consumerlink provider orientation packet

Provider Orientation Packet

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This document Revised April 2015

• A “clean claim” paid by the MCPN to any subpanel provider organization, SHALL MEET ALL OF THE FOLLOWING CRITERIA:

– A covered service defined in the Person’s applicable benefit plan, as contained in the Authority’s “Covered Benefits Policy” guideline (Note: Medicaid, Healthy Michigan, General Fund, or the General Fund Exception);

DWMHA “Clean Claim” Standards

• A “clean claim” … shall meet all of the following criteria:

– The Person having an assessed need completed by a qualified credentialed practitioner, with supporting evidence contained in the medical record;

– The covered service is documented in the person’s “Person-Centered Plan” (and IPOS), as an authorized medically necessary service;



– Documentation in the medical record that details what covered services were provided to the individual on the date of the service [e.g. a progress note or assessment];


• A “clean claim” … shall meet all of the following criteria:– Documentation in the medical record that

the covered service was provided by an appropriately credentialed practitioner, qualified to render the covered service (Note: in the case of CLS, staff must have current training and meet the standards in the Medicaid manual);

– Documentation in the medical and/or administrative records that the Provider Organization maximized all applicable first and third party payments due prior to submitting a claims encounter to the MCPN and…



– Assurance that the claim encounter was submitted timely [60 days from date of service] and in accordance with the ConsumerLink’s claims payment protocols


• For Providers of Community Living Supports, Respite, and/or Supports Coordination

• This area is not applicable to other service providers and can be skipped in those situations

Progress Note Information

• Completes top portion of provider progress note regarding:

– Member information

– Relevant expected outcome, goal statement from IPOS and/or FAST

Role of the Supports Coordinator or Therapist

• Completes top portion of provider progress note regarding:

– Interventions and action steps indicated in IPOS/FAT pertaining to expected delivery of Community Living Supports, Personal Care and/or Respite.

– Faxes a copy of the progress note with completed top section to the staffing provider.



• Provides in-service/orientation to the staffing provider staff within 30 days of the IPOS or service authorization effective date and reviews expected service delivery areas in the IPOS and as described in the provider progress note.

• Reviews provider progress notes monthly for provision of services identified in IPOS and progress toward identified outcomes and updates the PCP/IPOS as needed.

• Initials progress notes to indicate review (7 days).


• Ensures that a copy of the IPOS, including the current FAST, and any plans related to ancillary staff (psychology, occupational therapy, dietary, etc.) are available on site AND in DASH for staff review at supported housing and specialized residential sites.

• For Community Living Supports provided in the family home (H2015) or In-home Respite services (T1005), documents listed above should be made available at the staffing provider’s office.


• Provides copies of progress notes for review by supports coordinator a minimum of monthly, during site visits or upon request of documents for review if CLS is being provided in the family home (H2015)

• Contacts Supports Coordinator or Supports Coordinator Supervisor with concerns about delivery of services according to IPOS defined scope, duration and frequency or changes in level of need.


• Delivers and describes services according to Medicaid service definitions:

– Community Living Services (CLS)

– Personal Care (PC)


• Completes one progress note daily on each CLN member indicating:

– Start and stop time of delivery of each service provided (CLS, Personal Care and/or ancillary plan interventions)

• Times do not have to be back to back

• Entries can indicate CLS services not connected to a goal but evident from the FAT assessment tool as a skill that the person needs to develop.


• When documenting time you should reflect actual time spent as closely as possible

• Avoid rounding up

Role of Staffing Provider

• Marks objective from IPOS (uses codes provided on the Progress Note)

• Example: Under CLS Joan has 3 areas she is working on under Safety. “B” is to work on learning to identify risk factors in the home. You work with Joan for 20 minutes on this area. You would document “CLS “B”) under the “Objective Area from IPOS” column of your Progress Note.


• Indicates Progress based on measurable outcome identified and/or intervention described by marking the correct box (Decreased, Same, or Improved).

• Provides additional Comments as needed on the progress note

• Signature and initials of each staff completing the progress note should be present.


