The provider should not submit claims solely on the basis of the prior authorization, but must base claims upon documentation of actual services rendered. The participant may have been in the hospital or nursing home during a month, may have been away from the home visiting family or friends, or there may have been other reasons why all services which were prior authorized were not necessary or could not be delivered. The prior authorization merely establishes the maximum number of hours and types of services which may be given to a participant during a time period. All units billed to MO HealthNet must be supported by the documentation of delivery as described in this section.
Pursuant to the above, providers can only bill for actual services rendered. If, for example, a month only has 28 days, the provider cannot provide services on the 29th, 30th or 31st day. Specifically, if a service is authorized to be provided once a day, and the month only has 28 days, then the service can only bill for the days service provided up to a maximum of 28 days.
2. Question: How will MMAC conduct audits with regard to signatures? MMAC has posted guidance on this issue on its website. 3. Question: How will MMAC conduct audits with regard to nurse visits? Specifically, is a pre-printed form acceptable with a short narrative or short notes, and a signature (a form with check boxes), or does the whole form need to be handwritten? A pre-printed form is acceptable with a short narrative or short notes, and a signature. The whole form does not have to be hand-written. If, however, the type of information required to be documented is not susceptible for being captured in a pre-printed form, then the information must be supplied. For example, if the required information is to provide the participant’s vital signs, a “check the box” option would not be acceptable. The participant’s actual vital signs must be documented on the form. 4. Question: Is it acceptable for an LPN to do certain activities on the authorized nurse visit, as opposed to an RN? 13 CRS 70-91.010(6)(0)4 provides: The RN may provide nail care for a diabetic or client with other medically contraindicating conditions, if the recipient is unable to perform this task.Although section 335.099 RSMo states LPNs are “qualified” to perform certain services, it uses the qualifier “as required by the department of social services”. The Department of Social Services requirements include that the LPN’s work be under the direction of an RN. The Missouri State Medicaid Plan specifies that nurse services and personal care oversight are to be provided by an RN. For that reason, the Department of Social Services requires that the LPN’s work be under the direction of an RN. 13 CSR 70-91.010(6)(0)7 provides: The visits authorized under subsection (6) except (6)(0)6 may be carried out by an LPN, if under the direction of an RN.Section 13.8 of the MO HealthNet Medicaid Personal Care Manual states: The authorized nurse visits listed above may be provided by an LPN, if under the direction of an RN, except an RN must perform the on-the-job training and competency testing for advanced personal care aides.In order to comply with the above, MMAC requires documentation to prove that there is an RN on staff with the agency.
Personal Care Services Provided in a Residential Care Facility Setting or the Participant’s Home
Please note that, pursuant to 13 CSR 70-91.010(4)(A) 2.F., documentation for services delivered by the provider in the Personal Care Program must include the following:
F. For each date of service: the signature of the recipient, or the mark of the recipient witnessed by at least one (1) person, or the signature of another responsible person present in the recipient’s home or licensed Residential Care Facility I or II at the time of service. “Responsible person” may include the personal care aide’s supervisor, if the supervisor is present in the hom e at the time of service delivery. The personal care aide may only sign on behalf of the recipient when the recipient is unable to sign and there is no other responsible person present.
Please also note that the MO HealthNet Personal Care Program Manual 13.7.D(1) states:
6. For each date of service: the signature of the participant, or the mark of the participant witnessed by at least one person, or the signature of another responsible person present in the participant’s home or licensed Residential Care Facility I or II at the time of service. A responsible person may include the personal care aide’s supervisor, if the supervisor is present in the home at the time of service delivery. The personal care aide may only sign on behalf of the participant when the participant is unable to sign and there is no other responsible person present. The entire signature of the participant or witness to the mark or the responsible party must be present in the record for each date of service billed to MO HealthNet. Initials are not acceptable in lieu of the entire signature. The participant’s DCN is not required on the time sheet.
The regulation and the manual do not establish a hierarchy of preferences regarding the signature. As long as the signature of the recipient (in its entirety; initials are not permitted), the witnessed mark of the recipient (the witness’s entire signature must be present; initials of the witness are not permitted) or the signature (in its entirety; initials are not permitted) of another responsible person present in the recipient’s home or RCF I or II at the time of the service (“responsible person” may include the personal care aide’s supervisor, if the supervisor is present in the home at the time of service delivery) is present for each date of service, then the above- requirements will be fulfilled. However, the personal care aide may only sign on behalf of the participant when the participant is unable to sign and there is no other responsible person present (the reason for the participant’s inability to sign must be documented.
The same standards apply if a recipient has made a blanket signature statement, such as, “the requirement is too burdensome and I therefore authorize the provider’s staff to sign on my behalf.” If the recipient has chosen to do this, the entire signature of the other responsible person must still be present for each date of service. The personal care aide still may only sign when there is no other responsible person present, and in such case, the recipient must be unable to sign. Documentation must be provided to support the reason the recipient was unable to sign.
In a Residential Care Facility setting, note that all tasks performed for each recipient by date of services and by staff shifts during each twenty-four (24)-hour period must be documented. For example, if three (3) aides provide services to one recipient in a twenty-four (24)-hour period, each aide must document all tasks performed by each recipient by date of services, but the recipient need only sign (in accordance with the above-guidance) once in the applicable (24)- hour period.
