Claims & Appeals Process

Q: Can providers bill per diem for dates of service during which a customer is admitted to the hospital, etc.?

A: The provider who is responsible for the customer’s care when they go to sleep for the night is able to bill for that day.

Q: What is being done about the lack of communication between fiscal intermediaries and other providers with regards to overlapping claims?

A: Concerns with billing and documentation are being investigated at a regional level. If one provider has unsuccessfully attempted to contact another to work through duplicate claims issues, they should inform Summit Pointe.

Q: What is the process for duplicate provider claims if sufficient documentation is presented by both providers?

A: If there is no resolution upon review of provider documentation, both providers will be notified of the overlapping claims and both will be denied. Providers will be asked to come to an agreement and resubmit claims for the services provided.

Q: Do providers need to submit a form for the second level appeal?
A: Yes, the updated form will have the option to select if it is a first level or second level appeal.

Q: What is the difference in the second level appeal?
A:

  1. To give the provider the opportunity to submit additional information to support the claim
  2. A second review to ensure nothing was missed or changed during the first review

Q: What form would providers use to submit a third level review to SWMBH?
A: Providers should use the Summit Pointe appeal form to indicate “Level 3- SWMBH” on the appeal form. This information will be sent to SWMBH for review.

Q: Would overlapping services be a reason to appeal?
A: Yes. You would need to submit the documentation to the support the services and the time(s) the services were provided (face-to-face programming time).

Q: What is the expected response time when we submit an appeal?
A: 30 calendar days from the date the appeal was submitted.

 

Trends in Compliance

Q: Which areas (in the “Trends” section) were repeat citations?
A:

  1. Staff trained on the IPOS
  2. Documentation of providing choice to customers
  3. Documentation of opportunities for customers/guardians to provide feedback on services.

Q: Are providers supposed to be documenting on everything in the plan, including all of the information in the narrative section of the intervention?
A: Summit Pointe is making and effort to focus on basic “Case Management 101” techniques. We are training our staff to ensure they are using SMART goals and objectives. The narrative in the intervention is the “how.” It is how the provider will assist the customer to master their objectives to achieve their goals. It is important for providers to work with the case manager to ensure the intervention section corresponds with the services being provided. Also, providers should check the intervention section to verify what goals and objectives pertain to the services that the agency is providing. Providers should document on those goals, objectives, and interventions that apply to your agency.

 

Behavior Plans

Q: What is the process for submitting data tracking forms to Summit Pointe?

A: Data tracking sheets must be submitted by the 7th of each month to Bridget Avery. They can be faxed or emailed. Please DO NOT send to recipient rights.

Q: Can Summit Pointe coordinate the providers to do one meeting for the behaviors plan training and updates?
A: Yes. We can work with the BCBAs to start doing this process.

Q: Behavior plan tracking sheets- How do providers track behaviors, such as tantrums, that last 3-4 hours? Does that go one one tracking sheet with the start and stop time?

A: The plan should indicate how to document these incidents. If the behavior did last that long, please include as much information as you can to support and provide information related to the behavior on the data tracking sheet. The BCBA will also want to look at additional information such as the daily progress notes.

Q: How do providers know when the plan expires? Can we get documentation of it?

A: The plans do not technically expire, however the BCBAs are required to review and update the plan annually. The plan should go no longer than a year without review. If a provider has plans that have not been reviewed in a year, please contact Sean Field. The BCBA should be providing a discharge summary along with recommendations for future supports.

Q: Providers are still having a lot of difficulty getting the signature page of the behavior plan with the guardian’s signature. Is there a process in place to address this?

A: In the last month, Summit Pointe has developed an internal tracking system. If you continue to see this issue and are unsuccessful getting a copy from the case manager, please notify Sean Field or Bridget Avery.

Q: Can a Provider participate in a Behavior Treatment Committee (BTC) meeting to discuss a particular individual?

A: Yes. Providers can email Sean Field  and Bridget Avery and request to be added to the meeting agenda.

 

Home and Community Based Services

Q: How are providers expected to handle situations in which a customer puts themselves at risk for sexual abuse?

