSTIN 101100000000 ATN 3 FRANKLIN OSA001010 suo ! 0.40 S 0.40 suo 000000000 -------------------------- PROGRAM S1,370.48 10.00 11,370.48 CNTRNAME !1,370.48 so.oo 11,370.48 CNTRNUM 11,370.48 10.00 11,370.48
S1,370.48 so.oo 11,370.48
N • 18 TOtal N • 18
The billed report shows what claims were successfully processed by DODD, and will be sent to ODJFS. Available Friday following the production date.
Billing Information AIA Glance Individual Options Waiver
PAWS Staff Group Service Usual authorization Service title
code
Homemaker/
Billing Staff Billing code size unit
size size county required? required? required?
Customary Rate
required?
personal care 15 A22 Routine APC 1 minutes YES YES YES YES
15 agency provider AMW 2 minutes YES YES YES YES
15 aoency provider AMX 3 minutes YES YES YES YES
15 aoencv provider AMY 4 minutes YES YES YES YES
15 agencv provider AMZ 5 minutes YES YES YES YES
A44
Homemaker/ personalcare
On-site/On-call
AOC
1
15
minutes
YES
YES
YES
YES
agency provider
AOW
2 15
minutes
YES
YES
YES
YES
agency provider
AOX
3 15
minutes
YES
YES
YES
YES
agency provider
AOY
4 15
minutes
YES
YES
YES
YES
agency provider
AOZ
5 15
minutes
YES
YES
YES
YES
ADP
Homemaker/ personalcare independent
provider
ADP
day
Only used for sites where individuals share services. ORA must be used to generate costs
AOL
Homemaker/ personalcare
aoencv provider
AOL
dav
Only used for sites where individuals share
services.ORA must be used to oenerate costs
ATN Transportati on ATN N/A mil e NO YES NO YES
AAE YES
AVN Environmental modifications YES
Adult foster care
independent AFA provider AFA N/A dav NO YES YES YES
AFO YES
This list is illustrative only, and does not cover all service codes. For a complete list of service codes,please see the service-specific rule(s) available on our website.http://dodd.ohio.gov/rules
n code
I I I I l
Billi ng Information At A Glance Level 1 Waiver
PAWS Staff Group Service Usual
authorizatio Service title Billing Staff Billing size size county Customar code size unit required required required y Rate
? ? ? required?
Homemaker/ personal care 15
F22 Routine FPC 1 minut.es YES YES YES YES 15
agency provider FMW 2 minutes YES YES YES YES 15
agency provider FMX 3 minutes YES YES YES YES 15
agency provider FMY 4 minutes YES YES YES YES 15
agencv orovider FMZ 5 minutes YES YES YES YES
F44
Homemaker/ personalcare
On-site/On-<:all
FOC
1
15
minut.es
YES
YES
YES
YES
aaency provider
FOW
2 15
minutes
YES
YES
YES
YES
aaency provider
FOX
3 15
minutes
YES
YES
YES
YES
agency provider
FOY
4 15
minutes
YES
YES
YES
YES
agencv provider
FOZ
5 15
minutes
YES
YES
YES
YES
FTN Transeortation FTN N/A mlie NO YES NlO YES
IAdaptive/ass stiv I FAE e eauioment FAE N/A NO NO NO YES
Environmental FVN modifications NO NO YES
This list is illustrative only,and does not cover all service codes.For a complete list of service codes,please see the service-speci fic rule(s) available on our website.http://dodd.ohio.gov/rules
Third Party Liability
• Your client’s Medicaid card will show if there is TPL [insurance]. • Bill as you normally would, but put an “S” in Other Source Code. • Once a year, send an invoice billing the insurance carrier for services rendered
to your client. You should get a response from the company stating that the policy does not cover your services. Keep this for your records. This is to prove to the Auditor’s that you attempted to bill all other sources before billing Medicaid. Remember, Medicaid is the “payer of last resort.”
• Do not wait to hear back from the insurance company before billing Medicaid. Billing the insurance company is done for your records. Bill as you normally would.
• ODJFS does run a random edit, so if your client has TPL, be certain you bill accordingly; otherwise, you could have errors where you previously didn’t. Also, do not automatically put “S” in Other Source Code, because if your client does not have TPL, your claims could error.
Only about 9% of clients have patient liability [PL].
If a client has multiple providers,
only one will be responsible for reporting the PL.
Every 18 months, a report is run to
reconcile PL. If the correct amount has not been identified in the provider’ s billing, the total amount will be taken out of future billings.
The client’ s PL is updated 2-4 times
per year. Contact your county board to ensure you are reporting the correct amount.
Note: The amount of PL reported
must be equal to or less than the amount billed for that claim.
