Districts can claim reimbursement for administering the COVID-19 vaccine to students.
(December 2021)
Nurses, under the supervision of an MD can bill for the time spent vaccinating Medi-Cal eligible students with the COVID-19 vaccine, as this is considered a covered EPSDT service. No health plan is required but parent/guardian must give consent if the student is under the age of 18. Please see details in the link below.
Clarification for SLP Assessments: Language Evaluation Only
(Evaluation of speech sound production with evaluation of language)
Four new assessment codes were developed by ASHA's Health Care Economics Committee (HCEC) in collaboration with experts in the field. The HCEC has been working with the American Medical Association (AMA) to change most speech-language pathology codes since 2009. These most recent changes took effect in California on October 1, 2016.
Since then, there has been some confusion concerning how to bill for an assessment that only includes language evaluation. We have clarification from ASHA and their website explains this in their FAQ’s ( http://www.asha.org/Practice/reimbursement/coding/New-CPT-Evaluation-Codes-for-SLPs/#7). The SLP should document that his/her clinical judgement was used to determine a student’s speech capabilities and whether or not the student should receive a sound production assessment. According to ASHA, this clinical judgement implies that an assessment was made even if it was determined that there was no need for a formal assessment for sound production. Below is the response from ASHA:
“If two or more procedures are billed together at least 51% of the time, it is standard to develop a bundled CPT code for that set of services. During the code development process, ASHA surveyed practices and clinics and confirmed that a patient evaluated for language is also evaluated for speech sound production ability more than 80% of the time. However, the reverse is not true. It is common practice for a patient to be evaluated for speech sound production ability independent of a language evaluation, which is why there is a stand-alone code for speech sound production evaluation
However, SLPs will often address both speech and language throughout the evaluation process, even if only evaluating speech sound production informally. In these instances, SLPs may document that speech sound production is within normal limits and could also provide further detail regarding intelligibility at the sentence and conversational level, as well as explain the results of an orofacial examination for structure and function of articulators.”
The DHCS conference call on Wednesday, September 17th provided some good news and not so good news. The good news is that CMS (Federal Medicaid Agency) has given DHCS permission to:
A. End, immediately, the interim Reasonable Test Criteria (RTC) process for evaluating MAA invoices from Q3-2009/10 thru Q4-2013/14
B. Release MAA funds to school districts for each quarterly invoice based on the following percentages
$25,000 and under Paid at 100%
$25,000-$50,000 Paid at 75%
$50,000-$250,000 Paid at 40%
Over $250,000 Paid at 25% The not so good news is that CMS / DHCS:
A. Have not determined when the MAA funds based on the percentages above will be released.
B. Have determined that the remaining percentages will not be paid to districts until the completion of four quarters of Random Moment Time Surveys (RMTS):
RMTS Q3-2014/15
RMTS Q4-2014/15
RMTS Q1-2015/16 (Averaged Quarter therefore no survey)
RMTS Q2-2015/16
RMTS Q3-2015/16
C. Will base the payments for the remaining percentages on the above RMTS results and calculations that are yet to be determined by DHCS/CMS.
D. Will not complete payment for the remaining percentages until the end of 2017 or 2018. Questions that SBR has for DHCS:
A. When will the funds be released to school districts?
B. Will the payments be made based on the original MAA invoice amounts or the RTC adjusted MAA invoices?
C. Why was the RTC process terminated? Why not complete it ASAP and reimburse districts at 100%?
D. What invoice methodology do districts employ for 2013/14?
E. This is the third change to the MAA invoice process, will DHCS modify it again?
-Michael deAnda
Hello,
With the uncertainty of the MAA Program, let's focus on the LEA Billing Program to help ensure your district continues Medi-Cal reimbursement.
We at SBR have enhanced our Medi-Cal billing system and it is easier than ever for school districts to capture all possible avenues of billing. Let us schedule a system demo and share with you what we have developed from listening to our users requests.
Four new CPT codes will replace the one code that is used now. These new codes will be incorporated into the SBR WEB-LEA assessment input screen and the LEA claim file will be adjusted to include these codes. SBR will amend our training material to reflect these changes and present this at our fall in-service for each of our clients.
Beginning July 1, 2016 school districts will be able to submit billing for SLP assessment and treatment services conducted by licensed Speech-Language practitioners via telemedicine which utilizes interactive audio, video or data communication.
Click Here for more information
CMS is requiring that California’s Medi-Cal LEA Billing Option Program transition to the use of RMTS as a part of the Medicaid reimbursement methodology. The results of the RMTS will be used to determine direct services percentages. DHCS submitted their SPA by the CMS required deadline of September 30, 2015 and CMS responded on December 10th requesting changes. There is no information as of yet regarding instructions, training and new cost reporting formats. Under the new methodology, practitioners will continue to document their services; RMTS will not replace qualification or documentation requirements. The process for approving this SPA could take several years.
