Home and Community-based Services (HCS) Program Billing Guidelines

HCSBG, Section 1000, Introduction

Revision 15-2; Effective October 30, 2015

 

 

1100 General Information and Statutory Requirements

Revision 10-1; Effective June 1, 2010

 

Department of Aging and Disability Services (DADS) rules at 40 TAC §9.170 set forth requirements for Home and Community-based Services (HCS) Program providers to receive payment for HCS Program services. Specifically, 40 TAC §9.170(d) requires a program provider to prepare and submit service claims in accordance with the HCS Program Billing Guidelines. Also, Sections II. H. and II. T. of the HCS Program Provider Agreement require program providers to comply with the HCS Program Billing Guidelines. In addition, 40 TAC §9.170(k) sets forth circumstances under which a program provider will not be paid or Medicaid payments will be recouped from the program provider.

 

1200 Service Components

Revision 15-2; Effective October 30, 2015

 

The HCS Program consists of the following service components:

 

1300 Billing and Payment Reviews

Revision 10-1; Effective June 1, 2010

 

Billing and payment reviews are conducted to determine if a program provider has complied with DADS rules and these billing guidelines. Billing and payment reviews and residential visits are distinct from the reviews described in 40 TAC §9.171, which are performed to determine a program provider’s compliance with the program certification principles contained in 40 TAC §§9.172-9.179. Appendix I, Billing and Payment Review Protocol, describes how billing and payment reviews are conducted.

HCSBG, Section 2000, Definitions

Revision 15-3; Effective December 8, 2015

 

 

The following words and terms, when used in these billing guidelines, have the following meanings unless the context clearly indicates otherwise:

ADLs or activities of daily living — Basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing and transferring.

Adult — A person who is 18 years of age or older.

Annual vendor — A vendor that provides to a program provider, for a calendar year, one or more adaptive aids costing less than $500.

Behavior support plan — A written plan prescribing the systematic application of behavioral techniques regarding an individual that contains specific objectives to decrease or eliminate targeted behavior.

Billable activity — An activity for which a service claim may be submitted for service components and subcomponents listed in Section 3100, Applicable Service Components.

Calendar day — Midnight through 11:59 p.m.

Calendar month — The first day of a month through the last day of that month.

Calendar week — Sunday through Saturday.

Calendar year — January through December.

CFC PAS/HAB or Community First Choice Personal Assistance Services/Habilitation — A state plan service that consists of:

(A) personal assistance services that provide assistance to an individual in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) based on the individual's person-centered service plan, including:

(I) non-skilled assistance with the performance of the ADLs and IADLs;

(II) household chores necessary to maintain the home in a clean, sanitary and safe environment;

(III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and

(IV) assistance with health-related tasks; and

(B) habilitation that provides assistance to an individual in acquiring, retaining and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs and health-related tasks, such as:

(I) self-care;

(II) personal hygiene;

(III) household tasks;

(IV) mobility;

(V) money management;

(VI) community integration, including how to get around in the community;

(VII) use of adaptive equipment;

(VIII) personal decision making;

(IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and

(X) self-administration of medication.

Clean claim — In accordance with the Code of Federal Regulations, Title 42, §447.45(b), defined as a service claim submitted by a program provider for a service delivered to an individual that can be processed without obtaining additional information from the provider of the service or from a third party.

Competitive employment — Employment in the competitive labor market, performed on a full-time or part-time basis, that pays an individual:

(A) at or above the applicable minimum wage; and

(B) not less than the customary wage and level of benefits paid by an employer to individuals without disabilities performing the same or similar work.

Co-payment — A fixed fee an individual pays for a service at the time the service is provided.

DADS — The Department of Aging and Disability Services.

Deductible — Payment made by an individual in a specified amount for a service received before coverage begins for that service under the insurance policy.

DFPS — The Department of Family and Protective Services.

Extended shift — During a 24-hour period, a combined period of time of more than 16 hours.

Face-to-face — Within the physical presence of another person who is not asleep.

Focused assessment — An appraisal of an individual's current health status that:

(A) contributes to a comprehensive assessment conducted by a registered nurse;

(B) collects information regarding the individual's health status; and

(C) determines the appropriate health care professionals or other persons who need the information and when the information should be provided.

Four-person residence — A residence approved in accordance with 40 TAC §9.153:

(A) that a program provider leases or owns;

(B) in which at least one person but no more than four persons receive:

(I) residential support;

(II) supervised living;

(III) a non-HCS Program service similar to residential support or supervised living (for example, services funded by DFPS or by a person’s own resources); or

(IV) respite;

(C) that, if it is the residence of four persons, at least one of those persons receives residential support;

(D) that is not the residence of any persons other than a service provider, the service provider’s spouse or person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and

(E) that is not a dwelling described in §9.155(a)(5)(H) of this subchapter (relating to Eligibility Criteria and Suspension of HCS Program Services).

Guardian — A guardian of the person or estate appointed for a person in accordance with state law.

GRO —General Residential Operation. As defined in Texas Human Resources Code, §42.002, a child-care facility that provides care for more than 12 children for 24 hours a day, including facilities known as children's homes, halfway houses, residential treatment centers, emergency shelters and therapeutic camps.

Health-related tasks — Specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under state law to be performed by a service provider of CFC PAS/HAB. These include tasks delegated by a registered nurse, health maintenance activities, as defined in 22 Texas Administrative Code (TAC) §225.4, Definitions, and activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist or speech-language pathologist.

IADLs or instrumental activities of daily living — Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing and other essential items; performing essential household chores; communicating by phone or other media; traveling around and participating in the community.

ICF/IID —Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which ICF/IID Program services are provided and that is licensed in accordance with Texas Health and Safety Code Chapter 252 or certified by DADS.

ID/RC assessment — A form used by DADS for making an LOC determination and LON assignment.

Implementation plan — A written document developed by the program provider for an individual that, for each HCS program service on the individual’s IPC not provided through the CDS option, includes:

(A) a list of outcomes identified in the PDP that will be addressed using HCS Program services;

(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:

(I) observable, measurable, and outcome-oriented; and

(II) derived from assessments of the individual's strengths, personal goals, and needs;

(C) a target date for completion of each objective;

(D) the number of HCS Program units of service needed to complete each objective;

(E) the frequency and duration of HCS Program services needed to complete each objective; and

(F) the signature and date of the individual, LAR, and the program provider.

Individual — A person enrolled in the HCS Program.

Integrated employment — Employment at a work site at which an individual routinely interacts with people without disabilities other than the individual's work site supervisor or service providers. To the same extent that people without disabilities in comparable positions interact with other people without disabilities, integrated employment does not include:

IPC or individual plan of care — A written plan that:

IPC year — A 12-month period of time starting on the date an authorized initial or renewal IPC begins.

Legally authorized representative — A person authorized by law to act on behalf of an individual and may include a parent, guardian or managing conservator of a minor, or the guardian of an adult.

Licensed vocational nurse — A person licensed to practice vocational nursing in accordance with Texas Occupations Code, Chapter 301.

Local Authority — An entity to which the Health and Human Services Commission's authority and responsibility, as described in Texas Health and Safety Code, §531.002(11), has been delegated.

LOC or level of care — A determination given to an individual by DADS as part of the eligibility determination process based on data submitted on the ID/RC Assessment.

LON or level of need — An assignment given to an individual by DADS upon which reimbursement for day habilitation, host home/companion care, residential support and supervised living is based. The LON assignment is derived from the service level score obtained from the administration of the Inventory for Client and Agency Planning (ICAP) to the individual and from selected items on the ID/RC Assessment.

Managing conservator — a managing conservator appointed for a minor in accordance with state law.

Minor — An individual under 18 years of age.

PDP or person-directed plan — A written plan, based on person-directed planning and developed with an applicant or individual in accordance with Form 8665, Person-Directed Plan, that describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual (and LAR on the applicant’s or individual’s behalf) and ensure the applicant’s or individual’s health and safety.

Prior approval — Assurance from DADS, prior to a program provider purchasing a requested adaptive aid or minor home modification, that the program provider will be paid for the adaptive aid or minor home modification if the program provider complies with Section 5000, General Requirements for Service Components Not Based on Billable Activity, and Section 6170, Authorization for Payment.

Pre-enrollment minor home modifications —Minor home modifications completed before an applicant is discharged from a nursing facility, an ICF/IID or a GRO and before the effective date of the applicant's enrollment in the HCS Program.

Pre-enrollment minor home modifications assessment —An assessment performed by a licensed professional as required by Appendix X, Billable Minor Home Modifications, to determine the need for pre-enrollment minor home modifications.

Preselection visit — An individual’s temporary stay in a residence in which the individual receives the residential assistance subcomponent of host home/companion care, residential support or supervised living and such subcomponent is different than the residential assistance subcomponent authorized by the individual’s IPC.

Program provider — An entity that provides HCS Program services under a Medicaid Provider Agreement for the Provision of HCS Program Services with DADS.

Registered nurse — A person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301.

Residence — A place of bona fide and continuous habitation that is a structure with a common roof and common walls, except if the structure contains more than one dwelling such as an apartment complex or duplex, “residence" means a dwelling within the structure. A person may have only one residence.

RN clinical supervision — The monitoring for changes in health needs of the individual, overseeing the nursing care provided and offering clinical guidance as indicated, to ensure that nursing care is safe and effective and provided in accordance with the nursing service plan for the individual.

RN nursing assessment — An extensive evaluation of an individual's health status that:

(A) addresses anticipated changes in the conditions of the individual as well as emergent changes in the individual's health status;

(B) recognizes changes to previous conditions of the individual;

(C) synthesizes the biological, psychological, spiritual and social aspects of the individual's condition;

(D) collects information regarding the individual's health status;

(E) analyzes information collected about the individual's health status to make nursing diagnoses and independent decisions regarding nursing services provided to the individual;

(F) plans nursing interventions and evaluates the need for different interventions; and

(G) determines the need to communicate and consult with other service providers or other persons who provide supports to the individual.

Self-employment Work in which the individual solely owns, manages and operates a business, is not an employee of another person, entity or business, and actively markets a service or product to potential customers.

Service claim — A request submitted by a program provider to be paid by DADS for a service component or subcomponent.

Service coordination — A service as defined in Chapter 2, Subchapter L of this title.

Service coordinator — An employee of a local authority who provides service coordination to an individual.

Service planning team — As defined in 40 TAC §9.153, a planning team consisting of an applicant or individual, LAR, service coordinator and other persons chosen by the applicant or individual or LAR on behalf of the applicant or individual (for example, a program provider representative, family member, friend or teacher).

Service provider — A staff member or contractor of the program provider who performs billable activity.

Staff member — A full-time or part-time employee of the program provider.

Supervision — The process of directing, guiding and influencing the outcome of an unlicensed staff's performance.

TAC — Texas Administrative Code.

Three-person residence — A residence:

(A) that a program provider leases or owns;

(B) in which at least one person but no more than three persons receive:

(I) residential support;

(II) supervised living;

(III) a non-HCS Program service similar to residential support or supervised living (for example, services funded by DFPS or by a person’s own resources); or

(IV) respite; and

(C) that is not the residence of any person other than an HCS service provider, the service provider's spouse or person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and

(D) that is not a dwelling described in 40 TAC §9.155(a)(5)(H).

Transportation plan — A written plan, based on person-directed planning and developed with an applicant or individual using Form 3598, Individual Transportation Plan. An individual transportation plan is used to document how transportation will be delivered to support an individual’s desired outcomes and purposes for transportation as identified in the PDP.

Volunteer work — Work performed by an individual without compensation that is for the benefit of an entity or person other than the individual and is performed in a location other than the individual’s residence.

HCSBG, Section 3000, General Requirements for Service Components Based on Billable Activity

Revision 15-2; Effective October 30, 2015

 

 

3100 Applicable Service Components

Revision 15-2; Effective October 30, 2015

 

This section applies only to the following service components:

 

3200 Service Claim Requirements

Revision 10-1; Effective June 1, 2010

 

 

3210 General Requirements

Revision 12-1; Effective July 23, 2012

 

Except as provided in Sections 3220 and 3230, a program provider must submit an electronic service claim that meets the following requirements. The claim must:

3220 Service Claim for Residential Assistance Subcomponent During Preselection Visit

 

Revision 10-0; Effective October 1, 2009

 

If a program provider submits an electronic service claim for a residential assistance subcomponent for an individual on a preselection visit, the service claim must meet the requirements described in Section 4580, Submitting a Service Claim for Residential Assistance During a Preselection Visit.

 

3230 Service Claim for Host Home/Companion Care, Residential Support or Supervised Living for Individual on a Visit with Family or Friend

 

Revision 14-1; Effective March 21, 2014

 

If a program provider submits an electronic service claim for host home/companion care, residential support or supervised living for an individual on a visit with a family member or friend, the service claim must meet the requirements described in No. 9 in Section 4550, Host Home/Companion Care Subcomponent; No. 9 in Section 4560, Residential Support Subcomponent; or Item No. 9 in Section 4570, Supervised Living Subcomponent.

 

3300 Activity Not Billable

Revision 15-2; Effective October 30, 2015

 

The following activities by a service provider do not constitute billable activity:

 

3400 Qualified Service Provider

Revision 10-1; Effective June 1, 2010

 

 

3410 General Requirements

Revision 10-0; Effective October 1, 2009

 

To be a qualified service provider, a person must:

 

3420 Service Provider Not Qualified

Revision 14-1; Effective March 21, 2014

 

  1. Service Coordinator Not Qualified as Service Provider
    1. Service Coordinator On Duty

During the time a service coordinator is on duty as a service coordinator, the service coordinator is not qualified to provide any service component or subcomponent to an individual.

  1. Service Coordinator Off Duty

During the time a service coordinator is off duty as a service coordinator, the service coordinator is not qualified to provide any service component or subcomponent to an individual if the individual is receiving service coordination from the service coordinator.

  1. Spouse Not Qualified as Service Provider

A service provider is not qualified to provide a service component or subcomponent to the service provider’s spouse.

