SCENARIO 1 Shawn lives with her mother, but her Mom is getting too frail to lift or hold her. Shawn uses a wheelchair and her bedroom and bathroom are on the 2 nd floor. Despite her physical challenges, Shawn is a very strong-willed person and refuses to move away from her Mom. The possibilities of Shawn having an everyday life is at risk. Shawn is enrolled in the PFDS Waiver and receives job supports and transportation from ABC, Inc. Shawn’s ISP stated that she needed a safer environment and staff supports due to her mobility issues. Her preferences were clearly stated that she wants to continue to live with her mother. Her ISP addressed her desire to move due to the physical challenges and the inability to assure her health and safety. However, in the Individual Preference section, it states that living with her mother is very important to her. Referrals were sent to providers with Shawn’s plan. Shawn, with her team including her Mom and the SC chose XYC, Inc. While the cost for purchase or lease of a home are not allowable expenses (ODP will not participate in the cost of occupancy for private homes), the new provider and SC assisted Shawn and her mom with referrals to a public agency to sell their home and develop a trust for Shawn to pay future rent. Shawn and her Mom both found an apartment that was accessible, and Shawn now receives job supports; transportation; home modifications and in-home supports under the PFDS Waiver. www.dpw.state.pa.us > > 27 www.dhs.state.pa.us
BACK-UP PLAN 55 PA Code Chapter 51. OFFICE OF DEVELOPMENTAL PROGRAMS HOME AND COMMUNITY-BASED SERVICES Subchapter A. GENERAL PROVISIONS § 51.3. Definitions Back-up plan— (i) A strategy developed by a provider to ensure the HCBS the provider is authorized to provide is delivered in the amount, frequency and duration as specified in the participant’s ISP. www.dpw.state.pa.us > > 28 www.dhs.state.pa.us
ISPs What does this mean for you as a prospective provider? www.dpw.state.pa.us > > 29 www.dhs.state.pa.us
RULES & REGULATIONS www.dpw.state.pa.us > > 30 www.dhs.state.pa.us
RULES & REGULATIONS RULES & REGULATIONS The Mental Health & Intellectual Disability Chapter 1101 Act of 1966 MA Regulations & Policy 55 PA Code Chapter 51 55 PA Code Chapter 2380 Waiver Program Regulations Adult Training Facility Licensing Regulations 1915(c) Home and Community-Based 55 PA Code Chapter 2390 Services Waiver Vocational Facilities Licensing Regulations Consolidated Waiver 1915(c) Home and Community-Based 55 PA Code Chapter 6400 Services Waiver Community Homes Licensing Regulations Person/Family Directed Support Waiver 55 PA Code Chapter 6500 55 PA Code Chapter 3800 Family Living Homes Licensing Regulations Child Residential and Day Treatment Facilities 55 PA Code Chapter 5310 ODP Waiver Provider Agreement Community Residential Rehabilitation Services for the Mentally Ill www.dpw.state.pa.us > > 31 www.dhs.state.pa.us
55 PA Code Chapter 51 All Consolidated and P/FDS waiver services are regulated by 55 PA Code Chapter 51. There are 4 subchapters to 55 PA Code Chapter 51: A. General provisions: 51.1 B. Provider qualifications and participation: 51.11 C. Payments for services: 51.41 D. Closures and termination: 51.151 www.dpw.state.pa.us > > 32 www.dhs.state.pa.us
CERTIFICATE OF COMPLIANCE The following must be included with an Application for Certificate of Compliance/Licensure: . • Articles of Incorporation (if appropriate); • Pennsylvania Department of State Fictitious Name Approval (if appropriate); • Certificate of Occupancy (UCC permit); • Civil Rights Compliance Questionnaire must be completed and mailed to the appropriate Bureau of Equal Opportunity office www.dpw.state.pa.us > > 33 www.dhs.state.pa.us
