Palliative Care is specialized medical care focused on providing relief from the symptoms and stress of a chronic condition or life-threatening illness. The goal is to improve quality of life for both the child and the family. It is appropriate at any stage of a chronic condition or life-threatening illness and can be provided along with curative treatment.
Children must meet Level of Care LOC functional criteria and suffer from the symptoms and stress of chronic medical conditions OR illnesses that put individuals at risk for death before age Palliative Care benefits may not duplicate Hospice or other State Plan benefits accessible to participants.
Palliative care is specialized medical care focused on providing relief from the symptoms and stress of a chronic condition or life-threatening illness. Children must meet LOC functional criteria and suffer from the symptoms and stress of chronic medical conditions OR illnesses that put individuals at risk for death before age Bereavement counseling services are inclusive for those participants in receipt of Hospice care through a Hospice provider.
Palliative Care Massage Therapy benefits may not duplicate Hospice or other State Plan benefits accessible to participants. Palliative care Services are specialized medical care services focused on providing relief from the symptoms and stress of a chronic condition or life-threatening illness.
The goal is to improve quality of life for both the child and family. The services are appropriate at any stage of a chronic condition or life-threatening illness and can be provided in addition to curative treatment. Palliative Care Expressive Therapy art, music, and play helps children better understand and express their reactions to their illness or condition through creative and kinesthetic treatment.
Palliative Care Expressive Therapy benefits may not duplicate Hospice or other State Plan benefits accessible to participants. Planned Respite also includes skill development activities.
Planned Respite Services:. Assistance with acquisition, retention or improvement in self-help, socialization and adaptive skills including communication, and travel that regularly takes place in a non- residential setting, separate from the person's private residence or other residential arrangement.
Activities and environments are designed to foster the acquisition of skills, appropriate behavior, greater independence, community inclusion, relationship building, self-advocacy and informed choice. Individual Day Habilitation a one-to-one, individual-to-worker provided service with an hourly unit of service and Group Day Habilitation services are on a regularly scheduled basis for 1 or more days per week or less frequently as specified in the participant's Plan of Care POC.
Meals provided as part of these services shall not constitute a "full nutritional regimen" 3 meals per day. All Day Habilitation services Group and individual have the same service description and focus on enabling the participant to attain or maintain his or her maximum functional level and shall be coordinated with any physical, occupational or speech therapies in the POC.
In addition, Day Habilitation services may serve to reinforce skills, behaviors or lessons taught in other settings. Group and individual Day Habilitation cannot be billed as overlapping services. Supplemental services are not available to individuals residing in certified residential settings, because the residence is paid for staffing on weekday evenings and anytime on weekends.
Any child receiving HCBS under this waiver may receive this service. Children have a maximum daily amount of services that are available to individuals based upon their residence.
Individuals residing in certified settings are limited to a maximum of six hours of non-residential services or its equivalent which must commence no later than 3 pm on weekdays. Day Habilitation services will not include funding for direct, hands-on physical therapy, occupational therapy, speech therapy, nutrition, or psychology services.
Habilitation is divided into individual and group services. Acquisition, maintenance and enhancement are defined as:. Acquisition is described as the service available to a physically and mentally capable individual who is thought to be capable of achieving greater independence by potentially learning to perform the task for him or herself.
There should be a reasonable expectation that the individual will acquire the skills necessary to perform that task within the authorization period. These identified services will be used as a means to maximize personal independence and integration in the community, preserve functioning and prevent the likelihood of future institutional placement.
For this reason, skill acquisition, maintenance and enhancement services are appropriate for persons who have the capacity to learn to live in the community, with or without support.
Community Habilitation may be delivered in individual or group modality. ADL, IADL Skill Acquisition, Maintenance and Enhancement is related to assistance with functional skills training and may help a person accomplish specific tasks who has difficulties with skills related to:.
Services may not be duplicative of any services that may be available under Community First Choice Option:. Teaching health-related tasks is defined as specific tasks related to the needs of a person, which can be delegated or assigned by licensed health-care professionals under State law to be performed by a certified home health aide or a direct service professional.
Health related tasks also include tasks that home health aides or direct service professionals can perform under applicable exemptions from the Nurse Practice Act.
Some specific health-related tasks available for assistance include, but are not limited to: Teaching the individual to perform simple measurements and tests; assisting with the preparation of complex modified diets; assisting with a prescribed exercise program; pouring, administering and recording medications; assisting with the use of medical equipment, supplies and devices; assisting with special skin care; assisting with a dressing change; and assisting with ostomy care.
These services can be delivered at any home or community setting. Approved settings do not include an OPWDD certified residence or day program, a social day care or health care setting in which employees of the particular setting care for or oversee the enrollee. Foster care children meeting LOC may receive these services in a home or community-based setting where they reside that is not an institution.
