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Level of Care
Service Plan Questions
How do I become an ADvantage Provider?
All Provider agencies must contact the AAU Contracts Department regarding request to become an ADvantage Provider. At that time information will be given to the Provider Agency as to the procedure for certification as an ADvantage Provider.
Where can I get more information on Case Management Standards, the Conditions of Provider Participation, or other contractual documents?
Case Management Standards and Conditions of Provider
Participation are accessible through the OKDHS website under "ADvantage
Program Contractual Documents". If questions remain, then Submit a PQ
How do I change my agency's referral status or add or delete services?
Contact the ADvantage Administration Unit via ProviderQuestions. Your inquiry will be forwarded to the Contracts Department.
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Who is eligible to receive ADvantage services?
To receive ADvantage Program services, individuals must meet the following criteria:
- Meet nursing facility level of care criteria
- Be age 65 or older OR
Be age 21 or older with a physical disability OR
Be age 21 to 65 with a developmental disability without having an intellectual disability or cognitive impairment related to the developmental disability.
- Meet Medicaid financial eligibility requirements.
How do I make a referral for ADvantage services?
Complete Part I of the UCAT Part I (.pdf, 5 pp, 363 KB) with the applicant. Completed forms should be faxed to 405-230-8018. Applications will be logged and forwarded to the appropriate OKDHS county office for processing.
Individuals may also initiate the application process by calling the ADvantage Administration Resource Center at 1-800-435-4711. The information to complete the UCAT Part I will be taken over the phone and forwarded to the appropriate DHS county office.
Individuals may also contact their OKDHS county office directly to work with an ADvantage coordinator.
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What if a member’s needs are too extensive to be met by an ADvantage Program service plan?
Contact ADvantage Administration Escalated Issues Team through a PQ in Harmony
. Please send only general information as someone will be in contact with you.
What if I feel that the Member no longer meets Level of Care?
Please email all pertinent information regarding your
request, through a PQ in Harmony. All services should continue until you
are notified by OKDHS.
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How soon after referral of a new Member should a case manager submit the new service plan?
The case manager should submit the service plan as soon as possible in order to start delivery of services but no later than ten business days after the AAU date of referral.
How often is a case manager required to submit a service plan for review by the AAU?
The case manager must submit a service plan for approval when an ADvantage Program Member enters the program. The case manager must also submit a service plan for each Member they serve every 12 months for review by the SPA unit. Case managers are also required to submit a service plan addendum for review any time a change in the Member’s health or informal supports requires a change in the type or frequency of ADvantage Program services required to meet the Member’s needs.
Are all service plans reviewed by the AA?
Under federal regulations only services that have been prior authorized through a service plan review/approval process are eligible for reimbursement through Medicaid. Each service plan submitted to the AAU is reviewed by the Service Plan Authorization (SPA) unit.
The AA authorizes the individual service plan and all service plan amendments for each ADvantage member. When the AAU verifies member ADvantage eligibility, plan cost effectiveness, that service providers are ADvantage authorized and SoonerCare contracted, and that the delivery of ADvantage services are consistent with the member's level of care need, the service plan is authorized.
Why does AAU review service plans submitted by case managers?
Federal regulations governing home and community based waiver programs like ADvantage require that any Medicaid waiver service be documented on a care plan approved by the State. OKDHS – ADvantage Administration is the entity responsible for those State of Oklahoma reviews.
As part of the waiver program approval authorization, the State assures CMS that each member's health, safety and welfare can be maintained in their home. If a member's identified needs cannot be met through provision of the ADvantage program or Medicaid State Plan Personal Care services and other formal or informal services are not in place or immediately available to meet those needs, the individual's health, safety and welfare in their home cannot be assured. AAU determines ADvantage program eligibility through the service plan approval process.
How long does it take for the AA to approve a service plan?
If the SPA unit staff does not need additional information from the case manager to approve a service plan, or the service plan does not need a clinical review, the AAU will approve the service plan within 3 to 5 business days of receipt from the case manager.
How soon after Member request for service change or case manager identified need for service change should a case manager submit the amended Service Plan?
The case manager should submit the amended service plan within four business days of assessed need.
Will providers be paid for ADvantage Program services delivered that are not on an approved service plan?
Under Medicaid rules, ADvantage Program services will not be paid by the Oklahoma Health Care Authority (OHCA) unless those services are on an approved service plan. In the past service plans were occasionally back-dated to prevent a lapse in payment for services delivered. Technically the Centers for Medicaid and Medicare Services (CMS) can deny federal participation (68% of reimbursement) in payment for those services delivered and paid within a back-dated period. The practice of back-dating service plan begin dates has ended. To prevent any lapse in service delivery or risk of non-payment for services delivered but not authorized, case managers must submit reassessment plans at least, but not more than, 60 days before the end-date of each existing service plan. At this time plans submitted within 30 days of the reassessment date are considered late if not driven by Member related factors.
