Medicare Regulatory Terms and abbreviations

V. Regulatory Impact Analysis Regulations Text Acronyms

In addition, because of the many organizations and terms to which we refer by acronym in this final rule, we are listing these acronyms and their corresponding terms in alphabetical order below:

A1c Hemoglobin A1c

AAA Abdominal aortic aneurysms

ACO Accountable care organization

AMA American Medical Association

ASC Ambulatory surgical center

ATA American Telehealth Association

ATRA American Taxpayer Relief Act (Pub. L. 112–240)

AWV Annual wellness visit

BBA Balanced Budget Act of 1997 (Pub. L. 105–33)

BBRA [Medicare, Medicaid and State Child Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106–113)

BLS Bureau of Labor Statistics

CAD Coronary artery disease

CAH Critical access hospital

CBSA Core-Based Statistical Area

CCM Chronic care management

CEHRT Certified EHR technology

CF Conversion factor

CG–CAHPS Clinician and Group Consumer Assessment of Healthcare Providers and Systems

CLFS Clinical Laboratory Fee Schedule

CoA Certificate of Accreditation

CoC Certificate of Compliance

CoR Certificate of Registration

CNM Certified nurse-midwife

CP Clinical psychologist

CPC Comprehensive Primary Care

CPEP Clinical Practice Expert Panel

CPT [Physicians] Current Procedural Terminology (CPT codes, descriptions and other data only are copyright 2015 American Medical Association. All rights reserved.)

CQM Clinical quality measure

CSW Clinical social worker

CT Computed tomography

CW Certificate of Waiver

CY Calendar year

DFAR Defense Federal Acquisition Regulations

DHS Designated health services

DM Diabetes mellitus

DSMT Diabetes self-management training  eCQM Electronic clinical quality measures

ED Emergency Department

EHR Electronic health record

E/M Evaluation and management

EMT Emergency Medical Technician

EP Eligible professional eRx Electronic prescribing

ESRD End-stage renal disease

FAR Federal Acquisition Regulations

FDA Food and Drug Administration

FFS Fee-for-service

FQHC Federally qualified health center

FR Federal Register

FSHCAA Federally Supported Health Centers Assistance Act

GAF Geographic adjustment factor

GAO Government Accountability Office

GPCI Geographic practice cost index

GPO Group purchasing organization

GPRO Group practice reporting option

GTR Genetic Testing Registry

HCPCS Healthcare Common Procedure Coding System

HHS [Department of] Health and Human Services

HOPD Hospital outpatient department

HPSA Health professional shortage area

IDTF Independent diagnostic testing facility

IPPE Initial preventive physical exam

IPPS Inpatient Prospective Payment System

IQR Inpatient Quality Reporting

ISO Insurance service office

IT Information technology

IWPUT Intensity of work per unit of time

LCD Local coverage determination

MA Medicare Advantage

MAC Medicare Administrative Contractor

MACRA Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114– 10)

MAP Measure Applications Partnership

MAPCP Multi-payer Advanced Primary Care Practice

MAV Measure application validity [process]

MCP Monthly capitation payment MedPAC Medicare Payment Advisory Commission

MEI Medicare Economic Index

MFP Multi-Factor Productivity

MIPPA Medicare Improvements for Patients and Providers Act (Pub. L. 110–275)

MMA Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub. L. 108–173, enacted on December 8, 2003)

MP Malpractice

MPPR Multiple procedure payment reduction

MRA Magnetic resonance angiography

MRI Magnetic resonance imaging

MSA Metropolitan Statistical Areas

MSPB Medicare Spending per Beneficiary

MU Meaningful use

NCD National coverage determination

NCQDIS National Coalition of Quality Diagnostic Imaging Services

NP Nurse practitioner

NPI National Provider Identifier

NPP Nonphysician practitioner

NQS National Quality Strategy

OACT CMS’s Office of the Actuary

OBRA ’89 Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101–239)

OBRA ’90 Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101–508)

OES Occupational Employment Statistics

OMB Office of Management and Budget

OPPS Outpatient prospective payment system

OT Occupational therapy

PA Physician assistant

PAMA Protecting Access to Medicare Act of 2014 (Pub. L. 113–93)

PAMPA Patient Access and Medicare Protection Act (Pub. L. 114–115)

PC Professional component

PCIP Primary Care Incentive Payment

PE Practice expense

PE/HR Practice expense per hour

PEAC Practice Expense Advisory Committee

PECOS Provider Enrollment, Chain, and Ownership System

PFS Physician Fee Schedule

PLI Professional Liability Insurance

PMA Premarket approval

PPM Provider-Performed Microscopy

PQRS Physician Quality Reporting System

PPIS Physician Practice Expense Information Survey

PPS Prospective Payment System

PT Physical therapy

PT Proficiency Testing

PT/INR Prothrombin Time/International Normalized Ratio

PY Performance year

QA Quality Assessment

QC Quality Control

QCDR Qualified clinical data registry

QRUR Quality and Resources Use Report

RBRVS Resource-based relative value scale

RFA Regulatory Flexibility Act

RHC Rural health clinic

RIA Regulatory impact analysis

RUC American Medical Association/ Specialty Society Relative (Value) Update Committee

RUCA Rural Urban Commuting Area

RVU Relative value unit

SBA Small Business Administration

SGR Sustainable growth rate

SIM State Innovation Model

SLP Speech-language pathology

SMS Socioeconomic Monitoring System

SNF Skilled nursing facility

TAP Technical Advisory Panel

TC Technical component

TIN Tax identification number

TCM Transitional Care Management

UAF Update adjustment factor

UPIN Unique Physician Identification Number

USPSTF United States Preventive Services Task Force

VBP Value-based purchasing

VM Value-Based Payment Modifier

What is Clinical trials and well child care

Clinical Trials

CMS has specific billing requirements for Clinical Trials. For clinical trials other than IDE A and B devices and Clinical Evidence Development, traditional Medicare A or B will pay primary, waiving any deductible. To ensure claims are processed correctly, it is extremely important that claims are billed according to CMS guidelines. Additional Electronic Billing requirements can be obtained in the Availity Companion Guide.

