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Provider Manual

Skilled Nursing Facility

Last Updated on December 19, 2019

For information related to claim processing, reimbursement and consolidated billing see the Skilled Nursing Facility page under the Claims Processing Policies and Procedures section of the Provider Manual.

For purposes of the Medicare Advantage plan, skilled care services are defined as skilled nursing or skilled rehabilitation services provided according to a physician’s order and:

  • require the skills of qualified technical and professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists, or audiologists; and
  • must be provided by or under the supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result

Part A: All Part A Skilled Nursing Facility (SNF) stays require prior authorization. Please review the ‘Skilled Nursing Facility Admission’ section of the prior authorization page for more information. SNFs must notify Security Health Plan of an admission within 24 hours or the next business day of admission.

  • SNF care must occur at a Medicare certified facility.
    • Most plans have in and out of network coverage with the exception of the Ally Rx D-SNP plan, which must receive services from in-network SNFs only.
  • Admissions will be reviewed based on Medicare’s criteria for skilled care with the exception of the 3 day prior hospital stay.

Security Health Plan will cover up to 100 days of care in a SNF each benefit period. A new benefit period begins when a member is not admitted to a Hospital, Skilled Nursing Facility or Swing Bed for 60 consecutive days. 

Benefits may differ based on member’s eligibility. Verify member specific eligibility and benefits utilizing the online Provider Portal or by reviewing the member’s Evidence of Coverage for the appropriate plan.

  • Members who have a copay per day benefit will have copay days start over with each new admission.
  • SNF admissions to an out of network facility may have higher cost share.
  • Members pay 100% after the 100 day benefit period is exhausted.
    • Once a Part A stay’s benefit period has been exhausted Part B services may still qualify for coverage. See the Part B section below for details.
  • Members pay 100% for stays that do not meet Medicare criteria including custodial care.

Part B: All outpatient rehabilitation services require prior authorization. Please review the ‘Outpatient Therapy Treatment’ sections of the prior authorization page for more information.

Benefits may differ based on member’s eligibility. Verify member specific eligibility and benefits utilizing the online Provider Portal or by reviewing the member’s Evidence of Coverage for the appropriate plan.

Comprehensive Medication Review (CMR):  For purposes of the Medicare Advantage plan, Security Health Plan must offer Medication Therapy Management Program (MTMP) to all members receiving care in a long-term care setting (LTC).  This is required per the HPMS memo dated 4/10/12.  In order to actively engage Medicare Advantage members, skilled nursing facilities must notify Security Health Plan of Admission of an Medicare Advantage member within 24 hours or the next business day of admission regardless of coverage,   Part A, Part B, custodial, etc.   Notification is required EVEN IF Security Health Plan is not paying for the Medicare Advantage member’s stay.