PA NF ASSESSMENT AND RESIDENT DAY REPORTING
Contents
1. eee eee teet reir 24 Helpdesk Assistance 4 rrt rette nete trie It eher prep rore pen tereti dr 25 Problems Not Supported eterne tie rtt ete ir pert pei ie pelea e recipe 25 SECTION 5 GLOSSARY 26 Common Terms and Abbreviations ener trennen rennen 26 APPENDIX A INSTRUCTIONS AND BULLETINS 30 Downloading 2 Eoi ette iet Shoat ai heen bts p ive 30 Figure A 1 Security W arming x ete OE RR at Sie aoe 30 Figure A 2 Save AS WatidOw tete teet E eee 31 APPENDIX B EXAMPLE BILL 32 APPENDIX C EXAMPLE PRINTED RDR FORM 34 APPENDIX D SIGNATURE ON FILE FORM 36 Page ii Revised 01 27 2014 SECTION 1 BACKGROUND Glossary Terms Used In This Section Assessment Day Assessed Nursing Facility Assessment Quarter Assessment Rate Department Due Date Exempt Nursing Facility Medical Assistance MA Nursing Facility Provider PA NF Assessment Program Qualified Nursing Facility Quarterly Assessment Payment RDR Form Resident Day Reporting Form Resident Day Quarter Supplemental Payment Title XIX Web Site Definitions for these terms are found in Section 5 INTRODUCTION The Medicare Voluntary Contribution and Provider Specific Tax Amendments to Title XIX of the Social Security Act allow states to impose assessment fees on eighteen 18 categories of health care providers including nursing facilities and to use the dollars they collect to draw down Federal matching funds so long as the assessments meet the r2. If a CTX type payment was made for more than one nursing facility the amount displayed will only be the amount apportioned to the individual nursing facility by the Bill Number and payment amounts placed in the addenda record s and not the total transaction amount Payments for interest and penalties do not appear on the history screen Page 17 Revised 01 27 2014 If overpayments occur refunds will not be issued electronically through the ACH network but rather will be initiated outside of the ACH network Should an emergency arise which prevents a payment from being transmitted contact the Department to make arrangements for an alternate payment format ACH CREDIT TRANSACTION RECORD DETAILS The only acceptable record formats for payment of the QAPs are CCD or CTX These file structures are designed according to the recommended industry standard format developed by NACHA the Electronic Payments Association Choose the appropriate type of payment for your situation based on the following information One Payment Per Transaction CCD format accommodates one addenda record and may be used by facilities making only one QAP per transaction i e one provider and one quarter s payment in each transaction Multiple Payments Per Transaction CTX format accommodates multiple addenda records and is required by entities making payments for more than one facility in one transaction or more than one QAP for the same facility or a combina
3. day of service for which payment is made to the Assessed Nursing Facility under Medicare Part A Days in an independent living portion of a facility are not subject to the assessment Assessed Nursing Facility Any nursing facility that is not an exempt nursing facility Assessment Quarter The calendar quarter in which a Quarterly Assessment Payment is due Assessment Rate The rate determined on an annual basis by the Secretary of Public Welfare in consultation with the Secretary of the Budget which is used to calculate Quarterly Assessment Payments owed by Assessed Nursing Facilities Bill A document showing detail of the Quarterly Assessment Payment owed to the state by an Assessed Nursing Facility which is generated by the PA NF Submission System after the facility submits a RDR Form and calculates its Quarterly Assessment Payment for an Assessment Quarter Bookmark A feature of a web browser that allows the user to save the address URL of a web page so that the page can easily be revisited at a later date Browser see web browser Continuing Care Retirement Community CCRC A continuum of care offering independent living and access to a higher level of care such as personal care or a nursing facility which is licensed through a Certificate of Authority issued by the Pennsylvania Insurance Department Continuing Care Retirement Community CCRC Facility An assessed nursing facility that has been determi
4. 01 27 2014 SECTION 4 HELPDESK Glossary Terms Used In This Section Bill Department Internet Internet Explorer MA MA 11 Cost Report NIS Nursing Facility Information System PA NF Assessment Program PA NF Submission System QAP RDR Form Supplemental Payment Validation Web Site Definitions for these terms are found in Section 5 MYERS AND STAUFFER HELPDESK When contacting the helpdesk please indicate that you have a question concerning the PA NF Assessment Program Myers and Stauffer is a Department consultant contracted to administer the PA NF Submission System the Nursing Facility Information System NIS calculate MA Case Mix Reimbursement rates and provide technical support for the submission of the Minimum Data Set MDS records The Myers and Stauffer Helpdesk is available for questions from nursing facilities concerning the submission of its RDR Form validations and printing of bills The phone number for the helpdesk is 717 541 5809 If the staff is unable to answer your call directly due to heavy call volume or during non business hours leave a voice mail message with your name the nursing facility name or organization name and the phone number It is also important to indicate that the question concerns the PA NF Assessment Program since the helpdesk staff also support MA 11 Cost Report and MDS submissions The amount of space in the voice mail account is limited so callers should leave only the mini
5. Code 2 05 Page 18 Revised 01 27 2014 Data Element Name Length Contents Free Form Field 80 RMT Segment see below for layout detail Special Addenda 4 Numeric Identifies the Sequence Number addendum sequence Input is always 0001 for the first addenda record or as specified in the instructions provided by the financial institution Entry Detail 7 Numeric Assigned by the Sequence Number financial institution sending the payment and matches the item number portion of the trace number RMT Segment Layout The RMT Remittance Advice Segment must be used The following is the layout and specification of the Free Form field in the addenda record Data Element Name Length Contents Segment Identifier 1 RMI Delimiter 4 ue Reference Number 2 TV Qualifier Delimiter 4 nd Reference Number 1 30 BILL NUMBER Delimiter 1 idi Monetary Amount 1 15 QAP amount Leading zeroes can be suppressed Terminator 1 VN The Bill Number is located on the quarterly Bill that is generated after completing the RDR Form and is located in the upper left hand side in the header portion of the Bill Based on this sample information Bill Number 1035020008 QAP Amount 1000 52 The sample RMT segment would look like this RMT IV 1035020008 1000 52 NOTE Each RMT segment must begin on a new ACH addenda record Please contact your F
6. Quarter has reported the information requested by the Department in the manner and time period specified by the Department for the Resident Day Quarter and has paid the QAP for the corresponding assessment quarter For example if a nursing facility closes on March 15 the last quarter in which it would report resident day data is for the October 1 December 31 Resident Day Quarter Both the RDR Form and the assessment payment would be due on the last day of the Assessment Quarter which would be March 31 A Supplemental Payment would be received by the nursing facility for the January 1 March 31 quarter if the provider submitted its RDR Form Change of Ownership An Assessed Nursing Facility that undergoes a change of ownership is required to submit a RDR Form for the Resident Day Quarter and remit a QAP in the Assessment Quarter in which the ownership change occurs When an Assessed Nursing Facility undergoes a change in ownership it is the obligation of the owner of the facility at the time the RDR Form and QAP are due to submit the Form and make the payment If the prior owner has failed to submit the RDR Form or make a QAP the obligation to do so becomes the responsibility of the new owner When Myers and Stauffer receives notification of a change of ownership it will inactivate the old owner s account information and only the new owner will be allowed to complete the RDR Form The receipt of the Password and Connectivity Document
7. SUPPLEMENTAL PAYMENT METHODOLOGY Each fiscal year in which the PA NF Assessment Program is in effect the Department uses some of the state revenues collected under the Program and the associated Federal matching funds to reimburse nonpublic MA facilities for the MA portion of their QAP to provide a quarterly Supplemental Payment to qualified nursing facilities and to increase the MA Day One Incentive payment made to county nursing facilities The MA portion of the QAP is reimbursed as an add on to a nursing facility s per diem rate and will be paid in lump sum on a quarterly basis A qualified nursing facility s Supplemental Payment is equal to the supplemental per diem times the facility s MA days reported for the Resident Day Quarter immediately preceding the quarter in which the Supplemental Payment is being made The supplemental per diem in effect during a fiscal year is available in advance to the public on the OMAP web site at the following address http www portal state pa us portal server pt community pennsylvania 20nursing 20fa cility 20assessments 19369 Only qualified nursing facilities are eligible to receive a Supplemental Payment For information concerning new nursing facilities those that have closed and those undergoing a change of ownership see page 20 For each year including the start up year important submission and payment dates will be posted on the www PANFSubmit com website and the OMAP website at
