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MEDICAID SCHOOL-BASEDADMINISTRATIVE CLAIMING GUIDE
 
May 2003
 
 
MEDICAID SCHOOL-BASEDADMINISTRATIVE CLAIMING GUIDE
 
TABLE OF CONTENTS
I. INTRODUCTION...............................................................................................................................................................1II. MEDICAID IN THE SCHOOL SETTING.....................................................................................................................3III. INTERAGENCY AGREEMENTS...........................................................................................................................5A.
 
G
ENERAL
......................................................................................................................................................................5
B.
 
E
LEMENTS OF THE
I
NTERAGENCY
A
GREEMENT
.........................................................................................................6
IV. PRINCIPLES OF ADMINISTRATIVE CLAIMING..................................................................................................7A.
 
G
ENERAL
......................................................................................................................................................................7
B.
 
O
PERATIONAL
P
RINCIPLES
..........................................................................................................................................7
1.
 
 Proper and Efficient Administration
......................................................................................................................7 
2.
 
Capture 100 Percent of Time
..................................................................................................................................8
3.
 
 Parallel Coding Structure: Medicaid and Non-Medicaid Codes for Each Activity
..............................................9
4.
 
 Duplicate Payments
.................................................................................................................................................9
5.
 
Coordination of Activities
......................................................................................................................................10
6.
 
 Performing Direct Services v. Administrative Activities
.......................................................................................11
a. Case Management as Administration
..................................................................................................................................11
b. Case Management as a Service
............................................................................................................................................12
7.
 
 Allocable Share of Costs
........................................................................................................................................12
8.
 
 Enhanced FFP Rates
............................................................................................................................................14
a. Skilled Professional Medical Personnel (SPMP) School-Based Administrative Claiming
............................................14
b.
 
Claiming for Administration of Family Planning Services
.............................................................................................16
9.
 
 Provider Participation in the Medicaid Program
.................................................................................................16 
10.
 
 Individualized Education Program (IEP) Activities
.............................................................................................18
11.
 
 Review and Approval of Program and Codes by CMS 
.........................................................................................19
12.
 
Free Care
...............................................................................................................................................................20
C.
 
A
CTIVITY
C
ODES
: D
ESCRIPTIONS AND
E
XAMPLES
...................................................................................................21
1.
 
 Introduction
...........................................................................................................................................................21
CODE 1.a.
 
 NON-MEDICAID OUTREACH 
.............................................................................................................23
CODE 1.b.
 
 MEDICAID OUTREACH 
.......................................................................................................................24
CODE 2.a.
 
FACILITATING APPLICATION FOR NON-MEDICAID PROGRAMS 
...........................................25
CODE 2.b.
 
FACILITATING MEDICAID ELIGIBILITY DETERMINATION 
.....................................................25
CODE 3.
 
 SCHOOL-RELATED AND EDUCATIONAL ACTIVITIES 
................................................................26 
CODE 4. DIRECT MEDICAL SERVICES 
...........................................................................................................27 
CODE 5.a.
 
TRANSPORTATION FOR NON-MEDICAID SERVICES 
..................................................................28
CODE 5.b.
 
TRANSPORTATION-RELATED ACTIVITIES IN SUPPORT OF MEDICAID COVERED SERVICES 
.................................................................................................................................................................28
CODE 6.a.
 
 NON-MEDICAID TRANSLATION 
.......................................................................................................29
CODE 6.b.
 
TRANSLATION RELATED TO MEDICAID SERVICES 
...................................................................29
CODE 7.a.
 
 PROGRAM PLANNING, POLICY DEVELOPMENT, AND INTERAGENCY COORDINATION  RELATED TO NON-MEDICAL SERVICES 
...........................................................................................................30
CODE 7.b.
 
 PROGRAM PLANNING, POLICY DEVELOPMENT, AND INTERAGENCY COORDINATION  RELATED TO MEDICAL SERVICES 
.....................................................................................................................31
CODE 8.a.
 
 NON-MEDICAL/NON-MEDICAID RELATED TRAINING 
..............................................................32
CODE 8.b.
 
 MEDICAL/MEDICAID RELATED TRAINING 
..................................................................................32
CODE 9.a.
 
 REFERRAL, COORDINATION, AND MONITORING OF NON-MEDICAID SERVICES 
.............33
CODE 9.b.
 
 REFERRAL, COORDINATION, AND MONITORING OF MEDICAID SERVICES 
.......................34
i
 
 
CODE 10.
 
GENERAL ADMINISTRATION 
...........................................................................................................35
V. CLAIMING ISSUES.......................................................................................................................................................37A.
 
D
OCUMENTATION
.......................................................................................................................................................37
B.
 
S
AMPLING
/T
IME
S
TUDIES
..........................................................................................................................................38
1.
 
 Sample Universe
....................................................................................................................................................39
2.
 
 Sampling Plan Methodology
.................................................................................................................................40
3.
 
Treatment of Summer Period 
................................................................................................................................41
4.
 
Time Study Documentation
...................................................................................................................................42
5.
 
Training for Staffing Time Study
..........................................................................................................................43
6.
 
 Monitoring Process
................................................................................................................................................43
C.
 
O
FFSET OF
R 
EVENUES
................................................................................................................................................44
D.
 
C
OST
A
LLOCATION
P
LANS
.........................................................................................................................................44
E.
 
A
DMINISTRATIVE
C
LAIMING
I
MPLEMENTATION
P
LAN
............................................................................................45
F.
 
T
IMELY
F
ILING
R 
EQUIREMENTS
...............................................................................................................................46
G.
 
S
TATE
L
AW
R 
EQUIREMENTS
.....................................................................................................................................47
H.
 
C
ONTINGENCY
F
EES
...................................................................................................................................................47
I.
 
P
ROVIDER 
A
GREEMENTS
...........................................................................................................................................48
J.
 
T
HIRD
P
ARTY
L
IABILITY
(TPL)/M
EDICAID AS PAYOR OF LAST RESORT
/F
REE
C
ARE
............................................48
K.
 
T
RANSPORTATION AS
A
DMINISTRATION
...................................................................................................................49
APPENDIX..............................................................................................................................................................................50A.
 
M
EDICAID
...................................................................................................................................................................50
1.
 
 Medicaid’s Role In School-Based Health Services Programs
.............................................................................50
2.
 
 Early and Periodic, Screening, Diagnostic and Treatment (EPSDT)
..................................................................51
a. EPSDT Screening
..................................................................................................................................................................51
b. EPSDT Treatment
................................................................................................................................................................51
c. EPSDT Administrative Claiming
.........................................................................................................................................51
3.
 
 State Children’s Health Insurance Program (SCHIP)
........................................................................................52
B.
 
I
NDIVIDUALS WITH
D
ISABILITIES
E
DUCATION
A
CT
(IDEA)
....................................................................................53
1.
 
 Purpose of IDEA
...................................................................................................................................................53
2.
 
Child Find 
..............................................................................................................................................................54
3.
 
 Evaluation and Assessment Activities
...................................................................................................................54
4.
 
 Individualized Education Program (IEP)
.............................................................................................................55
a. Pre-IEP
..................................................................................................................................................................................56
b. Development of IEP
..............................................................................................................................................................56
c. Review/Revision of IEP
.........................................................................................................................................................56
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