Skilled nursing facility (SNF) care, Medicare
Medicare Advantage plans
Skilled nursing facility care coverage
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.
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.
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.
See our Ambulance services page for details on how Medicare and MAPD plans cover non-emergent transportation.
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.
Terminating skilled nursing services
When it's determined that a Medicare Advantage plan member no longer needs skilled nursing care, a SNF may issue a CMS-10123 Medicare Notice of Non-coverage form to the patient to let them know that services will no longer be covered by their plan. See details.