3. SBHS Program Overview
The School-Based Health Care Services (SBHS)
website is located at Washington State Health Care
Authority
School-Based Health Care Services for Children in Spec
SBHS Website Resources
• Latest updates
• Reminders
• Understanding the Program Updates
• Intergovernmental Transfer Process (IGT)
flowchart
• How to contact the fiscal staff regarding
invoices and the IGT process
• National Provider Identifier (NPI)
instructions
• How to contact the SBHS Program
Specialist
• Locating the SBHS Medicaid Provider Guide
(MPG)
• SBHS WACs
• Provider Update Form (PUF) requirements
3
4. What is the SBHS Program?
• The SBHS program reimburses school districts for
covered health-care-related services provided to
Medicaid-eligible children in Special Education.
These services must:
– Be included in the child’s current Individualized
Educational Program
– Be medically necessary
– Be provided by a licensed heath care practitioner
– Be diagnostic, evaluative, habilitative, or rehabilitative
in nature
– Identify, treat, and manage the education-related
disabilities
4
5. SBHS Program Overview
SBHS Program Website
•Latest updates
•Reminders
•Program updates
•Claiming
•Provider Qualifications Requirements
•Resources
•Contact and Medicaid Customer Service
5
7. SBHS Program Overview
• Covered Services:
– Evaluations when the child is determined to have a disability, and needs
special education and health care-related services.
– Re-evaluations to determine whether a child continues to need special
education and health care-related services.
• Direct health-care-related services, including:
– Audiology services
– Counseling services
– Nursing services
– Occupational therapy services
– Physical therapy services
– Psychological services
– Psychological assessments
– Speech-language therapy services
7
10. What Documentation Requirements are
there for School Districts?
Sufficient documentation must support and
justify the billed and paid claims, and be
maintained for a minimum of six years from
the date of service.
10
11. Processing a Claim
Claim
entered into
ProviderOne
ProviderOne
•Assign a Transaction Control Number
(TCN)
•Verifies the e-claim and direct data entry
claims
History and Claims
Analysis
Suspended Claim
•Authorization
•Eligibility
•Coordination of
Benefits (COB)
•Program limitations
•Invoice school district
for local match
requirement
•Intergovernmental
Transfer process
Final Claim
Disposition
• Remittance Advice
generated
• Warrant issued
• Electronic Funds
Transferred
11
12. What about third-party liability?
School districts may rebill a denied claim only after
doing both the following:
•Receiving a denial letter or Explanation of Benefits
(EOB) from the child’s primary insurance carrier.
•Forwarding the written denial with the claim to the
agency’s Coordination of Benefits section.
12
13. SBHS Overview
SBHS reminders:
•RAs are a good source for checking compliance. The
paid section of the RA can be used to check against a
child’s file for completed treatment notes. You will
want to make sure notes have:
– Documented activities and interventions
– The child’s name
– The child’s ProviderOne Identification
– The child’s date of birth
– The date of service, time-in/time-out, and the number of
billed units
– Identified if treatment was for individual or group therapy (if
applicable)
13
14. SBHS Overview
• School districts must submit their required local
matching funds within one hundred twenty (120)
days from the date HCA sends an invoice to the
district.
• School districts bear full responsibility for all
submitted billing information completed by them or
their billing agent.
– A good practice to perform is to communicate with the
billing agent at least monthly.
14
16. Accessing ProviderOneAccessing ProviderOne
16
Before logging into ProviderOne:
• Make sure you are using Microsoft
Internet Explorer version 6.0 and above
• Turn OFF the Pop Up Blocker
• Make sure you are using a PC (MACs are
not supported by ProviderOne)
18. How to Get Access into the SystemHow to Get Access into the System
• Review the ProviderOne Security Manual at
http://www.hca.wa.gov/medicaid/providerone/pages/ph
• New provider who do not have the correct
form to access ProviderOne, should email
ProviderOne Security at
provideronesecurity@hca.wa.gov. In the
subject line enter Request for Provider
Supplemental Information Request
Form
18
19. How to Get Access into the SystemHow to Get Access into the System
19
• The Provider Supplemental Information Request form is for a newly
enrolled Facility, Clinic, Individual Provider, or a new Office Administrator.
• Complete the form and fax it in to 360-586-0702 for ProviderOne access.
20. How to Set Up a UserHow to Set Up a User
20
• Log in with the System
Administrator profile
• Click on Maintain Users
• The system now displays
the UserList screen
• Click on the Add button
21. How to Set Up a UserHow to Set Up a User
• Adding a user
• Fill in all required boxes that has an asterisk (*)
• The address is not needed here
21
22. How to Set Up a UserHow to Set Up a User
To Display the new user
• In the With Status box display In Review, then click Go
• The user’s name is displayed with In Review status.
• Click the box left of the user’s name, then click the
Approve button to approve this user.
22
23. How to Set Up a UserHow to Set Up a User
Adding Profiles
• Get here by clicking on the users name on the
previous screen.
• On the Show menu click on Associated Profiles.
23
24. How to Set Up a UserHow to Set Up a User
Adding Profiles
• Click on the Add button to select profiles
24
25. How to Set Up a UserHow to Set Up a User
Adding Profiles
Highlight Available Profiles desired
• Click double arrow and move to Associated
Profiles box then click the OK button.
25
26. How to Set Up a UserHow to Set Up a User
Adding Profiles
To Display the new profiles
•In the With Status box display All, then click Go.
•The profiles are displayed with In Review status.
•Click the box left of the profile name, then click the
Approve button. Profiles will then be approved.
26
27. How to Set Up a UserHow to Set Up a User
How to set up a user’s password
27
28. How to Manage a UserHow to Manage a User
How to reset a password
•Enter the new temporary password and click Save
28
To lock or
unlock a
User, click
this box!
29. How to Manage a UserHow to Manage a User
How to end a user in ProviderOne
• Enter the end date and click the save button.
• The account will be removed from view after the system
refreshes overnight.
29
32. Enrolling Servicing ProvidersEnrolling Servicing Providers
Log into ProviderOne using the File
Maintenance or Super User profile
32
• Under Provider click on the
hyperlink Manage
Provider Information
• At the Business Process
Wizard click on Step
15: Servicing
Provider Information
33. Enrolling Servicing ProvidersEnrolling Servicing Providers
When the Add Servicing Provider screen
opens, click on the Add button.
On the Add Servicing Provider screen:
Enter the provider’s NPI number or ProviderOne ID
Enter their Start Date at your school district
Click on the Confirm Provider button
33
34. Enrolling Servicing ProvidersEnrolling Servicing Providers
If the provider is already entered in ProviderOne their name
will be confirmed.
•Click the OK button to add the provider to your list.
•Remember to click Step 17: Submit Modification for
Review.
•Provider Enrollment will review the school district’s request.
http://www.hca.wa.gov/medicaid/providerenroll/pages/enroll.aspx#provider
34
35. Adding New Servicing ProvidersAdding New Servicing Providers
There are two ways to add a new servicing
provider to your domain:
• Follow the steps in the previous slide. When you
Confirm the servicing provider and they are not
currently in the system, follow the next several
enrollment steps.
• In the ProviderOne portal click Initiate New
Enrollment.
35
Click on Individual to add the
servicing provider to your Domain.
36. At the Basic Information page for the rendering
provider enrollment:
• Most important is to check the SSN radio button!
• When filling in the rest of the data fields be sure to
select Servicing Only as the Servicing Type.
36
Adding New Servicing ProvidersAdding New Servicing Providers
37. • Once the Basic Information page is complete click
the Finish button.
• The basic information on the enrollment application is
submitted to ProviderOne which generates an
application number.
• Be sure to record this application number for future use
to tracking the status of the enrollment application. Now
click OK.
37
Adding New Servicing ProvidersAdding New Servicing Providers
38. The steps with the RED arrow are required for the SBHS
program.
38
Adding New Servicing ProvidersAdding New Servicing Providers
40. How Do I Check Eligibility In ProviderOneHow Do I Check Eligibility In ProviderOne
Select the proper user profile
Note: There are three different
profiles that can be used for
checking Medicaid eligibility in
ProviderOne:
• EXT Provider Eligibility Checker
• EXT Provider Eligibility
Checker-Claims Submitter
• EXT Provider Super User
Select Benefit Inquiry under the
Client section of the Provider Portal
40
41. How Do I Obtain Eligibility In ProviderOneHow Do I Obtain Eligibility In ProviderOne
An unsuccessful check would look like this:
Use one of the search
criteria listed along with
the dates of service to
verify eligibility.
