Medicaid Accountability in the I-Suite

How to document Medicaid services in the I-Suite to assist

with compliance with Medicaid standards.

April 24, 2023

“What criteria must a child meet in order for the district to bill Medicaid under the SHARS program?

The child must: be enrolled in a public school’s special education

program; be 20 years of age or younger; Have an ARD/IEP documenting the medical

necessity for services [Documentation requirements can be found in the current Texas Medicaid Provider Procedures Manual (TMPPM), in the Provider Enrollment and Responsibilities Section and in the SHARS Section];

Have a disability or chronic medical condition; Be Medicaid eligible.

2Source: TEA SHARS Frequently asked questions 2011

Review TMPPM – Billing Guidelines can be reviewed with Providers for training.

Services covered by SHARS includes:

Audiology services Counseling Nursing services Occupational therapy (OT) Personal care services (PCS) Physical therapy (PT) Physician services Psychological services, including assessments Speech therapy (ST) Transportation in a school setting

These services must be provided by qualified personnel who are under contract with or employed by the school district. Furthermore, the school district must be enrolled as a SHARS Medicaid provider in order to bill Texas Medicaid for these services.

Source: Texas Medicaid Provider Procedures Manual (TMPPM) 2011 published by TMHP

Retained for 7 years

Documentation

ARD/IEP documents (medical necessity; examples of SHARS services) Attendance records Assessment/evaluations Provider qualifications (current licenses and certifications) Written agreements (contract) for contracted service providers Required prescriptions or referrals for services Supervision logs Session notes or service logs Transportation documentation (daily trip logs; maintenance logs/records; bus

documentation; documentation for cost report) Claims Submittal and Payment Histories (R&S Reports and General Ledger) Copies of signed/notarized quarterly Certification of Funds (COF) letters and

supporting documentation, including quarterly COF Reports Non-school SHARS provider affiliation letter and attachments (if applicable) Cost Report Documentation

4Source: TEA SHARS Frequently Asked Questions 2011

“The child’s name and Medicaid number should appear on every page of the medical records (see the Provider Enrollment and Responsibilities Section of the current TMPPM). This would include each page of the ARD/IEP document, session notes and service logs, and evaluations.”

ARD Documents

Adding the Medicaid ID to forms needs to be turned on in File Maintenance. Non-(SM)2 clients

Manually input the Medicaid ID into Student Information - General (SM)2 clients

Medicaid ID automatically inserted on all forms each month when Medicaid eligiblity is obtained.

Automatic label reminder can be turned on in FM – Options/Directories to print labels to stick on ARD documents

FM – Form Setup Can indicate how many labels are needed per form.

Could be considered part of consent and if parent refuses number on forms then they are refusing to give consent to bill


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Session Notes

(SM)2 program keeps session notes. Non-(SM)2 clients need to collect and store

separately.

Source: TEA SHARS Frequently Asked Questions 2011

“Are schools required to obtain parental consent prior to billing Medicaid for SHARS services?”

“Yes, Section 300.154(d) of the reauthorized IDEA 2004 requires districts to obtain informed parental consent. More guidance on this issue may be found on TEA’s Division of IDEA Coordination website at: www.tea.state.tx.us/special.ed/guidance/medserv.html “


http://www.tea.state.tx.us/special.ed/guidance/medserv.html

http://www.tea.state.tx.us/special.ed/guidance/medserv.html

Parental Consent is obtained in 2 places in SEM

ARD Signature page (pg. 7) Should be obtained at EVERY ARD – not just

the Annual There is now an initial line next to consent.

SHARS Letter Can be given when obtaining initial consent as

it also includes the Right to Provider section.B

oth locations provide space for a Consent Expiration date.

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Note: If there is an error message when entering the SHARS letter, the district needs to enter the district specific information in the Popups in File Maintenance – SHARS Information.

ARD Page 7

(SM)2 reads PC from signature page of ARD as well as SHARS Letter

Will not bill TMHP if there is no consent at the time of the service

Reports can be run to show who has consent and who does not

When the letter is returned signed, the dates need to be entered into (SM)2 Parental Consent Tracker or on the letter itself.

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It may be reassuring to let parents know that:• billing Medicaid is not a new process• SHARS is reimbursement money to the schools• their child’s ability to receive services outside of the school setting will not beimpacted• SHARS is a program under EPSDT and is not subject to any type of limit or“cap” on services• they can withdraw permission at any time

“Could billing SHARS cause a child to exceed any ‘cap’ or lifetime maximum on their Medicaid benefits?”

There is no lifetime benefit cap for Medicaid services to children 20 years of age or younger. SHARS is a program under the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) program. Under EPSDT, there are no set limitations or cap on Medicaid services to clients 20 years of age or younger, so long as the service is medically necessary. The Medicaid services the child receives at school do not affect the type or amount of Medicaid services the child receives outside the school.

Personal Care Services (PCS) in ARD

“Indication of placement in a self-contained setting [i.e., Life Skills classroom, Preschool Programs for Children with Disabilities (PPCD), etc.] is not sufficient IEP documentation to support Medicaid reimbursement for PCS.”

Sufficient documentation should answer:(1)Is the service provided on a one-on-one basis or

group or both; (2)examples of PCS; (3)when/where are the PCS needed; and (4)the reason(s) for PCS, such as medical

necessity, etc.


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Refer to SHARS FAQ for examples of good documentation.

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Refer to SHARS FAQ for examples of good documentation.

