Arizona Medicaid School Based Claiming
Regional Information Sessions
September 2009
September 2009
 Arizona Project Team
 General Updates
 Monthly DSC & MAC Trainings
 Coordinator Responsibilities
 Timely Filing
 Health Aides
 Speech Language Pathology Assistant (SLPA)
 Audits
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September 2009
Arizona Project Team
Florie Wong, Project Manager
Lisa Pavelek, Deputy Project Manager
Chris Meola, DSC Program Lead
Marilyn Caylor, DSC Coordinator
Jasmina Tarver, Sr. Auditor
LEA Account Managers:
Cindi Carter
Kristy Ferguson
Lisa Gutierrez
Jamey Harrison
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September 2009
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General Updates
 Coming Soon – Updated Program Handbooks
 Updated DSC and MAC Handbooks will be available on PCG website
 Coming Soon! EFT Option for DSC and MAC Checks
 LEAs can opt to have their DSC and MAC checks deposited directly to their bank
 LEAs will need to submit an EFT authorization form
 Paper checks will still be available
September 2009
Monthly DSC & MAC Trainings
 Understanding the process and
requirements for both the DSC and MAC
program is vital to your success!
 Monthly trainings will be provided via
 LEAs can attend each month and are
designed to assist LEAs with new
 DSC training topics will include:
 Services eligible for reimbursement
 How to register Providers and LEAs
 How to read a remittance advice (RA)
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September 2009
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Monthly DSC & MAC Trainings
 MAC training topics will include:
 RMTS Online System
 Staff Roster
 Electronic RMTS Forms
 Benefits of utilizing the Electronic RMTS
 Training schedule will be posted to the
project website
September 2009
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Coordinator Responsibilities - DSC
 Coordinate Qualified Medical/Service Providers
 Ensure Medical Providers are correctly licensed/certified
 Assist new Providers with obtaining individual NPI & registering with AHCCCS
and verify that Providers are linked to LEA and can submit claims
 Keep AHCCCS (Provider Registration) updated on provider changes
 Establish Internal Policies
 Create billing forms/service records and clinical notes forms
 Establish process for completing and submitting forms (by providers)
 Provide Training
 Provide DSC Program training, information, & requirements to Medical
Providers, health aides, bus drivers, SPED teachers and support staff.
 Train Medical Providers on billing forms/service records and clinical notes and
how/when to submit them
September 2009
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Coordinator Responsibilities - DSC
 Identify Eligible SPED Students
 Determine if SPED Students have reimbursable Medical Services prescribed in
their IEP, then verify that they are enrolled in AHCCCS
 Submit DSC Claims
 Review remittance advice after claims are processed
 Establish TPL policy, if needed
 Work with Finance Department
 Ensure payments are processed timely and Certification of Match Forms are
completed and submitted to PCG
 Maintain Audit Records, Files, & Documentation for a minimum of 5
 Participate In/Coordinate Compliance Audits & Reviews
 Work with Assigned PCG Account Manager
September 2009
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Coordinator Responsibilities - MAC
 Identify the staff in your LEA that routinely perform Medicaid
Administrative and Outreach Activities.
 Prepare and submit Staff Rosters electronically using the RMTS system
on a quarterly basis and Position Classification Forms (PCFs) annually.
 Distribute training materials to the participants prior to completing the
on-line training.
 Monitor employees’ participation - LEA Compliance
 Review the RMTS Compliance Report weekly and conduct follow-up
September 2009
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Coordinator Responsibilities - MAC
 Coordinate with the LEAs finance personnel to ensure that the cost
information of the RMTS selected staff is included.
 Submit the District Wide Student Rosters on a semi-annual basis to
PCG along with the Certification of Student Roster Form in order to
determine the Medicaid Eligibility Rate (MER).
 Maintain program Audit files for a period of no less than 5 years after
the end of a participating quarter.
 Work with your assigned PCG LEA Account Manager throughout the
quarter for assistance and success in the MAC Program!
September 2009
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DSC – Timely Filing
 Claiming Time Limits – Initial Claims, Re-Bills, and TPL
 Regardless of the LEA’s billing method, all claims must be received in a timely
manner at PCG in order to be considered for payment.
