1. Ohio Home and Community-Based Service Waivers
PCG Health
4/20/2017
Ohio Home and Community-Based Service Waivers
Ohio Home Care Waiver
Provider Education and Technical Assistance
Public Consulting Group is the provider oversight contractor and is tasked with provider education and technical assistance for the Ohio Home and Community-Based Service Waiver providers.

2. Training Overview Priorities for Ohio Home Care Waiver:
PCG Health
4/20/2017
Training Overview
Priorities for Ohio Home Care Waiver:
Waiver Population and Services-3-5
Changes to Transition Waiver- Page 6-7
Waiver Rules-Pages 8-10
Waiver Requirements-Pages 11-41
Incident Reporting-Pages 42-46
Billing-Pages 47-54
International Classification of Diseases (ICD-10)- Pages
Purpose of this training—is to present home and community based waiver providers with the need to know priorities specific to the Home Care and Transitions II Carve Out Waivers. We will begin with an overview of the 2 waivers including the target populations, changes to the transitions carve out waiver, specifics about the waiver rules, waiver requirements, incident reporting, provider billing, and changes to the International Classification of Diseases.

3. Waiver Overview PCG Health 4/20/2017
Over view of the Home Care Waiver and Transitions II Carve-Out Waiver

4. About Ohio Home and Community-Based Waiver Services
PCG Health
4/20/2017
About Ohio Home and Community-Based Waiver Services
The Ohio Department of Medicaid (ODM) currently administers and operates two home and community-based waiver programs: Ohio Home Care Waiver and the Transitions II Aging Carve-Out Waiver.
The ODM-administered waiver programs provide eligible individuals in need of long-term care facility services with a cost-effective home and community-based alternative that recognizes the need for autonomy and independence.
The waiver programs support the individual’s right to choose to live in the community, encouraging them to live as independently as possible and with self-determination, while providing the services, supports and safeguards needed to ensure their health and welfare.
The Ohio Department of Medicaid (ODM) administers and operates two home and community-based waiver programs: the Ohio Home Care Waiver and the Transitions II Aging Carve-Out Waiver.
The Ohio Department of Medicaid-administered waiver programs provide eligible individuals in need of long-term care facility services with a cost-effective home and community-based alternative that recognizes the need for autonomy and independence.
These programs are called waiver programs because, under current law, eligible individuals with disabilities and chronic conditions are entitled to facility-based care, but home and community-based care is considered optional. Therefore, states must apply for waivers from the federal government in order for Medicaid to provide home and community-based services.
The waiver programs support the individual’s right to choose to live in the community, encouraging them to live as independently as possible and with self-determination, while providing the services, supports and safeguards needed to ensure their health and welfare.

5. Waiver Target Population and Services
PCG Health
4/20/2017
Waiver Target Population and Services
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.
Transitions Carve-Out Waiver
Serves Medicaid eligible individuals age 60 and older who were previously enrolled on the Home Care waiver and continue to need services that would otherwise be met in a hospital or nursing facility.
Waiver services include nursing, personal care aide services, home care attendant services, adult day health center services, home-delivered meals, home modifications, supplemental adaptive and assistive devices, supplemental transportation, out-of-home respite and emergency response systems.
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 Transitions II Aging Carve-Out Waiver Serves Medicaid eligible individuals age 60 and older who were previously enrolled on the Ohio Home Care waiver and continue to need services that would otherwise be met in a hospital or nursing facility.
Waiver services include nursing, personal care aide services, home care attendant services, adult day health center services, home-delivered meals, home modifications, supplemental adaptive and assistive devices, supplemental transportation, out-of-home respite and emergency response systems.

6. Changes to Transition Carve-Out Waiver
PCG Health
4/20/2017
Changes to Transition Carve-Out Waiver
The Transitions Carve-Out waiver is ending on June 30, 2015 and its services are moving to the PASSPORT waiver operated by the Ohio Department of Aging (ODA).
Individuals who are currently receiving transition carve-out services will be transitioning to PASSPORT on February 1, Individuals enrolled on the Home Care waiver who are turning 60 will also be moving to PASSPORT.
Providers who wish to continue to deliver services to this population must:
Be an ODA-certified PASSPORT provider for current service delivery, or
Apply to become an ODA-certified PASSPORT provider, if not one already
The Transitions Carve-Out waiver is ending on June 30, 2015 and its services are moving to the PASSPORT waiver operated by the Ohio Department of Aging (ODA).
Individuals who are currently receiving transition carve-out services will be transitioning to PASSPORT on February 1, Individuals enrolled on the Home Care waiver who are turning 60 will also be moving to PASSPORT.
Providers who wish to continue to deliver services to this population must:
Be an ODA-certified PASSPORT provider for current service delivery, or
Apply to become an ODA-certified PASSPORT provider, if not one already

