CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skilled Nursing Facility / Nursing Facility Care Services

Defines coverage, medical necessity prerequisites, and billing/documentation guidance for skilled nursing facility (SNF) and nursing facility care services across Medicaid (including RHP/RHE, RIte Care, EFP exclusions), Commercial, and INTEGRITY lines of business for Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySkilled Nursing Facility / Nursing Facility Care Services

Policy CodePolicy N/A

Change TypeNo Content Changes (format review)

Effective DateJul 1, 2016

Next Review Date

Key ActionAll admissions as ordered by a network physician must meet medical necessity criteria and require authorization; providers must verify eligibility, retain supporting medical records, and submit claims per contractual coding and timely filing guidelines.

POLICY UPDATE CHANGES

10/01/2022 Policy Review Date Format changes No Content Changes.

07/01/2017 Review Date recorded in history.

07/01/2016 Effective Date recorded in history.

30RHP/RHE Medicaid inpatient coverage limit before disenrollment

365INTEGRITY maximum coverage per year (skilled/custodial when ordered)

1-800-963-1001Provider contact number for questions

Coverage Summary

Medical Necessity Criteria

General Medical Necessity

Covered when ALL of the following are met:

Inpatient status: Member is an inpatient at a skilled nursing facility or nursing facility.
Medical necessity: Services rendered are medically necessary (Neighborhood may use LCD, NCD, InterQual, RI EOHHS recommendations, Clinical Medical Policies to determine medical necessity).
Ordered by plan physician: Admission and services are ordered by a network/health plan physician (authorization required where specified).

Provider responsibilities: Providers must verify eligibility, coverage, and authorization criteria and retain medical records supporting billed services and medical necessity.

Contact Provider Services at 1-800-963-1001 for questions.

Medicaid-specific Coverage

Medicaid coverage conditions and limits

Medicaid inpatient coverage: Skilled nursing facility/nursing facility care services (custodial and skilled levels 1-4) are covered for members while inpatient at a skilled nursing facility.

EFP exclusion: Skilled nursing facility services are non-covered for Extended Family Planning (EFP) members.

RHP/RHE 30-day rule: RHP and RHE members may stay inpatient for up to 30 consecutive days at skilled or custodial level; members with stays longer than 30 days are disenrolled from RHP/RHE by EOHHS and enrolled in Medical Assistance.30 days

EOHHS disenrollment after 30 days.

RIte Care coverage includes all skilled levels of care when ordered by a health plan physician.

Commercial-specific Coverage

Commercial plan coverage conditions

PCP referral: Care in a Skilled Nursing Facility is covered if the network PCP refers the member to skilled nursing services.

Daily requirement: Services are required on a daily basis.

Skilled needs: The member's condition must need skilled nursing services, skilled rehabilitation services, or skilled nursing observation.

Non-skilled exclusions: Custodial care, rest care, or non-skilled care in any facility (convalescent homes, nursing homes, halfway houses, other residential facilities) is not covered under Commercial plans.

Claims for such care will be denied/not covered.

INTEGRITY line Coverage

INTEGRITY-specific statements

Covered skilled levels during approved admission: Skilled nursing facility/nursing care services are covered for members while inpatient during an approved admission; skilled levels of care (1-4) are covered.

In-network admission requirement: Admission to an in-network skilled nursing facility/nursing facility is required unless the network does not have an appropriate facility for the individual member.

Medical necessity and authorization: All admissions as ordered by a network physician must meet medical necessity criteria and require authorization.

Up-to-365 days coverage: Coverage includes all skilled and custodial levels of care when ordered by a health plan physician up to 365 days a year and is not subject to stop loss provisions.365 days

Provider Actions & Requirements

Prior Authorization

Authorization required for admissions

All admissions as ordered by a network physician must meet medical necessity criteria and require authorization (INTEGRITY; general requirement).

Documentation Required

Medical record documentation

Providers must retain and provide medical records that support billed services and medical necessity. Neighborhood reserves the right to request medical records for any service billed and follows CMS standards for documentation.

Billing Rule

Claim submission and coding standards

Providers must submit complete claims for payment within contractually determined timely filing guidelines. Claims and coding must follow AMA CPT, ICD-10-CM, and HCPCS Level II standards; billable services are subject to contractual agreements.

Denial Risk

Non-covered custodial care

Claims for custodial care, rest care, or non-skilled care in non-covered facility types (including convalescent homes, nursing homes, halfway houses, and other residential facilities) are not covered and will be denied under Commercial plans.

Documentation Required

Eligibility and benefit verification

Providers are responsible for verifying member eligibility, coverage, and authorization criteria prior to rendering services. For questions related to this policy, contact Provider Services at 1-800-963-1001.

Coding

Revenue CodesRevenue

0191	Level I revenue code
0192	Level II revenue code
0193	Level III revenue code
0194	Level IV revenue code

CPT / HCPCS E/M CodesCPTCovered

99304	Initial nursing facility care, detailed/comprehensive history/exam; MDM straightforward or low complexity
99305	Initial nursing facility care, comprehensive history/exam; MDM moderate complexity
99306	Initial nursing facility care, comprehensive history/exam; MDM high complexity
99307	Subsequent nursing facility care, problem focused; straightforward MDM
99308	Subsequent nursing facility care, expanded problem focused; MDM low complexity
99309	Subsequent nursing facility care, detailed interval; MDM moderate complexity
99310	Subsequent nursing facility care, comprehensive interval; MDM high complexity
99315	Nursing facility discharge management; 30 minutes or less
99316	Nursing facility discharge management; more than 30 minutes
99318	E/M annual nursing facility assessment

Other HCPCSHCPCSCovered

G0490	Face-to-face home health nursing visit by RHC/FQHC in shortage area (RN or LPN only)
G9685	Physician or other qualified professional evaluation/management for acute change in condition in nursing facility (demonstration project)

Background and Definitions

Background: This policy addresses covered services furnished to members who are inpatients of a skilled nursing facility or nursing facility. It applies to Medicaid (excluding Extended Family Planning/EFP), Commercial, and INTEGRITY product lines and outlines covered services (therapies, medical social services, pharmaceuticals, DME, and additional nursing and personal care) and the requirement that services be medically necessary per referenced criteria.

Medical Necessity: Services that meet criteria per Local Coverage Determination (LCD), National Coverage Determination (NCD), InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies as determined by Neighborhood.

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