Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

Billing for the Five Non-ICC Waiver Services for Individuals

For quick reference, please refer to the Billing Rules Chart Guide

Documentation for All Waiver Services:

Planned delivery of service must be authorized and documented in the child's service plan. All services must clearly support the achievement of the Waiver child’s identified goals. Services delivered on an emergency basis (unplanned) must be approved by the Individualized Care Coordination agency and documented in the service plan. A Progress Notes must be written for every contact and all fields must be completed.

All Waiver Services: Billing, Service Provision and Transportation

Transportation is not a Waiver service. The Waiver services are Respite, Family Support, Skill Building, Intensive In-Home, Crisis Response Services and Care Coordination. The delivery of these services is not location-specific and could, at times, be delivered to the Waiver child, or other billable family member, in part while that person is being transported. Progress Notes must specifically describe the services performed and how these specifically relate to the child’s identified service plan objectives during the billed service time regardless of where the service is provided.

Staff travel time to meet with the client or family is not a Medicaid service and can not be counted in billing.

Paper Claims and Electronic Billing

The unit's field on the paper UB04 claim is #45. For electronic billing, units are billed as follows: Loop 2400 Segment - SV2 - Institutional Service Line.

Billing Rules for Respite, Family Support, and Skill Building Services for Individuals

The following rules apply to Respite, Skill Building, and Family Support Services:

• Billing claims must indicate actual date of service delivery.
• Billing must be made in 15 minute increments.
• Each Respite, Skill Building, and Family Support Service must be conducted for a minimum of 30 minutes in a day in order to bill.
• Each contact must be continuous for a minimum of 30 minutes.
• Rounding is always down to the closest 15 minutes of service delivered. For instance, one hour and 42 minutes would equal six 15 minute billing units; one hour and ten minutes would equal four 15 minute billing units; 35 minutes would equal two 15 minute billing units.
• Rounding is daily only for each contact.
• Reimbursement is only for face-to-face contacts.
• Services may be provided in the child’s home and in other venues.
• Services must be documented in the child’s service plans and pertain to the child’s goal.
• The service identified must match the service definition.

To recap, the following changes, effective February 1, 2010, have been made to billing rules for Respite, Skill Building and Family Support Services:

• Each Respite, Skill Building, and Family Support Service must be conducted for a minimum of 30 minutes in a day in order to bill.
• Each contact must be continuous for a minimum of 30 minutes.

Additional Rules for Respite Services:

• Billing for Respite must be based on face-to-face interactions with the Waiver child.
• Respite billing is limited to six (6) hours (24 units) per child per day. The maximum of six (6) hours (24 units) is equivalent to a daily rate. The daily Respite rate code is no longer being used.
• Rules for Respite in Community and Crisis Residences (CR): Community Residences and Crisis Residences cannot use any of their CR beds for respite. Only a designated respite bed can be used for respite for a Waiver child. There must be a one-on-one Waiver Respite worker with the Waiver child during waking hours. The Individualized Care Coordinator must make a determination as to whether it would be sufficient to have an on-call Waiver Respite worker available during the time that the Waiver child is sleeping or if this is not necessary per the child’s acuity.
  To illustrate, if the Waiver child was placed in the CR respite bed at 6:00 p.m. on a Friday, the CR could bill for six (6) hours of respite on Friday (6:00 p.m. to midnight). If the child is returned home from respite on Saturday at 1:00 p.m., the CR could bill for six (6) hours of respite on Saturday.

Additional Rule for Skill Building Services:

• Billing for Skill Building must be based on face-to-face contacts with the Waiver child, sibling, parents or caregivers who have been documented as providing frequent and regular care giving responsibilities.

Additional Rule for Family Support Services:

• Billing for Family Support Services must be based on face-to-face contacts with the Waiver child’s parents or caregivers who have regular care giving responsibilities for the child.

Note: Information regarding billing for Respite, Skill Building and Family Support Services group work is found in 600.4.

Billing Rules for Bundled Intensive In-Home and Crisis Response Services (Billing Rules Chart Guide )

Reimbursement for sixty five hours of Intensive In-Home (IIH) and Crisis Response Services (CRS) annually per slot is included in the monthly reimbursement for the Waiver Individualized Care Coordinator. OMH is currently suspending consideration of unbundling these services pending anticipated major program revisions in the foreseeable future. To gather information about the current pattern of delivery of these bundled services, OMH requires Waiver agencies to submit each month Medicaid claims for these services. Bundled IIH and bundled face-to-face CR, including a fixed number of CR telephone contacts, are billed in 15 minute units at 25 cents a unit effective April 1, 2010 to be consistent with billing increments for the other non-ICC services.