PATIENT LIABILITY CASES As a Provider, you are responsible for checking with the County Board to see if the individual you are serving has a PL. A PL is the amount the individual has to pay for services each month. This is determined at the county level by Job and Family Services. It is similar to an insurance co- pay. ODMRDD has nothing to do with determining PL. If the individual has a PL, you must identify the amount on your billing. Bill as you normally would; however, enter "1" in the Other Source field. In the Other Source Amount field, enter the amount claimed for PL until the amount of the PL is satisfied. The County Board will advise you as to how to collect the PL.
EXAMPLE - The client has a $96.00 per month PL. You start providing services on the 11th. You would normally bill for 32 units of Homemaker/Personal Care-1 staff (APC) at $2.25 per unit for every day you worked. You would submit your billing as follows:
Day of Service Units of Other Source Other Source Service Code Service UCR Code Amount 11 APC 32 225 1 72.00 12 APC 32 225 1 24.00 13 APC 32 225 14 APC 32 225 The MBS system will automatically pay you the difference. In this case, on the
second day [the 12th] you will be paid $48.00, which is what you billed for minus the $24.00 that you entered as PL. The $96.00 PL has been satisfied for the month.
Note: Patient liability must be reported through the billing process. For
instance, if as in the above example the individual had a $96 PL you would not skip billing for the first day of service, enter $24.00 into other source amount the next day, and assume that the reporting was complete for the month.
For more information about reporting patient liability, click here (this will open a new window) :
http://mrdd.ohio.gov/providers/billingdocs/patient-liability.ppt
Inclusion on this list is by request of the billing agent, who retains complete and sole responsibility for ensuring the accuracy of any information on this list. Billing agents are not employed by the Department of Developmental Disabilities, and DODD does not train, certify, monitor, or endorse any billing agent, nor guarantee their performance. DODD shall not be responsible or liable directly or indirectly for any loss or dispute related to the use of a billing agent. Providers remain responsible for the accuracy and completeness of all claims, including those submitted by billing agents. In addition, providers are responsible for meeting all HIPAA requirements, including a signed Business Associate Agreement with the billing agent. This Agreement is required by federal law, and it explains the billing agent’s obligations for confident iality.
For more information on Business Associate Agreements:
http://www.hhs .gov/oc r/privac y/hipaa/understanding/coveredentities /contrac tprov.html Rev. 7/13
Name Addres s City S T Zip Contact Name Phone Email Accus oft Billing LLC 9431 W es tport Road, Suite 136 Louis ville KY 40241 Sean B. Swick (614) 364-4694 ohwb@accus oftbilling.com Advanced Billing Services PO Box 26172 Columbus OH 43226 Chris t ie W ard 866-460-2455/fax-614-890-5485 Agency Sys tems 7645 Production Dr./PO Box 37410 Cincinnati OH 45237 Gary Puckett 513-761-5610 All Ohio claims Michael allo hio cla ims @ao l.com Beeton Provider Services , Inc. P O Box 232 Hilliard OH 43026 Theres a Beeton 614-529-6562 BJ's I/O W aiver Billing Services 1790 McTaggart Dr Akron OH 44320 Bobbie W illiams 330-869-5208 or 330-869-5887 Bout Time Medical Billing Service 23660 Miles Rd Suite 105 Bedford Hts . OH 44128 Louis e Hill 216-663-1400 www.bouttimellc.com Brenda Fos ter 2358 W aterfall Lane Columbus oh 43209 Brenda fos ter 614-235-2850 fos [email protected] Carl Potter OH Carl Potter CarlJes s [email protected] Clearwater COG 8200 W State Rte 163 Oak Harbor OH 43449 Michelle Thorbahn 419-898-8264 Contemporary Bus ines s Group Inc. 1147 Columbus Pike #209 Delaware OH 43015 Ken Greiner 740-369-4616 or 740-971-6933 Falcon Financial Services P O Box 465 Maumee OH 43537 Todd Frick 419-297-6577 Goodwill Data Entry Services 419 W es t Market St Sandus ky OH 44870 Jocelyn Bis s on 888-417-5576 Hattie Larlham Community Srvcs . 