Long Term Care Coverage Guidelines

Claim Billing Guidelines

Instructions for completing the UB-04 claim form are on the Claims Processing page.

Covered Services

The basic rate includes basic room and board, such as meals, bed and bed sheets, pillow, basic room appliances, non-prescription drugs, and durable medical equipment and supplies, transportation to and from a hospital outpatient department, physician’s office, dental office or medical laboratory. Nursing and physical therapy services are also included in the basic rate.

Nursing services covered include one registered nurse for every floor of the facility. Basic housekeeping services are also covered.

Limitations/Special Requirements

The day of discharge is not covered under the Medicaid Program. The day of admission is a covered day.

Non-Covered Services

The basic rate does not include dental services, prescription drugs, personal items (ie. hearing aids, eyeglasses, prosthetic devices), hospitalization or physician services. The facility can separately bill prescription drugs if it has a pharmacy on the premises.

Out of State Providers

Out-of-state nursing facilities are not enrolled in the Rhode Island Medicaid program.

Prospective Reimbursement System

Every three years, or more often if necessary, nursing facilities (NF) are audited for prospective rate determination. The NF is responsible for maintaining all financial records and census data for audit purposes. Each facility, upon audit completion, receives a copy of the audit report and is provided an exit audit conference to accept or dispute audit adjustments. The NF can appeal audit adjustments to higher authorities. In the event the audit reveals provider fraud, a referral to the Attorney General’s office is made for possible prosecution.

Provider Participation Guidelines

To participate in the Medicaid Program, providers must be located and performing services in Rhode Island. Providers enrolled to provide nursing home services must be licensed by the Department of Health and certified by HCFA through the Department of Health to provide services in the State of Rhode Island. Refer to the Provider Enrollment page for further provider enrollment information.

Recertification

Nursing facilities (NF) are annually recertified by HCFA through the Department of Health (DOH). The license expiration date for NF’s is December 31. Providers obtain license renewal through DOH and then forward a copy of the renewal documentation to Hewlett Packard Enterprise. Hewlett Packard Enterprise should receive this information at least five business days prior to the expiration date of the license. Failure to do so will result in suspension from the program.

A nursing facility may appeal to the DOH if the facility does not meet the recertification criteria. If the appeal to DOH is not successful, the facility may then appeal to the Centers for Medicare and Medicaid (CMS).

Reimbursement Guidelines

Rates for individual nursing facilities are established based on a Prospective Reimbursement System established by EOHHS. These rates are subject to an annual cost of living allowance. Every three years, or more often if necessary, a facility’s rates are “rebased” or reevaluated.

Medicare Coinsurance/Deductible Rates for nursing facilities are determined by Medicare. The facility will be reimbursed at the lesser of the coinsurance/deductible rate or the individual nursing facility rate. Recipient Placement Level (RPL) code 001 should be used to designate if the recipient has Medicare coverage.

Medicaid reimbursement is considered payment in full except if the recipient goes to the hospital and the family wants to reserve the nursing facility bed for the patient’s return. The family can privately pay to reserve the nursing facility bed during the recipient’s absence.

NF’s are not paid for the day of discharge. For example, if a recipient leaves the facility to enter a hospital, and the billed dates of service for the facility and the hospital overlap, then only the hospital day(s) can be billed.

Providers must notify EOHHS of all discharges from the nursing facility or transfers to another facility. Nursing facilities must notify EOHHS of a recipient’s discharge to the hospital and the recipient’s return to the facility.

If the recipient has any personal income (such as Social Security or other pension benefits) that income must be applied to the cost of their care in the facility.

Currently, the first $50 of the recipient’s income is disregarded as a personal needs allowance.

Except for those situations in which the patient has a liability for payment, Medicaid reimbursement is considered payment in full. The nursing facility is not permitted to seek further payment from the recipient in excess of the Medicaid rate.

For specific questions you may contact the Customer Service Help Desk at (401) 784-8100 for In-state and long distance callers, or 1-800-964-6211 for In-state toll callers and border communities.

 

 

 

 

 

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