See the PA PROMISe Provider Handbook/for the 837 Institutional/UB-04 Provider link to this:
http://www.dhs.pa.gov/publications/forproviders/promiseproviderhandbooksandbillingguides/ for complete billing instructions.
The CAO will give the LTC facility a copy of the notice which includes information about the amount the individual must pay toward the cost of care. The LTC facility will submit claims to DHS via the electronic media claim (EMC) or the Long Term Care Invoice (UB-04) to request payment for LTC facility services. The invoice must list the individual’s payment towards the cost of care, medical insurance premiums, drug expenses, and other medical expenses separately.
The individual’s payment toward the cost of care listed on the notice is the amount of income remaining after all deductions allowed by the CAO. See Chapter 468, Eligibility and Payment. The individual’s payment toward cost of care is entered into the TPL system automatically by CIS. Two entries are made if the first month’s payment towards cost of care is different than the second month. The amount of the individual’s payment towards the cost of care shown in the TPL system must be the same amount as is listed by the LTC facility on the UB-04
Effective with the April 2024 Release, verified medical expenses entered in eCIS are deducted from the cost of care calculation instead of simply being listed as medical expenses on the PA 162 for the LTC facility to deduct from the cost of care. CAOs must enter all verified medical expenses the LTC facility applicant or recipient is responsible to pay for, such as paid Medicare premiums and supplemental insurance premiums, on the Medical Expense screen in eCIS. If the individual or the LTC facility provides the CAO with verified medical expenses, the CAO must add the expenses in eCIS and generate a new PA 162.
The LTC facility submits one claim for the cost of LTC facility services provided to the individual for the first billable day to the last day of the calendar month.
If the CAO notifies the LTC facility of a change in the individual’s payment towards the cost of care, the LTC facility will bill DHS based on the new amount for LTC facility services provided to the person beginning the effective date of the change.
EXAMPLE: On 5/17, the CAO sends the LTC facility a copy of an Advance Notice for an increase in the individual’s payment towards cost of care effective 6/1. The facility will apply the new amount beginning with the date of service of 6/1. The LTC facility will use the new amount when billing DHS for the calendar month of June.
NOTE: If the individual or their representative timely reports a change which results in ineligibility or an increase in the individual’s payment towards the cost of care, the CAO will make the change effective the month for which appropriate notice can be provided prior to the billing month. If the notice expires before the end of the month, the change can be effective in the month of the notice. If the individual fails to timely report, the CAO will complete an overpayment referral. The CAO will not request the LTC facility do a claim adjustment in either situation unless the individual waives his right to advance notice and requests the change be made.
The CAO will refer all LTC facility billing questions to:
Office of Long Term Living
Bureau of Provider Supports
P.O. Box 8025
Harrisburg, PA 17105
Telephone: 1-800-932-0939
Email: RA-ProviderOperation@pa.gov
55 Pa. Code § 1187.101 applies to the entire section
The Department will pay the LTC facility to hold a bed while the individual is away from the facility for a continuous 24-hour period because of hospitalization or therapeutic leave. Payment by DHS is limited to:
A maximum of 15 consecutive days for each hospitalization.
NOTE: The facility will be paid for a benefit hold day if they maintain the approved MA occupancy rate.
A maximum of 30 days per calendar year for therapeutic leave (must be included in the plan of care and be ordered by a doctor).
For hospitalizations, the Department will pay the LTC facility for reserved bed days for a period of hospitalization at a rate which is 1/3 of the current MA LTC rate for the facility. This includes a period of hospitalization covered by Medicare. The LTC facility will indicate these hospital days when billing DHS. The LTC facility will not apply the individual’s payment towards the cost of care to hospital reserved bed days.
NOTE: During a period of hospitalization, the individual may have income which is not applied to the cost of LTC facility services. The LTC facility must put this excess income aside for the individual’s personal use. The CAO should review the individual’s resource eligibility upon his return to the LTC facility. The LTC facility may not apply the individual’s excess income to a future billing.
If the individual returns to the LTC facility within 15 days following his hospital stay, the LTC facility must return him to the same bed. If the absence exceeds the 15 days and the individual still needs the LTC facility services provided by the LTC facility, the LTC facility must permit the resident to return to the first available bed in a semi-private room.
