Form 3625/3625-S
Instructions

Documentation of Services Delivered

11-2010

PURPOSE

  • To serve as the primary source billing document for services provided to eligible applicants/individuals by the Community Living Assistance and Support Services (CLASS) case manager.
  • To serve as the primary source billing document for services provided by employees of the CLASS direct service agency.
  • To serve as the primary source billing document for services provided by non-employees of the CLASS direct service agency through personal service agreement, contract with another agency, and/or direct purchase.

PROCEDURE

When to Prepare

The case manager or direct service agency may complete Section A, Applicant/Individual Information, and Section B, Provider Agency Information, before the month of service.

The individual delivering services must complete the balance of the form upon completion of service delivery. If services are provided in more than one month, prepare a separate Form 3625 for each calendar month.

For case management agencies, when billing for both types of service (Pre-Enrollment Assessment Fee(s) and ongoing case management) in the same month, complete a separate Form 3625 for each service.

Number of Copies

Complete an original of Form 3625 for each service and for each individual providing that service for the month of service.

Transmittal

The provider agency retains the original.

Form Retention

Keep this form according to record retention requirements documented in the CLASS Provider Manual.

Supply Source

This form may be downloaded through the DADS website at www.dads.state.tx.us/handbooks/classpm/forms/index.asp.

DETAILED INSTRUCTIONS

Note: A timekeeper must be designated to verify that the hours recorded on the billing document were worked. The timekeeper may be the supervisor or other designated person but may not be the provider of the service.

Written approval must be obtained from the CLASS unit manager if a different primary source billing document is to be used instead of Form 3625 and instructions.

If Form 3625 is not completed correctly, financial exceptions may result.

Section A — Applicant/Individual Information

The service provider completes this section.

1. Service Month and Year — Enter month and year that services are to be provided.

2. Applicant/Individual Name — Enter the applicant's/individualís full name as shown on his Medicaid Identification (Form 3087), his Social Security card, or the full name as provided by the applicant/individual on the individualís Form 3621, Individual Plan of Care. If the applicant's/individualís name is different on any or all documentation, use the name as shown on the Medicaid card.

3. Medicaid No. — Enter the applicant's/individualís nine-digit Medicaid number.

4. Social Security No. for CLASS applicants only —Enter the applicant's nine-digit Social Security number as it appears on his Social Security card. For enrolled CLASS individuals, leave this item blank. The Medicaid number must be documented in Item 3.

Section B — Provider Agency Information

5. Agency Type — Check the appropriate box for Case Management Agency (CMA) or Direct Services Agency (DSA).

6. Agency Name — Enter the name of the case management or direct services agency.

7. Vendor No. — Enter the nine-digit vendor number assigned by the Texas Department of Aging and Disability Services (DADS).

Section C — Pre-Enrollment Assessment Fees: CMA/DSA

This section is to be completed by the CMA or DSA when billing for pre-enrollment assessment fees.

8. Case Management Services — Check the appropriate box for billing either Full Assessment or Partial Assessment.

Full Assessment —Check this box for reimbursement for a full assessment provided during the initial assessment process. Full assessment activities result in the development of an IPC authorizing the services agreed to by members of the service planning team.

Submit to DADS the completed Form 3625 along with the individual's initial Form 3621, CLASS IPC, Page 1.

Partial Assessment — Check this box for reimbursement for a partial assessment provided during the initial assessment process when an applicant is determined ineligible or does not want CLASS services.

Submit to DADS the completed Form 3625 along with Form 2067, Case Information, notifying DADS that the applicant is determined ineligible or is terminating the pre-enrollment process.

9. DSA Services — Check the Full Assessment box to bill for the DSA Pre-Enrollment Assessment Fee.

Submit to DADS the completed Form 3625 along with completed/DADS-processed Form 8578, Mental Retardation/Related Condition Assessment.

Section D — Case Management Services

This section is to be completed by the CMA only.

10. Case Manager Name — Enter the name of the case manager assigned to the individual.

11. Case Management Services — Check this box for ongoing case management services provided for service category Case Management Services Ongoing 12.

Section E — Direct Services

This section is to be completed by the DSA only.

12. Method of Delivery (Check only one) — Check the box that represents the method by which services will be provided to the individual.

Employee — Name of Employee — Check the box marked "employee" if the person providing services is an employee of the DSA. Enter the name of the employee providing the service. The employee must sign and date Section G — Certification on the signature line "Person Delivering Services."

If the employee is not available to sign and date Section G — Certification, document the reason in the "Comments" section. The timekeeper must sign/date the form after verifying the accuracy of the information on Form 3625.