• All claims must be billed with V700.7 (ICD9) or Z00.6 (ICD10) in the first or second diagnosis position

• Each claim submitted must include the clinical trial number

• Outpatient claims must contain an appropriate modifier

• Q1 on each line to denote routine service

• Q0 on each line billed for investigational services

• Electronic claims billed for IDE A or B devices must have an LX in REF01, loop 2300 and Clinical Trial claims must have P4 in REF01, loop 2300

• Clinical Trial Claims (other than IDE and Clinical Evidence Development) must be submitted to traditional Medicare first, then submitted to the Medicare Advantage plan with the Medicare EOB


Well-Child Care

Well-child care refers to physician-provided preventive health care services for children. The well-child benefit applies to an insured dependent child under BlueOptions, BlueChoice or Traditional products.

Well-child services include:

• The first newborn examination in the hospital by a physician other than the delivering obstetrician or anesthesiologist

• Periodic examinations to monitor the normal growth and development of a child

• Specified immunizations (see chart)

• Specified laboratory tests (see chart)

Well-child services are not subject to a calendar-year deductible and are reimbursed at the contracted percentage of the allowed amount.

Note: Florida Blue HMO (Health Options, Inc.) product, uses the USPSTF guidelines for preventive care and the recommended childhood immunization schedule published and updated annually by the Centers for Disease Control and Prevention.

What is Document Control Number (DCN) - How to read

The DCN number is located on the remittance advice. This number must be used with adjustment/cancellation bills.
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CLAIMS PROCESSING

A brief description of claims processing methods follows. All paper submitted claims are assigned a unique Document Control Number (DCN). The DCN identifies and tracks claims as they move through the claims processing system. This number contains the Julian date, which indicates the date the claim was received. It monitors timely submission of a claim.

Document Control Numbers are composed of 11 digits:

2-digit plan year
3-digit Julian date
2-digit BCBSTX reel identification
4-digit sequential number

Claims entering the system are processed on a line-by-line basis except for inpatient claims. Inpatient claims are processed on a whole-claim basis. Each claim is subjected to a comprehensive series of checkpoints called edits. These edits verify and validate all claim information to determine if the claim should be paid, denied or pended for manual review.

You are responsible for all claims submitted with your Provider number, regardless of who completed the claim. If you use a billing service you must help ensure that your claims are submitted properly.

Note: Entities submitting claims for services rendered by a Healthcare Provider are subject to Texas HHSC suspension if they submit claims for a Provider who is suspended from HHSC.

Medicare Definition of Clean Claim

A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.
The following bullets are some examples of what are considered clean claims:

• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);

• Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).

• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);

• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;

• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;
• Are developed on a postpayment basis; and,

• Have all basic information necessary to adjudicate the claim, and all required supporting documentation


1. Clean claim defined: 

A clean claim has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements, or revisions to data elements, attachments and additional elements, of which the provider has knowledge. Claims for inpatient and facility programs and services are to be submitted on the UB-04 and claims for individual professional procedures and services are to be submitted on the CMS-1500. State guidelines may supersede these requirements. In addition, claims may be submitted electronically through a contracted clearinghouse or on Magellan’s Webbased claims submission application. Magellan does not typically, but may require attachments or other information in addition to these standard forms (as noted below). Magellan may request treatment records for review.

2. Required clean claim elements: 

The Centers for Medicare and Medicaid Services (CMS) developed claim forms that record the information needed to process and generate provider reimbursement. The required elements of a clean claim must be complete, legible and accurate.


Clean and Unclean Claims

Because UnitedHealthcare Oxford processes claims according to state and federal requirements, a “clean claim” is defined as a complete claim or an itemized bill that does not require any additional information to process it. A clean claim includes at least all of the following*:

• Patient name and UnitedHealthcare Oxford Member ID number

• UnitedHealthcare Oxford provider ID number

• Provider information, including federal tax ID number (FTIN)

• Date of service (DOS)

• Place of service

• Diagnosis code

• Procedure code

• Individual charge for each service

• Provider signature

*More specific requirements are set forth below.

An “unclean claim” is defined as an incomplete claim, a claim that is missing any of the above information, or a claim that has been suspended in order to get more information from the provider. If you submit incomplete or inaccurate information, we may reject the claim, delay processing or make a payment determination (e.g., denial, reduced payment) that may be adjusted later when complete information is obtained.

UnitedHealthcare Oxford applies the appropriate state and federal guidelines to determine whether the claim is clean.



CMS-1500

In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the CMS-1500 claim form.

 Subscriber’s/patient’s plan ID number (field 1a);
• Patient’s name (field 2);
• Patient’s date of birth and gender (field 3);
• Subscriber’s name (field 4);
• Patient’s address (street or P.O. Box, city, zip) (field 5);
• Patient’s relationship to subscriber (field 6);
• Subscriber’s address (street or P.O. Box, City, Zip Code) (field 7);
• Whether patient’s condition is related to employment, auto accident, or other accident (field 10);
• Subscriber’s policy number (field 11);
• Subscriber’s birth date and gender (field 11a);
• HMO or preferred provider carrier name (field 11c);
• Disclosure of any other health benefit plans (field 11d);
• Patient’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 12);
• Subscriber’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 13);
• Date of current illness, injury, or pregnancy (field 14);
• First date of previous, same or similar illness (field 15);
• Name of Referring Provider or Other Source (field 17);
• Referring Provider NPI Number (field 17b);
• Diagnosis codes or nature of illness or injury (current ICD-10 codes are required effective 10/1/15) (field 21);
• Date(s) of service (field 24A);
• Place of service codes (field 24B);
• EMG (field 24C);
• Procedure/modifier code (current CPT or HCPCS codes are required) (field 24D);
• Diagnosis code (ICD-10 codes are required effective 10/1/15) by specific service (field 24E);
• Charge for each listed service (field 24F);
• Number of days or units (field 24G);
• Rendering provider NPI (field 24J);
• Physician’s or provider’s federal taxpayer ID number (field 25);
• Total charge (field 28);
• Signature of physician or provider that rendered service, including indication of professional license (e.g., MD, LCSW, etc.) or notation that the signature is on file with the HMO or preferred provider carrier (field 31);
• Name and address of facility where services rendered (if other than home or office) (field 32);
• The service facility Type 1 NPI (if different from main or billing NPI) (field 32a);
• Physician’s or provider’s billing name and address (field 33); and
• Main or billing Type 1 NPI number (field 33a)

Medicare definition - Clean claim

A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.

The following bullets are some examples of what are considered clean claims:

• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);

• Not require external development (i.e., are investigated within the claims, medical review, or
payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).

• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);

• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;

• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;

• Are developed on a postpayment basis; and,

• Have all basic information necessary to adjudicate the claim, and all required supporting documentation

The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim). The receipt date is used to: determine if the claim was timely filed (see §70.3), determine the “payment floor” for the claim (see §80.2.1.2), determine the “payment ceiling” on the claim (see §80.2.1.1) and, when applicable, to calculate interest payment due for a clean claim that is not timely processed, and to report to CMS statistical data on claims, such as in workload reports.

A paper claim that is received by 5:00 p.m. on a business day, or by closing time if the contractor routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the contractor does not open the envelope which contains the claim or does not enter the claims data into the claims processing system until a later date. A paper claim that is received after 5:00 p.m., or after the contractor’s routine close of business between 4:00 p.m. and 5:00 p.m., is considered as received on the next business day.

A paper claim is considered as received if it is delivered to the contractor’s place of business by the U.S. Postal Service, picked up from a P.O. box, or is otherwise delivered to the contractor’s place of business by its routine close of business time. If the contractor uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box at least once per business day unless precluded on a particular day by the emergency closing of its place of business or that of its postal box site. As electronic claim tapes and diskettes that may be submitted by providers or their agents to an FI are also subject to manual delivery, rather than direct electronic transmission, the paper claim receipt rule also applies to establish the date of receipt of claims submitted on such manually delivered tapes and diskettes.

All claims (i.e., paid claims, partial and complete denials, no payment bills) including PIP and EMC claims are subject to the above requirements.

Interest must be paid on claims that are not paid within the ceiling period. The count starts on the day after the receipt date and it ends on the date payment is made. For example, for clean claims received October 1, 1993, and later, if this span is 30 days or less, the requirement is met.

The RAPs submitted by home health agencies under the HH PPS (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not Medicare claims as defined under the Social Security Act. Since they are not considered claims, they (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not subjected to payment ceiling standards and interest payment.

See Chapter 24, § 30.2 for definitions of electronic and paper claims for use in application of the Medicare payment floor. See Chapter 1, § 80.2.1.2 for differentiation between electronic claims that comply with the requirements of the standard implementation guides adopted for national use under HIPAA and those submitted electronically using pre-HIPAA formats supported by Medicare. This HIPAA format differentiation applies to the payment floor, but not to the ceiling.

The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made.

The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt. There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply:

An “electronic claim” is a claim submitted via central processing unit (CPU) to CPU transmission, tape, direct data entry, direct wire, or personal computer upload or download. A claim that is submitted via digital FAX/OCR, diskette, or touch-tone telephone is not considered as an electronic claim.

A “paper claim” is submitted and received on paper, including fax print-outs. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology.

Claims Paid Upon Appeal

Interest payments are not payable on clean claims initially processed to denial and on which payment is made subsequent to the initial decision as a result of an appeal request. This applies to appeals where more than the applicable number of days elapsed before an initial denial, but the claim was later paid upon appeal

Contractors shall report the number of other-than-clean claims processed in 45 days or less on Form Y of the Contractor Reporting of Operational and Workload Data (CROWD) report. Use identifier code “0005” in column 1 to report this information. Report the number of other-than-clean claims processed in 46 days or longer on Form Y of the CROWD system, under column 1 on a line using code “0006” as the identifier.

Condition Codes

12-14 - Not currently used by Medicare.
15 – Clean claim is delayed in CMS Processing System.
16 – SNF Transition exception.
60 – Operating Cost Day Outlier.
61 – Operating Cost Outlier.
62 – PIP Bill.
63 – Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.
64 – Other Than Clean Claim.
65 – Non-PPS Bill.
98 – Data Associated With DRG 468 Has Been Validated.
EY – Lung Reduction Study Demonstration Claims.
M0 – All-Inclusive Rate for Outpatient - Used by a Critical Access Hospital electing to be paid an all-inclusive rate for outpatient services.
M1 – Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV).

Code indicates the influenza virus vaccine or pneumonia vaccine (PPV) is being billed via the roster billing method by providers that mass immunize.

M2 – Allows Home Health claims to process if provider reimbursement > $150,000.00.
HHA Payment Significantly Exceeds Total Charges. Used when payment to an HHA is significantly in excess of covered billed charges.
M3 – SNF 3 Day stay bypass for NG/Pioneer ACO waiver.
M4 – M9 Not used by Medicare.
MA – GI Bleed.
MB – Pneumonia.
MC – Pericarditis.
MD - Myelodysplastic Syndrome.
ME - Hereditary Hemolytic and Sickle Cell Anemia.
MF - Monoclonal Gammopathy.
MG – Grandfathered Tribal Federally Qualified Health Centers.
MH-MT – Not currently used by Medicare.
MZ – IOCE error code bypass
UU – Not currently used by Medicare

Clean Claim A claim that can be processed without obtaining additional information from the provider of the service or its designated representative. It includes a claim with errors originating in a state’s claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.

BCBS insurance id starts with VMB, VMA, XJQ, XJX and VME

How will our office recognize an Exchange member?

Our member identification (ID) cards will not change. However, there will be new alpha prefixes on ID cards for Exchange members:

VMB = Individual HMO
VMA = Individual PPO
XJQ = Small Group HMO
XJX = Small Group
VME/VMD = Individual HMO and PPO off-Exchange

How do I verify member benefits?

You may verify eligibility and benefits for Florida Blue members on the Exchange as you do today for any other Florida Blue member. Providers and/or their designees (billing services, clearinghouses, etc.) should use clinical, financial and administrative electronic self-service capabilities including those accessed through Availity®1. These capabilities include but are not limited to:

• Submitting administrative inquiries electronically through Availity using Authorizations and Referrals Review and Inquiry, Eligibility and Benefits, CareCalc®, the Claim Reconciliation Tool and Claims Status.

• When using certain Availity transactions (Authorizations and Referrals Review and Inquiry, Eligibility and Benefits Inquiry), providers should use the automated transaction capability and obtain a transaction ID through Availity. Providers will not receive eligibility and benefits information from Florida Blue without a transaction ID. This transaction ID will also provide fast-path priority service if you should need to call the Florida Blue Provider Contact Center for assistance. You may call the Provider Contact Center at (800) 727-2227.

What if a member does not have an ID card or I can’t find eligibility and benefits information in Availity?

If you cannot find member information in Availity, call the Provider Contact Center at (800) 727-2227 for enrollment status or have the member call the number on the back of their ID card. As a reminder, if the member does not have an ID card and does not know their member ID number, you can check eligibility and benefits in Availity by using the member’s name and date of birth.

