Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
Information Specific To Skilled Nursing Facilities
Under Medicare Advantage
11/11/2005
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
Skilled Nursing Facility Care for FreedomBlue Members
Benefit
FreedomBlue provides for 100 days of skilled care in a skilled nursing facility
per benefit period.
A new benefit period becomes available when the member has not been
receiving skilled care or inpatient hospital care for 60 consecutive days.
“Medicare
skilled level of
care” and
benefit days
The FreedomBlue skilled nursing benefit applies when the member is
receiving a Medicare skilled level of care and when there are benefit days
available during the current benefit period. (“Medicare skilled level of care”
means that the services rendered to the member meet Medicare’s definition of
skilled care.)
Authorization
is required
As with other inpatient services, care in a skilled nursing facility must be
authorized by Healthcare Management Services (HMS). It is important that
facilities provide complete information at the time of authorization and
throughout the member’s stay so that the appropriate level(s) of care can be
identified.
Levels of care
During the authorization process, the FreedomBlue Care or Case Manager
will assign a level of care (1, 2 or 3) according to the patient’s condition and
the services required.
Each level of care corresponds to a reimbursement level, which is identified
with a particular “accommodation” revenue code. When the facility submits
a claim for this member’s care, it must use the accommodation revenue code
which corresponds to the level of care which has been authorized:



Level 1 corresponds to revenue code 0128.
Level 2 corresponds to revenue code 0200.
Level 3 corresponds to revenue code 0120.
In processing the claim for the skilled nursing services, Highmark Blue
Shield’s system must find a match between the level of care authorized by
HMS and the revenue code submitted by the facility for the inpatient care.
Please be aware that claims on which the revenue code does not match
the assigned level of care will be rejected.
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
Level of Care Guidelines for FreedomBlue Members in a
Skilled Nursing Facility
Level of care
guidelines
Level I
The tables below are a summary of the criteria based on which the level of
care is assigned to a skilled nursing facility stay for a FreedomBlue member:
Service Category
Enteral tube feedings
High-risk medical
Intramuscular injections
Intravenous fluids
Ostomies
Rehabilitation
Respiratory therapy
(nebulizer or chest PT)
Wound care
Level II
Service Category
IV medications
Rehabilitation
Respiratory – CPAP or
BiPAP
Tracheostomy care
Wound care
Indications
Calorie intake via tube route greater than 50% of
daily intake
Conditions requiring assessment at least once every
eight hours – e.g., COPD, CHF, pneumonia or direct
admissions from ER/home.
Insulin dependent diabetes mellitus must involve
physician orders or physician visit.
Daily or more frequent with qualifying MD orders
or visit.
With clinically correlated dehydration with ongoing
evaluation
New ostomy or ostomy education
Up to four units per day (up to 60 minutes per day)
At least 15 minutes per shift with documented
assessment
Multiple stage II, stage III or IV ulcers with daily
dressing, without mattress replacement (includes
surgical wounds.
Indications
Two or three IV medications per 24-hour period
Five to ten units per day (1.25 to 2.5 hours per day)
For therapy requiring ongoing assessment with
nocturnal pulse oximetry, respiratory assessment
and/or setting adjustments
Multiple stage II, stage III or stage IV ulcers with
either more than one dressing change per day or
mattress replacement pressure reduction or airfluidized bed (includes surgical wounds)
Continued on next page
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
Level of Care Guidelines for FreedomBlue Members in a
Skilled Nursing Facility, Continued
Level of care guidelines (continued)
Level III
11/11/2005
Service Category
Intravenous medications
Mechanical ventilation
Parenteral nutrition
Peritoneal Dialysis
Rehabilitation
Indications
Four or more medications per 14-hour period
(Does not include BiPAP or CPAP)
TPN
Greater than ten units per day (greater than 2.5
hours per day)
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
Consolidated Billing for Skilled Nursing Facility Services
Bill for all
services
rendered
during the stay
Participating skilled nursing facilities are responsible for billing Highmark
Blue Shield for all services the member receives during his or her inpatient
stay.
This “consolidated billing” requirement includes services provided by the
facility and those which are provided by outside vendors, including but
not limited to lab, radiology and therapy services.
