Section 471-31-005 - BILLING AND PAYMENT FOR INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DP) SERVICES005.01BILLING.005.01(A)GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter govern.005.01(B)SPECIFIC BILLING REQUIREMENTS.005.01(B)(i)REPORTING BED HOLDING DAYS. Intermediate care facility for individuals with developmental disabilities (ICF/DD) must report bed holding days on the appropriate claim. The appropriate bed holding days are reported as outlined in claim submission instructions: the "nursing facility days"? are adjusted to the actual number of days the client was present in the intermediate care facility for individuals with developmental disabilities (ICF/DD) at midnight.005.01(B)(ii)BILLING FOR THE ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is performed solely to meet the Medicaid requirement, the physician must use the appropriate Healthcare Common Procedure Coding System code and submit the claim to Medicaid. If the physical examination is performed for diagnosis or treatment of a specific symptom, illness, or injury and the individual has Medicare or other third party coverage, the physician must submit the claim through the usual Medicare or other third party process. 005.02PAYMENT.005.02(A)GENERAL PAYMENT REQUIREMENTS. Nebraska Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter govern.005.02(B)SPECIFIC PAYMENT REQUIREMENTS. Medicaid will pay for intermediate care facility for individuals with developmental disabilities (ICF/DD) services only when prior authorized.005.02(B)(i)INITIAL CERTIFICATION. Medicaid must approve payment to an intermediate care facility for individuals with developmental disabilities (ICF/DD) for services rendered to an eligible client beginning on the date: (1) The client is formally admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD) following the admission evaluation process:(2) The client's eligibility for Medicaid is effective, if later than the admission date; or(3) The date Form DM-5 is signed and dated, if Form DM-5 is signed and dated more than 48 hours (two working days) after admission or the date eligibility is determined. If the physician's examination is submitted instead of Form DM-5, the date the physician's examination is signed and dated, if this execution is more than 48 hours (two working days) after admission or the date eligibility is determined. If Form DM-5 is signed and dated more than 30 days before admission, or the date eligibility is determined, Medicaid will not approve payment unless a new or updated Form DM-5 is obtained.005.02(B)(ii)DEATH ON DAY OF ADMISSION. If a client is admitted to an intermediate care facility for individuals with developmental disabilities (ICF/DD) and dies before midnight on the same day, Medicaid allows payment for one day of care.005.03INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) RATE REQUIREMENTS.005.03(A)REPORTING REQUIREMENTS AND RECORD RETENTION. Providers must submit cost and statistical data on Form FA-66, Long-Term Care Cost Report, and Form FA-66 Intermediate Care Facility For Individuals With Developmental Disabilities (ICF/DD), Long-Term Care Cost Report Supplement. Data must be compiled on the basis of generally accepted accounting principles and the accrual method of accounting for the report period. If conflicts occur between generally accepted accounting principles and requirements of this regulation, the requirements of this regulation prevail. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. All records must be readily available upon request by Medicaid for verification of the reported data. If records are not accurate, sufficiently detailed, or readily available, Medicaid may correct, reduce, or eliminate data. Providers are notified of changes. 005.03(A)(i)TIMELINE. Each facility must complete the required schedules and submit the original, signed Report to Medicaid within 90 days of the close of the reporting period, when a change in ownership or management occurs, or when terminated from participation in Medicaid. Under extenuating circumstances, an extension not to exceed 45 days may be permitted. Requests for extensions must be made in writing before the date the cost report is due. 005.03(A)(ii)FAILURE TO PROVIDE. When a provider fails to file a cost report prior to expiration of 90 days from the close of the reporting period, Medicaid will suspend payment. At the time the suspension is imposed, Medicaid will send a letter informing the provider that if a cost report is not filed, all payments made since the end of the cost report period are deemed overpayments. The provider must continue to care for residents and maintain levels of care if Medicaid suspends payment.005.03(A)(iii)LEGAL ACTION. If the provider takes no action to comply with the obligation, Medicaid may refer the case for legal action.005.03(A)(iv)SUMS DUE. If a cost report has not been filed, the sum of the following is due: (1) All payments made during the rate period to which the cost report applies;(2) All payments made subsequent to the accounting rate period to which the cost report applies: and(3) Costs incurred by Medicaid in attempting to secure reports and payments.005.03(A)(v)AUDIT. if the provider later submits an acceptable cost report, Medicaid will undertake the necessary audit activities. Providers will receive all funds due to them reflected under the properly submitted cost reports less any costs incurred by Medicaid as a result of late filing. 