Information for Skilled Nursing Facilities, Hospice R&B Providers & Supportive Living Programs: Authorizations, Billing and Claims

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1 Information for Skilled Nursing Facilities, Hospice R&B Providers & Supportive Living Programs: Authorizations, Billing and Claims

2 Skilled Nursing Facility Services Custodial Care, SLP and Hospice R&B (LTSS/ILS) VS Skilled Care

3 Humana Covered Services Post Hospital Sub-Acute Care Prescription drugs therapy services for restorative purposes Individualized DME Oxygen (2 nd tank and beyond) Transportation (through Logisticare) SNFist or PCP services All traditional Medicare services SLP Ancilliary Services such as PT, OT or Home Health Hospice Care for ICP members ILS Covered Services Custodial Per-Diem Room and Board Over the counter drugs therapy services for maintenance purposes Standard DME Oxygen (1 st tank) SLP Per-Diem Room and Board Hospice Room and Board

4 Authorizations ILS does NOT REQUIRE authorization for SNF custodial room and Board ILS REQUIRES preauthorization for Hospice Room and Board and Supportive Living Programs.* Humana REQUIRES Preauthorization for skilled care services 4

5 Hospice Services MMAI member Hospice service is covered under traditional Medicare and should be billed under Medicare ICP member Hospice service must be authorized by Humana and should be billed directly to Humana To request an authorization call Humana Provider authorization hotline #(800)

6 Hospice R&B Authorization Authorization is needed for all Hospice R&B members (MMAI & ICP) Members must be receiving Custodial Care at a Nursing Home Contact the Provider Hotline at #(855) or Submit a copy of the members Hospice Benefit election form with Date of Service and LTC facility name via fax #(877) Authorizations range from up to a 6 months time frame or specified dates of service

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8 Clean Claims A clean claim can be processed without obtaining additional information from the service provider or from a third party once a member is on the state s Patient Liability Report. Providers may submit their claims in two ways: Electronic Claim Submission using a 837i Paper Claim Submission on a UB04 also known as CMS1450 8

9 Electronic Claims (ILS) Custodial Room and Board (per diem) The INDEPENDENT LIVING SYSTEM EDI payer ID is ILS uses Emdeon as its EDI vendor should a provider want to utilize Emdeon as its clearinghouse, please call or go to to set up an account 9

10 Electronic claims (Humana) Professional Services Humana uses AVAILITY and their payer ID is Humana uses Availity as its EDI vendor and should a provider want to utilize Availity, please call AVAILITY or go to to set up an account

11 Paper Claims Facilities can submit hard copy claims on the red and white CMS UB04/1450 forms directly to ILS via U.S. mail at: UB 04 for Room and Board: Independent Living Systems P.O Box 5787 Hauppauge, NY PLEASE REMEMBER THE SIGNATURE! 11

12 Timely Filing You must submit a claim to ILS in a timely manner in order to receive reimbursement for that service Timely filing is considered 60 days from the date(s) on which covered service were rendered, no more than state mandates (180 days). 12

13 Sample UB 04/CMS 1450

14 Completing the CMS 1450/UB 04 Required fields for CMS-1450/UB-04 1 Provider name, phone and mailing address 42* 4-digit revenue code 2 Provider billing address or payment address 46 Service units 3b Medical record number 47 Total charges 4* Type of bill 48 Totals 5 Federal tax ID number 50a-50c Payer 6 Statement coverage period 51 Health plan ID number 8a Patient name 52a-52c Release of information (Must read as YES) 9a-9d Patient address 53 ASG BEN (form on file authorizing Payment) 10 Patient date of birth 56 National Provider Identifier (NPI) number 11 Patient sex 57, 78 or 79* Other provider ID 12 Admission date 58 Insured s name 13 Admission hour (2-digit military time) 60 Insured s unique ID 15* Admission source 69 Admitting diagnosis 17* Patient status 76 Attending physician 31* Occurrence code and date 80* Remarks 36* Occurrence code with date span 81a* CC ( taxonomy number) 39-41* Patient responsibility (patient liability) 81d* Level of care 43* Revenue code descriptions *see reference tables below

