CHAPTER 1000 BASIS FOR REIMBURSEMENT

1001. General
Reimbursement for COMP services is made by the Division of Medicaid to providers who have completed the enrollment process and rendered services to eligible participants with a current level of care and valid prior authorization subsequent to the screening and assessment by the Intake and Evaluation Team. Reimbursement is made only for services contained in the Individual Service Plan and authorized by the Regional DBHDD Office (See Appendix A). Failure to adhere to any provision of the COMP Program will require that the provider repay all funds collected for services, including funds collected for services for which required documentation was not prepared and completed. In addition, if a provider is judged to have provided inadequate justification for services rendered, the Department will review all relevant documentation before authorizing payments.
1002. Reimbursement Methodology
The rates for COMP services are prospective rates based on historical costs where available, and based on State Plan costs for comparable services for new services where historical cost was not available.
In extraordinary circumstances related to transition of an individual from an institution or imminent risk of institutionalization of an individual, providers may request:
(1) the payment of a rate that exceeds the established maximum rate for the following COMP services:
 Community Residential Alternative Services
 Community Living Support Services
 Community Access Group Services
 Respite Overnight Services
(2) the approval of units that exceed the maximum allowable units for the following COMP services:
 Specialized Medical Supplies
 Specialized Medical Equipment
Exceptional rate approval or approval to exceed the maximum allowable units is tied to the assessment of individual needs of the participant as documented in the Intake and Evaluation approved Individual Service Plan (ISP). The Interdisciplinary Team must approve the need for an exceptional rate or exceeding the maximum allowable units, as
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documented in the ISP (see Appendix H for required documentation for consideration of an exceptional rate and the protocol for review of exceptional rate requests). Exceptional rate requests and requests to exceed the maximum allowable units are subject to the DBHDD approval with notification of approval to the Department. Exceptional rates are approved according to established tier rates, but in no instance, will an exceptional rate be approved that exceeds the actual provider costs to provide services. The DBHDD review of exceptional rate requests include consideration of the configuration of residential setting that is most cost effective for the State.
Providers must be authorized by the DBHDD Regional Office and the Division of Developmental Disabilities to receive exceptional rates beyond the Medicaid maximum rates for waiver services or for additional units beyond the Medicaid allowable maximum units. Any approval of an exceptional rate or additional units beyond the maximum allowable units is time limited to a maximum of one year. The provider must maintain a copy of the exceptional rate or additional units beyond the maximum approval letter in the participant’s record.
1003. General Claims Submission Policy for Ordering, Prescribing, or Referring (OPR) Providers
The Affordable Care Act (ACA) requires physicians and other eligible practitioners who order, prescribe and refer items or services for Medicaid beneficiaries to be enrolled in the Georgia Medicaid Program. As a result, CMS expanded the claim editing requirements in Section 1833(q) of the Social Security Act and the providers’ definitions in sections 1861-r and 1842(b)(18)C. Therefore, claims for services that are ordered, prescribed, or referred must indicate who the ordering, prescribing, or referring (OPR) practitioner is. The department will utilize an enrolled OPR provider identification number for this purpose. Any OPR physicians or other eligible practitioners who are NOT already enrolled in Medicaid as participating (i.e., billing) providers must enroll separately as OPR Providers. The National Provider Identifier (NPI) of the OPR Provider must be included on the claim submitted by the participating, i.e., rendering, provider. If the NPI of the OPR Provider noted on the Georgia Medicaid claim is associated with a provider who is not enrolled in the Georgia Medicaid program, the claim cannot be paid.
Effective 4/1/2014, DCH will begin editing claims submitted through the web, EDI and on CMS-1500 forms for the presence of an ordering, referring or prescribing provider as required by program policy. The edit will be informational until 6/1/2014. Effective 6/1/2014, the ordering, prescribing and referring information will become a mandatory field and claims that do not contain the information as required by policy will begin to deny.
For the NEW CMS-1500 claim form:
Enter qualifiers to indicate if the claim has an ordering, referring, or prescribing provider to the left of the dotted line in box 17 (Ordering = DK; Referring = DN or Supervising = DQ).
