Handout Y

SPECIAL EDUCATION Third Party Billing

Self Assessment

IEP Services Billing to Minnesota Health Care Programs

Record Review Summary

Completed by:______Date: ______

Findings reported to______Date:______Follow-up review date: ______

Summary:

Corrective action(s) recommended: / Results of follow-up review: / Notes:
1. / 1.
2. / 2.
3. / 3.
4, / 4,
5. / 5.
____ Corrective actions are minor and can be corrected immediately. Continue billing.
____ Corrective actions are major.
Stop billing until all issues are resolved. / ____ Corrective actions completed. Billing should continue.
____ Corrective actions remain unresolved. Stop billing until all issues are resolved.

MDE MCGriffin 2/09 RELuehr 10/12

Third Party Billing: IEP Health Related Services

Self Assessment Checklist: Record Review Review Date:

Identifying Information

School District Name / Type/
Number / NPI# / Finance Records / Notes
Payment (from Remittance Advice) date:
Check/EFT date:
Account #
Student Name / ID# / PMI# / IEP and Services Records / Notes

Conditions for Third Party Billing:

√ / Medically Necessary Service and IEP / Codes / Location of documentation: / Notes
Diagnosis/conditionthat corresponds to the services billed to MHCP: / MCHP diagnosis/condition and code:
Spec Ed Category(ies) of Eligibility: /  DB  DHH  OHD
 PI SL  VI  TBI
Dates IEP is in effect: / ______to ______

Consent/Notice: The parent/legal representative:

√ / Type of document / Form/Date signed / Begin date / End date / Location of documentation: / Notes
Parent consent to release information to DHS/ private insurance for billing: One time consent. / None unless withdrawn / __ MHCP application
__ District form
Parent consent to bill MHCP and private insurers. One time consent. / None unless withdrawn / __ MHCP application
__ District form
Annual Notice of district’s intent to bill / __ Procedural Safeguards form

Comments

Authorization / Orders:

√ / Type of document / Form/Date signed / Begin date / End date / Location of documentation: / Notes
Parent Consent to contact medical office:
Renew start of new year and whenever there is a major service change. / End of school yr / __MHCP application
__District form
Medical order for certain nursing services - annual / End of school yr
Physician notified of Personal Care Assistance need and services

Comments

Billable Health Related Services:

√ / Service Category: (from RA) / Months per Year of Service / # Encounters/ Units / On IEP / Notes
Physical Therapy T1018 U1 / Yes / No
Occupational TherapyT1018 U2 / Yes / No
Speech TherapyT1018 U3 / Yes / No
MH Evals / ServicesT1018 U4 / HE / Yes / No
Nursing ServicesT1018 U5 / Yes / No
Personal Care ServicesT1018 U6 / Yes / No
Assist Tech DeviceT1018 U7 NU RR RP / Yes / No
Special TransportationT1018 U8 / Yes / No
InterpreterT1013 / Yes / No

Quality of IEP Description:Service:

Complete a Quality of IEP Description check for each service. Copy and paste the section for additional services.

√ / Notes
Evaluation prior to development of the IEP(Limited to certain providers.) / Yes / No / NA
Services correspond to diagnosis/condition. / Yes / No
Service is identified on IEP. / Yes / No
Service sufficiently described on IEP: frequency, amount, duration / Yes / No / NA
Dates of service match service grid, if applicable. / Yes / No / NA
Dates of service are within overall IEP dates. / Yes / No / NA
Services provided after IEP end date? If Yes, is stay put in effect? / Yes / No / NA

Qualified Provider:

√ / Service Category: (from RA) / Licensure / Credentials Location / Comments
Physical Therapist / Current MN License / Yes / No
Physical Therapist Assistant / __ Accredited Am PT Assoc grad.
__ Comparable agency / Yes / No / S
Occupational Therapist / Current MN License and NBCOT Certificate / Yes / No
Occupational Therapy Assistant / Current MN License and NBCOT Certificate / Yes / No / S
Speech Therapist or ESLP / Current CCC / Yes / No
ESLP with Master’s in Speech / _Once a CCC _ CCC equivalent
_Now in supervision for CCC / Yes / No
Audiologist / Current CCC / Yes / No
Nursing Services
Licensed School Nurse / Current MN BoT and BoN Licenses / Yes / No / EDRS
Public Health Nurse – contracted / Current MN BoN License / Yes / No
Registered Nurse (RN) / Current MN BoN License / Yes / No
Licensed Practical Nurse (LPN) / Current MN BoN License / Yes / No / S
Personal Care Services Any training?
DHS required training – one time / _CNA _HHA _Nu.Schl _Other
DHS certificate / Yes / No
Yes / No / S
Mental Health Professional / LP LPP LICSW Clinical Nurse Spec MH Psychiatrist LFMT / Yes / No
Mental Health Practitioner / School Psych EGS LSW: BA/BS + 2,000 6,000 hrs Master’s / Yes / No
Assist Tech Device
Transportation
School Bus Minn. Stat. 169.01,Subd. 6
Spec Trans Vehicle. Minn. Stat. 174.30 / _Defined as school bus
_ Spec Trans Vehicle Cert. / Yes / No
Oral Language Interpreter / _ Fluent in child’s lang.______
_ Fluent ASL interpreter / Yes / No

*S Require supervision.

Supervision
√ / Services: / Supervisor:
Qualified Personnel / Training Documented / Supervision
Documented / Daily services, progress, results documented / Notes
LPN / LSN/PHN/RN
Personal Care Assistance
COTA / Occupational Therapist
PTA / Physical Therapist

Comment: Was supervision documented and done in a timely manner?

Documentation:Activity /Service Logsfor each service:

# / Criteria
1 / Legible.
2 / Student’s name and birthdate is on each page.
3 / Each encounter includes: date, length and type of service.
4 / Each log includes notes of student response/results/progress.
5 / Each log includes a) signature of the provider, b) supervisor if required.
6 / Each set of notes are dated and initialed.
7 / Special transportation: a) mileage verified. b) corresponds to another billable service for each date billed
8 / Interpreter service corresponds to another billable service for each date billed
9 / School calendar supports date(s) of service.
10 / Attendance records support date(s) of services.
√ / Services / Review: List Criteria # from above if needs improvement / Notes
Physical Therapy T1018 U1
Occupational TherapyT1018 U2
Speech TherapyT1018 U3
MH Evals / ServicesT1018 U4 / HE
Nursing ServicesT1018 U5
Personal Care ServicesT1018 U6
Assist Tech DeviceT1018 U7 NU RR RP
Special TransportationT1018 U8
InterpreterT1013

Billing: Health Insurance Coverage

√ / Services: / Documentation location: / Notes
Public program only: MA or MinnCare: Currently enrolled?
including Managed Care Organizations contracted to provide MA / Yes / No
Private insurer: MDE has denial letter in Share Point: Download and keep in student’s file or accessible common file. . / Yes / No
Private insurer: MDE has no response: Print 3 ltr attempts; Prepare coversheet and fax to DHS when filing MN-ITS. / Yes / No
Private insurer: Requires individual client review: Date letter sent. / Yes / No

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