Western Highlands Network

Friday E-Mail Newsletter

Number 82
1/5/2007

The Friday E-Mail is a weekly update for providers by the Services Management Department of Western Highlands Network. Please distribute to all your staff.

Update on Children's Residential Room and Board Rates...Get the details!

The NC Department of Health and Human Services, Division of Mental Health, Developmental Disabilities and Substance Abuse Services (Division) developed statewide Local Management Entity standardized Room and Board authorization and reimbursement guidelines, specified in Division Communication Bulletin #06, Standardized Guidelines for the Payment of Room and Board for Medicaid Eligible Children in Residential Placement, Oct 16,2006.

The guidelines were developed on the bases of parental responsibilities, state and federal regulations governing DSS room and board payments and Supplemental Security Income (SSI). These guidelines were developed to offer consistent authorization throughout the state.

State and Federal funds allocated by the Division may be used to fund the cost of room and board for Medicaid-eligible children from families whose gross family income is at or below 200% of the federal level.

The Division will not allow State funds to support room and board for Medicaid-eligible children from families with gross family incomes over 200% of the federal poverty level and when the parent/guardian refuses to make application of SSI or refuses to remit SSI funds received to the provider.

Although these guidelines are similar to present Western Highlands' authorization and reimbursement policies and procedures some revisions exist to align our program with the state standardized model.

Standard Authorization Guidelines

Authorization for room and board State funds is considered under the following guidelines.

a. Children's Residential Treatment Level II - IV services have been authorized by ValueOptions. When the policies regarding the LME's concurrent review of Person Centered Plans for high risk/high cost consumers have been developed by the state, the LME must agree with-or not dispute- the ValueOptions' authorization.

b. A child is Medicaid-eligible and Medicaid County of eligibility is in the LME's catchment areas. (WHN catchment area: Buncombe, Madison, Henderson, Yancey, Mitchell, Polk, Rutherford, and Transylvania)

c. The parent/guardian is Medicaid-eligible; OR the parent/guardian's gross income is at or below 200% of federal poverty. This eligibility determination is supported by either a copy of the parent/guardian pay stubs or a recent Food Stamp approval notice.

d. If the child is not in DSS custody, the parent/guardian must make application for Supplemental Security Income (SSI) funding, and if approved must use those funds to cover the cost of room and board. If the client's SSI funding is below the $603/month, reimbursement is based on an annualized prorated daily rate. Case responsible providers must submit the Residential Room and Board SSI Worksheet with the SAR to determine the SSI daily payment rate and Western Highlands cost share.

e. Since SSI appeal may occur during placement, cost sharing will be adjusted upon SSI approval retroactively up to six months. The case responsible provider must submit the Residential Room and Board SSI Worksheet to WHN reimbursement department.

Service Authorization Requests

Western Highlands will accept room and board Service Authorization Requests (SAR) with the standardized state Authorization of Room and Board letter from the case responsible provider to substantiate authorization guidelines have been met. Additionally, if the client's SSI funding is below the full reimbursement rate, Western Highlands requires the Residential Room and Board SSI Worksheet to determine the SSI benefit and Western Highlands cost share.

Western Highlands will pend the Service Authorization Requests without an Authorization of Room and Board letter, Residential Room and Board SSI worksheet or if either of these forms are incomplete. Western Highlands will accept either copies of the parent/guardian pay stubs or a recent Food Stamp approval notice to support proof of a family income below 200% of poverty.

Room and Board Rates

The Division also established standard state wide reimbursement rates effective Nov 1, 2006. Since this may be your first notice and Level III - IV rates decreased, Western Highlands will begin reimbursing providers Level III - IV rates effective with dates of service February 1, 2007. The Level II rates are based upon foster care rates and Level III - IV rates were based upon the maximum individual SSI payment in NC ($603/month). Level II rates increased and are effective November 1, 2006. Western Highlands will continue to prorate SSI reimbursement when the SSI is less than $603/month.