Will providers who already use electronic transactions have to do anything differently?

No. Providers should continue to follow the same processes in place today.

What is the coverage effective date for members enrolled on the Exchange?

For members who enroll on the Exchange between Oct.1, 2013 – Dec. 23, 2013, the coverage effective date is Jan. 1, 2014.

Exchange open enrollment continues from Dec. 23, 2013 – Mar. 31, 2014.  Applications received prior to the 15th day of the month are effective the first day of the following month. For example, if an application is received on Mar. 10, 2014, the coverage effective date is Apr. 1, 2014.  

What is credentialing and re-credentialing - definition

Credentialing

Credentialing  is  the  process  by  which  the  appropriate  committee  reviews  documentation  for  each individual physician/provider to determine participation in the health plan network. Such documentation may  include,  but  is  not  limited  to,  the  applicant’s  education,  training,  clinical  privileges,  experience, licensure, accreditation, certifications, professional liability insurance, malpractice history, professional competency, and physical and mental impairments. The credentialing process includes verification that the  information  obtained  is  accurate  and  complete.  The  physician/provider  must  respond  to  any reasonable CarePlus Health Plans, Inc. (CarePlus) request for additional information including, but not limited to, a medical record review as well as a site visit as applicable. 

CarePlus recognizes the physician’s/provider’s right to review information submitted in support of the credentialing application to the extent permitted by law and to correct erroneous information. Providers may obtain information regarding the status of their credentialing or recredentialing process by calling CarePlus. 

The  credentialing  process  generally  is  required  by  law.  The  fact  that  the  physician/provider  is credentialed is no intended as a guarantee or promise of any particular level of care or services. 
 
Council for Affordable Quality Healthcare (CAQH): CarePlus thru its parent company Humana Inc., is a member of the Council for Affordable Quality Healthcare (CAQH), which is an online single, national process  that  eliminates  the  need  for  multiple  credentialing  applications.  Physicians/providers  who  are members  of  CAQH  can  provide  CarePlus  with  the  appropriate  information  in  lieu  of  completing  a CarePlus credentialing or re-credentialing application. Additional information may be requested. 

CarePlus Credentials Committee: Is conducted at a corporate level thru its parent company in Louisville, KY.  The  Credentials  Committee  is  composed  of  a  chairperson  and  employed  and  participating physicians/providers. Functions of the committee include credentialing, ongoing and periodic assessment, recredentialing,  and  establishment  of  credentialing  and  recredentialing  policies  and  procedures.  The physician’s/provider’s documentation is provided to the corporate credentials committee for approval or denial  for  participation  in  the  network.  Notification  of  approval  or  denial  of  credentials  is  sent  to  the physician/provider. 

Recredentialing:  Recredentialing  is  conducted  at  least  every  three  (3)  years  in  accordance  with  the CarePlus  credentialing  and  recredentialing  process.  The  recredentialing  process  is  conducted  with  the same standards as those for initial credentialing. The decision concerning re-appointment or failure to re-appoint will be conveyed to the physician/provider in writing.

DEFINITIONS - Complaint, Grievance, Appeal, reconsideration , Quality improvment organization (QIO)

Complaint:
Any expression of dissatisfaction by a Member, including dissatisfaction with the administration, claims practices, or provision of services, which related to the quality of care provided by a provider pursuant to the organization’s contract and which is submitted to the organization or to a state agency.  

Grievance:
Any complaint or dispute, other than one involving an organization/coverage determination, expressing dissatisfaction  with  the  manner  in  which  CarePlus  or  delegated  entity  provides  health  care  services, regardless of whether any remedial action can be taken.  An enrollee or their representative may make the complaint or dispute, either orally or in writing, to CarePlus, provider or facility.  An expedited grievance may also include a complaint that CarePlus refused to expedite an organization/coverage determination, reconsideration or redetermination or invoked an extension to an organization/coverage determination or reconsideration/redetermination time frame.

In  addition,  grievances  may  include  complaints  regarding  the  timeliness,  appropriateness,  access  to, and/or  setting  of  a  provided  health  service,  procedure,  or  item.    Grievance  issues  may  also  include complaints  that a  covered health service procedure or item  during  a course of treatment  did not  meet accepted standards for delivery of health care.

Quality Improvement Organization (QIO):
Organizations comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and improve the care given to Medicare enrollees.  QIOs review complaints raised by  enrollees  about  the  quality  of  care  provided  by  physicians,  inpatient  hospitals,  hospital  outpatient department, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans,  and  ambulatory  surgical  centers.  The  QIOs  also  review  continued  stay  denials  for  enrollees receiving care in acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs, and CORFs.

Initial determination (Organization Determination):
A member must ask for a standard organization determination by making a request with the Plan, or if applicable, the entity responsible for making the determination (as directed by the Plan), in accordance with the following: the request may be made orally or in writing, except where the request is for payment.

An  organization  determination  is  any  determination  made  by  the  Plan  with  respect  to  any  of  the following:

** Payment for temporarily out of the area renal services, emergency services, post-stabilization care or urgently needed services.
** Payment for any other health services furnished by a provider or supplier other than CarePlus, that the Member or former Member believes are covered under Medicare; or if not covered under Medicare, should have been furnished, arranged for, or reimbursed by CarePlus.
** A refusal by CarePlus to provide or pay for services in whole or in part, including the type or level of services that the Member believes should be furnished or arranged for by CarePlus.
** Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment.
** Failure of CarePlus to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.

Appeal:  
Any of the procedures that deal with the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the member), or any amounts the enrollee must pay for a service as defined in 42 CFR 422.566 (b).  These procedures include reconsideration by the Health plan and if necessary, an independent review entity, hearings before Administrative  Law  Judges  (ALJ’s),  review  by  the  Medicare  Appeals  Council  (MAC),  and  judicial review.

Reconsideration:   

A member’s first step in the appeals process after an adverse organization determination; the health plan or independent review entity may re-evaluate an adverse organization determination, the findings upon which it was based, and any other evidence submitted or obtained.

What is Expedited Appeals Expedited Appeals

An expedited appeal is a review of a time-sensitive adverse organization determination or coverage determination that a member believes that he/she is entitled to receive, including:

** Any delay in provding, arranging for, or approving health care services/medications that would adversely affect the health of the member

** Reduction or stoppage of treatment or services that would adversely affect the member’s health

Note: Time-sensitive is defined as a situation in which applying the standard decision time frame could seriously jeopardize a member’s life, health, or ability to regain maximum function.

