FY 2020-2021 SBHS CERTIFICATION APPLICATION MATERIALS(For both initial and re-certification)The Medicaid School-Based Health Services (SBHS) program is beginning its twentieth year of assisting districts and KSD and KSB in seeking reimbursement for medically necessary services including services covered health services listed in the individual education programs (IEP) of children who are eligible under both the Individuals with Disabilities Education Act (IDEA) and Medicaid. The same application may be used if you are applying to initially enroll or continuing to participate in the Medicaid SBHS program. If your district previously participated in the program and your district's certification has lapsed, you may re-enter the program by completing this application for re-certification for 2020-2021.If your district wishes to participate, please complete the attached application in the GMAP Application.Applications submitted via email or mail will not be accepted.Please complete and return only one application. MEDICAID SCHOOL-BASED HEALTH SERVICES APPLICATIONINSTRUCTIONS FOR CERTIFICATION AND RECERTIFICATIONThe “Application for Medicaid Certification – 2020-2021” is the first step to enrolling in the Medicaid School-Based Health Services program. Please follow these instructions for completing the application forms labeled KDEMED1, KDEMED2A and KDEMED2B to reduce processing delays. Please Note…..these forms are in an Excel Workbook, each form is a separate worksheet within this workbook.KDEMED1 – Application for Medicaid Certification – 2020-2021SCHOOL DISTRICT INFORMATIONPlease complete the identifying information in the top left box.The Medicaid Liaison listed is the person to whom all correspondence, notices, and Medicaid related information would be sent. The liaison may be the director of Special Education or some other person assigned to facilitate the implementation of this program in the district. It is recommended listing more than one person as the Medicaid Liaison. SERVICES TO BE PROVIDEDIn the top right box, please check the services for which you anticipate submitting claims to Medicaid for reimbursement. If you plan on billing for assistive technology and/or transportation, you may make sure to check those boxes. You must have a practitioner listed and credentials for that practitioner for each service marked.Transportation and Assistive Technology Devices do not require the listing of practitioners on KDEMED2A or KDMED2B. All other services require listing practitioners.STATE PROVIDER NUMBER Enter the “21” or “71” number provided by the Department of MedicaidNATIONAL PROVIDER NUMBER (NPI)Enter the NPI numberWill your district be participating in SBHS Expansion?This is referring to the non-IEP part of the program. Only check this box, if you will definitely be participating. DOES YOUR DISTRICT CONTRACT WITH A THIRD PARTY BILLING AGENT (do you pay an outside vendor to submit the claims to Medicaid on your behalf?)Enter either Yes or No LIST THE NAME OF THE CONTRACTOREnter the name of the contractor/billing agent (the company that does your billing)SUPERINTENDENT SIGNATURESuperintendent verification that the assurances will be fulfilled is denoted by the superintendent’s dated signature. KDEMED2A – School-Based Health Services 2020-2021 Practitioner ListList each practitioner’s name, title and current license or certification number for whose services you anticipate seeking Medicaid reimbursement. . Legible copies of current licenses or certificates must be attached. Please check expiration dates.Please refer to the “Qualified Medicaid Practitioners” (QMP1) to determine the licensure or certification requirements, practitioner title and practitioner modifier. Please do not send information regarding your bus drivers.The employee identifier is the three digit code that is unique to that practitioner.KDEMED2B – Medicaid Health Aide List – 2020-2021Complete this section only if you anticipate seeking reimbursement for health related services that may be delegated by a licensed nurse to an appropriately trained and supervised person.Practitioners listed on this page may include paraprofessionals, instructional assistants, teachers, or other district staff.The supervising nurse must complete and sign the certification statement.The supervising nurse must be listed on KDEMED2A and a copy of the current Kentucky Board of Nursing license attached.The employee identifier is the three digit code that is unique to that practitioner.KDEMED3 –Quality Assurance OutlinePlease review the “Quality Assurance Outline” The Medicaid liaison must establish local procedures within one year of initial Medicaid certification.Technical assistance from the Department of Education is available on request.NOTE: If this is your second year of Medicaid certification…you must submit the District’s Quality Assurance Procedure document.Mailing InstructionsAll applications must be submitted via GMAP by September 7, 2020.Late applications will not have an August 1st effective date and will result in the school district not being able to bill for the entire school year. For questions, please contact Stephanie O’Connor at (502) 564-1979 or stephanie.oconnor@education.ky.gov This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. Document ID GeneratorSynchronous100011000Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429cMicrosoft.Office.DocumentManagement.Internal.DocIdHandlerDocument ID GeneratorSynchronous100021001Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429cMicrosoft.Office.DocumentManagement.Internal.DocIdHandlerDocument ID GeneratorSynchronous100041002Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429cMicrosoft.Office.DocumentManagement.Internal.DocIdHandlerDocument ID GeneratorSynchronous100061003Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429cMicrosoft.Office.DocumentManagement.Internal.DocIdHandlerDocumentLibraryFormDocumentLibraryFormDocumentLibraryForm2003-2004 MEDICAID SBHS CERTIFICATION APPLICATION MATERIALSrbaileyO'Connor, Stephanie - Division of Budget and Financial Management42007-04-28T17:31:00Z2019-04-24T18:04:00Z2020-05-28T18:13:00Z16018064596Microsoft Office Word03810falseTitle12003-2004 MEDICAID SBHS CERTIFICATION APPLICATION MATERIALSkdefalse5392false5701734005mailto:stephanie.oconnor@education.ky.govfalse16.0000KYED-257-102b06bcf77-6d0c-414b-a8ca-1b0cd5b77141https://education.ky.gov/specialed/_layouts/15/DocIdRedir.aspx?ID=KYED-257-102, KYED-257-102