Revision 06-1; Effective April 10, 2006

1100 Introduction

Revision 06-1; Effective April 10, 2006

Emergency Response Services (ERS) are provided through an electronic monitoring system used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the individual can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps to ensure that the appropriate person or service provider responds to an alarm call from an individual.

This handbook provides general information to potential and current ERS providers. You are responsible for complying with all rules pertaining to ERS.

1200 Legal Base

Revision 06-1; Effective April 10, 2006

Emergency response is an optional service authorized under 45 CFR, Part 96, and the Human Resources Code, Title II, Chapter 22. The Texas Legislature authorized its implementation in June 1979 to ensure alternatives to institutionalization for eligible individuals.

1300 General Requirements for Participation

Revision 06-1; Effective April 10, 2006

Provider enrollment is the method of contracting for Emergency Response Services (ERS). A legal entity may apply to receive a contract if the legal entity meets the requirements specified in 40 Texas Administrative Code (TAC), Chapter 52, Contracting to Provide Emergency Response Services, and 40 TAC, Chapter 49, Contracting for Community Care Services.

Become familiar with the following rules. Remember, you have licensure requirements as well. Contact the Department of State Health Services for the particular rule citation. There may be additional rules from other agencies. It is your responsibility to obtain them. All rules can be accessed at the following website: http://www.dads.state.tx.us/rules/TAC.html.

• 1 Texas Administrative Code (TAC), Part 15, Chapter 355, Subchapter A, §§355.101-111, Cost Determination Process
• 40 TAC, Chapter 48, Community Care Aged and Disabled, Subchapter J
• 40 TAC, Chapter 49, Contracting for Community Care Services
• 40 TAC, Chapter 52, Contracting to Provide Emergency Response Services
• 40 TAC, Chapter 69, Contract Administration
• 40 TAC, Chapter 79, Legal Services

1310 Licensure Requirement

Revision 06-1; Effective April 10, 2006

You must submit a copy of your renewed license to your regional contract manager within 10 days of receipt from the Department of State Health Services' Personal Emergency Response Services. Not submitting a current license is a basis for automatic vendor hold on your contract.

1320 Delinquency in Payment of Franchise Tax

Revision 06-1; Effective April 10, 2006

State law prohibits the awarding of a contract or the granting of a license or permit by the state or a state agency to any corporation that is delinquent in its payment of franchise tax. You may obtain a Certificate of Good Standing by contacting:

Tax Assistance Section, State Comptroller's Office
Telephone Bank Operations
Interstate WATS: 1-800-252-5555
Austin: 512-463-4600

1330 Exclusion

Revision 06-1; Effective April 10, 2006

You cannot be excluded from participating in Title 18 and/or Title 19 of the Social Security Act. This is specified in Chapter 49, Contracting for Community Care Services.

1340 Required Disclosure of Previous Employment and Certification

Revision 06-1; Effective April 10, 2006

Chapter 79, Legal Services, states that the contractor must disclose the employment history of anyone employed by him or those individuals who are an owner, director, consultant, etc. If a former or current Department of Aging and Disability Services (DADS) employee or former or current council member or relative is an officer, director, owner or employee, the commissioner of DADS (or designee) must approve the contract or contract renewal. DADS can terminate a contract if you do not provide correct information or you subcontract to avoid the application process.

1350 Denial of Contracts

Revision 06-1; Effective April 10, 2006

In most instances, a contract may be terminated for validated reports of abuse, neglect or exploitation and the perpetrator is an employee, volunteer or owner who has or will have access to employees as outlined in Chapter 49, Contracting for Community Care Services; however, there may be unusual circumstances involved. If a validated report was minor, old and a one-time action, the Department of Aging and Disability Services (DADS) may choose to award a contract.

It is DADS' responsibility to investigate and document the validated reports. If you take remedial action to prevent the occurrence from repeating, DADS has the option to award or continue the contract.

