Service Coordinator Orientation & Training PA OLTL Vendor - - PowerPoint PPT Presentation

Service Coordinator Orientation & Training

PA OLTL Vendor Fiscal/Employer Agent Financial Management Services Participant Directed Model of Service

October 2017

Agenda What this Training will Cover

• Program Background
• Principles of Self Direction
• PPL Background
• Roles & Responsibilities
• Enrollment Process
• Authorization Creation, Modification, and Troubleshooting
• Managing Participant Services

What this Training will not Cover

• Transition to MLTSS

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Questions

Attendees phones have been muted. We encourage you to reach out to your Regional Enrollment Manager to ask questions following this presentation. PPL will be recording this training session to make it available for future reference on our website;

www.PublicPartnerships.com/Programs/Pennsylvania/Index.html

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Program Background

Home and Community-Based Services (HCBS) offer persons with disabilities and Pennsylvania’s Seniors a choice on how their services are delivered. The PA DHS OLTL models of service are as follows:

• The Agency Model which allows participants to select a provider from an approved list of

agencies to provide services.

• Self-Directed Services (or Participant-Directed Services) which enable participants to take

more control of services giving them the power to manage their own workers as the common law employer.

• Employer authority – participants employ their own workers to provide services based
• n the hours and activities specified in an individual service plan.
• Budget authority (or Services My Way) – available in Aging and Attendant Care waivers
• nly -is a model of services that gives participants the option to manage a flexible

budget (Individual Spending Plan) and decide for themselves the type of goods and services that best meet their service needs.

Participants may utilize a combination service plan where they receive some services from an agency and some through one of the self-directed models.

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Principles of Self Direction

• Self Direction is a service delivery model that gives participants choice and

control over their services so they may live as independently as possible in the community. Self Direction is also referred to as Consumer Direction or Participant Direction.

• Participants will recruit, select, hire, and manage their own employees

including friends and family to help with activities of daily living as defined in their service plan or under their budget.

• To use Self Direction, participants must be willing to do the following:
• Accept the risks, rights and responsibilities of self-direction
• Accept the responsibilities as an employer or appoint a representative to serve as

the employer.

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PPL Background

• PCG Public Partnerships (PPL) acts as the Fiscal/Employer Agent

providing the Financial Management Services (FMS) needed to assist Common Law Employers with the responsibilities of self direction, such as processing payroll and performing required tax functions.

• PPL maintains two offices in Pennsylvania:
• Harrisburg
• Philadelphia (by appointment)
• PPL Regional Enrollment Managers, located throughout PA, assist with

participant concerns and enrollment and educate Service Coordination Entity staff on using PPL’s BetterOnline Web Portal, program processes, and program rules.

• PPL Enrollment Specialists, located throughout PA, provide in-home

and telephone visits to new participants to assist with the initial enrollment paperwork and provide orientation and training to the CLE.

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Recent Year Updates

• CLE Welcome to PDS Letter
• Enrollment Specialists
• Provider Directory
• Mobile Timesheet Application
• FLSA Overtime Rules
• Difficulty of Care Federal Income Tax Exclusion

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Home Page

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MyChoice4Care.com

What is it?

• Online directory that allows participants to post jobs and find care workers.

Who is it for?

• New participants considering self-direction or existing participants who need new

workers Why is it needed?

• Participants worry about finding care on their own. The directory enables them to hire

someone that fits their needs.

Available resources:

• “Using MyChoice4Care.com” – overview information for you
• “MyChoice4Care.com” – overview information for participants
• “MyChoice4Care Website Guide” – step-by-step guide for you and participants

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Search Page

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Roles and Responsibilities

Roles and Responsibilities

• PPL Roles & Responsibilities
• PPL Enrollment Manager Roles & Responsibilities
• Service Coordinator Roles & Responsibilities
• Participant/CLE Roles & Responsibilities
• Direct Care Worker Roles & Responsibilities

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PPL Roles and Responsibilities

General responsibilities:

• Provide pre-populated Common Law Employer (CLE) enrollment forms

and Direct Care Worker (DCW) enrollment packets

• Provide over-the-phone enrollment for DCWs
• Provide assistance in completing CLE and DCW paperwork
• Process and review completed CLE and DCW paperwork including

perform all necessary record checks on prospective DCW’s

• Issue payments to DCW’s bi-weekly following the receipt of properly

submitted timesheets

• Provide payments to vendors through Services My Way program

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PPL Roles and Responsibilities

General responsibilities cont.:

• Complete all payroll duties including

withholding and depositing payroll taxes and filing payroll tax returns.

