You are using an outdated browser. Please upgrade your browser to improve your experience.
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.
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.
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.
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 Medicare 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 Medicare based PDPM code is used for the HIPPS code claims. 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 PDPM 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.
For dates of service up to 12/31/2019 TRICARE will use the RUG-III codes.
Effective 1/1/2020 TRICARE will follow Medicare use of PDPM codes.
Prior Authorization and Concurrent Authorization
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.
SNF's will be responsible for performing the resident assessment using the Medicare MDS assessment form and guidelines, for determining the medical necessity of services. SNF’s shall use the default HIPPS rate code of ZZZZZ on the claim in the case of an off-schedule or late patient assessment, or in the case of no patient assessment at all.
Other Health Insurance (OHI)
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. Submission of Medicare Explanations of Benefits showing all 100 covered days have been 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
- Claim form is missing the Occurrence code 70 and the 3 day qualifying hospital stay
- Claims submitted to TRICARE For Life as a primary payer which have incorrect codes such as PDPM when we need RUG-III or RUG-III when we need PDPM will be returned for corrections.
If you need further clarification on any of the information provided please contact us. We will be happy to assist!