1400 Licensing Information

Revision 06-1; Effective April 10, 2006

For information about licensing and general correspondence, contact:

Personal Emergency Response Services
Department of State Health Services
1100 West 49th Street
Austin, Texas 78756-3183

To renew a license and mail a check, contact:

Personal Emergency Response Services
Department of State Health Services
P.O. Box 12197
Capitol Station
Austin, Texas 78711-2197

Revision 06-1; Effective April 10, 2006

2100 Contracting Requirements

Revision 06-1; Effective April 10, 2006

If this is the first time you have contracted with the Department of Aging and Disability Services (DADS) to provide Emergency Response Services (ERS), you must receive service-specific training before any referrals from DADS can be made. To receive orientation/ training, contact the contract manager in the regional office. A list of regional office telephone numbers can be found in Appendix II, Regional Contacts.

If you currently have a contract with DADS (for the same service in another region) and have already received orientation, you do not have to receive the service-specific orientation/training from the contract manager in the region again. Documentation indicating that orientation has previously been received must be presented to the regional contract manager.

Remember, failure to have adequate staff available to provide services upon receipt of training may lead to contract termination.

Providers:

• must comply with the complaint procedures outlined in Chapter 49, Contracting for Community Services;
• must comply with Executive Order 11246, titled "Equal Employment Opportunity," as amended by Executive Order 11375 and supplemented in Department of Labor regulations at 41 CFR, Part 60;
• must comply with applicable provisions of the Clean Air Act (42 U.S.C., 7401 et seq.) and the Federal Water Pollution Control Act, as amended (33 U.S.C., 1251 et seq.), if funding under this contract exceeds $100,000;
• must comply with §231.006, Texas Family Code, which stipulates that the individual or business entity named in the contract, bid or application certifies it is not ineligible to receive the specified grant, loan or payment and acknowledges that the contract may be terminated and payment may be withheld if this certification is inaccurate; and
• are responsible for their behavior, as well as the behavior of their staff and subcontractors to ensure a violence-free contractual relationship. Any remarks, gestures or actions toward DADS employees, volunteers and/or individuals that carry an implied threat of any kind, even if intended to be in jest, will be taken seriously and may lead to corrective action, up to and including revocation of the contract.

The contractor certifies that the goods and/or service(s) covered by this contract are designed to be used before, during and after calendar year 2000 A.D. The goods and/or service(s) will operate during such time periods without error relating to date data that represent different centuries or more than one century.

2200 Advertising and Solicitation of Individuals

Revision 06-1; Effective April 10, 2006

The Department of Aging and Disability Services (DADS) may investigate complaints of solicitation of coerced individuals. Validated complaints may lead to adverse actions. Such sanctions may lead to termination of your contract.

You are in violation of your Emergency Response Services (ERS) contract if you employ a person:

• who is paid money each time the employee recruits a new Medicaid recipient; or
• whose sole responsibility is recruitment, regardless of how the employee is compensated.

You may have an employee who is responsible for recruitment in addition to other assignments, as long as the employee is paid a regular salary and does not receive bonuses or anything that could be construed as a bonus for recruitment of individual Medicaid recipients.

2300 General Contracting Requirements

Revision 06-1; Effective April 10, 2006

Provider enrollment is the method of contracting for Emergency Response Services (ERS). A legal entity may apply to receive a contract if the legal entity meets the requirements specified in Chapter 49, Contracting for Community Care Services.

When a provider applies to provide ERS, regional staff send the provider an application package. The package includes a list of current providers, unit rate(s) paid to each provider and the areas each provider serves. The applicant specifies in the completed package a unit rate for the counties in the region that the applicant plans to serve. Only one unit rate is allowed for each contract in each region, regardless of the number of counties served. The unit rate may not exceed the lesser of the:

• statewide ceiling; or
• average private-pay rate for services delivered according to the Department of Aging and Disability Services standards.

2310 Enrollment

Revision 06-1; Effective April 10, 2006

Regional contract staff enroll providers in the Emergency Response Services program. To have your enrollment-related questions answered, call the the Department of Aging and Disability Services regional office in your city. See Appendix II, Regional Contacts.

2320 Compliance with the Americans with Disabilities Act of 1990

Revision 06-1; Effective April 10, 2006

Because the Americans with Disabilities Act of 1990 (ADA) requires both private and public facilities to be accessible without discrimination, the Department of Aging and Disability Services can refuse to contract with a facility that has been licensed but does not meet ADA requirements.

