June 21, 2021
FY22 Developmental Disabilities Administration (DDA)
Invoicing Instructions for Community Pathway’s Waiver
(CPW) and COVID-19 Non-Fee Payment System (Non-FPS)
Services
Transmittal # DDA2021004
Effective Date: July 1, 2021
CONTENTS
CONTENTS ..................................................................................................................................................................... 1
AUDIEN C E ..................................................................................................................................................................... 2
PU RPOSE ........................................................................................................................................................................ 2
OVERVIEW .................................................................................................................................................................... 2
COMMU N ITY PATHWAYS AND COVID -19 NON-F PS SERVICES ............................................... 3
STATE-ONLY FUN DED SE RVIC ES ................................................................................................................................. 5
BILLING P R EREQU IS ITES & REQ UIREMENTS .................................................................................... 6
DDA PROVI D ER WAIVER STATUS ............................................................................................................................... 6
DDA PART ICI PANT WAIVER STAT U S .......................................................................................................................... 6
SERVICE S ARE ON THE PERSON -CENTER E D PLAN (PCP) ...................................................................................... 6
INVOICING INSTRUC TIONS ............................................................................................................................. 7
FREQUENCY AND TIMING ............................................................................................................................................. 8
INVOICING SUBMISSION REQUI R EMENTS ................................................................................................................. 8
TAB A: COVER PAGE ............................................................................................................................................. 8
TAB B: CONSUMER BUDGET............................................................................................................................. 9
TAB C: CONSUMER SERVICE DETAIL ......................................................................................................... 10
CPW A N D COVID-19 NON-FPS SER VICES MED ICAID CLAIMS SUBMISSION .............. 11
CMS 1500 FO RM BI LLIN G ......................................................................................................................................... 11
CMS 1500 FO RM BI LLIN G INSTRUC TIONS ............................................................................................................. 11
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AUDIENCE
DDA Community Pathways Providers
PURPOSE
To update the invoicing and federal billing instructions and procedures for FY22 DDA Community
Pathway’s Waiver Non-FPS Services including guidance to bill for eligible Non-FPS COVID-19 related
costs and additional authorizations for current services.
On January 19, 2021, the Centers for Medicare and Medicaid Services (CMS) approved the Maryland
Department of Health (MDH) Developmental Disabilities Administration (DDA) Waiver Amendment
#3 2020 with an effective date of January 19, 2021.
A change in Amendment #3 of the DDA Waiver program applications consolidated the three nursing
support services (i.e. Nursing Consultation, Nurse Health Case Management, and Nurse Case
Management and Delegation) into a single DDA Waiver program service, now called Nursing Support
Services effective March 1, 2021.
OVERVIEW
These instructions have been updated to accommodate billing for temporary modifications to DDA’s
Waiver programs set forth in Appendix K, submitted to and approved by the Centers for Medicare and
Medicaid Services, and DDA State Funded services to address the State of Emergency for the COVID-
19 pandemic beginning March 13, 2020.
To support the health, safety, and wellbeing of participants and providers, the DDA is implementing
temporary service requirements exceptions and operational changes including flexibilities related to
financial support, settings, and staffing.
Therefore, there is a need for providers to be able to bill for eligible Community Pathways Non-FPS
COVID-19 related costs for services currently billed using this invoicing process and for Shared Living
providers to be able to bill for isolation days.
For the COVID-19 services in the Family Supports Waiver and Community Supports Waiver, providers
will follow the same invoicing process in PCIS2 for payment. Additionally, any additional or new
authorized Behavioral Support Services will be billed using the current invoicing process for those
services. To receive payment for services rendered for FY22 dates of service for all other CPW Non-
FPS services and COVID-19 services, providers will submit invoices and federal billing claims to the
Regional Offices for approval and processing and will continue to enter attendance in PCIS2 for the FPS
services.
Comprehensive guidance regarding the Appendix K changes and billing for services can be found in the
guidance documents posted on DDA’s website here: DDA Appendix K.
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COMMUNITY PATHWAYS AND COVID -19 NON-FPS SERVICES
In FY22, all non-FPS services should be set up on the Services screen in PCIS2 as “Community
Pathways Non-FPS”. PCIS2 has been updated to include all of the non-FPS services included in the
Community Pathways Waiver that may be authorized on a Person Centered Plan (PCP). The
Community Pathways Non-FPS Service will allow all non-FPS services authorized in the PCP to be
listed along with their budgeted amounts under this Service.
