The Texas Health and Human Services Commission (HHSC) approved payment rates for Nursing Facilities (NF) effective September 1, 2025. HHSC will transition NF providers from the Resource Utilization Group, Version III (RUG-III) payment methodology to the Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) payment methodology, effective September 1, 2025.
As a reminder, Community First Health Plans, Inc. (Community First) will be rejecting Nursing Facility submissions that do not meet the definition of a clean claim.
Clean Claims are defined as claims for services rendered to a member with the data required for Community First to adjudicate and accurately report the claim to the state. If a claim does not contain all the elements necessary to adjudicate, it is rejected and returned to the nursing facility so that the Nursing Facility may provide the information required. A claim rejection is not a denied claim and providers may resubmit the rejected claim once the identified issue has been corrected.
Community First will use the initial and Daily Service Authorization System (SAS) provider rate data, member hold data, and provider hold data, determined by HHSC, in the adjudication of Nursing Facility claims. Providers must have an approved Department of Aging and Disability (DAD) number and Daily Care Level (PDPM Level) assigned by HHSC for claims to be accepted as clean claims.
Community First validates all provider National Provider Identifier (NPI) and taxonomy information on the claim. All institutional claims require the attending provider NPI and taxonomy. The NPI for both the billing and attending cannot be the same. The claim will be rejected if the attending NPI is the same as the billing NPI.
Providers must use correct revenue codes to identify daily care services to avoid a claim rejection. Nursing Facility daily care claims must be submitted using revenue code 0100 or 0160. Providers must use revenue code 0101 when submitting claims for Medicare skilled services. Claims containing future dates of service will be rejected. Community First will also validate the NPI on the daily SAS file, which must match the NPI submitted on the claim. If Community First determines there is a mismatch the claim will be rejected in accordance with state requirements.
Daily care and add-on services must be submitted on separate claims. Nursing Facility providers cannot combine any other services when billing for daily care (revenue codes 0100, 0160 and 0101). Nursing Facilities may submit claims for add-on physician-ordered therapies on behalf of employed or contracted therapy providers. Add-on therapy claims must be submitted separately from the Nursing Facility daily unit rate. Combining the services will result in rejection of the claim. Durable Medical Equipment (DME) add-on claims from DME providers must submit claims directly to Community First.
Community First will validate all member information submitted on the claim. The member must be age 21 or older to qualify for placement in a Nursing Facility. If the member is under age 21, the claim will be rejected. The member’s name will need to match the first name and last name Community First has on record. Additionally, providers are required to validate that the member’s name on the claim matches the name on the member’s Community First insurance card. Providers may also register for a Provider Portal account with Community First to verify member eligibility and name. Matching what Community First has in both the first and last name fields will ensure claims do not receive a member name rejection.
Community First will receive a daily member and provider hold file from the state. Claims associated with enrolled members and providers listed on the hold files will be rejected until the pending issue with Texas Medicaid & Healthcare Partnership (TMHP) is resolved.
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