What is a Service Plan Review (SPR)?
A Service Plan Review (SPR) is a communication tool provided to the Case Manager/Case Manager Supervisor for the purpose of:
- Providing explanations/education regarding authorization determinations
- Requesting additional information
- Providing feedback regarding documentation submitted
The SPR is automatically attached. Is addressed in the plan notes in the
Who can I speak to about problems I have with an SPR?
Agencies needing assistance from the AA about a
specific service plan should. Submit a PQ in Harmony.
How long do I have to respond to an SPR?
The more quickly a response
is received the faster the issue can be resolved and the plan approved.
What services must be listed on a service plan?
If a service is necessary to ensure the Member’s safety in the home, it must be included on the service plan. This includes ADvantage services, Medicaid state plan, Medicare or other formal (paid) services. Informal (unpaid) and privately paid supports necessary to ensure the Member safety must also be included on the service plan, even though they may be delivered by the member’s family, friends or other parties.
What happens at the AA after a service plan is submitted?
Upon receipt, the service plan is recorded as received by the AA and scanned as an electronic record. It is then reviewed by AAU staff members of the Service Plan Authorization Unit (SPA). SPA staff will determine if the services requested appear appropriate to meet the Member’s assessed needs, and will authorize the service plan if documentation supports the services requested. If SPA staff requires additional information to support authorization of the service plan, they communicate specific issues to the case manager via Conditions and/or Service Plan Reviews (SPRs).
Some service plans require a clinical review. The necessity for this review is often based on the complex needs of the Member. Sometimes, the review is based on the appearance that services on the plan may exceed the amount or type necessary to keep the Member safe in their home. In these situations the clinical review nurse will review all documentation prior to authorizing the plan and will either approve if appropriate, or will contact the case manager for further information via Condition or SPR.
What happens if the amount of services requested on the service plan does not fall within guidelines for authorization by SPA unit reviewer?
If the assessment documentation received by the SPA unit reviewer does not support the type or amount of services requested, or if the amount of services requested exceeds the amount the guidelines will allow, the SPA unit reviewer may submit the plan for clinical review or they may return the unapproved service plan to the case manager for further documentation.
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What services are available through the ADvantage Program?
Services may include:
- Adult day health care
- Case management
- Home-delivered meals
- Home modification
- Occupational therapy
- Personal care
- Physical therapy
- Prescription drugs
- Specialized equipment and supplies
- Speech therapy
- Supported restorative assistance
There are also two service options available to Members in select areas of Oklahoma:
- Assisted Living service option
- Consumer directed personal assistance services & supports (CD-PASS) service option
I need more skilled nurse visits on my current service plan which service code do I use, T1002 or G0154?
If your agency is attempting to bill for additional RN Assessment/Evaluation Units, please use the T1002 service code. If your agency is attempting to bill for Skilled Nursing-Home Setting Units, please use the G0154 service code.
What is the difference between T1002 and G0154, and when do I use each code?
The T1002 service code is used for RN Assessment/Evaluation, and is used for the Registered Nurse only. The G0154 service code is used for Skilled Nursing-Home Setting and may be used for either the Licensed Practical Nurse or a Registered Nurse. For example, filling a one week supply of insulin syringes, setting up oral medications, or providing nail care for the diabetic Member would use G0154. For more information and details please see the ADvantage Program Standards.
Note: the T1002 code/visit is used for the Registered Nurse only. The G0154 code /visit may be either an Licensed Practical Nurse or a Registered Nurse.
How many units can I initially bill on the initial service plan for skilled nurse visits using the T1002 code?
Fifteen units per year for initial plans.
What Hospice services must be listed & how is the rate reflected on the Member’s Service Plan?
The hospice provider receives daily reimbursement regardless of whether they provide daily or weekly services; the service plan needs to reflect this per-diem rate which is the standard payment structure for Medicare, Medicaid and ADvantage (Hospice). The hospice is responsible for incontinence products, personal care, and in some instances nutritional supplements. The plan must be amended to reflect the appropriate payer source. The Hospice Plan of Care must include:
- Certification/Re-certification of Terminal Illness (a statement indicating the Member has a life expectancy of less than 6 months, signed by a Physician)
- Begin and end dates of the hospice certification period
- A comprehensive assessment of the needs of the Member
- The identification of services to be provided by the hospice, including scope and frequency, to the Member and the Member’s family.
