Expert Billing & More, Inc

Documentation Requirements / APD / Delmarva

We’ve mentioned documentation requirements several times in past newsletters; however, a lot of providers have been cited recently for inadequate documentation during their Delmarva reviews. As a courtesy, this newsletter will focus on provider responsibilities with regard to documentation. However, this info should not be used as your only source as it only focuses on a few guidelines.

Whether you are a long time provider or a brand new one, you are responsible to adhere to the guidelines in the DD Waiver Handbook for the services you provide. Failure to comply with the guidelines could result in recoupment, and for continual non-compliance, possible decertification.

We strongly encourage all providers to attend trainings offered by your local APD office. Some areas even have a Delmarva liaison that is willing to meet with providers to review procedures and documentation and offer suggestions for improvement. We also strongly encourage all providers to review the most current Handbook (current Handbook is dated June 23, 2005) which can be downloaded from the EDI website. As a reminder, new changes are in the works so it is imperative that providers stay in the loop and when the new Handbook is promulgated, download the new Handbook and immediately implement any changes that affect the services you provide.

The Handbook clearly outlines the following for each service:

ð Description of service – if you are unaware of what your service entails, this is where you would find out about it. As a suggestion, even if you think you know the details of your service, read this section because you could have been given incorrect information and if you provide a service outside of the description noted in the Handbook you could be targeted for recoupment. (This will be especially important when the new Handbook is promulgated because several services are being changed significantly.)

ð Limitations – this section details the limitations of the services you provide; i.e., limited to a certain number of quarter hours per day or month or a service must be provided in the community. As a suggestion, even if you think you know the limitations of your service, read this section because you could have been given incorrect information and if you provide a service outside of the limitations noted in the Handbook you could be targeted for recoupment. (This will be especially important when the new Handbook is promulgated because several services are being changed significantly.)

ð Documentation Requirements – this section details the documentation required for the services you provide. Each service has different documentation requirements but the one consistent item for all services is a copy of the claims submitted or payment. For billing purposes with Expert Billing this would also be considered the invoice you submit to us for processing.

ð Place of Service – this section details where a service must be performed, i.e., in the community. As a suggestion, even if you think you know the where you are eligible to provide your service, read this section because you could have been given incorrect information and if you provide a service where it is not allowed, you could be targeted for recoupment. (This will be especially important when the new Handbook is promulgated because several services are being changed significantly.)

ð Special Considerations – this section details any special considerations such as providing the service to more than one individual at a time and reducing the rate based on the client to staff ratio.

As a courtesy, Expert Billing has provided “generic” invoices for providers that choose to use them. However, it is still the provider’s responsibility to ensure that all required information is included on the invoice. For providers that create their own invoices, the required information must still be included for auditing purposes.

As described in the Handbook, billing documentation must include the following information:
ð Client full name
ð Client social security number
ð Client Medicaid number
ð Provider name
ð Provider Medicaid number
ð Service name
ð Service procedure code
ð Dates service was provided
ð Service times and how many units billed on each day
ð Total billed for the period submitted

There may be other information required depending on the service you provide; however, the info listed above is consistent with every service.

The confusion seems to come into play when a provider does not provide all required documentation for auditing purposes or it is not labeled correctly.

For example, if you provide Companion services, the required documentation as described in the Handbook is:

ð Copy of claims submitted for payment (invoice)
ð Copy of service log

If you do not provide both items listed above, you are out of compliance. Each item listed above has its own requirements so you need to be sure that the required information is on ALL documents as described in the Handbook.

If a provider does not complete the exact times the service was provided on the invoice, then the service log must have it. Same with client Medicaid number, procedure code, etc. if it is not on the invoice, it must be on the service log or you are out of compliance. Some providers choose to only include billing info on the invoice and service delivery info on the service log, which is okay as long as both documents are presented together as “billing documentation” and all the required info is present.

It is also recommended that each document be labeled correctly, i.e., “Invoice” or “Service Log”. This way there is no confusion for the reviewer.

PLEASE DO NOT CONFUSE AUDITING REQUIREMENTS FOR EXPERT BILLING’S REQUIREMENTS.

ALL EXPERT BILLING NEEDS IS AN INVOICE WITH THE ITEMS NOTED ABOVE.