• The child is
not eligible for
your search
dates; or
• Check your
keying!
41
42. Successful Eligibility CheckSuccessful Eligibility Check
Note: The eligibility information can be printed
out using the Printer Friendly Version link
located in the upper left corner.
42
43. Successful Eligibility CheckSuccessful Eligibility Check
After scrolling down the page the first entry is the Client
Eligibility Spans which show:
•The eligibility program (CNP or MNP only)
•The date span for coverage
43
44. Coordination of Benefits InformationCoordination of Benefits Information
Successful Eligibility CheckSuccessful Eligibility Check
• Will display phone number and any policy or group
numbers on file with WA Medicaid for the commercial
plans listed.
• For school districts who do direct data entries, the
Carrier Code (Insurance ID) is found under the
Coordination of Benefits Information.
44
45. Gender and Date ofGender and Date of
Birth UpdatesBirth Updates
A large number of claims are denied due to mismatching
between birth dates in the provider's record and the
ProviderOne's client eligibility file. School districts can
send a secure email to mmishelp@hca.wa.gov with the
child's ProviderOne ID, child’s name, and the correct birth
date. The same process is true if school districts find a
gender mismatch.
45
46. Coverage status can change at any time!
• Verify Medicaid eligibility before submitting a claim
• Print the Benefit Inquiry results for student records
If eligibility changes after this verification, HCA will honor
the printed screen shot.
oException: Medicaid-eligible children in Special
Education with commercial insurance coverage
who are loaded after eligibility verfication;
commercial insurance must be billed first.
Verifying EligibilityVerifying Eligibility
46
48. Reading the Remittance AdviceReading the Remittance Advice
(RA)(RA)How do I retrieve the PDF file for the RA?
• Log into ProviderOne with a Claims/Payment
Status Checker, Claims Submitter, or Super
User profile.
• ProviderOne should open a list of available RAs.
• Click on the RA/ETRR Number in the first column to
view an entire RA.
At the Payment heading click on
the hyperlink View Payment to
view payments to the school
district.
48
49. Reading the Remittance AdviceReading the Remittance Advice
(RA)(RA)The Summary Page of the RA shows:
• Billed and paid amount for paid claims
• Billed amount of denied claims
• Provider adjustment activity (Provider Adjustments)
• Total amount of adjusted claims
49
50. Reading the Remittance AdviceReading the Remittance Advice
(RA)(RA)
Provider Adjustments:
• These adjustment amounts can carry over to the
next RA until the amount is resolved or reduced by
the amount paid out for previous claims
adjudicated.
• Claims that cause carry over adjustment amounts
will be on previous RAs.
• Credits will have a check number applied on the RA
(e.g., JVAH0223344556677800).
• ProviderOne automatically sends the credit after
180 days.
50
52. Reading the Remittance AdviceReading the Remittance Advice
(RA)(RA)EOB Codes
• The Adjustment Reason Codes; and
• The Remark Codes for denied claims & payment
adjustments are located on the last page of the RA.
• The complete list of Federal codes can be located
on http://www.wpc-edi.com/reference/
52
54. Online Services
Helpful links related to Medicaid eligibility
•For the following fact sheets, use the hyperlink listed below
Client Services Card Fact Sheet
Client Eligibility Verification Fact Sheet
Interactive Voice Response Fact Sheet
http://www.hca.wa.gov/medicaid/provider/pages/factsheets.aspx
•E-Learning webinar on how to check eligibility in ProviderOne
http://www.hca.wa.gov/medicaid/provider/Pages/webinar.aspx
•Self-paced online tutorial on how to check Medicaid eligibility at
http://www.hca.wa.gov/medicaid/ProviderOne/pages/phase1/tutorials.aspx
•ProviderOne Billing and Resource Guide
54
55. Online Services
• Visit the providers training website for links to recorded webinars, E-
learning, and resource manuals at http://
www.hca.wa.gov/medicaid/provider/pages/training.aspx.
• Provider Enrollment’s website is located at http://
www.hca.wa.gov/medicaid/provider/pages/newprovider.aspx. The
Provider Enrollment Unit is available to assist with enrolling servicing
providers under the school district’s billing NPI number. They can be
reached at 800-562-3022 ext. 16137.
• ProviderOne billing questions can be forwarded to the Provider
Relations Unit or to the SBHS Program Manager.
55
56. Questions?Questions?
For more information, please contact
Jim Harvey, Program Manager
School-Based Health Care Services for Children in Special Education
Community Services/Health Care Services
Health Care Authority
Direct: 360-725-1153
Fax: 360-725-1152
Matt Ashton, Provider Relations Consultant
Provider Relations
Health Care Authority
Direct: 360-725-1614
56
Hinweis der Redaktion
JIM
Welcome to today’s webinar Medicaid 101, School-Based Health Care Services. The facilitators for today’s webinar will be Jim Harvey, SBHS Program Manager and Matt Ashton with the Health Care Authority Provider Relations Unit. Today’s webinar is being recorded so school districts and educational service districts that are not able to participate today will be able to access it online via the SBHS website. We ask that everyone allow 7-10 days for the webinar to be uploaded. The PowerPoint presentation will also be posted onto the SBHS website which will allow all districts to print the slides. We will be moving in and out of the PowerPoint presentation to show items on the SBHS and ProviderOne websites. Another option we encourage school districts and educational service districts is to record the webinar onto a CD-R for future reference.
All participants in today’s webinar will receive an email with a link to a survey in 3-5 business days. We ask that everyone take a moment to complete the survey. This survey is confidential and will only be open for one week from the date sent. Feedback is reviewed and used to improve future webinar presentations. if you have unanswered questions or need clarification after the conclusion of today’s webinar, please email Jim Harvey at james.harvey@hca.wa.gov or Matt Ashton at providerrelations@hca.wa.gov.
Matt and I will be providing an overview of the program and how to better utilize the ProviderOne system. Before we get started we would like to give all participants an overview of who your presenters are.
My name is Jim Harvey, and I am the Program Specialist for the School-Based Health Care Services (SBHS) program here at the Washington State Health Care Authority (HCA). HCA is Washington State’s single state Medicaid agency for all providers and programs enrolled under Medicaid. I completed my undergraduate, graduate and terminal degree education from western Kentucky (CHECK SPELLING/proper name) in human services and counseling at Murray State University. I have approximately 24 years of experience in the fields of social services, human services, and education throughout Alaska, Kentucky and Washington. I have worked in direct mental health services for almost twenty years providing clinical counseling, behavioral analysis, and crisis services for both children and adults. Many of the services provided were to special populations involving dual diagnosis, autism, traumatic brain injury as well as mild to profound mental retardation. Currently, I am working toward completing my doctorate in clinical psychology through California Southern University; Irvine. I am also a Board Certified Professional Counselor (BCPC) through the American Psychotherapy Association and the American Board of Professional Counselors for the United States and Canada, and I am a qualified mental health and mental retardation specialist.
Matt
My name is Matt Ashton and I have worked for WA Medicaid for the past 15 years. I started working in the claims department and worked my way onto the client and provider toll free lines. Today you will find me working as a Provider Relations Consultant in the Provider Relations office where I have been for the past 10 years. In my job I assist providers with outreach and training for the WA Apple Health (Medicaid) program, Specialize in the use of the ProviderOne payment system, and assist the various program managers with program and policy questions that may arise. I like to consider myself as a personal contact for the provider community with questions that may have.
JIM
Today’s webinar is designed to give school districts and educational service districts a basic overview of the School-Based Health Care Services program for children in Special Education. This webinar will not prepare you to become a self-billing school district; however, the webinar will give you an in-depth overview of the program. In the future, there will be webinars offered for those districts interested in self-billing through ProviderOne. If you have additional questions about self-billing, please contact Jim Harvey directly.
During the webinar we will present an overview of the School-Based Health Care Services program involving:
1. What is the Health Care Authority?
2. How to find the SBHS website, and what are the resources every participating school district and educational service district should use to their advantage?
3. How to complete the Provider Update Form commonly known as the PUF form and when the form should be submitted?
4. What school districts and educational service districts should do if they have questions about their local matching requirements?
