016.06.07 Ark. Code R. 065
To participate in the Arkansas Medicaid Program, providers must adhere to all applicable professional standards of care and conduct.
Providers of targeted case management (TCM) services must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program:
Targeted case management provider applicants must complete and submit to Provider Enrollment a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print a provider application (DMS-652), a Medicaid Contract (DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9).
Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid provider contract. Persons and entities that are excluded or debarred under any state or federal law, regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.
Providers must be licensed or certified to serve their respective target population(s).
NOTE: Individual employees of the Department of Health and Human Services (DHHS) are excluded from enrolling as Medicaid providers for the Targeted Case Management Program; however, the Division of Health may enroll as a TCM provider agency.
Management for Beneficiaries Under the Age of Twenty-One (21) Who Are Not Receiving Division of Developmental Disabilities Services Alternative Community Services (DDS ACS) Waiver Program Services
Providers of targeted case management services who are restricted to serving beneficiaries under the age of twenty-one (21) who participate in the Child Health Services/EPSDT Program and are not receiving services from the DDS ACS waiver program must:
A copy of the applicant's license or certification must accompany the provider application and Medicaid contract. Subsequent licensure and/or certification renewals must be submitted to Provider Enrollment within 30 days of issuance in order for the provider to maintain continuous enrollment.
Management for Beneficiaries Under the Age of Twenty-One (21) Who Are Not Receiving DDS ACS Waiver Services
In situations where the case manager is a member of a group of case managers, each individual case manager and the group must both enroll according to the following criteria:
Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid provider contract. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.
The provider must be licensed or certified to serve their respective target population.
All group providers are "pay to" providers only. Group providers may bill and receive reimbursement only for services performed by a licensed/certified Medicaid enrolled case manager who is a member of the group.
Management for Beneficiaries Age Twenty-One (21) and Younger Eligible for Developmental Disabilities Services (DDS)
Providers of targeted case management services who are restricted to serving beneficiaries age twenty-one (21) and younger who are eligible to receive services from the Division of Developmental Disabilities Services (See section 212.000) must:
A copy of the applicant's certification must accompany the provider application and Medicaid contract. Subsequent certification renewals must be submitted to Provider Enrollment within 30 days of issuance to maintain continuous enrollment.
Management for Beneficiaries Age Twenty-One (21) and Younger Eligible for DDS
In situations where the case manager is a member of a group of case managers, each individual case manager and the group must both enroll according to the following criteria:
All group providers are "pay to" providers only. Group providers may bill and receive reimbursement only for services performed by a licensed/certified Medicaid enrolled targeted case manager who is a member of the group.
Management for Beneficiaries Age Twenty-Two (22) and Older with a Developmental Disability Who Are Not Receiving DDS ACS Waiver Services
Providers of targeted case management who are restricted to serving persons age twenty-two (22) and older who have a developmental disability, but are not receiving DDS ACS waiver services, (See section 213.000) must be a Division of Developmental Disabilities Services Licensed Community Program.
A copy of the current license must accompany the provider application and Medicaid contract. Subsequent license renewals must be submitted to Provider Enrollment within 30 days of issuance to maintain continuous enrollment.
Management for Beneficiaries Age Sixty (60) and Older
Providers of targeted case management who are restricted to serving persons sixty (60) years of age and older must be certified by the Division of Aging and Adult Services as an organization qualified to provide targeted case management services.
In order to be certified by the Division of Aging and Adult Services, the provider must meet the following qualifications:
A copy of the current certification must accompany the provider application and Medicaid contract. Subsequent renewals must be submitted to Provider Enrollment within 30 days of issuance in order to maintain continuous enrollment.
Case management is an activity that assists individuals in gaining and coordinating access to necessary care and services appropriate to the needs of the individual. Medicaid covered targeted case management is a referral for servicethat assists beneficiaries in accessing all medical, social, educational and other services appropriate to the beneficiary's needs.
Targeted case management services are covered when they are:
A targeted case manager may maintain a maximum active caseload of 70 Medicaid beneficiaries at a time.
Receiving DDS ACS Waiver Services
This target population consists of beneficiaries who are age twenty-one (21) and younger who:
Developmental Disabilities Services
This target population consists of beneficiaries who are age twenty-one (21) and younger and who:
DDS certified case managers enrolled as Medicaid targeted case managers must obtain written verification that any beneficiary they wish to bill for has been certified as eligible to receive services from the Division of Developmental Disabilities Services. This documentation must be obtained from the DDS service coordinator responsible for the beneficiary's county of residence and must be maintained in the beneficiary's record. Providers may request a list of DDS service coordinators and their locations from the local DHHS county office.
