ADvantage Program

and

Medicaid State Plan Personal Care Program

Provider
Certification
Application

November 2014

Table of Contents

Introduction

Instructions

Purpose and Scope – Provider Certification

PROVIDER Certification Application

Part A: General

Part B: Administrative

Part C: Financial

Part D: Certification Documentation

Part I: Attachments

Part E: Programmatic Certification

PART II: ATTACHMENTS

PART III: CERTIFICATION AND VERIFICATION

Provider Qualifications, Licensure, and Certification Chart

Medicaid State Plan Personal Care Program

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Introduction

Introduction

ADvantageProgram Description

Through Section 2176 of the Omnibus Budget Reconciliation Act of 1981, states are permitted to finance non-institutional long-term care services through Medicaid waivers. ADvantage creates a new system of Medicaid home and community-based long-term care for frail, elderly individuals 65 and older and adults, 21 and older, who have physical disabilities. To be eligible for the program, these individuals must also require nursing home level of care.

The ADvantage Program has two primary goals. The first is to provide long-term care Members with choices in their long-term care service options. The second is to prevent premature or inappropriate nursing home placement. The program is funded by Title XIX of the Social Security Act, and Social Services Block Grant funds (Title XX of the Social Security Act).

The ADvantage Program offers Members a range of service options including: Case Management, Personal Care, Respite Care, Environmental Modifications, Adult Day Care, Therapies, Skilled Nursing, Advanced Supportive/Restorative Assistance, Hospice, Specialized Medical Equipment and Supplies, Assisted Living, and Home Delivered Meals. Those services assist individuals to remain independent for as long as possible. Case Management services develop an individualized service plan for each Member and monitor service delivery.

The ADvantage Program is administered by the Oklahoma Department of Human Services, Aging Services Division, ADvantage Administration (DHS). The DHS share the following administrative responsibilities: service plan certification, service provider certification, contract monitoring; policy analysis and research; program research and development; service standards development and management information systems; case manager training and certification; and claims authorization/billing agent for ADvantage services.

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Instructions

Application for Certification to provide ADvantage AND
Medicaid State Plan Personal Care
Programs Services

Instructions

The application includes: (1) Application Form, (2) Conditions of Provider Participation, (3) Member Assurances, and (4) ADvantage Program Service Standards. All documents must be fully completed and executed with appropriate signatures to be considered for certification. Return the completed application with original signatures to the Department of Human Services/ADvantage Administration.

It is recommended that providersmake a copy of their completed provider information update.

The General section, Administrative Certification section, Financial Certification section, and Certification Documentation section (pages 7 through 29) of the Provider Certification Application must be typed and submitted by December 10, 2014

The certification application (and any subsequent amendments) must be signed by the following person(s) dependent upon the type of provider, management and ownership:

If the agency is public (i.e., County, City, etc.) applications must be signed by the person who is the head of the governmental department having jurisdiction over the agency (i.e., Chairman of County Board or Chairman of Commission) or his duly authorized representative. The authorization of that person must be in writing, notarized, and submitted along with this application.

If the agency is private, applications must be signed by the following, depending on the type of business organization:

TYPESIGNER

Sole Proprietorship-Owner

Partnership-One of the partners

Corporation, Church, or-Two officers of the board or duly authorized representative Non-Profit Association

If someone other than,or in addition to the above named, is authorized to sign in the organization’s behalf, such authorization must be in writing, notarized, and attached to the application.

The application must be returned to:

Department of Human Services/ADvantage Administration

P. O. Box 50550

Tulsa, Oklahoma 74150

The Provider Certification Application is available on alternative media for individuals who are visually impaired.

Certification applications post marked after the announced due date will be returned unprocessed to the submitting agency.

Incomplete applications could result in the applicant organization’s delayed eligibility to participate in ADvantage or Medicaid State Plan Personal Care program services. After notifying the applicant of receipt of an incomplete application, DHS will take no further action on the application until required information is received.

Applications which inadequately address requested information could result in a provider’s ineligibility to be certified.

If you have questions call the ADvantage Administration at (918) 933-4900 and ask for Contracts.

Evidence of a minimum of two (2) years experience providing services for which you are applying is required.

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Purpose and Scope

Purpose and Scope – Provider Certification

The smooth and effective operation of the ADvantage Program and the Medicaid State Plan Personal Care Program depends on, among other things, the providers' ability to effectively manage the administrative and financial aspects of their businesses. The certification review process screens out and precludes the certification of providers who are unable to manage the ADvantage and Medicaid State Plan Personal Care Programs in a prudent and businesslike fashion. Further, the providers will be continually monitored to identify and quickly address potential provider problem situations as they arise.