• Issue a W-2 statement to each DCW in

January

• Operate a customer service phone line

for participants and DCWs during regular business hours

• Provide 24/7 on-line access to

information via PPL Web Portal

• Provide training and user guides on

how to use PPL Web Portal

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Enrollment Manager Roles and Responsibilities

• Serve as main point of contact for Service Coordinators (SC) and

Service Coordination Entities (SCE)

• Respond to day-to-day participant direction issues identified by SCs
• The primary support system available to participants and DCWs is PPL Customer Service
• Support the training and education need of the SCs and SCEs
• Work with SC Administrators to maintain web portal access for SCs
• Communicate significant changes and updates, including billing (denied

claims) and authorization issues.

• Inform SCs of errors causing participants not to receive services
• Missing authorizations
• Gap in Service Issues

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Service Coordinator Roles and Responsibilities

• Determine suitability, for participation in the Participant Directed

Services program, of waiver eligible individuals– assisting with the designation of an alternate CLE where necessary and allowed

• Present the Participant Directed Services option to all suitable

individuals

• Make referrals to PPL using the PPL Better Online web portal
• Develop and update the ISPs through HCSIS/SAMS
• Initiate informal supports or agency services until the participant is ready

to receive services through PPL and DCW is good to go

• May assist participants with completing enrollment forms
• Help participants develop and implement a backup plan

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Service Coordinator Roles and Responsibilities

• Monitor the delivery of services and supports:
• Review PPL utilization reports and the Service Plan with participant

to ensure services are being provided in accordance with the Service Plan.

• PPL does not have access to the ISP to determine schedule
• Note: HCSIS is not a good indicator of utilization; it will only show

SCs what PPL has billed, not what PPL has paid out.

• Provide PPL with any temporary gaps in

service in a timely fashion.

• Keep participant demographics

up to date in HCSIS/SAMS

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Common Law Employer Roles and Responsibilities

• Recruit, hire, train, schedule, manage, and dismiss DCWs
• Verify DCW and vendor qualifications
• Ensure that DCWs complete the enrollment requirements
• Train DCWs in providing services described in the ISP
• Decide how much to pay DCW, within state guidelines
• Monitor adherence to Service Plan and budget
• Develop and implement a backup plan
• Approve and submit all timesheets to PPL
• Report suspicions of Medicaid fraud or financial abuse

related to the delivery of participant-directed services

• Designate a representative to assist with CLE duties, as

necessary

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Designating a Representative to Act as the Common Law Employer

• The Aging, Independence and OBRA Waivers* allow an

alternate to enroll as the CLE; the Attendant Care Waiver and Act 150 Program do not.

• An alternate CLE will be required for any individual who is

unable to:

• Understand his/her own personal care needs;
• Make decisions about his/her own care;
• Manage his/her lifestyle and environment by making these choices;
• Understand or have the ability to learn how to recruit, hire, train, and

supervise providers of care; or

• Understand the impact of his/her decisions and assume responsibility for the

results.” *CommCare particpants will transfer to other waivers by 12/31/2017.

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Direct Care Worker Roles & Responsibilities

• Complete DCW enrollment paperwork and required

background checks

• A DCW must complete enrollment paperwork and required

background checks for each CLE for whom s/he works

• A DCW may not be a spouse, Power of Attorney, person

under 18 years of age, Designated Rep, or Rep Payee of the person receiving services

• Alert PPL to any address changes
• Complete a Live In Exemption form if moving into or out of

the home of the participant to whom services are provided

• Provide services to participant as described in ISP

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Direct Care Worker Roles & Responsibilities, continued

• Meet all qualification requirements and complete training as

identified in the ISP

• DCW may not submit time for any time period for which a

participant is admitted to a hospital, nursing home, rehabilitation facility or for any period where the participant is not eligible for waiver services

• Being aware of guidelines related to their own withholdings
• Do not submit timesheets before the end of pay period, future pay

periods or dates not worked.

