Nursing Facility Provider Liaison Meeting Frequently Asked Questions (FAQ) Document

Transcription

1 Nursing Facility Provider Liaison Meeting Frequently Asked Questions (FAQ) Document The questions MDHHS received from providers in response to L-Letter 17-18: Medicaid Nursing Facility Provider Liaison Meeting were compiled into this FAQ document. Updates were made to questions 1, 2, 5, 24, 25, and 34 since the Liaison Meeting was held. Eligibility 1. When a redetermination is completed the redetermination date is not updated in CHAMPS. Is there a system issue causing this? a. The redetermination date is system generated in BRIDGES when the redetermination has been completed. The date is then sent to CHAMPS in an overnight batch. 2. For how many local MDHHS offices will cases be moved to the central Lansing office? Current Pilot counties are taking an average of 2 months longer to process applications and case workers are wanting families to bring residents to Lansing. a. Gladwin, Ingham, Eaton, Shiawassee and Clinton County. Case workers do not need to meet face to face with residents, so they should not be asking families to bring residents to Lansing. 3. Some Medicaid applications are not being registered by the local office, so providers are not seeing these cases as pending in CHAMPS and an LOCD is not completed. a. LTC applications can be turned in to any MDHHS office in the State. Once the application is accepted by that local office, it will scan the application in, and notification is made to the local county office the beneficiary is currently residing in. Local offices are required to register the date it was received. We would need examples if this is not happening to research. 4. Will the 2565 and Medicaid application become electronic? a. The MSA-2565 will become electronic beginning January It is called the Modernization of Continuum of Care (MCC). Provider Relations will be doing outreach in the coming months. 5. In some instances resident Patient Pay Amounts (PPA) are changing retroactively with no notice given, so providers are not aware until they see it on the CHAMPS member screen. Does a notice need to be given when the Patient Pay Amount is increased? a. This should never happen unless the amount of the PPA is a decrease. MDHHS is required to provide notice at least 10 days prior to a PPA increase because this is considered an adverse action. The family can request a hearing when there is a retro increase in the PPA. PPAs can be adjusted at case open when the determination of eligibility is delayed. If the PPA is increased and no notice has been sent, the case worker needs to create a ticket to get the issue fixed. 6. Why are changes being made to LTC cases that are nowhere near the redetermination date? a. There are several times in the year when there are changes to most if not all LTC cases outside of the redetermination of the case eligibility. The federal standards for income increase in April, RSDI increases in January, and community spouse standards increase in January, July, and October. 7. Can an alien resident qualify for Medicaid nursing facility services? Page 1

2 a. Yes and no, it depends on what alien registration they have. This can be identified on their most current citizenship card, which will include a code indicating which type of citizenship they fall under. The caseworker/nursing facility can look that code up and, if it is an eligible citizenship status per policy, they can qualify for Medicaid NF services. If they do not have an eligible citizenship status then they are limited to Emergency Services Only. 8. What is causing Medicaid pending applications to take more than 30 days to show up in CHAMPS with a registration date? a. This is a known system issue, and the goal is to have it corrected with a December fix. 9. Who should providers contact when a Medicaid application is not processed within 45 days? a. County offices are required to register the application with the date it was received. If it is not processed timely, we recommended you follow up the local office chain of command to the management level. 10. Will Provider Support continue to provide eligibility information older than a year? a. Yes, as long as eligibility HIPPA rules are followed. Level of Care Determination (LOCD) 11. Some providers are still having B7 LOCD issues going back to Providers cannot access this information if it is over a year old. Is there a timeline for when the B7 issues will be fixed and automated? Can providers do anything to prevent these issues? Are there plans to allow providers to view information that is older than a year? a. A lot of these issues have been resolved going forward. But, the LOCD s that have incorrect start and end dates in CHAMPS prior to these fixes, still need to go through Provider Support to have them corrected. If newer claims are still denying with B7, please see the status of the LOCD. If it states waiting for eligibility or LOC, you need to verify eligibility status and LOC status. If it is not correct or not there, Provider Support cannot fix it until that is updated. Eligibility needs to be addressed with the caseworker and LOC segments that are missing or incorrect need to have the MSA sent in to Central Scan or ed to MSA2565@michigan.gov to be updated. LOCD s are accessible over one year. 12. Is it necessary to redo the LOCD if there is a resident divestment for one day for a resident who originally had retrospective eligibility? a. Current policy reads the LOCD is not required if the beneficiary is readmitted to same facility AND the LOCD was previously conducted whereby the beneficiary met criteria AND LOC code has not changed. If the LOC code did change, another LOCD is required (NF Coverages Chapter, Section 5.1.D.1.). 13. For a resident qualifying through Door 2 of the LOCD are the BIMs or Mini Mental an appropriate tool to use? a. The scoring for any door must be supported by the beneficiary s record. For Door 2, a secondary assessment may be an important part of that support. The Mini-Mental State Exam (MMSE) is appropriate because the Page 2

