Skilled Nursing Facility Gold Card (prior authorization waiver)
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This policy formalizes Blue KC's waiver of prior authorization for admissions to skilled nursing and residential care facilities and describes notice and utilization management requirements. It affects facility providers and applies across Blue KC commercial and Medicare Advantage lines.
Blue KC will no longer require a prior auth for admittance to skilled nursing or residential care facilities.
Notice of admission is still required per terms of facility contract and member certificate.
All skilled nursing facility admissions are subject to concurrent review for ongoing medical necessity per Blue KC Utilization Management protocol.
Skilled Nursing / Residential Admission Criteria
SNF Gold Card coverage criteria
Covered when the conditions below are met:
Policy formalizes prior temporary waiver used during the COVID public health emergency into an ongoing Gold Card Payment Policy.
Providers must continue to send admission notices even though prior authorization is waived.
Concurrent review processes and potential utilization management decisions continue to apply after admission.
Coverage and payment determinations remain subject to member eligibility, benefits, provider agreement, coding and date-of-service rules.
Coding
| No codes listed |
Provider Actions and Notification Requirements
Gold Card prior authorization waiver — notice required; concurrent review applies
Prior authorization is not required for admission to skilled nursing or residential care facilities; however, notice of admission is still required per the terms of the facility contract and the member certificate. After admission, all skilled nursing facility stays are subject to concurrent review for ongoing medical necessity under Blue KC Utilization Management protocol.
- Prior auth waived for SNF/residential admissions.
- Facility must still provide notice of admission per contract and member certificate.
- Concurrent review for ongoing medical necessity applies after admission.
Definitions
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