OMIG AUDIT PROTOCOL – OFFICE OF MENTAL HEALTH

COMMUNITY REHABILITATION SERVICES FOR ADULTS

Revised 5/20/16

Audit protocols assist the Medicaid provider community in developing programs to evaluate compliance with

Medicaid requirements under federal and state statutory and regulatory law. Audit protocols are intended

solely as guidance in this effort. This guidance does not constitute rulemaking by the New York State Office

of the Medicaid Inspector General (OMIG) and may not be relied on to create a substantive or procedural

right or benefit enforceable, at law or in equity, by any person. Furthermore, nothing in the audit protocols

alters any statutory or regulatory requirement and the absence of any statutory or regulatory requirement from

a protocol does not preclude OMIG from enforcing the requirement. In the event of a conflict between

statements in the protocols and either statutory or regulatory requirements, the requirements of the statutes

and regulations govern.

A Medicaid provider’s legal obligations are determined by the applicable federal and state statutory and

regulatory law. Audit protocols do not encompass all the current requirements for payment of Medicaid

claims for a particular category of service or provider type and, therefore, are not a substitute for a review of

the statutory and regulatory law. OMIG cannot provide individual advice or counseling, whether medical,

legal, or otherwise. If you are seeking specific advice or counseling, you should contact an attorney, a

licensed practitioner or professional, a social services agency representative, or an organization in your local

community.

Audit protocols are applied to a specific provider type or category of service in the course of an audit and

involve OMIG’s application of articulated Medicaid agency policy and the exercise of agency discretion. Audit

protocols are used as a guide in the course of an audit to evaluate a provider’s compliance with Medicaid

requirements and to determine the propriety of Medicaid expended funds. In this effort, OMIG will review and

consider any relevant contemporaneous documentation maintained and available in the provider’s records to

substantiate a claim.

OMIG, consistent with state and federal law, can pursue civil and administrative enforcement actions against

any individual or entity that engages in fraud, abuse, or illegal or improper acts or unacceptable practices

perpetrated within the medical assistance program. Furthermore, audit protocols do not limit or diminish

OMIG’s authority to recover improperly expended Medicaid funds and OMIG may amend audit protocols as

necessary to address identified issues of non-compliance. Additional reasons for amending protocols

include, but are not limited to, responding to a hearing decision, litigation decision, or statutory or regulatory

change.

OMIG AUDIT PROTOCOL – OFFICE OF MENTAL HEALTH

COMMUNITY REHABILITATION SERVICES FOR ADULTS

Revised 5/20/16

This document is intended solely for guidance. No statutory or regulatory requirement(s) are in any way altered by any statement(s)

contained herein. This guidance does not constitute rulemaking by the OMIG and may not be relied on to create a substantive or

procedural right or benefit enforceable, at law or in equity, by any person.

Missing Documentation of Rehabilitation Service

OMIG Audit

Criteria

If the record does not document the rehabilitation services billed, the claim will be

disallowed.

Regulatory

References

18 NYCRR Section 504.3(a)

14 NYCRR Section 595.14(a)

14 NYCRR Section 595.14(b)(8)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

Missing Progress Note

OMIG Audit

Criteria

If a progress note or notes were not documented during the sampled month, the claim will

be disallowed.

Regulatory

References

14 NYCRR Section 593.6(e)

14 NYCRR Section 595.11(c)

14 NYCRR Section 595.14(b)(7)

Failure to Document Four Different Rehabilitation Services For a Full Month Claim

OMIG Audit

Criteria

A full month claim must include at least 4 different community rehabilitation services.

(1) Assertiveness/Self advocacy Training

(2) Community Integration

(3) Daily Living Skills

(4) Health Services

(5) Medication Management & Training

(6) Parenting Training

(7) Rehabilitation Counseling

(8) Skill Development

(9) Socialization

(10) Substance Abuse Services

(11) Symptom Management

If two or three different community rehabilitation services were provided, the full month claim

will be reduced to a half month claim and the difference will be disallowed. If less than two

different community rehabilitation services were provided, the entire claim will be disallowed.

Regulatory

References

14 NYCRR Section 593.4(b)

14 NYCRR Section 593.7(b)(1)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

Failure to Document Two Different Rehabilitation Services for a Half Month Claim

OMIG Audit

Criteria

If less than two different community rehabilitation services were provided, the entire claim

will be disallowed.

Regulatory

References

14 NYCRR Section 593.4(b)

14 NYCRR Section 593.7(b)(2)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

OMIG AUDIT PROTOCOL – OFFICE OF MENTAL HEALTH

COMMUNITY REHABILITATION SERVICES FOR ADULTS

Revised 5/20/16

This document is intended solely for guidance. No statutory or regulatory requirement(s) are in any way altered by any statement(s)

contained herein. This guidance does not constitute rulemaking by the OMIG and may not be relied on to create a substantive or

procedural right or benefit enforceable, at law or in equity, by any person.