5. What should servicing provider’s know about licensure requirements to bill Medicaid, and where to find this information?
6. Where to locate the Medicaid Provider Guide (MPG) and why it is important that all licensed health care servicing providers have a copy?
After we finish the overview of the SBHS program, websites, and resources associated to the program, the webinar will transition to Matt where he will talk about the State of Washington’s Medicaid Management Information System, commonly known as ProviderOne, and why districts need to understand ProviderOne.
ProviderOne operations, which Matt will discuss during the presentation, involve:
1. How to register for a user account and log into ProviderOne
2. How to enroll a licensed servicing provider into ProviderOne
3. Pitfalls that all districts should be aware of when using ProviderOne
4. How to check for Medicaid eligibility monthly
5. How to check the claim status for submitted claims
6. How to locate and print Remittance Advices (commonly known as an RA report) from ProvideOne.
Understanding where to find this report will be helpful when districts are trying to prepare their annual SafetyNet Application that must go to the Office of Superintendent of Public Instructions (OSPI). Many of Washington school districts and educational service districts use a billing agent to process their claims daily. Understanding how to find this information will be helpful for Medicaid Coordinators and Special Education Directors to understand how much has been reimbursed to the school districts.
The last few slides of the webinar we will discuss where to access the different reference materials and resources that are available to the participating districts. The Medicaid Provider Guide (formerly known as billing instructions) is the bible not only to better understand the SBHS program, but the guide provides you information to:
1. CPT/HCPCS coding
2. Documentation requirements
3. Licensure requirements
4. Supervision requirements if you are a licensed therapist, nurse, or social worker and mental health counselor assigned an assistant.
Jim
I would like everyone to click the hyperlink called School-Based Health Care Services for Children in Special Education. The SBHS website can be accessed by clicking on the link in the middle of this slide. As you can see, the website is filled with an abundance of information and resources for school districts, educational service districts, and licensed health care practitioners. This website is the central communication portal where districts are to go to regarding the SBHS program. Please click on the hyperlink and open the site in a new tab as Matt and I will be referencing the SBSH website during today’s webinar presentation.
The first topic that needs to be discussed is, “Who is the Health Care Authority?” HCA oversees the state’s two top health care programs known as Medicaid and the Public Employees Benefits Board (commonly known as PEBB) programs, in addition to other programs throughout Washington State. The PEBB program provides insurance coverage for eligible employees of state agencies, higher education institutions, certain employer groups, and their families.
Historical Overview of the School-Based Health Care Services Program
Lets briefly talk about the history of the SBHS program. On July 1, 2011, all Medicaid programs were combined under the auspices of the Washington State Health Care Authority. The purpose of this move was to make the State’s health care programs operate more efficiently for all citizens of Washington. During this same time frame, changes to the School-Based Health Care Services program were considered by the Legislature. As a direct result, the Legislature appropriated funds in the 2011-2013 Budget proviso, “…solely for continued provision of school-based medical services by means of an intergovernmental transfer (IGT) arrangement. Under the arrangement, the state shall provide forty percent (40%) and school districts sixty percent (60%) of the nonfederal matching funds required for receipt of federal Medicaid funding for the service.”
The SBHS program is an optional federal program for the State of Washington. The program is administered under Title XIX (Medicaid) or section 1903 of the Social Security Act, which gives HCA the authority to reimburse districts for Individuals with Disabilities Education Act, commonly known as IDEA, Part B (3-21 years of age) & Part C (birth thru 2 years of age) health-care-related-services for Medicaid-eligible children in Special Education. IDEA sets high standards for the achievement and guides how special help and services are made available in schools to address children in Special Education individual needs. More than 6 million children around the United States with disabilities receive Special Education and health-care-related services in the public schools each year. IDEA Part B & C helps make this possible because it represents the two parts of the law itself – Assistance for Education of All Children with Disabilities. More information about IDEA can be found on the National Dissemination Center for Children with Disabilities website or the United States Department of Education (ed.gov) website. You are also encouraged to contact the Office of Superintendent of Public Instructions (OSPI) if you have specific questions related to Special Education in Washington.
School-Based Health Care Services Program Overview
I would like to take a brief moment and talk about the website and how it benefits everyone. The first part of the SBHS website has to do with updates, reminders and program updates which are important because this is information that is immediate. School districts and educational service districts need to read and print the Frequently Asked Questions and memos that are posted for future reference. Licensed health care practitioners need to understand the clarifying memo which talks about the importance of original signature. All participating school districts and educational service districts need to carefully understand that original signatures are a requirement for each dates of services (DOS) billed to the HCA. Treatment notes must justify services and billings. In 2013, there were concerns from participating districts around Washington that not enough information was in the Medicaid Provider Guide explaining what was expected in a good billable treatment note. This clarifying memo should be read by all licensed health care professionals who are billing Medicaid for their services. A good treatment note will include:
1. A descriptive narrative of activities and interventions
2. The child’s name, date of birth, and ProviderOne identification (commonly known as the Washington Medicaid number)
3. Date of Services (DOS), time in/out, number of billed units
4. Indication if the treatment was for individual or group therapy. This is not applicable for nursing services.
5. The licensed provider’s original signature, title and NPI number.
As a reminder each October, participating districts must complete and submit a current Provider Update Form (PUF) with copies of each health care practitioner’s current license. For newly hired providers, a copy of their National Provider Identifier (NPI) is also required when submitting the PUF. Complete and return the PUF by mail, email or fax to (360) 725-1152. The form is located below under the subheading labeled “resources”.
Please note: This is the district’s responsibility. We ask that districts do not submit expired credentials as it will result in claims denial for that provider. Keep in perspective that if a licensed practitioner waits until the last minute to renew his/her license on their birthday, this does not guarantee that person is good to go. It takes the Department of Health (DOH) several days to process the licensure payment. In the mean time while the provider is waiting for an updated license, claims are being denied. What school districts and educational districts need to do is monitor closely licensure expiration dates to make sure there are no lapse in licensure. This will directly impact your reimbursement if a practitioner’s professional license lapse. DOH always sends a licensed practitioner their annual notice 90 days prior to expiration. Anyone who is license will be able to renew their license online and usually within two weeks receive an updated license from DOH.
Lets continue to scroll down the SBHS website to the Intergovernmental Transfer Process labeled, “claiming”. The IGT process is a unique process where invoices are sent to participating school districts and educational service districts by email, notifying them of their required local match. This is known as local tax-based dollars.
Over the past several years, new and existing licensed practitioners wanted to know what are the qualifications to bill Medicaid. Under the subheading labeled “provider qualifications requirements”, you will see the entire WAC 182-537-0350. Licensed providers must meet both federal and the State of Washington’s licensing requirement. Any licensed practitioners who bills the SBHS program for IDEA Part B and Part C health-care-related services should have a copy of this WAC.
Provider Update Form (PUF) Process
The next part of the website that needs to be discuss is how to complete the Provider Update Form (PUF) correctly.
Instructions on how to find and process the PUF can be found in the MPG in pg. 4, and the detail instructions are at the top of the form. School districts must use the current form from the SBHS website to list all licensed health care providers. Participating school districts and educational service districts must submit this form to Medicaid annually before October 31 listing your servicing providers for the new school year. You should attach current licenses and NPI numbers for new hires. Please remember:
Current and newly hired health care professionals. If your district has a newly hired licensed health care provider, when you submit the PUF to Medicaid, you will include only copies of the health care provider’s license, NPI number, and if possible their transcript or degree. The ESA certification is not needed and does not represent a license issued by the Washington State Department of Health.
Please remember that to receive payment from the HCA for providing services, school districts and educational service districts must provider verification of the health care professional’s education, license, and NPI number within 30 days after the start of employment.
Complete the form and list the:
School district’s name, phone and fax numbers
Medical Assistance Provider Number that is 7 digits only
Original signature of the director or designee, title, and date the PUF was signed
Servicing provider’s name
Service specialty and degree credentials
License or certification number issued by the DOH
NPI number issued by the National Plan and Provider Enumeration System – The individual health care practitioners are responsible for keeping their profile on the National Plan and Provider Enumeration System (NPPES).
Once the registration for an NPI number has been complete, the licensed health care providers will never have to reapply for a new number. If a new practitioner has questions regarding how to complete the online or paper application for an NPI, they are encouraged to contact NPPES Customer Service at 1-800-465-3203 or email them directly at customerservice@npienumerator.com.