15 Fields 1-8 Field Location Field Label Name Patient Type Inpatient Field Content Explanation or Usage Detail R= Required NR= Not Required C=Conditional 1 Unlabeled R Complete provider name, phone number and mailing address 2 Unlabeled NR 3a Pt. Control Number NR Provider created ID number for patient s account 3b Medical Record Number R Facility medical or health record number 4* Type of bill R 3 digit type of bill as specified by the CMS 1450/UB 04 National Uniform Billing Manual (see acceptable list of codes below) Type of Bill Field 4 5 Federal Tax ID Number R 9 digit number assigned by the federal government for tax reporting purposes 6 Statement Covers Period R Billing period for the this statement 7 Unlabeled NR 8a Patient Name R Patient's last name, first name and middle initial 8b Unlabeled NR

16 Fields a-d Patient Address R (except line e) Complete mailing address of the patient a - Street Address b - City c - State d - Zip Code e - Not Required 10 Patient Date of Birth R DOB as (MMDDYYYY) 11 Patients Sex R use M or F only 12 Admission Date R Date of admission as (MMDDYY) 13 Admission Hour R Hour of admission using 2 digit 24 military time 12:00am thru 12:59pm use :00pm - 11:59pm use Admission Type NR 15 Admission Source R 1 digit code indicating the source of admission 1 - Physician referral 2 - Clinic referral 4 - Transfer from hospital 6 - Transfer from another health care facility 7 Transfer from emergency room 8 - Court enforced 9 - Information not available

17 Fields Discharge Hour NR 17 Patient Status R 2 digit discharge code as specified by the CMS 1450/UB 04 National Uniform Billing Manual of the Patient s status on the last day of services billed (see acceptable list of codes below) Patient Status Codes: Field Condition Codes C REQUIRED when there is a condition relating to the bill that may affect payer processing. For a list of codes and additional instructions refer to the NUBC UB 04 Uniform Billing Manual 29 Accident State NR 30 Unlabeled NR Occurrence Codes C Typically used when there is a coordination of benefits. ( See below for list of when an occurrence code is required.) Occurrence codes and span Fields -31, 36 For a list of additional codes and instructions refer to the NUBC UB 04 Uniform Billing Manual Occurrence Span Code C Typically used when there is a coordination of benefits. Additional instructions can also be found in the NUBC UB 04 Uniform Billing Manual 37 Unlabeled NR 38 Responsible Party NR

18 Fields Patient Responsibility R When Patient Responsibility is no/zero (responsibility, enter code 80 in box 39 and value code amount of 31 (# of units/days) When there is a patient responsibility amount, enter code 23 in box 39 and the value amount in the adjacent cells This field is only required when reporting Covered or Non-Covered Days. Covered Days Value Code 23 Patient Responsibility 80 Covered Days 81 Non Covered Days Value Amount Enter the number of covered or non-covered days in adjacent cells 42 Revenue Code R 4 digit revenue code for as specified Illinois HFS (see acceptable list of codes below) Rev Codes- Field 42, Revenue Code description R (see acceptable list of descriptions below) 44 HCPCS Codes NR 45 Service Date C Not required for inpatient claims

