Provider Notice issued 04/24/14

Cost Calculation for Medicaid School-Based Health Services for FY13

Local education agencies (LEAs), enrolled with the Department of Healthcare and Family Services (HFS) to provide Medicaid covered medical services to children with an individualized education plan (IEP), are required to bill HFS the actual cost of providing a medical service. LEAs will be required to use Fairbanks' system to register individuals authorized to submit and certify data for the LEA and to assure that the costs submitted are valid and from enrolled LEAs. In previous years, submissions were done through HFS' Medical Electronic Data Interchange (MEDI) system.

LEAs must submit their cost information by completing an electronic cost calculation form for each school-based health service it provided during the 2012-2013 school year (i.e., fiscal year 2013). Between now and June 6, 2014, each LEA should complete, and submit, an electronic cost calculation form for each type of direct medical service provided by the LEA, and billed to HFS for Medicaid match. LEAs that do not complete the Web-based cost reporting process by June 6, 2014, will not receive adjustments to claims submitted previously for the 2012-2013 school year. In order for HFS to process future claims, a rate must be loaded in the HFS system for each school-based health service provided in order for the LEA to claim reimbursement.

After LEAs submit their electronic cost calculation forms for fiscal year 2013, HFS will review the information, and follow up with individual LEAs, as appropriate. HFS will process adjustments using the computed rates to re-price all claims with dates of service between July 1, 2012, and June 30, 2013. HFS will make these adjustments automatically; LEAs should not re-submit previously filed claims in order to receive their claim adjustments.

The cost calculation form must be accessed through Fairbanks. In order for LEAs, or billing agents on behalf of an LEA, to log-in and access Fairbanks, a username is required. Instructions to obtain a username and access Fairbanks may be acquired by calling Fairbanks at 877-219-1343.

In order to complete a cost calculation form, all requested information must be reported. This includes number of employees, hours worked, and salaries and benefits. Training is available on the Fairbanks website.

After the submission closure date, HFS staff will review the submitted cost data and final calculated rates for validity and reasonableness. HFS will not process claims from LEAs with costs that appear unreasonable or unsupported. All reported costs are subject to documentation reviews by HFS. Any claims that include costs that are not adequately supported will be subject to recoupment by the federal government.

Final costs calculated by HFS will be used to determine total claimable amounts for Medicaid matchable services. Federal matching dollars will be claimed at these amounts, regardless of the amount billed on individual claims. After HFS completes its review of the submitted information and approves the final calculated rates, HFS will notify LEAs of their final computed service costs for each of the service types submitted. All claim adjustments will be performed retroactively by HFS.

Questions concerning this notice should be directed to the School-Based Health Services at 217-558-1389 or by e-mail to hfs.sbhs@illinois.gov.

Theresa A. Eagleson, Administrator

Division of Medical Programs