ODP Announcement 19-123 was issued to provide an update to the QA&I process for Cycle 1, Year 3. In July 2018, ODP issued Bulletin 00-18-04, “Interim Technical Guidance for Claim and Service Documentation,” which provided guidance to providers of Consolidated, Community Living, and P/FDS waiver services and Targeted Support Management. The QA&I Cycle 1, Year 3 review process includes a review of the documentation specified in this bulletin. This review of claims and service documentation is intended to verify that services were provided as authorized, in accordance with established policies.

ODP conducts a review of a proportionate random representative sample of paid claims for services in the Consolidated, Community Living, and P/FDS waivers based on the providers and SCOs being monitored in the current year of the QA&I cycle to ensure that the claims are supported by adequate documentation. As part of the year 3 process, ODP has reached out to providers who did not initially submit sufficient information in order to clarify the information required and provide additional time for submission. This was done to:

• Assure a common understanding of the requirements;
• Assist in verifying that all the available information was used in the assessment of compliance;
• Enable ODP to pinpoint issues related to any non-compliance; and
• Provide information to support future training and the revision planned to ODP Bulletin #00-18-04 when the 55 Pa. Code Chapter 6100 regulations are promulgated.

This has extended the review process. As a result, ODP is revising the expectations outlined in the Quality Assessment and Improvement Process document, dated 6/6/19, related to claims and service documentation only. The Assigned AE will receive a copy of the ODP findings letter and the provider’s response to the Corrective Action Plan (CAP) or Directed Corrective Action Plan (DCAP).

If the Assigned AE receives the above information prior to the onsite visit to the provider, they are expected to review and validate completion of the Plan to Prevent Recurrence (PPR), when the CAP submitted by the provider included a PPR. This review should include progress made in implementation and, if implementation occurred prior to the onsite visit, an examination of records to see if the changes made are having the desired result. This information shall be noted in the Comprehensive Report and added to the CAP form.

In situations where the Assigned AE receives a copy of the ODP findings letter and the provider’s response to the CAP or DCAP after their onsite visit to the provider, the AE shall notify ODP and include the date(s) of the site visit. This information shall be noted in the Comprehensive Report.

Questions regarding this communication should be directed to this email.