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Provider Manual

Skilled Nursing Facility Denial of Medicare/Medicaid Payment

Last Updated on August 28, 2018

Security Health Plan requires affiliated skilled nursing facilities to notify Security Health Plan within 3 business days if the Department of Health Services Bureau of Quality Assurance imposes a denial of Medicare payment for new and/or existing admissions or imposes the restriction of no admissions. In addition, Security Health Plan requires full cooperation during the investigation period. Security Health Plan also requires immediate notification of resolution of imposed remedies.

Procedure

Security Health Plan requires affiliated SNF’s to submit the following information when the Department of Health Services Bureau of Quality Assurance imposes a denial of payment for new and/or existing admissions or imposes the restriction of no admissions:

  • A copy of the Department of Health Services Statement of Deficiencies identifying corrective action needed
  • A copy of the letter from the Department of Health Services indicating the enforcement remedies, state violations and date the plan of correction is needed
  • A copy of any subsequent letter from the Department of Health Services indicating SNFs substantial compliance with state and federal participation requirements

Information should be stamped confidential and faxed to Security Health Plan’s contract manager at Security Health Plan at 715-221-9699. Please include the name and number of a contact person Security Health Plan can call to discuss the information you submit.

If the SNF does not remedy the deficiencies and the SNF is excluded, Security Health Plan’s contract language is imposed: Section 4.14 Exclusion From Federal Health Care Programs. The affiliated facility hereby represents and warrants that it is not and at no time has been excluded from participation in any federally funded health care programs, including Medicare and Medicaid.

The affiliated facility hereby agrees to immediately notify Security Health Plan if it or any of its employees are threatened to be or are excluded from any federally funded health care program, including Medicare and Medicaid. In the event that the affiliated facility or any of its employees are excluded from participation in any federally funded health care program during the term of this agreement, or if at any time after the effective date of this agreement it is determined that the affiliated facility is in breach of this requirement, this agreement shall, as of the effective date of such exclusion or breach, automatically terminate.

If Medicare is not paying for any new and/or existing admissions, payment will not be made under this Security Health Plan product for such admissions, per the Medicare Advantage Affiliated Skilled Nursing Facility contract.