Medicaid Requirements Page 1

Medicaid Requirements page 1

Title: / MEDICAID REQUIREMENTS
Purpose: / The Birth to Three System seeks payment from the Medicaid Program to offset the state’s expenditure for Birth to Three Services.

Overview

Services reimbursable by Medicaid will be billed by the Department of Developmental Services through the Department of Administrative Services Financial Services Center (FSC). The billing will be based on information provided by the performing providers who will deliver the services. The dollars are deposited into the state’s general fund.

Generally, providers will not bill Medicaid directly. The exception is for durable medical equipment (i.e. assistive technology device). If Medicaid pays the provider for the equipment, the provider must accept it as payment in full.

Medicaid Billing

Connecticut Birth to Three programs are prohibited from billing Medicaid directly for early intervention services other than assistive technology devices that are considered durable medical equipment. If a child has a need for medical services, then the child’s health care provider should be providing and billing Medicaid for those services. For information about billing Medicaid directly for durable medical equipment, see the Assistive Technology procedure.

On the attendance record in the data system, click on the “bill Medicaid” box if everything is in place to bill Medicaid for services to that Medicaid eligible child for that month. Once this has been clicked the first time, it will be the default setting for that child unless it is changed. The Connecticut Birth to Three System will bill Medicaid for all programs on an “all inclusive” rate and will also bill separately for initial evaluations.

If a child is covered by both Medicaid and commercial insurance, the commercial insurance must be billed first. If the commercial insurance benefits have run out for the year, or if a blanket denial for coverage of all services has been received, then Medicaid billing should resume until such time as the commercial benefits would resume.

Transdisciplinary Team Documentation of Medical Expertise

Under the Connecticut State Regulations for the Department of Social Services Sections 17b-262-597 through 17b-262-605, if a child covered by Medicaid (Husky A), is receiving any services from an Early Intervention Teacher, Early Intervention Specialist, Early Intervention Associate, or Assistant, Board Certified Behavior Analyst (BCBA), or a Board Certified Behavior Analyst (BCBA), Board Certified Associate Behavior Analyst (BCABA), then evidence must be available to the Centers for Medicare and Medicaid Services (CMS) of participation by all members of a transdisciplinary team in the delivery of services. At least once per quarter, one or more of the medically licensed professionals on the team must sign that they have reviewed the child’s progress and have had discussions with the early intervention teacher, specialist, associate, assistant or BCBA, about the child’s program. The medically licensed staff should indicate their area of licensure or discipline (such as OT, PT, SP, etc.) on the Transdisciplinary Team Documentation of Medical Expertise, Form 2-6. The form should be filed in the child’s early intervention record.

Medicaid Documentation

1. Each provider program will be required to complete a performing provider agreement with the Department of Social Services in order to obtain a Medicaid performing provider number. DDS will provide the necessary forms.
2. Families are required to sign Form 1-3 prior to having their Medicaid benefits billed for any Birth to Three Services. No family will be required to enroll in the Medicaid program in order to receive Birth to Three services
3. Attendance must be entered into the data system for each child served. If the child is eligible for Medicaid, an “X” in the Bill Medicaid Box indicates that all necessary billing information is in the child’s file: ICD Code, Medicaid number, IFSP signed by the parent and Physician’s signature on the IFSP.
4. Signed and dated progress or running notes for each service indicated on the attendance form must be on file in the child’s record.
5. A current IFSP signed by the child’s physician is required for Medicaid billing.
6. Each program should indicate on the attendance that an evaluation was performed to indicate the child’s initial eligibility evaluation.

Medicaid Audits

Documentation to support Medicaid and insurance billing must be maintained in the child’s file for a period of six years.

The child’s file is subject to audit to support Medicaid billing. This may be accomplished as part of a quality assurance review or as part of a Medicaid audit performed by DDS, the Department of Social Services or the Centers for Medicare and Medicaid Services (CMS).

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References:

Form 2-6,Transdisciplinary Team Documentation of Medical Expertise,

Form 3-1, Individualized Family Service Plan (IFSP)

17a-248g of the C.G.S.

Section 17b-262-597-605 of the Regulations of CT State Agencies

34 CFR Section 303.520 and 303.521