Physical Speech and Occupational Therapy - Outpatient
Last Updated on August 28, 2018
- Benefits are limited to the number of days specified in the member’s plan. Coverage is provided to members with a skilled nursing facility (SNF) benefit. The member's medical condition must also require daily nursing or therapy care for the same condition or diagnosis as the qualifying hospitalization. The patient must require daily skilled services as certified by the member’s physician. SNF must prior authorize skilled nursing facility admissions with naviHealth at (phone) 855-512-7002 or (fax) 855-847-7243. For more information about naviHealth click here.
- Confinement in a swing bed in a hospital is considered the same as SNF confinement. Services require prior authorization and approval by Security Health Plan in order to be considered for coverage. Prior authorization is required by calling Security Health Plan at 1-800-548-1224 or by submitting a prior authorization.
- Custodial care is excluded from coverage. This includes, but is not limited to, care provided by community based residential facilities (CBRF), intermediate care facilities (ICF), day care and group facilities, and residential hospice facilities
- To request a full version copy of a specific Security Health Plan Medical policy, call 1-800-548-1224 ext. 19671.
RUG INFORMATION SPECIFIC ONLY TOSecurity Health Plan MEDICARE ADVANTAGEMEMBERS:
- The naviHealth-assigned Resource Utilization Groups (RUG) and Health Insurance Prospective Payment System code 60 (HIPPS code 60) are required on claims submitted for Medicare Advantage members. Claims submitted with a different RUG from what was assigned by naviHealth will be denied. You can resubmit the claim with the assigned naviHealth RUG or submit a provider appeal.
- Security Health Plan recognizes the RUG level assigned by naviHealth may differ from the RUG level you obtain from your Minimum Data Set (MDS). However, naviHealth performs a prospective review, and the MDS is a retrospective review of our member. We understand that with traditional Medicare patients you are required to submit MDS information for reimbursement. For your Security Health Plan Medicare Advantage members, we do not use MDS RUG for reimbursement; we base our reimbursement decision on the RUG assigned by naviHealth. When submitting the claim, be sure to include HIPPS code 60 to ensure proper payment of the claim. The HIPPS code is required on claims to ensure accurate encounter data submission to CMS.
- Reminder: There is a process for advocating for a different RUG level versus the naviHealth-assigned RUG level. Please reach out to your assigned naviHealth Care Coordinator to initiate this request.