005.03(A)(vi)RETENTION OF RECORDS. Providers must retain financial records, supporting documents, statistical records, and ail other pertinent records related to the cost report for a minimum of five years after the end of the report period or until an audit started within the five years is finalized, whichever is later. Records relating to the Acquisition and disposal of fixed assets must be retained for a minimum of five years after the assets are no longer in use by the provider. Medicaid-retains all cost reports for at least five years after receipt from the provider.005.03(A)(vii)OTHER SERVICES. Facilities providing any services other than certified intermediate care facility for individuals with developmental disabilities (ICF/DD) services must report all costs separately, based on separate cost center records. As an alternative to separate cost center records and for shared costs, the provider may use a reasonable allocation basis documented with the appropriate statistics. All allocation bases must be approved by Medicaid before the report period. Any Medicare certified facility must not report costs for a level of care to Medicaid which have been reported for a different level of care on a Medicare cost report. 005.03(B)AUDITS. Medicaid will perform an initial desk audit on all cost reports. Payment rates are determined after the initial desk audit is completed. Subsequent desk audits or a periodic field audit may also be performed for each cost report. Performance of a desk audit includes the review of information submitted, and may require additional information to be submitted by the provider. Performance of a field audit requires an onsite visit to the provider to review information. 005.03(B)(i)SUBSEQUENT AUDITS. Selection of subsequent desk audits and field audits are made as determined necessary by Medicaid to maintain the integrity of the program. Medicaid may retain an outside independent public accounting firm, licensed to do business in Nebraska or the state where the financial records are maintained, to perform the audits. Audit reports must be completed on all field audits and desk audits. All audit reports are retained by Medicaid for at least three years following the completion and finalization of the audit.005.03(B)(ii)INITIAL AUDITS. An initial desk audit is completed on all cost reports. Payment rates are determined after the initial desk audit is completed.005.03(B)(iii)SUBSEQUENT AUDITS. All cost reports, including those previously desk audited but excluding those previously field audited, are subject to subsequent desk audits. To initiate a subsequent desk audit, Medicaid sends a notification letter to the provider identifying the primary period(s) and subject(s) to be desk audited. The provider must deliver copies of schedules, summaries, or other records requested by Medicaid as part of any desk audit. 005.03(B)(iv)FIELD AUDITS. Ail cost reports, including those previously desk-audited but excluding those previously field-audited, are subject to field audit by Medicaid. The primary period(s) to be field-audited are indicated in a confirmation letter, which is mailed to the facility before the start of the field work. A field audit may be expanded to include any period that has not previously been subjected to a field audit. The scope of each field audit is determined by Medicaid. The provider must deliver to the site of the field audit, or an alternative site agreed to by the provider and Medicaid, any records requested by Medicaid as part of a field audit.005.03(C)SETTLEMENT AND RATE ADJUSTMENTS. When an audit has been completed on a cost report, Medicaid will determine if an adjustment to the rate is required. If necessary, a settlement amount is determined. Payment, or arrangements for payment, of the settlement amount, by either Medicaid or the provider, must be made within 45 days of the settlement notice unless an administrative appeal filed within the appeal period is also filed within the 45-day repayment period. Administrative appeals filed after the 45-day payment period will not stay repayment of the settlement amount. The filing of an administrative appeal will not stay repayments to Medicaid for audit adjustments not included in the appeal request. If an audit is completed during the applicable rate period, Medicaid will adjust the rate for payments made after the audit completion. 