Ohio Home and Community-Based Service Waivers

Ohio Home and Community-Based Service Waivers
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Ohio Home Care Waiver Provider Education and Technical Assistance

PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Training Objectives Providers will understand the Ohio Administrative Code (OAC) rules regulating the Ohio Home Care Waiver (OHCW) Program. Providers will be knowledgeable of the required documentation within their waiver roles. Providers will be able to identify any issues or events that cause or could reasonably cause harm to a Waiver individual & the required reporting responsibilities to ensure the health and safety of the individuals we serve.

Training Overview Provider Conditions of Participation, slides 11- 23
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Training Overview Provider Conditions of Participation, slides (Updated 1/1/2019 for aligned Waiver services.) (For Waiver services that have not been aligned.) Provider- Type-Specific Requirements, slides , and Developing your Clinical Records, slides , , , Person Centered Service Plans & Provider Billing, slides Structural Review, slides 57-61 Incident Management and Reporting, slides (Updated 7/1/2019)

Ohio Home Care Waiver Rules
Ohio Home and Community-Based Service Waivers Ohio Home Care Waiver Rules Please note, that this is not an all-inclusive list of Ohio Home Care Waiver rules. These rules are being highlighted as the most commonly referenced rules for the waiver programs and be found on LAWriter, see How to obtain notifications of when rules have been updated. Link: From this link, you can subscribe for the following: Rule and Policy updates published in the Ohio Medicaid Eligibility Manual Medicaid Information Technology System (MITS) Updates Rule and policy updates published for all Ohio Medicaid Provider types You will provide your address, Name, Company Name and Provider ID

Waiver’s Target Population and Services
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Waiver’s Target Population and Services The Ohio Home Care Waiver: Serves Medicaid eligible individuals under the age of 60 with long-term care needs that, in the absence of certain services, would require their needs to be met in a hospital or nursing facility. The service benefit package includes but is not limited to: Nursing Personal Care Home Care Attendant Transportation Home Delivered Meals Adaptive & Assistive Devices Personal Emergency Response Systems Adult Day Health

Provider requirements: Conditions of Participation (COP)
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Provider requirements: Conditions of Participation (COP) Ohio Department of Medicaid (ODM) – all administered waiver providers shall/ must: Maintain a professional relationship with individuals to whom they provide services Furnish services that follows the individual’s approved Person Centered Services Plan (PCSP). Refrain from any behavior that may jeopardize the individual’s health & welfare Comply with all program rules and regulations. Ohio Administrative Code (OAC) ,

Provider requirements per the COPs: Prohibited actions
Ohio Home and Community-Based Service Waivers Provider requirements per the COPs: Prohibited actions At no time shall the ODM – Administered waiver service providers: Do anything that causes or may cause physical, verbal, mental, emotional distress or abuse to the individual, or exhibit any behavior that may compromise the health & welfare of the individual Engage in an activity that may take advantage of or manipulate the individual or his or her authorized representative, family or household members, or engage in an activity may result in a conflict of interest, exploitation, or any other advantage for personal gain Misrepresent yourself by the deliberate intent of your actions to deceive, either for profit or advantage OAC ,

PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Provider requirements per the COPs: Coordinating services & missed visits You will work with the individual and case manager to coordinate service delivery, including, but not limited to: Agreeing to provide services as specified on the individual's approved Person Centered Services Plan Participating in the development of a back-up plan In an event of a planned absence, you shall contact the individual and case manager no later than 72 hours prior to the absence & verify their receipt of information about the absence In the case of an emergency, you must immediately activate the individual’s back-up plan, then contact the individual and Case Manager. To ensure that there is not a break in service delivery, you must verify their receipt of information about the absence. Verbalize examples: amount, scope, location, etc; discuss bullet points in detail or examples OAC ,

PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Provider requirements per the COPs: Notifications to the Case Manager within 24 hours You MUST report to the Case Management Agency within 24 hours when you are aware of issues that may affect the individual and/or any provider’s ability to render services as directed in the individual’s PCSP. Issues may include, but are not limited to the following: The individual consistently declines services The individual plans to, or moves to another residential address There are changes in the physical, mental, and/or emotional status of individual OAC ,