HIPAA The Health Insurance Portability and Accountability Act (HIPAA) • The Privacy Rule requires actions including: - Notifying participants about their rights - Adopting and implementing privacy procedures - Training employees - Privacy Officer - Securing records • Protected Health Information (PHI] • Information that a provider receives or creates about the participant that relates to a past, present or future physical or mental health condition, or treatment or payment for the treatment that can be used to identify the participant. • Must be kept confidential http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative- Simplification/HIPAAGenInfo/AreYouaCoveredEntity.html www.dpw.state.pa.us > > 34 www.dhs.state.pa.us
ODP WAIVERS www.dpw.state.pa.us > > 35 www.dhs.state.pa.us
ODP WAIVERS ODP’s Home and Community-Based Waivers Two of ODP’s approved waivers are: • Consolidated • Person/Family Directed Support [P/FDS] Each waiver specifies the types of services that may be provided in home and community settings Each waiver caps the number of people who may receive services under the waiver Each waiver limits the services to people with specific eligibility The need for services must be established through an assessment process, reviewed and discussed with the planning team and documented in an ISP. Each waiver includes standards to meet the required waiver assurances Individuals can only be in one waiver at a time Not every individual supported by ODP is enrolled in the Waiver. www.dpw.state.pa.us > > 36 www.dhs.state.pa.us
WAIVER ASSURANCES The Federal HCBS Waiver Assurances are : Level of Care Service Plan Qualified Providers Health and Welfare Financial Accountability Administrative Authority www.dpw.state.pa.us > > 37 www.dhs.state.pa.us
CMS FINAL RULE The purpose of the CMS HCBS rule is to make sure individuals receive services in settings that are integrated in the community and individuals receiving services have access to community resources equal to that of those who do not receive services. Individuals receiving services should be able to: • Have opportunities to seek employment and work in competitive and integrated settings. • Engage in community life. • Control personal resources. • Obtain services in the community. www.dpw.state.pa.us > > 38 www.dhs.state.pa.us
WAIVER SERVICES • Assistive Technology • Respite • Advanced Supported Employment • Shift Nursing • Behavioral Support • Supports Broker • Benefit Counselling • Supports Coordination • Communication Specialist • Specialized Supplies • Community Participation Support* • Supported Living • Companion • Therapy Services • Consultative Nutrition Services • Transportation • Education Support • Financial Management Services • Family/Caregiver Training Agency with Choice (AWC) – • Home and Vehicle Adaptations Vendor Fiscal/Employer – Agency (VF/EA) • Housing Transition and Tenancy • Vendor Services • Homemaker/Chore Public Transportation • Lifesharing* – • Residential Habilitation* www.dpw.state.pa.us > > 39 www.dhs.state.pa.us
WAIVER SERVICE DEFINITIONS Elements of a Waiver Service Definition • Description of the service • Frequency (how often) duration (how long) and intensity (the levels of support that may be offered) • Information on where and how the service may be provided • Applicable regulation and licensing requirements • Qualifications of providers and staff • Qualifications of staff that provide specialized supports and therapy • Limits to service provision (amount, location, duration, or services which are exclusionary of each other) • Billing codes (in ISP Manual) • Definition of the service unit (in ISP Manual) www.dpw.state.pa.us > > 40 www.dhs.state.pa.us
SUPPORTS COORDINATION Supports Coordination is a critical service that involves the primary functions of locating, coordinating and monitoring needed services and supports for waiver participants. Locating services and supports consists of assistance to the participant and his or her family in linking, arranging for, and obtaining services specified in an Individual Support Plan [ISP], including needed medical, social, habilitation, education or other needed community services. Activities included under the locating function include all of the following in addition to the documentation of activities. www.dpw.state.pa.us > > 41 www.dhs.state.pa.us