The following rules apply to Bundled Intensive In-Home (IIH) and Bundled Crisis Response (CR) Services (Note: all changes in the rules below are effective February 1, 2010 unless otherwise noted.):

• Bundled Intensive In-Home and Bundled Crisis Response Services are billed the first of the month following the month of service delivery because they are part of the monthly Individualized Care Coordination rate.
• Billing for IIH must be based on face-to-face contacts with the Waiver child, siblings, parents or caretakers.
• Billing for Crisis Response must be based on face-to-face contacts with the Waiver child, parents or caretakers with the following exception pertaining to crisis telephone contacts:
• Effective April 1, 2010, up to 48 fifteen minute Crisis Response telephone contacts are billable per slot. Each contact must be at least 15 minutes in duration; rounding is down to the nearest 15 minutes. Each 15 minute contact counts as 15 minutes (i.e., four 15 minute contacts equals one hour). For billing purposes, please note that there is no separate rate code for telephone contacts; consequently, providers must track the number of contacts to assure that billing is within the allowable limit of 48 contacts per slot.
• Effective April 1, 2010, bundled IIH and CR, including allowable CR telephone contacts, are billed to the Medicaid system at twenty-five cents for each 15 minutes of contact.
• IIH and CR face to face contacts must be continuous for a minimum of 30 minutes in a day to be counted for billing.
• Rounding is always down daily to the closest 15 minutes of service delivered. For instance, one hour and 42 minutes would equal six 15 minute billing units; one hour and ten minutes would equal four 15 minute billing units; 35 minutes would equal two 15 minute billing units.
• At the end of the calendar month, all of the 30 minute face to face contacts for IIH, CR services and the 15 minute allowable Crisis Response telephone contacts are totaled for each child to determine units to be billed. Note: Rounding down per contact is daily only and not monthly under any circumstances; rounding up or down at the end of the month is no longer sanctioned.
• Bundled services may be delivered by the Individualized Care Coordinator or by a provider with whom the Individualized Care Coordination agency contracts. If the bundled services are provided through a subcontracted provider, the Individualized Care Coordination agency pays the provider a negotiated rate from the enhanced Individualized Care Coordination rate.
• Services may be provided in the child’s home and in other venues.
• Services must be documented in the child’s service plans and pertain to the objectives.
• The service identified must match the service definition.

To recap, the following changes have been made to the monthly claims for IIH and CRS to assure increased uniformity in billing for the five non-ICC Waiver services:

• Effective February 1, 2010, like the other non-ICC Waiver services, these two services are now delivered in 15 minute increments with a minimum of 30 minutes for a “countable” service. This is a change from the requirement of a minimum of one hour for a “countable” service.
• Effective February 1, 2010, rounding is down to the nearest 15 minutes and only on a daily basis. This is a change from the requirement to total the number of hours delivered and round up or down at the end of the month.
• Effective April 1, 2010, the $1.00 Medicaid payment of each IIH and CRS hour of service delivered has been reduced to $.25 (25 cents) for each 15 minute increment. The minimum service claim has been reduced to $.50 (50 cents) for each 30 minute visit (2x$.25). A 45 minute visit will be 3x$.25 units, etc. Up to 48 fifteen minute Crisis telephone contacts per slot is countable; each 15 minute contact counts for 15 minutes (i.e., four contacts would equal one hour).

Rules for Intensive In-Home Visits and ICC Contacts on the Same Day

Because Individualized Care Coordination (ICC) and Intensive In Home (IIH) are different services, distinct and separate bundled IIH contacts of at least 30 minutes duration can occur on the same day as the ICC qualifying child contact and the ICC qualifying collateral contact (see section 600.2). If IIH is a bundled service performed by the Individualized Care Coordinator, the coordinator may make one visit to the child's home and accomplish all three contacts. If IIH is provided by someone other than the Individualized Care Coordinator, the coordinator may make a maximum of two contacts as described above (one with the child and one with the collateral) and the IIH worker may complete one distinct contact. Contacts may be made in the home or in the community, but are limited to a total of three in a day as described above. Documentation must clearly show relevancy not only to the child's goal, but to the distinct service provided. OMH strongly recommends spreading the ICC billable and non-billable contacts with the child and collaterals over the entire month.

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.