Medicaid Requirements for Billing

Medicaid Requirements for Billing

NURSING FACILITY ELIGIBILITY

There are five components that determine beneficiary eligibility and Medicaid nursing facilityReimbursement.

• Verification of financial Medicaid eligibility

• PASARR Level I screening

• Physician-written order for nursing facility services

• A determination of medical/functional eligibility based upon a web-based version of the MichiganMedicaid Nursing Facility Level of Care Determination (LOCD) that was conducted online at thetime the resident was either Medicaid eligible or Medicaid pending and conducted within thetimeframes specified in the Michigan Medicaid Nursing Facility Level of Care Determinationsubsection of this chapter.

• Computer-generated Freedom of Choice (FOC) form signed and dated by the beneficiary or thebeneficiary's representative.

Financial Eligibility Medicaid

VERIFICATION OF FINANCIAL MEDICAID ELIGIBILITY

The CHAMPS member page will work also.

Medicaid reimbursement for nursing facility services for an individual requires adetermination of Medicaid financial eligibility for that individual by the MichiganDepartment of Human Services (DHS). When a Medicaid financially-eligible beneficiary isadmitted to a nursing facility, or when a resident becomes Medicaid financially eligible while in a facility, the nursing facility must submit the Facility Admission Notice (MSA-2565-C) to the local DHS office to establish/confirm the individual's eligibility for Medicaid

benefits. The facility should also submit the MSA-2565-C for residents who arepotentially financially eligible.

DHS will return a copy of the MSA-2565-C to the facility noting an individual's Medicaid financial eligibility status and patient-pay amount (do not wait for DHS to return a copyof the MSA-2565-C; the online Michigan Medicaid Nursing Facility Level of CareDetermination must be conducted within the required timeframe for Medicaid orMedicaid-pending beneficiaries). A copy of the MSA-2565-C is available on the MDCH

website and in the Forms Appendix of this manual.

PHYSICIAN ORDER FOR NURSING FACILITY SERVICES

A physician-written order for nursing facility admission is required. By renewing orders,the physician certifies the need for continuous nursing facility care. The order must besigned and dated by the physician. The physician's degree must appear with thesignature. A stamped signature is not acceptableWith the exception of beneficiaries 21 years of age or under residing in a psychiatricfacility, a physician (MD or DO) must approve a beneficiary's need for long-term care not more than 30 calendar days prior to the beneficiary's admission to a nursing facility.

For an individual who applies for Medicaid financial eligibility while a resident in a nursingfacility, the physician must reaffirm the need for long-term care not more than 30calendar days prior to the submission of the application for Medicaid financial eligibility

PASARR

One of the required items to bill the Medicaid Program for reimbursement according to the Medicaid ManualSECTION 8 – PASARR PROCESSis thePASARR Level I screeningPre-admission Screening/Annual Resident Review (PASARR) in Michigan is a two-level screening andevaluation process. The Level I screening and Level II evaluation procedures and forms are the same forPre-admission Screening (PAS) and Annual Resident Review (ARR). The forms may be obtained from the

MDCH website.

The PASARR process must be completed:

• Prior to admission to a nursing facility;

• Promptly after a significant change in a resident’s physical or mental condition; and

• Not less than annually.

COMPLIANCE

Failure of a nursing facility to comply with OBRA PASARR requirements will result in the loss of Medicaidreimbursement to the facility for services provided for that resident for any period during which a correctand timely screening or review was not completed for that resident. A claim should not be submitted fordates of services provided during periods for which required Pre-admission Screening or Annual ResidentReview has not been completed.

The resident or parties responsible for the resident cannot be charged for the loss of reimbursementcaused by the facility’s failure to meet PASARR requirements.

Care Plan

Evidence of Person-Centered Care Planning must be demonstrated through the following:

The medical record must include the following:

• care plans that clearly document participant strengths and skills and chosen interventions to foster these abilities, as well as participant-stated goals for care.

• evidence through progress notes and care planning documents that the participant fully and actively participates in making the decisions that affect quality of life. Planning strategies and resources must be consistent with the desired outcomes and needs of the participant.

• documented planned interventions acknowledging a participant’s cultural background issues when they affect the planning and decision-making process.

• evidence through progress notes and care planning documents that the participant expresses their preferences, if they choose, during the person-centered planning process with the support of family, friends, and staff if necessary.

• documentation that the participant chose whether or not other persons should be involved in the person-centered planning process.

• documentation that the participant chose their desired care outcomes, and caregivers whenever possible.

• evidence that the participant’s preferences and outcomes were seriously considered and, in situations where it was difficult to implement their planned interventions, the team arrived at a compromise acceptable to the participant.

The care plan must remain current at all times.

LOCD (Level Of Care Determiniation)

A Michigan Medicaid Nursing Facility Level of Care Determination (LOCD) must be completed for every Medicaid beneficiary prior to admission to a nursing facility. The nursing facility must verifybeneficiary appropriateness for nursing facility care by completing the online version of the

LOCD. Beneficiaries who do not demonstrate functional/medical eligibility through the online

LOCD are not eligible for nursing facility care. Refer to the Coveragesportion of the NursingFacility Chapter for additional information regarding the LOCD.

Annual online LOCDs are not required, however, subsequent redeterminations, progress notes, or participant monitoring notes must demonstrate that the participant continues tomeet the level of care criteria on a continuing basis. If waiver agency staff determines

that the participant no longer meets the functional level of care criteria for participation (e.g., demonstrates a significant change in condition), another face-to-face online versionof the LOCD must be conducted reflecting the change in functional status. Thissubsequent redetermination must be noted in the case record and signed by theindividual conducting the determination.

In order for Medicaid to reimburse for nursing facility services from the date of admission of a Medicaid-eligible beneficiary, the Medicaid beneficiary must be in aMedicaid-certified bed, and the LOCD must be conducted online ONLY for Medicaideligible or Medicaid pending beneficiaries and within the timeframes outlined inthe Michigan Medicaid Nursing Facility Level of Care Determination subsection of

this chapter.

Freedom of Choice Form

FREEDOM OF CHOICE

When a Medicaid-pending or Medicaid-eligible beneficiary has qualified for services under the LOCD criteria, the computer-generated FOC form lists LTC service options. Thecomputer-generated form must be printed hard copy, and the beneficiary must chooseand note on the form the services they choose to receive. This election must take placeprior to initiating nursing facility services under Medicaid.

The applicant (or representative) must be informed of services available through:

• Medicaid-reimbursed nursing facilities
• The MI Choice program

• The Program of All-Inclusive Care for the Elderly (PACE) program, where available.

If applicants are interested in community-based care, the nursing facility must provide appropriate referral information as identified in the Access Guidelines to MedicaidServices for Persons with Long Term Care Needs. The guidelines are available on theMDCH website. Applicants who prefer a community long term care option, but areadmitted to a nursing facility because of unavailable slots or other considerations, must

also have an active discharge plan documented for at least the first year of care.

Applicants must acknowledge that they have been informed of their program options in writing by signing the computer-generated Freedom of Choice form. If the applicant hasa legal representative, the legal representative must sign the computer-generatedFreedom of Choice form. The health professional conducting the Michigan Medicaid

Nursing Facility LOC Determination must also sign and date the form. The completed form (i.e., signed and dated) must be kept in the medical record if the applicant choosesto receive nursing facility services. A copy of the completed form for non-admissionsmust be retained for a period of three years. A copy of a non-computer generatedFreedom of Choice form is available on the MDCH website.