Disability Who Are Not Receiving DDS ACS Waiver Services
This target population consists of beneficiaries who are age twenty-two (22) and older and who: are:
This target population consists of beneficiaries age sixty (60) and older who have limited functional capabilities in two or more ADLs or lADLs resulting in a need for coordination of multiple services and/or other resources or are in a situation or condition that poses imminent risk of death or serious bodily harm and who demonstrates the lack of mental capacity to comprehend the nature and consequences of remaining in that situation or condition.
The following provides examples of case management services that are covered by Arkansas Medicaid. The list includes but is not limited to:
This assessment process refers to assessing the individual's service needs to assist in accessing services that currently may or may not be in place. It does not refer to a medical assessment or replace any eligibility requirement for any Medicaid program.
This is a service plan that meets the requirements of the TCM program. It does not replace any required plan of care or service plan for a Medicaid waiver program or any other Medicaid program.
This includes, but is not limited to, medical appointments, transportation services and appointments with DHHS.
These type contacts must be documented.
Services that are not appropriate for targeted case management services and are not covered by the Arkansas Medicaid Program include, but are not limited to:
Follow-up calls on pending applications are not a targeted case management function. These calls are not covered.
This includes staffing for personal care. Information shared between two departments of the same agency in order to best serve the beneficiary is the responsibility of the agency providing care. This service is not part of case management.
Time spent making a referral is covered.
This is the responsibility of the TCM agency and the targeted case manager in order to successfully provide the TCM service.
The attempt to contact individuals who may or may not be eligible for case management services or other Medicaid services is not considered a coverable TCM service.
For example, targeted case management services provided to foster children duplicate services provided by a public agency and are therefore not covered.
Discharge planning is a service required of physicians, other practitioners and inpatient facilities. Case management is not a covered service for any date the beneficiary is an inpatient of a facility or institution. These facilities include, but are not limited to, acute care hospitals, rehabilitative hospitals, inpatient psychiatric facilities, nursing homes and residential treatment facilities.
A physician must prescribe all services provided by an enrolled targeted case management provider. However, the physician is not medically responsible for the services and does not supervise the TCM provider or the service provider.
Targeted case management services for beneficiaries under age twenty-one (21) who are not eligible for DDS must be prescribed as a result of a Child Health Services/EPSDT screen. The prescription must be renewed within the applicable periodicity schedule, not to exceed a maximum of twelve (12) months. The original and all subsequent renewed prescriptions must be signed and dated by the physician (no stamped signatures will be accepted) and must be filed and retained by the targeted case manager in the beneficiary's record. Obtaining the physician's orders and prescriptions is not a covered TCM service.
Targeted case management services for all other target groups must be prescribed after the physician examines the beneficiary. The prescription must be renewed every 12 months. The initial and all subsequent renewed or revised prescriptions must be signed and dated by the physician (no stamped signature will be accepted) and must be filed and retained by the targeted case manager in the beneficiary's record. It is the responsibility of the TCM provider to ensure the MD order for TCM services is complete, signed and dated.
If a beneficiary is required to participate in the ConnectCare Primary Care Case Management (PCCM) Program, the beneficiary's PCP must write the prescription for targeted case management services after the physician has examined the beneficiary. Additional information regarding the PCP Program may be found in section I.
The targeted case manager must develop and maintain sufficient written documentation to support each service for which billing is made. Written description of services provided must emphasize how the goals and objectives of the service plan are being met or are not being met. All entries in a beneficiary's file must be signed and dated by the targeted case manager who provided the service, along with the individual's title. The documentation must be kept in the beneficiary's case file.
Documentation must consist of, at a minimum, material that includes:
This must include the start time and the stop time for each TCM service.
The targeted case manager providing the service must initial each entry in the case file. If the process is automated and all records are computerized, no signature is required. However, there must be an agreement or process in place showing the responsible party for each entry.
The tracking is to avoid a beneficiary's case from being closed unnecessarily.
DHHS requires retention of all records for five (5) years. All medical records shall be completed promptly, filed and retained for a minimum of five (5) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. Failure to furnish records upon request may result in sanctions being imposed.
Each TCM must maintain a tickler system for tracking purposes.
The following targeted case management services must be provided by a targeted case management provider and billed on a per unit basis:
This component is an annual face-to-face contact with the beneficiary and contact with other professionals, caregivers or other parties on behalf of the beneficiary. Assessment is performed for the purpose of collecting information about the beneficiary's situation and functioning and to determine and identify the beneficiary's problems and needs.