  1. Relative, Guardian or Managing Conservator Not Qualified as Service Provider for Certain Services

A service provider is not qualified to provide case management, residential support, supervised living, behavioral support services or social work services to an individual if the service provider is:

  1. Parent, Spouse of Parent or Contractor Not Qualified as Service Provider for Minor

A service provider is not qualified to provide a service component or subcomponent to a minor if the service provider is:

  1. Contractor Not Qualified as Service Provider for an Adult Individual

A service provider is not qualified to provide to an adult individual:

 

3430 Relative, Guardian or Managing Conservator Qualified as Service Provider

Revision 15-2; Effective October 30, 2015

 

If a relative, guardian or managing conservator is not otherwise disqualified to be a service provider as described in Section 3420 of this section or in Section 4000, Specific Requirements for Service Components Based on Billable Activity, the relative, guardian or managing conservator may provide audiology services, dietary services, occupational therapy, physical therapy, speech and language pathology services, day habilitation, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, transportation as a supported home living activity, host home/companion care, respite, employment assistance or supported employment if the relative, guardian or managing conservator is a qualified service provider for the particular service component or subcomponent being provided.

 

3500 Unit of Service

Revision 10-1; Effective June 1, 2010

 

 

3510 15-Minute Unit of Service

Revision 15-2; Effective October 30, 2015

 

The following service components and subcomponent have a unit of service of 15 minutes:

 

3520 Daily Unit of Service

Revision 14-1; Effective March 21, 2014

 

The following service components and subcomponents have a unit of service of one day:

 

3600 Calculating Units of Service for Service Claim

Revision 10-1; Effective June 1, 2010

 

 

3610 15-Minute Unit of Service

Revision 15-2; Effective October 30, 2015

 

  1. Service Event

For service components and subcomponents that have a unit of service of 15 minutes, a service event:

Example:

If a service provider performs billable activity for registered nursing from 12:00-12:30, performs activity that is not billable from 12:30-12:36, then performs additional billable activity from 12:36-12:48, two service events have occurred, one for 30 minutes (12:00-12:30), and another for 12 minutes (12:36-12:48).

  1. Service Time
    1. Professional Therapies, Nursing Service Components, Supported Employment and Employment Assistance

A program provider must use the following formula for calculating the service time for professional therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, supported employment and employment assistance:

Number of service providers x length of service event divided by the number of persons served = service time.

In this formula, "person" means a person who receives a service funded by DADS, including an individual and a person enrolled in the intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID) program or a waiver program other than HCS.

Examples

    No. of Service Providers X Length of Service Event ÷ No. of Persons = Service Time per Individual
    1 X 20 min. ÷ 3 = 6.66 min.
    1 X 30 min. ÷ 2 = 15 min.
    2 X 30 min. ÷ 2 = 30 min.
    2 X 30 min. ÷ 1 = 60 min.
    1 X 45 min. ÷ 4 = 11.25 min.
    1 X 60 min. ÷ 1 = 60 min.
    1 X 60 min. ÷ 2 = 30 min.
    1 X 60 min. ÷ 3 = 20 min.
    2 X 120 min. ÷ 6 = 40 min.
    1. Transportation as a Supported Home Living Activity

    A program provider must determine service time for transportation as a supported home living activity in accordance with No. 7 in Section 4540, Supported Home Living Billing Requirements.

    1. Respite

    A program provider must use the length of the service event as the service time for respite.

    1. Units of Service for Service Claim

    A program provider must convert a service time to a unit(s) of service for a service claim in accordance with Appendix III, Conversion Table.

     

    3620 Daily Unit of Service

    Revision 14-1; Effective March 21, 2014

     

    1. Host Home/Companion Care, Residential Support, Supervised Living, Respite

    A program provider may include only one unit of service per calendar day on a service claim for host home/companion care, residential support or supervised living.

    1. Day Habilitation

    A program provider may include one-quarter (.25), one-half (.5), three-quarters (.75) or one unit of service per calendar day on a service claim for day habilitation.

     

    3700 Billing Service Components Provided at the Same Time and Billing Day Habilitation Provided at the Same Time as Service Coordination

    Revision 11-1; Effective September 1, 2011

     

     

    3710 One Service Provider

    Revision 10-0; Effective October 1, 2009

     

    One service provider may not provide different service components or subcomponents at the same time to the same individual.

     

    3720 Multiple Service Providers

    Revision 15-2; Effective October 30, 2015

     

    1. Providing Different Service Components or Subcomponents
    1. Compliance with this Paragraph

    Multiple service providers may provide different service components or subcomponents at the same time to the same individual only as provided in this paragraph.

    1. Service Provider of Professional Therapies

    A service provider of professional therapies may provide a service to an individual at the same time a service provider of any other service component or subcomponent is providing a service to the same individual if:

    Example:

    An occupational therapist observes and assesses an individual's fine motor skills while the individual receives day habilitation services. A program provider may submit a service claim for both occupational therapy and day habilitation for the overlapping time period because billable activity for both day habilitation and occupational therapy was occurring at the same time.

    Example:

    An individual receives day habilitation from 8:00 a.m.-9:00 a.m. A speech therapist provides speech therapy to an individual at the day habilitation site from 9:00 a.m.-10:00 a.m., but the individual is unable to participate in the day habilitation activities while the therapy is provided. The individual receives day habilitation again from 10:00 a.m.-11:00 a.m. A program provider may submit a service claim for four units of speech therapy for this time period, but may not submit a service claim for day habilitation because the program provider provided only two non-consecutive hours of day habilitation.

    1. Service Provider of Respite, Host Home/Companion Care, Residential Support or Supervised Living

    A service provider of respite, host home/companion care, residential support or supervised living may provide a service to an individual at the same time a service provider of professional therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, day habilitation, employment assistance or supported employment provides a service to the same individual.

    1. Service Provider of Transportation as a Supported Home Living Activity

    A service provider of transportation as a supported home living activity may perform a face-to-face service for an individual at the same time a service provider of professional therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, and Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB) provides a service to the same individual.

    1. Multiple Service Providers of the Same Service Component or Subcomponent with a 15-Minute Unit of Service

    Multiple service providers of the same service component or subcomponent with a 15 minute unit of service, as listed in Section 3510, 15-Minute Unit of Service, may perform an activity at the same time for the same individual if multiple service providers are needed to perform the activity.

     

    3730 Service Coordination and Day Habilitation Provided at the Same Time

    Revision 11-1; Effective September 1, 2011

     

    A service provider of day habilitation may provide day habilitation to an individual at the same time a service coordinator is providing service coordination to the individual at the day habilitation setting.

     

    3800 Written Documentation

    Revision 10-1; Effective June 1, 2010

     

     

    3810 General Requirements

    Revision 15-2; Effective October 30, 2015

     

    1. Legible

    A program provider must have written, legible documentation to support a service claim.

    1. Required Content
      1. All Service Components or Subcomponents (Except for Nursing Service Components, Some Professional Therapies and Transportation as a Supported Home Living Activity)

    Except as provided in subparagraphs (b), (c) and (d) of this paragraph, the written documentation to support a service claim for a service component or subcomponent must include:

    1. Nursing Service Components
      • The written documentation to support a service claim for the nursing service components of registered nursing, licensed vocational nursing, specialized registered nursing and specialized licensed vocation nursing must:
        • be written after the service is provided; and
        • include:
          • the name of the individual who was provided the nursing service component;
          • the day, month and year the nursing service component was provided;
          • the nursing service component that was provided;
          • a detailed description of activities performed by the service provider and the individual that evidences the performance of one or more of the billable activities described in Section 4000, Specific Requirements for Service Components Based on Billable Activity, for the particular nursing service component being claimed;
          • a brief description of the location of the service event, as described in Section 3610, 15-Minute Unit of Service (see No. 1), such as the address or name of business;
          • the exact time the service event began and the exact time the service event ended documented by the nurse making the written documentation;
          • a description of the medical need for the activity performed during the service event;
          • a description of any unusual incident that occurs such as a seizure, illness or behavioral outburst, and any action taken by the registered nurse or licensed vocational nurse in response to the incident;
          • for any activity simultaneously performed by more than one registered nurse or more than one licensed vocational nurse, a written justification in the individual's implementation plan for the use of more than one registered nurse or licensed vocational nurse; and
        • be supported by information that justifies the length of the service event, as described in Section 3610 (see No. 1), such as an explanation in the documentation or implementation plan of why a billable activity took more time than typically required to complete.
      • The following are unacceptable as a description of the activities in written documentation to support a service claim for a nursing service component:
        • ditto marks;
        • words or symbols referencing:
          • other written documentation that supports a claim for nursing services; or
          • written service logs or written summary logs;
        • non-specific statements such as "had a good day," "did ok," or "no problem today;"
        • a statement or other information that is photocopied from:
          • other written documentation that supports a claim for nursing services; or
          • written service logs or written summary logs; and
        • a medication log.
    1. Reimbursement of Co-payment or Deductible for a Professional Therapies Subcomponent

    Co-payment

    A program provider must have written documentation to support a service claim to obtain reimbursement for a co-payment for a professional therapies subcomponent that meets the requirements of Section 4270, Insurance Co-Payment and Deductible (see No. 1, Item c.).

    Deductible

    A program provider must have written documentation to support a service claim to obtain reimbursement for payments made toward a deductible for a professional therapies subcomponent that meets the requirements of Section 4270 (see No. 2, Item c.).

    1. Transportation as a Supported Home Living Activity

    A program provider must have written documentation to support a service claim for transportation as a supported home living activity that meets the requirements of Section 4540, Supported Home Living Billing Requirements (see No. 8, Item b.).

     

    3820 Written Service Log and Written Summary Log

    Revision 14-1; Effective March 21, 2014

     

    1. Required Content and Timeliness
    1. Written Service Log

    A written service log must:

    1. Written Summary Log

    A written summary log must:

    1. Unusual Incidents or Progress Toward Objectives

    The description of the activities in a written service log or written summary log must include a description of any unusual incident that occurs such as a seizure, illness or behavioral outburst, and any action taken by the service provider in response to the incident.

    1. Unacceptable Content

    The following are unacceptable as a description of the activities in a written service log or written summary log:

    1. Separate Written Service Log or Written Summary Log for Service Component, Subcomponent or Service Event

    A program provider must have a separate written service log or separate written summary log for each service component or subcomponent, as described in Section 3810, General Requirements (see No. 2(a), fourth bullet), and for each service event as described in Section 3610, 15-Minute Unit of Service (see No. 1).

     

    3830 Proof of Service Provider Qualifications

    Revision 10-0; Effective October 1, 2009

     

    A program provider must have the following documentation as proof that a service provider is qualified:

     

    3840 Proof of Location of Residence of Service Provider

    Revision 15-2; Effective October 30, 2015

    1. Photo ID, Voter’s Registration Card, Lease or Utility Bill

    Except as provided in No. 2 below, a program provider must have two documents from the following categories to prove the location of the residence of a service provider of host home/companion care or transportation as a supported home living activity or respite services:

    1. Other Proof

    At its discretion, DADS may accept other written documentation as proof of the location of the residence of a service provider of host home/companion care, respite or transportation as a supported home living activity.

     

    3850 Example Forms

    Revision 15-2; Effective October 30, 2015

     

    Form 4118, Respite Service Delivery Log, and Form 4119, Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log, may be used to document a service component or subcomponent (except for day habilitation for an individual receiving supported employment, employment assistance and for transportation as a supported home living activity) in accordance with this section. These documents are only examples. A program provider may document a service component or subcomponent in any way that meets the requirements of this section and the written documentation requirements described in Section 4000, Specific Requirements for Service Components Based on Billable Activity, for the particular service component or subcomponent being claimed.

    HCSBG, Section 4000, Specific Requirements for Service Components Based on Billable Activity

    4100 Reserved for Future Use

    Revision 10-1; Effective June 1, 2010

     

     

    4200 Professional Therapies

    Revision 14-1; Effective March 21, 2014

     

     

    4210 General Description of Service Component

    Revision 14-1; Effective March 21, 2014

     

    The professional therapies service component consists of the following subcomponents:

     

    4220 Billable Activity

    Revision 15-2; Effective October 30, 2015

     

    The only billable activities for the professional therapies service component are:

    1. assessing the targeted behavior so a behavior support plan may be developed;
    2. training of and consulting with an individual, family member or other persons involved in the individual's care regarding the implementation of the behavior support plan;
    3. monitoring and evaluating the effectiveness of the behavior support plan;
    4. modifying, as necessary, the behavior support plan based on the monitoring and evaluation of the plan's effectiveness; and
    5. educating an individual, family members or other persons involved in the individual's care about the techniques to use in assisting the individual to control maladaptive or socially unacceptable behaviors exhibited by the individual;
    6. for cognitive rehabilitation services, in addition to the activities listed above, provide and monitor the provision of cognitive rehabilitation therapy to the individual in accordance with the plan of care developed by a qualified professional following a neurobehavioral or neuropsychological assessment.

     

    4230 Activity Not Billable

    Revision 14-1; Effective March 21, 2014

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the professional therapies service component.

    1. Activities Not Listed in Section 4220

    Any activity not described in Section 4220, Billable Activity, is not billable for the professional therapies service component.

    1. Examples of Non-billable Activities

    The following are examples of activities that are not billable for the professional therapies service component:

     

    4240 Qualified Service Provider

    Revision 14-3; Effective September 1, 2014

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the professional therapies subcomponents must be as follows:

     

    4250 Unit of Service

    Revision 14-1; Effective March 21, 2014

     

    1. 15 Minutes

    A unit of service for the professional therapies service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for professional therapies may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

     

    4260 Written Documentation

    Revision 14-1; Effective March 21, 2014

     

    Except as provided in Section 4270, Insurance Co-payment and Deductible (see No. 1, Item c and No. 2, Item c), a program provider must have written documentation to support a service claim for professional therapies that:

     

    4270 Insurance Co-payment and Deductible

    Revision 14-1; Effective March 21, 2014

    1. Co-payment
      1. Number of Units on Service Claim

    If a program provider is aware that an individual is covered by an insurance policy that requires a co-payment for a professional therapies subcomponent, and the policyholder requests to be reimbursed for the co-payment and provides the documentation described in the first, second and third bullets of Item c below to the program provider, the program provider must submit a service claim for the professional therapies subcomponent for the lesser of the maximum number of units of service for which payment by the HCS Program will not exceed the amount of the co-payment paid by the policyholder.

