CurrentCentenePolicy CC.PP.206

Payment Policy: Skilled Nursing Facility Leveling

Defines Centene-affiliated health plan payment requirements for billing and reimbursing skilled nursing facility (SNF) levels of care (Levels 1–5 or 1–4 depending on contract) based on hours of skilled nursing, skilled therapy, high-acuity conditions, or administration of specified high-cost drugs. Affects contracted SNFs and providers submitting claims to Centene-affiliated plans.

Policy Summary

PayerCentene

PolicySkilled Nursing Facility Leveling (Payment Policy)

Policy CodePolicy CC.PP.206

Change TypeAnnual review; coding table removed (no material clinical changes)

Effective Date

Next Review Date

Key ActionProviders must bill the SNF level of care that reflects services performed and ensure documentation meets the stated skilled nursing and skilled therapy hour thresholds or clinical high‑acuity criteria.

SourceLink

POLICY UPDATE CHANGES

03/2025 annual review; CPT code table removed.

08/2024 header updated to reflect that policy is a payment policy.

09/08/2023 payment rules transitioned from retired CP.MP.206 SNF Facility Leveling with note that examples of clinical circumstances for intensive care were clarified.

Levels 1–5Defined SNF levels referenced

>4 hoursNursing threshold for higher levels

≥3 hoursTherapy threshold for higher levels

Drug listHigh-cost drug trigger

Medicare manualPrimary guidance source

SNF Level Reimbursement Criteria

SNF level reimbursement criteria

Covered when ALL of the following are met for the reported SNF level of care:

Provider documents services that meet the specific skilled nursing and/or skilled therapy time thresholds, or documents qualifying high-acuity clinical circumstances or administration of a listed high-cost drug.

Level 1 (Rev Code 191)

Skilled nursing up to 4 hours per 7‑day week.
Skilled therapy 1–2 hours on at least 5 days per week.

Level 2 (Rev Code 192)

Skilled nursing at least 4 hours per 7‑day week.

Policy Summary

PayerCentene

PolicySkilled Nursing Facility Leveling (Payment Policy)

Policy CodePolicy CC.PP.206

Change TypeAnnual review; coding table removed (no material clinical changes)

Effective Date

Next Review Date

SourceLink

On This Page

Coding Guidance and Thresholds

Coding guidance and CPT tablemixed

No codes listed

Skilled nursing hours threshold — Level 1–5 (per 7-day period)

Level 1 (Rev Code 191)Skilled nursing up to 4 hours per 7-day week

Level 2 (Rev Code 192)Skilled nursing at least 4 hours per 7-day week

Level 3 (Rev Code 193)Skilled nursing more than 4 hours per 7-day week

Level 4 (Rev Code 194)Skilled nursing more than 4 hours per 7-day week (required for medically complex/intensive needs)

Level 5 (Rev Code 199) — where applicableSkilled nursing more than 4 hours per 7-day week (contract-dependent intensive level)

Skilled therapy minutes/hours threshold — Level-specific (days/week and hours)

Level 1 (Rev Code 191)Skilled therapy 1–2 hours on at least 5 days per week

Level 2 (Rev Code 192)Skilled therapy at least 2 hours on at least 5 days per week

Level 3 (Rev Code 193)Skilled therapy at least 3 hours on at least 5 days per week

Level 4 (Rev Code 194)Skilled therapy at least 3 hours on at least 5 days per week (required for medically complex/intensive needs)

Billing and Documentation Expectations

Documentation Required

Billing and documentation expectations for SNF level assignment

Providers must bill the SNF level that accurately reflects the services performed. Payment for each SNF level requires meeting both the skilled nursing and/or skilled therapy time criteria for that level. Claims that report a higher level than supported by clinical documentation or billed hours may be denied or recouped.

Bill the revenue code that corresponds to the member's assigned level of care (e.g., Rev Code 191 for Level 1, 192 for Level 2, 193 for Level 3, 194 for Level 4, 199 for Level 5).
Ensure clinical and therapy documentation demonstrates the required skilled nursing and/or skilled therapy time for the billed level: Level 1 — skilled nursing up to 4 hours/7 days OR skilled therapy 1–2 hours on ≥5 days/week; Level 2 — skilled nursing ≥4 hours/7 days OR skilled therapy ≥2 hours on ≥5 days/week; Level 3 — skilled nursing >4 hours/7 days AND skilled therapy ≥3 hours on ≥5 days/week; Level 4 — skilled nursing >4 hours/7 days AND skilled therapy ≥3 hours on ≥5 days/week or high-acuity conditions (e.g., catastrophic trauma, stabilized spinal cord injury, severe head injury/CVA, ventilator-dependent); Level 5 — skilled nursing >4 hours/7 days OR administration of an approved high-cost drug.
Document time-based skilled nursing and therapy services (dates, start/stop times, total minutes/hours, discipline providing service) and clinical justification linking the care to skilled needs.
Retain and submit supporting clinical records on request (therapy notes, nursing flow sheets, medication administration records, orders) to validate billed level of care.
Do not bill a higher level of care based solely on diagnosis or facility contract level without corresponding documented skilled service time and skilled clinical need.
Providers should follow any prior authorization or contractual requirements for specific levels or high-cost drug administration when applicable.

Key Definitions

Skilled nursing facility (SNF) definition

Institutional licensingAn institution (or part of an institution) licensed under state law whose primary focus is to provide skilled nursing care and related services

Primary focusProvides skilled nursing care and related services for residents requiring medical or nursing care; may also provide rehabilitation services

Setting examplesCan be an institution or a distinct part of an institution delivering SNF services per state licensure

Skilled nursing/skilled rehabilitation services definition

Physician-ordered servicesServices must be furnished in accordance with physician orders

Qualified personnelRequire the skills of qualified technical or professional personnel (RNs, LPNs, PTs, OTs, SLPs/audiologists)

Skill necessityNecessary when services are of such complexity that RN or, when regulation permits, LPN skills are required to safely and effectively perform them

SupervisionProvided directly by or under the general supervision of skilled nursing or rehabilitation personnel to assure patient safety and achieve the medically desired result