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This is a reminder of the requirements for primary care physicians (PCP)
when rendering services to members in long-term care (LTC) facilities. It is
important to adhere to these requirements when providing such services or your
claims may be denied and the member may be adversely affected.
Member must be on PCP's LTC panel
Please note the following requirements related to PCPs and their LTC panel:
- PCPs who provide services to members in an LTC/custodial setting must
have a separate LTC provider number established in our system. This
separate provider number must be used when submitting claims for services
rendered to members residing in an LTC facility (custodial members).
- If you do not have a separate LTC provider number and you are seeing
Independence members residing in an LTC/custodial setting, please contact your
Network Coordinator to establish an LTC provider number.
- The members you provide care to in the LTC setting must be on your LTC
panel or the claim may be denied. This could also affect normally capitated
services that the member may receive while residing in the LTC/custodial
setting.
- Remind your Independence LTC patients who are not included on your LTC
panel that they, or their legal representatives, need to contact Customer
Service to select your LTC location. You may also want to consult with
the administrative staff of the LTC facility to assist with educating members
and/or their legal representatives of the need to be on their PCP's LTC panel.
Please note that LTC locations are not listed in the online Find
a Doctor/Hospital tool.
Setting up a PCP LTC panel
To set up an LTC panel, PCPs should contact their Network Coordinator.
A PCP's LTC panel uses the same NPI and address as the PCP's office.
However, he or she is assigned the Continuing Care Retirement Center taxonomy
code of 311Z00000X to distinguish the LTC setting from the office setting.
Following the creation of this new provider record, PCPs will need to
register it on the NaviNet® web portal and set up electronic
funds transfer (EFT) ? even if they already use these tools at their current
practice location.
Billing requirements for members in an LTC
facility
Services for members in an LTC facility are to be billed with Place of
Service code 32. Taxonomy code 311Z00000X should be used by providers to
identify that they are billing for their LTC panel.
PCP LTC panels are reimbursed on a fee-for-service basis.
Failure to submit claims for services performed in the office or LTC
facility with the applicable NPI and correct
correlating taxonomy code may result in incorrect claims processing.
Referral requirements for members in LTC
PCPs with an LTC panel must issue a referral to an in-network provider for
any professional service or consultation for an LTC panel member in LTC. This
requirement includes:
- podiatry, physical therapy, and radiology services
- consultation or follow-up with a specialist
- ancillary services
Note: LTC panel members do not have capitation requirements for
laboratory, physical therapy, or radiology services. However, members who
remain on the PCP office panel will be held to the capitation requirements of
their benefits plan. PCPs should submit referrals for LTC panel members in
advance of the service being provided. Referrals should be submitted through
NaviNet, and they should be submitted in a timely manner to allow for
appropriate claims processing. Claims
will not be authorized for
payment without a referral on file. In addition, consultants and ancillary
providers are encouraged to provide the referral information with the claim to
assist in processing.
If you have any questions about LTC services or setting up a PCP LTC panel,
please contact your Network Coordinator.
NaviNet is a registered trademark of NaviNet, Inc., an
independent company.
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