Facility
responsibilities
To comply with the consolidated billing requirement, facilities will need to
enter into a financial arrangement with any outside vendors providing
services to their FreedomBlue patients. The facility will need to bill
Highmark Blue Shield for the services received, via the member’s inpatient
skilled nursing claim. The facility’s per-diem payment is inclusive of such
services, and no additional payment will be made for them. The facility is
then responsible for reimbursing the vendor according to the arrangement
these two entities have made. The vendor is not permitted to bill either
Highmark Blue Shield or the FreedomBlue member.
Exclusions
from
consolidated
billing -inpatient
Certain services (generally those outside the scope of the skilled nursing
facility’s license) have been excluded from the inpatient consolidated billing
requirement. They include the following:
FreedomBlue
participating
providers
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


Prosthetics*
Orthotics*
Complex diagnostic procedures such as Magnetic Resonance Imaging
(MRI), Computed Axial Tomography (CT scans), nuclear medicine
and fluoroscopy
In order to be paid at the highest level of benefits, such services must be
rendered and billed to Highmark Blue Shield by a FreedomBlue
participating provider.
*These items must be authorized through Wright and Filippis.
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
When a FreedomBlue Member Has Exhausted the Inpatient
Skilled Nursing Benefit or Is No Longer Receiving a Medicare
Skilled Level of Care
When the
inpatient
benefit cannot
be provided
FreedomBlue members can use their inpatient skilled nursing facility benefit
only when they are receiving a Medicare skilled level of care and when
benefit days are available. Both conditions must be met.
When either of these conditions cannot be met, FreedomBlue can no
longer pay for the member’s inpatient (“Part A”) skilled nursing facility
care.
Member
notification
The Centers for Medicare and Medicaid Services (CMS) requires skilled
nursing facilities to notify members at least two days before the coverage of
their inpatient care will cease, and provide them with information on their
right to appeal the associated decisions. Use the forms named in the table
below to provide notification and appeal rights to members with
coverage under FreedomBlue. Samples of each form will be distributed
to participating providers
When coverage will be terminated
because…
He or she no longer requires a
Medicare skilled level of care
He or she no longer has benefit days
available
Deliver this form to the member or
the member’s representative…
Notice of Medicare Non-Coverage
(NOMNC)
Notice of Denial of Medicare
Coverage (NDMC)
For full
information on
this important
responsibility
Please see pages 25-28 for information on delivery of these forms to
FreedomBlue members, as well as information on next steps if the member
should choose to file an appeal.
“Part B”
ancillary
services still
covered
When the member no longer requires a Medicare skilled level of care or has
exhausted the inpatient benefit, FreedomBlue still covers certain ancillary
services which under Original Medicare would have been covered under Part
B. These include radiology (including mobile X-ray), lab, physical therapy,
speech therapy, occupational therapy and certain durable medical equipment.
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
When a FreedomBlue Member Has Exhausted the Inpatient
Skilled Nursing Benefit or Is No Longer Receiving a Medicare
Skilled Level of Care, Continued
Skilled nursing
facility must
bill for all “Part
B” ancillary
services
Participating skilled nursing facilities must bill Highmark Blue Shield for all
“Part B” ancillary services rendered to the member when the inpatient benefit
has been exhausted or the member no longer requires a Medicare skilled level
of care.
This consolidated billing requirement includes services provided by the
facility and those which are provided by outside vendors, including but
not limited to lab, radiology (including mobile x-ray) and outpatient
therapy services.
Facility
responsibility:
make
arrangements
with vendors
providing
ancillary
services
To comply with the consolidated billing requirement, facilities will need to
enter into a financial arrangement with any outside vendors providing “Part
B” ancillary services to FreedomBlue members. The facility will need to bill
Highmark Blue Shield for the services via the member’s claim. Assuming
that all other requirements (e.g., authorization of therapy services) have been
met, payment will be made to the skilled nursing facility. The facility is then
responsible for reimbursing the vendor according to the arrangement those
two entities have made. The vendor is not permitted to bill either
Highmark Blue Shield or the FreedomBlue member.
