CurrentHighmark Blueshield NenyPolicy N/A

Skilled Nursing Facility (SNF) Episodic Bundled Payment Program

Defines the SNF Episodic Bundled Payment Program for Highmark skilled nursing facility network participants, governing reimbursement, authorization, episode management, and reporting for Highmark Medicare Advantage members.

Policy Summary

PayerHighmark Blueshield Neny

PolicySkilled Nursing Facility (SNF) Episodic Bundled Payment Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and required Admission/Recertification Surveys via Home & Community Care Transitions (Availity/portal/phone/fax); complete Admission Survey in Helion Portal by day 5.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-daystandard SNF Episode length

Medicare Advantagemember population included

dailySNF Reimbursement Report

day 5Admission Survey deadline

SNF Episode Coverage & Administrative Rules

SNF Episode Coverage Criteria and Administrative Requirements

Episode rules and episode attribution

Standard SNF Episode is 30 days; episodes may be extended by approval via Home & Community Care Transitions.

If a patient is not ready for discharge on day 28 and continues to meet CMS Chapter 8 criteria, the SNF must submit an authorization request via Home & Community Care Transitions for the next 30-day episode.

Home & Community Care Transitions will review clinicals and either: recommend issuance of a Notice of Medicare Non‑Coverage (NOMNC) if Chapter 8 criteria are not met, or approve additional days in a new authorization for the subsequent 30-day episode beginning on day 31.

If the member disagrees with a recommendation to issue a NOMNC, Home & Community Care Transitions will issue the NOMNC on behalf of Highmark and no further authorization or payment will be provided past day 30.

While in an established 30-day SNF Episode, if the patient is discharged and then readmitted to a SNF within the same SNF entity, the episode is attributed to the first admitting SNF and the readmission is considered a continuation of the original SNF Episode.

A new authorization is required via Home & Community Care Transitions for any readmission that is considered a continuation of the original episode.

Concurrent clinical updates/reviews within a 30-day episode are no longer required; SNFs must manage continued skilled services and ensure the patient continues to meet CMS Chapter 8 criteria. Follow CMS regulations for MDS completion (no program-specific MDS requirements).

Assessment, Coding, and Risk Adjustment

Assessment/Coding changemixedNot Covered

RUG	Resource Utilization Group assignment

Risk-adjusted payment inputs — proprietary model

Proprietary model inputsRecent authorization history; diagnosis codes indicated on SNF authorization request; claims history; other data points; member age and demographic profile

Purpose of inputsUsed to calculate the Highmark Episodic SNF risk-adjusted payment (member-level acuity)

Distinct calculation noteDifferent from the Home & Community Care Transitions metric for likelihood of hospital admission from SNF in <30 days

Authorization, Episode Management, and Appeals

Prior Authorization

Prior Authorization and Episode Extensions

SNFs must submit all prior authorization requests for admissions and episode extensions through Home & Community Care Transitions (via Availity, the Access portal, phone, or fax). If Availity is unavailable, use the Access portal or phone/fax to submit. Home & Community Care Transitions confirms admission, reviews submitted clinical documentation, and completes the Predict Outcome report to determine authorization for the initial 30‑day SNF Episode.

Submit initial prior authorization through Home & Community Care Transitions (Availity, Access portal, phone, or fax).
If patient is not ready for discharge on day 28 and continues to meet CMS Chapter 8 criteria, submit an authorization request for the next 30‑day SNF Episode via Home & Community Care Transitions.
Home & Community Care Transitions will review clinicals and either: recommend a Notice of Medicare Non‑Coverage (NOMNC) if Chapter 8 criteria are not met, or approve additional days by issuing a new authorization for the subsequent 30‑day episode beginning on day 31.

Denial Risk

Denials and Appeals Process

If an admission or authorization decision is denied and you or the member disagree, the SNF is responsible for managing the appeal directly with Highmark or the applicable Quality Improvement Organization (QIO). Follow Highmark’s DENIALS Administrative Guide for detailed procedures and timelines for filing and pursuing appeals.

SNF handles the appeal/denial process directly with Highmark or the QIO as appropriate.
Reference the DENIALS Administrative Guide for required forms, timelines, and submission methods.

Program Definitions and Notices

SNF Episodic Program — overview and operational facts

Program definitionAn enhanced value-based reimbursement program for the Highmark skilled nursing facility network that applies to Highmark Medicare Advantage members

ObjectiveRewards participants for managing Highmark patient population toward quality care and efficiency outcomes

Standard episode length30-day SNF Episode; extensions require authorization for the next 30-day episode via Home & Community Care Transitions

Admission/authorization processSNFs must obtain prior authorization via Home & Community Care Transitions (request methods include Availity/Access portal, phone, fax) and complete required Admission Survey via Helion Portal by day 5

Notice of Medicare Non-Coverage (NOMNC) — SNF responsibilities

NOMNC requirementWhen SNF determines patient no longer meets CMS Chapter 8 criteria, SNF must issue the Notice of Medicare Non-Coverage (NOMNC) and send a valid signed copy to Home & Community Care Transitions

Information to submit with NOMNCSend patient discharge date and submit patient summaries and treatment logs to Home & Community Care Transitions for reconciliation and authorization closure

Disagreement processIf Home & Community Care Transitions recommends NOMNC but SNF disagrees, Home & Community Care Transitions may issue the NOMNC on behalf of Highmark; no further authorization/payment given past day 30