Skip to main content
  • Medicaid Provider Alert: Provider revalidation has begun and those not completing the process risk disenrollment.  Check your account now to learn when your revalidation is due. More information here.
Elizabeth M. Whitehorn, Director

Provider Notice Issued 01/29/2021

Date:   January29, 2021                                                   

 

To:      LongTerm Care Facilities - Nursing Facilities (NF), Intermediate Care Facilitiesfor Individuals with Intellectual Disabilities (ICF/IID), Supportive LivingProgram (SLP) Providers, Medically Complex for the Developmentally DisabledFacilities (MD/DD) and Specialized Mental Health Rehabilitation Facilities(SMHRF)

 

Re:     Discontinuation of Payment Review Request Form(LTC) HFS 3725 for Dates of Service 12/01/16 and After

______________________________________________________________________________________

 This notice informs long term care(LTC) providers thatthe Payment Review Request Form (LTC) HFS 3725 should not be completed forclaims with dates of service 12/01/16 and after. This form should only be usedfor dates of service in which the Department initiates the monthly billing viathe HFS 3402 LTC Prepayment Report, which applies to dates of service prior to12/01/16.  

Tobe considered for additional payment, any disputes regarding payment of a claimfor dates of service prior to 12/01/16 rendered after the date of completion ofthe admission transaction, the Payment Review Request Form must be submitted tothe Department within 180 days after the: 

-         date of the remittance advice that initiallyshows the adjudication for the date(s) of service that are disputed;

-         date of the remittance advice that rejects apreviously adjudicated claim, if rejection is the basis for the disputedpayment; or

-         date of the remittance advice that adjusts apreviously adjudicated claim, if the adjustment is the basis for the disputedpayment. 

Questionsregarding billing for fee-for-service claims with dates of service 12/01/16 andafter should directed to the Bureau of Long Term Care at 1-844-528-8444.

  

Kelly Cunningham, Administrator

Division of Medical Programs​