 If the LEA is a self biller, or uses a biller who bills electronically, “received”
indicates the date the file is confirmed by PCG for a direct-post submitter.
 An initial claim must be received by PCG no later than 6 months from the date
of service.
 Claims received beyond the 6-month time frame will be denied.
 A denied claim can be resubmitted (ReBilled) for up to 12 months from the date
of service.
 TPL claims for students must be submitted
with supporting documentation to PCG
within 6 months of the date of service.
September 2009
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DSC- Health Aides
 If a student is prescribed more than 2 hours (8 units) of Health Aide
services in their IEP, then the LEA must submit a request to PCG for
approval prior to billing more than 8 units.
 Health Aide services must be identified in the IEP.
 Scope, frequency, and duration must be clearly addressed and written in the IEP
as prescribed by a qualified provider through the appropriate IEP documentation
and supporting medical records.
 Request should specify amount of time or additional units being sought for
 Only time/units associated with allowable activities of daily living (ADLs) will be
 PCG will deny requests for additional units that are provided in a range. e.g. 4 – 6
hours per day.
 Regardless of the number of units billed, LEAs must have proper
documentation in place to support claim.
September 2009
DSC- Health Aides
 Health Aide Results
 Total IEP’s Reviewed – 117
 Total IEP’s Approved – 52
 Total IEP’s Denied – 62
 Denial Reasons
 31 - no supporting documentation on IEP, (Scope, Frequency & Duration)
 12 - documentation less than 2 hours of Health Aides services
 12 - requested services for reinforcement of therapy goals
 3 - educational services
 2 - no supporting documentation to justify 2 hours of HA services
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September 2009
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DSC- Health Aides
 Preventing Billing Errors:
 Only time spent actually providing a covered medical service may be billed. A
health Aide may not log, record or bill more hours than the time worked in a
day, regardless of the number of children in the classroom.
 Verify that the service log matches the items in the related services section of the
 Verify that the service is within the “Scope of Practice” of the Health Aide. For
example, a health aide providing catheter care or tube feedings is not working
within their “Scope of Practice” when billing for Medicaid services.
 If you are unclear if a service may be billed by a Health Aide, please contact
your PCG Account Manager.
Please see the PCG website for guidance for Health Aide Documentation,
September 2009
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DSC- Health Aides
 Example of Health Aide Language on a IEP
 An Aide will meet Johnny’s personal care needs by assisting Johnny daily for one
hour to help with ADLs including mobility, transfers, and positioning throughout
the duration of the IEP.
 Example of HA Language on a IEP Exceeding 8 units (120 min)/Day
 An Aide will assist Sally with Eating/Feeding for one hour daily.
 An Aide will assist Sally with grooming for 15 minutes daily.
 An Aide will assist Sally with dressing for 15 minutes daily.
 An Aide will assist Sally with toileting for one hour daily.
 An Aide will assist Sally with transfers, positioning, and mobility for one hour
Note: Each ADL is clearly separated by ADL and time.
September 2009
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Speech Language Pathology Assistant (SLPA) Update
 AHCCCS is reviewing current policies regarding future SLPA services &
 SLPAs must have proper credentials to be reimbursed (See AZ DOHS website for
information on licensing requirements)
 SLPA will be required to keep proper documentation according to license
 LEA Reminders
 LEAs cannot claim for SLPAs that do not have proper licensing AND supervision
 SLPAs cannot write progress notes (must be done by supervising SLP)
September 2009
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MAC - Background
 CMS has recently increased scrutiny of the MAC program nationally.
 CMS had identified areas of concern and has required States to
update their MAC Claiming Methodologies.
 Per CMS request, Arizona submitted a proposed Claiming
Methodology in June of 2009 that reflected modifications requested
by CMS.
 AHCCCS and PCG has communicated these changes through memos
and the newsletter.
September 2009
MAC- Significant Impact to LEAs
 Increased RMTS Sample Size
 Going Electronic – No More Paper
 Return Rate Compliance
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September 2009
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MAC- Increased RMTS Sample Size continued…
 CMS requires an increased sample size to better capture the
percentage of time spent doing outreach and administration activities.
