what is retrospective claim review and denied claim appeal


The contracting provider shall have the right to a retrospective review of any claim denied in whole or in part. The purpose of a retrospective review is to allow the provider to contact customer service to determine whether the original adjudication was correct.

A. All requests for retrospective review must be submitted (in writing or by phone) to and received by BCBSKS Customer Service within 120 days from the date of the remittance advice.

B. The provider will be given a response to the request for a retrospective review as soon as possible, but no later than 60 days from receipt date. In cases where claims are adjusted, the remittance advice will serve as the response


A request made from a contracting provider to change a claim, (e.g., changing information on the service line, modifier addition, diagnosis correction, etc.) that has previously processed is considered a corrected claim. The submission of a corrected claim must be received by BCBSKS within the 15-month timely filing deadline. Claims denied requesting additional information (e.g. by letter or adjustment reason code) should never be marked "corrected claim" when resubmitted. Instead, providers should submit a new claim with the requested information.

When a claim denial or adjustment is made as a result of a BCBSKS audit, the provider may not submit a corrected claim to reverse the decision. The provider’s next course of action is to enter into the appeal process.


After completion of the retrospective review process (see Section II. Retrospective Claim Reviews), contracting providers may appeal certain pre and post-service claim denials. Only claims denied as not medically necessary may be appealed on the provider’s own behalf as set forth in the policies and procedures. When BCBSKS requests records to support a claim denial, but does not receive them within the 45-day time limit, the service will be denied not medically necessary and will be a provider write-off. The provider may be designated as the member’s authorized representative for appeal purposes according to the terms of the member’s contract.

NOTE: Medical policies including Content of Service (COS) as described in BCBSKS Policy Memos 1-12 or provider’s obligations specified in their provider contracts are not considered eligible claims appeals as outlined in Section III. DENIED CLAIMS APPEALS PROCEDURE. Annually, BCBSKS outlines any changes to the Policy Memos and forwards them to providers for their review. Once providers accept these changes, they are part of the provider’s contract and therefore not considered for claims appeals. Providers disagreeing with any policies should submit their position and supportive documentation to BCBSKS staff for future consideration.

Appeals as the Member’s Authorized Representative: Appeals that you can make as the member’s authorized representative according to the terms of the member’s contract are claims for which the member is financially responsible. When you act as the member’s authorized representative, you are not separately entitled to any appeals pursuant to this Contracting Provider Agreement. Appeals Pursuant to Contracting Provider’s Agreement

First Level: Written notification of disagreement highlighting specific points for reconsideration of a claim denied not medically necessary shall be provided to BCBSKS within 60 days from the date of the retrospective review determination. This notice shall be considered an initial appeal and be forwarded with all pertinent medical records to BCBSKS Customer Service. Medical records submitted with the request for initial appeal will be referred to the appropriate consultant and a determination will be rendered. This decision will be binding unless the provider files a second-level appeal within 60 days of notification of such decision.

Second Level: Forward a written request for the second-level appeal to BCBSKS customer service within 60 days following the first-level appeal denial notification. The second and final appeal determination shall be made by a physician or clinical peer. The contracting provider agrees to abide by the second-level appeal determination.

All appeal decisions under this agreement must be provided within 60 days of receipt of the provider's request. Any appeals decision not provided within the aforementioned time frames shall be considered as decisions made in favor of the provider and claim payments will be adjusted accordingly.

A contracting provider agrees to accept the determination made at each level or to appeal the determination at the next step of the appeals process. If throughout the appeals process the decision on the claim changes in the provider's favor, an additional payment will be made. However, a refund will be requested if the decision reverses a previous determination (either partially or totally).

The result of the appeals process shall be binding on the provider and BCBSKS subject only to the provision for binding arbitration previously stated herein.

Nursing Care services Billing overiview


Nursing services are covered on an intermittent (separated intervals of time) basis when provided by, or under the direct supervision of, a registered nurse (RN).

A nursing visit may include, but is not limited to, one or more of the following nursing services:

* Administering prescribed medications that cannot be self-administered.

* Changing an indwelling catheter.

* Applying dressings that require prescribed medications and aseptic techniques.

* Teaching the beneficiary, available family member, willing friend or neighbor, or caregiver (paid or unpaid) to carry out all or some of the services, as detailed below.

* Observation and evaluation, as detailed below.

