School Based Administrative Claiming

Title 23: Medicaid

Administrative Code Title 23: Medicaid Part 301 School Based Administrative Claiming

Table of Contents Table of Contents Title 23: Division of Medicaid....................................................................................................... 1 Part 301: School Based Administrative Claiming .......................................................................... 1 Part 301 Chapter 1: School Based Administrative Claiming ..................................................... 1 Rule 1.1: Purpose ................................................................................................................ 1 Rule 1.2: Provider Qualifications ....................................................................................... 1 Rule 1.3: Quality Assurance & Monitoring Plan ................................................................ 2 Rule 1.4: Reimbursement.................................................................................................... 5

Title 23: Division of Medicaid Part 301: School Based Administrative Claiming Part 301 Chapter 1: School Based Administrative Claiming Rule 1.1: Purpose A. The Division of Medicaid, the Mississippi Department of Education (MDE) and individual schools share in the responsibility for promoting access to healthcare for students in the public school system, preventing costly or long term healthcare problems for at-risk students, and coordinating student’s healthcare needs with other providers. B. The Medicaid School-Based Administrative Claiming program (SBAC) allows school districts to be reimbursed for some of their costs associated with school-based health and outreach activities which are not claimable under the Medicaid School Health-Related Services “fee for service” program or under other Medicaid “fee for service” programs. In general, the types of school-based health and outreach activities funded under SBAC are the referral of students/families for Medicaid eligibility determinations, the provision of health care information and referral, coordination and monitoring of health services and interagency coordination. These activities include: 1. Medicaid Outreach, 2. Facilitating application for Medicaid and eligibility determination, 3. Transportation-related activities in support of Medicaid covered services, 4. Medicaid related Translation services, 5. Program planning, policy development and interagency coordination related to medical services, 6. Medicaid specific training, and 7. Referral, coordination and monitoring of Medicaid services. Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; 42 CFR 430.1 and 42 CFR 431.15; OMB Circular A-87 Rule 1.2: Provider Qualifications State school districts that participate in the School Based Administrative Claiming (SBAC) program must meet the following requirements: A. Have a signed agreement with the Mississippi Department of Education (MDE), 1

B. Attend staff training conducted by MDE, C. Keep time studies of work activities via computer generated electronic documentation, D. Determine statistically valid time sample results, E. Prepare cost determinations and allocations, F. Prepare and submit to MDE a quarterly invoice, and G. Follow the yearly calendar published by MDE. Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; .1 and .15; OMB Circular A-87 Rule 1.3: Quality Assurance & Monitoring Plan A. The Division of Medicaid will establish and maintain a quality assurance process which ensures the quality management of the program. It is necessary to monitor the SBAC program in order to assure that Medicaid dollars are utilized to make Administrative Claiming available to eligible Mississippi Public School Districts enrolled in the SBAC program. B. Mississippi Department of Education (MDE) Oversight and Monitoring 1. MDE will implement and provide oversight and monitoring actions to ensure that school districts are in compliance with SBAC requirements. At a minimum, these actions are to ensure that: a) The time study is performed correctly, b) The time study results are valid, c) The financial data submitted is true and correct, d) Training requirements are met, and e) Appropriate documentation is maintained to support the time study and invoices. C. Division of Medicaid Oversight and Monitoring 1. Validation of the program will include the Division of Medicaid performing the following actions quarterly: a) Randomly select ten (10) percent of the sampled responses, 2

b) Review the sampled responses and independently code the activities of the ten (10) percent selected, and c) Validate the accuracy of the original coder. 2. Documentation must be readily accessible and available to the Division of Medicaid or CMS. The MDE agrees to share data as a apart of the quality assurance program timely upon request by the Division of Medicaid. The MDE will make available to the Division of Medicaid the documentation/records/reports maintained for the SBAC program. 3. The Division of Medicaid areas of review include: a) The time study – sampling methodology, the sample, and time study results, b) Compliance with training requirements, c) Financial reviews, and d) Documentation compliance. 4. The school districts will make available to the Division of Medicaid the documentation/records/reports maintained from the SBAC program. 5. These documentation/records/reports include, but are not limited to: a) Random Moment Sampling (RMS) documents, b) Methodology that supports the construction of the Administrative Claiming billing process, c) Revenue projection reports, and d) School district quarterly reports. 6. The school districts must submit copies of the time logs for each participating school in the area to MDE. 7. The Division of Medicaid will verify a small percentage of time logs quarterly to ensure accuracy. Verification will be through direct face-to-face contact with the sampled participants. 8. Each quarter the Division of Medicaid will audit the following: a) A percentage of the time logs of the sampled school staff to ascertain if the sampled participants understood the instructions on sampling time forms, and 3