2400 Contract Assignment

Revision 06-1; Effective April 10, 2006

If you plan to assign your contract, you (the assignor) must notify the regional office in writing of the intent 60 days before assigning the contract. You and the assignee must complete Form 5881, Contract Assignment and Agreement, which includes information regarding:

• your and the assignee's authority to enter into the contract agreement; and
• any bankruptcy actions pending in court for you and the assignee.

Form 5881 must be notarized and include an original official notary seal. The Department of Aging and Disability Services(DADS) will use the information on the form to determine whether to approve a contract assignment. Failure to provide the form will result in the denial of the contract assignment. Submission of false information on the form will result in adverse action, up to and including denial of the contract assignment and/or termination of the assignor/assignee's contract. DADS may also refer providers that submit false information for prosecution. The written notification from the assignor must be notarized and signed by the person authorized to sign the contract. Form 5881 must be mailed to the regional office.

The DADS regional office mails a contract assignment application to the assignor within seven days after receipt of written notification to DADS of the intent to assign a contract.

The guidelines for a contract assignment agreement are found in Appendix I, Assignment of Contracts, and Chapter 49, Contracting for Community Care Services.

2500 Subcontracts

Revision 06-1; Effective April 10, 2006

You must not subcontract any services to be performed under the contract without written prior approval from the Department of Aging and Disability Services, Community Care Section (state office).

2600 Method of Payment

Revision 06-1; Effective April 10, 2006

The Health and Human Services Commission (HHSC) determines a unit rate ceiling for Emergency Response Services based on data obtained from the cost report submitted to HHSC by each individual service contractor. Rates can be accessed at: https://pfd.hhs.texas.gov.

To find information about HHSC's methodology for setting a reimbursement rate, establishing allowable and unallowable costs, and establishing cost-report requirements, see 40 TAC, Chapter 52, Contracting to Provide Emergency Response Services, and 1 TAC Part 15, Chapter 355, Subchapter A, §§355.101-111, Cost Determination Process.

2700 Misrepresentation

Revision 06-1; Effective April 10, 2006

Sometimes individuals or representatives of private businesses contact Community Services providers and misrepresent themselves as having affiliation with the Department of Aging and Disability Services (DADS) in order to provide services or to inquire about purchasing a provider. At times these individuals are providing false information concerning issues such as rate cuts or proposed changes in program policies.

In order to make these Community Services contacts, it appears that these individuals or private businesses have obtained a list of Community Services providers either from DADS state office or other sources. Although any individual or private business may, under state law, have a list of all Community Services providers, that in itself in no way indicates an affiliation with DADS.

Revision 06-1; Effective April 10, 2006

 

Eligibility

 

The Department of Aging and Disability Services case manager completes Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to determine the individual's needs. The additional eligibility requirements are outlined under Chapter 48, Community Care for Aged and Disabled.

Revision 06-2; Effective June 9, 2006

 

 

5100 Overview

Revision 06-1; Effective April 10, 2006

 

This section describes the interaction between the Department of Aging and Disability Services (DADS) and the Emergency Response Services (ERS) staff. This material is presented in a routine and chronological sequence of events, following the individual from initial application for services through service delivery and suspension/termination of services.

 

5110 Forms Needed

Revision 06-1; Effective April 10, 2006

 

• Form 2059, Summary of Client's Need for Service
• Form 2067, Case Information (The provider may use this form to meet Chapter 52, Contracting to Provide Emergency Response Services, requirements, as long as the provider ensures that the required information is documented on or attached to the form.)
• Form 2101, Authorization for Community Care Services
• Form 2110, Community Care Intake

 

5120 Referrals to Facility

Revision 06-1; Effective April 10, 2006

 

An applicant may be referred to an Emergency Response Services provider by the case manager. Section 5200, Provider Response to Case Manager Referral, describes the process you follow to initiate services for an individual referred through the case manager.

 

5130 Case Manager Service Planning Process

Revision 06-1; Effective April 10, 2006

 

Applicants/individuals apply for services by contacting a Community Care for Aged and Disabled (CCAD) case manager. The case manager conducts face-to-face interviews to determine if applicants meet eligibility criteria for the service. The case manager may authorize services for up to one year.