WAIVER CAPACITY Waiver Capacity is the number of individuals that may be enrolled in the Consolidated and P/FDS Waivers at any given time. Currently, there are over 30,000 individuals enrolled in the waiver. www.dpw.state.pa.us > > 42 www.dhs.state.pa.us
PUNS Waiver enrollment is prioritized based on the PUNS: P rioritization of U rgency of N eed for S ervices www.dpw.state.pa.us > > 43 www.dhs.state.pa.us
REFERRAL & PROVIDER SELECTION • The Individual Support Plan is the primary source of information for referrals to providers • Waiver participants have the right to choose from any willing and qualified provider • Providers shall respond to referrals with information to the individual, family and SC of whether they are able to offer the services in the plan or if not, why not. • Providers must have a reasonable basis for rejecting a referral www.dpw.state.pa.us > > 44 www.dhs.state.pa.us
PROVIDER ADMISSION & DISCHARGE POLICIES • Services for individuals accepted by the Provider must begin within 45 days of waiver enrollment. • If an individual selects another willing and qualified provider to replace the current provider, both providers shall cooperate during the transition between providers. • A provider that is no longer willing to provide an HCBS to a participant shall provide written notice at least 30 days prior to the date of discharge. www.dpw.state.pa.us > > 45 www.dhs.state.pa.us
CHOICE & CONTROL • Federal policy encourages states to increase the level of choice and control to individuals. • The Commonwealth has implemented programs for individuals and their families to self-direct services. • Person Centered Planning enhances the choice and control that waiver recipients have in selecting services and providers • Individuals and their families are encouraged and supported with making more decisions www.dpw.state.pa.us > > 46 www.dhs.state.pa.us
48 > > www.dpw.state.pa.us www.dhs.state.pa.us HOME AND COMMUNITY SERVICES INFORMATION SYSTEM
SCENARIO 2 Melissa has lived in a group home for a few years. She decided she will move to an apartment to be more independent. Her team plans to support her during and beyond this move. The group home she left at Provider Z, now has an opening or a vacancy. Since Melissa is still using her waiver ‘slot’ for the new place, the group home opening can only be filled by a person who is waiver eligible and has been approved by the AE and an individual who has selected Provider Z. Some vacancies can remain vacant for a long time and cannot be billed. Therefore, a strong understanding and careful management of a provider’s capacity is essential. www.dpw.state.pa.us > > 48 www.dhs.state.pa.us
WAIVER SERVICES What does this mean for you as a prospective provider? www.dpw.state.pa.us > > 49 www.dhs.state.pa.us
BECOMING A PROVIDER www.dpw.state.pa.us > > 50 www.dhs.state.pa.us
BECOMING A PROVIDER – PROCESS FLOW www.dpw.state.pa.us > > 51 www.dhs.state.pa.us
GETTING STARTED These are the steps you’ve already taken as a provider applicant: • Expressed interest in rendering Consolidated and/or P/FDS Waiver services within ODP • Received the Provider Applicant [aka ‘Getting Started’] e- mail from ODP or AE • Registered to attend this session on MyODP www.dpw.state.pa.us > > 52 www.dhs.state.pa.us
PROVIDER APPLICANT ORIENTATION Provider registers for Applicant Orientation, attends session and takes test. www.dpw.state.pa.us > > 53 www.dhs.state.pa.us
PROVIDER APPLICANT ORIENTATION If the provider applicant passes the test … … ODP will forward Applicant Orientation certificate along 25, with Applicant Orientation & Next Steps e-mail to Provider www.dpw.state.pa.us > > 54 www.dhs.state.pa.us
PROVIDER APPLICANT ORIENTATION The Certificate expires 120 days from the date it is issued. If the provider does not become qualified within 120 days, they will need to attend a second Provider Applicant Orientation session and take the test again. www.dpw.state.pa.us > > 55 www.dhs.state.pa.us
