Alaska Medical
Assistance Program
Long-term Care Facility
Provider Billing Manual
Dear Medical Assistance Provider:
We are pleased to provide you with the enclosed provider billing manual to help you prepare your Medical Assistance claim forms.
This billing manual has been prepared by First Health Services Corporation for the State of Alaska. First Health Services is the fiscal agent for the Alaska Department of Health and Social Services.
The manual contains basic information on coverage and billing for medical services you provide to qualified recipients of our various medical assistance programs. It is designed to help you: 1) fill out health insurance claim forms for your eligible patients, 2) understand what medical services are reimbursable, and 3) understand the policies and procedures of these programs.
As policies and procedures change, you will receive the updated information through bulletins and replacement pages to this manual. Your manual has been arranged in a loose-leaf format divided by sections and numbered so that replacement pages can be easily inserted.
It is important to review and insert the updated information promptly to keep a current reference. Claim forms with outdated information may cause the automated payment system to reject the claim request. It is extremely important that you and your claims personnel follow the instructions described in the manual for your claims to be processed quickly and efficiently.
It is our intention to make this manual useful to you, and we welcome any suggestions about the format that you believe would be helpful.
Alaska Medical Assistance Program Provider Billing Manual
How To Use This Manual
Information about how to bill the Alaska Medical Assistance program for reimbursement of services rendered to medical assistance recipients is contained in this provider billing manual.
Provider billing manuals are specific to type of service (for example, there are separate manuals for inpatient hospital, physician services, pharmacy, chiropractic, etc.). Manual pages are printed on three-hole paper and mailed to providers in a loose leaf format to make updating easy. The manuals are organized in three numbered sections to assist you in finding the information you need.
Section I contains specific information about how to bill Medical Assistance for a particular type of service.
Section II contains information about supplemental documents and instructions.
Section III contains general Medical Assistance program information.
Appendices are included at the end of the manual for additional information.
A Table of Contents is included beginning on page vii of each provider billing manual. Use the Table of Contents to help locate information in your manual.
Updated 09/02
Written Correspondence and Provider Training
The provider billing manuals are meant to be used in conjunction with other provider communication, including Remittance Advice (RA) Messages, letters and other written correspondence, and information delivered at provider training seminars.
Providers are notified of changes in billing and reimbursement policy in weekly RA Messages. An RA is issued weekly to providers with claims activity. The Message Page of the RA will contain important provider billing information (including new information, clarifications and reminders). Revised manual pages are mailed to providers after the RA Messages are issued.
Provider training topics, dates and locations are also announced in the RA Messages.
For information, questions or suggestions about the provider billing manuals, other correspondence, or provider training, contact First Health Services Corporation or the Division of Health Care Services at the phone numbers or addresses listed on pages v and vi.
Telephone Inquiries
First Health Services Corporation
Questions? Please call First Health Services Corporation at (907) 644-6800 or our in-state toll free number, 1-800-770-5650, about your participation in Alaska Medical Assistance. The First Health Services staff has been fully trained to answer most of your questions immediately. The following numbers can help you with other, more specific, questions:
Billing Procedures
(8:00 a.m. – 5:00 p.m.) in-state toll free 1-800-770-5650
(907) 644-6800 Claims & Eligibility Status
(8:00 a.m. – 5:00 p.m./Claims) in-state toll free 1-800-770-5650
(8:00 a.m. – 5:00 p.m./Eligibility) (907) 644-6800
Electronic Data Interchange (EDI)
in-state toll free 1-800-770-5650 (907) 644-6800 Electronic Commerce Customer Support (ECCS) Coordinator
(907) 644-6800 Eligibility Verification System (EVS)
(24-hour access) toll free 1-800-884-3223
Enrollment
(8:00 a.m. – 5:00 p.m.) in-state toll free 1-800-770-5650
(907) 644-6800 Fax
for Provider Inquiry (PI) (907) 644-8126 or (907) 644-8127
for Prior Authorization (PA) (907) 644-8131
for EDI Attachments (907) 644-8122 or (907) 644-8123
for Resubmission Turnaround Documents (907) 644-8122 or (907) 644-8123
Prior Authorization (PA)
(8:00 a.m. – 5:00 p.m.) in-state toll free 1-800-770-5650
(907) 644-6800 Provider Inquiry/Provider Services
(8:00 a.m. – 5:00 p.m.) in-state toll free 1-800-770-5650
(907) 644-6800 Report Fraud, Waste, Abuse, or Misuse of the Medicaid Program by Providers or
Recipients
(24-hour access) toll free 1-800-256-0930
Internet
Addresses
First Health Services Corporation P.O. Box 240807
Adjustment/Voids
Anchorage, AK 99524-0807 First Health Services Corporation Appeals
P.O. Box 240808 1st Level
Anchorage, AK 99524-0808 Division of Health Care Services Claims Appeal Section
4501 Business Park Boulevard, Suite 24 Appeals:
2nd Level
Anchorage, AK 99503-7167 First Health Services Corporation P.O. Box 240729
Hospital, ESRD, and LTC
Anchorage, AK 99524-0729 P.O. Box 241609
(IHS) Indian Health Services
Anchorage, AK 99524-1609 P.O. Box 240649 Pharmacy Anchorage, AK 99524-0649 P.O. Box 240769 Claims: All Others Anchorage, AK 99524-0769 First Health Services Corporation EMC Department/ECCS Department P.O. Box 240808
Electronic Media Claims (EMC)/Electronic Commerce Customer Support (ECCS)
Anchorage, AK 99524-0808 First Health Services Corporation Provider Enrollment
P.O. Box 240808 Enrollment
Anchorage, AK 99524-0808 First Health Services Corporation Provider Services Unit
P.O. Box 240808 Inquiries and Correspondence
Anchorage, AK 99524-0808 First Health Services Corporation Prior Authorization Unit
P.O. Box 240808 Prior Authorization
Anchorage, AK 99524-0808 First Health Services Corporation Surveillance and Utilization Review P.O. Box 240808
SURS (Surveillance and Utilization Review Subsystem)
Anchorage, AK 99524-0808
State of Alaska
Alaska Department of Health and Social Services* Internet Web Site: http://www.hss.state.ak.us
Call: (907) 465-3030
Alaska Medical Assistance/Division of Health Care Services Internet Web Site: http://www.hss.state.ak.us/dhcs/contacts.htm
Call: (907) 465-3355
Medicaid Provider Fraud Control Unit, Department of Law To report fraud of the Medicaid program by providers
Call: (907) 269-6279
Write: Medicaid Provider Fraud Control Unit
State of Alaska, Department of Law Criminal Division
310 K Street, Suite 300 Anchorage, AK 99501
