Frequently Asked Questions

As stated on page 91 of the 2023 Comprehensive Guide to Medicaid Services and Administrative Claiming, as required by CMS, the supporting documentation file for each claim of FFP must include, at a minimum, the following:

• Date of service
• Name of recipient
• Medicaid identification number
• Name of provider agency and person providing the service
• Nature, extent, or units of service
• Place of service

Within an IEP many of the above requirements may be found, including:

• Name of recipient/child
• Eligibility for IDEA services and the child’s present level of achievement
• Name of provider agency/LEA
• Nature, extent, or units of service (called the frequency and duration of services)
• Place of service (called either the location or placement)

LEAs should review their State’s guidance for service documentation. Many States require additional information beyond the CMS requirements, such as a diagnosis code.

FAQ ID:162371

If medical necessity has been determined, Code 4C. Direct Medical Services – Covered on a Medical Plan of Care, Not Covered as IDEA/IEP Service is the correct code. This code should be used when district staff (employees or contracted staff) provide covered direct medical services under the SBS Program where documented on a medical plan other than an IEP/IFSP or where medical necessity has been otherwise established.

FAQ ID:162396

The system used to identify Medicaid members is unique to each State. The Technical Assistance Center can help with research and work with States to identify best practices to address this issue. We recommend the SMA work with LEAs to develop an integrated system used by both entities.

FAQ ID:162406

States have broad flexibility to determine what services can be delivered via telehealth. Further information can be found in the Telehealth Toolkits (COVID-19 & February 2024 Versions), accessible through this link: State Medicaid and CHIP Telehealth Toolkits landing page.

FAQ ID:162401

There are no federal requirements for Current Procedural Terminology or International Classification of Diseases codes for Medicaid billing. States may have their own requirements, however. We advise communication between SMAs, SEAs, and LEAs within a State to ensure proper SBS coding guidance.

FAQ ID:162381

No, for the LTSS Comprehensive Care Plan and Update measure, the care plan does not have to take place in the member’s home. However, it must be done face-to-face unless certain exceptions are met. These exceptions include circumstances in which:

• The member was offered a face-to-face discussion and refused (either refused a face-to-face encounter or requested a telephone discussion instead of a face-to-face discussion).
• The state policy, regulation, or other state guidance excludes the member from a requirement for face-to-face discussion of a care plan.

FAQ ID:89146

Use the most recently updated care plan.

FAQ ID:89151

To meet the LTSS Comprehensive Care Plan and Update measure numerator, the care plan must be signed by the member, unless the care plan is under appeal in the specified timeframe, and there is documentation that the care plan was in appeal. There is an exclusion for members who refuse to take part in care planning. This exclusion is reported with the measure rate, so the overall measure rate can be interpreted correctly. For example, a plan that is not successful at engaging members in care planning, indicated by a high exclusion rate, would suggest the overall rate on the measure should be interpreted with caution.

FAQ ID:89166

There must be documentation that at least three attempts were made to reach the member, and they could not be reached. The rate of exclusion due to inability to reach a member should also be reported along with the measure performance rate.

FAQ ID:89176

In these circumstances, MLTSS plan records should clearly document that no caregiver was involved to satisfy the measure criteria. For example, there are situations in which it may not be appropriate to engage the caregiver, including cases in which the member refused to involve the caregiver, or the invited caregiver declined to participate. Reasons for lack of caregiver involvement are not required; documentation that a caregiver was not involved suffices.

FAQ ID:89181