The Level of Care (LOC) in the PointClickCare^® Census and Rates resident tab is used for the management of No Pay and Exhaust claim billing for residents, after a Medicare Part A skilled stay. The LOC has no other function but to drive this process. Skilled Nursing Facilities (SNFs) are required to submit claims to Medicare for residents to report the benefit period even though no benefits may be payable. The Centers for Medicare & Medicaid Services (CMS) maintains a record of all inpatient services for each beneficiary, whether those services are covered by Medicare or not.

***Managed Care residents should not have Level of Care information entered as there is no requirement to submit No Pay or Exhaust claims to Medicare. SNFs are required to submit notification claims to Medicare for residents utilizing their skilled benefits through a Medicare Advantage plan. This functionality is addressed in the AR Insurance tab of the resident record. ***

PointClickCare® will auto-populate the LOC for residents who are admitted as Medicare Part A. The system will enter a “skilled” status as of the admission date. If the resident discharges, the system will automatically update the ineffective date of the skilled stay. If the resident is cut from Medicare A with benefit days available to them, the system will auto-populate the ineffective date of the skilled stay, and will add a new effective date for the "non-skilled" level of care. From that point on, until the resident discharges, users can create No Pay claims monthly on demand. If claims are not created, the system will auto-create the Final Discharge No Pay claim with the routine monthly billing.

If the resident exhausts their benefits and remains in the facility, the system will maintain the "skilled" status until such time as clinicians determine that the spell of illness is broken, and then enter a new effective date with the "non-skilled" status. Until such time as the spell of illness is broken, the system will automatically generate an Exhaust claim with the monthly routine billing for Medicare Part A.

Keep in mind, there may not be a break in the spell of illness for a period of time after the benefit exhaust. For example, a resident with a new gastric tube who exhausts their Medicare Part A benefits will remain at a skilled level of care, even after the exhaust, until they are no longer receiving skilled services for their gastric tube. This could continue through the rest of the beneficiary’s life. However, if there is a time when the resident no longer needs the gastric tube, given that 26 percent of calories and less than 500 ml of fluids are going through the tube, then the resident could change to an unskilled level of care. The 60-day break reset would start at that time. If the resident experiences a full 60 days with no skilled services or re-hospitalization, then the resident would be eligible for a new 100-day benefit period.

Benefits Exhaust Claim

The SNF must submit a benefits exhaust claim monthly for those patients who continue to receive skilled care, regardless of whether the benefits exhaust bill will be paid by Medicaid, a supplemental insurer or private payer. There are two types of benefits exhaust claims:

• Full benefits exhaust claims: no benefit days remain in the beneficiary’s applicable benefit period for the submitted statement covers the from/through date of the claim
• Partial benefits exhaust claims: only one or some benefit days in the beneficiary’s applicable benefit period remain for the submitted statement covers the from/through date of the claim

A Note About No-Payment Claims

SNF providers must submit no payment claims for beneficiaries who have previously received Medicare-covered care and subsequently dropped to a non-covered LOC, but continue to reside in a Medicare certified area of the facility.

For additional information on LOC in PointClickCare® for the management of No Pay and Exhaust bills, check out these resources:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R930CP.pdf  

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM4292.pdf

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