The greatest scrutiny should be applied, during both certification and performance monitoring processes, to those situations where the potential loss of a provider would have the greatest negative impact on the Member, the long term care service system or the ADvantage Program. Factors influencing the impact of the loss of a provider include the nature of the service provided, the skill levels or facilities required to provide the service, and the availability of viable alternatives in the affected marketplace. Accordingly, the Department of Human Services/ADvantage Administration of Tulsa will consider and evaluate a variety of factors in both the original certification process as well as in the continuing process of performance monitoring.

The process of provider certification is accomplished in two phases. During the first phase the provider's organizational and administrative capabilities as well as financial stability will be evaluated. During the second phase of the certification process information related to the prospective providers' programmatic capabilities will be reviewed and evaluated along with determination that providers have the requisite certifications and licenses required to perform the service(s) under application. Procedures covering that phase of the certification process are addressed in subsequent sections of this application.

Based on the evaluations, DHS will make its certification determination and assign the provider to a monitoring category. An explanation of the evaluations is given to the provider at the completion of the certification process.

Factors in the evaluation of sound business management practices include:

Organizational and Administrative Practices including [a] provider's legal structure; [b] general administrative and financial capabilities and personnel; [c] experience with medical claims (CMS 1500) and electronic billing systems; [d] the effectiveness of operational and financial record keeping systems; [e] the effective use of budgeting and cost control processes; [f] the existence and extent of internal controls; and [g] the nature and extent of internal or external oversight.

Business Volumes including [a] projected annual business volumes from all sources;[b] business growth rates; and [c] the percentage of total business volumes derived from the ADvantage and Medicaid State Plan Personal Care Programs.

Financial Position including [a] the provider's ability to withstand normal business and cash flow cycles associated with the health care services industry; [b] overall net worth; [c] care services, and the financial failure ; and [d] access to external financing.

Provider Classification

A two-part classification will be assigned to prospective providers during certification which will also be used in the performance monitoring process. The first part of the classification is shown in Table 1 and is related to the type of service(s) to be provided. A provider with multiple services would be assigned the most inclusive category unless conditions warrant otherwise.

TABLE 1 - PROVIDER PROGRAM CATEGORIES
Case Management
Personal Care and Advanced Supportive Restorative
Skilled Nursing and RN Assessment/Evaluation
In-Home Respite
In-Home Therapy Services
Speech/Language Therapy
Occupational Therapy
Physical Therapy
Facility-based Services - Respite Care, Adult Day Health Care
Home Delivered Meals
Hospice
Assisted Living

The second part of the classification is the provider certification status. The status represents an overall evaluation of a combination of business, organizational, administrative and financial factors. Table 2 shows the monitoring levels (and frequency) which will be assigned to an agency as a function of the certification process.

TABLE 2 - PROVIDER MONITORING LEVELS
ADMINISTRATIVE AND FINANCIAL
Low Monitoring: an annual fiscal year end financial statement must be sent to ADvantage Administration no later than the end of the fourth month after the close of Provider Agency's fiscal year.
High Monitoring: a quarterly financial statement must be sent to ADvantage Administration 45 days after the quarter ends. In addition, an annual fiscal year end financial statement must be sent to ADvantage Administrationno later than the end of the fourth month after the close of Provider Agency's fiscal year.
Other information requested as indicated, including administrative and/or management reports.
PROGRAMMATIC
The audit process encompasses continuous evaluation and feedback regarding agency compliance with ADvantage Program requirements through Member home visits and agency chart reviews.

DHSRoles And Responsibilities

In the performance of the DHS certification responsibilities in the ADvantage Program and the Medicaid State Plan Personal Care Program, DHS is the only party owing any obligation to the provider.

As part of the ADvantage and Medicaid State Plan Personal Care Program's continuing certification process, the licenses and certifications of the provider and its employees may be the subject of periodic inquiry or discussion between DHS and appropriate state or federal agencies, and that in connection with such inquiries and discussions pertinent information about the provider and its personnel may be given to such agencies.

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Provider Certification Application: General

PROVIDER Certification Application

Part A: General

  1. Name and location of provider’s home office:

Name of Provider
Finding Address
City / County / State / Zip
Mailing Address
City / County / State / Zip
Telephone Number / Fax Number
  1. List names and addresses of branch offices, if any:
  1. ADvantage Program servicesthat are currently being provided:

CaseManagement Hospice

In-Home Respite Skilled Nursing

Extended In-Home Respite Extended Skilled Nursing

In-Home Therapies Advanced Supportive/Restorative Assistance

Physical Adult Day Care

Occupational Assisted Living

Speech

  1. Medicaid State Plan services for which certification is being applied:

Personal care

  1. List counties in which the above applied services are being provided and the address of the office to oversee providing services in those counties. For each county, specify the address of the supervising office.
  1. Name, title, and address of individual authorized to sign for agency:

Name / Title
Finding Address
City / County / State / Zip
  1. Name, title, address of provider staff to whom correspondence should be mailed:

Name / Title
Finding Address
City / County / State / Zip

Assisted Living Facility Applicants Only

  1. List names and addresses of additional facilities applying for ADvantage certification, if any. Please include the Oklahoma State Department of Health license number and number of rental units, per facility, that are requesting to be ADvantage certified for each location (minimum of 10 rental units required).