Children living in community residences with professional staffing may only receive this service on weekdays with a start time prior to 3 pm. For school-age children, this service cannot be provided during the school day. Time spent receiving another Medicaid service cannot be counted toward the Habilitation billable service time. If a child requires medically necessary services that are best delivered in the school setting by a community provider, the service must be detailed on the POC.
Excluded are those adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the child. Adaptations that add to the total square footage of the home's footprint are excluded from this benefit except when necessary to complete an adaptation e.
Also excluded are pools and hot tubs and associated modifications for entering or exiting the pool or hot tub. However, in reasonable circumstances determined and approved by the State, a second modification may be considered for funding as follows: if a person moves to another home; if the current modifications are in need of repair, worn- out or unsafe; or if a participant wishes to spend considerable time with a non-cohabitating parent in their home and such modifications are required to ensure health and safety during these periods.
Services that began prior to April 1, should not be stopped or delayed due to this transition. In instances where SPV funding and prior approval are requested for the same service, the requests should be submitted for processing together. If either request is not approved, the LDSS will be so notified. If additional information is needed, the disbursement may be delayed pending submission of the additional information.
Standard provisions of the NYS Finance Law and procurement policies must be followed to ensure that contractors are qualified, and that State required bidding procedures have been followed.
Services are only billed to Medicaid or the MCO once the contract work is verified as complete and the amount billed is equal to the contract value. Vehicle Modifications are limited to the primary means of transportation for the child. The vehicle may be owned by the child or by a family member or non-relative who provides primary, consistent and ongoing transportation for the child.
All equipment and technology used for entertainment is prohibited. Costs may not exceed current market value of vehicle. However, in reasonable circumstances determined and approved by the State, a second modification may be considered for funding if the current modifications are in need of repair, worn-out or unsafe. Replacements, repairs, upgrades, or enhancements made to existing equipment will be paid if documented as a necessity.
In addition, when the modification must be replaced or repaired, a depreciation schedule will be used to determine the limit of the amount to be applied to the cost.
Such devices cannot be used for the purpose of surveillance, but to support the person to live with greater independence, Devices to assist with medication administration, including tele-care devices that prompt, teach or otherwise assist the participant, Portable generators necessary to support equipment or devices needed for the health or safety of the person, and stretcher stations.
Adaptive and Assistive Equipment Services include: A. Adaptive Devices are expected to be a one-time only purchase. Replacements, repairs, upgrades, or enhancements made to existing equipment will be paid if documented as a necessity and approved by the State or its designee. Ongoing monitoring associated with telecare support services or other approved systems authorized under this definition may be provided if necessary, for health and safety and documented to the satisfaction of the State or designee.
Warranties, repairs or maintenance on assistive technology may be reimbursed only when they are the most cost effective and efficient means to meet the need and are not available through the Medicaid state plan at a , CFCO or third-party resources.
Services are only billed to Medicaid once the equipment is procured and the amount billed is equal to the purchased value. Standard provisions of the NYS Finance Law and procurement policies must be followed to ensure that vendors are qualified, and that State required bidding procedures have been followed. Services are only billed to Medicaid or the MCO once the equipment is verified as received and the amount billed is equal to the contract value. Billing guidance for Health Home services can be found here.
Health Home Care Management provides person-centered, child and family-driven care planning and management. Health Homes deliver person-centered planning through six core services, including comprehensive care management, care coordination, health promotion, comprehensive transitional care, child and family support, referral to community and social supports and service linkages using health information technology.
Requests for these services will be managed directly with the Managed Care Plan for those children enrolled in a plan. Service limits are as follows:. In all cases, service limits are soft limits that may be exceeded due to medical necessity. This justification must be submitted to NYSDOH along with the request for service packet in order to obtain approval of the request. Environmental and Vehicle modifications are non-medical services and will need to be billed from provider to plan using invoices.
Plans will need to convert these invoices into claims. EPSDT is the key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, developmental, and specialty services. In instances where such combinations are discovered, NYS will make the appropriate recoveries and referrals for judicial action.
Subject to additions 6 7. Subject to additions 7 8. Subject to additions 8. Navigation menu. A Medicaid Managed Care Plan has discretion to deny a claim from an out of network provider. Exception: For any of the newly carved-in services, if a provider is delivering a service to the enrollee prior to the implementation date and does not contract with the MMCP, the MMCP must allow a provider to continue to treat an enrollee on an out of network basis for up to 24 months following the implementation date.
Medicaid Managed Care Plans must execute SCAs with non-participating providers to meet clinical needs of children when in- network services are not available. Providers should always verify that claims are submitted to the correct MMCP. Multiple Services Provided on the Same Date to the Same Individual In some cases, an individual can receive multiple services on the same day.
Services Provided While in Transit Services that are delivered in transit are allowable and may be billed within the daily limits of the service.
