SCL Questions and Answers
Questions Related to Units/Limits
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Q. | CMs are very confused about the amount of time that CCT PAs are good for. |
A. | Prior Authorization (PA) for up to 90 days may be issued for Consultative Clinical and Therapeutic Services per request. |
Q. | Under Clinical, Consultative and Therapeutic Services for Behavior Supports, what if someone is getting other services? Do all services have to stay within the 160 units a year, or 160 units for each service (code)? |
A. | For Clinical, Consultative and Therapeutic Services, it is a total of 160 units per year. All services are included in the 160 units per year. |
Q. | If all of the CCT units that have been approved are used prior to the end of the three-month PA, can the team request additional units before the three months are up? |
A. | Yes, this is just a modification. The total amount of units requested, however, may not exceed the 160-unit limit for the LOC year. |
Q. | Is the annual cap on units based upon the units that have been approved or the units that have been billed? That is, if a clinician is approved for 12 monthly units and one month only uses 4 units, can the 8 units be approved again later in the year or are they lost? |
A. | The cap is monitored through the MMIS via audits on claims. The case manager should note when requesting units that appear to be over the annual cap that previously authorized monthly units were not used. |
Q. | In regard to billing for Community Access Group: CA pays $8 per unit and CA Group pays $4 per unit. In the instance that two participants want to receive their CA together, would the first be billed as CA ($8) and second as CA Group ($4)? This is what we assume, but we don't see it clearly stated anywhere in the regulation. |
A. | The service for this event would be Community Access Group for both individuals at $4.00 per unit. |
Q. | What is the cap on allowable units for Community Access? I believe it’s only authorized for six months, but I can’t find the cap allowances. |
A. | Community Access will be prior-authorized for up to six months. Community Access, in combination with Day Training, Supported Employment (including employment hours), and Personal Assistance cannot exceed 16 hours daily. If Community Access services are needed beyond the PA’d six months, the case manager should submit a modification with justification for continuing use.
Community Access services are designed to result in an increased ability by the participant to access community resources by natural or unpaid supports. Community Access services shall have an emphasis on the development of personal social networks for the person. A person may have Community Access services for more than one outcome, or have Community Access in and out of their POC as needed to make the community connections.
There is no cap as to the number of units a person may need during the POC year. The focus is more on how it is used rather than how much is used. |
Q. | Is there a limit of outcomes that day training has to have for approval of services? |
A. | There is no specified limit of outcomes for day training. However, the outcomes should be individualized to the person’s needs and interests and reasonable for the amount of units requested. |
Q. | If approved for 40 one-time units for a Functional Assessment, could the provider complete the FA as quickly as possible, say over two days working on it five hours each day (total of 40 units)?
If so, when the provider bills it, would we submit the billing for the day the FA was completed?
Since there was only one billing date of service (for the 40 units), would we only complete one progress note detailing what was accomplished during those 40 units? |
A. | The PA will be issued for a three-month period for a specific number of units. The provider will have the entire three-month period to utilize all authorized units. So using the example below, a PA would be issued for the FA and the provider could complete it in however many days were necessary, documenting and billing for the correct amount of units used on each date of service.
The provider would bill each date of service independently for the corresponding number of units used that day.
A progress note should be done documenting all activities completed on the corresponding date of service. If units are billed on separate dates, each day the behavior specialist works on the FA we would expect to see a separate staff note for each date, including start and end times and a summary of what was done. |
Q. | What are the maximum units for SE on a weekly and/or monthly basis? |
A. | Person-Centered Job Selection: Up to 120 (15-minute) units per LOC.
Job Development and Analysis: Up to 90 (15-minute) units per LOC.
Job Acquisition with Support: Up to 800 (15-minute) units per LOC.
Long–Term Support and Follow-Up: up to 24 (15-minute) units per month.
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