Nursing Facility Frequently Asked Questions

Please use the appropriate PROMISe™ Billing Guides and Desk References to assist with submitting your Medical Assistance invoices.

GENERAL
 
1. Who should I contact with Billing Related Questions?
 
Response: Contact the Provider Call Center at 1-800-932-0939.
 
2. Who should our software company contact to address software related issues?
 
Response: Contact the Provider Assistance Center at 1-800-248-2152 or local at 717-975-4100
 
UB-04 Medical Invoice
 
3. In Form Locator (FL) 39 through 41 lines a-d, do we enter the PA162 amount or the PA162 amount minus medical expenses?
 
Response: The amount entered in FL 39-41 lines a-d for the Gross Patient Pay would be the amount from the PA 162.
 
4. When completing FL 54, do we enter the amount of money we expect to receive from Medicare or our per diem?
 
Response: Enter the amount reimbursed from Medicare paid for the Co-insurance Days in the billing period which can be taken off of the EOMB. Also if recipient has a Third Party that was utilized you will combine the amounts from TPL and Medicare and list on line a in that field.
 
5. If a Long Term Care insurance policy paid, does this go into FL 50?
 
Response: Yes, if a Long Term Care insurance policy is paying for services during the billing month, enter the information into FL 50, 54 line b, and the applicable FL 58 through 62.
 
6. Can FL 42 be spaced between information?
 
Response: Revenue Code lines on the UB-04 should be completed sequentially. DO NOT LEAVE BLANK LINES BETWEEN REVENUE CODES. Leaving blank lines between Revenue Codes will result in denial of the claim.
 
7. FL 15: What Admission Source Codes should we use for residents converting from private pay to Medical Assistance? (Note: They were not admitted in current month but they were just approved for Medical Assistance.)
 
Response: Use the Admission Source Codes as it relates to their actual admission to the nursing facility. Refer to the UB-04 Desk Reference for Long Term Care Facilities (pdf download) for the appropriate Admission Source Codes.
 
8. Do the full Medicare days need to be on the very first line or can it be anywhere in FL 30?
 
Response: The full Medicare Days should be entered on line 1 in this FL.
 
9. When putting a commercial insurance name in FL 50, how should it be entered?
 
Response: The specific name of the plan or insurance must be spelled out, ex; 1 Senior Blue. Refer to the Medical Assistance Billing Guide for complete instructions.
 
BILLING
 
10. Are there Types of Bills for claim adjustments?
 
Response: Refer to the appropriate billing guide for type of bill information: for the UB-04 see FL 4; for 837 Institutional –Long Term Care, refer to loop 2300, segment CLM (Claim Information). When submitting claim adjustments, for the third character use a 7 for Type of Bill (TOB).
 
11. Does the admission date change if the resident goes to the hospital and returns to the facility? Do we use a new admission date (day returned from the hospital)?
 
Response: No, the only time the admission date would change is if the resident was discharged from the facility with no intention of returning but at a future date was admitted to the facility again.
 
12. What are the appropriate Type of Bill (TOB) codes to be used for LTC claims?
 
Response: Nursing facilities will use the following TOB codes:
  • 260 - Non-payment/Zero Claim
  • 261 - Admit Through Discharge Claim
  • 262 - Interim – First Claim
  • 263 - Interim – Continuing Claim
  • 264 - Interim – Last Claim
  • 267 - Replacement of a Prior Claim
  • 268 - Void/Cancel of a Prior Claim
ICFs/MR, ICFs/ORC and State ICFs/MR will use the following TOB codes:
  • 650 - Non-payment/Zero Claim
  • 651 - Admit Through Discharge Claim
  • 652 - Interim – First Claim
  • 653 - Interim – Continuing Claim
  • 654 - Interim – Last Claim
  • 657 - Replacement of a Prior Claim
  • 658 - Void/Cancel of a Prior Claim
13. If the resident has Medicare Part A commercial insurance that does not cover the service period and is not otherwise involved with payment calculations for Medical Assistance purposes, does it have to be listed as a resource and payer?
 
