Document 6517383

Sunflower State Health Plan has reached out to and received feeback from many of our stakeholders who will be
impacted by the inclusion of Persons with Intellectual and Developmental Disabilities on January 1, 2014. Below we
address the key concerns and questions we have heard. We do encourage our providers to register on our secure web
portal and to sign up for our email alert system which enables them to get the most up-to-date information regarding
changes in policies and procedures.
What is LifeShare and what is their involvement in providing Medicaid services?
 Centene Corporation recently purchased an interest in LifeShare Management Group, Inc. as a nationwide IDD
partner to help Sunflower and other Centene health plans develop and refine our Managed Care Model for
persons with IDD.
 LifeShare is a nationally-accredited Home and Community Based Services provider in eight (8) states
 LifeShare WILL NOT be a direct service provider in Kansas, for ANY service including Targeted Case Management
 LifeShare will employ LOCAL Kansas staff, within Sunflower State Health Plan, to provide training and best practice
support and crisis clinical services
 Local LifeShare staff in Kansas will include three (3) members of a Rapid Crisis Response System team as well as a
Director of LifeShare’s Pathways program.
 The Pathways program is designed to provide trainings, cultural competency and capacity building support for the
Sunflower team, providers, the community, and members/guardians in the areas of:
1. Emotional & Behavioral Health
2. Natural & Family Supports
3. Community Based Residential Support
4. Integrated Employment & Day Support
5. Member (participant) Directed Support
 LifeShare employees in Kansas will be housed within the offices of Sunflower State Health, and will work closely
with Sunflower staff
 Sunflower State Health Plan members should not see Sunflower or LifeShare as being separate organizations. We
are all a part of Sunflower State
What is the difference between Targeted Case Management (TCM) vs. Care Coordination?
 Sunflower State is NOT providing Targeted Case Management.
 Sunflower State will be paying for Targeted Case Management services provided by licensed providers
 Persons with IDD, who are members of Sunflower State, will be assigned a Care Coordinator, but will also be able
to retain their Targeted Case Management Services.
 Sunflower State Care Coordinators will be an additional support to Targeted Case Managers.
 Targeted Case Managers will continue to perform and bill for the functions they have always performed as
allowed through State regulations
 The State recently provided seven (7) training opportunities and a clarification memo on the allowed, billable
functions of Targeted Case Managers. These have not changed.
 Sunflower State Care Coordinators will be developing the individual’s Home and Community Based Plan of Care in
conjunction with the Member and his/her TCM and guardian (if applicable)
 The Community Developmental Disability Organizations (CDDOs) will continue to determine eligibility for IDD
services and will continue to perform the BASIS assessment
 Sunflower State Care Coordinators will have access to the BASIS assessment information, and the individual’s
Person Centered Support Plan. Our Care Coordinators can participate in Person-Centered Planning meetings if
desired by the member
Four Pine Ridge Plaza | 8325 Lenexa Dr., Lenexa, KS 66214 | 1-877-644-4623 | www.sunflowerstatehealth.com
 Sunflower State’s Care Coordinators can help the member access supports, such as Value-Added Services,
knowledge of providers within our network, and consideration of services that are not traditionally covered by
Medicaid.
 Sunflower State will NOT take over Targeted Case Management. TCM is written into the DD Reform Act, and the
removal of it would require a change in statute.
How are benefits different for members on the waiting list?
 Sunflower State does have access to information regarding which of our members are eligible for IDD services and
are on the State’s waiting list
 There is currently a list of persons who receive no Home and Community Based Services, but may receive
Targeted Case Management (unserved persons)
 There is also a list of persons who receive some Home and Community Based Services but are on a waiting list for
additional services (underserved list)
 We will assign Care Coordination to all members with IDD, including members on both of these lists
 Once we receive direction from the State, as approved by CMS, we will know how to address the needs of those
on the underserved list.
 The CDDOs and State will continue to determine, for persons who have no Home and Community Based Services,
who is allowed crisis access to those services.
What is and should the relationship between Sunflower (and other MCOs) and the CDDOs be?