Below you will find a list of the FY22 Non-FPS Services that may be authorized in the Community
Pathways Waiver and that would be billed using the Invoice template (Behavioral Support Services will
be billed using a different process and invoice template). When selecting services on the Consumer
Service Detail tab, column I will prepopulate with the correct procedure code to be used for the federal
billing.
Non-FPS Services
Service
Unit
Waiver
Procedure
Code
Documentation
need with
Invoice
1
Assistive Technology and Services
UPL
W5690
Receipt
2
Environmental Assessment
Milestone
W5740
Receipt
3
Environmental Modification
UPL
W5750
Receipt
4
Family and Peer Mentoring Supports
Hour
W5760
Receipt
5
Family Caregiver Training and Empowerment
UPL
W5770
Receipt
6
Housing Support Services
Hour
W5630
Receipt
7
Live-In Caregiver Supports
Month
W5877
Receipt
8
Nursing Support Services
15 minutes
W5804
9
Participant Education, Training and Advocacy
UPL
W5780
Receipt
10
Remote Support Services
UPL
W5820
Receipt
11
Respite Care-Camp
UPL
W5850
12
Respite Care-Day
Day
W5822
13
Respite Care-Hour
Hour
W5830
14
Transition Services
UPL
W5860
Receipt
15
Transportation (not Add-On)
UPL
W5862
16
Vehicle Modification
UPL
W5871
Receipt
17
Community Living Group Home Trial
Experience (formerly Community Exploration)
Day
W0215
Receipt
18
Supported Living
Day
W5620
For the services that do not require receipts with the invoice, providers should maintain documentation
of service provision. The DDA may conduct random audits of non-FPS services invoices by requesting
all detailed documentation such as timesheets, logs, case notes, payroll and other evidence to
substantiate invoice data.
For COVID-19 related service, the service flexibilities and financial supports that will be paid using this
form are noted below:
1. Retainer Payment (Supported Living)
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During the COVID-19 epidemic, some participants may choose to stay with their families or may be
supported in other systems (e.g. hospitals, nursing facilities, etc.) In these situations, providers may
request a COVID-19 Retainer Payment when they are not providing or paying for services, for a
particular person. If Supported Living billing for an individual has transitioned to LTSSMaryland,
retainer payments as of their transition date would need to be billed on the LTSSMaryland Billing
Claims Summary form that can be found on the DDA’s website under the Forms section here: DDA
Appendix K.
See additional guidance regarding this topic on DDA’s website here: DDA Appendix K #1- Retainer
Payment Guidance- Revised Feb. 11, 2021.
NEW: A service for COVID-19 Supported Living Retainer Payment was added to this invoice for
this purpose.
2. Day Time Shared Service Hours Authorization (Supported Living)
Due to State Executive Orders (including the closures of day programs and schools) and Governor
Hogan's Stay at Home Executive Order 3-30-20, the DDA is authorizing a set amount of shared day
time service hours to support the additional staffing agencies are providing. For Supported Living, the
additional hours will be added automatically to one participant at the location and PCIS2 will adjust the
rate accordingly. You will invoice the rate calculated using the approved Residential rate in PCIS2
which will include the additional hours for the home using the current service, Supported Living. See
additional guidance regarding this topic on DDA’s website here: DDA Appendix K #2 - Residential Day
Time Shared Hours Authorization.
3. Increase Rate When Supporting People with COVID-19 Virus (Nursing services,
Supported Living, and Shared Living
Rates may be increased for directly supporting participants that tested positive for the COVID-19 virus,
and therefore are isolated to account for increased cost such as excess overtime of direct support
professionals to cover staffing needs, additional infection control supplies, and service costs. The DDA
may increase rates by up to 50% to account for the added risk and cost. See additional guidance
regarding this topic on DDA’s website here: DDA Appendix K #7 - Increased Rate for Supporting
Person with COVID-19 Virus- Revised July 9, 2020. If Supported Living billing for an individual has
transitioned to LTSSMaryland, isolation payments as of their transition date would need to be billed on
the LTSSMaryland Billing Claims Summary form that can be found on the DDA’s website under the
Forms section here: DDA Appendix K.