7. How to become a PASSPORT provider
PCG Health
4/20/2017
How to become a PASSPORT provider
ODA is accepting applications from Home Care and Transitions Carve-Out agencies, non-agency nurse, and non-agency home care attendant providers.
Non-agency personal care aides will be contacted individually, as their waiver individual is ready to transition to the PASSPORT waiver.
To submit an on-line application for PASSPORT certification, please visit the website:
If you are already an ODA PASSPORT provider, go to local PASSPORT agency to verify the waiver services you deliver are included in certification:
If the service is not included in your certification, please request a service addition to your certification.
Please direct any certification questions to ODA at phone or
Ohio Department of Aging is accepting applications from Home Care and Transitions Carve-Out agencies, non-agency nurse, and non-agency home care attendant providers.
Non-agency personal care aides will be contacted individually, as their waiver individual is ready to transition to the PASSPORT waiver.
To submit an on-line application for PASSPORT certification, please visit the website:
If you are already an ODA PASSPORT provider, go to local PASSPORT agency to verify the waiver services you deliver are included in certification:
If the service is not included in your certification, please request a service addition to your certification.
Please direct any certification questions to ODA at phone or

8. Waiver Rules PCG Health 4/20/2017
Waiver Rules are discussed in the next two slides.

9. Ohio Administrative Code
PCG Health
4/20/2017
Ohio Administrative Code
Enrolled waiver providers have agreed to follow the rules and standards of the waiver program(s) based on their provider agreement with the ODM. Waiver providers must read and understand the Ohio Administrative Code rules.
; Definitions
; Individual Choice and Control
; Incident Management, Investigation, Response System
; Structural Reviews and Alleged Overpayments
; Conditions of Participation
For the official rule(s), refer to codes.ohio.gov/oac
Based on the provider agreement with the Ohio Department of Medicaid, all enrolled waiver providers are obligated to abide by the regulations and policies put forth by the State. Therefore, waiver providers must read and understand the Ohio Administrative Code.
For the rules pertaining to both the Home Care and Transitions II Carve-Out Waivers, refer to Rule 5160-Chapter 45. This rule covers the many need to know areas as a waiver provider including definitions, conditions of participation, individual choice, structural reviews and alleged overpayments, and incident management, investigation, response system.
Each one of these areas will be presented and discussed throughout the training.

10. Ohio Administrative Code continued
PCG Health
4/20/2017
Ohio Administrative Code continued
Ohio Home Care Waiver Program
; Covered Services, Requirements, Specifications
; Home Care Attendant Services
; Reimbursement Rates and Billing
; Home Care Attendant Rates and Billing
For the official rule(s), refer to codes.ohio.gov/oac
The code specific to the Home Care waiver may be found in rule 5160-chapter 46.
This rule includes covered services, requirements; reimbursement rates and billing; and home care attendant services, rate, and billing.
All of these Ohio Administrative Codes may be found on the Law Writer website: codes.ohio.gov/oac

11. Waiver Requirements PCG Health 4/20/2017
Requirements as a Waiver Provider are described in the next several slides.

12. Structural Reviews of Providers
PCG Health
4/20/2017
Structural Reviews of Providers
Waiver providers are subject to Structural Reviews to evaluate provider compliance with all applicable Ohio Administrative Codes.
Medicare-certified and/or otherwise accredited agencies as defined in rule of the OAC are subject to reviews in accordance with their certification and accreditation, and therefore shall be exempt from a regularly scheduled structural review.
If requested to do so by ODM or its designee (PCG), agencies shall submit a copy of their updated certification and/or accreditation, and shall make available to ODM or its designee within 10 business days, all review reports and accepted plans of correction from the certification and/or accreditation bodies.
Ohio Administrative Code:
For the official rule, refer to codes.ohio.gov/oac
Waiver providers are subject to a Structural Review to evaluate provider compliance with all applicable Ohio Administrative Codes.
Medicare-certified and/or otherwise accredited agencies as defined in rule 5160-chapter 45-Section 1 of the Ohio Administrative Code are subject to reviews in accordance with their certification and accreditation, and therefore shall be exempt from a regularly scheduled structural review.
If requested to do so by ODM or its designee (PCG), agencies shall submit a copy of their updated certification and/or accreditation, and shall make available to ODM or PCG within 10 days, all review reports and accepted plans of correction from the certification and/or accreditation bodies.

13. Structural Reviews continued
PCG Health
4/20/2017
Structural Reviews continued
All other ODM-administered waiver procedures shall be subject to structural reviews by ODM or its designee during each of the first three years after a provider begins furnishing billable services. Thereafter, reviews shall be conducted annually unless, at the discretion of ODM, biennial reviews may be conducted, when all of the following apply:
There were no findings against the provider during the provider’s most recent structural review;
The provider was not substantiated to be the violator in an incident described in rule ;
The provider was not the subject of more than one provider occurrence during the previous 12 months; and
The provider does not live with an individual receiving ODM-administered waiver services.
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.
All other ODM-administered waiver procedures shall be subject to structural reviews by ODM or its designee (PCG) during each of the first three years after a provider begins furnishing billable services. Thereafter, reviews shall be conducted annually unless, at the discretion of ODM, biennial reviews may be conducted, when all of the following apply:
There were no findings against the provider during the provider’s most recent structural review;
The provider was not substantiated to be the violator in an incident described in rule 5160-Chapter 45-Section 5;
The provider was not the subject of more than one provider occurrence during the previous 12 months; and
The provider does not live with an individual receiving ODM-administered waiver services.
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.

