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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAmbetter Nevada SNF Leveling Policy Update | OpenP…
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    CurrentAmbetter NevadaPolicy CC.PP.206

    Payment Policy: Skilled Nursing Facility Leveling

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    Defines reimbursement requirements for reporting and paying skilled nursing facility (SNF) levels of care (levels 1–5 where applicable) for Ambetter Nevada/health plans affiliated with Centene; applies to contracted SNF providers submitting claims.

    Policy Summary
    PayerAmbetter Nevada
    PolicySkilled Nursing Facility Leveling
    Policy CodePolicy CC.PP.206
    Change TypeNo material change
    Effective Date
    Last ReviewMar 1, 2025
    Next Review DateMar 1, 2025
    Key ActionProviders must document and report the SNF level of care that matches services performed based on skilled nursing hours and/or skilled therapy hours.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Levels 1–4 (or 1–5)SNF levels described
    50+High-cost drugs listed

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    >4 hrs/dayNursing threshold
    3 hrs/dayTherapy threshold
    Medicare ManualPrimary source

    Skilled Nursing Facility Level Payment Criteria

    SNF level payment criteria

    Payment is permitted when facility documentation supports the applicable level-of-care criteria:

    Level 1 (Rev Code 191): Skilled nursing up to 4 hours per day, 7 days per week, OR skilled therapy 1–2 hours per day, at least 5 days per week.
    Level 2 (Rev Code 192): Skilled nursing at least 4 hours per day, 7 days per week, OR skilled therapy at least 2 hours per day, at least 5 days per week.
    Level 3 (Rev Code 193): Skilled nursing more than 4 hours per day, 7 days per week, AND skilled therapy at least 3 hours per day, at least 5 days per week.
    Level 4 (Rev Code 194): Skilled nursing more than 4 hours per day, 7 days per week, AND patient requires Level 4 due to high-acuity need such as one of the following: catastrophic multiple traumas; severe head injury or CVA; stabilized spinal cord injury; weanable and non-weanable ventilator-dependent patients; OR administration of a high-cost drug listed in the policy.
    Level 5 (Rev Code 199) — where applicable for contracted facilities with levels 1–5: Skilled nursing more than 4 hours per day, 7 days per week, OR administration of a listed high-cost drug.

    Revenue Codes and Thresholds

    Revenue codes referencedmixed
    191Revenue Code for Level of Care 1 (Rev Code 191) — Skilled Nursing Services / up to 4 hrs/day or therapy 1–2 hrs/day
    192Revenue Code for Level of Care 2 (Rev Code 192) — Comprehensive Care / at least 4 hrs/day nursing or therapy or at least 2 hrs/day
    193Revenue Code for Level of Care 3 (Rev Code 193) — Medical/Surgical / >4 hrs/day nursing and at least 3 hrs/day therapy
    194Revenue Code for Level of Care 4 (Rev Code 194) — Intensive/Medically Complex / >4 hrs/day nursing and clinical high-acuity needs
    199Revenue Code for Level of Care 5 (Rev Code 199) — Intensive Care (where applicable) / >4 hrs/day nursing or administration of a listed high-cost drug
    Skilled nursing hours/day threshold
    Level 1 (Rev Code 191)Skilled nursing up to 4 hours per day, 7 days per week
    Level 2 (Rev Code 192)Skilled nursing at least 4 hours per day, 7 days per week
    Levels 3–5 (Rev Codes 193–199)Skilled nursing more than 4 hours per day, 7 days per week
    Skilled therapy hours/week threshold
    Level 1 (Rev Code 191)Skilled therapy 1–2 hours per day, at least 5 days per week
    Level 2 (Rev Code 192)Skilled therapy at least 2 hours per day, at least 5 days per week

    Documentation and Reimbursement Requirements

    Documentation Required

    Reimbursement requirements for SNF levels

    Providers must meet and document the applicable skilled nursing facility (SNF) level-of-care requirements to receive reimbursement. For facilities contracted for levels 1–4, reimbursement is allowed only when the facility documents the specific level criteria described below. For facilities with contracts that include level 5, the level 5 criteria also apply. Maintain clear, contemporaneous clinical records that demonstrate the frequency and type of skilled nursing and/or therapy provided, the medical necessity for the billed level, and any high-acuity indications (including administration of listed high-cost drugs) that justify higher-level payment.