Notifications to the Case Manager within 24 hours, Continued…
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Notifications to the Case Manager within 24 hours, Continued… Reportable issues may include, but are not limited to the following: Changes in the individual’s environmental conditions The individual’s caregiver status has changed The individual no longer requires medically necessary services as defined in rule of the Administrative Code The individual’s actions toward you are threatening or you feel unsafe or threatened in the individual’s environment OAC ,

Notifications to the Case Manager within 24 hours, Continued…
Ohio Home and Community-Based Service Waivers Notifications to the Case Manager within 24 hours, Continued… Issues may include, but are not limited to the following: The individual is consistently non-compliant with physician orders including actions that may jeopardize their own health and welfare The individual’s requests conflict with his or her Person Centered Services Plan / or may jeopardize his or her health and welfare Any other situation that affects the individual’s health and welfare OAC ,

PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Contact information for the Case Management Agencies During normal business hours, providers must call or the case manager using their contact information located on the individual’s Person Centered Services Plan. After hours, on the weekend or holidays, call the applicable number(s) below for further direction. Columbus region: CareSource (844) and CareStar (800) Cleveland region: CareSource (877) and CareStar (800) Cincinnati region: CareSource (855) and CareStar (800) Marietta region: CareSource (855) and CareStar (800)

Provider requirements per the COPs: Keeping contact information current You need to make arrangements to accept all correspondence sent by ODM or its designee, including but not limited to certified mail You need to ensure that your contact information, including but not limited to address, telephone number, fax number & address are current. You must notify ODM via the Medicaid Information Technology System (MITS) & its designee, no later than 7 calendar days after such events occurred You need to provide & maintain a current address to ODM and its designee in order to receive electronic notification of any rule adoptions, amendments or rescissions, & any other communication from ODM or its designee PCG Provider Relations (877)

What is My OhioHCP? This website organizes all a providers important Ohio Home Care program information onto a private, individualized page. It includes important records including PCSPs & structural review reports, news and updates, contact information, and more For log in issues contact PCG at

Provider requirements per the COPs: How to discontinue waiver services
Ohio Home and Community-Based Service Waivers Provider requirements per the COPs: How to discontinue waiver services You need to submit written notification to the individual and ODM or its designee (Case Management Agency) at least 30 calendar days before you terminate services. Exceptions to the 30 - day advanced notification: You must submit verbal and written notification to the individual and ODM or its designee at least 10 days before the anticipated last date of service IF the individual: Has been admitted to the hospital Has been placed in an institutional setting Has been incarcerated ODM may waive advanced notification for you upon request and on a case-by-case basis. Waiver & MyCare providers can contact ODM to request the advanced notification to be waived by ing ODM at: OAC ,

Provider Requirements per the COPs: Prohibited actions, Continued…
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Provider Requirements per the COPs: Prohibited actions, Continued… While rendering services ODM–administered waiver service providers shall/ must not (examples but not limited to): Take the individual to your home Bring children, animals, friends, relatives, other individuals or anyone else to the individual's home Provide care to anyone other than the individual Smoke without the consent of the individual Sleep Consume the individual’s food and/or drink without his or her offer and consent Engage in any activity that is not related to the services you are providing to the extent that the activity distracts or interferes with service delivery Including, but not limited to: Using electronic devices for personal or entertainment Deliver services when you are medically, physically, or emotionally unfit. Engage in socialization with persons other than the individual. OAC ,

Provider requirements per the COPs: Prohibited actions, Continued…
Ohio Home and Community-Based Service Waivers Provider requirements per the COPs: Prohibited actions, Continued… Use or be under the influence of alcohol, illegal drugs, chemical substances or controlled substances that may adversely affect your ability to furnish services Engage in any activity or conduct that may reasonably be interpreted as sexual in nature, regardless of whether it is consensual Engage in any behavior that may reasonably be interpreted as inappropriate involvement in the individual’s personal beliefs or relationships OAC ,

Provider requirements per the COPs: Prohibited actions, Continued…
Ohio Home and Community-Based Service Waivers Provider requirements per the COPs: Prohibited actions, Continued… This includes but is not limited to: Accepting, obtaining, attempting to obtain, borrow, or receive money or anything of value including, but not limited to gifts, tips, credit cards or other items Being designated on any financial account including, but not limited to bank accounts and credit cards Using the individual’s real or personal property Lending or giving money or anything of value Engaging in the sale or purchase of products, services or personal items Engaging in any activity that takes advantage of or manipulates ODM-administered waiver program rules OAC ,

