North Carolina Medicaid: Submitting hospice claims for members in skilled nursing facilities

Avoid denied room and board claims by following billing protocol

This serves as a reminder that hospice health care providers are responsible for billing UnitedHealthcare Community Plan of North Carolina for room and board provided to members in skilled nursing facilities (SNFs). Upon reimbursement, the hospice provider pays the SNF a per diem rate, per the contractual agreement between the 2 entities.

Claims denied for duplicate billing

We’ve seen an increase in both the hospice provider and SNF submitting identical claims for room and board (R&B) services. This situation can result in:

• Both claims being denied for duplicate billing
• Claims paid at incorrect rates, creating contractual and audit risks
• Claims denied for incorrect revenue codes

How to bill SNF hospice services

To help ensure smooth claims processing and timely reimbursement, please follow these billing structure guidelines established by the North Carolina Department of Health and Human Service (NCDHHS):

• Claims for room and board
  • Billing entity – The attending hospice provider bills UnitedHealthcare Community Plan of North Carolina on behalf of the SNF
  • Frequency – Monthly, using appropriate dates of service
  • Payment flow
    • UnitedHealthcare Community Plan reimburses the hospice provider for services rendered. The amount is based on 95% of the per diem for the individual SNF and is reduced by the amount of the patient monthly liability (PML), when applicable.
    • Hospice provider reimburses the SNF at the negotiated rate determined by the contractual agreement
  • Claim details
    • Service Facility Provider – Enter the National Provider Identifier (NPI) number for the SNF
    • Attending Provider – Enter the NPI for the hospice provider
    • Revenue codes – Codes must match the level of care covered under Medicaid (FL-2)
      • Intermediate level of care – 0658
      • Skilled level of care – 0659
• Claims for hospice services
  • Billing entity – The hospice provider files a claim with UnitedHealthcare Community Plan of North Carolina
  • Payment flow – UnitedHealthcare Community Plan of North Carolina reimburses the hospice provider for services rendered
  • Claim details
    • Attending Provider field – Enter the NPI for the hospice provider
    • Revenue codes – Select the appropriate revenue code from the following chart to report the unit(s) of service administered to the member:

How to prepare and submit a corrected claim

When filing for R&B as a hospice provider, you can resubmit a corrected claim within the time frame given in the original denial notice. This is either the explanation of benefits (EOB) or provider remittance advice (PRA).

• Allow the original claim to be adjudicated prior to submitting a correction
• Ensure the correction(s) you submit represents a complete replacement of the previous claim
• Include the appropriate code/modifier for any claim we denied
• Use the correct frequency code or bill type to show it’s a replacement claim

Please communicate with the SNF that you will submit the R&B claim on their behalf.

Use any of the following methods to submit the corrected claim:

• Electronic Data Interchange (EDI)
  • Enter frequency code/bill type 7 into the 2300 Loop CLM05-03
  • Include the Original Reference Number (claim identifier) in the REF02 segment
• UnitedHealthcare Provider Portal
  • From any page on UHCprovider.com, select Sign In and enter your One Healthcare ID
    • If you don’t have a One Healthcare ID, register now.
  • Select Claims & Payments > Look up a claim or ticket and enter your search criteria
  • On the Claims Summary page, select > Act on a Claim > Submit corrected claim

For detailed instructions, visit our Claims Interactive Guide.

• Paper claims
  • Enter frequency code 7 in box 22, in the left-justified position
  • Include the original claim number in the Original Reference Number box

Submitting corrected claims through the portal is a fast and easy solution that provides quick results.