Introduction

Welcome and congratulations! You are now a provider of Medicaid Waiver Assisted Living for the Home and Community-Based Services Medicaid Waiver administered by the Nebraska Department of Health and Human Services. Thank you for joining our team!

We've designed this handbook to help you with your job. Remember, however, this is not a substitute for the Service Provider Agreement signed by you and a Nebraska Department of Health & Human Services staff person. You may want to review the Service Provider Agreement/DSS-9 (Appendix A ) paying special attention to the “Terms of Agreement” and “General Provider Standards.”

As a new partner with DHHS, we want to make sure you know and understand some of our often-used terms: “DHHS” refers to the Nebraska Department of Health and Human Services. DHHS's mission is to create and sustain a unified, accessible, caring and competent health and human services system for each Nebraskan. DHHS staff and contractors are charged to work with clients, providers and communities to make sure quality services are delivered to aged persons and adults and children with disabilities.

The Home and Community-Based Services Medicaid Waiver for Aged Persons and Adults with Disabilities, sometimes referred to as the Aged and Disabled (A & D) Medicaid Waiver, offers Medicaid-eligible individuals the chance to receive necessary supportive services in the least restrictive and most homelike setting.

You are an important part of the A & D Medicaid Waiver program. You and other service providers enable residents to maintain independence in their own homes —their units in your facility.

Along with your Waiver clients, you'll work with Services Coordinators, Resource Developers and Local DHHS Office Medicaid Eligibility Workers. Services Coordinators help residents determine their needs and available resources. Resource Developers will work with you, the provider, to ensure that standards are met and to eliminate gaps and barriers to service delivery. Local DHHS Office Medicaid Eligibility Workers determine eligibility and keep everyone informed of changes regarding residents' eligibility and financial matters such as “spenddown” or Paid from Other Sources (POS) amounts.

Services Coordinators (sometimes referred to as Case Managers) and Resource Developers may be employees of the Nebraska Department of Health and Human Services. On the other hand, either or both may be employed by an agency, which contracts with DHHS to provide Services Coordination and/or Resource Development. Therefore, in addition to DHHS clients and staff, you may be working with one or more staff of a contractor such as one of the three Independent Living Centers or the eight Area Agencies on Aging located throughout the State.

Also, in order to improve the readability of this Handbook, we've taken some shortcuts. Client/residents are usually referred to simply as residents but may also be called clients. In any case, there is no real difference. For simplicity sake, we have also abbreviated Medicaid Waiver Assisted Living Services by simply saying Waiver Services.

What are Medicaid Waiver Assisted Living Services?

Medicaid Waiver Assisted Living Services are:

• a broad range of support services
• provided in the residents' own living units
• that allow residents to take charge of their lives and participate in decision in a homelike environment

To understand how the process works, let's invent an imaginary resident, “Jane.” First, she must be financially eligible for Medicaid, the Nebraska Medical Assistance Program. Jane is then assessed by a Services Coordinator who determines that she meets the level of care required for waiver eligibility. This will help identify the adequacy of assisted living and other services available under the Home and Community-Based Services Medicaid Waiver.

If “Jane” is determined eligible for Waiver Services and chooses assisted living, a Services Coordinator will work with her and the Assisted Living Facility to develop a Resident Service Agreement. This Agreement ensures that the facility “Jane” chooses includes the services she needs as identified in her Plan of Services and Supports/DSS-12AD (Appendix B ).

Along with the services required under your Assisted Living license, the following service components are required, based on the resident's individual assessment, when you become a Medicaid Waiver Provider. Please remember that while an Assisted Living Facility must be able to provide all of these services, individuals may not need them all. The Plan of Services and Supports and the Resident Service Agreement are designed to keep the resident as independent as possible.

