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I/DD Residential Billing Policy Changes, Provider Documentation Required

Date: 09/20/16

The following is a joint message from all 3 MCOs:


Per State Policy E2016-082, effective Sept. 1, 2016, the criteria for billing I/DD Residential Habilitation (T2016) has changed. In accordance with this policy, MCO care coordinators will be making adjustments to the integrated service plan for each member receiving Residential Habilitation to reflect the number of units per month the participant needs.

During initial implementation, Sept. 1 through Dec. 31, 2016, residential providers will be required to submit documentation supporting the actual utilization of residential services for each participant authorized for this service on Sept. 1, 2016.  Any new person approved for Residential Service after Sept. 1, 2016, will be assessed by the MCO to determine the number of monthly units needed.

This documentation will be utilized by the MCO care coordinator to adjust the participant’s integrated service plan to reflect actual, historical services utilized.  The MCO may also complete an assessment, if needed.

The definition of a Residential Habilitation service includes: “activities of daily living, such as, personal grooming and cleanliness, bed making and household chores, food preparation, and the social and adaptive skills necessary to enable the beneficiary to reside in a non-institutional setting.”

The staff member must have physically provided one of the defined services and provided, “assistance, acquisition, retention, and/or improvement in skills,” to the participant. The participant does not have to be present for all of the residential service provided. Residential Habilitation cannot be billed if the participant is absent from service for the entire 24 hour period (in the hospital, home visiting family, etc.)

Instructions:

  1. The provider of Residential Habilitation must complete this coversheet for each participant authorized for and participating in this service as of Sept. 1, 2016. The supporting documentation must include at least 90 days of data prior to the date of submission, unless the participant has not been in service the full 90 days.
  2. The supporting documentation must demonstrate the number of days, during the 90 day period, that the participant received a residential service as defined above.  The types of supporting documentation that can be submitted and the deadlines for submission are outlined below.
  3. The information must be submitted to the participant’s MCO, at the address indicated below. If emailed, please put, “Residential Documentation,” in the subject line and be sure to secure the email.

Deadline for Submission:

  • Participants Tiers 4 & 5: Due to MCO by Oct. 30
  • Participants Tier 3: Due to MCO by Nov. 30
  • Participants Tiers 1 & 2: Due to MCO by Dec. 30

Supporting Documentation:

At least one of the following types of supporting documentation must be submitted:

  • Direct Care Staff Case Notes indicating what Residential Service was physically provided to the participant for that day
  • Direct Care Staff timesheets or payroll indicating time worked physically providing a residential service for the participant
  • Behavioral or Health Data collected by Direct Staff with the participant during the course of the day
  • Medication Administration Records indicating the Direct Care Staff administered medication to the participant during that day
  • Skill Acquisition Data collected by Direct Staff with the participant during the course of the day
  • Member Activity Schedule confirming Residential Habilitation activities physically completed by the Direct Care staff with the participant during that day
  • On Call Response Log which indicates a staff person was sent to assist the member with a defined Residential Service, and the service was provided.

Once the MCO has received the coversheet and supporting documentation, the Care Manager may adjust the units for Residential Habilitation based upon the previous 90 days of utilization. The MCO may complete an assessment or request additional documentation, if needed. This documentation must be provided within 5 business days by the provider.

If the units of service are changed, the MCO will provide the revised ISP, authorization letters, and Notice of Action to the provider and member.

For questions the provider may contact each MCOs customer service center.