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Enrollment

Enrollment

• Program Rules & Policies
• Participant Referral Process
• Enrollment Timeline
• Enrollment Paperwork
• What Enrollment Assistance

is Available

• Good to Go Notification and Service

Start Date

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Program Rules & Policies

• DCW may not be a spouse, Power of Attorney, person under 18 years of age or Rep

Payee

• A Direct Care Worker may NOT start to work until:
• All enrollment paperwork has been processed by PPL
• All required background checks have been completed and verified
• PA State CRC
• Child Abuse (as applicable)
• FBI CRC (as applicable)
• PPL has received an active authorization
• PPL has notified CLE that DCW is “good-to-go” and their start date
• PPL cannot pay timesheets for services worked unless there is an authorization in

place for those services

• Approval for a DCW to provide services to one participant is not approval to provide

services to any other participant.

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Participant Referral Process

• SC and participant determine the Common Law Employer (CLE)
• The CLE is the legal Employer of Record and is responsible for managing DCWs. CLE must

agree to be responsible for key employer related tasks

• In some waivers, participant may appoint someone else to serve as CLE
• SCs should ask participants if they have a pre-existing EIN
• Pre-existing EINs add additional time to the enrollment process. Please use the SC Pre-

existing tool kit provided on PPL’s PA OLTL program website to assist participants with preexisting EINs.

• SC enters in new participant referral through the PPL Web Portal
• Participants who re-enroll or transfer from Options, must be submitted via paper referral form
• SC submits service plans/orders to OLTL from HCSIS/SAMS

immediately after entering the new participant referral

• FMS Start-up Begin Date = Date of Referral
• FMS Admin Begin Date = First day of the month after the FMS Start-up
• Service Authorization (PAS, Respite, PDCS, PDGS) = 30 days from the date the plan was

submitted to OLTL and referral was made to PPL.

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Enrollment Timeline

• PPL estimates the enrollment process to take around 30 days.
• The process starts with the SC entering a new participant referral into

the PPL Better Online web portal.

• SC submits ISP to OLTL for approval with service start date to begin 30

days from the date of the referral.

• Within 3 business days of referral, PPL will mail the CLE pre-populated

enrollment paperwork.

• PPL customer service will call the CLE’s phone number on file to

schedule a CLE orientation and skills training home or phone visit.

• The potential DCW should call the over the phone enrollment team to

complete the DCW Application Request form and start any required background checks.

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Enrollment Timeline Continued

• An Enrollment Specialist will call the CLE to confirm the home

visit.

• The Enrollment Specialist will assist the CLE and the DCW with

completing the CLE & DCW packets.

• The Enrollment Specialist submits the CLE & DCW Packets for

processing.

• PPL conducts all necessary background checks and screenings.
• PPL will verify that an authorization for services has been

received.

• PPL will send a Welcome Packet to the CLE with the DCW good

to go start date.

• Good to go DCW may start providing service and be paid under

the PA OLTL PDS program effective on the start date of the letter in the Welcome Packet.

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Enrollment Paperwork

Required Enrollment Paperwork:

 Common Law Employer (CLE)  Direct Care Worker (DCW)

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Enrollment – New Participants

CLE Confirmation of Information CLE Designation CLE Agreement IRS Form SS-4 Application for Employer Identification Number IRS Form 2678 Employer Payer Appointment

• f Agent

IRS Form 8821 Tax Information Authorization

New participants are required to complete the following documents:

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Enrollment – New DCWs

DCW Application DCW Agreement DCW Qualification Form Qualified DCW Rate Sheet IRS Form W-4 USCIS Form I-9 Application for Tax Exemption Residency Certification Form Workers Compensation Notification Form