The case manager gives eligible applicants an explanation of the service. The applicants/individuals are advised that they are required to:

• participate in the service delivery requirements; and
• sign a release statement allowing the responder to enter the individual's home by force, if necessary, to assist the individual.

 

 

5140 Referral Process

Revision 06-1; Effective April 10, 2006

 

The region maintains a list of all Emergency Response Services providers. The list includes:

• vendor number,
• geographic areas served, and
• rate(s).

This information is provided to the individual to assist in making an informed choice. If the individual has no preference of providers, a referral will be made to the provider with the lowest rate. If more than one provider has the same lowest unit rate, referrals to individuals will be made on a rotating basis.

The case manager gives verbal approval when the individual needs an immediate response to the request for services. The service begin date is negotiated between the provider and case manager.

Providers will receive the referral packet within seven days from the verbally approved date.

 

5150 Interest Lists

Revision 06-1; Effective April 10, 2006

 

If, due to fiscal constraints, the Department of Aging and Disability Services initiates an interest list, the case manager explains to the individual that the service is not currently available, and a referral will be made to the provider originally selected by the individual when intake is opened.

 

5200 Provider Response to Case Manager Referral

Revision 06-2; Effective June 9, 2006

 

When Form 2101, Authorization for Community Care Services, is received, the provider:

• contacts the individual to make an appointment to install the emergency response home unit equipment; and
• prepares a file on the individual, which includes applicable provider forms (individual information, home entry release statement, ownership of equipment statement and complaint procedure).

 

 

5210 Securing Responders

Revision 06-1; Effective April 10, 2006

 

The provider refers to the Comments section of Form 2101, Authorization for Community Care Services, to determine if the case manager identified potential responders for the individual. The provider begins to identify responders during the initial contacts while arranging for a home visit. The provider may ask the individual if there is a relative, friend or neighbor willing to participate. If one or more responders are identified for an individual, the provider may request that the person(s) be present on the day the equipment is to be installed to learn about the service and the responder's responsibilities. If the responders are unable to be present, the provider may orient the responders by telephone or in writing on or before the date the responder is first contacted and asked to respond to an alarm call. The provider must document the required information. More information regarding responder orientation can be found in Chapter 52 Contracting to Provide Emergency Response Services.

If two responders are not secured for the individual, the provider will:

• identify the individual's sole responder and document the reason(s) why two responders were not secured for the individual; and
• document the date the written procedures were mailed to the sole responder; or
• designate public service personnel in place of the individual's responders; and
• send written notification to the case manager of the inability to secure the names of any responders within 14 days after initiating services.

 

 

5220 Home Visit

Revision 06-1; Effective April 10, 2006

 

During the home visit, the installer connects the equipment and obtains the information needed to complete the applicable provider forms.

If the provider is unable to complete installation, document the reason for the delay, the anticipated date the equipment will be installed, and a description of ongoing efforts to install the equipment, if applicable.

After installing the equipment, the provider demonstrates the equipment and allows the individual to activate an alarm call to familiarize him with the equipment. The provider explains the individual is responsible for the following service delivery requirements:

• participating in the monthly systems checks;
• contacting the provider if he moves or has his telephone number changed; and
• contacting the provider if he becomes aware of changes related to responder(s).

The installer provides the individual with a written copy and an explanation of the complaint procedures.

The case manager must discuss service delivery requirements with the individual. If the individual refuses to sign the release statement, the case manager must withdraw the referral.

 

5230 Provider Follow-Up Procedures

Revision 06-2; Effective June 9, 2006

 

The provider:

• documents the day that services began.
• maintains ongoing communication with the case manager and the regional contract manager by discussing:
  • individual-specific issues with the case manager; and
  • contract management issues (overall service delivery, policies and procedures) with the regional contract manager.

 

 

5300 Ongoing Service Delivery

Revision 06-1; Effective April 10, 2006

 

 

 

5310 Alarm Calls

Revision 06-1; Effective April 10, 2006

 

Activated alarms received at the response center are responded to within 60 seconds. The provider keeps track of an incident from the time the alarm is activated to the time the individual receives assistance. Each activated alarm call must be considered an emergency, not an accident.

The provider immediately contacts the responder(s) and/or proper authorities when the individual activates an alarm. If the provider contacts the individual before a responder, the provider must talk to the individual to verify that an emergency exists.

