CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skilled Nursing Facility / Nursing Facility (SNF/NF) Coverage Criteria

Governs coverage and requirements for skilled nursing facility (SNF) and nursing facility inpatient services for Neighborhood Health Plan of Rhode Island members across Medicaid, Commercial, and INTEGRITY lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySkilled Nursing Facility / Nursing Facility (SNF/NF) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdded language for INTEGRITY skilled therapyMedicaid exclusion added

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all SNF admissions and ensure documentation supports skilled-level medical necessity.

SourceLink

POLICY UPDATE CHANGES

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

30 daysMedicaid RHP/RHE limit

≤365 daysINTEGRITY allowance

Levels 1-4Skilled levels covered

99304-99310; G0490Example CPT/HCPCS listed

0191-0194

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Coverage Criteria

General coverage criteria

Covered when ALL of the following are met:

Product-specific ordering: Admission is ordered by a network physician or health plan physician as required by product (network PCP referral for Commercial; network physician or health plan physician ordering for INTEGRITY).

Supported by chunks 4,5,8

Medical necessity and authorization: Services meet medical necessity criteria and, where specified, prior authorization is obtained for the admission.

Supported by chunks 2,7,8

Skilled need: Member requires skilled nursing services, skilled rehabilitation services, or skilled nursing observation provided on a daily basis; custodial or non-skilled care alone is not sufficient for coverage (custodial care is not covered when billed as skilled).daily skilled need

Supported by chunks 4,6,7

Level of care: Skilled levels of care (levels 1-4) are covered for inpatient SNF/NF members per product policy language.Levels 1-4

Supported by chunks 3,5

Custodial care, also described as rest care or non-skilled care, is not covered when provided in any facility setting. Examples include care delivered in convalescent homes, nursing homes, homes for the aged, halfway houses, or other residential facilities. Such care focuses on assistance with activities of daily living rather than skilled clinical services and falls outside the scope of SNF/NF coverage.

Skilled services billed for members who are actually in custodial-level care are not covered. The policy specifies that skilled services are not covered for members in custodial care, and services that are custodial in nature but billed as skilled may be denied. Providers should ensure that billed services meet the policy’s skilled-level requirements to avoid claim denials.

Admission Criteria for SNF / Nursing Facility

SNF / Nursing facility — Admission criteria

Ordered by physician: Admission must be ordered by a network physician or health plan physician as applicable; in‑network admission is required unless an appropriate in‑network setting is unavailable.

Supported by chunks 4,5,8

Authorization: Prior authorization is required for SNF admissions per product rules (INTEGRITY explicitly requires authorization).

Supported by chunk 8

Medical necessity and documentation: Admission must meet medical necessity criteria and documentation in the medical record must support the need for skilled services on a daily basis.

Supported by chunks 2,5

Continued Stay Criteria

SNF / Nursing facility — Continued stay criteria

Medicaid RHP/RHE 30-day guidance: For RHP/RHE Medicaid members: inpatient stays (skilled or custodial) are allowed for up to 30 consecutive days; stays beyond 30 days result in disenrollment from RHP/RHE and enrollment in Medical Assistance FFS per EOHHS.<=30 days

Supported by chunk 6

INTEGRITY allowance: For INTEGRITY members: coverage includes skilled and custodial levels of care when ordered by a health plan physician for up to 365 days and is not subject to stop‑loss provisions.<=365 days

Supported by chunk 8

Discharge Criteria

Discharge from the SNF/NF must be documented and supported in the medical record; specific discharge management services are identified by CPT codes 99315 (discharge management, ≤30 minutes) and 99316 (discharge management, >30 minutes). Documentation should justify discharge planning and the time spent, consistent with these codes.

Provider Actions and Requirements

Prior Authorization

Prior authorization required for SNF admissions

All SNF admissions ordered by a network physician must meet medical necessity criteria and require prior authorization; admission to an in-network skilled nursing facility is required unless an appropriate in-network setting is unavailable.

Prior authorization is required for INTEGRITY and per product rules.
In-network admission required unless network lacks appropriate setting.

Step Therapy

Medical necessity review sources

Neighborhood may use LCDs, NCDs, industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and internal Clinical Medical Policies when determining medical necessity for SNF services.

Providers are responsible for verifying eligibility, coverage, and authorization criteria prior to rendering services.

Coding and Billing

Revenue Codes by LevelRevenue

0191	Level I, Revenue Code
0192	Level II, Revenue Code
0193	Level III, Revenue Code
0194	Level IV, Revenue Code

Revenue Codes by Level (duplicate)Revenue

0191	Level I, Revenue Code
0192	Level II, Revenue Code
0193	Level III, Revenue Code
0194	Level IV, Revenue Code

Listed CPT/HCPCS CodesCPT | HCPCS

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

1–10 of 12

1/2

Day Limits and Duration

Day limits — product-specific

Medicaid RHP/RHE limitFirst 30 consecutive days of inpatient SNF/NF care for RHP and RHE members; stays beyond 30 days result in disenrollment from RHP/RHE and enrollment in Medical Assistance FFS per EOHHS.

INTEGRITY allowanceCoverage of skilled and custodial levels of care when ordered by a health plan physician for up to 365 days; not subject to stop-loss provisions.

Other productsLength of stay and coverage beyond specified product limits are determined per the member’s plan benefits and medical necessity review.

Definitions

SNF/NF services — definition

DefinitionSkilled nursing facility (SNF) / nursing facility (NF) services are provided to a member who is an inpatient of a SNF/NF and may include skilled nursing and/or rehabilitation care, room and board, physical/occupational/speech therapies, medical social services, pharmaceuticals, and durable medical equipment.

Coverage scopeCovered for members while inpatient at a skilled facility; custodial-level and skilled-level care (levels 1–4) are recognized in policy and may be covered depending on product rules.

Admission settingAdmission to an in-network skilled nursing facility / nursing facility is required unless the network does not have an appropriate setting for the individual member.

Skilled level of care — Levels 1–4

Scope of levelsSkilled levels of care are defined as Levels 1–4 and represent services requiring skilled nursing or skilled rehabilitation provided to inpatients.

Background

Skilled nursing facility (SNF) inpatient services encompass a combination of clinical and supportive services provided to members who require skilled-level care. Typical SNF services include skilled nursing, rehabilitation therapies (physical, occupational, speech), medical social services, administration of medications, and provision or coordination of durable medical equipment. Evaluation, annual assessments, and discharge planning are described with specific E/M and discharge codes (for example, CPT 99318, 99315, and 99316) and should be supported by contemporaneous documentation.