If the health care practitioner is actively working in your school district, you will mark their status “A” only. The start date is the date the licensed health care provider was initially licensed (first issue date) through the DOH. The issue date is on the health care practitioner’s license or you can get this information from the DOH website. When the health care practitioner resigns from their position you will complete the PUF, marking their status “D”. When a health care practitioner resigns from their position, school districts are responsible for notifying Medicaid immediately. A modified PUF must be submitted to Medicaid listing the providers who continue to work and those who have recently resigned, dates of resignation, and their supervisor’s name. This form will indicates to Medicaid that you are deleting the health care provider from your list of servicing providers.
Later into the webinar, Matt will show you how to deactivate a licensed provider in ProviderOne.
Conclusion on Resources
As we finish reviewing the SBHS website, please note you can also find the SBHS Medicaid Provider Guide under the subheading called resources. All licensed health care professionals must have a copy of the SBHS MPG at all times. This guide is the bible to billing Medicaid correctly. The SBHS MPG also list the current CPT codes that can be used in this program, documentation requirements, and if you access the guide online, all hyperlinks will take you to the appropriate websites. Under resources you will also see the instructions to checking Medicaid eligibility and how to register for an NPI number. Later on in the webinar, Matt will go over the steps needed for checking a child’s Medicaid eligibility.
TIPS
As you can see there is a wealth of information on the SBHS website. School districts and educational service districts are encouraged to develop a resource binder. Some of the districts across Washington have subdivided a binder to include the program updates, instructions how to register for an NPI or check for Medicaid eligibility, Provider Update Form (PUF), a list of potential Medicaid eligible children, a copy of the SBHS MPG, and a section of commonly used CPT codes that are used with which child weekly. Other districts take this idea even further to include an Excel spreadsheet with a list of their health care practitioner’s licenses and expiration dates. How your district operationalize the program is entirely up to the districts, but we encourage everyone to check the SBHS website at least once a month for updates. A good way to make sure you are keeping persistent is to set a reminder in your Outlook to repeat monthly. Please remember that when you have changes in leadership (e.g., Superintendent, Special Education Directors, business managers), the SBHS Program Specialist must be notified.
When there are changes in a school district’s or educational service district’s leadership, who accesses ProviderOne regularly, establishing a resource binder will help transfer the knowledge needed. If there is a situation where the keeper of this information is not in the office, at least your Special Education Director will have an immediate resource to turn to in the event of an emergency.
Last but not least, HCA encourages the school districts and educational service districts to enroll with HCA Listserv. Where there are changes and updates to the program, if you are enrolled, you will get notified immediately. If a district or licensed health care practitioner has a program policy question, contract concern, or need to speak directly to Program, anyone can email me directly through the SBHS website. All you have to do is scroll down to the subheading called contact and click the email hyperlink. If you have immediate concerns, emailing Jim Harvey directly through this website you can ensure your communication will be received.
Matt – Do you have any additional comments that needs to be added?
Jim
So what is the School-Based Health Care Services Program?
The School-Based Health Care Services (SBHS) program reimburses school districts for covered health care services provided to Medicaid-eligible children in Special Education. These services must be included in the Medicaid-eligible child’s current Individualized Education Program (IEP), be medically necessary, and be provided by licensed heath care providers. More information can be located in the SBHS Medicaid Provider Guide on pg. 1 and in WAC 182-537-0100.
Jim
Lets take a moment to review the details to the website. As we proceed with today’s webinar, Matt and I will be navigating in and out of the website. If you get lost, no worries, the webinar is being recorded and will be available on the SBHS website 7-10 business days after today for one year.
The SBHS website, as mentioned before, is filled with helpful information and resources for school districts, educational service districts, and licensed health care professionals. The first part of the website allows the audience to see that the SBHS program reimburses school districts for Medicaid covered health care services provided to Medicaid eligible children in Special Education. Immediately, you read these services must be included in the student’s current Individualized Education Program (IEP) and be provided by a licensed health care provided. As a reminder to all participating districts, the Education Staff Associate (ESA) certificate is not a license and can not be used in place of a state health care license to bill Medicaid for health-care-related services.
Lets start with the subheadings “latest updates, Reminders, and Program update” sections of the website. When there are program updates the memos will always be posted under these subheadings. All participating districts are encouraged to print and have the memos handy at all times. Some districts will develop a resource binder strictly related to this program to place the memo into for quick reference. Special Education Directors, Business Managers, and licensed health care practitioners should be reading the memos.
Under the subheading “reminder”, districts should be submitting their Provider Update Form each October with supporting documentation. For newly hired providers, a copy of their National Provider Identifier (NPI) is also required. Complete and return the PUF in it’s entirety by mail, email or fax to (360) 725-1152. The form is located below under “resources”. Please remember that you must have an original signature from the Special Education Director on the form or their designee. The only time you complete the resignation date on the PUF is when a licensed practitioner has resigned from the district. Then you will send this form to the SBHS Program Specialist and deactivate their provider file in ProviderOne. Matt will talk more about how to deactivate a provider’s file in ProviderOne later into the webinar. On pg. 4 of the SBHS Medicaid Provider Guide, districts must enroll their licensed health care practitioners under their billing NPI number before submitting nay claims to the HCA. Failure to enroll licensed health care providers will result in claims being denied automatically.
The next subheading labeled “claiming” explains that when a district has a fully executed contract, they can begin submitting claims. When there are questions regarding their claims, the IGT process or accounting issues, this is where districts can submit questions or concerns directly to the fiscal analyst who finalize the payments for school-based services.
The next subheading labeled “provider qualifications requirements” has to do with licensed health care practitioners. WAC 182-537-0350 outlines what licenses are required to bill Medicaid for the SBHS program. It is important that all participating districts have their licensed health care practitioners read the WAC.
The final subheading labeled “resources” is where districts can find:
Provider licenses under the DOH Provider Credential Search – This is where districts will print the licenses directly from the DOH website, and attach to the Provider Update Form (PUF).
Frequently Asked Questions (FAQs)
How to Register for a National Provider Identifier (NPI) number
The IGT flowchart
The Provider Update Form (PUF) that is due each October
Instructions on how to check Medicaid Eligibility – Later into the webinar Matt will go over how to check for Medicaid eligibility in ProviderOne.
I would like to reiterate that if school districts have questions or concerns, to please contact the SBHS Program Specialist directly for assistance.
Jim
On this slide you can see the different provider types who can bill for health-care-related services under IDEA Part B and Part C. All provider types must be enrolled providers through Provider Enrollment under their school district’s billing NPI number. Once a licensed health care practitioner has been enrolled, the practitioner can then begin to submit claims to Medicaid for IDEA Part B & C health-care-related services provided to a Medicaid-eligible child in Special Education. If a servicing provider has any questions on the enrollment process, they should contact the SBHS Program Specialist directly. If a district has questions about changing their licensed practitioner’s effective start date of enrollment, they should contact the SBHS Program Specialist directly. Districts are being asked that you try and enroll the rendering providers under the school district’s billing NPI number before submitting a claim. The Provider Update Form (commonly known as the PUF) does not suffice this requirement. Matt will talk more about how to enroll a licensed health care practitioner later into the webinar.
Throughout the webinar today, Matt and I will be interchanging the term rendering provider and servicing provider. To help better understand the difference, rending provider is the school district or the contractor. A servicing provider is the employees or licensed health care practitioner.
Jim
HCA School-Based Health Care Services program pays school districts and educational service districts to provide certain health-care-related services under IDEA Part B & Part C. These services HCA reimburses for in the schools are:
Audiology
Counseling
Nursing
Occupational
Physical
Psychological services and assessments
Speech-language
These services must be delivered by a licensed health care practitioner who has been enrolled under their district’s billing NPI number, and holds a current professional license and NPI number. The NPI number is issued by the federal Centers for Medicare and Medicaid Services (CMS) which is never a cost to the licensed health care practitioner or the districts. Districts must ensure that health care practitioners meet the professional licensing and certification requirements in Washington before submitting any claims to HCA. On pg. 3 of the SBHS Medicaid Provider Guide, the licensure requirements for this program are outlined carefully for each provider type. It is the district’s and the licensed health care practitioner’s responsibility to meet these requirement before billing Medicaid for any health-care-related services. If your practitioner is only credentialed with interim permit, they will not be able to submit claims until their license has been finalized by the Department of Health (DOH).