If the plan of care is not received the Hospice line cannot be authorized.
How many hours of Adult Day Health can be authorized per day?
Effective July 1, 2013, the maximum authorization for ADvantage Adult Day Health services will increase from 24 units (6 hours) per day to 32 units (8 hours) per day. Effective 7/01/2013, the current code (S5100) will be utilized with a modifier of “U1” for all requests for Adult Day Health.
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How far in advance should a case manager submit a Reassessment service plan to the AAU to insure no disruption in services?
For annual service plan renewals, the case manager should submit the service plan to the AAU at least 30 to 60 days before the Member’s current service plan end date.
For a reassessment, how many T1002 skilled nurse visit units do I use?
Ten units per year for reassessments.
If I need more units than what has been authorized on skilled nursing visits how do I go about requesting those units?
As a case manager you would need to complete an additional case management unit request in Harmony.
What if I have a claim, PA or eligibility issue?
First, review the service plan to determine if there are any conditions (incorrect pay source, not ADvantage covered etc.) present.
Second, contact the case manager to determine if there were any changes to the service plan that could affect this.
Third, if you are still unable to resolve the issue. Contact
the Claims department (918-933-4981) for assistance in resolving any PA,
eligibility or claims issue. Or, create a PQ in Harmony to determine
How does an agency receive assistance with resolving a PA, eligibility or claims issue?
Contact the Claims department
(918-933-4981) for assistance in resolving any PA, eligibility or claims issue.
Or, create a PQ in Harmony to determine.
Will an agency be paid for services provided after the closure effective date when the agency was not notified until after the date of closure?
The agency would need to submit an Adv21 form identifying this and fax to 918-933-4981 for ADM12 review process.
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How does an agency receive a current authorization to check the status of a service line in clinical review?
If you have a service plan with a service line in clinical review, please wait ten business days from submission of plan & then email your request to provider question.
If the service delay is going to jeopardize the Member's health and safety, the provider can request an update at any time but should justify this in the body of the email. In addition, the subject line should reflect this case as a priority.
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If the Member’s services are reduced as a result of the service plan review, does the Member have the right to appeal that decision?
Yes, under Medicaid rules any action that reduces the amount or duration of any Medicaid service that a Member is receiving may be considered an adverse action which the Member has the right to appeal. Since ADvantage Program services are Medicaid services, any reduction in the amount of service a Member was previously approved to receive qualifies for a fair hearing. The case manager must provide and explain Form 02CB016E; Notice in Change of ADvantage Services, to the member when this circumstance occurs. A copy of the signed document should be provided to the AAU.
How does a Member ask to appeal the reduction in services?
The Member should contact the OKDHS county office where their Medicaid eligibility was determined. The social service specialist who determined their financial eligibility can provide them with the forms to complete. OKDHS will assist them in completing the forms if necessary and inform them of legal assistance that may be available to them. Those forms are submitted to the county OKDHS office.
How long does a Member have to file a hearing after they are told their services are being reduced?
The Member has thirty calendar days from the date they signed the service plan reducing their services to file for a hearing. If they do not file for a hearing within that time period, they are not eligible for the hearing.
Can a Member continue to have their previous amount of services delivered until the hearing process is completed?
If the Member requests a hearing within ten business days of the date they signed the service plan reducing their services, the Member is eligible to continue receiving services at the previous amount until the hearing process is completed.
If the Member wishes to continue to have services delivered at the previously-approved amount, the agency may deliver those services and will be reimbursed through the existing process.
However, if the hearing is not in the Member’s favor, the Member may be required to reimburse the state for services delivered in excess of the amount being reduced. For example, if a Member was receiving 30 units of personal care per week and the reduced amount approved by OKDHS is 20 units per week, the Member would be responsible for repaying the state for 10 units per week for personal care delivered between when they signed the service plan reducing their hours and the hearing date. This only applies if the hearing officer determines that the reduction in units was appropriate. If the hearing officer determines that there should not have been a reduction in units, the Member is not required to reimburse the state for those units of service.
How do I advocate for a Member when I think they need a service that has been denied?
The best way to advocate for your Member is to fully document the Member’s needs and create a service plan that meets those needs. If you believe that OKDHS is not authorizing the proper amount or type of services to meet those needs and you believe your documentation supports those services, the AAU staff is available to discuss the case with you so we can fully understand your request.
When a Member requires ADvantage Program services, yet there is still discussion between the case manager and AAU about the type and amount to be approved, all lines on the service plan which are not in question will be approved and the lines in question will be conditionally approved for 30 days. This will insure that services may continue while we seek resolution on the services in question.
