Medi-Cal Provider Manual, Part 2, Hospice Care: General Billing Instructions, Room and Board Billing Instructions

When billing for room and board codes, the following information is required in the Remarks

field of the claim, or on an attachment to the claim:

• The recipient resides in a certified NF or Intermediate Care Facility (ICF)

• The name and address of the NF or ICF

• A Minimum Data Set (MDS) on file at the NF verifies that the recipient meets the NF or

ICF level of care

Note: A TAR is not required for hospice care room and board provided in an NF or ICF.

Share of Cost (SOC)

Long Term Care Share of Cost (SOC) should be cleared by a hospice provider on the UB-04

claim by completing the Value Codes and Amounts field (Boxes 39 – 41). The value code is

“23” and the value amount is what has been paid or obligated by the patient for SOC. Refer

to the Hospice Care Billing Examples section in this manual for an illustration.