Intermittent (separated intervals of time) nurse visits are intended for beneficiaries who generally require nursing services on a short-term basis (typically 60 days or less) for the treatment of an acute illness, injury, or disability and who cannot receive these services in an outpatient setting. Intermittent nursing visits may last from 15 minutes to one or two hours and are reimbursed at a flat rate (i.e., Medicaid feescreen for a visit) regardless of the length of the visit.

Intensive care (for cases that require five or more visits per week or beyond 60 days) may be reviewed by MDHHS during post-payment audit to determine if home care was medically appropriate and a cost effective alternative to institutional care.

Intermittent nurse visits are not covered for a beneficiary receiving Private Duty Nursing Services.


The following nursing services are covered home health care services. Limitations, conditions and special considerations are noted when applicable. (Refer to the Billing & Reimbursement for Institutional Providers Chapter of this manual for billing information.)


When use of a catheter is temporary, visits made by the nurse to change the catheter must also include instruction to the beneficiary in bladder training methods. The actual bladder training (e.g., forcing fluids or other measures) does not require the skills of a nurse. After the catheter is removed, a limited number of visits (maximum two visits per month) are allowed to observe and evaluate the effectiveness with which the bladder training has been accomplished (e.g., the degree to which the bladder is emptying).


A physician’s order is required for a HHA to make home visits regarding blood lead poisoning. Medicaid reimburses up to two nurse visits per child, regardless of the number of children in the home diagnosed with blood lead poisoning.

HHAs who suspect beneficiaries may have evidence of blood lead poisoning or blood lead levels above accepted state levels in the home should refer the beneficiary to the local health department (LHD).


Giving enemas usually does not require the skills of a nurse, and Medicaid does not cover such visits unless the physician has ordered that a nurse give the enema because of clinical indications.


Two nurse visits are allowed to teach the administration of eye drops and topical ointments. Nurse visits solely to perform these services are not covered.


If the beneficiary is in need of intravenous infusion and an infusion clinic or ancillary Medicaid provider (who has no nurse) does not cover the service, or family member/care giver will not accept this task, the HHA may perform this service and bill accordingly.

Medicaid will reimburse claims for professional services (e.g., nursing services) associated with the administration of Medicare Part D drug(s) to dually eligible Medicaid/Medicare beneficiaries.


Nurse visits related to neonatal jaundice require supporting documentation in the beneficiary's medical record that the nurse visits are required for a specific medical condition. Supporting documentation should include pertinent laboratory values.


If the attending physician determines that the beneficiary’s condition is unstable and that significant changes may occur, Medicaid covers nurse visits for observation/evaluation. Once the beneficiary’s condition has stabilized and there has been no significant change (e.g., no change in medication or vital signs, no recent exacerbation in the beneficiary’s condition) for a period of three weeks, and no other necessary nursing services are being furnished, nursing visits solely for observation/evaluation are no longer covered. Visits for observation/evaluation to ensure stability of a beneficiary who has an established disability or frail condition are covered by Medicaid if circumstances, conditions, or situations exist that prevent the beneficiary from obtaining services from a physician’s office or outpatient clinic as described in the Home Setting Section of this chapter. Such visits are limited to two visits per month.

Nurse visits for observation/evaluation to insure stability of a beneficiary’s condition cannot be billed within a 30-day period of an initial/subsequent postpartum/newborn follow-up nurse visit, suspected abuse nurse visit or aide visit.


Administration of oral medications does not usually require the skills of a nurse in the home setting. Visits are covered only if the complexity of the beneficiary’s condition and/or the number of drugs prescribed require the skill or judgment of a nurse to detect and evaluate side effects (adverse reactions) and/or provide necessary teaching and instruction.

Placing medication in envelopes/cups, giving reminders, etc., to assist the beneficiary in remembering to take them does not constitute a nursing service.


Home visits for assessment, evaluation and teaching are covered for women and newborns following delivery when a physician has determined the mother or newborn may be at risk. The goals of these services include:

* Fostering a positive outcome for the mother and newborn by detecting medical complications manifested during the
postpartum/newborn period;

* Instructing the mother in newborn care; and

* Identifying situations that may require intervention with medical and community resources.

The HHA must assess and document, in writing, that the beneficiary is receiving services by a Maternal Infant Health Program (MIHP) provider. If the HHA is also an enrolled MIHP provider, services for the mother and newborn cannot be billed as home health care but must be billed as MIHP services. If the beneficiary is receiving MIHP services from another provider and the HHA is also providing services, the POC must clearl  identify why home health services are needed in addition to MIHP and that the two providers do not duplicate services.