NEW: Services added to the invoice to bill for isolation rates include:
a) COVID-19 Nursing- Nurse Case Management and Delegation Services-Isolation Rate
(ended 2/28/21)
b) COVID-19 Nursing- Nurse Health Case Management-Isolation Rate (ended 2/28/21)
c) COVID-19 Nursing Support Services (New 3/1/21)
d) COVID-19 Supported Living- Isolation Rate
e) COVID-19 Shared Living- Isolation Rate
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4. Additional hours of Respite Service available without preauthorization
Participants can access up to an additional 360 respite service hours, or 15 days, specifically related to the
COVID -19 emergency without prior authorization by the DDA. See additional guidance regarding this
topic on DDA’s website here:
DDA Appendix K #4 - Exceptions to Pre-Authorization and Service Requirements- Revised May 3, 2020.
NEW: Services added to the invoice for additional units of Respite services include:
a) COVID-19 Respite-Daily
b) COVID-19 Respite-Hourly
Below you will find a list of eligible COVID-19 services that may be authorized in the Community
Pathways Waiver and that would be billed using the Invoice template (Behavioral Support Services will
be billed using a different process and invoice template). When selecting services on the Consumer
Service Detail tab, column I will prepopulate with the correct procedure code to be used for the federal
billing.
New services included on this invoice are labeled as COVID-19 and are to be used to bill for services
eligible for retainer payment, isolation rates, or to authorize additional units of service for period of the
public health emergency.
COVID-19 Services
Service
Unit
Waiver
Procedure
Code
Documentation
need with
Invoice
1
COVID-19 Nursing- Nurse Case Management
and Delegation Services- Isolation Rate (ended
2/28/21
15 minutes
W5804
*
2
COVID-19 Nursing- Nurse Health Case
Management-Isolation Rate (ended 2/28/21)
15 minutes
W5802
*
3
COVID-19 Nursing Support Services (New
3/1/21)
15 minutes
W5804
*
4
COVID-19 Respite- Daily
Day
W5822
*
5
COVID-19 Respite- Hourly
Hour
W5830
*
6
COVID-19 Supported Living- Isolation Rate
Day
W5620
*
7
COVID-19 Supported Living Retainer Payment
Day
W1983
*
8
COVID-19 Shared Living-Isolation Rate
Month
W2123
*
*No documentation needs to be sent with this invoice for COVID-19 services; however providers must
maintain case notes and documentation of direct service delivery including the date of service, service
provided, time of service, and name of person that provided the service. Information such as a positive
COVID-19 test determination and case notes for the isolation rate must be submitted to the DDA upon
request.
STATE-ONLY FUNDED SERVICES
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Participants may be authorized to receive services that are not included in the current Community
Pathways Waiver program but are authorized to be paid with State funds. This invoice template may be
used to bill for these services as well, but they would not be eligible for federal matching funds. So,
1500 forms would not be required for these services. The State-Only funded services are included in the
list below.
1
Other (State-Only Funded)
2
Rent-Individual Support (State-Only Funded)
3
Skilled Nursing (State-Only Funded)
4
Camp-Non-Respite (State-Only Funded)
5
Respite (State-Only Funded)
6
Transportation (State-Only Funded)
BILLING PREREQUISITES & REQUIREMENTS
DDA PROVIDER WAIVER STATUS
You must be an authorized DDA provider to provide DDA services, and you must be an authorized
service provider on a participant’s Person Centered Plan (PCP) to bill for a participant. If you are NOT
listed as the authorized provider for the service on the PCP, you may not provide or bill for the service.
Additional information on billing prerequisites and requirements may be found in Appendix C:
Participant Services of the Community Pathways Waiver Amendment #3 application.
DDA PARTICIPANT WAIVER STATUS
Providers should verify the participant’s Medical Assistance eligibility prior to submitting an invoice
and claim for the participant. An individual’s waiver eligibility status can be located in PCIS2 under the
“Consumer” module, under the “Waiver” tab. A provider can also verify the participant’s Medical
Assistance eligibility by calling the Eligibility Verification System (EVS) at 1-866-710-1447. EVS is an
automated system that you can use 24 hours a day, 7 days a week. To use EVS, you will need your
provider number and either the participant’s medical assistance number or the participant’s social
security number and the date(s) of service. To retrieve an EVS Brochure call 410-767-6024 to request
one or go to the website https://encrypt.emdhealthchoice.org/emedicaid/eDocs/eMedicaid_web.pdf. The
provider should notify the individual’s Community Coordinator (CCS) to resolve any eligibility issues.