Fraud Control Unit, Division of Public Assistance, Department of Health and Social Services
To report recipient Fraud and Abuse of Medicaid and other public assistance programs
Toll free: 1-800-478-6406 In Anchorage (907) 269-1060 In Wasilla (907) 352-2534 In Kenai (907) 283-2947 Call: In Fairbanks (907) 451-2802
Write: Fraud Control Unit
State of Alaska, DHSS Division of Public Assistance 3601 C Street, Suite 200 Anchorage, AK 99503
Table of Contents
Long-term Care Facilities
Introductory Letter... iii
How To Use This Manual... iv
Telephone Inquiries ... v
Addresses... vi Section I—Long-term Care Facility Services Policies and Claims Billing Procedures ...I-1
Provider Participation Requirements ...I-1 Facility Services...I-2 Skilled Nursing Facility (SNF)...I-2 Intermediate Care Facility (ICF) ...I-2 Admission Procedures and Determination of Level of Care ...I-2 Authorization for Admission ...I-2 Determination of Level of Care...I-3 Table I-1. Long Term Care Authorization Form (AK-LTC-1) Information ...I-3 Absence from Facility ...I-4 Transfer of Recipients ...I-4 Long Term Care Authorization Form (AK-LTC-1) Instructions ...I-5 Section I: To Be Completed by the Receiving Facility (All Fields Are Required) ...I-5 Section II - To Be Completed by Attending Physician or Designee (All Fields All Required) ...I-6 Section III - To Be Completed by DSDS (Division Of Senior and Disabilities Services) or
Designee ...I-6 Section IV - To Be Completed by the SNF or ICF...I-7 Payment Methodology...I-14 Rates ...I-14 Other Payments ...I-14 SNF/ICF Chargeable Days ...I-14 Medicare Coinsurance ...I-14 Covered Services ...I-15 Coverage for SNF/ICF Services ...I-15 Recipient’s Personal Incidental Funds...I-15 Personal Incidental Items, Supplies, or Services ...I-15 Management of Recipient’s Personal Incidental Funds ...I-16 Recipient’s Personal Property ...I-16 Prescribed Drugs: Prior Authorizations and Limitations...I-16 Recipient Eligibility...I-17 Verification...I-17 Table I-2. Advantages of EVS...I-17 Eligibility Codes...I-17 Table I-3. Eligibility Codes: Long Term Care Facility Services...I-17
TPL (Third Party Liability) ...I-20 Federal TPL Waiver ...I-20 Recipients with VA, Medicare, and Medicaid...I-20 Obtaining a VA Medicaid Denial Letter ...I-21 Providers Can Attach Other Insurance Benefit Booklet Pages ...I-22 Third Party Liability (TPL) Avoidance ...I-22 Claims Billing Procedures ...I-25 Claims: General Instructions ...I-25 Completing the Long Term Care UB-92 Claim Form...I-25 UB-92 Instructions ...I-27 Billing for Changes in Level of Care Within the Facility ...I-34 Revenue Codes and Descriptions ...I-37 Medicare/Medical Assistance Crossover Billing...I-40 Billing Medical Assistance for Services Denied or Limited by Medicare ...I-40 Receiving Payment from Medical Assistance ...I-40 Completing the Medicare/Medical Assistance Crossover Billing...I-41
Section II—Supplemental Documents and Instructions ...II-1
Attachments to the Claim Form... II-1 Proof of Timely Filing Documentation ... II-1 Electronic Claims Attachment Transmittal ... II-1 Insurance Explanation of Benefits (EOB) ... II-3 Explanation of Medicare Benefits/Medicare Remittance Notice (EOMB/MRN) or
Medicare Payment Report ... II-3 Prior Authorization Request (AK-PA) ... II-4 Requesting Authorization... II-4 Requesting Retroactive Authorization... II-4 Completing the Prior Authorization Request (AK-PA): By Provider ... II-4 Reviewing the Prior Authorization Request (AK-PA) ... II-6 Completing the Prior Authorization Request (AK-PA): By FHSC... II-6 Correcting Errors on the Prior Authorization Request (AK-PA) ... II-6 Submitting the Claim... II-6 Transportation Authorization and Invoice (AK-04) ... II-8 Requesting Transportation/Accommodation Services ... II-8 Step By Step ... II-9 Remittance Advice... II-13 Cover Page... II-13 Message Page ... II-14 Adjudicated Claims (Paid and Denied Claims) ... II-15 Adjustment Claims ... II-17 Voided Claims ... II-19 In-Process Claims... II-20 Financial Transactions... II-22 EOB Description Page... II-23 Remittance Summary ... II-25 Resubmission Turnaround Document (RTD)... II-28 Adjustment/Void Request Form (AK-05) ... II-33 General Guidelines ... II-33 Adjustment ... II-33 Void ... II-33 Overpayment/Refund ... II-34 Completing the Adjustment/Void Request Form (AK-05) ... II-34
Claim Inquiry Form (AK-11) ... II-37 General Guidelines ... II-37 Completing the Claim Inquiry Form (AK-11) ... II-37 Forms Order Request... II-39
Section III—Alaska Medical Assistance Program General Program Information ...III-1
Program Introduction...III-1 Program Background...III-1 Program Objectives ...III-1 Program Fiscal Agent ...III-1 Table III-1. Guidelines to Efficient Telephone Inquiries ...III-2 Provider Billing Information ...III-2 Claims Processing Overview...III-2 HCPCS Coding...III-2 Unlisted Codes...III-3 Diagnosis Codes ...III-3 Coding Updates ...III-4 Claims Submission ...III-4 Table III-2. Advantages of EDI Transactions...III-4 Computer Operations...III-4 Adjudication ...III-4 Payment ...III-5 Services...III-5 Medical Assistance Covered Services...III-5 Chronic and Acute Medical Assistance (CAMA) Covered Services ...III-6 Denali KidCare...III-6 Out-of-State Services...III-7 Medically Necessary Services ...III-7 Medical Assistance Providers...III-8 Eligible Providers ...III-8 Non-Eligible Providers...III-9 Provider Enrollment Requirements ...III-10 Eligible Recipients...III-11 Recipient Residency Requirements ...III-11 One-Day/One-Month Eligibility...III-12 Eligibility Verification System (EVS)...III-12 Table III-3. Advantages of EVS ...III-12 Medical Authorization: ID Cards and Coupons ...III-12 Table III-4. Codes on Recipient’s Card or Coupon...III-13 Medical Assistance Eligibility Codes...III-15 Table III-5. Medical Assistance Eligibility Codes ...III-15 Chronic and Acute Medical Assistance (CAMA) Subtype ...III-16 Table III-6. CAMA Eligibility Subtype ...III-16 Resource Codes ...III-16 Eligible Medical Assistance Recipients ...III-18 Retroactive Eligibility for Eligible Medical Assistance Recipients ...III-19 Eligible Chronic and Acute Medical Assistance (CAMA) Recipients...III-19 Regulations and Restrictions ...III-20 Discriminatory Practices ...III-20
Conditions for Payment...III-22 Recovery or Recoupment of an Overpayment...III-23 Appeals Process...III-24
Glossary... Glossary-1 Appendix A—Directory Assistance... A-1 Appendix B—Julian Date Calendar... B-1 Appendix C—Surveillance and Utilization Review Subsystem (SURS)... C-1 Appendix D—Forms ... D-1 Appendix E—Transportation and Accommodation Resource Materials... E-1 Appendix F—Telemedicine ...F-1
Section I
Long-term Care Facility Services
Policies and Claims Billing Procedures
Long term care facility services are covered for Medical Assistance recipients who need supervised nursing care services of a certified and licensed Skilled Nursing Facility (SNF), or an Intermediate Care Facility (ICF). All long term care facility services require prior authorization by the State of Alaska, Division of Senior and Disabilities Services (see Appendix A). Recipients must be eligible for long term care Medical Assistance services (see Table I-3 for eligibility information).