 Sunflower State and the other two MCOs have been working with the State and a small group of CDDOs to
develop workflows regarding interactions that need to occur between the MCOs and CDDOs.
 Sunflower State is excited to partner with CDDOs to work on issues of crisis access to services, extraordinary
funding, gatekeeping, and especially capacity building of local provider networks.
 Sunflower State understands that the CDDOs will determine eligibility. Sunflower State will not determine
eligibility for IDD services.
 Sunflower State understands the CDDO role of providing consumers with a choice of local service provider
options, and making recommendations about extraordinary funding and institutional placement.
 Sunflower also understands the CDDO role with local quality assurance and dispute resolution and will
communicate with CDDOs, when appropriate and legal, about issues that arise with our members related to
local services.
 Sunflower is currently providing training through some local CDDO affiliate meetings.
 Sunflower State has also invited a local CDDO to help provide training to our Care Coordinators on the role of a
CDDO.
How will claims and billing processes change?
 Span Billing will be allowed effective January 1, 2014.
 Span Billing is allowed during pilot and on January 1, 2014 – We encourage you to bill date span and correct number
of units that match (You can bill daily, weekly or monthly). The date span on a claim must include a timeframe that
is within a single month , and cannot overlap months. For example 01/15/14 thru 02/10/14 – would be two claims,
one for January and one for February.
 During the Pilot Project, date range and number of units must match. Otherwise, only one unit (day) of service will
be paid.
 Day Supports (T2020/T2021) and Residential Services (T2016) must be billed as separate claims.
 Overview of Day Service Billing: Per KMAP policy, effective with dates of service October 1, 2013, providers
participating in the DD pilot may not submit fractional units for procedure code T2020 (Day Services). During the
pilot 1 unit = 1 day.
Four Pine Ridge Plaza | 8325 Lenexa Dr., Lenexa, KS 66214 | 1-877-644-4623 | www.sunflowerstatehealth.com
 Effective with dates of service beginning January 1, 2014 and thereafter, the current HCBS I/DD Day Supports
procedure code and unit of service T2020 (1 unit = 1 day) will be replaced with T2021 (1 unit = 15 minutes).
Maximum limits for T2021 are as follows: 32 units per day, 100 units per week (a week is defined as 7 days), 460
units per month (a month is defined the 1st to 31st of any calendar month). The State currently only allows for a 23
day maximum for day services.
What are the Claim Submission Options?
Providers may submit claims through a variety of channels:




Electronically through an established claim clearinghouse – our electronic payer ID is 68069
Through the KanCare Front End Billing option
Through our web portal by registering at www.sunflowerstatehealth.com
On paper – the paper claim address is:
o KMAP, P.O. Box 3571, Topeka, KS 66601-3571
 Some HCBS service require Electronic Visit Verification (EVV) and are billed via AuthentiCare
What are the NPI Billing Requirements?
Providers need to obtain a NPI number to be contracted with Sunflower State. The National Provider Identifier (NPI) is a
Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique
identification number for covered health care providers. Covered health care providers and all health plans and health
care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a
10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other
information about healthcare providers, such as the state in which they live or their medical specialty.
The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions. Typically, one NPI
number for services is sufficient for all HCBS-I/DD program services. However, separate NPI numbers are needed for
ICF/MR, other HCBS program services, and WORK ILC services.
How can a health care provider apply for and obtain a National Provider Identifier (NPI)?
A health care provider may apply for an NPI in one of three ways:
1. Apply through a web-based application process. The web address to the National Plan and Provider Enumeration
System (NPPES) is https://nppes.cms.hhs.gov.
2. If requested, give permission to have an Electronic File Interchange Organization (EFIO) submit the application data on
behalf of the health care provider (i.e., through a bulk enumeration process). If a health care provider agrees to permit
an EFIO to apply for the NPI, the EFIO will provide instructions regarding the information that is required to complete
the process.
