Nursing Services Provider Policy Manual - Maryland

1 Nursing Services Provider Policy Manual 2017. Office of Health Services MDH- division of Nursing Services MDH- division of Nursing Services Provider Policy Manual . Nursing Services Nursing Services Program Policy Revision Table Revision Dates Section(s) Revised Description 1. MDH- division of Nursing Services Provider Policy Manual . Nursing Services Table of Contents I. Overview 5. Service Definition 6. II. Provider Enrollment 6. 1 General Criteria 6. III. Provider Conditions of Participation 9. 1 Registered Supervisory Nurse Responsibilities 9. 2 Provider Responsibilities 10. 3 Provider Policies and Procedures 11.

2 4 Personnel Documentation Requirements 11. 5 Provider Contact Notification to Participants 12. 6 Complaint Investigation 12. 7 Backup Services 12. 8 Termination of Services 13. 9 Provider Reconsideration/Appeal Process 13. IV. Documentation 14. 1 Maintenance of Records 14. 2 Initial Assessment by Registered Nurse 14. 3 Written Plan of Care 14. 4 Physician Orders (485) 15. Verbal Orders 15. 5 Progress Notes 15. 2. MDH- division of Nursing Services Provider Policy Manual . Nursing Services V. Reimbursement 16. 1 Methodology 16. Units and Flat Rates 16. 2 Payment 16. VI. Preauthorization 16.

3 1 General Criteria 16. 2 Requirements (Eligibility Verification System) 16. 3 HealthChoice (Medicaid's Managed Care Program) 16. 4 Staffing Hours 16. VII. General Guidelines for Nursing Services Authorization 17. 1 Initial Assessment/Preauthorization Procedures 17. 2 Review for Continuation of Services 18. 3 Willing and able Caregiver Requirement 18. 4 Transportation 18. 5 School Absences and Closures 18. 6 Vacations/Out-of-state Services 19. 7 Banked Hours 19. VIII. Determination of Nursing Services Hours 19. 1 Ongoing 24/7 Services 19. 2 Duplicate Services 19. 3 Overnight Hours 20. 4 Work/School Hours 20.

4 3. MDH- division of Nursing Services Provider Policy Manual . Nursing Services 5 Referrals 20. Appendices 21. Appendix A Nursing Services Procedure Codes 21. Appendix B HealthChoice, Managed Care Program and the Eligibility Verification System (EVS) 22. Appendix C Preauthorization Procedures 23. Appendix D Medical Appointments/Transportation Memos 28. Appendix E Personnel Review Memo 31. Forms Form 485 Home Health Certification and Plan of Care 33. SKL Example Skills Checklist (Example) 34. DONS PA Preauthorization Intake Form 37. 4. MDH- division of Nursing Services Provider Policy Manual .

5 Nursing Services Nursing Services Program Policy I. Overview Medicaid State Plan Services Nursing is an available State Plan service for Medicaid participants under the age of 21. These Services are typically provided in the home (rather than an institution). Services authorized must be medically necessary and may include care rendered by a registered nurse (RN), licensed practical nurse (LPN), certified Nursing assistant (CNA) or home health aide (HHA)* also certified as a medication technician (CMT). Rare and Expensive Case Management (REM) Program and Model Waiver Medicaid adults enrolled in the REM and Model Waiver programs are also provided medically necessary Nursing Services .

6 Adult Medicaid participants must meet eligibility for REM or Model Waiver in order to receive Nursing Services . Eligibility for REM. A. An individual is eligible to participate in the REM program if the individual: (1) Has one or more of the specified diagnoses in accordance with COMAR. Eligibility for Model Waiver A. To be eligible for the Model Waiver several conditions must be met. These conditions are: 1. Admission must be completed before the individual becomes 22 years old. 2. The individual must meet the definition of a disabled child at the time application for Model Waiver Services is made.

7 The term disabled child means a chronically ill or severely impaired child, younger than 22 years old, whose illness or disability may not require 24-hour inpatient care, but which, in the absence of home care Services , may precipitate admission to or prolong stay in a hospital, Nursing facility, or other long-term facility (COMAR ). *Please see the following Maryland Board of Nursing link: HHAs are required to work in licensed home health agencies. 5. MDH- division of Nursing Services Provider Policy Manual . Nursing Services 3. The individual must be certified as in need of a hospital or Nursing facility level of care.

8 This level of care is determined by a state contracted reviewer using information supplied by the referring physician. 4. The individual's medically necessary and appropriate community based medical Services must be cost neutral. That is, the cost of the community-based Services must not exceed the cost of institutional care. Under the Model Waiver, the parents' income and assets are waived during the financial eligibility process. This means that the child is considered an eligibility unit of one even though he or she will live in the community with the parent(s). Service Definition Nursing Services are authorized through the division of Nursing Services (DONS).

9 For participants who require more individual and continuous skilled care than as defined in 42 CFR , Home Health Services . Nursing Services may be provided by a single nurse to an individual in the individual's home or to multiple participants in a non-institutional group setting. The nurse-participant ratio will not exceed 2 participants per nurse unless authorized by the Department. Nursing Services are provided to Medicaid participants in their home or other appropriate community setting as an alternative to institutional care. II. Provider Enrollment I. General Criteria Prerequisites Prior to submitting an application for enrollment as a Maryland Medicaid Provider , applicants must successfully obtain licensure as a Residential Service Agency (RSA) or Home Health Agency via the Office of Healthcare Quality (OHCQ).

10 All questions regarding the RSA or Home Health licensure application process should be directed to 410-402-8267, or applicants may visit the OHCQ website at 6. MDH- division of Nursing Services Provider Policy Manual . Nursing Services After obtaining Maryland licensure, applicants may submit an application packet to enroll as a Maryland Medicaid Provider to the Provider Enrollment Unit. All questions regarding the application or the process should be directed to 410-767-5340. Step 1 Receipt of Application After the Maryland Medicaid Provider Enrollment Unit has processed a completed application packet, staff will forward the application packet to the division of Nursing Services (DONS).