Open dialogue between OKDHS and the provider agency on a case in question will expedite resolution of the issues. It will also lessen the possibility of disruption of the Member’s ADvantage Program services.
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If a Member has been notified by the county DHS office that their case has been closed, what needs to be done to close the case?
Submit an email to provider questions to request closure of the case. The county DHS office will be contacted to verify eligibility. If the case has been closed, the systems will be updated and a closure notice faxed to all provider agencies for the Member. You will be advised of the outcome through provider question.
If a Member has been notified by the county DHS office that their case has been reactivated what needs to be done to get services re-opened?
Submit an email to provider questions to request reactivation of the case. The county DHS office will be contacted to verify eligibility. If the case can be reactivated, the system will be updated and a reactivation notice faxed to the case management agency. You will be advised of the outcome through provider question.
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What if I have a grievance or complaint to report?
Providers should contact the ADvantage Administration Unit via PQ. Everyone else may contact the AAU at 918-933-4900.
How can a case manager receive assistance in resolving an issue after multiple unsuccessful attempts to correct a condition?
Submit an email to provider questions regarding the request for assistance and someone with the Member Relations department will be in touch with you by phone to assist in resolving the condition. The Escalated Issues department may be asked to review and work with the involved parties to assist with resolution of issues at this point.
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Will an agency be reimbursed for services provided to a Member even though they have not received a authorization?
For a new member, any ADvantage Program services provided before the effective date on the authorization received by the provider agency may not be reimbursed.
For existing Members, submittal of annual reassessment service plan at least 30 days before the end date of the existing service plan will ensure that the AAU has sufficient time to process the new reassessment service plan and issue the authorization prior to the expiration date of the existing service plan. ADvantage Program services provided between the expiration date of a previous plan and the renewal date on an authorization received by the agency are not eligible for payment under Medicaid. If during a 30-day conditional approval, a plan is not successfully negotiated the plan may be “not authorized”.
In the past service plans occasionally have been back-dated to prevent a lapse in payment for services delivered. Technically, CMS can deny federal participation in payment for those services delivered and paid within a back-dated period. Oklahoma will no longer back date service plans.
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How does a member qualify for the Assisted Living service option?
The Member must meet one or more of the following criteria:
- Member’s current residence is physically unsafe;
- Member has barriers limiting activities of daily living or instrumental activities of daily living function that are not easily modified;
- Member is at risk for losing housing;
- Member requires assistance for taking medications or frequent monitoring at times for which in-home care is no longer available;
- Member currently resides in an Assisted Living Center;
- Member currently resides in a Nursing Facility; or
- Member had a recent loss of informal support.
What does a person interested in Assisted Living need to do?
Before an applicant can be considered for Assisted Living, they must first become an ADvantage Member. They may do this by contacting the AAU, ADvantage Careline at 1-800-435-4711, and apply for ADvantage, mentioning that they are interested in Assisted Living.
If someone is not already on ADvantage, how long does it take OKDHS to determine if they qualify both medically and financially for the program?
Although every situation is different, on average it takes 45 days to determine financial and medical eligibility for ADvantage. However, the time frame depends very much upon the applicant’s timeliness in providing information and documentation required to determine financial eligibility.
After someone is declared eligible for ADvantage, what steps need to be taken before a move can be made into the Assisted Living?
All applicants must have an Assisted Living referral made on their behalf and reviewed by the AAU for determination and tiering. All applicants must have an interdisciplinary team (IDT) meeting with their ADvantage Case Manager at the Assisted Living Facility. A new Member will require a new Service Plan approval date. An existing Member will require an Addendum to their existing Service Plan. New Service Plans take up to 14 calendar days to be written and submitted to AA. A complete service plan can be authorized within our average turnaround time of 3-4 days, with the authorized Service Plan (also referred to as the 6g) being sent to the Case Manager and the Assisted Living center, via fax.
What other ADvantage services can a person residing in an Assisted Living receive?
Since ADvantage is a Medicaid or SoonerCare program, the ADvantage program is eligible to receive any medically necessary service that SoonerCare covers for adults. This would include hospice services as well as Medicare Home Health, as applicable. The Member may not receive personal care service or other services that are the responsibility of the Assisted Living center.
What can a Member expect when residing in an Assisted Living?
Every Assisted Living has their own Lease Agreement. This agreement is something the Member must read and understand thoroughly as it will outline what the Assisted Living allows and doesn’t allow. The policies for private pay residents and ADvantage residents are the same. Some centers have a policy that prohibits smoking and pets. Some centers allow pets but there is a weight limit and often a pet deposit. These should all be explained to the Member, before choosing an Assisted Living, so that they may make an informed choice about where they want to reside.
