How to bill DSS for adult day care in North Carolina

If your center serves participants paid for through the county Department of Social Services, the monthly DSS invoice is how you get paid. The work is not hard, but it is exact. A missing ID number or a day billed when the center was closed can hold up a whole month.

This guide walks through the usual steps. Your county contract has the final word, so keep a copy close and ask your county DSS when something here doesn't match.

Who pays for adult day care through DSS

Every adult day care and adult day health program in North Carolina must be certified by the state, regardless of how it is funded. Once you are certified, a county DSS can buy services from you.

The state's Adult Day Care and Adult Day Health Services Procedures Manual describes it this way. The county DSS signs a contract with a certified program, negotiated each year, that sets which services it will buy and a fixed rate per day of service. The county then authorizes services for each eligible person.

The money behind that contract can come from different places:

• The State Adult Day Care Fund, which the manual ties to the Social Services Block Grant.
• The Home and Community Care Block Grant (HCCBG), which serves adults 60 and older. Each county has a lead agency for HCCBG, and in some counties that is DSS.
• Medicaid's CAP/DA waiver, which includes adult day health as a service. CAP/DA follows NC Medicaid's rules, so ask the participant's CAP case manager how those days are billed.

Rates are set in your contract. We don't list them here because they change and can differ by service. Use the rate in your current signed contract.

One more rule worth knowing: the manual says programs may not charge an enrollment fee to participants whose care is paid with federal or state funds, such as the State Adult Day Care Fund or HCCBG.

What to keep on file for each participant

The county, not the center, decides who is eligible. Your job is to make sure you have the county's decision in writing before you bill, and that the details on your invoice match it.

• The service authorization. The manual names the DSS-5027 as the form used to authorize services for an eligible client, and payment starts on the date shown on it. Ask your county which form or system they use today, and keep a copy in the participant's file.
• The level of service. Adult day care or adult day health. In a combination program, each person is enrolled for one level, and that decides the service code you bill.
• The enrollment plan. Which days of the week the person is expected. Full-time means five days a week, and part-time means fewer.
• The identifiers your invoice asks for. The county invoice templates we work with list each person's name, date of birth, last four digits of their Social Security number, their SIS client number and an activity code. Copy them exactly from the county's paperwork.
• The rest of the participant file. The enrollment application, completed before the first day of attendance, and the medical examination required for admission and periodically after that.

When the county ends or changes a service, file the new paperwork right away. Days after an end date are one of the easiest mistakes to make.

Record attendance every day

In the state manual, reimbursement is a per diem rate and a unit is one day of service. Your attendance record is the proof behind every unit, so it needs to be written the same day, not rebuilt at month end.

A few rules from the manual shape how you count:

• Providers are not paid for holidays, hazardous weather days, emergencies or any day the program is not open.
• A visit before someone enrolls does not count as daily attendance.
• The number of people in attendance on any day can't go over your certified capacity, even if enrollment does. Staff-to-participant ratios are based on attendance too.
• Absences are handled by contract. The manual says a program may seek reimbursement for a participant absent up to 10 consecutive scheduled days, but not from day 11 on, and it encourages counties to ask programs to let them know after one or two days of absence. Your contract may treat absences differently. Follow yours.

If you use rides, note them on the same sheet: no ride, one way, or a round trip. Our free attendance sheet template has a column for each.

Units and service codes

Each service on the invoice has a code. These are the adult day codes named in the state manual. Your county may use only some of them.

Two things vary by county, so confirm them before your first invoice. First, whether a round trip counts as one transportation unit or two. Second, whether your template splits each service into under-60 and over-60 sheets. Some do, because HCCBG serves people 60 and older.

Building the monthly invoice

The county templates we work with have a summary page and a detail sheet for each service. Here is a steady order to work in.

1. Close out attendance for the month. Make sure every open day has a record for every enrolled participant, and closed days are marked as closed.
2. Check each person against their authorization. Look at start and end dates, the level of service, and whether days billed fit the enrollment plan and your absence rules.
3. Fill in the detail sheets. One line per participant with their identifiers, a mark for each day of service, and the total units.
4. Multiply units by the contract rate. Do it per sheet, then total the sheet.
5. Complete the summary. Clients, units and cost for each service code, and a total for the center, with your contract number and service dates.
6. Handle past months separately. If you missed a day last month or billed one by mistake, use the retro or credit sheet your county provides instead of changing this month's numbers.
7. Get sign-off and send it by the county deadline. Keep an exact copy of what you sent.

Check these before you send it

Run down this list before the invoice goes out. Each one is a simple mistake that can send it back.

• An SIS number, date of birth or name that doesn't match the county's records.
• Days billed before the authorization start date, or after services ended.
• A unit on a holiday, a weather closing or another day the center was closed.
• Units that don't match the attendance sheets for the month.
• Adult day care billed for someone enrolled in adult day health, or the other way around.
• Someone on the under-60 sheet who turned 60, or the wrong age sheet altogether.
• Absences billed past what your contract allows.
• Rides billed with no ride recorded, or a round trip counted the wrong way.
• A last-month correction mixed into this month's totals.
• Arithmetic that doesn't add up, or a missing signature or date.

Record keeping

Keep the paperwork behind each invoice together: the attendance sheets, ride records, authorizations and changes, the invoice you sent and any letters about it. When a state or county reviewer looks into a concern, the manual lists participant attendance sheets and staff time cards for those days among the records they review.

Participant records are confidential. The manual says to store them in a locked file with access limited to the staff who need them. How long to keep billing records is set by your contract and funding source, so ask your county DSS for the retention period in writing.

How Senior Care Connected does it

Senior Care Connected builds the DSS invoice from the attendance your staff already take. Here is what that looks like.

• In Company Info, you add your DSS provider details, contract number and a rate for each service. If you bill under more than one contract, each gets its own invoice.
• On each participant's chart, you turn on DSS billing and add their SIS number, service code (such as 030 adult day care or 155 adult day health), activity code and whether rides are billed.
• On the Participants screen, staff mark people present and tap meals and rides (T1 one way, T2 round trip) on each card.
• At month end, each attended day is one unit. Rides are one unit per ride day, and you can set round trips to count as two. Participants land on a sheet for their service and age group, under 60 or over 60.
• The summary shows clients, units and cost for each code. Past-month fixes go on retro or credit sheets. You download CSV or an Excel file laid out like the DSS template.
• SIS numbers and billing profiles are encrypted before they're stored.

You still check the invoice against authorizations and your contract before you send it. The app counts the days. Your judgment decides what gets billed.

See the invoice screen on the DSS billing page, or book a demoand we'll set it up with your county's codes.

Sources

• NC DAAS, Adult Day Care and Adult Day Health Services Procedures Manual
• NC DHHS, Adult Day Services / Adult Day Health Services
• NC Medicaid, Community Alternatives Program for Disabled Adults (CAP/DA)