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Division of Community and Family Health Services NAME OF AGREEMENT: Interagency Coordination - Title V, Title XIX
AGREEING PARTIES: This agreement is between the Utah Department of Health,
Division of Community and Family Health Services (DCFHS) as the designated Title V
(Maternal and Child Health) agency and the Utah Department of Health, Division of
Health Care Financing (DHCF) as the designated Title XIX (Medicaid) agency.
PURPOSE OF AGREEMENT: The purpose of this agreement is to formalize and
strengthen the relationship between DCFHS and DHCF in areas of mutual interest and
concern, avoid duplication of effort, improve access to Title XIX (Medicaid) and Title V
[(Maternal and Child Health (MCH)] to eligible Medicaid clients; to enhance the quality
of Medicaid and MCH services; to enhance program coordination and information
exchange to the extent possible.
CONTRACT PERIOD: This agreement is effective April 1, 2001, and will not terminate
unless in accordance with the terms of this agreement.
ATTACHMENTS:
Attachment A: Coordination Forum Designees.
Attachment B: Utah Medicaid Provider Manual, Medical Supplies List, Nutrients
Attachment C: PKU “U” Codes
Attachment D: Medicaid Provider Agreement
Attachment E: Presumptive Eligibility
Attachment F: Enhanced Services for Pregnant Women
Attachment G: Definitions
SPECIAL PROVISIONS:
Assign the Director of Health Care Financing, or designee, to be the Division liaison to DCFHS, and represent DHCF on the MCH AdvisoryCommittee.
Coordinate and collaborate with DCFHS in planning and implementing Medicaid services related to maternal and child health populations, including butnot limited to: Early Periodic Screening, Diagnosis and Treatment Early Intervention (diagnostic/rehabilitation services) Care coordination for children with special health care needs 1915( c) Home and Community Based Waiver for Collaborate with DCFHS to improve access to and quality of services for Medicaid recipients who need MCH services: Children with special health care needs in managed Women and children in Medicaid managed care Reimburse DCFHS, in accordance with the 42 Code of Federal Regulation (CFR) 431.615 paragraph c4, for the cost of services furnishedMedicaid recipients by DCFHS and Title V grantees.
Provide the CHEC Program Plan which includes sections on needs assessment, outreach, and participation data, for use in the MCH BlockGrant Application and Annual MCH Report.
Coordinate CHEC outreach activities with related programs.
Collaborative efforts will include joint contract development and monitoring whereapplicable.
Coordinate outreach efforts related to the “Baby Your Baby” Program, including the “Hotline” and “Check Your Health” Program media efforts,and making referrals to DCFHS.
Collaborate with DCFHS in efforts to improve the immunization Provide, upon request, at no cost to DCFHS, non-confidential and readily available enrollment, utilization and quality assurance data orsimilar information to assist DCFHS in accomplishing its mission. Providesuch data that are not readily available to DCFHS for the cost associatedwith the request. Provide shared access for designated and trained staff tothe Division Data Warehouse.
Disseminate information, annually, through Medicaid Information Bulletins or other such publication informing Medicaid recipients andproviders of the procedures to bring policy issues to the attention of theMedical Care Advisory Committee or the Maternal and Child HealthAdvisory Committee.
Coordinate and collaborate with DCFHS in planning, implementing and evaluating QA/QI projects related to MCH and chronic disease population.
Coordinate and collaborate with DCFHS in monitoring services provided by managed care organizations to MCH and chronic disease populations.
Assure that all managed care contracts include provisions requiring managed care plans to contract with and/or pay DCFHS for minimum screeningand follow-up services provided by DCFHS to eligible children with special healthcare needs. Payments will be at least at the current Medicaid rates.
Establish the Division of Community and Family Health Services as a Medicaid provider for selected enteral and metabolic products, and payDCFHS for those products according to the Medicaid fee schedule.
Recognize the director of the Bureau of Children with Special Health Care Needs as a member of the EPSDT subcommittee for the MedicaidUtilization Review committee.
Assign the Director, Bureau of Maternal and Child Health, with theresponsibility to ensure the coordination of services, outreach and education provided by the Title V (MCH) programs, including butnot limited to: Reproductive Health; Women, Infants, and Children(WIC); Child, Adolescent and School Health; Oral Health andImmunizations with services and outreach provided by Medicaid.
2. Assign the Director, Bureau for Children with Special Health Care Needs with the responsibility to ensure coordination of services,outreach and education provided by the Title V (MCH) programsincluding but not limited to: Children’s Special Health Care Needsprograms.