ICD-10 implementation, which replaced the ICD-9 codes, was effective on October 1, 2015. This was a nationwide implementation deadline established by the Federal government. In July 2015, CMS announced a one-year grace period on ICD-10 claims, stating that claims won’t be denied because the ICD-10 wasn’t specific enough. SBR had the new codes up and running for the October 2015 billing submissions.
The latest SPA proposes changes that include adding new assessment and treatment services; new practitioner types; and a Random Moment Time Survey (RMTS) methodology to the LEA Medi-Cal Billing Option Program. Of great interest is the inclusion of personal care as a new billable treatment and the addition of SLPA’s and Psych Interns to the list of eligible practitioners.
The Free Care Policy was approved by Governor Brown on October 8, 2015. This new law requires DCHS to seek Federal Financial Participation on behalf of school districts for services delivered to a Medi-Cal eligible child regardless of whether or not the child has an IEP or IFSP in place. The law will also require that the district pursue payment or denial from a legally liable 3rd party insurance. However, if the legally liable 3rd party does not respond within 45 days to the districts reasonable request for payment or denial, the law authorizes the district to submit billing to Med-Cal. Notice of the 3rd party request must be kept on file with the district for three years. The SPA 15-021, which addresses these changes, is not yet approved by CMS and districts should not move forward with billing for non IEP/IFSP services until they receive confirmation to do so by DHCS.
As of July 1, 2015, the Evergreen PPA will replace the previously required three year PPA. This new agreement will remain in effect perpetually until terminated by either DHCS or the school district.
The Provider Participation Agreement for SY 2013-14 has been extended; it is now due November 30 2014.
Quarter 1 Invoices for Fiscal Year 2013-14 have been extended from December 31 2014 to April 30, 2015. This means that all Invoices for School Year 2013-14 are now due by April 30, 2015.
The newest DHCS SMAA update postponed the conference call with stakeholders set for the week of June 23, 2014 to a later undetermined date in order to give DHCS more time to come up with a more detailed outline of how they will implement RMTS for this school year.
The good news is DHCS has begun to accept RTC submission and submit invoices to CMS for payment. The deadline for resolving the deferred invoices that were paid for the Quarters December 2011, March 2012, and June 12 is September 30, 2014. The September 2012 invoice deadline is October 31, 2014.
DSMAA Time Survey Submission deadlines have been changed for all Fiscal years. DHCS provided a chart outlining claims submission deadlines per Quarter per Fiscal year.
DHCS announced that CMS has decided to move forward with RMTS the implementation will take place July 1 2014. The plan was submitted to CMS for approval June 16 2014. Next Steps for RMTS have been posted with a rough outline of how RMTS will be implemented. The first Moments are set to be issued September 2014.
DHCS has scheduled a conference call with stakeholders for the week of June 23, 2014
The next SMAA Stakeholders Forum will take place on March 24th in Sacramento. SBR will attend, and will announce any new news.
DHCS has asked CMS to prolong the current billing module for the 2014-2015 school year, and implement the RMTS module for the 2015-16 school year. Although the state of California is still making plans to move to RMTS for next year, we will have to wait and see what happens!
The first SMAA Stakeholders Forum took place at DHCS Headquarters in Sacramento. Centers for Medicare and Medicaid Services (CMS) has not yet approved regulations for SMAA Random Moment Time Study (RMTS) in California. Also, DHCS removed the three to five year RMTS experience requirement for vendors and instead require that they have experience working with the SMAA Program.
PPL No.14-004Q4 MAA time survey will begin Monday April 28. LEA’s Participant Universe Grid is due to DHC by March 28th.
PPL No.14-001Q3 MAA time survey will begin Monday March 24. LEA’s Participant Universe Grid was due to DHCS by February 24th.
PPL-13-012
: DHCS in conjunction with CMS has developed a process (Reasonableness Test Criterion-RTC) to adjudicate deferred MAA invoices for 2010/11 thru 2013/14. School districts must perform this analysis:
Review and remove all job classifications that are not found in the following Attachment from the claiming unit of any given invoice. If there is a need for specific job classifications that are not listed then the LEA must complete the RTC Certification Form in order to justify the additional positions, and attach a job description/duty statement.
Review all clerical and administrative job classifications and limit the overall number of positions to no more than twenty percent of the total number of job classifications in the participant universe. For example if a district has 100 MAA Participants, the district would be limited to a maximum of 20 combined Administrators and classified staff. If there is a need for specific job classifications to exceed this percentage, the LEA must complete the RTC Certification Form in order to justify the additional positions, and attach a job description/duty statement.
Review overall Time Survey Results to make sure that participants did not exceed Benchmark Time Survey Percentages set by DHCS. This criterion will be used in order for DHCS to determine the level of detail required to review the overall Time Survey results.
Once this analysis has been completed and the requisite document(s) prepared, LEA’s must submit the RTC Certification form and if necessary, revised MAA invoice packet(s) to DHCS. DHCS will review these forms and if approved will forward the package to CMS for their final approval.
All materials must be gathered, reviewed and submitted within the next six months to DHCS. Any packages received after 04/30/2013 will forfeit reimbursement.