• Adult day care/socialization activities - Structured social, habilitative and health activities geared to each resident's individual needs.
• Escort - Accompanying or assisting a resident unable to travel or wait alone. This may include assistance to and from a vehicle and/or place of local destination or providing or making arrangements for supervision and support to the resident while s/he's away from the Assisted Living Facility.
• Essential shopping - Helping a resident unable to obtain clothing and personal care items for him/herself. This does not include financing the purchases of clothing or special request personal care items.
• Health maintenance activities - Noncomplex health care interventions that can safely be performed according to exact directions that do not require alterations of standard procedure and for which the results and residents' responses are predictable. For example, these interventions could include recording height and weight, monitoring blood pressure and blood sugar and providing insulin injections as long as the resident's condition is stable and predictable as defined in the "Nurses Practices Act" and the "Medication Aide Act." Each resident's individual needs determine the need for health maintenance activities.
• Housekeeping activities - Cleaning of private residences such as dusting, vacuuming, cleaning floors or bathrooms and making and changing beds. Change bed linens as soiled or at least weekly. Make clean bath linens available daily.
• Laundry - Washing, drying, folding and returning a resident's clothing to his/her room. Dry cleaning is each resident's responsibility but please assist in arranging for it, if needed.
• Meals - Provision of three meals per day, seven days per week, as well as access to between-meal snacks. Each meal must:
  • consist of a variety of properly prepared foods containing at least one-third of the Minimum Daily Nutritional Requirements for adults; and
  • take into account cultural and personal preferences for foods served at specific times of the day.
  Deliver meals to the room of any temporarily ill resident.
• Medication assistance - Giving help to residents taking prescription and/or nonprescription medications, if needed.
• Personal Care - Assistance with activities of daily living (ADL's) such as transferring, dressing, eating, bathing, toileting and incidents of bladder and bowel incontinence. Helping residents with meals and snacks including opening packages, cutting food, adding condiments and performing other activities which the resident cannot. If a resident cannot eat independently for a short period of time, feed him/her or assure that other meal and snack arrangements are made. Provide personal care services to each resident in a way that helps them maintain as much independence and privacy as possible.
• Transportation - Transporting or making arrangements for transporting residents to and from local community resources. These resources are identified during each client's assessment and included in his/her Plan of Services and Supports and his/her Resident Service Agreement as directly contributing to his/her ability to remain in an Assisted Living Facility.

To become a facility providing Medicaid Waiver Assisted Living for the Home and Community-Based Services Medicaid Waiver, you should have:

• Worked with Nebraska Department of Regulation and Licensure staff and received an Assisted Living license;
• Worked with DHHS and/or its contracted Resource Developers to complete Medicaid Waiver certification including completing and singing one each: a Service Provider Agreement; an Assisted-Living Service Provider Addendum/MILTC-22 (Appendix C); and an Assisted Living Service Provider Checklist/MILTC-1AD (Appendix D);
• Provided DHHS Resource Development staff and/or that of its contractor with your agency's hiring and reporting policies for background checks of the Adult Protective Services Central Registry and the Child Abuse/Neglect, Central Register and verification that checks show there are no substantiated or inconclusive reports of abuse or neglect by you and/or your current direct care staff as well as all new hires;
• Provided a statement concerning any felony and/or misdemeanor arrests, convictions and pending criminal charges involving you and your direct care staff and if asked, signed a release of information to allow DHHS to get any additional information that may be needed; and
• Proven that you and your direct care staff have not been convicted of or admitted to evidence of crimes against a child or vulnerable adult. Those crimes include but are not limited to, bodily harm, illegal use of a controlled substance or crimes involving moral turpitude.

Provider Duties and Responsibilities

To receive Medicaid payments, an Assisted Living Facility must be licensed as such and must be certified as a Medicaid Waiver Assisted Living Provider according to DHHS Rules and Regulations. In your role as a Medicaid Waiver Services Provider, you will:

• Ensure that there is a written Resident Service Agreement for each resident that was developed jointly with the resident, his/her Services Coordinator and the facility staff. Resident Service Agreements must include:
  • the resident's strengths, needs and desired outcomes;
  • the service components to be provided (when and by whom);
  • an up-to-date listing of medications and treatments and any special dietary requirements; and
  • a description of any limitations of the resident that keep him/her from participating in activities.
• Review and revise the Resident Service Agreement with the resident and his/her Services Coordinator at least annually but more often if services or medical information need to be added or changed. You also need to keep his/her Services Coordinator informed of changes in the resident's condition, transfers, et cetera.
• Submit copies of original and revised Resident Service Agreements to the resident and his/her Services Coordinator;
• Attend training provided by DHHS staff on billing procedures, service provision, et cetera;
• Provide a private living unit with bath (toilet and sink) for each resident receiving Waiver Services. If funding is received from the Nebraska Health Care Trust Fund, “bath” also includes a tub or shower. Inclusion of a tub and/or shower being required for the “bath” also applies to all new constructions;
• Only upon “special request” from the residents involved, provide a semiprivate living unit. The Services Coordinator must get written consent from the residents and document their preference by using a Client Consent for Multiple Occupancy/MILTC-21 (Appendix E ). Prior to providing a semiprivate room, you must have a properly completed and signed consent form on record; and
• If providing Medicaid Waiver Assisted Living Services within a nursing facility, have Waiver certification of separately located areas to include separate dining and common areas.

By signing the Service Provider Agreement and the Assisted Living Service Provider Addendum, you have agreed to:

• Participate as a member of the resident/family's team;
• Make available each service component required to meet residents' needs as noted in their Plan of Services and Supports and Resident Service Agreements;
• Report any suspected abuse or neglect to Adult Protective Services by calling the Adult Protective Services/Child Protective Services Hotline at 1-800-652-1999;
• Respect every resident's right to confidentiality;
• Respect and accept responsibility for each resident's safety and property;
• Certify that direct care staff have:
  1. training and/or experience in working with adults in a health care or social setting;
  2. knowledge of first aid and current cardiopulmonary resuscitation (CPR) certification;
  3. the ability to recognize distress and signs of illness in residents;
  4. knowledge of available medical resources; and
  5. access to information on each resident's physician and emergency medical contacts; and

• Keep the following information in each resident's file for a minimum of four years:
  • 
    
  • The current Resident Service Agreement (no specific DHHS form required);
  • The current Plan of Services and Supports;
  • Phone numbers of emergency contacts and the resident's physician's name and telephone number;
  • Supporting documentation for provision of services for each resident served under the Waiver; and
  • Documentation determined necessary by DHHS to support the selection and provision of services included in the Plan of Services and Supports.

You have also agreed to:

• Bill only for days when services were authorized;
• Submit billing documents within 90 days after services are provided (see Section 6 for instructions to complete the required billing forms);
• Not provide services to any resident for whom a facility owner or administrator is his/her spouse;
• Keep the facility license and Waiver certification current;
• Reserve the right to discharge any resident whose personal care needs exceed, for more than a temporary period, a level beyond your facility's service capability;
• Work with the Services Coordinator to arrange for alternative services if it becomes necessary to discharge a resident;
• Report the death of any resident in accordance with the procedures of the “Home and Community-Based Services Waiver Death Review Committee.” This includes notifying Carol Lieske at 1-402-471-9190 no later than the next DHHS working day following the resident's death;
• Keep on file for a minimum of four years:
  • Copies of all Long Term Care Facility Turnaround Billing Documents/MC-4 (Appendix F ) and Long Term Care Facility Add-On Turnaround Billing Documents/MC-4 (Appendix G) submitted to DHHS for services you provided to the residents; and
  • Provider agreements with DHHS;
• To provide a homelike environment for each resident. If a Waiver resident has no access to essential furniture, the facility will provide, at a minimum, a bed, a nightstand or table and a chair; and
• To supply normal, daily personal hygiene items. This includes at a minimum but not limited to: soap; shampoo; facial tissue; dental hygiene products; and toilet paper.

Department Responsibilities

As a partner with the Nebraska Department of Health and Human Services, your facility provides residents with the best possible selection of services. DHHS Services Coordinators or those of agencies contracting with DHHS to provide Services Coordination and Resource Developers can help you address the needs of your residents and assist you and your staff in your efforts to receive payments for those services. DHHS takes the responsibility to:

• Contract with you annually to ensure that all applicable Federal, State and local laws and regulations are met;
• Provide you with a detailed, written description which clearly defines the parameters of service delivery including:
  • the amount and frequency of service provision;
  • specific service components authorized; and
  • any applicable time limitations;
• Process payments for services listed on Long Term Care Facility Turnaround Billing Documents and Long Term Care Facility Add-On Turnaround Billing Documents.