Encourage Title V-funded and other DCFHS-sponsored programs to screen families for possible eligibility for Medicaid benefits; to informthose potentially eligible of services available through the Medicaidprogram; and to refer families to the appropriate eligibility offices.
Provide health care consultation and technical expertise for CHEC, Children with Special Health Care Needs, Reproductive Health, OralHealth and Preventive Child Health Services. These functions include, butare not limited to, recommending: Components of physical examination and screening Data to be collected from screening exams as to the health status of the woman and child services provided;f.
Standards for expanded services provided through the Criteria and definitions to be used in determining medical necessity and making recommendations to the Utilization ReviewCommittee.
Provide dental consultation and serve as liaison with the dental Recommend criteria and definitions to be used in determining medical necessity and appropriateness;b.
Recommend criteria and definitions of quality dental care; Recommend scope of Medicaid benefits, criteria, and determinations for the dental provider community; andd.
Explain the directions of the Medicaid dental program.
Designate DCFHS staff to coordinate the Child, Adolescent and School Health program; and other related programs with CHEC outreach,education, and case management activities with the DHCF CHECCoordinator and the CHEC staff at the local community level.
Provide upon request at no cost to DHCF readily available MCH data related to Medicaid clients, or other similar information, to assistDHCF in accomplishing its mission. Provide such data that are not readilyavailable to DHCF for the cost associated with the request.
DCFHS agrees to bill DHCF for selected enteral products subject When a WIC client of any age has part or all of the gastric system which is absent, damaged or malfunctioning (eithertemporarily or permanently), and When the patient must be fed through a gastrostomy or jejunostomy tube that has been surgically attached, or must be fedthrough a nasogastric or nasojejunal system (an NG tube that isonly used occasionally does not qualify a client for billing of thisservice), and When the client and/or DCFHS meet all of the criteria as specified in the Medical Supplies manual, which includes but is notlimited to: Determining the client is fee-for-service, Billing using the proper forms procedures, and according to manual specifications,vi.
Using the proper “B” codes, as specified in Billing any and all third party insurers before billing DDCFHS agrees to be responsible for any federal disallowance stemming from error or mistake by DDCFHS.
DDCFHS agrees to bill Medicaid for metabolic products subject to When a WIC client’s gastric system cannot metabolize nutrients due to an enzyme deficiency, and When the product has been prescribed (ordered) by a physician (order includes quantity, dosage per day, duration), and When all of the provisions of the Medicaid supplies manual have been met, this includes but is not limited to: Determining the client is in fee-for-service status, Using the proper forms, procedures, and in compliance with provider manual specifications,iv.
Billing the proper codes, as specified on Attachment Billing any and all third party insurers before billing DCFHS agrees to be responsible for any federal disallowance stemming from error or mistake by DCFHS.
DCFHS agrees to bill Medicaid for selected enteral and metabolic products for specificWIC clients when these clients: Have a severe biological or functional anatomical deficiency that gravely affects the assimilation of food, i.e., hepatic, lactate,lung, kidney, amino acid (phenylketonuria), lipid, and Have a prescription order from a physician (which includes product, quantity, dosage and duration), and Have obtained prior approval from DHCF.
DCFHS agrees to bill DHCF for these clients subject to the Determining the clients are Medicaid eligible and are Using only the T codes as specified in Attachments Following the procedures and using the appropriate forms as shown in the Medical Supplies manual, andiv.
Billing any and all third party insurers before DCFHS agrees to be responsible for any federal disallowance stemming from error or mistake by DCFHS.
DCFHS agrees to abide by the terms and conditions as stated in the modified Medicaid Provider Agreement in Attachment D.
DCFHS agrees to coordinate and interface with Medicaid managed care plans to follow the care of any person covered by provision B-8 or B-9, or B-10 of this agreement who is, may be, or was eligible for carethrough a managed care plan.
Both DHCF and DCFHS will conduct mutual collaboration and coordination through the use of forums which will address matters relatingto each of the component areas of the MCH Block Grant. Each Divisionwill designate specific individuals for each forum to coordinate activitiesrelating to that component area (Attachment A). MCH component areasare: a. Component A: Preventive and Primary Services for PregnantWomen, Mothers and Infants up to age one.
b. Component B: Preventive and Primary Services for Childrenand Adolescents.
c. Component C: Family-Centered, Community-Based,Coordinated Care and the Development of Community-BasedSystems of Care for Children with Special Health Care Needs.
d. Component D: Health Promotion activities including but notlimited to: Tobacco Prevention and Control; Chronic Diseases;other programs and grant projects related to health promotion andcommunity health.
