Skilled Nursing Facility (SNF) level of care
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Defines Fallon Health clinical coverage criteria for SNF level of care, who requires prior authorization, and when admission and continued stay in a SNF are covered for Fallon products and members.
No material clinical or coverage changes in this revision.
Skilled Nursing Facility (SNF) Coverage Criteria
inv-01: SNF Level of Care — Admission and Continued Stay — Covered when ALL of the following are met
Covered when ALL of the following are met
If any one factor is not met, SNF stay is not covered.
inv-02: Rehabilitation frequency requirement — Clarification for rehabilitation-only cases
Clarification for rehabilitation-only cases
If therapy services are provided less than 5 days/week, the 'daily' requirement is not met.
inv-03: Skilled physical therapy coverage criteria — Covered when ALL of the following are met (skilled therapy services)
Covered when ALL of the following are met (skilled therapy services):
See documentation requirements and Section E. Maintenance Therapy for guidance regarding maintenance programs; thorough and timely documentation of treatment goals, patient response, and plan for future care is required.
inv-04: Skilled nursing coverage criteria — Nursing services considered skilled when:
Nursing services considered skilled when:
A service is not skilled merely because a nurse performs it or because no competent unskilled person is available; complexity and need for nursing skill must be documented.
inv-05: MassHealth SNF clinical eligibility — MassHealth clinical eligibility for SNF services (per 130 CMR 456.409)
MassHealth clinical eligibility for SNF services (per 130 CMR 456.409):
MassHealth members have coverage for up to 100 days per ACO contract year at a nursing facility, chronic or rehabilitation hospital, or any combination thereof; requests must include completed clinical assessment and supporting documentation that alternatives were considered and inadequate.
Care that is less intensive than SNF level of care is not covered. SNF care is only justified when the patient’s medical condition, safety, or health would be at significant and direct risk if managed in a less intensive setting. Factors such as inconvenience, travel burden, time or money required for home care, or caregiver worry alone do not meet the threshold for SNF level of care and therefore do not justify admission or continued stay.
The services of a private duty nurse or a private duty attendant (aide) are excluded from coverage and are not considered SNF-level services.
A stay in a SNF is not medically necessary if any one of the required SNF criteria is not met. The four required criteria are: need for physician-ordered skilled nursing or skilled rehabilitation services; requirement for those skilled services on a daily basis; that, as a practical matter, the daily skilled services can be provided only in an inpatient SNF; and that the services are reasonable and necessary in duration and quantity. If the member needs only intermittent rather than daily skilled services, coverage is not supported.
Coding, Billing & Therapy Thresholds
| 0022 | HIPPS - Skilled nursing facility |
| 0120 | Room and board - use for room and board SNF Level A |
| 0190 | Subacute care - use for room and board SNF Level B |
| 0191 | Subacute care - use for room and board SNF Level C |
| 0192 | Subacute care - use for room and board SNF Level D |
| 0193 | Subacute care - use for room and board SNF Level E |
| 0194 | Subacute care - use for room and board SNF Level F |
| 0199 | Subacute care - use for room and board SNF Level G |
Authorization, Documentation, and Provider Responsibilities
Prior authorization required for SNF care
Prior authorization is required for SNF level of care.
Include required documentation with authorization requests
Requests for authorization for skilled nursing facility services must include the documentation described in the policy; Fallon follows Medicare NCDs/LCDs and applicable MassHealth criteria when making determinations.
- Include completed clinical assessment and other nursing/medical/psychosocial evaluations for MassHealth ACO members (see MassHealth variation).
- Provide all documentation described under 'Documentation to Support Skilled Care Determinations' so reviewers can determine skilled involvement and that services are reasonable and necessary.
Plan first assesses need for skilled services
The Plan first determines whether a member needs skilled care; if no skilled service is needed, the 'daily' and 'practical matter' inpatient requirements are not evaluated.
Check product or employer benefit plan limits
Coverage and authorization may be limited by a member's specific product or employer group benefit plan; consult the product Evidence of Coverage or contract for exclusions or other benefit limitations.
