CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Short Term Stay Criteria and Evaluation Process

Defines eligibility, required documentation, examples/scenarios, MCO evaluation process, and billing guidance for authorizing payable Short Term Stays (<=90 days) in a nursing facility under Medicaid (not SNF or LTC custodial coverage).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyShort Term Stay Criteria and Evaluation Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a Short Term Stay request with complete required documentation (most recent MDS with all sections, H&P within 6 months, care plan, therapy records, MAR/TAR if applicable) dated within last 30 days to obtain a payable authorization; MCO will issue bed-day authorization but not NFLOC if approved.

POLICY UPDATE CHANGES

No material changes to clinical criteria or coverage (has_material_change=false).

90Maximum authorized stay length

30Clinical documentation recency (days)

6H&P allowed age (months)

0191Designated revenue code

Coverage Summary

Scope: This policy defines eligibility, required documentation, MCO evaluation process, and billing guidance for authorizing payable Short Term Stays (<= 90 days) in a nursing facility under Medicaid when the stay is not covered as Skilled Nursing Facility (SNF) or Long Term Care (LTC) custodial care.

Background overview: The benefit provides Nursing Facility reimbursement through the member's Medicaid coverage for stays that are short-term in nature (<=90 days) and are not covered under SNF or LTC custodial levels of care. The Managed Care Organization (MCO) reviews clinical documentation to determine medical necessity and, when appropriate, issues a payable authorization with bed days but does not assign a Nursing Facility Level of Care (NFLOC).

Key thresholds and billing code for Short Term Stay

Maximum Short Term Stay length<= 90 calendar days

Recency of clinical documentation requiredWithin the last 30 calendar days

History & Physical allowed ageWithin 6 months (signed and dated by provider; if unsigned, must include date, name, credentials)

MDS completion frequencyMDS must be most recent; completed every 90 calendar days per CMS guidelines

Designated revenue code to bill0191

Provider Actions

Prior Authorization

Request payable authorization for Short Term Stay

Submit a Short Term Stay request with complete required documentation dated within the last 30 calendar days (most recent MDS with all sections, H&P within 6 months, care plan, therapy records, MAR/TAR if applicable) to obtain a payable authorization. If approved, the MCO will issue a payable authorization with bed days but will NOT issue a Nursing Facility Level of Care (NFLOC).

Revenue:0191

Denial Risk

Incomplete documentation may trigger administrative denial

If requested documentation is incomplete or not received, the MCO will issue an Administrative Denial and request the Nursing Facility obtain a complete NFLOC packet to determine Nursing Facility Level of Care.

Billing Rule

Billing guidance for Short Term Stay

When authorized as a Short Term Stay, bill Revenue Code 0191 (Subacute Care/Inpatient Care in a Nursing Facility). Do not bill the authorized Short Term Stay under Skilled Nursing Facility or LTC custodial revenue codes.

0191

Background & Definitions

This benefit covers Nursing Facility reimbursement for members whose stays are short-term (<= 90 calendar days) and do not meet criteria for SNF or LTC custodial care. The MCO reviews all clinical documentation provided to determine medical necessity and appropriateness of level of care. If the Short Term Stay request is authorized, the MCO will issue a payable authorization that includes bed days but will not issue an NFLOC. If the member requests an NFLOC evaluation, the member will instead be reviewed for LTC custodial services.

Required documentation for review includes the Minimum Data Set (MDS) with all sections completed and the most recent MDS, dated within the last 30 calendar days; a History & Physical within six (6) months (signed and dated by the provider, or clearly showing date, name, and credentials if not signed); Care Plan and interdisciplinary notes; rehabilitative therapy documentation (therapy notes, goals, therapy grids with minutes) if applicable; Medication Administration Record (MAR) and Treatment Administration Record (TAR) if applicable. An MDS must be completed in alignment with CMS guidelines every 90 calendar days.

If documentation is incomplete or not received, the MCO will issue an administrative denial and request the Nursing Facility to obtain a complete NFLOC packet to determine Nursing Facility Level of Care. Billing guidance: when authorized as a Short Term Stay, the Nursing Facility should bill Revenue Code 0191 (Subacute Care/Inpatient Care in a Nursing Facility) and must not bill under SNF or LTC custodial revenue codes for the authorized Short Term Stay.

Short Term Stay: A nursing facility stay requested for <= 90 calendar days that is not considered SNF or LTC custodial care and where the member does not intend to transition to LTC custodial care.

NFLOC: Nursing Facility Level of Care assessment used to determine eligibility for LTC custodial services; an NFLOC is not issued when a Short Term Stay is authorized.

MDS: Minimum Data Set; a standardized assessment required for nursing facility residents. The MDS must be the most recent assessment, with all sections completed, and is completed in alignment with CMS guidelines every 90 calendar days.