Form 3618
Instructions

Resident Transaction Notice

08-2010

(For Nursing Facilities Only)

PURPOSE

  • To inform Texas Health and Human Services Commission (HHSC) staff about transactions and status changes for Medicaid applicants and recipients.
  • To provide Texas Department of Aging and Disability Services (DADS) state office with information necessary to initiate, close or adjust vendor payments. These payments are made on behalf of eligible recipients in contracted Title XIX facilities.
  • To provide data necessary for statistical reports.

PROCEDURE

Electronic Submission Only

Form 3618, Resident Transaction Notice, can only be submitted electronically by completing Form 3618 on the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Portal.

Electronic submission is prescribed by the Texas Administrative Code, 40 TAC §19.2615, which states:

A nursing facility must electronically submit to the state Medicaid claims administrator a resident transaction notice within 72 hours after a recipient's admission or discharge from the Medicaid nursing facility vendor payment system. The nursing facility administrator must sign the resident transaction notice.

The nursing facility must print out and complete all items on Form 3618, including Item 13 with the nursing facility administrator's State Board license number, and have the nursing facility administrator sign and date Form 3618 for Item 14.

When to Prepare

The nursing facility administrator prepares Form 3618 for recipients who are:

  • eligible Medicaid recipients,
  • applicants for medical assistance, or
  • Medicaid recipients who are being discharged from the Medicaid program.

The nursing facility administrator prepares a separate Form 3618 for each transaction. Each admission into or discharge from the facility requires a Form 3618 except approved therapeutic passes. An admission or discharge between payor sources also requires Form 3618 or Form 3619, Medicare/Skilled Nursing Facility Patient Transaction Notice. Example: Form 3619 discharge from Medicare and Form 3618 admission to Medicare to change payor source from Medicare to Medicaid.

Form 3618 must be completed and all copies submitted within 72 hours of the date of the transaction.

Form 3618 is not used to report transactions involving private-pay residents, except when a resident who has been private pay is applying for Medicaid or when a recipient has been receiving Medicaid and is denied.

Number of Copies

The nursing facility administrator completes an original and one copy of Form 3618 for each transaction for the purpose of form retention for the nursing facility and notification of transactions to HHSC.

Form Retention

The nursing facility keeps the original Form 3618 in accordance with its Medicaid Nursing Facility Provider Agreement, which states, "The resident's medical records and documents will be kept for a minimum of five (5) years after the termination of the contract period." See electronic submission above.

Submission to HHSC

The nursing facility must send the copy to the Medicaid Eligibility for the Elderly and People with Disabilities (MEPD) specialist assigned to the facility. HHSC sends letters addressed to the administrator/bookkeeper indicating which MEPD specialist is assigned to the facility when assignments change.

DETAILED INSTRUCTIONS

The Nursing Facility Administrator must complete Items 1 through 11 (12 if comments are necessary), 13 and 14 on each Form 3618 transaction.

Item 1 — Medicaid Recipient No. — If the resident is a Medicaid recipient, enter the recipient number exactly as it appears on the Medicaid identification card. Do not use the application number from the Medicaid application.

Item 2 — Social Security No. — Enter the recipient's Social Security number (if available) exactly as shown on the Social Security card.

Item 3 — Medicare or RR Retirement Claim No. — Enter the recipient's Medicare number exactly as it appears on the medical insurance card or on the report of eligibility; or enter the railroad retirement claim number, if known. Example: 4 4 8 3 6 0 6 5 0 A. Railroad retirement numbers have an alpha prefix. Example: M A 1 2 3 4 5 6 7 8. In either case, enter the number beginning in the far left blank. If there are fewer than 10 digits, leave the unused spaces blank. If there is no number, leave blank.

Item 4 — Name of Recipient — Enter the last name, then the first name, then the middle name. Do not use Sr. or Jr. If the resident is a Title XIX recipient, enter the name as it appears on Form 3087. If the recipient is an applicant, contact HHSC Medicaid eligibility staff and enter the recipient's name exactly as it appears in HHSC records.

