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Skilled Nursing Facility Guidelines

What is a Skilled Nursing Facility?

A skilled nursing facility provides skilled nursing, rehabilitation, or other care, including medication administration. SNFs are not nursing homes or intermediate facilities. The need for services provided by Skilled Nursing Facilities (SNFs) is common for TRICARE For Life (TFL) beneficiaries and there is coverage available for the services.

Skilled Nursing information from the Defense Health Agency.

Skilled Nursing fact sheet from the Defense Health Agency.

It is important to note the differences between skilled nursing facility care and the services they provide as compared to custodial care, long-term care and nursing homes. TFL does not cover custodial care, long-term care or nursing homes.

Below is some information on coverage, guidelines, and authorization requirements that will be helpful for you and your provider. Our goal is to help you better understand expectations and policies under the TFL program and give the highest level of customer service. It is our intent to provide as much support and education as necessary to maximize our promise to you and consistently provide benefits under the TFL program. If you need further clarification on any of the information provided please contact us.

Coverage

Medicare pays 100% for days 1-20 in a benefit period. For days 21 to 100, Medicare covers all costs except for the required Medicare copayment; TRICARE for Life covers the copayment. After day 100, TFL is primary payer for covered skilled care and the patient is responsible for the TFL cost-share. A new benefit period starts again with Medicare once the patient has not received any inpatient hospital or SNF care for 60 consecutive days.

Participation Agreement       

For a beneficiary who is both Medicare and TFL eligible, TFL can pay secondary for a SNF that participates in Medicare and has entered into a Participation Agreement with TFL. Upon exhaustion of Medicare benefits, TFL may pay primary to such SNFs. SNF providers are required to sign a SNF Prospective Payment System (PPS) agreement with TFL in order to be considered an authorized TFL provider. Claims for SNFs that do not have this agreement on file will be denied.

SNF PPS Consolidated Billing

TFL has adopted Medicare's SNF PPS payment methods and reimbursement rates, consolidated billing requirements, and Minimum Data Set (MDS) assessment requirements effective with all SNF admissions occurring on/after 08-01-2003.

Bill Types and HIPPS Codes

Bill type 21X must be submitted on the claim form, along with Revenue Code 0022 and the corresponding HIPPS codes for the charges being billed. The HIPPS code is a five-digit number, consisting of two parts. The first three digits are the alpha/numeric code identifying the RUG-III classification; the last two digits are the indicators of the reason for the MDS assessment. During Medicare's 100-day benefit period, SNF's will use the same HIPPS codes for TFL patients as those used under Medicare. After the 100th day in a benefit period, SNF's will use, for TFL eligible beneficiaries, the appropriate RUG-III code with a TFL -specific two-digit modifier that makes up the HIPPS code. All five digits must be present in order to prevent delays in processing and the return of claims by TFL to develop for this required information. 
The TFL specific two-digit modifiers are:

120-day assessment 8A 
150-day assessment 8B
180-day assessment 8C 
210-day assessment 8D
240-day assessment 8E 
270-day assessment 8F 
300-day assessment 8G 
330-day assessment 8H
360-day assessment 8I 
Post 360-day assessments with 30-day intervals 8X 

Prior Authorization

See Skilled Nursing Authorization Requests.

Billing Charges

In addition to the 0022 Revenue Code(s) and corresponding HIPPS code(s), all SNF claims must contain a line item listing (by Revenue Code) of all services rendered to the SNF inpatient resident during the dates of service on the claim and the billed amount for each. This line item listing should include a room rate charge (Revenue Code 10x, 11x, 12x, etc.) for the number of bed days equal to the date span of services billed.

Leave of absence or transfer to acute care

Any leave of absence bed days must be billed with the applicable 18x Revenue Code. If a SNF resident returns to the SNF following a temporary absence due to hospitalization or therapeutic leave, it will be considered a readmission, and any leave of absence days will be disallowed. As under Medicare, neither TFL nor the patient are responsible for any charges related to leave of absence days.

MDS Assessments

SNF's will be responsible for performing the resident assessment every 30 days after the 90th day, using the MDS assessment form, for determining the medical necessity of services. SNF’s shall use the default HIPPS rate code of AAA00 on the claim in the case of an off-schedule or late patient assessment, or in the case of no patient assessment at all.

Review for Medical Necessity

On the 100th day of the stay, TFL will review the stay to verify the medical necessity and level of care being provided, and will require a copy of the 90-day MDS Assessment performed for the final Medicare segment, along with medical records from the date of admission. On the 150th day of the stay, a copy of the 150-day MDS Assessment must be submitted, along with the medical records not previously submitted, covering days 90 through 150. Beginning with day 210 of the stay and continuing every 60 days thereafter, a copy of the current MDS Assessment and medical records back to the previous assessment must be submitted.

Medical Records

No medical necessity determination is made by TFL when Medicare is paying as primary. Records needed for medical necessity reviews beginning on the 100th day will include:

    MDS Assessments 
    Admission history and physical exam from an M.D.
    Doctors' orders 
    Doctors' progress notes 
    Nurses' notes - daily narrative not weekly summaries
    Physical, occupational and speech therapy progress notes

Medical records which are NOT required for review:

    Medication records
    Laboratory test results
    X-ray reports
    I & O records
    Dietary notes
    Social worker notes
    Care plans
    Monthly/weekly summaries
    RAP's
    Admission face sheets

Other Health Insurance (OHI)

See How does TRICARE For Life work with OHI section.

Signature Requirements

UB04 claim forms submitted with the corresponding Medicare EOB's do not require a signature by the facility's authorized representative; however, once Medicare benefits have been exhausted and if no Medicare EOB is attached to the claim form, an authorized representative must sign the claim form in or around FL 80. A computer generated name, stamped signature, handwritten signature or initials are acceptable.

Documenting Medicare exhaustion of benefits

Occurrence code A3 and the date of exhaust can only be accepted on the electronic crossover claim from Medicare. Other acceptable forms of documentation of either the Medicare or the secondary OHI's exhaustion date are an EOB showing exhaustion, or correspondence from CMS or the secondary OHI plan. Information from the Medicare A Online System can also be used.

Common Claim Return or Denial Reasons

Missing or invalid/incomplete: Type of Bill code (FL 4), Admission Date (FL 12), Discharge Status (FL 17), Occurrence Code and date (FL 35-36), Revenue Code 0022 and accompanying five-digit HIPPS code, Revenue Code 0022 with a billed amount but no line item listing of all services rendered (FL 42-47), Diagnosis Code(s) (FL 66-69) 

  •  No Medicare or Medicare supplement Explanation of Benefits, showing payment or reason for denial/definition(s) of denial code(s) 
  •  No documentation of Medicare exhaust date 
  •  Illegible EOB’s or unsigned claim form (signature on file is not acceptable for provider signature) 
  •  Missing or incomplete medical documentation/records 
  •  Date span billed and number of units for HIPPS codes and room charges not agreeing

Questions?

If you need further clarification on any of the information provided please contact us. We will be happy to assist!