Tags Posts tagged with "Claims"


The purpose of this bulletin is to provide guidance on documentation needed to substantiate a claim as well as provide guidance on the service documentation processes. This information is applicable to providers and Supports Coordination Organizations (SCO) that render services through the Consolidated, Community Living, P/FDS, and Adult Autism Waivers as well as Targeted Support Management (TSM) and base-funded services.

Documentation to provide a record of services delivered to an individual must be prepared and kept by the provider, SCO, or common-law employer for the purposes of substantiating a claim and documenting service delivery. The Office of Developmental Programs (ODP) has developed Technical Guidance for Claim and Service Documentation for providers of services in the Adult Autism Waiver and providers of services for all other waivers and base-funded services, which provide specific information for providers and SCOs on the documentation that must be kept for each service in order to support a claim and to document service delivery. These apply to services rendered by providers and SCOs that have enrolled directly with ODP, organized health care delivery systems, and services delivered through both self-directed services models, Agency with Choice, and Vendor Fiscal/Employer Agent.

Providers are encouraged to review and consider using the Medical Assistance Provider Self Review Protocol to proactively identify and address any claim documentation-related problems. The protocol can be found here.

The Office of Developmental Programs (ODP) has shared the message that the Provider Electronic Solutions software, commonly referred to as PES, will be sunset on June 15, 2022. PES was distributed free of charge to providers as a method of submitting HIPAA-ready transactions such as claims and eligibility to the PROMISe system.

Effective June 15, 2022, the software will not work with Microsoft Edge or other commonly used internet browsers. The Department of Human Services (DHS) will no longer upgrade PES due to the product’s age, limited configurability, and end-user experience. The Provider Assistance Center (PAC), which was maintained by Gainwell Technologies, will no longer provide user support for PES effective June 15. 2022.

Providers are encouraged to use the PROMISe Provider Portal to submit claims, validate eligibility, conduct claim inquires, and access their weekly remittance advice. The PROMISe Provider portal is available free of charge and allows single-entry interactive submissions. Additionally, users can purchase certified software from software vendors or contract with a clearinghouse to handle ongoing HIPAA transaction needs.

ODP Announcement 22-021 provides guidance on the upcoming rate increases for the Adult Autism Waiver. Compensation is beginning March 1, 2022; the new rates will be implemented in the Home and Community Services Information System (HCSIS) on March 1, 2022. All Individual Support Plans (ISPs), including ISPs in draft, pending review, or pending approval status, will be updated with the new rates for each of the applicable services. An additional fiscal segment will automatically be added on each ISP for each service that is impacted by the rate change.

Providers are strongly encouraged to review Service Authorization Notices or the Provider Service Detail report in HCSIS to confirm the new rates were loaded, authorized, and that they are billing the increased Fee Schedule Rate before attempting to bill for any services rendered March 1, 2022, and after.

Compensation for the Period July 1, 2021, through February 28, 2022

Providers should bill normally for any services rendered from July 1, 2021, through February 28, 2022. ODP will be compensating providers, via gross adjustments, for the difference between the rate billed and the updated fee schedule rate for dates of service rendered during the period July 1, 2021, through February 28, 2022. This is intended to eliminate the provider’s effort of voiding and re-billing claims.

ODP anticipates processing gross adjustments during the April to May 2022 timeframe to ensure all billing for dates of service July 1, 2021, through February 28, 2022, has been completed. Because the rates will be loaded into HCSIS effective July 1, 2021, and the gross adjustment compensation will be issued by ODP, providers should not adjust any claims after April 1, 2022, submitted for services rendered on July 1, 2021, through February 28, 2022.

Adjustment of a claim(s) for services delivered during these dates will result in a duplication of payment that will need to be repaid. Providers are strongly encouraged to bill in a timely manner to minimize the need for corrections.

For questions on how to resolve billing errors for services that were rendered on July 1, 2021, through February 28, 2022, contact Amber Bennett.

Correction to Rates for Small Group Employment and Residential Habilitation Ineligible Fees

Because of an internal editing error, the rates for Small Group Employment and Residential Habilitation: Community Home Ineligible published in the Pennsylvania Bulletin (52 Pa.B. 1326, February 26, 2022) were incorrect. The correct rates, with the corresponding procedure codes, are higher than what was published. The corrected rates are also available on the Department of Human Services’ website.