SERVICES ARE ON THE PERSON-CENTERED PLAN (PCP)
Prior to providing and/or billing for any waiver services, the provider should confirm that the services
are on the PCP and that the providing agency is the authorized provider for those services. Services or
costs should be billed according to the cost detail in the PCP. For instance,
• PCP that has respite services with annual allowable units of 14 days, should be billed using the current daily unit
rate. A provider should not invoice for more than 14 days of respite annually.
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• PCP that has respite services with annual allowable units of 112 hours, should be billed using the current hourly unit
rate. A provider should not invoice for more than 112 hours of respite annually.
If the service is NOT on the PCP, a provider may not be paid for that service. A provider may not bill
for units or costs that exceed the budgeted or allotted units on the PCP. If a waiver participant has other
insurance besides Medical Assistance, such as Medicare, private insurance, or other health insurance
coverage, the participant’s other insurance carriers should be contacted to verify if the waiver service is
covered.
For COVID-19 related services:
To support the immediate need for services and supports and provide flexibility with service
requirements and limits, the DDA is issuing temporary exceptions to services requirements as outlined
in the guidance on DDA’s website here: DDA Appendix K #4 - Exceptions to Pre-Authorization and
Service Requirements -Revised May 3, 2020.
To support the immediate need for new COVID-19 related services and supports, the DDA is issuing a
new temporary services authorization request process that can be found on DDA’s website here: DDA
Appendix K #5 - COVID-19 New Services Authorization Request Process- Revised June 1, 2020.
Providers will complete the Revised Cost Detail Sheet or DDA COVID-19 Request and Notification -
Service Authorization form (DDACOVIDForm#1) as applicable.
INVOICING INSTRUCTIONS
These procedures do not apply to any FPS services and their add-on services currently billed through
PCIS2. Those services are paid through the quarterly prepayment and PCIS2 automatically submits
claims to Medicaid. These procedures are for services and/or costs identified as Non-FPS Services and
listed under the participant’s services under the Community Pathways Non-FPS service on the Services
screen and/or Supplemental Services list in PCIS2 and for COVID-19 related costs identified in the
DDA Appendix K guidance documents to be billed using this invoice.
PCIS2 Supported Living Billing Instructions: The invoice total for this service on a date of service
should be the Base Rate plus any add-on rates. Invoicing for the add-on’s separately from the Base rate
results in duplicate claims being submitted for the same date of service causing them to be denied.
COVID-19 Services Billing Instructions:
• COVID-19 Nursing services Isolation Rates- The isolation rate are prepopulated for these
services and will calculate the amount based on the number of units entered.
• COVID-19 Respite Services- Invoice these services for up to 15 days or 360 hours during the
time period covered by Appendix K.
• COVID-19 Supported Living- Retainer Payment- Invoice the Base Rate only amount
authorized in PCIS on relevant dates of service.
• COVID-19 Supported Living- Isolation Rate- To invoice for isolation days, increase the
authorized daily rate from PCIS2 by 50% and invoice the full 150% rate on the relevant dates
of service for the isolated individual.
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• COVID-19 Shared Living- Isolation Rate- Submit additional isolation costs at 150% of the
costs to the Regional Office who will authorize the costs and update the contract amount in
PCIS2. Include the additional costs on this invoice along with a 1500 form for the amount of
the invoice billed on the last day of the month of service that included the isolation costs.
FREQUENCY AND TIMING
Effective July 1, 2019, non-FPS services costs will be paid on a reimbursement funding system using the
invoice template and procedures outlined in this guidance.
A provider may submit a non-FPS service invoice at any point during the state fiscal year. A provider
has two months after the end of a fiscal year, September 1
st
, to submit invoices for that fiscal year.
Charges incurred for the prior fiscal year will not be processed for payment after the two month deadline
of September 1
st
.
