What is a Skilled Nursing Facility?
Because TRICARE For Life beneficiaries may need to use a skilled nursing facility (SNF), coverage for those services is available.
Medicare pays 100% for the first 20 days of 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 becomes the primary payer for covered skilled care. The patient must pay the TFL cost-share. Once a patient has not had any inpatient hospital or SNF care for 60 consecutive days, a new Medicare benefit period begins.
For a beneficiary who is eligible for both Medicare and TRICARE For Life (TFL), TFL can be the secondary payer for:
- An SNF that participates in Medicare; and
- Has entered into a Participation Agreement with TFL
When Medicare benefits run out, TFL may be the primary payer to SNFs that meet those conditions. An SNF provider must sign an SNF Prospective Payment System (PPS) agreement with TFL in order to be an authorized TFL provider. If you do not have this agreement on file, we will deny claims for SNFs.
SNF PPS Consolidated Billing
TFL uses Medicare's per diem prospective payment system (PPS) for skilled nursing facilities.
Under the PPS system, Medicare makes payments based on fixed amounts. The amounts are based on the type of service. The PPS applies to:
- Reimbursement rates
- Consolidated billing requirements
- Medicare Minimum Data Set (MDS) assessment requirements
The PPS system applies to all SNF admissions that began on or after August 1, 2003.
Bill Types and HIPPS Codes
You must submit bill type 21X on the claim form. You also must include Revenue Code 0022 and the Health Insurance Prospective Payment System (HIPPS) codes for charges you are billing.
Use the Medicare-based Patient-Driven Payment Model (PDPM) for the HIPPS code claims. During Medicare's 100-day benefit period, please use the same HIPPS codes for TFL patients as you use for those under Medicare.
For TFL patients, after the 100th day in a benefit period, use the appropriate PDPM that makes up the HIPPS code. Be sure to use all five digits to help prevent processing delays and returned claims.
For dates of service up to December 31, 2019, TRICARE will use the RUG-III codes. Effective January 1, 2020, TRICARE will follow Medicare use of PDPM codes.
Prior Authorization and Concurrent Authorization
All SNF claims must include:
- The 0022 revenue code(s)
- The corresponding HIPPS code(s)
- A line-item listing (by revenue code) of all services rendered to the SNF inpatient resident during the dates of service on the claim
- The billed amount for each service.
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
You have to bill any leave of absence bed days with the applicable 18x revenue code. Sometimes a patient will return to the SNF after a temporary absence due to a hospital stay or therapeutic leave. TFL considers this a readmission and will disallow any leave of absence days. Neither TFL nor the patient will be responsible for charges related to leave of absence days.
SNFs have to perform a patient assessment. Please use the Medicare MDS assessment form and guidelines to judge the medical need of services.
Use the default HIPPS rate code of ZZZZZ on the claim when there is:
- An off-schedule patient assessment
- A late patient assessment
- No patient assessment at all
Other Health Insurance (OHI)
When you submit a UB-04 claim form with a Medicare EOB, you do not need a representative from the facility to sign. Once benefits are exhausted, that changes. If you do not attach a Medicare EOB to your claim form, an authorized representative must sign the form in or around FL 80.
Acceptable options include:
- A computer-generated name;
- A stamped signature;
- A handwritten signature;
Documenting Medicare exhaustion of benefits
You must use the electronic crossover claim from Medicare to use occurrence code A3 and show the date of exhaust.
Other ways to prove benefits from Medicare or other insurance have run out include:
- An EOB showing exhaustion;
- Correspondence from Centers for Medicaid & Medicare Services;
- Correspondence from the secondary OHI plan;
- Information from the Medicare A Online System;
- Submission of Medicare EOBs showing all 100 covered days.
Common Claim Return or Denial Reasons
Some of the most common reasons you may have a claim returned or denied include:
- It is missing, invalid, or 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).
- There is no Medicare or Medicare supplement EOB showing payment or the reason for denial/definition(s) of denial code(s).
- There is no documentation of the Medicare exhaust date.
- The EOBs are Illegible or the claim form is not signed (the signature on file is not acceptable as a provider signature).
- The medical documentation/records are missing or incomplete.
- The date span billed and number of units, HIPPS codes, and room charges do not agree.
- The claim form is missing the occurrence code 70 and the three-day qualifying hospital stay.
- The claims submitted to TRICARE For Life as a primary payer have incorrect codes. For example, the codes are PDPM when we need RUG-III or RUG-III when we need PDPM. We will return these claims for corrections.
If you need further clarification on any of the information provided please contact us. We will be happy to assist!