Required documents for new DCWs to complete:

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Enrollment – New DCWs

PA Child Abuse Clearance Forms FBI Fingerprinting Application Local Services Tax Exemption Form Direct Deposit Application FLSA Live-in Exemption Form Difficulty of Care Exclusion Form

Conditional documents for new DCWs to complete:

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What Enrollment Assistance is Available

The following resources are available to help CLEs and DCWs complete their paperwork:

• Customer Service
• Enrollment Specialist (New CLEs and their 1st DCW)
• PPL Website:

http://www.publicpartnerships.com//programs/Pennsylvania/PADPWOLTL/index.asp

• Informational Packets
• Video Recorded Trainings

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Good to Go Notification & Service Start Date

Being “Good-to-Go” means all of the following:

• PPL received and processed all required CLE documents and obtained an Employer

Identification Number (EIN) for CLE.

• PPL completed the required background checks for DCW and received and processed all

DCW enrollment paperwork

• Participant has a current authorization in place for services

Good-to-Go Start Date

• When a DCW is good-to-go and may start providing services PPL will notify the CLE in

writing by mailing them a Welcome Packet with the DCW notified of good-to-go date.

• A DCW is not qualified to work before receiving the good to go date hence the DCW will

not be paid for any services provided prior to being notified of the good-to-go date

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Authorization Creation, Modifications, and Troubleshooting

Authorization Agenda

Authorization Creation

• SAMS – Aging Waiver Participants
• HCSIS – Under 60 Waiver Participants

Authorization Modifications

• Adding Units
• Waiver Changes
• Terminations

Solutions to Common Authorization Errors

• Solutions to common errors

Denied Billing

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Authorization Creation: Aging Waiver Participants

Authorization Creation: Aging Waiver

SAMS

• Authorizations are received from OLTL weekly (normally at the

beginning of the week)

• It can take up to 2-3 weeks for an authorization to be received once

created

• Authorizations are loaded through an automation process when

received (unless received after 3 pm)

• Authorization start and end dates for W1792, W1792TU, W1900,

W1901, S5150, S5150TU, and W7341 service codes should span the entire month*

• *The first PAS auth does not need to start at the beginning of the month

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Authorization Creation: Aging Waiver Continued

• New service authorizations should start 30 days from date the was participant

referred to PPL; however, sometimes the PPL Enrollment Process takes less than 30 days. At your discretion the service plan can be modified to allow an earlier start date.

• W7341 Start-up Fee (U4 modifier) should be for month before services are

expected to begin or when participant was referred to PPL

• Authorization quantities for all service codes must be a whole number (i.e.10.0

instead of 10.15)

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Authorization Creation: Under 60 Waiver Participants

Authorization Creation: Under 60 Waivers

HCSIS

• Authorization files for current and previous fiscal years

received daily and contain authorizations last modified up to the previous day

• Authorizations loaded through automation process
• 2 – week filter based on Last Authorized Date
• Authorization start and end dates for W1792, W1792TU,

W1900, W1901, S5150, S5150TU, and W7341 service codes should span the entire fiscal year*

• *PAS and FMS authorizations do not need to start at the

beginning of the current fiscal year for newly enrolled/referred participants

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Authorization Creation: Under 60 Waiver Participants Continued

• Due to the 2 – week filter based on the Last Authorized Date, the participant’s service plan

should be created in HCSIS as soon as the participant is referred to PPL.

• W7341 Start-up Fee should be for month when participant was referred to PPL, or the month

before services are expected to begin, as the start up fee and the per-member-per-month fee can not occur in the same month.

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Authorization Modifications: Aging Waiver

Authorization Modifications: Aging Waiver

• Addition or Subtraction of units
• Adding or subtracting units must be done to the entire authorization period, not

a date range, and the units must be added or subtracted from the total amount

• f units on the original authorization.
• The start or end date of an authorization can only be modified if PPL has not

paid for services prior to or after the new date. Before modifying a date, please review the participant’s authorization in Portal to see if services have been paid

• ut. To review this, click on the Authorization button at the bottom of the

participant’s profile page. Then Select the Display Detail button under the Actions column for the month in question.