All information regarding recipients of services provided directly or indirectly through DHCF or DCFHS shall be treated as confidential.
Publication of any information that would identify an individual recipient is prohibited except upon written consent of the recipient or theresponsible parent or guardian.
No modifications or changes will be made to this agreement unless in writing and signed by the Directors of both DHCF and DCFHS.
Both parties are governmental entities under the Governmental Immunity Act and public entities under the Indemnification of PublicOfficers and Employees Act, and consistent with the items of those acts,agree to hold each other harmless for their wrongful or negligent acts orthose of their employees, officers, or agents.
This agreement may be terminated by either party upon 90 days Both parties will review this document annually and update as Reference to agreements included in this Contract but not attached
Memorandum of Agreement
Division of Community and Family Health Services SIGNATURES
DIVISION OF COMMUNITY AND FAMILY HEALTH SERVICES
___________________________________ _______________George W. Delavan DIVISION OF HEALTH CARE FINANCING
UTAH DEPARTMENT OF HEALTH
Division of Community and Family Health Services Designees
Director, Bureau of Coverage and Reimbursement Policy Director, Bureau of Maternal and Child Health Director, Bureau for Children with Special Health Care Needs 1. Purpose: To provide delineation of responsibilities and administration for the presumptiveeligibility program.
2. DCFHS will select Qualified Providers and monitor service offered under the PresumptiveEligibility Program.
DCFHS shall pay for any disallowance of federal financial participation for failing to meet the terms of this agreement and the MOA between DCFHS andthe QP; failure of DCFHS agencies or QPs to comply with federal rules andregulations; or expenditures not qualifying for federal financial participation.
DHCF shall bill DCFHS quarterly for any disallowance as per 3. A once that disallowance is made known to DHCF by the CMS Regional office DHCF shall process for payment all claims submitted for PE clients in accordance with established state Medicaid policy.
DHCF shall receive all billings from providers of services to presumptively eligible individuals, check to determine if the individual has beendetermined to be Medicaid eligible, and approve the billing for payment from theappropriate fund.
DHCF shall establish provider types, unique provider numbers, and categories of service authorized for each qualified provider (QP) identified byDCFHS.
DHCF shall provide administrative support for the program.
DHCF shall suspend all claims submitted for presumptively eligible applicants, those from Qualified Providers, and those claims with publishedcodes, based on the period of time beginning on the day PE is approved by aqualified provider and ending on the last day of the month following the month ofthe PE application has been approved, or the expiration date on the PE card.
Those individuals who are found to be Medicaid eligible will be processed through the normal MMIS process. Suspended claims will beresolved using Adjudication Decision Tables acceptable to all parties.
DHCF shall process all claims for PE clients against Medicaid funding based on B.5 (above). In the event the client is determined by authorizedeligibility staff to be ineligible for Medicaid, all claims up to the date of expirationof the PE card will be processed against the Medicaid program.
DHCF shall adjudicate PE claims that are suspended for TPL reasons.
These claims will be referred to the Office of Recovery Services (ORS) forpossible collection activity.
DHCF shall send to ORS, copies of all forms containing TPL information on PE recipients who are determined not to be Medicaid eligible, but who havereceived services while qualified as PE. This information will be used for collectionactivity by ORS.
DHCF shall periodically review all claims paid through the PE program to determine if, following payment from the PE program funds, the individualsubsequently became Medicaid eligible. In the event an individual becomes eligiblefor Medicaid, DHCF shall process an adjustment to pay for authorizedexpenditures using Medicaid funding.
DHCF shall conduct training sessions for QPs to acquaint them with the prior approval process, billing procedures, and services coverage limits ofMedicaid when requested by DCFHS.
DHCF shall store PE forms for a period of time to meet access and DCFHS shall ensure that all QPs have a current Memorandum of Agreement which clearly states the minimum expectations as defined in the StatePlan, 88-13.
DCFHS shall monitor all QPs to ensure that all terms of their MOA are DCFHS shall identify to DHCF all QPs to be assigned unique provider numbers for the purpose of billing under the PE program.
DCFHS shall ensure that only those services which are defined in the ‘Enhanced Services to Pregnant Women Service Codes and Definitions”(Attachment ??) or those previously approved for payment under Medicaid areprovided under this program. Inappropriate referrals from QP s for services willbe the responsibility of DCFHS.