19 Fields Service Units R Enter number of units/days 47 Total Charges R Enter Total charges for each service line 48 Totals R Enter the total charges for all service lines 49 Unlabeled NR 50a-c Payer R Enter the name of all appropriate payers. Note: ILS is the payer for SLF and SNF and Hospice custodial room & board. Humana is the payer for Sub-Acute patient stay in SNF 51 Health Plan ID Number R Payer ID for each of the payers listed in #50. ILS ID# is Humana ID# is (This is only for skilled care claims) 52a-c REL INFO R Release information is required for every payer (must be Y) 53 ASG BEN R 'Y' or 'N' to indicate a signed form is on file authorizing payment by the payer directly to the provider for services 54 Prior payments C Used for COB 55 EST Due AMT NR 56 NPI R Provider s 10 character NPI number 57, 78 or 79 Other Provider ID R for Hospice Room and Board Hospice Room and Board claims MUST include the services SNF s NPI in one of these identified field. 58 Insured's Name R Name of the person who carries the Humana ICP or MMP policy

20 Fields Patient Relationship NR 60 Insured's Unique ID R Humana s Member ID# which can be found on the Humana ID card. (see Appendix C for copy of card) 61 Group Name NR 62 Insurance Group Number NR 63 Treatment Authorization Codes NR 64 Document Control Number C 65 Employer Name NR 66 Diagnosis Code C Required for members enrolled in the SLP Dementia demonstration: Dx code for Dementia demonstration is F a-q Other Diagnosis Codes C Usually does not apply to Nursing Home claims 68 Unlabeled NR 69 Admitting Diagnosis Code R Valid ICD10 diagnosis code for SNF and Hospice Claims SLP Claims should use the Dx code on your authorization. 70 Patient Reason Code NR 71 PPS/DRG Code NR

21 Fields 72-81D 72 External Cause Code NR 73 Unlabeled NR 74 Principal Procedure Code NR 75 Unlabeled NR 76 Attending Physician R Name of Physician 77 Operating Physician NR Other Physician C Hospice Room and Board claims can choose to use these fields for the servicing SNFs NPI 80 Remarks C Hospice Room and Board Claims can choose to include the servicing SNF name and address in this field 81a CC R Taxonomy number of billing provider (see below for list of acceptable taxonomies) Taxonomy code Field -81a 81D Level of Care R 3 digit code for Nursing Facilities only as specified by the CMS 1450/UB 04 National Uniform Billing Manual (see acceptable list of codes below) Level of Care Codes- field 81d

22 Type of Bill Field 4 Fields 1-8 First 2 digits identify the type of care provided 65x Intermediate care intermediate care level I (custodial R&B for SNF) Billed to ILS 81x General Hospice Room and Board To be billed to ILS 89x Specialty Facility other outpatient claim (SLP) To be billed to ILS 3rd digit identifies the sequence of the claim xx0 Nonpayment/ Zero Claim xx1 Admit through Discharge Claim One claim for entire stay xx2 Xx3 Xx4 First Claim Continuing Claim Last Claim Xx5 Late Claim Dates of service billed are after the date of discharge billed on a previous claim Xx7 Replacement of Prior Claim Completely replaces a previous claim; the original bill is considered null and void

23 Patient Status Codes: Field 17 Code Patient Status Patient s Status on the last date of service for billing period 01 Discharged to Home or Self Care (Routine Discharge) 02 Discharged/Transferred to Short-Term Hospital for Inpatient Care 03 Discharged/Transferred to Skilled Nursing Facility (SNF) with Medicare Certification 04 Discharged/Transferred to Intermediate Care Facility (ICF) for Custodial or Supportive Care 05 Discharged/Transferred to a Designated Cancer Center or Children s Hospital 06 Discharged/Transferred to Home Under Care of Organized Home Health Service Organization 07 Left Against Medical Advice or Discontinued Care 15 Planned Acute Care Hospital Inpatient 20 Expired 21 Discharged/Transferred to Court/Law Enforcement 30 Still a Patient 40 Expired at Home