3 scoring corresponds to the five levels of cognitive performance on the LOCD. The BIMs scoring does not have that 1:1 correspondence, so it may not support the LOCD scoring. 14. There are some cases where the LOC 02 drops off. Is there a specific issue causing this? What is the State doing to monitor and fix this issue? a. Under certain conditions a change in the Bridges system can cause a LOCD to fall off CHAMPS. This will be corrected with the implementation of the Modernization of Continuum of Care (MCC) on December 29, There will be more information on the MCC in the near future. 15. Some providers are having issues with getting an LOC 05 in CHAMPS for ICOs. Is there a process separate from the 2565 to get this accomplished? a. We have had some problems getting the LOC 05/15 added correctly by the MDHHS local offices due to process confusion. We have updated their manuals, so hopefully this will improve. If issues are brought to our attention by a provider or our ICOs, we will add the LOC 05 manually. If there are additional issues, please contact MSA-MHL- Enrollment@michigan.gov so MDHHS can try to get things resolved. 16. When should a provider complete an LOCD if a Medicaid application is not ready within 14 days of admission? a. Current policy requires the LOCD to be conducted online within 14 calendar days from the date the application is registered by MDHHS: Within 14 calendar days from the date a Medicaid financial application was registered with MDHHS (i.e., date-stamped by MDHHS on the date the application is received) by a current privatepay nursing facility resident requesting Medicaid as the payer for nursing facility services. If the MA financial application was not ready for submission to MDHHS, the LOCD would not be conducted until after that application was actually received by MDHHS [having been sent]. The provider has between 1 and 14 days from the date it s received to conduct the LOCD. 17. Can a provider bill a resident that refuses to sign the LOCD freedom of choice form? a. If that beneficiary met LOCD criteria, no the provider cannot bill the resident. If the beneficiary refuses to sign, make note of that refusal in the medical record. 18. Is there a time limit to get the freedom of choice form signed? a. Current policy requires the FOC to be signed on the date that LOCD was conducted. MDHHS understands often times the beneficiary has a guardian or legal representative who is not present at the time that LOCD was conducted. In such cases, make a copy of the FOC, send the copy to the guardian or representative and request their signature and return of that FOC. Make note of sending the FOC for signature. If/when received, file it in the medical record. 19. Providers are having issues with case workers not changing the LOC 02 to a new provider in a timely manner. Page 3

4 a. The Preferred method of having LOC s updated is to first fax the MSA-2565 to the Central Scan Fax number These are then time stamped and forwarded to the correct caseworker. If the LOC does not get updated within 30 days, please the 2565 as a PDF attachment to MSA2565@michigan.gov. 20. For a beneficiary disenrolled from a MHP what is considered the date of disenrollment for LOCD purposes? What field does this correspond to in CHAMPS? a. The date the disenrollment is processed, if retro disenrollment Provider Support will review to backdate. The department recommends that the provider conduct an LOCD at the same time it initiates the disenrollment process. This will avoid problems with a retroactive disenrollment date. 21. How can a facility conduct a valid LOCD when a resident is discharged prior to the completion of a Medicaid application that provides retroactive eligibility? a. Policy requires the LOCD to be conducted for current private-pay residents as follows: Within 14 calendar days from the date a Medicaid financial application was registered with MDHHS (i.e., date-stamped by MDHHS on the date the application is received) by a current private-pay nursing facility resident requesting Medicaid as the payer for nursing facility services. If a resident never applied for MA during their stay, they were not MA pending or MA eligible during their stay. Medicaid Health Plans (MHPs) 22. Why do Medicaid Health Plans not pay the Quality Assurance Supplement (QAS) for managed care residents? Are the MHPs paid the QAS by the State? a. The health plans are not responsible for providing long-term custodial care in nursing facilities. The MHPs dis-enroll Medicaid beneficiaries from the plan 45 days after entering the nursing home. Therefore, it does not make practical sense for the health plans to pay the QAS. This is obviously very different from the MI Health Link program in which ICOs are responsible for providing long-term custodial care in nursing facilities. The health plans are not paid the QAS. 23. Disenrollments from MHPs are taking 6 to 9 months and no notification is given to providers when the disenrollment is complete. Could providers receive a notice when the disenrollment is complete? Is the State taking steps to shorten this process? a. Disenrollments from MHPs that are submitted complete, accurate & timely are usually processed within days. Both the MHPs & the facilities are mailed a copy of the disenrollment letter. 24. Are MHPs exempt from paying Medicare Part A co-insurance? a. No, MHPs pay for Medicare Part A co-insurance. If a MHP refuses to pay the co-insurance please contact Theresa Landfair at landfairt@michigan.gov, and provide specific examples. 25. If a Medicare resident is admitted, but does not have a 3 day qualified hospital stay, can the nursing facility bill the MHP for room and board like it can for FFS? Page 4