Provider Registration • ODP Licensed Providers will be required to self register, to obtain a user id that will allow them access to the Provider Self Service portal for Certification and Licensing. Cr eat e Pr ovi der Sel f Cr eat e Pr ovi der Sel f Ser vi ce Account Ser vi ce Account www.dpw.state.pa.us > > 56 www.dhs.state.pa.us
LICENSING Licensed Providers (2380, 2390, 6400, 6500) must email the ODP Regional Waiver Capacity Manager for site clearance and receive an approval letter. www.dpw.state.pa.us > > 57 www.dhs.state.pa.us
PROVIDER AGREEMENT Provider to complete ODP Provider Agreement ODP Waiver Instructions and Agreement www.dpw.state.pa.us > > 58 www.dhs.state.pa.us
Quality Assessment & Improvement Contact Information • Complete the Quality Assessment & Improvement Contact Information questionnaire • Send the confirmation to the AE in which you intend to provide the majority of services www.dpw.state.pa.us > > 59 www.dhs.state.pa.us
60 > > www.dpw.state.pa.us PROVIDER QUALIFICATION www.dhs.state.pa.us
MEDICAL ASSISTANCE (MA) PROGRAM ENROLLMENT Provider applies for services for which they are qualified. ODP Provider Enrollment unit will review application • License (if required) and if approved, enroll in • ODP agreement PROMIS e TM . • Approved APC letter • Approved DP FORM 1059 www.dpw.state.pa.us > > 61 www.dhs.state.pa.us
PROVIDER ADDS SERVICE Notification is received from the HCSIS Help Desk that the provider may add services for which they are qualified in HCSIS. Provider logs into HCSIS to adds services. www.dpw.state.pa.us > > 62 www.dhs.state.pa.us
MEDICAL ASSISTANCE (MA) PROGRAM ENROLLMENT Rates loaded into PROMIS e TM and contracts created in HCSIS within 5-7 business days. If participants choose the provider’s services, the Supports Coordinator can add the services to the ISP. The Supports Coordinator submits the ISP to the Administrative Entity for review. The Administrative Entity authorizes services and the provider may begin to provide services. www.dpw.state.pa.us > > 63 www.dhs.state.pa.us
Scenario 3 Phil owns a empty house. He is considering using this home to support people with disabilities. He has asked how he may get paid. The answer to this is not easy. • Phil could simply lease or sell the home to an individual or a provider. In this case, he is a landlord and does not need to be enrolled in the system. • If Phil wants to ‘rent rooms’ but not provide any waiver services, this is not eligible for ODP funding. • Phil can establish a community home for people with an intellectual disability. He must complete the registration and enrollment process, become qualified for Residential Habilitation services, complete the Provider Applicant Orientation. • Get licensed, obtain ODP approval for site size, enroll in PROMISe™ and if Phil’s agency is the provider of choice for an individual enrolled in the Consolidated Waiver, begin services. www.dpw.state.pa.us > > 64 www.dhs.state.pa.us
BECOMING A PROVIDER What does this mean for you as a prospective provider? www.dpw.state.pa.us > > 65 www.dhs.state.pa.us
MONITORING OF PROVIDERS www.dpw.state.pa.us > > 66 www.dhs.state.pa.us
MONITORING OF PROVIDERS Licensing • DHS determines compliance with applicable regulations QA&I Self-Assessment • Annual • Provider assesses their own performance with regulations and waiver assurances QA&I On-Site • Triennial • AE’s determine provider’s performance with regulations and waiver assurances ISP Monitoring by Supports Coordinators • Frequency determined by which waiver, ISP and special circumstances • Health, Welfare and Safety • Service Provision as specified in the ISP IM4Q • Independent monitors measure quality of life and level of individual and families’ satisfaction with services www.dpw.state.pa.us > > 67 www.dhs.state.pa.us
MONITORING OF PROVIDERS • Requirement per Consolidated and P/FDS Waivers and applicable regulations • Must be completed and approved prior to qualification and before a PROMIS e™ enrollment application is approved by ODP • Required for providers both initially and on an ongoing basis www.dpw.state.pa.us > > 68 www.dhs.state.pa.us
