Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.04-070 - Children's Services Targeted Case Management Update Transmittal #5

Current through Register Vol. 49, No. 6, June, 2024
SECTION II
			 CHILDREN'S SERVICES TARGETED CASE MANAGEMENT CONTENTS
200.000 CHILDREN'S SERVICES TARGETED CASE
			 MANAGEMENT GENERAL INFORMATION
201.000
Arkansas Medicaid Participation
			 Requirements for Children's Services Targeted Case Management (TCM)
			 Program
The provider of targeted case management for Children's
				Services must meet the following criteria in order to be eligible for
				participation in the Arkansas Medicaid Program:
A. The Children's Services targeted case
			 management (TCM) provider must complete a provider application (form DMS-652),
			 a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification
			 Number and Certification (form W-9) with the Arkansas Medicaid Program.
View or print a provider application (DMS-652), a Medicaid
			 contract (DMS-653) and a Request for Taxpayer Identification Number and
			 Certification (W-9).
B. The provider application (DMS-652) and
			 Medicaid contract (DMS-653) must be approved by the Arkansas Medicaid
			 Program.
C. The Children's Services
			 targeted case management staff must be licensed or certified in accordance with
			 the requirements in Section
			 201.100 to serve their respective
			 target population.
201.100
Qualifications of Children's
			 Services TCM Provider
Providers of Children's Services targeted case management
				services must be certified and have a demonstrated capacity to provide all core
				elements of case management, which includes:
A. Assessment
B. Care or service plan
C. Development
D. Linking or coordination of
			 services
E. Reassessment
F. Follow-up of services
The case management staff for targeted case management for
				Children's Services may include registered nurses, licensed social workers,
				pediatricians, registered dieticians, parent aides and clerical support staff
				who are credentialed or who are under the direct supervision of an
				appropriately credentialed case manager.
The qualifications for credentialed case manager
				include:
A.
Registered
			 Nurse
This individual must be licensed as a registered nurse by the
				Arkansas Board of Nursing and have satisfactorily completed a one-month
				(four-week) case management orientation provided by Children's Services.
B.
Social
			 Worker
This individual must be a licensed social worker in the State
				of Arkansas or be qualified through education, training or experience to work
				in a social work role and have satisfactorily completed a one-month (four-week)
				case management orientation provided by Children's Services.
C.
Pediatrician
This individual must be a licensed M.D. in the State of
				Arkansas and have satisfactorily completed a one-month (four-week) case
				management orientation provided by Children's Services.
D.
Parent Aide
This individual must be employed by Children's Services for the
				purpose of assisting families to access services and be a parent of a child
				with special health care needs. The parent aide must have satisfactorily
				completed the one-month (four-week) orientation provided by Children's
				Services. A parent aide cannot be a case manager of his or her own
				child.
E.
Clerical Support Staff
This individual must have two years of experience with a
				program for children with special health care needs; experience with assisting
				families to obtain needed medical, social and educational services and must
				have demonstrated the ability to assist families appropriately to access needed
				services. The individual must have satisfactorily completed a two-week
				orientation training class with Children's Services.
202.000 Children's
			 Services Targeted Case Management Providers in
Bordering and Non-Bordering States
The Arkansas Medicaid Children's Services Targeted Case
				Management Program is limited to in-state providers only.
210.000 PROGRAM COVERAGE
210.100 Introduction
Children's Services serves as the Title V (Children with
				Special Health Care Needs) Agency within the single state agency, the
				Department of Human Services.
211.000 Scope
Medicaid-covered Children's Services targeted case management
				services are services that assist recipients in accessing needed medical,
				social and other support services appropriate to the recipient's needs.
Children's Services targeted case management services are
				covered when they are:
A. Medically
			 necessary;
B. Provided to
			 outpatients only;
C. Provided at
			 the option of the recipient and by the provider chosen by the
			 recipient;
D. Provided to
			 recipients who have no reliable or available support to assist them in gaining
			 access to needed care and services;
E. Services that directly affect the
			 recipient but may not require the recipient's active participation (e.g.,
			 housing assistance) and
F.
