DADS CLASSPM, Section 7000, Billing/Record Keeping Requirements

Health and Human Services Commission/Texas Department of Aging and Disability ServicesCommunity Living Assistance and Support Services Provider ManualRevision: 15-2Effective: November 20, 2015

Section7000

Billing/Record Keeping Requirements

7100 Billing and Claims Payment

Revision 15-2; Effective November 20, 2015

The following services may be billed under the Community Living Assistance and Support Services (CLASS) Program:

Case Management
CFC PAS/HAB
Transportation-Hhabilitation Services
Supported Employment
Employment Assistance
Prevocational Services
Nursing Services (e.g., registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing)
Physical Therapy
Occupational Therapy
Speech and Language Pathology
Specialized Therapies, that include:
Massage Therapy
Recreational Therapy
Music Therapy
Aquatic Therapy
Hippotherapy
Therapeutic Horseback Riding
Auditory Enhancement Training
Dietary Services
Behavioral Support
Cognitive Rehabilitation Therapy
Support Family Services
Continued Family Services
Transition Assistance Services
Respite
Adaptive Aids — vehicle modifications are billed as adaptive aids
Dental Services
Minor Home Modifications
Services specifically for individuals who choose the Consumer Directed Services (CDS) option that include:
Financial Management Services
Support Consultation

Note: For purposes of this section, the term "provider agency" means a CLASS Case Management Agency (CMA) or Direct Services Agency (DSA), as applicable.

Each DSA must ensure that each CLASS program service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application. The approved service definition for each of the services described in this section are contained within the Texas Administrative Code (TAC). Those service definitions are located in 40 TAC §45.103, Definitions.

Each CLASS service delivered to an individual must be recorded as a distinct event by each service provider. Documentation of services delivered may be provided on Form 3625, CLASS/CFC – Documentation of Services Delivered, by fax or via the electronic visit verification (EVV) system.

Service delivery documentation must be completed according to the Department of Aging and Disability Services (DADS) instructions.

Each provider agency must designate a timekeeper to sign Form 3625 to verify its accuracy.

CLASS payment rates are set by the Health and Human Services Commission (HHSC) Rate Analysis. For current rates, see

7110 Case Management Agency (CMA) Services

Revision 11-1; Effective June 13, 2011

Case management services provided after the individual has been enrolled in the CLASS program are based on a monthly rate. The number of case management units needed by the individual are determined by the service planning team (SPT) and approved by DADSHHSC/DADS on the Individual's Plan of Care (IPC). The monthly case management fee may only be billed during a month when a billable contact has occurred. The case manager must record time spent providing case management services on Form 3625, CLASS/CFC – Documentation of Services Delivered.

A CMA is entitled to payment if the individual receiving CLASS services appeals a decision to reduce, suspend, or terminate services within the required time frame and the individual continues to receive services during the appeal process, except in cases where the individual threatens the health and safety of himself or others. If the individual/LAR requests a fair hearing before the effective date of the termination, as specified in the written notice, of CLASS Program services and CFC services, , the CMA must continue to provide services to the individual.

7120 Direct Services Agency (DSA) Services

Revision 11-1; Effective June 13, 2011

A DSA is entitled to payment if the individual receiving CLASS services appeals a decision to reduce, suspend, or terminate services within the required time frame and the individual continues to receive services during the appeal process, except in cases where the individual threatens the health and safety of himself or others.If the individual/LAR requests a fair hearing before the effective date of the termination of CLASS Program services and CFC services, as specified in the written notice, the DSA must continue to provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

7121 Personal Service Agreement or Contract with Another Agency

Revision 11-1; Effective June 13, 2011

With the exception of CFC PAS/HAB, transportation-habilitation, and in-home respite, the DSA may contract with an individual or agency to provide CLASS services. The DSA is responsible for ensuring all service providers meet required direct service provider qualifications and training requirements.

CLASS services provided through a personal service agreement or contract with the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, or by fax and authenticated by the service provider.

7122 Minor Home Modifications and Adaptive Aids

Revision 11-1; Effective June 13, 2011

The DSA will only be reimbursed for adaptive aids and minor home modifications included in Appendix I, Adaptive Aids, and Appendix II, Minor Home Modification Services, and authorized by DADSHHSC/DADS on the individual's IPC. Minor home modifications and adaptive aids purchased by the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, and signed by the appropriate representative of the DSA. The DSA representative must be a:

program director or meet program director qualifications;
registered nurse (RN); or
licensed vocational nurse (LVN).

The DSA must have a signed and dated invoice from the vendor indicating work performed and/or services delivered and the date of completion. The DSA must keep required documentation related to procurement and cost.

A provider agency is entitled to payment if the individual receiving CLASS services appeals a decision to reduce, suspend or terminate services within the required time frame and the individual continues to receive services during the appeal process, except in cases where the individual threatens the health and safety of himself or others.