MONITORING OF PROVIDERS NEW PROVIDER PROVIDER CORRECTIVE AE ONSITE SELF SELF ACTIONS REVIEW ASSESSMENT ASSESSMENT I N I T I A L LY ANNUALLY T R I E N N I A L LY A S NEEDED www.dpw.state.pa.us > > 69 www.dhs.state.pa.us
MONITORING OF PROVIDERS Agency Policies and Procedures shall include: • Mission/vision statement • Response to individual health • Staff Qualification requirements and behavioral emergencies/crises • Checking if staff or sub-contractors are eligible to provide waiver • Ensure implementation of back- services up plans • Restraint policy • Conflict of interest • Record Management • Ensure replacement of lost and damaged property • Emergency disaster response plan • Appropriate transition of • Grievance procedures individuals • Policies/procedures for checking • Incident Management staff on LEIE, SAM and Medicheck • Annual training curriculum, as • Accessibility for Individuals who per regulations are deaf Protocol www.dpw.state.pa.us > > 70 www.dhs.state.pa.us
NEW PROVIDER SELF-ASSESSMENT www.dpw.state.pa.us > > 71 www.dhs.state.pa.us
INDEPENDENT MONITORING for QUALITY Essential Data Elements (EDE) Survey Satisfaction Choice and Control Dignity Relationships Respect and Rights Inclusion www.dpw.state.pa.us > > 72 www.dhs.state.pa.us
73 > > www.dpw.state.pa.us www.dhs.state.pa.us INCIDENT MANAGEMENT
INCIDENT MANAGEMENT ODP Incident Management Bulletin # 6000-04-01 Title 55, Human Services Subpart A. Statement of Policy Chapter 6000 Subchapter Q Incident Management www.dpw.state.pa.us > > 74 www.dhs.state.pa.us
INCIDENT MANAGEMENT INCIDENT CLASSIFICATIONS TO BE REPORTED BY ALL PROVIDERS WITHIN 24 HOURS Abuse Law Enforcement Activity Death Missing Person Emergency Closure Misuse of Funds Emergency Room Visits Neglect Fire Psychiatric Hospitalization Hospitalization Rights Violation Individual to Individual Abuse Suicide Attempt Injury Requiring Treatment Beyond First Aid INCIDENT CLASSIFICATIONS TO BE REPORTED BY ALL PROVIDERS WITHIN 72 HOURS Medication Error Restraints www.dpw.state.pa.us > > 75 www.dhs.state.pa.us
76 > > www.dpw.state.pa.us www.dhs.state.pa.us CERTIFIED INVESTIGATIONS INCIDENT MANAGEMENT –
LIFECYCLE OF AN INCIDENT Immediately, Immediately, Within 24 hours of Within 24 hours of Incident is Incident is occurrence, occurrence, actions are taken actions are taken recognized or recognized or reportable incident reportable incident to protect health to protect health report entered into report entered into and safety and safety discovered discovered system system Within 24 hours of Within 24 hours of Within 30 days of Within 30 days of entry in EIM, entry in EIM, the report, the report, Within 24 hours of Within 24 hours of Oversight Entities Oversight Entities determine determine the report, the report, review initial review initial outcome of outcome of Investigation Investigation reportable incident reportable incident investigation – if investigation – if initiated – if initiated – if report report applicable applicable applicable applicable Within 30 days of Within 30 days of Development Development the final report the final report Final incident Final incident and and submission , Final submission , Final report entered report entered implementation of implementation of incident incident Corrective Action Corrective Action into system into system report is reviewed report is reviewed Plans Plans and closed by and closed by Oversight entities Oversight entities www.dpw.state.pa.us > > 77 www.dhs.state.pa.us
INCIDENT MANAGEMENT Provider roles and responsibilities: 1. Assign an individual with overall responsibility for incident management. 2. Develop a policy for incident management. 3. Ensure that staff, individuals and families are trained on incident management policies and procedures. 4. Assign roles within their organization for reporting and investigation of incidents. 5. Assure corrective action to individual incidents. 6. Conduct analysis of data on incidents and the quality of investigations. 7. Identify and implement individual and systemic changes based on risk management analysis. www.dpw.state.pa.us > > 78 www.dhs.state.pa.us
