Please note: This FAQ page will be updated continuously as new questions are received that could be useful to all providers. Please check this page periodically to see updates.
All questions related to claims denial should be directed to HPE, the DCH claims manager CLICK HERE.
See also COMP Waiver Renewal Program Changes
What should I do if I can see my PA and it looks correct but my claim is paid at the old rate?
First, check to make sure that the procedure code listed on the claim includes the two modifiers exactly as listed on the prior authorization. Then, if the PA and claim both appear to reflect the correct procedure code and modifiers, contact HPE via the GAMMIS website or call: 770/325-9600 or toll free 800/766-4456.
- Where can providers find the new service procedure codes?
Procedure codes for the new service types were published by the Department of Community Health via banner message on 3/17/17 on the GAMMIS website. This notification is found under “Provider Notices” CLICK HERE.
Procedure codes are also listed in the COMP policy and procedure manuals on the GAMMIS website (see above reference).
- What is the process for getting rates fixed that appear to be either not updated yet on GAMMIS and/or updated but seemingly incorrect?
Please contact the Operational Analyst in the Regional Field Office.
- GAMMIS “PA” information does not list all the information like on an actual PA [WIS-generated] document and these are not printable (only can print a screen shot). Providers are required to have actual PA funding documents in our files before we can bill and these screen shots do not provide the level of detail needed on a funding document. We will need the OA’s to send us the actual revised PA’s.
Prior authorizations are printable via the GAMMIS system and DCH/DBHDD released the following instructions and reviewed in provider forums. In the future the Division will consider resuming the process of printing and sending prior authorizations downloaded and printed from the DBHDD Waiver Information System but at this time all resources are being directed to generation of PAs to allow provider billing of the new rates.
Instructions for printing prior authorizations from the GAMMIS system:
- Log into the web portal (using the provider number approved for the service)
- Select Web Portal
- Click Prior Authorization and
- Select Search Prior Authorization from the drop-down list
- Enter the Member ID and Date Range – Search
- Click File in upper left corner, and
- Select Print from the drop-down list
- How does a vacant slot in the home affect the budget calculation of minimum hours in a house for Additional Residential Staffing requirements?For example, if you have a 4 bed home but there are currently only 3 occupants due to a vacancy, and each of the 3 occupants is a Tier 3—would the minimum hours in the homes be 66.5*3=199.50 or do you need to put in some hours for a 4th person that is not currently in the home?(Minimum hours meaning you have at least those recommended hours already and then you are requesting more for Additional Residential Staffing)
Additional Residential Staffing is primarily based on the needs of the individual on whose behalf the request is submitted. While the cumulative total hours in the home for all occupants of that home will be considered for potential staff sharing, the absence of a 4th individual in the home will not jeopardize the health or safety of the waiver participant at highest risk.
- For those individuals who are remaining on their existing exceptional rates for CRA, will the 27 day cap be lifted? Right now the PA’s for those folks have not changed and therefore we are still limited to 27 days per month (so unable to recoup for lost days in later months if needed).
The 27-day per month cap will continue to apply to existing exceptional rates. As the authorizations expire, members will be transitioned to the new fee schedule with a 344-day per year billing limit and they can be considered for Additional Residential Supports.
- We have an existing ER approval letter that is still in effect until the next ISP date (in this case 2018). We want to move to the new tier system for this person (because that system provides us with more flexibility in the home for this person and other house-mates who do not have ER’s). Is there a way for us to request that (even though the ER rate is higher than the new tier rate)?
DBHDD will convert a current exceptional rate to the to the assessed rate category on request by a provider. Please contact Annie Webb at email@example.com.
- Currently we go into a lot of homes to deliver CLS and deliver 6.5 hours per day. Under which CLS billing code would we bill under? We do not break the hours up for the majority of individuals; it is billed at six hours.
If the service is delivered to more than one waiver participant you will use the shared CLS code most applicable to the number of individuals receiving service. Also, if delivered to more than one individual but either of two or three individuals requires his/her own focused direct support staff person, services delivered by two staff will be billed using the 1:1 CLS procedure code. In this case, since you state that the service is delivered for six continuous hours, you will use the extended CLS code.
- I care for individuals with exceptional rates and I understand that the conversion will align with their plan year or ER end date, but my question is this: I have reviewed the rates and the rates are lower than what I'm currently receiving as an exceptional rate.