9772 Diagonal Road Mantua OH 44255 Donna Love 330-274-2272 or 800-233-8611 Healthcare Billing Services (HBS) 7678 Slate Ridge Blvd Reynolds burg OH 43068 Kenneth Albert 614-866-6646 Healthcare Proces s Cons . (HPC) 8050 Corporate Circle, Suite #4 N. Royalton OH 44133 Frank or KarenOBres ky 440-884-3688 Home Financial Services 1240 W ildwood Drive W oos ter OH 44691 Judy Holmes 330-345-2041 Hope Swindell 440.748.8078 Kels eys [email protected] Independence, Inc 161 Eas t Main St Ravenna OH 44266 Teran Morrow 330-296-2851 Interactive Financial Solutions Inc. 1290 North Shoop Ave,OSuite 1000 W aus eon OH 43567 Jrffrey Rutledge 419-335-1280 Internet Billing 30755 Barrington Madis on Hts MI 48071 Ken Cerka 800-396-6877 Jeff Brown 3864 Snows hoe Ave. Grove City OH 43123 Jeff Brown (614) 875-9538 [email protected] Jerry Kuhling, CPA 3865 Bach Buxton Rd Amelia OH 45102 Jerry Kuhling 513-752-0240 Katris ha Kops ch 5919 W ero Dr Hilliard OH 43026 Katris ha Kops ch 614-876-6420 Kevin Palicki Kevin Palicki 614-519-9059 [email protected] KMS Billing Services 3821 Lockwood Ave Toledo OH 43612 Kimberly Spielman 419-269-1938/419-349-8088 LarCor 325 S. Sandus ky St #303 Delaware OH 43015 Kimberley Diets ch 740-971-6933/fax-740-369-5829 Lenore Covington Cincinnati OH 513-542-0420 l.covington@ zoomtown.com McDonald Billing & Cons ulting Svc. 2000 Lee Road, St 116 Cleveland OH 44118 Cas s andra McDonald 216-624-8098 Medical Services Bureau, Inc. 430 Grant St Akron OH 44311 Maureena Mountcas tle 330-434-1922 Nips , Andeas , Brown & Leppert Inc. 648 Taylor Rd Gahanna OH 43230 Betty Kohr 614-577-1101 / 800-336-4444 North Heights Group Home 255 N. Heights Ave Youngs town OH 44504 Diane Reviere 330-746-3636/fax-330-743-3728 Primary Solutions , Inc 1080 Kings mill Parkway, Ste. 150 Columbus OH 43299 Anita Pars ly/Tom Hous er 614-430-0355 Robert Savala 1716 DuBois Dr. Piqua OH 45356 "Jay" 937-778-3780 Scarlette Streeter 18314 W indward St. Cleveland OH 44119 Scarlette Streeter 216-738-0173 fax-216-373-0319 Schrader Billing Service 155 N. Dugan Rd. Urbana OH 43078 Ticia Schrader Stat Claims Management 3634 Mount Carmel Rd Cincinnati OH 45244 Pamela or Robert Durham 513-474-7605 Sus an Loy 112911th St. NE Mas s illon OH 44646 Sus an Loy 330.323.7211 provider.billingbys us [email protected] The Billing Connection, Inc 11001 SW Broad Street Patas kala OH 43062 Melis s a Skaggs , VP 740-964-0043/1-800-995-0043 www.billingconnection.net W ynn-Reeth PO Box 785 Green Springs OH 44836 Jarrod Hunt 419-639-2094 ext 104
COST OF DOING BUSINESS (CODB) CATEGORIES AND FACTORS
(OAC 5123:2-9-19)
Factor Counties in Category
Category 1 0.9651 Adams Athens Belmont Gallia Guernsey
Harrison Jefferson Keogs Monroe Pike
Ross Scioto Tuscarawas Vinton Washington
Category 2
0.9751
Carroll Crawford Defiance Highland Hocking
Jackson Lawrence Mercer Morgan Muskingum
Noble Paulding Perry Van Wert Wyandot
Category 3
0.9851
Allen Auglaize Brown Clinton Columbiana Coshocton
Fayette Hancock Holmes Knox Marion Morrow
Putnam Richland Seneca Shelby Williams
Category 4
0.9951
Ashland Darke Erie Fairfield Fulton Hardin
Henry Huron Licking Logan Mahoning
Pickaway Sandusky Stark Trumbull Wood
Category 5
1.0051
Ashtabula Champaign Clark Delaware Greene
Lucas Madison Miami Montgomery
Ottawa Preble Union Wayne
Category 6
1.0151
Clermont Franklin Geauga
Lake Lorain Medina
Portage Summit
Category 7
1.0251
Butler
Cuyahoga
Warren
Category 8
1.0351
Hamilton
Iodi\.Jdu.al Options Wa.iver APC LenO! ne Waiver FPC Level One Waiver Emernocv Assistmoe EPC
ACTION:Final D DATE:06/21/2010 9:5&AM
5123:2-9-06
5123:2-9-06 APPENDIX A P'ie I
BD.LING UNITS, SERVICE CODES, AND PAYMENT RATES FORHCBS WAIVER SERVICES
HoiDflll>kodPmoDll Cm (Routine) -Independent Pro..,idor
BilliDI: Uoit: Fifttmmimte.
Senioe Codes:
Payment R..tes: Listed below. Based oo cost-of-doinj:-busioess ..t.gocy aod number ofiDdhduals recei\--ingsenices. To obtainthe per person r.rte when two or more individuals receive service simu.lmly.the base rate in tbt appropriate group eategory is divided by ibe number ofindi•-iduili in tbo group.