Providers contact a responder whenever an alarm call is activated and the provider is unable to reach the individual.

A provider must document an alarm call at the time the call is received and after it is resolved. Documentation requirements are outlined in Chapter 52, Contracting to Provide Emergency Response Services.

A provider must submit written notification to the case manager by the next workday after an alarm call that results in a responder being dispatched to an individual's home.

 

5320 Monthly System Checks

Revision 06-1; Effective April 10, 2006

 

The provider conducts monthly checks during normal working hours, unless otherwise negotiated with the individual. The purpose of the monthly system check is to:

• ensure the individual can successfully make an alarm call;
• ensure that the equipment is working properly; and
• remind the individual how the system works and how to activate an alarm in an emergency.

The test involves contacting the individual and instructing him to press the call button to activate the alarm call.

If two individuals live in the same residence, the provider conducts a monthly system check for each individual. Be sure to document the system check. Documentation requirements are outlined in Chapter 52, Contracting to Provide Emergency Response Services.

The following procedures apply when the provider is unable to reach the individual to conduct a monthly system check.

Calendar	Procedures
For three consecutive months	Try to reach the individual at least three times on three different days during the month. After three attempts, contact a responder and try to find out why the individual is unable to participate in the test. If a provider is unable to complete a system check during a calendar month, the provider must provide written notification to the case manager as outlined in Chapter 52, Contracting to Provider Emergency Response Services.
-	Note: If within three consecutive months a monthly system check is not successful, the provider may continue to receive payments if attempts to conduct system checks and convene an IDT meeting continue.

 

Note: In each of the three months, the provider is eligible for payment if all the requirements are met. The provider is not eligible for partial payment for partial completion of procedures.

The provider documents the reasons why the individual is unable to participate in the monthly system check. The provider will contact the responder if no documented reason why the system checks have not been completed exists. The provider must ask the responder to find out why the individual is unable to complete the system check. The information must be documented in the individual's case folder or the monthly log of systems checks. Written notification is provided to the case manager as outlined in Chapter 52, Contracting to Provide Emergency Response Services.

 

5330 Service Breaks

Revision 06-1; Effective April 10, 2006

 

The provider must ensure that the equipment remains functional and that each individual receives services during the entire authorization period.

The following persons may report equipment malfunctions to the provider:

• individual;
• individual's family members;
• individual's responders;
• case managers; or
• providers (subcontractors or provider staff).

As equipment malfunctions are reported, the provider sends the installer to the individual's home to repair or replace the equipment.

The provider documents each equipment failure and low battery signal in the provider files.

 

5400 Notification Requirements

Revision 06-1; Effective April 10, 2006

 

 

5410 Changes and Serious Incidents

Revision 06-1; Effective April 10, 2006

 

A change is an event in the individual's status or condition that may require a change in the individual's service authorization. Events include:

• hospitalization;
• changes in functional abilities (or ability to operate unit);
• complaints of pain;
• change of address;
• changes in the household composition;
• an emergency involving the individual that receives a response; and
• three unsuccessful attempts to contact the individual for the monthly systems test.

The provider notifies the case manager in writing of changes. An interdisciplinary team may need to be called if monthly system checks are unsuccessful or an individual or someone in the home engages in illegal discrimination against a provider staff or a Department of Aging and Disability Services employee. The case manager notifies the provider if services should continue or be terminated.

The case manager and provider will ensure that both parties are aware of any changes involving an individual (examples: hospitalization, change of residence or visits with relatives).

 

5420 Interdisciplinary Team (IDT) Meetings

Revision 06-1; Effective April 10, 2006

 

The provider will convene an IDT meeting when the need arises. A meeting is called for situations in which the provider is unable to resolve issues with the individual. IDT requirements are outlined in Chapter 52, Contracting to Provide Emergency Response Services.

 

5430 Provider Changes

Revision 06-1; Effective April 10, 2006

 

The provider sends Form 2067, Case Information, to the regional contract manager to notify him of a change in the provider address or telephone number.

 

5440 Client Rights and Responsibilities

Revision 06-1; Effective April 10, 2006

 

For information regarding an individual's rights and responsibilities, see Chapter 49, Contracting for Community Care Services.