To be eligible for support through the Aged and Disabled Medicaid Waiver, a potential client must meet the following general criteria:

1. Be eligible for the Nebraska Medical Assistance Program (NMAP/Medicaid);
2. Have participated in an assessment with a Services Coordinator;
3. Have care needs, which would otherwise require services to be provided in a Nursing Facility (NF). Medicaid criteria for admission to a nursing facility is found in Title 471, Chapter 12 of the Nebraska Administrative Code (471 NAC 12-000);
4. Have received an explanation of NF and waiver services and elected to receive waiver services; and
5. Work with the Services Coordinator to develop an individualized, outcome-based, cost-effective service plan.

Services Coordinators collect information on each individual seeking waiver services to determine the functional abilities and care needs of that individual.

• Information may be gathered from a variety of sources (e.g. the individual, family, care providers, physicians, facility staff, case files, medical charts) using observation, documentation review and/or interviews until sufficient information is obtained to determine the individual's current functioning in each area.
• Persons who require assistance, supervision, or care in at least one of the following four categories meet the level of care criteria for Nursing Facility of Aged and Disabled Home and Community-Based Medicaid Waiver services:
  1. Limitations in three or more Activities of Daily Living AND medical treatment or observation;
  2. Limitations in three or more Activities of Daily Living AND one or more Risk factor;
  3. Limitations in three or more Activities of Daily Living AND one or more Cognition factor; OR
  4. Limitations in one or more Activities of Daily Living AND one or more Cognition factor AND one or more Risk factor.
• For those clients that meet NF level of care, the Services Coordinator shall then determine if the client meets priority criteria.

If the potential client does not meet the NF level of care criteria, the Services Coordinator shall inform the referral source of this decision and provide notice to the potential client/guardian. The Services Coordinator shall also provide appropriate information and referral. Notices to clients must contain:

1. A clear statement of the action to be taken;
2. A clear statement of the reason for the action;
3. A specific policy reference which supports such action; and
4. A complete statement of the client's rights to appeal.

Overview of Payment Structure

Payment for Medicaid Waiver Assisted Living, as it applies to the DHHS Home and Community-Based Services Medicaid Waiver for Aged Persons and Adults with Disabilities, consists of two main components. The first is Room and Board and the second is Medicaid Waiver Assisted Living Services.

Medicaid Waiver Assisted Living Rates Medicaid Waiver Assisted Living Rates, also referred to as “Per Day Equivalents,” are calculated to cover the total of all Medicaid Waiver Assisted Living costs/payments. Rates are applied as “"Standard vs. Health Care Trust Fund,” “Urban vs. Rural” and “Single vs. Multiple Occupancy.” Standard Rates for 1999 are illustrated in the Assisted Living Rates Chart (Appendix H). “Health Care Trust Fund” rates are computed at 95% of the corresponding Standard Rate (Per Day Equivalent).

Only the Services portion is billed on the Long Term Care Facility Turnaround Billing Document and paid under the DHHS Home and Community-Based Services Medicaid Waiver for Aged Persons and Adults with Disabilities.

Payment for Room and Board Medicaid does not pay for Room and Board. Each resident is financially responsible for his/her own Room and Board and should be contacted directly for payment. Residents may pay Room and Board with funds they receive from any of several sources such as Social Security benefits, Supplemental Security Income (SSI), a retirement/pension or a DHHS grant (Aid to the Aged, Blind and Disabled/AABD or State Supplemental).

As of this Handbook's printing, residents pay $440 per month for the Room and Board component.

Prorate each resident's payment for Room and Board in the month the resident is initially authorized for Medicaid Waiver Assisted Living by dividing $440 by the number of days in the applicable month and multiplying that by the number of days the client is an authorized Medicaid Waiver resident of the assisted living facility.

For example, let's say that “Jane” is an eligible Waiver resident from the 19th through the end of February in 1999. You should divide $440 by the 28 days in February. You'd get a daily rate of $15.71 which you'd then multiply by 10 (19th-28th) and charge “Jane” $157.10. This means that the amount to be charged for ten days of Room and Board in February will be different than that charged for ten days in other months since the number of days per month varies.