Exclusions
from the
consolidated
billing
requirement
(“Part B”
ancillary
services)
Certain services have been excluded from the skilled nursing facility’s
FreedomBlue consolidated billing requirement for “Part B” ancillary services.
They include the following:
FreedomBlue
participating
providers
In order to be paid at the highest benefit level, these services must be
rendered and billed by a FreedomBlue participating provider.
* These items must be authorized through Wright and Filippis.





Durable medical equipment*
Prosthetics*
Orthotics*
Respiratory therapy
Complex diagnostic procedures such as Magnetic Resonance Imaging
(MRI), Computed Axial Tomography (CAT) scans, nuclear medicine
and fluoroscopy
Continued on next page
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
When a FreedomBlue Member Has Exhausted the Inpatient
Skilled Nursing Benefit or Is No Longer Receiving a Medicare
Skilled Level of Care, Continued
Authorization
of ancillary
services
Although the initial authorization for the member’s skilled nursing facility
stay applies to all the services the member receives while the facility is
receiving the FreedomBlue inpatient per-diem payment, this changes when
the member exhausts the inpatient benefit or is no longer receiving a
Medicare skilled level of care.
Once the facility is no longer receiving the inpatient per-diem payment for
this member’s care, any services which require authorization now require a
separate one. This includes outpatient therapies, even if the member had
been receiving the same services from the same provider during the time
when the facility was receiving a FreedomBlue per-diem payment.
An example
For example, a FreedomBlue member might spend 100 days as a patient of
Facility X. During that time, he might receive five days of physical medicine
or occupational therapy each week. No separate authorization would be
required for his therapies, because the initial authorization for the admission
applies to all the services he receives during the 100 inpatient days paid under
FreedomBlue.
On the 101st day, the member still needs the same 5-day-per-week therapy
regimen. But since the inpatient per-diem benefit has been exhausted, the
therapy services must now be authorized. Depending upon the number of
therapy services the member’s condition requires, this may involve
submission of a Plan of Treatment. (See pages 15-16 for more information
about the Plan of Treatment.)
Reimbursement
In the example above, the facility reports the authorized therapy services via
the member’s outpatient UB-92 claim. Highmark Blue Shield reimburses the
facility according to the FreedomBlue fee schedule. The provider of the
therapy services bills the facility for them, and the facility reimburses the
therapy provider according to the arrangement those two entities have made.
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Issues Specific to Skilled Nursing Facilities Under Medicare Advantage
When a FreedomBlue Member Has Exhausted the Inpatient
Skilled Nursing Benefit or Is No Longer Receiving a Medicare
Skilled Level of Care, Continued
Billing for
ancillary
services
The table below specifies billing instructions for skilled nursing facilities to
follow when billing for ancillary services provided to a FreedomBlue member
who has exhausted the inpatient skilled nursing benefit or is no longer
receiving a Medicare skilled level of care:
Loc. #
Locator Name
Entry
4
Type of Bill
221- Inpatient ancillary
6
Statement Covers Period From = First date in this billing month
on which services were rendered
Through = Last date in this billing
month on which services were rendered
42
Revenue Codes
Valid revenue codes for SNF “Part B”
claims are the following:
030X – Laboratory
031X – Laboratory/Pathological
032X – Radiology/Diagnostic
042X – Physical Therapy
043X – Occupational Therapy
044X – Speech Language Pathology
0730 – EKG/ECG (Electrocardiogram)
44
HCPCS Codes
As appropriate for the service rendered.
45
Service date
A date of service must be entered for
each service reported
46
Units
Units must equal 1
Authorization
of durable
medical
equipment,
orthotics and
prosthetics
Durable medical equipment (DME), prosthetics, orthotics and respiratory
therapy equipment defined by the Durable Medical Equipment Regional
Carrier (DMERC) is not authorized through Healthcare Management Services
(HMS). Medical management of these items is reserved to Wright and
Filippis, FreedomBlue’s DME management vendor.
Contacting
Wright and
Filippis
Wright and Filippis can be reached at 1-877-345-4774 for authorization of
DME, prosthetics, orthotics and respiratory therapy equipment (including
oxygen).
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