Updated 01/05
Provider Participation Requirements
A facility that is certified and licensed as a Skilled Nursing Facility (SNF), or an Intermediate Care Facility (ICF) by the State of Alaska, Division of Public Health, Certification and Licensing office (see Appendix A) may apply for enrollment with Alaska Medical Assistance.
The facility must:
Have written policies stating it will accept only recipients whose needs can be met by the facility directly or in cooperation with community resources or other providers of care with which it is affiliated or has a contract.
Monitor admissions carefully to ensure that only recipients are admitted whom it has the capability to treat.
Notify the Division of Senior and Disabilities Services (DSDS) and assist in prompt transfer of a recipient to another facility that can provide the care needed if the facility is unable to provide appropriate care.
An enrolled provider with a current provider agreement on file with the Alaska Division of Health Care Services may provide and be reimbursed for covered long term care facility services rendered to eligible recipients. See general enrollment requirements in Section III.
Out-of-state providers must meet the licensing requirements of their state, be enrolled in their state’s Medicaid program, and be enrolled in the Alaska Medical Assistance program.
Facility Services
Skilled Nursing Facility (SNF)
Services of a Skilled Nursing Facility (SNF) are characterized by the following:
Recipient’s need for skilled nursing1 or structured rehabilitation for an unstable condition Services ordered by and under the direction of a licensed physician
Services provided either directly by or under supervision of qualified technical or professional personnel2 who must be on the premises at the time services are rendered
Updated 04/03
Intermediate Care Facility (ICF)
Services of an Intermediate Care Facility (ICF) are characterized by the following:
Recipient’s need for intermediate nursing services3 or therapy for a stable condition Services ordered and under the direction of a licensed physician
Services that do not require the care in a hospital or Skilled Nursing Facility
Updated 04/03
Admission Procedures and Determination of Level of Care
Authorization for Admission
A recipient may receive authorization for long term care facility services as a new admission, transfer, or continuing placement. The recipient may currently be receiving acute care in a hospital or an inpatient psychiatric facility or non-acute care in a skilled nursing facility (SNF), an intermediate care facility (ICF), a home or other non-acute care setting. In each case, authorization is requested by the facility or hospital on a Long Term Care Authorization form (AK-LTC-1). The Consent Form (AK-LTC-2) and MI/MR Supplement Assessment Level I form must also be completed. These forms are submitted to the Division of Senior and Disabilities Services for approval. The AK-LTC-1 will include recommendations for placement that have been established, where appropriate, by preliminary evaluation, utilization review committee, interdisciplinary team, or the Division of Senior and Disabilities Services. The AK-LTC-2 is a consent form to indicate that the recipient has been involved in his/her own planning and would like to go to a nursing home. The MI/MR Supplement Assessment Level I is used to identify mental illnesses or mental retardation diagnoses and determine if a nursing home will meet the recipient’s needs or if active treatment in another setting is required. See sample forms in Figures I-1 - I-6 and refer to accompanying instructions.
Updated 01/05
1 Skilled nursing services are the observation, assessment, and treatment of a recipient's unstable condition requiring
the care of licensed nursing personnel to identify and evaluate the recipient's need for possible modification of treatment, the initiation of ordered medical procedures, or both, until the recipient's condition stabilizes.
2 Qualified technical or professional personnel include registered nurse, licensed practical nurse, physical therapist,
licensed physical therapy assistant, occupational therapist, certified occupational therapy assistant, speech pathologist, and audiologist.
3 Intermediate nursing services are a) the observation, assessment and treatment of a recipient with long-term illness
or disability whose condition is relatively stable, with emphasis on maintenance rather than rehabilitation; or b) care for a recipient nearing recovery and discharge whose condition is relatively stable, but who continues to require professional medical or nursing supervision.
Determination of Level of Care
When long term care is approved, the level of care for the recipient and the length of stay are also authorized. The recipient’s level of care is determined by considering the type of care required, the qualifications of the person who will provide direct care, and the stability of the recipient’s overall condition. Oral information will not be accepted to support a level-of-care decision.
Updated 04/03
Level of Care for New or Continuing LTC Recipient
A current, approved AK-LTC-1 form and all utilization review reports must be on file with DSDS to support each recipient’s level-of-care placement. Reauthorization requests should be submitted one month prior to the end of the current authorization period. See Table I-1 for information to include on the form.
Table I-1. Long Term Care Authorization Form (AK-LTC-1) Information
Medical reason for continued stay
Information supporting the level-of-care decision of the utilization review committee4 Plan of care established for the treatment prescribed by the attending physician
Recipient’s diagnoses, symptoms, complaints, and complications indicating the need for admission or continued stay
Description of the functional level of the recipient Written objectives
Orders for medications, treatments, restorative and habilitative services, therapies, diet, activities, social services, and special procedures to meet these objectives
Plans for continuing care, including provision for review and necessary modification of the plan Reasons why alternative placement is not feasible or appropriate
Plan for discharge
Updated 01/05
Level of Care for Recipient in Acute Care
If a decision is made to transfer a recipient from acute care (in a hospital or inpatient psychiatric facility), a preliminary evaluation must be prepared to establish the need for long term care placement. This evaluation is made by the attending physician, director of nursing, and any therapist, specialist or other professional involved in the care of the recipient. The evaluation is submitted with the AK-LTC-1 forms to the Division of Senior and Disabilities Services within one week of the recipient’s admission to a long term care facility. Following evaluation of the AK-LTC-1 forms, DSDS will approve the placement or request additional information to support a level-of-care decision. If the placement is approved, the facility is notified of the length of certification and the date of the next review by the facility’s utilization review committee. If the placement is disapproved after reviewing additional information, admission will not be reimbursed by DHCS.
Absence from Facility
The long term care facility must submit a request in writing to DSDS for any leave of absence that exceeds 12 days. Written approval must be received by the facility before the leave begins. The Division of Health Care Services will not pay for:
More than 12 consecutive days of leave of absence without written prior authorization.
More than 12 total days of absence within a 12-month period per recipient without written prior authorization5.
Authorized leaves include visits with relatives and friends of not more than 12 days in duration, and leave to participate in therapeutic or rehabilitative programs6. The purpose and plan of all therapeutic or
rehabilitative leave must be documented in the recipient’s plan of care at the facility.
Updated 01/05
Transfer of Recipients
For ICF/SNF recipients, transfer to another facility requires 10 days’ prior written notice to the recipient and, where appropriate, the family or guardian, the attending physician, the regional office, and the medical practice review section of the facility, depending on whether the division or the facility is proposing transfer.
For ICF/SNF recipients, transfer to another facility requires 30 days’ prior written notice to the recipient and, where appropriate, the family or guardian and to the Division of Health Care Services, and either the Division of Senior and Disabilities Services or the facility, depending on whether DSDS or the facility is proposing the transfer.
Recipients who receive notice of a proposed transfer have hearing rights as set out in 7 AAC 49.
Updated 01/05
5 "12-month period" refers to 12 months from the day of admission or anniversary of the admission date.
6 Therapeutic or rehabilitative programs include, but are not limited to: a) trial visits to alternative care settings to
determine if permanent placement is feasible; b) gradual increased length of visits to prepare recipients for returning to their home or community; and c) extended absences to participate in workshop evaluation for rehabilitative programs.