 

5500 Suspension and Termination of Services

Revision 06-1; Effective April 10, 2006

 

 

5510 Suspension of Services

Revision 06-1; Effective April 10, 2006

 

The provider will suspend services if the individual:

• permanently leaves the state or moves to a county in which the provider does not have an Emergency Response Services (ERS) contract;
• permanently moves to a location where ERS is not provided;
• dies;
• is admitted to an institution for more than 120 consecutive days; or
• is no longer mentally alert enough operate the equipment properly.

Detailed information regarding the suspension of ERS can be found in Chapter 52, Contracting to Provide Emergency Response Services.

 

5520 Termination of Services

Revision 06-1; Effective April 10, 2006

 

The individual's right to appeal if services are terminated is governed by the Fair and Fraud Hearings Handbook.

If the Department of Aging and Disability Services terminates Emergency Response Services (ERS), a provider may be paid for the last month of service, regardless of how many days of service were provided that month, if the provider has complied with the requirements outlined in Chapter 52, Contracting to Provide Emergency Response Services.

The provider requests termination of services when the individual is no longer mentally alert enough to operate the equipment properly. Situations include, but are not limited to, when the individual:

• damages the equipment;
• disconnects the equipment and has previously received two warnings that are documented in the case record; or
• refuses to participate in the monthly systems checks.

The provider requests that the installer remove the equipment from the individual's home after the interdisciplinary team meeting and the case manager authorizes that services be terminated.

A provider may leave ERS equipment in an individual's home and continue services until the end of the month the service authorization expires. The provider receives payment for the month the service authorization ends, as long as:

• monitoring continues until the equipment is picked up; and
• the equipment is tested during the same calendar month or at the time of pickup.

The provider notifies the individual by telephone before discontinuing service, and follows up in writing to the individual and the case manager.

If the suspension results in case closure or termination of ERS, the case manager coordinates closure and the termination date with the provider to allow time for individual notification of the right to appeal.

 

5530 Equipment Removal

Revision 06-1; Effective April 10, 2006

 

The provider documents staff's inability to test the home unit in the individual's case file.

The individual is not liable for payment for lost or damaged equipment.

 

5600 Reauthorization

Revision 06-1; Effective April 10, 2006

 

The individual's situation is reassessed annually. You will be notified by the case manager when the individual is reassessed and if services are terminated.

Revision 15-2; Effective June 1, 2015

6100 Billing Requirements

Revision 06-1; Effective April 10, 2006

You are entitled to payment for services only if you:

• have prior approval for eligible individuals; and
• bill according to the Department of Aging and Disability (DADS) requirements.

You are liable for monetary exceptions if you:

• do not have prior approval from DADS and/or you do not have the documentation, that indicates services were provided;
• do not have documentation that you billed for services within the established time frames; and
• did not notify the case manager that you were having problems billing because the individual's service authorization was not entered or not entered correctly on the Service Authorization System (SAS).

6110 Rejections/Resubmittals

Revision 06-1; Effective April 10, 2006

If the department rejects a claim because of errors, you must research the errors and return the corrected claim to the Texas Medicaid and Healthcare Partnership (TMHP).

Address any questions about claim rejections or error(s) or both to TMHP. If TMHP is unable to provide assistance, you will be directed to your regional contract manager.

6120 Electronic Billing

Revision 15-2; Effective June 1, 2015

Texas Medicaid and Healthcare Partnership (TMHP) provides electronic software for submitting claims for payment free of charge.

The electronic billing system is:

• designed for data entry;
• designed for transmittal of a claim via modem line; and
• subject to the same system edits as the conventional paper billing.

To obtain information on the electronic billing systems, call TMHP at 1-800-626-4117, press 1, or write to:

Texas Medicaid and Healthcare Partnership
P.O. Box 200105
Austin, Texas 78720-0105

If you bill electronically, you are encouraged to bill twice a month from the:

• 1st to the 15th, and
• 16th to the end of the month.

6130 Status of Claim

Revision 15-2; Effective June 1, 2015

To ask about the status of your reimbursement claim, contact Texas Medicaid and Healthcare Partnership (TMHP). If TMHP is unable to provide assistance, you will be directed to your regional contract manager.

