CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skilled nursing facility / nursing facility care services

Policy governs coverage, medical necessity prerequisites, documentation, billing codes, and member responsibilities for skilled nursing facility (SNF) and nursing facility care across Medicaid (including RHP/RHE/RIte Care), Commercial, and INTEGRITY product lines 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 TypeAuthorization and INTEGRITY coverage updates

Effective DateJul 1, 2016

Next Review Date

Key ActionAll admissions for INTEGRITY require prior authorization; providers must verify and obtain required authorizations per product rules.

SourceLink

POLICY UPDATE CHANGES

03/11/2024: Added authorization language to prerequisite section.

09/05/2023: Added Skilled services language for INTEGRITY and added Medicaid exclusion language.

10/01/2022: Format changes; no content changes.

07/01/2016: Effective Date established.

365INTEGRITY maximum covered days per year

30Medicaid RHP/RHE covered consecutive inpatient days

30Covered hospice days for RHP/RHE in nursing home setting

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Coverage Summary & Scope

This payment policy defines coverage and reimbursement for skilled nursing facility and nursing facility services, including skilled nursing and/or rehabilitation care, room and board, therapies, medical social services, pharmaceuticals, durable medical equipment, and other necessary routine services for members who are inpatients of a skilled nursing facility or nursing facility. It governs coverage, medical necessity prerequisites, documentation, billing codes, and member/provider responsibilities across Medicaid, Commercial, and INTEGRITY product lines. The policy effective date is 2016-07-01 and the last review was on 2024-03-11.

Scope-level coverage metrics

INTEGRITY maximum covered days per year365

Medicaid RHP/RHE covered consecutive inpatient days30

Covered hospice days for RHP/RHE in nursing home setting30

Skilled level of care designations coveredLevels 1-4

Medical Necessity Criteria (by product / population)

General medical necessity

Services are covered when ALL of the following are met:

Inpatient status: Member is an inpatient of a skilled nursing facility or nursing facility.
Medical necessity: Services must be medically necessary; Neighborhood may use LCD, NCD, InterQual, RI EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.
03/11/2024: Added authorization language to prerequisite section.
Covered services: Services may include 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.
Provider responsibilities:

Codes and Billing Categories

Revenue CodesRevenue

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

Covered E/M and facility codes (examples provided)CPT|HCPCSCovered

99304	Initial nursing facility care, detailed/comprehensive exam; ~25 minutes
99305	Initial nursing facility care, comprehensive history/exam; ~35 minutes
99306	Initial nursing facility care (higher complexity)
99307	Subsequent nursing facility care, straightforward MDM; ~10 minutes
99308	Subsequent nursing facility care, expanded problem focused; ~15 minutes
99309	Subsequent nursing facility care, detailed; ~25 minutes
99310	Subsequent nursing facility care, comprehensive/high complexity; ~35 minutes
99315	Facility discharge management; 30 minutes or less
99316	Facility discharge management; more than 30 minutes
99318	Annual nursing assessment E/M for nursing facility; ~30 minutes

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Provider Actions & Operational Requirements

Prior Authorization

Authorization requirement for INTEGRITY and some products

All admissions for INTEGRITY require prior authorization; providers must verify eligibility, coverage, and obtain required authorizations per product rules.

Documentation Required

Facility notification to UM

The facility must notify Neighborhood Utilization Management (UM) of any admission, discharge, level-of-care change, or member expiration regardless of duration.

Documentation Required

Medical record documentation

Documentation in the medical record must support billed services and the medical necessity of the services. Neighborhood reserves the right to request medical records for any service billed and follows CMS standards for proper documentation requirements.

Definitions & Background

This policy references Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), industry-accepted criteria such as InterQual, Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations, and Neighborhood Clinical Medical Policies (CMP) to determine medical necessity. It also relies on internal Clinical Medical Policies and coding standards (CPT/HCPCS and revenue codes) for claims and reimbursement.

Definitions

Background / References

Revision History

03/11/2024revisedLatest

Added authorization language to prerequisite section; indicates prior authorization requirement (noted for INTEGRITY and added general prerequisite info).

09/05/2023added

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

10/01/2022clarified

Medicaid - General

Medicaid-specific coverage rules

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

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 up to 30 consecutive days in a skilled nursing facility or nursing facility at a skilled or custodial level of care; stays longer than 30 days result in disenrollment from RHP/RHE by EOHHS and enrollment in Medical Assistance fee-for-service.30 days

RHP/RHE hospice in nursing home: Neighborhood will cover the first thirty (30) days of hospice care for RHP and RHE members when delivered in a nursing home setting; starting on the first day Medical Assistance FFS will reimburse hospice care and room and board.30 days

Conflict on custodial therapy coverage: Policy notes conflicting language: some Medicaid lines state custodial and skilled levels (1-4) are covered while another statement indicates skilled services are not covered for members in custodial care; see product-specific rules (e.g., INTEGRITY, RIte Care) for clarification.

INTEGRITY product line

INTEGRITY-specific rules

INTEGRITY inpatient coverage: Skilled nursing facility/nursing facility services are covered for members while inpatient at an approved admission; skilled level of care (levels 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 the appropriate setting for the individual member.

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

03/11/2024: Added authorization language to prerequisite section.

Custodial coverage for INTEGRITY: 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 per year

Separate reimbursement note: Skilled services will be reimbursed separately for INTEGRITY members in custodial care (custodial therapy may be separately reimbursed).