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Skilled Nursing Facility Coinsurance for Dual Eligible Members Receiving Fee-For-Service Medicaid – Claim Adjudication

Last updated on 6/24/2020

Information posted June 24, 2020

Effective January 1, 2020, Medicare Advantage Plans (MAPs) including Medicare Advantage Dual Eligible Special Needs Plans (MA-DSNPs) are responsible for the reimbursement of Skilled Nursing Facility (SNF) Medicare coinsurance payments for dual eligible members receiving fee-for-service (FFS) Medicaid that are also enrolled in a state-contracted MAP. Before payment can be issued by the MAPs, providers must follow the process listed below in conjunction with the submission of their claims to the MAPs.

For HHSC to properly adjudicate SNF Medicare coinsurance claims for these members, nursing facility providers must:

  • Submit Form 3619, Medicare/Skilled Nursing Facility Patient Transaction Notice, to the Long-Term Care Online Portal.
  • Bill claim dates of service (DOS) through TexMedConnect.
    • Providers will receive a denial F0304* Explanation of Benefits (EOB) on the Remittance and Status (R&S) Report which must be submitted to the respective MAP. This provides the MAP evidence that the member is in FFS Medicaid.
    • Providers who have already received a denial F0304 EOB on their R&S Report must also submit to the respective MAP. As mentioned above, this provides the MAP evidence that the member was in FFS Medicaid.

For assistance with billing or your R&S Report, call the TMHP Long-Term Care Help Desk at 800-626-4117, Option 1.

* Denial code F0304 is used when a member is enrolled in a Medicare Part C Advantage Plan (MAP) contracted with HHSC to cover all cost sharing obligations.