CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skilled nursing facility / nursing facility care services - Coverage Criteria

Governs coverage, authorization, billing, and documentation for skilled nursing facility (SNF) and nursing facility inpatient services for Neighborhood Health Plan of Rhode Island members across Medicaid, Commercial, and INTEGRITY products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySkilled nursing facility / nursing facility care services - Coverage Criteria

Policy CodePolicy N/A

Change TypeAuthorization and coding additions

Effective DateJul 1, 2016

Next Review DateN/A

Key ActionVerify member eligibility, coverage, and obtain prior authorization for INTEGRITY admissions before rendering services.

SourceLink

POLICY UPDATE CHANGES

Added custodial care coding grid and added to claims submission section.

Added authorization language to prerequisite section.

Added Skilled therapy services language for INTEGRITY and added Medicaid exclusion.

30 daysRHP/RHE inpatient SNF max

365 daysINTEGRITY annual limit

Levels 1-4Skilled levels covered

0191-0194Revenue codes

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Medicaid Inpatient Coverage

Covered when ALL of the following are met:

Medicaid SNF Coverage

Medical necessity: Services are medically necessary per NCD/LCD/Interqual/EOHHS/CMP
Provider must verify eligibility and authorization prior to services
Network: Admission to an in-network skilled nursing facility/nursing facility is required unless the network does not have the appropriate setting for the member
Product limits and exclusions: RHP/RHE members may stay up to 30 consecutive days; skilled nursing facility services are non-covered for Extended Family Planning (EFP) members<= 30 consecutive days
RHP/RHE members with stays >30 days are disenrolled to Medical Assistance

Skilled nursing facility services are explicitly excluded for certain member groups and care types. Skilled nursing facility services are non-covered for Extended Family Planning (EFP) members. Additionally, services that constitute custodial care, rest care, day care, or other non-skilled care provided in any facility (including convalescent homes, nursing homes, homes for the aged, halfway houses, or other residential facilities) are not covered.

Care that is custodial in nature (non-skilled personal care and room and board) is not medically necessary when billed as skilled services and is therefore not covered. Providers should ensure the level of service billed reflects the actual care delivered because custodial care, rest care, day care, or non-skilled care billed as skilled services may lead to claim denial.

Admission Criteria for SNF/Nursing Facility

SNF — admission criteria

SNF admission criteria: Admission must be ordered by a network or health plan physician and meet medical necessity criteria; verify eligibility and prior authorization where required

INTEGRITY requires prior authorization; Commercial requires network PCP referral; admission to in-network facility required unless appropriate setting not available

Continued Stay / Renewal Criteria

SNF — continued stay criteria

Continued stay: Coverage may continue when skilled need persists and medical necessity continues to be met

INTEGRITY covers up to 365 days/year when ordered by plan physician; RHP/RHE members transition after 30 days to Medical Assistance; providers must notify Utilization Management of status changes

Discharge Criteria

Providers must notify Neighborhood's Utilization Management Department of any changes to a member's status, including discharge. Documentation supporting discharge and any services billed must be available on request and must meet Neighborhood's documentation standards. All services billed must be medically necessary as determined by applicable criteria (NCD/LCD, Interqual, EOHHS, CMP), and records must substantiate the rationale for discharge and any post-discharge billing.

Coverage Day Limits by Product

SNF — day limits

RHP/RHE day limitFirst 30 consecutive days covered for RHP/RHE members; stays beyond 30 days result in disenrollment from RHP/RHE and enrollment in Medical Assistance

INTEGRITY annual limitCoverage for skilled and custodial levels up to 365 days per year when ordered by a health plan physician

Scope by level of careApplies to skilled and custodial levels (RHP/RHE: skilled or custodial; INTEGRITY: skilled levels 1-4 and custodial when ordered by plan physician)

Revenue, CPT/HCPCS Codes and Coding Limits

Revenue CodesRevenue

0191	Level I, Revenue Code
0192	Level II, Revenue Code
0193	Level III, Revenue Code
0194	Level IV, Revenue Code
0100	Custodial Care Room and Board, Revenue Code

CPT/HCPCS Codesmixed

99304	Initial nursing facility care, per day (low severity; ~25 minutes)
99305	Initial nursing facility care, per day (moderate severity; ~35 minutes)
99306	Initial nursing facility care, per day (high complexity; ~45 minutes)
99307	Subsequent nursing facility care, per day (problem focused; ~10 minutes)
99308	Subsequent nursing facility care, per day (expanded problem focused; ~15 minutes)
99309	Subsequent nursing facility care, per day (detailed; ~25 minutes)
99310	Subsequent nursing facility care, per day (high complexity; ~35 minutes)
99315	Nursing facility discharge day management; 30 minutes or less
99316	Nursing facility discharge day management; more than 30 minutes
99318	Annual nursing facility assessment evaluation and management

