Provder Update:

Billing: Billing for services provided by an ineligible provider may result in recoupment for the entirety of the services provided by an ineligible caregiver within the previous 12 month period.  Upon discovery, agencies will be granted 30 days to back out ineligible billing prior to seeking recoupment. A grace period of 30 days will be allowed from the date of this bulletin to identify and cease billing for services by any ineligible spouse or legal guardian. Any ineligible billing identified during this period by provider agencies will not be subject to recoupment. The agency must notify the ADvantage Administration to receive a letter of exemption.

Form Updates: The Eligible Provider Exception Request form replaces the Request for Spouse of Legal Guardian to Serve as Paid Caregiver form, effective immediately. Previous request form will not be accepted after 11/1/14. A new form for quarterly reporting, the Eligible Provider Exception Quarterly Review form, is also being introduced and will be required for all quarterly reviews completed on or after 11/1/14, replacing the submission of case management notes. (Please note: These forms are currently not available online, but you may request them by contacting Provider Questions.)

Exception Criteria
Exceptions are only allowable under one of the following three conditions:

1. No other provider is available; or
2. Available providers are unable to provide necessary care to the Member; or
3. The needs of the Member are so extensive that the spouse or legal guardian who provides the care is prohibited from working outside the home due to the Member's need for care.

When exceptions are approved, ADvantage paid services are not intended to take the place of regular care and general maintenance tasks or meal preparation typically shared or done for one another by spouses or other adults who live in the same household. The service and the provider must also meet all other standards identified in OAC 317:30-5-761(8)(B) and (C). 

Exception Requests and Quarterly Reporting: Exception requests are submitted by the Case Manager utilizing the Eligible Provider Exception Request form. Approvals are in effect for the duration of the Member’s current Service Plan year and a new exception request must be submitted annually at the time of reassessment. Failure to submit an annual exception request or quarterly reporting will result in an automatic denial of any existing exception. Quarterly reporting from the Case Management provider is required through submission of the Eligible Provider Exception Quarterly Review form every three months after approval (case management notes are no longer required). Conditions are expected to change as the Member’s needs and the availability of care in the Member’s community changes; therefore, annual resubmissions should not be expected to be routinely authorized from year to year.

Justification: Professional documentation is required to support every exception request, including annual requests to renew. At a minimum, the Member’s UCAT I and III, Service Plan Goals, authorized services, and RN Evaluations are reviewed. Information about a Member’s needs and abilities must be consistent across all documents in order to support an exception. 

Home Care and Adult Day Health Providers on referral in the Member’s county of residence are often overlooked as being available providers. It is expected that the Member work with multiple agencies and consider all available services before determining that no providers are available. Documentation must support the determination that available providers are unable to perform the Personal Care and/or Advanced Supportive/Restorative Assistance (PCA and/or ASR) tasks listed in the Service Plan. Specifically, the documentation must specify what additional qualifications, training, or capabilities are required to perform these tasks and why available providers cannot meet these qualifications. When a spouse is unable to work outside the home due to the Member’s need for care, professional documentation must identify the extensive needs of the Member and how these needs prohibit the spouse from working outside the home. 

Decisions: Upon approval, denial, extension, or other action based on a request, the Case Management and Home Care providers will be notified of the action. The Case Manager must review the decision with the Member and coordinate the delivery of services. A denial of a previously approved exception will allow for 30 days to coordinate provision of personal care services by an eligible caregiver. Extensions may be granted in limited circumstances upon request. Resubmissions will be accepted if additional updates to the request and UCAT III (at a minimum) are provided.

Service Plan and Monitoring Implications:  A formal back-up plan is required on all Members, including those with approved exceptions. If exception is approved, Back-Up plan will need to be adjusted, as the primary informal support (spouse/legal guardian) is no longer available as the back-up.

References:
OAC 317:30-5-761. Eligible Providers
OAC 317:35-17-14. Case Management Services
Conditions of Provider Participation, 08-2010
Case Management Standards, Implementation Date 06.01.07

If you have any questions regarding the information provided above, please feel free to contact us via Smarter Mail at:  aauproviderquestion@aau.okdhs.org

*No exceptions are allowed for CD-PASS services for a Power of Attorney, Legal Guardian, or other legal representative of the Member to be their paid caregiver for CD-PASS services.