As mentioned on pg. 4 of the Medicaid Provider Guide, services provided under the supervision of a physical therapist, occupational therapist, speech-language pathologist, nurse, counselor or social workers, the documentation of supervision must be provided face-to-face at a minimum of once per month. Supervisors are responsible for approving and co-signing all treatment notes written by the supervisee before submitting claims for payment. Documentation of supervisory activities must be recorded and available to the Health Care Authority upon request.
Under nursing services on pg. 9, registered nurses are able to bill Medicaid for nurse delegation involving training and supervision. Keep in perspective that as a nurse, he or she must document their supervision time aside from their billing activities. If a nurse bills for delegation time, they would use code T1002 only. Licensed Practical Nurses cannot bill for nurse delegation but must be supervised by a registered nurse. The only time a registered nurse can bill for services provided by their paraprofessional is during training and supervision is when they witness the task. Otherwise, the should not bill for services provided by a paraprofessional when not witnessed.
Jim
Starting from pg. 6 to pg. 12 of the Medicaid Provider Guide, are the explanations to the services and the Current Procedural Terminology (CPT) codes. The CPT codes in the Medicaid Provider Guide is a registered trademark of the American Medical Association. This means that HCA publishes only the official, short CPT code descriptions for licensed health care practitioners to review. Participating school districts are encouraged to invest in CPT manuals annually which provides the full descriptions of these codes. The CPT codes are the only codes that can be used by the licensed health care practitioner listed in the Medicaid Provider Guide. If a practitioner is not sure what code to use, they should contact the SBHS Program Specialist or they can contact their state association for guidance.
You will also notice that in some of the covered services, there is a hyperlink to the fee schedule. If you select the hyperlink, you will be redirected to the SBHS program fee schedule. The fee schedule provides each district an Excel spreadsheet outlining how much the reimbursement is per code. Some of the codes are billed to Medicaid in 15 or 1 hour increments. The fee schedule is updated annually in July with new rates for this program, and each school district is expected to check the HCA’s website for the current program fee schedule.
On pg. 13 is a list of services the SBHS Program does not cover. It is important that when you are billing for IDEA Part B and Part C health-care-related services, that your district submits claims that links back to the child’s Individualized Education Program (IEP).
Jim
On pg. 13 of the Medicaid Provider Guide, you will see a list of services that are not covered under this program. Services that are marked with an asterisk are built in to the reimbursement rate for covered services. It is important that when submitting claims for payment, that your treatment notes do not address any of these services. The services not covered under the SBHS program range from Applied behavioral analysis, attending meetings, charting, equipment preparations to continuous observation. As a health care practitioner who is providing the services, it is crucial that treatment notes are not developed around these services on pg. 13. In all clinical practices, treatment notes must give a clear, comprehensive picture of the continual status, the care being provided, and the response to the intervention.
Jim
Licensed health care practitioners (commonly known as the servicing provider) must document all health-care-related services billed to HCA. Assistants, as defined in the Provider Qualifications section of the Medicaid Provider Guide, who provide health-care-related services, must have their supervisor co-sign any documentation in accordance with the supervisory requirements for the provider type. Sufficient documentation must support and justify the billed and paid claims, and original copies be maintained for a minimum of six years from the date of service, and include at a minimum:
Professional assessment reports completed by a licensed professional.
Evaluation and reevaluation reports by the individualized education program (IEP) team members.
A comprehensive IEP.
Treatment notes for each date of service the licensed provider billed to the agency. Treatment notes must include:
A descriptive narrative outlining the activities and interventions involved that are directly related to the current IEP. Clinical treatment notes must reflect the amount, scope, and duration of the service, (e.g., a brief description of the service provided, how long it took to complete the intervention or service, the reason for changes in interventions, changes in the student’s behavior, and any training and supervision provided by a registered nurse).
A few examples of the level of detail the SBHS program requires are:
Discussion on the activities of daily living, such as buttoning skills.
Description of the Range of Motion (ROM), such as elbow or wrist ROM.
Medication management, Tegretol, 200 mg (oral).
Narrative of the student’s progress or response to each service delivered (required for nursing services and recommended for all other services).
Documentation the child was present at the IEP meeting.
The child’s name and ProviderOne Client ID (this could be their Washington State Medicaid ID).
The child’s date of birth.
The date of service, actual time-in and time-out, and the number of billed units for the service.
Indication if the treatment note was for individual or group therapy (e.g., counseling, occupational therapy, physical therapy, psychological services, and speech therapy).
The licensed provider’s original signature, title, and National Provider Identifier (NPI) number. Electronic signatures are allowed only on electronic applications, enrollment forms, and eligibility documents in accordance to RCW 41.05.014. For more information regarding NPIs, refer to the agency’s School-Based Health Care Services webpage.
The following documents requires the licensed practitioner’s original signature, they are:
Individual Health Plans (nursing only)
Treatment notes
Therapy plans
Written treatment protocols
All documentation related to Medicaid-covered services provided to a Medicaid eligible child. Examples include, but not limited to:
Assessments
Treatment notes
Daily documentation (other notes that support treatment notes)
Encounter notes (nursing only)
Medication Administration Reports
Nursing-services documentation must include the outcomes of service, for example, whether or not the services were effective, what the response was, and the method used if the initial method did not work. Documentation of results is required for all nursing services.
In all clinical practice, treatment notes must give a clear, comprehensive picture of the continual status, the care being provided, and the response to the intervention. The notes must state the time in, time out, and the time of any sudden change in the child’s condition.
As described in WAC 182-502-0020, all records must be easily and readily available to the agency upon request.
If a district is using a billing agent to process the claims through ProviderOne, it is imperative that you communicate and work closely with them daily. To help ensure communications from HCA are being received in a timely manner, we suggest the following:
Daily that…
Business Managers check their email inbox and SPAM filters for new invoices sent from HCA fiscal staff.
Districts respond to 30, 60, and 90 day local match notices. Provide the HCA with a date when the local matching funds will be sent so reimbursements can be scheduled.
Monthly
Business Managers contact your billing consultant to confirm claims have been sent to the HCA within the past 30 days. If claims have been submitted, contact HCA fiscal staff regarding your local match invoice. This can be done through the SBHS program website.
If you are a district who self-bills claims through ProviderOne (P1) direct data entry (DDE), then contact your HCA fiscal staff directly.
Anytime
Business Managers contact the SBS Program Manager and HCA fiscal staff via email when there is any superintendent, financial and business management staff, or Special Education Director changes.
Jim
Many districts have asked for us to explain the internal process for handling a claim. The best way to understand this complex system is to see the process visually in the form of a flowchart. As you can see on this slide, the process may appear simple but it is actually complex in paying a claim.
Electronic claims as well as direct data entry (DDE) claims are entered through ProviderOne and assigned a transaction control number (TCN). The system verifies the data on the claim and incorrect information causes the claim to immediately deny. ProviderOne goes thru an adjudication cycle every 15 minutes working claims that are submitted by billing agents or self-billing school districts. If a claim is a “clean” claim by our standards, the claim goes into a “to-be-paid” status and sits in the payment que. If the claim is a secondary claim, has an authorization, or seems to violate a program rule in ProviderOne, then it is suspended for human review. On a daily basis manual claim reviews are averaging between 20-20,000 claims daily. Cutoff for claim payments is Tuesday at 6 PM for payment the following Monday. ProviderOne then sends these “To-Be-Paid” claims to the Office of Financial Management for payment to be generated.
Overview of the IGT Process
Lets revisit the Intergovernmental Transfer Process necessary to get a clean claim paid. On the SBHS website, under the subheading called “resources”, you will find a flowchart labeled “Intergovernmental Transfer Process”. If you are a business manager who authorizes the transfer of local matching dollars to the HCA, you will want this flowchart nearby. When a school district submits their claims for completed School-Based Healthcare Services (through ProviderOne), typically this is either done by a billing consultant on the district’s behalf or by a district who is self-billing. Districts are required to submit their local match within 120 days from the date of their invoice to HCA in the form of a warrant (check) or through an established automatic clearing house (ACH). Once HCA receives the required local match, claims are processed for reimbursement. This means districts receive their local match and they receive state and federal matching funds for reimbursement. The flow-chart that is provided on the SBHS website, illustrates how the IGT process works. Click the hyperlink, school districts and educational service district can print the flow chart directly from the SBHS website. Often people become confused about the IGT process, and this flow chart is there to provide clarity. Anytime there are questions related to the IGT process, school districts and educational service districts are encouraged to contact the HCA’s accounting unit directly. Anyone can send the fiscal techs an email directly through the SBHS website under the subheading labeled “claiming”.
