CurrentmhnPolicy CC.PP.206

Skilled Nursing Facility Leveling

Defines reimbursement requirements for skilled nursing facility levels of care (levels 1–5 depending on contract) for health plans affiliated with Centene Corporation; applies to contracted SNFs and claims submission for Medicare product types.

Policy Summary

Payermhn

PolicySkilled Nursing Facility Leveling

Policy CodePolicy CC.PP.206

Change TypeRevised

Effective Date

Next Review Date

Key ActionAssign the appropriate revenue code (191, 192, 193, 194, 199) for the billed SNF level and ensure documentation demonstrates the required skilled nursing and/or therapy service intensity to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Payment rules transitioned from the retired CP.MP.206 SNF Facility Leveling; clarified that listed clinical circumstances are examples of intensive care.

Levels 1-4 (or 1-5 if contracted)SNF levels of care described

Rev Codes 191, 192, 193, 194, 199Revenue codes associated with levels

High-Cost Drug ListDrugs that can qualify for higher level

Reimbursement requirements by SNF level of care

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ANY of the following

Level 1 (Rev Code 191): Skilled nursing up to 4 hours/day, 7 days/week OR skilled therapy 1–2 hours/day, at least 5 days/week.
Level 2 (Rev Code 192): Skilled nursing at least 4 hours/day, 7 days/week OR skilled therapy at least 2 hours/day, at least 5 days/week.
Level 3 (Rev Code 193): Skilled nursing >4 hours/day, 7 days/week AND skilled therapy at least 3 hours/day, at least 5 days/week.
Level 4 (Rev Code 194): Skilled nursing >4 hours/day, 7 days/week AND patient requires Level 4 due to high acuity (examples include catastrophic multiple traumas; severe head injury or CVA; stabilized spinal cord injury; weanable and non‑weanable ventilator dependent patients; administration of a listed high‑cost drug).
Examples of high‑cost drugs are listed in the policy's High‑Cost Drug List.
Level 5 (Rev Code 199) — when contracted: Skilled nursing >4 hours/day, 7 days/week OR administration of a listed high‑cost drug.

Revenue, CPT, and Drug Codes Referenced

Revenue codes by levelRevenue

191	Rev Code 191 — Level of Care 1
192	Rev Code 192 — Level of Care 2
193	Rev Code 193 — Level of Care 3
194	Rev Code 194 — Level of Care 4
199	Rev Code 199 — Level of Care 5

CPT and therapy codes referencedCPT

99304	Initial nursing facility care, per day (various complexity descriptors provided)
99305	Initial nursing facility care, per day
99306	Initial nursing facility care, per day
99307	Subsequent nursing facility care, per day
99308	Subsequent nursing facility care, per day
99309	Subsequent nursing facility care, per day
99310	Subsequent nursing facility care, per day
99315	Nursing facility discharge day management; 30 minutes or less
99316	Nursing facility discharge day management; more than 30 minutes
99318	Evaluation and management of patient involving an annual nursing facility assessment

1–10 of 34

1/4

High-cost drug listNDC/misc

Long alphabetical list of specific high-cost drugs (examples: Adempas, Advate, Afinitor, Aldurazyme, Apokyn, Avastin, Benefix, Bexarotene, Bosulif, Cimzia Starter Kit, Cinryze, Cubicin, Cuprimine, Daklinza, Daraprim, Dificid, Disperz, Elaprase, Eloctate, Erivedge, Esbriet, Exjade, Farydak, Ferriprox, Firazyr, Gammagard Liquid, Gamunex-C, Gattex, Glassia, Geevec, Hrvoni, Herceptin, Hetlioz, HP Acthar, Humira Pen, Ibrance, Iclusig, Ilaris, Imbruvica, Increlex, Inlyta, Jadenu, Jakafi, Juxtapid, Kalydeco, Kuvan, Lazanda, Sovaldi, and many others). Inclusion of these drugs can justify Level 4 or Level 5 in some contracted scenarios.

Billing, Documentation, and Authorization Requirements

Billing Rule

Level-of-care revenue code assignment

Assign the appropriate revenue code corresponding to the SNF level billed (Rev Code 191, 192, 193, 194, 199) and ensure documented skilled nursing and/or therapy service intensity meets the level criteria for reimbursement.

Rev Code 191
Rev Code 192
Rev Code 193
Rev Code 194
Rev Code 199

Documentation Required

Medical documentation to support level

Maintain physician orders and clinical documentation that demonstrate skilled nursing hours per day and skilled therapy minutes/hours per day and days per week, and document clinical indications supporting high‑acuity Level 4 or Level 5 care (including administration of listed high‑cost drugs or ventilator dependence).

Prior Authorization

Contract-dependent level availability

Verify the facility’s contract and any prior authorization (PA) requirements with the Health Plan because payment for Level 5 (Rev Code 199) or the availability of certain levels depends on the facility’s contract and may require prior authorization.

Confirm which SNF levels are contracted with the Health Plan.
Confirm any prior authorization requirements for Level 5 or other contracted levels before billing.

Policy context and scope

Background: This policy codifies the service-intensity criteria used to assign skilled nursing facility (SNF) reimbursement levels and is based on Medicare guidance about what constitutes skilled nursing and skilled rehabilitation services. The Medicare Benefit Policy Manual synopsis used here emphasizes that skilled services must be furnished in accordance with physician orders, require the skills of qualified nursing or rehabilitation personnel, and be of such complexity or complication that they can only be safely and effectively performed by, or under the supervision of, those professionals. Skilled nursing is not defined solely by who performs the service; it must meet the clinical criteria described in Medicare guidance.

Scope and applicability: This policy applies to contracted SNFs and to claims submitted for the Medicare product types affiliated with Centene Corporation. It defines the requirements that facilities contracted for each level must meet to be reimbursed for that level (Levels 1–4; Level 5 where available by contract). For Medicare members, applicable National and Local Coverage Determinations should be reviewed and take precedence where relevant. Per the policy notice, inclusion or exclusion of codes and references to CPT are informational and do not guarantee coverage; state/federal rules and plan documents govern final coverage and payment determinations.

Policy Summary

Payermhn

PolicySkilled Nursing Facility Leveling

Policy CodePolicy CC.PP.206

Change TypeRevised

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Skilled Nursing Facility Leveling

Reimbursement requirements by SNF level of care

Revenue, CPT, and Drug Codes Referenced

Billing, Documentation, and Authorization Requirements

Numeric and Service Intensity Thresholds

Policy context and scope

Defined Terms

Policy updates

Skilled Nursing Facility Leveling

Reimbursement requirements by SNF level of care

Revenue, CPT, and Drug Codes Referenced

Billing, Documentation, and Authorization Requirements

Numeric and Service Intensity Thresholds

Policy context and scope

Defined Terms

Policy updates

Cross-references