WHN Reimbursement Rates

Standardized Parent/Guardian and DSS Letters

The Division produced standardized letters for the residential service providers to notify the County Department of Social Services or the parents/guardians of Medicaid eligible children receiving treatment of their responsibilities regarding room and board payments. The residential services provider is responsible for sending these letters to their intended recipient. Likewise, the Community Support worker should inform the parent/guardian of this process, when the possibility of utilizing residential treatment is first discussed. As instructed by the Division, these standardized letters are replicated on Western Highland's letterhead for residential services providers to use. These letters may be found attached to WHN Communication Bulletin #51, which will be posted on WHN's website.

A Quick Reminder to Residential Treatment Providers:

You also have a responsibility to make sure that you have all the authorizations you need in order to provide services and receive reimbursement for those services. As the reimbursable agent Western Highlands offers the following to facilitate proper authorization.

a. Remind the Community Support (CS) worker at least several weeks before the Room & Board authorization will expire.

b. If you do not receive either a copy (from the CS) of the SAR submitted to WHN, or an LON from WHN before the current authorization expires, continue to remind the Community Support worker. If you do not get a response within an appropriate period of time, contact the community support worker's supervisor. DOCUMENT all of your efforts to get a SAR generated and submitted. You may want to communicate with the case responsible agency through email - this will guarantee a "paper trail".

c. If your SAR is pended, that means we are waiting for approval from ValueOptions. Check the pend code, it is not necessary to call about requests that are pended awaiting ValueOptions approval.

d. If you have not received either a copy (from the CS) of the SAR submitted to WHN, or an LON from WHN by the first day after the expiration of the previous authorization, email Kim Kuhn kimberlk@westernhighlands.org or Candace Rice rice1014@westernhighlands.org with the following information:
Consumer ID # - NO NAMES PLEASE, Date that the previous authorization expired, Service & Service Code needing authorization Name & email of the community support worker, Name & email of community support worker's supervisor. List all documented efforts & dates to get the SAR generated and sent to WHN.

e. This email must be received no later than two (2) working days following the expired authorization. For example, the authorization for Suzy’s Residential Treatment Room & Board expires on Tuesday, 11/15/05. You wait until Wednesday 11/16/05 to see if it arrives. If it does not, you must submit your request along with the required information by email to WHN no later than Thursday, 11/17/05. Your request must be submitted via email. If we receive your request later than the allowed window, we can not act on your request for assistance nor can we consider reimbursement without authorization.

Western Highlands will:

f. If your request arrives within the above timeframe, and with the required information, it will be researched. If the SAR for Room & Board has in fact been received by WHN, you will be notified by email. Please do not send your request in more than once.

g. If a SAR for the Room & Board has not been received by WHN, Provider Relations staff will follow up by sending your email request to the community support worker, community support worker's supervisor & case responsible agency administrator. Provider Relations staff will communicate with you via email to follow up on the status of your request. This will most likely take a few days, so we request your patience as we juggle many types of requests.

Important Footnote: This does not guarantee reimbursement for Room & Board that has not been authorized. If you follow the above procedure we will work with you to help resolve problems you may have with late authorizations.

So you are not getting your Letters of Notification?

Please note that in order to receive your Letters of Notification, your email address must be 32 characters or less on your submitted SAR.

And just one more thing...

This is just a friendly reminder that Provider Level 1 Quarterly Incident Reports are due to Western Highlands Network by January 10, 2007 for the 2nd Quarter (Oct., Nov., Dec. 2006). Please be sure to fill in all the blanks. Fax to Lynn Trotter 828 225-2784 or Email to lynn@westernhighlands.org

Charlie Schoenheit
Director of Services Management
Western Highlands Network
356 Biltmore Avenue
Asheville, NC 28801
Telephone: (828)258-3511 x2219
FAX: (828) 225-2779
E-Mail: Charlie@westernhighlands.org
Website: westernhighlands.org