1. Information correct as of July 20161 Part 3 Claiming and Reporting DVA Community Nursing Education Package for July 2016

2. Information correct as of July 20162 Objectives At the end of this session you will have: –A good understanding of DVA’s claiming and reporting requirements and obligations within the Notes –A good understanding of DVA’s preferred method of claiming and how to complete the MDS Collection Tool in line with the Notes

3. Information correct as of July 20163 A CN provider retrospectively claims for the delivery of community nursing services to an entitled person through the Department of Human Services (Medicare) An entitled person must never be asked to provide additional payment for the delivery of community nursing services by a CN provider A claim for payment for community nursing services, must be submitted to Medicare within six months of the first day of the 28-day claim period Claiming

4. Information correct as of July 20164 In submitting a claim for payment the CN provider certifies that the community nursing services: were delivered by the CN provider or a subcontractor were provided under a treatment/care plan for the entitled person are a true representation of the community nursing services actually provided Submitting Claim for Payment

5. Information correct as of July 20165 DVA has systems in place to monitor the servicing and claiming patterns of services provided under the DVA Community Nursing program Inappropriate claiming can incorporate: Over-servicing Under-servicing Fraud DVA will recover any overpayments identified during regular contract management post-payment monitoring processes as part of the QMF and take appropriate action under the Agreement Please see section 11.14 of the Notes Inappropriate claiming for services

6. Information correct as of July 20166 Providers are required to submit data on all community nursing services delivered to entitled persons in each 28-day claim period Data is presented in the DVA Minimum Data Set (MDS) format DVA uses MDS data to: monitor the appropriateness of the provision of community nursing services substantiate community nursing claims ensure that an entitled person receives quality health outcomes assist in research into program development Please see Attachment F of the Notes Data reporting requirements

7. Information correct as of July 20167 The MDS collects information on: Claim Details entitled person’s surname, file number, item number and claim start date Staffing Resources Used (in the 28-days) level of personnel delivering community nursing services to the entitled person visits/occurrences and hours of care provided by each level of personnel delivering community nursing services to the entitled person Minimum Data Set

8. Information correct as of July 20168 Visit vs Occurrence Visit: A visit is where only 1 type of care is delivered. For example, A NSS only providing personal care in a visit Occurrence: An occurrence is defined as the total number of different visit types completed by the RN or EN. Each component of the care delivered should be counted and recorded in the MDS as a separate occurrence There is a possibility in one visit there maybe three separate occurrences of services being delivered, e.g: core item opposing schedule add-on palliative care (other items add-on)

9. Information correct as of July 20169 An RN makes four visits in a 28-day claim period (one visit per week), each visit lasts 1½ hours. Within each visit, half an hour of personal care services are delivered by the RN and one hour of Clinical Care. A total of eight visits/occurrences will be recorded over the 28-day claim period, with the MDS being reflected as follows: Example of an occurrence for MDS purposes?

10. Information correct as of July 201610 How to submit MDS Data: Online to Department of Human Services Medicare (Medicare) as part of the Medicare claim (preferred) MDS data must be submitted at end of each 28-day claim period If a CN provider has multiple sites with multiple provider numbers, each site must submit its own MDS data If a CN provider is unable to claim online through Medicare, contact DVA for prior approval to report MDS manually Submitting Minimum Data Set

11. Information correct as of July 201611 MDS Submission example The entitled person has multiple wounds / ulcers on both legs requiring wound care x 3 per week, each visit taking 45 minutes and requires hygiene assistance x 3 per week and due to cognitive issues and frailty, hygiene assistance takes 45 minutes Provider A - RN provides both the clinical and Personal Care Provider B - NSS provides Personal Care and RN to provides Clinical Care Classification is the same in each case, as is the fee paid, however the MDS will be reflected differently Same classification, different staff resources used

12. Information correct as of July 201612 Same classification different staff resources used MDS

13. 13 Contacting Department of Human Services Enquiries relating to claiming e.g. rejected claims, can be addressed by contacting the Department of Human Services (Medicare) on 1300 550 017 (option 2)