Complete only for each admit action. The Bureau of Long Term Care (BLTC) must correct an admit date.
Section A - Transaction Information
| Admit |
Enter an X in this box. Form 2299 is used for admits only. |
| Effective Date of Admit |
Enter the date (MM/DD/YY) the client is admitted. The admit date cannot be earlier than the client's effective date of medical eligibility and cannot be earlier than the date of the screening, if required. If appropriate, include admission dates for
Medicare covered SNF services. |
| Submittal Number |
Enter a 3-digit number. In the first position enter the last digit of the current year. In the 2nd and 3rd positions, enter the number of Form 2299s that have been submitted for the client in the calendar year. For example, the 3rd
Form 2299 submitted in 2004 is number 403. This shows the client has had 3 admits this year. |
| Caseload |
Enter the caseload number from Form 552. |
| Caseworker |
Enter the ID number assigned to the employee and used on Form 552 to report REDE. |
| Authorization Date |
Enter the form's completion date (MM/DD/YY). |
Section B - General Client Information
| Client Name |
Enter client's first name, middle initial, and last name. |
| Client Number |
Enter the RIN from Form 552, Item 60. |
| Usual L/A |
Enter the code that best describes the client's usual living arrangements before being admitted to the facility: |
|
L1 - alone (the client has been living alone) |
|
L2- with spouse |
|
L3 - with spouse and children |
|
L4 - with children |
|
L5 - with other relative |
|
L6 - with nonrelative |
|
L7 - in LTC or SLF facility |
|
L8 - in general hospital |
|
L9 - other (specify) |
| Diagnosis 1 |
Enter the primary diagnosis from Long Term Care Facility Notification (Form 1156). The diagnosis code is next to the "Admitting Diagnosis" on Form 1156. |
| Diagnosis 2 (Optional) |
Enter the secondary diagnosis, if Form 1156 shows one. An entry is not required. |
| Attending Physician's Name |
Enter the name of the client's doctor. If treatment is provided by medical school students, enter the name of the Physician Director of the School. |
| Attending Physician's Number |
Enter the doctor's AMA number, state license number, or SSN. |
Section C - Client Available Income
| 1 Begin Date |
Enter the date (MM/DD/YY) to begin deducting income and/orassets for the billing period. If income and/or assets are to be deducted for the entire billing period, enter the first day of the billing period, otherwise enter the exact day of the month.
For example, if a client is admitted on 01/20, and the screening is met on or before that day, enter 01/20. Item 1 information shows the earliest date the facility is eligible for payment (including admission for a person receiving
Medicare covered SNF services). |
| End Date |
Enter an "End Date" only when the client is entitled to medical coverage in the facility for a previous billing period. If an "End Date" is entered, complete Items 2 and/or 3, as appropriate, with more recent information. |
| Amount |
Enter the total of client's income and/or assets available for the calendar month for the billing period. Only one entry (Box 1) should be made unless the client is entitled to medical assistance coverage in the facility for a previous billing
period. Enter zeroes when there is no credit amount to apply to the cost of care. Do not leave blank. |
| 2 - 3 |
Enter the date (MM/DD/YY) the billing period starts and the total amount of income, or zeroes, for that billing period when the client is entitled to medical coverage in the facility for a previous billing period. Enter "End Dates" as
appropriate. |
Complete box 2 and/or 3, as appropriate, if a client moves from one facility to another and the new facility was not paid for the previous billing period and the income changed.
Leave 2 and 3 blank if the client is not entitled to medical coverage in the facility for a previous billing period.
Example: Client enters a facility on 01/03. The screening requirement is met on that date. Form 2299 is completed 02/06. Enter information in Sections A, B, D, and E. Complete Section C, as follows:
- Enter in Item 1 the beginning date of 01/03 and an end date of 01/31. Under income, enter zeroes.
- Enter in Item 2 the beginning date of 02/01. Do not enter an end date. Under income enter the amount available to apply to the cost of care.
NOTE: Income changes for billing months after the current billing month cannot be submitted until the new billing month. Use Form 2449 to submit changes.
Section D - Evaluation of Need for Care
| Effective Date |
Enter the date (MM/DD/YY) the client is eligible for HFS to pay the facility (including admissions for individuals receiving Medicare covered SNF services). |
| End Date |
For Central Office use only if the date the authorization is to stop is later than the last day of the current month's billing period. |
|
Enter only when the exact date the payment is to stop is known, such as, the client has died, has already transferred to another facility, or is no longer eligible for Medicare coinsurance benefits. |
| Category of Service |
Enter the code for the category of service provided: |
|
*38 Exceptional Care (Central Office use only) |
|
*65 Full Medicare Coverage |
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***70 Skilled (SNF) |
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***71 Intermediate (ICF) |
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*72 Medicare Coinsurance |
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***73 Intermediate/MR (ICF/MR) |
|
***74 Intermediate/MR (SNF/PED) |
|
*76 Intermediate/MR-SLC (ICF/MR/SLC) |
|
**77 Psychiatric, Age 65 and Over |
|
**78 Psychiatric, Under Age 21 |
|
**79 Psychiatric, One Month Only (Age 22 - 64) |
|
*87 Supportive Living (SLF) |
| Negotiated Rate |
For Central Office use only. A rate negotiated for exceptional care can only be approved by the BLTC. BLTC notifies the FCRC in writing of an approval and the effective date of the rate for exceptional care. |
* Private facility only
** State institution, entered only by DHS facility
*** Private facility or state institution.
Section E - Provider Information
| Facility I.D. |
Enter the facility's 12-digit ID number from the Long Term Care/Supportive Living Facilities Provider Information Sheet which must be obtained by the FCRC from each facility. For most facilities, the ID number has the 9-digit FEIN number followed by a
3-digit number assigned by HFS. For DHS facilities, the ID number has 3 zeroes, the 2-digit hospital number, the 4-digit sub-unit number followed by 001. The facility's ID number is located under the heading "Provider Key" that appears in the upper
left-hand corner of the printout. |
| Prov. Ref. No. (Opt.) |
Enter the provider reference number if supplied by the facility. An entry is not required. (Maximum of 10 characters may be entered.) |
| Facility Name |
Enter the name of the facility exactly as it appears on the Long Term Care/Supportive Living Facilities Provider Information Sheet. Do not abbreviate names, add hyphens, dashes, or special characters not appearing on the
printout. |
| Facility Address |
Enter the street, city, state, and zip code from the Long Term Care/Supportive Living Facilities Provider Information Sheet. |
| Signature of Worker |
Sign form. |
| App. Signature (Opt.) |
Sign form if supervisory approval is required by FCRC policy. |
