Level of Care (LOC) Billing Guidelines

The Agency for Health Care Administration (AHCA) reimburses health plans for nursing home services that meet the following criteria:

  • Are determined to be medically necessary
  • Do not duplicate another service
  • Meet the criteria as specified in AHCA's Nursing Facility Services Coverage Policy Handbook including, but not limited to, Level of Care (LOC)

The values for LOC information listed below are a requirement in either Box 81d of the UB-04 paper claim form or in the NTE segment of loop 2300 for electronic claim submissions.

Paper claims

The LOC should contain three data elements:

  1. Qualifier 02
  2. LOC code (see below for valid values)
  3. Per diem rate

Values for Adding Level of Care (LOC) to Box 81d

81 d

Code-Code Field

Long Term Care Facilities (Skilled Nursing Facilities and Intermediate Care Facilities for the Developmentally Disabled (ICF-DDs):

In the first field, enter Qualifier Code 02.

In the second field, enter the established level of care (LOC) code to indicate the type of care that the recipient has been determined to require:

  • 1 = Skilled
  • 2 = Intermediate I
  • 3 = Intermediate II
  • 4 = State Mental Health Hospital
  • 6 through 9 = ICF-DD Levels of Care
  • H = AIDS Per Diem
  • U = Skilled Fragile Children Under 21
  • X = Medicare Part A Coinsurance Payment

In the third field, enter the facility’s per diem. For level of care X, enter the respective Medicare per diem

Source: UB-04 Billing Requirements (PDF)

Electronic data interchange (EDI) claims

The LOC should contain the below data elements in this format: UPI  LOCAMT=[Level of Care];[999,999,999.00]

  1. UPI
  2. LOCAMT=
  3. LOC code followed by a semicolon; (see below for valid values)
  4. Per diem rate

Level of Care Values and Contract Amount Input Scenarios

Note: For ENCOUNTER and Fee-or-Service (FFS)

The following is a Level of Care mapping example and values:

EXAMPLE: NTE*UPI*LOCAMT=3;1000.00~

  1. NTE01 (Note Reference Code) = UPI
  2. NTE02 (Claim Note Text Description) is a concatenation of the following values:
    1. First component — Unique prefix of the string — “LOCAMT=”
    2. Second component — Level of Care (LOC) — one of the eleven Florida Medicaid Long-Term Care Level of Care values (see below) followed by a semi-colon (;)
      1. 1 = Skilled
      2. 2 = Intermediate I
      3. 3 = Intermediate II
      4. 4 = State Mental Health Hospital
      5. 5 = DVS Severe Behavioral
      6. 6 through 9 = ICF-DD Levels of Care
      7. H = AIDS Per Diem
      8. U = Skilled Fragile Children Under 21
      9. X = Medicare Part A Coinsurance Payment
    3. Third component – Contact Amount – (Sum of SVD02 elements in the 2430 loop), values without decimal precision will be considered whole numbers.

Source: FMMIS 837 Institutional Health Care Claim and Institutional l Encounter Claim Companion Guide (PDF)

Providers