Patient Credit file Janene Brickey Healthcare and Family Services Bureau of Long Term Care 201 South Grand Ave East Fl 3 Springfield IL /

WHO? The patient credit file applies to individuals that have been determined eligible for Medicaid and have been approved for payment of long term care (LTC) services.

WHAT? The patient credit file provides the Recipient Identification Number (RIN), Last name, First name, Provider ID(s), begin date, end date, and amount of patient credit. One individual may have multiple segments due to changes in the patient credit amount. The patient credit file will contain up to 12 months of patient credit information. RIN Last Name First name LTC Provider ID Hospice Provider ID Patient Credit Patient Credit Patient Credit Filler Begin date End date Amount Doe, John [example: August 25, 2015 $ ] * Patient credit begin and end dates are based on the Julian calendar (perpetual)

WHERE? WHEN? The patient credit file is reported to the Health Plans through a monthly interface from Healthcare and Family Services (HFS). This report is available to the Health Plans the first weekend of each month. This report will reflect the information that has been processed by HFS and/or Department of Human Services (DHS). It will not reflect outstanding transactions that have been submitted by the facility through Medical Electronic Data Interchange (MEDI) or EDI vendor in which a DHS caseworker has not yet processed.

WHY? The patient credit is the amount an individual is responsible for contributing towards the cost of their care each month. This amount may vary month to month most commonly due to income changes or fluctuations. These changes may increase or decrease the payment remitted to the facility for an individual.

THE PROCESS In order to determine the patient credit, there are multiple steps that must take place. These steps may run concurrently.

STEP 1 Medicaid eligibility The individual must be determined Medicaid eligible before the approval for payment of long term care services can be authorized. If the individual is already eligible for Medicaid, skip this step. If the individual has not applied for Medicaid, the facility will need to submit an application for Medicaid utilizing the ABE application portal ( A family member, Power of Attorney, or Guardian may also facilitate this process.

Determining Medicaid eligibility Once the application for Medicaid has been submitted, a DHS caseworker will review the application, request additional information if necessary, and determine eligibility. The length of time to process an application varies based upon several financial and non-financial factors. An individual may request medical coverage up to 3 months prior to the date of the application. Generally speaking, upon approval, eligibility will begin with the month of application or up to 3 months prior if requested and eligible. Once a decision on the Medicaid application has been made, the DHS caseworker will continue with Step 2 if Medicaid is approved.

STEP 2 Approval for Long Term Care services Once Medicaid eligibility has been established, a request for payment of long term care services must be processed. A request must be made to DHS using form HFS 3654, Additional Financial Information for Long Term Care Applicants. The DHS caseworker must verify that Medicaid eligibility has been established before processing the request for payment of long term care services. This process may take several months depending on the complexity of the Medicaid application and whether an additional review by the Office of the Inspector General is required based upon the information submitted on the HFS The facility must submit an admission transaction through MEDI or EDI vendor within specified timeframes. This transaction will be reviewed by a DHS caseworker and processed accordingly.

Patient Credit file is created Once Medicaid eligibility has been established (Step 1), the DHS caseworker will review the request for payment for LTC services (Step 2). The authorization for payment of LTC services will not occur until Medicaid eligibility has been established. When payment for LTC services has been authorized, the DHS caseworker will process the admission transaction that has been submitted by the facility through MEDI or EDI vendor. This will create a long term care admission segment for the Medicaid eligible individual which will include the patient credit amount. The patient credit file may retroactively reflect the admission to capture the first month(s) of residence.

834 Report The Health Plans will be able to verify Medicaid eligibility utilizing the daily 834 report. This report is the source of record for Medicaid eligibility.

Patient Credit File Report The Health Plans will be able to verify the patient credit amount utilizing the monthly Patient Credit File report. This report is the source of record for the Health Plans payment to the facility. The Health Plans will make payment based on the amount verified by the patient credit file. Facilities will enter transactions through MEDI or EDI vendor which may affect the patient credit amount. These transactions must be processed before a change in the patient credit amount is reflected in the patient credit file report. The length of time for a DHS caseworker to process income changes varies. Once a DHS caseworker has processed a transaction that may affect the patient credit amount, the Health Plans will make any adjustments accordingly. These changes may affect payment retroactively.