3. Fill out and mail a paper application form to the NPI Enumerator. Health care providers may wish to obtain a copy of
the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator
located in Fargo, ND, whereby staff at the NPI Enumerator will enter the application data into NPPES. This form is now
available for download from the CMS website (http://www.cms.gov/cmsforms/downloads/CMS10114.pdf) or by
request from the NPI Enumerator. Health care providers who wish to obtain a copy of this form from the NPI
Enumerator may do so in any of these ways:
Four Pine Ridge Plaza | 8325 Lenexa Dr., Lenexa, KS 66214 | 1-877-644-4623 | www.sunflowerstatehealth.com
Phone: 1-800-465-3203 or TTY 1-800-692-2326
E-mail: [email protected]
Mail:
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
Explanation of Billing Codes and Limitations:
HCBS – Intellectual/Developmental Disabilities
The Home and Community Based Services (HCBS) for those with Intellectual and Developmental Disabilities (I/DD)
program is designed to meet the needs of beneficiaries who would be institutionalized without these services. The
variety of services described below are designed to provide the least restrictive means for maintaining the overall health
and safety of those beneficiaries with the desire to live outside of an institution. It is the beneficiary’s choice to
participate in the HCBS program.
BENEFIT DESCRIPTION
Residential Supports
HCPCS/Modifier
DIAGNOSIS
LIMITS
Regular Tier 1-5
T2016
MRDD
1 unit = 1 Day, Max of 31 per month. (Can not be
billed with S5125, T1019, H0045 & T2025/deny)
Super Tier 1-5
Day Supports
T2016
MRDD
MRDD
Regular Tier 1-5
T2021
MRDD
1 unit = 15 minutes, Max of 460 units a month).
Super Tier 1-5
T2016 May be billed daily
or span billed (weekly or
monthly, will max out once
you reach monthly limits)
T2021 May be billed daily
or span billed (weekly or
monthly with units used,
once you reach max of 460
units claims will deny)
OTHER I/DD CODES
T2021
MRDD
1 unit = 15 minutes, Max of 460 units a month).
Supportive Home Care
S5125
MRDD
1 unit = 15 minutes, Max of 1824 per month. (If
T2016 bill on same claim Deny).
1 unit = 1 Day, Max of 31 per month. (Can not be
billed with S5125, T1019, H0045 & T2025/deny)
Four Pine Ridge Plaza | 8325 Lenexa Dr., Lenexa, KS 66214 | 1-877-644-4623 | www.sunflowerstatehealth.com
Respite Overnight
Personal Assistant Services
Supported Employment
Sleep Cycle Support
Specialized Medical Care
(RN)
Specialized Medical Care
(LPN)
Medical Alert Rental
Financial Management
Services
Wellness Monitoring
Assistive Services
PBS (POSITIVE
BEHAVIORAL SUPPORTS)
H0045
T1019
H2023
T2025
T1000TD
T1000
S5161
MRDD
MRDD
MRDD
MRDD
1 unit = 1 Day, 60 days per calendar year. (Deny if
billed with T2016 Residential Supports)
1 unit = 15 minutes, 1824 Units per month.
1 unit = 15 minutes (limit controlled in Auth)
1 unit = 1 Day, Max of 31 per month.
MRDD
1 unit = 15 minutes, limited to 1824 units per
month (372 hours). (Deny EX96 if T2016 is also
billed).
MRDD
MRDD
1 unit = 15 minutes, limited to 1824 units per
month (372 hours). (Deny EX96 if T2016 is also
billed).
1 unit = 1 month, max of 12 per year
T2040U2
S5190
S5165
780.99 1 unit = 1 month, max of 12 per year
1 unit per 60 days
No limit for IDD members
MRDD
MRDD
DD Screening
T2024
MRDD
1 unit = 1 assessment per year
PBS Environmental
Assessment
H2027
MRDD
1 unit = 15 minutes max of 120 units per year (Max
of $1,200 year)
PBS Treatment
H2027 (U3)
MRDD
1 unit = 15 minutes, max of 240 units per year (Max
of $6,000 year)
PBS Person-Centered
Planning
Targeted Case Mgt
90882 (22)
T1017
MRDD
MRDD
1 unit = 15 minutes, max of 40 hours (Max of
$1,600 year)
1 unit = 15 minutes/240 Units per year
*ALL CODES REQUIRE PRIOR AUTHORIZATION
*IF 1 unit = 1 day, May be billed daily or span billed (weekly or monthly, will max out once you reach monthly limits)
*If 1 unit = 15 minutes, May be billed daily or span billed (weekly or monthly with units used, once you reach max #
of units claims will deny)
*A claim should always be billed within the same month, never cross into another month on the same claim, i.e.
