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What is Direct Service Claiming (DSC)?
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The Direct Service Claiming (DSC) program is a federally funded program that allows school districts to receive reimbursement for costs associated with providing select Medicaid services to an eligible student. A student is considered eligible when he or she meets these requirements:
- The student is AHCCCS/Title XIX eligible and enrolled
- The student is eligible under the Individuals with Disabilities Education Act (IDEA), Part B and has an active Individualized Education Program (IEP)
- The student is age 3 through 21 years on the date of service
Note: AHCCCS recipients eligible under the KidsCare, SOBRA Family Planning and the Emergency Services Programs are not eligible in this program.
Effective dates of eligibility can be verified by the AHCCCS system. Verification of Medicaid eligibility is not a guarantee of payment.
Services included in the Fee-for-Service Program are determined by CMS and the State. Services must be within the Medicaid scope of services and included in the State's Plan. In Arizona, services are part of the Early Periodic Screening Diagnosis and Treatment (EPSDT) program. Furthermore the services must be rendered by a registered Arizona Medicaid Provider.
Covered Services
In accordance with the Individuals with Disabilities Education Act (IDEA) Part B, school districts are required to provide medical services to students with disabilities when deemed appropriate.
If identified on the IEP as medically necessary, claimable services include:
- Audiology
- Behavioral Health/Mental Health Services
- Health Aide Services (restrictions apply)
- Nursing Services
- Occupational Therapy
- Physical Therapy
- Speech Therapy
- Transportation (restrictions apply)
Through the Direct Service Claiming program, LEA's are paid for rendering covered services. For a service to be considered covered, the service must be:
- Provided to an eligible child
- Provided by a qualified provider
- A service approved by the State
- Medically necessary
- Provided on site
Medically Necessary
For purposes of the DSC program, "medically necessary" means a Medicaid covered service provided through the DSC program by a licensed practitioner, or qualified provider of the healing arts within the scope of their practice under state law to:
1. Allow the student to obtain an education through the public school system;
2. Prevent death, treat/cure disease and ameliorate disabilities or other adverse health conditions; and
3. Prolong life.
The documentation in the student's record is important when evaluating the medical necessity of services. Key components include:
- Evaluations completed by AHCCCS-registered providers that specifically identify rationale and treatment recommendations;
- An Individualized Education Plan (IEP) that specifies goals to correlate with the professional recommendations;
- Signed and dated progress notes or treatment summaries that specifically address the progress being made towards the identified goals and why continued treatment is required; and
- Descriptions of the services to be provided by all DSC-eligible providers
Update on Audiology Services
The audiology service for Direct Service Claiming (DSC) include the screening and evaluation process that is performed as ordered in the child’s IEP. Some pre-IEP evaluations are also covered.
Service included in the IEP
If the child’s IEP states that the child’s medical condition requires an audiology evaluation and/or screening, that evaluation and/or screening is given and it results in a covered service, that service may be billed. Refer to the list of approved services for guidance.
Pre-IEP Services
The evaluation/screening that is done prior to the development of the IEP that determines the need for hearing services may be covered. The service must be performed by an AHCCCS-registered audiologist and must be on the list of covered services. If that service results in the development of a hearing impaired plan or some type of audioloty service in the IEP, that service may be billed.
Exclusions
- General hearing screening done for all students is not covered
- Annual hearing screening done for all Special Education students is not covered
- Screening and evaluation that do not result in an audiology/hearing impaired plan are not covered
- Services performed by a person other than an audiologist are not covered.
Who Can Participate?