 Effective with the 4th quarter of 2009 (October – December) the
number of moments will increase from 1,200 to 6,000
 Two cost pools each containing 3,000 sampled moments – 6,000
sampled moments per quarter statewide.
 Why two sample pools?
 To ensure the participant’s costs are either associated with Direct Medical
Services and the related Administrative /Outreach Activities or the
Administrative /Outreach Activities.
September 2009
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MAC- Increased RMTS Sample Size continued…
 The staff roster is separated into two different cost pools based on the
participant’s job title.
 1 - Direct Service Cost Pool
 2 - Administrative Personnel Cost Pool
September 2009
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MAC- Electronic – No Paper
 Beginning with the October – December 2009 quarter there will no
longer be an option to receive paper RMTS forms. All moments must
be completed electronically.
 LEAs may elect to still have participants receive notification of their
selected moments on paper.
NOTE: As a special note to the LEA MAC Coordinators, paper
notification cannot be provided to the participant more than five days
prior to the moment. Therefore, LEAs choosing to continue with paper
notification for some or all of their participants will need to have a
process in place to track and distribute moments within the appropriate
timeframes for each participant.
September 2009
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MAC- Electronic – No Paper continued…
 If a LEA elects to have participants receive a paper notification of a
participant(s) selected moment(s), a written request from the MAC
Coordinator sent via e-mail to your PCG Account Manager will be
required. In addition:
LEAs will need to create internal procedures for handling paper notifications.
LEA will need to create a tracking file.
Paper notifications cannot be provided to the participant more than 5 days prior to
the moment.
Documents when the paper notifications were provided to each
Internal procedures and tracking files will be subject to audit and therefore must
adhere to the record retention guidelines for the Program.
September 2009
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MAC- Electronic – No Paper continued…
 Benefits of utilizing the Electronic RMTS System.
Built in compliance for electronic moment notifications, participant training and
information required to complete moment.
Participant specific log-in is unique and records ‘signature and date’ when a
moment is completed.
 System generated reports are available to assist the MAC Coordinator
in managing the MAC Program.
Individual Master Sample File – list of current LEA moments
Compliance Report – status of past and current LEA moments
 Reduces clerical activities for the MAC Coordinator.
No longer need training sign-in sheets, scheduling training sessions, and
making/mailing copies of paper forms.
September 2009
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MAC- Electronic – RMTS Forms
 All sampled moments must be completed on-line by the participant
within 5 days from the moment in time.
Forms not completed within 5 days are considered non-responsive and can
affect reimbursement for all LEAs as well as the LEA’s ability to participate in the
 No paper forms will be provided. For replacements contact your
assigned Account Manager prior to the sampled moment.
 PCG will continue to provide a Moment List (Control List) prior to the
start of the quarter. The MAC Coordinator cannot provide the
moment notification to the participant more than 5 days in advance.
September 2009
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MAC- Electronic – Staff Rosters
 Q4-09 staff rosters will be updated in the RMTS System.
 A certification process is required to submit the staff roster.
 1 - Direct Service Cost Pool
 2 - Administrative Personnel Cost Pool
 The process for submitting annual Position Classification Forms will remain the
September 2009
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MAC- Electronic – Staff Rosters
Use of Vacant Positions
 Vacant Positions will no longer be allowed on the Staff Roster effective
 Based on PCG monitoring sampled Vacant Positions, it was found that
the majority of Vacant Positions were never filled and/or carried over
to subsequent Staff Rosters.
 Due to the increase of the RMTS sample size, the number of Vacant
Positions being sampled will increase. This could have a detrimental
impact on the RMTS results percentage, which can result in a an
invalid sample.
September 2009
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MAC- Electronic – Participant Training Changes
 Participant training will no longer be conducted annually by the MAC
 Participant training will be completed by the participant electronically
when they log on to complete the RMTS form in the RMTS system.
 MAC Coordinators will no longer have
to maintain training sign-in sheets.
 Instead MAC Coordinators will be
responsible for distributing to
participants training material from PCG
that explains how to access and use the
RMTS system.