1–10 of 12

1/2

RHP/RHE SNF stay limit

Limit value<= 30 consecutive days

Consequence after limitMembers with stays >30 days are disenrolled from RHP/RHE by EOHHS and enrolled in Medical Assistance

Applies to levelsApplies to both skilled and custodial levels of care for RHP/RHE members

Provider Requirements, Authorization & Documentation

Prior Authorization

INTEGRITY Prior Authorization Required

All INTEGRITY admissions require prior authorization and must meet medical necessity. Providers must verify member eligibility, coverage and authorization criteria with Neighborhood prior to rendering services.

Prior authorization required for all INTEGRITY admissions
Coverage includes skilled and custodial levels when ordered by a health plan physician (up to 365 days/year)
Providers should refer to Neighborhood's Prior Authorization Reference page for plan-specific requirements

Denial Risk

Out-of-Network Admission

Admission to an in-network skilled nursing facility is required for Commercial and INTEGRITY members unless the network does not have an appropriate facility for the member. Out-of-network SNF admissions may be denied if an appropriate in-network facility is available. Providers must obtain authorization when applicable and document the reason an in-network facility was not used.

In-network admission required unless network lacks appropriate facility
Out-of-network admissions may be denied without prior approval or documented justification
Providers must notify Neighborhood UM of admissions, discharges, level-of-care changes, and member status changes

Note

Provider Operational Responsibilities

Providers must verify eligibility, coverage and authorization prior to rendering services and notify Neighborhood's Utilization Management of any changes to member status. All services must be medically necessary to qualify for reimbursement.

It is the provider's responsibility to verify eligibility, coverage and authorization criteria
Notify Neighborhood UM of admission, discharge, level-of-care change, expiration, etc.
For questions contact Provider Services at 1-800-963-1001

Documentation Required

Medical Record & Claims Documentation

Medical records must support billed services and the medical necessity of those services. Documentation must meet CMS standards and coding/documentation requirements (CPT, ICD-10-CM, HCPCS). Neighborhood reserves the right to request medical records for any billed service.

Documentation must support services billed and meet CMS/CPT/ICD-10/HCPCS standards
Billable services are subject to contractual timely filing guidelines and must be submitted in chronological order
Records may be requested by Neighborhood for review to validate medical necessity

Denial Risk

Non‑Skilled Care Billed as SNF

Custodial care, rest care, day care, or non-skilled care billed as SNF is not covered and may be denied. Admissions must meet medical necessity and be ordered by a network/plan physician when applicable.

Custodial/non-skilled care billed as SNF is not covered
All SNF admissions must meet medical necessity and be ordered by a network physician when applicable

Key Definitions

Skilled nursing facility/nursing facility care services

Definition of SNF/NF servicesServices rendered to an inpatient of a skilled nursing facility or nursing facility including skilled nursing and/or rehabilitation care, room and board, therapies (physical, occupational, speech), medical social services, pharmaceuticals, durable medical equipment, additional nursing and personal care, and other necessary routine services

Skilled levels coveredSkilled levels 1-4 are covered when ordered by a health plan or network physician

Admission network requirementAdmission to an in-network SNF/NF is required unless the network does not have an appropriate setting

Custodial care

Definition of custodial careCustodial care refers to non-skilled personal care and room and board (non-skilled services)

Coverage differences — INTEGRITYINTEGRITY: custodial levels are covered when ordered by a health plan physician and skilled therapy services will be reimbursed separately for members in custodial care (coverage up to 365 days/year)

Background

Skilled nursing facility services encompass care and services delivered to an inpatient requiring a skilled level of care. This includes skilled nursing, rehabilitation therapies (physical, occupational, speech), medical social services, pharmaceuticals, durable medical equipment, room and board, and other necessary routine services. Coverage and applicable rules vary by product line: for example, Medicaid RHP/RHE members have a limit of up to 30 consecutive days and RIte Care covers all skilled levels when ordered by a health plan physician, while Commercial admissions must meet medical necessity and be ordered by a network physician. Providers are responsible for verifying eligibility, coverage, and authorization prior to rendering services.

Revision History & Policy Changes

2024-12-11coding_updateLatest

Added custodial care coding grid and updated claims submission section to include custodial care coding guidance.

2024-03-11authorization_update

Added authorization language to the prerequisites section requiring verification of eligibility, coverage, and prior authorization prior to rendering services.

2023-09-05coverage_update

Added skilled therapy services language for INTEGRITY and added Medicaid exclusion for certain members.

2016-07-01effective_date

Policy effective date established.