Quality ManagementMedicaidDecember 27, 2023

Intermediate care facility for developmentally disabled Long Term Care claims reference sheet

The attachment to this article was updated on May 2, 2024.

Thank you for your participation in the long-term care (LTC) carve-in benefit for intermediate care facilities for the developmentally disabled (ICF/DD) for 2024. This claims reference sheet provides information on billing for institutional services using the CMS-1450 (UB-04) form for ICF/DD, ICF/DD-H and ICF/DD-N homes. Please note that additional information on utilizing invoices is provided on a separate reference sheet.

Anthem encourages electronic filing of claims for ICF/DD LTC room and board. Providers billing for institutional services must complete the CMS-1450 (UB-04) form. The form must be completed in accordance with the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual 2023. Paper claims follow the same editing logic as electronic claims and will be rejected with a letter sent to the provider indicating the reason for rejection if non-compliant.

Anthem’s timely filing period for LTC ICF/DD claims is 180 days.

Refer to attachment to view full details

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CABC-CD-044138-23, CABC-CD-048548-23, CABC-CD-057010-24

ATTACHMENTS: ICF/DD long-term care claims reference sheet and remittance advice (pdf - 0.18mb)