Recipient Not in Residence 21 Days in Month

OMIG Audit

Criteria

If the client was in residence less than 21 days but 11 days or more, the full month claim will

be reduced to a half month claim and the difference will be disallowed. If the client was in

residence less than 11 days in the month, the entire full month claim will be disallowed.

Regulatory

References

14 NYCRR Section 593.7(b)(1)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

Recipient Not in Residence 11 Days in Month

OMIG Audit

Criteria

If the client was in residence less than 11 days in the month, the entire half month claim will

be disallowed.

Regulatory

References

14 NYCRR Section 593.7(b)(2)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

Failure to Perform Rehabilitation Services on Different Days

OMIG Audit

Criteria

If more than one rehabilitation service was performed on any day of the month, only one

billable contact is counted for that day. If 2 or 3 billable contacts are counted and a full

month claim was billed, the claim will be reduced to a half month claim and the difference

will be disallowed. If fewer than 2 billable contacts are counted, then the entire claim will be

disallowed.

Regulatory

References

14 NYCRR Section 593.7(b)(3)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

Failure to Meet Minimum Duration Requirements

OMIG Audit

Criteria

A rehabilitation service lasting less than 15 minutes in duration will not be counted as a

billable contact. If 2 or 3 billable contacts are counted and a full month claim was billed, the

claim will be reduced to a half month claim and the difference will be disallowed. If fewer

than 2 billable contacts are counted, then the entire claim will be disallowed.

Regulatory

References

14 NYCRR Section 595.14(b)(8)

14 NYCRR Section 593.7(b)(3)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

OMIG AUDIT PROTOCOL – OFFICE OF MENTAL HEALTH

COMMUNITY REHABILITATION SERVICES FOR ADULTS

Revised 5/20/16

This document is intended solely for guidance. No statutory or regulatory requirement(s) are in any way altered by any statement(s)

contained herein. This guidance does not constitute rulemaking by the OMIG and may not be relied on to create a substantive or

procedural right or benefit enforceable, at law or in equity, by any person.

Rehabilitation Service Provided Not Included in Service Plan

OMIG Audit

Criteria

If the community rehabilitation service provided is not specified on the resident’s service

plan, then that service is not counted as a billable contact. If 2 or 3 billable contacts are

counted and a full month claim was billed, the claim will be reduced to a half month claim

and the difference will be disallowed. If fewer than 2 billable contacts are counted, then the

entire claim will be disallowed.

Regulatory

References

14 NYCRR Section 595.11(b)(5)

14 NYCRR Section 593.7(b)(4)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section I

10.

Duration of Rehabilitation Service Not Documented

OMIG Audit

Criteria

If the duration of service is not documented, the service will not be counted as a billable

contact. If 2 or 3 billable contacts are counted and a full month claim was billed, the claim

will be reduced to a half month claim and the difference will be disallowed. If fewer than 2

billable contacts are counted, then the entire claim will be disallowed.

Regulatory

References

14 NYCRR Section 595.14(b)(8)

14 NYCRR Section 593.7(b)(3)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

11.

Failure to Document Date Rehabilitation Service Performed

OMIG Audit

Criteria

If the record does not indicate the date that the service was performed, the service will not

be counted as a billable contact. If 2 or 3 billable contacts are counted and a full month

claim was billed, the claim will be reduced to a half month claim and the difference will be

disallowed. If fewer than 2 billable contacts are counted, then the entire claim will be

disallowed.

Regulatory

References

14 NYCRR Section 595.14(b)(8)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section I

12.

Billing for Non-Reimbursable Contact

OMIG Audit

Criteria

A rehabilitation service performed while the client was at an outpatient clinic, an inpatient at

a hospital, residing at another residential facility or not performed face-to-face, will not be

counted as a billable contact. If 2 or 3 billable contacts are counted and a full month claim

was billed, the claim will be reduced to a half month claim and the difference will be

disallowed. If fewer than 2 billable contacts are counted, then the entire claim will be

disallowed.

Regulatory

References

14 NYCRR Section 593.7(b)

14 NYCRR Section 593.7(b)(5)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section III

OMIG AUDIT PROTOCOL – OFFICE OF MENTAL HEALTH

COMMUNITY REHABILITATION SERVICES FOR ADULTS

Revised 5/20/16

This document is intended solely for guidance. No statutory or regulatory requirement(s) are in any way altered by any statement(s)

contained herein. This guidance does not constitute rulemaking by the OMIG and may not be relied on to create a substantive or

procedural right or benefit enforceable, at law or in equity, by any person.

13.

