Targeted Case Management
(TCM) is a comprehensive service that includes coordinating medical and
non-medical procedures for the student.
TCM is a Medicaid service
that is reimbursable through the School Supportive Health Services Program
(SSHSP). It is in addition to
Occupational Therapy, Physical Therapy, Speech Therapy, Counseling, Skilled
Nursing Services and their corresponding evaluations.
Students eligible for TCM
reimbursement include Medicaid (MA) eligible school-age students referred to
the Committee on Special Education (CSE) or classified as disabled and an
Individualized Education Program (IEP) is developed. TCM is not reimbursable
for preschool students.
Medicaid may be billed for
five distinct TCM procedures: initial review, requested/amended review, annual
review, triennial review, and Ongoing Service Coordination. The four reviews
may only be claimed on or after the date the IEP review was completed.
Part 200 of the Regulations
of the Commissioner now identifies three types of reviews. The crosswalk
between the fee schedule for Medicaid billing reviews and the definitions under
Part 200 of the Commissioner's Regulations is as follows:
|
Part 200 of
the Commissioners Regulations definition: |
SSHSP Codes
and Fees |
Medicaid
Billing Reviews |
|
Initial
Review |
NYC
5491 $1,333 ROS
5491 $775 |
An Initial
Review is
provided for a student who is not classified as disabled and may
require special education services pursuant to Part 200 of the Regulations of
the Commissioner |
|
|
NYC-5494 $1,333 ROS-5494 $520 |
An
Amended/Requested Review is provided for a classified student, receiving special
education services and may require a formal evaluation in at least one
discipline area. |
|
Review |
NYC-5492 $347 ROS-5492 $265 |
An Annual
Review is
provided for a classified student, once within every 12-month period
to determine continued eligibility and the appropriateness of special
education services being provided. |
|
Reevaluation |
NYC-5493 $1,333 ROS-5493 $492 |
A Triennial
Review is
provided for a classified student, at a minimum of once within a
36-month period or whenever a review is requested where more than one
discipline area requires formal evaluations |
The cover of
all reviews should appropriately identify the review type for Medicaid
Reimbursement.
For a school-age student
with a disability, an appropriate committee meeting must be convened and
appropriate members of the Committee or Subcommittee on Special Education who
conducted the review must have attended the meeting.
A unit of service
includes:
·
At least one contact by
the student's service coordinator or CSE, with the student's parent or other
responsible individual, on the student's behalf, relating to the development of
the initial IEP, (the CSE Chairperson is considered the service coordinator
during the review process), and
·
The activities leading
up to and including the writing of the IEP, and
·
Conducting and convening
the CSE conference to develop the IEP, and
·
Notifications to parents
as per Part 200 of the Regulations of the Commissioner of Education.
·
For Ongoing Service
Coordination, other documentation is required (see Page 30).
An
initial review can only be billed when an unclassified student is referred to
the CSE for an initial IEP and a CSE meeting is held.
School
districts may bill Medicaid for developing an initial IEP for a student not
subsequently classified. If the student was not classified as a result of a
prior referral, or was declassified, and is referred again, the school district
may bill for developing another initial IEP.
A CSE meeting, however, must have been held as a result of the second
referral.
No more than two initial reviews may be
claimed in any nine months.
NOTE: An
initial review is not done for a classified preschool child transitioning to
school age.
Review (Amended/Requested
Review)
Regulations
require that a student's IEP be reviewed and, if appropriate, reviewed on an
interim basis upon request of the professionals on the CSE or the request of
the child's parent(s) or other responsible individual.
Multiple
amended IEPs may be billed within a given year, however, for each review, a
separate CSE meeting must be held. A
new IEP must be created or the minutes of the meeting would be required indicating
services were no longer necessary.
No more than three amended/requested
reviews may be claimed in a nine-month period.
An annual review is a
required CSE review, which must occur once within every 12-month period to
determine whether the existing IEP is appropriately meeting the child's needs.
No more than one annual review may be
billed in a four-month period.
Re-Evaluation (Triennial Review)
A
re-evaluation (triennial) review must occur within or at least every 36 months
to provide current assessment information for a student in special education
pursuant to IDEA. However, a
re-evaluation may occur when ever the CSE requires one. The re-evaluation (triennial) review should
be billed at least once every 36 months or as necessary. However, it may not be
billed more than once every nine months.
Service Documentation is the completed IEP (identified as to the type of
review), minutes of the CSE meeting, when recorded (updated 11/14/05)
and the parental notification. IEP reviews
may only be claimed on or after the completion date of the review.
Students
Transitioning from Preschool to School Age
Special
Education Programs
School
Districts are responsible programmatically for all students with disabilities
ages 3 - 21 years. Students
transitioning from the Preschool Program, pursuant to Section 4410 of the
Education Law, to the School Age Program, pursuant to Section 4402 of the
Education Law, had their Initial Review conducted by the CPSE and were
classified as disabled with an IEP. The
CSE is required to review each of these students when they become school
age. Parental permission is not
required to review a transitioning student for continued eligibility although
consent must be requested if additional evaluations are being conducted as part of the
review process. This review is
considered, for Medicaid funding purposes as, either a Requested Review or a
Re-evaluation Review depending on the number of discipline areas requiring a
formal evaluation. This review is
not considered an Initial Review, since the purpose of the review is to
determine the student's continued need for special education following the
student's prior identification as a preschool student with a disability. This is consistent with IDEA mandates that Special Education be
provided to students with disabilities, ages 3 - 21 years, through a
programmatically seamless system.
The same rule would apply for a Preschool Student
transitioning to School Age Programs, but enrolling in a school district
different from the one that had CPSE responsibility. School age students with disabilities
transferring in New York State to another school district will provide the new
school district with the existing preschool IEP. The new school district would place the student in a similar
program (pendency) pending their CSE review.
