Form 3619
Instructions

Medicare/Skilled Nursing Facility Patient Transaction Notice

11-2010

(For Certified Medicare Skilled 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 Medicare skilled coinsurance payments. These payments are made on behalf of eligible recipients in Medicare skilled nursing facilities.
  • To provide data necessary for statistical reports.

PROCEDURE

Electronic Submission Only

Form 3619, Medicare/Skilled Nursing Facility Patient Transaction Notice, can only be submitted electronically by completing Form 3619 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 3619 including Item 14 with the nursing facility administrator's State Board license number, and have the nursing facility administrator sign and date Form 3619 for Item 15.

When to Prepare

The nursing facility administrator prepares Form 3619 for recipients who are Medicaid recipients/applicants approved by Medicare for a Medicare skilled nursing facility (SNF).

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

Form 3619 must be completed and all copies submitted within 72 hours of the date of the transaction.

Form 3619 is not used to report transactions involving private-pay residents.

Number of Copies

The nursing facility administrator completes an original and one copy of Form 3619 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 3619 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 12 (13 if comments are necessary), 14 and 15 on each Form 3619 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 (Form 3087). 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 space 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 recipient 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 recipient's address before admission. If discharge, enter the recipient's address after discharge from the Medicare SNF section.

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 — Check the location or the eligibility status from which the recipient is entering the Medicaid program. An admission may be a first coinsurance admission or a readmission.
2. Discharged To — Check the location to which a recipient is discharged and physically moved. Any move out of the Medicare SNF section is a discharge. On the day after all coinsurance benefits are used, the recipient must be reported as discharged.
  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. Full Medical Coverage
  4. Home
  5. Institution
  6. Other/Unknown
3. Deceased — Check this box if the recipient is being discharged because they passed away.
4. Correction — Check this box if Form 3619 is being used to correct a previously submitted Form 3619.

Item 11 — Date of Above Transaction — For an admission, enter the recipient's 21st day of care. For a discharge, enter the exact date of discharge.

Item 12 — Dates of Qualifying Stay — Enter the dates of stay(s) of full Medicare coverage.  At least one set, 12.a. or 12.b., is required on the form.  Do not enter dates of coinsurance or the Acute Hospital stay in this field.

The "Dates of Qualifying Stay" for traditional Medicare must add up to exactly 20 non-duplicative days. If the form does not refect exactly 20 days of Qualifying Stay, the form should be corrected to include all 20 days of Full Medicare as indicated on your Medicare Remittance Advice or an explanation must be included in the "Comment" section of the form.

If additional sets of dates are needed to document the "Qualifying Stay," a second Form 3619 must be completed, using the same "Date of Above Transaction," in order to supply the additional set(s) of dates. This form will also require an explanation in the "Comment" section.

If the client has a Medicare replacement policy, the full coverage (20 day) requirement may vary. Medicare Replacement is also known as Medicare Advantage and/or Medicare HMO. Include the following information in the "Comment" section of Form 3619: Medicare replacement, name of the insurance carrier, number of co-pay days allowed and daily co-pay amount.

Item 13 — Comments — This section is provided for the nursing facility to provide any comments it believes necessary as additional information.

Item 14 — State Board License No. — The nursing facility administrator must enter their state board license number.

Item 15 —Signature – Administrator/Date — The nursing facility administrator must sign and date each Form 3619 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”.  The date signed cannot precede the 21st day of the recipient's care under Medicare SNF. 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.