Members, their representatives, or any treating or prescribing physician (regardless of whether the provider is affiliated with Tufts Medicare Preferred HMO) can request an expedited appeal. Verbal and written requests for expedited appeals are accepted. If the request meets the necessary time-sensitive criteria, a decision will be made within 72-hours of receipt of the request, unless an extension is needed. Extensions of up to 14 calendar days can be granted if in the best interest of the member.

Note: Extensions are not allowed for expedited Part D appeals.

who is NPP, physician, patient, provider and qualified professional - definition

NONPHYSICIAN PRACTITIONERS (NPP) means physician assistants, clinical nurse specialists, and nurse practitioners, who may, if state and local laws permit it, and when appropriate rules are followed, provide, certify or supervise therapy services.

PHYSICIAN with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only). Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.


PATIENT, client, resident, and beneficiary are terms used interchangeably to indicate enrolled recipients of Medicare covered services.

PROVIDERS of services are defined in §1861(u) of the Act, 42CFR400.202 and 42CFR485 Subpart H as participating hospitals, critical access hospitals (CAH), skilled nursing facilities (SNF), comprehensive outpatient rehabilitation facilities (CORF), home health agencies (HHA), hospices, participating clinics, rehabilitation agencies or outpatient rehabilitation facilities (ORF). Providers are also defined as public health agencies with agreements only to furnish outpatient therapy services, or community mental health centers with agreements only to furnish partial hospitalization services. To qualify as providers of services, these providers must meet certain conditions enumerated in the law and enter into an agreement with the Secretary in which they agree not to charge any beneficiary for covered services for which the program will pay and to refund any erroneous collections made. Note that the word PROVIDER in sections 220 and 230 is not used to mean a person who provides a service, but is used as in the statute to mean a facility or agency such as rehabilitation agency or home health agency.


QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies. Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law. Assistants are limited in the services they may provide (see section 230.1 and 230.2) and may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP. See §230.5 of this manual. Qualified personnel may or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure.

what is EPISODE, Evaluation, and interval in outpatient therapy billing

The EPISODE of Outpatient Therapy – For the purposes of therapy policy, an outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting.

During the episode, the beneficiary may be treated for more than one condition; including conditions with an onset after the episode has begun. For example, a beneficiary receiving PT for a hip fracture who, after the initial treatment session, develops low back pain would also be treated under a PT plan of care for rehabilitation of low back pain. That plan may be modified from the initial plan, or it may be a separate plan specific to the low back pain, but treatment for both conditions concurrently would be considered the same episode of PT treatment. If that same patient developed a swallowing problem during intubation for the hip surgery, the first day of treatment by the SLP would be a new episode of SLP care.



EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions.

RE-EVALUATION provides additional objective information not included in other documentation. Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care. Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines. The decision to provide a reevaluation shall be made by a clinician.

INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individual’s needs. A physician/NPP may certify a plan of care for an interval length that is less than 90 days. There may be more than one certification interval in an episode of care. The certification interval is not the same as a Progress Report period.

Definition - Active participation, Assessment, certification, clinician and complexities

ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.


ASSESSMENT is separate from evaluation, and is included in services or procedures, (it is not separately payable). The term assessment as used in Medicare manuals related to
therapy services is distinguished from language in Current Procedural Terminology (CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment, which may be payable). Assessments shall be provided only by clinicians, because assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's status since the last visit/treatment day and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or re-evaluation (see definitions below) is indicated. Routine weekly assessments of expected progression in accordance with the plan are not payable as re-evaluations.


CERTIFICATION is the physician’s/nonphysician practitioner’s (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

The CLINICIAN is a term used in this manual and in Pub 100-04, chapter 5, section 10 or section 20, to refer to only a physician, nonphysician practitioner or a therapist (but not to an assistant, aide or any other personnel) providing a service within their scope of practice and consistent with state and local law. Clinicians make clinical judgments and are responsible for all services they are permitted to supervise. Services that require the skills of a therapist, may be appropriately furnished by clinicians, that is, by or under the supervision of qualified physicians/NPPs when their scope of practice, state and local laws allow it and their personal professional training is judged by Medicare contractors as sufficient to provide to the beneficiary skills equivalent to a therapist for that service.


COMPLEXITIES are complicating factors that may influence treatment, e.g., they may influence the type, frequency, intensity and/or duration of treatment. Complexities may be represented by diagnoses (ICD-9 codes), by patient factors such as age, severity, acuity, multiple conditions, and motivation, or by the patient’s social circumstances such as the support of a significant other or the availability of transportation to therapy.

A DATE may be in any form (written, stamped or electronic). The date may be added to the record in any manner and at any time, as long as the dates are accurate. If they are different, refer to both the date a service was performed and the date the entry to the record was made. For example, if a physician certifies a plan and fails to date it, staff may add “Received Date” in writing or with a stamp. The received date is valid for certification/re-certification purposes. Also, if the physician faxes the referral, certification, or re-certification and forgets to date it, the date that prints out on the fax is valid. If services provided on one date are documented on another date, both dates should be documented.

Definition - physicians, practitioners, interns and residents

Physicians
The Medicare Program defines physicians to include the following:

Chiropractors;
Doctors of dental surgery or dental medicine
; Doctors of medicine and doctors of osteopathy
; Doctors of optometry
; or Doctors of podiatry or surgical chiropody.

In addition, the Medicare physician must be legally authorized to practice by a State in which he or she performs this function. The services performed by a physician within these definitions are subject to any limitations imposed by the State on the scope of practice. The issuance by a State for a license to practice medicine constitutes legal authorization. A temporary State license also constitutes legal authorization to practice medicine. If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, the local standards are used in determining whether the physician has legal authorization. If the State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within these limitations are covered



Practitioners




The Medicare Program defines a practitioner as any of the following to the extent that an individual is legally authorized to practice by the State and otherwise meets Medicare requirements: Anesthesiologist assistant (AA); Certified nurse midwife (CNM); Clinical nurse specialist (CNS); Certified registered nurse anesthetist (CRNA); Clinical psychologist (CP); Clinical social worker (CSW); Nurse practitioner (NP); Physician assistant (PA); or Registered dietician or nutrition professional.


