CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skilled Nursing Facility Payment Policy

Governs submission, authorization, coverage, and billing rules for skilled nursing facility (SNF) services for Neighborhood Health Plan of Rhode Island members across specified product lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySkilled Nursing Facility Payment Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2016

Next Review DateJul 1, 2017

Key ActionAll admissions ordered by a network physician require prior authorization and must meet medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS 1450required claim form

30 daysRHP/RHE limit

365 daysUNITY/INTEGRITY limit

Bill Types 211-228accepted TOBs

0100,0128-0129,0191-0194example revenue codes

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SNF coverage criteria by product

Coverage and payment depend on the member's product; all admissions require medical necessity and prior authorization.

Admission must be to an in-network skilled nursing facility unless the network does not have the appropriate facility for the member; all admissions, as ordered by a network physician, must meet medical necessity criteria and require prior authorization.

By product

RHP / RHE: Custodial level of care is covered only for RHP or RHE members; benefit limited to up to 30 consecutive days in a skilled nursing facility or nursing facility at a skilled or custodial level of care. Members who have stays longer than 30 days are disenrolled from RHP/RHE (they remain on the plan until the last day of the month in which the 30th day occurs).
UNITY / INTEGRITY: Coverage includes all skilled and custodial levels of care when ordered by a health plan physician up to 365 days per year. Patient share is deducted from day one until the member's share amount has been exhausted; for INTEGRITY, days 21–100 patient share is applied at the Medicare coinsurance rate until member's share is exhausted, and days 101+ patient share is deducted until exhausted.
Rite Care: Coverage includes all skilled levels of care when ordered by a health plan physician; custodial care is not covered for Rite Care unless specified elsewhere.

Exclusions and restrictions: Extended Family Planning (EFP) members do not have SNF benefits. Health Benefit Exchange (HBE) members do not have custodial, rest, day, or non-skilled care in any facility. Non-emergency medical transportation from a facility is subject to restrictions and should be used only when the patient cannot be transported by other means and required services cannot be provided within the facility.

Member financial responsibility

Copayments, deductible, patient share and/or coinsurance may apply depending on the benefit plan.
UNITY: patient share will be deducted until the member's share amount has been exhausted.
INTEGRITY: days 21–100 patient share applied at Medicare coinsurance rate until member's share is exhausted; days 101+ patient share deducted until exhausted.

Facility billing and therapy rules: Providers must submit correct CPT/HCPCS and diagnosis codes and follow claim submission guidelines; skilled therapy services may be reimbursed separately for certain products per billing guidelines.

Billing, Bill Types, and Revenue Codes

Accepted bill typesRevenue

211-228

Bill Types accepted

Example revenue codes for room/level billingRevenue

0100	Custodial Room and Board
0128	Custodial Room and Board with Ventilation Bed - Rehabilitation
0129	Custodial Room and Board with Ventilation Bed - Other
0191	Level I revenue code
0192	Level II revenue code
0193	Level III revenue code
0194	Level IV revenue code

RHP/RHE SNF consecutive day limit

RHP/RHE consecutive day limitUp to 30 consecutive days in a skilled nursing facility or nursing facility (skilled or custodial level); member remains on plan until the last day of the month in which the 30th day occurs

UNITY/INTEGRITY annual SNF coverage limit

UNITY/INTEGRITY annual SNF coverage limitCoverage of all skilled and custodial levels of care when ordered by a health plan physician, up to 365 days per year

Authorization and Provider Requirements

Prior Authorization

Prior authorization required for all admissions

All admissions to a skilled nursing facility ordered by a network physician must obtain prior authorization and meet medical necessity criteria. Follow the plan's Prior Authorization Reference Guide for submission steps and any required documentation.

Obtain prior authorization before admission for any SNF/NF inpatient stay ordered by a network physician.
Ensure the admission meets medical necessity criteria per the plan; include supporting clinical documentation with the authorization request.
Use the Prior Authorization Reference Guide for the exact prior authorization process and required forms.

Key Definitions

Skilled nursing facility/nursing facility care services

Definition of SNF/NF servicesInpatient services for members in a skilled nursing facility or nursing facility that may include skilled nursing and/or rehabilitation care and/or custodial 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 nursing scopeIncludes skilled nursing and rehabilitation services provided during an approved inpatient admission at a skilled nursing facility

Additional services includedTherapies, medical social services, pharmaceuticals, DME, and other routine services required for the member's care

Level of care

Skilled levels of care (Levels 1-4)Skilled levels 1-4 are covered for all lines of business when provided during an approved inpatient SNF/NF admission

Custodial level of careCustodial care coverage varies by product: covered for RHP or RHE members (subject to RHP/RHE limits) and included for UNITY and INTEGRITY when ordered by a health plan physician; Rite Care does not cover custodial care unless specified elsewhere

Product variance noteCoverage of custodial care depends on product — UNITY/INTEGRITY include custodial coverage (up to 365 days), RHP/RHE permit custodial care only within the 30-consecutive-day benefit limit

OpenPayer

Skilled Nursing Facility Payment Policy

Skilled Nursing Facility Coverage Criteria

Billing, Bill Types, and Revenue Codes

Authorization and Provider Requirements

Key Definitions