Payment Policy: Skilled Nursing Facility Leveling
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Defines reimbursement requirements for reporting SNF levels of care (levels 1–5 where applicable) for facilities contracted with Community Health Plan Washington/Centene-affiliated health plans and the clinical/service expectations tied to each level.
No material clinical or coverage changes in this revision.
SNF Level Reimbursement Criteria
SNF level reimbursement criteria
Reimbursement is authorized when facility-documented services meet the level-specific skilled nursing or therapy intensity requirements or when specified clinical circumstances apply.
ALL of the following
- Skilled nursing more than 4 hours per day, 7 days per week.
AND one of the following
- Patient has high acuity need (examples include catastrophic multiple traumas; severe head injury or CVA; stabilized spinal cord injury; weanable and non-weanable ventilator dependence).
- Administration of a listed high-cost drug (see High-Cost Drug List).
Revenue Codes and Service Thresholds
| Rev Code 191 | Level of Care 1 — Skilled Nursing Services Requirements: Skilled nursing up to 4 hours per day, 7 days per week, or skilled therapy 1 to 2 hours per day, at least 5 days per week. |
| Rev Code 192 | Level of Care 2 — Comprehensive Care Services Requirements: Skilled nursing at least 4 hours per day, 7 days per week, or skilled therapy for at least 2 hours per day, at least 5 days per week. |
| Rev Code 193 | Level of Care 3 — Medical/Surgical/Sub-Acute (or Medical/Surgical) Services Requirements: Skilled nursing for more than 4 hours per day, 7 days per week, and skilled therapy for at least 3 hours per day, at least 5 days per week. |
| Rev Code 194 | Level of Care 4 — Intensive/Medically Complex Services Requirements: Skilled nursing for more than 4 hours per day, 7 days per week, and patient requires Level 4 due to high acuity (examples: catastrophic multiple traumas; severe head injury or CVA; stabilized spinal cord injury; weanable and non-weanable ventilator dependence) and/or skilled therapy as specified. |
| Rev Code 199 | Level of Care 5 — Intensive Care Services (where applicable): Skilled nursing required for more than 4 hours per day, 7 days per week, or administration of a high-cost drug listed in the policy. |
Documentation and Reporting Requirements
Document and report SNF level and supporting service intensity
Providers must document and report the SNF level of care (Level 1–4 or Level 1–5 where applicable) that corresponds to the skilled nursing and/or skilled therapy intensity described in the policy in order to be reimbursed. Documentation should clearly indicate the facility-designated level (e.g., Rev Code 191, 192, 193, 194, 199 where applicable) and the supporting service intensity (hours per day of skilled nursing and hours per day and days per week of skilled therapy) or the presence of qualifying high-acuity conditions or administration of a listed high-cost drug. Failure to document/report the correct level and supporting service intensity may result in nonpayment or denial of the claim.
- Report the facility-designated SNF level (Level of Care 1–4; Level of Care 5 where applicable).
- Include supporting service intensity: nursing hours per day and therapy hours per day with days/week (e.g., Level 1: up to 4 nursing hrs/day OR therapy 1–2 hrs/day, ≥5 days/week; Level 2: ≥4 nursing hrs/day OR therapy ≥2 hrs/day, ≥5 days/week; Level 3: >4 nursing hrs/day AND therapy ≥3 hrs/day, ≥5 days/week; Level 4/5: >4 nursing hrs/day plus high-acuity example or listed high-cost drug).
- When applicable, document qualifying high-acuity conditions (catastrophic multiple traumas, severe head injury/CVA, stabilized spinal cord injury, ventilator dependence) or administration of a listed high-cost drug to support Level 4/5 billing.
- Use the applicable revenue code (Rev Code 191, 192, 193, 194, 199) to reflect the reported level on claims.
Key Definitions
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