Post acute care

Medicare Advantage (MA) and Medicare Advantage with Prescription Drug (MAPD) plans may cover benefits, make authorizations and pay claims differently from Original Medicare. This affects skilled nursing facilities (SNFs) and home health providers differently from other types of providers.

Priority Health aligns billing guidelines to CMS regarding qualifying hospital stay for SNF. While Priority Health does not require a qualifying hospital stay, an appropriate condition code or occurrence span code must be used.

CMS Clarification of Skilled Nursing Facility (SNF) Billing Requirements for Beneficiaries Enrolled in Medicare Advantage (MA) Plans

For the purpose of posting MA claims to the benefit period without payment, a prior three day qualifying hospital stay is not a requirement. SNF and Swing Bed (SB) providers must submit covered claims with the condition code 04 (information only bill) for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness in the Common Working File (CWF).

CMS Revision to the Reporting Requirements of Qualifying Hospital Stays on Inpatient Skilled Nursing Facility (SNF) and Swing Bed (SB) Claims

CMS Transmittal R1618CP states that for Medicare Fee-For-Service (FFS) "SNF and SB providers must submit a qualifying hospital stay or appropriate condition code, if applicable, on all claims, including initial and subsequent claims that are submitted as covered. This is applicable for submitted bill types 21x and 18x where "x" does not equal "0 (zero)". This includes all covered claims, including claims submitted for benefits exhaust denials. Covered claims that do not include a qualifying hospital stay or an appropriate condition code to indicate why a qualifying hospital stay is not applicable will be denied with the appropriate reason code indicating a qualifying hospital stay is not present.

Billing SNF PPS Services

The Medicare Claims Processing Manual, Chapter 6, Section 30 - Billing SNF PPS Services states:

''SNFs must also report occurrence span code ''70'' to indicate the dates of a qualifying hospital stay of at least three consecutive days which qualifies the beneficiary for SNF services. Use Type of Bill 021X for SNF inpatient services or 018X for hospital swing bed services.'' In addition, Section 40.3.2 - Patient Readmitted Within 30 Days After Discharge states the ''SNF must complete condition code ''57'' on the claim to indicate the patient previously received Medicare covered SNF care within 30 days of the current SNF admission.''

Covered and non-covered services under an SNF contract

Always refer to the member's Priority Health contract to identify what services will be paid by Priority Health. This is particularly important as it will guide you in understanding if certain ancillary services are their responsibility.

If a member doesn't know what their contract covers, they can contact their facility administrator for information. Their Priority Health Case Manager doesn't know the specifics of their contract.

Priority Health aligns billing guidelines to CMS regarding qualifying hospital stay for SNF. While Priority Health does not require a qualifying hospital stay, an appropriate condition code or occurrence span code must be used.

CMS Clarification of Skilled Nursing Facility (SNF) Billing Requirements for Beneficiaries Enrolled in Medicare Advantage (MA) Plans

For the purpose of posting MA claims to the benefit period without payment, a prior three day qualifying hospital stay is not a requirement. SNF and Swing Bed (SB) providers must submit covered claims with the condition code 04 (information only bill) for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness in the Common Working File (CWF).

CMS Revision to the Reporting Requirements of Qualifying Hospital Stays on Inpatient Skilled Nursing Facility (SNF) and Swing Bed (SB) Claims

CMS Transmittal R1618CP states that for Medicare Fee-For-Service (FFS) "SNF and SB providers must submit a qualifying hospital stay or appropriate condition code, if applicable, on all claims, including initial and subsequent claims that are submitted as covered. This is applicable for submitted bill types 21x and 18x where "x" does not equal "0 (zero)". This includes all covered claims, including claims submitted for benefits exhaust denials. Covered claims that do not include a qualifying hospital stay or an appropriate condition code to indicate why a qualifying hospital stay is not applicable will be denied with the appropriate reason code indicating a qualifying hospital stay is not present.

Billing SNF PPS Services

The Medicare Claims Processing Manual, Chapter 6, Section 30 - Billing SNF PPS Services states:

''SNFs must also report occurrence span code ''70'' to indicate the dates of a qualifying hospital stay of at least three consecutive days which qualifies the beneficiary for SNF services. Use Type of Bill 021X for SNF inpatient services or 018X for hospital swing bed services.'' In addition, Section 40.3.2 - Patient Readmitted Within 30 Days After Discharge states the ''SNF must complete condition code ''57'' on the claim to indicate the patient previously received Medicare covered SNF care within 30 days of the current SNF admission.''

Standard contracted services

All contracts include room, board, skilled services provided by the facility and drugs. The Jimmo v Sebelius Settlement clarified CMS rules for skilled care and related documentation. See our Jimmo v Sebelius page for details and requirements for SNF education.

Ancillary services

These services which may or may not be covered under the member's contract. Check their contract to determine if they are responsible for covering ancillary services such as transportation, dialysis, DME, chemotherapy, etc. If their contract covers these ancillary services, they're not responsible for paying the provider.

If their contract doesn't cover these ancillary services, they're responsible for paying the service provider. If they get a bill, direct the provider to submit the claim for reimbursement to Priority Health.

Non-emergent transportation

See our Ambulance services page for details on how Medicare and MAPD plans cover non-emergent transportation.

Retrospective authorizations

If you provide a service that requires prior authorization to an MA/MAPD plan member without first getting authorization, you can't send us an authorization request after the fact. You must submit a Request for payment. See Retrospective authorizations for details.

Notice of Medicare Non-coverage (NOMNC)

In most cases, providers cannot notify MA/MAPD plan members that their plan will not cover/pay for a service. The provider must request the plan to provide a Pre-service Organization Determination (PSOD).

However, SNFs must use the CMS-10123 form, Notice of Medicare Non-coverage, to inform MA/MAPD plan beneficiaries and/or their legal representatives that the plan and the SNF have determined that skilled nursing is no longer required.

Providers are responsible for preparing the NOMNC and presenting it to the member. The process is:

  1. Complete the form per CMS requirements and instructions.
  2. Provide it to the patient no later than two days prior to proposed discharge or termination of services.
  3. Ask the member to sign the form to acknowledge receipt and that he/she understands he/she may appeal the decision.
  4. Make a copy of the signed form for the SNF records.

Also see:

Appointment of Representative

Incompetent and incapacitated members for how to determine if a member is competent/understands the NOMNC, and what to do if not.

Documentation

If an assistive device, witness or interpreter is used for notice delivery, note it in the medical record.

If the member refuses to sign but notice was given to the member, note it in the medical record.

Find more information on home health care Medicare coverage for providers and Medicare in-home safety assessments.