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.

Covered and non-covered services under your SNF contract

Always refer to your 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 your responsibility.

Don't know what your contract covers? Contact your facility administrator for information. Your Priority Health Case Manager does not know the specifics of your contract.

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 your contract. Check your contract to determine if you are responsible for covering ancillary services such as transportation, dialysis, DME, chemotherapy, etc. If your contract covers these ancillary services, you are not responsible for paying the provider.

If your contract does not cover these ancillary services, you are responsible for paying the service provider. If you 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