    Example:

    An individual receives four units of service (one hour) of physical therapy and the insurance policy covering the individual requires a $20 co-payment, for which the policyholder requests to be reimbursed. If the HCS Program pays $17.50 per unit of service of physical therapy, the program provider must submit a service claim for one unit of service of physical therapy (the maximum number of units of service for which payment will not exceed the amount of the co-payment).

    1. Program Provider Must Pay Policyholder Amount of Service Claim

    A program provider that submits a service claim to obtain reimbursement for a co-payment must pay the policyholder the amount the program provider receives as payment for the service claim.

    Example: Using the facts given in the example above, the program provider must pay the policyholder $17.50.

    1. Written Documentation

    A program provider must have written documentation to support a service claim submitted to obtain reimbursement for a co-payment made for a professional therapies subcomponent. The written documentation must include:

    1. Deductible
    1. Number of Units on Service Claim

    If a program provider is aware that an individual is covered by an insurance policy that requires a deductible for a professional therapies subcomponent, and the policyholder requests to be reimbursed for the deductible and provides the documentation described in the first, second and third bullets of Item c below to the program provider, the program provider must submit a service claim for the professional therapies subcomponent for the maximum number of units of service for which payment by the HCS Program will not exceed the amount of the deductible paid by the policyholder for the professional therapies subcomponent.

    Example:

    An individual receives four units of service (one hour) of physical therapy services. The policyholder pays $100 for the services, which is applied toward a deductible, and requests to be reimbursed. If the HCS Program pays $17.50 per unit of service of physical therapy, the program provider must submit a service claim for the number of units of service the individual received, or four units of service of physical therapy.

    1. Program Provider Must Pay Policyholder Amount of Service Claim

    A program provider that submits a service claim to obtain reimbursement for payment made toward a deductible for a professional therapies subcomponent must pay the policyholder the amount the program provider receives as payment for the service claim.

    Example: Using the facts given in the example above, the program provider must pay the policyholder $70 ($17.50 X 4 units of service).

    1. Written Documentation

    A program provider must have written documentation to support a service claim to obtain reimbursement for a payment made toward a deductible for a professional therapies subcomponent. The written documentation must include:

     

    4300 Day Habilitation

    Revision 11-1; Effective September 1, 2011

     

     

    4310 General Description of Service Component

    Revision 10-0; Effective October 1, 2009

     

    The day habilitation service component is the provision of assistance to an individual that is necessary for the individual to acquire skills to reside, integrate and participate successfully in the community.

     

    4320 Requirements of Setting

    Revision 11-1; Effective September 1, 2011

     

    Day habilitation may be provided to an individual only in a setting that is not the residence of the individual, unless the provision of day habilitation in a residence is justified because of the individual's medical condition or behavioral issues or because the individual is of retirement age, and such justification is documented in the individual's record.

     

    4330 Billable Activity

    Revision 14-3; Effective September 1, 2014

     

    The only billable activities for the day habilitation service component are:

     

    4340 Activity Not Billable

    Revision 10-0; Effective October 1, 2009

     

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the day habilitation service component.

    1. Activities Not Listed in Section 4330

    Any activity not described in Section 4330, Billable Activity, is not billable for the day habilitation service component.

    1. Meeting Vocational Production Goal Not Billable Activity

    Assisting an individual for the sole purpose of meeting a vocational production goal is an example of an activity that is not billable for the day habilitation service component.

     

    4350 Restrictions Regarding Submission of Claims for Day Habilitation

     

    Revision 14-3; Effective September 1, 2014

     

    A program provider may not submit a service claim for:

     

    4360 Qualified Service Provider

    Revision 10-0; Effective October 1, 2009

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the day habilitation service component must have one of the following:

     

    4370 Unit of Service

    Revision 11-1; Effective September 1, 2011

     

    1. One Day

    A unit of service for the day habilitation service component is one day.

    1. Service Claim for Unit of Service
    1. One-quarter Unit of Service

    A program provider may submit a service claim for day habilitation for one-quarter (0.25) unit of service if the program provider provides at least one and one-quarter hours of consecutive day habilitation on a calendar day.

    1. One-half Unit of Service

    A program provider may submit a service claim for day habilitation for one-half (0.5) unit of service if the program provider provides at least two and one-half hours of day habilitation on a calendar day. Two of the two and one-half hours must be consecutive.

    1. Three-quarters Unit of Service

    A program provider may submit a service claim for day habilitation for three-quarters (.75) unit of service if the program provider provides at least three and three-quarter hours of day habilitation on a calendar day. Two of the three and three-quarter hours must be consecutive.

    1. One Unit of Service

    A program provider may submit a service claim for day habilitation for one unit of service if the program provider provides at least five hours of day habilitation on a calendar day. Two of the five hours must be consecutive.

     

    4380 Written Documentation

    Revision 11-1; Effective September 1, 2011

     

    A program provider must have written documentation to support a service claim for day habilitation that:

     

    4400 Registered Nursing

    Revision 10-1; Effective June 1, 2010

     

     

    4410 General Description of Service Component

    Revision 10-0; Effective October 1, 2009

     

    The registered nursing service component is the provision of professional nursing, as defined in Texas Occupations Code, Chapter 301 (link is external), provided to an individual with a medical need.

     

    4420 Billable Activity

    Revision 15-2; Effective October 30, 2015

     

    The only billable activities for the registered nursing service component are:

     

    4430 Activity Not Billable

    Revision 14-1; Effective March 21, 2014

     

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the registered nursing service component.

    1. Activities Not Listed in Section 4420

    Any activity not described in Section 4420, Billable Activity, is not billable for the registered nursing service component.

    1. Examples of Non-billable Activities

    The following are examples of activities that are not billable for the registered nursing service component, regardless of whether they constitute the practice of registered nursing:

     

    4440 Qualified Service Provider

    Revision 10-0; Effective October 1, 2009

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the registered nursing service component must be a registered nurse.

     

    4450 Unit of Service

    Revision 11-1; Effective September 1, 2011

     

    1. 15 Minutes

    A unit of service for the registered nursing service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for registered nursing may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

     

    4460 Accumulation of Service Times

    Revision 12-2; Effective October 1, 2012

     

    A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for registered nursing provided to one individual on a single calendar month. The service times of more than one registered nurse may be accumulated on the last day of the month. The service times of more than one registered nurse may be accumulated on the last day of the month.

    Example:

    A registered nurse provides registered nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 25, 2012, 8:00-8:05 p.m. (5 minutes).

    Without accumulating service times, two units of service for registered nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

    If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for registered nursing are billable.

    If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for registered nursing are billable (2 + 1).

    Example:

    Nurse A provides 7 minutes of registered nursing to an individual. During the same month , Nurse B provides 7 minutes of licensed vocational nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

     

    4470 Written Documentation

    Revision 11-1; Effective September 1, 2011

     

    A program provider must have written documentation to support a service claim for registered nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

     

    4471 Licensed Vocational Nursing

    Revision 10-1; Effective June 1, 2010

     

     

    4471.1 General Description of Service Component

    Revision 10-0; Effective October 1, 2009

     

    The licensed vocational nursing service component is the provision of licensed vocational nursing, as defined in Texas Occupations Code, Chapter 301 (link is external), to an individual.

     

    4471.2 Billable Activity

    Revision 15-2; Effective October 30, 2015

     

    The only billable activities for the licensed vocational nursing service component are:

     

    4471.3 Activity Not Billable

    Revision 14-1; Effective March 21, 2014

     

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the licensed vocational nursing service component.

    1. Activities Not Listed in Section 4471.2

    Any activity not described in Section 4471.2, Billable Activity, is not billable for the licensed vocational nursing service component.

    1. Examples of Non-billable Activities

    The following are examples of activities that are not billable for the licensed vocational nursing service component, regardless of whether they constitute the practice of licensed vocational nursing:

     

    4471.4 Qualified Service Provider

    Revision 10-0; Effective October 1, 2009

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the licensed vocational nursing service component must be a licensed vocational nurse.

     

    4471.5 Unit of Service

    Revision 11-1; Effective September 1, 2011

     

    1. 15 Minutes

    A unit of service for the licensed vocational nursing service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for licensed vocational nursing may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

     

    4471.6 Accumulation of Service Times

    Revision 12-2; Effective October 1, 2012

     

    A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for licensed vocational nursing provided to one individual during a single calendar month. The service times of more than one licensed vocational nurse may be accumulated on the last day of the month.

    Example:

    A nurse provides licensed vocational nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

    Without accumulating service times, two units of service for licensed vocational nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

    If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for licensed vocational nursing are billable.

    If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for licensed vocational nursing are billable (2 + 1).

    Example:

    Nurse A provides 7 minutes of licensed vocational nursing to an individual. During the same month, Nurse B provides 7 minutes of registered nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

     

    4471.7 Written Documentation

    Revision 11-1; Effective September 1, 2011

     

    A program provider must have written documentation to support a service claim for licensed vocational nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

     

    4472 Specialized Registered Nursing

    Revision 10-1; Effective June 1, 2010

     

     

    4472.1 General Description of Service Component

    Revision 10-0; Effective October 1, 2009

     

    The specialized registered nursing service component is the provision of professional nursing, as defined in Texas Occupations Code, Chapter 301 (link is external), to an individual who has a tracheostomy or is dependent on a ventilator.

     

    4472.2 Billable Activity

    Revision 15-2; Effective October 30, 2015

     

    The only billable activities for the specialized registered nursing service component are:

     

    4472.3 Activity Not Billable

    Revision 14-1; Effective March 21, 2014

     

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized professional nursing service component.

    1. Activities Not Listed in Section 4420

    Any activity not described in Section 4420, Billable Activity, is not billable for the specialized registered nursing service component.

    1. Examples of Non-billable Activities

    The following are examples of activities that are not billable for the specialized registered nursing service component, regardless of whether they constitute the practice of registered nursing:

     

    4472.4 Qualified Service Provider

    Revision 10-0; Effective October 1, 2009

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the specialized registered nursing service component must be a registered nurse.

     

    4472.5 Unit of Service

    Revision 11-1; Effective September 1, 2011

     

    1. 15 Minutes

    A unit of service for the specialized registered nursing service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for specialized registered nursing may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

     

    4472.6 Accumulation of Service Times

    Revision 12-2; Effective October 1, 2012

     

    A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for specialized registered nursing provided to one individual during a single calendar month. The service times of more than one specialized registered nurse may be accumulated on the last day of the month.

    Example:

    A nurse provides specialized registered nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

    Without accumulating service times, two units of service for specialized registered nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

    If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for specialized registered nursing are billable.

    If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for specialized registered nursing are billable (2 + 1).

    Example:

    Nurse A provides 20 minutes of specialized registered nursing to an individual. On the same calendar day, Nurse B provides 20 minutes of specialized licensed vocational nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

     

    4472.7 Written Documentation

    Revision 11-1; Effective September 1, 2011

     

    A program provider must have written documentation to support a service claim for specialized registered nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

     

    4473 Specialized Licensed Vocational Nursing

    Revision 10-1; Effective June 1, 2010

     

     

    4473.1 General Description of Service Component

    Revision 10-0; Effective October 1, 2009

     

    The specialized licensed vocational nursing service component is the provision of licensed vocational nursing, as defined in Texas Occupations Code, Chapter 301 (link is external), to an individual who has a tracheostomy or is dependent on a ventilator

     

    4473.2 Billable Activity

    Revision 15-2; Effective October 30, 2015

     

    The only billable activities for the specialized licensed vocational nursing service component are:

     

    4473.3 Activity Not Billable

    Revision 14-1; Effective March 21, 2014

     

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized licensed vocational nursing service component.

    1. Activities Not Listed in Section 4420

    Any activity not described in Section 4420, Billable Activity, is not billable for the specialized licensed vocational nursing service component.

    1. Examples of Non-billable Activities

    The following are examples of activities that are not billable for the specialized licensed vocational nursing service component, regardless of whether they constitute the practice of licensed vocational nursing:

     

    4473.4 Qualified Service Provider

    Revision 10-0; Effective October 1, 2009

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the specialized licensed vocational nursing service component must be a licensed vocational nurse.

     

    4473.5 Unit of Service

    Revision 11-1; Effective September 1, 2011

     

    1. 15 Minutes

    A unit of service for the specialized licensed vocational nursing service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for specialized licensed vocational nursing may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

     

    4473.6 Accumulation of Service Times

     

    Revision 12-2; Effective October 1, 2012

     

    A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for specialized licensed vocational nursing provided to one individual during a single calendar month. The service times of more than one specialized licensed vocational nurse may be accumulated on the last day of the month.

    Example:

    A nurse provides specialized licensed vocational nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

    Without accumulating service times, two units of service for specialized licensed vocational nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

    If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for specialized licensed vocational nursing are billable.

    If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for specialized licensed vocational nursing are billable (2 + 1).

    Example:

    Nurse A provides 20 minutes of specialized licensed vocational nursing to an individual. On the same calendar day, Nurse B provides 20 minutes of specialized registered nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

     

    4473.7 Written Documentation

    Revision 11-1; Effective September 1, 2011

     

    A program provider must have written documentation to support a service claim for specialized licensed vocational nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

     

    4500 Residential Assistance

    Revision 10-1; Effective June 1, 2010

     

     

    4510 General Description of Service Component

    Revision 15-2; Effective October 30, 2015

     

    The residential assistance service component is the provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills.

    The residential assistance service component consists of the following subcomponents:

     

    4520 Restrictions Regarding Submission of Claims for Residential Assistance

    Revision 10-0; Effective October 1, 2009

     

    A program provider may not submit a service claim for multiple residential assistance subcomponents provided to the same individual on the same day.

     

    4530 Residential Location

    Revision 14-1; Effective March 21, 2014

     

    1. "Own/Family Home"

    A program provider must document a residential location of "own/family home" on an individual's IPC if no service provider provides host home/companion care, residential support or supervised living to the individual.

    Example:

    A minor is living with a parent or a person contracting with DFPS to provide residential child care to the minor and no service provider is paid to provide host home/companion care, residential support or supervised living to the minor. The minor must have a residential location of "own/family home" on her IPC.