A: Providers are to allow customers to make their own decisions regarding consensual sexual activity. In the event that a provider is held liable for misconduct as a result of a consumer’s own decision, they may follow the formal appeal process. Specialized residential providers may encourage residents to create agreements for how they will respect each other’s privacy and maintain a favorable living environment for all parties.

Q: How are providers expected to handle customer marijuana possession and use?

A: Marijuana is still considered to be criminalized from a federal perspective. Providers may include policies on possession of illicit substances in the resident agreement. Providers may also establish a non-smoking facility in which residents are not allowed to smoke inside or within 25 feet of the facility. If a resident does not follow guidelines established in their signed resident agreement, they may be subject to discharge.

Q: Are providers responsible for resident funds if they are not the representative payee?

A: If residents keep a portion of funds in their home to use for personal expenses, they may ask the provider to hold money in a secure location. Providers must allow residents access to those funds upon request for any reason.

Q: Are restrictions, such as having knives locked up, now going to require the customers to have a behavior plan?

A: In most cases, no. Specific types of restrictions have been placed into our assessments in SPOT. The need for HCBS restrictions will be evaluated in the assessment and documented in the case manager’s treatment plan. 

Q: How do we get copies of the assessment review and the outcome?

A: Summit Pointe always has this documentation on file. It is the requirement of the CMH to manage restrictions. It  is the requirement of the case manager to demonstrate progress or barriers toward removing restrictions in their periodic reviews and treatment plan addendums.

Q: How do we address an individual’s freedom to access the community independently while continuing to monitor their safety?

A: If an individual is unable to access the community independently without putting themselves at risk, the IPOS may indicate that they are able to go into the community with staff support. It will need to be outlined very clearly in the authorization intervention how long a restriction will be in place and exactly how it will be restricted and monitored. AFC assessments may be updated to document an individual’s need for increased safety measures. 

Q: If one person living in a specialized residential home has a restriction in their treatment plan that affects other residents, do all residents need to have the restriction documented in their treatment plans?

A: Each resident’s individual treatment plan will need to cover all of the bases of HCBS. If there is a restriction in a resident’s plan based on the needs of another resident, it must be very clearly documented that this is the resident’s choice based on their living arrangements. Every person has a choice of roommate and will need to have their agreement to live with certain people with certain restrictions documented in their IPOS. Some people may even request specific restrictions (ex. having cigarettes held by staff) to safeguard their own property. They may remove this restriction at any point. Providers can utilize the person-centered planning process to develop ideas that meet individual health and safety needs. 

Q: For the  HAB Waiver CAPs, if it is a program issue notified, can the provider submit a CAP for the whole program? Or, do the providers need to have individual CAPs with the same issue identified for each customer?

A: You still need to address it on the individual level. The recommendation is that you list all of the WSA numbers that each programs issue applies to.

Q: Do providers need to CC anyone at Summit Pointe when submitting a CAP to SWMBH?

A: Yes, please CC Elizabeth Wygant.

Q: Providers are still seeing that case managers are listing that the customer will abide by house rules in the treatment plan. Can this be addressed as it does not align with the HCBS rule?

A: Yes.

Misc.

Q: How do I submit Recipient Rights trainings for employees?

A: Please submit evidence of Recipient Rights trainings electronically via Excel spreadsheet. Every employee’s may be uploaded at once with their most recent training. 

Q: Are the Summit Pointe training requirements the same as the SWMBH training requirements?

A: Yes, with the exception of the Recipient Rights training and CPR training. These need to be completed prior to working with customers. This exception is outlined in the contract. (Training Requirements Matrix)

Q: Is Summit Pointe still accepting the “train the trainer” for IPOS training and behavior plan training?

A: Yes.

Q: If I am registered for CHAMPS in one location, am I registered as a company?

A: The very last tool available on our CHAMPS page will show you how to verify if you’re officially registered. We will be running reports in January 2019 to verify that every provider is successfully enrolled. 

Q: How will we be notified of staff changes within Summit Pointe and new contact information?

A: For major staffing changes that affect our provider network, we will be sending out a general email blast. We will also be working towards a warm hand-off between case managers when cases are transferred so that all relevant parties are notified and provided with current contact information.