2012 CDP/DPH User’s Conference January 24, 2012

1. Consent for Services Requests for Over-riding Charges Reporting CHFS/DCBS Flu and Hep B (first responders) Trainer: Janet Overstreet Local Health Operations 2012 CDP/DPH User’s ConferenceJanuary 24, 2012

2. CONSENT for SERVICES • Revisions to the PHPR for 2012 • Use of the term “legal representative” for someone other than the parent to identify an adult with legal authority to sign consent for medical services for a minor • “Legal Representative” would be an adult that has been determined by the court as the Legal Guardian, Legal Custodian, or an adult with “power of attorney” for consent to limited medical services for a minor obtained by the parent or legal guardian and has been duly notarized.

3. Who Can Sign for Medical Consent? • Patient • Parent • Legal Representative (to include minors under the custody or control of the KY Court system or the Cabinet for Health and Family Services)

4. When Can a Minor Sign Medical Consent themselves? • Per KRS214.185, some situations when a minor (under age 18) may sign consent are: • they have contracted a lawful marriage • they are unmarried, but borne or fathered a child • they are seeking diagnosis and/or treatment for STDs, pregnancy, alcohol and/or drug abuse or addiction (the LHD may treat the minor for STDs, contraception, pregnancy or childbirth without consent or notification of the parent) • (KRS 216B.400) they are a victim of a sexual offense

5. Who Can sign when a minor is in custody of the Court or committed into Foster Care? • Emergency Custody Order involving the removal of a minor from the home due to suspected Abuse/Neglect through a DNA petition: • The District or Family Court Judge may determine a “temporary legal custodian” (in many cases it may be a relative) for possibly up to one (1) year while the parent is given an opportunity to resolve the issues that caused the minor to be removed from the home. In these situations, there court may determine there should be no contact by the parent with the minor during this time. • This “temporary custodian” will have legal authority and the responsibility to take care of all needs of the minor. • An KY Office of the Courts document, AOC-DNA-4, will be signed by the Judge for this order.

6. …Who Can sign when a minor is in custody of the Court or committed into Foster Care? • Per CHFS/DCBS policy, in Emergency or Temporary Custody when the child has been committed to CHFS/DCBS, the Parent or District Judge shall provide written approval for medical procedures, and for “emergency situations” the CHFS Social Worker (SW) may consent, if SW not accessible the Caregiver/Foster Parent may consent • Committed Custody to CHFS/DCBS, the SW would sign for consent, exception for “emergency situations” and the SW is not accessible the Caregiver/Foster parent may consent • CHFS DPP-106A(CHFS Authorization for Medical Treatment)

7. …Who Can sign when a minor is in custody of the Court or committed into Foster Care? • The power point entitled “Understanding DCBS Custody and Consent for Medical Services”provided by CHFS/DCBS staff will be added to the PHPR webpage under “Related Content”. • Debbie Acker, RN (Nurse Service Administrator, Medical Support Branch, CHFS/DCBS/DPP) • Todd Meade (CDP Specialist, Child Safety Branch, CHFS/DCBS/DPP)

8. A minor child in a Child Custody issue between parents? • If there is a Custody Order in place, the LHD should confirm through the Custody Order which parent is designated to assure the routine medical care needs of the child. • If NO Custody Order is in place and parents cannot agree on consenting for medical services, authorization only needs to be executed by one (1) parent.

9. Minors Probated or Committed to KY Dept. of Juvenile Justice (DJJ) • For PROBATED youths, the parent shall sign consent for the medical services • While in COMMITTED Care of DJJ, the assigned Juvenile Service Worker (JSW) or Supervisor may sign consent for needed medical/treatment services • DJJ youths may not always be removed from the home, but others may be located at group homes, treatment centers, foster homes, and other type facilities. DJJ either operates or contracts, with various outside agencies, to provide a continuum of services for youths committed or probated to the Department.

10. Legal Guardian • A person appointed by District Court to manage the affairs of a minor or an incompetent adult, or any one else who does not have the ability (“legal capacity”) to manage their own affairs. • KRS 387.065 covers powers, duties, and responsibilities of guardians; such as “(3)(b) Consent to medical or other professional care, treatment or advice for the ward…”

11. Power of Attorney • Parents or legal guardians may complete and get duly notarized a “Power of Attorney” document to allow another adult to consent to medical service for their minor child. • The KY Office of the Courts has drafted a document for use in the form of an AOC-796 http://courts.ky.gov/NR/rdonlyres/E13804A6-0CE1-427E-B9F2-00D4BA52AD84/0/796.pdf • CHFS has a helpful resource handbook for grandparents and other caregivers entitled “HELP-A Handbook for KY Grandparents and Other Relative Caregiver” http://www.bgadd.org/pdf/aging/HELP-A%20Handbook%20for%20Kentucky%20Grandparents.pdf

12. GENERL CONSENT for Medical Services when parent/legal representative CANNOT be present at the visit • When an appointment for LHD services is being made for a minor (and it is a service the minor cannot sign for themselves); the front desk staff need to ask: • What relationship the adult is to the minor? • Will the parent/legal representative being present with the child at the service? • If the LHD determines the parent or legal representative will not be with a minor when presenting for a medical service and there is no current General Consent on file; the CH-5B may be provided or mailed to the parent/legal representative with instructions for completion to include a daytime phone number where the parent/legal representative can be reached. • The CH-5B may be returned to the LHD by dropping it off at the clinic site or by mail (but no more than 30 days prior to the visit) or the adult accompanying the minor may bring it with them on the date of service.

