SECTION 317:35-17-22. Billing procedures for ADvantage services

(a)   Billing procedures for long-term care medical services are contained in the Oklahoma Medicaid Management Information Systems (OKMMIS) Billing and Procedure Manual. Questions regarding billing procedures that cannot be resolved through a study of the manual are referred to the Oklahoma Health Care Authority (OHCA).

(b)   The Oklahoma Department of Human Services (DHS) Aging Services (AS) approved ADvantage service plan is the basis for the Medicaid Management Information Systems (MMIS)service prior authorization, specifying the:

(1)   service;

(2)   service provider;

(3)   units authorized; and

(4)   begin- and end-dates of service authorization.

(c)   As part of ADvantage quality assurance, provider audits are used to evaluate if paid claims are consistent with service plan authorizations and documentation of service provision. Evidence of paid claims not supported by service plan authorization and/or documentation of service provision are turned over to the OHCA Clinical Provider Audits Unit for follow-up investigation.

(d)   All contracted providers for ADvantage Waiver services must submit billing to the State Medicaid agency, Soonercare using the appropriate designated software, or web-based solution to submit all claims transactions. When the designated system is unavailable, contracted providers submit billing directly to OHCA.

(e)   Service time of personal care, case management, case management for transitioning, nursing, advanced supportive/restorative assistance, in-home respite, consumer-directed personal assistance services and supports (CD-PASS), personal services assistance, and advanced personal services assistance is documented solely through the Electronic Visit Verification System (EVV) when provided in the home. Providers are required to use the EVV system. The EVV system provides alternate backup solutions when the automated system is unavailable. In the event of EVV system failure, the provider documents time in accordance with internal policy and procedures. This documentation suffices to account for in-home and office services delivered. Provider agency backup procedures are only permitted when the EVV system is unavailable.

(f)   The provider must document the amount of time spent for each service, per Oklahoma Administrative Code (OAC) 317:30-5-763. For service codes that specify a time segment in their description, such as fifteen (15) minutes, each timed segment equals one (1) unit. Only time spent fulfilling the service for which the provider is authorized, per OAC 317:30-5-763 is authorized for time-based services. Providers do not bill for a unit of time when not more than one-half of a timed unit is performed, such as, when a unit is defined as fifteen (15) minutes, providers do not bill for services performed for less than eight (8) minutes. The rounding rules utilized by the EVV and web-based billing system to calculate the billable unit-amount of care, services provided for duration of:

(1)   less than eight-minutes (8-minutes) cannot be rounded up and do not constitute a billable fifteen-minute (15-minute) unit; and

(2)   eight (8) to fifteen (15) minutes are rounded up and do constitute a billable fifteen-minute (15-minute) unit.

(g)   Providers required to use EVV must do so in compliance with OAC 317:30-3-4.1, Uniform Electronic Transaction Act (UETA). Providers must ensure:

(1)   an established process is in place to deactivate an employee's access to EVV or designated system records upon termination of employment of the designated employee;

(2)   safeguards are put in place to ensure improper access or use of EVV or designated system is prohibited and sanctions will be applied for improper use or access by staff;

(3)   that staff providing or delivering in-home personal care services must use the EVV system for checking-in and checking out when providing services;

(4)   staff delivering personal-care services is trained in the use of the EVV system;

(5)   a record of services delivered is maintained;

(6)   that staff confirms in writing that they will use the system as they are trained or directed;

(7)   that staff will access the system using their assigned personal identification number (PIN) for in-home service delivery;

(8)   staff accessing EVV or other designated systems for billing, properly use the authentication features of the system to properly document work and confirm work that is submitted for billing for services that were rendered;

(9)   procedures as outlined in the UETA pertaining to electronic signatures, will be applied at such time when use of the electronic signatures is approved and applicable for necessary transaction;

(10)   the EVV or other designated system is responsible for retention of all records that are associated with and generated for the purpose of claims and billing submitted for payment of services rendered;

(11)   that they produce and enforce a security policy that outlines who has access to their data and what transactions employees are permitted to complete as outlined; and

(12)   when using EVV or other designated system for billing and claims submissions, each new invoice or claim, must include the following information in (i) through (vi). The:

(A)   type of service performed;

(B)   individual receiving the services;

(C)   date of the service;

(D)   location of service delivery;

(E)   individual providing the service; and

(F)   time the service begins and ends.

[Source: Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95; Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802, eff 5-27-97; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 19 Ok Reg 338, eff 11-14-01; Amended at 19 Ok Reg 1071, eff 5-13-02; Amended at 20 Ok Reg 376, eff 1-1-03 (emergency); Amended at 20 Ok Reg 1979, eff 6-26-03; Amended at 26 Ok Reg 558, eff 2-1-09 (emergency); Amended at 26 Ok Reg 2149, eff 6-25-09; Amended at 27 Ok Reg 635, eff 2-1-10 (emergency); Amended at 27 Ok Reg 1504, eff 6-11-10; Amended at 31 Ok Reg 1746, eff 9-12-14; Amended at 34 Ok Reg 726, eff 9-1-17; Amended at 36 Ok Reg 945, eff 9-1-19]