Long Term Care Authorization Form (AK-LTC-1) Instructions
Authorization for long term care facility services is requested by the receiving facility on a Long Term Care Authorization form (AK-LTC-1). The receiving facility completes Section I and Section IV, as appropriate, of the AK-LTC-1 according to the following instructions. In addition, if the request is for an initial authorization, the AK-LTC-2 and the MI/MR Supplement Assessment Level I forms must be completed. If the request is for a reauthorization, complete only the AK-LTC-1 form.
Updated 01/05
Section I: To Be Completed by the Receiving Facility (All Fields Are
Required)
AK-LTC-1 Field Number Explanations and Instructions
1. Type of Request Place an “X” on the applicable line: initial, reauthorization, corrections, level of care change, or retroactive request.
If “corrections” is marked, the changes needed should be clear and concise.
2. Recipient Name Enter the patient’s full name: last, first, and middle initial.
3. Recipient I.D. No. Enter the recipient’s 10-digit Alaska Medical Assistance identification number as it appears on the eligibility coupon/label.
4. Sex Place an “X” on the applicable line.
5. Birth Date Enter the patient’s date of birth using MM/DD/YY characters; for example, June 15, 1925 - 06-15-25.
6. Age Enter the age of the recipient.
7. Recipient Presently At Place an “X” on the applicable line: home, acute care, or other (specify place in 7a)
7a. Name of Facility Currently At
Specify place recipient is currently at (if indicated “other” in field 7)
Requesting Placement at:
8. Name of Facility Enter the name of the receiving long term care facility.
9. Facility I.D. No. Enter the Alaska Medical Assistance provider identification number of the receiving long term care facility.
10. Date of Admission: (Planned or Actual)
Enter the planned date of admission to the long term care facility or the actual date the patient was admitted.
11. Period of Care Requested
Enter the “from” and “to” dates requested for period of care (maximum 90 days for SNF and 180 days for ICF).
12. Recommended Level of Care
Place an “X” on the applicable line indicating the level of care being recommended: skilled nursing facility (SNF), intermediate care facility (ICF), hospital swing bed (Swing), or administrative wait days (AW Days).
13. Facility U.R. Committee Signature and Date
A representative of the utilization review committee of the receiving long term facility must sign and date here.
Section II - To Be Completed by Attending Physician or Designee (All Fields
All Required)
AK-LTC Field Number Explanations and Instructions
14. Primary Diagnosis Enter a written description of the primary diagnosis.
15. Primary Diagnosis Code Enter the ICD-9-CM7 diagnosis code of the primary diagnosis.
16. Secondary Diagnosis Enter a written description of the secondary diagnosis, if applicable. If an additional diagnosis applies, enter the description on the extra line here.
17. Secondary Diagnosis Code
Enter the ICD-9-CM code of any applicable secondary diagnosis, if applicable. If an additional diagnosis applies, enter the description and ICD-9-CM code on the extra line here.
18. Medications Enter the name of the medication, the dosage, and the frequency prescribed by the physician or attach appropriate medication sheets. 19. Physician
Recommended Level of Care
Place an “X” on the applicable line, indicating the level of care recommended by the attending physician: skilled nursing facility (SNF), intermediate care facility (ICF), hospital swing bed (Swing), or administrative wait days (AWD).
20. Period of Care Requested
Enter the “from” and “to” dates requested for period of care. 21. Physician Name and
Address
Enter the attending physician’s name and address.
22. I.D. # Enter the Alaska Medical Assistance provider identification number of the attending physician.
23. Physician Signature The attending physician or designee must sign here if signature is not on discharge plan/order for LTC.
Note: For re-authorizations, the signature may be “on file.” 24. Date Enter the date that the attending physician completed Section II.
Updated 01/05
Section III - To Be Completed by DSDS (Division Of Senior and Disabilities
Services) or Designee
After completing its portion of the AK-LTC-1, the receiving long term care facility submits both the original and copy of the form to the Division of Senior and Disabilities Services. The Division will review and evaluate the information on the form, complete Section III, and notify the facility requesting authorization of the determination. Note that the agency name and address at the top of the AK-LTC-1 form have changed. See Alaska Division of Senior and Disabilities Services, in Appendix A.
Updated 01/05
Section IV - To Be Completed by the SNF or ICF
The SNF or ICF completes Part A on all initial requests and completes both Part A and B on reauthorization requests. Required fields are indicated by *.
AK-LTC-1 Field Number Explanations and Instructions
*32. Recipient’s Name Be sure that the recipient’s name is entered here.
Part A
*33. Current Nursing Needs (Services recipient requires that can only be provided by licensed nursing personnel)
Summarize the patient’s current nursing needs. List services that can be provided only by licensed nursing personnel (defined earlier in this section).
*34. Rehabilitation Goals Enter an “X” on the applicable line. If “active rehab” is checked, state goals, progress, and projected time frame.
*35. Discharge Plan Enter an “X” on the applicable line. If “yes” is checked, state the discharge plan with the time frame. If “no” is checked, state the reason of no discharge plan.
*36. Signature of Person Completing This Section
The person completing this section of the form must sign here.
*37. Title Enter the title of the person signing this section of the form. *38. Date Enter the date that this section was completed.
DIVISION OF SENIOR & DISABILITIES SERVICES 3601 C STREET, SUITE 310 ANCHORAGE AK 99503 Phone (907) 269-3666 Fax (907) 269-3689
DATE SENT TO FIRST HEALTH ____________________________
LONG TERM CARE FACILITY AUTHORIZATION
CONTROL NUMBER:
__________________________________
1. TYPE OF REQUEST: 2. RECIPIENT NAME
INITIAL (LAST) (FIRST) (MI)
REAUTHORIZATION 3. RECIPIENT
CORRECTIONS** ID NUMBER: __________4. SEX: M F LEVEL OF CARE CHANGE
RETROACTIVE REQUEST 5. BIRTHDATE: _ 6. AGE:
7. RECIPIENT PRESENTLY AT: HOME ACUTE CARE OTHER (PLEASE SPECIFY IN SPACE-7a) ____ 7a. NAME OF FACILITY CURRENTLY AT: __________________________________________________________________ REQUESTING PLACEMENT AT:
8. NAME OF FACILITY: __________ 9. FACILITY ID#: 10. DATE OF ADMISSION: 11. PERIOD OF CARE REQUESTED: _____ TO (PLANNED OR ACTUAL)
12. RECOMMENDED LEVEL OF CARE: _____ SNF ____ ICF ____ SWING ____ AW DAYS 13. FACILITY U.R. COMMITTEE SIGNATURE: DATE:
SECTION II - TO BE COMPLETED BY ATTENDING PHYSICIAN
14. PRIMARY DIAGNOSIS: 15. CODE:
16. SECONDARY DIAGNSIS: 17. CODE:
CODE:
18. MEDICATIONS: 19. PHYSICIAN RECOMMENDED LEVEL OF CARE: __ SNF __ ICF __ SWING _ AWD 20. PERIOD OF CARE REQUESTED:
TO
21. PHYSICIAN NAME: 22. ID#
ADDRESS:
TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE ACCURATE AND COMPLETE. THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT.