The maximum units allowed for this service may not exceed twelve (12) units per assessment/service plan visit when providers are dealing with beneficiaries age 21 and over.
This component includes activities that focus on needs identification. Activities, at a minimum, include:
Documentation in the beneficiary's case file must support the reassessment, such as a life-changing diagnosis, major changes in circumstances, death of a spouse, change in a primary caregiver, etc. Any time an assessment is completed, the circumstances resulting in a new assessment rather than a monitoring visit must be documented and must support the activity billed to Medicaid.
NOTE: Annual reassessments and service plan development are allowed, in fact, encouraged. This policy does not prohibit annual reassessments and service plan development. Reassessments may be conducted any time the case manager deems it appropriate, however, when reassessments are performed more frequently than annually, justification for conducting a full reassessment, rather than a monitoring visit, must be included in the documentation contained in the case record.
This component includes activities that help link Medicaid eligible beneficiaries with medical, social, educational providers and/or other programs and services that are capable of providing needed services. For example, making referrals to providers for needed services and scheduling appointments may be considered case management. This component details:
This activity is required but it is considered administrative paperwork and is not a billable TCM activity.
See section 262.100 forthe appropriate procedure code.
This component includes activities and contacts that are necessary to ensure the care plan is effectively implemented and adequately addressing the needs of the Medicaid-eligible beneficiary.
The maximum units allowed for this service may not exceed four (4) units per monitoring visit when providers are dealing with beneficiaries age 21 and over.
Provider "A" has been chosen by the beneficiary to provide home delivered meals. The beneficiary has also chosen provider "A" for case management services. Case management by provider "A" may not be billed for any activity associated with the provision of home delivered meals. It is the responsibility of the direct service provider to ensure quality services are provided. In this example, the home delivered meal provider is responsible for ensuring meals are delivered timely and to the beneficiary's satisfaction. Case management activity does not include monitoring the provision of home delivered meals by the same agency.
This same policy applies to any service where the case management agency is the same agency providing the in-home service.
Provider "B" has been chosen by the beneficiary to provide personal care. The beneficiary has also chosen provider "B" for targeted case management services. Case management by provider "B" may not be billed for any activity associated with the quality of the personal care services being provided by the same agency. It is the responsibility of the direct service provider to ensure quality services are provided.
In this example, the personal care provider is responsible for ensuring personal care services are provided to the satisfaction of the beneficiary and according to the plan of care (POC) that includes the personal care service. This includes whether or not the aide performs the duties assigned, arrives timely, stays the assigned period of time, is courteous and meets the requirements established for the Personal Care Program by the Arkansas Medicaid Program.
See section 262.100 for the appropriate procedure code and modifier.
Contacts with non-Medicaid eligible individuals outside the TCM targeted group are allowed when the purpose of the contact is directly related to the management of the eligible individual's care. It may be appropriate to have family members involved in all components related to the beneficiary's case management because they may be able to help identify needs and supports, assist the eligible individual to obtain services, provide case workers with useful feedback and alert them to changes.
Contacts with non-Medicaid eligible individuals or individuals outside the TCM targeted group are not allowed when the case management is being provided to an individual not eligible for Medicaid TCM as described in this provider manual.
Based on the state fiscal year (SFY) July through June, beneficiaries age twenty-one (21) and older are limited to one hundred four (104) hours (416 units) of targeted case management services per year.
Regardless of the overall SFY benefit limit, each waiver plan of care must specify the number of units being authorized and documentation must reflect how those units are utilized. Utilization must be reasonable, documented, and justified in the case record, based on the beneficiary's overall medical condition, support services available to the beneficiary, and in-home services currently in place.
If a TCM beneficiary is also a home and community based waiver beneficiary, such as ElderChoices, the waiver plan of care supersedes any other plan of care. Therefore, the number of units authorized on the waiver plan of care may not be exceeded unless prior approved by the DHHS RN. Approval will not be granted after the services are already provided.
For audit purposes, the authorization must be in writing, placed in the beneficiary's file, and available for auditors.
Prior authorization (PA) is not applicable for targeted case management (TCM) services for those beneficiaries who are twenty-one (21) years of age and older, who have been diagnosed with a developmental disability, nor for beneficiaries sixty (60) years of age and older (ElderChoices Program).
Eligible Beneficiaries Under Age 21
Prior authorization for TCM services for Medicaid eligible beneficiaries under age twenty-one (21) is required.
