Currentblue cross blue shield - michiganPolicy N/A

Skilled nursing facility coverage and reimbursement

This document governs Medicare Plus Blue (BCBSM) coverage, payment, member cost-sharing, and billing instructions for services provided in Medicare-certified skilled nursing facilities for Medicare Plus Blue PPO and Group PPO members.

Policy Summary

Payerblue cross blue shield - michigan

PolicySkilled nursing facility coverage and reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits and collect applicable member cost-sharing at time of service; bill on UB-04 or 837 institutional forms.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100 daysstandard days per benefit period

120 daysgroup-only option days per benefit period

Unlimitedgroup-only option (days)

PPS ratepayment method

Waived3-day stay waiver

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Skilled Nursing Facility Coverage & Payment Criteria

SNF coverage and payment criteria

Coverage and payment are generally consistent with Original Medicare except where Medicare Plus Blue provides enhancements or waivers.

Services must be provided in a Medicare-certified skilled nursing facility; coverage is for members under select Medicare Plus Blue PPO and Group PPO plans.

Eligibility requirements (Original Medicare): member must have at least a three-consecutive-calendar-day inpatient hospital stay prior to discharge and be transferred to the SNF within 30 days of hospital discharge; the 30-day period may be extended in certain predictable circumstances.

Medicare Plus Blue variations

Medicare Plus Blue waives the three-day hospital stay requirement for all Medicare Plus Blue members.
Select Medicare Plus Blue Group PPO plans may offer extended days per benefit period: standard 100 days, group option 120 days, or unlimited days per benefit period as specified by the group.
Member cost-sharing for Medicare Plus Blue is determined by the group; providers should collect applicable copayment, coinsurance, or deductible at time of service when possible.

Conditions for payment (general): eligible provider, payable location, frequency, CPT coding, diagnosis and age restrictions are consistent with Original Medicare unless otherwise noted.

Reimbursement: BCBSM pays the SNF prospective payment system rate consistent with Original Medicare, minus the member's cost-share for all Part A inpatient services; this payment is payment in full and providers may not balance bill the member.

Billing instructions: bill on UB-04 (CMS-1450) or 837 equivalent; follow Medicare Advantage PPO unique billing requirements; report CPT/HCPCS and diagnosis codes to highest specificity; include NPI; submit claims to local BCBS plan and use electronic billing per companion documents.

Claim Coding, Forms, and Payment Basis

Claim coding and formsmixed

Report CPT/HCPCS and diagnosis codes to the highest level of specificity; use UB-04 or 837 institutional claim forms; follow Medicare Advantage PPO unique billing requirements.

Payment basis

Payment methodProvider paid the Skilled Nursing Facility prospective payment system (SNF PPS) rate

Member cost-shareProvider payment is reduced by the member's cost-share for all Part A inpatient services

Balance billingPayment represents payment in full; providers may not balance bill members for the difference between allowed amount and charge

Pre-Admission & Eligibility Rules / Provider Actions

Prior Authorization

Pre-Admission / Eligibility Rules — Provider Action

Original Medicare requires a 3-consecutive-calendar-day inpatient hospital stay and transfer to a Medicare-certified skilled nursing facility within 30 days of hospital discharge for SNF coverage; the 30-day transfer period may be extended when, at discharge, extended care is predictable. Medicare Plus Blue plans provide at least the same coverage as Original Medicare and may waive the 3-day hospital stay requirement for Medicare Plus Blue members; select Medicare Plus Blue Group PPO plans may offer extended days per benefit period (e.g., 120 days or unlimited days for group options) and member cost-sharing is determined by the group. Conditions for payment (eligible provider, payable location, CPT codes, diagnosis and age restrictions) are consistent with Original Medicare unless otherwise noted by the member's Medicare Plus Blue plan.

Original Medicare: 3-day inpatient hospital stay required prior to SNF admission; transfer to SNF within 30 days of discharge required.
Medicare Plus Blue: 3-day hospital stay requirement is waived for Medicare Plus Blue members; select Group PPO plans may provide 120 or unlimited days per benefit period; member cost-sharing set by group.
Conditions for payment: Eligible provider, payable location, frequency, CPT codes, diagnosis and age restrictions are consistent with Original Medicare unless plan-specific enhancements apply.

Key Definitions

Skilled nursing facility

DefinitionA skilled nursing facility provides skilled nursing or rehabilitation services to individuals who can no longer care for themselves following an injury or illness; may be a separate facility or part of a hospital or other health care facility.

CertificationServices must be provided in a Medicare‑certified skilled nursing facility to qualify under Medicare Plus Blue coverage rules.

Scope of servicesCovers skilled care such as nursing and rehabilitation services consistent with Original Medicare clinical rules.

Medicare Plus Blue

Plan definitionMedicare Plus Blue plans provide at least the same level of benefit coverage as Original Medicare and may include enhanced benefits within a single health care plan.

SNF coverage variationsThe three-day hospital stay requirement under Original Medicare is waived for all Medicare Plus Blue members; select Group PPO plans may offer additional days per benefit period.

Member cost-sharing and plan limitsCoverage for SNF services is available under select individual Medicare Plus Blue PPO and select standard Group PPO plans; the member's cost-sharing levels are determined by the group.