Submitting Claims for Non-Sequential Time for the Same Service, on the Same Day If the same service is delivered to the same individual on the same day but at non- sequential times, the total time spent on the service may be submitted as a combined claim.
Timed Units per Encounter of Service Range of minutes per face-to-face encounter Billable minutes Billable units 15 minutes per unit Under 8 minutes minutes Not billable minutes 15 minutes 1 unit minutes 30 minutes 2 units minutes 45 minutes 3 units minutes 60 minutes 4 units minutes 75 minutes 5 units minutes 90 minutes 6 units minutes minutes 7 units minutes minutes 8 units Submitting Claims for Daily Billed Services Services that are billed on a daily basis should be submitted on separate claims.
Please refer to UM Guidance for details on annual and daily limits. Claims for OLP initial evaluation are defined using a distinct rate code. See Appendix A. Off-site services will be billed with one claim for the service rate code and a second claim for the off-site rate code. These would both have the same procedure code and different modifiers as described in Appendix A. Claims are billed daily, in minute units, with a limit of 36 units per calendar year.
Each claim must include the appropriate procedure code and modifier as noted in the rate table. Off-site is billed daily in minute units, with a limit of 36 units per calendar year. Claims are billed daily, in minute units, with a daily unit limit of four units 1 hour per service. Each counseling claim must include the CPT code. Counseling claims must also include the appropriate modifier s in addition to CPT code. A separate claim is submitted for off-site.
Off-site is billed daily, in minute units, with a daily limit of four units. If individual counseling and family counseling are provided on the same day, up to eight units may be billed if the service provision required separate travel to and from the location of service.
NOTE: When submitting a fee-for-service claim for both individual and family counseling occurring on the same day, the provider must include both services on one claim line with all appropriate modifiers and combined service units e.
Medicaid managed care claims for Individual and Family Counseling will continue to be submitted using two separate claim lines. Group sessions are billed daily, with a separate claim for each member in the group, in minute units, with a daily unit limit of four units 1 hour per individual.
Each group counseling claim must include the CPT code and modifier s. Group size may not exceed more than eight members. Group sessions may be provided on-site or off-site.
When group sessions are provided off-site, each member of the group bills using two claims: the first using the service rate code and the second using the off-site group add-on rate code.
Off-site is billed daily in minute units with a limit of four units per day. OLP - Crisis Off-site Claims are billed daily, in minute units, with a daily unit limit of eight units two - hour daily maximum.
Each crisis claim must include the appropriate CPT code and modifier s. May only be provided off-site. Only one claim is submitted for OLP Crisis; a separate off-site claim is not permissible. OLP - Crisis Triage by telephone Claims are billed daily, in minute units, with a daily unit limit of two units minute daily maximum.
OLP - Crisis Complex Care follow-up to Crisis Claims are billed daily, in five-minute units, with a daily unit limit of four units minute daily maximum. Crisis Complex Care is provided by telephone. CPST services are billed daily, in minute units, with a limit of six units per day 1. CPST may be provided on-site or off-site. Off-site CPST claims will be billed with one claim for the service rate code and a second claim for the off-site rate code. Off-site CPST is billed daily in minute units, with a limit of six units per day.
If an individual CPST and family CPST service are provided on the same day, up to six units may be billed if the service provision required separate travel to and from the location of service. CPST group services are billed daily, in minute units, with a limit of four units per day 1 hour. No arbitrary limitations on services are allowed, e.
Providers should consult the Rates and Fee Schedule web page to determine if the procedure code requires prior authorization. Medical necessity or a medically necessary service is defined as a good or service that will or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability.
For EPSDT, medical necessity includes a good or service that will or is reasonably expected to, assist the member to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living, and meets the criteria, Code of Colorado Regulations, Program Rules 10 CCR To request services that a provider feels are medically necessary but are not currently covered, please visit the Billing Manuals section of the Department's website.
Health First Colorado makes the final determination of medical necessity and it is determined on a case-by-case basis. Provider recommendations will be taken into consideration but are not the sole determining factor in coverage. Colorado determines which treatment it will cover among equally effective, available alternative among equally effective treatments.
The provider and member will receive the final PAR determination letter from the Department's fiscal agent. A member who receives a denial notification letter has the option to submit a written request for an appeal to the Office of Administrative Courts.
Services for which Colorado has a waiver are also not considered to be state plan benefits, and therefore are not a benefit under EPSDT. Items such as respite, in-home support services, and home modifications are examples of waiver services. To request services that a provider feels are medically necessary but are not currently covered by the state plan, a prior authorization request must be completed as well as a letter of medical necessity.
Both should be sent to the authorizing agent listed in Appendix D under the Appendices drop-down section on the Billing Manuals web page. Three 3 screens per year for children aged 0 - 30 months. Health First Colorado covers developmental screening for children ages 0 - 4 up to 59 months , using a standardized, validated developmental screening tool i.