All services offered under this program are subject to established Medicaid service limits and prior approval requirements.
Reports. DHCF shall provide DCFHS with mutually agreed upon reports summarizing all claims paid through the PE program and administrative expenditurescharged to the program.
Department of Health, Division of Health Care Financing (DHCF) - The agency assigned
responsibility to administer the Medicaid program in the State of Utah.
Department of Health, Division of Community and Family Health Services (DCFHS) -
The agency with responsibility to administer Title V programs in the State of Utah.
Centers for Medicare and Medicaid (CMS) Regional Office - Region VIII CMS office in
Denver, Colorado. This regional office, under direction of the Central Office of the Centers for
Medicare and Medicaid Services, is responsible for oversight of Utah Medicaid.
Third Party Liability (TPL) - Possible sources of funds to cover the services offered under the
Medicaid and Title V programs. Sources could be other insurance programs, verteans benefits,
other governmental programs, etc.
Office of Recovery Services (ORS) - The office within the Department of Human Services
with contractual responsibility to investigate and collect TPL on Medicaid claims.
Managed Care Organization (MCO) - An organization contracted with the Medicaid program
to provided necessary health services to recipients.
Presumptive Eligibility (PE) - A period of time beginning on the day PE is approved by a
qualified provider and ending the last day of the month following the month thewoman is approved for PE.
Presumptive Eligibility Determination - the process of completing the presumptive eligibility
application form and submitting the form to DHCF. Presumptive eligibility determination is
made on the basis of preliminary information that the woman’s household income does not
exceed the applicable income standard for a household of the same size. Presumptive eligibility is
based on household income and a verifiable pregnancy. Presumptive eligibility determination is
made by appropriate staff of a qualified provider.
Qualified Provider (QP) - A facility or organization identified by DCFHS and bound by a
Memorandum of Agreement as qualified to determine presumptive eligibility and provide
services in accordance with the established DCFHS Reproductive Health Program and by the
Code of Federal Regulations.
The Qualified Provider must meet criteria established by the Social Security Act, Section 1920,and amendments, as noted below: Is eligible for payment under an approved State Plan; and Outpatient hospital services (section 1905(a)(2)(A) of the Act), ural health clinic service (if contained in the State Plan) (Section 1905(a)(2)(B)),nic service furnished by or under the direction of a physician, without regard towhether the clinic itself is administered by a physician (Section Is designated by the State (DCFHS) in writing as being capable of making presumptive eligibility determinations based on family income.
A qualified provider meets one of the following: igrant Health Centers or Community Health Centers (Section 329, 330, or 340 of the Public Health Service Act); ernal and Child Health Services Block Grant Program (Title V of IIf the Indian Health Care Improvement Act; The Special Error! Bookmark not defined.Supplemental
Food Program for Women, Infants and Children (Section 17 of the ChildNutrition Act of 1966) The Commodity Error! Bookmark not
defined.Supplemental Food Program (Section 4(a) of the Agriculture and
Consumer Protection Act of
Participates in a State perinatal program; or Is the Indian Health Service or is a health program or facility operated by atribe or tribal organization under the Indian Self Determination Act (P.L.
93-638) Risk Assessment - the systematic review of relevant client data to identify potential problems
and to plan for care directed at preventing or ameliorating those problems. A formalized risk
assessment tool is to be used by all providers authorized to complete the risk assessment. The
care plan for low risk client incorporates a primary care service package and additional services
specific to the needs of the individual client. High risk care includes referral to or consultation
with an appropriate specialist, individualized counseling, and services designed to address theparticular risk factors involved.
Expanded or Enhanced Services - Approved ambulatory services provided to Medicaid eligible
pregnant women to meet individual needs without having to offer comparable services to all other
categorically eligible individuals. This provision was established by SOBRA 1985. The
expanded or enhanced service include care coordination, mental health counseling, nutritional
assessment and counseling, health education, and home visits.
Title V MCH and CSHCN – Federally funded program to states which includes funding for
programs for mothers, infants and children and children and youth with special health care needs.
EPSDT/ CHEC -
WIC – Supplemental Food and Nutrition Education Program for Women, Infants and Children
which provides nutrition assessment and education as well as food vouchers for income eligible
pregnant and postpartum women and infants and children at nutritional risk up to age five years.

Source: http://www.mchlibrary.info/IAA/states/UT_1_1.pdf