Registered Nurse (RN) & Licensed Practical Nurse (LPN) Requirements
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Registered Nurse (RN) & Licensed Practical Nurse (LPN) Requirements Nurses must: Have a valid, unrestricted Ohio nursing license Possess an active Medicaid provider agreement or be employed by an entity that has an active Medicaid provider agreement Ensure the physician’s order (plan of care) is updated at least once every 60 days Ensure all verbal orders are documented & include the date and time the order was taken along with the name of the physician. Verbal orders must be signed by the physician, or the order is not valid & nurses do not have the authorization to BILL for services both OAC

Waiver Nursing Services Limitations:
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Waiver Nursing Services Limitations: Waiver nursing services cannot be used in lieu of similar services available through third-party insurers, community supports, resources or other Ohio Medicaid state plan services when it has been determined an individual’s needs can be met by those services. If you cannot assist an individual with an assessed need, you shall notify ODM, ODA or their designee, in writing, of your service limitations(s) before you can be included on the PCSP. Waiver nursing services are reimbursable when sequentially, but not concurrently, performed with any other service during a visit in which the RN is furnishing billable home health, private duty nursing, RN assessment, RN consultation, and/ or any other similar service that is reimbursable through the Ohio Medicaid program Both OAC

Licensed Practical Nurse (LPN) Requirements
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Licensed Practical Nurse (LPN) Requirements LPNs must have a face-to-face visit at least every 60 days with the directing RN, LPN, and Indivdiual/Guardian to evaluate the provision of waiver nursing services, LPN performance, and to assure services are being delivered in accordance with the approved plan of care and within the LPN’s scope of practice. Have a face-to-face visit before initiating services and at least every 120 days with directing RN, LPN, and individual/guardian to evaluate all of the above in addition to the individual’s satisfaction with care delivery. The LPN must provide clinical notes, signed and dated by the LPN, documenting the face-to-face visits between the LPN and the directing RN. The LPN must maintain documentation of plan of care review and physician orders that was completed by directing RN. Both OAC

Personal Care Aides (PCA) Requirements
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Personal Care Aides (PCA) Requirements You must obtain a certificate of completion of either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio Department of Health, or the Medicare competency evaluation program for home health aides; or other equivalent training program that includes the following: Training on assisting individuals with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) needs, Basic home safety, and Universal precautions IP OAC

Personal Care Aide (PCA) requirements: Continuing education
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Personal Care Aide (PCA) requirements: Continuing education Both agency and non-agency PCAs must obtain and maintain first aid certification from a class. The class can’t be solely internet-based and MUST include hands-on training by a certified instructor. Annually, PCAs must complete 12 hours of in-service continuing education on or before: An agency aide’s employment anniversary Agency and program specific orientations are exempt from the required 12 hours of continuing education. A non – agency aide’s Medicaid provider enrollment anniversary. Continuing education must be implemented immediately and must be completed annually thereafter. We encourage providers to view PCG’s online training courses. PCG contains 6 credit hours for free that is beneficial for Ohio Home Care Waiver Providers IP OAC

Agency Personal Care Aide (PCA) supervision
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Agency Personal Care Aide (PCA) supervision Agency employed PCAs must receive supervision from an Ohio Licensed Registered Nurse (RN) or an Ohio Licensed Practical Nurse (LPN) at the direction of a RN. The supervising nurse shall: Conduct a face-to-face individual home visit explaining the expected activities of the personal care aide and identifying the individual’s personal care aid services to be provided. Agency only OAC

Agency Personal Care Aide (PCA) supervision
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Agency Personal Care Aide (PCA) supervision The supervising nurse shall: Conduct a face-to-face individual home visit at least every 60 days while the PCA is present & providing care to evaluate the provision of PCA services, and the individual’s satisfaction with care delivery and PCA performance. Document the face-to-face consumer home visits in the individual’s record. Discuss the evaluation of PCA services with the case manger. Agency only OAC