    Example:

    An adult individual is living alone or with parents and no service provider is paid to provide host home/companion care, residential support or supervised living to the individual. The individual must have a residential location of "own/family home" on his IPC.

    1. "Host Home/Companion Care"

    A program provider must document a residential location of "host home/companion care" on an individual's IPC if:

    Example:

    The residence of one individual and the host home/companion care provider is leased by the individual but the program provider does not lease or own the residence. The individual must have a residential location of "host home/companion care" on his IPC.

    Example:

    The residence of three individuals and the host home/companion care provider is owned by the host home/companion care provider, but the program provider does not lease or own the residence. The three individuals must have a residential location of "host home/companion care" on their IPCs.

    1. "3-Person Home"

    A program provider must document a residential location of "3-Person Home" on an individual's IPC if:

    1. "4-Person Home"

    A program provider must document a residential location of "4-Person Home" on an individual's IPC if:

     

    4540 Supported Home Living Billing Requirements

    Revision 15-2; Effective October 30, 2015

     

    1. Billable Activity

    The only billable activity for the supported home living subcomponent is transporting the individual, except from one day habilitation, employment assistance or supported employment site to another.

    1. Residential Location

    A program provider may provide transportation as a supported home living activity to an individual only if the program provider has documented a residential location of "own/family home" on the individual's IPC, as described in Section 4530, Residential Location (see No. 1).

    1. Activity Not Billable
    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for transportation as a supported home living activity.

    1. Activities Not Listed in No. 1 Above

    Any activity not described in No. 1 above is not billable for transportation as a supported home living activity.

    1. Restrictions Regarding Submission of Claims for Transportation as a Supported Home Living Activity

    A program provider may not submit a service claim for:

    1. Qualified Service Provider

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of transportation as a supported home living activity:

    1. Unit of Service
    1. 15 Minutes

    A unit of service for transportation as a supported home living activity is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for transportation as a supported home living activity may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

    1. Determining Unit of Service for Transportation as a Supported Home Living Activity

    General Process

    The unit of service for a service claim for transportation as a supported home living activity is determined by:

    1. Calculating Transportation Time, Passengers, Service Providers
    1. How to Calculate

    Transportation time, number of passengers and number of service providers must be calculated using Method A or Method B as described below.

    1. Use of Only One Method on a Single Calendar Day

    A program provider may not use Method A and Method B on the same calendar day.

    1. Definitions Applicable for Method A and Method B

    The following definitions apply to Method A and Method B:

    1. Method A

    Using Method A, the transportation time, number of passengers and number of service providers are the same for all individuals transported in a single trip:

    1. Method B

    Using Method B, the transportation time, number of passengers and number of service providers are determined separately for each individual transported in a single trip in segments that begin and end when the number of passengers or the number of service providers changes during the trip.

    1. Determining Service Time
    1. How to Determine

    Service time must be determined using the transportation time, number of passengers and number of service providers for an entire trip (if using Method A) or for each segment of a trip (if using Method B).

    1. Formula

    The formula for calculating the service time is:

    Service Time = [Number of Service Providers times Transportation Time] ÷ Number of Passengers

    1. Converting Service Time to Units of Service

    Service time must be converted to units of service for a service claim as set forth on Appendix III, Conversion Table.

    1. Examples of Determining Unit of Service for Transportation as a Supported Home Living Activity

    See Appendix V, Determining Units of Service for the Supported Home Living Activity of Transporting an Individual, for examples of determining the units of service for a service claim for transportation as a supported home living activity.

    1. Accumulation of Service Times
    1. For Single Calendar Day

    A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for transporting one individual on a single calendar day. The service times of more than one service provider may be accumulated.

    1. Example of Accumulating Service Time

    See Appendix V, Determining Units of Service for the Supported Home Living Activity of Transporting an Individual, for an example of accumulating service time for transportation as a supported home living activity.

    1. Transportation as a Supported Home Living Activity
    1. Specific Information

    A program provider must have written documentation to support a service claim for the supported home living activity of transporting an individual. The written documentation must include:

    1. Example Form

    Form 2124, Community Support Transportation Log, may be used to document transportation as a supported home living activity. This log is only an example, however. A program provider may document such activity in any way that meets requirements.

     

    4550 Host Home/Companion Care Subcomponent

    Revision 14-1; Effective March 21, 2014

     

    1. Requirements of Setting
    1. Residence of Individual

    An individual receiving host home/companion care must:

    1. Service Provider's Residence and Availability

    The service provider must:

    1. Billable Activity

    The only billable activities for the host home/companion care subcomponent are:

    1. Residential Location

    A program provider may provide host home/companion care to an individual only if the program provider has documented a residential location of "host home/companion care" on the individual's IPC, as described in Section 4530, Residential Location (see No. 2).

    1. Activity Not Billable
    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the host home/companion care subcomponent.

    1. Activities Not Listed in Paragraph (2)

    Any activity not described in No. 2 above is not billable for the companion care subcomponent.

    1. Restrictions Regarding Submission of Claims for Host Home/Companion Care

    A program provider may not submit a service claim for host home/companion care:

    1. Qualified Service Provider

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the host home/companion care subcomponent must have one of the following:

    1. Unit of Service
    1. One Day

    A unit of service for the host home/companion care subcomponent is one day.

    1. Maximum Number and Fraction of a Unit of Service

    A service claim for host home/companion care may not:

    1. Written Documentation

    Except as provided in No. 9 below, a program provider must have written documentation to support a service claim for host home/companion care. The written documentation must:

    1. Submitting a Service Claim for an Individual on a Visit with Family or Friend
    1. Length of Visit

    A program provider may submit a service claim for host home/companion care for an individual who is on a visit with a family member or friend away from the individual's residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

    1. Only Requirements of this Paragraph Apply

    This is the only paragraph of this subsection that applies to a service claim submitted for host home/companion care for an individual on a visit with a family member or friend.

    1. Written Documentation

    A program provider must have written documentation to support a service claim for host home/companion care for an individual on a visit with a family member or friend. The written documentation must include:

     

    4560 Residential Support Subcomponent

    Revision 14-3; Effective September 1, 2014

     

    1. Requirements of Setting
    1. Residence of Individual

    The residence of an individual receiving residential support must be a three-person residence or a four-person residence.

    A program provider:

    1. Availability and Presence of Service Provider

    A service provider must be:

    1. Billable Activity

    The only billable activities for the residential support subcomponent are:

    1. Residential Location

    A program provider may provide residential support to an individual only if the program provider has documented a residential location of "3-Person Home" or "4-Person Home" on the individual's IPC, as described in Section 4530, Residential Location (see No. 3 and No. 4).

    1. Activity Not Billable
    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the residential support subcomponent.

    1. Activities Not Listed in Paragraph (2)

    Any activity not described in No. 2, Billable Activity, is not billable for the residential support subcomponent.

    1. Restrictions Regarding Submission of Claims for Residential Support

    A program provider may not submit a service claim for residential support:

    1. Qualified Service Provider

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the residential support subcomponent:

    1. Unit of Service
    1. One Day

    A unit of service for the residential support subcomponent is one day.

    1. Maximum Number and Fraction of a Unit of Service

    A service claim for residential support may not:

    1. Written Documentation

    Except as provided in No. 9 below, a program provider must have written documentation supporting a service claim for residential support. The written documentation must:

    1. Submitting a Service Claim for an Individual on a Visit with Family or Friend
    1. Length of Visit

    A program provider may submit a service claim for residential support for an individual who is on a visit with a family member or friend away from the individual's residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

    1. Only Requirements of this Paragraph Apply

    No. 9 is the only portion of Section 4560 that applies to a service claim submitted for residential support for an individual on a visit with a family member or friend.

    1. Written Documentation

    A program provider must have written documentation to support a service claim for residential support for an individual on a visit with a family member or friend. The written documentation must include:

     

    4570 Supervised Living Subcomponent

    Revision 14-3; Effective September 1, 2014

     

    1. Requirements of Setting
      1. Residence of Individual

    The residence of an individual receiving supervised living must be a three-person residence or a four-person residence.

    A program provider:

    1. Availability and Presence of Service Provider

    A service provider must be:

    1. Billable Activity

    The only billable activities for the supervised living subcomponent are:

    1. Residential Location

    A program provider may provide supervised living to an individual only if the program provider has documented a residential location of "3-Person Home" or "4-Person Home" on the individual's IPC, as described in Section 4530, Residential Location (see No. 3 and No. 4).

    1. Activity Not Billable
      1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the supervised living subcomponent.

    1. Activities Not Listed in No. 2, Billable Activity

    Any activity not described in No. 2 above is not billable for the supervised living subcomponent.

    1. Restrictions Regarding Submission of Claims for Supervised Living

    A program provider may not submit a service claim for supervised living:

    1. Qualified Service Provider

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the supervised living subcomponent:

    1. Unit of Service
      1. One Day

    A unit of service for the supervised living subcomponent is one day.

    1. Maximum Number and Fraction of a Unit of Service

    A service claim for supervised living may not:

    1. Written Documentation

    Except as provided in No. 9 below, a program provider must have written documentation to support a service claim for supervised living. The written documentation must:

    1. Submitting a Service Claim for an Individual on a Visit with Family or Friend
      1. Length of Visit

    A program provider may submit a service claim for supervised living for an individual who is on a visit with a family member or friend away from the individual's residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

    1. Only Requirements of this Paragraph Apply

    No. 9 is the only portion of Section 4570 that applies to a service claim submitted for supervised living for an individual on a visit with a family member or friend.

    1. Written Documentation

    A program provider must have written documentation to support a serviceclaim for supervised living for an individual on a visit with a family member or friend. The written documentation must include:

     

    4580 Submitting a Service Claim for Residential Assistance During a Preselection Visit

     

    Revision 14-1; Effective March 21, 2014

     

    A program provider may submit a service claim for residential assistance while an individual is on a preselection visit only if:

     

    4600 Respite

    Revision 11-1; Effective September 1, 2011

     

     

    4610 General Description of Service Component

    Revision 15-2; Effective October 30, 2015

     

    1. Temporary Provision of Assistance

    The respite service component:

    1. Room and Board

    If respite is provided in a setting other than the individual's residence, the program provider must provide room and board to the individual free of charge.

     

    4620 Billable Activity

    Revision 14-3; Effective September 1, 2014

     

    The only billable activities for the respite service component are:

     

    4630 Respite in Residence or During Overnight Stay in Non-residence

    Revision 10-0; Effective October 1, 2009

     

    1. Residence

    If an individual receives respite in a residence, the residence must be:

    1. Non-residence

    If an individual is receiving respite during an overnight stay in a setting that is not the residence of any person, no more than six persons receiving HCS Program services or a non-HCS Program service similar to HCS Program services may be in the setting.

     

    4631 Residential Location

    Revision 10-0; Effective October 1, 2009

     

    A program provider may provide respite to an individual only if the program provider has documented a residential location of "own/family home" on the individual's IPC, as described in Section 4530, Residential Location (see No. 1).

     

    4640 Activity Not Billable

    Revision 10-0; Effective October 1, 2009

     

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the respite service component.

    1. Activities Not Listed in Section 4620

    Any activity not described in Section 4620, Billable Activity, is not billable for the respite service component.

     

    4650 Submitting a Service Claim for Respite

    Revision 10-0; Effective October 1, 2009

     

    1. Respite Provided in an Individual's Residence

    If a program provider provides respite in an individual's residence, the program provider may submit a service claim for no more than 96 units of service (24 hours) in one calendar day.

    1. Respite Provided in Location Other Than the Individual's Residence

    If a program provider provides 10 hours or more of respite to an individual in one calendar day in a location other than the individual's residence, the program provider may submit a service claim for no more than 40 units of service.

     

    4651 Restrictions Regarding Submission of Claims for Respite

     

    Revision 15-2; Effective October 30, 2015

     

    A program provider may not submit a service claim for:

     

    4660 Qualified Service Provider

    Revision 10-0; Effective October 1, 2009

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the respite service component:

     

    4670 Unit of Service

    Revision 10-0; Effective October 1, 2009

     

    1. 15 Minutes

    A unit of service for the respite service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for respite may not include a fraction of a unit of service.

     

    4680 Payment Limit

    Revision 10-0; Effective October 1, 2009

     

    The maximum amount DADS will pay a program provider for respite provided to an individual is 1200 units of service (300 hours) per IPC year.

     

    4690 Written Documentation

    Revision 11-1; Effective September 1, 2011

     

    A program provider must have written documentation to support a service claim for respite. The written documentation must:

     

    4700 Supported Employment

    Revision 14-2; Effective April 10, 2014

     

     

    4710 General Description of Service Component

    Revision 14-3; Effective September 1, 2014

     

    Supported employment means assistance provided in order to sustain competitive employment or self-employment to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which individuals without disabilities are employed. Supported employment includes employment adaptations, supervision, training related to an individual’s assessed needs, and earning at least a minimum wage (if not self-employed).

     

    4720 Billable Activity

    Revision 15-2; Effective October 30, 2015

     

    The only billable activities for the supported employment service component are:

     

    4730 Activity Not Billable

    Revision 15-2; Effective October 30, 2015

     

    1. Activities in Section 3300

    The activities listed in Section 3300, Activity Not Billable, are not billable for the supported employment service component.

    1. Activities Not Listed in Section 4720

    Any activity not described in Section 4720, Billable Activity, is not billable for the supported employment service component.

    1. Examples of Non-billable Activities

    The following are examples of activities that are not billable for the supported employment service component:

     

    4740 Qualified Service Provider

    Revision 14-2; Effective April 10, 2014

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the supported employment service component:

     

    4750 Restrictions Regarding Submission of Claims for Supported Employment

    Revision 14-2; Effective April 10, 2014

     

    A program provider may not submit a service claim for supported employment provided to an individual if supported employment is available to the individual through the public school system.