Personal Service Agreement — Name of Individual — Check the box marked "personal service agreement" if the individual providing services is not an employee of the agency. Enter the name of the individual providing services under a Personal Service Agreement. This individual must sign/date Section G — Certification on the signature line "Person Delivering Services."

Contract With Another Agency — Name of Individual and Company — Check the box marked "Contract With Another Agency" if the individual providing services if not an employee of the DSA. Enter the name of the individual and the company providing services under a DSA sub-contract. This individual must sign/date Section G — Certification, on the signature line "Person Delivering Services."

If the professional contracted by the DSA under a Personal Service Agreement and/or Contract with Another Agency is not available to sign/date Form 3625, document the reason(s) in the "Comments" section. The timekeeper must sign/date the form after verifying the accuracy of the information on Form 3625.

Direct Purchase — Use only for service categories Adaptive Aids — 15; Minor Home Modifications — 16; Written Specifications for Adaptive Aids — 41C; and Written Specifications/Inspections Fee for Minor Home Modifications — 41D. Check "direct purchase" if the DSA or a contractor will be making the direct purchase. Direct purchase is only for service category Adaptive Aids — 15, and Minor Home Modifications — 16. A representative of the vendor completing the work or DSA designated timekeeper must sign/date Form 3625.

Authorized Service — Enter only one service category and the matching requisition fee, if applicable, for each Form 3625.

13. Service Category — Enter the authorized service category being billed, for example, Physical Therapy, Occupational Therapy, Adaptive Aids, Minor Home Modifications, etc.

14. For Service Category 42, name specialized therapy – Enter the specialized therapy being billed. For example, hippo therapy, aquatic therapy, etc.

15. Service Code — Enter the service code of the authorized service. Service codes for each authorized CLASS service are listed on the CLASS Service and Billing Code Information.

16. Bill Code — Enter the billing code of the authorized service. The billing codes for each authorized service category are listed on the CLASS Service and Billing Code Information.

17. Requisition Fee (if applicable to services stated in Field 13, Service Category) — Enter the authorized requisition fee related to a service category stated in Field 13, if applicable. For example, requisition fee for massage therapy, recreational therapy, music therapy, etc.

18. Requisition Fee Service Code — Enter the requisition fee service code related to Field 18. Service codes for each authorized CLASS service are listed on the CLASS Service and Billing Code Information.

19. Requisition Fee Bill Code — Enter the requisition fee billing code related to Field 18. The billing codes for each authorized service category are listed on the CLASS Service and Billing Code Information.

Comments — Use this section to document any applicable information or to give a brief description of services to be provided and the proposed schedule or frequency.

Section F — Record of Time

This section is to be completed by the individual providing the service.

Record of Time — Complete this section based on the service categories checked in Section C, Pre-Enrollment Assessment Fees: CMA/DSA; Section D, Case Management Services; or Section E, Direct Services.

Day represents the number of days in the calendar month of service. Calendar months with less than 31 days will end service delivery on the last day of the calendar month of service.

Time In/Time Out/Units must be documented by "a" for a.m., "p" for p.m., or in military time with a total number of hours/units for each day.

Example: 11:00a-2:00p (3) or 1100-1400 (3).

Amount must be documented for service categories/codes that are billed in dollar amounts, for example, Adaptive Aids — 15, and Minor Home Modifications — 16, etc.

Service Category 40A, Pre-Enrollment Assessment Fees

Note: DADS enters into the Claims Management System (CMS) the last calendar day entry documented in the Record of Time section and the appropriate amount authorized for CMA and DSA pre-enrollment assessment fees.

Case Management Services — Full Assessment — The individual records the time spent daily completing the pre-enrollment assessment process. The last calendar date recorded in the Record of Time section must be before the IPC effective date documented on Item 14, Form 3621, CLASS IPC, Page 1.

Case Management Services — Partial Assessment —The individual records the time spent daily until the date the applicant, individual and/or legally authorized representative (LAR) informs the case manager they do not want CLASS services and/or the applicant is determined ineligible to receive CLASS services.

Direct Services Agency — Full Assessment — The DSA records daily the time spent completing the pre-enrollment assessment process. The last calendar date recorded in the Record of Time section must be the same date as Item 89, Date Signed by Reviewer, of Form 3650, Level-of-Care, and before the IPC effective date documented on Item 14, Form 3621, CLASS IPC, Page 1.

Service Category Case Management Services Ongoing — 12 — The case manager records the time and units spent daily providing billable units of service only.

Service Category(ies) OT — 7; PT — 8; Speech — 9; Nursing — 13; Psychological Services — 14; and Specialized Therapies — 42 — The individual providing services records the time and units spent daily with the individual. For Specialized Therapies — 42 — The individual providing services records the time spent daily with the individual and the invoice amount of the service.