7200 Billable Activities

Revision 11-1; Effective June 13, 2011

7210 Case Management

Revision 11-1; Effective June 13, 2011

The following activities are billable and must include a face-to-face or telephone contact with the individual/LAR:

assessing the individual's needs;
enrolling the individual into the CLASS Program;
developing the individual's service plan;
coordinating the provision of CLASS services;
monitoring the effectiveness of the CLASS services and the individual's progress toward achieving the outcomes identified;
revising the individual's service plan, (limited to time spent meeting with the SPT);
accessing non-waiver services, including Medicaid State Plan services;
resolving crisis situations in the individual's life; and

advocating for the individual.pre-enrollment assessment before the individual is enrolled in the CLASS program;

face-to-face or telephone contact regarding the individual's services, with the individual or legally authorized representative (LAR) or other persons acting on behalf of the individual such as an advocate or family member; and

participation on the SPT.

Note: A face-to-face or telephone contact with the paid caregiver (e.g., CFC PAS/HAB, transportation-habilitation staff, respite care provider, nurse, etc.) does not establish a billable activity.

Effective March 20, 2016, each case manager must have at least one face-to-face or telephone contact with the individual or LAR or other persons acting on behalf of the individual, such as an advocate or family member, per month to provide case management. Case management in the CLASS program is paid a monthly rate based on at least one billable contact as described in this paragraph.The CMA must ensure billing for this contact agrees with with the date of the billable contact. The CMA must have at least one billable contact in a month to be eligible to submit a claim for reimbursement for services delivered to the individual. Case management billing is prorated during a month when the individual is terminated from the CLASS program or transfers to another CMA.

Case management billing must be documented on Form 3625, CLASS/CFC – Documentation of Services Delivered, and supported by documented contact notes that include:

the date of contact;
the description of the case management provided;
the progress or lack of progress in achieving goals or outcomes in observable/measurable terms that directly relate to the specific goal or objective addressed;
the person with whom the contact occurred; and
the case manager who provided the contact.

7220 Nursing

Revision 11-1; Effective June 13, 2011

The following activities may be billed under the CLASS program if included in the individual's approved IPC:

direct delivery of nursing services by an RN or LVN within the scope of their licensure;
delegation activities performed by the RN, including the direct training and supervision of unlicensed persons in the performance of health-related tasks;
nursing assessments performed by the RN; and
participation on the SPT when the individual has an identified need for nursing services.

7221 Specialized Nursing

Revision 11-1; Effective June 13, 2011

Nursing services provided to an individual who requires tracheostomy care or is ventilator dependent must be billed to the CLASS program if included in the individual's authorized IPC.

7230 Therapies

Revision 11-1; Effective June 13, 2011

7231 Behavioral Support Services

Revision 15-2; Effective November 20, 2015

Behavioral support services are specialized interventions that assist an individual in increasing adaptive behaviors and replacing or modifying challenging or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in the community.

A program provider must ensure the behavioral support services provider is a:

licensed psychologist;
provisionally licensed psychologist;
licensed psychological associate;
licensed clinical social worker;
licensed professional counselor; or
behavior analyst certified by the Behavior Analyst Certification Board, Inc.

The behavioral support services provider must have received training in behavioral support or have experience in providing behavioral support. The Direct Service Agency (DSA) may document a behavioral support provider’s compliance with this requirement by listing any training related to behavioral support the provider states has been completed. The DSA program director or RN may also document observation of positive outcomes for any individual receiving behavioral support services. The DSA may also document observation of the behavioral support provider successfullyby completing the billable tasks listed below.

The following activities may be billed under the CLASS program if included in the individual's authorized Individual Plan of Care (IPC):

conducting a functional behavior assessment;
developing an individualized behavior support plan;
training and consulting with an individual, family member, or other persons involved in the individual's care regarding the implementation of the behavior support plan;
monitoring and evaluating the effectiveness of the behavior support plan;
modifying, as necessary, the behavior support plan based on monitoring and evaluating the plan's effectiveness; and
counseling and educating an individual, family members, or other persons involved in the individual's care about the techniques to use in assisting the individual to control challenging or socially unacceptable behaviors.

The behavioral support provider must provide justification for time required to develop an individualized behavior support plan. The justification should include time necessary to conduct the functional assessment, any review of individual records, and time spent developing an individualized behavior support plan.

Seclusion

CLASS rules prohibit use of seclusion during the provision of CLASS services. Seclusion is defined as the involuntary separation of an individual away from other individuals and the placement of the individual alone in an area from which the individual is prevented from leaving. Seclusion offers no beneficial purpose and presents a significant health and safety risk to the individual.

7232 Occupational Therapy, Physical Therapy, and Speech and Language Pathology

Revision 15-2; Effective November 20, 2015

A current physician's order for each therapy is required before the delivery of occupational therapy, physical therapy and speech and language pathology. Physician's orders are not necessary for an evaluation only.