Response: All third party resources that might apply should be entered even if they do not apply during the service month. If a resident has four or more resources, enter the resources most relevant to long term care services.
 
14. Would you ever have two condition codes on a claim?
 
Response: Having two conditions codes would be possible if the recipient had two or more resources on file.
 
The possible codes to list in condition code 18 & 19 would be X4, X2 and Y6. Please review the UB-04 billing guide.
 
15. Can you adjust a claim that is suspended or denied?
 
Response: You must wait until the claim is processed. Claims cannot be adjusted until they have been processed and paid.
 
16. When submitting a claim adjustment, which ICN should we use as the adjustment ICN?
 
Response: You must always use the last paid ICN when adjusting a claim. However, if the last claim was a Void, you will have to submit a new claim.
 
17. Do we have to show the entire month in dates of service when some of the days are full Medicare and or non-covered days?
 
Response: Yes. The dates of service should include the full Medicare and non-covered days. The billing period for long term care providers equals one month or the last date of the month in which the service was provided and for which the facility is billing.
 
18. Can we split bill?
 
Response: In accordance with regulation §1101.68(b)(3), the billing period for long term care providers equals 1 month or the last date of the month in which the service was provided and for which the facility is billing. Split billing will constitute a regulatory violation. Unless directed by the department, a provider should not split bill.
 
MEDICARE
 
19. Where does the Medicare Co-insurance amount due from Medical Assistance go on the UB-04? This happens when a Medicare patient is utilizing Co-insurance Days and they do not have Blue Cross.
 
Response: There is no Revenue code for co-days but form locators 42,43,44,46 & 77 are must fields. Please follow the instructions below. (Also refer to the UB-04 billing guide.)
 
 
Form Locators 39a - 41d - When submitting a claim for a service period where all of the days are Medicare Coinsurance Days, using the appropriate value code in Form Locator 39a through 41d list all days within the service month that are Medicare Coinsurance days. Value codes should be entered in numerical sequence starting in Form Locators 39a through 41a, 39b through 41b, 39c through 41c and lastly 39d through 41d.
Form Locators 18 - 28 (Condition Codes) - Enter X2.
Form Locator 42 (Rev Cd) –
Enter Revenue Code 0100.
Form Locator 43 (Description) – Enter Facility Days.
Form Locator 44 (HCPCS/Rate) – Enter the MA rate.
Form Locator 46 (Serv Units) – Enter a zero (0).
Form Locator 47 (Total Charges) – Enter the MA rate times the number of coinsurance days as the Total Charges. Also carry this figure down to Line 23 of Form Locator 47 in the Total field.
All other Form Locators on the UB-04 must be completed as per the billing guide
 
20. If a resident has days paid 100 percent by Medicare, do you have to enter an amount in FL 54? Medicare only looks for Co-insurance from day number 21 to day number 100?
 
Response: Days paid in full by Medicare are entered in FL 30 line 1. The amount in FL 54 of the UB-04 does not include amounts paid for days 1-100 (Full Medicare Days).
 
21. Do you include all Co-insurance Days whether covered by Medical Assistance or not?
 
Response: Yes, all Co-insurance days must be reported appropriately on the invoice with the corresponding payment.
 
22. Do we still have to show Part B Premiums as a deduction from the Patient Pay?
 
Response: Yes. You would enter Value Code 35 and the amount of the premium.
 
23. How do you know the Medicare paid date when filing electronic Medical Assistance claims? I bill Medicare the same day I bill Medical Assistance and I have no idea when Medicare will pay the claim. How does this affect my Medical Assistance claim and processing and payment receipt?
 
Response: DHS is requesting the date of notification from Medicare on the status of your claim. MA is the payer of last resort. Providers shall not bill the program for services rendered until all other resources are exhausted. Refer to General Regulations §1101.64.