RNHCI - Religious Nonmedical Health Care Institutions

What is a RNHCI? (pronounced rink-key)
A Religious Nonmedical Health Care Institution is a facility that provides nonmedical health care items and services to people who need hospital or skilled nursing facility care, but for whom that care would be not be consistent with their religious beliefs. The RNHCI benefit is for Part A only.

The Boston Regional Office has the primary responsibility for the approval and certification process to ensure and verify a RNHCI conforms to the specific Conditions of Coverage and all of the Conditions of Participation. To qualify as a Medicare or Medicaid RNHCI, an institution must meet all ten of the following requirements:

1. Is described in subsection (c)(3) of §501 of the Internal Revenue Code of 1986 and is exempt from taxes under subsection 501(a);
2. Is lawfully operated under all applicable Federal, State, and local laws and regulations;
3. Furnishes only nonmedical nursing items and services to beneficiaries who choose to rely solely upon a religious method of healing, and for whom the acceptance of medical services would be inconsistent with their religious beliefs. (NOTE: Religious components of the healing are not covered);
4. Furnishes nonmedical items and services exclusively through nonmedical nursing personnel who are experienced in caring for the physical needs of nonmedical patients. For example, caring for the physical needs such as assistance with activities of daily living; assistance in moving, positioning, and ambulation; nutritional needs; and comfort and support measures;
5. Furnishes nonmedical items and services to inpatients on a 24-hour basis;
6. Does not furnish, on the basis of religious beliefs, through its personnel or otherwise, medical items and services (including any medical screening, examination, diagnosis, prognosis, treatment, or the administration of drugs) for its patients;
7. Is not owned by, under common ownership with, or has an ownership interest of 5 percent or more in, a provider of medical treatment or services and is not affiliated with a provider of medical treatment or services or with an individual who has an ownership interest of 5 percent or more in a provider of medical treatment or services (permissible affiliations are described in §403.739(c));
8. Has in effect a utilization review plan that meets the requirements of §403.720(a)(8);
9. Provides information CMS may require to implement §1821 of the Act, including information relating to quality of care and coverage determinations; and
10. Meets other requirements CMS finds necessary in the interest of the health and safety of the patients who receive services in the institution.

The provisions are specified in 42 CFR 403.720 - 746, Conditions for Coverage. The provider must meet the definition described in the regulations.

How often is it covered?
In RNHCIs, religious beliefs prohibit conventional and unconventional medical care. If the beneficiary qualifies for hospital or skilled nursing facility care, Medicare will only cover the inpatient non-religious, non-medical items and services. Examples include room and board, or any items or services that don’t require a doctor’s order or prescription like un-medicated wound dressings or use of a simple walker. The cost of religious services is a personal financial responsibility. The beneficiary is responsible for applicable Part A deductible/coinsurance costs.

Note: The beneficiary is always able to get medically necessary Part A services.

For Part A coverage, these conditions must be met:

• The RNHCI is currently certified to participate in Medicare
• The RNHCI Utilization Review Committee agrees that the beneficiary would require hospital or skilled nursing facility care if the beneficiary was not in the RNHCI
• The RNHCI has a written election on file with Medicare stating the beneficiary’s need for RNHCI care is based on both eligibility and religious beliefs. The election must also state that if the beneficiary decides to accept standard medical care, the election must be canceled and the beneficiary may have to wait one to five years to be eligible for a new election to get RNHCI services.

Requirements for RNHCI Election by beneficiary:

• Must have a condition that would qualify under inpatient hospital or skilled nursing facility services
• Must make a written election signed by the beneficiary or the beneficiary’s legal representative attesting that the individual is conscientiously opposed to acceptance or non-excepted medical treatment and the individual’s acceptance of such treatment would not be consistent with the individual’s sincere religious beliefs
• Completed election form must be filed with the specialty contractor Palmetto GBA and retained by the RNHCI provider

An election may be revoked.

• Must be in writing
• By receiving non-excepted medical care
• Once an election has been revoked, Medicare payment cannot be made unless a new valid election is filed
• Multiple revocations may affect the beneficiary’s ability to access the RNHCI benefit in the future

How to submit the Notice of Election for RNHCI?
Elections, revocations and cancellations of elections may be submitted to the contractor via the paper Form CMS-1450 or via the contractor’s Direct Data Entry (DDE) system. The RHNCI does not need to complete items not listed.