Developing your Clinical Records, what is required?
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Developing your Clinical Records, what is required? Non-agency personal care aide service providers: Must leave a legible copy of the complete clinical record including the daily visit note & a copy of the PCSP in the individual’s home Must keep the original in your place of business. Your place of business must be a location other than the individual’s residence (typically your home). You must ensure that your copy of clinical record is secure. Retain all records of service delivery and billing for a period of 6- years IP only OAC

Clinical Records, Continued…
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Clinical Records, Continued… All waiver nursing providers, including Medicare-certified or otherwise accredited agencies, shall also maintain a record at the individual’s residence or primary service location in order to encourage sharing of information between caregivers & enhance person-centered care. Storage shall be in a manner that protects confidentiality of these records. The record may include a communication log, treatment record and/or medication administration record, if they exist. Documents in the record shall reflect a minimum of at least the past 60 calendar days, with the individual’s right to maintain more if he or she so chooses. The individual shall identify the location in his or her residence or the primary service location where the record will be safely maintained. Agency only OAC

Clinical Records for the individual must contain the following information: Identifying information, including but not limited to name, address, date of birth, gender, gender identity, race, significant phone numbers and health insurance identification numbers of the individual. The name and current contact information for the individual’s parent/guardian/authorized representative and or/emergency contact. Health Insurance Identification Numbers Medical History The name of individual's treating physician, which is also needed for billing A copy of the initial and all subsequent Person Centered Services Plan (PCSP) A copy of any advance directives including but not limited to: Do Not Resituate (DNR) or Medical Power of Attorney (POA) if they are provided Documentation of all drug & food interactions, allergies, and dietary restrictions OAC

Clinical Records: Service/visit records
Ohio Home and Community-Based Service Waivers Clinical Records: Service/visit records Service documentation is required for each visit and must contain all of the following: Date and location of service delivery Service start and end times Details of the tasks performed or not performed during each visit Verification of service delivery includes signatures of both the provider & the individual verifying the service delivery upon completion of each service delivery. Your inability to produce these clinical records could result in an overpayment finding even if you provided the service. OAC , ,

Clinical Records: Service/visit records
Ohio Home and Community-Based Service Waivers Clinical Records: Service/visit records PCA Progress notes signed and dated by the PCA, documenting all communications with the case manager, treating physician, other members of the multidisciplinary team, and documenting any unusual events occurring during the visit, and the general condition of the individual. Nurses Clinical notes signed and dated by the nurse, documenting the general condition of the individual, and any unusual events occurring during the visits and the service tasks performed or not performed. All communications with the individual, case manager, RN supervisor if one exists, primary care physician, and other members of the individual’s team. OAC ,

Nursing Clinical Records shall include the following:
Ohio Home and Community-Based Service Waivers Nursing Clinical Records shall include the following: Information regarding medical diagnoses, treatment and preferences. The individual’s medication profile & medication administration record, as applicable. Nurse assignments. Initial and all subsequent plans of care, specifying the type, frequency, scope and duration of the nursing services being performed. An LPN’s clinical record shall include documentation that the RN reviewed the plans of care with the LPN. OAC

Acceptable signatures on your Clinical Records:
Ohio Home and Community-Based Service Waivers Acceptable signatures on your Clinical Records: Acceptable signatures include handwritten signature, initials, a stamp or a mark, or an electronic signature, including electronic visit verification (EVV). NOTE: Any accommodations to the individual’s or the authorized representative’s signature shall be documented in the PCSP. OAC , ,

PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers EVV went live January 8, 2018 Electronic Visit Verification (EVV) went live on January 8, 2018 for all providers who deliver the following services: State Plan Services State Plan RN Assessment Ohio Home Care Waiver (OHCW) Nursing OHCW Personal Care Aide OHCW Home Care Attendant Private Duty Nursing (PDN) OAC

Electronic Visit Verification (EVV)
Ohio Home and Community-Based Service Waivers Electronic Visit Verification (EVV) EVV is the use of technology, including a mobile device utilizing global positioning system (GPS) technology, telephone or manual visit entry, to verify the data elements related to the delivery of a Medicaid covered service. Data collected for each visit includes: Information identifying the individual receiving the service & the direct care worker; The date, time and location at the start & the end of the visit; The service provided. The device allows individual receiving service to voice record or sign digitally to verify the visit. Telephone only allows for voice verification, and a manual entry would require supporting documentation with the required verification of services. OAC

EVV requirements do not apply to the following circumstances:
Ohio Home and Community-Based Service Waivers EVV requirements do not apply to the following circumstances: Services provided in a group visit. Effective 7/12/2019, the Managed Care Organization (MCO), Department of Developmental Disabilities (DODD) and the Ohio Department of Aging (ODA) are included in the EVV program. EVV claims submission update: Please ensure your visits are in a verified or processed state prior to submitting claims. NOTE: “Verified” or “Processed State” means all exceptions have been cleared in the EVV system before submitting a claim in MITS.