The Arkansas Foundation for Medical Care, Inc., (AFMC) must approve all requests for prior authorization for targeted case management services for Medicaid eligible beneficiaries under age 21.
The following information must be submitted to AFMC for Child Health Services (EPSDT) beneficiaries and for DDS eligible beneficiaries under the age of 21:
NOTE: A family group should be managed by only one case manager for any targeted case management service.
The PA request and documentation must be submitted by mail or fax to Arkansas Foundation for Medical Care, Inc., (AFMC). View or print AFMC contact information.
Medicaid Eligible Beneficiaries Under Age 21
Requests for prior authorization must be submitted to the Arkansas Foundation for Medical Care Inc., (AFMC) using Form DMS-601 titled Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21. View or print form DMS-601. Requests may be submitted to AFMC via mail, facsimile, UPS or FedEx. The documentation submitted with the prior authorization request must support the medical necessity of the requested services.
A medical necessity determination will be made within fifteen (15) working days of receipt of a completed prior authorization request. For prior authorization requests meeting the medical necessity requirements, AFMC will issue an authorization number designation, the length of services, procedure codes and units approved for the requesting provider. For denied requests, a letter containing case specific rationale that explains why the request was not approved will be mailed to the requesting provider and to the Medicaid beneficiary.
Determinations
The provider may request reconsideration of the denial within thirty-five (35) calendar days of the denial date. Requests must be made in writing and include additional documentation to substantiate the medical necessity or program criteria of the requested services. Reconsideration is available only once per prior authorization request. A subsequent prior authorization request will not be reviewed if it contains the same documentation submitted with the previous authorization and reconsideration requests.
If the decision is reversed during the reconsideration review, an approval is forwarded to all relevant parties specifying approved units and services. When the denial is upheld, AFMC will notify the provider and the Medicaid beneficiary in writing of the review determinations.
When an adverse decision is received from AFMC, the beneficiary may request a fair hearing of the reconsideration decision regarding the denial of services from the Department of Health and Human Services (DHHS).
The appeal request must be made in writing and received by the Appeals and Hearings Section of the Department of Health and Human Services within thirty (30) days of the date on the letter from AFMC explaining the denial. Appeal requests must be submitted to the Department of Health and Human Services Appeals and Hearing Section. View or print the DHHS Appeals and Hearing Section contact information.
Reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowable for each procedure.
Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time the service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying the beneficiary is eligible for Medicaid prior to rendering services.
Targeted case management services must be billed on a per unit basis, as reflected in a daily total, per beneficiary, perTCM service. One unit equals 15 minutes.
One (1) unit = 5 -15 minutes Two (2) units = 16-30 minutes Three (3) units = 31-45 minutes Four (4) units = 46-60 minutes
Providers must accumulatively bill for a single date of service. Providers are not allowed accumulatively bill for spanning dates of service. For example, a targeted case manager may make several referrals on behalf of a beneficiary on Monday and then again on Tuesday. The targeted case manager is allowed to bill for the total amount of time spent on Monday and the total amount of time spent on Tuesday, but is not allowed to bill for the total amount of time spent both days as a single date of service.
All billing must reflect a daily total, perTCM service, base on the established procedure codes. No rounding is allowed.
Case management documents reflect:
10:00 a.m. to 10:02 a.m.: Scheduled food stamp appointment and reviewed list of required information with the county eligibility worker. (Referral and Linkage)
11:00 a.m. to 11:06 a.m.: Contacted beneficiary's daughter and verified hospitalization dates of service and discussed any change in beneficiary's condition and any additional services needed. (Service Monitoring)
1:30 p.m. to 1:36 p.m.: Called DHHS RN and reported hospitalization of client and conversation with client's daughter (also sent 9511).
TOTAL BILLING: 6 minutes (1 unit) (CALL TO DHHS RN AND PAPERWORK IS NOT BILLABLE. Two minute Referral and Linkage does not equal a unit, therefore, is not billable.)
Case management documentation reflects:
8:30 a.m. to 8:36 a.m.: Contacted beneficiary and discussed need for diapers and durable medical equipment, as requested by DHHS RN. Also scheduled home visit. (Monitoring)
10:00 a.m. to 10:02 a.m.: Scheduled transportation for eligible client. (Referral and Linkage)
10:30 a.m. to 11:00 a.m.: Delivered diapers and 3 pronged cane to eligible client.
