Clarification of HealthChoice Coverage for Long Term Care Facilities

IMMEDIATE: Billing team must implement the following changes for all HealthChoice MCO enrollees at long-term care facilities: (1) Require prior authorization from the MCO BEFORE admission to nursing homes, chronic hospitals, or specialty pediatric hospitals—do not process claims without MCO authorization; (2) Establish internal tracking to monitor authorization status throughout the 90-day period and flag cases approaching day 75 for UCA level-of-care determination requests; (3) Update billing logic to distinguish between skilled nursing rate reimbursement (when enrollee meets MCO's evidence-based medical necessity criteria) and administrative day rate reimbursement (when enrollee meets Department's level of care criteria but not MCO skilled nursing criteria); (4) Train billing staff on the appeal process—LTCFs may assist enrollees in appealing denied authorizations only with written enrollee/representative consent; (5) Do NOT bill enrollees balance amounts between administrative day rate and skilled nursing rate for covered days; (6) Coordinate with care management to ensure discharge planning compliance when MCOs deny authorization or determine enrollee no longer meets skilled nursing level of care. Consequences of inaction: Claims will be denied without MCO prior authorization; balance billing enrollees for covered days violates policy; failure to request UCA determination by day 75 may result in improper MCO payment responsibility beyond 90 days.