Prorating the Room and Board amount also applies for months when residents are discharged.

The Room and Board portion may be collected at the beginning, ending or during each month or according to whatever agreement is reached between the resident, his/her family and the facility.

Payment for Medicaid Waiver Assisted Living Services The balance of the monthly Medicaid Waiver Assisted Living amount is for Waiver Services. The Services portion (Level of Care amount minus $440) is used to calculate the Per Day Equivalent for each Level of Care.

Payment to the facility for the Medicaid Waiver Assisted Living Services portion must be prior authorized by the Services Coordinator. Waiver providers will receive a Medicaid payment directly from DHHS. In addition to Room and Board, the resident may have funds s/he must obligate before DHHS will assume financial responsibility for the Services component.

Each resident may have a monthly “spenddown” obligation. This “spenddown” or “Share of Cost” is called the Paid from Others Sources (POS) Amount and will be preprinted on the Long Term Care (LTC) Facility Turnaround Billing Document received by your facility near the end of each month. Please work closely with the resident, his/her family and local DHHS Medicaid Eligibility workers to arrange for collection of the POS Amount.

In summary:

• Payment of each claim is dependent on the authorized Per Day Equivalent and the Prior Authorization record, regardless of changes made by facilities to their Long Term Care Facility Turnaround Billing Documents.
• DHHS needs to receive each Long Term Care Facility Turnaround Billing Document within 90 days after the last day of the month for which the document was generated. If more than 90 days have passed, facility staff must attach justification to the documents in order for the claims to be considered for payment.
• The facility also has 90 days from the date of an Explanation of Medical Claims Activity/MC-7 (Appendix I) to request reconsideration or adjustment of a claim that has been denied, reduced, not paid or paid incorrectly. This can be done in writing or by calling the Nebraska Medicaid Provider Inquiry Line toll free at 1-877-255-3092. If calling from Lincoln, dial 471-9128. You will then receive several prompts in order to reach an DHHS Nursing Home/Assisted Living representative. The Medicaid Provider Inquiry Line is available Monday, Wednesday, and Friday, 9:00 a.m. to noon and 1:00 p.m. to 4:00 p.m. (Central Time).

If no payment or response is received within 30 days from the date the request is submitted to DHHS, call the Medicaid Provider Inquiry Line and an DHHS Nursing Home/Assisted Living representative will help you.

Assisted Living Rates

Aged & Disabled Medicaid Waiver Assisted Living Rates for Individuals Qualified under the Waiver January 1, 2008 through December 31, 2008 (Refer to Section III for payment changes)

*Urban Counties - Cass, Dakota, Dixon, Douglas, Lancaster, Sarpy, Saunders, Seward and Washington Counties

1. Facility will collect Room and Board from the client. This amount must be prorated for clients whose “Prior Authorization for Assisted Living Waiver Service”is for a partial month. Medicaid does not pay for room and board. Each client is financially responsible for his/her own room and board with funds received from any of several sources, such as, Social Security benefits, Supplemental Security Income (SSI) retirement/pension or a DHHS grant (Aid to the Aged, Blind or Disabled/AABD or State Supplemental).
2. The client may have a“Share-Of-Cost”(POS) that must be obligated before DHHS will assume financial responsibility for the service component. The client, waiver facility, and Services Coordinator receive a“Notice of Finding”from the Medicaid Eligibility Worker. The POS amount will also be indicated on the Turnaround Billing Document (MC-4). The POS is NOT pro-rated; the full amount must be paid before Medicaid payment is figured. The POS is always taken out at the location the client is at the beginning of the month. Any change in amount as identified in the Notice goes into effect the following month.
3. The MC-4 includes the TOTAL amount Medicaid will pay. (Per day equivalent x number of days in the month minus any POS/Share-Of-Cost).
4. The total amount received by facility each month may be slightly more or slightly less than the figure in #1 on the above chart, depending on the number of days in the month.
5. Waiver clients retain a personal need allowance of $60 per month. In some cases this amount may vary, refer to Medicaid Eligibility Worker for questions.
6. Urban rates apply to facilities in Cass, Dakota, Dixon, Douglas, Lancaster, Sarpy, Saunders, Seward and Washington counties.
7. Multiple occupancy requires:
   1. prior approval by DHHS
   2. consent form signed by the client and roommate
8. Trust Fund Grantees must maintain specified occupancy levels of Medicaid beneficiaries for a period of 10 years.
9. Refer to the Assisted Living Provider Handbook for detailed instructions.