6140 Reimbursement Payments

Revision 06-1; Effective April 10, 2006

Reimbursement payments are made by warrant or direct deposit.

6141 Special Handling

Revision 06-1; Effective April 10, 2006

Special handling of payments is not allowed. Special handling includes sending payments by overnight express mail or making warrants available at DADS.

6142 Direct Deposit

Revision 06-1; Effective April 10, 2006

Reimbursement may be directly deposited to the bank of your choice. Information packets regarding direct deposit may be obtained by calling Claims Correction, Fiscal Management Services, at 512-438-4005.

6200 Record Documentation Requirements

Revision 06-1; Effective April 10, 2006

Documentation requirements can be found under Chapter 49, Contracting for Community Care Services, and Chapter 69, Contract Administration.

6210 Cost Reports

Revision 06-1; Effective April 10, 2006

Contract violation may result in the department withholding all payments until an acceptable cost report is submitted.

More information about cost reporting can be found at 1 Texas Administrative Code, Part 15, §§355.101-111.

6220 Duplication of Records

Revision 06-1; Effective April 10, 2006

The provider may request copies of missing service records from Department of Aging and Disability Services (DADS) staff. The provider reimburses DADS for the actual cost of reproduction. Reproduction cost includes the actual cost of staff time and equipment used and a minimal charge for each page reproduced. This service does not remove the provider's contractual obligation to maintain records.

Revision: 15-3; Effective: June 25, 2015

The Department of Aging and Disability Services (DADS) conducts monitoring reviews of program contracts it administers. Rules that apply to this section are found in 40 Texas Administrative Code, Chapter 49, Subchapter D, Division 2, Monitoring and Investigation of a Contractor.

See Appendix VII, DADS Contract Management, which includes a general overview of the contract monitoring protocol.

7100 Contract Monitoring Tools

Revision 15-3; Effective June 25, 2015

The Department of Aging and Disability Services Contract and Fiscal Compliance Monitoring Tools for the Emergency Response Program are:

• Form 3854, Contract/Program Compliance – Individual Record Evaluation (Emergency Response Services); and
• Form 3061, Emergency Response Services Financial Errors Standard.

A provider agency should direct questions about the tools or requests for additional assistance to its contract manager.

Revision 06-1; Effective April 10, 2006

 

8100 Provider Fraud and Abuse

Revision 06-1; Effective April 10, 2006

 

The Department of Aging and Disability Services (DADS) identifies, investigates and refers cases of suspected fraud or abuse of Medicare, Medicaid or social services programs.

When a provider commits fraud or abuse, DADS may take action against the provider, including:

• exclusion from program reimbursement;
• suspension from the program;
• referral to the Health and Human Services Commission (HHSC) for civil monetary penalties; and
• debarment from Medicaid programs.

DADS refers suspected fraud and abuse to Medicaid Program Integrity at HHSC.

 

8110 What is Provider Fraud?

Revision 06-1; Effective April 10, 2006

 

The Department of Aging and Disability Services (DADS) believes that people who provide services are entitled to the same protection under the law. However, when there is an indication of fraud, the allegations must be investigated.

Fraud is the intentional misstatement or concealment by the provider, which may result in a payment from DADS. Some examples of provider fraud are:

• practicing without a proper license or obtaining a license under false pretenses;
• billing for services that were not provided;
• billing for services provided by inappropriate persons;
• filing false claims;
• continuing inappropriate billing after provider education visits; and
• using improper billing practices.

 

8120 What is Abuse?

Revision 06-1; Effective April 10, 2006

 

Abuse is provider practices that are inconsistent with sound fiscal, business or medical practices.

These inconsistent practices result in unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of health care or standards required by contract, statute, regulation or interpretations of a statue or regulation sent to the provider.

Some examples of provider abuse are:

• providing services that are not medically necessary;
• billing for services provided by inappropriate persons;
• practicing without a proper license or obtaining a license under false pretenses; and
• violating the contract or provider agreement.

