Provider Eligibility for Medicaid Service Payment
(1)In addition to meeting the licensing standards and conditions set forth in these rules, a provider must have an approved prior authorization through the Department payment system for individuals receiving Medicaid-funded services before the provider is eligible to claim for delivering Medicaid-funded services. The prior authorization includes dates of authorized services and the funding amount allocated.
(2)A provider may only claim for a day of service when:
(a)An individual sleeps in the home overnight; or
(b)An individual does not sleep in the home overnight, but intends to return to the home, and the provider was responsible for and provided an accumulated period of eight hours for the primary care, support, safety, and well-being of the individual, including any of the following:
(A)Providing intermittent physical support or care.
(B)Providing stand-by support with the ability to respond in person within the response times as outlined in the individual’s ISP.
(C)Being responsible to communicate reciprocally within the response times agreed upon by the individual’s ISP team and documented in the individual’s ISP, based on the individual’s identified support needs.
(3)A day of service does not apply when an individual:
(a)Has been admitted to an acute care hospital unless the individual’s ISP authorizes attendant care for the individual in an acute care hospital and the day of service criteria in section (2)(b) of this rule is met. An ISP may only authorize attendant care for an individual who has been admitted to an acute care hospital when the support is not a duplication of service that the hospital provides and the individual has one of the following:
(A)Challenging behavior that interferes with getting medical care. The challenging behavior must require specific training or experience to support and must be able to be mitigated by a developmental disability service provider to an extent that medical care is improved.
(B)An inability to independently communicate with hospital staff that interferes with getting medical care. This must not be solely due to limited or emerging English proficiency.
(C)Support with one or more activities of daily living that may only be adequately met by someone familiar with the individual.
(b)Has been admitted to a nursing facility;
(c)Has been admitted to a mental health facility;
(d)Is held in detention or jail; or
(e)Is outside of the United States.
(4)A provider may only claim for a day of service under section (2)(b) of this rule when an individual is away from the home, accompanied by a provider or staff, for up to 30 consecutive days or 45 calendar days in an ISP year.
(a)The provider is not paid for the 31st and following consecutive days when an individual is away from the home.
(b)A provider is not paid for the 46th and following non-consecutive days an individual is not at the licensed home overnight.
(c)Days not paid do not count in the 45-calendar day total.
Rule 411-325-0490 — Provider Eligibility for Medicaid Service Payment,