† The facility must notify the Services Coordinator by the next working day of a medical absence in which a client is admitted to a hospital or nursing facility. This notice is required in order for the Services Coordinator and Central Office to determine continued appropriateness of the assisted living authorization. Failure to report medical absences to the Services Coordinator may result in the facility being required to reimburse the Department for days the client was out of the facility for medical reasons.

Billing DHHS for Payment

Review the following instructions carefully. Knowing how a Long Term Care Facility Turnaround Billing Document is created, processed and paid will save you time and energy.

Each month DHHS will send your facility two carbon-free copies of a Long Term Care Facility Turnaround Billing Document. This is a computer-generated billing document, prepared approximately the 25th of each month for each Medicaid Waiver Assisted Living Facility. It includes those Medicaid-eligible Waiver residents with active Prior Authorization records that identify your facility as the Medicaid Waiver Service Provider providing Assisted Living Services to the identified residents. Your staff should review the documents for accuracy and completeness, make adjustments and correct any errors by crossing out inaccuracies and clearly indicating corrections by using bold-colored ink or highlighter.

INSTRUCTIONS FOR COMPLETION OF THE LONG TERM CARE FACILITY TURNAROUND BILLING DOCUMENT (MC-4):

• The heading of each page of the Long Term Care Facility Turnaround Billing Document includes: The facility's Medicaid Provider Nbr; The facility's Provider Name; The facility's Address, City, State, and Zip; The beginning and ending month, day and year which the claims cover (centered under title); and Other claim identifying information for DHHS use only.
• The remainder of the LTC Facility Turnaround Billing Document contains individual claims, each separated by a row of asterisks. Each claim contains the elements listed below. Facility staff may change and/or enter applicable information for those elements herein underlined.
• Recipient: The client's name, last name first and his/her Medicaid ID number. Clients will be listed in alphabetical order.
• Claim Number: A unique, nonrepeating, eleven-digit number assigned by the computer. This number will also appear on your Explanation of Medical Claims Activity that will be attached to your payment and gives detailed information regarding claims processed and paid. All inquiries regarding a particular claim/document must include the claim number.
• Prior Auth Nbr: A nine-digit number assigned by the computer when a Prior Authorization for Assisted Living Waiver Service/MC-9AD (Appendix H) is data entered into the computerized Medicaid Management Information System (MMIS) which processes your claims for payment.
• Payment Effect Date: The current Medicaid “Waiver Payment Effective Date” from the Prior Authorization for Assisted Living Waiver Service.
• Level of Care: The appropriate level of care approved for the resident. Correct the number if the client is receiving a level of care different than that indicated: NF40 - rural single occupancy NF41 - rural multiple occupancy NF42 - urban single occupancy NF43 - urban multiple occupancy
• Room Number: Facility staff may enter the resident's room number for their reference.
• Daily Rate: The authorized Medicaid Waiver Per Day Equivalent for the resident's level of care.
• Admit Date: This is the day the resident was actually admitted to the Assisted Living Facility and should be the same date as the “Service Begin Date” on the Prior Authorization for Assisted Living Waiver Service. This may differ from the “Payment Effect Date” and is not necessarily the date DHHS begins payment. Please enter in month/day/year (mm/dd/ccyy) format (Be sure to include the century).