ProviderOne then places the claims into an “In Process” mode, and HCA fiscal staff notifies the school district of the required local match. This is a very good thing for the school districts because this means that the HCA has money ready to reimburse the districts. The school district’s match is then submitted via electronic transfer or in the form of a warrant (paper check) directly to the HCA. If the school district's required local match is not received, the claims will not be released for payment. If local matching requirements are not received within 120 day from the date of the invoice, claims will automatically be denied in ProviderOne. Once the required local match has been received, HCA fiscal staff then moves the claims out of the “in process” mode and processes for reimbursement. More information on the requirements for payment, can be found on pg. 15 through pg.20 in the SBHS Medicaid Provider Guide. As a reminder to all participating school districts, when you have questions or concerns regarding the accounting or IGT process, the fiscal staff can be contacted directly. On the SBHS website, under the subheading labeled “claiming”, will be an email dropbox hyperlink. This is the quickest way to get communications to the fiscal staff.
Jim
On pg. 19 in the Medicaid Provider Guide, and as per WAC 182-501-0200, districts must bill the child’s primary insurance before seeking reimbursement from the agency for health-care-related services. This means that knowing a child’s eligibility status prior to billing is very important. If the HCA receives a bill for services provided to a child with primary insurance, the claim will be denied automatically. Federal law makes Medicaid the payer of last resort in situation like this involving other insurance coverage. Medicaid is only payer of first resort when there are no other insurances involved.
The district may rebill a denied claim only after doing both the following:
Receiving a denial letter or Explanation of Benefits (EOB) from the child’s primary insurance carrier.
Forwarding the written denial with the claim to the agency’s Coordination of Benefits section at the HCA.
School districts may choose not to bill the agency for services provided to special education children who have other insurance. However, the school district must:
Bill other carriers before billing the agency.
Have on file at the school district written consent from the child’s parent or guardian to bill their insurance carrier.
When the agency is being billed, follow the instructions found in the agency’s ProviderOne Billing and Resource Guide.
Matt – Do you have any additional comments that you would like to add?
Jim
(Read the slide only)
Jim
ProviderOne places the claims into an “In Process” mode, and the HCA fiscal staff notifies the school district of the required local match. This is a very good thing for the school districts because this means that the HCA has money ready to reimburse the districts. The school district’s match is then submitted via electronic transfer or in the form of a warrant (paper check) directly to the HCA. If the school district's required local match is not received, the claims will not be released for payment. If local matching requirements are not received within 120 days from the date of the invoice, claims will automatically be denied in ProviderOne. Once the required local match has been received, HCA fiscal staff then moves the claims out of the “in process” mode and processes for reimbursement.
More information on the requirements for payment, can be found on pages 15-20 in the SBHS Medicaid Provider Guide. As a reminder to all participating school districts, when you have questions or concerns regarding the accounting or IGT process, the fiscal staff can be contacted directly. On the SBHS website, under the subheading labeled “claiming”, will be an email hyperlink. This is the quickest way to get communications to the fiscal staff.
Matt
In this section we will review the abilities and functions of the ProviderOne system including user setup, entry of claims, verifying eligibility ,and file maintenance.
Matt
IE version 6 – 9 – fix coming for IE 10 soon – in meantime you can run compatibility mode – shown in handouts provided at start of training. The ProviderOne uses pop-ups as part of the system’s processing. ProviderOne utilizes pop ups within the program which will need to be disabled on the computer for the program to work correctly. Lastly as the slide states, currently only PC computer systems are supported and Apple system products are not.
Jim
Matt can you explain briefly what IE versions mean exactly, and how will this benefit the schools who do use PC computers only? What happens when the Medicaid Coordinator attempts to use an Apple computer?
Matt
The Health Care Authority establishes system administrators for your domain/NPI. System administrators will be able to:
Assign profiles to other ProviderOne users as necessary
Assign one or more security profiles to meet their job duties, and provide lower level ProviderOne access to supporting users
Assist other ProviderOne users with unlocking passwords, if needed. Otherwise, System Administrators would need to contact HCA’s security department directly for assistance if they get locked out.
The ProviderOne Security web site hyperlink is located at the bottom of this slide. School districts should save this hyperlink in their favorites to access in the event they do get locked out of ProviderOne and the ProviderOne system administrator is not available.
Matt
On this slide we provide you with the hyperlink needed to access the ProviderOne Security web site. The website provides step-by-step instructions on the process to accessing ProviderOne. You can also find a list of all the different profiles and what they can do in the Provider Portal and a tutorial on setting up ProviderOne system users.
We have also provided you with an email address to ProviderOne Security. If you become locked out of ProviderOne and there is no one available in your office who can unlock your account, or you are trying to set up a user in a new domain, this email address is where school districts send their request to have an account unlocked. The Medicaid Assistant Call Center can not unlock a user or set up a user in a new domain. The domain is a seven digit number that is utilized when logging into ProviderOne. The NPI number of the school district is attached to this domain number.
The first step will be to get access to your ProviderOne Provider Portal, and this requires that school districts contact ProviderOne Security at the email shown and enter into the subject line, Request for Provider Supplemental Information Request Form. ProviderOne Secuirty will then send you a form to be completed.
Matt
This is the top half of the form that will need to be completed for new ProviderOne users as well as for new self-billing school districts. Current self-billing school districts will not be required to re-do the Provider Supplemental Information Request, unless the current system administrator has left and a replacement administrator was not created prior to the departure. The top half of this form is the only section that will be required to be completed, The bottom half contains some useful links to other pages.
After you have completed the ProviderOne Security Administration section of the form, school districts are to fax the form to 360-586-0702 or email the form to provideronesecurity@hca.wa.gov. The ProviderOne Security Department will set-up the user as a System Administrator. This profile will be the security profile for your domain. The only privileges you have as a System Administrator is adding additional profiles to your user account or establishing additional users to access ProviderOne.
The ProviderOne Security Department will send you two emails, one with your user name and the other will be your temporary password. Please remember to secure your login information in the event you need to access ProviderOne and cannot remember your user name and password. After entering your login information for the first time into ProviderOne, the system will prompt you to reset you password. Passwords must contain at least 8 characters, with at least 1 number, and one special character symbol located in number row of your keyboard. We strongly suggest that you answer the secret question so that if you have forgotten your password, you can still get into the Provider Portal.
Matt
The first step to adding a new user is to log into the ProviderOne system with the correct profile. The only profile that can add the additional user is the System Administrator. Choose this option if available to start the process. If the system administrator profile is not listed you currently are not set up to grant access into ProviderOne for other office workers. This profile is the security function for ProviderOne.
Once you are logged into the ProviderOne system, you will need to scroll down and in the lower left hand corner you will the “ADMIN” section. Select the Maintain Users listed here.
When the manage users page is displayed, you will need to click on the ADD button on the top left side of your computer screen.
Matt
After clicking on the Add button you will get a screen that looks like you are ready to add a new user. The only information needed on this screen are the items that have a red asterisk next to an empty field. These are considered required data fields for adding a new user. Enter the first and last name (middle name not required) and then ProviderOne will generate a new user login identification. Please remember to NOT share his/her login identification to access ProviderOne. System Administrators can change the login information later if necessary.
The User Type field needs information entered (use the default), and it does not matter which option you chose from the drop-down menu. The Date of Birth is a mandatory field, and we suggest using the person’s actual birthday as this is one of the security questions if the user get locked out of ProviderOne. If the actual birthday is not used, we suggest that you use something that the person knows in case they get locked out of the system and have to contact our ProviderOne Security to restore user access.
The EID number is the Employee identification number. This can also be whatever number you want to assign to the ProviderOne user. Do not use a person’s social security number. Whomever is to act as the System Administrator, can always lock and unlock users from accessing ProviderOne. We suggest that there be at least two System Administrators identified and registered with the enrolled school district. The benefit is to allow each other the ability to unlock each other if needed. After you have filled out everything click the Next button in the bottom right hand corner of the screen.