Service Category Habilitation — 10 — The individual providing habilitation services records the time and units spent daily with the individual.

Service Category Habilitation-Delegated Nursing — 10A — The individual providing delegated nursing tasks records the time and units spent daily with the individual.

Service Category Supported Employment/Pre-Vocational Services — 10B — The individual providing the supported employment/pre-vocational services will enter the actual amount billed. All supported employment/pre-vocational services provided in a month are added together.

Service Category In-Home Respite — 11 —The individual providing in-home respite records the actual time/hours spent daily with the individual.

Service Category Out-of-Home Respite — 11A — Record the invoice amount (actual cost) or the daily rate for each day services are provided by the licensed, certified and/or contracted facility (for example, camps).

Service Category Adaptive Aids — 15 — Record the invoice amount of each adaptive aid on the date the item was delivered to the individual.

Service Category Minor Home Modifications (MHM) — 16 — Record the total amount of the MHM on the date the inspector signs Section II, Minor Home Modification, on Form 3848, CBA Documentation of Completion of Purchase.

Service Categories Adaptive Aids Requisition Fees — 41; Minor Home Modifications Requisition Fees — 41B; Written Specifications for Adaptive Aids — 41C; Written Specifications and/or Inspections for Minor Home Modifications — 41D — Record the requisition fees, written specifications and/or inspection fees for adaptive aids/minor home modifications on the day delivered to the individual during the service month according to the CLASS Service and Billing Code Information.

Total Units/Amount

Service Category Pre-Enrollment Assessment Fees — 40A — Add the total time for cost reporting purposes only. Enter one unit for each individual.

Service Categories OT — 7; PT — 8; Speech — 9; Nursing — 13; and Psychological Services — 14 — Enter the total units of the service provided. Services billed in hours and minutes must be converted to the decimal equivalent in hours.

Examples: 1 hour and 30 minutes, 1:30 = 1.5 units; 1:45 = 1.75.

Service Categories Supported Employment/Pre-Vocational Services — 10B; Adaptive Aids — 15; Minor Home Modifications — 16; and Specialized Therapies — 42 —  Enter the total dollar amount of service(s) provided during the service month.

Service Categories Habilitation — 10; Habilitation Delegated — 10A — Enter the sum of all units recorded in the Record of Time section. The monthly total should be rounded to the nearest quarter unit. Services billed in hours and minutes must be converted to decimal equivalent in hours. See Examples above.

Service Category Respite In-Home — 11 — Enter the sum of all in-home respite units recorded in the Record of Time section. In-home respite may be billed in 1/4 unit increments (15 minute increments). If the total is not a whole number, round up to the nearest 1/4 unit increment and convert the partial unit to its decimal equivalent for billing purposes.

Service Category Out-of-Home Respite — 11A — Enter the sum of all out-of-home respite daily rates (for 24-hour periods) or the invoice amount recorded in the Record of Time section for the service month. To calculate the number of unit(s) for the invoice amount, divide the total actual cost by the current daily rate.

Service Category Case Management — 12 — Enter one unit if billable services were provided during the service month.

Service Category Adaptive Aids Requisition Fees — 41; Minor Home Modifications Requisition Fees — 41B; Written Specifications for Adaptive Aids — 41C; Written Specifications and/or Inspections for Minor Home Modifications — 41D — Enter the Requisition Fee(s), Inspection Fees and/or Written Specifications amount for the item(s)/service(s) on the date the item was delivered to the individual.

Service Category Specialized Therapy Requisition Fees — 41F — Enter the Requisition Fee for services on the dates the services were provided. The form may be completed on a monthly basis.

Section G — Certification

Signature —Applicant/Individual/LAR and Date (mm/dd/yy) —The applicant’s/individual’s/LAR’s signature/date is OPTIONAL. The applicant/individual/LAR may sign and date Form 3625 to indicate that the services were provided and are accurate.

Signature — Person Delivering Service/Date (mm/dd/yy) — The individual who provides the service must sign and date Form 3625 certifying that services recorded were provided to the individual. For nursing services, the nurse must include credentials.

If the individual who delivered the service is not available for signature, document the reason(s) in the Comments section. The timekeeper must sign and date the form after verifying the accuracy of the information on Form 3625. If the person delivering the service is the timekeeper, then another designated timekeeper must sign/date Form 3625.

Signature — Timekeeper/Date (mm/dd/yy) — The designated timekeeper must sign and date Form 3625 to approve the accuracy of the information on Form 3625.

Note: Form 3625 must not be pre-signed or pre-dated.