Interns and Residents
Interns and residents include individuals who: Participate in approved Graduate Medical Education (GME) programs; or Are not in approved GME programs, but are authorized to practice only in a hospital setting (e.g., have temporary or restricted licenses or are unlicensed graduates of foreign medical schools). Also included in this definition are interns, residents, and fellows in GME programs recognized as approved for purposes of direct GME and Indirect Medical Education payments made by Fiscal Intermediaries (FI) or A/B Medicare Administrative Contractors (MAC). Receiving staff or faculty appointments, participating in fellowships, or whether a hospital includes physicians in its full-time equivalency count of residents does not by itself alter the status of "resident."


Teaching Physicians
Teaching physicians are physicians (other than interns or residents) who involve residents in the care of their patients. Generally, teaching physicians must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service in order for the service to be payable under the Medicare Physician Fee Schedule (MPFS).

Medicare HIC Prefixes and Suffixe code and explanation

Medicare HIC Prefixes and Suffixes

HIC Suffix      Sex      Explanation

A     M or F     PRIMARY CLAIMANT

B     F     AGED WIFE, AGE 62 OR OVER (FIRST CLAIMANT)

B1     M     AGED HUSBAND, AGE 62 OR OVER (FIRST CLAIMANT)

B2     F     YOUNG WIFE, WITH A CHILD IN HER CARE (FIRST CLAIMANT)

B3     F     AGED WIFE (SECOND CLAIMANT)

B4     M     AGED HUSBAND (SECOND CLAIMANT)

B5     F     YOUNG WIFE (SECOND CLAIMANT)

B6     F     DIVORCED WIFE, AGE 62 OR OVER (FIRST CLAIMANT)

B7     F     YOUNG WIFE (THIRD CLAIMANT)

B8     F     AGED WIFE (THIRD CLAIMANT)

B9     F     DIVORCED WIFE (SECOND CLAIMANT)

BA     F     AGED WIFE (FOURTH CLAIMANT)

BD     F     AGED WIFE (FIFTH CLAIMANT)

BG     M     AGED HUSBAND (THIRD CLAIMANT)

BH     M     AGED HUSBAND (FOURTH CLAIMANT)

BJ     M     AGED HUSBAND (FIFTH CLAIMANT)

BK     F     YOUNG WIFE (FOURTH CLAIMANT)

BL     F     YOUNG WIFE (FIFTH CLAIMANT)

BN     F     DIVORCED WIFE (THIRD CLAIMANT)

BP     F     DIVORCED WIFE (FOURTH CLAIMANT)

BQ     F     DIVORCED WIFE (FIFTH CLAIMANT)

BR     M     DIVORCED HUSBAND (FIRST CLAIMANT)

BT     M     DIVORCED HUSBAND (SECOND CLAIMANT)

BW     M     YOUNG HUSBAND (SECOND CLAIMANT)

BY     M     YOUNG HUSBAND (FIRST CLAIMANT)

C1-C9, CA-CZ     M or F     CHILD (INCLUDES MINOR, STUDENT OR DISABLED CHILD)

D     F     AGED WIDOW, 60 OR OVER (FIRST CLAIMANT)

D1     M     AGED WIDOWER, AGE 60 OR OVER (FIRST CLAIMANT)

D2     F     AGED WIDOW (SECOND CLAIMANT)

D3     M     AGED WIDOWER (SECOND CLAIMANT)

D4     F     WIDOW (REMARRIED AFTER ATTAINMENT OF AGE 60) (FIRST CLAIMANT)

D5     M     WIDOWER (REMARRIED AFTER ATTAINMENT OF AGE 60) (FIRST CLAIMANT)

D6     F     SURVIVING DIVORCED WIFE, AGE 60 OR OVER (FIRST CLAIMANT)

D7     F     SURVIVING DIVORCED WIFE (SECOND CLAIMANT)

D8     F     AGED WIDOW (THIRD CLAIMANT)

D9     F     REMARRIED WIDOW (SECOND CLAIMANT)

DA     F     REMARRIED WIDOW (THIRD CLAIMANT)

DC     M     SURVIVING DIVORCED HUSBAND (FIRST CLAIMANT)

DD     F     AGED WIDOW (FOURTH CLAIMANT)

DG     F     AGED WIDOW (FIFTH CLAIMANT)

DH     M     AGED WIDOWER (THIRD CLAIMANT)

DJ     M     AGED WIDOWER (FOURTH CLAIMANT)

DK     M     AGED WIDOWER (FIFTH CLAIMANT)

DL     F     REMARRIED WIDOW (FOURTH CLAIMANT)

DM     M     SURVIVING DIVORCED HUSBAND (SECOND CLAIMANT)

DN     F     REMARRIED WIDOW (FIFTH CLAIMANT)

DP     M     REMARRIED WIDOWER (SECOND CLAIMANT)

DQ     M     REMARRIED WIDOWER (THIRD CLAIMANT)

DR     M     REMARRIED WIDOWER (FOURTH CLAIMANT)

DS     M     SURVIVING DIVORCED HUSBAND (THIRD CLAIMANT)

DT     M     REMARRIED WIDOWER (FIFTH CLAIMANT)

DV     F     SURVIVING DIVORCED WIFE (THIRD CLAIMANT)

DW     F     SURVIVING DIVORCED WIFE (FOURTH CLAIMANT)

DX     M     SURVIVING DIVORCED HUSBAND (FOURTH CLAIMANT)

DY     F     SURVIVING DIVORCED WIFE (FIFTH CLAIMANT)

DZ     M     SURVIVING DIVORCED HUSBAND (FIFTH CLAIMANT)

E     F     MOTHER (WIDOW) (FIRST CLAIMANT)

E1     F     SURVIVING DIVORCED MOTHER (FIRST CLAIMANT)

E2     F     MOTHER (WIDOW) (SECOND CLAIMANT)

E3     F     SURVIVING DIVORCED MOTHER (SECOND CLAIMANT)

E4     M     FATHER (WIDOWER) (FIRST CLAIMANT)

E5     M     SURVIVING DIVORCED FATHER (WIDOWER) (FIRST CLAIMANT)

E6     M     FATHER (WIDOWER) (SECOND CLAIMANT)

E7     F     MOTHER (WIDOW) (THIRD CLAIMANT)

E8     F     MOTHER (WIDOW) (FOURTH CLAIMANT)

E9     M     SURVIVING DIVORCED FATHER (WIDOWER) (SECOND CLAIMANT)

