Provider Notice Issued 07/17/2017

Local Education Agencies (LEA) Payment Error Rate Measurement (PERM) Audit Findings and Claim Changes

Date:  July 17, 2017

To:     Local Education Agency Providers

Re:     Local Education Agencies (LEA) Payment Error Rate Measurement (PERM) Audit Findings and Claim Changes

All services for which claims are made to the Department of Healthcare and Family Services (HFS) are subject to audit. Audits are an important and necessary part of the Department’s monitoring of health care facilities and services, as required by both federal and state law. Audit findings against a provider will result in the recovery of resulting overpayments. This notice reminds Local Education Agencies (LEA)s of documentation requirements that were found deficient during the Federal Fiscal Year 2015 Payment Error Rate Measurement (PERM) program audit.

Additionally, this notice informs LEAs of new policies HFS is initiating as a result of PERM findings identified for LEAs related to National Provider Identifier (NPI) numbers for ordering/referring practitioners.

Missing or Insufficient Documentation: Maintenance of Records

PERM errors included instances of providers not submitting sufficient documentation to support the service billed. HFS policy requires providers to maintain the following records:

·       Any and all professional records that relate to the quality of care given by the provider or that document the care for which payment is claimed, including, but not limited to:

·       Medical records for applicants and participants in the Department’s Medical Programs (copies of claims alone will not meet this requirement);

·       Complete copy of the Individualized Education Programs (IEP) in effect for date of service claimed;

·       Daily case documentation or progress notes for date of service claimed;

·       Medication Administration Records for all medication given;

·       Transportation logs (U-210.213) for all transportation services claimed; and

·       Other professional records required to be maintained by applicable federal or state law or regulations.

·       Any and all business records that may indicate financial arrangements between the provider and other providers in the program or other entities, or that are necessary to determine compliance with federal and state requirements, including, but not limited to:

·       Original signed billing certification forms for each voucher received.

Refer to the Handbook for Local Education Agencies, Chapter U-200, for detailed record requirements. The required business and professional records must be kept in accordance with accepted business and accounting practices and must be legible.

Ordering/Referring National Provider Identifier (NPI) Numbers

PERM errors included instances of providers not submitting the NPI of the ordering/referring practitioner for the service billed.

The Department requires that all claims for services that were ordered or referred contain the NPI of the physician or other professional who ordered or referred such services. Furthermore, the Department requires those ordering or referring physicians or other professionals be enrolled as participating providers.

Beginning with dates of service on and after January 1, 2018, services that require an order/referral will be required to have an individual practitioner’s NPI included on the claim. Providers enrolled with HFS as a Facility, Agency, Organization (FAO) will not be accepted as an ordering/referring practitioner. Ordering/referring practitioners will be required to enroll in IMPACT as Individual Rendering/Servicing Providers. If an individual NPI is not included or the provider is not enrolled with HFS, claims will reject.

Questions related to enrolling in IMPACT can be directed to the IMPACT Help Desk:

·       By email: IMPACT.HELP@Illinois.gov

·       By phone: (877) 782-5565 Listen for IMPACT option.

Felicia F. Norwood

Director