Person Centered Services Plan (PCSP)
Ohio Home and Community-Based Service Waivers Person Centered Services Plan (PCSP) The Person Centered Services Plan is the document which identifies person-centered goals, objectives, and interventions including any authorized medically necessary services. As a provider of the Medicaid waiver program, you are responsible to assure the following: Prior to delivery of any service(s), you must verify the individual’s Medicaid eligibility and that their PCSP is accurate and contains the following: The individual’s PCSP must list your name, the correct type of service(s) you agreed to provide, a correct procedure code for those services, and an approved start of care date You need to assure that the authorized hours listed on the goals page matches the authorization on the units page OAC ,

Ohio Home and Community-Based Service Waivers Person Centered Services Plan (PCSP) Service authorizations are listed under “Methods” and “Units” sections of the Individual’s PCSP. The “Goals” section of the PCSP identifies the waiver service being provided The “Objective” section of the PCSP identifies what the individual hopes to achieve through implementation of interventions such as medically necessary services. The “Methods” section will detail the days, hours, and times you are authorized to work.

Ohio Home and Community-Based Service Waivers Person Centered Services Plan (PCSP) The “Units” page of the PCSP identifies how many shifts are authorized, the services billing code, and the monthly cost of the service (if all of the services are delivered that month as authorized.) Any changes to an individual’s care or services must be updated on the individual’s PCSP and distributed to the service providers by the case manager. You may accept verbal approval from the Case Manager to make a change in schedule. However, you may not bill for these services until the PCSP has been updated with this written authorization.

PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Person Centered Services Plan (PCSP) Providers should always verify that the information contained on PCSP is accurate on both the Goals page and Units page.

Ohio Home and Community-Based Service Waivers Person Centered Services Plan (PCSP)

Reimbursement Rates & Billing Procedures
Ohio Home and Community-Based Service Waivers Reimbursement Rates & Billing Procedures Providers must bill in accordance to the Ohio Home Care Waiver rules as it pertains to the base and unit rates outlined in Ohio Administrative Code Base Rate means the amount reimbursed by Ohio Medicaid for the first 35 to 60 minutes of service delivered time. Unit Rate means the amount reimbursed by Ohio Medicaid for each 15 minutes of service delivered when the visit is: Greater than 60 minutes in length Ohio Medicaid will reimburse a maximum of one unit of service when the service delivery is equal to or less than 15 minutes in length Ohio Medicaid will reimburse a maximum of 2 units if the service delivery is 16 through 34 minutes in length OAC

Reimbursement Rates & Billing Procedures
Ohio Home and Community-Based Service Waivers Reimbursement Rates & Billing Procedures When the initial visit is greater than 60 minutes For a visit in length beyond the initial hour of service, the base rate plus the rate amount for each 15‐minute unit over the initial one hour may be claimed for services performed which does not exceed the prescribed OAC limits (e.g., visits not more than 4 hours for home health; more than 4 hours for Private Duty Nursing; or the individual’s PCSP). Length of visit Your billing should reflect: minutes One Unit minutes Two Units minutes One Base Unit 1 hour and 15 minutes One Base Unit + One Unit 1 hour and 30 minutes One Base Unit + Two Units