The school district should not provide an Initial Review since the
student is already classified but would provide either a Requested or Re-evaluation
Review based on the needs of the student.
Ongoing
service coordination must be documented as indicated on Page 31 of the guidebook. It is rendered subsequent to implementing a student's IEP and
is not required on the IEP. A
service coordinator must be assigned to the student. Service Coordination must be discussed at the CSE meeting. The student or the student's parent or
guardian should agree to the service coordination.
The individual service
coordinator or case manager must be assigned to each student in writing by an
appropriate school official, before any billing may take place. All staff involved with the student must be
notified of the service coordinator or case manager assigned to the student.
Reimbursement of ongoing service coordination is a monthly fee.
A unit of service includes
at least two documented contacts, on a monthly basis, (see examples on Page 32) by the service coordinator or other staff involved
with the student relating to the child's ongoing service coordination. The service coordinator shall:
·
Act
as the central point of contact relating to IEP services for a child and any
case notes by any other individual involved with the student.
·
Maintain
contact with direct service providers.
·
Assist
the child in gaining access to services specified in the IEP.
·
Discuss
with direct service providers whether the appropriate services are being
provided.
·
Provide
a student or a student's parent or other responsible individual with
information and direction that will assist them in successfully accessing and
using the services recommended in the IEP.
·
Provide
assistance or intervention regarding any educational, social or medical
condition affecting the student's ability to meet the goals and
objectives specified in their IEP.
NOTE: Contacts
involving the IEP reviews are not reimbursable as part of ongoing service
coordination. Those contacts are
reimbursed through the appropriate Review fee.
Department of Health (DOH) staff must approve Ongoing Service
Coordination case notes prior to initial claiming process.
An
individual recommended as a child's ongoing service coordinator shall be:
·
employed
by or under contract to a school district/§4201 school, and
·
chosen
by the school district/§4201 school taking into consideration the primary
disability manifested by the child, the child's needs, and the services
recommended in the IEP.
NYS licensed or certified
staff could include an audiologist, school counselor, registered nurse,
practical nurse, occupational therapist, physical therapist, psychologist,
social worker, speech therapist, speech pathologist, teacher, school
administrator or school supervisor.
Service Documentation:
A written document that
notifies the parent of the identification of the service coordinator. The
service coordinator or case manager must document all contacts relating to
service coordination. The contact notes
will serve as documentation that the service was provided. (See examples on
Page 32).
Documentation that ongoing
service coordination was provided consists of case notes that meet the
following criteria:
1.
Issue:
- the reason for a coordination contact,
2.
Notes:
- a brief summary of what transpired during the contact,
3.
Action:
- an action, reaction, or decision by the coordinator.
Codes and Fees: Code Monthly Fee
SSHSP (Rest of State) Fee 5495
$100.00
Billing information is student specific. The Review being billed
for each eligible student must clearly identify whether it is an initial,
amended/requested, annual or re-evaluation [triennial] review. A CSE meeting must have been held. Part 200 of the Regulations of the
Commissioner identify the three types of reviews; initial, review and
re-evaluation. A crosswalk of the
original four reviews is on page 27.
For each review, the IEP will serve as documentation that all necessary
coordination,
including contacts with parents, educators and health care professionals,
committee meetings and follow-up, was completed. Parental notification must be maintained as part of the
documentation required by Medicaid.
All IEPs must be appropriately closed with a date. You may claim for an IEP review on or after the date the IEP is
completed. If taken, minutes of the
meetings must also be available as documentation of the review. When a student is not classified upon
review, the minutes, if available, and the parental notification will serve as
the appropriate documentation of the review.
For Ongoing Service Coordination, the service coordinator must be
assigned and must document all contacts regarding the student's ongoing service
coordination on a monthly basis. Ongoing service coordination is not required on the
IEP.
TCM need not be written on the IEP for school districts to bill
Medicaid for developing a review.
Ongoing Service Coordination need not be written on the IEP as well. However, the cover of the IEP should indicate which review it
represents.
Sample Ongoing Service Coordination Case Notes
STUDENT NAME: ______Erica P._________________________________DOB__3/19/85__________________
Person
contacted: D.G. Title: Teacher Date
Contacted: 2/4/97
Issue: Poor Academic Progress
Notes: Met with Teacher regarding Erica. Continues to do poorly academically. Student's parent is working with guidance
center.
Action: Will follow up next month.
Person
contacted: L.A. Title:
Guidance Counselor Date
Contacted: 2/4/97
Issue: Follow-up re: Academic progress
Notes: Spoke to Mrs. A.; parents looking for homework help for Erica. Got reading
assignments.
Action: Will follow-up next month.
Person
contacted: B. P. Title:
Therapist Date
Contacted: 2/24/97
Issue: Follow-up in progress.
Notes: Parent asked for update on Speech: Erica continues with speech and language
services. Tries hard,
progress is slow
but consistent.
Action: Will follow up with parent.
Person
contacted: Mrs. P.
Title: Parent Date Contacted: 2/26/97
Issue: Follow-up with Parent Concerns.
Notes: Mrs. P. will come in to discuss changes for
Erica. She's worried about
progress. She doesn't think
Erica is getting
her medications during school hours.
Action: Scheduled a Team meeting, and will talk to
school nurse.
Person contacted:
C. B. Title:
School Nurse Date
Contacted: 2/26/97
Issue: Follow-up
regarding medications
Notes: Erica is
going to the Nurse's Office on a regular basis for medication. Nurse has no problem with Erica.
Action: Will
inform Parents at meeting.
SIGNATURE/TITLE________________________________________________________DATE:____________