Provider Notice issued 04/19/16

New Monthly Billing Process for Long Term Care Services - Effective July 1, 2016

To: Long Term Care Facilities - Nursing Facilities (NF), Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Supportive Living Program (SLP), and Specialized Mental Health Rehabilitation Facilities (SMHRF)
Date: April 19, 2016

Re: New Monthly Billing Process for Long Term Care Services - Effective July 1, 2016

This Informational Notice provides detailed information to Long Term Care (LTC) Providers regarding monthly fee-for-service billing processing that will be implemented July 1, 2016.  The information contained in this notice will be the basis for an upcoming webinar presented by the Department. As this notice contains detailed billing instructions, it may be helpful for providers to utilize a copy of the UB-04 Data Specifications Manual for reference. The UB-04 Data Specifications Manual identifies and defines institutional claim elements. To become a UB-04 Subscriber, refer to the National Uniform Billing Committee (NUBC) website.

Provider Enrollment

The new Long Term Care (LTC) billing process requires 837I claims to be submitted with a National Provider Identifier (NPI) registered on the National Plan and Provider Enumeration System (NPPES).  The NPI used to submit claims must also be the NPI used when enrolling as an Illinois Medicaid provider in the IMPACT system.

The Department of Healthcare and Family Services (HFS) requires that a unique NPI is used to enroll each twelve (12) digit provider identification number (PIN) assigned to each enrolled Medicaid provider.  For example, if a nursing facility is also enrolled as a durable medical equipment (DME) provider, HFS assigns a PIN to the nursing facility and a different PIN to the DME provider.  Therefore, the provider must use two different NPI numbers when enrolling in IMPACT.  One NPI should be registered for the enrolled nursing facility PIN and a different NPI for the DME PIN.

If the NPI used to submit an LTC claim is not a registered NPI in the NPPES system, or cannot be cross walked to a unique HFS PIN, the claim will be rejected. 

Medical Electronic Data Interchange (MEDI)

Providers or their billing agents must submit claims electronically.  No paper claims will be accepted.  Providers will be able to submit claims for consideration through the HFS Internet Electronic Claim (IEC) system that is accessible through the Medical Electronic Data Interchange (MEDI) system.  To gain access to the IEC links, providers must complete the payee information during registration.  For assistance in registering please contact the MEDI HelpDesk at (800) 366-8768 option 1 and then option 3 or contact the Bureau of Long Term Care at (217) 782-0557.

Through the IEC link, authorized providers/payees can currently review procedures for claim submission as an uploaded claim file or as a direct data entered claim. No LTC claims will be allowed for service periods prior to July 1, 2016. Service periods prior to July 1, 2016 will continue to have claims auto generated for services by HFS.  There is no change in the requirements for submitting changes in a recipient’s information to assure proper LTC payment of service periods through June 30, 2016. 

Regardless of the service period, LTC providers will be required to electronically submit admission, discharge, changes in income and third party liability (TPL) coverage information as outlined in the 89 Ill. Adm. Code 140.20 and 140.513.  For service periods on or after July 1, 2016, providers will no longer be required to submit temporary absences (bed reserves) or Medicare coverage through the electronic data interchange LTC links.  This information will be derived from claim information for service periods on or after
July 1, 2016. 

Pre Payment Report Changes

The Pre Payment Report process of generating LTC claims will continue for services prior to July 1, 2016 until it has been determined that all timely filing requirements for services prior to July 1, 2016 have been exhausted.  Claims submitted for service periods after June 30, 2016 will only generate remittance advices that are viewable and downloadable through the IEC links in MEDI.  Proprietary remittance advices will continue to be mailed. 

Claim Submittal

Effective with dates of service on or after July 1, 2016, providers will follow the UB04 and 837I Implementation guidelines to submit claims electronically.  Electronic claims will be submitted via an X12 file transfer or direct data entry (DDE) through the IEC links in MEDI.  No paper claims will be accepted. 

All LTC facilities will be required to submit an “’inpatient” claim, with the exception of Supportive Living Program (SLP) facilities, who will be required to submit “outpatient” claims.