Medicaid allows one initial postpartum visit, one initial newborn visit, and one subsequent visit to mother and newborn for a total of three visits per pregnancy.

* The initial postpartum visit must be billed using the mother’s Medicaid ID number.

* The initial newborn visit must be billed using the newborn’s Medicaid ID number.

* The subsequent visit may be billed under either the mother’s ID number or newborn’s ID number, based on the most time spent with each beneficiary.


Medicaid covers home visits for a specific pregnancy related medical condition provided by a HHA.

Home visits provided for preventive health services which address psychosocial issues, provide education, provide transportation, etc. and that do not provide treatment for an illness or injury are a covered service of the MIHP, not Home Health.


The recognized stages of decubitus ulcers are classified as:

* Stage I - Inflammation or redness of the skin;

* Stage II - Superficial skin break with erythema of surrounding area;

* Stage III - Skin break with deep tissue involvement; and

* Stage IV - Skin break with deep tissue involvement with necrotic tissue present.

The existence of Stage III or IV decubiti or other widespread skin disorders may necessitate the skills of a nurse. The physician’s orders for treating the skin determine the need for this service.

The presence of Stage I or II decubiti, rash, or other relatively minor skin irritations do not indicate a need for nursing care unless ordered by a physician. Bathing the skin, applying creams, etc. are not covered nursing services.

Home Health care billing - Detailed overview


This chapter applies to Home Health providers.

Home health is a covered Medicaid benefit for beneficiaries whose conditions do not require continuous medical/nursing and related care, but do require health services on an intermittent basis in the home setting for the treatment of an injury, illness, or disability. Medicaid covered services may be provided in the home only if circumstances, conditions, or situations exist which prevent the beneficiary from being served in a physician’s office or other outpatient setting. Except as detailed in this chapter, the beneficiary’s primary need must be for nursing care and/or physical therapy, rather than personal care or physician’s care.

A Home Health Agency (HHA) is an organization that provides home care services, such as skilled nursing care, physical therapy (PT), occupational therapy (OT), speech therapy (ST) and care by home health aides. The HHA must be Medicare certified to enroll as a Medicaid provider and must comply with the Medicare/Medicaid Conditions of Participation (42 CFR § 484) and the policies outlined in this manual.

Services solely to prevent an illness, injury or disability are only covered for women/newborns following delivery. For postpartum/newborn follow-up nurse visits, a nursing diagnosis can be used to establish medical necessity. Otherwise, a medical diagnosis is required to establish medical necessity. Medicaid beneficiaries are expected to be an active participant in the planning for their home health care. For beneficiaries enrolled in a Medicaid Health Plan (MHP), the HHA must contact that health plan for authorization to provide services to their members.

Medicaid home health services must be ordered, in writing, by the beneficiary’s attending physician (MD, DO) as part of a written plan of care (POC) and reviewed by this physician every 60 days. The physician’s order and POC must be only for functions that are within the scope of his current medical practice and Medicaid guidelines.

This chapter includes information about services covered for Medicaid and Children’s Special Health Care Services (CSHCS) beneficiaries unless otherwise noted.


A physician certifying eligibility for home health services must provide documentation of a face-to-face encounter with the beneficiary within 90-days prior to or 30-days after the start of care. The face-to-face encounter may occur through telehealth in compliance with Section 1834(m) of the Social Security Act. NOTE: The face-to-face encounter requirement pertains only to initial certification for home health services.

Only a physician may order home health services and certify a beneficiary's eligibility for the benefit. The face-to-face encounter ensures that the orders and certification for home health services are based on current knowledge of the beneficiary's clinical condition, and will identify the primary reason for home health services.

In a situation where a physician orders home health services based on a new condition that was not evident during a visit within the 90-days prior to the start of care, the certifying physician or nonphysician practitioner (NPP) must see the beneficiary within 30 days of admission to home health services.

The certifying physician must document the face-to-face encounter regardless of whether the physician or a permitted NPP performed the encounter. When the face-to-face encounter is performed by a NPP, he/she must document the clinical findings of the face-to-face encounter and communicate those findings to the physician; the physician must then sign the certification.

Permitted NPPs include:

* A nurse practitioner or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act) who is working in collaboration with the physician in accordance with state law;

* A certified nurse-midwife (as defined in section 1861(gg) of the Social Security Act, as authorized by State law); or

* A physician assistant (as defined in section 1861(aa)(5) of the Social Security Act) under the supervision of the physician.