     

    4760 Unit of Service

    Revision 14-2; Effective April 10, 2014

    1. 15 Minutes

    A unit of service for the supported employment service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for supported employment may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

     

    4770 Written Documentation

    Revision 14-2; Effective April 10, 2014

     

    A program provider must have written documentation to support a service claim for supported employment. The written documentation must:

     

    4780 Supported Employment Documentation Requirements

    Revision 14-3; Effective September 1, 2014

     

    A program provider must have written documentation to support a service claim for supported employment. The written documentation must:

     

    4800 Employment Assistance

    Revision 14-2; Effective April 10, 2014

     

     

    4810 General Description of Service Component

    Revision 14-3; Effective September 1, 2014

     

    Employment Assistance means assistance provided to an individual to help the individual locate paid competitive employment in the community or self-employment.

     

    4820 Employment Assistance Billable Time/Activities

    Revision 15-2; Effective October 30, 2015

     

    Employment Assistance services consist of developing and implementing strategies for achieving the individual’s desired employment outcome, including more suitable employment for individuals who are employed. Services are individualized, person-directed, and may include:

    For self-employment, services may additionally include:

     

    4830 Employment Assistance Non-billable Time/Activities

    Revision 15-2; Effective October 30, 2015

     

    Unit of Service: 15 minutes

     

    4840 Employment Assistance Qualified Service Provider

    Revision 14-2; Effective April 10, 2014

     

    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the employment services component:

     

    4850 Unit of Service

    Revision 14-2; Effective April 10, 2014

     

    1. 15 Minutes

    A unit of service for the supported employment service component is 15 minutes.

    1. Fraction of a Unit of Service

    A service claim for supported employment may not include a fraction of a unit of service.

    1. Service Time

    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

     

    4860 Employment Assistance Documentation Requirements

    Revision 14-2; Effective April 10, 2014

     

    Documentation will be maintained in the file of each participant receiving Employment Assistance verifying that such assistance is not otherwise available to the participant under a program funded under the Rehabilitation Act of 1973 or Public Law 94-142. See the DADS/DARS MOA for more detail on coordination and documentation processes: http://www.dads.state.tx.us/providers/supportedemployment/dars-collaboration.html (link is external).

    A service log for each service event that describes the service and, when appropriate, includes information pertaining to the individual's progress toward goals and objectives.

    The service log must include:

    HCSBG, Section 5000, General Requirements for Service Components Not Based on Billable Activity

    Revision 10-0, Effective October 1, 2009

     

     

    5100 Applicable Service Components

    Revision 10-0; Effective October 1, 2009

     

    Section 5000 applies only to the following service components:

     

    5200 Service Claim Requirements

    Revision 14-1; Effective March 21, 2014

     

    A program provider must submit an electronic service claim that meets the following requirements:

     

    5300 Written Documentation

    Revision 10-0; Effective October 1, 2009

     

    1. Legible

    A program provider must have written, legible documentation as described by this section and Section 6000 to support a service claim.

    1. Proof of Licensed Professional Qualifications

    A program provider must have a written document from the appropriate state licensing agency or board to prove that a licensed professional, as required by Section 6160, Required Documentation for an Adaptive Aid (see No. 1, Item a), and a provider of dental treatment, as described in Section 6350, Provider of Dental Treatment, is properly licensed.

    HCSBG, Section 6000, Adaptive Aids, Minor Home Modifications and Dental Treatment

    Revision 15-3; Effective December 8, 2015

     

     

    6100 Adaptive Aids

    Revision 10-1; Effective June 1, 2010

     

     

    6110 General Description of Service Component

    Revision 10-0; Effective October 1, 2009

     

    An adaptive aid is an item or service that enables an individual to retain or increase the ability to perform activities of daily living or to control the individual's environment.

     

    6120 Billable Adaptive Aids

    Revision 10-0; Effective October 1, 2009

     

    The only billable items and services for the adaptive aids service component are listed in Appendix VII, Billable Adaptive Aids. The repair and maintenance of a billable item not covered by warranty is also billable for the adaptive aids service component.

     

    6130 Items and Services Not Billable

    Revision 14-1; Effective March 21, 2014

     

    1. Items and Services Not Listed in Appendix VII

    Any item or service not listed in Appendix VII, Billable Adaptive Aids, is not billable under the adaptive aids service component.

    1. Examples of Non-Billable Items and Services

    The following are examples of items and services that are not billable for the adaptive aids service component:

     

    6140 Property of Individual

    Revision 10-0; Effective October 1, 2009

     

    Except for a vehicle lift, a billable item must be the exclusive property of the individual to whom it is provided.

     

    6150 Payment Limit

    Revision 10-0; Effective October 1, 2009

     

    The maximum amount DADS pays a program provider for all adaptive aids provided to an individual is $10,000 per IPC year.

     

    6160 Required Documentation for an Adaptive Aid

    Revision 14-1; Effective March 21, 2014

     

    1. Adaptive Aid Costing $500 or More

      For an adaptive aid costing $500 or more, a program provider must obtain the documentation described below before purchasing the adaptive aid.

      1. Written Assessment

    A program provider must obtain a written, legible assessment by one of the licensed professionals noted for the specific adaptive aid, as shown in Appendix VII, Billable Adaptive Aids. The written assessment must:

    1. Individual and Program Provider Agreement

    An individual or legally authorized representative and program provider must:

    1. Proof of Non-coverage by Medicaid and Medicare
      1. Adaptive Aids Noted with a (1) or (2) on Appendix VII, Billable Adaptive Aids
        1. Documentation Required

    Except as provided in II, Nutritional Supplements, below, for an adaptive aid noted on Appendix VII, Billable Adaptive Aids, with a (1) or, for an adaptive aid noted with a (2) for an individual who is under 21 years of age, the program provider must obtain one of the following as proof of non-coverage by Medicaid:

    1. Additional Documentation Required for Individuals Who are Eligible for Medicare

    In addition to the documentation required by Item i above, for an individual eligible for Medicare, a program provider must obtain one of the following for an adaptive aid noted with a (1) or (2) on Appendix VII:

    1. Unacceptable Documentation

    The following are examples of documentation that are not acceptable as proof of non-coverage:

    1. Nutritional Supplements

    For a nutritional supplement (service code 121), the program provider must obtain one of the following as proof of non-coverage by Medicaid:

    1. Bids
      1. Required Number of Bids

    A program provider must obtain comparable bids for the requested adaptive aid from three vendors, except as provided in clause III. below. Comparable bids describe the adaptive aid and any associated items or modifications identified in the assessment required by Item a. above.

    1. Required Content and Time Frame

    A bid must:

    1. Program Provider Not Required to Obtain Three Bids
      1. One Bid

    A program provider may obtain only one bid for the following adaptive aids:

    1. One or Two Bids

    A program provider may obtain only one bid or two comparable bids for an adaptive aid, other than one listed in Item i. above, if the program provider has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

    1. Request for Payment of Higher Bid
      1. Documentation Required

    If a program provider will request authorization for payment, as described by Section 6170, that is not based on the lowest bid, the program provider must have written justification for payment of a higher bid.

    1. Examples of Justification That May Be Acceptable

    The following are examples of justifications that support payment of a higher bid:

    1. Proof of Ownership

    If applicable, a program provider must obtain proof that the individual, individual's family member or host home/companion care provider owns the vehicle for which a vehicle lift (service code 101) is requested.

    1. Adaptive Aids Costing Less Than $500

    For an adaptive aid costing less than $500, a program provider must obtain the documentation described in this paragraph before purchasing the adaptive aid.

    1. Individual and Program Provider Agreement, Proof of Non-Coverage, Bids and Proof of Ownership

    For an adaptive aid costing less than $500, a program provider must obtain:

    1. Approval of Annual Vendor

    In lieu of obtaining bids in accordance with (1)(d) above for an adaptive aid costing less than $500 monthly, a program provider must, in accordance with this subparagraph, obtain DADS approval of an annual vendor.

    1. Documentation Required

    To obtain approval of an annual vendor, a program provider must submit the following written documentation to DADS:

    1. Approval Period and Time Frame for Submission
      1. Approval Period

    An approval of an annual vendor by DADS is only valid for a calendar year.

    1. Time Frame for Submission

    To obtain approval of an annual vendor, a program provider must submit documentation required by No. I above:

    1. Approval of Multiple Vendors

    DADS may approve more than one annual vendor for a program provider per calendar year.

    1. Vendor Used for All Individuals

    If DADS approves an annual vendor to provide an adaptive aid, a program provider must use the vendor to supply the adaptive aid to all individuals of the program provider who need the adaptive aid.

     

    6170 Authorization for Payment

    Revision 11-1; Effective September 1, 2011

     

    1. Requesting Authorization for Payment
      1. Adaptive Aids Costing $500 or More

    To obtain authorization for payment for an adaptive aid costing $500 or more, a program provider must:

    1. Adaptive Aid Costing Less than $500

    To obtain authorization for payment for an adaptive aid costing less than $500, a program provider must:

    1. Requisition Fee

    A program provider may request authorization for payment of a requisition fee for an adaptive aid in accordance with the instructions on Appendix IX, Minor Home Modifications, Adaptive Aids or Dental Summary Sheet.

    Time Frame for the Request for Authorization for Payment

    A program provider must request authorization for payment for an adaptive aid no later than 12 months after the last day of the month in which the individual received the adaptive aid.

    1. Notification for Authorization for Payment
      1. Authorization for Payment Given or Denied

    DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):

    1. Corrected Requests

    If a request for authorization for payment is denied, a program provider must submit a corrected request no more than 12 months after the last day of the month in which the individual received the adaptive aid.

     

    6200 Minor Home Modifications

    Revision 10-1; Effective June 1, 2010

     

     

    6210 General Description of Service Component

    Revision 15-3; Effective December 8, 2015

     

     

    A minor home modification is a physical adaptation to an individual's residence that is necessary to address the individual's specific needs and that enables the individual to function with greater independence in the individual's residence or to control his or her environment.

    A minor home modification includes a pre-enrollment minor home modification.

     

    6220 Billable Minor Home Modifications

    Revision 10-0; Effective October 1, 2009

     

    The only billable adaptations for the minor home modification service component are listed in Appendix X, Billable Minor Home Modifications. The repair and maintenance of a billable adaptation not covered by warranty is also billable for the minor home modifications service component.

     

    6230 Adaptations Not Billable

    Revision 10-0; Effective October 1, 2009

     

    1. Adaptations Not Listed in Appendix X

    Any adaptation not listed in Appendix X, Billable Minor Home Modifications, is not billable under the minor home modification service component.

    1. Examples of Non-Billable Adaptations

    The following are examples of adaptations that are not billable for the minor home modification service component:

     

    6240 Payment Limit

    Revision 15-3; Effective December 8, 2015

     

    Payment by DADS to a program provider for minor home modifications is subject to the following limitations:

     

    6250 Required Documentation for a Minor Home Modification

    Revision 15-3; Effective December 8, 2015

     

    1. Pre-enrollment Minor Home Modifications Costing Any Amount and Other Minor Home Modifications Costing $1,000 or More

    For a pre-enrollment minor home modification costing any amount and for a minor home modification (other than a pre-enrollment minor home modification) costing $1,000 or more, a program provider must obtain the documentation described in this paragraph before purchasing the minor home modification.

    1. Written Assessment

    A program provider must obtain a written, legible assessment by one of the licensed professionals noted for the specific minor home modification on Appendix X, Billable Minor Home Modifications. The written assessment must:

    1. Individual and Program Provider Agreement

    An individual or legally authorized representative and program provider must:

    1. Bids
      1. Required Number of Bids

    A program provider must obtain comparable bids for the requested minor home modification from three vendors, except as provided in No. III below. Comparable bids describe the minor home modification and any associated installation specifications identified in the written assessment required by Item a. above.

    1. Required Content and Time Frame

    A bid must:

    1. Program Provider Not Required to Obtain Three Bids

    A program provider may obtain only two comparable bids for the requested minor home modification if the program provider has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.

    1. Request for Payment of Higher Bid
      1. Documentation Required

    If a program provider will request authorization for payment, as described by Section 6170, Authorization for Payment, that is not based on the lowest bid, the program provider must have written justification for the payment of a higher bid.

    1. Examples of Justification That May be Acceptable

    An example of justification that supports payment of a higher bid is the inclusion of a longer warranty for the minor home modification.

    1. Minor Home Modifications (Other Than Pre-enrollment Minor Home Modifications) Costing Less Than $1,000

    For a minor home modification (other than a pre-enrollment minor home modification) costing less than $1,000, a program provider must obtain the following documentation before purchasing the minor home modification:

     

    6260 Pre-enrollment Minor Home Modification Prior Authorization Process

    Revision 15-3; Effective December 8, 2015

     

    1. Requirement for Prior Authorization from DADS

    DADS requires a program provider to obtain prior authorization from DADS for a pre-enrollment minor home modification before DADS will pay for the minor home modification. A program provider must request prior authorization in accordance with this section.

    1. Documentation Required
      • To obtain prior authorization for a pre-enrollment minor home modification, the program provider must:
        • complete, with the applicant or legally authorized representative and service coordinator, Form 8611, Pre-enrollment MHM Authorization Request; and
        • obtain and give the following documentation to the service coordinator:
          • a pre-enrollment minor home modifications assessment, as described in Section 6250, Required Documentation for a Minor Home Modification (see No. 1, Item a.);
          • service planning team meeting documentation evidencing agreement with the recommendation(s) of the applicant’s need for the pre-enrollment minor home modification, as described in Section 6250 (See No. 1 Item b.);
          • three bids, as described in Section 6250 (see No. 1, Item c.) and;
          • if applicable, and subject to approval by DADS, written justification for less than three bids or payment of a higher bid, as described in Section 6250 (see No 1. Item c. (III) and (IV)).
      • The service coordinator submits completed Form 8611 and the above described documentation to DADS.
    2. DADS Review of Form 8611

      DADS reviews completed Form 8611 and the documentation submitted by the service coordinator and indicates on the form whether it authorizes or denies a requested pre-enrollment minor home modification. DADS sends a copy of signed Form 8611 to the service coordinator who then sends a copy of the form to the program provider.