The Handbook for Electronic Processing (Chapter 300 Companion Guide) contains supplemental information to the X12 (5010) or NCPDP (5.1 or 1.1 batch) Implementation Guides. This handbook contains the companion guides for all providers who will be submitting X12 or NCPDP electronic transactions to the Department.  The unique data elements required by HFS related to claim submitter, receiver, billing provider and payer information will remain the same.

Requirements for timely claims submittal will continue to be enforced.  For payment consideration, an LTC claim either as an initial or resubmitted claim following prior rejection, must be received by the Department no later than 180 days after the date of service or no later than 180 days after the date of completion of the admission transaction.  For payment consideration, the Department must receive claims after disposition by Medicare or its fiscal intermediary no later than 24 months after the date of service.

Electronic claims submitted for LTC services must be for a single month of service.  Claims that are submitted for more than one calendar month will be rejected.   Service months must also be submitted in sequence as prior claim information related to temporary absences and Medicare coverage will be reviewed for proper pricing of current claim. 

Medicare Part A

Recipients with Medicare Part A coverage must be billed to Medicare for any covered service prior to billing Medicaid.  Claims submitted to Medicare will crossover to Medicaid through a fiscal intermediary.  To assure proper pricing of Medicare crossover claims, LTC providers should submit LTC claims for a single calendar month of service to Medicare for dually eligible recipients.

Multiple Admissions Within The Same Month

Separate claims must be submitted for recipients who have more than one admission segment on LTC system for a given month.  For example, if an individual is admitted to a facility on July 1, 2016 and discharges to the community on July 5, 2016, then readmits to the facility on July 24, 2016 for an ongoing stay, two claims would be submitted for the month of July.  Please note that if a facility is “holding” a bed for a resident whose return is anticipated, a discharge transaction is not required until the facility learns that resident is not returning or has been admitted into another LTC facility.  Completed facility admission information can be reviewed through the EDI LTC links.

Third Party Liability (TPL)

Third Party Liability (TPL) payments will be allowed as a reduction from payable charges submitted on the LTC claim as “Other Payer”. Providers may refer to the “Source Code” field found in the TPL section of the MEDI eligibility verification for a recipient’s three-digit TPL code.  If the recipient has Hospital Insurance Benefits (HIB) or Qualified Medicare Beneficiary (QMB), the submitted claim must reflect Medicare as the primary payer even if the benefit has been exhausted.  If the recipient has a TPL such as Blue Cross Blue Shield or any other commercial payer and TPL is not reported on the submitted claim, the claim will be rejected.  If the claim is Medicaid only or has a TPL other than Medicare, use Value Code 80 for the covered days and Value Code 81 for non-covered days.  Covered days must equal the covered accommodation days on the claim.

Patient Credit

Patient credit amounts should be reported as a Value Code 23 – Recurring Monthly Income.  The amount of patient credit applied to a claim will be based on the amount of patient credit entered into the LTC patient credit segments by the Department of Human Services (DHS) caseworker.  Providers will continue to submit income changes and review patient credit amounts electronically through the EDI LTC links. 

Upon implementation of the new LTC billing process, the application of the monthly patient credit amount applied to the fee-for-service LTC or Hospice claims will be processed on a first come first serve basis until the entire patient credit amount has been applied for the month.  If a portion of the patient credit is used on the first claim received (either hospice or LTC) the remaining balance will be applied to the second claim. 

Hospice Services

Recipients who have elected Hospice services and are receiving the hospice services in the facility should be reported as Type of Bill Frequency 1 or 4 showing the patient is discharged with a discharge status code of 51 – Discharged to Hospice Medical Facility (Certified) providing Hospice level of Care. Providers should not submit a discharge transaction through the EDI LTC links unless the resident is discharged into a community based hospice program, then a full discharge from the facility should be sent by submitting a discharge transaction through the EDI LTC links.  Claims with a bill frequency of “1” or “4” should show a discharge status code of 50 – Hospice Home or discharge status code of 01.

If hospice election ends and recipient is still a resident of the facility the LTC facility may resume billing for services.  The first claim submitted after a hospice covered period should be billed as an interim-first Claim, Type of Bill Frequency 2.  Note that the statement from date and the admit date of the claim must match and be the first day not covered by hospice election.

