Home care billing in South Dakota

Fee-for-service. CMS's 2024 state tables list a single South Dakota managed care program, PRIME, a statewide primary care case management program under 1932(a) authority that started October 2, 2002 and lists case management as its only covered benefit; home health, state plan personal care, HCBS waiver services, private duty nursing and hospice are not among its benefits, and no MCO appears in the tables.² PRIME still matters for home health: the Home Health Agency Services manual, cited below, requires services for a recipient in a Care Management Program to be ordered or referred by that recipient's Care Management provider. Disabled children under 19 are exempt from PRIME, according to the program notes in the same CMS tables.

Open vendor model. South Dakota offers Therap at no cost for HOPE waiver, state plan personal care, home health and private duty nursing, and FOCOS at no cost for the ADLS and Family Support 360 waivers; a provider that finds the state system not feasible may file the Provider Request for Approval for Alternative IT System for EVV form, or, for home health and private duty nursing, choose another third party at its own cost that can interface with the Therap Aggregator.³ The Aggregator is the centralized database that collects, validates and stores EVV data, and it is mandatory for submitting home health and private duty nursing EVV data to the MMIS for claim adjudication, a requirement in effect from December 31, 2023. The February 2024 manual says HOPE, ADLS and Family Support 360 visits do not yet go through the Aggregator. Manual entry is a last resort for no more than 25 percent of services, and a manually entered visit or one with an exception does not count as compliant EVV. CMS lists South Dakota compliant with the home health EVV requirement as of January 1, 2024, in the status table listed in the sources.

Services under EVV³

• HOPE waiver in-home services (personal care, homemaker, adult companion, chore, respite and nursing) from January 1, 2021
• State plan personal care, homemaker and nursing visits from January 1, 2021
• Self-directed personal care under the ADLS waiver and personal care under the Family Support 360 waiver from January 1, 2021
• Home health (nursing, aide, therapy, social work and injection visits) and private duty nursing from January 1, 2024

By the Department of Human Services, Division of Long Term Services and Supports (LTSS). For state plan personal care, LTSS runs a needs assessment at least once every twelve months and writes a service plan that sets the number of personal care hours, and agency-based personal care is limited to 500 hours in a plan year running July 1 to June 30 for recipients 21 and older; an agency must hold a Purchase of Services Agreement with LTSS and a Therap account to receive and acknowledge referrals.⁴ For HOPE, the LTSS Case Management Specialist and the participant build an Individual Support Plan that must be finalized before services start, and the HOPE manual, cited below, denies services not authorized and acknowledged in Therap beforehand and recoups payment for units beyond the total, frequency or duration on the Therap Service Authorization. Home health needs the attending physician or other licensed practitioner's order before the first visit, a face-to-face encounter within the 90 days before or 30 days after the start of services, and recertification at least every 60 days for nursing, aide and therapy services, as the Home Health Agency Services manual sets out. Private duty nursing and extended home health services need a prior authorization request of their own, according to the Prior Authorization Requests manual.

To South Dakota Medicaid, fee-for-service. Under ARSD 67:16:35:04 the department must receive a provider's completed claim form within 6 months following the month the services were provided, so a January visit must be received by the end of July. The limit can be waived only for an adjustment or void received within 3 months of the paid claim, a claim received within 3 months of a denial, a claim within 6 months of a retroactive eligibility decision made on appeal, a claim filed with the primary insurer's EOB within 6 months of that payer's payment or denial, or to correct a department error.⁶ Home health, agency personal care and HOPE waiver services are all billed on the CMS-1500 or an 837P, according to the program manuals cited below; HOPE claims can also go through the provider's Therap account or the South Dakota Medicaid portal, and EVV claims for HOPE must carry the prior authorization number from the Therap Service Authorization. For services under EVV, span dates cannot be billed: each date of service and each procedure code goes on its own claim line, as the EVV manual cited above states.

CGS Administrators, the A/B MAC for Jurisdiction 15, processes Medicare home health and hospice claims for South Dakota, along with Colorado, Delaware, the District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, Utah, Virginia, West Virginia and Wyoming.⁸ For South Dakota Medicaid, an agency must be recognized as a Medicare-certified home health agency for each enrolled location, home health visits are limited to one a day and five days a week, with more than one same-day visit of a discipline covered only when the attending practitioner documents the medical necessity, and if Medicare denies a service as not medically necessary the individual is ineligible for Medicaid home health, as the Home Health Agency Services manual, listed in the sources, states.