Item 5 — Address — Complete the address for admission and discharge recipients only. If admission, enter the resident's address before admission. If discharge, enter the recipient's address after discharge from the facility.

Item 6 — DADS Vendor No. — Enter the four-digit DADS vendor number as it appears on the Contract to Provide Nursing Facility Services Under the Texas Medical Assistance Program for the nursing facility providing services to the recipient.

Item 7 — Contract No. — Enter the provider's nine-digit number as it appears on the Medicaid contract.

Item 8 — Service Group — Enter the service group identifier that is assigned to the Medicaid contract. The only service groups that use this form are Service Group 1 (Nursing Facility) and Service Group 10 (Swing Bed).

Item 9 — NPI No. — Enter the National Provider Identifier number assigned by the National Plan and Provider Enumeration System.

Item 10 — Transaction — Check the box for the transaction being reported.

1. Admission From — Refers to a recipient entering a Title XIX nursing facility. An admission may be either a first admission or a readmission. If the recipient enters from a hospital and is a new admission to the Medicaid program, enter the date the recipient originally was admitted to the nursing facility. If the recipient is entering the Medicaid program from private-pay status, check Number 8, Private Pay, and enter the date of physical admission to private pay.
2. Discharged To — Refers to a recipient leaving a Title XIX nursing facility. The term discharge does not include a recipient's departure for therapeutic home visits as defined in the Long Term Care Nursing Facility Requirements for Licensure and Medicaid Certification. The term does include a recipient's physical move to a hospital for inpatient care, to another Title XIX nursing facility, to a Medicare (SNF) facility, to a state institution and to a recipient's home or to another location. Recipients denied Medicaid and leaving the nursing facility are reported as discharges.
 
Discharge Type — Refers to the type of discharge recorded on the MDS discharge tracking form. The type of discharge recorded on Form 3618 must be consistent with the type of discharge recorded on the MDS discharge tracking form. Check A - Return Not Anticipated if the recipient is not expected to return to the nursing facility. Check B - Return Anticipated if the recipient is expected to return to the nursing facility. Check C - Prior to Completing Initial Assessment if the recipient was discharged before completing the initial MDS assessment.
  Location — Check the box to show either the location of the recipient before being admitted to the nursing facility or after being discharged from the nursing facility:
 
  1. Hospital
  2. Nursing Facility
  3. Community ICF-IID
  4. Medicare/SNF
  5. Home
  6. State Institution
  7. Hospice
  8. Private Pay
  9. Other/Unknown
3. Deceased — Check this box if the recipient is being discharged because they passed away.
4. Correction — Check this box if Form 3618 is being used to correct a previously submitted Form 3618.

Item 11 — Date of Above Transaction — Record the date the transaction in Item 10 occurred.

Item 12 — Comments — This section is provided for the nursing facility to provide any comments it believes necessary as additional information.

Item 13 — State Board License No. — The nursing facility administrator must enter their state board license number.

Item 14 — Signature – Administrator/Date — The nursing facility administrator must sign and date each Form 3618 to provide certification of the statement, “I certify that, to the best of my knowledge, the date in Item 11 (Date of Above Transaction) is for services provided, and the date is not included in the 100% Medicare Part A reimbursement time frame.” If the administrator is not available for signature, a pre-assigned authorized person must sign for the administrator.

In accordance with 40 TAC §19.1902(a)(1) and (2):

The governing body of the nursing facility must:

(1)
designate a person to exercise the administrator's authority when the facility does not have an administrator. The facility must secure a licensed nursing home administrator within 30 days; and
(2)
ensure that a person designated as being in authority notifies the Texas Department of Human Services [DADS] immediately when the facility does not have an administrator.

If the facility is without an Administrator:

  • This must be stated in the comments.
  • Use "999999" in the State Board License No. field.
  • A pre-assigned authorized person must sign.