     

    6270 Authorization for Payment

    Revision 15-3; Effective December 8, 2015

     

    1. Requesting Authorization for Payment
      1. Pre-Enrollment Minor Home Modifications To obtain authorization for payment for a pre-enrollment minor home modification:
        • for an individual who enrolls with a program provider, the program provider must:
          • submit a completed Form 4116-MHM-AA, Minor Home Modification/Adaptive Aids Summary Sheet, to DADS in accordance with the form instructions; and
          • keep in the individual's record the documentation required by Section 6260, Pre-Enrollment Minor Home Modification Prior Authorization Process (see No. 2); and
        • for an individual who does not enroll with a program provider, the program provider must:
          • complete Form 8612, TAS/MHM Payment Exception Request, based on the pre-enrollment minor home modifications and pre-enrollment minor home modification assessments authorized by DADS on Form 8611, Pre-Enrollment MHM Authorization Request; and
          • submit completed Form 8612 to DADS no sooner than 30 days after the individual’s proposed enrollment date but within 12 months after the last day of the month in which the pre-enrollment minor home modification was completed.
      2. Minor Home Modifications (Other Than Pre-enrollment Minor Home Modifications) Costing $1,000 or More

    To obtain authorization for payment for a minor home modification (other than a pre-enrollment minor home modification) costing $1,000 or more, a program provider must:

    1. Minor Home Modifications (Other Than Pre-enrollment Minor Home Modifications) Costing Less Than $1,000

    To obtain authorization of payment for a minor home modification (other than a pre-enrollment minor home modification) costing less than $1,000, a program provider must:

    1. Requisition Fee

    A program provider may request authorization for payment of a requisition fee for a minor home modification (including a pre-enrollment minor home modification) in accordance with the instructions in Appendix IX, Minor Home Modifications, Adaptive Aids or Dental Summary Sheet.

    1. Time Frame for the Request for Authorization for Payment

    A program provider must request authorization for payment for a minor home modification no later than 12 months after the last day of the month in which the minor home modification was completed.

    1. Notification for Authorization for Payment
      1. Authorization for Payment Given or Denied DADS notifies a program provider on the Client Assignment and Registration (CARE) System Reimbursement Authorization Inquiry (C77):
        • that authorization for payment is given or denied;
        • if given, the amount which DADS has authorized; and
        • if denied, the reason for denial.
      2. Corrected Requests

    If a request for authorization for payment is denied, a program provider must submit a corrected request no later than 12 months after the last day of the month in which the minor home modification was completed.

     

    6300 Dental Treatment

    Revision 10-1; Effective June 1, 2010

     

     

    6310 General Description of Service Component

    Revision 10-0; Effective October 1, 2009

     

    The dental treatment service component includes emergency dental treatment, preventive dental treatment, therapeutic dental treatment and orthodontic dental treatment.

     

    6320 Age Requirement

    Revision 10-0; Effective October 1, 2009

     

    Dental treatment may be provided only to an individual 21 years of age or older.

     

    6330 Billable Dental Treatment

    Revision 10-0; Effective October 1, 2009

     

    The only billable services for the dental treatment service component are:

     

    6340 Services Not Billable

    Revision 10-0; Effective October 1, 2009

     

    1. Items and Services Not Listed in Subsection (C)

    Any service not listed in Section 6330, Billable Dental Treatment, is not billable under the dental treatment service component.

    1. Examples of Non-Billable Services

    The following are examples of services that are not billable for the dental treatment service component:

     

     

     

    6350 Provider of Dental Treatment

    Revision 10-0; Effective October 1, 2009

     

    A provider of the dental treatment service component must be a person licensed to practice dentistry in accordance with Texas Occupations Code, Chapter 256.

     

    6360 Payment Limit

    Revision 15-1; Effective September 1, 2015

     

    The maximum amount DADS pays a program provider for all dental treatment provided to an individual is $2,000 per individual plan of care (IPC) year.

     

    6370 Authorization for Payment

    Revision 12-3; Effective November 19, 2012

     

    1. Requesting Authorization for Payment
      1. Dental Treatment

    To obtain authorization for payment for dental treatment, a program provider must:

    1. Requisition Fee

    A program provider may request authorization for payment of a requisition fee for dental treatment in accordance with the instructions in Appendix IX. The requisition fee is not counted toward the payment limit that DADS pays a program provider for dental treatment, as described in Section 6360, Payment Limit.

    1. Time Frame for Request for Authorization for Payment

    A program provider must request authorization for payment for dental treatment no later than 12 months after the last day of the month in which the individual received the dental treatment.

    1. Notification for Authorization for Payment
      1. Authorization for Payment Given or Denied

    DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):

    1. Corrected Request

    If a request for authorization for payment is denied, a program provider must submit a corrected request no later than 12 months after the last day of the month in which the individual received the dental treatment.

     

    6400 Transition Assistance Services (TAS)

    Revision 15-3; Effective December 8, 2015

     

     

    6410 General Description of Service Component

    Revision 15-3; Effective December 8, 2015

     

    Services provided to assist an applicant in setting up a household in the community before being discharged from a nursing facility, an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or a general residential operation (GRO) and before enrolling in the HCS Program.

     

    6420 Billable TAS

    Revision 15-3; Effective December 8, 2015

     

    Transition Assistance Services (TAS) consists of:

     

    6430 Reserved for Future Use

    Revision 115-3; Effective December 8, 2015

     

     

    6440 Property of Individual

    Revision 15-3; Effective December 8, 2015

     

    A billable item must be the exclusive property of the individual for whom it is purchased.

     

    6450 Payment Limit

    Revision 15-3; Effective December 8, 2015

     

    1. DADS Payment to Program Provider

    Payment by DADS to a program provider for Transition Assistance Services (TAS) is limited to:

    1. Lifetime Limit

    An individual may receive TAS only once in the individual's lifetime.

     

    6460 TAS Prior Authorization Process

    Revision 15-3; Effective December 8, 2015

     

    1. Requirement for Prior Authorization from DADS

    DADS requires a program provider to obtain prior authorization from DADS for Transition Assistance Services (TAS) before DADS will pay for TAS. A program provider must request prior authorization in accordance with this section.

    1. Documentation Required
      1. Form 8604, Transition Assistance Services (TAS) Assessment and Authorization To obtain prior authorization for TAS, the program provider must complete Form 8604 with the applicant or legally authorized representative and service coordinator.
      2. Submission of Form 8604 to DADS The service coordinator submits the completed Form 8604 to DADS.
    2. DADS Review of Form 8604

    DADS reviews completed Form 8604 and indicates on the form whether it authorizes or denies the requested TAS. DADS sends a copy of signed Form 8604 to the service coordinator, who then sends a copy of the form to the program provider.

     

    6470 Authorization for Payment for TAS

    Revision 15-3; Effective December 8, 2015

     

    1. Requesting Authorization for Payment
      1. Payment for Transition Assistance Services (TAS) To obtain authorization for payment for TAS:
        • for an individual who enrolls with a program provider, the program provider must keep in the individual's record:
          • completed Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, authorized by DADS; and
          • itemized receipts from vendors evidencing the purchase of TAS authorized by Form 8604 that includes:
            • the name of the vendor;
            • a description of each item or service;
            • the cost of each item or service; and
            • the date of purchase of each item or service; and
        • for an individual who does not enroll with a program provider, the program provider must:
          • complete Form 8612, TAS/MHM Payment Exception Request, based on the TAS authorized by DADS on Form 8604; and
          • submit completed Form 8612 to DADS no sooner than 30 days after the individual’s proposed enrollment date, but within 12 months after the last day of the month in which TAS is purchased.
      2. TAS Service Fee

    A program provider may request authorization for payment of a service fee (a flat fee) for TAS authorized by DADS on Form 8604. 

    1. Time Frame for the Request for Authorization for Payment

    A program provider must request authorization for payment for TAS no later than 12 months after the last day of the month in which TAS was purchased.

    1. Corrected Request

    If a request for authorization for payment is denied, a program provider must submit a corrected request no later than 12 months after the last day of the month in which TAS was purchased.

    Appendices

    HCSBG, Appendix I, Billing and Payment Review Protocol

    Revision 11-1; Effective September 1, 2011

     

    1. Introduction

    This protocol is used to conduct a billing and payment review of a Home and Community-based Services (HCS) Program provider. A billing and payment review is a review conducted by DADS staff of written documentation maintained by a program provider and submitted to DADS upon request. The purpose of a review is to determine whether the program provider is in compliance with the HCS Program Billing Guidelines. DADS recoups from a program provider for a service claim that DADS cannot verify is supported by written documentation in accordance with the Billing Guidelines and may require corrective action by the program provider.

    1. Types of Reviews
      1. Routine reviews

    A routine review is a billing and payment review conducted by DADS for an HCS program provider at least once every two years per program provider. During a routine review, DADS reviews documentation required by the Billing Guidelines for:

    • services provided during a three-month period of time; and
    • the following number of individuals:
      • for an HCS provider for which a routine review resulted in a recoupment amount that is 10% or less of the total amount of the claims reviewed, five individuals plus 5% of the total number of individuals provided services during the review period;
      • for an HCS provider for which a routine review has not been conducted:
        • if the program provider provided HCS Program services to 10 or fewer individuals during the review period, the number of individuals provided services during the review period, but in no case more than five individuals; or
        • if the program provider provided HCS Program services to more than 10 individuals during the review period, five individuals plus 10% of the total number of individuals provided services during the review period; or
      • for an HCS provider for which a routine review resulted in a recoupment amount that is more than 10% of the total amount of the claims reviewed:
        • if the program provider provided HCS Program services to 10 or fewer individuals during the review period, all of the individuals; or
        • if the program provider provided HCS Program services to more than 10 individuals during the review period, 10 individuals plus 10 % of the total number of individuals provided services during the review period.
    1. Special reviews

    A special review is a billing and payment review conducted by DADS for one or more HCS provider agreements as a result of a billing anomaly identified by DADS staff or as a result of information related to billing issues received from a source other than DADS staff. During a special review, DADS reviews documentation for:

    • any length of time as determined by DADS;
    • any number of individuals as determined by DADS; and
    • any type of service as determined by DADS.
    1. Methods of Review
      1. On-site review

    An on-site review is a billing and payment review conducted at a program provider’s place of business.

    1. Desk review

    A desk review is a billing and payment review conducted at a DADS office.

    1. Routine Review Process
      1. On-site review
        1. DADS notifies a program provider of an on-site review by telephone at least 14 days before and by facsimile at least one day before the date the on-site review is scheduled to begin. The telephonic and written notices include a statement that all written documentation required by the Billing Guidelines related to a specified program provider agreement must be made available to the DADS review team at a specified time and place.
        2. At least two business days before the on-site review, DADS faxes to the program provider a list of individuals for whom records will be reviewed who receive services outside the waiver contract area of the on-site review location.
        3. Upon arrival at the program provider's place of business, the DADS review team informs the program provider of the individuals receiving services in the waiver contract area in which the review is being conducted and time period for which written documentation will be reviewed. During the review, the review team may expand the time period under review and may request documentation related to individuals who were not initially included in the review.
        4. The review team reviews the documentation submitted by the program provider. The review team does not accept any documentation created by the program provider during the review.
        5. When the review team completes the initial review of the documentation submitted by the program provider, the review team gives the program provider a list of all unverified claims and explains why the claims are unverified. The review team allows the program provider to provide additional documentation and refute the unverified claims.
        6. The review team conducts an exit conference with the program provider. During the exit conference the review team summarizes the findings of the review, provides technical assistance to improve documentation practices, and answers questions from the program provider. The review team also gives an estimate of the amount of claims to be recouped. DADS does not allow the program provider to submit additional documentation or refute any unverified claims after the exit conference.
        7. DADS sends a letter by certified mail to the program provider. Generally, DADS sends this letter within 30 days after the exit conference. If DADS did not identify any unverified claims, the letter notifies the program provider of such. If DADS identified unverified claims, the letter includes a detailed report of the unverified claims, the reason the claims were not verified, the amount to be recouped by DADS, any required corrective action and notice of the right to request an administrative hearing. Examples of corrective actions that DADS may require a program provider to take are submitting a plan to improve the program provider’s billing practices and reviewing documentation beyond the scope of the billing and payment review.
        8. If DADS requires a program provider to take a corrective action and the program provider does not request an administrative hearing for the recoupment, DADS includes in the letter described in paragraph (f) above a date by which the program provider must take the corrective action. If the program provider does not take the required corrective action by the date required by DADS, DADS may:
          • impose a vendor hold on payments due to the program provider under the HCS provider agreement until the program provider takes the corrective action; and
          • terminate the provider agreement.
      2. Desk review
        1. DADS notifies a program provider of a desk review by telephone and certified mail. The written notice specifies the individuals and time period to be reviewed, as well as the documentation the program provider must submit to DADS for the desk review. The notice states that the documentation must be received by DADS within 14 calendar days after the program provider receives the notice. The date the notice is received by the program provider is the date of the signature appearing on the “green card” – Postal Service form 1138. If the signature is not dated, the received date will be the date the “green card” is postmarked.
        2. DADS will accept one of the following as proof of its receipt of the documentation submitted by the program provider:
          • the dated signature of a DADS employee on a “green card” – Postal Service form 1138;
          • a dated signature of an agent of DADS evidencing receipt of the documentation; or
          • a dated, traceable receipt from a commercial courier service or the U.S. Postal Service.
        3. DADS does not accept documentation submitted via facsimile or documentation received by DADS after the 14-day time period described in the notice.
        4. The review team reviews the documentation submitted by the program provider. During the review, the review team may expand the time period under review and may request documentation related to individuals who were not initially included in the review.
        5. DADS sends a letter by certified mail to the program provider. If DADS did not identify any unverified claims, the letter notifies the program provider of such. If DADS identified unverified claims, the letter includes a detailed report of the unverified claims, the reason the claims were not verified and the amount to be recouped by DADS. The letter also gives the program provider an opportunity to submit additional documentation for certain unverified claims and a written argument to refute any unverified claim. Further, the letter states that the additional documentation and written argument must be received by DADS within 14 calendar days after the program provider receives the letter. The date the letter is received by the program provider is the date of the signature appearing on the “green card” – Postal Service form 1138. If the signature is not dated, the received date will be the date the “green card” is postmarked.
        6. Proof of receipt by DADS of any additional documentation and written argument submitted by the program provider is the same as the proof of receipt of documentation described in paragraph (b) directly above.
        7. DADS does not accept additional documentation or a written argument submitted via facsimile or received by DADS after the 14-day time period described in the letter.
        8. The review team reviews any additional documentation and argument submitted by the program provider. DADS sends a letter by certified mail to the program provider that either upholds the unverified claims listed in the previous letter or revises the unverified claims and adjusts the amount to be recouped by DADS. The letter also gives the program provider notice of the right to request an administrative hearing.
    2. Special Review Process

    A special review is generally conducted in accordance with the process for a routine review except:

    • DADS may not always give a program provider prior notice of an on-site review;
    • during an on-site review, DADS may interview an individual or program provider staff and may visit an individual’s residence or any other location where an individual receives HCS Program services; and
    • in addition to documentation required by the Billing Guidelines, DADS may request the program provider to submit documentation required by state or federal law, rule or regulation for DADS review.
    1. Payment of Unverified Claims

    Payment to DADS by a program provider of an unverified claim is accomplished by DADS recouping the program provider’s HCS Medicaid payments for the amount of the unverified claim. Such recoupment is done electronically through the automated billing system. A program provider may determine the unverified claim upon which recoupment was based by referring to the applicable electronic billing report.

