Informational Memo #023-15 - Office of Developmental Programs

Informational Memo
CLARIFICATION ON INFORMATIONAL PACKET 045-14
MONEY FOLLOWS THE PERSON (MFP) INITIATIVE
BILLING FOR START-UP AND
SUPPORTS COORDINATION TRANSITION SUPPORT
ODP Communication Number: Memo 023-15
The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to
achieve greater independence, choice and opportunity in their lives.
AUDIENCE: Unlicensed and Licensed Waiver Funded Residential Habilitation Providers, Direct
Vendors, Organized Health Care Delivery System (OHCDS) providers, Supports
Coordination Organizations (SCOs) and Administrative Entities (AEs).
PURPOSE: This Office of Developmental Programs (ODP) communication is intended to clarify
the claims submission and billing requirements for providers to use when billing
PROMISeTM for approved Money Follows the Person (MFP) funding requests.
BACKGROUND
ODP Informational Packet 045-14 announced that the Centers for Medicare and Medicaid
Services (CMS) approved the Department of Human Services’ (DHS’s) MFP proposal. The
proposal provides enhanced federal matching funds to support the movement of people to
community settings. Informational Packet 045-14 also explained how providers may request
start-up funding or payment for supports coordination transition activities provided to a person
moving from a private or public intermediate care facility (ICF)/intellectual disability (ID) setting
to a waiver funded setting serving four or fewer people. Refer to Informational Packet 045-14,
page 2, for additional conditions that must be met in order to obtain MFP reimbursement.
DISCUSSION:
In order to receive payment for procedure codes W0400, MFP provider start-up, and procedure
code W0401, MFP supports coordination (SC) transition services; providers must adhere to
specific billing rules. Any deviation from these billing rules will cause your claim submission to
deny.
ISSUE DATE: 03/23/15
ODP COMMUNICATION NUMBER: Memo 023-15
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RULE 1:
For procedure codes W0400, MFP provider start-up, and W0401, MFP supports
coordination transition services, only one claim submission per service per
consumer is permitted to be submitted for payment.
RULE 2:
The date of service fields on the claim should reflect one day only and must
either be the same date or a greater date than the consumer’s effective date of
waiver enrollment.
RULE 3:
RULE 4:

PROMISeTM Internet and Provider Electronic Solutions Software (PES): The
dates of service fields on these two claim submission methods are called the
“From DOS” field and the “To DOS” field. These two fields are both required
fields on the transaction and must contain the exact same date. The date
entered must be the consumer’s effective date of waiver enrollment or a
later date.

CMS 1500 paper claim: There is a “From” and “To” field in the “Date(s) of
Service” block, which is Block 24a. ONLY complete either the “From” or the
“To” field NOT BOTH. Whichever field you choose to use, enter a date that is
either greater than or equal to the consumer’s effective date of waiver
enrollment.
The number “1” is required in the unit(s) field on the claim.

For both procedure codes W0400, MFP provider start-up and W0401, SC
transition services, enter the number “1” in the unit(s) field found on the
claim submission.

ODP recognizes that SC transition services has a 15 minute unit of service,
however, due to billing system restrictions, providers must enter the number
“1” in the unit field on the claim in order to be paid for these services.

NOTE: Units rendered for MFP provider start-up and MFP SC transition
services, are eligible for payment up to a maximum of 180 days prior to the
person’s waiver enrollment start date. Only waiver eligible SC activities are
reimbursable. The number of units billed must be substantiated by service
notes in the Home and Community Services Information System (HCSIS) and
marked as “non-billable”.
For procedure code W0401 only, MFP SC transition services, providers are
required to enter the accumulated units delivered for this service and the SC
ISSUED DATE 03/23/15
ODP COMMUNICATION NUMER: 023-15
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services rate per unit in a specific field on the claim. This field is referred to by
a different name for each of the following claim submission methods:
RULE 5:

PROMISeTM Internet: “Patient Account #” field. This field has a 38 character
limitation.

Provider Electronic Solutions Software (PES): “Account Number” field.

CMS 1500 paper claim: “Patient’s Account Number”, Block no. 26. This field
has a 10 character limitation.

NOTE: The units entered in this field should be based on 15 minute units of
service increments. For example, if the SC rendered MFP SC transition
services to the individual for a two week period and the accumulated units of
service delivered is 50 hours, 200 units would be entered in this field on the
claim.

The data entered in this field will appear on the remittance advice (RA).
Correct calculation of the dollar amount requested/billed amount on the claim.


The dollar amount requested, also referred to as the billed amount, for
services rendered is entered in a specific place on the claim depending on the
claim submission method:
-
PROMISeTM Internet and Provider Electronic Solutions Software (PES):
For these two claim submission methods the dollar amount the
provider is requesting for service(s) rendered is called the “Billed
Amount” field.
-
CMS 1500 paper claim: Enter the requested amount/billed amount
for services rendered in the field called “$Charges”, which is found in
Block 24F on the CMS 1500 paper claim form.
For procedure code W0400, MFP provider start-up:
For this particular service, enter the actual costs incurred up to the amount
approved by ODP on the claim. This dollar amount should not exceed
$5,000. If a dollar amount is submitted on the claim in excess of $5,000, the
claim will deny. If a dollar amount is submitted and it exceeds the amount
approved by ODP, the claim will deny.
NOTE: If you submit the incorrect dollar amount on your claim for this
service, you will not be able to adjust the claim or void it. Any adjustments
ISSUED DATE 03/23/15
ODP COMMUNICATION NUMER: 023-15
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or voids submitted after the original claim was submitted will be denied.
Therefore, it is very important that you review your claim prior to submission
and ensure the dollar amount/billed amount is accurate.

For procedure code W0401, MFP supports coordination transition services:
To calculate the dollar amount to enter in the “Billed Amount” or “$Charges”
field on the claim for this service, multiply your SCO (unit of service) rate by
the number of units of transition planning support/activities provided to the
individual. Depending on which claim submission method you use, the units
rendered to the individual should be entered/found in the “Patient Account
#”, “Account Number” or “Patient’s Account Number” fields on the claim.
POST CLAIM SUBMISSION PROCESS PERFORMED BY ODP
Claims submitted to PROMISeTM for procedure codes W0400, MFP provider start-up, and
W0401, MFP supports coordination transition services, will be suspended for review by ODP
Claims Resolution staff. ODP Claims Resolution staff will make a payment determination based
on:



NOTE:
Whether there is an ODP Regional Fiscal Office (RFO) approval on file;
The individual is enrolled in the Consolidated waiver; and
The provider requesting payment is authorized to provide waiver funded
services
All compensable expenses and services should be included on the initial invoice.
Claim adjustments and voids will be denied.
RESOURCES
The PROMISeTM Internet User Manual is available to assist providers with program specific
billing rules. Click on the following hyperlink to view this manual:
http://www.dhs.state.pa.us/cs/groups/public/documents/manual/s_002302.pdf
The Provider Electronic Solutions User Manual is available as a billing resource:
http://promise.dpw.state.pa.us/ePROM/_ProviderSoftware/PDFs/omapPESUserManual.pdf
The instructions provided in the CMS 1500 Billing Guide for ODP services are available at:
http://www.dhs.state.pa.us/cs/groups/webcontent/documents/manual/s_001927.pdf
ISSUED DATE 03/23/15
ODP COMMUNICATION NUMER: 023-15
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INQUIRIES
Questions regarding MFP may be directed to your Regional Fiscal Officer or Regional Program
Manager. Billing questions should be addressed to ra-odpclaimsres@pa.gov.
ISSUED DATE 03/23/15
ODP COMMUNICATION NUMER: 023-15
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