14. Background Check for Non-Agency Providers
PCG Health
4/20/2017
Background Check for Non-Agency Providers
Each enrolled non-agency waiver provider, before the anniversary date of their Medicaid provider agreement, shall be informed of the requirement to:
provide a set of fingerprint impressions, and
complete a criminal records check.
This is a requirement for continued approval as a provider.
Provider background check(s) must be conducted by the Ohio Bureau of Criminal Identification and Investigation (BCI&I), following the receipt of fingerprint impressions and required document(s).
If BCI&I does not receive the report within the required timeframe, ODM will move forward with revoking the provider’s agreement with the department.
Failure to submit the annual background check will lead to termination of provider number.
Each enrolled non-agency waiver provider, before the anniversary date of their Medicaid provider agreement, shall be informed of the requirement to:
provide a set of fingerprint impressions, and
complete a criminal records check.
These are requirements for continued approval as a provider.
Who conducts the background checks?
Provider background check(s) must be conducted by the Ohio Bureau of Criminal Identification and Investigation (BCI&I), following the receipt of fingerprint impressions and required document(s).
If the Ohio Bureau of Criminal Identification and Investigation does not receive the report within the required timeframe,
Failure to submit the annual background check will lead to termination of provider number.
Background check results must be sent directly to Ohio Department of Medicaid from the Ohio Bureau of Criminal Identification and Investigation.

15. Background Check for Non-Agency Providers continued
PCG Health
4/20/2017
Background Check for Non-Agency Providers continued
To obtain a background check, you must go to a location that performs electronic Web Check.
A listing of Web Check agencies can be found on the Ohio Attorney General’s website at the following link, Web Check Community Listing:
ohioattorneygeneral.gov/Services/Business/WebCheck/WebcheckCommunity-Listing
Contact BCI&I by telephone at (877) for additional information.
Ohio Administrative Code:
For the official rule, refer to: codes.ohio.gov/oac
To obtain a background check, you must go to a location that performs electronic Web Check.
A listing of Web Check agencies can be found on the Ohio Attorney General’s website at the following link, Web Check Community Listing: ohioattorneygeneral.gov/Services/Business/WebCheck/WebcheckCommunity-Listing
These regulations are found in Ohio Administrative Code: 5160-Chapter 45-Section 8.

16. Background Check for Agency Providers
PCG Health
4/20/2017
Background Check for Agency Providers
Agency providers may not employ or continue to employ an individual if:
employee is included on the databases listed in OAC
employee fails to submit a records check conducted by BCI&I, including failure to access and complete fingerprint impression sheet
As a condition of continued employment, agencies shall conduct a criminal records check of employees at least once every five years.
Administrative Code:
For the official rule, refer to: codes.ohio.gov/oac
Agency providers may not employ or continue to employ an individual if:
--employee is included on the databases listed in Ohio Administrative Code
--employee fails to submit a records check conducted by BCI&I, including failure to access and complete fingerprint impression sheet
As a condition of continued employment, agencies shall conduct a criminal records check of employees at least once every five years.
These regulations are found in Ohio Administrative Code: 5160-Chapter 45-Section 7.

17. Background Check for Providers continued
PCG Health
4/20/2017
Background Check for Providers continued
New and existing providers are also required to submit a Federal Bureau of Investigation (FBI) background check in addition to the Ohio background check if any of the following applies:
You do not currently live in the State of Ohio.
You have not lived in Ohio for the last five consecutive years.
You have been arrested and/or convicted of a crime in another state.
ODM instructed you to obtain an FBI background check.
Background checks from either BCI& I and FBI must be sent directly to this ODM address:
The Ohio Department of Medicaid
Attention: BCI Coordinator
P.O. Box
Columbus, Ohio  43218
New and existing providers are also required to submit a Federal Bureau of Investigation (FBI) background check in addition to the Ohio background check if any of the following applies:
You do not currently live in the State of Ohio.
You have not lived in Ohio for the last five consecutive years.
You have been arrested and/or convicted of a crime in another state.
ODM instructed you to obtain an FBI background check.
Background checks from either BCI& I and FBI must be sent directly to this ODM address:
The Ohio Department of Medicaid
Attention: BCI Coordinator
P.O. Box
Columbus, Ohio  43218

18. Provider Requirements
PCG Health
4/20/2017
Provider Requirements
Provider requirements for Nurses and Personal Care Aides are on the next several slides.

19. Registered Nurse (RN) Requirements
PCG Health
4/20/2017
Registered Nurse (RN) Requirements
Registered Nurses must do the following:
Maintain a valid Ohio nursing license
Follow the Nurse Practice Act
Obtain physician orders and be listed on the All Services Plan (ASP) prior to delivering services to any individual
Physician’s order (plan of care) must be updated at least once every 60 days
Ensure all verbal orders are documented including date, time, and physician. If orders are not obtained before the end of 60 days, nurses do not have the authorization to deliver services.
Ohio Administrative Code(s):
For the official rule(s), refer to codes.ohio.gov/oac
Registered Nurses must do the following:
Maintain a valid Ohio nursing license,
Follow the Nurse Practice Act,
Obtain physician orders and be listed on the All Services Plan (ASP) prior to delivering services to any individual. The Physician order (Plan of Care) must be updated at least once every 60 days.
Directing RN’s are not reimbursed by the Ohio Department of Medicaid for any services as an RN supervisor.
Individual’s case manager must have the RN Supervisor contact information for the All Services Plan.
RN supervisor must make an initial assessment visit with LPN and individual prior to service delivery.
Ensure all verbal orders are documented including time, date, and physician. If orders are not obtained before the end of 60 days, nurses do not have the authorization to deliver services.
These regulations are found in Ohio Administrative Code: 5160—Chapter 46—Section 4.

