5101:3-3-39.1 Claim submission for nursing facilities (NFs).

(A) Claim requirements

(1) For dates of services commencing July 1, 2005, all nursing facilities (NFs) shall submit claims electronically for medicaid reimbursement for nursing facility services in compliance with electronic data interchange (EDI) standards established under the Health Insurance Portability and Accountability Act of 1996 using the ANSI 837 health care claim institutional (837I) transaction.

(2) Ohio Medicaid ANSI 837I claim specifications for nursing facilities are provided in the ohio department of job and family services (ODJFS) 837I companion guide (available on www.hipaa.oh.gov/odjfs).

(3) Claims must use the UB-92 national uniform billing data element specifications as developed by the national uniform billing committee(available on http://www.nubc.org/), to obtain and indicate codes in the ANSI 837I regarding provider information, bill type, demographic information, patient status, condition codes, occurrence codes, value codes, revenue codes and other codes as required in the ODJFS companion guide.

(4) Claims must use, if required by the claim format, "The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 2005 Edition" (available on http://www.cdc.gov/nchs/icd9.htm#RTF) to specify the diagnosis or nature of the injury of the resident related to the services provided as specified in rule 5101:3-1-19.2 of the Administrative Code.

(5) For dates of service preceding July 1, 2005, NFs shall continue to use the JFS 09400 rev. 12/2001 nursing facility payment and adjustment authorization.

(6) The following shall apply for dates of service beginning July 1, 2005 and ending November 30, 2005, for providers who are unable to comply with paragraph (A)(1) of this rule:

(a) The monthly payment shall be calculated as follows:

(i) The NF's average fiscal year (FY) 2005 vendor payment will be calculated.

(ii) The amount calculated in paragraph (A)(6)(a)(i) of this rule will be reduced by ten per cent.

(b) For each month, the provider shall request the monthly payment calculated in paragraph (6)(a) of this rule, through the gross adjustment process.

(i) A written request must be received by ODJFS no later than noon on the first Friday of each month.

(c) For dates of service beginning July 1, 2005, and ending November 30, 2005, the provider is still required to submit claims on the 837I as required in paragraph (A)(1) of this rule.

(d) Each gross adjustment payment will be reversed the following month.

(e) Effective for dates of service on or after December 1, 2005, providers shall not be reimbursed for services unless claims for services are submitted on the 837I as required in paragraph (A)(1) of this rule.

(B) Criteria for claims submission:

(1) A provider submitting a claim for payment, either directly as a trading partner as defined in rule 5101:3-1-20.1 of the Administrative Code or through another trading partner, shall be a Medicaid provider in an active enrollment status and eligible to provide nursing facility services for all dates within the claim span.

(2) The claim must meet the requirements of the current version of the claim transaction required in paragraph (A) of this rule and as specified in the ODJFS 837I companion guide.

(3) A single claim shall include services provided by a single provider to a single recipient within a single calendar month and shall not cross a calendar month.

(4) Circumstances under which a partial month of services may be billed:

(a) Admission claims where the resident was admitted after the first of the month.

(b) Discharge claims where the resident was discharged, transferred or died during the month.

(c) The resident's coverage switches between medicare part A or medicare part C and medicaid within the month.

(C) Claim filing timing requirements:

(1) Claims must be received by ODJFS within three hundred sixty-five days of the actual date the service was provided, unless the provisions in paragraph (C)(2) or (C)(3) of this rule apply or the claim will be denied. Initial claims received beyond the three hundred sixty-five day time limit shall not be processed for payment by ODJFS. The "date of receipt," for purposes of this rule, is the date ODJFS receives a claim and assigns a transaction control number (TCN).

(2) If the claim submittal is delayed due to the pendency of either an administrative hearing decision by ODJFS or an eligibility determination by a county department of job and family services (CDJFS), it will be adjudicated if the claim is received within one hundred eighty days of the date of the administrative decision by ODJFS or eligibility determination by the CDJFS. The NF is required to maintain documentation from the CDJFS or ODJFS district office supporting the information included on the claim and be able to produce said documentation upon request by ODJFS. In no case shall a delay in processing eligibility information at the county level, as required in rule 5101:1-38-02 of the Administrative Code, be a basis for denial of payment under this provision.

