Upcoming Changes to Long Term Care Submission of 837 Professional, 837 Institutional, and 837 Dental Claims

The current Health and Human Services Commission (HHSC) Long Term Care (LTC) Bill Code Crosswalk allows providers to submit claims with:

  • Skipped modifiers (skipped modifiers scenarios are defined as any record on the HHSC LTC Billing Code Crosswalk table where a modifier is required and any preceding modifier position(s) is not required, or entered).
  • Same modifier in multiple modifier positions on the same Detail Service Line.

 

Beginning February 2019, to maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA), HHSC and TMHP will implement changes that will no longer allow Duplicate Modifiers and Skipped Modifiers to be submitted on the Same Detail Service Line. As a result, the following changes will be made:

HHSC LTC Bill Code Crosswalk

Updates will be made to the HHSC LTC Bill Code crosswalk to require that modifiers start in position 1 and any subsequent modifier will not be the same (duplicate). Note that these Bill Code crosswalk records will be retroactively changed. Any claims submitted beginning February 1, 2019, will be required to use updated crosswalk irrespective of the Date of Service on the claim.

Some of the records used for EVV (Electronic Visit Verification) fee-for-service claims will be updated in this Bill Code crosswalk.

TexMedConnect

Changes will be made to the TexMedConnect Claims Entry Screens.

  • Providers linked to multiple Service Groups (SGs) will be required to submit SG for Billing Provider in the Claim tab to indicate the SG that will apply to the services billed.
  • Providers linked to Hospice SG 8 have the option to submit Residence Service Group in the Claim tab to indicate individual previous residency.
  • Providers linked to Community Care SG 7 or Guardianship SG 20 have the option to submit Budget Number in the Claim tab to indicate the Budget Number that will apply to the services billed.

 

EDI

  • Duplicate modifiers at the Detail Service Line will no longer be allowed.
  • Skipped modifier positions will no longer be allowed.

TexMedConnect Submission of Claims:

Providers will start using an updated HHSC LTC Bill Code crosswalk where:

  • Data specified in the Modifier fields will be used to get the LTC bill code, and modifier location will be required to start in position 1 of the claim detail and following modifiers will be in sequential position order.
  • Duplicate modifiers within the same Service Detail line will not be allowed.

Modifiers in positions 1 and 2 will no longer be used to indicate SG, Residence Service Group, and Budget Number. Billing Providers will now indicate this information in the new fields located in the claim header tab in TexMedConnect:

  • SG for Billing Providers which are associated with multiple SGs for LTC 837 Professional, Institutional, and Dental claims.
  • Residence SG when Billing Provider is SG 8 to indicate individual’s residence at the time of service for LTC 837 Institutional claims.
  • Budget Number for Title XX services for LTC 837 Professional claims.

 

Note: Billing Providers will continue to use modifiers in position 1, 2, 3, and 4, based on the HHSC LTC Bill Code Crosswalk to get the LTC bill code.

Updates to Professional, Institutional, and Dental claim templates and/or drafts will be required to accommodate these changes.

EDI Submission of Claims:

Providers, third-party submitters, and trading partners will submit Service Group for Billing Provider, Residence Service Group, and Budget Number values at the 2300 Loop/NTE02 Segment of the 837 Professional, 837 Institutional, and 837 Dental Claims. Instructions for this will be provided in each of the transaction-specific Companion Guides, located on the TMHP website under EDI Technical Information Companion Guides for CMS and C21.

  • LTC 837 Professional
  • LTC 837 Institutional
  • LTC 837 Dental

Texas Medicaid will reject claims and report HIPAA Edit 0x39395df on the 277 Claims Acknowledgement, (277CA) when a claim is received with a skipped modifier.

Texas Medicaid will reject claims and report HIPAA Edit 0x39395ee on the 277 Claims Acknowledgement (277CA) when a claim is received with a duplicate modifier on the same Detail Service Line.

Third-Party Submitters

Third-party submitters must be informed of these changes for claims to be successfully submitted. Providers are responsible for notifying third-party submitters regarding the changes outlined.

 

TexMedConnect Long Term Care User Guide

Information included in the TexMedConnect Long Term Care User Guide will change. Enhancements will be made to accommodate the above mentioned TexMedConnect claims submission changes.

 

Trading Partner Testing

Trading partner testing will begin November 15, 2018, and will be completed by January 4, 2019. Providers are strongly encouraged to test during this window to ensure no disruption to the processing of Long Term Care 837 Professional, 837 Institutional, and 837 Dental Claims transactions upon implementation of these changes.

Failure to test could impact the processing and payment of Long Term Care claims.

For more information, email LTC-TPT@tmhp.com