Sm>inl: I Sen>inJ: 2 Sm>inl: 3 s.Mnc 4 or Moi> lndividwl lndividuili Individuals lndi\.um.ls
Catuorv I S3.91 4.18 M.57 $5.08 Category2 S3.95 S4.22 M.62 $5.13 Category3 S3.99 $4.27 $4.67 $5.19 Category4 $4.03 $4.31 $4.71 $5.24 Category 5 M.07 $4.35 $4.76 $5.29 Category6 M.ll $4.40 $4.81 $5.34 Category7 :14.15 4.44 :14.86 5.40 Category8 :14.19 4.48 .:14.90 5.4>
IMPORTANT TO REMEMBER FOR BILLING
LEVEL 1 WAIVER
Home Maker Personal Care (HPC) FPC Transportation FTN
Examples: HPC Unit Rate - Cuyahoga County
Transportation mileage
$4.15 (15 mins.)
$.45/mile (all providers and categories to access
Waiver services not included under the Non-Medical Transportation category below)
Informal Respite
FIN Unit Rate (per 15 minute period) $2.75
INDIVIDUAL OPTIONS WAIVER
Home Maker Personal Care (HPC) APC Transportation mileage ATN
Examples: HPC Unit Rate - Cuyahoga County $4.15 (15 mins.)
Transportation mileage (all providers and categories to access Waiver services not included under the Non-Medical Transportation category below)
$.45/mile
Foster Care varies per person
NON-MEDICAL TRANSPORTATION (OAC 5123:2-9-19) (For transportation to Adult Day Support, Vocational Habilitation, Supported Employment-Enclave or Supported Employment-Community)
CODB Category RATE / MILE CODB Category RATE / MILE
1 $1.25 5 $1.27 2 $1.25 6 $1.29 3 $1.27 7 $1.29 4 $1.27 8 $1.29
NAVIGATING THE PROVIDER PAGE ON THE CCBDD WEBSITE
www.cuyahogabdd.org
Click on “Are You a Provider” tab Or Provider Resources
From this page you can access: Provider Resources Information
Provider Certification and Renewal Information
A variety of Forms (including documentation sheets)
*
PROVIDER RESOURCES PAGE:
File Edit VIew Favor tes Tools Help
j Favorites : ruBehavioral& Healthcar... ltJ Best of the Web j[J Free Hotmoll Launch Internet Explore... Microsoft Cj MSN i!.J MSN.com ru Product News
j Provider Resources - Cuyahoga County Boor... [
f'.1ission Calendar Community Forum News Room Newsletters
Ill Volunteer LegalNotices Links Bed Bugs
B Provider Resources C •rt flc tfon
Provider Reso urces If youhave any questions.call(216) 931- 7474 or email provider.suppon©CuvahooaBOO.oro.
Provider Selection Individuals who rece1ve serv ces paidfor With a MediCaid wa1ver may select any pro der who IS certified for and willing to prode the requested service
• Proyjder Se! ectjoo Process and Free Cho jce ofProyjder
Provider Search Tool The Soard of DO has developed a web-based Proylder Search Tool(PSDthat allows pro ders to search forreferrals of consumers looking for seMces.The PST also enables consumers to search for certifiedproVIders by name, funding source and seMce certifications.
• Provider Search ToolInstructions for Aaencv Providers
• Provider Search ToolInstructions for Independent Providers
Need to Reach Someone? Here's a ill2.Qn: wtth the names. assi nments.phone numbers. email addresses and locations of all the staffin our Community & r tedicaid Services Department. (You maywant to enlarge the view on )OUr screen The type In this directory Is small to accommodate the numerous Items oflnfo.)
Majo r Unusual Incidents This resource assists providers In understandlnQ major unusualinadents andthe various activ1ties and responsibilities that occur when one Is reported
• What Is a l.la jor Unusua11ncide11t?
• How to Report a l.la jor UnusualIncident
CERTIFICATION PAGE:
FORMS PAGE:
Many of these forms can be filled out on line and saved or printed for your convenience.
Take the time to look around on the Provider Page, it has a great deal of information that will be useful to providers.
Information at your fingertips, 24 hours a day.
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To: Medicaid HC S Waiver Providers
Fro
: Debbie Hoffine, MDA Operations Administrator
Date: August 13, 2013
Subject: Audits of claims paid This memo provides information pertaining to audits of providers of Medicaid Home an
Community Bas
d Services (HCBS) waiver services. These au
its establish whether claims should have been paid. Service documentation to support claims paid is a critical component of these audits performed by the Division of Fiscal Administration/Audit
Office at DODD.
how long.
Your documentation must show what service was delivered and for
If you have not properly doc mented the services you provided, you may be required to
pay
s back the amount of t
e claim plus accrued interest. Failure to keep proper
service documentation or re
pond promptly to a request for service documentation could
also result in termination of your provider certification. Per your Medicaid Provider
Agreement, you must submit any requested service documentation within thirty (30)
days of the request. You are required to maintain all service documentation to support Medicaid
reimbursement.