			 Furnished in accordance with a service plan.
212.000 Target Population Covered by
			 Children's Services
Children's Services targeted case managers are restricted to
				serving recipients who are not receiving case management services under an
				approved waiver program, are not placed in an institution and are:
A. Aged 0 to 21 years and meet the medical
			 eligibility criteria of Children's Services;
B. Recipients in the state's Title V Children
			 with Special Health Care Needs Agency or
C. SSI/TEFRA Disabled Children Program
			 recipients, aged 0 to 16 years, with any diagnosis.
213.000 Description of Service Activities
Children's Services must provide the following targeted case
				management activities.
A. Needs
			 Assessment
1. A written comprehensive
			 assessment (by Children's Services) of the child's needs, including analysis of
			 recommendations (e.g., medical records) regarding the service needs of the
			 child.
2. Review of records of
			 medical/psychological evaluations in order to assess the child's
			 needs.
3. Development of a service
			 plan with the family.
4. Assisting
			 the recipient in accessing needed services.
B. Service Plan
Monitoring the child's progress by making referrals to service
				providers through telephone, written or personal contacts; tracking the child's
				appointments; performing follow-up on services rendered and performing periodic
				reassessments of the child's changing needs (including reviews of the child's
				medical records).
C.
			 Preparing and maintaining case records and documenting contacts, needed
			 services, reports, and the child's progress, etc. These activities may apply to
			 either the needs assessment or the service plan.
214.000
Exclusions
Services not appropriate for Children's Services targeted case
				management and not covered under the Arkansas Medicaid Program include, but are
				not limited to:
A. Targeted case
			 management for recipients who are receiving case management services through
			 the DDS Alternative Community Services Waiver Program.
B. The actual provision of services or
			 treatment. Examples include, but are not limited to:
1. Training in daily living skills.
2. Training in work skills, social skills
			 and/or exercise.
3. Training in
			 housekeeping, laundry and cooking.
4. Transportation services.
5. Counseling or crisis intervention
			 services.
C. Services
			 that go beyond assisting individuals in gaining access to needed services.
			 Examples include, but are not limited to:
1.
			 Supervisory activities.
2. Paying
			 bills and/or balancing the recipient's checkbook.
3. Observing a recipient receiving a service,
			 e.g., physical therapy, speech therapy and classroom instruction.
4. Travel and/or waiting time.
D. Case management services that
			 duplicate services provided by public agencies or private entities under
			 another program authorized for the same purpose. For example, targeted case
			 management services provided to foster children duplicate payments made to a
			 public agency and are therefore not reimbursable.
E. Case management services that duplicate
			 integral and inseparable parts of other Medicaid or Medicare services (for
			 example, home health services) when provided on the same date of
			 service.
F. Case management
			 services provided to inpatients. Discharge planning is a required service of
			 inpatient facilities. These facilities include, but are not limited to acute
			 care hospitals, rehabilitative hospitals, inpatient psychiatric facilities,
			 nursing homes and residential treatment facilities.
G. Case management services provided while
			 transporting a recipient.
H. Time
			 spent billing for targeted case management services.
I. Time spent determining medical and
			 financial eligibility for Children's Services.
J. Any activity related to Children's
			 Services authorization and payment of services.
215.000 Documentation Requirements
The Children's Services targeted case management providers must
				keep and properly maintain written records. At a minimum, the following records
				must be included in the provider's files.
215.100 General Records
General records that must be available for review
				include:
A. A copy of the Arkansas
			 Medicaid contract (form DMS-653) for participation in the Arkansas Medicaid
			 Program.
Copies of the Children's Services TCM staff's licensures and/or
				certifications.
215.200 Documentation in Recipient Files
The Children's Services targeted case manager must develop and
				maintain sufficient written documentation to support each service for which
				billing is made. All entries in a recipient's file must be signed and dated by
				the Children's Services targeted case manager who provided the service, along
				with the individual's title. The documentation must be kept in the recipient's
				case file.