23. PHYSICIAN SIGNATURE: 24. DATE:
SECTION III - TO BE COMPLETED BY DSDS (DIVISION OF SENIOR & DISABILITES SERVICES)
25. DATE RECEIVED IN DSDS: 26. ACTION TAKEN: APPROVED AS REQUESTED APPROVED AS MODIFIED 27. APPROVED LEVEL OF CARE: __ SNF _ ICF _ SWING _ AWD DEFERRED DATE
DENIED
28. PERIOD APPROVED FOR: TO (*27 & 28 ONLY IF MODIFIED BY REVIEWER) 29. COMMENTS:
30. SIGNATURE: 31. DATE
NOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT’S ELIGIBILITY. BE SURE THE IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICE.
**What is change? (ID & Document)
Rev. 11/2004
SECTION 1 - TO BE COMPLETED BY THE RECEIVING FACILITY
32. RECIPIENT’S NAME
SECTION IV - SNF & ICF (COMPLETE PART A ON INITIAL REQUESTS. COMPLETE BOTH PART A&B ON REAUTHORIZATION REQUESTS.)
PART A
33. CURRENT NURSING NEEDS. (SERVICES RECIPIENT REQUIRES THAT CAN ONLY BE PROVIDED BY LICENSED NURSING PERSONNEL)
34. REHABILITATION GOALS: MAINTENANCE ACTIVE REHAB. IF ACTIVE, STATE GOALS, PROGRESS AND PROJECTED TIME FRAME.
35. DISCHARGE PLAN: _ _ YES NO (IF YES, STATE PLAN WITH TIME FRAME, IF NO, INDICATE WHY NOT.)
STATE OF ALASKA
DIVISION OF SENIOR & DISABILITIES SERVICES 3601 C STREET, SUITE 310
ANCHORAGE, AK 99503 907-269-3666
TO ALL PERSONS REQUESTING ADMISSION TO NURSING HOMES:
Federal regulations require that every person applying for admission to a nursing home be screened to identify mental illness and mental retardation diagnoses and determine whether people with those diagnoses require nursing home services or active treatment in another setting. IN ORDER TO INDICATE THAT YOU HAVE BEEN INVOLVED IN YOUR OWN
PLANNING AND THAT YOU DO WANT TO GO TO A NURSING HOME, YOU MUST SIGN THE STATEMENT BELOW:
REQUEST FOR LONG TERM CARE AUTHORIZATION
I, _______________________________________, request that DHSS authorize my placement in the nursing home named in the attached document (AK-LTC-1).
I authorize the Department of Health and Social Services to have access to my medical and treatment records to compile the needed information. The information, my situation and my needs may be discussed with my family, my physician, the facility to which I am applying, and ______________________________________________.
It SHALL NOT be discussed with ___________________________________.
____________________ __________________________________
Date Signature of Applicant
__________________________________ Address
__________________________________ Address
If a person is unable to apply on his/her own behalf, name of person applying for him/her ______________________. Basis of authority for acting on applicant’s behalf _____________. If you are acting on a Power of Attorney, does the instrument contain a durable cause? Yes ___ No___ Relationship to applicant: _____________________________________
________________ ____________________________________________________________
Date Signature of individual applying on applicant’s behalf
____________________________________________________________ Street, Apt. P.O. Box
____________________________________________________________ City, State, Zip Code
____________________________________________
Phone #
DIVISION OF SENIOR & DISABILITIES SERVICES PHONE: 269-3666 FAX: 269-3689 AUTHORIZATION UNIT
MI/MR SUPPLEMENT ASSESSMENT LEVEL 1
Client/Applicant Name ______________________________ Date of Birth _________________ Social Security Number ______________________________ Medicaid Number _____________ Nursing Facility ____________________________________ Date of Admission ____________ 1. Does the individual have a current diagnosis of major MI or MR: ______ Yes _______ No
If yes, please indicate the diagnosis: _____________________________________________ Describe symptoms observed or reported in the last two years:
2. Does the individual have a history of MI or MR? _____ Yes ______ No If yes, describe briefly and list date(s) of onset:
3. Has the individual been referred by an agency serving persons with mental retardation or a
developmental disability? ______ Yes ______
If yes, specify agency, location, type of service provided, contact person, and telephone number:
4. Does the individual have a prescribed major tranquilizer on a regular basis in the absence of a
justifiable neurological disorder? ______ Yes ______
Specify all psychotropic medications below. An attached list from medical records will be adequate as long as the following information is provided. Specify each medication by
medication name, dosage, route of administration, purpose and degree of supervision. The degree of supervision should indicate if medication is self-administered or if the family provides
assistance, provided by lay persons, or registered nurses. (Please specify) MEDICATION NAME
No
No
DOSAGE ROUTE OF ADMIN. PURPOSE SUPERVISION
CLIENT/APPLICANT NAME: ____________________ FACILITY: _____________________ 5. CLINICAL AND PSYCHOSOCIAL DATA: Please indicate with a check any of the
following behavior(s) which the individual has exhibited:
_____ is combative ____ experiences difficulty learning new skills
_____ sets fires ____ demonstrates severe maladaptive behavior
_____ bizarre behavior ____ face or body twitches or jerks
_____ is destructive to self/property ____ unable to understand simple commands _____ suicidal thoughts, ideation’s, or gestures ____ self-stimulatory behavior (* e.g. rocks
back & forth)
_____ appetite disturbance ____ seriously impaired judgment
_____ sleep disturbance ____ displays inappropriate social behavior
_____ withdrawn ____ hallucinates
_____ talks about his/her worthlessness ____ has delusions
_____ has epilepsy ____ disoriented
_____ bangs head ____ thought disorders, please specify:
_____ cannot communicate basic needs ____ other, please specify: Please describe the context in which any of the above-checked behaviors occurs:
6. Will a nursing facility or some additional resource beyond what is usually provided by a nursing facility be required to meet the mental, emotional, or training needs of this resident? ____ Yes ____ No
If yes, please explain.
7. Is there evidence of a dementia (including Alzheimer’s disease or a related disorder)? ___Yes ___ No
If there is a diagnosis of dementia, please provide supporting documentation including the relevant diagnostic criteria. Copies of existing medical records may be adequate.
CLIENT/APPLICANT NAME: ________________________FACILITY:__________________ 8. Recommendation: _____ refer to DBH for Level II determination for MI or MR
_____ assessment does not indicate need for DBH referral because individual:
_____ does not have known or suspected diagnosis of MI or MR _____ has Alzheimer’s disease or dementia as primary diagnosis _____ terminal illness without need for active treatment
_____ severe illness without need for active treatment _____ convalescent leave without need for active treatment
_______________________________ __________________________
Evaluator’s Signature Title
________________________________ __________________________
Date Telephone number
This section to be completed by DSS:
_____ refer to DBH for Level II determination: Date sent: _______ To whom: ___________ _____ process pre-authorization request; individual does not meet Level II screening criteria _____ no indication of MI or MR
_____ terminal illness without need for active treatment _____ severe illness without need for active treatment _____ convalescent leave without need for active treatment
__________________________________ __________________________
DSS Nurse Reviewer Date
Payment Methodology
Rates
Rates for facilities in Alaska will be determined by the Medicaid Rate Advisory Commission (AS 47.07.070).
Rates will not be issued to out-of-state facilities. Payment for care in out-of-state facilities will be made under the general provisions of the rules established by the Medicaid state agency in the state where the facility is located. The rate of payment may not exceed the maximum rate established by the division for Alaska facilities.
Updated 04/03
Other Payments
Payment by the division constitutes payment in full for authorized services. If the facility obtains additional payment from another source for the care provided to a recipient for services paid by Medical Assistance, it is the facility’s obligation to refund or credit payment to the division.