• Discharge Date: The service end date, if applicable, is entered here in month/day/year (mm/DD/ccyy) format (Be sure to include the century). No date is entered if the resident is still residing in the Medicaid Waiver Assisted Living Facility at midnight on the service end date. This information may be preprinted if the discharge date or date of death has been received from the DHHS office or if the resident's Medicaid Waiver eligibility has ended.
• Discharge Rsn: Facility staff shall use the following codes to indicate the reason for discharge. A code number must be entered if a discharge date is entered. If the discharge reason is preprinted, the facility staff should correct it as needed.
  1. Returned home;
  2. Entering a nursing home;
  3. Death;
  4. Hospital (use only if resident is not returning); or
  5. Other such as moved to another Assisted Living facility.
• Nur Home Days: The number of days for which the facility expects to get paid. Payment is based on the client's status as of midnight at the end of the day of residence. Payment, therefore, will be made for the day a resident is admitted or enters the facility, regardless of the hour but payment will not be made for the day the resident is officially discharged. The number of days in the month is preprinted. Facility staff should adjust the number of days, if necessary, to reflect the total number of days the resident was officially in the facility at midnight including those days in which the resident was in the hospital or out of the facility on a temporary basis. The facility, resident and the resident's family should work closely with the Services Coordinator to determine the appropriateness of short-term absences from the facility. This includes overnight hospital stays and/or overnight visits to family, friends and other places/events providing gratification to the resident.
• Leave Days - Therapeutic/Hospital: Leave this field blank.
• Total Amount: This is the total amount of the claim (“Nursing Home Days” multiplied by the “Daily Rate”). Facility staff may adjust, if necessary.
• Paid Other Sources Amt: This is preprinted. If the amount is incorrect, facility staff should correct it. Waiver facilities receive a “Notice of Finding” from the Medicaid eligibility worker stating the resident's share, if any. If correction to the claim information is necessary, also attach a copy of the most current “Notice of Finding” so that DHHS can update their files. Correct information will then be reflected on any subsequent LTC Facility Turnaround Billing Document.
• Net Amount: This is the “Total Amount” minus “Paid Other Sources Amt.” The computer will calculate the net amount for each claim but facility staff may want to calculate and enter the “Net Amount” on the facility's copy.
• In the blank area by the individual claim, enter any additional information that will assist in processing and paying the claim.
• Following the last claim, a line with totals of the LTC Facility Turnaround Billing Document is printed. These amounts are the totals of all claims on the document. When other changes or corrections have been made, facility staff may calculate the “Total Amount,” the total “Paid Other Sources Amt” and the total “Net Amount” but it is not required.
• Signature of Administrator/Authorized Representative: The administrator or his/her authorized representative must sign the LTC Facility Turnaround Billing Document. The signature binds the facility to the statement on the document regarding Civil Rights and Rehabilitation Acts, regulations of DHHS, finality of charges claimed and documentation of each service.
• Date: Enter the date the administrator or his/her authorized representative signed the document. This date must be on or after the first day of the month following the month for which services are claimed.
• Phone: Enter the phone number of a person who can answer questions and inquiries regarding the claims/document.