Chapter 5123:2-9 of th
Ohio Administrative Code lists the specific
service documentation requirements for each HCBS waiver ser
ice. As a
edicaid
HCBS waiver provider, it is your responsibility to fa
iliarize yourself with the service documentation requirements for the service(s) that you deliver and to be fully compliant
with those requirements. The rules are readily available to all providers at the Rules in
Effect page of DODD’s website (https://doddportal.dodd.ohio.gov/rules/ineffect/Pages/default.aspx).
The rules are also available on DODD’s mobile app (http://dodd.ohio.gov/Pages/Mobile.aspx).
Please also review the memo we sent you on June 11, 2013.
It is very important that you prepare your service documentation yourself either at the
time or shortly after you deliver the service. You should not be preparing documentation when asked for it by an auditor or other reviewer. Write down the time you begin
delivering the services, make any appropriate notes of activities performed, and then
close out by writing down the time you stopped delivering services. If you have more than one start time and end time on the same day, these should be documented
separately. If multiple staff are delivering services, these items should be clearly
identified for each staff member. Documentation Maintenance:
Service documentation must be maintained for six years from the date you were paid or
until any audit initiated during that six year period has been resolved, whichever is longer. This means that if an audit has been started before the end of the six year period
after the date a claim was paid, you must keep all of your service documentation for that
time period being reviewed - until all issues identified have been addressed and the audit has been closed. Remember that DODD, the Ohio Department of Medicaid, the Ohio
Auditor of State, and the Federal government all have the authority to audit your paid
claims. Therefore, even if DODD has audited you and closed its audit before the end of
the six year period, you should still keep your service documentation for the full six years because any of the other agencies could decide to audit you before the six years are up.
If an audit has not been initiated before the end of the six year period after the date a
claim was paid or all audits that were begun during that period have been closed, then you may destroy the documentation that supports the claim. Please be careful to destroy
the records in a secure manner (shredding, for example), as the documentation contains
personal health information which is protected under the Health Insurance Portability and
Accountability Act (HIPAA). Risk factors included in DODD’s selection process for these audits:
For the first time this past year, DODD used a risk-based approach for selecting providers for audit for state fiscal years 2010 and 2011 (July 1, 2009 through June 30,
2011). Below is a sample of some of the criteria we used to select our audits.
• Providers who generated billings per individual much higher than average;
• Providers who were among the highest paid in their respective peer group (i.e. independent providers, private agencies, public agencies);
• Independent providers who consistently billed for more than ninety (90) hours per
week of awake services;
• Providers who had a significant number of adjustments to their claims; or
• Providers who had a significant number of claims being billed but rejected for
exceeding authorized unit or dollar maximums. Primary issues noted for Homemaker Personal Care Providers in these audits:
15 minute unit billing: Some providers have been unable to provide any service documentation, or what they did provide was not compliant with rules. The primary
missing element and the most problematic is the lack of arrival and departure times.1
This element is a key component to proper reimbursement as it verifies that the number
of units paid equals the number of units delivered. The number of units (of service
delivered) is also a critical companion element for proper documentation. Without these
two elements, documentation is not compliant with the waiver requirements. Such claims
paid are then subject to repayment plus any accrued interest. Daily Billing Unit: Providers using the daily billing unit for Homemaker/Personal Care
services should be using the Daily Rate Application (DRA) as part of the Medicaid
Services System (MSS) to determine the appropriate rate to bill for services delivered.
Proper documentation must be maintained to support the number of hours entered in DRA. This documentation must include time sheets to show the number of hours
worked by each staff each day. If this documentation is not maintained, the entire
amount paid, plus any accrued interest, is subject to repayment by the provider in the case of an audit finding.
If the documentation exists, but does not equal the hours entered into the DRA, a revised rate may be recalculated based on the hours of service delivery that the
1 As of April 19, 2012, providers of Homemaker/Personal Care who bill in 15-minute units must document the begin and end times of the delivered service rather than arrival and departure times.
documentation reflects. In this case, the provider would be required to repay any amount, plus any accrued interest, that is in excess of the correctly calculated amount.
DODD will continue to review provider service documentation as part of its greater
commitment to properly administer Medicaid HCBS waivers. Ohio relies heavily on the Federal funding that supports these waivers in order to serve the citizens of our state
with developmental disabilities. We must all be diligent in our compliance
responsibilities and must make a concerted effort to hold ourselves accountable. Please take this opportunity to review your own service documentation and ensure that it is in full compliance with the associated rule requirements.
Thank you.
April 26, 2012
Dear Provider,
CUYAHOGA COUNTY
Board of Developmental Disabilities
The CCBDD Community and Medicaid Services Department has developed a Revision Request Form and process for changes to services authorized by a Support Administrator in an ISP or ISP addendum.A copy of the form is attached and you may also obtain a copy on the Provider Search Tool (https://providers.cuyahogabdd.org/Provider lnformation.aspx) or from the Support Administrator (SA). Please email a completed form, requesting a plan revision, to the SA, as this will also provide you with an electronic receipt. If it is not possible to submit via email, fax will be accepted.