Reimbursement Rates: OAC 5160-46-06 & 5160-12-06
Ohio Home and Community-Based Service Waivers Reimbursement Rates: OAC & Modifier Description Requirement U1 Infusion Therapy Must be used with code G0154 for the purpose of identifying home infusion therapy provided in accordance with OAC rule U2 Second Visit Must be used to identify the second visit for the same type of service made by a provider on a date of service per individual in accordance to OAC rule U3 Third Visit Must be used to identify the third or more visit for the same type of service made by a provider on a date of service per individual in accordance to OAC rule U5 Healthchek Must be used to identify the individual receiving services due to Healthchek in accordance to OAC rule HQ Group Visit Must be used to identify individual receiving services in accordance to OAC rule TD RN Visit Must be used to identify a visit conducted by a registered nurse (RN) for home health nursing service billed to Ohio Medicaid. TE LPN Visit Must be used to identify a visit conducted by a licensed practical nurse (LPN) for home health nursing service billed to Ohio Medicaid. Billing Code Service Base rate Unit rate T1002 Waiver nursing services provided by an agency RN $47.40 $8.72 Waiver nursing services provided by a non-agency RN $38.95 $7.03 T1003 Waiver nursing services provided by an agency LPN $40.65 $7.37 Waiver nursing services provided by a non-agency LPN $33.20 $5.88 T1019 Personal care aide services provided by an agency personal care aide $23.12 $3.84 Personal care aide services provided by a non-agency personal care aide $18.64 $2.95

Service & Billing Overview
Ohio Home and Community-Based Service Waivers Service & Billing Overview Providers shall only bill for services when those services were delivered face-to-face with an individual or up to three individuals in a group setting. Providers shall not bill for services while the individual receives care at another healthcare setting, physician’s office, hospital, or extended care facility. , ,

Service & Billing Overview, Continued…
Ohio Home and Community-Based Service Waivers Service & Billing Overview, Continued… Providers must submit billing claims to the individual’s insurance prior to billing Medicaid. If the cost of service is covered by insurance, the provider shall not submit any billing claims to Medicaid. Providers should review billing after each submission to assure accuracy of claims which includes service delivery dates, units billed reflects time on timesheets, and bank deposit is the same as what was billed. ODM has 30 days to make a payment from the date of a clean submission.

Billing Accuracy/Remittance Advice - What should you look for?
Ohio Home and Community-Based Service Waivers Billing Accuracy/Remittance Advice - What should you look for? Ensure your claims have the correct code, date of service, and individual Ensure that the clinical documentation matches the appropriate individual, length of visit, date billed, and PAID amount Review your billing claims after each submission to assure all claims are submitted accurately, including the amount PAID If an overpayment is found or a claim was billed incorrectly, you have 60 days to resubmit a correction to the claim All other remittance advice statements for claims submitted on or after 08/02/2011 are available through the MITS system.

Billing References for Agencies, Nurses, & PCAs
Ohio Home and Community-Based Service Waivers Billing References for Agencies, Nurses, & PCAs Reference Information: MITS Website: Provider home page, log-in, enrollment, set-up/ registration Web Portal Eligibility Verification: Explains how to read the Web Portal eligibility screen Provider Billing: Website contains training on how to adjust overpayments.

Billing References for Agencies, Nurses, & PCAs
Ohio Home and Community-Based Service Waivers Billing References for Agencies, Nurses, & PCAs Provider Training: Website contains a wealth of information and online training opportunities. Billing training is provided by ODM’s ombudsman unit. To request said Training or Consultation provided by ODM’s Ombudsman Unit contact For Claims issues contact Ordering, Referring, Prescribing Numbers (ORP) Info:

ICD-10 Resources Public Consulting Group (PCG): Centers for Medicare and Medicaid Services (CMS): Ohio Department of Medicaid (ODM):

Structural Reviews of Providers
Ohio Home and Community-Based Service Waivers Structural Reviews of Providers Waiver providers are subject to Structural Reviews to evaluate provider compliance with all applicable Ohio Administrative Codes. Note: All ODM-administered waiver providers may be subject to an announced or unannounced Structural Review at any time as determined by ODM or its designee. OAC

Structural Reviews of Providers, how often will you participate?
Ohio Home and Community-Based Service Waivers Structural Reviews of Providers, how often will you participate? All ODM administered waiver providers shall be subject to Structural Reviews by ODM or its designee during each of the first three years. Thereafter, reviews shall be conducted annually unless, at the discretion of ODM, biennial reviews may be conducted, when all of the following apply: You had no findings during your most recent Structural Review You were not substantiated to be the violator in an incident described in rule You were not the subject of more than one provider occurrence during the previous 12 months You do not live with an individual receiving ODM-administered waiver services OAC

