N.D. Medicaid Billing and Policy Manual, Hospice Services, Reimbursement Methodology and Claim Instructions

Timely Filing

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty

(180) days from the date of service. The time limit may be waived or extended by ND

Medicaid in certain circumstances. The Timely Filing Policy contains additional

information.

Third-Party Liability

Medicaid members may have one or more additional source of coverage for health

services. ND Medicaid is generally the payer of last resort. Providers must pursue the

availability of third-party payment sources. The Third Party Liability Policy contains

additional information.

Client Share (Recipient Liability)

Client share (recipient liability) is the monthly amount a member must pay toward the

cost of medical services before the Medicaid program will pay for services received. The

Client Share Policy contains additional information.

Reimbursement

A claim for services must be submitted at the provider’s usual and customary charge.

Payment for services is limited to the lesser of the provider’s usual and customary

charge or the ND Medicaid calculated reimbursement.

The hospice provider will be reimbursed at one of four predetermined rates for each day

a member is under the care of the hospice. The four rates exclude payment for

physician services that are separately paid.

The hospice provider will be reimbursed an amount applicable to the type and intensity

of services provided each day to the member. The four levels of care into which each

day of care is classified are:

• Routine Home Care – This level of care is used for each day the member is

under the care of the hospice and the member is not classified at another level of

care. This level of care is paid without regard to the volume or intensity of

services provided.

• Continuous Home Care – This level of care is used for each day the member

receives nursing services on a continuous basis during a period of crisis in the

member’s home. The hospice is paid an hourly rate for every hour or part of an

hour of continuous care furnished up to a maximum of 24 hours a day.

• Inpatient Respite Care – This level of care is for each day a member is in an

inpatient facility and receiving respite care. Payment for inpatient respite care is

limited to 5 consecutive days beginning with the day of admission but excluding

the day of discharge. Any inpatient respite care days in excess of 5 consecutive

days must be billed as routine home care. Inpatient respite care may not be paid

when a member resides in a long- term care facility.

• General Inpatient Care – This level of care is for each day the member receives

inpatient hospice care in an inpatient facility for control of pain or management of

acute or chronic symptoms that can’t be managed in the home. The day of

admission to the facility is general inpatient care and the day of discharge is not

general inpatient care unless the member discharged is deceased. Payment for

general inpatient care may not be made to a long-term care facility when that

facility is considered the resident’s home; however, payment for general inpatient

care can be made to another long-term care facility.

Payment for inpatient care days will be limited according to the number of days of

inpatient care furnished to members by the hospice in a year. The maximum number of

payable inpatient respite and general inpatient days may not exceed twenty percent of

the total number of days of hospice care provided to all members by the hospice. If the

maximum number of days exceeds twenty percent of total days, an adjustment will be

made to pay the excess days at the routine home care rate, and the difference will be

recovered from the hospice provider. The limitation on inpatient care days does not

apply to members diagnosed with acquired immunodeficiency syndrome (AIDS).

Claim Form

Hospice services must be billed using the UB 04 claim form or 837i. Detailed claim

instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual

webpage.