8. TOTAL A calculated field containing the Calculated MEDICARE DAYS sum of Item 14a and Item 14b Nursing Facilities are NOT liable for the NF Assessment payment on Total Medicare Days 15 TOTAL RESIDENT A calculated field containing the Calculated DAYS sum of Item 13 and Item 14c 16 Ending Licensed The number of licensed beds at Must be between 8 and 910 If Beds end of the Resident Day Quarter different than the number of beds on record with the Department a message will be display saying WARNING the number of beds reported is different than the number of beds on record with the Department Please check for accuracy before continuing 17a An indicator that the nursing Must match the CCRC status on facility is a continuing care record with the Department retirement community CCRC facility as determined by the Department See CCRC Facility on page 16 17b County Nursing An indicator that the nursing Calculated Facility facility is a long term care nursing facility that is controlled by the county institution district or county government if no county institution district exists as determined by the Department 18 Contact Name The name of the person to contact if Must not be blank submission problems occur or if there are questions about the submitted data 19 Contact Phone The phone number of the person Valid phone number listed in Contact Name Item 18 20 Verification Verification t
9. XIX of the Social Security Act 42 U S C 1396 et seq entitled Grants to States for Medical Assistance Programs Uniform Resource Locator URL The global address of documents and other resources on the World Wide Web The first part of the address indicates what protocol to use and the second part specifies the IP address or the domain name where the resource is located URL see Uniform Resource Locator Validation An analysis of the submitted resident day data and the assessment payment calculation These validations are created by the Department in order to provide consistency completeness and greater accuracy in reporting All validations must be passed prior to saving the resident day data and generating a bill Web Browser browser A software application used to locate and display web sites Web Site A site location on the World Wide Web Each web site contains a home page which is the first document users see when they enter the site The site may also contain additional documents and files Each site is owned and managed by an individual company or organization The PA NF Submission System web site was developed by Myers and Stauffer under contract with the Department World Wide Web A vast series of documents called web pages or web documents that are linked together over the Internet This means you can access another document by clicking on hot spots Not all Internet servers are part of the Wo
10. http www portal state pa us portal server pt open 5 14 amp objID 734405 amp mode 2 These websites will also include RDR Form submission deadlines for providers who wish to receive early payments Page 3 Revised 01 27 2014 SECTION 2 PA NF RESIDENT DAY REPORTING Glossary Terms Used In This Section Assessment Day Assessed Nursing Facility Assessment Quarter Assessment Rate Bill Bookmark Browser CCRC CCRC Facility Contractor County nursing facility Department Download Due Date Guest Internet Internet Explorer Internet Service Provider MA MA 11 Cost Report MA Program MA Nursing Facility Provider NF Nonpublic nursing facility Nursing Facility PA NF Assessment Program Password and Connectivity Document PC Public Use Area QAP QAP RDR Form Resident Day Quarter Signature on File Form Supplemental Payment Uniform Resource Locator URL User Account Validation Web Browser Web Site Definitions for these terms are found in Section 5 PA NF SUBMISSION SYSTEM WEB SITE An Assessed Nursing Facility must submit resident day data for each Resident Day Quarter using the on line RDR Form developed by the Department at http www PANFsubmit com The portal used for this submission is a web site developed to electronically submit this data This web site and the features that it contains are called the PA NF Submission System The PA NF Submission System may be accessed using one of two methods Users that hav
11. is notification to the facility that the new owner information is recorded in the PA MA Submission System An Assessed Nursing Facility that undergoes a change of ownership is not disqualified from receiving a quarterly Supplemental Payment so long as the facility continuously participated in the MA Program from the first day of the calendar quarter prior to the calendar quarter for which the Supplemental Payment is made through and including the date on which the Supplemental Payment is made and the facility submits its RDR Form in the manner and time specified by the Department The Supplemental Payment will be made to the owner of the nursing facility i e the current provider on the date the Supplemental Payment is processed by the Department A public nursing facility including a county nursing facility that becomes a nonpublic nursing facility whether as a result of a change in ownership or control will be assessed at the applicable assessment rate of a nonpublic nursing facility beginning on the Assessment Quarter for which the private nursing facility designation was effective for one full associated Resident Day Quarter CENSUS RECORD RETENTION For each year the Department or its contractor may perform a review of the resident days submitted on the RDR Form In order to support the submitted days the nursing facility Page 21 Revised 01 27 2014 must retain and upon request furnish to the Department or its contractor the sou
12. itemm een de a 2 orabant Loe 2 Ps m IS 2 Fesdag ALERT For rach reader wibe Arps reported PA an apeipkanon for MA meon already been to the CAO Chhyerwus fut drs dhoudd be reported a Preeate Pay Other 10 Enna Licenred Beds WARNING The wander sheds reported i than the oumber sf beds o6 recoot with the Deparmest Please check for arzurary before contesse Al eshdbyacos hava been met Tour total ASSESSMENT PATMENT DUE fox ie cedent daya reported oe the Asitimes Quarter ending 12 51 2063 i 12100 00 Ber the B besten you are chat Hes the correct and a b will be generated Y ther amount is mot RETURN to the PA Bender Duy Reporting Foe E E LU Figure 7 Submission Results if No Errors After selecting the Generate Bill button a bill is generated Figure 8 below The bill contains all the data that was submitted on the on line form as well as the name of the person who signed the Signature on File form Select File then Print and print a copy of the bill See Appendix C for an example of a bill Upon printing the bill choosing the browser s back button or choosing ESC the user is returned to the Resident Day Reporting and Payment History screen Select the Log Out button to exit that provider s data Page 15 Revis
13. meet the occupancy requirements per 1187 104 12 TOTAL OTHER A calculated field containing the Calculated DAYS sum of Item 10 and Item 11 13 TOTAL A calculated field containing the Calculated ASSESSMENT sum of Item 9 and Item 12 The DAYS total resident days for which the nursing facility is liable for the NF Assessment Payment 14 Medicare FFS Days The total days of service for which Must not be blank If no Medicare Medicare Part A is invoiced FFS Days complete the field with through a fee for service program a 0 Must be a number from 0 to Resident s admission day is 50 000 If greater than zero must counted as a Medicare FFS Day be a certified Medicare nursing Resident s day of discharge is not facility counted 14b Medicare HMO PPO The total days of service for which Must not be blank If no Medicare Days a Medicare health maintenance plan HMO PPO Days complete the such as Geisinger Gold or other field with a 0 Must be a number Medicare Advantage programs from 0 to 50 000 If greater than invoiced Resident days covered by zero must be a certified Medicare Medicare supplemental insurance nursing facility should be recorded as Private Pay and Other Days and not Medicare days Resident s admission day is counted as a Medicare HMO PPO Day Resident s day of discharge is Page 12 Revised 01 27 2014 Item Item Heading Description Validation cin 14c
14. period specified by the Department for the Resident Day Quarter and 3 the provider has paid the QAP for the corresponding assessment quarter QAP see Quarterly Assessment Payment Quarterly Assessment Payment QAP A fee paid to the Department each Assessment Quarter by an Assessed Nursing Facility under the PA NF Assessment Program RA Remittance Advice RDR Form see Resident Day Reporting Form Resident Day Reporting Form RDR Form An on line form on the PA NF Submission System website used to 1 collect resident day data by payor source 2 calculate Quarterly Assessment Payments owed by Assessed Nursing Facilities under the PA NF Assessment Program and 3 calculate the Supplemental Payments payable to Qualified Nursing Facilities under the Commonwealth s approved State Plan Resident Day Quarter The calendar quarter that immediately precedes an Assessment Quarter and for which days of service are reported on the on line RDR Form Signature on File Form A form used to collect the provider s signature certifying that the information submitted on the Resident Day Reporting Form for each Resident Day Quarter is accurate and complete as submitted The file must be received by the Department prior to activation of the provider s password Supplemental Payment A lump sum payment made in a calendar quarter to a Qualified Nursing Facility in addition to its case mix per diem rate payments Title XIX Title