79 > > www.dpw.state.pa.us Incident Management Certified Investigator Representative Point Person www.dhs.state.pa.us PROVIDER IM ROLES
PROVIDER IM ROLES Point Person Receive verbal or other reports of allegations or • suspicion of incident Safeguard the individual • Ensure Incident Report is submitted • Communicate with others involved in investigation • Follow up • Review of Incidents • www.dpw.state.pa.us > > 80 www.dhs.state.pa.us
PROVIDER IM ROLES Incident Management Representative Overall agency responsibility • Ensure activities of initial reporter and point person are • completed Finalization of Incident report within 30 days • Peer Review • Evaluate the quality of incident investigations • Maintain an investigation file within the agency • www.dpw.state.pa.us > > 81 www.dhs.state.pa.us
PROVIDER IM ROLES Certified Investigator Receive training and certificate • Maintain certification • Conduct prompt investigations • Enter investigation summary in EIM • www.dpw.state.pa.us > > 82 www.dhs.state.pa.us
PROVIDER IM RESPONSIBILITIES • Promote the health, safety, rights and enhance the dignity of individuals receiving services. • Ensure that staff and others associated with the individual have proper orientation and training to respond to, report and prevent incidents. • Develop provider-specific policy/procedures for incident management. – Includes the possible immediate and long-term effects to the individual from an incident or multiple incidents”. • • Provide ongoing training to individuals and families on the recognition of abuse and neglect. www.dpw.state.pa.us > > 83 www.dhs.state.pa.us
OVERSIGHT ENTITY’S ROLES • Review actions to protect health, safety and rights that were taken by the provider • Request additional information from providers regarding the incident, actions taken and recommend additional actions to protect health, safety and rights as appropriate • Communicate with individual, their family, guardian or other designee as appropriate about the incident • Assist with securing supports or services that are needed as a result of the incident • Determine if an investigation needs to be completed in addition to the requirement placed upon the provider www.dpw.state.pa.us > > 84 www.dhs.state.pa.us
CHILDREN AND ADULT PROTECTIVE SERVICES Adult Protective Services Act [APS] Act 70 Older Adults Protective Services Act [OAPSA] Act 79-1987 SUSPECT ELDER ABUSE OR ABUSE OF AN ADULT WITH A DISABILITY? CALL: 1-800-490-8505 Child Protective Services Act [CPS] Act 3490 REPORTING CHILD ABUSE, CALL 800-932-0313 (TDD: 866-872-1677) www.dpw.state.pa.us > > 85 www.dhs.state.pa.us
INCIDENT MANAGEMENT What does this mean for you as a prospective provider? www.dpw.state.pa.us > > 86 www.dhs.state.pa.us
87 Incident Management is reactive, > > Risk Management is proactive. www.dpw.state.pa.us INCIDENT MANAGEMENT AND www.dhs.state.pa.us RISK MANAGEMENT
RISK MANAGEMENT • Risk management promotes a positive quality of life for individuals with intellectual disability and/or autism by ensuring their health, safety and well-being. • A risk management system identifies factors that increase risk to individuals and to develop practices that reduce risk. • A risk management system uses data to track incidents and plan preventative measures for the future www.dpw.state.pa.us > > 88 www.dhs.state.pa.us
RISK MANAGEMENT Provider risk management process needs to include, but not limited to: • The review and analysis of incident management data, certified investigation findings and other information such as complaints, service reviews, etc.; • Discovery of root cause and contributing factors directly related to occurrence; and • Individual-specific and systemic actions to manage and/or mitigate risk. • Providers must relate preventive measures directly to the cause of the incident for them to have an impact on occurrence or recurrence. www.dpw.state.pa.us > > 89 www.dhs.state.pa.us
