CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skilled Nursing Facility Payment Policy

Governs submission, authorization, coverage limits, and billing requirements for skilled nursing facility (SNF) and nursing facility claims for Neighborhood Health Plan of Rhode Island members in specified programs.

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 must meet medical necessity criteria and require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysRHP/RHE custodial / SNF benefit limitation

up to 365 daysUNITY & INTEGRITY coverage

UB-04Required claim form

211-228Accepted bill types

0100,0128-0129,0191-0194Revenue codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria by product

Coverage varies by product; skilled levels are generally covered when ordered by a health plan physician and inpatient admission is authorized. Custodial coverage is limited by product.

Admission must be to an in‑network skilled nursing facility or nursing facility unless the network does not have appropriate services; prior authorization and medical necessity criteria apply.

See authorization requirements.

Product-specific coverage rules

UNITY: Skilled and custodial levels covered when ordered by a health plan physician, up to 365 days per year.
INTEGRITY: Skilled and custodial levels covered when ordered by a health plan physician, up to 365 days per year; therapy services in custodial care reimbursed separately (may be billed on TOB 22X).
RHP / RHE: Skilled levels 1–4 covered; custodial level covered only for RHP or RHE members with a limit of up to 30 consecutive days; members with stays beyond 30 days may be disenrolled from RHP/RHE.
Rite Care: Skilled levels covered when ordered by a health plan physician; custodial care is not covered as a standard benefit.

Plan exclusions and special cases

Extended Family Planning (EFP) members: SNF services are not included in the restricted benefit package.
Health Benefit Exchange members: Custodial/non‑skilled care in facilities (convalescent homes, nursing homes, homes for the aged, halfway houses, or other residential facilities) is not covered.
Transportation: Non‑emergency medical transportation from SNF/ICF is allowed only when the facility cannot provide transport and the required service cannot be provided within the facility; emergency transport only for severe cases.

Required Forms, Revenue Codes, and Patient Share

Required forms and revenue codesmixedCovered

UB-04	CMS 1450 claim form required for SNF submissions
0100	Custodial Room and Board revenue code
0128	Custodial Room and Board with Ventilation Bed - Rehabilitation revenue code
0129	Custodial Room and Board with Ventilation Bed - Other revenue code
0191	Level I revenue code
0192	Level II revenue code
0193	Level III revenue code
0194	Level IV revenue code

Patient share application thresholds

UNITY — Skilled carePatient share will be deducted until the member's share amount has been exhausted.

INTEGRITY — Skilled care Days 21-100Patient share will be at the Medicare coinsurance rate for days 21-100 until the member's patient share amount has been exhausted.

INTEGRITY — Skilled care Days 101+Patient share will be deducted until the member's share amount has been exhausted.

UNITY and INTEGRITY — Custodial carePatient share will be deducted from day one until the member's share amount has been exhausted.

Admission without qualifying 3-day hospital stayIf a member is admitted for skilled care without a qualifying 3‑day hospital stay, patient share will be deducted from day one until the member's share amount has been exhausted.

Skilled Nursing Facility / Nursing Facility Care Services

Skilled nursing facility / nursing facility care services

Scope of servicesIncludes skilled nursing, rehabilitation care, 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.

SettingServices are rendered to a member who is an inpatient of a skilled nursing facility or nursing facility.

Care typesEncompasses skilled nursing, rehabilitation, and custodial (non-skilled) care.

Support servicesMay include therapies, medical social services, pharmaceuticals, DME, and other routine services required during the inpatient stay.