The face-to-face beneficiary encounter must be a separate and distinct section of, or an addendum to, the certification and must be clearly titled, dated and signed by the certifying physician. Use of a specificform for the certification or the plan of care is not required.

Documentation of the face-to-face encounter must reflect the certifying practitioner’s assessment of the beneficiary and include:

* Date of the encounter,

* Primary reason for the encounter (medical condition),

* Clinical findings that support the need for skilled nursing or therapy services, and

* Clinical findings that support home health eligibility.

An addendum may consist of clinical documents from a hospital or post-acute facility (e.g., emergency visit record or discharge summary). It is allowable for the certifying physician to use such a document as an addendum for the face-to-face encounter if:

* The addendum contains all of the documentation requirements for face-to-face documentation;

 * The addendum document, which is serving as the face-to-face documentation, is clearly titledand dated as such; and

* The certifying physician signs and dates the addendum, demonstrating that the certifying physician received that information from the allowed NPP or physician who performed the faceto- face encounter, and that the certifying physician is using that addendum document as his/her documentation of the face-to-face encounter.

While typically the same physician will certify, establish and sign the POC, it is allowable for physicians who attend to the beneficiary in the acute and post-acute settings to certify the need for home health care based on their face-to-face contact, initiate the orders (POC) for home health services, and "hand off" the beneficiary's care to the community-based physician to review and sign off on the plan of care.


Home health services are intended for beneficiaries who are unable to access services (nursing, OT, PT, speech and language pathology therapy [ST]) in an outpatient setting. However, it is not required that beneficiaries be totally restricted to their home. A determination and documentation is required by the HHA that the home is the most appropriate setting in which to provide the service(s). Home health services are not provided solely on the basis of convenience.

All covered home health services must be rendered in a beneficiary’s home, except for those services listed below. Home may be the beneficiary’s owned/rented home, an apartment, Assisted Living Facility, Adult Foster Care (AFC) facility, or home of another family member (secondary residence of the beneficiary, i.e., joint custody situation for a minor child).

* Home Health aide services are not a covered benefit for beneficiaries who reside in a Home for the Aged (HFA) or Adult Foster Care (AFC) facility as this would be duplication of personal care services already provided by staff of these facilities.

* Michigan Department of Health and Human Services (MDHHS) does not cover any Home Health services rendered to a beneficiary in a hospital, nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), Intermediate Care Facility for the Mentally Ill (ICF/MI), school or adult day care.

To determine if services in the home, rather than in an outpatient setting, are most appropriate, consider the following:

* Is in-home care necessary for the adaptation, training or teaching of nursing or treatment procedures, plans, equipment, appliances or prosthetics in the home setting*

* Is in-home care necessary to prevent undue exposure to infection and/or stress for the beneficiary as identified and documented by a health care professional*

* Is leaving the home medically contraindicated, as identified and documented by a health care professional*

* Is in-home care necessary to prevent a documented problem with access to services, continuity of care or provider, or coordination of services, as documented by a health care professional*

* Is in-home care the most cost-effective method to provide care*

Services must be appropriate and necessary for the treatment of an identified illness, injury or disability. The services provided must be consistent with the nature and severity of the beneficiary’s illness, injury or disability, his particular medical needs and accepted standards of medical practice. Beneficiaries with established frail conditions may need assessments by skilled nurses to prevent further decline of the frail condition.


The plan of care (POC) must include the following:

* Date of most recent hospitalization.

* Medical diagnosis and impact of functional limitation.

* Specific circumstances, conditions, or situations that require services to be provided in the home and not in a physician’s office or outpatient clinic.

* Date of the HHA’s first visit for this admission.

* The date for which the HHA began providing home care. (This date remains the same on subsequent POCs until the beneficiary is discharged from home health care services.)

* Detailed description of each service to be provided, including frequency and duration of services.

* Detailed description of current goals as related to the services provided and the goal for discharge planning.

* A full description of the reason(s) that initial and/or continued home care is needed (e.g., pertinent laboratory values, medications, wounds, abnormal vital signs).

* Environment status (e.g., electricity, telephone, indoor plumbing).

* Identification of other resources used by the beneficiary (e.g., Area Agency on Aging, Protective Services, Home Help Services).

* Date of physician’s last contact.

* Role of family or support person.

