WAG 20-08-15: Approval of Payment for Care

  1. (BLTC) Notifies FCRC about licensure level, bed capacity, and Medicare certification for each facility in their area.
  2. (Facility) Revised textNotifies the FCRC of the following current transactions using the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) system vendors:
    • admissions and readmissions;
    • discharges and deaths;
    • begin and end dates of Medicare-covered SNF services;
    • income (including lump sum payments) and/or Revised textresources;
    • insurance benefits or other TPL sources; and
    • any other changes affecting eligibility.

Revised textAdmissions, discharges, income changes, TPL, Medicare-covered SNF services, etc. are no longer reported using a hard copy of Form 1156.

  1. (Facility) For an admission reported Revised textelectronically, the facility does not mail the Report of Resident of Private Long Term Care Facility (Form 26), or as needed, Interagency Certification of Screening Results (Form 2536) to the FCRC. These forms are available for print at the FCRC.
  2. (FCRC) Follow up on any actions that may be required as a result of the reported admission, income, or TPL information. Complete Form 552, as necessary. For an admission, New textenter in the MMIS LTC subsystem or complete Long Term Care Authorization (Form 2299). For an income change, verify income, enter in the LTC subsystem and complete Revised textNursing Home/Supportive Living Facility Resource Calculation (Form 2500).
  3. (Facility) Uses the LTC EDI system (via MEDI or REV) for the central update of MMIS with a revised Revised textNH or SLF credit due to an income change. A facility is not to use the LTC EDI system for the central update of MMIS with a revised Revised textNH or SLF credit due to an earned income change. The change in the credit is effective for the current month or the following month. If the change may result in a spenddown amount, the credit will not be centrally updated. If a credit amount cannot be centrally updated in MMIS, the facility may report the income change using the LTC EDI system.

    NOTE: The LTC EDI system does not provide for the central update of credit information on Form 552. The FCRC is required to update Form 552, as necessary.

  4. (CO) LTC EDI Credit Update Information (Form 1156A) is electronically printed at the FCRC for each transaction in which MMIS is centrally updated with the revised credit amount. Form 1156A is an attachment to Form 1156 and contains the following information:
    • new credit amount; 
    • effective month of change;
    • the amount of change from the previous credit; and
    • date the income verification was sent to the FCRC.
  5. (CO) Sends Notice of Change in The Amount Owed For Care (Form 2434F) to each customer whose credit was centrally updated in MMIS. Form 2434F informs the customer of the amount available to apply to the cost of care. A copy is not sent to the FCRC.

    (FCRC) NOTE: If the customer has a representative, complete and send Revised textNursing Home/Supportive Living Facility Resource Calculation (Form 2500) to the representative.

  6. (FCRC) Follow up on any actions that may be required as a result of the credit update. Review the change, verify income, and complete Form 2500 and Form 552, as necessary. If a correction in the credit is required as a result of the review, Revised textenter in the LTC subsystem and complete and send Form 2500 to the customer.
  7. (Facility) Attests to and maintains documentation to support changes reported through the LTC EDI system.
  8. (CO) Directly updates MMIS with discharge, credit, and Medicare-covered SNF service information reported through the LTC EDI system.

    (FCRC) NOTE: Do not complete Form 2449 for changes updated through the LTC EDI system.

  9. Deleted text(CO) Sends reports to FCRC for transactions updated through the LTC EDI system. The reports are produced daily. Information contained in the reports includes:
    • discharge destination code;
    • date of discharge or death;
    • address;
    • customer funds; and
    • begin and end dates of Medicare-covered SNF services.
  10. (CO) Enters admission, TPL, and income transactions reported through the LTC EDI system on the Update EDI Tracking Database. Provides a transaction status code, code description, and a unique Transaction Audit Number (TAN) for each transaction. This database is accessed through the MMIS LTC Subsystem. 

    NOTE: Status codes and code descriptions are provided to check the status of each transaction reported by a facility. Each transaction is initially given a "pending" status.

  11. (CO) Enters the TAN on each form electronically printed at the FCRC.

  12. (FCRC) Review the reported change or credit information and update the transaction status code in the MMIS LTC Subsystem. Enter the TAN in the MMIS LTC Subsystem when processing admission, income, credit, and TPL information.

    NOTE: When a TAN is entered with data that updates the Recipient Database (RDB), the tracking database will be automatically updated with the completed status code. For transactions which do not require an update of the RDB, enter the TAN and correct status code in the tracking database section of the MMIS LTC Subsystem. 

  13. (FCRC) Use the Transaction Audit LTC Inquiry System to review pending and completed transactions reported through the LTC EDI system by TAN, recipient, or provider.
  14. (CO) Reports transactions pending for 30 days or more on the LTC EDI Transaction Aged Report. This report is generated weekly and sorted by FCRC. The report contains the status code for each pending transaction.
  15. (FCRC) Follow up and update the tracking database for each transaction reported on the LTC EDI Transaction Aged Report.
  1. (FCRC) Process information and follow up on any other actions that may be necessary from information received Deleted textthrough the LTC EDI system and from BLTC.
  2. (FCRC) Revised textEnter a discharge in the MMIS LTC subsystem when information from BLTC shows customer has been discharged. Do not wait for Revised textan entry in the LTC EDI system.
  3. (FCRC) Cancel the case when BLTC provides information that the customer has died. Do not wait for Revised textan entry in the LTC EDI system.
  4. (FCRC) Notify BLTC when there is a discrepancy between dates of death or discharge provided by BLTC and the facility:
    • copy Form 2449;
    • cross out incorrect information; and
    • above the old entry, print (in red) the correct death or discharge date provided by the nurse.
      • Distribute corrected Form 2449. See WAG 26-04-08 for completion and distribution of Form 2449. Send copy to BLTC.
  5. (FCRC) Review patient funds to decide continued eligibility when BLTC says customer has Revised textreceived income or Revised textresources.
  6. (Facility) Revised textUses MEDI or REV to enter data which was formerly provided by completing Report on Resident of Private LTC Facility (Form 26).
  7. (FCRC) Revised textIf data entered by the facility using the LTC EDI system is incomplete, request missing data from the facility.
  8. (FCRC) Approve payment based on the one cycle calendar month billing period. The billing period is the first day of the calendar month through the last day of the calendar month.

    NOTE: Do not approve payment until Revised textall necessary information has been received. 

  9. (FCRC) Revised textEnter in the MMIS LTC subsystem or complete Long Term Care Authorization (Form 2299) to start payment for each resident.
  10. (BLTC or FCRC) Completes Problem Resolution Request (Form 2738) when a problem comes up. Form 2738 is a turnaround form sent to the appropriate office when an issue, concern, or problem comes from a facility.
  11. (Form 2738 Receiver) Outlines specific clarification, follow-up activity, or problem resolution on bottom portion of form within 30 calendar days of date of request.
  12. (Form 2738 Sender) Sends follow-up copy of Form 2738 if no response is received within 30 days.
  13. (Form 2738 Sender) Sends 2nd follow-up Form 2738 to receiver's supervisor and receiver if no response is received to first follow-up within 15 days.