Contributions or donations from friends or relatives have a direct affect upon the recipient’s eligibility and upon payment by the division. The facility must notify the local DPA offices of all contributions and donations made on behalf of a recipient toward his/her cost in the facility.
Billings to Alaska Medical Assistance may not exceed the rate charged to private patients for any item or service charged by the facility.
Updated 04/03
SNF/ICF Chargeable Days
Alaska Medical Assistance will pay for the day of admission but not for the day of discharge, transfer, or death. Transfer includes transfer from one level of care to another within a single facility as well as between different facilities.
Updated 04/03
Medicare Coinsurance
Alaska Medical Assistance will pay, on behalf of eligible recipients, the coinsurance established under Part A of Medicare, for care rendered from the 21st through the 100th day of care in a SNF. The division will pay the SNF rate established for care in that particular facility beyond the 100th day.
Rejection or non-payment by Medicare of services provided by a SNF because the services were custodial in nature or because the facility did not choose to participate as a Medicare provider is not, by itself, justification for the division to make full payment to a SNF during the period from the 1st to the 100th day of care at a SNF. The division will make payment to the facility for that level of care appropriate to the recipient’s needs as determined by the utilization review committee and approved by the division.
Covered Services
Coverage for SNF/ICF Services
The following are included in the all-inclusive rate: 1. Periodic oxygen.
2. Rehabilitative nursing care.
3. Non-physician consultation and training of patients and staff regardless of whether the consultant or trainer is employed by the facility or on contract with the facility.
4. Direct patient care services including physical therapy, occupational therapy, speech therapy, and respiratory therapy, if prescribed by a physician.
5. All transportation related to the recipient’s care and recreation in the facility’s vehicle. 6. Routine annual physical exams.
The following are examples of items/services that are not included in the all-inclusive rate: 1. Prescribed legend drugs and biologicals.
2. Physician services, with the exception of routine annual physical exams. 3. Personal items paid for by personal funds.
4. Dental services.
5. X-ray and laboratory procedures, provided in or out of the facility.
6. Essential transportation for recipients to and from the source of medical care. Payment will be made directly to the carriers.
7. Any services included in the all-inclusive rate cannot be paid by Medical Assistance directly to any other provider regardless of the place of service.
8. Non-periodic, heavy use of oxygen
Updated 04/03
Recipient’s Personal Incidental Funds
The recipient is allowed a monthly personal allowance for clothes or day-to-day incidentals that may not be applied toward the recipient’s cost of long term care facility services. The recipient has the right to manage this allowance, unless adjudged incompetent under state law. Any delegation of management to the long term care facility must be in writing by the recipient, indicating who has been delegated this responsibility. The facility must retain a copy of the written documentation.
Updated 04/03
Personal Incidental Items, Supplies, or Services
Personal incidental items, supplies, or services that are furnished by the facility at the request of the recipient may be paid for from the recipient’s personal allowance or from other resources (for example, from relatives or friends). A periodic flat rate for routine items such as beverages or cigarettes is not allowed. The facility is responsible for:
Not charging a Medical Assistance recipient for items or services if it does not charge all non-Medical Assistance patients for those same items and services.
Not charging more than the actual cost to the facility.
Updated 04/03
Management of Recipient’s Personal Incidental Funds
When a recipient delegates management of funds to the long term care facility, the facility is responsible for applicable provisions of the Alaska Administrative Code (7 AAC 43.250), which includes the following:
Depositing recipient’s funds in a bank account separate from any other account of the facility; ensuring that any earned interest is credited to the recipient. Funds should be available to the recipient upon request during normal banking hours, and no withdrawal shall be made without the recipient’s permission, unless the recipient has been adjudged incompetent.
Maintaining account records of all money belonging to the recipient showing amounts received and disbursed, listing description and price of all items purchased.
Retaining receipts for three years.
Providing quarterly accounting of financial transactions made for the recipient.
Updated 04/03
Recipient’s Personal Property
The recipient’s personal property must be clearly marked with the recipient’s name. The facility must keep up-to-date records of the recipient’s personal property, separate from the facility’s inventory. Circumstances of lost items must be documented.
Updated 04/03
Prescribed Drugs: Prior Authorizations and Limitations
The Division of Health Care Services (DHCS) may designate that specific drugs require the prescribing
provider to obtain a prior authorization before the drug is dispensed.
In an emergency, up to a 120-hour (5 day) supply of the drug may be dispensed before the drug has been authorized. Prior authorization requests for these drugs will be responded to within 24 hours of the request. If the prior authorization for the drug is approved, Alaska Medical Assistance will reimburse the provider for the drug, including the amount dispensed before the authorization was reviewed. If the prior authorization request is denied, Alaska Medical Assistance will not pay for the drug, including the amount dispensed before the authorization was reviewed.
DHCS may also limit the allowed quantity (either minimum quantity or maximum quantity) of a specific prescribed drug or of a therapeutic drug class. The allowed number of refills for a specific prescribed drug or for a therapeutic drug class may also be limited by DHCS.
Recipient Eligibility
Verification
Before rendering services, the provider is responsible for verifying the following: the age of the recipient
that the recipient is Medical Assistance-eligible and also eligible for the specific services that the services are covered by Medical Assistance
Age and eligibility can be verified by telephoning FHSC’s automated Eligibility Verification System (EVS), described in Section III. EVS is time-saving and cost-effective (see Table I-2, “Advantages of EVS”).
Table I-2. Advantages of EVS
1. Verifies recipient’s month of eligibility.
2. Provides recipient’s Medical Assistance identification number by use of recipient’s Social Security Number.
3. Identifies any third party liability (i.e., insurance). 4. Accessible 24 hours, 7 days a week.
The provider can also verify the patient’s age and eligibility by:
Checking the patient’s Medical Assistance identification card or coupon (refer to Section III for samples).
Telephoning Provider Inquiry of the Provider Services Unit. See Page v for telephone numbers.
Updated 10/03
Eligibility Codes
Recipients with the eligibility codes in Table I-3 are eligible to receive long term care facility services.
Table I-3. Eligibility Codes: Long Term Care Facility Services Code Category
10 Public Health Service (IHS, AANHS, and CHAMPUS) 11 Pregnant Woman (Alaska Healthy Baby Program) 15 Incapacity/Pregnancy Determination 20 No Other Eligibility Codes Apply
24 300% Institutionalized
25 Disability and Blindness Exams 30 Adult Disabled, Waiver Only 31 Adult Disabled, Waiver Medical
34 Adult Disabled, Waiver Adult Public Assistance/Qualified Medicare Beneficiary 40 Older Alaskan, Waiver Only
Code Category
50 Under 21
51 Aid to Families with Dependent Children/Juvenile Court Ordered Custody of Health & Social Services
52 Post Aid to Families with Dependent Children 53 Illegal Alien Emergency Coverage
54 Disabled/Supplemental Security Income (SSI) Child
67* Qualified Medicare Beneficiary (QMB) Only - Eligible Only for Medical Assistance Payment of Medicare Deductible and Coinsurance for Medicare-covered Services
69 Adult Public Assistance (APA)/Qualified Medicare Beneficiary (QMB) - (Dual Eligibility) 70 Mental Retardation and Developmental Disabilities, Waiver Only
71 Mental Retardation and Developmental Disabilities, Waiver Medical
74 Mental Retardation and Developmental Disabilities, Waiver Adult Public Assistance and Qualified Medicare Beneficiary
80 Children with Medically Complex Conditions, Waiver Only 81 Children with Medically Complex Conditions, Waiver Medical
Updated 01/05
* A Qualified Medicare Beneficiary (QMB) over 21 years of age is eligible only for payment of deductible and
Reimbursement
General
Timely Filing
All claims must be filed within 12 months of the date services were provided to the recipient. The 12-month timely filing limit applies to all claims, including those that must first be filed with a third-party carrier. In these cases, providers must bill Medical Assistance within 12 months of the service date and attach explanation of benefits documentation from the third-party carrier to the Medical Assistance claim. “Timely filing” of claims is discussed in greater detail in Section III.