Employees and contractors of Districts are eligible to bill for their services if they are qualified providers properly licensed/certified and registered with AHCCCS. Providers include:
- Audiologists
- School Speech Therapists
- Licensed Practical Nurses (LPN)
- Licensed Clinical Social Workers (LCSW)
- Licensed Marriage and Family Therapists (LMFT)
- Licensed Professional Clinical Counselors
- Licensed Professional Counselors (LPC)
- Licensed Psychiatrists
- Licensed Psychologists
- Occupational Therapists
- Physical Therapists
- School Psychologists
- Registered Nurses (RN)
- School Based Guidance Counselor
- Speech & Hearing Therapist
Provider Registration
In order for services to be reimbursed both the LEA and rendering provider must be registered Arizona Medicaid Providers and have a valid AHCCCS Identification Number and National Provider ID. Furthermore the rendering provider must be affiliated (grouped) to the LEA where the services are provided. In the DSC program, there are three types of AHCCCS ID numbers:
- Group Billing ID number (LEA ID number)
- Individual provider ID number
- Transportation ID number (type 92)
AHCCCS Provider Registration is the governing body for all provider related issues. To register a LEA, provider, or to group them together contact AHCCCS Provider Registration. For your convenience a link to their website has been included in the related links page of this website.
Billing Services Provided
Although it is not a program requirement, LEAs may choose to utilize a billing agent/consultant to prepare their DSC Claims. To assist LEAs in making an informed decision as to whether to use a billing agent/consultant, PCG has prepared a brief power point presentation that identifies several items of interest. Currently there are four billing agents/consultants working with Arizona LEAs on the DSC Program including:
- MeccaTech
- PracticeMax
- Southwest Educational Billing Services (SEBS)
LEAs electing to utilize a billing agent/consultant must complete a Biller Authorization Form and submit it to PCG in order for HIPAA related information to be given to the agent/consultant. Both the power point presentation and the Biller Authorization Forms are available on the download page of this website. Additional information (contact) for the listed billing agents/consultants currently working with Arizona LEAs for the DSC Program is provided on the related links page of this website. If you have additional questions please feel free to contact your assigned PCG Account Manager.
How Claims are Paid
Once services are provided and appropriately documented on the provider service logs, LEAs (or their designee) create claims and submit them to PCG. Claims are accepted in two formats:
Paper claims: Claims data provided on a CMS1500 form (including all required fields); or
Electronic submission: Electronic claims file created in NSF 3.01 format or ANSI X12 format and submitted to PCG either through an approved clearinghouse or directly to PCG after an approved testing process
A LEA has three basic options for submitting claims to PCG:
- submitting their own paper claims,
- submitting their own electronic claims, or
- hiring a Biller to format and submit claims (usually in an electronic format)
Regardless of the billing method elected by the LEA, all claims must be timely received at PCG in order to be considered for payment. If the LEA bills on paper, the claim mailed to PCG is considered "received" when the mail arrives at PCG. If the LEA is a self biller who bills electronically or uses a Biller who bills electronically, "received" means the date the file is confirmed by either the clearinghouse, or PCG if direct-post submitted.
Timeliness
In accordance with ARS §36-2904 (G), Arizona Administrative Code R9-22-703, and the AHCCCS Provider Manual, an initial claim must be received by PCG no later than 6 months from the date of service. Claims initially received beyond the 6-month time frame will be denied.
If the claim is originally received within the 6-month time frame and denied, the claim can be resubmitted up to 12 months from the date of service. If a claim does not achieve clean claim status within 12 months, PCG is not liable for payment.
Clean Claims
As defined by ARS §36-2904 (G), a clean claim is "a claim that may be processed without obtaining additional information from the provider of service or from a third party but does not include claims under investigation for fraud or abuse or claims under review for medical necessity".
PCG is the Administrator of the DSC program, and therefore cannot alter the claims once they have been received. Therefore, all proper claims preparation must be done before the submission of the claim. Once a claim is processed, PCG prepares a Remittance Advice (RA) that provides a detailed explanation of the claims' status including (but not limited to) information such as: adjudication status, denial reasons, and reimbursement amounts. If an LEA chooses to work with a billing consultant/agent, then they would be responsible for reconciling the LEAs processed claim payment on behalf of the LEA. LEAs that self bill would be responsible for reconciling the claims.
Additional information about the claims process and requirements is included in the Arizona Medicaid School Based Claiming Program Handbook available on the Download page of this website.
It is important that the DSC Coordinator at the LEA understand the claims process regardless of whether the LEA utilizes a billing consultant/agent. PCG is available to answer any questions and to provide assistance to the DSC Coordinators.
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