In the absence of established risk factors or parental or provider concerns, the AAP recommends developmental screens at the 9-, , and months and not at every visit. Depression Health First Colorado covers an annual depression screening for individuals aged 11 and older, using a standardized, validated depression screening tool at the member's periodic visits.
The exact frequency of validated, standardized screening depends on the concerns of the child's parents, adult member or the provider as to whether routine surveillance suggests the member may be at risk for depression.
The Depression benefit includes the option for reimbursing pediatricians or family medicine for screening new mothers for depression at well-child visits.
As of July , the Department will allow for up to three 3 screenings for the mother. Suggested screening times are at the 0 to 1-month visit, the 2-month visit, and either the 4-month or 6-month visit, however, providers may screen any time up to 12 months. Since other providers may also bill for the three postpartum depression screens, the Department recommends providers coordinate care with the member's obstetrician and any home visitor who provides services to the member.
If possible, providers should bill under the mother's Medicaid ID, but, if not, the provider may bill for the screen under the child's Medicaid ID. Resources for screening, discussing postpartum depression, and referring for positive screens can be found at the CDPHE Resource Hub for providers.
Autism Health First Colorado covers autism screening for children aged and months, using a standardized, validated autism screening tool i. A non-emergency oral examination, dental prophylaxis, and fluoride topical application once every six months are benefits of the EPSDT program. Health First Colorado recommends regular periodic examinations by a dentist with eruption of the first tooth or at age one, and continuing every six 6 months or as recommended by a dentist.
Orthodontia is available for children who have been diagnosed with a severely handicapping malocclusion. More information can be found on the DentaQuest website. Dentally necessary radiographs, restorations, endodontics, periodontics, prosthodontics and oral surgery are also benefits. Audiological benefits include identification, diagnostic evaluation, and treatment for children with hearing impairments. Benefits include hearing aids and other assisted devices, auditory training in the use of hearing aids, therapy for children with hearing impairments, and family-focused home-based early language intervention for children, birth to three years of age , with hearing loss through the Colorado Home Intervention Program CHIP.
Vision diagnostic and treatment services may be performed by an ophthalmologist or optometrist. Referral is not required for vision care.
Single and multifocal vision lenses and frames, as well as repair or replacement of broken lenses or frames, are benefits of EPSDT and may be provided by an ophthalmologist, optometrist, or optician.
Contact lenses are available in some medically necessary situations and require prior authorization. Complete billing instructions for vision services are included in the vision billing manual. Other children's health care services are billed on the CMS , using national standard codes. The codes are used for submitting claims for services provided to Health First Colorado members and represent services that may be provided by enrolled certified Health First Colorado providers.
The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies DMEPOS when used outside a physician's office.
Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits. If there is no time designated in the official descriptor, the code represents one unit or session. Providers should regularly consult monthly bulletins on the Provider Services Bulletins web page. To receive electronic provider bulletin notifications, an email address can be entered into the Web Portal in the MMIS Provider Data Maintenance area or by completing and submitting a publication preference form.
Bulletins include updates on approved procedures codes as well as the maximum allowable units billed per procedure. Always remember that any code or service can be requested, even if the code is not open in the fee schedule or listed in this or other billing manuals. The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the EPSDT claim form.
For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual. Colorado Official State Web Portal. Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems. These codes must be used in conjunction with diagnosis codes for a well- child exam including , Note: Used in conjunction with the appropriate diagnosis codes excluding the well-child diagnosis codes: Z Example: A Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year.
Example: for July 1, Place an X in the appropriate box to indicate the sex of the member. If there is no signature on file, leave blank or enter "No Signature on File". Enter the date the claim form was signed.
Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year.
If the member is still hospitalized, the discharge date may be omitted. This information is not edited. Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office. Practitioners may not request payment for services performed by an independent or hospital laboratory.
Enter applicable ICD indicator. List the original reference number for resubmitted claims. When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field. The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line. Do not enter more than six lines of information on the paper claim.
If more than six lines of information are entered, the additional lines will not be entered for processing. Each claim form must be fully completed totaled. Do not file continuation claims e. The field accommodates the entry of two dates: a From date of services and a To date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: for January 1, Enter a Y for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life- threatening condition or one that requires immediate medical intervention.
If a Y for YES is entered, the service on this detail line is exempt from co-payment requirements. Enter the HCPCS procedure code that specifically describes the service for which payment is requested.
CPT is updated annually. Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form. Claim diagnosis code s must identify a condition unrelated to the surgical procedure. Professional component Use with diagnostic codes to report professional component services reading and interpretation billed separately from technical component services.
Report separate professional and technical component services only if different providers perform the professional and technical portions of the procedure. Read CPT descriptors carefully.
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