15. the QAPs owed by Assessed Nursing Facilities in that fiscal year Each annual assessment rate must be approved by the Governor Before implementing an annual assessment the Secretary publishes a notice in the Pennsylvania Bulletin that specifies the assessment rate that is being proposed for the fiscal year explains how the rate was determined and identifies the aggregate impact on Assessed Nursing Facilities Interested parties have thirty 30 days to submit comments to the Secretary After considering the comments received during the 30 day period the Secretary publishes a second notice announcing the annual assessment rate for the fiscal year The annual assessment rate is also available to the public on the OMAP web site at the following address Page 2 Revised 01 27 2014 http www portal state pa us portal server pt community pennsylvania 20nursing 20fa cility 20assessments 19369 Each Assessed Nursing Facility s QAP for an Assessment Quarter is calculated by applying the following formula to the data reported by the Assessed Nursing Facility on the RDR Form for the applicable Resident Day Quarter QAP assessment rate x assessment days in the Resident Day Quarter For example assume the annual assessment rate is 15 91 A nursing facility that has 10 000 assessment days for the quarter will be assessed 159 100 15 91 x 10 000 159 100 The assessment fees are published in The Pennsylvania Bulletin for each year
16. the reference date the nursing facility is using to base the responses to the payor source items Since the believed payor source may change at later dates it is important for the Department to be able to determine the point in time the nursing facility is using to complete the RDR Form It is not expected that the nursing facility will adjust the payor source items at a later date nor will they be allowed to adjust the payor source except in very limited circumstances and within a time period specified by the Department For example if the Based on Census Records as of date is 10 05 2003 and the facility receives a PA FS 162 on 10 10 2003 which contains notification of a resident s eligibility for PA MA nursing facility services the facility should not edit the RDR Form to subtract the resident from the PA MA Pending item and add the resident to the PA MA Facility Days item After completing the Item 2 date the user then continues to complete the remaining entries in the order presented on the form D fecta b thet Q a Ld PA NF Resident Day Reporting Form a Enter Sie oderat the quater Whee completed select the SUBMIT button Frat tbe aererated b See PA Rendez Dey Eegomoy Manni fos further details Por o desceptos of each nem chek bere Facility ID Frovider 1 Reselent Dev Quarter Ending 130 com Dags reported are used to calculate the QAP due foe tie Assessment Quarter e
17. 16 Ending Licensed Beds 17a CCRC 17b County Nursing Facility Assessment Rate Per Diem QUARTERLY ASSESSMENT PAYMENT DUE John Doe 717 541 1203 x0001 12 31 2003 01 05 2003 4 500 200 100 0 20 300 5 120 0 3 000 3 000 8 120 100 100 200 8 320 100 Yes No 1 50 12 180 00 This is not an actual bill To generate a bill click on the Submit button on the PA NF Resident Day Reporting Form Page 35 APPENDIX D SIGNATURE ON FILE FORM Revised 01 27 2014 pennsylvania DEPARTMENT OF PUBLIC WELFARE PROVIDER ATTESTATION FOR SIGNATURE ON FILE NURSING FACILITY ASSESSMENT RESIDENT DAY REPORTING FORM Provider Name Facility ID By signature and date below I certify that I possess all necessary powers and authority to make the representations set forth on the quarterly Resident Day Reporting Form and to execute the same on behalf of the Provider and in so doing to bind the Provider including the owner s of the Provider and any persons who derive any rights from the Provider and its enrollment in the Medical Assistance Program I further certify that the information submitted on the Resident Data Reporting Form for each Resident Day Quarter is accurate and complete as submitted I understand that this information is being relied upon to make payment of Federal and State funds and that if the information is false or if there has been any material concealment of material facts 1 I may be subject to those pena
18. F Assessment Program assessed facilities must Report their resident day data for each Resident Day Quarter using a web based form located at www PANFsubmit com Calculate their Quarterly Assessment Payment QAP from these reported days and Remit their QAP on or before the due date for each Assessment Quarter This end user manual provides important instructions and guidance for assessed facilities to follow to comply with the PA NF Assessment Program This manual also contains Page 1 Revised 01 27 2014 instructions and guidance for qualified nursing facilities to follow to receive their quarterly allowable cost and supplemental payments ASSESSED AND EXEMPT NURSING FACILITIES Under the PA NF Assessment Program every nursing facility that is not an Exempt Nursing Facility must make a QAP to the Department on or before the due date in each Assessment Quarter A nursing facility that is not an Exempt Nursing Facility is an Assessed Nursing Facility IMPORTANT DATES The PA NF Assessment Program is effective July 1 2003 and remains in effect through June 30 2012 The General Assembly enacted Act 80 of 2012 to reauthorize the Assessment Program beginning FY 2012 2013 through 2015 2016 The first Assessment Quarter for which each Assessed Nursing Facility must submit a QAP is the calendar quarter July 1 through September 30 2003 The QAP for the first Assessment Quarter will be calculated using resident day data reported on the r
19. F Submission System and navigating the site gt Assistance in interpreting any error messages gt Identifying steps to be taken to complete necessary corrections as a result of error messages gt Assistance in accessing saving or opening the files available using the Instructions and Bulletins and Supplemental Payments links Every effort will be made to answer the caller s question promptly If the helpdesk representative 1s unable to answer the caller s question the helpdesk representative will take the caller s name and phone number and research the question The caller will be contacted when a response is determined PROBLEMS NOT SUPPORTED Some problem areas will not be supported by the Myers and Stauffer Helpdesk because they are the responsibility of other entities or are outside of the PA NF Submission System arena gt Support for installation of hardware devices printer etc gt Support for browsers Questions regarding receipt of the QAPs or bills received other than those generated from the web site should be directed to the Department at 717 346 1484 or 717 772 2094 Page 25 Revised 01 27 2014 SECTION 5 GLOSSARY COMMON TERMS AND ABBREVIATIONS This manual section provides definitions of terms and abbreviations used in this manual Assessment Day An actual day of service including hospital reserve bed hold and therapeutic leave days provided to a resident by an Assessed Nursing Facility other than a
20. PA NF ASSESSMENT AND QUARTERLY RESIDENT DAY REPORTING FORM m iml 2 End User Manual Revised 01 27 2014 Department of Public Welfare and Myers and Stauffer LC This manual was produced using Doc To Help by WexTech Systems Inc Revised 01 27 2014 CONTENTS SECTION 1 BACKGROUND 1 Introduction 1 Assessed and Exempt Nursing 2 Important Dates irn FO RTT PO TR tested Pe ETE ERO REUH ERE FREU Te 2 Quarterly Assessment Payment Methodology eese eene enne 2 Supplemental Payment Methodology sese enne 3 SECTION 2 PA NF RESIDENT DAY REPORTING 4 PA NF Submission System Web Site essen enne nennen 4 User Account and Password n nente e neneebiemntiec tee eere 4 Web Site Guests neben PRODR Oe pip 5 Web Site Options pbi RE DURER Te ERROR T Leere 5 Figure 1 Initial Web Site Welcome Page seen 5 Submitting Resident Day Datta 6 Figure 2 User Login Window eine eise ee tere petes 6 Figure 3 Resident Day Reporting and Payment History sees 7 Figure 4 On line RDR Form Part nre 8 Figure 5 On line RDR Form Part 2 sss 9 Form Completion and Validations eeseessseesesesseeeeee eene ener enne tene 9 Figure 6 Submis
21. ails to provide the requested census documentation in the requested timeframe adjustments will be made to reclassify all submitted days to Private Pay and Other days The nursing facility will be provided with a copy of the adjustments and the amount owed and will have two weeks from the date of the report to provide census documentation If the material is not received within that period the adjustments will become final and the NF Assessment unit will notify the facility of the amount owed to the Commonwealth The Commonwealth will notify the facility in writing and the facility has fifteen 15 days from the notice date to remit the amount due to the Commonwealth If payment is not received by the due date the Commonwealth will issue a second and final notice Failure to make the payments owed will subject the facility to the interest and penalty provisions set forth on page 20 of this manual The time frame of these reviews could be up to 18 months from the original remittance advice date For nursing facilities that did not receive an allowable cost or supplemental cost payment the 18 month date will be the same as if the facility would have received an RA and associated payments Page 22 Revised 01 27 2014 SECTION 3 RELATED WEB SITE INFORMATION Glossary Terms Used In This Section Download NF Nonpublic Nursing Facility PA NF Assessment Program PA NF Submission System Supplemental Payment Web Site Definitions for these terms are fo
22. amount of time that you are connected to the PA NF Submission System during a single session If necessary time limits will be imposed at a later date Once you have connected to the system through the Internet the PA NF Submission System Welcome Page will appear Figure 1 below D Gh piw ok b amp DAA v uere deme V d Bi 4 8 ore tert corm wes E Welcome to the Pennsylvania Nursing Facility Submission System Department of Public Welfare Nursing Facility Assessment Resident Day Reporting Instructions and Bulletins Points of Contact Ja cocks to tew our bil qua sant laret ended for website Somr werent of browse asd browse piap en de mt alow psp zy widow Suce we do wer pop up window for any advernang is salt te adow pop upe from our webege Consi your bever or pop sp ssdiwiew Trip p de fee formation oa bow to resters pop ups 2 xw Figure 1 Initial Web Site Welcome Page There are three options available on this page They include Nursing Facility Assessment Resident Day Reporting Contains the individual nursing facility assessment information and allows access to the on line RDR Form This is available only to nursing facilities with a non guest User Account and password Instructions and Bulletins Contains files that may be downloaded and viewed or printed Points of Contact Provides a l
