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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

600.3 Billing for the Five Non-ICC Waiver Services

Billing for the Five Non-ICC Waiver Services for Individuals

For quick reference, please refer to the Billing Rules Chart Guide

Documentation for All Waiver Services:

Planned delivery of service must be authorized and documented in the child's service plan. All services must clearly support the achievement of the Waiver child’s identified goals. Services delivered on an emergency basis (unplanned) must be approved by the Individualized Care Coordination agency and documented in the service plan. A Progress Notes must be written for every contact and all fields must be completed.

All Waiver Services: Billing, Service Provision and Transportation

Transportation is not a Waiver service. The Waiver services are Respite, Family Support, Skill Building, Intensive In-Home, Crisis Response Services and Care Coordination. The delivery of these services is not location-specific and could, at times, be delivered to the Waiver child, or other billable family member, in part while that person is being transported. Progress Notes must specifically describe the services performed and how these specifically relate to the child’s identified service plan objectives during the billed service time regardless of where the service is provided.

Staff travel time to meet with the client or family is not a Medicaid service and can not be counted in billing.

Paper Claims and Electronic Billing

The unit's field on the paper UB04 claim is #45. For electronic billing, units are billed as follows: Loop 2400 Segment - SV2 - Institutional Service Line.

Data Element Ref - SV204 Valid Value - UN (for units)
Data Element Ref - SV205 Service unit count (number of units)

Billing Rules for Respite, Family Support, and Skill Building Services for Individuals

The following rules apply to Respite, Skill Building, and Family Support Services:

To recap, the following changes, effective February 1, 2010, have been made to billing rules for Respite, Skill Building and Family Support Services:

Additional Rules for Respite Services:

Additional Rule for Skill Building Services:

Additional Rule for Family Support Services:

Note: Information regarding billing for Respite, Skill Building and Family Support Services group work is found in 600.4.

Billing Rules for Bundled Intensive In-Home and Crisis Response Services (Billing Rules Chart Guide)

Reimbursement for sixty five hours of Intensive In-Home (IIH) and Crisis Response Services (CRS) annually per slot is included in the monthly reimbursement for the Waiver Individualized Care Coordinator. OMH is currently suspending consideration of unbundling these services pending anticipated major program revisions in the foreseeable future. To gather information about the current pattern of delivery of these bundled services, OMH requires Waiver agencies to submit each month Medicaid claims for these services. Bundled IIH and bundled face-to-face CR, including a fixed number of CR telephone contacts, are billed in 15 minute units at 25 cents a unit effective April 1, 2010 to be consistent with billing increments for the other non- ICC services.

The following rules apply to Bundled Intensive In-Home (IIH) and Bundled Crisis Response (CR) Services (Note: all changes in the rules below are effective February 1, 2010 unless otherwise noted.):

To recap, the following changes have been made to the monthly claims for IIH and CRS to assure increased uniformity in billing for the five non-ICC Waiver services:

Rules for Intensive In-Home Visits and ICC Contacts on the Same Day

Because Individualized Care Coordination (ICC) and Intensive In Home (IIH) are different services, distinct and separate bundled IIH contacts of at least 30 minutes duration can occur on the same day as the ICC qualifying child contact and the ICC qualifying collateral contact (see section 600.2). If IIH is a bundled service performed by the Individualized Care Coordinator, the coordinator may make one visit to the child’s home and accomplish all three contacts. If IIH is provided by someone other than the Individualized Care Coordinator, the coordinator may make a maximum of two contacts as described above (one with the child and one with the collateral) and the IIH worker may complete one distinct contact. Contacts may be made in the home or in the community, but are limited to a total of three in a day as described above. Documentation must clearly show relevancy not only to the child’s goal, but to the distinct service provided. OMH strongly recommends spreading the ICC billable and non-billable contacts with the child and collaterals over the entire month. (Crisis Response contacts are not included in the contact count for ICC and IIH visits the same day).