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:

  • professional therapies, which consist of the following subcomponents:
    • physical therapy,
    • occupational therapy,
    • speech and language pathology,
    • audiology,
    • social work,
    • behavioral support,
    • dietary services, and
    • cognitive rehabilitation therapy;
  • day habilitation;
  • registered nursing;
  • licensed vocational nursing;
  • specialized registered nursing;
  • specialized licensed vocational nursing;
  • residential assistance, which consists of the following subcomponents:
    • host home/companion care,
    • residential support,
    • supervised living, and
    • supported home living (transportation);
  • respite;
  • employment assistance; and
  • supported employment.

 

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:

  • be for a service component or subcomponent that is authorized by an IPC that meets the requirements of 40 TAC §9.159;
  • be for an HCS service component or subcomponent identified in an individual's PDP that is provided in accordance with the individual's implementation plan, as required by 40 TAC §9.158(r);
  • be for a service component or subcomponent provided during a period of time for which the individual has an LOC;
  • be based on the LON that is authorized by an ID/RC assessment that meets the requirements of 40 TAC §9.163;
  • be based on billable activity, as described in Section 4000, Specific Requirements for Service Components Based on Billable Activity, for the particular service component or subcomponent being claimed;
  • not be based on activity that is not billable, as described in Section 3300, Activity Not Billable, and in Section 4000 for the particular service component or subcomponent being claimed;
  • must be based on activity performed by a qualified service provider as described in Section 3400, Qualified Service Provider, and in Section 4000 for the particular service component or subcomponent being claimed;
  • be for a service component or subcomponent provided to only one individual;
  • be for a service component or subcomponent provided on only one date;
  • be for the date the service component or subcomponent was actually provided;
  • be for units of service determined in accordance with Section 3600, Calculating Units of Service for Service Claim;
  • be supported by written documentation, as described in Section 3800, Written Documentation, and in Section 4000 for the particular service component or subcomponent being claimed; and
  • be a clean claim and be submitted to the state Medicaid claims administrator no later than 12 months after the last day of the month in which the service component was provided.

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:

  • traveling by a service provider if the service provider is not accompanied by an individual;
  • documenting the delivery of a service component (for example, writing written narratives, completing forms and entering data);
  • reviewing an individual’s written record, except as allowed by Section 4220, Billable Activity; Section 4420, Billable Activity; Section 4471.2, Billable Activity; Section 4472.2, Billable Activity; and Section 4473.2, Billable Activity;
  • drafting an implementation plan;
  • performing an activity regarding a staff member’s employment or contractor’s association with the program provider (for example, attending conferences and participating in the performance evaluation of a staff member or contractor); and
  • performing an activity regarding the preparation, submission, correction or verification of service claims.

 

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:

  • be an adult;
  • be a staff member or contractor of the program provider;
  • be paid by the program provider to provide the particular service component or subcomponent being claimed;
  • not be disqualified by this section to provide the particular service component or subcomponent being claimed;
  • meet the minimum provider qualifications described in Section 4000 for the particular service component or subcomponent being claimed;
  • not have been convicted of an offense listed under §250.006 of the Texas Health and Safety Code; and
  • not be designated in either the Employee Misconduct Registry or the Nurse Aid Registry maintained by DADS as having abused, neglected or exploited a person or misappropriated a person's property.

 

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:

  • a relative of the individual (Appendix II, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these guidelines);
  • the individual’s guardian; or
  • the individual’s managing conservator.
  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:

  • the minor’s parent;
  • the spouse of the minor’s parent; or
  • a person contracting with DFPS to provide residential child care to the minor, or is an employee or contractor of such a person.
  1. Contractor Not Qualified as Service Provider for an Adult Individual

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

  • a service component or subcomponent if the service provider is a person contracting with DFPS to provide residential child care to the individual, or is an employee or contractor of such a person; or
  • host home/companion care if the service provider is a person contracting with DADS to provide adult host home care to the individual, or is an employee or contractor of such a person.