23. ate Per Diem QUARTERLY ASSESSMENT PAYMENT DUE John Doe 717 541 1203 0001 09 30 2003 12 01 2003 4 500 200 100 0 20 300 5 120 0 3 000 3 000 8 120 100 100 200 8 320 100 Yes No 1 50 12 180 00 Your facility s quarterly assessment payment in the amount of 12 180 00 must be received by ACH credit transaction in Wells Fargo account 2000012644119 by the due date Your facility has filed a Signature on File form certifying that the information submitted on the Resident Day Reporting Form for each Resident Day Quarter is accurate and complete as submitted Signature on File Signed Date JOHN DOE 01 01 2005 Page 33 APPENDIX C EXAMPLE PRINTED RDR FORM Revised 01 27 2014 Pennsylvania Nursing Facility Assessment For the Assessment Quarter Ending 03 31 2004 Facility ID 00000000 Contact Name Provider Name TEST FACILITY Contact Phone Reported Resident Days and Quarterly Assessment Payment Amount 1 Resident Day Quarter Ending 2 Based on Census Records As Of 3 PA Facility amp Therapeutic Leave Days 4 PA MA Hospital Days 5 Managed Care Days 6 LIFE Formally LTCCAP Program 7 Hospice Days 8 Pending 9 TOTAL PA MA DAYS 10 Other States MA Days 11 Private Pay amp Other Days 12 TOTAL OTHER DAYS 13 TOTAL ASSESSMENT DAYS 14a Medicare FFS Days 14b Medicare HMO PPO Days 14c TOTAL MEDICARE DAYS 15 TOTAL RESIDENT DAYS
24. ay Resident s day of discharge is not counted Include residents funded through a PA MA HMO either voluntary or mandatory The total Long Term Care Capitated Assistance Program LTCCAP days LIFE Formally LTCCAP Program is the Department s community based managed care program for the frail Validation Must be a valid date for a day that is on or after the Resident Day Quarter Ending date in Item 1 Must not be blank If no PA MA Facility amp Therapeutic Leave Days complete the field with a 0 Must be a number from 0 to 85 000 If greater than zero must be an MA nursing facility Must not be blank If no PA MA Hospital Days complete the field with a 0 Must be a number from 0 to 30 000 If greater than zero must be an MA nursing facility Must not be blank If no PA MA Managed Care Days complete the field with a 0 Must be a number from 0 to 85 000 If greater than Zero must be an MA nursing facility Must not be blank If no LIFE Formally LTCCAP Program Days complete the field with a 0 Must be a number from 0 to 50 000 If greater than zero must Page 10 Revised 01 27 2014 Item Item Heading Description elderly based on the federal Program of All inclusive Care for the Elderly PACE Resident s admission day is counted as a LIFE Formally LTCCAP Program Day Resident s day of discharge is not counted 7 PA MA Hospice Days The total days pa
25. e access to the Internet through an Internet service provider may complete their on line RDR Form using a web browser to access and to login to the Internet web site User Account and Password To complete and submit a RDR Form a nursing facility must use the User Account and password issued to the nursing facility by the Department These User Accounts and passwords are facility specific and only allow the nursing facility to submit its own resident day data and access its own historical information and reports They do not allow the nursing facility to submit resident day data or access information for any other nursing facility A nursing facility that uses an accountant s or other third party service to complete and submit its RDR Forms must provide its User Account and password information to that third party service Whenever a new nursing facility is licensed a new User Account and password is generated for the facility by Myers and Stauffer a contractor to the Department after notification by the Department and sent by certified mail to the administrator of the facility Page4 Revised 01 27 2014 Web Site Guests The PA NF Submission System web site is also accessible to the general public to download or view informational documents and access information on Supplemental Payments made to qualified nursing facilities You do not need a User Account and password WEB SITE OPTIONS The Department retains the right to limit the
26. e nursing facility will not be qualified to receive a Supplemental Payment unless and until it has been an MA nursing facility provider for a full Resident Day Quarter For example if a nursing facility is certified as new on January 15 it would first report resident day data for the April 1 June 30 Resident Day Quarter Both the RDR Form and the QAP would be due on the last day of the Assessment Quarter which would be September 30 A Supplemental Payment could be received by the nursing facility for the July 1 September 30 quarter Page 20 Revised 01 27 2014 Closed Nursing Facilities A nursing facility that operates for any period of time during an Assessment Quarter is required to remit a QAP for that Assessment Quarter even though the facility closes during the Assessment Quarter The nursing facility s final QAP will be calculated using the data reported on the RDR Form for the Resident Day Quarter immediately preceding its final Assessment Quarter A nursing facility may receive a Supplemental Payment in a quarter in which it closes so long as the facility remains qualified for a Supplemental Payment A nursing facility that is no longer participating in the MA Program on the day on which the supplemental payment is being made will still be eligible to receive a supplemental payment so long as it meets the definition of a general nursing facility has participated continuously in the MA Program during the entire Resident Day
27. ed The User Login window will appear only when you initially access the NF Assessment Resident Day Reporting Form page Once you have entered a correct User Account and password and selected OK the Quarterly Resident Day Reporting and Payment History page will appear Figure 3 below Page 6 Revised 01 27 2014 PAM Dery Repactiog Mecreecdt Tp 2il ix fe pk dee Hye jh c m tet 0 0 ent aee eem 0 2 RE d dires dt pont mrt conte ae ew bis a Quarterly Resident Day Reporting and Payment History Farii ID Pronde Wane Bassdent Dey Assessment Quarter Quarter Submission Assessment Assessment Last Paid Total Allowable Supplemental Teal Ending Ending Date Days Amoust Date Pad Cost Return E 0 2003 6222200 2 000 31 820 00 00 200 100 12 31 2003 EA 2 000 31 220 00 200 200 200 Cirk op a Renders Day Quarter date to ww a copy of the tl The tucplenertal amut proposed anonsi bared on reported daps these amounts may change based on adgutmenti catered to Be orignal nimisaon data gry 12 duw the tent 2 a 4 ni glo E Figure 3 Resident Day Reporting and Payment History This page tracks on a quarterly basis the submission date assessment days QAP amount date the payment was received by the Department the amount received the allowable cost and supplemental payment and the total of these payments An Assessed Nursing Facility may use this page to verify that its QAPs have be
28. ed 01 27 2014 E Pennsylvania Nursing Facility Assessment Microsoft Internet Explorer ni x File Edit View Favorites Tools Help Send Ea Pennsylvania Nursing Facility Assessment For the Assessment Quarter Ending 12 31 2003 Bill Number 0000000002 Contact Name John Doe Bill Date 02 16 2005 Contact Phone 717 541 1203 0001 Facility ID 00000000 Provider Name TEST FACILITY Reported Resident Days and Quarterly Assessment Payment Amount Resident Day Quarter Ending 09 30 2003 Based on Census Records As Of 12 01 2003 PA MA Facility Therapeutic Leave Days 4 500 PA MA Hospital Days 200 PA MA Managed Care Days 100 LTCCAP Days 0 PA M Hospice Days 20 P M Pending 300 TOTAL PA MA DAYS 5 120 Other States MA Days 0 Private Pay Days 3 000 TOTAL OTHER DAYS 3 000 TOTAL ASSESSMENT DAYS 8 120 Medicare Days 200 TOTAL RESIDENT DAYS 8 320 Figure 8 Bill Screen CCRC FACILITY While completing the RDR Form the nursing facility completes an indicator that the nursing facility is or is not a continuing care retirement community CCRC Facility as determined by the Department according to guidelines set forth in the Pennsylvania Bulletin As of July 1 2010 only grandfathered CCRC nursing facilities have CCRC status and no new requests for CCRC status will be considered See 40 Pa B 7297 and 41 Pa B 6942 for further explanation of a grandfathered CCRC nursing facility If a grandfathe
29. ed in 55 Pa Code 1187 2 relating to Definitions PA MA Hospice Day A hospice day paid by the Department PA MA Hospital Reserve Day A day for which the nursing facility reserves a bed because of hospitalization as defined in 55 Pa Code 1187 104 1 relating to Limitations on payment for reserved beds PA MA Managed Care Day A day of care funded through an MA HMO either voluntary or mandatory PA MA Pending Day A day of care for which the nursing facility believes will be paid by the MA program upon receiving the resident s NF eligibility notification but no active MA ID number for MA nursing facility services has been received An application must have been submitted to the County Assistance Office and the nursing facility must have a reasonable expectation that the application will be approved PA MA Therapeutic Leave Day A day for which the nursing facility reserves a bed because of therapeutic leave as defined in 55 Pa Code 1187 104 2 relating to Limitations on payment for reserved beds PA NF Assessment Program The program established to implement and collect nursing facility assessments in accordance with Article VIII A of the Public Welfare Code the Act of June 13 1967 P L 31 No 21 as amended by the act of September 30 2003 P L 169 No 25 1 PA NF Submission System A web site developed by Myers and Stauffer under contract with the Department that allows submission of the MA 11 C