b) Verify that the time study form turned in was completed by the individual who signed the form and that he/she accurately reported his/her activity at the time he/she was sampled, to the best of his/her knowledge. D. Monitoring Objectives: Monitors from various organizations review the Administrative Claiming program documents and provide performance standards to validate whether or not the providers and/or Administrative Claiming program have: 1. Complied with federal and state laws, regulations and policies, 2. Complied with the terms of the Administrative Claiming Guide agreement, 3. Billed the Division of Medicaid for those services that were authorized and actually delivered in compliance with the Administrative Claiming Guide, and 4. Provided a service which produced an effective and cost effective outcome for beneficiaries and the Medicaid program. E. Desk Reviews: Periodically the Division of Medicaid staff may conduct desk reviews of Administrative Claiming services. These desk reviews include, but are not limited to, the analysis of required documentation and various reports. F. On-Site Visits: The on-site visits will be scheduled periodically to be conducted by Medicaid Administrative Claiming staff. During on-site visits, required records and documents will be reviewed for consistency with claims submitted and with applicable program requirements. G. Cooperation Required of the Provider During Monitoring Activities 1. The school districts must cooperate fully with monitoring activities, evaluations or other reporting requirements authorized by the Division of Medicaid. Records and supporting information must be made available as required for any authorized monitoring activities. 2. The school districts’ Administrative Claiming Coordinator or authorized representatives must cooperate fully with monitoring activities, evaluations or other reporting requirements authorized by the Division of Medicaid. Records and supporting information must be made available as required for any authorized monitoring activities. He/she must also be available to answer questions during the monitoring review and to receive the results of the review. H. Findings from Monitoring Reviews 1. The Division of Medicaid staff that conducts the monitoring review will prepare a report of monitoring activity. A copy of the report will be forwarded to the school district with a request, when appropriate, for a response to be submitted to the Division of Medicaid within thirty (30) days after the receipt of the report. The response should include a plan 4

of correction, as necessary, which addresses any deficiencies noted in the monitoring report. 2. The staff of the Division of Medicaid will review the response and contact the reviewer within thirty (30) days of the receipt of the response regarding the acceptance of the response and approval of the plan of correction. 3. The school district will be notified in writing by the Division of Medicaid of any administrative noncompliance with provider agreement terms or applicable regulations. 4. If items of noncompliance are not corrected, the Division of Medicaid may take appropriate actions to ensure correction by the school district of noted problem(s), or the Division of Medicaid may terminate the provider’s participation in the Medicaid Administrative Claiming program. 5. Erroneous overpayments to providers are subject to restitution. The provider is entitled to notification by the Division of Medicaid of the erroneous payment(s). If the provider has been overpaid, he/she will be contacted regarding the repayment schedule. I. Technical Assistance Provided by Medicaid 1. Medicaid staff is available to provide technical assistance to the Administrative Claiming provider and SBAC districts in resolving any contractual or performance problems. However, technical assistance visits by the Division of Medicaid staff are not comprehensive reviews of the services under the terms of contracts or provider agreements for services. If deficiencies are not identified during the provision of technical assistance, the provider is still responsible for audit exceptions and correcting any other contractual or performance problems noted during monitoring activities. 2. The Division of Medicaid is not liable for acts or omissions of the Administrative Claiming provider, contracted providers, school districts or their employees. The provider should seek their own legal counsel regarding questions of liability. J. All records pertaining to the Administrative Claiming program must be maintained for a period of five (5) years after each quarterly claim is filed with the Division of Medicaid, unless an ongoing audit or resolution of an audit exception is in process which requires that the records be maintained until the audit is resolved. Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; .1 and .15; OMB Circular A-87 Rule 1.4: Reimbursement Reimbursement under the SBAC program is paid from those invoices filed during the quarter directly following the quarter of billing, for reported allowable reimbursable activities, in accordance with the Mississippi School Based Administrative Claiming Guide (as approved by 5

CMS), following applicable federal and state rules and regulations. However, it is imperative that claims for all allowable reimbursable activities be documented. The school district will be responsible for any refund due to an audit exception or denial considered appropriate by CMS or the Division of Medicaid. In the event of determination by federal authorities of non-compliance with federal regulations and standards, the school district will be liable to the Division of Medicaid in full for all penalties, sanctions and disallowances assessed against the Division of Medicaid. Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; .1 and .15; OMB Circular A-87

6