005.03(i).FINAL ADJUSTMENT. Medicaid will determine a final adjustment to the rate and settlement amount after the audit is final and all appeal options have been exhausted. Payment for any final settlement must be made within 30 days, if payment is not made, Medicaid will immediately begin recovery from future facility payments until the amount due is recovered. 005.03(ii)REPORT. Medicaid will report an overpayment to the federal government on the appropriate form no later than the second quarter following the quarter in which the overpayment was found.005.03(D)APPEAL PROCESS. Final administrative decision or inaction in the allowable cost determination process is subject to administrative appeal. The provider may request an appeal in writing from the Director of Medicaid within 90 days of the decision or inaction. The request for an appeal must include identification of the specific adjustments or determinations being appealed and basis or explanation of each item. After the Director issues a determination in regard to the administrative appeal, Medicaid will notify the facility of the final settlement amount Repayment of the settlement amount must be made within 30 days of the date of the letter of notification.005.03(E)ADMINISTRATIVE FINALITY. Administrative decision or inaction in the allowable cost determination process for any provider, which is otherwise final, may be reopened by Medicaid within three years of the date of notice of the decision or inaction. "Reopening" means an action taken by the Director of Medicaid to reexamine or question the correctness of a determination or decision that is otherwise final. The Director is the sole authority in deciding whether to reopen. A provider does not have the right to appeal a finding by the Director that a reopening or correction of a determination or decision is not warranted. The action may be taken: (i) On the initiative of Medicaid within the three-year period:(ii) In response to a written request from a provider or other entity within the three-year period. Whether the Director will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with the law, regulations and rulings, or general instructions; or(iii) Any time fraud or abuse is suspected.005.03(F)SANCTIONS. See 471 NAC 2.005.03(G)CHANGE OF HOLDER OF PROVIDER AGREEMENT. A holder of a provider agreement receiving payments under this section must notify Medicaid 60 days before any change or termination regarding the holder of the provider agreement. If any known settlement is due Medicaid by that provider, payment must be made immediately. If the provider is subject to recapture of depreciation on the anticipated sale or if an audit is in process, the provider is required to provide a guarantee of repayment of Medicaid's estimated settlement either by payment of that amount to Medicaid, providing evidence that another provider receiving payments under this section has assumed liability, or by surety bond for payment. All estimated or final amounts, regardless of appeal status, must be paid before the transfer of ownership. 005.03(G)(i)UNPAID SETTLEMENT. Medicaid will not enter into a provider agreement with a new provider if there is an unpaid settlement payable to Medicaid by a prior provider of services at the same facility unless the new provider has assumed liability for the unpaid amount. Parties to a facility provider change may receive information about unpaid settlement amounts owed to Medicaid by making a written request.005.03(H)ADDITIONAL PAYMENT TO NON-STATE-OPERATED INTERMEDIATE CARE FACILITY FOR PERSONS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) PROVIDERS. in accordance with Neb. Rev. Stat. $ 68-1804(3)(d), non-state-operated intermediate care facility for individuals with developmental disabilities (ICF/DD) providers may be eligible to participate in an additional distribution. For fiscal years 2011-12, 2012-13, and 2013-14, Medicaid determines the amount available in the intermediate care facility for individuals with developmental disabilities (ICF/DD) Reimbursement Protection Fund. Following the distributions of the payments identified in Neb. Rev. Stat § 68-1804(3) (a-c), the amount remaining in the Fund, not to exceed a total of $600,000, is distributed to non-State-operated intermediate care facility for individuals with developmental disabilities (ICF/DD) providers.471 Neb. Admin. Code, ch. 31, § 005
Amended effective 10/20/2015.Amended effective 12/26/2021