SCENARIO 4 Matthew, age 23, lives at home with his mother and brother. His brother is paid by a provider to provide Home and Community Habilitation services to him 3x a week. . During a monitoring visit, Matthew tells the Supports Coordinator that his brother has been leaving him home alone so his brother can go out when he was supposed to be working with him. . Matthew’s ISP states that he needs supervision when in his home. The Supports Coordinator [SC] discusses this with Matthew’s mother and identifies this as a concern in the service notes. No incident was reported. On the next monitoring visit by the SC, Matthew doesn’t say anything, and the SC didn’t bring it up either. www.dpw.state.pa.us > > 90 www.dhs.state.pa.us
91 > > www.dpw.state.pa.us www.dhs.state.pa.us FINANCIAL MANAGEMENT
RATE SETTING • Cost-based Rates • Cost Report Rates • Area Average Rates • Lowest Rates • Department-established fee rates • Market-based approach • Determination of cost components • Geographical areas • Vendor • Good or services offered to the general public www.dpw.state.pa.us > > 92 www.dhs.state.pa.us
RATE SETTING How Rates are Assigned to Providers Once a provider has their account(s) established in HCSIS and PROMIS e ™ and have been qualified they can begin to add the services in HCSIS to each AE that will be authorizing services Services are added by procedure code, by AE Once the rate is added to PROMISe™, the rate will be loaded to HCSIS and will be available for inclusion in an ISP www.dpw.state.pa.us > > 93 www.dhs.state.pa.us
CLAIMS When Providers can bill for services The provider’s Service and Supports Directory (SSD) is updated appropriately The provider’s service or services have already been attached to an Individual’s Support Plan (ISP) and authorized by the Administrative Entity The provider has viewed the Service Authorization Notice(s) found in HCSIS > Provider Self Service prior to rendering and billing for an ODP service and has confirmed that the data elements contained in it are accurate The provider has already rendered the service per the frequency indicated in each individual’s ISP, and that the service or services rendered are documented in your organization’s file notes or record keeping system www.dpw.state.pa.us > > 94 www.dhs.state.pa.us
CLAIM AND SERVICE DOCUMENTATION • Every time a claim is billed, there must be supporting documentation which shows that the service that was billed matches the authorized service from the ISP. • Providers are responsible to ensure that the amount, frequency, duration, staffing ratio, and types of services that are billed to PROMISe™ correctly match the authorizations from individual’s ISPs, and providers must maintain supporting documentation to substantiate each claim. www.dpw.state.pa.us > > 95 www.dhs.state.pa.us
CLAIM AND SERVICE DOCUMENTATION Claims must be supported by documentation that the services is: • Provided to a Medicaid-eligible individual • Provided by a qualified provider • Authorized based on accessed need • Rendered as authorized in an ISP • Includes: – Date the service was rendered – Name of the recipient – Medicaid identification number – Name of provider and person providing the service – Nature, extent or units of service The place the servic e was – rendered. www.dpw.state.pa.us > > 96 www.dhs.state.pa.us
PROGRESS NOTES • Progress notes are to be completed during the calendar month the service is provided. • Progress notes must be written every time a service is delivered if the service is occurring on a less than monthly basis, (for example the service is provided every 6 weeks or every 90 days). www.dpw.state.pa.us > > 97 www.dhs.state.pa.us
FINANCIAL MANAGEMENT What does this mean for you as a prospective provider? www.dpw.state.pa.us > > 98 www.dhs.state.pa.us
99 > > www.dpw.state.pa.us www.dhs.state.pa.us QUALITY MANAGEMENT
QUALITY MANAGEMENT Quality Management is a methodology by which organizational performance is continuously measured, evaluated, and improved. Individuals and other stakeholders are engaged in designing and improving services. www.dpw.state.pa.us > > 100 www.dhs.state.pa.us
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