24 Patient Status Codes- Field 17 cont. Fields Expired in a Medical Facility such as a Hospital, SNF, ICF or Free-standing Hospice 42 Expired, Place Unknown 43 Discharged/Transferred to a Federal Health Care Facility 50 Discharged to Hospice, at Home 51 Discharged to Hospice, at a Medical Facility Providing Hospice Level Care 61 Discharged/Transferred within this Institution to Hospital Based Medicare Approved Swing Bed 62 Discharged/Transferred to Inpatient Rehabilitation Facility (IRF) Including Distinct Part Units of a Hospital 63 Discharged/Transferred to a Medicare-Certified Long Term Care Hospital (LTCH) 64 Discharged/Transferred to a Nursing Facility Under Medicaid but Not Certified Under Medicare 65 Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital 66 Discharged/Transferred to a Critical Access Hospital (CAH) 69 Discharged/Transferred to a Designated Disaster Alternate Care 70 Discharged/Transferred to Another Type of Health Care Institution Not Defined Elsewhere

25 Occurrence codes and span Fields - 31, 36 Fields An occurrence code and date of occurrence are required under two circumstances: In the case of a member s death, place an occurrence code 55 in field 31 with the date of death in the adjacent box In the case of a noncovered leave of absence, place an occurrence code 74 in field 36 with the date span in adjacent boxes

26 Rev Codes- Field 42, 43 Fields Facility Type Rev Code LTC Custodial Care LTC Custodial Care--VENT 0194 General Room and Board Supportive Living 0240 Hospice Room and Board 0658 Bed Hold--General 0180 Bed Hold--Patient Convenience 0182 Bed Hold--Therapeutic Leave 0183 Bed Hold-- Hospitalization 0185 Bed Hold--Other LOA 0189

27 Taxonomy code Field -81a Fields 72-81D Type of Facility Code Dementia special care and Specialized Mental Health Facilities 038 and 028 (LTC MI demonstration-dementia care, SLP demonstration-dementia) X Nursing facility/intermediate care facility 033 (nursing facility) 034 (nursing facility and state-operated long-term-care facility) 313M00000X Supportive Living Facilities 087 Assisted Living Facility X

28 Level of Care Codes- field 81d Fields 72-81D In the first field, enter 02 In the second field, enter the established level of care code (see below) In the third field, enter the facilities per diem. For level of care X, enter the respective Medicare per diem. In the second field, enter the established level of care code to indicate the type of care that the patient has been determined to require 1 Skilled Care 2 Intermediate I 3 Intermediate II X Medicare Part A Coinsurance Payment

29 Example of A Clean CMS UB04/CMS 1450 SNF Custodial Claim Hospice Room & Board Claim Supportive Living Program Claim

30 Receipt of Claims For electronic submissions- 24 hours after receipt of claim For paper claims- 15 days after receipt of claim For Custodial claims status contact ILS provider relations at or For Professional Services claim status contact Humana at

31 Tips on Clean Billing Typing form rather than handwriting is always preferable Using the actual red and white forms Legible handwriting Complete paper claim forms in blue or black ink Always sign the claim Be sure you always include your billing address and that it matches what is in the ILS system Remember to submit claims 60 days from date of service to ensure timely filing. 31

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33 Helpful Contact Information ILS Provider Hotline: ILS Provider Fax: ILS Members Hotline: ILS Claims Hotline: ILS Provider Portal Beacon Pre Auth Hotline: Humana Pre Auth Hotline: Humana Member Line (MMP) Humana Member Line (ICP) Humana Provider Portal Humana LTSS/DON/Transfer Paperwork Humana DME Referrals Humana Transportation: Logisticare MMAI: ICP: Humana Health & Wellness MEDI REV System IL Enrollment Broker(Maximus) IL Benefit Eligibility, Assitance & Monitoring (BEAM)

34 Thank You! ILS Provider Relations Team: Kathryn Schmit, Manager of Provider Relations LTSS Network x 5010, kschmit@ilshealth.com Rasheda Coleman, Provider Relations Specialist x 5007, rcoleman@ilshealth.com Vicky Hunt, Provider Relations Specialist x 5113, vhunt@ilshealth.com Provider Relations illinoisproviders@ilshealth.com 34