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Provider Manual

Skilled Nursing Facility (SNF) and Consolidated Billing

Last Updated on March 02, 2020

For information related to benefits see the Skilled Nursing Facility page under the Benefit Information section of the Provider Manual.

 

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.

 

Claim Submission

 

Security Health Plan follows Medicare billing requirements as outlined in Table 1. SNF Billing Requirements of the following document https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNFSpellIllnesschrt.pdf.

 

Security Health Plan follows CMS guidelines for billing and payment of Skilled Nursing Facility claims except the requirement for the three day inpatient stay.

 

The HIPPS (effective 10/01/2019) or RUG (prior to 10/01/2019) submitted on the claim must match what was prior authorized by naviHealth. In the event you submit a different HIPPS or RUG than what was assigned by naviHealth, your claim will be denied.

 

Skilled Nursing Patient-Driven Payment Model (PDPM)

 

Effective October 1, 2019, Centers of Medicare and Medicaid (CMS) implemented a new Skilled Nursing Patient-Driven Payment Model (PDPM).  PDPM is a fundamental shift from RUGs IV and will replace RUGs entirely for Medicare Part A payment to Skilled Nursing Facilities (SNFs).  Payment is based upon an array of patient characteristics, primarily medical information, associated with newly designed direct care components. 

Security Health Plan has implemented the new payment model to its SNF Medicare Advantage contracts to stay compliant with Medicare Advantage contractual language and CMS reimbursement requirements.     

Security Health Plan has partnered with naviHealth to provide additional information related to PDPM www.navihealth.com/pdpm.

Additional information regarding the PDPPM can be found at the following locations.

Consolidated Billing

Security Health Plan Medicare Advantage follows Consolidated Billing rules for members in a Medicare covered skilled nursing facility (SNF) stay.

The consolidated billing rule states that the SNF is responsible to bill for all rendered services, including those performed by outside providers, during a Medicare covered Part A stay except for those that are considered excluded from the consolidated billing requirement. See https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-B-MAC-Update.html for a list of services that are excluded from consolidated billing and can be billed directly by the provider to Security Health Plan.

Providers who perform services included in the consolidated billing requirement should seek reimbursement directly from the SNF. Any claims submitted directly to Security Health Plan will be denied CO190 ‘Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay’. It is the provider’s responsibility to validate with the SNF that the member is a resident in a covered Part A stay.

For example: when a Medicare Advantage member is in an approved Part A SNF stay and has a comprehensive metabolic panel performed outside the SNF at a clinic, the clinic should seek payment from the SNF rather than bill Security Health Plan for this test.

For members in a non-covered stay (Part B SNF stay) only specific therapy services are subject to consolidated billing. All other covered part B services can be separately billed to Security Health Plan.

Below are sites for more information on Consolidated Billing: https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html

https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2017-General-Explanation.pdf

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/SE0440.pdf