EA     F     MOTHER (WIDOW) (FIFTH CLAIMANT)

EB     F     SURVIVING DIVORCED MOTHER (THIRD CLAIMANT)

EC     F     SURVIVING DIVORCED MOTHER (FOURTH CLAIMANT)

ED     F     SURVIVING DIVORCED MOTHER (FIFTH CLAIMANT

EF     M     FATHER (WIDOWER) (THIRD CLAIMANT)

EG     M     FATHER (WIDOWER) (FOURTH CLAIMANT)

EH     M     FATHER (WIDOWER) (FIFTH CLAIMANT)

EJ     M     SURVIVING DIVORCED FATHER (THIRD CLAIMANT)

EK     M     SURVIVING DIVORCED FATHER (FOURTH CLAIMANT)

EM     M     SURVIVING DIVORCED FATHER (FIFTH CLAIMANT)

F1     M     FATHER

F2     F     MOTHER

F3     M     STEPFATHER

F4     F     STEPMOTHER

F5     M     ADOPTING FATHER

F6     F     ADOPTING MOTHER

F7     M     SECOND ALLEGED FATHER

F8     F     SECOND ALLEGED MOTHER

J1     M or F     PRIMARY PROUTY ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND)

J2     M or F     PRIMARY PROUTY ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND)

J3     M or F     PRIMARY PROUTY NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND)

J4     M or F     PRIMARY PROUTY NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND)

K1     F     PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (FIRST CLAIMANT)

K2     F     PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (FIRST CLAIMANT)

K3     F     PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (FIRST CLAIMANT)

K4     F     PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (FIRST CLAIMANT)

K5     F     PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (SECOND CLAIMANT)

K6     F     PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (SECOND CLAIMANT)

K7     F     PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (SECOND CLAIMANT)

K8     F     PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (SECOND CLAIMANT)

K9     F     PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (THIRD CLAIMANT)

KA     F     PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (THIRD CLAIMANT)

KB     F     PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (THIRD CLAIMANT)

KC     F     PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (RSI TRUST FUND) (THIRD CLAIMANT)

KD     F     PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.) (GENERAL FUND) (FOURTH CLAIMANT)

KE     F     PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C (FOURTH CLAIMANT)

KF     F     PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.)(FOURTH CLAIMANT)

KG     F     PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.)(FOURTH CLAIMANT)

KH     F     PROUTY WIFE ENTITLED TO HIB (LESS THAN 3 Q.C.)(FIFTH CLAIMANT)

KJ     F     PROUTY WIFE ENTITLED TO HIB (OVER 2 Q.C.) (FIFTH CLAIMANT)

KL     F     PROUTY WIFE NOT ENTITLED TO HIB (LESS THAN 3 Q.C.)(FIFTH CLAIMANT)

KM     F     PROUTY WIFE NOT ENTITLED TO HIB (OVER 2 Q.C.) (FIFTH CLAIMANT)

T     M or F     UNINSURED-ENTITLED TO HIB UNDER DEEMED OR RENAL PROVISIONS

TA     M or F     MQGE (PRIMARY CLAIMANT)

TB     M or F     MQGE AGED SPOUSE (FIRST CLAIMANT)

TC     M or F     MQGE DISABLED ADULT CHILD (FIRST CLAIMANT)

TD     M or F     MQGE AGED WIDOW(ER) (FIRST CLAIMANT)

TE     M or F     MQGE YOUNG WIDOW(ER) (FIRST CLAIMANT)

TF     M     MQGE PARENT (MALE)

TG     M or F     MQGE AGED SPOUSE (SECOND CLAIMANT)

TH     M or F     MQGE AGED SPOUSE (THIRD CLAIMANT)

TJ     M or F     MQGE AGED SPOUSE (FOURTH CLAIMANT)

TK     M or F     MQGE AGED SPOUSE (FIFTH CLAIMANT)

TL     M or F     MQGE AGED WIDOW(ER) (SECOND CLAIMANT)

TM     M or F     MQGE AGED WIDOW(ER) (THIRD CLAIMANT)

TN     M or F     MQGE AGED WIDOW(ER) (FOURTH CLAIMANT)

TP     M or F     MQGE AGED WIDOW(ER) (FIFTH CLAIMANT)

TQ     F     MQGE PARENT (FEMALE)

TR     M or F     MQGE YOUNG WIDOW(ER) (SECOND CLAIMANT)

TS     M or F     MQGE YOUNG WIDOW(ER) (THIRD CLAIMANT)

TT     M or F     MQGE YOUNG WIDOW(ER) (FOURTH CLAIMANT)

TU     M or F     MQGE YOUNG WIDOW(ER) (FIFTH CLAIMANT)

TV     M or F     MQGE DISABLED WIDOW(ER) FIFTH CLAIMANT

TW     M or F     MQGE DISABLED WIDOW(ER) FIRST CLAIMANT

TX     M or F     MQGE DISABLED WIDOW(ER) SECOND CLAIMANT

TY     M or F     MQGE DISABLED WIDOW(ER) THIRD CLAIMANT

TZ     M or F     MQGE DISABLED WIDOW(ER) FOURTH CLAIMANT

T2-T9     M or F     DISABLED CHILD (SECOND TO NINTH CLAIMANT)

W     F     DISABLED WIDOW, AGE 50 OR OVER (FIRST CLAIMANT)

W1     M     DISABLED WIDOWER, AGE 50 OR OVER (FIRST CLAIMANT)

W2     F     DISABLED WIDOW (SECOND CLAIMANT)

W3     M     DISABLED WIDOWER (SECOND CLAIMANT)

W4     F     DISABLED WIDOW (THIRD CLAIMANT)

W5     M     DISABLED WIDOWER (THIRD CLAIMANT)

W6     F     DISABLED SURVIVING DIVORCED WIFE (FIRST CLAIMANT)

W7     F     DISABLED SURVIVING DIVORCED WIFE (SECOND CLAIMANT)

W8     F     DISABLED SURVIVING DIVORCED WIFE (THIRD CLAIMANT)

W9     F     DISABLED WIDOW (FOURTH CLAIMANT)

WB     M     DISABLED WIDOWER (FOURTH CLAIMANT)

WC     F     DISABLED SURVIVING DIVORCED WIFE (FOURTH CLAIMANT)

WF     F     DISABLED WIDOW (FIFTH CLAIMANT)

WG     M     DISABLED WIDOWER (FIFTH CLAIMANT)

WJ     F     DISABLED SURVIVING DIVORCED WIFE (FIFTH CLAIMANT)

WR     M     DISABLED SURVIVING DIVORCED HUSBAND (FIRST CLAIMANT)

WT     M     DISABLED SURVIVING DIVORCED HUSBAND (SECOND CLAIMANT)

SNF - Skilled Nursing Facility - Definition

What Is a Skilled Nursing Facility?