    HCSBG, Appendix II, Degree of Consanguinity or Affinity

    HCSBG, Appendix III, Conversion Table

    HCSBG, Appendix IV Reserved for Future Use

    HCSBG, Appendix V, Determining Units of Service for the Supported Home Living Activity of Transporting an Individual

    Revision 10-0; Effective October 1, 2009

     

     

    Determining Units of Service for a Single Trip (Examples 1 and 2)

    Example 1

    Example 1 Facts

    • A program provider transports Individuals A, B and C, who are individuals receiving HCS supported home living, and Passenger D, a person enrolled in the program provider’s ICF/IID program, in the same vehicle, using one service provider.
    • Individual A departs at 8:15 a.m., Individual B departs at 8:25 a.m., and Individual C and Passenger D depart at 9:00 a.m.
    • Individuals A and B arrive at 9:15 a.m. Individual C and Passenger D arrive at 10:00 a.m.
    Individual Departure Time Arrival Time
    A 8:15 9:15
    B 8:25 9:15
    C 9:00 10:00
    D 9:00 10:00

    Example 1: Method A

    Transportation time for Individuals A, B, and C is 105 minutes, with four passengers (A, B, C and D) and one service provider: The first individual (A) departed at 8:15 a.m. and the last individual (C) arrived at 10:00 a.m. The time between 8:15 and 10:00 is 105 minutes.

    Passenger D does not need units of service determined because he is not enrolled in the HCS program. However, he is counted when determining the number of passengers.

    The service time for individuals A, B, and C is 26.25 minutes:

    Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

    • Service Time = (1 x 105) ÷ 4
      Service Time = 105 ÷ 4
      Service Time = 26.25 minutes<

    Using Appendix III, Conversion Table, the service time of 26.25 minutes is converted to 2 units of service.

    Using Method A, Individuals A, B and C all have 2 units of service.

    Example 1: Method B

    Individual A’s transportation time has three segments:

    • transportation time of 10 minutes (8:15-8:25) with one passenger (A only) and one service provider;
    • transportation time of 35 minutes (8:25-9:00) with two passengers (A and B) and one service provider; and
    • transportation time of 15 minutes (9:00-9:15) with four passengers (A, B, C and D) and one service provider.

    Individual B’s transportation time has two segments:

    • transportation time of 35 minutes (8:25-9:00) with two passengers (A and B) and one service provider; and
    • transportation time of 15 minutes (9:00-9:15) with four passengers (A, B, C and D) and one service provider.

    Individual C’s transportation time has two segments:

    • transportation time of 15 minutes (9:00-9:15) with four passengers (A, B, C and D) and one service provider; and
    • transportation time of 45 minutes (9:15-10:00) with two passengers (C and D) and one service provider.

    Passenger D does not need units of service determined because he is not enrolled in the HCS program. However, he is counted when determining the number of passengers.

    Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

    Individual A’s service time for each segment:

    • Service Time = (1 x 10) ÷ 1
      Service Time = 10 ÷ 1
      Service Time = 10 minutes
    • Service Time = (1 x 35) ÷ 2
      Service Time = 35 ÷ 2
      Service Time = 17.5 minutes
    • Service Time = (1 x 15) ÷ 4
      Service Time = 15 ÷ 4
      Service Time = 3.75 minutes

    Individual B’s service time for each segment:

    • Service Time = (1 x 35) ÷ 2
      Service Time = 35 ÷ 2
      Service Time = 17.5 minutes
    • Service Time = (1 x 15) ÷ 4
      Service Time = 15 ÷ 4
      Service Time = 3.75 minutes

    Individual C’s service time for each segment:

    • Service Time = (1 x 15) ÷ 4
      Service Time = 15 ÷ 4
      Service Time = 3.75 minutes
    • Service Time = (1 x 45) ÷ 2
      Service Time = 45 ÷ 2
      Service Time = 22.5 minutes

    Total service time for each individual is determined by adding the service time of each segment:

    • Individual A: 10 minutes + 17.5 minutes + 3.75 minutes = 31.25 minutes
    • Individual B: 17.5 minutes + 3.75 minutes = 21.25 minutes
    • Individual C: 3.75 minutes + 22.5 minutes = 26.25 minutes

    Using Appendix III, Conversion Table, service time is converted to units of service:

    • Individual A: 31.25 minutes = 2 units of service
    • Individual B: 21.25 minutes = 1 unit of service
    • Individual C: 26.25 minutes = 2 units of service

    Using Method B, Individual B has 1 unit of service, and Individuals A and C each have 2 units of service.

    Example 2

    Example 2 Facts

    • A program provider transports two individuals, Individuals E and F, in the same vehicle using two service providers.
    • Individual E departs with a service provider at 2:00 p.m. Individual F departs with another service provider at 2:10 p.m.
    • Individuals E and F arrive at 2:40 p.m.
    Individual Departure Time Arrival Time
    E 2:00 2:40
    F 2:10 2:40

    Example 2: Method A

    The transportation time for Individuals E and F is 40 minutes, with two passengers (E and F) and two service providers. The first individual (E) departed at 2:00 and the last individuals (E and F) arrived at 2:40. The time between 2:00 and 2:40 is 40 minutes.

    The service time for individuals E and F is 40 minutes:

    Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

    • Service Time = (2 x 40) ÷ 2
      Service Time = 80 ÷ 2
      Service Time = 40 minutes

    Using Appendix III, Conversion Table, the service time of 40 minutes is converted to 3 units of service.

    Using Method A, Individuals E and F each have 3 units of service of supported home living for the transportation provided.

    Example 2: Method B

    Individual E’s transportation time has two segments:

    • transportation time of 10 minutes (2:00-2:10) with one passengers (E only) and one service provider; and
    • transportation time is 30 minutes (2:10-2:40) with two passengers (E and F) and two service providers.

    Individual F’s transportation time has one segment:

    • Transportation time is 30 minutes (2:10-2:40) with two passengers (E and F) and two service providers.

    Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

    Individual E’s service time for each segment:

    • Service Time = (1 X 10) ÷ 1
      Service Time = 10 ÷ 1
      Service time = 10 minutes
    • Service Time = (2 X 30) ÷ 2
      Service Time = 60 ÷ 2
      Service Time = 30 minutes

    Individual F’s service time:

    • Service Time = (2 X 30) ÷ 2
      Service Time = 60 ÷ 2
      Service Time = 30 minutes

    Total service time for Individual E is determined by adding the service time of each segment:

    • Individual E: 10 minutes + 30 minutes = 40 minutes

    Using Appendix III, Conversion Table, service time is converted to units of service:

    • Individual E: 40 minutes = 3 units of service
    • Individual F: 30 minutes = 2 units of service

    Using Method B, Individual E has 3 units of service and Individual F has 2 units of service.

    Determining Units of Service for Multiple Trips (Example 3)

    Example 3

    Example 3 Facts

    • A program provider transports Individuals A, B and C and Passenger D, as described in Example 1 (this will be referred to as the “outgoing trip”).
    • The program provider transports Individuals A, B and C and Passenger D back to their original locations later the same day (the “return trip”).
    • Service times for the return trip for Individuals A, B and C are the same as the service times for the outgoing trip.

    Example 3: Method A Service Times (see Example 1: Method A)

    Individual Outgoing Trip
    Service Time
    Return Trip
    Service Time
    A 26.25 26.25
    B 26.25 26.25
    C 26.25 26.25

    Example 3: Method A – Without Accumulation of Service Times

    Service times for the outgoing and return trips for Individuals A, B and C are notaccumulated; units of service from the outgoing trip (see Example 1: Method A) are combined with the units of service of the return trip: 2 units of service + 2 units of service = 4 units of service.

    Using Method A without accumulating service times for the outgoing and return trips, Individuals A, B and C each have 4 units of service.

    Example 3: Method A – With Accumulation of Service Times

    Service times of the outgoing and the return trips for Individuals A, B and C are accumulated for a total service time of 52.5 minutes: 26.25 minutes + 26.25 minutes = 52.5 minutes.

    Using Appendix III, Conversion Table, the total service time of 52.5 minutes is converted to 3 units of service.

    Using Method A and accumulating service times for the outgoing and return trips, Individuals A, B and C each have 3 units of service.

    Example 3: Method B Service Times (see Example 1: Method B)

    Individual Outgoing Trip
    Service Time
    Return Trip
    Service Time
    A 31.25 31.25
    B 21.25 21.25
    C 26.25 26.25

    Example 3: Method B – Without Accumulation of Service Times

    Service times for the two trips are not accumulated; units of service from the outgoing trip (see Example 1: Method B) are combined with the units of service of the return trip:

    • Individual A: 2 units of service + 2 units of service = 4 units of service
    • Individual B: 1 unit of service + 1 unit of service = 2 units of service
    • Individual C: 2 units of service + 2 units of service = 4 units of service

    Using Method B without accumulating service times for the outgoing and return trips, Individuals A and C each have 4 units of service; Individual B has 2 units of service.

    Example 3: Method B – With Accumulation of Service Times

    Service times of the outgoing and the return trips for Individuals A, B and C are accumulated for a total service time:

    • Individual A: 31.25 minutes + 31.25 minutes = 1 hour, 2.5 minutes
    • Individual B: 21.25 minutes + 21.25 minutes = 42.5 minutes
    • Individual C: 26.25 minutes + 26.25 minutes = 52.5 minutes

    Using Appendix III, Conversion Table, the total service time is converted to units of service:

    • Individual A: 1 hour, 2.5 minutes = 4 units of service
    • Individual B: 42.5 minutes = 3 units of service
    • Individual C: 52.5 minutes = 3 units of service

    Using Method B and accumulating service times for the outgoing and return trips, Individual A has 4 units of service, and Individuals B and C each have 3 units of service.

    HCSBG, Appendix VI, Example of Supported Home Living Transportation Log

    Revision 10-0; Effective October 1, 2009

     

    For information about document accessibility, contact DADS at handbookfeedback@hhsc.state.tx.us

    PdfExample of Supported Home Living Transportation Log

    HCSBG, Appendix VII, Billable Adaptive Aids

    Revision 13-1; Effective January 1, 2014

    1. Abbreviations and Numbers

    The following abbreviations and numbers, as used in this attachment, have the following meanings:

    1. Licensed Professionals
      • (AU) – A person licensed as an audiologist in accordance with Chapter 401 of the Texas Occupations Code.
      • (DI) – A person licensed as a dietitian in accordance with Chapter 701 of the Texas Occupations Code.
      • (NU) – A person licensed to practice professional or vocational nursing by the Board of Nurse Examiners in accordance with Chapter 301 of the Texas Occupations Code.
      • (MD) – A person licensed as a physician in accordance with Texas Occupations Code, Chapter 155.
      • (OT) – A person licensed as an occupational therapist in accordance with Chapter 454 of the Texas Occupations Code.
      • (OPH) – A person licensed as a physician in accordance with Texas Occupations Code, Chapter 155, and certified by the American Board of Ophthalmology.
      • (OPT) – A person licensed as an optometrist or therapeutic optometrist in accordance with Texas Occupations Code, Chapter 351.
      • (PT) – A person licensed as a physical therapist in accordance with Chapter 453 of the Texas Occupations Code.
      • (PS/BS) – A person licensed as a psychologist, provisional license holder or psychological associate in accordance with Chapter 501 of the Texas Occupations Code; a person certified by DADS as described in 40 TAC §5.161; or a behavior analyst certified by the Behavior Analyst Certification Board, Inc.
      • (SP) – A person licensed as a speech-language pathologist in accordance with Chapter 401 of the Texas Occupations Code.
    2. Other Abbreviations and Numbers
      • (1) – The item is available through Texas Medicaid Home Health Services and Medicare for all individuals.
      • (2) – The item is available through Texas Health Steps for all individuals under the age of 21.

     

    1. List of Billable Adaptive Aids

    The following items and services, listed by category, including repair and maintenance not covered by warranty, are billable adaptive aids:

    • Lifts
    101 a vehicle lift adaptation for a vehicle owned by an individual, an individual’s family member or foster/companion care provider if it is the primary mode of transportation for the individual, but not to exceed one lift every five years. Repairs and maintenance not covered by warranty are not limited to the five-year requirement.