Name of facility / Address / License Number / # Rental Units

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Provider Certification Application: General

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Provider Certification Application: Administrative

  1. Facility Service Agreement: please attach a copy of theservice agreement or resident contract specifically written for ADvantage Members (please see attached checklist to ensure all points are covered in the agreement).

Part B: Administrative

  1. Check the category which best describes your organization and its ownership:

PublicGo To Question 2

PrivateGo To Question3

Not for ProfitGo To Question 7

Public Agencies
  1. For public agencies, specify the name of the Governing Unit and the individual who heads the governmental department having jurisdiction over your agency.

Governing Unit:
Department Head:

List the members of your Governing Board.

Name and Title / Address

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Provider Certification Application: Administrative

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Provider Certification Application: Administrative

PUBLIC AGENCIES SKIP TO QUESTION 8

Privately Owned Agencies
  1. If privately owned, check the type of legal organization:

Sole ProprietorshipGo To Question 4

PartnershipGo To Question5

CorporationGo To Question6

Other (Please Specify):

  1. List the name and address of the sole proprietor:
  1. Do you have an interest in any other organization? If yes, list name(s) and address(es):
  1. If the organization is a Partnership, list the names and addresses of your partners.

Name and Title / Address

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Provider Certification Application: Administrative

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Provider Certification Application: Administrative

  1. Do the partners have an interest in any other organization? Yes No

If yes, list name(s) and address(es):

Name and Title / Address

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Provider Certification Application: Administrative

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Provider Certification Application: Administrative

  1. If a Corporation, list the names and addresses of the Corporate Officers.

Name and Title / Address

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Provider Certification Application: Administrative

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Provider Certification Application: Administrative

  1. List the names of all shareholders owning more than 5% of the outstanding stock:

Name / Address / Percent

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Provider Certification Application: Administrative

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Provider Certification Application: Administrative

  1. Does the corporation or its major shareholders own 20% or more stock of another corporation? Yes No
  2. If yes, list name and address of corporation:

Name / Address

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Provider Certification Application: Administrative

PRIVATELY OWNED AGENCIES SKIP TO QUESTION 8

Not for Profit
  1. If the agency is organized as a Not for Profit, list the names and addresses of the officers of the Board of Trustees or other governing body including a full list of board members:

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Provider Certification Application: Administrative

Name and Title / Address

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Provider Certification Application: Administrative

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Provider Certification Application: Administrative

  1. Describe the frequency of board meetings:
  1. Describe the role of the board in policy/management activities:
  1. Describe board committee structure and indication of the areas where the board is active.
  1. Describe documentation of board meetings.
All Agencies
  1. When was the organization created?
  1. Have you provided the services for which you are applying for a minimum of two (2) years?
    Yes No
  2. If no, please explain:
  1. If the organization, or any of its principle owners have previously been licensed, certified, or otherwise professionally authorized under a different name than is being used in this application, list the other name and provider I.D. number(s):

List reasons for discontinuing the other operation(s):
  1. If the organization, any of its owners, or key employees have ever been sanctioned or otherwise disciplined (e.g., vendor hold; administrative inquiries) by the Medicare or Medicaid Programs or other cognizant agencies, complete below:

Type and date of sanction(s):
Entity or individual(s):
Outcome/result of sanction(s):
  1. List any special circumstances that would result in, or be perceived as, conflicts of interest for your organization in performing the services on this form(see explanation on page 28) and explain below:
  1. Provide an overview of the health care administration experience of your organization, addressing specifically the areas listed below.

Attach résumé of the Administrator and the head of the finance/accounting department.

  1. Number of years of experience with electronic billing systems and plans for processing CMS Form 1500 medical claims.
  1. Procedures for controlling accuracy of charges.
  1. The existence and extent of policy and procedure manuals; organization charts; and position descriptions:
  1. Provide an overview of the payroll administration experience of your organization, addressing specifically the areas listed below:
  2. The existence and extent of payroll policy and procedure manuals:
  1. Name and address of any outside payroll services used:
  1. Provide an overview of your accounting and financial record keeping capabilities, addressing specifically the areas listed below:
  2. The existence and extent of accounting policy and procedure manuals:
  1. Positions, staffing levels, and supervision of accounting personnel:
  1. Independent accountants used for auditing, reviews, compilations or tax return preparation:
  1. Provide an overview of your current planning and budgeting capabilities, addressing specifically the areas listed below:
  2. Responsibility for preparation and approval of the budget:
  1. The integration of the budget with the accounting records:
  1. The extent of monthly variances normally experienced:
  1. The number of budget revisions normally performed each year:

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