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.

If DHHS receives any Long Term Care Facility Turnaround Billing Documents that are not completely and correctly filled out, signed and dated, the document will be returned for correction and resubmission.

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.

What to do with the completed Long Term Care Facility 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:

Nebraska Department of Finance and Support Client Payments & Claims Processing Unit P.O. Box 95026 Lincoln, NE 68509-5026

Note: LTC Facility Turnaround Billing Documents may not be submitted to DHHS before the first day of the month following the month for which it was generated. Example: Claims for service dates April 1 through April 30 may not be submitted before May 1.

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Attached to the end of each Long Term Care Facility Turnaround Billing Document, you will find several pages of Long Term Care Facility “Add-On” Turnaround Billing Documents. These pages contain blank claims to be completed for Medicaid Waiver clients for whom prior authorization has been received but whose names do not appear on the preprinted portion of the document. INSTRUCTIONS FOR COMPLETION OF THE LONG TERM CARE FACILITY ADD-ON TURNAROUND BILLING DOCUMENT (MC-4):

• 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:

Nebraska Department of Finance and Support Client Payments & Claims Processing Unit PO Box 95026 Lincoln, NE 68509-5026

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.