Medicaid Billing Module Transportation Billing Form Transportation Billing

Medicaid Billing Module Transportation Billing Form

Transportation Billing Form Demographics Section Medicaid Number Last Name First Name County School WVEIS # Diagnosis Code Date of Birth Month/Year Vehicle Type Modified

Demographics Section • Complete the top row of demographic information using the county and school codes. • On the bottom row fill in the full WVEIS #, Diagnosis Code should be left blank until further notice, date of birth and the Month and Year for billing. • The billing form cannot have data from multiple months.

Transportation Billing Form Demographics Section EXAMPLE Medicaid Number Last Name First Name County School 000001 Doe Jane 058 301 WVEIS # Diagnosis Code Date of Birth Month/Year Vehicle Type 99999 01 -01 -1900 August 2015 Modified

Procedure Code and Instruction

Procedure Code Section • Check the line next to T 2001 SE for modified bus with an aide. This is used for a bus with a lift only. • This procedure is for a one way trip. (We no longer need round trips to bill. ) • Typically you can bill two trips per instructional day. • If a student is taken to a billable service during the instructional day you could bill up to four trips in a day.

Procedure Code Section • Procedure Code T 2002 SE is only used for a modified bus (with a lift) that doesn’t have an aide. • Unlikely you will have any billable trips for this code. • If using this code complete the mileage column instead of start and stop times.

Data Entry Section Date Departure Location Arrival Location Start Time Stop Time Purpose: To provide access to the following billable service(s). Mileage

Data Entry Section • For Procedure T 2001 SE the aide or driver will complete the first five columns per one -way trip. • Mileage is not needed and should be left blank • The last column will be completed by staff at the school, county or RESA level.

Data Entry Section • Date: Enter the date of the trip • Departure Location: This is the location that the student enters the bus. Use the terms school or designated stop. If the child would enter the bus at a different location list the name of the location (ie street address, intersection name, business name etc. ) • Location: This is the location that the student leaves the bus. Use the terms school or designated stop. If the child would depart the bus at a different location list the name of the location (ie street address, intersection name, business name etc. ) • Designated stop is the agreed upon/assigned regular stop. The district must have this location(s) documented in case of an audit.

Data Entry Section Continued • Start Time: Document the time the student boarded the bus. • Stop Time: Document the time the student exited the bus. • Start and stop times must be actual times each day not the regularly scheduled times. Actual times will vary based upon weather, traffic, and other factors.

Data Entry Section Date Departure Location Arrival Location Start Time Stop Time Mileage Purpose: To provide access to the following billable service(s). 8 -17 -15 School 7: 32 7: 50 8 -17 -15 Designated Stop School 2: 55 3: 18 Designated Stop

Data Entry Section • Students who are transported with a specially equipped bus to a location during the day to receive a Medicaid billable services, such as physical therapy, audiological services, or physician visit the trips can be counted for Medicaid billing purposes. • If a student was transported to RESA for an Audiology Evaluation during the school day with a modified bus and aide you could document this as follows.

Data Entry Section Date Departure Location Arrival Location Start Time Stop Time Mileage Purpose: To provide access to the following billable service(s). 8 -17 -15 Designated Stop School 7: 32 7: 50 Designated Stop School 2: 55 3: 18 7: 30 7: 50 RESA 8 9: 30 10: 15 8 -17 -15 8 -18 -15 Designated Stop School 8 -18 -15 RESA 8 School 11: 30 12: 15 8 -18 -15 School Designated Stop 2: 55 3: 25

Data Section Purpose Column • This section will be completed by an employee who has access to the student’s completed billing forms for the month. • Enter the billable service provided for trips that match the date of service • If there was not a billable service for a trip date enter NA • Only one billable service needs to be entered per trip.

Data Entry Section • Billable services include: Speech, Occupational Therapy, Physical Therapy, Audiological, Nursing, Personal Care, Psychological (testing or psychotherapy) and Targeted Case Management (TCM).

Data Entry Section Date Departure Location Arrival Location Start Time Stop Time Mileage Purpose: To provide access to the following billable service(s). 8 -17 -15 Designated Stop School 7: 32 7: 50 NA Designated Stop School 2: 55 3: 18 NA 7: 30 7: 50 Speech Designated Stop School 2: 55 3: 25 Speech 7: 32 7: 50 TCM Designated Stop 2: 55 3: 22 TCM 8 -17 -15 8 -18 -15 8 -19 -15 Designated Stop School

Data Entry Section • After completing the purpose column fill in the number of total trips, total billable trips, and total non-billable trips. • This information will be used by the financial department for year end calculations.

Data Entry Section Date 8 -17 -15 8 -18 -15 8 -19 -15 Total Trips Departure Location Arrival Location Designated School Stop School Designated Stop 6 Start Time Stop Time Mileage Purpose: To provide access to the following billable service(s). 7: 32 7: 50 NA 2: 55 3: 18 NA 7: 30 7: 50 Speech 2: 55 3: 25 Speech 7: 32 7: 50 TCM 2: 55 3: 22 TCM Total Billable Trips 4 Total Non-Billable Trips 2

Signatures and Credentials • • Driver is required to sign this form. Driver credential is Bus Driver Aide is required to sign this form. Aide credential is the classification of employment such as Aide I, Aide III. • Drivers and Aides are only documenting that the student rode the bus, not that the student received a billable service at school. Drivers and aides should keep a copy of the signed original that is submitted to the district offices. This serves as proof of what was documented by the signatures.

Attendance Verification • It is important to verify that the student was present in school on the day that billable trips were listed. • Compare attendance logs to ensure accuracy. • A student could have a tardy, early departure, or a half-day absence and still have one billable trip.

Terry Riley – Coordinator Office of Special Education tjriley@k 12. wv. us 304 -957 -9833 ext 53223 WVDE Medicaid Website: http: //wvde. state. wv. us/osp/medicaid. html