System Transition FAQs

New/updated questions will be posted to the top of this list.

Posted:  28 September 2007

• When do we begin to implement new service limits with a level 1 client?  If the answer is at their 180, I wonder if we can begin to do it sooner if we choose.

The service hours identified for each level are meant to be guidelines and not limits.  If you have a level 1 consumer who needs more than ten hours, the consumer should be assessed to determine if they need a different level of care using the CA/LOCUS.  If the consumer clearly does not need a higher level of care, the clinician should document the consumer need in the chart and provide the medically necessary services.

• What do we do with clients who are currently being seen by out of network clinicians?  What do we do if these folks never had an RSN eligibility assessment?  Do we need to do an assessment now – before October – and then get permission from NSMHA or what?  What are the options for using documentation/forms provided by the out of network provider (e.g. assessment)?

Consumers should have an intake assessment prior to receiving services.  If you have consumers who have not had an assessment, they should receive one right away.  If they do not have a current authorization, this should also be requested.  Out of network services will be paid based on the encounter data submitted.  Per policy #1522, out of network referrals/services are to be managed by the provider agencies.  NSMHA providers are responsible for having a complete chart for a consumer receiving out of network services that meets CMS, state, and NSMHA standards.  The documentation may be completed by the either the out of network provider or the NSMHA provider as deemed appropriate by the NSMHA provider.

• How do we bill for second opinions especially when it is not an assessment situation?  Are there audit issues if the usual assessment paperwork is not done?

This issue is currently being researched.

• How can data be entered for out of network provider services without an NPI number?

The providers will check with Sound Data.

• How will the NSMHA give credit to agencies for all of their trainings ~ if they want lots of clinicians to go?

The NSMHA-sponsored trainings in the past few months have given CEUs.  For those trainings that providers are required to provide to their staff, the time has been accounted for in the calculation of productivity. 

The number of hours allocated for training as part of the productivity calculation is currently being researched.

• How do we get paid for the cost of interpreters that we need for our clients or for out of network folks?

Interpreters will be paid for through cost reimbursement for in and out of network after a provider has submitted a bill to NSMHA.  Encounter data should be submitted for interpreter services using T1013 (see p. 26 of the Encounter Manual).

• How will we be paid for special population evaluation?

Special population evaluations will be paid on encounter data.  How special population consultation payment is currently being researched.

• Will referrals go to the NSMHA regarding IOP starting October 1st?

Referrals for IOP, wraparound, and day support will go to NSMHA beginning October 1st (PACT already has an established referral process and residential placement is a slightly different process).  Refer to the transition plan for IOP, PACT, residential placement, and day support for consumers in these services prior to October 1st.  NSMHA is working with providers of wraparound regarding the referral process and criteria.

• Will some clients be “bumped” from IOP if a higher need client comes in and we have all slots filled?

Consumers will not be “bumped.”  NSMHA does expect consumers to transition out of IOP and other high intensity services when appropriate.  If IOP slots are not available, the provider should provide services to meet the consumer’s need.

• Does FBG have a flex funds component?

If you applied for flex funds as part of your FBG proposal, you have a flex funds component.  If you did not incorporate flex funds into your proposal and you want to have a flex funds component, your agency can request a contract amendment to designate part of your current grant for flex funds.  The grant amount cannot be exceeded however.

• How detailed does the flex fund bill to NSMHA need to be?  Can the flex funds for the year be spent in a shorter time frame or is there a monthly limit?

A flex fund bill shall indicate the amount being billed and the category for which the funds were used.  Categories will be developed in conjunction with providers at the 10/1 meeting and then posted here.

Flex funds may be spent in the timeframe deemed appropriate by individual providers.

• In Snohomish County, does the referral to provider system include where the client lives?  E.g. is there a catchment area?

There were four geographic sections of Snohomish County in the RFQ.  VOA will assign all cases to reach the RFQ award.  If a consumer lives in South or East Snohomish County, VOA will inform the consumer or their parents of the services located in their area and that there are other providers in the county.  If the consumer/parent chooses to go to a provider outside the area they live, they would be included in the RFQ award percentages.

Consumer choice is the first priority in determining where a consumer will be referred for intake.

• What happens if/when a provider meets their monthly cap for billing?  How often is the cap adjusted?

They will receive 100% of their fees even after the first three month budget payments. I think you are asking what happens if a provider go over their cap after the first three months? Providers who do go over their billing cap can apply for funds left over from other providers not billing up to their cap (if available). This will be done on a monthly basis.

If providers believe they are significantly exceeding their billing caps, they need to consider their risk of potentially not being paid for these services.  NSMHA will transfer funds from providers who are under their billing caps to providers who have gone over their billing caps.  Providers who are exceeding their billing cap need to evaluate whether the intensity of services they are providing are clinically necessary.  NSMHA will be monitoring this through its UR process.

The caps will be examined in the 3rd quarter of the transition to determine whether there will be adjustments.  Quality of data will be an important factor in this process.

• Does the RSN have any expectation of where clinician caseloads should be?  We expect they could go much higher if the referrals keep coming and there are not wait lists or re-distribution of cases.

Other than services that have suggested staffing ratios, it would be up to the provider to determine caseload size using consumer levels and productivity expectations.

• How are assessments billed?  Based on the credentials of the person?  A flat rate?  How many hours can be billed for an intake given the amount of time it takes to perform the intake and do all the paperwork?  Most CPT codes have a time limit, but there is none for 90801s.

On a fee for service basis for the number of minutes the assessment was conducted.  An assessment can be longer than an hour or even extend or several sessions.  If the service goes over the suggested time for a particular code, the agencies should pick the most appropriate code and the agencies will be paid for the actual minutes.  There are codes for incomplete or in progress assessments that should be used.

CMS/Medicaid will not pay for any service when the consumer or person being interviewed is not present.  Hence, unless the documentation is done with the consumer in the room, it cannot be billed. 

• For dual-funded consumers, how is the data prevented from being reported to NSMHA?

This issue is currently being researched.

• Does telephone case management still exist as a code since I didn’t see it in the encounter manual?

Telephone case management is still a viable option and should be billed using code H2015.

• How are consumers on LRs served if they do not meet Access to Care Standards?

Consumers on LRs who do not meet Access to Care Standards should be served using state-only funds.