 

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:

  • audiology services;
  • dietary services;
  • occupational therapy;
  • physical therapy;
  • behavioral support services;
  • social work services;
  • speech and language pathology services;
  • cognitive rehabilitation therapy;
  • registered nursing;
  • licensed vocational nursing;
  • specialized registered nursing;
  • specialized licensed vocational nursing;
  • respite;
  • supported employment;
  • employment assistance; and
  • transportation as a supported home living activity.

     

    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:

    • day habilitation;
    • host home/companion care;
    • residential support; and
    • supervised living.

     

    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:

    • is a discrete period of continuous time during which billable activity for one service component is performed by one service provider;
    • consists of one or more billable activities; and
    • ends when the service provider stops performing billable activity or performs billable activity for a different service component.

    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:

      • the professional therapies activity is an assessment or observation of the individual; and
      • the assessment or observation is actually occurring at the same time the other service component or subcomponent is being provided.

      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:

      • the name of the individual who was provided the service component or subcomponent;
      • the day, month and year the service component or subcomponent was provided;
      • the service component or subcomponent that was provided; and
      • a written service log, as described in Section 3820, Written Service Log and Written Summary Log, for each individual in accordance with the following:
        • for professional therapies, residential support, supervised living, respite, employment assistance and supported employment, a written service log written by a service provider who delivered the service component or subcomponent; and
        • for host home/companion care and day habilitation, a written service log or a written summary log by a service provider who delivered the service component or subcomponent.
      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:

      • be written after the service is provided;
      • for service components or subcomponents with a 15-minute unit of service, as listed in Section 3510, 15-Minute Unit of Service, include:
        • a description or list 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 for the particular service component or subcomponent being claimed; and
        • 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;
      • 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 written service log or implementation plan of why a billable activity took more time than typically required to complete;
      • for service components or subcomponents with a daily unit of service, as listed in Section 3520, Daily Unit of Service, include:
        • a description or list of activities performed by the service provider and the individual that evidences the performance of the billable activities described in Section 4000 for the particular service component or subcomponent being claimed; or
        • for host home/companion care, residential support and supervised living, if the individual was not available to receive services, an explanation for the unavailability;
      • be made within reasonable time after the activity being documented is provided; and
      • include the signature and title of the service provider making the written service log.
      1. Written Summary Log

      A written summary log must:

      • be written after services have been provided;
      • include information that identifies the individual for whom the written summary log is made;
      • include a general description or list of activities performed during the calendar week in which the service component or subcomponent was provided;
      • be made within a reasonable time after the week being documented; and
      • include the signature and title of the service provider making the written summary log.
      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:

      • ditto marks;
      • references to other written service logs or written summary logs using words or symbols;
      • 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 completed or partially completed written service logs or written summary logs; and
      • a medication 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:

      • to prove the age of a service provider, a government issued document, such as a driver’s license or birth certificate;
      • to prove the level of education of a service provider:
        • a written document from an educational institution, such as a diploma; or
        • a high school equivalency certificate issued in accordance with the law of the issuing state;
      • to prove the job experience of a service provider, a written record of where the job experience was obtained;
      • to prove competency to perform services:
        • a successfully completed written competency-based assessment demonstrating the ability to provide the applicable service and document the provision of such service as required by the HCS Program Billing Guidelines; and
        • written personal references which evidence the service provider’s ability to provide a safe and healthy environment for the individual from at least three persons who are not relatives of the service provider (Appendix II, Degree of Consanguinity or Affinity, explains who is considered a “relative” for purposes of these billing guidelines); and
      • to prove that a service provider is properly licensed, a written document from the appropriate state licensing agency or board.

       

      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:

      • a driver’s license or other government issued photo identification of the service provider;
      • a voter’s registration card of the service provider;
      • a lease agreement for the time period in question with the name of the service provider as the lessee or an occupant; or
      • a utility bill for the time period in question in the name of the service provider.
      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.