Provider Name, Address, and Telephone Number
Required - The minimum entry is the RNHCI’s name, city, State, and ZIP code. The post office box number or street name and number may be included. The State may be abbreviated using standard post office abbreviations. Five- or nine-digit ZIP codes are acceptable. The RNHCI uses the information to reconcile provider number discrepancies. Phone and/or FAX numbers are desirable.

Type of Bill
Required - The RNHCI enters the three-digit numeric type of bill code. The first digit identifies the type of facility. The second digit classifies the type of care. The third digit (commonly referred to as a “frequency” code) indicates in this instance the nature of the election related transaction.

• The RNHCI enters type of bill 41A, 41B, or 41D as appropriate

Valid codes for RNHCI elections:
1st Digit - Type of Facility
4- Religious Nonmedical Health Care Institution

2nd Digit - Classification (Special Facility)
Inpatient (Part A)

3rd Digit - Frequency
A - RNHCI election notice
B - RNHCI revocation notice
D - Cancellation

The RNHCI submits type of bill 41D to the specialty contractor as a cancellation of a previously submitted notice of election or notice of revocation, when it was submitted in error. In situations where the RNHCI is correcting a previously submitted date, they submit a new type of bill 41A to the contractor for processing.

Patient’s Name
Required - The RNHCI enters the patient’s name with the surname first, first name, and middle initial, if any.

Patient’s Address
Required - The RNHCI enters the patient’s full mailing address including street name and number, post office box number or RFD, city, State, and ZIP code.

Patient’s Birth Date
Required - (If available) The RNHCI enters the month, day, and year of birth. If the date of birth cannot be obtained after a reasonable effort, the field will be zero-filled.

Patient’s Sex
Required - The RNHCI enters an “M” for male or an “F” for female.

Admission Date
Required - The RNHCI enters the date of the election, revocation or cancellation.

National Provider Identifier
Required - The RNHCI enters their National Provider Identifier (NPI). During Medicare processing, the NPI is matched to the RHNCI’s CMS Certification Number (CCN). RNHCI CCNs are composed of a 2-digit state code and a 4-digit provider identifier in the range 1990-99.

Insured’s Name
Required - The RNHCI enters the beneficiary’s name on line A if Medicare is the primary payer. The RNHCI enters the name as it appears on the beneficiary’s Medicare card. If Medicare is the secondary payer, the RNHCI enters the beneficiary’s name on line B or C, as applicable, and enters the insured’s name on line A.

Insured’s Unique Identification
Required - On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is, the RNHCI enters the patient’s HICN. The RNHCI enters the number as it appears on the patient’s Medicare Card, Social Security Award Certificate, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice, etc., or as reported by the Social Security Office.

How to Bill for RNHCI Services?
RNHCIs submit claims to their Medicare contractor in the following situations:

• At the time of beneficiary's discharge, or death
• At the time the beneficiary's benefits are exhausted
• On an interim basis monthly

RNHCIs submit a claim even where the charges do not exceed the beneficiary's deductible. (Refer to IOM 100-04 Medicare Claims Processing Manual, Chapter 3, Section 40 for instructions regarding reporting of utilization days.)

Required Data Elements on Claims for RNHCI Services
The Social Security Act at §1862 (a)(22) requires that all claims for Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at §1862 (h) applies. The electronic form required for billing RNHCI claims is the ASC X12 837 institutional claim transaction. Since the data structure of the ASC X12 837 institutional claims transaction is difficult to express in narrative form; and to provide assistance to small providers exempt from the electronic claim requirement, the instructions below are given relative to the Form CMS-1450 paper claim.

Both the electronic claim transaction and the paper claim form are suitable for use in billing multiple third party payers. This section details only those data elements required for Medicare billing. When RNHCIs are billing multiple third parties, they complete all items required by each payer who is to receive a claim for the services.

Provider Name, Address, and Telephone Number
Required - The RNHCI must enter their name, city, State, and ZIP Code. The post office box number or street name and number may be included. The State may be abbreviated using standard post office abbreviations. Five or 9-digit ZIP Codes are acceptable. This information is used in connection with the Medicare provider number to verify provider identity. Phone/Fax numbers are desirable.

Patient Control Number/Medicare Record Number
Optional - The RNHCI may report a beneficiary's control number if they assign one and need it for association and reference purposes.

Type of Bill
Required - This 3-digit alphanumeric code gives three specific pieces of information. The first digit identifies the type of facility. The second classifies the type of care. The third indicates the sequence of this claim in this particular episode of care. It is a "frequency" code.