01/15/14 thru 02/15/14
this would need to be 2 claims, one for January charges and one for February charges
*You can not pre-bill services, must bill for services after services given/received
* Refer to the HCBS Financial Management Services Provider Manual for criteria and information
How will Third Party Liability (TPL) be Handled for IDD Services?
Sunflower State Health Plan will exclude IDD waiver HCPCS from the initial Coordination of Benefits process and pay the
claims as the primary carrier. The health plan will then look for other carrier responsibility and recovery as applicable.
Four Pine Ridge Plaza | 8325 Lenexa Dr., Lenexa, KS 66214 | 1-877-644-4623 | www.sunflowerstatehealth.com
How Should Claim Corrections be Submitted?
Electronic
Submit corrected claims electronically via your Clearinghouse using the values specified for the fields below:
HCFA 1500 / Professional Claims:
• Field CLM05-3 = 6
• REF*F8 = Must contain the original claim number from the Explanation of Payment (EOP)
UB / Institutional Claims:
• Field CLM05-3 = 7
• REF*F8 = Must contain the original claim number from the Explanation of Payment (EOP)
Paper Claims
Submit corrected paper claims to Sunflower State Health Plan using the values specified for the fields below:
HCFA 1500 / Professional Claims:
• Box 22 = Must contain the original claim number from the Explanation of Payment (EOP)
UB / Institutional Claims:
• Box 4 = Must contain a Bill Type that indicates a correction e.g., 0XX7
Provider Portal Claims
Submit corrected claim via the secure Provider Portal at www.sunflowerstatehealth.com
1. Click Claims at the top of the screen.
2. Select an individual paid claim to see the details.
3. The claim displays for you to correct as needed. Click Correct Claim.
4. Proceed through the claims screens correcting the information that you may have omitted when the claim was
originally submitted.
5. Continue clicking Next to move through the screens required to resubmit.
6. Review the claim information you have corrected before clicking Submit.
7. You receive a success message confirming your submittal.
Please contact your Provider Relations Specialist if you are interested in training to use our secure Provider Portal.
Contact information may be viewed here:
http://www.sunflowerstatehealth.com/for-providers/provider-resources/
If you have further questions, please review the Sunflower State Health Plan Provider Manual located on our
website or contact our provider services team at 877-644-4623.
What Website Resources are Available?
1. Our secure provider website allows providers to:
• Check member eligibility
• View Members’ health records
• View the PCP panel
• View member cost of care/client obligation amounts
• View and submit claims and adjustments
•
View payment history
Four Pine Ridge Plaza | 8325 Lenexa Dr., Lenexa, KS 66214 | 1-877-644-4623 | www.sunflowerstatehealth.com
•
•
•
•
View and submit authorizations
View member gaps in care
View quality scorecard
Contact Sunflower State representatives securely and confidentially
The secure provider website is accessible only to participating providers and their office staff who have
completed the registration process once the contract is complete and to non- participating providers who have
submitted a claim to Sunflower State. Registration is quick and easy. There is also a reference manual on the site
to answer any questions you may have. On the home page, select the Login link on the top right to start the
registration process. We are continually updating our website with the latest news and information, so save this
site to your Internet “Favorites” list and check our site often.
2. Our email alert system helps keep providers updated on important policies and procedures. In order for our providers
to get the latest information, they should sign up for Sunflower’s email alerts (by logging on to
www.sunflowerstatehealth.com).
Four Pine Ridge Plaza | 8325 Lenexa Dr., Lenexa, KS 66214 | 1-877-644-4623 | www.sunflowerstatehealth.com