QUEST Integration – Acute Wait-Listed Claims

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

When a patient’s condition improves to the point where only nursing facility care is needed, but there are no bed openings at nursing facilities, the patient’s continued confinement at the acute facility will be at a reduced level of care.

Claim Information

• The type of bill (FL 04) first digit for the room and board claim must identify the type of facility (hospital).The bill classification and frequency codes should be the appropriate codes for the confinement.
• The type of bill first digit for the ancillary services should identify the level of care the patient is receiving while in the wait-listed status, i.e. 2 for skilled nursing or 6 for intermediate care.The bill classification and frequency codes should be the appropriate codes for that confinement.
• The provider number used should coincide with the patient’s level of care, i.e., an SNF wait-listed claim should be billed using the SNF wait-listed provider number.
• The admission date should be the date the reduced level of care became effective.
• The Point or Origin for Admission or Visit (FL 15) must be completed with the applicable code
• The patient discharge status (FL 17) must match the type of bill third digit. For example, interim continuing claims must indicate patient status 30.
• Occurrence span code (FL 35) must provide the level of care and dates of confinement at that level.

Reimbursement Information

• For facilities eligible for APR-DRG reimbursement, covered acute wait-listed claim charges are included in the DRG payment. Refer to the All Patient Refined Diagnosis Related Groups (APR-DRG) Overview (hmsa.com) article for more information.
• For all other facilities, payment is based on a negotiated per diem rate. The per diem does not include ancillary services; these may be billed separately using the wait-listed ancillary provider number.
• The State of Hawaii Level of Care (LOC) and At Risk Evaluation (DHS 1147 Form) approval is required.

Revision History