Skilled Nursing Facility Gold Card
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Waives prior authorization for admission to skilled nursing and residential care facilities; notice of admission remains required and all admissions are subject to concurrent review for ongoing medical necessity across applicable lines of business.
No material clinical or coverage changes in this revision.
Skilled Nursing Facility Gold Card Coverage
SNF Gold Card Coverage Criteria
Covered when the following conditions and requirements are met:
ALL of the following
- Prior authorization for admission to skilled nursing or residential care facilities is not required under this policy.
- Notice of admission to Blue KC is still required per the terms of the facility contract and member certificate.
- All skilled nursing facility admissions remain subject to concurrent review for ongoing medical necessity per Blue KC Utilization Management protocol.
- Coverage remains subject to member eligibility, applicable benefit limits, provider agreements, and standard coding and claims adjudication rules.
Operational notes
- This Gold Card Payment Policy formalizes the prior-authorization waiver that was implemented during the COVID public health emergency.
- Providers should continue to submit notice of admission as required by contract and member certificate to ensure timely concurrent review.
Provider Notice and Admission Requirements
Prior authorization waived; admission notice and concurrent review required
Blue KC will no longer require prior authorization for admittance to skilled nursing or residential care facilities; however, notice of admission is still required per the facility contract and member certificate. All SNF admissions remain subject to concurrent review for ongoing medical necessity under Blue KC Utilization Management protocol.
- Prior authorization for SNF/residential admissions is waived.
- Notice of admission must be provided per facility contract and member certificate.
- Admissions are subject to concurrent review for ongoing medical necessity.
Definitions
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