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Authorization Modifications: Under 60 Waivers

Authorization Modifications: Under 60 Waivers

• Change in Waiver or County
• If a participant changes waivers or moves to a new county, please end

date the current service plan in HCSIS as soon as possible to ensure that the authorization modification is uploaded in the PPL Portal before services are paid out past the last date that the participant was eligible under the old authorization. This also ensures that the new authorization will load and not disrupt services to the participant.

• Alert your Regional Enrollment Manager as soon as possible of the

change in case PPL needs to manually inactivate the current authorization so the new authorization will load.

• Termination
• Please end date the service plan in HCSIS so the modified

authorization will load into the PPL Portal before services are paid out past the last dated that the participant was eligible*.

• *If it is discovered that the service plan has been removed from HCSIS,

PPL will inactivate any current PAS authorizations until the service plan is

• restored. Please do not delete any plans for which PPL has released funds.

Instead, properly modify the date(s).

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Common Authorization Errors: Aging & Under 60 Waivers

Solutions to Common Authorization Errors: Aging & Under 60 Waiver Participants

Error! - Consumer Medicaid ID [999988877] not in correct format

• This Aging and Under 60 Waiver error is caused when the participant’s Medicaid

ID is not coming over correctly on the authorization file. Please review the participant’s Medicaid ID in SAMS or HCSIS to confirm that there are no spaces between the numbers and that the Medicaid ID is ten digits long.

Error! - Auth Qty is not an Integer

• This Aging Waiver error is the result of the authorization quantity not being a

whole number. Please update the service plan in SAMS so the authorization will load into the PPL Portal when it is next received. .

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Solutions to Common Authorization Errors: Aging & Under 60 Waiver Participants Continued

Error! – Invalid Start Date, Paid/Good To Pay found outside of New date range

• This Aging and Under 60 Waiver error is caused when PPL has already paid for

services before the new start date listed on the modified authorization. Please review the participant’s authorization the PPL Portal to see when the first date of service was paid, and then modify the service plan in HCSIS or SAMS to cover the date(s) of service.

Error! – Invalid End Date, Paid/Good To Pay found outside of New date range

• This Aging and Under 60 Waiver error is caused when PPL has already paid for

services past the new end date listed on the modified authorization. Please review the participant’s authorization the PPL Portal to see when the last date of service was paid, and then modify the service plan in HCSIS or SAMS to cover the date(s) of service.

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Denied Billing

Denied Billing

PPL works with SCs to review and resolve any billing issues and denied claims. Please ensure when creating or modifying an authorization that the information is accurate and

• correct. Below are common denial reasons along with suggestions on how to fix the

claims.

• ESC 950 – No Authorized services are found in HCSIS. Please check to make sure

that the authorization was entered correctly, and upload it again.

• ESC 952/953 – Missing Invalid DOS in HCSIS. Please ensure that the begin and end

dates of the authorization are correct and upload it again.

• ESC951 – Missing/Invalid Procedure code. The procedure code is incorrect in

HCSIS, please update the authorization and upload it again

• ESC 954 – Missing Invalid Provider ID (HCSIS). The Provider ID is not correct in

HCSIS.

• ESC 971- Service Indicated but no Units in HCSIS. Please check to make sure that

the authorization was entered correctly, and upload it again.

• Paid $0 claims. Please add a rate to the authorization. The claims have come across

as paid but have paid an amount of $0.00 meaning that there is no rate in the authorization.

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Managing Participant Services

Managing Participant Services

• Participant/CLE changes
• Eligibility
• PPL Tools
• PPL Customer Service
• Contact PPL

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Participant/CLE Changes

• Common Law Employer and Participant Services Change Form:
• Notify PPL of a temporary halt of services
• Gaps in service will prevent payment of services during this temporary stop
• Notify PPL of a participant termination
• Request a change in Common Law Employer
• Common Law Address/Phone Change Form
• New Participant FMS Referral Form with Options Transfer
• Participant wants to re-enroll with PPL
• Participant wants to change Service Coordination Organizations
• Service Plan moves with the participant
• Do not end date Service Plan or PPL services
• Only change Service Coordination services

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Reporting Terminations and GAPs in Service

• Modifying the Start or End Date due to

a Termination or GAP in Service

• If a participant is no longer eligible for

services, please update the end date of the month that the participant was last active.