Discharge Due to Death

Discharge due to death must be reported as a Discharge Status code 20 on the claim in addition to reporting through the EDI LTC links within the reporting requirements outlined in 89 Ill. Adm. Code 140.513. HFS will continue to make payment to the facility for a resident’s day of death only when the individual is considered a resident of the facility on the day of death. 

Temporary Leaves of Absence

Temporary leaves of absences or bed reserves must be reported on the submitted claim as a Revenue Code.  Leave of absence days will be identified from the claim, using ‘Leave of Absence’ Revenue Codes with Occurrence Span Code 74, ‘Non-Covered Days’. A Value Code of 81 must be used even though some bed hold days may be priced as payable. Pricing of bed hold days will be based on provider and bed hold type coverage rules.
The Occurrence Date Span of non-covered days reported with Occurrence Span Code 74, ‘Non-Covered Days’, associated with ‘Leave of Absence’ Revenue Codes must match the number of non-covered days listed with Value Code 81.  HFS will accept the following Leave of Absence Revenue Codes:

• 0182 (Patient Convenience)
• 0183 (Therapeutic Leave)
• 0185 (Hospitalization)

NOTE: The number of days listed with Value Code 81 (non-covered days) plus the number of days listed with Value Code 80 (covered days) must add up to the total number of days calculated based on the reported ‘Statement’ dates for each claim.

Medicaid Room and Board

Medicaid Room and Board services provided by an LTC provider will be reported as Revenue Codes on the claim.  In order to identify appropriate reimbursement rates, HFS will require specific Taxonomy code, Type of Bill and Value Codes.  For an example of the crosswalk of the HFS legacy Provider Type and level of care Category of Service to 837I coding requirements, please see attached chart.

Exceptional Care

Exceptional Care coverage requirements and processes will not change.  Once a recipient has been approved for coverage, the provider may submit claims for payment of exceptional care services by reporting Revenue Codes 019X.  See attached chart for exceptional care Revenue Codes accepted for each provider type.  Claims submitted with exceptional care Revenue Codes for a recipient without the prior approval being entered will not be priced at the exceptional care rate.

Approved exceptional care coverage will continue to be entered as a level of care category service code 38.  Providers can review approved coverage and other information by inquiring the level of care through the EDI LTC Links. 

Claim Adjustment

Adjustment for rate changes will continue to be completed by HFS.  Providers should continue to address adjustments to the patient credit amounts by assuring all residents income changes have been reported timely through the EDI vendor or MEDI LTC income change links.  For questions regarding the status of submitted or completed income changes contact the appropriate DHS LTC Unit.

Upon implementation of the new billing process, the system will not have the capability to electronically accept  a Type of Bill Frequency Code ”7”, Replacement of Prior Claim or a “8”, Void/Cancel of Prior Claim. Until this process is functional, providers must request the incorrect paid claim to be voided by submitting an HFS 2249 Adjustment (Hospital) form to the Bureau of Long Term Care.  Adjustments should be sent to:

The Illinois Department of Healthcare and Family Services
Bureau of Long Term Care
201 South Grand Avenue East
Springfield, IL  62763-0002

After the void transaction has been completed, providers may submit a new claim for the service period with a Type of Bill Frequency Code 1-4, as applicable.  Providers will be notified of completed void transactions via the remittance advice.  Providers are also encouraged to review “Claim Status” through the IEC links.
Rate and patient credit changes will be processed through an automatic adjustment process and only prior paid claims with incorrect coding will require a void.  Coding errors may include, but not limited to, invalid Revenue Code or Occurrence Spans.  NOTE: Timely filing requirements will continue to be enforced for claims submitted for services where payment has been previously voided.

Questions regarding this notice should be submitted to the Bureau of Long Term Care at HFS.LTC@illinois.gov with the Subject line: Monthly Billing Process.  Your questions and answers will be posted in a Frequently Asked Questions document that will be routinely updated and will be accessible on the HFS Home Page Medical Providers.  The website will also provide information regarding future trainings, webinars, and addition ongoing support.

Felicia F. Norwood
Director

Attachment

• Category of Service Crosswalk 2016 (xlsx)