Targeted Case Management Medicaid Manual - Kentucky

1 ;-, Kentucky Medicaid PROGRAMPOLICIES AND PROCEDURES MANUALFORTITLE V SERVICES PROVIDED BYTHE DEPARTMENT FOR SOCIAL SERVICESC abinet for Health ServicesDepartment for Medicaid ServicesFrankfort, Kentucky 40621 CABINET FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICES,mTITLE V SERVICES PROVIDED BY DSSTABLE OF CONTENTSI. AgentII. Kentucky Medicaid Law 92-603 (As Amended) Process for Refund Submission of of Provider ParticipationIII. CONDITIONS OF Manager Service Provider RecordsIV. PROGRAM of Targeted case Management of Targeted case Management case Management ServicesPAGE #l07/96 CABINET FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICESTITLE V SERVICES PROVIDED BY DSSTABLE OF CONTENTSAPPENDIXA ppendix I -Appendix II -Appendix III -Appendix IV -Provider Agreement (MAP-343)Provider Information Sheet (MAP-344)Provider Agreement Electronic Media Addendum (MAP-3 80)Agreement Between the Kentucky Medicaid Program andElectronic Media Billing Agency (MAP-246)Appendix V - Medicaid Program Fiscal Agent InformationTRANSMITTAL # -___.

2 I--TRANSMITTAL #l07/96 CABINET FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICES,pTITLE V SERVICES PROVIDED BY DSSSECTION I - Manual provides for Title V Services Provided by Department for SocialServices. The Manual was formulated to provide Medicaid providers with auseful tool for interpreting the procedures and policies of the Kentucky has been designed to facilitate the processing of your claims forservices provided to qualified recipients of Manual shall provide basic information concerning coverage and policy. Itshall assist providers in understanding what procedures are reimbursable, andshall also enable you to have your claims processed with a minimum of timeinvolved in processing rejections and making inquiries. It has been arranged in aloose-leaf format, with a decimal page numbering system which shall allowpolicy and procedural changes to be transmitted to providers in a form which maybe immediately incorporated into the Manual ( , page might be replaced bynew pages and ) after amendment process completed to correspondingadministrative adherence to policy shall be imperative.

3 In order that claims may beprocessed quickly and efficiently, it shall be extremely important that the policiesand instructions described in this Manual be followed. Any questions concerningagency policy shall be directed to the Office of the Commissioner, Department forMedicaid Services, Cabinet for Health Services, 275 East Main Street, Frankfort, Kentucky 4062 1, or Phone (502) 564-4321. Questions concerning the applicationor interpretation of agency policy with regard to individual services should bedirected to the Division of Program Services, Department for Medicaid Services,Cabinet for Health Services, 275 East Main Street, Frankfort, Kentucky 4062 1, orPhone (502) 564-6890. Questions concerning billing procedures or the specificstatus of claims shall be directed to the Kentucky Medicaid fiscal agent (seeAppendix: Kentucky Medicaid Fiscal Agent).

4 TRANSMITTAL #l07/96 Page FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICESTITLE V SERVICES PROVIDED BY DSSSECTION I - AgentThe Department for Medicaid Services contracts with a fiscal agent for theoperation of the Kentucky Medicaid Management Information System (MMIS).The fiscal agent receives and processes all claims for medical services provided toKentucky Medicaid recipients. Information regarding the fiscal agent shall beincluded in the #l07196 Page Medicaid PROGRAMSECTION IITRANSMITTAL # .. _ .._I. >..~ .. _~.,_ .._>.,_ .._l_\. _ .._. FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICESrTITLE V SERVICES PROVIDED BY DSSSECTION II - Kentucky Medicaid Medicaid InformationThe Kentucky Medicaid Program shall be administered by the Cabinet forHealth Services, Department for Medicaid Services.

5 The MedicaidProgram, identified in Title XIX of the Social Security Act, was enacted in1965, and operates according to a State Plan approved by the Health CareFinancing XIX is a joint Federal and State assistance program which providespayment for certain medical services provided to Kentucky recipients wholack sufficient income or other resources to meet the cost of medical basic objective of the Kentucky Medicaid Program shall be to aid themedically indigent of Kentucky in obtaining quality medical Department for Medicaid Services shall be bound by both federal andstate statutes and regulations governing the administration of the StatePlan. The state shall not be reimbursed by the federal government formonies improperly paid to providers for non-covered Kentucky Medicaid Program, Title XIX, shall not be confused, withMedicare. Medicare is a Federal program, identified as Title XVIII,basically serving persons sixty-five (65) years of age and older, and somedisabled persons under that Kentucky Medicaid Program serves eligible recipients of all Medicaid coverage and limitations of covered health careservices specific to this program shall be specified in the body of thismanual in Section #l07196 Page FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICESTITLE V SERVICES PROVIDED BY DSSSECTION II - Kentucky Medicaid StructureThe Department for Medicaid Services of the Cabinet for Health Servicesshall bear the responsibility for developing, maintaining, andadministering the policies and procedures, scopes of benefits, and basis forreimbursement for the medical care aspects of the Program.