30. en received in a timely manner or to print any of its quarterly bills A bill may be viewed and printed by clicking on the appropriate Resident Day Quarter Ending date on the Resident Day Reporting and Payment History page The submission of resident day data is on a quarterly basis It is critical that the nursing facility provide the correct census days for the coordinating assessment period The table below defines the Resident Day Quarter the period for which the census is derived and the Assessment Quarter for which this data is reported Resident Day Quarter Assessment Quarter 04 01 06 30 07 01 09 30 07 01 09 30 10 01 12 31 10 01 12 31 01 01 03 31 01 01 03 31 04 01 06 30 To submit new quarterly resident day data select the Submit a New Quarter button Select the correct Resident Day Quarter ending date by clicking on the correct date The only dates available for selection are for dates in which a RDR Form has not been saved A RDR Form cannot be submitted for a Resident Day Quarter before the end of the Quarter Page 7 Revised 01 27 2014 After selecting the Resident Day Quarter the user is directed to the PA NF Resident Day Reporting Form Figure 4 below and Figure 5 on page 11 Item 1 the Resident Day Quarter Ending is pre filled with the user s selected date derived from the previous step Item 2 Based on Census Records as of should be completed with
31. equirements of the Federal law On September 30 2003 the Pennsylvania General Assembly enacted amendments to the Public Welfare Code authorizing the Department of Public Welfare the Department to implement a Pennsylvania Nursing Facility PA NF Assessment Program consistent with the Federal law beginning July 1 2003 and ending June 30 2007 In June 2007 the state legislature through the passage of the Act of June 30 2007 P L 49 No Act 16 Act 16 directed the Department to continue the Assessment Program for Fiscal Years 2007 2008 through 2011 2012 and also provided the Department with the authority to include the county nursing facilities in the Assessment Program The General Assembly enacted Act 80 of 2012 to reauthorize the Assessment Program beginning FY 2012 2013 through 2015 2016 Under the PA NF Assessment Program the Department collects an assessment fee from nursing facilities Assessed Nursing Facilities and uses the revenues collected and the Federal match to maintain the per diem payment rates to Medical Assistance MA nursing facility providers The Department also uses some of the assessment revenue to pay nonpublic MA nursing facility providers the MA portion of their allowable assessment cost and to make supplemental payments to qualified nursing facilities In addition the Department uses some of the assessment revenue to increase MA Day One Incentive payments made to county nursing facilities To comply with the PA N
32. esident day reporting form RDR Form for the applicable Resident Day Quarter i e the calendar quarter immediately preceding the first Assessment Quarter the calendar quarter April 1 2003 through June 30 2003 The QAP due in each subsequent Assessment Quarter will be calculated using resident day data reported on the RDR Form for the applicable Resident Day Quarter for that Assessment Quarter i e the calendar quarter immediately preceding the Assessment Quarter An Assessed Nursing Facility may submit its RDR Form for a Resident Day Quarter beginning on the first business day of the applicable Assessment Quarter i e the calendar quarter immediately following that Resident Day Quarter Each Assessed Nursing Facility must submit its RDR Form for a Resident Day Quarter and remit its QAP to the Department no later than the due date of the applicable Assessment Quarter If the due date falls on a state holiday or weekend the due date is the next business day For each year including the start up period important submission and payment dates will be posted on the www PANFSubmit com website and the OMAP website at http www portal state pa us portal server pt open 5 14 amp objID 734405 amp mode 2 QUARTERLY ASSESSMENT PAYMENT METHODOLOGY Each fiscal year in which the PA NF Assessment Program is in effect the Secretary of Public Welfare in consultation with the Secretary of the Budget determines the assessment rate used to calculate
33. hat the NF Must be checked Assessment has been calculated by the facility 21 Signature on File Verification that a Signature on File Must be checked form certifying that the information submitted on the Resident Data Page 13 Revised 01 27 2014 Item Item Heading Description Validation Reporting Form for each Resident Day Quarter is on file with the Department The user may select any one of the buttons at the bottom of the form Submit Selection of the Submit button saves the data and activates the validation of the entered items using the data entry rules described in the Validation column in the previous table Save Selection of the Save button allows the user the option to save any data that has been entered and to come back to the RDR Form at a later date or time to complete the form and submit the data The user is automatically returned to the previous screen Clicking on the Edit item takes the user back to the RDR Form so that the form may be completed and submitted Data is not deemed as being submitted until the Submit button is selected and a bill is generated Selecting the Save button is optional since the data is also saved upon selection of the Submit button Print Selection of the Print button allows the user to print the data items on the screen This printed document is not a bill and is optional Reset Selection of the Reset button clears the screen of any items entered by
34. he field with a 0 Must be a number from 0 to 50 000 If greater than zero must be an MA nursing facility If greater than zero a message will be displayed ALERT For each resident whose days are reported as PA MA Pending an application for MA must have been submitted to the CAO AND the nursing facility must have a reasonable expectation that the application will be approved Otherwise the resident days should be reported as Private Pay and Other Calculated Must not be blank If no Other States MA Days complete the field with a 0 Must be a number from 0 to 30 000 Must not be blank If no Private Pay and or Other days complete the field with a 0 Must be a number from 0 to 85 000 Page 11 Revised 01 27 2014 Item Item Heading Description Validation insurance or other parties not specified in other payor source categories are invoiced for the resident s care Include days of service for which the Veterans Administration is invoiced for the resident s care Record bed hold days for private pay residents if they are included on the facility s census Resident s admission day is counted as a Private Pay and Other Day Resident s day of discharge is not counted Record MA hospital reserve bed days after day 15 Record MA hospital reserve bed days for which the nursing facility is not eligible for payment for the Resident Day Quarter because the facility failed to
35. id by the Department for residents receiving hospice services whether through MA or Medicare Resident s admission day is counted as a MA Hospice Day Resident s day of discharge is not counted 8 PA MA Pending The total days the nursing facility believes will be paid by the MA program upon receiving the resident s NF eligibility notification but for which no active MA ID number for MA nursing facility services has been received An application must have been submitted to the County Assistance Office Resident s admission day is counted as a PA MA Pending Day Resident s day of discharge is not counted 9 TOTAL MA DAYS A calculated field containing the sum of Item 1 through Item 8 10 Other States MA Days The total days for which another state s Medicaid program is invoiced for the resident s care Resident s admission day is counted as an Other States MA Day Resident s day of discharge is not counted 11 Private Pay and Other Days The total days provided by the nursing facility for which the resident private insurance include Blue Cross HMOs etc or other insurance include Workers Compensation and non health Validation be an MA nursing facility Must not be blank If no PA MA Hospice Days complete the field with a 0 Must be a number from 0 to 50 000 If greater than zero must be an MA nursing facility Must not be blank If no MA Pending Days complete t
36. inancial Institution to initiate ACH payments Page 19 Revised 01 27 2014 PENALTIES AND INTEREST An Assessed Nursing Facility that fails to submit its quarterly RDR Form will be assessed 1 000 for the first day that the Form is overdue and 200 for each additional day the Form is overdue An Assessed Nursing Facility that fails to pay either a QAP ora penalty in the amount or on the date required will be assessed interest on the unpaid amount at the rate provided in section 806 relating to interest on taxes and bonus due the Commonwealth of the act of April 9 1929 P L 343 No 176 known as The Fiscal Code from the date prescribed for its payment until the date it is paid In addition to payment of penalties and interest when a nursing facility that is a MA provider or that is related through common ownership or control as defined in 42 CFR 413 17 b toa MA provider fails to pay all or part of a QAP or penalty within 60 days of the date that payment is due the Department may deduct the unpaid assessment or penalty and any interest owed from any MA payments due to the nursing facility or to any related MA provider until the full amount is recovered Any such deduction shall be made only after written notice to the MA provider and may be taken in amounts over a period of time taking into account the financial condition of the MA provider The Department will notify the Pennsylvania Department of Health of any nursing facility that has as
