Name of Manual - Blue Cross and Blue Shield of Minnesota

Adult Day Care Bath
Services
Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Bath services provided by Adult Day Care providers are a covered
benefit for Public Program members under the following
programs:
SecureBlue – groups beginning with PP2
Minnesota Senior Care Plus (MSC+) – groups beginning with
PP0
These members must also be on an Elderly Waiver program.
Services should be coordinated with the member’s care
coordinator and part of the member’s comprehensive care plan.
The Adult Day Care providers must have record of the individual’s
care plan that documents the necessity for the services. Eligible
providers must be listed on the Minnesota Department of Human
Services website as licensed Adult Day Care providers.
Claim Submission
Submit the claim on the 837P claim format.
Bill code S5100-TF (day care services, adult; per 15 minutes).
Eligible providers may be reimbursed for a maximum of two
units of service per day.
Enter each date of service on a separate line with units of
service for each date.
Reimbursement will be based on the usual pricing methodology
for Public Programs.
RAP Claim Submission Home health providers submitting Medicare RAP (Request for
Anticipated Payment) claims should submit zero charges ($0.00)
with the HIPPS code on the 0023 revenue code line. Claims
submitted with charge amounts other than $0.00 on the 0023
revenue code line will be denied and returned to the provider
without processing.
Products Affected
This change applies to home health RAP claims submitted for the
following Medicare enrollees:
Product Name Member ID alpha prefix
CareBlue XZS
SecureBlue XZS
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
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