Community HealthChoices Operations Manual for Vendors

Nursing Facility Services - Hospital Reserved Bed Days

4-100-18-01

CHC Agreement Section V-A-15: Program Requirements, Covered Services, Nursing Facility Services

a.    General Policy

i.    The CHC-MCO must comply with 55 Pa. Code § 1187.104 and 1189.103 except as it pertains to payment rates.

ii.   A resident receiving nursing facility services is eligible for a maximum of 15 consecutive reserved bed days per hospitalization.

iii.  The CHC-MCO will pay a nursing facility at a negotiated rate for a hospital reserved bed day if the nursing facility meets the overall occupancy requirements under §§  1187.104(b)(ii)(B) or 1189.103(b)(ii)(B) as applicable.

b.    Definitions

i.    N/A

c.    Regulatory Citations & Other References

i.    55 Pa. Code §§ 1187.104 and 1189.103

ii.   Pennsylvania Medicaid State Plan, Attachment 4.19C

d.    Process/Steps

i.    Nursing facilities will continue to be notified by the department if they meet the qualifying criteria via the CMI report which is produced quarterly for each nursing facility. The CMI report will inform the nursing facility if they may bill for hospital reserved bed days in accordance with 55 Pa. Code §§ 1187.104(b)(ii)(B) or 1189.103(b)(ii)(B) as applicable. For example:

1.    A qualifying nursing facility bills at the beginning of February for January hospital reserved bed days.

2.    The nursing facility refers to their CMI report for the preceding August 1 picture date to determine if they qualify.  See example CMI Report below.

ii.   CHC-MCOs will receive a report from the department listing nursing facilities that do not qualify for payment for hospital reserved bed days. This report will be deposited into DocuShare prior to the first day of each calendar quarter. See Appendix A.

iii.  CHC-MCOs must develop a billing process for nursing facilities that qualify for payment of hospital reserved bed days.

e.    Examples

i.    Example CMI Report (Resident Data Reporting Manual Chapter 6).

f.     Appendices

i.    Appendix A:  Example Hospital Reserved Bed Days Report (NFsNotQualifiedForHospitalReserveBedDayPmtJanuary 2018RateQuarter.xls)

04/06/2018