Medicaid in Education Alert Issue #11‐01 Attachment 1
SSHSP Targeted Case Management Billing Guidance

Preschool/School Supportive Health Services Program (SSHSP): Targeted Case Management Billing Guidance

Targeted Case Management (TCM) is a comprehensive service that includes coordinating medical and nonmedical procedures for the student. TCM is a Medicaid service that is reimbursable through the School Supportive Health Services Program (SSHSP). Medicaid reimbursement is available for TCM services provided on or before June 30, 2010. TCM services for this time period included initial evaluation review, amended/requested individualized education program (IEP) review, annual IEP review, triennial/re-evaluation IEP review, and ongoing service coordination.

Please note: Some of the services described below may no longer be called by the same name (e.g., “triennial review”); however this billing guidance is for pre-July 1, 2010 and relies on billing systems that are already in place.

Initial Evaluation Review (Rate Code 5491)
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. An initial review can only be billed when an unclassified student is referred to the Committee on Special Education (CSE) for an initial IEP and a CSE meeting is held. School districts may bill Medicaid for an initial CSE meeting to make an eligibility determination 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 conducting another initial CSE meeting. 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 a nine-month period.

NOTE: An initial review is not done for a classified preschool child transitioning to school age or for a classified school age child transferring school districts.

Amended/Requested IEP Review (Rate Code 5494)
An Amended/Requested Review is provided for a classified school age student who is receiving special education services and who may require a formal evaluation in at least one discipline area. Multiple amended IEP reviews may be billed within a given year, however, for each review, a separate CSE meeting must have been held. A revised IEP or amendments to the IEP must have been created or the minutes of the meeting or prior written notice documentation is required indicating the meeting was held and no revisions to the IEP were determined necessary. No more than three amended/requested reviews may be claimed in a nine-month period.

Annual IEP Review (Rate Code 5492)
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.

Triennial /Re-evaluation IEP Review (Rate Code 5493)
A Re-evaluation Review must occur at least once every 36 months (triennial evaluation) unless the parent and district agree in writing that the re-evaluation is not necessary to provide current assessment information for a student in special education. In addition, the CSE must arrange for a re-evaluation more frequently if the needs of the student warrant a re-evaluation or if requested by the student’s teacher or parent.1 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.

Documentation Needed to Support Medicaid Claims

  • The IEP serves as documentation that all necessary coordination, including contacts with parents, educators and health care professionals, committee meetings and follow-up, was completed.
    • Letter inviting parents to the CSE meeting or documentation of parents’ presence at the CSE meeting.
    • Letter informing parents of due process rights.
  • You may claim for an IEP review on or after the date the IEP is developed. TCM need not be written on the IEP for school districts to bill Medicaid.
  • When the CSE meeting does not result in the development of an IEP (e.g., when a student is not classified or has been declassified) the following will be required:
    • Notifications to parents (meeting notice, prior written notice) as required by Part 200 of the Regulations of the Commissioner of Education.
    • CSE Meeting minutes, if available.
    • Other documentation indicating which review took place.

Ongoing Service Coordination (Rate Code 5495)
School districts and §4201 schools who were approved prior to July 1, 2009 by the Department of Health (DOH) to claim Medicaid reimbursement for Ongoing Service Coordination, may resume Medicaid billing for these services provided on or before June 30, 2010 if the requirements listed below are met.

Ongoing service coordination is rendered subsequent to implementing a student's IEP and is not required to be listed as a separate service 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 and the student’s parent or guardian must be informed in writing of the identity of the service coordinator. All staff involved with the student must be notified of the service coordinator or case manager assigned to the student.

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.
  • Appropriately licensed or certified (this 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.)

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.

A unit of service includes at least two documented contacts, on a monthly basis, by the service coordinator or other staff involved with the student relating to the child's ongoing service coordination.

Documentation Requirements:

  • Documentation that ongoing service coordination was discussed at the CSE meeting,
  • A written document notifying the parent of the identification of the service coordinator prior to billing Medicaid,
  • Case notes for all contacts (minimum 2/month required) relating to service coordination containing:
    • Issue: the reason for a coordination contact,
    • Notes: a brief summary of what transpired during the contact,
    • Action: an action, reaction, or decision by the coordinator.
Medicaid Coding and Fees
Review Rate Code Reimbursement Rate
Initial Evaluation Review 5491

NYC $1,333 Rest of State $775

Amended/Requested IEP Review 5494 NYC $1,333 Rest of State $520
Annual IEP Review 5492 NYC $347 Rest of State $265
Triennial/Re-evaluation IEP Review 5493 NYC $1,333 Rest of State $492
Ongoing Service coordination 5495 Rest of State $100

1. Note that a re‐evaluation cannot be conducted more frequently than once a year unless the parent and school district representative on the CSE agree otherwise. 8 NYCRR §200.4(b)(4) Medicaid in Education Alert Issue #11‐01 Attachment 1 SSHSP Targeted Case Management Billing Guidance

Last Updated: December 20, 2018