Potential financial impact - Limitations and billing procedure changes to respite procedure codes T1005 and S5150

Changes to limitations and billing procedures for respite procedure codes will go into effect for claims received on or after November 1, 2024. This change will affect Respite Procedure Codes T1005 (Agency Directed) and S5150 (Consumer Directed).

These codes will be limited to 480 hours per State Fiscal Year (SFY) from July 1 to June 30.

Once these changes are in place, any claims submitted with Respite codes S5150 and T1005 will be denied once the benefit limit of 480 hours within the SFY is met. In addition, the new logic will deny any claims that span between two fiscal years.

Claims submitted with units exceeding the benefit limit will be paid based on the number of valid reimbursable units.

Example: 10 units are billed, and the reimbursement is $19.83 per unit, but only five units remain, the claim would pay $99.15 and generate a denial that the benefit limit is met.

Providers should pay close attention to ensure that claims are billed at the correct and current allowable DMAS rate. If billed at a lesser rate, claim reimbursement will be reduced due to the provider billing error.

A corrected claim will be required to adjust the billed and paid charge amount for any claims that do not meet the requirements of this policy.

For a smooth transition to these updates, all providers are encouraged to review and modify their billing practices accordingly.

As a reminder, when a member transitions to another provider during the fiscal year, the discharging and admitting provider should work together to validate hours used. This cooperation ensures that the number of hours authorized for the remainder of the year is accurate. The discharging provider should list the number of hours used on the Medicaid LTC Communication Form (DMAS 225) for documentation purposes.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.