Provider Notice issued 03/17/15

Reporting Requirements for Long Term Care (LTC) Facilities

The purpose of this Notice is to remind providers of Long Term Care (LTC) that an individual’s enrollment status in a Managed Care Organization (MCO) does not affect the providers’ responsibility to electronically report admissions and changes in the status of Medicaid-eligible LTC residents to the Department using the Electronic Data Interchange (EDI) system, Medical Data Interchange (MEDI) or Recipient Eligibility Verification (REV). Failure to comply may result in the delay or denial of payment or suspension or termination of the facility’s Medicaid certification.

Current reporting requirements for admissions are listed below:

• All admissions must be reported within 15 business days through one of the Electronic Data Interchange (EDI) system vendors as outlined in 89 Ill Adm Code 140.513. An Informational Notice  to our Long Term Care providers posted to the Healthcare and Family Services (HFS) website December 12, 2014, which provides guidance regarding the submission of admission information to the Department of Human Services (DHS).

• Admission submissions should only be completed for residents that are applying for Medicaid or are currently receiving Medicaid. Admission submittals shall be rejected if there is no corresponding application for Medicaid or when Medicaid eligibility cannot be verified. Admissions shall also be rejected when an application for Medicaid has been denied; when the individual is enrolled in the Qualified Medicare Beneficiary (QMB) only Program; or when there is a duplicate submission. The facility must submit another admission electronically if an application for Medicaid is submitted at a later time.

• The provider can verify processed admission information by using the LTC inquiry option in MEDI or REV.

Current reporting requirements for changes are listed below:

• Changes in the resident’s status including, but not limited to, death, discharge, bed reserve/temporary absence, change in patient credit, third party liability (TPL) and Medicare coverage must be reported within five business days through the MEDI or REV systems after the admission has been processed into the payment system by the caseworker as outlined in 89 Ill Adm Code 140.513.

• Changes to Medicare coverage or bed reserves/temporary absences must be reported to and accepted by the Department before the 13th of the month following the service month in order to be reflected on the pre-payment report. Changes which require further review by the Department, may not appear on the pre-payment report.

• All changes that result in an adjustment to payment including, but not limited to, bed reserve, level of care, and resubmitted claims must be submitted no later than 180 days as outlined in 89 Ill Adm Code 140.20.

Claims (request for payment) that are not submitted and received in compliance with the requirements will not be eligible for payment under the Department’s Medical Assistance Program and the State shall have no liability for payment of the claim.

Any disputes regarding payment for services provided from the date of admission must be submitted to the Department on the Payment Review Request form HFS 3725 (pdf) as outlined in 89 Ill Adm Code 140.20.

All transactions completed through the MEDI or REV systems are assigned a confirmation number also known as the Transaction Audit Number (TAN). This number shall be retained by a facility to verify timely submittal of transactions and for future reference, including audit purposes.

For assistance with the MEDI registration process or making electronic remittance advices available, please submit an inquiry electronically using the “Contact Us” link on the MEDI Web site or by calling the MEDI help desk at 1-800-366-8768.

Questions regarding this notice may be directed to the Bureau of Long Term Care at 217-782-0545.

James M. Parker, Acting Administrator

Division of Medical Programs