20. Licensed Practical Nurse (LPN) Requirements
PCG Health
4/20/2017
Licensed Practical Nurse (LPN) Requirements
Face-to-face visits at least every 60 days with the directing RN to evaluate the provision of waiver nursing services, LPN performance, and to assure services are being delivered in accordance with approved All Services Plan
Face-to-face visits 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
Maintain documentation of plan of care review and physician orders by directing RN
All parties must sign and date the face-to-face documentation
Ohio Administrative Code(s):
For the official rule(s), refer to codes.ohio.gov/oac
All non-agency Licensed Practical Nurses must obtain and maintain a directing Registered Nurse with an active license at all times.
Face-to-face visits must occur at least every 60 days with the directing RN to evaluate the provision of waiver nursing services, LPN performance, and to assure services are being delivered in accordance with the approved All Services Plan.
Face-to-face visits must occur 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.
LPN must maintain documentation of plan of care review and physician orders by directing RN.
All parties must sign and date the face-to-face documentation.
These regulations are found in Ohio Administrative Code: 5160—Chapter 46—Section 4.

21. Personal Care Aide (PCA)
PCG Health
4/20/2017
Personal Care Aide (PCA)
Obtain a certificate within the last 24 months from a competency program. The approved program must include:
personal care aide services,
basic home safety, and
universal precautions for prevention of disease transmission
Obtain and maintain first aid certification from a class that is not solely internet-based and includes hands-on training by a certified instructor.
Complete twelve hours of in-service continuing education annually that must occur on or before the anniversary date of their enrollment as a provider.
Ohio Administrative Code(s):
For the official rule(s), refer to codes.ohio.gov/oac
All Personal Care Aides must obtain a certificate within the last twenty-four months from a competency program. The approved program must include:
personal care aide services,
basic home safety, and
universal precautions for prevention of disease transmission.
PCA’s must obtain and maintain first aid certification from a class that is not solely internet-based and includes hands-on training by a certified instructor.
PCA’s must complete twelve hours of in-service continuing education annually that must occur on or before the anniversary date of their enrollment as a provider.
These regulations are found in Ohio Administrative Code: 5160-Chapter 46—Section 4.

22. Medication Administration PCA Requirements
PCG Health
4/20/2017
Medication Administration PCA Requirements
PCA’s cannot administer medications. They may only assist individuals with self-administration of medications. Examples: PCA may hand pill bottle to individual, but never the actual medications; PCA may provide pill box, but never place pills in box.
Ohio Administrative Code(s):
Personal Care Aides cannot administer medications. They may only assist individuals with self-administration of medications through reminders and physical assistance.
These regulations are found in Ohio Administrative Code: 5160—Chapter 46, Section 4.
For Consumer Supplied Training Options (CSTO’s) , the provider must have completed the training document from the individual, submitted to both the case manager and state with approval prior to any service delivery.

23. PCG Health
4/20/2017
What is My Ohio HCP?
Website that organizes all of a provider’s important Ohio home care program information onto a private, individualized page. It includes important records, forms, tools, surveys, news and updates, contact information and more.
To create your individualized account go to:
What is My Ohio HCP?
It is a resourceful website that organizes all of a provider’s important Ohio home care program information onto a private, individualized page. It includes important records, forms, tools, surveys, news and updates, contact information and more.
To create your individualized account go to:
This image will appear on your computer screen. You will click on “Sign up for myOhioHCP”.

24. Creating an Account You will click on “create account”
PCG Health
4/20/2017
Creating an Account
You will click on “create account”
Complete all fields and hit “save”
Click on “create account”
Once you have completed all the field information, hit save so your account may be created.
ODM encourages providers to check their MyOhioHCP account frequently to view the latest updates and news related to requirements.

25. Documentation Requirements
PCG Health
4/20/2017
Documentation Requirements
Waiver documentation requirements are described in the next several slides.

26. All waiver nursing and personal care aide service providers:
PCG Health
Clinical Records
4/20/2017
All waiver nursing and personal care aide service providers:
Must maintain two copies of individual’s clinical record.
Must leave a legible copy of complete clinical record including the daily visit note in the individual’s home.
Must keep the original in their place of business.
Ohio Administrative Code(s):
For the official rule(s), refer to codes.ohio.gov/oac
All waiver nursing and personal care aide service providers:
Must maintain two copies of individual’s clinical record.
Must leave a legible copy of complete clinical record including the daily visit note in the individual’s home.
Must keep original in their place of business.
These regulations are found in the Ohio Administrative Code: 5160—Chapter 46, Section 4.