37. ist of contacts names addresses phone numbers and E mail addresses as applicable This option is available for public use Additional options may be added in the future Point and click on the underlined text option to go to the desired window For MA nursing facilities used to assessing the MA 11 Submission Website a link to the PA NF Submission System is also available on that website Page 5 Revised 01 27 2014 SUBMITTING RESIDENT DAY DATA After selecting the Nursing Facility Assessment Resident Day Reporting Form option users are directed to log in using their pre assigned User Account and password Figure 2 on page 6 aii x fe GM p Feet jede Wo Send he 930 D ghe 2 29 oJ diem Uns User Login Please enter the user nccoant and password below rer Aroceust accord Togn Res 2 GCA vre Arn enl x dedi E ae 0 20 200 GCNOSG 690P uw Figure 2 User Login Window You must point and click in the first field User Account to begin entering the required information provided to you on the Password and Connectivity Document The guest User Account may not be used to submit the RDR Form You may use the Tab key or point and click in the second field password to type in the password provided to you by the Department Once you have entered both a valid User Account and password press Enter or point and click on OK You may select Cancel if you do not wish to proce
38. lties pertaining to unsworn falsifications to authorities as set forth at 18 Pa C S Section 4904 2 the Provider s participation in the Medical Assistance Program may be terminated and 3 criminal or civil penalties may be imposed against the Provider its owner s and other responsible persons This representation is valid until Signature on File is replaced with a Signature on File with a later signature date Signature of Provider Signature Date Print Name Email Address If you would like to add or remove an employee from our contact list please contact RA NH Assessments pa gov Or you may return the signed and dated form to the below address Please indicate the fifth floor on your return envelope FOR OFFICE USE ONLY RECEIVED ENTERED INITIAL Bureau of Finance Office of Long Term Living 555 Walnut Street Harrisburg PA 17101 717 787 1171 F717 265 7833 www dpw pa gov REV 12 12 Page 37
39. mum amount of information necessary to identify the caller the nursing facility the telephone number with area code and extension and PA NF Assessment Program question This will allow as many callers as possible to leave messages before the voice mail account is full and will not accept any more messages The voice mail account will be checked by the helpdesk frequently during business hours to avoid having the account become full However during non business hours when the account is not being checked it may become full and no longer accept any messages If you are unable to leave a voice mail message because the account is full you may choose to fax your question as described below Messages that are left in the voice mail account will be answered in the order that they are received The FAX number for the helpdesk is 717 541 5802 Please be as descriptive as possible so that the helpdesk representative may research your question prior to calling you When faxing a question please include your name and the nursing facility name and MA number if applicable The help desk will contact you as soon as possible please do not fax the same message multiple times The hours and days of operation for the helpdesk are Monday through Friday from 8 00 a m to 5 00 p m eastern time Page 24 Revised 01 27 2014 HELPDESK ASSISTANCE The following types of problems will be supported by the Myers and Stauffer Helpdesk gt Accessing the PA N
40. n operation during the full calendar quarter prior to the Assessment Quarter or iv provides services free of charge to all residents are also exempt or excused from making a QAP An Exempt Nursing Facility is excused from making a QAP in an Assessment Quarter Guest A term used in this manual to indicate a User Account that may be used by the general public to access certain areas or pages of the PA NF Submission System Internet A global network connecting World Wide Web sites There are a variety of ways to access the Internet Most online services such as America Online offer access to some Internet services It is also possible to gain access through a commercial Internet service provider ISP Internet Explorer Microsoft s web browser that enables the user to view World Wide Web sites Internet Service Provider A company that provides access to the Internet For a monthly fee the service provider gives you a software package User Account password and access phone number MA see Medical Assistance MA 11 Cost Report The financial and statistical report form that is prepared and filed on an annual basis by nursing facility providers Medical Assistance MA Payment for specific kinds of medical items and services including nursing facility services identified in an approved State Plan which is provided to individuals eligible under the joint Federal and state funded Medicaid program established pursuan
41. ndmg 03 31 2007 Based an Cenent Records OF 5 PA MA Facility amp Therapentic Leave Days 4 PA MA Hecpital Reserve Daye 5 PA MA Managed Care Days 6 Days Hospice Dass 8 PA MA Pending 0 9 TOTAL PA MA DAYS Sus len 3 5 lo Uther Staves Days HI Privato Pay aud Other Days a 12 TOTAL OTHER DAYS Suss leme 10 11 I5 TOTAL ASSESSMENT DAYS bem 9 Irem 12 Figure 4 On line RDR Form Part 1 Page 8 Revised 01 27 2014 DPA NE Residen Day Reparting T t Bh de ti Se O 2 TOTAL ASSESSMENY DAYS 9 Item 12 lda Medicare FPS Days 14b Medicare PPO Days Li TOTAL METHCARE DAYS 14a Tem 145 is TOTAL RESIDENT DAYS Rem 15 14 l6 Ending Licensed Beds 17a CCRC 1 County Faribty 18 Cantart Name 19 Contact Telephone Number 20 Everify that I have the payment due for the Ansexement Quarter erding 0 112007 I verify that Signature On File existe for the Provider attesting to the accuracy and tompbetounss of the Resident Day ax vulinstied Assessment Rate Pes Dien QUARTERLY ASSESSMENT PAYMENT DUE ben 13 x Aucecanent Pape Per Dum E stunsted Allowable Cost ben QAP hem 15 x ltem 9 Estimated Suppleinear al ben 9x 5 00 Estimated Toral Renau Com Supplemental Figure 5 On line RDR Form Part 2 FORM COMPLETION AND VALIDATIONS All items must be The on li
42. ne RDR Form displays types of payor sources for a nursing facility s days of completed on the on service As each cell is completed select the Tab key click on the next cell or select line RDR Form If a the Enter key to move down the list of items The form should be completed in the nursing facility does order of the items listed on the screen No item or cell should be left blank rather the not have any days of item must be completed with a zero if there are no days of service service for a Calculations for Total PA MA Days Total Other Days Total Assessment Days Total Medicare Days Total Resident Days Assessment Rate Per Diem Quarterly Assessment Payment Due Allowable Cost Supplemental and Total Return are completed by the system as the user completes the form particular payor source the item must be completed with a zero 0 Item descriptions and validations are listed below in the order they appear on the form Item Item Heading Description Validation 1 Resident Day The last day of the calendar quarter Must be a valid date for a calendar Quarter Ending that immediately precedes an quarter that has not already been Assessment Quarter and for which submitted by the nursing facility days of service for the quarter are and the date must be less than reported on the on line RDR Form today s date Must not be blank Note The nursing facility will NOT be allowed to submit if the quarter hasn t ended or they
43. ned to be a part of a CCRC by the Department Contractor An entity working under contractual agreement with the Department to provide requested services e g Myers and Stauffer LC is the contractor that developed and manages the PA NF Submission System the NIS and the MA case mix reimbursement calculations CCRC see Continuing Care Retirement Community Page 26 Revised 01 27 2014 County Nursing Facility A nursing facility that is controlled by a county institution district or county government if no county institution district exists The term does not include intermediate care facilities for the mentally retarded controlled by a county institution district or county government Department The Pennsylvania Department of Public Welfare Download To copy data usually an entire file from a main source to a peripheral device The term is used in this manual to describe the process of copying a file from the PA NF Submission System to one s own computer Due Date The last day of an Assessment Quarter or the thirtieth day following the date on which the final notice announcing the Assessment Rate in effect for the fiscal year in the Pennsylvania Bulletin in which the Assessment Quarter occurs whichever date is later Exempt Nursing Facility A nursing facility that i is owned or operated by the state or federal government or ii is a Veteran s Administration nursing facility or 11 was not licensed and i
44. ost Report and resident day reporting by nursing facility providers Password and Connectivity Document A document mailed to each new nursing facility containing information needed to submit data to the PA NF Submission System The document is sent by certified mail to the nursing facility administrator and must be forwarded to the person or entity responsible for the submission of the nursing facility s RDR Form and Quarterly Assessment Payment information PC Personal computer PDA Pennsylvania Department of Aging Waiver Day A day of care in which respite services are provided in an approved long term care facility to relieve family members or primary caregivers who normally provide care Private Pay Day A day of care for which a resident private insurance including Blue Cross HMOs etc or other insurance including Workers Compensation and non health insurance are invoiced for the resident s care Public Use Area The pages of the PA NF Submission System that may be viewed by the general public without a facility specific User Account and password Qualified Nursing Facility A nonpublic nursing facility that is an MA nursing facility provider and meets all of the following requirements 1 the provider continuously Page 28 Revised 01 27 2014 participates in the MA Program during the entire Resident Day Quarter 2 the provider has reported information requested by the Department in the manner and time