Updated 08/03
Billing Guidelines
A provider must bill Medical Assistance the provider’s lowest charge (except as noted below) that is advertised, quoted, posted, or billed for that same procedure and unit of service and provided on the same day, regardless of the source or method of payment, including any discounted price offered to any other purchaser of services. Exceptions to this policy include:
Medicare Assignment. The Medicare exception applies when a provider accepts Medicare assignment, which requires billing Medicare at the Medicare fee schedule. Enrolled Medical Assistance providers are not required to bill Medical Assistance at the Medicare fee schedule.
Sliding Fee Schedule. The sliding fee schedule exception applies when a provider has a written policy that establishes a sliding fee schedule based on the federal poverty level for Alaska (families and
individuals with income equal to or less than 250 percent of the federal poverty level). Enrolled Medical Assistance providers are not required to bill Medical Assistance at the sliding fee discounted rate.
Contract for Group Discounts. This exception applies when a provider executes or enters into a contract to provide health care services at a discounted rate for a specified group of patients. Enrolled Medical Assistance providers are not required to bill Medical Assistance at the discounted rate if the revenue from a single contract does not exceed 20 percent of the provider’s annual gross income, or if the contract is with a state or federal agency.
Provider’s Employee Benefits. The employee benefits exception applies when a provider offers a reduced rate for health care services to the provider’s employees as part of an employment benefit package. Enrolled Medical Assistance providers are not required to bill Medical Assistance at that reduced rate.
TPL (Third Party Liability)
Alaska Medical Assistance is the “payer of last resort.” Providers who bill Alaska Medical Assistance are required to bill all third party resources (except IHS) prior to billing Alaska Medical Assistance.
However, if the services provided fall under the Federal TPL Waiver, Alaska Medical Assistance will seek reimbursement from the third party.
Updated 04/03
Federal TPL Waiver
Alaska Medical Assistance has been granted a Federal TPL Waiver for certain providers that offer specific categories of service. At this time, providers who offer the services listed below are not required to bill third party resources:
Pharmacy services Dental services
Transportation and accommodation services (except Air Ambulance and Ground Ambulance services)
Home and Community Based Waiver provider services Personal Care Assistant services
EPSDT screening services Prenatal Care services Preventive Pediatric services
Eye wear (lenses/frames - This applies only to the contract supplier of eyewear.)
If you provide one (or more) of the services listed above, you are not required to bill a third party resource before you bill Alaska Medical Assistance. Alaska Medical Assistance will reimburse you up to the allowed amount and then seek reimbursement from the third party.
You may choose to bill the third party resource if the service provided is covered by that resource and the payment will exceed the expected Alaska Medical Assistance reimbursement amount.
Providers who offer services that are not listed above are required to
bill all third party resources (except IHS) before billing Alaska Medical Assistance, and include all TPL resource payments on Alaska Medical Assistance claims.
Updated 10/03
Recipients with VA, Medicare, and Medicaid
Alaska Medical Assistance (Medicaid) is always the payer of last resort. Therefore, if a patient is eligible for VA, Medicare, and Medicaid, all VA and Medicare benefits must be exhausted or you must submit valid documentation of non-coverage from VA or Medicare before you bill Alaska Medical Assistance. Valid documentation may include an Explanation of Benefits showing non-coverage or a Medicaid Denial Letter from the Veteran’s Administration (refer to “Obtaining a VA Medicaid Denial Letter” below for additional information).
A Medical Assistance recipient who is eligible for VA and Medicare can use either as his/her primary resource. However, the following conditions apply in regards to Alaska Medical Assistance paying anything for the claim:
If VA is pursued as the recipient’s primary payer (instead of Medicare), the claim is considered satisfied, and neither Medicare nor Medicaid will pay anything more.
If Medicare is pursued as the recipient’s primary payer (instead of VA), 1. VA will not pay for anything over the amount paid by Medicare.
2. Alaska Medical Assistance may pay the Medicare co-pay and/or deductible if the Medicare Remittance Notice (MRN) and the VA denial are attached to the claim.
3. Alaska Medical Assistance may reimburse according to the applicable Alaska Medical Assistance rates if the services billed are non-covered Medicare services and a Medicaid Denial Letter from the VA is attached to the PA request and/or claim. (Refer to “Obtaining a VA Medicaid Denial Letter” below.)
Therefore, if a recipient is eligible for VA, Medicare, and Medicaid, Alaska Medical Assistance will not pay anything for the claim unless you have followed these steps:
1. Bill VA first and receive a formal denial (in writing) from VA or receive a Medicaid Denial Letter.
Note: If you have an applicable Medicaid Denial Letter from the VA, you do not have to bill VA first. Refer to “Obtaining a VA Medicaid Denial Letter” below.
2. Bill Medicare correctly.
3. Bill Alaska Medical Assistance correctly and attach the denial from VA and the Medicare Remittance Notice (MRN).
If these steps are followed and if the claim is billed correctly, Alaska Medical Assistance may pay the Medicare co-pay and/or deductible.
Explanation
VA is considered primary because they pay 100% of their allowed amount.
Medicare is considered secondary because they pay 80% of their allowed amount with a 20% co-pay, which Alaska Medical Assistance can cover under the correct billing process.
However, Alaska Medical Assistance will not use state funds for a 20% Medicare co-pay if the claim could have been satisfied with 100% federal funds (VA is federally funded).
Please refer to the back of the CMS-1500 claim form (“Refers to Government Programs Only”) for rules and information related to billing multiple federally funded programs.
Updated 04/04
Obtaining a VA Medicaid Denial Letter
To provide freedom of choice for veterans with medical needs, the veteran can request a Medicaid Denial Letter from the Veteran’s Administration. This letter, which is for specific services, can be submitted to the Alaska Medical Assistance program as an explanation of Veteran benefits. Therefore, if the veteran chooses not to use VA as his/her primary payer, you should attach a copy of this letter to any related prior authorization requests and/or claims sent to Alaska Medical Assistance.
Important: All other Medical Assistance billing requirements still apply to claims submitted with a Medicaid Denial Letter, including
▪ ▪
Timely filing of claims
Exhaustion of all other benefit resources (including Medicare) before billing Medical Assistance
A Medicaid Denial Letter should be requested from the Anchorage office of the Veteran’s Administration by the veteran.
Department of Veteran’s Affairs
Alaska Healthcare System and Regional Office 2925 DeBarr Road
Anchorage, AK 99508-2989 (907) 257-6904
1-888-353-7574 ext. 6904
The VA Coordinated Care or Social Work department will mail the Medicaid Denial Letter to the veteran, any affected medical providers identified by the veteran, and Alaska Medical Assistance.