6 The fiscalagent for the Department for Medicaid Services shall make the paymentsto the providers of medical services who have submitted claims forservices within the scope of covered benefits which have been provided toeligible of the eligibility status of individuals and families forMedicaid benefits shall be a responsibility of the local Department forSocial Insurance offices, located in each county of the CouncilThe Kentucky Medicaid Program shall be guided in policy-makingdecisions by the Advisory Council for Medical Assistance. In accordancewith the conditions set forth in KRS , the Council shall becomposed of eighteen (18) members, including the Secretary of theCabinet for Health Services, who serves as an exofficio member. Theremaining seventeen (17) members shall be appointed by the Governor tofour-year terms. Ten (10) members represent the various professionalgroups providing services to Program recipients, and shall be appointedfrom a list of three (3) nominees submitted by the applicable professionalassociations.

7 The other seven (7) members shall be citizens of Kentuckywho share a basic concern for health care in this accordance with , the Advisory Council shall meet at leastevery three (3) months or as often as deemed necessary to accomplish #107196 Page FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICESTITLE V SERVICES PROVIDED BY DSSSECTION II - Kentucky Medicaid PROGRAMIn addition to the Advisory Council, the statute includes a provision for afive (5) or six (6) member technical advisory committee for certainprovider groups and recipients. Membership on the technical advisorycommittees shall be decided by the professional organization that thetechnical advisory committee represents. The technical advisorycommittees shall provide for a broad professional representation to theAdvisory necessary, the Advisory Council shall appoint subcommittees or ad hoccommittees responsible for studying specific issues and reporting theirfindings and recommendations to the basic objective of the Kentucky Medicaid Program shall be to ensurethe availability and accessibility of quality medical care to eligibleprogram 1967 amendments to the Social Security Law stipulate that Title XIXP rograms have secondary liability for medical costs of program is, if the patient has an insurance policy, veteran s coverage, or otherthird party coverage of medical expenses, that party shall be primarilyliable for the patient s medical expenses.

8 The Medicaid Program shallhave secondary liability. Accordingly, the provider of service shall seekreimbursement from the third party groups for medical services providedprior to billing a provider receives payment from a recipient,payment shall not be made by a payment is made by a thirdparty, Medicaid shall not be responsible for any further payment above theMedicaid maximum allowable addition to statutory and regulatory provisions, several specific policieshave been established through the assistance of professional advisorycommittees. Principally, some of these policies are as follows:..__;,TRANSMITTAL #l07196 Page FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICESTITLE V SERVICES PROVIDED BY DSSSECTION II - Kentucky Medicaid PROGRAMAll participating providers shall agree to provide medical treatmentaccording to standard medical practice accepted by their professionalorganization and to provide Medicaid services in compliance with federaland state statutes regardless of age, color, creed, disability, ethnicity,gender, marital status, national origin, race, religion, or sexual shall comply with the Americans with Disabilities Act and anyamendments, rules and regulations of this medical professional shall be given the choice of whether or not toparticipate in the Medicaid Program.

9 From those professionals who havechosen to participate, the recipient shall select the provider from whom therecipient wishes to receive their medical the Department makes payment for a covered service and the provideraccepts this payment in accordance with the Department s fee structure,the amounts paid shall be considered payment in full; a bill for the sameservice shall not be tendered to the recipient, and payment for the sameservice shall not be accepted from the provider may bill therecipient for services not covered by Kentucky of medical services or authorized representatives shall attest, bytheir signatures, that the presented claims shall be valid and in good claims shall be. punishable by fine or imprisonment, or , stamped or computer generated signatures shall not claims and substantiating records shall be auditable by both theGovernment of the United States and the Commonwealth of provider s adherence to the application of policies in this Manual shallbe monitored through either postpayment review of claims by theDepartment, or computer audits or edits of computer audits oredits fail to function properly, the application of policies in this manualshall remain in effect.

10 Therefore, claims shall be subject to postpaymentreview by the #l07196 Page FOR HEALTH SERVICESDEPARTMENT FOR Medicaid SERVICESTITLE V SERVICES PROVIDED BY DSSSECTION II - Kentucky Medicaid PROGRAMAll claims and payments shall be subject to rules and regulations issuedfrom time to time by appropriate levels of federal and state legislative,judiciary and administrative services made to eligible recipients of this Program shall be on a levelof care at least equal to that extended private patients, and on a levelnormally expected of a person serving the public in a recipients shall be entitled to the same level of confidentiality affordedpersons NOT eligible for Medicaid services shall be periodically reviewed by peer groups withina given medical services shall be periodically reviewed for recipient and abuse by the provider may result in suspension fromProgram participation.