• The heading of each page of the Long Term Care Facility Add-on Turnaround Billing Document includes: The facility's Medicaid Provider Number; The facility's Provider Name; The facility's Address, City, State, and Zip; and Other claim identifying information for DHHS use only.
• Within the row of asterisks above the claim headings you will note that “Claims on this page will not be accepted by the Department of Social Services (now DHHS) after mm/DD/ccyy.” Add-on claims not used prior to the date identified will be deleted from the computerized claims processing system and cannot be used for payment by DHHS after the expiration date.
• The remainder of the LTC Facility Add-on Turnaround Billing Document contains individual claims, each separated by a row of asterisks. Each claim contains the elements listed below. Facility staff may enter applicable information for those elements herein underlined.
• Claim Number: A unique, nonrepeating, eleven-digit number assigned by the computer. This number will also appear on your Explanation of Medical Claims Activity that will be attached to your payment and gives detailed information regarding claims processed and paid. All inquiries regarding a particular claim/document must include the claim number.
• Prior Auth Nbr: Leave this field blank.
• Recipient Number/ID: Enter the resident's 11-digit Medicaid Recipient ID number. All claims must contain a Medicaid Recipient ID number in order to be processed and paid by DHHS.
• Level of Care: Enter the appropriate level of care according to the resident's Prior Authorization for Assisted Living Waiver Service. 40 - rural single occupancy 41 - rural multiple occupancy 42 - urban single occupancy 43 - urban multiple occupancy
• Payment Effect Date: Enter the date, in month/day/year (mm/DD/ccyy) format, (Be sure to include the century) when service began according to the Medicaid “Waiver Payment Effective Date” on the Prior Authorization for Assisted Living Waiver Service.
• Daily Rate: The authorized Medicaid Waiver Per Day Equivalent for the resident's level of care.
• Diagnosis - Prim/Sec: Please leave this field blank.
• Service Dates - Beginning/Ending: Enter the dates, in month/day/year (mm/DD/ccyy) format (Be sure to include the century), indicating the dates of service being claimed for payment. Each calendar month or partial month must be on a separate claim.
• Patient Account Nbr: If your facility has a patient account numbering system, write in the client's account number here. This number will appear with the claim information on the Explanation of Medical Claims Activity that accompanies payment.
• Admit Date: This is the day the resident was actually admitted to the Assisted Living Facility and should be the same date as the “Service Begin Date” on the Prior Authorization for Assisted Living Waiver Service. This may differ from the “Payment Effect Date” and is not necessarily the date DHHS begins payment. Please enter in month/day/year (mm/DD/ccyy) format (Be sure to include the century).
• Discharge Date: The service end date, if applicable, is entered here in month/day/year (mm/DD/ccyy) format (Be sure to include the century). No date is entered if the resident is still residing in the Medicaid Waiver Assisted Living Facility at midnight on the service end date.
• Discharge Rsn: Facility staff shall use the following codes to indicate the reason for discharge. A code number must be entered if a discharge date is entered.
  1. Returned home;
  2. Entering a nursing home;
  3. Death;
  4. Hospital (use only if resident is not returning); or
  5. Other such as moved to another Assisted Living facility.
• Nursing Home Days: The number of days for which the facility expects to get paid. Payment is based on the client's status as of midnight at the end of the day of residence. Payment, therefore, will be made for the day a resident is admitted or enters the facility, regardless of the hour but payment will not be made for the day the resident is officially discharged. Facility staff should enter the total number of days the resident was officially in the facility at midnight including those days in which the resident was in the hospital or out of the facility on a temporary basis. The facility, resident and the resident's family should work closely with the Services Coordinator to determine the appropriateness of short-term absences from the facility. This includes overnight hospital stays and/or overnight visits to family, friends and other places/events providing gratification to the resident.
• Therapeutic Leave Days: Leave this field blank.
• Hospital Days: Leave this field blank.
• Room Nbr: Facility staff may enter the resident's room number for their own reference.
• Attending Phys Lic Nbr - 28-01-: This is always “MD” but may be left blank.
• Recipient: Enter the name of the resident identified by the Recipient Number/ID above.
• Total Amt-$: This is the total amount of the claim (Nursing Home Days multiplied by the Daily Rate).
• Paid Other Sources Amt-$: Enter the amount to be paid by sources other than DHHS's Home and Community-Based Services Medicaid Waiver. Waiver facilities receive a “Notice of Finding” from the Medicaid eligibility worker stating the resident's share, if any.
• Net Amount: This is the Total Amount minus Paid Other Sources Amt. The computer will calculate the net amount for each claim but facility staff may want to calculate and enter the Net Amount on the facility's file copy.
• In the blank area by the individual claim, enter any additional information that will assist in processing and paying the claim.
• Signature of Administrator/Authorized Representative: The administrator or his/her authorized representative must sign each page of the LTC Facility Add-on Turnaround Billing Document on which claims are submitted. The signature binds the facility to the statement on the document regarding Civil Rights and Rehabilitation Acts, regulations of DHHS, finality of charges claimed and documentation of each service.
• Date: Enter the date the administrator or his/her authorized representative signed the document. This date must be on or after the first day of the month following the latest month for which services are claimed.
• Phone: Enter the phone number of a person who can answer questions and inquiries regarding the claims/document.

What to do with the completed Long Term Care Facility Add-on Turnaround Billing Document (MC-4):

Your facility should keep one copy for its records and submit one copy of the completed MC-4, signed and dated by the administrator or authorized representative of the facility, to:

Note: LTC Facility Add-on Turnaround Billing Documents may not be submitted to DHHS before the first day of the month following the latest month of any claim being submitted. Example: Claims for service dates April 1 through April 30 may not be submitted before May 1.

Appendices