INVOICING SUBMISSION REQUIREMENTS
The invoice must be completed accurately to process payment to the provider. For an invoice to be
processed the provider will need to submit all of the following to their Regional Office:
1. An electronic copy of the invoice (excel file)
2. A printed copy of the cover page with the provider signature in blue ink
3. Corresponding Medical Assistance claims for all waivered services for waivered individuals or the Remittance
Advice of claims that were submitted through eMedicaid
4. Receipts, if applicable
Electronic copies should be emailed to:
• Central Maryland Regional Office (CMRO): [email protected]
• Eastern Shore Regional Office (ESRO): [email protected] and copy
[email protected]
• Southern Maryland Regional Office (SMRO): [email protected]
• Western Maryland Regional Office (WMRO): [email protected] Invoice Template
Instructions
The Non-FPS services invoice is an excel workbook that is composed of three worksheets, identified by
a tab and tab title at the bottom of the workbook. The instructions are organized by the tabs in the
workbook. Please enter values into corresponding blank cells that can be selected. The spreadsheets
include cells that automatically calculate values, which are identified by a gray coloring.
TAB A: COVER PAGE
The cover page consists of basic provider information necessary for the DDA to identify the provider
agency and process payment. All fields must be completed.
Multiple non-FPS services costs may be billed on one invoice.
To complete the Service line, if the non-FPS services are still bundled under an FPS service and listed in
the Supplemental services screen in PCIS2, choose the correct FPS service to populate the correct PCA.
If the non-FPS service is listed under the Community Pathways Non-FPS service on the Services screen,
select Non-FPS Service in the dropdown to populate the correct PCA code created for these services.
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COVID-19 UPDATE: Shared Living service has been added to the list of Services in order to bill for
the Shared Living Isolation Rate once the additional costs are authorized by the Regional Office and
included in PCIS.
TAB B: CONSUMER BUDGET
Part B serves to monitor spending relative to the individual’s budget. The DDA will only pay up to the
budgeted amount for the individual. In the spreadsheet insert the service by individual. If an individual
has more than one non-FPS service cost, then there needs to be a separate row for each service.
Below are explanations for the columns on the spreadsheet.
COVID-19 UPDATE: Budgets for COVID-19 services that don’t require preauthorization should be
entered into the Consumer Budget with an (G) Actual Budget amount for at least the amount of the
costs to be included on the invoice. If the budgeted amount for the service is not high enough to cover
the costs included in the Available Budget for Charges, the expenditures will go into the Unfunded
Amount on the Cover Page and will not be included in the Total Invoice Charges.
Col
Column Title
Description
Calculation
A
Consumer Last Name
Input last name
B
Consumer First Name
Input first name
C
Consumer MA #
Input consumer’s medical assistance
# (11 digits)
D
Waiver Eligible (Yes/No)
Choose “Yes” or “No” from the
dropdown list
E
Non-FPS Service
Choose the Non-FPS Service,
COVID-19 service or State-Only
Funded service from the dropdown
list
F
Regional Log #
Inputs SFP #
G
Actual Budget
Input the actual budget for the
supplemental service, one-time-only
costs, or COVID-19 costs
H
Year-to-Date Paid Charges
Input the total amount paid for the
service or cost for the year; don’t
enter an amount here for COVID-19
costs if billing for new costs
I
Remaining Budget
Excel automatically calculates
G -H
J
Requested Invoice Charges
Excel automatically calculates
The sum of charges for
that individual for that
service calculated on
tab C column H
K
Amount to be Paid
Excel automatically calculates
If J > I, then K = I
If J < I, then K = J
L
Unfunded Invoice Charges
Excel automatically calculates
If J > I, then L = I - J
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M
Denied Claims
Excel automatically calculates
TAB C: CONSUMER SERVICE DETAIL
Col
Column Title
Description
CMS 1500 Form
Fields
A
Consumer MA #
Excel automatically populates from
Consumer Budget tab column (C)
Field 9a on 1500 form
B
Consumer Last Name
Input last name
Field 2 on 1500 form;
Last Name first, First
Name last
C
Consumer First Name
Input first name
D
Non-FPS Service*
Choose the Non-FPS Service, State-
Only Funded service, or COVID-19
service from the dropdown list.
E
Date of Service**
Input date that service was provided
or cost was incurred (must be in
FY22); Cannot be duplicate for the
same service and person; COVID-19
services effective March 13, 2020-
March 12, 2021
Field 24A on 1500 form
F
Unit Charge
Excel automatically populates the rate
for rate-based services; No rates will
populate for UPL or Milestone
services
G
Costs or Units†
Must be populated; Input the total
number of units (whole numbers
only) that were provided for the date
of service or the cost of the Milestone
or UPL service.