* HHA’s name, address and provider NPI number, and beneficiary’s name, date of birth, and Medicaid ID number.

* The attending physician’s signature and date he signed the POC. The POC must be signed and dated by the beneficiary’s attending physician before the HHA submits a claim to MDHHS for payment.

If the attending physician signs the POC after the service(s) is rendered, there must be a pre-existing written or verbal order for the service(s) to be covered by Medicaid. If the service(s) is rendered prior to the date the physician dated the POC and there is no pre-existing written or verbal order, Medicaid does not cover the service(s) provided. The verbal order obtained from the ordering physician must contain the signature of the HHA staff person who obtained the verbal order and the date the verbal order was received. All verbal orders must be countersigned and dated by the ordering physician before the claim is submitted to MDHHS for payment.

Ordering physicians must determine that medical/health services are medically necessary and/or appropriate. Any increase in the frequency of services, addition of new services, or modifications of treatment during a certification period must be authorized by the attending physician and documented in the beneficiary’s medical record by way of a verbal order or written order prior to the provision of the increased, additional, or modified treatment.

The POC signed by the attending physician, along with any written or verbal orders as needed, and progress notes must be retained in the beneficiary’s medical record.


The Centers for Medicare & Medicaid Services (CMS) requires Medicare certified HHAs to use a standard assessment data set, referred to as the Outcome and Assessment Information Set (OASIS). The requirement to collect and submit OASIS clinical data applies to all beneficiaries receiving Medicare and/or Medicaid home health services. This means beneficiaries under Medicaid traditional fee-for service (FFS), MHP, Children’s Waiver, Home and Community Based Services Waiver for the Elderly and
Disabled (MI Choice Waiver), Habilitation Supports Waiver, Healthy Michigan Plan, and CSHCS who receive home health services are to have OASIS information collected by the HHA. Assessments for all beneficiaries are to be conducted in compliance with Medicare certification requirements.

HHAs are also required to electronically transmit the OASIS data to the designated state agency responsible for collecting OASIS data in accordance with CMS specifications. MDHHS contracts with a vendor to provide OASIS transmission assistance. HHAs needing assistance with transmitting data to the state repository should contact the MDHHS contractor. (Refer to the Directory Appendix for contact information.)

The CMS rules for OASIS are published in the Federal Registers that are available online at the OASIS website. (Refer to the Directory Appendix for website information.)


Ordering physicians must determine that medical/health services are medically necessary and/or appropriate. All home health services ordered are subject to review for conformity with accepted medical practice and Medicaid coverage and limitations. Post-payment reviews of paid claims may be conducted to assure that the services provided, as well as the type of provider and setting, were appropriate, necessary, and compliant with Medicaid policy. Post-payment review also includes verification that appropriate procedure codes were used to bill the services provided.

Post-payment review includes verification that all third-party resources were utilized to their fullest extent prior to billing MDHHS. If post-payment review reveals that MDHHS was billed prior to utilizing these resources and the HHA knew the beneficiary had other insurance coverage for the service rendered, it may be considered fraud.

The General Information for Providers Chapter of this manual contains additional information regarding post-payment review and fraud.

Vision and Development screen billing overview


PCPs must perform a subjective vision screening (i.e., by history) at each well child visit. For asymptomatic children 3 years of age and older, an objective screening must occur as indicated on the AAP periodicity schedule. For children of any age, referral to an optometrist or ophthalmologist must be made if there are symptoms or other medical justification (e.g., parent/guardian has suspicions about poor vision in the child). The AAP requires a vision risk assessment at each well child visit. MDHHS requires vision testing at specific well child visits for children 3 years of age and older.


Due to behavior and comprehension ability of children younger than 3 years of age, the standard screening is subjective. An objective screening should begin at 3 years of age. An objective vision screening is accomplished using a standardized screening tool and may be performed on Medicaid eligible preschool-age children each year beginning at 3 years of age through 6 years of age by qualified Local Health Department (LHD) staff.

If the child is uncooperative, the screening should be re-administered within six months.

LHDs may provide objective vision screening services and accept referrals for screening from the PCP and from Head Start agencies. In an effort to promote communication with the child’s medical home, the objective vision screening results must be reported to the child’s PCP. In the event the LHD is unable to report the objective vision screening results to the child’s PCP, the LHD must clearly document why this could not be accomplished. If the LHD receives authorization, the results may be shared with the Head Start agency if that agency was the referral source.