NOTE: If the individual indicates in writing that he wants to pay the LTC facility to hold his bed beyond the 15 days, the LTC facility may bill the individual at the MA LTC rate charged immediately prior to the transfer to the hospital for the additional days. The LTC facility may not charge the individual to hold any bed other than the bed the individual occupied before the transfer to the hospital.
An individual must reside in the LTC facility for at least 24 hours between hospitalizations to begin another 15 consecutive day period.
The individual still qualifies for MA LTC during a period of hospitalization. If, when discharged from the hospital, the individual does not return to the LTC facility, the CAO will decide if the individual qualifies for continuing MA.
For therapeutic leave day, the Department will pay the LTC facility their current rate on file with the Department. The LTC facility will apply the individual’s payment towards the cost of care to a therapeutic leave day.
55 Pa. Code § 1187.104 applies to the entire section
The LTC facility will begin billing on the date of admission or date the CAO decides that the individual qualifies for payment of LTC services. The CAO will tell the LTC facility the amount of the individual’s payment towards the cost of care for the initial month and for the following months.
NOTE: If the CAO decides that an individual qualifies for MA LTC, the facility must bill DHS based on the MA LTC rate beginning the date eligibility is decided.
When a resident moves from one LTC facility to another LTC facility, each LTC facility will bill for the number of days LTC facility services were provided. The former LTC facility will bill through the day before the day of discharge. The new LTC facility may begin billing on the date of admission.
NOTE: The former LTC facility will subtract the individual’s payment towards the cost of care from its billing for the calendar month. The new LTC facility will count only that income remaining after the individual paid the former LTC facility as the individual’s payment to the new LTC facility.
If an individual moves from an LTC facility in one county to an LTC facility in another county, the new LTC facility may bill DHS using the case number information from the former CAO until the individual or the LTC facility receives the notice from the new CAO.
If the individual is discharged or dies, the LTC facility may bill the Department for services provided through the day before the date of discharge or death.
55 Pa. Code § 1187.101 applies to the entire section
The LTC facility must submit all original invoices, resubmissions of original invoices, and claim adjustments within 180 days from the end date of the service. If the invoice dates of service are beyond 180 days because of a CAO or third party delay or administrative error, the facility must request an exception and document details. The exception will be approved if:
the LTC facility was not at fault for the error or delay; and
the MA LTC application was sent to the CAO within 60 days of the end date of service and DHS received the exception request within 60 days of the mail date on the qualifying notice from the CAO; or
a request for third party reimbursement was made within 60 days of the end date of service and DHS received the exception request within 60 days of receiving the statement from the third party.
If one of the above criteria is met, the LTC facility will submit the original invoice and the 180-Day Exception Request Detail Page to:
Office of Long-Term Living
Bureau of Provider Support
ATTN: 180-Day Exception
Unit
P.O. Box 8025
Harrisburg, PA 17105
Telephone: 1-800-932-0939
Email: RA-ProviderOperation@pa.gov
The CAO does not have to complete a 180 Day Exception Request Detail Page letter (see Appendix A) when a person qualifies for MA LTC. This form is a check list and is used by the LTC service provider to tell DHS why the person did not qualify for MA LTC sooner. The CAO should give the LTC service provider copies of any documents needed to send the 180 day exception request to DHS. The LTC service provider can see MA Bulletin 25-02-01 for further information on this process.
55 Pa. Code § 1101.68 applies to the entire section
Payment may continue to be made to a nursing facility that has temporarily transferred residents, as the result or threat of a strike or disaster situation, to the closest medical institution able to meet the resident’s needs, if the institution receiving the residents is licensed and certified to provide the required services. If the nursing facility transferring the residents can demonstrate that there is no certified nursing facility available for the safe and orderly transfer of the residents, the payments may be made so long as the institution receiving the residents is certifiable and licenses to provide the services required.
The resident assessment submissions for the transferring nursing facility residents shall be maintained under the transferring nursing facility provider number as long as the transferring nursing facility is receiving payment for those residents. If the nursing facility to which the residents are transferred has a different per diem rate, the transferring nursing facility shall be reimbursed at the lower rate. The rate established on the date of transfer will not be adjusted during the period that the residents are temporarily transferred. The nursing facility shall immediately notify the Department in writing of an impending strike or a disaster situation and follow with a listing of MA residents and the nursing facility to which they will be or were transferred.
Updated June 13, 2024, Replacing March 26, 2020