DD Provider FAQs
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.
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
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
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
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 othe
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 protected].
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 exception
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
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 kn
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
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
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 medica
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
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.
Where are the NOW and COMP waiver services that were mentioned on the PowerPoint listed along with the associated policies?
The manuals can be found at https://www.mmis.georgia.gov/portal/, Department of Community Health- Waiver Manuals (select Provider then Provider manuals)
Are any of the following covered under the NOW/COMP?
- Dental –Waiver Supplemental services can be used as available and needed for qualifying dental services
- Long term planning, guardianship, special needs trusts, wills – Not Covered
- Van modification – Yes, under vehicle adaptation
- Bathroom adaptation – Yes, under environmental modification
- Assistive technology – Not covered at this time
- Please give an example something covered under Goods and Services.
- Incontinent supplies are one example of something covered under Goods and Services. Please refer to the waiver manuals for more details.
Can the waiver ever be lost?
The NOW and COMP waivers are available to individuals who maintain Medicaid and clinical eligibility and abide by participant responsibilities as outlined in the waiver manuals.
Can a family member be paid to be direct support staff?
There is a family hire exception in policy for participant-direction. It is approved on a very limited basis and is reviewed on a case by case basis. There are strict restrictions found in Chapter 1200 of the NOW and COMP Part II policy manual.
Are therapy services considered a part of waiver services or are they separate? Is there a monthly cap on the amount of therapy services that someone can receive?
Yes, adult speech, adult occupational, adult physical therapies are available waiver services for individuals with clinically assessed need. Yes, there is a cap in the amount of therapy an individual can receive, which can be found in the NOW and COMP waiver manuals.
There is a cap on CAG of $17,000 per year. If this does not cover the full cost of CAG services, what should a family do?
Discuss other service options such as Supported Employment and Community Access Individual with the individual’s support coordinator.
What is Employment Express and how do you access it?
Employment Express is actually employment express funding. This is a funding stream using state dollars to support individuals who are on the planning list and wanting to pursue supported employment. Job development and procurement is funded through the Georgia Vocational Rehabilitation Agency (GVRA) and Employment Express funding is used to provide support to an individual while on the job (working) once their case is closed with GVRA.
Do employers receive incentives for hiring individuals with IDD?
Does employment affect SSI?
Each case is different. GVRA offers benefits counseling to help people see which earnings are affected and how they could impact benefits. Payroll earning must be reported to Social Security.
Does competitive employment affect a waiver?
No, but income can affect Medicaid eligibility.
Can individuals on the planning list receive supported employment before receiving a waiver? How do families access Supported Employment services if they don’t have a waiver?
Yes, individuals on the planning list can contact the Regional Field Office to request a referral to GVRA to begin the supported employment service.
6. If Vocational Rehab deems an individual unemployable, what are other options?
DBHDD needs to be made aware of this occurrence as DBHDD does not consider anyone who desires to work to be unable to seek and achieve employment.
If an individual with I/DD wants to pursue self-employment, are there resources to help?
DBHDD is working to find resources and tools for self-employment.
How does someone apply for a waiver?
Contact the Regional Field Office or .
Is there an age that an individual should apply for waivers?
There is no age restriction on when a person can apply for NOW and COMP waiver services.
What determines most-in-need? How do individuals receive waivers?
DBHDD utilizes an objective, validated needs assessment tool and most-in-need questionnaire to determine who moves into waiver services. The planning list is not based on when you apply for service. The tool is updated at least annually. DBHDD encourages families to contact their DBHDD Regional Field Office at any time during the year if there is a change in condition or circumstance so the assessment tool can be updated.
Do the new autism services from DCH impact the ability for an individual to be on the planning list and/or receive services?
The services available through the Autism State Plan do not affect the ability of an individual to be on the planning list. However, because the waiver is the payor of last resort, individuals who should be receiving services through the Autism State Plan will not be eligible to receive those services through the waiver.
If there is no longer a waiting list for NOW and COMP waivers, do those of us on the previous waiting list have to reapply when our kids graduate and leave high school?
DBHDD maintains a Planning List for individuals with IDD who have applied for waiver services and have been determined pre-eligible. Annually, the regional field office contacts the individual to update the needs assessment. People come off the planning list and move into services based on the needs assessment and most-in-need criteria. If the individual has a change of circumstance at any time during the year, they must contact the Regional Field Office to have the needs assessment updated by a Planning List Navigator (specific staff person who manages this work).
Who do we contact when we need to re-activate our application or reapply?
Contact the Regional Field Office.
What is intensive support coordination and how does it specifically serve the individual?
Intensive support coordination is provided to individuals who demonstrate significant behavioral/medical needs based on assessment tools. An intensive support coordinator provides more in-depth oversight, more frequent visits, and works with a clinical supervisor to address more intensive clinical needs.
If a family is not pleased with the level of service from the support coordinator, who should they contact? Can families change support coordination agencies?
If an individual is unhappy with their support coordinator, they should first contact the leadership of the support coordination agency and express their concerns. If they feel that their concerns are not being addressed, they can contact the Regional Field Office to communicate their concerns. An individual is offered choice and can move to another support coordination agency if they so choose. If that is desired, they will need to contact the Regional Field Office to let them know of the desire to change and which agency they would like to change to. There are 7 support coordination agencies to choose from in Georgia, but not all of the 7 agencies cover all areas of the state.
Please discuss the new ISP template. Can families review prior to the ISP meeting?
IDD Connects will not enable an individual or their family members to review the ISP prior to scheduling and completion of the ISP meeting being held. Authorized representatives will have access to the ISP prior to signing it and once it has been approved.
Are providers being trained in autism, especially triggers and de-escalation?
Yes, DBHDD is providing some training through START (Systemic, Therapeutic, Assessment, Resources, and Treatment) is a tertiary care research-based model of services and supports. While providing training, assessment, and crisis intervention services, START services are implemented in the context of a comprehensive, systems-linkage approach to improve capacity in the system as a whole.
The Center for START Services, developed in 2009, is a national initiative based at the University of New Hampshire Institute on Disability/UCED and provides educational and capacity-building services, promotes and evaluates evidence-informed practices and approaches, and facilitates START model program implementation across the United States with the aim of improving the lives of individuals with IDD and behavioral health needs.
Are there autism specific crisis respite homes for individuals over 17?
Individuals over 17 who require the services of a crisis respite home would be placed in a regular crisis home for individuals with I/DD.
What are the steps to change to the participant direction service delivery model?
Contact your support coordinator and inform them of your interest. Sign-up and complete the six-hour mandatory training provided by DBHDD Participant Direction staff. Provide the support coordinator the copy of the certificate of completion then select and enroll with the one of the three fiscal intermediaries within 90 days of completion of the training. You will also need to read and understand the NOW and COMP Medicaid policy for participant direction.
Is there a participant direction handbook or manual for families?
Yes, it is posted on the DBHDD website with other helpful resources on participant direction at: https://dbhdd.georgia.gov/be-compassionate/home-services/participant-direction
If a family chooses to go self-direct, does the family also choose the support coordination agency?
Yes, all individuals can choose their support coordination agency.
Does the mobile crisis unit avoid the needs for emergency room admission? 1013?
Yes, the purpose of the mobile crisis team is to deescalate crisis situations I the community. For more information on accessing crisis services, go to: https://www.georgiacollaborative.com/providers/georgia-crisis-and-access-line-gcal/
Does GA have crisis care for children/adults with I/DD and MH – inpatient, out of home?
Yes, DBHDD has in-home and out-of-home crisis options that are accessible through GCAL (1-800-715-4225) with an expected response time of 60 minutes.