A subjective vision screening must be performed at each well child visit; an objective screening shall be performed as indicated on the AAP periodicity schedule.


A vision screening is to be performed at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years of age. A risk assessment is to be performed, with appropriate action to follow if positive, for newborns and during the ages of:

* 3 to 5 days

* 1 month

* 2 months

* 4 months

* 6 months

* 9 months

* 12 months

* 15 months

* 18 months

* 24 months
* 30 months

* 7 years

* 9 years

* 11 years

* 13 years

* 14 years

* 16 years

* 17 years

* 19 years

* 20 years


A developmental/behavioral assessment is required at each scheduled EPSDT well child visit from birth through adolescence as recommended by the AAP periodicity schedule. The PCP should screen all children for developmental and behavioral concerns, including engaging in risky behavior, using a validated and standardized screening tool as indicated by the AAP periodicity schedule.

A maximum of three objective standardized screenings may be performed in one day for the same beneficiary by a single provider. (Refer to the Billing & Reimbursement for Professionals Chapter for billing instructions.) If the screening is positive or suspected problems are observed, further evaluation must be completed by the PCP, or the child should be referred for a prompt follow-up assessment to identify any further health needs. The provider may administer additional screenings, surveillance, or assessments as described in the following subsections.


A developmental screening using an objective validated and standardized screening tool must be performed following the AAP periodicity schedule at 9, 18 and 30 (or 24) months of age, and during any other preventive health care well child visits when there are parent/guardian and/or provider concerns. Developmental screening may be accomplished by using a validated and standardized developmental screening tool such as the Ages and Stages Questionnaire (ASQ) or Parents’ Evaluation of Developmental Status (PEDS). If the screening is positive, PCPs should further evaluate the child, provide counseling, and refer the child as appropriate.



CMDS clinics are required to operate under the authority of hospitals or medical universities. Hospitals and medical universities requesting CMDS clinic designation must adhere to the requirements as stated in this policy and acquire approval and oversight from the CSHCS program. Hospitals and medical universities that administer CMDS clinics require a separate National Provider Identifier (NPI) number with which to enroll and submit claims for the CMDS clinic fee. CSHCS-approved organizations with responsibility for CMDS clinics must enroll through the online MDHHS CHAMPS Provider Enrollment (PE) subsystem to be reimbursed for clinic fees for services rendered to eligible beneficiaries. Each CMDS clinic must operate under the unique CMDS National Provider Identifier (NPI) held by the organization responsible for those CMDS clinics and must identify the providers who render the services in the CMDS clinic as affiliated providers. All affiliated providers whose services are directly reimbursable per MDHHS policy must be separately enrolled in CHAMPS and must also receive a beneficiary-specific authorization from CSHCS prior to the clinic billing for the clinic fees.


In addition to medical services, CMDS clinics provide:

* A single place and extended appointment for the family to be seen by their team of pediatric specialty providers as well as other appropriate health care professionals during each appointment;

* An environment where providers come to the family for the single appointment at the clinic as opposed to the family needing to set separate dates and times to go to each provider as in the usual service methodology;

* Same day, face-to-face care coordination by all of the providers who saw the beneficiary at each appointment allows for immediate discussion, negotiation, coordination and duty assignment. The family does not need to interpret information from one provider to the next which risks misunderstanding as in the usual service methodology;

* Development and upkeep of a coordinated and comprehensive plan of care (POC) and treatment for beneficiaries, including clear statements of current comprehensive assessment and ongoing treatment plans available to the entire team;

* Facilities that are tailored to the needs of children and their families; and

* Opportunities for the parent/beneficiary to participate in treatment planning, allowing for timely feedback and discussion of concerns with specialists and other health care professionals simultaneously when needed.

Services are provided as a comprehensive package by a team of pediatric specialty physicians and other appropriate health care professionals. CMDS clinic fees are not intended for sporadic users of the services available through CMDS clinics such as support services only. CMDS clinic fees are intended for the comprehensive, coordinated and integrated services that CMDS clinics provide to beneficiaries who return for and continue to use this full package of services.


Each CMDS clinic must have the following basic staff available to provide the unique service delivery available through a CMDS clinic model:

Medical Director A Medicaid-enrolled and CSHCS-approved physician currently licensed to practice under Michigan state law, with special training and demonstrated clinical experience related to the diagnoses followed by the specific CMDS clinic type. Physicians are expected to remain familiar with current developments and standards of treatment in their respective fields. If the medical director is not a pediatrician, a board certified pediatrician must be available and function within
the scope of current medical practice.