The following activities may be billed under the CLASS program if included in the individual's authorized Individual Plan of Care:

direct contact with the individual;
time spent by a therapist to train the individual/legally authorized representative, primary caregiver or service provider in the proper use of an adaptive aid;
time spent teaching a service provider to reinforce therapy goals during activities of daily living (ADL);
time spent by a therapist to perform face to face evaluations to determine an individual's need for skilled therapy service, adaptive aids or minor home modifications; and
participation on the Service Planning TeamSPT may be billed as a professional service, only:
when the individual has an identified need for the service, and
for actual time spent in the capacity of the respective discipline.

7233 Specialized Therapies

Revision 15-2; Effective November 20, 2015

Specialized therapy services must be related to the individual's disability. Specific therapeutic goals must be in place for each specialized therapy provided under the CLASS program to address the individual's disability. A current physician's order for each therapy is required before the delivery of specialized therapy services. Physician's orders are not necessary for an evaluation only.

The following activities may be billed under the CLASS program if included in the individual's authorized Individual Plan of Care:

direct contact with the individual;
time spent by a therapist to train the individual/legally authorized representative, primary caregiver or service provider in the proper use of an adaptive aid;
time spent teaching a service provider to reinforce therapy goals during activities of daily living (ADL);
time spent by a therapist to perform face to face evaluations to determine an individual's need for skilled therapy service, adaptive aids or minor home modifications; and
participation on the SPT may be billed as a professional service, only:
when the individual has an identified need for the service, and
for actual time spent in the capacity of the respective discipline.

The following services are available under specialized therapies and may be billed under the CLASS program if included in the individual's authorized IPC.

Massage Therapy must be provided by a licensed massage therapist.
Recreational Therapy must be provided by a certified therapeutic recreation specialist awarded by the National Council of Therapeutic Recreation Certification (NCTRC) or a therapeutic recreation specialist certified by the Consortium for Therapeutic Recreation/Activities Certification, Inc (CTRAC).
Music Therapy must be provided by a board certified music therapist awarded by the Certification Board for Music Therapists.
Aquatic Therapy must be provided by:
a licensed massage therapist;
a certified therapeutic recreation specialist awarded by the NCTRC;
a certified therapeutic recreation specialist awarded by the CTRAC; and
hold a certificate of completion of the "Basic Water Rescue" course from the American Red Cross; or
be certified by the American Red Cross as a lifeguard.
Hippotherapy must be provided by:
a riding instructor certified by the Professional Association of Therapeutic Horsemanship International as a therapeutic riding instructor or by the North American Riding for the Handicapped Association; and
a licensed occupational therapist; or
a licensed occupational therapy assistant; or
a licensed physical therapist; or
a licensed physical therapist assistant.
Therapeutic Horseback Riding must be provided by a riding instructor certified by the Professional Association of Therapeutic Horsemanship International or the North American Riding for the Handicapped Association as a therapeutic riding instructor.
Dietary Services (Nutritional Services) must be provided by a licensed dietician.

Auditory Enhancement Training must be provided by a licensed audiologist or a licensed assistant in audiology.

Reimbursement Rates

The current specialized therapies unit rate ceiling per hour may be located on the Texas Health and Human Services Commission (HHSC) Rates Analysis website. For services with a unit rate ceiling, the rate negotiated with the provider agency must be at or below the approved ceiling rate; the negotiated rate then becomes the unit rate for that particular service.

Requisition Fees

Requisition fees are 10% of the expenditure for the specialized therapy.

7234Cognitive Rehabilitation Therapy

Revision 15-2; Effective November 20, 2015

Cognitive Rehabilitation Therapy (CRT) assists an individual in learning or relearning cognitive skills that have been lost or altered, as a result of damage to brain cells or brain chemistry, in order to enable the individual to compensate for lost cognitive functions. CRT includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

If an individual might need CRT, the assigned case manager must assist the individual in obtaining, in accordance with the Medicaid State Plan, a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional as a non-CLASS program service.

A program provider must ensure a CRT service provider provides and monitors the provision of CRT to the individual in accordance with the plan of care and is a:

licensed psychologist;
licensed speech-language pathologist; or
licensed occupational therapist.

The plan of care for CRT is developed based on a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional.

An acquired brain injury (ABI) is an injury to the brain that occurs after birth, is non-congenital and non-degenerative, and that disrupts the normal function of the brain. The definition of ABI also includes traumatic brain injury (TBI) and other brain injuries resulting from any anoxic condition. Additional information on acquired brain injuries is located on the website for the Texas Health and Human Services Commission office on Acquired Brain Injuries at

7235 Dietary Services (Nutritional Services)

Revision 15-2; Effective November 20, 2015

The provision of nutrition services is defined in Texas Occupations Code, Chapter 701. A program provider must ensure dietary services are provided by a licensed dietician.