13. …GENERL CONSENT for Medical Services when parent/legal representative CANNOT be present at the visit • General Consent may also be obtained verbally. It is recommended that verbal consent only be used if no other method of consent has been achievable. • Information my be collected and input into the system and labels placed on the CH-5 or a CH-5B may be completed. • LHD employees collecting the verbal information should document in the patient record and the adult presenting with the minor shall sign the CH-5/CH-5B designating their relationship to the minor. • For minor patients presenting for WIC certification, the adult accompanying the minor will be responsible for providing the information required for verifying ID, residency, and income.

14. INFORMED CONSENT for Medical Services when parent/legal representative CANNOT be present at the visit • Assure there is a current General Consent on file or one should be attained • Informed Consent has to meet the criteria required for the service received • Services provided by LHDs requiring Informed Consent are Immunizations and Family Planning • Situations with Family Planning, in most cases the minor may be signing for themselves for the services they are receiving • For immunizations, refer to the “Consent Section” of the PHPR, item V, starting on page 10.

15. Requests for Over-riding Charges • Prior to requesting over-rides: • Review the rate per CPT code on the 501 Service File (use the PFIH function) • 501 Service File rates are determined by using standardized rates for CPTs based on the Relative-Based Resource Values (RBRVs) of those codes as determined by the Center for Medicare and Medicaid (CMS) • 501 Service Files rates for vaccines and supplies are most usually determined by cost (i.e., vaccine rates are determined by the CDC Private Sector cost per dose based on the highest manufacturer’s price) • Determine if the rate per CPT code your agency wants to charge is different than the Fixed Full Charge rate

16. …Requests for Over-riding Charges • LHDs who wish to request Approval from DPH to over-ride clinical charges should: • submit your request through an e-mail to the Local Health Help Desk • within your request identify the exact CPT codes and rates you are requesting approval to over-ride • document within your submission your reason why or justification for why you are requesting the over-ride; be detailed as possible

17. …Requests for Over-riding Charges • if your agency plans on billing those same type services to Medicaid (for the Medicaid recipients) on the same day, DPH will not approve requests for rates that are considered “nominal” or “free” • Federal Medicaid Regulations does not allow for services to be provided free or at a reduced rate to patients and those same services billed to Medicaid for Medicaid recipients at a higher rate • Refer to the DPH Medicaid Preventive Fee Schedule for codes and rates • once your request has been received and review, DPH will respond to your agency with instructions and guidance regarding your request • keep e-mails from DPH outlining your request(s) and response from DPH • over-ride approvals will expire on June 30 of each fiscal year

18. Other Over-rides • Payor Code 8 agreements (per Administrative Reference I, Financial Management Section, page 12): • LHDs will be allowed to over-ride rates and enter them in the charge (Chrg/Qty) field, if the negotiated rate is greater than the DPH service file assigned rate, without submitting a written request to over-ride charges to Administration and Financial Management. A rate is required for services rendered and an appropriate audit trail should be documented. Invoices shall not be setup as “0”.

19. Fixed Full Charge Services • LHDs may charge a patient at a Fixed Full Charge when providing: • Non-VFC/KVP funded Pediatric/Adolescents Immunizations (LHD purchased vaccines); LHDs may only charge the administration fee to the patient or third party payers for vaccines that are provided free to the agency • TB services not included in Public Health Practice Reference (PHPR) • Diabetes services not included in PHPR • Adult (LHD purchased vaccine) Immunizations (to include flu and pneumonia) and Problem Visits not included in PHPR; LHDs may not charge the patient or third party payers for vaccines that are provided free to the agency • Above information can be found in Administrative Reference II, Patient Services Reporting System Section (PSRS), page 87

20. Reporting CHFS/DCBS Flu and Hep B (first responders) shots • CHFS and DPH have agreed to the provision and payment of DCBS field staff through a Memorandum of Agreement between DPH and the LHDs • A memo went out on 12/14/11 outlining the above information and process • LHDs will use Payor Code 8, Contract Code 701, for reporting these services; if not reported correctly LHDs may not receive timely payment for services provided • DPH will provide monthly payments to LHDs after validating services reported; DPH will bill CHFS/DCBS annually

22. Questions??? Contact Info: Janet Overstreet DPH/AFM/Local Health Operations Branch (502) 564-6663, ext. 3150 JanetD.Overstreet@ky.gov Visit our Branch webpage at: http://chfs.ky.gov/dph/info/lhd/lhob.htm