Physician A Medicaid-enrolled and CSHCS-authorized pediatric subspecialist, or adult subspecialist physician when serving adults, currently licensed to practice under Michigan state law with special training and demonstrated clinical experience related to the diagnoses treated by the specific CMDS clinic type. Physicians are expected to remain familiar with current developments and standards of treatment in their respective fields. Refer to the CMDS Clinic Guide, tables I and II, for subspecialty designations. The CMDS Clinic Guide is available on the MDHHS website. (Refer to the Directory Appendix for website information.)

Registered Nurse A Registered Nurse (RN) currently licensed to practice under Michigan state law and having a minimum of two years of pediatric nursing experience or adult nursing experience when serving adults. Certain CMDS clinics are exempt from this requirement (e.g., the Metabolic Diseases CMDS clinics) as long as they have the appropriate additional staff as required in the CMDS Clinic Guide.

Registered Dietitian A Registered Dietitian (RD) in possession of a master’s degree in human nutrition, public health, or a health-related field with an emphasis on nutrition, and two years of pediatric nutrition experience or adult nutrition experience whenserving adults in providing nutrition assessment, education and counseling. Social Worker A Licensed Master Social Worker (LMSW) or professional staff member in possession of a master’s degree in social work and two years of experience in counseling and providing service to children/youth, adults and their families.

Parent/Guardian and/or Beneficiary 

The parent/guardian and/or the beneficiary must be an actively participating team member in the development of the beneficiary’s comprehensive POC.

Additional Required Staff

Additional staffing requirements are based on clinic diagnosis type. Refer to the CMDS Clinic Guides on the MDHHS website for staffing requirements. (Refer to the Directory Appendix for website information.)


Beneficiaries with multiple, complex diagnoses may receive CMDS coordinated services from more than one CMDS clinic. However, the limits and numbers of CMDS clinic visit types indicate what the beneficiary is eligible to receive regardless of the number of CMDS clinics the beneficiary is accessing. Any CMDS clinic serving the beneficiary under the CMDS clinic process may submit claims for the appropriate clinic fee(s) up to the limit allowed per beneficiary. For example, there are 10 Support Visits allowed per beneficiary in a year. Any organization/clinic serving the beneficiary may bill for those support visits until the beneficiary limit has been reached. That might involve one CMDS clinic receiving reimbursement for all 10 of the Support Visits or a combination of CMDS clinics receiving reimbursement for some visits until the limit has been reached.

The CMDS clinics must document clinic visit levels to include the following:

* Support services must be indicated in the CMDS Plan of Care (POC) developed at a CMDS clinic Comprehensive Initial or Basic Evaluation visit or Management/Follow-up visit.

* The CMDS clinic must collaborate with other CMDS clinics the family/beneficiary may be using regarding which CMDS clinic is the lead CMDS clinic and how the fee billing will occur in coordination between the CMDS clinics that are both serving the same beneficiary.


The Initial Comprehensive Evaluation is performed during the CSHCS client’s first visit to the CMDS clinic. The medical team integrates assessments and recommendations and works with the family/beneficiary in the development of a coordinated and comprehensive POC and treatment for the beneficiary. The CMDS POC is required to be recorded. The CMDS clinic will communicate the written CMDS POC to the appropriate health care providers and the family/beneficiary. Written CMDS POCs may be provided to other appropriate health care providers for whom the parent/guardian/beneficiary has signed a medical release form. A copy of the CMDS POC is to be submitted to CSHCS medical consultants for review.

An Initial Comprehensive Evaluation visit must include the following:

* Physician specialist(s) and non-physician professionals examination or assessment of the beneficiary and submission of an established/confirmed diagnosis(es), identification of strengths and needs and, with family/beneficiary input, development of a course of action or plan for treatment;

* Integration of findings and recommendations at team conferences;

* Discussion of the medical findings and treatment recommendations with family/beneficiary in language the family/beneficiary can comprehend;

* Designation of identified staff to teach the family/beneficiary how to assist in the management of the beneficiary’s health problems if appropriate; and

* Compilation of an integrated CMDS POC from the findings of the various health care providers that includes:

* relevant history;

* medical findings by specialty;

* problem areas that may develop and for which the beneficiary should receive care;

* recommendations and prescriptions for braces, shoes, special equipment, medications, etc.;

* referral to physical therapy, speech-language therapy, occupational therapy, public health nurse, CMDS support services; and

* a description of how the CMDS POC will be implemented. Authorization and processes may differ per health plans and Fee-for-Service (FFS).