SBR is meeting with our clients in order to assist with completing these forms to ensure timeliness and compliance.
PPL-13-008
-2013-2014 Quarter 2 MAA Time Survey Dates have been informally announced. The Survey week is set to begin Monday December 9th and ends Friday December 13th. Prior to the Time Survey Week, Districts must clearly identify the Time Survey Participant Population. The following forms must be completed for each LEA and approved by DHCS before December 9th:
These forms must be turned into DHCS no later than November 25th!
Although CMS has yet to approve this plan, SBR will be meeting with our clients to assist with completing these forms to ensure timeliness and compliance.
As of August 15th, 2013, DHCS completed the following milestones as requested by CMS:
Reasonable test to be applied to Certification of deferred MAA invoices
New time study methodology based on Random Moment Time Study (RMTS) for SFY 2014-15
Back casting methodology from statewide RMTS to reconcile SFY 2012-13 and SFY 2013- 14 MAA claims
Before approving an interim claiming for SFY 2013-14, CMS has requested that DHCS complete the above tasks. DHCS has not made public any details of these items. SBR has requested clarification of item number 3.
Pending DHCS/CMS tasks
CMS approval of the above milestones
Restart the Certification process for deferred MAA invoices
DHCS Preparation of a “Progress Report of Deferral Status and Supporting Documentation” due by August 31, 2013. This report will be shared with the LEC and LGA Coordinators. LEAs may also request their specific information from DHCS. The report will show the:
name of the school claiming unit
date received
date reviewed and approved by DHCS
date submitted to CMS
approval from the deferral certification process
DHCS development of a Q&A document based on inquiries received through the mailbox. This document will be made public through the SMAA web page and will be updated periodically.
SBR Comments on deferred MAA invoices
DHCS just recently, August 15th, submitted their “reasonable test” to CMS and CMS will review and possibly approve it soon. We know that for the past 2-3 months DHCS and CMS have been working on this, so the approval might be quick in coming. However, DHCS and then CMS will review and approve the backlog of MAA certifications, which could take months. Hopefully we get a better picture once DHCS publishes their report.
The link below is a letter from the Superintendent of the California Department of Education (CDE), Tom Torlakson, to Diana S. Dooley, the director of the California Health and Human Services Agency (DHHS). DHHS oversees the Department of Health Care Services (DHCS). DHCS is the California agency that is responsible with implementing and managing the Medi-Cal (Medicaid) program in California. The issue of the MAA Deferral has now reached the highest levels of California State government thanks to the efforts of school districts who have appealed to CDE to intervene on this matter. We can only hope that Mr. Torlakson’s efforts can expedite the pending review process of participating districts’ MAA Certification with DHCS and finalizing the MAA methodology for this 2013/14 school year.
As identified in the link below to a PPL from DHCS, school districts are no longer required to employ a full time provider in order to bill for contracted services in a provider category.
Many school districts have not been able to claim for contracted services because they could not justify a full time employee for a Provider category. SBR has seen the following provider categories fall into this dilemma:
Occupational Therapy
Physical Therapy
Nursing Services
Counseling Services
School districts that provide health services to students that are prescribed in an IEP are no longer restricted from billing Medi-Cal based on those services being provided by contracted agencies (personal, private, or public). This will enhance Medi-Cal billing for districts.
You may be aware that the DHCS MAA online training scheduled for June 7th was postponed with no information on a new date and, for that matter, no information on how and when the MAA time survey will take place in the fall. We are hearing rumors that the state will average Q1 but that is not confirmed. We do know that CMS (Centers for Medicare and Medicaid Services) has notified DHCS that the state of California must have a new MAA implementation plan by September 1, 2013. At this point there are no details of what the new plan might look like and we, like all other vendors, are waiting for program direction from DHCS
Centers for Medicare and Medicaid Services (CMS) Deferral of MAA Payments Status – (Statewide data)
DHCS has received 665 MAA Invoice certifications from the 920 district MAA claiming units.
DHCS has submitted 251 certifications to CMS.
CMS has approved 54 certifications and released those districts from deferral status.
MAA Invoices are eligible for payment when a district is released from the deferral status.
DHCS is developing a deferral certification progress report to share with Co-Chairs of the Local Educational Consortium (LEC) Advisory Committee and the Local Governmental Agency (LGA) Committee. The information will be shared with districts.
Site Coordinators will be coming around with your MAA Time Surveys. Let’s get these signed sealed and delivered back to your district office.
Given the uncertainty of the MAA Program and the frozen MAA reimbursement stream, we at SBR want to help your district focus on maximizing the LEA Billing Program. We updated our LEA WEB system in January of 2013 and our clients are impressed with the result as it is now easier than ever. If you’re looking for a new system call us today.
Xerox; contracted in October of 2011 by DHCS to process claims, is undergoing system maintenance which will delay the LEA claims processing for districts. It appears that Xerox is in the process of transitioning to 5010 compliance which has resulted in system problems for the time being.
Our online billing service now supports multiple browsers (including iPads and Android based tablets.)