Individuals in community residential settings (host homes or CLAs) will be moved to the new rate categories as they begin the new plan year. If providers believe that the individual’s needs cannot be met under the hours-per-week structure on which each rate was developed, the provider can submit a request for Additional Residential Staffing hours.
Waiver participants living in their own homes or apartments and receiving CLS services must be individually evaluated prior to the end of the ER approval span. Individuals who are unable to live with others for clinical or behavioral reasons will be considered for use of Additional Residential Staffing.
- If we have a home with 4 people in the home, two with 1:1 and the other 2 without an ER, do we continue to provide one staff for each of the ERs as well as one support staff, and the staff recommended for the two people with the new rate structure?
Also in a home with 3 people with shared staffing, how do we staff that home as each of the birthdays come up with their ERs expiring? For example Joe shares with Bob and Bill. Joe’s BD is June, so he loses his ER and goes to the new rate, how do we share Bob and Bill? And then when Bob has his birthday and Bill has no one to share with, how do we continue to staff at that point? Does he then have a 1:1 staff until his ER expires? This scenario may be confusing but it does happen. It happened to us in the past with 2 people sharing. One passed away and then we had 1:1 staffing for 2 people with only the 3 person shared rate.
All members are being transitioned to the new fee schedule retroactive to March 1. For those with an exceptional rate that is higher than the new rate to which they would otherwise be assigned, the exceptional rate will remain in place through the end of the period for which it was authorized (at which point Additional Residential Staffing can be requested). For these exceptional rates, the provider should continue to deliver the level of staffing for which it was approved.
- This question has to do with homes licensed by HFR for a maximum capacity of 5. But, because of DBHDD's policy around the issue, each home only has 4 residents. If the rate is based on licensure capacity how will providers bill?
Can you please let me know whether or not we can correct this issue without reducing licensed capacity?
Homes approved for five or more individuals will continue to bill the existing rate, albeit with a 344-day per year cap rather than a 27-day per month cap. Providers that reduce their licensed capacity to four beds will be able to access rates developed for homes with that license capacity.
- For the people who have current exceptional rate approvals but the tier is higher (so they are supposed to go to the new tier level at 3/1/17 as the tier is higher than the ER rate), should providers then remove the ER language out of the ISP’s since they will be under the Tier system, not the ER rate?
Providers may contact the support coordinator assigned to that waiver participant and request an addendum. Additionally, DCH and DBHDD will be providing training on the new rate structure to staff with DCH Program Integrity and their designees.
- I understand that the maximum cap for Specialized Medical Supplies has increased to $3,800. If individuals are using more supplies than the previous cost cap allowed, can providers submit a request for funding sufficient to cover the cost of the supplies now?
Individuals whose need for medical supplies funding was not sufficient to fund the cost of prescribed supplies in the past may submit a Service Request/Technical Assistance (STAR) through his/her support coordinator. This change to the maximum cap will be considered a change of circumstance.
- How can a provider request that an individual be assessed by this algorithm? Will providers be given a list of the people that this algorithm identifies? What is the timing on that being done?
The Department presumes that this question is related to the use of the SIS and HRST assessments to determine level of need and corresponding rate category. Individuals receiving residential services have been assessed and assigned to rate categories. If providers have not seen a change to the prior authorization representing a rate category assignment, please contact the Operations Analyst in the Regional Field Office. Please note that the only services immediately impacted by the rate assignment are CRA (residential) and Respite services delivered in out-of-home overnight settings.
- If SIS/HRST scores do not give someone an appropriate tier level of funding, there is an algorithm at the State which is supposed to point this out and we can go through a “verification” process for behavior concerns or a “confirmation process” for medical concerns in order to put people in a tier that is higher than what their scores provide for.
The confirmation and verification process is internal to DBHDD and generated by a system determination that DBHDD clinical staff should review the most recent assessment information in order to confirm or validate assessment levels using additional information in the record.
- The SIS assessment format changed since Burns & Associates did the rate study back in July 2015. The documents showing how to calculate the new rates (taking the SIS and HRST assessment scores and using that to find the level and then the tier) show the old SIS assessment categories (for example “Community Support Needs” listed by Burns used to be 1B but now is 2B-Community Living). Can Burns or the Division update the chart to show the correct SIS categories/sections?
DBHDD will update the scoring sheet to reflect the new organization of the Supports Intensity Scale (reflecting the SIS-A version). Note that, for the sections of the SIS used to assign individuals to levels, there have been no changes to the questions themselves or the scoring; they have simply been reordered.