A skilled nursing facility is a location dedicated to the care of individuals in a residential facility, usually there on a long-term basis. These facilities specialize in the 24-hour care and observation of individuals whose needs are usually critical enough where they need constant watching, but not serious enough where hospitalization is required.

A skilled nursing facility may often be called a nursing home by some people. They are often called that because nurses, of varying degrees and certifications, take on the bulk of the patient care work. They carry out this care by working closely with a patient's team of personal doctors, following those physicians’ directions and holding consultations as necessary. Doctors also make visits, in some cases, to skilled nursing facilities to provide check-up examinations.

Traditionally, a skilled nursing facility has been used for care of the elderly, leading to the somewhat unflattering term "old folks home." However, since that time, many skilled nursing facilities have added rehabilitation to their list of services. An individual may check into a skilled nursing facility, for example, to work on physical therapy after a surgery like a hip or knee replacement.

Often, these types of surgery limit mobility and make it problematic, especially for someone who lives alone. Being at a skilled nursing facility gives these individuals a chance to have round the clock care and also receive physical therapy services in the same location.

In general, a skilled nursing facility is an option for those who can no longer carry out the functions of daily lives, either on a temporary or permanent basis. Staff at a skilled nursing facility will help the individual with a number of everyday tasks, including bathing, eating, grooming and toileting.

In the United States, time spent at a skilled nursing facility can be expensive and not always covered by health insurance. This has led many individuals to consider getting a supplement to their normal health insurance coverage that will specifically cover nursing home care. A study reported by New York Life, an American insurance company, noted the average cost of a private room at a skilled nursing facility in the United States has increase to $204 US Dollars (USD) per day. The average price of a shared room is $180 USD per day. Prices were highest in the state of Alaska, where a private room costs more than $350 USD per day.

Room arrangements in a skilled nursing facility are similar to those in hospitals. They can be either private or shared. Similarly, bathrooms can be either private or shared.


SERVICES OFFERED BY NURSING FACILITIES

Nursing and Rehabilitative Services: Nursing procedures require the professional skills of a registered or a licensed practical nurse. These skills include assessment, conducting treatments, injections and coordination care. Post-hospital stroke, heart, or orthopedic care is available with related services such as physical therapy, occupational therapy, speech therapy, dental services, dietary consultation, laboratory and x-ray services, and a pharmaceutical dispensary.
Personal Care: These services include help in walking, getting in and out of bed, bathing, toileting, and dressing, eating, and preparing special diets as prescribed by a physician.

Residential Services: These include general supervision and a protective environment, such as room and board and a planned program for the social and spiritual needs of the resident.

Medical Care: Each patient in a nursing facility is under the care of a physician, who visits periodically and is responsible for the patient's overall plan of care. In most cases, the patient's personal physician refers the patient to the facility and certifies the need for admission. Once the patient is admitted, the physician writes orders for any necessary medication and plays a role in the development of patient care plan, including restorative and rehabilitative procedures, special diets, and other treatments. Every nursing facility has at least one physician on staff or on call to handle emergencies.

SKILLED NURSING FACILITY

Skilled nursing facility (SNF) is a facility that primarily provides inpatient, skilled nursing care and related services to patients at a lesser intensity than an acute facility . SNF’s are used for patients who need medical, nursing care, or rehabilitation services.

Patients are usually treated on a long term basis and care is less expensive than in a hospital. The most common SNF facility is a nursing home. These facilities are usually run by nurses and would just have a visiting doctor on call.

NURSING FACILITY DETERMINATIONS

After the Medicaid application and MSA-2565-C have been submitted, the local MDHHS office determines eligibility for medical assistance. All allowable expenses and income are calculated, and any remaining income is considered excess income. Such excess income is then considered in determining the amount the beneficiary must pay toward his medical expenses each month. This monthly contribution by the beneficiary toward his care is called the patient pay amount.


Nursing facilities have the following options to obtain patient pay amount and eligibility information:

** DHS-3227 – If the local MDHHS office is unable to determine final eligibility status within five working days of receipt of the application for medical assistance, the Tentative Patient Pay Amount Notice (DHS-3227) is sent to the facility as notification of the person's tentative patient pay amount. When the final determination is made, a copy of the MSA-2565-C is returned to the facility.

** CHAMPS Eligibility Inquiry and/or other available eligibility options to obtain the Benefit Plan ID, LOC authorization, facility information and patient pay amount. (Refer to the Directory Appendix for contact and website information.)

The identity of residents in each facility is determined from the Medicaid Provider ID number and the NPI number entered on the MSA-2565-C submitted at admission or readmission.

It is very important that providers ensure that their provider numbers are valid.

CHAMPS Eligibility Inquiry and/or other available eligibility options should be used in the preparation of bills for services provided in that month. This avoids many billing problems stemming from eligibility information. The facility may contact the beneficiary's local MDHHS office as identified on the eligibility response if the information provided is incorrect.

The provider should contact MDHHS Provider Inquiry for answers to billing questions.



Facilities are responsible for collecting the patient pay amount. If the facility receives the DHS-3227, it indicates a tentative patient pay amount to be collected by the facility. In determining the tentative patient pay amount, MDHHS does not prorate for partial months. This amount is subject to change as the beneficiary's financial eligibility changes. The patient pay amount must be exhausted before any Medicaid payment is made.

A beneficiary who has a patient pay amount cannot legally be charged more than the Medicaid rate for a short stay in a facility. For example, if a beneficiary is in a long term care facility for two days in a month, the provider must collect no more than the Medicaid rate for two days from the patient pay amount (even if the patient pay amount For state-owned and -operated facilities, the following instructions apply:

** Item 13: attending physician - This item may be left blank.

** Item 19: if NF, specify per diem rate. The facility should enter its private pay routine nursing care per diem rate to facilitate determination of Medicaid eligibility.

Medicaid does not pay the facility services rendered if:

** The returned copy of the MSA-2565-C indicates the person is not eligible for Medicaid.

** The person has a divestment penalty (LOC Code 56).