Documentation should consist of, at a minimum, material that
				includes:
A. When applicable, a copy
			 of the original and all updates of the recipient's individualized education
			 plan (IEP) or individualized family service plan (IFSP).
B. The specific program services
			 provided.
C. The date services are
			 provided.
D. Updated progress notes
			 describing the nature and extent of specific services provided. Progress notes
			 are signed electronically.
E. The
			 recipient's name and Medicaid identification number.
F. The name and title of the Children's
			 Services targeted case manager providing the service.
G. A copy of the original and all updates of
			 the Children's Services recipient's service plan.
215.300 Record Keeping Requirements
All records must be completed promptly, filed and retained for
				a period of five (5) years from the date of service or until all audit
				questions, appeal hearings, investigations or court cases are resolved,
				whichever is longer.
All documentation must be made available, upon request, to
				authorized representatives of the Arkansas Division of Medical Services, the
				state Medicaid Fraud Control Unit, representatives of the Department of Health
				and Human Services and its authorized agents or officials.
At the time of an audit by the Division of Medical Services
				Medicaid Field Audit Unit, all documentation must be available at the
				provider's place of business during normal business hours. Requested
				documentation that is stored off-site must be made available to DMS personnel
				within three (3) business days.
If an audit determines that recoupment of Medicaid payments is
				necessary, DMS will accept additional documentation for only thirty days after
				the date of notification for recoupment. Additional documentation will not be
				accepted later.
Failure to furnish records upon request may
				result in sanctions being imposed.
240.000
PRIOR AUTHORIZATION
Prior authorization is not required for Children's Services
				targeted case management services.
250.000
REIMBURSEMENT
250.100
Method of Reimbursement
Reimbursement is based on the lesser of the billed amount or
				the Title XIX (Medicaid) maximum allowable for each procedure.
Reimbursement is contingent upon eligibility of both the
				recipient and provider at the time the service is provided and upon accurate
				completeness of the claim filed for the service. The provider is responsible
				for verifying the recipient is eligible for Medicaid prior to rendering
				services.
Children's Services targeted case management services must be
				billed on a per unit basis. One case management unit is the sum of all
				Children's Services targeted case management activities that occur within a
				day.
251.000
Rate
			 Appeal Process
A provider may request reconsideration of a Program decision by
				writing to the Assistant Director, Division of Medical Services. This request
				must be received within 20 calendar days following the application of policy
				and/or procedure or the notification of the provider of its rate.
Upon receipt of the request for review, the Assistant Director
				will determine the need for a program/provider conference and will contact the
				provider to arrange a conference if needed. Regardless of the program decision,
				the provider will be afforded the opportunity for a conference for a full
				explanation of the factors involved and the program decision.
Following review of the matter, the Assistant Director will
				notify the provider of the action to be taken by the Division within 20
				calendar days of receipt of the request for review or the date of the
				program/provider conference.
If the provider disagrees with the decision made by the
				Assistant Director, the provider may appeal the question to a standing rate
				review panel established by the Director of the Division of Medical Services.
				The rate review panel will include one member of the Division of Medical
				Services, a representative of the provider association and a member of the
				Department of Human Services (DHS) management staff, who will serve as
				chairperson.
The request for review by the rate review panel must be
				postmarked within 15 calendar days following the notification of the initial
				decision by the Assistant Director of the Division of Medical Services. The
				rate review panel will meet to consider the question(s) within 15 calendar days
				after receipt of a request for such appeal. The panel will hear the question(s)
				and will submit a recommendation to the Director of the Division of Medical
				Services.
260.000
BILLING PROCEDURES
261.000
Introduction To Billing
Children's Services targeted case management providers use the
				CMS-1500 form to bill the Arkansas Medicaid Program on paper for services
				provided to eligible Medicaid recipients. Each claim may contain charges for
				only one recipient.