TN 45 (09-12)

SI 02310.064 Title XIX Facility Match (D8 Diary)

A. Background for D8 diary

When a medical facility admits a Supplemental Security Income (SSI) recipient, and we do not receive a report of the admission, we receive a D8 diary, Title XIX Facility Match. The alert generated indicates the need for additional development. We conduct a monthly match against records maintained by the Centers for Medicare and Medicaid Services (CMS).

The Modernized Supplemental Security Income Claims System (MSSICS) generates an alert as soon as we receive notification of a recipient’s admission to a medical facility and a preliminary systems screening does not detect characteristics that eliminate the need for an alert (e.g., the recipient is already in a Federal living arrangement “D” or temporarily institutionalized). To avoid or reduce overpayments, you must promptly develop D8 diaries.

B. Description of match

1. Conditions that produce the D8 diary

MSSICS produces a D8 alert and sets a D8 diary when the following conditions exist:

  • the recipient is in current pay status for the month of the match, and

  • the recipient’s living arrangement code on the Supplemental Security Record (SSR) for the month of the match is other than “D”;

  • the admission date on the CMS record is later than the SSI date of eligibility; and

  • payment continuation under the “temporary institutionalization” provision is not present on the SSR.

2. Frequency of match

MSSICS generates alerts monthly.

3. Replacement alerts

You may find replacement alerts on the following NYNet link:

http://nynet2.ny.ssa.gov/ssi_alerts/

4. Minimum Data Set (MDS) alert format

C-A    D8 Title XIX Facility Alert

ST: XX        FO: XXX           RDT: XXXXXX

HUN: XXX-XX-XXXX               SSN: XXX-XX-XXXX

NAME: XXXXXXXXXXXXXXXXXXXX,   XXXXXXXXXX, X

DOE: MM/DD/YYYY    DD: MM/DD/YYYY

RD: MM/DD/YYYY     AED: MM/DD/YYYY

CPS: x               ELS: x

MDS Facility ID No.: xxxxxxxxxxxxxxxx

FAD:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

   XXXXXXXXXXXXXXXXXXXXXXXXXXXX   XX

FTEL:   XXX-XXX-XXXX

The following represent the data elements in the alert:

  • ST: State code of residence on the SSR when the system created the record selection

  • FO: Field office code

  • RDT: The run date of the match

  • HUN: The housed-under number for the record alerted

  • SSN: The Social Security Number (SSN) of the matched individual

  • NAME: Last, First, Middle Initial of the matched individual on the title XIX record

  • DOE: Admission date to the facility

  • DD: Discharge date from the facility

  • RD: Reentry date to the facility

  • AED: Assessment Effective Date; i.e., the date the facility recorded the information in the alert.

  • CPS: Current payment source. It is possible for a person’s cost-of-care to come from more than one source. If so, the first source in the list appears on the alert, as follows:

    • a: Medicaid per diem;

    • b: Medicare per diem;

    • c: Medicare ancillary part A;

    • d: Medicare ancillary part B;

    • e: TRICARE per diem;

    • f: Veterans Affairs (VA) per diem;

    • g: Self or family pays for full per diem;

    • h: Medicaid resident liability or Medicare co-payment;

    • i: Private insurance per diem (including co-payment); and

    • j: Other per diem.

  • ELS: Expected length of stay:

    • O: Expected Discharge more than 90 days after the AED

    • 1: Expected Discharge within 30 days of the AED

    • 2: Expected Discharge within 31-90 days of the AED

    • 3: Expected Discharge status uncertain

  • MDS Facility ID No.: Identification number of the title XIX provider. The CMS or the State providing Medicaid coverage may assign this ID number.

  • FAD: Facility name
    Street address
    City and State
    Zip Code

  • FTEL: Facility telephone number

C. Procedure for coordination with other pending posteligibility (PE) actions

You must coordinate D8 diary development with scheduled field office (FO) redeterminations (RZs) or other pending PE actions (e.g., other interface alerts, continuing disability reviews, or representative payee accounting).

D. Procedure for documentation and development of D8 diary

1. Review and compare the alert data

You must review the alert for date of admission, discharge information, and payment source to compare the admission and discharge dates with the living arrangement history on the SSR.

2. Alert data agree with SSR information

Do not take action if the information on the alert and the SSR agree and the MSSICS screens, SSR, or any electronic repository contains verification information per SI 02305.034E.4.