27. Identifying Information
PCG Health
4/20/2017
Identifying Information
The clinical record must contain the individual’s identifying information:
Name
Address
Date of birth
Age, Gender, Race, Marital Status
Significant Phone Number
Physician name and number
Medical history
Copy of any advance directives (DNR or medical power of attorney, if present)
Drug allergies/dietary restrictions
The clinical record must contain the individual’s identifying information:
Name
Address
Date of birth
Age, Gender, Race, Marital Status
Significant Phone Number
Physician name and number
Medical history
Copy of any advance directives (DNR or medical power of attorney, if present)
Drug allergies/dietary restrictions

28. All Services Plan (ASP)
PCG Health
4/20/2017
All Services Plan (ASP)
Provider must obtain the ASP prior to rendering services (must have your name, service, and approved start date).
Provider must deliver services as written in the ASP (not allowed to perform more and unidentified services)
Providers must keep a copy of the ASP in the individual’s home
ASP is the authorizing document for services
Any authorized changes must be updated in the ASP and distributed to all service providers by the case manager. Do not accept verbal changes from your waiver individual.
Provider must submit a written request to the case management agency when ASP update is overdue.
Provider must obtain the All Services Plan (ASP) prior to rendering services (must have your name, service, and approved start date).
Provider must deliver services as written in the ASP (not allowed to perform more and unidentified services).
Providers must keep a copy of the ASP in the individual’s home.
ASP is the authorizing document for services.
Any authorized changes must be updated in the ASP and distributed to all service providers by the case manager. Do not accept verbal changes from your waiver individual.
Provider must submit a written request to the case management agency when an ASP update is overdue.

29. Service Documentation
PCG Health
4/20/2017
Service Documentation
Service documentation is required for each visit and must contain all of the following:
Tasks performed/or not performed
Arrival and departure times
Dated provider signature
Dated individual or authorized representative signature
Note: Documentation must support the submitted claim(s).
Documentation is required for each and must contain all of the following:
Tasks performed/or not performed
Arrival and departure times
Dated Provider Signature
Dated Individual or Authorized Representative Signature
Note: Documentation must support the submitted claim(s).
The rules related to documentation requirements are found in Ohio Administrative Code: 5160—Chapter 46, Section 4.

30. Conditions of Participation
PCG Health
4/20/2017
Conditions of Participation
All Waiver providers must follow the conditions of participation which will be described in the next several slides.

31. Conditions of Participation (COP)
PCG Health
4/20/2017
Conditions of Participation (COP)
Ohio Administrative Code , often referred to as the Conditions of Participation (COP), outlines 5 main areas between the waiver provider and individual enrolled on a waiver:
Confidentiality
Boundaries
Behaviors
Significant Events
Terminating Services
For the official rule, refer to codes.ohio.gov/oac
Note: Providers are evaluated to assure their compliance with the Conditions of Participation on an on-going basis.
Ohio Administrative Code 5160-Chapter 45-Section10, often referred to as the Conditions of Participation (COP), outlines 5 main areas between the waiver provider and individual enrolled on a waiver. These areas are:
Confidentiality
Boundaries
Behaviors
Significant Events
Terminating Services
Each one of these areas will be presented in depth in the following slides.
Note: Providers are evaluated to assure their compliance with the Conditions of Participation on an on-going basis.

32. COP continued, Confidentiality of Information
PCG Health
4/20/2017
COP continued, Confidentiality of Information
Clinical records must be kept in a secure location.
Keep all records for 6 years.
All providers are required to keep individual clinical records in a secure location. Additionally, the clinical records must be kept for a minimum of six years.

33. COP continued, Boundaries
PCG Health
4/20/2017
COP continued, Boundaries
Health Insurance Portability & Accountability Act (HIPAA)
Individuals have a right to privacy which includes restricting with whom their personal information is shared. Individual’s privacy rights are protected under HIPPA.
Waiver providers must always deliver services both professionally and respectfully
Conflict of Interest or Taking Advantage of Individual
Waiver provider may not engage in behavior that might be considered a conflict of interest or allows one to take advantage of the relationship that develops due to service delivery.
Individuals have a right to privacy which includes restricting with whom their personal information is shared. Individual’s privacy rights are protected under the Health Insurance Portability & Accountability Act. (HIPAA)
Waiver providers must always deliver services both professionally and respectfully.
Waiver providers may not engage in behavior that might be considered a conflict of interest or allows one to take advantage of the relationship that develops due to service delivery.

34. COP continued, Provider Behaviors
PCG Health
4/20/2017
COP continued, Provider Behaviors
All waiver service providers shall not:
Submit a claim for services rendered while the individual is hospitalized, institutionalized, or incarcerated
Consume the individual’s food and/or drink
Bring family, friends, pets, or anyone else to the individual’s place of residence
Take the individual to the provider’s place of residence
Use illegal drugs or chemical substances
Consume alcohol/ be under alcohol influence while delivering services
Report for duty or remain on duty when provider is using any controlled substance
Deliver services to the individual when the provider is medically, physically, or emotionally unfit
All waiver service providers shall not:
Submit a claim for services rendered while the individual is hospitalized, institutionalized, or incarcerated.
Consume the individual’s food and/or drink.
Bring family, friends, pets, or anyone else to the individual’s place of residence.
Take the individual to the provider’s place of residence.
Use illegal drugs or chemical substances.
Consume alcohol/be under influence while delivering services to the individual.
Report for duty or remain on duty when provider is using any controlled substance.
Deliver services to the individual when the provider is medically, physically, or emotionally unfit.

