School districts may bill Medicaid for three types of therapies contained in IEPs: Occupational, Physical, and Speech Therapy. All therapies billed to Medicaid must be IEP directed. Districts are reimbursed by Medicaid approximately 60% of the allowed amount. Allowed amounts may be found under the "Procedure Codes and Allowed Amounts" link below. The district is responsible for paying the other 40% of the cost for the IEP therapy. See documentation required before billing Medicaid for Direct Services below.
- Billing Direct Services Webcast Power Point Presentation (2008)
- Medicaid Provider Therapy Manual
Required Certifications for Therapy Providers
- Board of Healing Arts Certified/Licensed Speech-Language Pathologist
- Board of Healing Arts Certified/Licensed Physical Therapist
- Board of Occupational Therapy Certified/Licensed Occupational Therapist
- DESE Certified Speech-Language Teacher
- OSEP Guidance on Parental Consent
- Parental Consent Requirements
- Individualized Education Plan
All services billed to Medicaid must be included in the current Individualized Education Plan (IEP). The Plan of Care (IEP) must contain the diagnosis (disability), desired outcome (goals), nature of treatment (type of therapy), frequency of treatment (minutes), and duration (length of time).
- Physician Scripts
All services billed to Medicaid must have a physician script signed by a Primary Care Provider or Medicaid enrolled provider. Scripts should contain Physician Medicaid Provider Number and signature, student name, date, type of therapy, and duration. Scripts are good for one year. Medicaid will accept scripts signed by a nurse practioner.
- Therapy Logs
All therapy logs must be dated, specify the activity, specify the time, and be signed by the therapist.
- HIPAA vs. FERPA
HIPAA 5010 Conversion
The following school districts have been identified as currently submitting version 4010 claims:
- Ferguson-Florissant R-II
- Houston R-I
- West Plain R-VI
To assure claims are not rejected on April 1, 2012, you need to contact your software vendor, clearing house, or whoever does your billing to find out when you will be upgraded to v5010. If you have any questions, the Wipro Infocrossing Help Desk may be reached at 573/635-3559 or via email at the HIPAA Support address [email protected].
For school districts enrolled with MO HealthNet, but not currently submitting claims, you must assure your software vendor, clearing house, or whoever does your billing has upgraded to version 5010 prior to claims submission. Claims submitted on eMOMED are automatically created in version 5010. If you have any questions, the Wipro Infocrossing Help Desk may be reached at 573/635-3559 or via email at the HIPAA Support address [email protected].
Medicaid Eligibility Codes
Supporting Information For Billing
Medicaid states that a district may claim a full unit of service if the remaining amount of time that is not face-to-face therapy is directed toward the student. For example, making more detailed therapy notes, or preparing materials for the next session with that child.
For districts with a large number of students, software is available to purchase for batching. Batching allows districts to send student information and claims into Medicaid in groups as opposed to doing so for each individual student. Batching software may be purchased at www.wpc-edi.com.
The formats needed are:
270 Eligibility Inquiry
|271 Eligibility Response|
276 Claims Status Inquiry
|277 Claim Status Response|
237 Claim Submission
|835 Remittance Advice|
Third Party Liability Insurance (TPL)
Third Party Liability Insurance
Medicaid is required by Federal law to bill any primary insurance (TPL) before paying claims. School districts may access primary insurance (TPL) through Medicaid with the parents consent if it does not affect any of the situations listed below. If the parent refuses consent, or one of the situations below apply, the district may send a letter to insurance asking for a denial not to pay IEP Services. It is very important that the district's legal council review letter before sending. See Sample Letter below.
-Decrease available lifetime coverage or any other insured benefit.
-Result in the family paying for services that would otherwise be covered.
-Increase premiums or lead to discontinuation of benefits.
-Risk loss of eligibility for home and community-based waivers
Medicaid will pay approximately 60% of the Federal portion of the allowed amount. If $10.00 is allowed for one unit, Medicaid will pay approximately $6.00. The district is responsible for the remaining 40% State portion. Direct Services reimbursement from Medicaid should go back into the Direct Services program.