Documenting Shifts

• Daily notes should always consistently show average hours of services to match FAST/IPOS during a 24 hour period.

• Notes should reflect IPOS/FAT identified needs and priorities related to both CLS and Personal Care if in a specialized residential facility.


Documenting Overnight Shifts

– If staff are present during sleeping hours and the IPOS states specific need for nighttime monitoring or interventions – Progress notes should show this.


• Community Living Supports are used to increase or maintain personal self-sufficiency, facilitating an individual’s achievement of his goals of community inclusion and participation, independence or productivity.

• Coverage includes:– Assisting, reminding, observing, guiding

and/or training in the following activities:

Definition of CLS

• Coverage includes: Assisting, reminding, observing, guiding and/or training in the following activities:

– meal preparation– laundry– routine, seasonal, and heavy household

care and maintenance– activities of daily living (e.g., bathing,

eating, dressing, personal hygiene)– shopping for food and other necessities

of daily living

Definition of CLS & What to Document

• Staff assistance, support and/or training with activities such as:– money management– non-medical care (not requiring nurse or

physician)– socialization and relationship building– transportation from the beneficiary’s

residence to community activities, among community activities, and from the community activities back to the beneficiary’s residence


• Staff assistance, support and/or training with activities such as:

– participation in regular community activities and recreation opportunities (e.g., attending classes, movies, concerts and events in a park; volunteering; voting)

– attendance at medical appointments– acquiring or procuring goods, other than

those listed under shopping, and– Reminding, observing and/or monitoring of

medication administration


• Respite services are available for CLN members only.

• The Respite provider should never provide Respite for other (none CLN) family members.

• Can be provided to more than one CLN member residing in the same home at the same time, however, the services must be documented on separate progress notes and it must be part of all the Plans.

Respite

ConsumerLink delegates some authorizations to the Supports Coordination Agencies (SCAs)

What follows is a description of what services require a prior authorization and who is responsible for providing

Authorized Services

• ConsumerLink is responsible for entering the prior authorizations via its Clinical Care Managers for the following services:

– Community Inpatient Hospitalization– State Hospitals– Personal Care and/or Community Living

Supports in a Licensed Setting (T1020 and H2016)

– Community Living Supports, per diem (H0043)

ConsumerLink Authorized Services

• Crisis Residential• Partial Hospitalization• Durable Medical Equipment• Assistive Technology• Environmental Modifications• Housing Assistance


• Enhanced Pharmacy• Electroconvulsive Therapy• Any outlier case or special circumstances –

those outside of established guidelines– For questions about ConsumerLink

authorized services call the main switchboard at 313-656-0000 and ask for a ConsumerLink representative


• PT, OT and/or Speech and Language Therapy

• Nursing Services – including Private Duty• Routine Community Living Supports• Respite• Therapeutic Camp• Some Assessment or Treatment Planning

Services (check your contracted Benefit Array to see which of your services require an authorization)

SCA Authorized Services

• Many of the answers to your questions can be found in:

1. The Medicaid Manual – Go to michigan.gov– Enter “Medicaid Manual” in Search field

on the home page– It will be the first item in the search

results• Do not print – it is over 1700 pages

Resources

• For questions about SCA authorized services, call the specific provider– Typically it is best to speak to a

supervisor or director• If you have difficulty connecting with a

provider please inform ConsumerLink

SCA Authorized Services

• The HCPCS/CPT/Encounter Code Lists– This lists all covered services (Google the

line above along with “Michigan”)• One version contains the coverage

(State Plan, HAB Waiver, etc.)• Another version lists the type of staff

who can use the code (add “Profession” to your Google search)

Resources

• The Authority’s website has the benefit plan for MI Health Link (dual eligible or people with Medicare and Medicaid)

• Go to dwmha.com and click “Documents” on the home page

Resources

• ConsumerLink’s Provider Manual – Found at www.consumerlink.org in the

Provider Portal

Resources

http://www.consumerlink.org/

consumerlink provider orientation packet

Healthcare