▪ A unit is a determinate quantity (i.e.
hour, day, and month). The
description of the unit should be
located in an individual’s PCP
▪ Milestone and Upper Pay Limit
(UPL) services units would be 1
Cost- Field 24F;
Supported Living daily
rate from PCIS2
Units- Field 24G on
1500 form; see Service
Units on page 3
I
Total Charge $ ††
Excel automatically calculates;
columns F*G
Field 28 on 1500 form
is Total of Charges in
fields 24F
J
Waiver Procedure Code
Excel automatically populates
Field 24D on 1500 form
K
Receipt Needed
Excel automatically populates. If
column K is “Yes,” then a receipt
and/or other documentation is needed
to substantiate the cost or service
COVID-19 services: No
documentation needs to be submitted
with the invoice but must be
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available to DDA upon request.
Includes documentation of a positive
COVID test for isolation rates.
L
Claim Needed
Excel automatically populates. If the
column L is “Yes,” then the provider
must submit a claim for the service or
good
*DDA is unable to obtain Federal Medical Assistance Participation if a service is listed as “State-Only
Funded.” The purpose of Column D is to gain a description of the services or good being provided in
order to help ensure that all allowable federal claims are submitted for reimbursement.
** The Date of Service may not be duplicated for the same service for the same person. A yellow
highlighted row on the invoice is a duplicate claim. Please revise the information to resolve the duplicate
claim error by correcting the date or adding all units together for the date.
† If Units are entered in column G, they must be whole numbers. If a unit is entered as a decimal
number it will be highlighted orange, which is a unit error. To resolve the unit error, please enter a
whole number based on the Service Unit for the service noted in the
†† For Supported Living, the Total Charge should be the Base Rate plus any add-on amounts added
together and invoiced on the same date of service. Please do not invoice add-on charges separately.
CPW AND COVID-19 NON-FPS SERVICES MEDICAID CLAIMS
SUBMISSION
Providers can submit a claim electronically or through paper format for Community Pathways Waiver
non-FPS services. COVID-19 services cost invoices must include paper 1500 forms for Waiver eligible
services and should not be submitted electronically.
CMS 1500 FORM BILLING
Providers must use the CMS-1500 billing form version 02/12. A sample form has been posted to the
DDA website, under the Provider tab
(http://dda.dhmh.maryland.gov/Pages/Developments/2015/sample%20cms%201500%20form%20icd10.
pdf) that shows all of the required fields that must be filled out. Make sure all information entered on the
claim form is legible and accurate, including your Provider Number and the Participant’s Medical
Assistance ID Number. For more instructions on federal billing, please visit the DDA website at
https://dda.health.maryland.gov/Pages/Federal%20Billing.aspx.
CMS 1500 FORM BILLING INSTRUCTIONS
• Name (2)- Last name first, first name last (Smith, John); must match spelling in MMIS
• Participant Medicaid # (9a)- always 11 digits; if 0 is the first digit, it must be listed
• Provider # (24J top; 33b)- always 9 digits
• NPI# (24J bottom; 33a)- 9 digit provider number with a 5 in front ex. 5xxxxxxxxx
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• Date (24A) - List each date of service in the 24A From column only. No date ranges should
be used. A date of service for the same service can only be billed one time. All units or costs
of a service provided on the same day must be added together and billed on the date of
service once. MMIS considers dates of service for the same service billed more than once as
a duplicate claim even if the units or costs are different. If changes need to be made to
previously submitted claims total units or costs, an adjustment of that claim must be
requested.
• Units (24G) - For hourly and quarter hour services, the number of units of service provided
(hours; 15 mins) must be listed. For example, for an hourly service, if 8 hours of service is
provided, 8 units would be listed. For quarter hour services, if 4 hours of service was
provided, 16 units must be listed. A unit of 1 is used for days, milestone services, or service
costs added together and billed on the same day, Upper Pay Limit services.
• Charges (24F)- Unit cost x # Units
• Total (28)- Total of charges
• Signature/Date (31)- Sign, print, or type name; signature date must be after dates of service
being billed
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