     

    • A vehicle that is expected to be modified or adapted must meet one of the following criteria:
      • vehicle is less than 5 years old and mileage is less than 50,000 miles; or
      • vehicle passed an independent inspection performed by a certified automotive technician.
    (OT, PT, MD)
    104 a hydraulic, manual or electronic lift (1, 2) (OT, PT, MD), replacement sling (1) (OT, PT, MD), a barrier-free (ceiling or wall mounted) lift system, a porch lift or stair lift
    128 a transfer bench (1, 2) (OT, PT, MD)
    • Mobility Aids
    106 a crutch, walker or cane (1, 2) (OT, PT, MD)
    107 an orthotic device, orthopedic shoes or a brace which is custom fabricated specifically for an individual (2) (OT, PT, MD)
    157 a manual or electric wheelchair or a necessary accessory (1, 2) (OT, PT, MD)
    158 a forearm platform attachment for a walker (1, 2) (OT, PT, MD)
    159 a portable wheelchair ramp (1, 2) (OT, PT, MD)
    160 a battery or charger for an electric wheelchair (1, 2) (OT, PT, MD, NU)
    161 a gait trainer or gait belt (1, 2) (OT, PT, MD, NU)
    163 a stroller, push-chair or travel seat (OT, PT, MD)
    • Positioning Devices
    151 a hospital bed (1) or crib (2) (OT, PT, MD)
    154 a standing board or frame, positioning chair, or wedge (1, 2) (OT, PT, MD)
    155 a trapeze bar (1, 2) (OT, PT, MD)
    156 a lift chair, but not the lift mechanism if it is reimbursable through Medicare (OT, PT, MD)
    162 a bath or shower chair (1, 2) (OT, PT, MD, NU)
    164 a toileting chair (1, 2) (OT, PT, MD, NU)
    165 a portable bathtub rail (1, 2) (OT, PT, MD)
    • Controls and Switches
    109 a sip and puff control (1, 2) (OT, PT)
    110 an adaptive switch used to operate items necessary for daily functioning (OT, PT)
    • Environmental Control Units
    111 an adaptive lock (OT, PT)
    112 an electronic control unit or automatic door opener (OT, PT)
    114 a voice, light, smoke or motion activated device (OT, PT,AU)
    • Medical Supplies
    120 diapers, briefs, pull-ons, liners, diaper wipes, disposable underpads, reusable underpads (1,2) (MD, NU)
    121 a multivitamin product with a prescription, a nutritional supplement listed in the Texas Medicaid Provider Procedures Manual (for example, Ensure, Boost, Glucerna) or Thick-It (2) (MD)
    122 an enteral feeding formula and supplies (1, 2) (MD)
    201 medically necessary supplies for tracheotomy care, decubitus care, ostomy care, respirator/ventilator care or catheterization (1, 2) (MD)
    206 a glucose monitor or other supplies for an individual’s use in self-monitoring (1, 2) (MD, NU)
    207 an adapted medication dispenser or pill crusher (MD, NU)
    208 an air humidifier, purifier or specialized air filter, or a medically necessary portable heating and/or cooling device to manage the symptoms of a seizure disorder, respiratory or cardiac condition, or inability to regulate body temperature (MD)
    209 a muscle stimulator (OT, PT, MD)
    210 temporary rental of a billable adaptive aid to allow for the repair, purchase or replacement of the adaptive aid (1, 2) (OT, PT, MD, NU)
    211 a urinal (1, 2) (MD, NU)
    212 a specialized thermometer (MD, NU)
    213 a specialized scale (MD, NU, DI)
    214 medical support hose (1) (MD, NU)
    215 specialized clothing (for example, a weighted vest), a dressing aid or bib (OT, PT, MD, NU)
    216 a specialized or treated mattress or mattress cover (2) (MD, NU)
    217 an egg-crate, sheepskin or other medically necessary mattress pad (1, 2) (MD, NU)
    218 a cleft palate feeder (1, 2) (MD, OT, PT, DI)
    219 a blood pressure or pulse monitor for an individual’s use in self-monitoring (1) (MD, NU)
    220 prescription eyeglasses beyond Medicaid limit (2) (OPH, OPT)
    221 non-sterile disposable gloves for individuals who require catheterization, have skin breakdown or require wound care, or have a documented disease that may be transmitted through urine or stool and the care of the individual is provided by a non-paid caregiver (1,2) (MD,NU)
    • Communication Aids (including batteries)
    124 a direct selection, alphanumeric, scanning or encoding communicator (2) (SP)
    125 a speech amplifier or augmentative communication device (1, 2) (SP)
    126 sign language interpreter service for non-routine communications, such as IDT meetings, or medical/professional appointments (SP, AU, MD)
    251 an emergency response system or service, monitoring device (MD, NU) or medical alert bracelet (MD, NU)
    254 a communication board or book (2) (SP)
    255 a closed-captioning device for an individual with a hearing impairment (AU)
    256 a signature stamp for an individual with a visual or physical impairment, muscular weakness or limited range of motion (OPH, OT, PT)
    257 a signature guide for an individual with a visual or physical impairment, muscular weakness or limited range of motion (OPH, OT, PT)
    258 a personal computer or accessory necessary for the individual to communicate independently (SP)
    259 specialized training for augmentative communication software, not to exceed $1,000 per individual, per IPC year (2) (SP)
    260 a hearing aid (2) (AU) or battery (2) (AU, MD, NU)
    • Adapted Equipment for Activities of Daily Living
    324 a lever door handle (OT, PT)
    401 a device or item used to enable an individual to independently pick up or grasp an object (for example, a reacher) (OT, PT)
    402 a device or item used to enable an object to be firmly positioned and secure (for example, a dycem mat) (OT, PT)
    403 a device or item used to enable an individual to independently hold and sustain control of an object (for example, a hand strap) (OT, PT)
    404 adapted dinnerware, an eating utensil or meal preparation device (OT, PT)
    405 a specialized clock or wristwatch for an individual with a visual or hearing impairment (OT, PT)
    406 an electric razor or electric toothbrush for an individual with a muscular weakness or limited range of motion who shaves self or brushes own teeth (OT, PT)
    407 a speaker, large button or braille telephone for an individual who is verbal but cannot use a conventional telephone (OT, PT)
    408 a microwave oven, if use of a conventional oven presents a safety hazard to the individual (OT, PT)
    409 a hand-held shower device (1, 2) (OT, PT)
    • Safety Restraints and Safety Devices
    113 a safety restraint (2) (PS, MD) or wheelchair tie down (OT, PT, MD, NU)
    450 a bed rail (1, 2) (OT, PT, MD, NU)
    451 safety padding (1, 2) (PS/BS, OT, PT, MD)
    452 a helmet used due to a seizure disorder or other medical condition (2) (PS/BS, MD, NU)
    453 an adaptation to furniture (PS/BS) (OT, PT)

    HCSBG, Appendix VIII, Reserved for Future Use

    HCSBG, Appendix IX, Minor Home Modifications, Adaptive Aids or Dental Summary Sheet

    HCSBG, Appendix X Billable Minor Home Modifications

    Revisions

    HCSBG, Revision 15-3, Miscellaneous Changes

    Revision 15-3; Effective December 8, 2015

    The following changes were made:

    Revised Title Change
    2000 Definitions Adds GRO or General Residential Operation, ICF/IID or intermediate care facility for individuals with an intellectual disability or related conditions, pre-enrollment minor home modifications and pre-enrollment minor home modifications assessment.
    6210 General Description of Service Component Adds a minor home modification includes a pre-enrollment minor home modification.
    6240 Payment Limit Adds “for repair and maintenance per individual plan of care (IPC) year.”
    6250 Required Documentation for a Minor Home Modification Adds pre-enrollment minor home modifications costing any amount and other minor home modifications costing $1,000 or more, and adds minor home modifications other than pre-enrollment minor home modifications costing less than $1,000.
    6260 Pre-enrollment Minor Home Modification Prior Authorization Process Adds a new section.
    6270 Authorization for Payment Moves and revises the content previously in Section 6260.
    6400 Transition Assistance Services (TAS) Adds new Sections 6400 through 6470.
    Forms Forms Table of Contents Adds Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, Form 8611, Pre-Enrollment MHM Authorization Request, and Form 8612, TAS/MHM Payment Exception Request.

    HCSBG, Revision 15-2, Miscellaneous Changes

    Revision 15-2; Effective October 30, 2015

    The following changes were made:

    Revised Title Change
    1200 Service Components Adds supported home living (transportation).
    2000 Definitions Adds ADLs or activities of daily living, CFC PAS/HAB or Community First Choice Personal Assistance Services/Habilitation, health-related tasks, IADLs or instrumental activities of daily living, and transportation plan.
    3100 Applicable Service Components Adds supported home living (transportation).
    3300 Activity Not Billable Deletes a reference to Section 4540.
    3430 Relative, Guardian or Managing Conservator Qualified as Service Provider Adds transportation as a supported home living activity.
    3510 15-Minute Unit of Service Adds transportation as a supported home living activity.
    3610 15-Minute Unit of Service Changes terminology to supported employment and employment assistance. Adds transportation as a supported home living activity.
    3720 Multiple Service Providers Adds transportation as a supported home living activity and adds CFC PAS/HAB. Deletes information regarding performance as a different activity.
    3810 General Requirements Adds transportation as a supported home living activity.
    3840 Proof of Location of Residence of Service Provider Adds transportation as a supported home living activity.
    3850 Example Forms Adds transportation as a supported home living activity.
    4220 Billable Activity Adds CFC PAS/HAB and transportation as a supported home living activity.
    4420 Billable Activity Adds CFC PAS/HAB and transportation as a supported home living activity.
    4471.2 Billable Activity Adds CFC PAS/HAB and transportation as a supported home living activity.
    4472.2 Billable Activity Adds CFC PAS/HAB and transportation as a supported home living activity.
    4473.2 Billable Activity Adds CFC PAS/HAB and transportation as a supported home living activity.
    4510 General Description of Service Component Adds supported home living (transportation).
    4540 Support Home Living Billing Requirements Changes the title and updates the first paragraph to the only billable activity for the supported home living subcomponent is transporting the individual, except from one day habilitation, employment assistance or supported employment site to another. Adds transportation as a supported home living activity.
    4610 General Description of Service Component Adds the respite service component is not a service provider of CFC PAS/HAB unless the service provider of CFC PAS/HAB routinely provides unpaid assistance and support to the individual and is used to provide temporary support to the primary caregiver.
    4651 Restrictions Regarding Submission of Claims for Respite Adds CFC PAS/HAB.
    4720 Billable Activity Adds determining how the individual will travel to and from a job.
    4730 Activity Not Billable Adds CFC PAS/HAB.
    4820 Employment Assistance Billable Time/Activities Adds determining how the individual will travel to and from a job.
    4830 Employment Assistance Non-billable Time/Activities Adds CFC PAS/HAB.

    HCSBG, Revision 15-1, Dental Limit Increase

    Revision Notice 15-1; Effective September 1, 2015

    The following changes were made:

    Revised Title Change
    6360 Payment Limit Increases the maximum amount for all dental treatment provided to an individual to $2,000 per individual plan of care (IPC) year.

    HCSBG, Revision 14-3, Miscellaneous Changes

    Revision 14-3; Effective September 1, 2014

    The following changes were made:

    Revised Title Change

    2000

    Definitions

    Revises the definitions for competitive employment, four-person residence, integrated employment, and adds self-employment.

    4240

    Qualified Service Provider

    Adds a licensed clinical social worker and a licensed professional counselor.

    4330

    Billable Activity

    Removes to develop opportunities for employment in the community.

    4350

    Restrictions Regarding Submission of Claims for Day Habilitation

    Adds day habilitation that is being provided by one service provider who is also the same service provider of a different component or subcomponent to the same individual at the same time, and adds day habilitation in the individual’s residence without prior justification.

    4420

    Billable Activity

    Moves the placement of information about checking medications.

    4471.2

    Billable Activity

    Moves the placement of information about checking medications.

    4472.2

    Billable Activity

    Moves the placement of information about checking medications.

    4473.2

    Billable Activity

    Moves the placement of information about checking medications.

    4540

    Supported Home Living Subcomponent

    Adds a link to Section 3720, Multiple Service Providers.

    4560

    Residential Support Subcomponent

    Adds a program provider may not have the same residence as the individual and must lease or own the residence. Adds a service provider must be available to provide services for at least two shifts in one calendar day (one shift during the day and one shift at night during sleeping hours).

    4570

    Supervised Living Subcomponent

    Adds a program provider may not have the same residence as the individual and must lease or own the residence. Adds a qualified service provider may reside in the residence with a spouse or parent with whom the service provider has a spousal relationship.

    4610

    General Description of Service Component

    Adds the respite service component is used to provide temporary support to the primary caregiver in non-routine circumstances.

    4620

    Billable Activity

    Adds any billable activity referenced in this section that occurs at a camp that is accredited by the American Camp Association.

    4651

    Restrictions Regarding Submission of Claims for Respite

    Adds respite provided to an individual on a routine basis.

    4710

    General Description of Service Component

    Adds self-employment to the first sentence.

    4720

    Billable Activity

    Adds several billable activities for the supported employment service component.

    4730

    Activity Not Billable

    Adds several activities that re not billable for the supported employment service component.

    4780

    Supported Employment Documentation Requirements

    Adds a new section regarding written documentation for supported employment.

    4810

    General Description of Service Component

    Adds competitive employment in the community or self-employment.

    4820

    Employment Assistance Billable Time/Activities

    Describes Employment Assistance services and adds several individualized, person-directed services.

    4830

    Employment Assistance Non-billable Time/Activities

    Adds using Medicaid funds paid by the Department of Aging and Disability Services.

    HCSBG, Forms

    Form Title
    2122 Service Delivery Log with Written Narrative/Written Summary
    2123 Adaptive Aid/Minor Home Modification Request for Prior Approval
    2124 Community Support Transportation Log
    4116-Dental Dental Summary Sheet
    4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet
    4117 Supported Employment/Employment Assistance Service Delivery Log
    4118 Respite Service Delivery Log
    4119 Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log
    4120 Day Habilitation Service Delivery Log
    4121 Supported Home Living/Community Support/Community First Choice Personal Assistance Services/Habilitation
    4122 Informacion en espanol Host/Companion Service Delivery Log
    4123 Nurse Services Delivery Log - Billable Activities
    8580 Request for Variance of Supported Employment - Employer Requirements
    8604 Transition Assistance Services (TAS) Assessment and Authorization
    8611 Pre-Enrollment MHM Authorization Request
    8612 TAS/MHM Payment Exception Request

     

     

    Informacion in espanol = form also available in Spanish.

    HCSBG, Contact Us

    For technical or accessibility issues with this handbook, please email: handbookfeedback@hhsc.state.tx.us

    For questions about the Home and Community-based Services Program Billing Guidelines, email: hcspolicy@hhsc.state.tx.us