35. COP continued, Provider Behaviors
PCG Health
4/20/2017
COP continued, Provider Behaviors
Discuss religion, politics, or personal issues with the individual
Accept, obtain or attempt to obtain money or anything of value from the individual
Borrow money, credit cards or other items from the individual, authorized representative, household or family members of individual
Be designated on a financial account or credit card held by the individual, authorized representative, household or family members of individual
Use of property of the individual, authorized representative, household or family members for personal gain
Lend or give the individual, authorized representative, household or family members money or other personal items
Discuss religion, politics, or personal issues with the individual.
Accept, obtain or attempt to obtain money or anything of value from the individual.
Borrow money, credit cards or other items from the individual, authorized representative, household or family members of individual.
Be designated on a financial account or credit card held by the individual, authorized representative, household or family members of individual.
Use of property of the individual, authorized representative, household or family members for personal gain.
Lend or give the individual, authorized representative, household or family members money or other personal items.

36. COP continued, Provider Behaviors
PCG Health
4/20/2017
COP continued, Provider Behaviors
Engage in behavior that causes or may cause physical, verbal, mental, or emotional distress or abuse to the individual
Leave the home for a purpose unrelated to the provision of services without notifying the appropriate parties
Use the individual’s motor vehicle, unless solely for the benefit of individual
Engage in activities that may distract from service
Engage in behavior that takes advantage of or manipulates the individual, the individual’s authorized representative or family, or the waiver program rules resulting in an advantage for personal gain
Use information about the individual, authorized representative, or the individual’s family for personal gain
Engage in behavior that causes or may cause physical, verbal, mental, or emotional distress or abuse to the individual.
Leave the home for a purpose unrelated to the provision of services without notifying the appropriate parties.
Use the individual’s motor vehicle, unless solely for the benefit of individual.
Engage in activities that may distract from service delivery.
Engage in behavior that takes advantage of or manipulates the individual, the individual’s authorized representative or family, or the waiver program rules resulting in an advantage for
personal gain.
Use information about the individual, authorized representative, or the individual’s family for personal gain.

37. COP continued, Significant Events
PCG Health
4/20/2017
COP continued, Significant Events
All waiver service providers must notify ODM or its designee (PCG) within twenty-four hours when the provider is aware of issues/significant events that may affect the individual and/or provider’s ability to render services as directed in the individual’s all services plan. Some issues include, but are not limited to:
Individual consistently declines services
Individual moves to another residential address
Changes in the physical, mental, and/or emotional status of individual
Changes in environmental conditions affecting the individual
Individual’s caregiver status has changed
Individual no longer requires medically necessary services
All waiver service providers must notify ODM or its designee (PCG) within twenty-four hours when the provider is aware of issues/significant events that may affect the individual and/or provider’s ability to render services as directed in the individual’s all services plan. Some issues include, but are not limited to:
Individual consistently declines services
Individual moves to another residential address
Changes in the physical, mental, and/or emotional status of individual
Changes in environmental conditions affecting the individual
Individual’s caregiver status has changed
Individual no longer requires medically necessary services

38. COP continued, Significant Events
PCG Health
4/20/2017
COP continued, Significant Events
Individual is behaving inappropriately toward the provider
Individual is consistently non-compliant with physician orders, or is non-compliant with physician orders that may jeopardize the individuals health and welfare
Individual’s requests consistently conflict with their all services plan
Individual is experiencing other health and welfare issues
Ohio Administrative Code(s):
For the official rule(s), refer to codes.ohio.gov/oac
Individual is behaving inappropriately toward the provider
Individual is consistently non-compliant with physician orders, or is non-compliant with physician orders that may jeopardize the individuals health and welfare
Individual’s requests consistently conflict with their all services plan
Individual is experiencing other health and welfare issues
These regulations are found in Ohio Administrative Code: 5160-Chapter 45-Section 10.

39. COP continued, How to Contact Case Management Agency
PCG Health
4/20/2017
COP continued, How to Contact Case Management Agency
During normal business hours, providers must call or the case manager using their contact information located on the ASP
After hours, on the weekend or holidays, call the applicable number(s) below for further direction:
Care Star: (800)
Care Source Marietta: (855)
Care Source Cleveland: (855)
Council on Aging: (855)
How does a provider contact a case management agency?
During normal business hours, providers must call or the case manager using their contact information located on the All Services Plan.
After hours, on the weekend or holidays, call the applicable number(s) below for further direction:
Care Star: (800)
Care Source Marietta: (855)
Care Source Cleveland: (855)
Council on Aging: (855)

40. COP continued, Terminating Services with an Individual
PCG Health
4/20/2017
COP continued, Terminating Services with an Individual
Submit written notification to the individual and ODM or its designee (PCG) at least 30 calendar days before the anticipated last date of service if the provider is terminating services to the individual.
Provider must submit verbal and written notification to the individual and PCG at least ten days before the anticipated last date of service.
Exceptions to the 30-day notice:
Hospitalized for 3 days
Individual admitted to extended care facility, incarcerated
Note: Discharge summary should be written on the last day of service and contain an overview of individual’s care requirements.
Steps for Providers when Terminating Services with an Individual
Submit written notification to the individual and ODM or its designee (PCG) at least 30 calendar days before the anticipated last date of service if the provider is terminating services to the individual.
Provider must submit verbal and written notification to the individual and PCG at least ten days before the anticipated last date of service.
Exceptions to the 30-day notice:
Hospitalized for 3 days
Individual admitted to extended care facility, incarcerated
Note: Discharge summary should be written on the last day of service and contain an overview of individual’s care requirements.

