Medical Services Required Practices Handbook August 6, 2015 PURPOSE OF THE MEDICAL SERVICES REQUIRED PRACTICES HANDBOOK 1 INTRODUCTION 2 PROVIDING EXCELLENT PHYSICAL RESTORATION SERVICES 3 HANDBOOK GOALS 4 CENTRAL OFFICE SUPPORT 4 4 4 (CRS) 4 5 DEFINITIONS 5 CASE MANAGEMENT 8 PHYSICAL RESTORATION SERVICE REQUESTS 9 COURTESY CASE RECEIPT AND ACKNOWLEDGEMENT 10 CONFIDENTIALITY OF CONSUMER RECORDS 10 CONSUMER HEALTH INFORMATION 11 OUT OF REGION HOSPITAL OR FACILITY SERVICES 12 SERVICE COORDINATION 14 GENERAL INFORMATION 15 15 MEDICAL AND COMPREHENSIVE REHABILITATION PROGRAM PROGRAM FOR FOR SPECIALIST FOR PROGRAM REHABILITATION PROGRAM SPECIALIST SPECIALIST
BASED COMPARABLE BENEFITS 15 PROVIDERS SPECIFICATIONS 16 PROFESSIONAL MEDICAL SERVICES 17 17 18 HOSPITAL BASED SERVICES 20 - 20 22 24 (PABI) 26 MEDICAL COMPLICATIONS FOLLOWING SURGERY 29 29 29 UNITS OF SERVICE 30 REDUCED PAYMENT AGREEMENTS 30 COORDINATING NON-CONTRACT HOSPITAL SERVICES 30 IMPLANTABLE DEVICES USED IN SURGERY 31 ROBOTIC ASSISTED SURGERY 32 REQUEST TO EXCEED MAPS 32 BARIATRIC SURGERY 32 MULTI-DISCIPINARY PRE-BARIATRIC OR WEIGHT LOSS PROGRAMS 32 BUDGET BUSTERS 33 HOSPITAL DISCHARGE SERVICE COORDINATION 33 CASE CLOSURE 34 34 34 PURCHASING MEDICAL SERVICES 36 PROCUREMENT STANDARDS 37 PURCHASE ORDERS 38 38 38 39 39 39 MEDICAL SERVICES PURCHASED BY MAXIMUM AFFORDABLE PAYMENT SCHEDULE (MAPS) 41 (ASC) 41 MAPS 42 MEDICAL SERVICES PURCHASED BY CONTRACT 43 43 (PABI) 44 (DME) 44 NON-CONTRACT DURABLE MEDICAL EQUIPMENT AND SUPPLIES 46 MEDICATION 46 COMPARABLE BENEFITS 46 (EOB) 46 47 47 / (PPO) / (HMO) 48 APPLYING COMPARABLE BENEFITS TO PHYSICAL RESTORATION SERVICES 49 49 SERVICES NECESSARY UNPLANNED AND PURCHASE ORDERS AND MEDICARE HOSPITAL PHYSICIAN MEDICAID COMPLICATIONS DISCHARGE PURCHASE PROVIDER DOCUMENTATION INSURANCE COMPLETED PREFERRED
SURGERY GUIDELINES 53 53 53 53 – 54 ANESTHESIA 54 55 PAYING MEDICAL SERVICE INVOICES 58 58 59 59 61 PURPOSE OF THE CRS 62 GUIDANCE ON MEDICAL CASE ISSUES 62 IMPORTANCE OF CLOSE CASE MONITORING 62 PURCHASING CRS SERVICES 63 CRS 63 CRS SERVICES 64 CREATING SERVICE RECORDS ISSUING CRS CONSUMERS WITH COMPARABLE BENEFITS 64 SERVICES THAT CAN BE PURCHASED THE CONSUMER IS ON THE CRS INTEREST WAITING LIST 65 SPECIFIC CRS SERVICES 66 (PABI) 66 68 68 (DME) 69 69 69 69 69 INTERCURRENT ILLNESS 70 PAYING CRS INVOICES 70 CRS 70 CASE CLOSURE 70 MSC-MST ADMINISTRATIVE ACTIVITIES 71 MEDICAL SERVICES COORDINATOR ESSENTIAL JOB FUNCTIONS 72 MEDICAL SERVICES COORDINATOR RESPONSIBILITIES 72 72 73 DRS 73 73 74 MSC MONTHLY ACTIVITY REPORT 74 MSC MONTHLY ACTIVITY REPORT FORM 75 RESOURCES 77 COURTESY CASE CHECKLIST 78 SURGERY SCHEDULING REQUEST 79 A PROVIDERS SERVICES SERVICES AND COMPREHENSIVE AND REHABILITATION PROGRAM DURABLE EQUIPMENT AND PROVIDER CROSSWALK AND AND
Transportation, mileage reimbursement per RPM, billed charges, or negotiated rate If consumer has verified comparable benefits, create service records the consumer portion not covered by the comparable benefit as the cost for the service. The consumer portion amount cannot exceed the hospital contract rate or the MAPS rate for the ancillary service whichever one applies. If consumer comparable benefits cannot be verified, create service records as if the consumer does not have any comparable benefits. If hospital cost is estimated to be $30,000 or above, follow encumbrance guidelines in the SERVICE COORDINATION – BUDGET BUSTERS. Contact counselor Provide total estimate for requested service(s) and anticipated ancillary services. Discuss Budget Busters if hospital cost is estimated to be $30,000 or greater and inform counselor that only $30,000 will be encumbered from the counselor’s budget and the remaining estimated cost will be requested from Budget Busters. Obtain counselor approval of encumbrance. Document contact and approval in a case note. Contact surgeon or surgeon’s representative. Obtain surgery date. Note: In some the consumer schedules the surgery date. Advise that purchase order(s) will be mailed or faxed. Issue purchase order(s) and send copy to surgeon, hospital, and ancillary service providers. Review the service records to confirm information is correct and ensure accurate purchase will be generated. Issue purchase order(s) for planned service and all anticipated ancillary services. If comparable