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For claims entered via the web:
Claims headers were updated to accept ordering or referring Provider ID and name for Dental and Institutional claims and the referring provider’s name for Professional claims. The claim detail was updated to accept an ordering or referring provider ID and name. Utilize the “ordering” provider field for claims that require a prescribing physician.
For claims transmitted via EDI:
The 837 D, I, and P companion guides were updated to specifically point out the provider loops that capture the rendering, ordering, prescribing, referring and service facility provider information that is now used to transmit OPR information.
The following resources are available for more information:
 Access the department’s DCH-i newsletter and FAQs at http://dch.georgia.gov/publications
 Search to see if a provider is enrolled at
https://www.mmis.georgia.gov/portal/default.aspx
Click on Provider Enrollment/Provider Contract Status. Enter Provider ID or NPI and provider’s last name.
1004. Limitations on Billing of Case Management
Case Management Services means services which will assist Medicaid eligible individuals to gain access to needed medical, social, educational and other services. Such services include but are not limited to, the following:
1) Assessment of eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical educational, social or other services.
2) Development of a specific care plan based on the information collected through assessment; that specifies the goals and actions to address the medical, social, educational and other services needed by eligible individuals.
3) Referral and related activities to help and individual obtain needed services.
4) Monitoring and follow-up activities, including activities and contacts that are necessary to ensure the care plan is effectively implemented and adequately addressing the needs of the individual.
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Duplication of Case Management Services
Federal policy and the Department of Community Health (DCH) prohibit the reimbursement for case management services to more than one agency or Medicaid provider that renders case management services to an individual. This policy is set forth according the federal Requirements and Limits Applicable to Specific Services defined in the State Medicaid Manual, section 4302.
It is the responsibility of the case manager to ensure that the member is not receiving case management services from any other agency. The case manager must obtain from the member information regarding any and all other services that he/she may be receiving prior to enrolling the member in a case management program. If the case manager should learn that the member is enrolled in another case management program, the case manager is advised not to render any case management services until it is verified that his/her case management services are primary. This may require termination of the member from another case management provider before case management from the new provider can be billed. It is the case manager’s responsibility to advise the member of the various case management choices available to the member and to allow the member to make an affirmative choice among them.
Basis for Reimbursement
DCH will reimburse only one provider agency for case management services. The Department has established the case management hierarchy below to define which case management is primary and will be reimbursed. The Department’s billing system has been modified to include edits to ensure the hierarchy is followed in the case of billing from more than one case management provider. The case management provider highest on the hierarchy will be reimbursed if 2 case managers should submit claims for the same month of service.
1) COS 830 – (Case Management Organization –CMO)
2) COS 851 – (SOURCE Case Management)
COS 930 – (SOURCE Case Management) When the procedure is T2022 and the modifier is SE alone or with any other modifier
3) COS 660 – (Independent Care Waiver)
COS 680/681 – (New Options Waiver/Comprehensive Supports Waiver)
4) COS 442 – (C-Bay)
5) COS 764 – (Child Protective Services Targeted Case Management) 6) COS 800 – (Early Intervention Case Management) 7) COS 765 – (Adult Protective Services Targeted Case Management)
8) COS 763 – (At Risk of Incarceration Targeted Case Management) 9) COS 762 – (Adults with AIDS Targeted Case Management)
10) COS 790 – (Rehab Services/DSPS)
11) COS 960 – (Children Intervention School Services)
NOTES: Persons enrolled in hospice have case managers who manage all of their care and may not receive case management from any other program
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while enrolled in hospice. The Department’s hospice lock-in system will automatically cause any other claims for case management to be denied.
1005. CMS 1500 Claim Form
Effective April 1, 2014, providers who submit paper claims will be required to use the revised CMS 1500 claim form (version 02/12) for claims received on and after April 1, 2014. The revised CMS 1500 form contains a number of changes. These changes includes but are not limited to references to ICD-10 codes, identification of Ordering, Prescribing, and Referring providers, and the expansion of number of possible diagnosis codes on a claims

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