41. COP continued, Change of Information
PCG Health
4/20/2017
COP continued, Change of Information
In the event of a change in contact information, the provider shall notify ODM via the Medicaid information technology system (MITS) and PCG, no later than seven calendar days after such changes have occurred. These changes might include the provider’s:
address
telephone and fax numbers
Note: Providers should also notify their Case Management Agency.
PCG Contact Information: Phone:   Fax:  
In the event of a change in contact information, the provider shall notify ODM via the Medicaid information technology system (MITS) and PCG, no later than seven calendar days after such changes have occurred. These changes might include the provider’s:
address
telephone and fax numbers
Note: Providers should also notify their Case Management Agency.
PCG’s Contact Information: Phone:   Fax:  

42. Incident Reporting PCG Health 4/20/2017
All providers need to know what are considered reportable incidents and actual reporting of incidents which are described in the following slides.

43. PCG Health
4/20/2017
Incident Management
ODM has designated PCG to perform investigatory functions set forth in Ohio Administrative Code:
PCG must initiate incident reports following identification during any PCG oversight processes
PCG must determine if an incident occurred, and if so, ensure that preventative measures are in place to prevent future occurrences
For the official rule, refer to codes.ohio.gov/oac
Note: All waiver providers are required to complete an Incident Management training by ODM. Attendance is reported to ODM. This may be viewed on PCG’s website at: ohiohcbs.pcgus.com
The Ohio Department of Medicaid has designated PCG to perform investigatory functions set forth in Ohio Administrative Code: 5160, Chapter 45.
At anytime during oversight processes including Structural Reviews, PCG must initiate an incident report following identification.
PCG must determine if an incident occurred, and if so, ensure that preventative measures are in place to prevent future occurrences
Reportable incidents and reporting on the incidents are also defined in the Ohio Administrative Code: 5160—Chapter 45.
Note: All waiver providers are required to complete an Incident Management training by ODM. Attendance is reported to ODM. This may be viewed on PCG’s website at: ohiohcbs.pcgus.com

44. PCG Health
4/20/2017
Reportable Incidents
Reportable incidents shall include, but not be limited to:
(1) Physical, emotional, mental and/or sexual abuse of an individual;
(2) Neglect of an individual;
(3) Abandonment of an individual;
(4) Exploitation of an individual;
(5) Death of an individual;
(6) Accident or injury of an individual;
(7) An unexpected crisis in the individual’s family or environment, with health and welfare implications for the individual;
(8) Loss of an individual’s informal caregiver or family member, with health and welfare implications for the individual;
(9) Inappropriate delivery of services to an individual, with health and welfare implications for the individual;
Reportable incidents shall include, but not be limited to:
(1) Physical, emotional, mental and/or sexual abuse of an individual;
(2) Neglect of an individual;
(3) Abandonment of an individual;
(4) Exploitation of an individual;
(5) Death of an individual;
(6) Accident or injury of an individual;
(7) An unexpected crisis in the individual’s family or environment, with health and welfare implications for the individual;
(8) Loss of an individual’s informal caregiver or family member, with health and welfare implications for the individual;
(9) Inappropriate delivery of services to an individual, with health and welfare implications for the consumer;

45. Reportable Incidents continued
PCG Health
4/20/2017
Reportable Incidents continued
(10) Services provided to an individual that are beyond the provider's scope of practice; (11) Services delivered to an individual without physician's orders; (12) Errors in the administration of medication to the individual; (13) Alleged illegal activity by the individual or in the individual’s environment; (14) Inappropriate use or abuse of substances by the individual; (15) Theft of the individual’s money; (16) Theft of the individual’s personal property; and (17) Theft of the individual’s medication.
(10) Services provided to an individual that are beyond the provider's scope of practice;
(11) Services delivered to a consumer without physician's orders;
(12) Errors in the administration of medication to the individual;
(13) Alleged illegal activity by the individual or in the individual’s environment;
(14) Inappropriate use or abuse of substances by the individual;
(15) Theft of the individual’s money;
(16) Theft of the individual’s personal property; and
(17) Theft of the individual’s medication.

46. Incident Reporting Reporting, notification and response requirements:
PCG Health
4/20/2017
Incident Reporting
Reporting, notification and response requirements:
If a waiver provider learns of a reportable incident, they must report the incident to the Case Management Agency within twenty-four hours.
Subsequently, PCG reviews within one business day of submission to verify:
Was immediate action taken to ensure the health and welfare of the Individual?
In the event of a death, was the county coroner notified if the disability of the Individual was a result of an accident, injury, or trauma?
Note: ODM may conduct a separate, independent review or investigation of any reportable incident.
If a waiver provider learns of a reportable incident, they must report the incident to the Case Management Agency within twenty-four hours.
Subsequently, PCG reviews within one business day of submission to verify:
Was immediate action taken to ensure the health and welfare of the Individual?
In the event of a death, was the county coroner notified if the disability of the Individual was a result of an accident, injury, or trauma?
Note: ODM may conduct a separate, independent review or investigation of any reportable incident.