The number of revisions received is beginning to exceed the capacity to process these, and working retroactively has become more complicated; guidelines and time limits must be established. Therefore, as of July 1, 2012, there will be a 15 calendar day limit on the time during which you may request a change.
As always, requests for changes to authorizations should be submitted prior to the change whenever possible. This includes changes to services discussed by the ISP team and authorized by the Support Administrator prior to the start of a waiver span.
After a plan has begun, if there is a change in services, the provider will have 15 calendar days to complete and submit the Revision Request Form to the CCBDD Support Administrator in order for the change to be considered. The request form should include clear explanation of what has happened with the individual, how their needs have changed and why this warrants a change in service. It should include clear information on the type of change being requested (service type, units, ratios, etc.) Failure to submit a completed request with all required information may result in a denial of the request. Approvals are not guaranteed.
Requests received more than 15 days after the change will not be approved back to the date of the change. In such an instance, and upon SA approval, the change will be made effective from the date of the notification forward.
1275 Lakeside Avenue East • Cleveland, Ohio 44114-1129 • (216) 241-8230 Fax- (216) 861-0253 • www.CuyahogaBDD.org
Richard V. Mazzola, PrP.sident ., Ara A Bagdasarian, Vice President • Andres Gonzalez, Secretary
Darnell Brown • David L. Deming • Diane Roman Fusco • Maggie Jackson
It is strongly recommended you understand the basics of MSS Cost Projection Tool (https://doddportal.dodd.ohio.gov/PRV/tools/mss/Pages/default.aspx) so that you can monitor which type(s) and amount(s) of services have been authorized and make sure it matches your understanding, otherwise you may not be paid for services you provide that are not authorized in CPT. If you have not already done so, you will need to sign a security affidavit for MSS through the Security Affidavit Wizard on the DODD website.
Also effective July 1, 2012, CCBDD will no longer mail copies of PAS/PAWS to providers. Providers must access this information via the State system (https://doddportal.dodd.ohio.gov/Pages/default.aspx) for waiver authorizations and www.ohiodd.com for local dollar authorizations.
This new procedure will be reviewed in more detail at the Quarterly Provider Meeting on May 9, 2012. If you have questions, I encourage you to attend that meeting.
Thank you for the support you provide each day.
John A. Parkowski Interim General Manager Community and Medicaid Services Department
Plan Revision Requests Consumer Name: Consumer Span Dates:
Provider Name (please print):
Effective Requested Start Date for this Revision: _
End Date for this Revision (specific date/ongoing):
What is currently authorized?
Change in Service Type/Levels that is being requested :
Why is this change needed for the health and safety of the individual? What has occurred in his/her life to require this change? How have the individual’s needs changed? (Please include documentation as necessary):
Provider signature: Date:
Phone number: Email address:
CCBDD Use Only:
Action Taken:
SA Name (print):
SA Signature: Date:
Implementation Guidelines Individual Options and Level One Waivers Homemaker/Personal Care-On-Site/On-Call
Rate Increase and Transportation Rate Increase Effective January 1, 2014
Effective for services delivered on or after 1/1/2014:
• the base rate for Transportation services under the Individual Options (IO) and
Level One (L1) waivers is increasing to $0.45 per mile
• the base rate for Homemaker/Personal Care-On-site/On-call (HPC-OSOC) under the IO and L1 waivers is increasing to $2.70* per 15-minute unit for agency providers
• the base rate for HPC-OSOC under the IO and L1 waivers is increasing to $1.90*
per 15-minute unit for independent providers *See OAC 5123:2-9-30-Appendix A for the new rates adjusted for Cost of Doing Business
• DODD is preparing a listing for each county to identify individuals who have
either of these services currently authorized in PAWS and/or identified in CPT/MSS for dates of service on or after 1/1/2014.
• The Cost Projection Tool (CPT) within the Medicaid Services System (MSS) and
the Payment Authorization for Waiver Services (PAWS) system will be available after December 6, 2013 for cost projecting and service authorization using the newly increased rates.
Transportation
• The Medicaid Billing System (MBS) will begin paying the new Transportation
rates (service codes ATN and FTN) for dates of service on or after 1/1/2014 for claims submitted by providers indicating the new rate as the provider’s charge for the service.
• PAWS plans that do not have enough total dollars available to cover the cost of
the higher rate will need to be revised at some point prior to the end of the service span. It is important to note, however, that MBS does not look to PAWS for rate information as PAWS does not house rate information, so it is not necessary to revise every PAWS plan that has Transportation on it prior to 1/1/2014. This can be done over time, as needed.