The next screen shot on the right has additional information that will need to be completed for adding a new user. The password that is entered here will be replaced so anything can be entered as long as it contains that required amount of alpha and special characters. Please use the persons actual email address and phone number. This information helps us to contact user directly if they have any issues with ProviderOne. The address section is not needed for the registration process. Click on the Finish button
Matt
After clicking on the Finish button, ProviderOne will take you back to the screen where you started from and will appear as if nothing happen. ProviderOne will only display information that is approved. If you go to the right side of your screen a box titled With Status is shown. Select the All option, and then hit Go, ProviderOne will display the new user you have just added. If you look at the 4th column, you will see that it is titled, Status. Under this column you should see where it says, In Review on the added user. At this point go just to the left of the users name and click the box to enter a check mark, and then go up and click on the Approve button. The system will then give you a couple pop up screens. Say OK to these questions. When ProviderOne refreshes you should then see the added user’s status is now approved. You have now entered a user into ProviderOne but have not given them any profiles, or authority to do anything in the ProviderOne system. To do this you now need to click on the users name.
Matt
After clicking on the users name you will see a screen that shows the information that was just entered.
To add the profiles to a users account, you will need to go to the right side of your screen to the drop down box titled Show. This is indicated by the red arrow on this slide. You will need to open the show menu options and select Associated Profiles.
Matt
When you see this screen appear, System Administrators should notice that it says No Records Found. This is because you have not added and approved any profiles for this user. Remember that ProviderOne only displays items that have been approved.
At this point you need to click on the Add button to start adding profiles.
Matt
After clicking on the Add button, the following ProviderOne field should appear on your screen. The left hand column are all the profiles that are available and can be assigned to a user. To select a profile click on the available profile you want to add. After you have selected the profiles you want the user to have, click on the box with the double arrows pointing to the right, as shown by the red arrow on this slide. The process will move the highlighted profiles from the Available Profiles to the Associated Profiles. After you have all the profiles you want the associated user to have, click on the OK button in the bottom right hand corner of your screen.
Matt
After you clicked the OK button, your screen will refresh and return to the previous screen showing No Records Found. Remember that ProviderOne will not display the information unless it has been approved by you telling the system to show the added user’s information. This is accomplished the same way as you did when trying to find the users name. The System Administrator goes to the With Status drop down field and selects the All option, and either hit the enter key or the Go button. System Users should now see the profiles assigned by them to the new user being entered. At this point System Administrators need to click on the boxes to the left of the profile names to select them then go up and click on the Approve button. ProviderOne will then show another window that required you to click on the OK button.
At this point you just need to click on the Close button until you are back to the User screen
Matt
The last step is to give the associate user another temporary password. This password will need to be used along with the domain and username to log into the ProviderOne system. Once this information is entered, ProviderOne will prompt the user to update their password that will be used for the next 120 days.
Click on the Save and then the Close button to return to the provider’s portal.
Matt
To reset a users password the System Administrator would click on the users name to make the necessary changes. On the example that you see, the System Administrator enters a new password and then confirms that password in the fields that are indicated by the red arrows. After entering and confirming the new password, click on the Save button in the upper left hand corner of the screen. Make sure that you give the employee the new password.
The screen that you are seeing shows where the Lock User button is located. If the user has been locked out or no longer works for the school district, System Administrator will need to check this box which prevents the user accessing the ProviderOne system. If the user has been locked out accidently, this box will be checked. Uncheck the box, give another temporary password, and have the user login again as usual. Click on the Save button and then the Close button to return to the provider’s portal.
Matt
To end a user in ProviderOne, the System Administrators should click on the users name to make the appropriate changes. On the bottom of the right hand column you should see a field that is called Expiration Date. The System Administrator only needs to end a user by changing the end date to today’s date then click on the Save button. The user will not be able to access the system after today from your domain. The expiration will be saved and the account will be removed from your view after the system has refreshed..
We also suggest that you lock the user as shown in the earlier topic on that subject.
Matt
How can we help in this process? If assistance is needed in getting billing and servicing providers enrolled you will want to contact our provider enrollment office at the phone number listed on this slide.
Assistance with adding/updating/end dating a user of ProviderOne from your office, you can send an email to the Provider Relations Unit directly. This email box is monitored by everyone in the Provider Relations Unite, and we will get back in touch with you to assist walking you through the process.
Matt
In this section we will show a couple of different ways to enroll an new servicing provider. The servicing providers are the individuals who are known as licensed health care practitioners.
Matt
Log into ProviderOne using with the Domain, User Name, and Password. When asked to choose a profile to use, you will want to select either the Super User or the Provider File Maintenance options. Do not use the Provider System Administrator as this again is only for setting up the office staff who are going to be using ProviderOne.
Once into the Provider Portal find the section titled Provider on the left hand side of the screen and click on the Manage Provider Information hyperlink.
The 17 or 18 step Provider File or known as the Business Process Wizard is shown. Go down to step 15 and click on that blue hyperlink.
Matt
After clicking on the step 15 hyperlink you will be shown a list of all the current providers that have been added to your school district. If the provider you are wanting to add is not listed click on this screen click on the “Add” button in the upper left side of the screen. Enter the NPI number of the servicing provider as well as the date that you would like on their provider file.
Click the Confirm Provider button. If the provider NPI number is already listed in ProviderOne the providers name will be displayed. If the provider NPI number is not enrolled in ProviderOne you will get an error message stating this.
Matt
If the servicing provider is already a Medicaid Provider and loaded in ProviderOne, their name will be confirmed on the screen. Simply click the OK button at this point. You will be taken back to the list of providers that are enrolled under your school district. Click on the Close button to return to the 17 step business process wizard.
Note: If the provider NPI number is not enrolled in ProviderOne you will get an error message stating this.
You must finish the enrollment process by submitting your modification request to the Health Care Authority’s Provider Enrollment office for approval.
Check the Provider Enrollment web page listed on this slide, or contact the enrollment office directly at 1-800-562-3022 ext 16137 to see what paper documentation may be needed to finalize the enrollment process.
Matt
If you had attempted to add a provider in the previous steps shown and the NPI number was not located in ProviderOne, follow the following slides to enter the provider information in.
From the provider portal under the Provider section click on the Initiate New Enrollment, which will display the screen shot shown on this slide. Click on the individual button and then the submit button.
Matt
When the Basic Information page opens you are ready to input a new servicing provider. Click on the servicing provider’s social security number (SSN) radio button, and the data fields become active. The System Administrator then fills in the name and other data fields as required. The Servicing Type is going to be Servicing Only. The W-9 entity type will always be Other, and then type in Servicing Only in the W-9 Entity Type (if other) box on the right. You can fill in the enrollment effective date but the Health Care Authority’s Provider Enrollment Office will fill in the effective date as the date the application is approved per WAC 182-502-0005.
Click on the Finish button
Matt
When you click the Finish button a pop-up window with Basic Information will appear on your screen. Record the application number. This application number can be used to track the progress of the application or if the application was not finished, it can be re-opened utilizing this number.
Click OK to continue processing the application.
Matt
The 18 step business process wizard for the servicing provider will be shown and as you can see by this slide only 5 steps will need to be completed.
Step 3: Specializations
This is the taxonomy code which tells Medicaid what type of provider you are
Step 5: Licenses and Certifications
The professional medical license will need to be entered into this step. Information needed to be entered includes the license number and the issue and expiration date of this license
Step 7: Identifiers (Optional)
Step 15: Billing Provider Details
This step is where the relationship of the servicing provider and the school district will take place. The school districts NPI number will be entered here and the servicing provider will be added to the school districts provider file
Step 18: Submit Modification for review
You will need to submit the updates to this servicing provider into our provider enrollment office for approval.
To access each of these steps click on the blue hyperlink
The illustration on this slide points out the required steps to enrolling a servicing provider under the school district’s billing NPI number.
Jim
I want to point out this process for some of the larger school districts can be tiring at times. If you get lost and need help with getting back on track with enrolling your servicing providers, please remember to contact Provider Relations. They can access your account, look at what has been completed, and guide you to finishing or updating your servicing providers.