TOTAL BILLING: 6 minutes (1 unit). (DELIVERY OF DIAPERS AND CANE IS NOT BILLABLE. Two minute Referral and Linkage does not equal a unit and is not billable.)
8:15 a.m. to 8:20 a.m.: Telephone call to DHHS County Office to verify status of pending food stamp application.
9:00 a.m. to 9:06 a.m.: Telephone call to applicant to report information regarding pending application.
9:15 a.m. to 9:16 a.m.: Telephone call to city staff to see if commodities were in and ready for distribution.
9:50 a.m. to 10:30 a.m.: Took client to grocery store and to pick up commodities.
TOTAL BILLING: 0 minutes. No activity is a covered TCM service.
262.100 Targeted Case Management Procedure Codes
The procedure code in this section must be billed either electronically or on paper with the proper modifier indicated. Prior authorization is required when billing for beneficiaries under age 21. There are benefit limits for TCM services for beneficiaries age 21 and over. See section 242.000 for prior authorization requirements and section 220.000 for information about benefit limits.
The column labeled All, U21 and 21+ indicates that the procedure code or the procedure code along with a particular modifier must be used when billing for all ages, for beneficiaries under age 21 or for those age 21 and over.
The following procedure codes and modifiers must be used to bill for targeted case management services:
*** (...) This symbol, along with text in parenthesis, indicates the Arkansas Medicaid description of the service.
National Code | Modifier | U21 21 + | Local Code Description |
T1017 | U21 | *** (Assessment/Service Plan Development) | |
T1017 | U2 | 21 + | *** (Assessment/Service Plan Development) |
T1017 | U4 | All | *** (Service Management/Referral and Linkage) |
T1017 | U1 | U21 | *** (Service Monitoring/Service Plan Updating) |
T1017 | U3 | 21 + | *** (Service Monitoring/Service Plan Updating) |
Attachment 3.1-A
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
CASE MANAGEMENT
Target Group:
Medicaid recipients age twenty-two and older who are diagnosed as having a developmental disability of mental retardation, cerebral palsy, epilepsy, autism or any other condition of a person found to be closely related to mental retardation because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with mental retardation or require treatment and services similar to those required for such persons and are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.
Targeted Case Management Services are limited to 104 hours per SFY.
The following are targeted case management service descriptions:
* Assessment/Service Plan Development:Face to face contact with the beneficiaryand contact with other professionals, caregivers, or other parties on behalf of the beneficiary. Assessment is performed for the purpose of collecting information about the beneficiary'ssituation and to determine functioning and to determineand identifythe beneficiary'sproblems and needs. Service Plan Development includes ensuring the active participation of the Medicaid-eligible beneficiary. The goals and actions in the care plan must address medical, social, education and other services needed by the Medicaid-eligible beneficiary. The maximum units allowed for this service may not exceed twelve (12) units per assessment/service plan visit with beneficiaries age 21 and over.
* Service Management/Referral and Linkage: Activities and contacts that link Medicaid-eligible beneficiaries with medical, social, education providers and/or other programs and services that are capable of providing needed services.Functions and processes that include contacting service providers selected by the beneficiary and negotiationfor the delivery of services identified in the service plan. Contacts with the beneficiaryand/or other professionals, caregivers, or other parties on behalf of the beneficiary may be apart of service management.
* Service Monitoring/Service Plan Updating: Activities and contacts that are necessary to ensure the care plan is effectively implemented and adequately addressing the needs of the Medicaid-eligible beneficiary. Verifying through regular contacts with service providers at least every other monththat appropriate services are provided in a manner thatis in accordance with the service plan and assuring through contacts with the beneficiary, at least monthly,that the beneficiarycontinues to participate in the service plan and is satisfied with services. The maximum units for this service may not exceed four (4) units per monitoring visit when providers are dealing with beneficiaries age 21 and over.
Definition of Services :
Refer to Attachment 4.19-B, Page 7a, C. for the definition of a unit of service.
CASE MANAGEMENT
Target Group:
Medicaid recipients age twenty-two and older who are diagnosed as having a developmental disability of mental retardation, cerebral palsy, epilepsy, autism or any other condition of a person found to be closely related to mental retardation because it results in impairment of general intellectual functioning or adaptive behavior similar to those of persons with mental retardation or require treatment and services similar to those required for such persons and are not receiving services through the DDS Alternative Community Services (ACS) Waiver Program.
Providers of targeted case management services for recipients as described above must be a Division of Developmental Disabilities Services Certified Case Manager who must maintain the following information
016.06.07 Ark. Code R. 065