5 a. An MHP will not pay for room and board without a 3 day qualifying hospital stay, unless the hospital is participating in the ACO demonstration project. If they re discharged from a hospital that is participating with the ACO demonstration project, and meet the criteria established, and bill with the required 62 a 3 day hospital stay is then not required. For residents enrolled in the MI Health Link program, the ICOs will pay for room and board for residents who have not had a 3 day qualifying hospital stay. 26. If a provider is having issues with a MHP that aren t being resolved under the normal process, can nursing facilities have a specific contact to resolve those issues? a. There are Contract Managers assigned to a specific HP. They are the mediator between the HP and Medicaid. Providers can call and will be forwarded to the appropriate person. Other 27. There was a recent rule that requires claims to be processed within a year of service. What do providers do if they re waiting for the local office or Provider Inquiry to fix an issue and it goes past the filing limit? a. Those will be addressed on a case by case basis, and if determined necessary a bypass will be granted. 28. What is the purpose of cost sharing letters? Do they apply to nursing facility residents? a. A beneficiary cannot be charged more than 5% of their group income, so there are two letters CHAMPS sends that informs them of their cap amount and if they ve met it for a quarter. CMS requires these letters to be sent. Beneficiaries that are excluded from copays, which includes beneficiaries with the NH (nursing home) Benefit Plan, should not receive these letters. However, there was a recent system issue where some of these excluded beneficiaries might have received a letter in error, so MDHHS stopped sending them until the issue is fixed. 29. Why do providers have to eat the cost of divestments? a. Nursing facilities should collect the private pay rate from the resident rather than bill Medicaid. Divestment penalties occur when an individual gave away resources that could have paid for LTC/waiver services in front of the Medicaid program. Facilities can also act to secure their payment via liens and other legal means to recover the medical debt from the estate. 30. There is an increase in the amount of suspended claims, including for claims that appear to be billed correctly. Are there systems issues causing more claims to be suspended? How long can a claim be suspended in the Medicaid system? a. Based on data from the last six months, the number of suspending TCNs fluctuates throughout the course of the month, usually with the largest volume at beginning and smallest during the middle. MDHHS has not noticed any drastic increases, and there are also no systems issues that are impacting the number of suspending nursing facility claims. While reviewing the current list of suspending TCNs, it was discovered that 75% of the claims set one of the following three edits: suspected duplicate of a paid claim in system history, claim past timely filing limitation, and claim Page 5

6 data not matching PA. These three edits require individual review by processors, thus causing the claim to suspend. 31. For NF claims reporting HLOA/TLOA days are providers supposed to report dates of service for revenue code 0120/0110 or just with revenue code 0183/0185? a. LOA days must be reported with revenue codes 0183 or 0185, whichever is applicable. Per Medicaid policy the from and to dates of service for 0183 and 0185 are required, and must match the from and to dates reported on the OSC For cases where a resident has a hospital stay and returns to the facility, some NFs are having billing issues because the NF start date bumps up against the hospital discharge date. a. Those claims will suspend for suspect duplicate due to the same dates being billed. They should get forced, however there are times when human errors are made and they reject in error. When that happens please call Provider Support and they can verify, and if determined to be rejected in error they can have the claim resurrected. 33. Why is the hospital admission status code 05 not being recognized for patient pay amount purposes, i.e. where to take the money from? a. Regardless of the admission source, the PPA is deducted from the first claim received. 34. When a resident is a QMB does the facility bill the State of Michigan for Medicare Part A coinsurance? a. If the resident is a QMB only, then the facility cannot bill the State for Medicare Part A coinsurance. Page 6