September 2009
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MAC- Return Rate Compliance
 With the enhanced sampling methodology, compliance is critical for
all participating LEAs! LEAs must be proactive with program
 LEAs should strive for 100% compliance and complete all moments
selected for participants in their district or charter. CMS requires a
minimum 85% compliance rate.
 Time study results are applied to all LEAs in a State-Wide
methodology. A reduction in the percentage of time spent on
reimbursable activities, will adversely affect the reimbursement of all
participating LEAs.
Every Moment Counts!
September 2009
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MAC- Return Rate Compliance continued...
 MAC Coordinators must monitor employee participation in completing
electronic RMTS forms.
All MAC Coordinators have access to the RMTS Compliance Report.
 In an effort to assist LEAs with monitoring compliance, PCG will be
sending a weekly Statewide RMTS Compliance Report.
 Due to more stringent oversight of the program, LEAs should expect
that penalties will result for failure to comply. PCG is currently
reaching out to LEAs who do not meet the 85% compliance rate.
Every Moment Counts!
September 2009
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MAC- Coordinator Validation Process
 The Validation process completed by MAC Coordinators will be
eliminated effective with the 4th quarter of 2009 (October –
 MAC Coordinators will no longer have to contact the participant to
validate the RMTS form.
 The MAC Coordinator will no longer have to complete the Validation
September 2009
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Program Audits
Enhancing the process to improve results!
September 2009
Compliance Review Audits
 PCG will resume the Compliance
Review Audits in keeping with our
contract with AHCCCS starting
Q4-09 (October – December).
 Compliance Review Audits and
Re-Audits were rescheduled until
sufficient claims were paid under
the PCG submitter ID at
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September 2009
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Compliance Review Audits
 LEAs chosen for an audit will be notified approximately thirty days before
the audit date to allow for preparation of required documentation.
 The audit time frame will be
2008/2009 school year for DSC
 The audit time frame for MAC
will be the last paid claim under
 PCG will not be utilizing
contractors or subcontractors.
September 2009
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Audit Process
 LEA Notification
 LEAs are contacted regarding the date of their on-site review
 Engagement letter
 Compliance Review Tool
 Student Files
 Entrance Meeting - The audit team explains the review process and answers
any questions
 File Review - All files will be reviewed according to the Compliance Review Tools
 Exit Meeting
Scheduled at the conclusion of the On-site Compliance Review
Exit Report- provides the LEA with areas of compliance and noncompliance
September 2009
Audit Process
 Components of the CAP
 Area of Non-Compliance (PCG)
 Strategy for Correction (Provided by the
 Person (s) Responsible & Timeline
(Provided by the LEA)
 Verification Data (Provided by the LEA)
 Annual Progress Report (PCG)
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September 2009
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Potential Participation Impact
 All participating LEA’s are scheduled for a Compliance Review Audit
every (3) years
 The LEA must achieve a 90% compliance rating in ALL the components that are
reviewed to be considered compliant.
 Components under the 90% compliance rate will require a CAP approved by
PCG and the LEA will be re-audited within 3-6 months for the components that
failed the initial audit.
 If the results of the focused Re-Audit are not above 90% compliance, the LEA is
scheduled for a Full 1 Year Compliance Review Audit.
 If any components of the 1 Year Review Audit are below 90%, the LEA is subject
to sanctions including temporary or permanent suspension of claiming.
September 2009
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Potential Participation Impact
 Compliance Rates
 Review of prior audits indicates LEAs are failing to come into compliance and
follow the approved CAP after an audit
 Impact for LEA’s
 AHCCCS is developing sanctions for continued non-compliance with program
 If any components of the 1 Year Review Audit are below 90%, the LEA is subject
to sanctions which may include temporary or permanent suspension of claiming
and participation in the MAC program
September 2009
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Audits Continued
 Reminder
 Participating LEAs must comply with record keeping requirements and must
maintain documentation for a period of five (5) years from the date a claim has
been paid.
 The LEA may be required to maintain documentation longer if information is
related to a time period undergoing a State or Federal Audit.
 Just because we do not audit a document, you still need to know the rules and
be compliant with the requirements of the DSC and MAC Claiming Program!
September 2009
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September 2009
Thank you for joining us have a wonderful day!
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