(3) When the claim cannot be submitted within three hundred sixty-five days due to the coordination of benefits with medicare and/or other third party payers, pursuant to rule 5101:3-1-08 of the Administrative Code, adjudication will be made if the claim is received within one hundred eighty days of medicare's and/or other third-party payers' adjudication.

(4) Providers may resubmit claims that have been denied. Providers resubmitting claims for reconsideration must meet the following provisions:

(a) The original claim was submitted within three hundred and sixty-five days of the date the service was provided unless the provisions in paragraph (C)(2) or (C)(3) of this rule apply.

(b) The resubmission must be within three hundred and sixty-five days from the date of service or within one hundred and eighty days from the date the claim was denied. ODJFS will not process a resubmitted claim if the claim is received more than seven hundred thirty days after the date of service or discharge except as set forth in paragraph (C)(2) or (C)(3)of this rule.

(c) The resubmitted claim must be in accordance with the specifications defined in paragraphs (A) and (B) of this rule.

(d) Resubmitted claims are not eligible for interest provisions as defined in rule 5101:3-1-19.7 of the Administrative Code.

(D) Claim payment will comply with the prompt payment and interest provisions of rule 5101:3-1-1.7 of the Administrative Code.

(E) Submission of adjustment to claims:

(1) All adjustments shall be submitted using an ANSI 837I transaction and meet the requirements as specified in paragraphs (A)(1), (A)(2), (A)(3) and (A)(4) of this rule.

(2) The submission of an adjustment claim shall be within three hundred and sixty-five days of the actual date of service or one hundred eighty days from ODJFS transaction control number (TCN) date on the original submission whichever is later, unless the provisions in paragraph (C)(2) or (C)(3) of this rule apply. There shall be no submission after seven hundred and thirty days from the actual date of service.

(3) If a prior claim covering only part of the calendar month was submitted and the NF needs to file a claim for an additional part of the same calendar month, the NF shall submit an adjustment claim reflecting the entire calendar month's claim information.

(4) Any interest incurred for an original claim will be included in the adjusted reimbursement amount. Additional interest shall not be paid based upon the length of time required to adjudicate the adjustment transaction. NFs submitting claims for adjustment (i.e., line items or entire claims having an erroneous payment or which are in a paid status with a zero payment) must submit the request within one hundred eighty days from the date the claim was adjudicated.

(F) Patient liability :

(1) The NF shall report on the 837I claim the entire monthly amount of patient liability as determined, in accordance with Chapter 5101:1-39 of the Administrative Code, including for the month of admission, discharge, or transfer to another facility.

(2) Patient liability will be applied toward the claim until medicaid cost of care is offset or patient liability is exhausted. If the patient liability exceeds the medicaid cost of care, the claim will be adjudicated with a zero payment.

(3) In the month a patient switches from medicare to medicaid, the NF shall report the entire monthly amount of patient liability on the 837I claim.

(G) Lump sum payments and their disposition regarding medicaid eligibility are defined in rule 5101:1-39-27.5 of the Administrative Code. If pursuant to rule 5101:1-39-27.5 of the Administrative Code, it is determined that the lump sum is to be paid to medicaid, the NF shall do the following:

(1) When a NF receives a lump sum payment on behalf of a medicaid recipient and the NF was previously paid by medicaid for the recipient's care, the NF shall submit adjustment claims reflecting receipt of the lump sum payment for as many prior months as necessary to fully offset the amount of the lump sum payment.

(2) If the lump sum payment exceeds the amount of prior payments, the NF shall report payments sufficient to offset the current medicaid cost of care on claims submitted for services until the lump sum is exhausted. If the recipient is discharged or passes away prior to exhausting the lump sum payment, the nursing facility shall return the balance to the recipient or his estate.

Effective: 07/01/2005
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02