Valid codes for RNHCI claims:
1st Digit-Type of Facility
4 - Religious Nonmedical Health Care Institution

2nd Digit Classification (Except Clinics and Special Facilities)
1 - Inpatient (Part A)

Statement Covers Period (From - Through)
Required - The RNHCI must enter the beginning and ending dates of the period covered by this bill. Enter the date of discharge or the date of death in the space provided under "Through." The statement covers period may not span 2 accounting years.

Patient's Name
Required - The RNHCI must enter the beneficiary's last name, first name, and middle initial, if any.

Patient's Address
Required - The RNHCI must enter the beneficiary's full mailing address, including street number and name, post office box number or RFD, City, State, and ZIP Code.

Patient Birth Date
Required - The RNHCI must enter the month, day, and year of birth (MM-DD-YYYY) of the beneficiary.

Sex
Required - The RNHCI must enter an “M” for male or an “F” for female.

Admission Date
Required - The RNHCI must enter the date the beneficiary was admitted for inpatient care (MM-DD-YY).

Type of Admission
Required - The RNHCI must enter the code indicating the priority of this admission. Valid codes for RNHCI claims:

3 – Elective: The beneficiary’s condition permitted adequate time to schedule the availability of a suitable accommodation.
9 - Information Not Available: Self-explanatory

Point of Origin for Admission
Required - The RNHCI must enter the code indicating the beneficiary’s point of origin. The RNHCI may use any valid point of origin code that applies to the particular admission.

Patient Discharge Status
Required - The RNHCI must enter the code indicating the patient's status as of the "Through" date of the billing period. The RNHCI may use any valid patient status code that applies to the discharge.

Condition Codes
Conditional - The RNHCI may enter any number of condition codes to describe conditions that apply to the billing period. If the RNHCI is submitting an adjustment or a cancellation claim, an applicable condition code from the ‘claim change reason’ series (D0 through D9 or E0) must be used.

If non-covered days are reported because the beneficiary’s inpatient benefits were exhausted; the RHNCI must indicate whether the beneficiary elects to use lifetime reserve (LTR) days.

• The RNHCI must indicate that the beneficiary chose to use LTR days on the claim by reporting condition code 68
• If a beneficiary elects NOT to use LTR days, the RNHCI must report condition code 67

Occurrence Codes and Dates
Conditional - The RNHCI may enter any number of occurrence codes and their associated dates to define specific event(s) relating to this billing period. Occurrence codes are 2 alphanumeric digits, and are reported with a corresponding date.

• If non-covered days are reported due to days not falling under the guarantee of payment provision, the RNHCI reports occurrence code 20
• If non-covered days are reported because the beneficiary’s inpatient benefits were exhausted, the RNHCI reports occurrence code A3 and the date benefits exhausted

Occurrence Span Code and Dates
Conditional - The RNHCI may enter any number of occurrence span codes and their associated dates to define specific event(s) relating to this billing period. Occurrence span codes are 2 alphanumeric digits, and are accompanied by from and through dates for the period described by the code.

If non-covered days are reported because the beneficiary was on a leave of absence and was not in the RNHCI, the RNHCI reports occurrence span code 74.

Document Control Number (DCN)
Conditional - The RNHCI must complete this field on adjustment requests (Bill Type, FL 4 = 417). An RNHCI requesting an adjustment to a previously processed claim must insert the ICN/DCN of the claim to be adjusted.

Value Codes and Amounts
Required - The RNHCI must report utilization days using the value codes described below.

Covered Days - The RNHCI must use value code 80 to enter the total number of covered days during the billing period, including lifetime reserve days elected for which Medicare payment is requested. Covered days exclude any days classified as non-covered, the day of discharge, and the day of death.

Covered days are always in terms of whole days rather than fractional days. As a result, the covered days do not include the day of discharge, even where the discharge was late.

The RNHCI does not deduct any days for payment made under workers' compensation, automobile medical, no-fault, liability insurance, or an EGHP for an ESRD beneficiary or employed beneficiaries and spouses age 65 or over. The specialty contractor will calculate utilization based upon the amount Medicare will pay and will make the necessary utilization adjustment.

