Adult Brain Injury Program Provider Manual

Participants served must meet established financial and medical eligibility requirements. (See Participant Eligibility section of this manual)

Staff and facility must meet established requirements described in this document.

A Treatment Plan and Monthly Progress Report form will be required for all services as described in this document.

Before providing services, all Providers must:

• Enroll as a Provider by completing a Provider Application Form-CC-35, sign a Participation Agreement for Professional and Special Services Provider (DH-74A); and
• Obtain written approval for services requested. Department of Health and Senior Services (DHSS) will not reimburse Providers for services that are not prior approved. Verbal approvals will not be given.

The Provider may terminate services with a participant by giving written notice at least thirty (30) calendar days prior to the effective date of such termination.

Approval of prior authorization request is subject to availability of appropriated funds.

The ABI Program is neither an entitlement program nor entitlement to lifelong care and treatment.

The Department may maintain a waiting list for rehabilitation services in the event requests for services exceed available funds.

All Providers must submit claims according to established Billing Guidelines as described in this document.

The Department will not make payment for any services for which payment has been made under any State compensation program including MO HealthNet, any insurance policy, any Federal, State, or County Program, or any third party resources. When reimbursement is available from any of these sources, claims must be submitted to these sources before submitting a claim to the ABI Program.

The Program does not duplicate services available through other public human service agencies, but works cooperatively and advocates with appropriate public and private programs to ensure that individuals have access to benefits for which they may be eligible.

All billings for services provided to approved participants must be submitted to the Department no later than sixty (60) days following the date services are provided or no later than (60) days following receipt of payment determination by a third party payer. At the close of a State fiscal year, the ABI Program shall request that the provider submit claims at an earlier date in order to ensure timely payment. The Department has the authority to review participant records and Provider billings to assure that program guidelines as written herein are followed.

Facility Requirements

If the Provider’s program involves a physical plant, the Provider shall provide a facility which:

• Meets American Disabilities Act (ADA) standards for accessibility;
• Has an effective plan in place for emergency egress;
• Meets local fire and safety codes; and
• Is maintained in good repair and is in safe, clean, and orderly condition.

Staff Requirements

The Provider shall provide qualified personnel to adequately staff the Provider’s program. Requirements for staff members offering each service are listed in each service description and summarized in a quick reference guide in the ABI Program Provider Qualifications section.

The Provider will be responsible for accurate and complete documentation of staff credentials. This documentation must demonstrate the necessary certification, licensure, education, training, and skills required to provide each service for which payment is made by DHSS. Provider’s onsite records are subject to review by DHSS in accordance with the Provider Participation Agreement.

Documentation Requirements

Providers must retain for three (3) years, from the last date of service, fiscal and treatment records that coincide with and fully document services billed to DHSS, and must furnish or make the records available for inspection or audit by the Department or its representative upon request. Failure to furnish, reveal, and retain adequate documentation for services billed to the Department may result in recovery of the payments for those services not adequately documented and may result in sanctions to the Provider's participation in Department programs. This policy continues to apply in the event of the Provider’s discontinuance as an actively participating DHSS Provider through change of ownership or any other circumstance.