Updated 04/03
Providers Can Attach Other Insurance Benefit Booklet Pages
Providers are required to bill all applicable third party resources and insurance carriers prior to billing Medical Assistance.
If the service is not covered according to the third party resource or insurance carrier benefit booklet, providers may attach a copy of the benefit booklet page(s) to the claim submitted to Medical Assistance. The benefit booklet page(s) must specify the patient’s benefit plan name and indicate that the service being billed to Medical Assistance is not covered. It may be necessary to copy the benefit booklet’s cover page which identifies the benefit plan name as well as any page(s) within the booklet that describes the coverage or non-coverage of the specific service category being billed to Medical Assistance.
Providers may also use benefit booklet pages as specified above when requesting Third Party Liability (TPL) Avoidance. The TPL Avoidance process is explained on the following pages.
Updated 09/02
Third Party Liability (TPL) Avoidance
Medical Assistance and First Health Services Corporation have developed a process to assist providers with Medical Assistance claims for clients who have primary (third party) insurance coverage. The process may affect claims that the third party carrier has denied because
The service is not covered by the benefit plan
The recipient’s yearly or lifetime maximum benefits for a service have been exhausted The servicing provider’s credentials do not meet requirements for coverage by the insurance
carrier
The Third Party Liability (TPL) Avoidance process allows the Medical Assistance claims payment system to bypass TPL editing when certain conditions are met. This procedure eliminates the need for providers to bill the primary insurance company for services that the insurance does not cover. The request for TPL Avoidance review must include documentation from the carrier specifically stating the services that are not covered and a valid reason for the denial. Services that were billed to the TPL carrier incorrectly or services for which required authorization was not received in advance are examples of conditions that would not qualify for TPL Avoidance. Other conditions may also apply. All requests for TPL Avoidance will be reviewed and if the request is approved, the requirement to bill the third party insurance will be waived.
Guidelines for Requesting TPL Avoidance and Criteria for Review
TPL Avoidance is limited to ongoing services.
Example: If a recipient receives an influenza injection and the TPL carrier does not cover the service, this is a one-time event and is not considered ongoing. However, if a recipient is receiving medication management as a continuing service and the TPL carrier does not cover it, it is considered an ongoing service and is a candidate for a TPL Avoidance review.
To request a review for TPL Avoidance for a specific recipient, complete the TPL Avoidance Request Form and attach the corresponding Explanation of Benefits (EOB), letter of explanation from the TPL carrier that specifically documents the reason for the non-payment of the service(s), or a copy of third-party resource benefit book page(s) that indicates the benefit plan name and that the service being billed is not covered. Both EOBs and denial letters must be specific to the recipient as well as the service rendered and must include a valid procedure code or ICD code and a valid reason for non-coverage.
Recipients may exhaust maximum lifetime or yearly limitations for services that their TPL carrier will cover. When the maximum has been reached, attach the EOB reflecting this to the completed TPL Avoidance Request form and submit for TPL Avoidance review.
A request for TPL Avoidance review requires attached documentation that meets the guidelines stated above. Once a TPL Avoidance record is approved and on file, matching claims do not require an attachment and do not require TPL review before payment can be made.
Documentation will need to be updated periodically for continued TPL Avoidance.
Updated 04/02
Non-covered Medicare HCPCS Codes
Codes published in the HCPCS coding manual that are indicated to be non-covered by Medicare are included in the Alaska Medical Assistance TPL Avoidance file. This file is updated annually. When codes are added to the TPL Avoidance file, the claims processing system will not search for related third-party information (e.g., Medicare in this example) when processing a claim with those codes. Therefore, if you bill for one of these codes, the code will be recognized as a non-covered Medicare code and you will not be required to bill Medicare. Please note that even though you will not be required to bill Medicare, it is not guaranteed that Medical Assistance will cover the item or service provided.
Claims Billing Procedures
Claims: General Instructions
Claim forms are designed for computer processing. When completed, the forms contain information necessary to process claims for services rendered to Medical Assistance recipients. Adhere to the following instructions for claims to be processed efficiently. Accuracy, completeness, and clarity are important.
1. Do not fold or crease claims.
2. Fill in handwritten claims neatly and accurately.
3. Keep names, numbers, codes, etc., within the designated boxes and lines.
4. Make corrections carefully. Do not strike or write over errors to correct. Correction fluid or tape may be used as long as the corrected information is readable.
5. Include a return address on all claims and mailing envelopes. 6. Send only required attachments.
Updated 04/02
Completing the Long Term Care UB-92 Claim Form
Long Term Care services are billed for reimbursement on the Uniform Bill (UB-92) claim form. A sample UB-92 claim form and instructions for completing it are found on the following pages. Each number listed in the instructions refers to the field on the sample claim forms. Fields that require
information are indicated with an asterisk (*).
Updated 04/03
Reporting Ancillary Services
Beginning December 1, 2004, nursing facility providers should report ancillary services rendered to recipients. To report these services, use the Revenue Codes listed later in this section to identify all the services provided during the period being billed.
The amount billed for each revenue code listed will not affect the facility’s payment; the facility will be paid an all-inclusive, per diem rate for each covered day billed.
Updated 01/05
Revenue Codes and Leave of Absence
Specific revenue category codes and descriptions for the level of care and leave of absence must be entered in Fields 42 and 43 of the claim form. Up to 12 leave of absence (LOA) days for therapeutic leave is payable by Medical Assistance. The leave days are for a 12-month period per recipient. These LOA days are paid at the same per diem rate as the days when the recipient is in the facility.
Continuous Flow Oxygen
The Alaska Administrative Code states that oxygen can be billed separately from the nursing home per diem rate when the patient requires non-emergency, continuous, and heavy use of oxygen that must be available at all times [7 AAC 43.255(f)]. Payment will be made to the facility at the facility’s cost for the oxygen. Cost for professional services and supplies are covered in the all-inclusive per diem rate and cannot be billed separately.
Prior authorization is required and it can be requested using the AK-PA form. (See Section II for instructions on how to fill out the AK-PA form.) Attach the following to the prior authorization request:
an oxygen saturation level or an arterial blood gas (ABG) on room air a doctor’s prescription or doctor’s orders
Make sure to include the diagnosis code and the narrative description of the diagnosis on the prior authorization request. Use revenue code 270 in field 15 (procedure/drug code) on the AK-PA form and specify the number of cubic feet of oxygen when filling out field 17 (requested unit/qty) on the AK-PA form.
When filing your claim for continuous flow oxygen with Alaska Medical Assistance: Use the revenue code 270 in field 42 (rev code)
Enter the number of liters/bottles used in field 46 (serv. units)
Enter the prior authorization number in field 63 (treatment authorization codes)
Include an attachment to the claim form identifying the dates the oxygen was given to the patient and the metered amount used
Updated 01/05
Patient Liability
Patient liability amounts are established by the Division of Public Assistance Income Credit Notice. Enter the full amount of the patient liability for the month of service in Field 54 (“Due from Patient”). If the patient liability amount shown on a claim exceeds the amount shown on the eligibility file, the larger amount shown on the claim will be deducted. Liability will be prorated on each claim during processing when billing for changes in level of care during the same calendar month. The patient liability will not be deducted from the month of the patient’s admission to or discharge from institutionalization. However, it will be deducted for all other months.