Document skilled involvement and medical necessity
Requests must include documentation showing that skilled involvement is required to furnish the services safely and effectively and that the services are reasonable and necessary in terms of nature, severity, duration, and quantity.
- Documentation should demonstrate skilled involvement is required for safe/effective provision and that services promote documented therapeutic goals.
- Show that the services are appropriate in duration and quantity and consistent with accepted standards of medical practice.
Specific documentation required to support SNF level of care requests
For requests for SNF level of care, include documentation that skilled involvement is required, that services are reasonable and necessary, the completed clinical assessment as relevant, skilled services provided, the patient's response, plan for future care, and a detailed rationale explaining the need and complexity of the skilled service.
- History and physical exam pertinent to care, including response to prior skilled services.
- Description of skilled services provided and the patient's response during the current visit.
- Plan for future care and detailed rationale explaining need and complexity of the skilled service.
MassHealth-specific documentation requirements
For MassHealth ACO members, include the completed clinical assessment, other nursing/medical/psychosocial evaluations or assessments, documentation that alternatives to SNF care were considered and deemed inadequate, and any additional assessments requested by the Plan.
Coverage denial if any SNF criterion not met
A stay is not covered if any one of the four required SNF criteria is not met (for example, when the patient requires intermittent rather than daily skilled services).
- The four required criteria: physician-ordered skilled services; need for daily skilled services; practical matter that services can only be provided inpatient; services are reasonable and necessary.
Denial risk for insufficient documentation
Insufficient documentation to demonstrate that skilled involvement is required and that the services are reasonable and necessary may result in denial of the request.
- Vague or subjective records (e.g., 'patient tolerated treatment well', 'continue with POC', 'patient remains stable') are not adequate to support skilled need.
- Documentation must illustrate goals, skilled services provided, patient response, and why skilled personnel are required.
Key Definitions
Skilled care comprises nursing and rehabilitation services that are so inherently complex or require such professional judgment that they must be performed by, or under the supervision of, licensed professionals. SNF services focus on subacute restorative and rehabilitative care where licensed nurses or qualified therapists provide assessments, skilled treatments, and training that cannot be safely or effectively delivered by non‑licensed personnel. Documentation should link skilled interventions to treatment goals and demonstrate why skilled personnel are required to achieve those goals or to prevent decline.
Admission to SNF — Clinical Requirements
inv-26: SNF — Admission criteria (top-level node)
If any one factor is not met, SNF admission is not covered.
inv-27: SNF — Admission criteria (top-level node, therapy focus)
Documentation must support skilled involvement, therapeutic goals, and initial evaluation prior to start of therapy (or on readmission).
inv-28: SNF — Admission criteria (MassHealth / regulatory node)
Include completed clinical assessment and documentation that alternatives were considered and inadequate.
Continued Stay / Ongoing SNF Eligibility
inv-29: SNF — Continued stay criteria (top-level node)
If skilled need ceases, daily/practical-matter requirements are not addressed and SNF level of care is not met.
inv-30: SNF — Continued stay criteria (therapy / skilled services node)
Medical record should document history/physical, skilled services provided, patient response, plan for future care, and rationale explaining need and complexity of skilled services.
Discharge & Transition Criteria
Discharge or step‑down from SNF level of care is appropriate when the patient’s condition, safety, or health are no longer at significant and direct risk in a less intensive setting, or when treatment goals are no longer reasonable or achievable. In such cases the plan of care must be revised, the patient reassessed, and documentation must support that the skilled services are no longer required for safe or effective care.
Additional scenarios that support discharge include completion of documented therapeutic goals or when ongoing care no longer requires skilled interventions. The medical record should clearly show reassessment, progress toward goals, or a revised plan demonstrating that services no longer meet the definition of skilled care.
Duration Limits & Medicare Rules
Policy Revision History
Policy effective date updated to 2026-06-01; clinical coverage criteria for SNF level of care published as current.
Policy last reviewed on 2026-04-28 with no material clinical policy statement changes identified.
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