    • Document skilled nursing hours per day and days per week and/or skilled therapy hours per day and days per week to support the billed level.
    • Level 1 (Rev Code 191): Skilled nursing up to 4 hours/day or skilled therapy 1–2 hours/day (≥5 days/week).
    • Level 2 (Rev Code 192): Skilled nursing ≥4 hours/day or skilled therapy ≥2 hours/day (≥5 days/week).
    • Level 3 (Rev Code 193): Skilled nursing >4 hours/day and skilled therapy ≥3 hours/day (≥5 days/week).
    • Level 4 (Rev Code 194): Skilled nursing >4 hours/day and patient meets high-acuity criteria (e.g., catastrophic trauma, severe head injury/CVA, stabilized spinal cord injury, ventilator dependence) or other intensive care needs.
    • Level 5 (Rev Code 199) — where contractually applicable: Skilled nursing >4 hours/day or administration of an approved high-cost drug (see policy list) justifying intensive care payment.

    Key Definitions

    Skilled nursing facility (SNF)
    DefinitionAn institution (or part of an institution) licensed under state laws whose primary focus is to provide skilled nursing care and related services for residents requiring medical or nursing care.
    Also may provideA place of rehabilitation services for injured, disabled, or sick members/enrollees.
    LicensingLicensed under applicable state law as a skilled nursing facility (SNF).
    Skilled nursing/rehabilitation services
    DefinitionServices furnished in accordance with physician orders that require the skills of qualified technical or professional personnel (RNs, LPNs where applicable, PT, OT, SLP/audiologists).
    SupervisionMust be provided directly by or under the general supervision of skilled nursing or skilled rehabilitation personnel to assure patient safety and achieve medically desired results.
    Policy Summary
    PayerAmbetter Nevada
    PolicySkilled Nursing Facility Leveling
    Policy CodePolicy CC.PP.206
    Change TypeNo material change
    Effective Date
    Last ReviewMar 1, 2025
    Next Review DateMar 1, 2025
    Key ActionProviders must document and report the SNF level of care that matches services performed based on skilled nursing hours and/or skilled therapy hours.
    SourceLink
    On This Page
    Skilled Nursing Facility Level Payment CriteriaRevenue Codes and ThresholdsDocumentation and Reimbursement RequirementsKey Definitions
    Levels 3–4 (Rev Codes 193–194)
    Skilled therapy at least 3 hours per day, at least 5 days per week
  1. When billing for a level based on administration of a high-cost drug, include drug administration documentation and reference to the drug in the medical record.
  2. Retain therapy plans of care, progress notes, and interdisciplinary documentation that substantiate therapy intensity and skilled nursing interventions.
  3. Failure to provide adequate documentation demonstrating the above elements may result in claim denial or recoupment.
    4. Note

    Contract-dependent level applicability

    Applicable reimbursable levels depend on the provider’s contract with the health plan. Some facilities are contracted for levels 1–4; others may be contracted for levels 1–5. Confirm the contractual level set with Ambetter Nevada before billing. Special payment considerations apply when the patient requires intensive care-level services or when payment is predicated on administration of a listed high-cost drug.

    • Verify contract scope (levels 1–4 versus 1–5) with the payer prior to billing higher levels.
    • If a claim is billed for Level 4 or Level 5 based on intensive care needs or high-cost drug administration, include supporting clinical rationale and drug administration records.
    • Contact provider relations or the payer's claims inquiry line for contract-specific billing guidance.
    When considered skilledA nursing service is 'skilled' only if it can be safely and effectively performed by or under the supervision of a registered nurse or, when regulation permits, a licensed practical nurse; complexity or patient complications may make otherwise non-skilled care skilled.