Non-covered Days - The RNHCI must use value code 81 to enter the total number of non-covered days in the billing period for which the beneficiary will not be charged utilization for Part A services. Non-covered days include:

• Days not falling under the guarantee of payment provision. See section 40.1. E
• Days not approved by the utilization review committee when the beneficiary does not meet the need for Part A services;
• Days for which no Part A payment can be made because benefits are exhausted. This means that either lifetime reserve days were exhausted or the beneficiary elected not to use them.
• Days for which no Part A payment can be made because the services were furnished without cost or will be paid for by the Veterans Administration (VA). (Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, section 50);
• Days after the date covered services ended, such as non-covered level of care;
• Days for which no Part A payment can be made because the beneficiary was on a leave of absence and was not in the RNHCI. See section 40.2.6;
• Days for which no Part A payment can be made because an RNHCI whose provider agreement has terminated may only be paid for covered inpatient services during the limited period following such termination. All days after the expiration of this period are non-covered.
  • See Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, section 10.6.4;

The RNHCI enters in "Remarks" a brief explanation of any non-covered days not described in the occurrence codes. Show the number of days for each category of non-covered days (e.g., "5 leave days").

Day of discharge or death is not counted as a non-covered day. All hospital inpatient rules for billing non-covered days apply to RNHCI claims.

Coinsurance Days - The RNHCI must use value code 82 to enter the number of covered inpatient days occurring after the 60th day and before the 9lst day for this billing period.

Lifetime Reserve (LTR) Days - The RNHCI must use value code 83 to enter the number of LTR days the beneficiary elected to use during this billing period. LTR days are not charged where the average daily charge is less than the LTR coinsurance amount. The average daily charge consists of charges for all covered services furnished after the 90th day in the benefit period and through the end of the billing period.

The RNHCI must notify the beneficiary of their right to elect not to use LTR days before billing Medicare for services furnished after the 90th day in the spell of illness. The determination to elect or withhold use of LTR days should be documented and kept on file at the provider.

Conditional - The RNHCI may at their option enter any number of other value codes and related dollar amount(s) to identify data necessary for the processing of this claim. Value codes are 2 alphanumeric digits, and a corresponding value amount. Negative amounts are never shown. If more than one value code is shown for a billing period, the RNHCI must show codes in ascending numeric sequence.

Revenue Code
Required - The RNHCI must enter the appropriate revenue codes to identify specific accommodation and/or ancillary charges. This code takes the place of fixed line item descriptions. The 4-digit numeric revenue code on the adjacent line explains each charge. The following revenue codes and associated descriptions are used where there are charges billed as covered by Medicare:

Any other revenue codes may be submitted with non-covered charges only.
Additionally, there is no fixed "Total" line in the charge area. On paper claims, the RNHCI must enter revenue code "000l" to report a total of the charges on the claim.

The RNHCI should list revenue codes other than revenue code “0001” in ascending numeric sequence and should not repeat revenue codes on the same claim to the extent possible.

Units of Service
Required - The RNHCI must enter the number of days for accommodations revenue codes.

Accommodation days are always in terms of whole days rather than fractional days. The accommodation days do not include the day of discharge, even where the discharge was late. Where a charge was made because the beneficiary remained in the RNHCI after checkout time for his own convenience, it is a non-covered charge and you can bill the beneficiary if that is your usual practice and if the beneficiary is given proper notice of their liability. In this instance, the RNHCI will enter the additional charge in non-covered charges.

Total Charges
Required - The RHNCI must sum the total charges (covered and non-covered) for the billing period by revenue code and enter them on the adjacent line. On paper claims, the last revenue code entered in revenue code "000l" represents the grand total of all charges billed. For all lines, the total charges minus any associated non-covered charges represent the covered charges.

Each line allows up to 9 numeric digits (0000000.00).

When submitting charges (covered/non-covered):

• Medicare is restricted by law and court order from paying for the religious portion of care or the training of personnel that provide that care. Additionally Medicare does not pay either based on charges or costs for training of nonmedical personnel. RNHCIs do not receive full Medicare payment for a beneficiary’s stay since the beneficiary is fiscally responsible for the religious aspects of care. Therefore, the original Medicare or Medicare health plan rate may be significantly lower than the RNHCI private pay rate that includes religious charges.
• As medical procedures are not performed in a RNHCI, the use of high cost medical supplies are not separately payable. Supplies that require a physician order (e.g., specialty dressings, compression stockings, alternating pressure mattress pads) are not separately payable in a RNHCI. The use of diapers, incontinence pads, chux/underpads, feminine hygiene products, tissues, and the materials for simple dressings (cleansing and bandaging) are included in the daily room and board portion of the charges and should not be reported separately as supplies.
• Medical equipment (e.g., wheelchair, walker, crutches) are institution inventory items for beneficiary use in the RNHCI. The use of these items during the beneficiary stay is part of the daily interim payment to the RNHCI. To receive Medicare payment for durable medical equipment (DME) following a RNHCI stay, a beneficiary would need to meet all of the criteria, including medical necessity, and obtain a physician order or prescription. A RNHCI is not authorized as a Medicare supplier and, therefore, may not offer DME items for purchase to beneficiaries.
• Nonmedical nursing personnel, for Medicare payment purposes, perform services (e.g., serving meals, assisting with activities of daily living) that are strictly nonmedical/non-religious. The statute and court order mandates only the coverage and payment under Part A for reasonable and necessary nonmedical/non-religious care.
• Medicare payment for religious/nonmedical nursing personnel in a RNHCI, as other inpatient facilities, is a component of the per diem rate and is not separately payable.