Reimbursement for the Initial Comprehensive Evaluation fee occurs only once per beneficiary per lifetime regardless of the number of diagnoses and/or CMDS clinics from which the beneficiary may be receiving services. Medical services continue to be billed as usual.


Basic and ongoing comprehensive evaluation is conducted with established CMDS patients. The evaluation(s) may include the entire CMDS clinic staff composition or asdeemed appropriate by each CMDS clinic Medical Director per visit and is documented in  the CMDS POC.

A basic and ongoing comprehensive evaluation may include the following activities:

* Comprehensive beneficiary assessment;

* Evaluation and identification of the beneficiary’s needs;

* Coordination of the beneficiary’s multi-disciplinary needs;

* Review and modification of the comprehensive CMDS POC;

* Assured implementation and follow-up; and

* Referrals to other professionals, resources, and services as applicable.

Reimbursement for the Basic and Ongoing Comprehensive Evaluation fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year regardless of the number of diagnoses or CMDS clinics the beneficiary may have.

Medical services continue to be billed as usual.


Management/follow-up visits to a CMDS clinic may be provided if they are recommended in the CMDS POC. In addition, a referral may be recommended based on a tertiary hospital inpatient discharge plan that was written within the previous 12 months of the referral. Every effort should be made to include all staff identified as participants in theCMDS POC or as recommended by the CMDS clinic Medical Director.

The management/follow-up visit may include:

* A physical exam by a pediatrician and/or physician subspecialist(s);

* Assessment by at least two of the clinic staff (in addition to the clinic physicians) designated for the clinic type;

* Follow-up on all components identified in the CMDS POC by appropriate staff;

* Update of condition and treatment, and revision of the CMDS POC; and

* Communication with the family/beneficiary, other providers, and other designated health care providers, including provision of copies of the CMDS POC to the family/beneficiary.

Reimbursement for the management/follow-up visit clinic fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics may provide support services. Services consists of counseling, specialized training, transition assistance and/or treatment. Support services must be ordered as part of the CMDS POC developed at a CMDS Clinic Initial Comprehensive Evaluation, Basic and Ongoing Comprehensive Evaluation, and/or Management/Follow-up Visit. CMDS clinic support services may be provided by any combination of one or more of the non-physician basic CMDS clinic staff to the family/beneficiary as outlined in the CMDS POC. Support services may be conducted by professional members of the team (i.e., nurses, dietitians, certified diabetes counselors, social workers or other clinical professional staff as appropriate). The presence of a physician is not required.

* The clinical encounter must be substantive with clinical information gathered, treatment recommendations provided, transition needs addressed and an update to the CMDS POC.

* The clinical content of the encounter is documented in the CMDS POC.

CMDS support service visits include and provide two different methods of delivery:

* Face-to-Face meetings between the appropriate clinic professional and thefamily/beneficiary; or

* Telephone meetings between the appropriate clinic professional and the family/beneficiary.

Reimbursement for support services clinic fees can be provided up to a maximum of ten (10) visits per beneficiary as a single method or as a combination of methods, per 12- month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics must establish and maintain an agreement with each Medicaid and MIChild Health Plan for health plan enrolled beneficiaries to ensure coordinated care planning and data sharing.

* CMDS clinics must establish a process for clinical staff to communicate with health plan staff on a regular basis to identify health plan enrollees using the CMDS clinic(s), review testing/assessment/screening results, treatment plans, CMDS POCs, and status of mutually served beneficiaries.

* CMDS clinics must collaborate with health plans on the development of referral procedures and effective means of communicating the need for beneficiary-specific referrals. For beneficiaries enrolled in a health plan, CMDS clinics must bill the Medicaid Health Plan (MHP) for medical services rendered according to the health plan billing rules.

The CMDS clinic fee is billed as a FFS claim through CHAMPS regardless of health plan status.

CMDS clinic fees must be billed according to instructions contained in the Billing & Reimbursement for Professionals Chapter of this Manual. CMDS clinics must bill clinic fees following Uniform Billing (UB) guidelines on the professional CMS-1500 claim format or the electronic Health Care Claim Professional (837) ASC X12N version 5010 information. CHAMPS NPI claim editing will be applied to the billing, rendering, supervising, attending, servicing and referring providers as applicable for payment.

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