Date: September 10, 2019
To: Long Term Care Facilities - Nursing Facilities (NF), Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Medically Complex for the Developmentally Disabled Facilities (MC/DD), Supportive Living Program (SLP) Providers and Specialized Mental Health Rehabilitation Facilities (SMHRF)
Re: Update: Long Term Care Rejected Admission Transaction Review Project
In the Provider Notice posted 05/16/19, long term care (LTC) providers were notified of a special project related to rejected LTC admission transactions.
Healthcare and Family Services (HFS) set up a process for LTC providers to inquire and follow up on electronically submitted LTC admission transactions that were rejected by the State without notification being sent to the LTC provider. From March 2016 through October 2018, notification letters were not consistently sent to LTC providers when an admission transaction was rejected. Therefore, LTC providers were unable to follow up with the State for an opportunity to reconcile the rejection.
LTC providers were instructed to submit spreadsheets of the rejected admission with the assigned transaction audit number (or “TAN”) to HFS through the LTC Exchange for this special project. HFS has logged the information and begun distributing the spreadsheets to the Department of Human Services (DHS) LTC Units (“hubs”). DHS will review each TAN to determine if the admit was rejected correctly and if a notice was sent to the LTC provider. LTC providers will be given the same opportunity for recourse they would have received if the rejection notification had been sent timely. If the State determines that a TAN was rejected incorrectly, it will be processed. To consolidate communication between DHS LTC hubs and LTC providers, each facility spreadsheet will be assigned to one caseworker for review and follow up.
LTC providers should expect to start receiving information requests from DHS regarding the rejected TANs. The following instructions were sent to DHS for the TAN review process. Please review the information below and make note of the timelines for LTC provider responses. It is very important that LTC providers return the required information within the prescribed timelines. These instructions are specific to the review of the rejected TAN special project ONLY and DO NOT apply to regular processing procedures.
Follow up procedures for all TAN rejections without a rejection letter OR TAN rejection in error
o If the admit was rejected due to lack of screening or LTC services denied because requested verifications were not received. Send a manual 267 requesting the information needed to determine eligibility.
§ Allow a 45 day due date. No extensions given.
§ Continue to process eligibility with standard procedures.
· If verifications are not provided, reject admit and send rejection letter to facility.
o If the admit was rejected because the application was denied.
§ First review to see if the facility received the denial notice.
· If the facility did not receive a denial notice or a rejection letter, send a rejection letter to the facility.
o Allow 45 days for the LTC provider/customer to provide all necessary information for the application to be reopened. If everything needed was received, process reopen and admit.
§ Review to see if all necessary verifications were received for the application to be reopened within 60 days.
· If so, process re-open and process admit if able.
o If a verification checklist (VCL) needs to be sent, allow 30 days for the LTC provider/customer to provide all necessary information for application to be reopened. If everything needed was received, process reopen and admit.
o If the application remains denied, send rejection letter to facility.
o If admit was rejected due to no active case or pending application.
§ Review to see if an application was submitted. No timeframe guidelines applied for this project.
· If so, process the admit as usual.
· If application is denied or LTC services are denied, send a rejection letter to the facility.
o If admit was rejected due to untimely filing.
§ No timely submission rules will be applied for this project.
· Process admit.
o If admit was rejected and no reason can be found.
§ Determine if admit can be processed and complete if able.
§ If the admit remains rejected, send a rejection letter to the facility.
If you have questions, contact the Bureau of Long Term Care toll free at 844-528-8444.