What is the cost of residing in an ADvantage contracted Assisted Living?
The Assisted Living center decides how much to charge for rental unit and board. However, the center may not charge an ADvantage Member more than the maximum allowed for rental unit and board under current rules for the program located at OAC 317:30-5-764 (a)(7). The Member may be charged no more than 90% of the SSI Federal Benefit Rate amount. This will allow the Member to retain at least 10% of their SSI check and any state supplement payment income to pay for personal needs.
Some Members may be required to pay a Vendor Payment. If an ADvantage Assisted Living Member has income exceeding 150% of the SSI Federal Benefit Rate, any income amount above the 150% level must be used to help pay for the Members ADvantage Assisted Living services. Before, and again upon entry into an Assisted Living center, the Member will be informed of their vendor pay obligation, if any, and the monthly amount of the vendor payment obligation. The AAU will send a Vendor Payment letter to the Member, Case Manager and the Assisted Living informing them of the vendor pay. OKDHS will also send a letter advising the Member and Assisted Living of the vendor payment obligation. A new letter will be generated if the amount should change for any reason. The Member will be required to pay this vendor payment directly to the Assisted Living center providing services.
How do I add the Assisted Living service option an existing plan?
To add the assisted living service option to an existing plan, a service plan cost sheet addendum must be submitted. The service plan cost sheet addendum must end the following service lines: T1002, T1019, S5161, S5170 and G0154 if they are receiving these services on the current plan. The ending date for these services must be 1 day prior to the start date for assisted living service line. Under services to be added the specific assisted living service line HCPC code and rate, as addressed in the tiering notification should be listed as well as a line for Room and Board.
How is the tier level determined?
Each Member is different and must be looked at on a Member-by-Member basis. The clinical staff review the current UCAT, any updates to the UCAT provided by the case manager or assisted living facility, and the Referral and Re-tiering Form that is submitted with the request to determine the appropriate tier level for the Member.
How do I request a re-tier for a Member residing in an Assisted Living Facility?
To request a retier, please submit form 02CB111E, Assisted Living Services Referral and Retiering Request. Requests for retiering can be initiated by the case manager at any time during the service plan year, especially after a significant change in the member's condition. A significant change is defined as a major change in the member's status that is not self-limiting, affects more than one area of the member's health status, and requires interdisciplinary review and/or revision of the care plan.
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What is CD-PASS?
Consumer-Directed Personal Assistance Services and Supports is a service option that allows the Member to self-direct their own personal care services. Instead of using a home care agency that sends a personal care aide to provide services, the CD-PASS service option empowers the Member and allows them to become the employer and hire their own employee, a personal services assistant (PSA). Once the service plan hours are determined, based on their personal care needs, the Member will negotiate pay with their employee (within the maximum limit) and develop a schedule that is suitable to both the Member and employee.
DHS has contracted a fiscal reporting agent that will assume the responsibility of payroll and tax related information. The Member will not directly pay their employee. Their employee will submit timesheets to the Member for approval, and the fiscal reporting agent will make payment based on those Member-approved timesheets.
In addition, designated staff at DHS will assist with application and enrollment into this service option. During application, the Member may also appoint an Authorized Representative, someone they know and trust, to assist them with any of their employer responsibilities. So, between the case manager, DHS, the Authorized Representative, and the fiscal reporting agent, the Member will have the supports needed to be successful with this service option.
Is everyone in the ADvantage Program eligible for this service option?
CD-PASS is available statewide. Every ADvantage Member is eligible to apply for CD-PASS.
How do Members apply for this service option?
Members are sent a CD-PASS brochure upon enrollment into the ADvantage Program. The brochure directs the Member to call the ADvantage Care Line at 1-800-435-4711 for more information. During this call the Member is encouraged to ask questions and see if this option might be right for them. If so, they are sent an application packet. In addition, case managers can also discuss this service option with Members during their initial and annual service planning.
What additional information do case managers need to know about this option?
Case managers are required to be certified as consumer-directed agents (CDA) before providing case management services to anyone who wishes to self- direct their personal care services. In addition, each agency is required to have a supervisor trained in this service option. Therefore, agencies need both a case manager and Case management supervisor certified as a CDA.
What is CDA Certification?
CDA certification is a one day training session that discusses the basics of the Consumer-Directed service option. Although this class stresses the importance of case management services being provided in the same manner for all ADvantage Members, there are some fundamental differences and requirements that are presented.
Where can I find additional information about CD-PASS?
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