Structural Reviews, what should you expect at the review?
Ohio Home and Community-Based Service Waivers Structural Reviews, what should you expect at the review? Structural reviews must be conducted in person between the provider & ODM or its designee with an ODM approved structural review tool The Structural Review shall not occur while you are providing services to an individual The Structural Review process consists of the following activities: Except for unannounced reviews, you shall be notified in advance of the review to arrange a mutually agreeable time, date & location for the review If you do not respond after 2 attempts to schedule your Structural Review, a Notice of Operational Deficiency (NOD) will be referred to ODM You shall be notified of the time period for which the review is being conducted OAC

Structural Reviews, what should you expect at the review? Continued…
Ohio Home and Community-Based Service Waivers Structural Reviews, what should you expect at the review? Continued… The Structural Review process consists of the following activities: You shall be provided with a list of the type of documents required for the review You shall ensure the availability of the required documents & maintain the confidentiality of information about the individual enrolled in the ODM-administered waiver The Structural Review shall include an evaluation of your compliance with Chapters and of the Ohio Administrative Code OAC

Structural Reviews, what should you expect?
Ohio Home and Community-Based Service Waivers Structural Reviews, what should you expect? A unit of service verification shall be conducted to assure that all waiver services are authorized, delivered, & reimbursed in accordance with the approved PCSP for the individual receiving services At the conclusion of the review you shall receive: an exit conference containing preliminary findings, any individual remediation, & other required follow-up You will receive a written findings report summarizing the overall outcome of the structural review. If areas of non-compliance are discovered, you will be asked to correct them with a Plan of Correction A Plan of Correction must be submitted within 45-day of the date of the report letter. The letter contains the due date for submitting the Plan of Correction OAC

Incident Management, what is an incident?
Ohio Home and Community-Based Service Waivers Incident Management, what is an incident? An incident is an alleged, suspected, or actual event that is not consistent with routine care of and/or service delivery to an individual. ODM operates an incident management system that includes the responsibilities for: Reporting incidents Responding to incidents Investigating incidents And remediating incidents ODM, its designee, & providers are responsible for ensuring individuals are protected from any threats to the individual’s health & wellbeing. OAC

Incidents include, but are not limited to, all the following:
Ohio Home and Community-Based Service Waivers Incidents include, but are not limited to, all the following: Upon discovery, ALL incidents MUST be reported to the Case Manager immediately upon discovery of the incident, but no later than 24 hours after discovering the incident: Abuse: the injury, confinement, control, intimidation, or punishment of an individual, including self-abuse, that has resulted in physical harm, pain, fear, or mental anguish. Abuse includes, but is not limited to: Physical, emotional, verbal and/or sexual abuse The use of unauthorized restraint, seclusion, or restrictive intervention The use of authorized restraint, seclusion, or restrictive intervention that results in, or could reasonably be expected to result in, physical harm, pain, fear, or mental anguish to the individual. Neglect: when there is a duty to do so, failing to provide an individual with any treatment, care, goods, or services necessary to maintain the health or welfare of the individual, including self-neglect. OAC

Incident types: Continued…
Ohio Home and Community-Based Service Waivers Incident types: Continued… Exploitation: the unlawful or improper act of using an individual or an individual’s resources for monetary or personal benefit, profit or gain. Misappropriation: depriving, defrauding, or otherwise obtaining the money, real or personal property (including prescribed medication) of an individual by any means prohibited by law. Unexplained Death: an unnatural or accidental death, that could not reasonably have been expected, and the circumstances or the cause of death are not related to any known medical condition of the individual, including inadequate oversight of prescribed medication or misuse of prescribed medication. Examples: Individual was victim of homicide; Individual died in a house fire OAC

Ohio Home and Community-Based Service Waivers Incident types: Continued… Health and welfare of the individual is at risk due to the following: Activities involving law enforcement intervention. Including the individual’s action/inaction, but also other people/situations around them that put the individual at risk. An unexpected crisis in the individual's family or environment resulting in an inability to ensure the individual's health and welfare in his or her residence. The individual's health and welfare is in immediate and serious jeopardy. Example: Individual left in car 2hrs; 90 degree; while PCA overdosed and died. The individual cannot be located. OAC