Non-Covered Charges
Required - The RHNCI must enter the total non-covered charges pertaining to the related revenue code, if any (e.g., religious items/services or religious activities performed by nurses or other staff, or convenience items that are not part of the Medicare daily interim payment rate.)

Examples of non-covered charges:

• Non-covered religious items include but are not limited to religious publications, religious recordings, any equipment for the use of those recordings, any reproduction costs for these materials, and attendance at religious meetings.
• Religious sessions with RNHCI staff or outside associates.
• Expenses related to student programs/subsistence, staff education/training, travel, or relocation to be factored into the development of charges for covered patient care services.
• Stays, items, and services that are not substantiated by appropriate documentation in the beneficiary’s utilization review file or care record.
• Convenience items (e.g., telephone, computer, beautician/barber).

Payer Identification
Required - If Medicare is the primary payer, the RNHCI must enter "Medicare" on line A. If Medicare is entered, this indicates that the RNHCI has developed for other insurance and has determined that Medicare is the primary payer.

All additional entries across line A supply information needed by the payer named. If Medicare is the secondary or tertiary payer, the RNHCI may identify the primary payer on line A and enter Medicare information on line B or C as appropriate.

National Provider Identifier
Required - The RNHCI enters their National Provider Identifier (NPI). During Medicare processing, the NPI is matched to the RHNCI’s CMS Certification Number (CCN). RNHCI CCNs are composed of a 2-digit state code and a 4-digit provider identifier in the range 1990-99.

Insured’s Unique Identification
Required - On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is shown, the RNHCI must enter the beneficiary's Medicare Health Insurance Claim Number. The RNHCI must show the number as it appears on the beneficiary's Medicare Card, Certificate of Award, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice, or as reported by the Social Security Office.

Principal Diagnosis Code
Required - While coding of a principal diagnosis is not consistent with the nonmedical nature of RNHCI services, the presence of diagnosis codes is a requirement for claims transactions under HIPAA. To satisfy this requirement on claims with Statement Covers “Through” dates, the RNHCI may report ICD-10 code R69 (defined “illness, unspecified”).

Other Diagnosis Codes
Required - While coding of diagnoses is not consistent with the nonmedical nature of RNHCI services, the presence of diagnosis codes is a requirement for claims transactions under HIPAA. To satisfy this requirement on claims with Statement Covers “Through” dates, the RNHCI may report ICD-10 code Z53.1 (defined “procedure and treatment not carried out because of patient's decision for reasons of belief”).

The RNHCI reports no additional diagnosis codes in the remaining fields. Similarly, RNHCIs do not use other fields relating to medical diagnoses and medical procedures.

Attending Provider
Required - While the participation of an attending provider is not consistent with the nonmedical nature of RNHCI services, reporting an attending provider is a requirement for claims transactions under HIPAA. To satisfy this requirement, the RNHCI must report the name and NPI of their director of nursing.

Remarks
Conditional - The RNHCI may enter any remarks needed to provide information that is not shown elsewhere on the bill but which is necessary for proper payment.

Provider Representative Signature and Date
Required - If using a hard copy claim, an RNHCI representative makes sure the claim record is complete and accurate before signing Form CMS-1450. A stamped signature is acceptable on Form CMS-1450.

RNHCI Resources

Basic Overview

• Religious Nonmedical Health Care Institutions
• Religious Non-Medical Health Care Institutions (RNCHI) Items and Services 
• 42 CFR 403.720§ 403.720, Subpart G—Religious Nonmedical Health Care Institutions—Benefits, Conditions of Participation, and Payment (PDF)
• Internet Only Manual 100-02 Medicare Benefit Policy Manual, Chapter 1 – Inpatient Hospital Services Covered Under Part A (PDF)
  • Section 130 – Religious Nonmedical Health Care Institution (RNHCI) Services
• Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter 3 – Inpatient Hospital Billing (PDF) 
  • Section 170 – Billing and Processing Instructions for Religious Nonmedical Health Care Institution (RNHCI) Claims
• Change Request (CR) 8857 (PDF)