47. Provider Billing PCG Health 4/20/2017
All waiver providers must follow the billing requirements which will be described in the next several slides.

48. Restrictions on Service & Billing
PCG Health
4/20/2017
Restrictions on Service & Billing
Only bill for the services provided
Only bill for services delivered face-to-face
Providers may not subcontract out their services
Providers may not bill for services provided while the individual is in the hospital or extended care facility
Insurances other than Medicaid must be billed first
If the primary insurance covers the entire service cost, provider may not bill Medicaid
ODM has 30 days to make a payment from the date of a clean submission
Claims must be submitted via the Medicaid Information Technology System (MITS) portal or Electronic Data Interchange (EDI)
MITS Web Portal
Only bill for the services provided
Only bill for services delivered face-to-face
Providers may not subcontract out their services
Providers may not bill for services provided while the individual is in the hospital or extended care facility
Insurances other than Medicaid must be billed first
If the primary insurance covers the entire service cost, provider may not bill Medicaid
State has 30 days to make a payment from the date of a clean submission
Direct deposit or mailed check
Information may be found under “provider tab”, “forms”—

49. Billing Accuracy/ Remittance Advice
PCG Health
4/20/2017
Billing Accuracy/ Remittance Advice
Providers must check all claims prior to submission for payment
If using a billing vendor, providers must ensure the claim has the correct code, date of service, and served individual
Providers must ensure that the clinical documentation matches the appropriate individual, length of visit, date billed, and PAID amount.
Review remittance advices after each payment by comparing to clinical documentation including the All Services Plan.
If an overpayment is found or a claim was billed incorrectly, provider has 60 days to resubmit a correction to the claim.

50. Base and Subsequent Units
PCG Health
4/20/2017
Base and Subsequent Units
Providers must bill pursuant to base and subsequent units:
1 Subsequent Unit = 15 minutes, after the base unit (first hour) of each visit
1 hour = 4 subsequent units
Example: 1 visit of 3 hours
1 Base (1 B)
8 Subsequent Units
(2 hours x 4 subsequent units) or 8 S
Ohio Administrative Code(s):
For the reimbursement rule(s), refer to codes.ohio.gov/oac

51. Example: Non-Agency/RN
Billing Code: T1002(Waiver Nursing); B=1; S=28
Authorized time period--2/11/ /27/2013
Mickey Mouse, RN  
B= 1 Visit or Shift
S= 28 Additional 15 minute increments or 7 hours (28/4=7)
From 2/11/13 thru 2/27/13
Total of 1 Shift not to exceed 8 hours (1+7=8)
8 Hours equals 32 units

52. Example: Agency/Private Duty Nursing
Billing Code: PDN/Agency T1000; B=28, S=784
Authorized time period: 3/1/2013 until the end of ASP date
Kerry Bates,
B= 28 Visits or Shifts
S= minute increments or 196 Additional Hours (784/4=196)
From 3/1/2013 until the end of the ASP date
Total of 28 Visits or Shifts not to exceed 224 hours (28+196=224)
Break down would be 224/28= 8, so 28~ 8 hour shifts per month until the end of the ASP.
8 hours equals 32 units per visit

53. Example: Non-Agency/PCA
Billing Code: T1019(Personal Care Services); B=13, S=160
Authorized time period: 3/1/2013-3/31/2013
Daniel P. Cryer, CSTO  
B= 13 Visits or Shifts
S= minute increments or 40 additional hours (160/4=40)
From 3/1/2013 thru 3/31/2013
Total of 13 Visits or Shifts not to exceed 53 hours (13+40=53)
Break down would be 53/13= 4, so 13~ 4 hour shifts for the month of March 2013.
4 hours equals 16 units per visit.

54. Billing for Agencies, Nurses, & PCA’s
PCG Health
4/20/2017
Billing for Agencies, Nurses, & PCA’s
Refer to the ODM training materials related to billing practices for:
Personal Care Aides
Non-Agency Nurses
Agencies
For the specific billing materials, visit ohiohcbs.pcgus.com

55. ICD-10 Transition What service providers are affected?
PCG Health
4/20/2017
ICD-10 Transition
What service providers are affected?
All providers that are currently required to include ICD-9 codes on claims will be required to use ICD-10 codes beginning with the date of service or date of discharge of October 1, 2015.
Ancillary service providers are included, such as transportation and waiver providers.

56. What ICD-10 codes should I use?
PCG Health
4/20/2017
What ICD-10 codes should I use?
Research the codes that will apply to your business
If another provider supplies your ICD-10 codes, you must ensure those providers are ICD-10 compliant
Consider identifying the most commonly utilized ICD-9 codes and determine the correlating ICD-10 codes
If you utilize a clearinghouse/ billing service, you must ensure the vendor will be ready to accommodate the ICD-10 transition. (Send test claims)

57. ICD-10 Resources PCG: http://ohiohcbs.pcgus.com/
PCG Health
4/20/2017
ICD-10 Resources
PCG:
CMS:
ODM:

58. PCG Health
4/20/2017
QUESTIONS
Please all waiver provider inquiries to:

59. Public Consulting Group, Inc.
PCG Health
4/20/2017
Public Consulting Group, Inc.
P.O. Box Columbus, Ohio 43215
(877) ,