Long Term Care Nursing Home Billing Overview

March 2014


  • HF Nursing Home General Billing Guidelines
  • HF Nursing Home Clean Claim Requirements
  • Common Causes of Claim Denials
  • Achieving Positive Claim Outcomes

HF NH General Billing Guidelines

  • Nursing Home (NH) services including Bed Hold Days require Prior Authorization
  • Nursing Home claims can be submitted:
    • Electronically using the 837 Institutional Health Care Claim transactions (837I) or
    • On paper using the UB04 claim form
  • Claims must be submitted within 180 days of the date of service
  • Claims must be submitted using Bill Type 21X
  • The following Revenue Codes will be used to reimburse custodial NH claims:
Custodial Level of Care Revenue Code
All inclusive Room and Board-Custodial Care & Respite 100
All inclusive Room and Board-Vent 101
All inclusive Room and Board-AIDS 120
Leave of Absence-Therapeutic Leave-(Bed Hold) 183
Leave of Absence-Nursing Home for Hospitalization-(Bed Hold) 185
All inclusive Room and Board-Head Injury 199

HF NH General Billing Guidelines

  • NH facilities must submit a claim for every month an eligible Member is in the facility.
  • All claims must be submitted on or after the 1st day of the month following the month in which services have been provided.
  • Any time a Member is out of the NH past midnight and is expected to return, it is considered a Break in Service.
    • A Break in Service is a hospitalization leave and/or a leave of absence for recreational purposes.
    • Each time there is a Break in Service the NH must submit an additional claim for each Statement Covers Period.
  • Facilities can bill for a partial month if the Member is discharged or if the Member expires before the end of the month.

HF Nursing Home Clean Claim Requirements

  • A Clean Claim is a claim that can be processed without obtaining additional information
  • NH claims will be considered clean when submitted with the following data elements:
    • Healthfirst Member ID Number
    • Patient Name
    • Patient Date of Birth
    • Patient Sex
    • Subscriber Name/Address
    • Patient Control Number
    • Facility Name and Address
    • Tax ID Number
    • National Provider Identifier-NPI
    • Type of Bill
    • Statement Covers Period
    • Admission Date and Type
    • Admission Source
    • Patient Discharge Status Code
    • Condition Code(s)
    • Occurrence Codes and Dates
    • Value Code(s) and Amounts
    • Revenue Code(s)
    • Service Units
    • Charges per Service and Total Charges
    • Principal, Admitting, and Other ICD-9 Diagnosis Codes
    • Prior Payments
    • Attending Physician Name and NPI
    • Healthfirst Authorization Number

Common Causes of Claim Denials

  • Claim missing information required for processing
  • Claim billed with invalid information. For example:
    • Incorrect Member ID#
    • Incorrect Provider NPI or TIN#
    • Invalid Rev Codes/Diagnosis Codes
  • Member not eligible for date of service billed
  • NH service prior authorization not obtained
  • Claim not filed on time
  • Claim is a duplicate of a previously submitted claim

Achieving Positive Claim Outcomes

  • Thoroughly review Billing Guidelines and share this information with your Billing Team
  • Verify Member eligibility with HF
  • Obtain prior-authorization from HF before providing NH custodial care services to an eligible HF Member
    • Inform the plan of any changes in care immediately
  • Submit clean claims - Ensure all required data elements are present
  • Submit claims within 180 days of the date of service
  • Submit your claims electronically and sign up for EFT/ERA to speed up claims processing and receipt of your payments
  • Monitor your claims submission regularly and promptly report issues to HF