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Independent Practitioner Services for Individuals with Developmental Disabilities

Independent Practitioner Services for Individuals with Developmental Disabilities
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Overview

IPSIDD services include the following clinical services, delivered by a clinician licensed in New York State or otherwise specified in the regulation, that are not delivered as part of an individual’s residential and/or day habilitation service:

  1. Occupational therapy
  2. Physical therapy
  3. Speech and language pathology
  4. Psychology
  5. Social work

Qualifications

The provider must be a clinician licensed in New York State whose name and credentials have been submitted to and verified by OPWDD. The provider must have had specialized training and two years of experience treating people with developmental disabilities, and has received approval from OPWDD to provide IPSIDD services to those people who meet the required eligibility criteria.

In addition, an Applied Behavior Sciences Specialist (ABSS) may provide IPSIDD services under the supervision of a licensed psychologist who meets the qualifications specified above. The ABSS must have a Master’s degree in a clinical and/or treatment field of psychology and/or a New York State license in Mental Health Counseling, and training in assessment techniques and behavioral program development.

Who can receive IPSIDD services?

People who are determined by OPWDD to have a developmental disability as defined in MHL 1.03(22), and people who are not enrolled at a facility or program that includes provision of the clinical services of OT, PT, SLP, psychology or social work as part of its service model and reimbursement rates (e.g., developmental center, specialty hospital, intermediate care facility for individuals with intellectual/developmental disabilities, etc.)

Locations IPSIDD services can be delivered

IPSIDD services can be delivered in the following locations: 

  • IRAs, CRs or Family Care homes certified by OPWDD, or private residences
  • Certified day habilitation, pre-vocational and day training facilities
  • Community settings as deemed appropriate by the clinician, including community settings where OPWDD services may occur, or
  • Clinician’s private offices

Locations where IPSIDD services cannot be provided

Services cannot be provided in the following locations: 

  • Educational settings serving students from preschool through grade 1
  • Private schools certified by OPWDD
  • ICFs/IIDs
  • Day treatment facilities
  • Clinic treatment facilities certified by OPWDD, DOH, OMH, and OASAS
  • Hospitals (including OPWDD-certified specialty hospitals)
  • Other licensed or certified residential or day healthcare settings that include the clinical services of OT, PT, SLP, psychology, or social work as part of its service model and reimbursement rates

Other limitations or restrictions

  • IPSIDD cannot be provided to people receiving or eligible to receive similar clinical services from the Early Intervention Program.
  • IPSIDD must not duplicate or replace Preschool Supportive Health services or School Supportive Health services that are authorized through an approved IEP. However, IPSIDD may address service needs of preschool and school-aged children that are not addressed in the IEP and are not school-related as determined by the child’s Committee on Special Education.
  • IPSIDD services must not duplicate or replace services available through the ICF/IID program, or OPWDD operated or certified residential or day programs.
  • IPSIDD services must not duplicate OPWDD funded HCBS services, including Intensive Behavioral Services or services provided in-clinic treatment facilities and hospital outpatient departments or services provided by Certified Home Health Agencies. However, services described by the same clinical procedure code may be provided to address different clinical needs.
  • Time spent receiving another Medicaid service cannot be counted toward IPSIDD billable service time in instances when the Medicaid service is received at the same time as IPSIDD services 13.

Enrollment

Options for the Delivery of IPSIDD 

Clinicians working as independent practitioners enrolled in Medicaid will receive direct payment from Medicaid for services rendered. 

Clinicians who are employees, members or affiliates of a group practice that is enrolled in Medicaid will no receive direct payment. The group practice will submit and receive payment for services rendered. 

Clinician Enrollment

Please click on the following links to visit enrollment information for those professions.

Licensed Psychologist

Licensed Clinical Social Worker

Physical Therapist / Occupational Therapist / Speech Pathologist

Before enrolling in Medicaid, Licensed Clinical Social Workers and Licensed Physical Therapists must first enroll in Medicare

Group Practice Enrollment

Once a Group Practice is established as a separate Professional Corporation or a Professional Limited Liability Company (LLC), the entity can proceed with the Medicaid enrollment process. However, before enrollment in Medicaid, the group practice must first enroll in Medicare if the group practice membership includes Licensed Clinical Social Workers and/or Physical Therapists. 

Once the group practice enrollment has been processed, and a Medicaid Provider ID is issued, OPWDD will need to be informed. When you receive notification that your enrollment has been processed, we ask that you email [email protected] with the name of the group practice and the Provider ID.

Clinicians providing service under a group practice will need to formally affiliate for the group practice to submit and receive payment for services rendered.

Billing and Payment

IPSIDD services will be submitted to Medicaid using the 837P (“Professional Claim”) transaction format.

This transaction format is different from all other OPWDD Medicaid services, which are submitted using the 837I (“Institutional Claim”) transaction format. However, most Article 16 clinic providers will be familiar with the 837P format because this is the format most clinics use to submit services to Medicare.