3. Alert data disagree with SSR information

You must contact the medical facility identified on the alert to verify admission and discharge information, the source of payment for the recipient’s care, and whether the recipient transferred directly from or to another facility, such as a hospital or other nursing home. You must contact each facility involved in a transfer to verify all admission and discharge dates, and source of payment for each. Be sure to consider an unreported change in the living arrangement and other D8 diary alerts on the record. For more information about deemed initial determinations, see SI 04070.010A.3. You must document the information and source of contact on a Documented Report of Contact (DROC) in MSSICS or on an SSA-5002, Report of Contact, scanned into the Non Disability Repository for Evidentiary Documents (NDRED) for non-MSSICS cases.

You must document the recipient’s eligibility for temporary institutionalization (TI) payments per SI 00520.140.

IMPORTANT: Upon receipt of a D8 diary alert, consider whether a capability determination is necessary. Refer to GN 00502.010 and GN 00502.060.

4. No Medicaid involvement in the cost of care

If private health insurance or Medicare is the payment source for all periods that a recipient is in a Title XIX facility, include this information on the DROC or SSA-5002.

NOTE: When you know the release date, you must diary the case to re-contact the facility and develop per SI 02310.064D in this section. Medicare only pays for a limited number of days. Medicaid may be paying the Part A premium for Medicare BIC M (Medicare-only) beneficiaries. If this is the case, then consider the payment a Medicaid payment.

5. Medicaid paying more than 50% of the cost of care

If Medicaid pays more than 50% of the cost of the stay and the recipient transferred from or to another facility, you must contact each facility to verify admission and discharge dates and source of payment. A stay in another facility may affect the date of the recipient’s change to a “D” living arrangement.

EXAMPLE: The FO receives a D8 alert showing that Mr. March entered a nursing home on May 5th and that Medicaid was the payment source. The claims representative (CR) calls the facility to confirm the admission and discharge dates, the source of payment, and that TI payments do not apply. The CR also learns that the recipient transferred to the nursing home directly from Einstein Hospital. The hospital confirms Medicaid as the source of payment and that Mr. March was there from April 22nd to May 5th. Therefore, Mr. March was in a “D” living arrangement beginning with the month of May.

In this same example, if Mr. March had Medicare Part A (not paid by Medicaid) and Medicare paid for his stay at the hospital and stay at the nursing home until June 20th, he would be in living arrangement “A” through June and living arrangement “D” in July.

6. Medicare or private health insurance pays first, then Medicaid pays

Once the recipient exhausts his or her Medicare or private health insurance benefits, Medicaid may begin paying the cost of care for a recipient in a medical treatment facility. Determine whether Medicaid paid more than 50% of the total cost of care for the month the source of payment changed.

EXAMPLE: Mrs. Jones has resided in a nursing home for several months and now she has exhausted her private, long-term care benefits. Beginning June 14th, Medicaid paid for the cost of her care. The CR contacts the nursing home to determine if Medicaid paid more than 50% of Mrs. Jones’ cost for the month of June. The nursing home verifies that long-term care paid $2000 and Medicaid paid $5000. Therefore, Mrs. Jones is in a “D” living arrangement for June.

E. Clearing the D8 diary

For MSSICS cases, make any necessary changes to the address and living arrangement screens and ensure you properly document all issues. You must clear the diary via the MSSICS TXIX Facility Interface Development (DXIX) screen (MSOM MSSICS 022.018), close the LI or RZ event, and build transaction to the SSR.

For Non-MSSICS cases, make any necessary changes to the address and living arrangement fields on the SSR via the SSA-1719-B, SSI Post-eligibility Input, and clear the limited issue (LI) or RZ by accessing the “PE Single Input” screen. [From the SSA Main Menu in PCOM, select 15 – SSI Data Inputs, then select 5 – SSI Single Inputs]. To clear the diary, you must also access the diary screen (UDIA) using Direct SSR Update in MSSICS.

F. References

  • SI 00520.140 Temporary Institutionalization (TI) Benefits

  • SI 04070.010 Title XVI Administrative Finality – General Reopening Policies


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0502310064
SI 02310.064 - Title XIX Facility Match (D8 Diary) - 04/05/2016
Batch run: 01/26/2017
Rev:04/05/2016