benefits are verified, or reported but not verified, note the specific comparable benefit in the Payment or Special Instructions section of the purchase order and request a copy of the Explanation of Benefits with the invoice for payment. Fax or mail purchase order(s) to surgeon, hospital and any ancillary service providers. Document the specific surgery, name of surgeon, hospital, and date of scheduled surgery in a case note. Also, include a list of ancillary providers and services purchased. Coordinate surgery date and pre-operative instructions with consumer. Contact the consumer by phone or letter to either notify the consumer of the scheduled surgery date or request that the consumer schedule the surgery date and notify the MSC. Verify if consumer has received any special pre-operative medical instructions from the surgeon’s office. Notify counselor of consumer’s surgery date. Contact hospital. Contact hospital to confirm consumer’s discharge date.
Physician Chiropractor Physician Assistant Nurse Practitioner Medical Evaluation Treatment MAPS Medical Report or Office Notes Surgeon Surgical Assistant Surgery MAPS Operative Report Anesthesiologist Certified Registered Nurse Anesthetist (CRNA) Anesthesia for diagnostic or surgical procedures MAPS Calculation using Anesthesia Crosswalk & Log Hospital Anesthesia Log & Surgeon’s Invoice with CPT Codes Therapy Clinic Occupational Therapy Physical Therapy Speech Therapy Cognitive Therapy MAPS Therapy Notes Lab/Pathology/Radiology Diagnostic Testing Prof. Interpretation Technical Prof. & Tech. MAPS Diagnostic Test Report Prosthetist/Orthotist Prosthesis or Orthosis MAPS Case Note documenting receipt of prosthesis or orthosis Ambulatory Surgery Center Day Surgery (ASC) MAPS Discharge Summary and/or Operative Report MEDICAL SERVICES PURCHASED BY CONTRACT The Regional Consumer Contract Specialist (RCCS) is responsible for managing the contracts that DARS/DRS has with hospitals, PABI facilities, and durable medical equipment vendors. Notify the RCCS if the counselor/RST or MSC/MST notes any issues with billing or the delivery of medical services as identified in the contract. Use the DARS1303 Contractor Performance Report to document the issue or incident of non-compliance, or send an email to the RCCS and include the contractor’s name, contract number, Texas payee identification number, type of service provider, and date of non-compliance or incident, description of the issue and a chronology of actions taken by DRS staff.
Accept Usage Terms Select Search Criteria MEDICARE Home Page - Go To: Medicare Resources Search Tools Find a Doctor or Other Healthcare Professional Find a Provider Select Search Criteria TEXAS MEDICAID & HEALTHCARE PARTNERSHIP Home Page – Go To: Look for a Provider Select a Plan Select Search Criteria MEDICAL WEBSITES MedlinePlus: WebMD: Mayo Clinic: MEDICATION ASSISTANCE PROGRAMS Rx Assist Patient assistance program to help access free or low-cost meds. Created by Vounteers in Health Care, a national, nonprofit resource center for uninsured. Income eligibility requirements based on percentage of Federal Poverty Income Level (FPL). Resources for meds. Searchable database by drug or pharmaceutical company. Online applications available.
Rx Outreach Mail order discount drug program. Eligibility based solely on income. $20 for 180-day supply for more than 150 medications; same price for any dose or strength. Together Rx Access card Prescription discount for individuals/families with no prescription drug coverage. 25-40% savings on brand-name prescription products. Savings also available on generic drugs. Pharmacy locator for card use. 1-888-743-7214 Drugstore.com Online discount drug program. Discounted medicines up to 70% on generic prescription drugs, up to 30% on brand-name prescription drugs. Cost comparison listing. A+ rating from Better Business Bureau. 425-372-3200 MEDICATION ASSISTANCE PROGRAMS NeedyMeds.org 501(c) (3) founded in 1997 as a resource for information about patient assistance programs. Provides links to companies and programs offering low cost medications. Web site includes comprehensive lists of programs and companies offering lower cost meds. Can search by brand name drugs, generic drugs, programs, and companies Provides online PAP applications, medication coupons,