Because IPSIDD service claims will be submitted to both Medicare and Medicaid using the same 837P transaction format, automated Medicare cross-over claiming will be possible.

OPWDD recommends providers interested in delivering IPSIDD services discuss the 837P transaction format with their billing software vendor. You will need to verify that your current software or web service supports the 837P transactions. Identify what instructional aides and resources are available for billing personnel. Also, identify what instructional aides and resources are available for billing personnel. You may review proposed IPSIDD regulations and Department of Health Provider Manuals at emedny.org

eMedNY

Providers will not be required to include any unique procedure codes, modifier codes, or other special identifiers when submitting IPSIDD service claims to eMedNY. Claims should be submitted in the same manner as outlined in the NYS Medicaid Provider Manual for the discipline providing services. 

eMedNY will identify IPSIDD claims automatically based on identifiers contained in Medicaid client and provider records at the time of claim adjudication.

eMedNY will recognize an independent practitioner claim as “IPSIDD-qualifying” when both of the following criteria are met:

  1. The patient is identified in eMedNYas eligible for OPWDD services. This means the patient:
    • Has been assigned Restriction Exception code 95 (RE95) in eMedNY.
    • Is registered in OPWDD TABS with up-to-date Medicaid information.
    • Has been formally determined eligible for OPWDD services or meets grandfathering criteria.
      AND
  2. The billing clinician meets IPSIDD’s specialized experience requirement. This means the clinician:
    • Has Specialty Code 979 assigned to his/her Medicaid provider enrollment record.
    • The clinician has filed an application with OPWDD.
    • OPWDD has reviewed and approved such application and transmitted an authorization to DOH Provider Enrollment.

IPSIDD services will be processed by eMedNY in the same manner as “regular” independent practitioner services for therapy, psychology, and social work services, except:

  1. All IPSIDD-qualified patients will remain exempt from the annual visit caps for OT, PT, and SLP services.
    • Without RE95, reimbursement of these services for adult patients would be limited to 20 visits per therapeutic discipline per year.
  2. IPSIDD services will be considered “carved-out” of Mainstream Medicaid Managed Care.
    • Similar Article 16 clinic services, you will be able to submit IPSIDD claims to FFS Medicaid, even for individuals enrolled in Mainstream Medicaid Managed Care.
    • IPSIDD services will not be carved-out of specialty managed care products that include long-term care benefits (e.g., MLTC, FIDA, or FIDA-IDD plans).
  3. Medicaid reimbursement of LCSW “regular” independent practitioner services is currently limited to Medicare cross-over services. LCSWs will be permitted to deliver IPSIDD services to both dual eligibles and Medicaid-only beneficiaries.
  4. IPSIDD services will be priced based on a special, enhanced fee schedule.

Differences between billing and payment of IPSIDD and Article 16 Clinics

  • IPSIDD claims will have no rate codes.
  • IPSIDD will not be processed through the 3M APG grouper-pricer.
    • No APG Base Rates and SIWs
    • No APG discounting
    • No APG consolidation
    • No capital add-on
  • IPSIDD claims will be priced based on the following factors:
    • CPT code describing the services rendered
    • Special IPSIDD regional fee assigned to the CPT code by MH Rate Setting
    • Where applicable, the CPT unit quantity
  • Service claims will be submitted to Medicaid under the personal NPI of the rendering/ supervising licensed clinician. However, payment may be reassigned to a group practice by inserting the group practice’s NPI in the “Pay to” Provider field of the claim.
    • All rendering/supervising clinicians must be enrolled providers of the NYS Medicaid program.

Billing and Payments of Dependent Clinicians

IPSIDD Services may be delivered by clinicians licensed by New York State to practice in the following disciplines: OT, PT, SLP, LCSW, and clinical psychology.

IPSIDD services may also be delivered by authorized dependent clinicians working under appropriate supervision.

  • An OTA working under the supervision of a licensed OT.
  • A PTA working under the supervision of a licensed PT.
  • A LMSW working under the supervision of an LCSW.
  • An ABSS or LMSW working under the supervision of a licensed psychologist.

Standards and requirements of supervision vary by discipline and are defined in both statutes and regulations governing each profession.

For eMedNY billing purposes, services of dependent clinicians will be submitted under the NPIs of their supervisors.

  • Supervising clinicians and their group practices are accountable for all services submitted under their NPIs, including any services rendered by the dependent clinicians they supervise.
    • For example, if a Medicaid audit reveals that a dependent clinician had fraudulently documented services not actually rendered, a possible consequence might be that both the dependent clinician and the supervising clinician (and, possibly, the supervisor’s group practice) are placed on excluded provider list for Medicaid.
  • Furthermore, evidence of poor or ineffective supervision of dependent clinicians is sufficient justification for the removal of OPWDD specialty designation. This would eliminate the clinician’s access to the enhanced IPSIDD fee schedule and managed care carve-out.