Failure to Document Staff Person Providing Rehabilitation Service

OMIG Audit

Criteria

If the staff person's name who provided the community rehabilitation service was not

documented, the service will not be counted as a billable contact. If 2 or 3 billable contacts

are counted and a full month claim was billed, the claim will be reduced to a half month

claim and the difference will be disallowed. If fewer than 2 billable contacts are counted,

then the entire claim will be disallowed.

Regulatory

References

14 NYCRR Section 595.14(b)(8)

14.

Missing Initial Physician Authorization

OMIG Audit

Criteria

If the record does not have the initial physician authorization or the initial authorization is

signed by an unauthorized person (e.g., nurse practitioner, social worker or therapist) the

claim will be disallowed.

Regulatory

References

14 NYCRR Section 593.6(a)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section I

15.

Missing Renewal/Reauthorization of Authorization

OMIG Audit

Criteria

If the reauthorization is missing from the record or the reauthorization is signed by an

unauthorized person (social worker or therapist) the claim will be disallowed.

Regulatory

References

14 NYCRR Section 593.6(b)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section I

16.

Authorization Lacks Required Authorization Period

OMIG Audit

Criteria

If the authorization for the recipient to receive services is not dated and/or lacks an

authorization period, the claim will be disallowed.

Regulatory

References

14 NYCRR Section 593.6(a)(2)

17.

Missing Service Plan/Service Plan Review

OMIG Audit

Criteria

If the record does not have a service plan developed within four weeks of admission to the

program or a service plan review effective for the sample month, the claim will be

disallowed.

Regulatory

References

14 NYCRR Section 593.6(c) and (f)

14 NYCRR Section 595.1(b)

14 NYCRR Section 595.11(a) and (d)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section I

OMIG AUDIT PROTOCOL – OFFICE OF MENTAL HEALTH

COMMUNITY REHABILITATION SERVICES FOR ADULTS

Revised 5/20/16

This document is intended solely for guidance. No statutory or regulatory requirement(s) are in any way altered by any statement(s)

contained herein. This guidance does not constitute rulemaking by the OMIG and may not be relied on to create a substantive or

procedural right or benefit enforceable, at law or in equity, by any person.

18.

Service Plan/Service Plan Review Not Reviewed and Signed by Qualified Mental

Health Staff Person (QMHSP)

OMIG Audit

Criteria

If the service plan/review effective for the sample month is not signed by a Qualified Mental

Health Staff Person, the claim will be disallowed.

Regulatory

References

14 NYCRR Section 593.6(d) and (f)(3)

14 NYCRR Section 595.4(a)(10)

14 NYCRR Section 595.11(b)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section I

19.

Missing Admission Note

OMIG Audit

Criteria

If an admission note was not documented at the time of admission, the claim will be

disallowed.

Regulatory

References

14 NYCRR Section 593.6(c)

14 NYCRR Section 595.11(a)

20.

Admission Note Not Completed by a Qualified Mental Health Staff Person

(QMHSP)

OMIG Audit

Criteria

If the admission note is not signed by a Qualified Mental Health Staff Person, the claim will

be disallowed.

Regulatory

References

14 NYCRR Section 595.4(a)(10)

14 NYCRR Section 595.11(a)

14 NYCRR Section 593.6(c)

21.

Billing Medicaid for Unlicensed Residence

OMIG Audit

Criteria

If the residence does not have an operating certificate or the certificate is invalid, the claim

will be disallowed.

Regulatory

References

14 NYCRR Section 593.5(a)

14 NYCRR Section 595.5(a) and (e)

Office of Mental Health Rehabilitation in Community Residences, Policy Guidelines,

Version 2006-1, Section I

OMIG AUDIT PROTOCOL – OFFICE OF MENTAL HEALTH

COMMUNITY REHABILITATION SERVICES FOR ADULTS

Revised 5/20/16

This document is intended solely for guidance. No statutory or regulatory requirement(s) are in any way altered by any statement(s)

contained herein. This guidance does not constitute rulemaking by the OMIG and may not be relied on to create a substantive or

procedural right or benefit enforceable, at law or in equity, by any person.

22.

Recipient Excess Income (Spend Down) Not Applied Prior to Billing Medicaid

OMIG Audit

Criteria

The spend-down amount should be applied beginning with the first service rendered in the

month and each service thereafter until the spend-down is exhausted. Each sampled claim

subject to spend-down application that was billed to Medicaid before the spend-down was

met will be disallowed.

NOTE: This finding only applies where the relevant county has assigned responsibility for

the spend-down to the provider and the sample claim must be impacted by the spend-down

Regulatory

References

18 NYCRR Section 504.3(a)

18 NYCRR Section 518.1(c)

18 NYCRR Section 360-4.8(c)(1)

18 NYCRR Section 360-4.8(c)(2)(ii)