• As cost projections are done in CPT/MSS, Transportation services entries that
are authorized using Span as the Frequency Period (not using Day, Week or Month) will need to be split into entries that do not cross the 1/1/2014 effective date of the rate increase. This will allow entries for dates of service through 12/31/2013 to be projected at the current rate and entries for dates of service on or after 1/1/2014 to be projected at the increased rate. Upon completion of the updated cost projection, the PAWS plan will be to be revised to reflect the newly authorized amounts.
P a g e | 1
HPC-OSOC not billed as part of a Daily Billing Unit
• MBS will begin paying the new HPC-OSOC rates (service codes AOC, AOW, AOX, AOY, AOZ, FOC, FOW, FOX, FOY, FOZ, EOC, EOW, EOX, EOY, EOZ) for dates of service on or after 1/1/2014 for claims submitted by providers indicating the new rates as the provider’s charge for the service.
• PAWS plans that do not have enough total dollars available to cover the cost of
the higher rate will need to be revised at some point prior to the end of the service span. It is important to note, however, that MBS does not look to PAWS for rate information as PAWS does not house rate information, so it is not necessary to revise every PAWS plan that has HPC-OSOC (PAWS roll-up codes A44, F44 and E44) on it prior to 1/1/2014. This can be done over time, as needed.
• As cost projections are done in CPT/MSS, HPC-OSOC entries that are not
identified on the HPC Calendar and are authorized using Span as the Frequency Period (not using Day, Week or Month), will need to be split into entries that do not cross the 1/1/2014 effective date of the rate increase. This will allow entries for dates of service through 12/31/2013 to be projected at the current rate and entries for dates of service on or after 1/1/2014 to be projected at the increased rate. Upon completion of the updated cost projection, the PAWS plan will be to be revised to reflect the newly authorized amounts.
HPC-OSOC billed as part of a Daily Billing Unit
• If HPC-OSOC incorporated into a Daily Billing Unit (service codes ADL and
ADP), MSS/CPT will need to be updated as close to 1/1/2014 as possible to allow the Daily Rate Application (DRA) to correctly calculate the daily amounts to be billed by providers for dates of service on or after 1/1/2014.
• If the implementation of the increased rates for HPC-OSOC causes the projected
daily rate for one or more individuals in a site to exceed $403.98 on a regular basis, the county may have to consider contacting the Department for assistance with a DRA exemption. This can be done via email to [email protected].
Level One Enrollees
• If the implementation of the increased rates causes the cost of services for an
individual enrolled on the Level One waiver to exceed the $5,000 annual cost cap, it is acceptable to utilize a portion of the Emergency Benefit ($8,000 over each three year period of enrollment) within the waiver to prevent a reduction in Medicaid services. If the utilization of the Emergency Benefit is insufficient to accommodate the increase cost of services as a result of the rate increase, services will need to be revised to fit within existing budget limitations.
• The county may have to consider contacting the Department for assistance with
a DRA exemption in the rare cases where a person enrolled on a Level One P a g e | 2
Waiver is residing in an MSS site that uses the DRA and the person receives HPC-OSOC. This can be done via email to [email protected].
ODDP Ranges and Prior Authorization
• If the implementation of the increased rates causes the cost of services for an
individual enrolled on the Individual Options (IO) waiver to exceed the top of the ODDP range, it is acceptable to request a Prior Authorization (PA) for the additional funds needed.
• If the implementation of the increased rates causes the cost of services for an
individual enrolled on the Individual Options (IO) waiver to exceed the previously approved PA funding level, it is acceptable to request a budget adjustment to the previously approved PA for the additional funds needed.
• In order to allow these budget adjustment requests to be handled as
expeditiously as possible, please follow the steps below: o Name your CPT version “rate increase” o Page 2 of IRF :
Check all boxes “yes” Enter “Rate Increase” into both “rationale” boxes Under PA Criteria, select Medical Condition, and copy and paste
“Rate Increase” o No uploads of ISP or other documents are necessary
Please contact the DODD Support Center at 1-800-617-6733 with specific questions or concerns.
P a g e | 3
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
MEDICAID #:
PROVIDER #:
RESIDENT #: SERVICE MONTH:
YEAR: _
***SERVICES ARE ROUTINE HPC UNLESS OTHERWISE INDICATED AS ON-SITE/ON CALL OR LEVEL ONE EMERGENCY***
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Time In
Time out # of Units
# OF INDIVIDUALS SHARING SUPPORTS , if
other than 1:1.
Supports in Plan Duration / Frequency
/
/
/
/
/
/
/
/
/
/
/
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service.
DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: INITIALS: DATE:
Prepared by AggieG 04/26/12
Homemaker Personal Care (HPC) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE: PROVIDER #:
MEDICAID #:
RESIDENT #: SERVICE MONTH:
YEAR: _
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time In Time out Time In Time out Total # of Units 1:1 ratio, unless otherwise noted Supports in Plan Duration / Frequency
/
/
/
/
/
/
/
/
/
/
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service
DATE Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: INITIALS: DATE:
Prepared by AggieG 042612
HOMEMAKER / PERSONAL CARE – SKILL DEVELOPMENT DOCUMENTATION CONSUMER NAME: PROVIDER:
ADDRESS: ADDRESS:
MEDICAID #: PROVIDER #:
RESIDENT #: MONTHLY SERVICE PERIOD: / /
to / /
SKILL DEVELOPMENT AREA: PROGRAM DURATION / FREQUENCY: /
PROGRAM DESCRIPTION / DESIRED OUTCOME:
DATE / SKILL DEVELOPMENT STEPS
/1
/2
/3
/4
/5
/6
/7
/8
/9
/10
/11
/12
/13
/14
/15
/16
/17
/18
/19
/20
/21
/22
/23
/24
/25
/26
/27
/28
/29
/30
/31
DOCUMENT TYPE of PROMPT NECESSARY TO PERFORM STEP: I=Independent, V=Verbal, G=Gestural, P=Physical, R=Refused, ND=Not Delivered ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION ON BACK PAGE
1.
2.
3.
4.
5.
6.
*SUPPORT STAFF’S INITIALS FOR DAYS SKILL DEVELOPMENT PROGRAM IS OFFERED ACCORDING TO DURATION AND FREQUENCY ON ISP
STAFF SIGNATURE: INITIALS: STAFF SIGNATURE: INITIALS:
COMMENTS (Unusual staffing & reasons, service locations if other than home, problems delivering services, reasons for refusal, etc.)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.
Comments on progress toward goal and recommendation for continuation, revision, or change
SIGNATURE: INITIALS: DATE:
Adult Family Living (Daily Rate) – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER:
ADDRESS of SERVICE:
MEDICAID #:
PROVIDER #:
RESIDENT #: SERVICE MONTH:
YEAR: _
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Supports in Plan Duration / Frequency
/
/
/
/
/
/
/
/
/
/
/
/
# OF INDIVIDUALS SHARING SUPPORTS , if other than 1:1.
R= Refused ND = Not Delivered
*ALL SERVICES ARE PROVIDED IN THE PERSON’S HOME UNLESS OTHERWISE NOTED IN THE COMMENTS SECTION BELOW.
DATE Service location, if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.
PROVIDER SIGNATURE: INITIALS: DATE:
Prepared by AggieG 042612
HPC Transportation – WAIVER SERVICE DELIVERY DOCUMENTATION – Cuyahoga County
CONSUMER NAME: PROVIDER: ADDRESS of SERVICE:
MEDICAID #:
PROVIDER #:
RESIDENT #: SERVICE MONTH: YEAR: _
Date Starting location address
Destination Addresses Ending location address
Miles Driven
1:1 ratio unless
otherwise noted
Staff Initials
DATE Comments, problems delivering services, refusal, unusual incidents & reasons, etc.
SIGNATURE: INITIALS: DATE:
Prepared by AggieG 01/18/13
NON MEDICAL TRANSPORTATION- MILEAGE - DOCUMENTATION – Cuyahoga County
Date of Service
License Plate #
Pick Up Time
Odometer Start
Drop Off Time
Odometer End
Total Miles Driven
Names of All Passengers & Medicaid # Staff Initials
SIGNATURE: Initials: SIGNATURE: Initials:
SIGNATURE: Initials: SIGNATURE: Initials:
SIGNATURE: Initials: SIGNATURE: Initials:
Prepared by AG 061512
WEEKLY PRE-TRIP INSPECTION REPORT
PROVIDER NAME PROVIDER # MONTH
YEAR, MAKE & MODEL LICENSE PLATE _ YEAR Date Date Date Date Date Date Date
Date Driver Initials
Items to inspect on each trip Windows and mirrors are clean and free of cracks/breaks? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Tie downs, if applicable, are present and function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Seat belts function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Wheelchair Lift, if applicable, is operating properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO All lights, including headlights and turn indicators, function properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO First Aid kit is in vehicle? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Fire extinguisher is in vehicle and indicates as "good"? YES NO YES NO YES NO YES NO YES NO YES NO YES NO The horn is working properly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Windshield wipers are working correctly? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Tread on all four tires is sufficient? YES NO YES NO YES NO YES NO YES NO YES NO YES NO Test service brakes? YES NO YES NO YES NO YES NO YES NO YES NO YES NO
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
Prepared by AggieG 04/26/12
NON MEDICAL TRANSPORTATION- PER TRIP - DOCUMENTATION – Cuyahoga County
PROVIDER NAME PROVIDER # MONTH YEAR
Date License Plate
Number
Odometer Start Start Time of Trip
Odometer End End Time of Trip
Miles Driven Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Name & Medicaid # Waiver Consumer
Staff Initials
DATE Names of all other passengers/riders, including paid staff and volunteers who were in the vehicle during any portion of the trip and/or commute.
SIGNATURE: SIGNATURE:
SIGNATURE: SIGNATURE:
Prepared by AggieG 12/28/12
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