Matt
In this section of today’s webinar, we will review the steps needed to check a student’s Medicaid eligibility in ProviderOne. Per the SBHS program memo update dated in October 2013, because student’s eligibility can change from one month to the next, school districts are responsible for conducting monthly updates on their Medicaid eligibility.
Matt
To verify eligibility in ProviderOne you will need to log in with the domain, username, and password. Once logged in you will need to choose one of three different profiles:
EXT Provider Eligibility Checker
EXT Provider Eligibility Checker/Claims Submitter
EXT Provider Super User
After choosing one of the profiles, ProviderOne will refresh and will display the provider portal. On the provider portal choose the hyperlink “Benefit Inquiry” located under the “Client” heading
Matt
Once the benefit inquiry hyperlink is chosen the system will refresh and the upper screen shot will display. To verify eligibility specific information will need to be entered:
ProviderOne Client ID(Client Identification Code) or
Last Name, First Name AND Date of Birth or
Last Name, First Name AND SSN or
SSN AND Date of Birth
ProviderOne Client ID(Client Identification Code), Last Name, First Name AND Date of Birth or
ProviderOne Client ID(Client Identification Code), Last Name AND Date of Birth or
ProviderOne Client ID(Client Identification Code) AND Last Name
After entering one of the search criteria bullets click on the submit button in the upper right corner of the screen.
The lower screen shot will show what is returned if the eligibility search is unsuccessful. The top of the result page will include the search criteria that you entered to conduct the search. The lower section you will notice that the left side is empty and that the right side has information about why the eligibility was not found.
If there was a keying error click the “Close” button in the upper left corner and you will be returned to the page to enter the search criteria. The infomration from the previous search will be still populated. Correct the keying error and then submit again.
If you have a brand new search to do click on the Submit Another Inquiry button in the upper left corner. This will return you to the page to enter the search criteria. Because you chose this option the previous search criteria is removed allowing you to enter the next eligibility search.
Matt
If the eligibility check was successful you will see information populated under the client demographic information section. A couple pieces of information you will want to document from this section will be the:
ProviderOne Client ID
Date of Birth
Gender
If you would want to print out a copy of the eligibility screen utilize the printer friendly version hyperlink in the upper left corner of the screen.
The following slides show additional information that you will want to look at when billing for the school based healthcare services.
Matt
The first section after you have verified the eligibility is active is to look at the “Client Eligibility Span” section. This will tell the school district what type of coverage the student currently has. Most kids will be on the “CNP” or categorically needy program, however you may also see a “MNP” for medically needy program or “ABP” for alternative medical program. Looking at this screen shot you will notice that the “CNP” is highlighted blue and is a hyperlink. If you click on the “CNP” it will bring up a list of services that are covered under this specific program.
The next thing on this slide that you will want to pay attention to is the Recipient Aid Category (RAC) code. This code is needed as there are a total of 10 of these 4 digit codes that are not eligible for school based healthcare services
When HCA is being billed, following the instructions found in the agency’s ProviderOne Billing and Resource Guide will be important.
Matt
Providers must bill the child’s primary insurance before seeking reimbursement from the HCA for IDEA-related health care services. This means that knowing a child’s eligibility status prior to billing is very important. If HCA receives a bill for services provided to a child with primary insurance, the claim will be denied automatically. Federal law makes Medicaid the payer of last resort when there is private insurance involved (e.g., TRICARE, Regents, GroupHealth).
The district may rebill a denied claim only after doing both the following:
Receiving a denial letter or Explanation of Benefits (EOB) from the child’s primary insurance carrier, and
Forwarding the written denial with the claim to HCA’s Coordination of Benefits section.
This information can be found in the SBHS MGP on pg. 20. The Coordination of Benefits is hyperlinked to take you directly to their website. School districts may choose not to bill HCA for services provided to special education children who have third-party insurance. However, the school district must:
Bill third-party carriers before billing the agency; and
Have on file at the school district written consent from the child’s parent or guardian to bill their insurance carrier.
Matt
(Read the slide only)
Matt
Children’s Medicaid eligibility status can change at any time. School districts are encouraged to:
Verify Medicaid eligibility before submitting a claim; and
Print the Benefit Inquiry result for your records monthly (if necessary)
Claims submitted on and after October 1, 2013, for students who are not Medicaid (Title XIX) eligible will be denied. For claims submitted prior to October 1, 2013, HCA will continue only reimbursing participating school districts for SBHS programming provided to Medicaid (Title XIX) eligible students. This information can be found on the SBHS website under the Program Update dated 10/01/2013. This memo will also list the RAC codes which represents non-Title XIX eligibility codes.
If eligibility changes after this verification HCA will honor a printed screen shot; however, districts will have to operationalize how they coordinate their efforts.
Exception: Students with private insurance carrier that is loaded after eligibility has been verified; commercial insurance must be billed first.
When districts are checking for Medicaid eligibility monthly, keep in perspective that you cannot do future dates in your eligibility search range. The range must be current or if you enter too big of a date range, ProviderOne will not return any eligibility information.
Matt
This slide illustrates how to access the PDF file of your Remittance Advice. On the list page ProviderOne users can download any listed RA by simply clicking on the RA number.
ProviderOne will hold RAs up to four years.
Matt
The summary page to an RA will show the Total Paid as a result of claim billing and finalization listed in the RA. Within an RA there is always sections paid claims, denied claims, and adjusted claims. The only exception is the right side of the summary page which contains provider adjustment amounts. Claim adjustments causes the listing on the RA or on previous RAs.
Matt
When there are adjustments involved, the remaining balance amount can carry over from one RA to the next because not enough claims are paying on the current RA to satisfy a balance. This can happen if school districts do not bill many claims under their billing NPI number or if you wait extended time periods before billing claims. ProviderOne will identify the adjustments by the school district’s NPI numbers as accounts that has a credit balance. Users can see if their district’s NPI is in a credit balance when RAs are retrieved and there is a strange looking check number in bold letters and numbers on the RA. ProviderOne automatically sends credit balance amounts to the Office of Financial Managements (OFM) after 180 days. The OFM then generates an overpayment letter which is mailed to the school district asking them for this amount to be paid to the HCA.
Jim
As a reminder school districts are required to submit their local matching funds within one hundred twenty (120) days from the date HCA fiscal staff submits to them an invoice for their local match. If the local match is not received within one hundred twenty (120) days, claims will be denied automatically in ProviderOne. Districts will then have to resubmit the claim into ProviderOne. Keep in perspective, this will not wave school districts from the 365 day rule applied to the date of service. Schools are still responsible for submitting claims within 365 days from the date of service.
Matt
The HIPAA denial codes are listed on the right side of the denied claim information lines on the RA.
Matt
The last page contains examples of denial codes and their definitions. HCA is also including the web site that has all the denial codes as well as the list of all taxonomy codes available. School districts are encouraged to go to this website and print a copy of the denial codes. HCA also encourage school districts to keep this hyperlink in their favorites for future reference.
Matt
This slide shows the hyperlink to the ProviderOne Billing and Resource Guide. The guide gives directions on how to navigate through ProviderOne, provider file updates instructions, and much more. Every school district should have a copy near by for referencing questions related to ProviderOne and billing correctly. When the ProviderOne Billing and Resource Guide is updated, notices are always sent through the State of Washington Listserve. It will be the district’s responsibility to keep a current copy of this near-by. If districts are having difficulty locating the guide, they can contact Provider Relations directly or contact the SBHS Program Manager for assistance.
Matt
The next several slides for today’s webinar are some helpful online hyperlinks for school districts to access. If you have questions related to the webinars or teaching questions, please contact Provider Relations directly. In the event the hyperlinks are not working, please contact the SBHS Program Manager.
Matt
The online services are available to the public. The websites are updated frequently with new trainings and resources. The websites are where school districts can print a copy of the ProviderOne Billing and Resource Guide, join the Medicaid email list, contact the Coordination of Benefits regarding third-party liability, or Medicaid Customer Service.
Jim
For any additional information on policies associated to the SBHS program, please contact the SBHS Program Manager directly. As a reminder to all Business Managers, Special Education Directors, and self-billing school districts, please send any questions regarding the intergovernmental transfer process to your assigned accounting analyst. The accounting analyst are there to assist school districts with processing the local match or if a district has questions regarding their reimbursement amount, they should contact them directly.
If you have additional questions, please contact myself or Provider Relations Unit directly. This concludes today’s webinar. Thank you for joining us.