Incident types, Continued…
Ohio Home and Community-Based Service Waivers Incident types, Continued… Any of the following prescribed medication issues: Provider error. Individual's misuse resulting in emergency medical services (EMS) response, emergency room visit, or hospitalization. Individual's repeated refusal to take a prescribed medication resulting in EMS response, emergency room visit, or hospitalization. **Please note: EMS treatment includes treatment that occurs in the home and transport to ER or hospital may not have occurred. OAC

Incident types, Continued…
Ohio Home and Community-Based Service Waivers Incident types, Continued… Death: other than unexplained death. Example: Individual died under Hospice care due to diagnosis of pancreatic cancer. Individual or family behavior, action, or inaction resulting in the creation of, or adjustment to, a Health and Safety Action Plan previously known as Acknowledgement of Responsibility Agreement (ARA) Example: While the provider was at the home, the individual was using heroin; as a result, a health & safety action plan was created. The health and welfare of the individual is at risk due to the loss of an individual’s caregiver. OAC

Ohio Home and Community-Based Service Waivers Incident types: Continued… Any of the following prescribed medication issues: Individual's misuse not resulting in EMS response, emergency room visit or hospitalization. Individual takes two prescribed Oxycodone rather than 1 as prescribed; Individual experienced no adverse effects; no EMS, ER, or Hospitalization. Individual's repeated refusal to take prescribed medications not resulting in EMS response, emergency room visit, or hospitalization. Individual repeatedly refused to take prescribed Lisinopril and not experiencing any adverse effects; no EMS, ER, or Hospitalization. Hospitalization that results in an adjustment to the person-centered services plan (PCSP): Individual is hospitalized for a fall and had surgery on a fractured ankle. She now needs help with ambulating that she didn’t need before. Eviction from place of residence. OAC

Incident Responding Responsibilities
PCG Health 1 October 2019 Ohio Home and Community-Based Service Waivers Incident Responding Responsibilities When you learn of any incident type; You must take immediate action to assure the health & welfare of the individual including, but not limited to seeking or providing medical attention Report the incident immediately to your supervisor (If you work for an Agency) or to the Case Manager (If you are an Independent Provider) upon discovery of the incident, but no later than twenty-four hours after discovering the incident. You must notify the appropriate authority depending upon the nature of the incident. Examples include, but are not limited to the following: Law enforcement (call 911 as appropriate) Adult / children’s protective agencies OAC

Mandatory requirement for Waiver Providers to review the Incident Management System’s OAC Upon entering into a Medicaid provider agreement, and annually thereafter, all providers must acknowledge in writing they have reviewed Ohio Administrative Code Rule Ohio Department of Medicaid (ODM)-administered waiver program: incident management system. Reviewing the Incident Management & Reporting rule can be done one of two ways: You can review the rule (and all other rules we reviewed today) by visiting or You can watch a video at the following web address: You will not receive notification of this requirement. You also must keep documentation of the completion of this requirement in your records. OAC

ohiohcbs.pcgus.com/index.html

ohiohcbs.pcgus.com/trainingmaterials/index.html

ohiohcbs.pcgus.com/trainingmaterials/verify.html

Public Consulting Group is excited to announce that Ohio’s Home Care Waiver providers now have the option to complete the Ohio Home Care Waiver Provider Training course online! Questions? or call PCG’s provider relations at

EVV Self Paced Training
Ohio Home and Community-Based Service Waivers EVV Self Paced Training The training method offered to providers for EVV is a self-paced training. Self-paced training includes recorded modules that provide instruction on the Sandata EVV system, the chosen EVV vendor for the Ohio Department of Medicaid. Self-paced training materials are available in the Learning Management System (LMS) The self-paced training will remain available for reference for the life of the program. If you have any questions about training options or registration, please call Sandata’s EVV Provider Hotline at

QUESTIONS Please all waiver provider inquiries to: Please all My Care Ohio inquiries, comments and concerns to the Ohio Department of Medicaid:

155 E. Broad St. 8th Floor Columbus, Ohio 43215
PCG Health 1 October 2019 155 E. Broad St. 8th Floor Columbus, Ohio 43215 (877) ,

Ohio Home and Community-Based Service Waivers

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