Group Home Billing Procedure for New Waivers

August 25, 2016

For group home services provided on 1 September or after:
  • the billing code will be H2022, but must be modified to reflect the licensed capacity of the residential site where the individual lives
  • failure to include the “modifier” will result in the claim being denied
  • see the 5/31/2016 Medicaid Memo for details of the use of the “modifier” – the memo is found here!
  • the “rate” to be billed for each individual also varies by the SIS Tier assigned; we have discussed how to calculate the SIS Level and Tier in previous documents. The VaMMIS Medicaid Billing system will pay the lesser of the amount authorized or the amount billed.  The assigned tier will be visible in the WaMS system for confirmation purposes.
  • service authorizations for “Group Home Residential – H2022” are being entered for the two month period of 9/1/2016 to 10/31/2016 automatically for all who have an authorization for group home services (97535) that extends beyond August 31st – you will receive the standard notice by post of the new authorization
  • service authorizations are already available on the Medicaid WebPortal and you may have received the notice in the post already; this will give you the opportunity to confirm that services are authorized going forward.
  • in the short term, through the end of October, providers will enter the Service Modifier which corresponds to the licensed capacity of the residential site – that capacity should be listed on the addendum to your license. If that addendum does not accurately reflect the capacity, you should contact your licensing specialist immediately.  The addendum will be your documentation for any audit done in the future.
  • During the months of September and October the “licensed capacity” will be entered into the WaMS system and a new Service Authorization containing the correct “modifier” will be issued. The procedures for doing this will be forthcoming.
  • Note: there are 18 “lines” in the Service Authorization file, if a new file is created because all the “lines” have been used then there will be a new authorization number assigned – this is not a new procedure, but do not forget to verify the service authorization number as it is required for billing!