 

8130 Reporting Fraud and Abuse

Revision 06-1; Effective April 10, 2006

 

The Medical Provider Sanctions section, Department of State Health Services, has established a toll-free hotline for reporting suspected cases of Medicaid fraud and abuse. The number is 1-800-252-8263 and is available daily. Individuals who suspect fraud or abuse of assistance benefits, including eligibility and provider services, are urged to use this toll-free service.

Definitions of Program Terms

 

§52.101 — The following words and terms, when used in this manual, shall have the following meanings, unless the context clearly indicates otherwise:

A C D E F I M N P R S

Abuse — Willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical harm, pain, or mental anguish; or the willful deprivation by a caretaker or oneself of goods or services that are necessary to avoid physical harm, mental anguish, or mental illness.

Activated alarm call — A signal transmitted from the individual's home unit to the response center indicating that the individual needs immediate assistance.

Adult — A person 18 years or older.

Aged or Elderly Person — A person age 65 or older.

Assignee — A legal entity that plans to take over a current emergency response contract through a legal assignment of the contract from another legal entity.

Assignor — A legal entity that plans to assign its current emergency response contract to another legal entity through a legal assignment of the contract.

A C D E F I M N P R S

Call button — An electronic device that, when pressed, triggers an alarm to the response center to alert the provider agency that the individual needs immediate assistance. The device may be held in the hand, worn around the neck, hung on a garment, or kept within the individual's reach.

Contractor — The provider agency.

A C D E F I M N P R S

[DADS — Department of Aging and Disability Services. Formerly the Texas Department of Human Services (DHS).]

Days — All are calendar days not workdays, unless otherwise noted in the text.

Department — The Texas Department of Aging and Disability Services.

Disabled person — A person who, because of physical, mental, or developmental impairment, is limited in his capacity to adequately perform one or more essential activities of daily living. Activities of daily living include, but are not limited to, personal and health care, mobility, communication, and money management.

A C D E F I M N P R S

Exploitation — The illegal or improper act or process of a caretaker or others using the resources of an adult for monetary or personal benefit, profit, or gain.

A C D E F I M N P R S

Fraud — A deliberate misrepresentation or intentional concealment of information to receive or to be reimbursed for services to which a person is not entitled.

A C D E F I M N P R S

Income eligible — An adult, who is not an SSI or AFDC individual, but who has income and resources equal to or less than the eligibility level established by the department.

Individual — A person who the case manager determines is eligible for emergency response services.

Installer — A volunteer, subcontractor, or an employee of the provider agency who connects the emergency response equipment in the individual's home.

Institution — A nursing home, personal care facility, state supported living center, or state hospital.

A C D E F I M N P R S

Medicaid Eligible — A person eligible for Medicaid as an SSI or AFDC individual or eligible for Medical Assistance Only while living in the community.

Monitor — A volunteer, subcontractor, or an employee of the provider agency who monitors services 24 hours a day, seven days a week and ensures that alarm calls are responded to immediately.

A C D E F I M N P R S

Neglect — The failure to provide for one's self the goods or services which are necessary to avoid physical harm, mental anguish, or mental illness or the failure of a caretaker to provide the goods or services.

A C D E F I M N P R S

Provider agency — The legal entity that has a contract with the department to deliver emergency response services to eligible individuals.

A C D E F I M N P R S

Responder — Any person(s) who responds to an emergency call activated by an individual. Responders may include a relative, neighbor, volunteer, or staff of a sheriff's department, police department, emergency medical service, or fire department.

Response center — The site where the emergency response base station equipment is located and monitored.

A C D E F I M N P R S

Subcontractor — An organization or individual who delivers a component of the emergency response service for the provider agency for a fee and is not an employee or volunteer of the provider agency.

Revision Number: 04-1
Effective date: September 1, 2004

 

ES = Spanish version available.

Form	Title
2059	Summary of Client's Need for Service
2060	Needs Assessment Questionnaire and Task/Hour Guide
2067	Case Information
2101	Authorization for Community Care Services
2110	Community Care Intake
3061	Emergency Response Services Financial Errors Standard
3854	Contract/Program Compliance -- Individual Record Evaluation (Emergency Response Services)

 

For technical or accessibility issues with this handbook, please email: form.handbook.request@hhs.texas.gov

For questions about the Emergency Response Services Provider Manual, email: erspolicy@hhsc.state.tx.us