45. r the 30 day from the date on which the assessment rate for the fiscal year is published in the Pennsylvania Bulletin whichever date is later If the due date falls on a state holiday or weekend the due date is the next business day Nursing facilities are required to remit their QAPs by direct payment through the Automated Clearing House ACH Credit system The ACH Credit method allows for the transfer of funds by instructing your financial institution to debit your account and to credit the Commonwealth s bank account Contact your financial institution regarding available ACH services It is recommended that you obtain ACH Credit services at least four weeks prior to your first payment since financial institutions may have lengthy set up and qualifying requirements Your financial institution may charge a fee for any setup costs and for each ACH Credit transaction initiated by your nursing facility These fees are normally minimal and are the responsibility of the nursing facility The Department has designated two acceptable ACH Credit transaction formats The Cash Concentration Disbursement CCD format accommodates one addenda record Optionally the Corporate Trade Payment CTX format may be used for entities wishing to make payments for more than one nursing facility or for multiple QAPS for the same facility in the same transaction The Bill Number seen on the quarterly Bill that is generated after completing the RDR Form is placed in
46. rce documents census reports from the nursing facility s billing or census program that were used to determine the number of days for each Resident Day Quarter and the payor source The date of these documents should coordinate with the Based on Census Records As Of date entered in Line 2 of the RDR Form Nursing facilities that fail to retain and furnish these historically accurate documents may be subject to sanctions and penalties REVIEW OF REPORTED RESIDENT DAYS If your nursing facility has been selected for a review of the resident days submitted on the RDR Form you will be required at a minimum to provide the following items The historical census documentation that was used to complete the RDR Form A detailed list of what insurances are reported on each line of the RDR form i e Blue Cross Tricare Auto and self pay residents are reported on Line 11 If your nursing facility has reported MA Pending days on Line 8 you may be required to provide the following documentation A roster of MA Pending residents which includes the beginning and end dates of the MA Pending period for each resident and the total MA Pending days for each resident A copy of the application that was sent to the County Assistance Office CAO A copy of all the PA 162 s received from the CAO If any of these items cannot be provided the nursing facility will be subject to adjustments of the days submitted on the RDR Form If the nursing facility f
47. red CCRC nursing facility no longer meets the guidelines under which it was approved for the CCRC rate notify the Department of Public Welfare at Department of Public Welfare Office of Long Term Living Bureau of Finance Division of Rate Setting and Auditing NH Assessment Unit Forum Place 6th Floor 555 Walnut Street Harrisburg PA 17101 1919 A grandfathered facility obtaining status as a CCRC Facility could begin reporting this status beginning on the Assessment Quarter for which the CCRC status was effective for one full associated Resident Day Quarter For example a CCRC status effective May 30 would first be reported for the Assessment Quarter October 1 December 31 Resident Day Quarter July 1 September 30 Page 16 Revised 01 27 2014 QUARTERLY ASSESSMENT PAYMENT You will be notified of the schedule used to submit RDR Forms and make QAPs for the implementation period Addenda records that are blank or incorrectly formatted will prevent the correct matching of the payment and most likely will cause late payment interest and or penalties Each Assessed Nursing Facility s QAP is calculated during the completion of the on line RDR Form and is automatically noted on a bill generated for the Assessment Quarter An Assessed Nursing Facility s QAP must be received by the Commonwealth no later than 5 00 p m on the due date of the Assessment Quarter The due date is the last day of the Assessment Quarter o
48. rld Wide Web There are several applications called web browsers that make it easy to access the World Wide Web Page 29 Revised 01 27 2014 APPENDIX A INSTRUCTIONS AND BULLETINS DOWNLOADING In addition to this end user manual there may be files available for download from the PA NF Submission System that will be useful in completing the RDR Form and interpreting error messages To download these files select the Nursing Facility Assessment Resident Day Reporting as described in this end user manual From the Welcome Page select the Instructions and Bulletins link After Instruction and Bulletins has been selected the Update Page will appear To download a file select an underlined option After selecting an option you may receive a warning message Figure A 1 depending on how your system is configured Warning There is a possible security hazard here Q Figure A 1 Security Warning Page 30 Revised 01 27 2014 If you receive this warning message choose the Save to Disk option and select the OK button After you have selected the OK button or if you did not receive the warning message the Save As window will appear Figure A 2 Acrobat3 lotus Program Files Archive My Documents Scratch MyFiles Timework Novell Vfp D asis32 Windows Detlog txt Orawin95 S Autoexec bat a ffastun ffa Pacrs40 an Bootlog prv an ffastun ffl MATTVLD20000501 doc Files z Figure A 2 Save As Windo
49. sessment penalty or interest amounts that have remained unpaid for 90 days or more The Department of Health shall not renew the license of any such nursing facility until the Department notifies the Department of Health that the nursing facility has paid the outstanding amount in its entirety or that the Department has agreed to permit the nursing facility to repay the outstanding amount in installments and that to date the nursing facility has paid the installments in the amount and by the date required by the Department The Secretary may waive all or part of the interest or penalties assessed against a nursing facility for good cause as shown by the nursing facility The provisions set forth in this section also apply to payments owed to the Department as a result of a review of reported resident days as described on page 22 NEW NURSING FACILITY CLOSED NURSING FACILITY AND CHANGE OF OWNERSHIP A RDR Form may only be submitted for an entire Resident Day Quarter This section details situations in which full quarters of resident day information may not be available because of new enrollments and other changes in operation New Nursing Facilities A new nursing facility is first required to submit a RDR Form for a Resident Day Quarter following the completion of its first full calendar quarter Until the nursing facility submits this first RDR Form for a Resident Day Quarter the nursing facility is not required to make a QAP Similarly th
50. sion Results with Errors eese 15 Figure 7 Submission Results if No Errors essere 15 Figure 8 BillScr en somete ener hee 16 CORE Facility ioc pU Pete 16 Quarterly Assessment Payment eere rote e EE e RP PER 17 ACH Credit Transaction Record Details esses nennen rennes 18 Bank Account Information esee 18 Addenda Record Layout sese nennen eene 18 RMT Segment Layouts ieser tees 19 Penalties and Interest retenue ne epe Pie peur 20 New Nursing Facility Closed Nursing Facility and Change of Ownership 20 New Nursing Facilities esses ener nennen nennen enne 20 Closed Nursing sieer 21 Change of Ownership a trennen trennen eene 21 Census Record Retention essent enne nennen nnne trennen trennen eren 21 Review of Reported Resident 22 SECTION 3 RELATED WEB SITE INFORMATION 23 Instructions and Bulletins sissien oiue eenn E eS enne ennt nren trennen nee 23 Points Of Contact eee ee seh ein Re ne a in e te s 23 Supplemental Payment Details eese eee 23 SECTION 4 HELPDESK 24 Pagei Revised 01 27 2014 Myers and Stauffer Helpdesk
51. t receive an allowable cost or supplemental cost payment the one year date will be the same as if the facility would have received an RA and associated payments If the user does not wish to submit the data at this time they may select the Return to Form button or exit the program To submit the saved data at a later time select Edit for the appropriate Resident Day Quarter on the Quarterly Resident Day Reporting and Payment History screen Figure 3 on page 10 Data that is saved but not submitted does not fulfill the nursing facility s obligation to submit the completed RDR Form Page 14 Revised 01 27 2014 Ue BM Peete m ond l 3 12 mec remm rm Moreno ool sd coo din ew MA Pedag ALERT For rach paride whees days are reported ar PA as apgdpicaten MA grt have been cibaxmed to the Chfsarerum the rendent dupe chou be reported ac Prreate Par oc Otter 14 Medeure Daye Mast oot be Hark Ens Medicare Days comptete the felt a U Mit be a icem D tu 50 000 Digeser thes zero mart be an MA mirang 16 Boing Licensed Beds WARNING The camber ul tedi than the af beds an record wet the Deparenent Plaser check axcurat y before 20 Verification Mast he checked ENTE y 3 a 7 Figure 6 Submission Results with Errors ee 1 weet DAD Baer