• Complete the Termination Section of the

CLE and Participant Services Change Form found on the PPL PA OLTL program website.

• If a participant services are temporarily on

hold, enter Service Hold information.

• Please also notify your Regional

Enrollment Manager so the participant’s enrollment status can be updated in Portal to stop any services from being paid after the last date the participant was eligible

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Participant Eligibility

• Service coordinators monitor and assist with participant issues

related to Medicaid and Waiver eligibility

• County Assistance Office (CAO)
• SCs assist participants during recertification process as needed and
• Coordinate county changes or waiver changes with CAO
• Notify your PPL Enrollment Manager as soon as you become aware
• f a county or waiver change to coordinate continuation of services

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PPL Tools

• PPL BetterOnline™ web portal
• Reports
• Customer Service
• Program website resources
• DCW over-the-phone-enrollment
• CLE Orientation & Skills Training

Handbook

• Program Management Staff, specifically,

Regional Enrollment Managers and Enrollment Specialists

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PPL BetterOnline™ web portal

• Provides real-time access to participant information
• Functions of the web portal for SCs include the following:
• Entering New Participant Referrals
• Accessing participant information, budgets and utilization details
• Information available on the portal
• Participant/CLE demographic information
• Associated Direct Care Workers and current/max pay rate
• Good to Go status for participant and DCW
• Timesheets and pend messages
• Gaps in service
• Participant reports
• SCs can work with their Enrollment Manager (EM) to receive

training on the BetterOnline™ web portal. Each SC can receive a portal id and password by requesting one from their EM.

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PPL Reports

• PPL provides participant reports detailing how services are being

utilized, when timesheets/invoices are missing, when timesheets are pending and why, and on direct care worker qualification and payment information.

• Monthly Utilization, DCW Summary, Over and Under Utilization and DCW 16+

Hours Shift

• PPL Reports are available to SCs in web portal; available reports

include the following:

• Monthly Utilization Report, Direct Care Worker Report, Ineligibility Report, Client Pend Report,

CLE Overutilization Reports, CLE Underutilization Reports, Missing Timesheet/Invoice Report, Overlapping Timesheet Report, Worker Qualification Report and Direct Care Worker Working 16+ hours per shift.

• Reports also available to CLEs in Portal.

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PPL Customer Service

• Provides toll-free customer service via phone,

fax and e-mail.

• Provides translation and interpreter service
• Provides assistance with completing CLE and

DCW paperwork

• Notifies CLE of missing or incorrect paperwork
• Notifies CLE of issues that may delay payroll to

DCWs

• Provides program materials in alternate formats

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PPL Customer Service Continued

PPL Customer Service Staff will:

• Reflect principles of self-determination
• Demonstrate cultural sensitivity

Customer Service Call Handling Features:

• Interactive Voice Response (IVR)
• Call recording for monitoring and training purposes
• Blaze calls to CLEs

IMPORTANT:

Only PPL staff, CLEs, Designated Representatives, SCs, and SC supervisors will be able to speak with PPL Customer Service staff about a participant’s services.

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Website Resources

PPL website:

• CLE and DCW forms to download
• Portal How-to Guides
• Payroll Schedules and timesheets
• Workers Compensation Information
• WebEx Recordings
• Frequently Asked Questions

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Contact PPL

Customer Service Hours: 8:30 am - 8:00 pm (Monday-Friday) 9:00 am - 1:00 pm (Saturday) Closed: Federal Holidays Toll Free: 877-908-1750 TTY/TDD: 800-360-5899 E-mail: cs-oltl@pcgus.com Mail to: P.O. Box 1108 Wilkes-Barre, PA 18773-9905

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Questions / Comments

Questions not answered today will be used to compile a FAQ document to be posted on the PA OLTL program website

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