This section of the PCS Supplement is to document exactly what the PCS look like in the school setting. This popup field can be edited by the district SEM Administrator.

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LOCATED IN SEMIn addition to the PCS Supplement, the Transportation Info form documents the need for a bus aide or monitor which would be billed as Personal Care on the Bus.



19Source: TEA SHARS Frequently Asked Questions




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In (SM)2, Providers need to enter Date, Start Time, and End Time.System calculates Total Minutes and Units.

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Documenting Speech and Related Services in the ARD

ARD Schedule Page Service type, frequency, and duration need to be

listed. Supports/Other line under subjects or related

services. IEP

Goals and objectives can be sufficient documentation for billing services

Deliberations Services can also be explained/described here.

Counseling as a Related Service ARD Schedule Page

“Counseling” is billed by LCSW or LPC “Psychological Services” is billed by LSSP

“BIP is needed to bill for emergency services and should list the need for emergency counseling”


Schedule Page of the ARD

Related Services Speech Therapy List time, frequency, and duration Any additional information can be entered on the

Supports/Other line.


Nursing Services

ARD Physical Section (pg 2) Adds service to Related Service section on Schedule Page Specific services can be listed in the Other Physical box.

“The ARD minutes should include recommendations derived from the RN/APN or physician’s evaluation of the student’s nursing services needs. Nursing services need to be stated with the same level of detail as is provided for the other related services. But, due to the type of services, it may be appropriate to add language such as “as needed”.


Transportation services in a school setting may be reimbursed when they are provided on a specially adapted vehicle and if the following criteria are met:

Provided to or from a Medicaid-covered service on the day for which the claim is made

A child requires transportation in a specially adapted vehicle to serve the needs of the disabled

A child resides in an area that does not have school bus transportation, such as those in close proximity to a school

The Medicaid services covered by SHARS are included in the student's IEP

The special transportation service is included in the student's IEP

28Source: Texas Medicaid Provider Procedures Manual (TMPPM) 2011 published by TMHP

A specially adapted vehicle is one that has been physically modified (e.g., addition of a wheelchair lift, addition of seatbelts or harnesses, addition of child protective seating, or addition of air conditioning). A bus monitor or other personnel accompanying children on the bus is not considered an allowable special adaptive enhancement for Medicaid reimbursement under SHARS specialized transportation. Specialized transportation services reimbursable under SHARS requires the Medicaid-eligible special education student has the following documented in his or her IEP:

The student requires a specific physical adaptation or adaptations of a vehicle in order to be transported

The reason the student needs the specialized transportation

Source: Texas Medicaid Provider Procedures Manual (TMPPM) 2011 published by TMHP

Transportation listed as a Related Service (SEM)

Transportation Eligibility Form (SEM)

Record medical necessity for the service Record special adaptive equipment needed.

Transportation Information (SEM)

Transportation Special Needs Report (RU) If student does not appear on this list with the special equipment

needed listed, districts may not want to bill for that student’s transportation.

For all students that will not be billed for transportation, mark their Transportation Non-billable in (SM)2

Entering all log data enables the system to calculate the transportation information for the SHARS Cost Report.

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This option needs to be selected and the textbox MUST document the

specific equipment THIS STUDENT needs on THIS BUS.

An additional adult or bus monitor is not special equipment. A bus monitor would

fall under Personal Care on the bus.

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Found in the Report Utility (RU)

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(SM)2 Administrator needs to mark which student’s bus routes are NOT billable.


At a minimum, the transportation log should include: The SHARS provider name (i.e., school district name) First Name and Last Name of each student for each trip, along with each student's ID One log per vehicle, indicating the route name/number [with documentation maintained somewhere that describes each route/trip as to the start and stop locations ] Method for identifying the number of one-way trips per day (e.g., AM and PM trips) [with documentation maintained somewhere that describes the times for each trip] -- Remember that the number of one-way specialized transportation trips must be counted for calculating the one-way trip ratio for allocating specialized transportation costs to the Medicaid program. Method for personal care services (PCS) provider, transportation aide, bus monitor, or assistant to verify own attendance for each trip and include a place for this person to sign and date the form. Method for drive to verify own attendance for each trip and include a place for this person to sign and date the form. Method for nurse to verify own attendance for each trip and include a place for this person to sign and date the form. The log can be maintained per day and for several days, with applicable dates noted on the log. Mileage needs to be maintained somewhere; but, not on the log.

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(SM)2 can assist with the compiling of the data for the Cost Report.

Calculates the IEP Ratio Identifies student who were Medicaid Eligible

at ANY time during the year. Identifies which students were receiving a

SHARS service. (SM)2 knows which students actually receive

PCS. Transportation logs track the number of one-

way trips

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IEP Ratio data

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Transportation Data

Can a SHARS provider provide services beyond the IEP requirements?

No, the IEP authorizes the maximum services that can be provided and billed. Under the Individuals with Disabilities Education Act (IDEA), districts are required to follow the IEP requirements. Any services billed to Medicaid in excess of those stated in the IEP could be subject to recoupment.


If a student needs constant monitoring all day, even during instructional time, is the entire day billable as personal care services?

The IEP should clearly justify the need for constant supervision or monitoring and any other PCS (such as toileting, feeding, etc.) required during the school day. The documentation needs to answer the following questions or provide the requested documentation: (1) examples of PCS; (2) when/where are the personal care services are

needed; (3) reason(s) for PCS (such as medical necessity,

etc.); and (4) why can’t the student perform the age

appropriate task?


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