52. t to Title XIX Medicare Part A Day A day of care covered either through the fee for service Medicare program or a Medicare health maintenance organization MA Program The Commonwealth s Medicaid program through which the Department provides medical assistance on behalf of eligible individuals MA Nursing Facility Provider A nursing facility that is enrolled by the Department as a provider of nursing facility services in the MA Program NF see Nursing Facility NIS see Nursing Facility Information System Nonpublic Nursing Facility Any nursing facility that is not 1 owned or operated by the state or federal government or ii a Veteran s Administration nursing facility or iii a county nursing facility Page 27 Revised 01 27 2014 Nursing Facility NF A long term care nursing facility licensed by the Department of Health pursuant to the Act of July 19 1979 P L 130 No 48 known as the Health Care Facilities Act The term does not include intermediate care facilities for the mentally retarded Nursing Facility Information System NIS The comprehensive automated database of nursing facility resident and fiscal information needed to operate the Pennsylvania Case Mix Payment System Other States MA Day A day of service provided by a nursing facility for which another state s Medicaid program is invoiced for the resident s care PA MA Facility Day An MA day of care as defin
53. the addenda record s for each of these payment formats to match the payment amounts to the correct nursing facility and Assessment Quarter in an automated manner You may initiate a prenotification prenote test to validate the state s bank transit number bank account number and payor information This should be done at least 10 calendar days prior to the due date of the first QAP and is a one time test unless you change banks or accounts A prenote test is a zero dollar transaction and should include all fields in each record Providers should initiate the payment with enough lead time so that the QAP amount is received by the Commonwealth on or before the due date The date received is based on the settlement date which is the date the payment was credited to the Commonwealth s bank account Each financial institution and the Federal Reserve has different processing deadlines You must check with your financial institution to determine when you should originate your payment so that it will be deposited to the Commonwealth s account by the required due date to avoid the imposition of penalties and interest Receipt of QAPs by the Commonwealth may be verified by viewing the history page for your facility on the www PANFSubmit com website Access the history screen using instructions beginning on page 5 The Payment Received column will identify the date the payment was received The Amount Received column displays the amount of the payment
54. the user Once the items are completed to the user s satisfaction the user selects the Submit button and the items are validated Descriptions of the items and validations are described in the previous table and may also be read on line by selecting the question mark icon at the top of the RDR Form At the conclusion of the validation process a message box appears on the screen which will contain one of three 3 types of messages A message containing a description of errors on one or more data items Figure 6 on page 17 Select the Return to Form button to correct the data items A message containing a description of a warning error on one or more data items Select the Return to Form button only if you are certain that the response you provided was correct A message stating that all validations have been met Figure 7 on page 17 Select the Return to Form button only if you decide to make changes in the resident day data Select the Generate Bill button to continue the submission process After selection of the Generate Bill button no changes to the resident day data may be made Nursing facilities may only make a change to resident days and or payor source items if an exception is granted by the NF Assessment unit Under no circumstances will an exception be granted if the request is more than one year from the remittance date for which the allowable cost and supplemental cost was originally paid For nursing facilities that did no
55. tion of these The CTX should be in the 820 Payment Order Remittance Advice Transaction Set For both types of electronic payments the following bank account information must be used Bank Account Information Data Element Name Contents Beneficiary Commonwealth of Pennsylvania Receiving Depository Wells Fargo Financial Institution RDFI RDFI Transit Routing Number 121000248 Receiver Account Number 2000012644119 Type of Receiver Account Checking The Department receives electronic payment information from Wells Fargo for each electronic payment received deposited To allow the Department to process and properly apply payments to the appropriate provider the nursing facility must use the addenda record format type 7 to provide the Bill Number and payment amount This information is placed in the Addenda Record Free Form portion of an electronic payment transmission using a separate EDI 820 Transaction Set Addenda Record Layout The following is the layout of the Addenda Record used with the CCD or CTX payment transaction When the CTX payment transaction is used for multiple payments the set is placed 80 characters at a time into multiple CTX Addenda Record Free Form Fields These fields should be completed according to the instructions for the specific service or software you obtain to create ACH Credit Transactions Data Element Name Length Contents 1 Sg Record Type Code Addenda Type
56. und in Section 5 INSTRUCTIONS AND BULLETINS The PA NF Submission System also contains additional information than that described elsewhere in this manual From the main Welcome Page select Instructions and Bulletins This option directs the user to a reporting manual for download and any bulletins applicable to the PA NF Assessment Program See Appendix B for instructions on how to download information listed under this option POINTS OF CONTACT From the main Welcome Page select Points of Contact for information concerning phone numbers for various types of questions SUPPLEMENTAL PAYMENT DETAILS Details regarding the calculation of the allowable cost and supplemental payment are presented in two places on the website As a nonpublic MA provider enters resident day information on the RDR Form these two calculations are performed at the bottom of the form Select the Print button once the form is completed but prior to submitting in order to have a record of this information Once the form has been submitted this information is no longer available The Allowable Cost and Supplemental payment amounts as well as the total amount are also presented on the Resident Day Reporting and Payment History screen once the payment date has been established No Supplemental Payment letters will be mailed to individual nursing facilities each quarter they ll be directed to the web site to view details of the calculation Page 23 Revised
57. ve already submitted for all quarters or they ve skipped a prior quarter Page 9 Revised 01 27 2014 Item Item Heading 2 Based On Census Records As Of 3 PA MA Facility amp Therapeutic Leave Days 4 PA MA Hospital Reserve Days 5 PA MA Managed Care Days 6 LIFE Formally LTCCAP Program Description The reference date used by the nursing facility to base the responses to the payor source items The total days of service for MA residents for which a continuous 24 hours of service has occurred Resident s admission day is counted as a MA Facility Day Resident s day of discharge is not counted as any type of resident day Include Therapeutic Leave days Do NOT include MA pending days MA pending days should be reported in Item 8 The total days of hospital reserve bed days for PA MA residents limited to 15 paid days per hospitalization Hospital reserve bed days for which MA payment is not received or the nursing facility is not eligible for payment of the hospital reserved bed days because the facility does not meet the overall occupancy requirements should be recorded on line 11 Private Pay and Other Days Resident s admission day back to the nursing facility is counted as a MA Facility Day Resident s day of discharge to the hospital is counted as a PA MA Hospital Day The total days of PA MA managed care days Resident s admission day is counted as a PA MA Managed Care D
58. w When this window appears the name of the file that you are downloading will appear in the File Name field Choose the directory where you would like to save this file and select the Save button After the Save button has been selected a status bar will appear tracking the progress of the download When the file has been successfully downloaded the status bar will disappear To view or use the downloaded file use the appropriate program to open the file It is very important that you remember where you saved the downloaded file so that you may find it later Page 31 APPENDIX B EXAMPLE BILL Revised 01 27 2014 Pennsylvania Nursing Facility Assessment For the Assessment Quarter Ending 12 31 2003 Bill Number Bill Date Facility ID Provider Name 0000000002 Contact Name 02 16 2005 Contact Phone 00000000 TEST FACILITY Reported Resident Days and Quarterly Assessment Payment Amount 13 Resident Day Quarter Ending Based on Census Records As Of PA MA Facility amp Therapeutic Leave Days PA MA Hospital Days PA MA Managed Care Days LIFE formerly LTCCAP Program PA MA Hospice Days PA MA Pending TOTAL PA MA DAYS Other States MA Days Private Pay Days TOTAL OTHER DAYS TOTAL ASSESSMENT DAYS 14a Medicare FFS Days 14b Medicare HMO PPO Days 14c TOTAL MEDICARE DAYS 15 16 TOTAL RESIDENT DAYS Ending Licensed Beds 17a CCRC 17b County Nursing Facility Assessment R
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