(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 which cannot be resolved through a study of the manual should be referred to the Oklahoma Health Care Authority (OHCA).
(b) The Department of Human Services Aging Services (DHS/AS) approved ADvantage service plan is the basis for the Medicaid Management Information Systems (MMIS)service prior authorization, specifying:
(c) As part of ADvantage quality assurance, provider audits are used to evaluate whether paid claims are consistent with service plan authorizations and documentation of service provision. Evidence of paid claims that are not supported by service plan authorization and/or documentation of service provision are turned over to the OHCA Provider Audit Unit for follow-up investigation.
(d) Service time of Personal Care, Case Management, Case Management for transitioning, Nursing, Advanced Supportive/ Restorative Assistance, In-Home Respite, CD-PASS Personal Services Assistance and Advanced Personal Services Assistance is documented solely through the Interactive Voice Response Authentication (IVRA) system when provided in the home. Providers are required to use the IVRA system after access to the system is made available by OKDHS. The IVRA system provides alternate backup solutions should the automated system be unavailable. In the event of IVRA backup system failure, the provider documents time in accordance with their agency backup plan; however, backup procedures are only permitted when the IVRA system is unavailable.
(e) The provider must document the amount of time spent for each service, per OAC 317:30-5-763. For service codes that specify a time segment in their description, such as 15 minutes, each timed segment equals one unit. Only time spent fulfilling the service for which the provider is authorized, per OAC 317:30-5-763, shall be authorized for timed based services. Providers shall not bill for a unit of time when not more than one-half of a timed unit is performed. For example, if a unit is defined as 15 minutes, providers should not bill for services performed for less than 8 minutes. The rounding rules utilized by the IVRA and web-based billing system to calculate the billable amount of a unit are:
(1) services provided for a duration of less than 8 minutes cannot be rounded up and do not constitute a billable 15 minute unit; and
(2) services provided for a duration of 8 to 15 minutes are rounded up and do constitute a billable 15 minute unit.