Currentpriority healthPolicy N/A

Skilled Nursing Facility / Non-Acute Inpatient Services

Defines coverage, documentation, billing, and clinical criteria for skilled nursing, subacute, and rehabilitation facility services for Priority Health members, and explains when services are covered, not covered, and how they must be documented and billed.

Policy Summary

Payerpriority health

PolicySkilled Nursing Facility / Non-Acute Inpatient Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 30, 2024

Next Review DateFeb 1, 2025

Key ActionAll skilled services in SNF, Subacute, or Rehabilitation Facilities must be authorized; obtain prior authorization or a PSOD when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60Improvement window (days)

dailyFrequency requirement

14Nursing assessment timeframe (days)

0191-0194Revenue codes

Occ Code 50Related denial token

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 — What Is (and Is Not) Covered

Covered Skilled and Rehabilitative Services

Covered when ALL of the following are met

Core skilled care coverage criteria: Skilled nursing and/or rehabilitative services must be primarily restorative and rehabilitative in nature; be needed on a daily (5-7 days/week) basis and, as a practical matter, can only be provided in a skilled nursing or hospital facility on an inpatient basis; be furnished pursuant to a physician's order; require the skills of technical or professional personnel; and be reasonably expected to result in a meaningful improvement in the member's ability to perform functional day-to-day activities within 60 days of initiation of therapy.daily (5-7 days/week); meaningful improvement within 60 days

Based on Priority Health medical policy language.

Examples of covered skilled nursing services: Application of dressings involving prescription medications and aseptic techniques; insertion and sterile irrigation and replacement of catheters; intravenous, intramuscular, or subcutaneous injections (excluding self-administered injections such as insulin); overall management and evaluation of a complex care plan; observation and assessment of changing condition; patient education to teach self-maintenance or self-administration of care; nasopharyngeal and tracheotomy aspiration; new IV/Levine tube/gastrostomy feedings teaching; treatment of extensive decubitus ulcers or other widespread skin disorder.

Examples to guide coverage determinations.

Examples of covered skilled rehabilitative services: Services to develop and manage a patient care plan including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, ADL testing, perceptual deficits, speech and language or hearing disorders; therapeutic exercises or activities that must be performed by or under supervision of a qualified PT/OT; hydrocollator, paraffin baths, and whirlpool when complicated by circulatory deficiency/open wounds/fractures; services of a speech pathologist or audiologist when necessary to restore function.

Need for rehabilitative services should be documented by referring provider.

Non-covered / Custodial Services

Not covered when

Non-covered routine/custodial services: Custodial care and general maintenance services are not covered, including administration of routine medications, eye drops and ointments; assistance in dressing, eating, and toileting; changes of dressings for noninfected postoperative or chronic conditions; general maintenance care of colostomy and ileostomy; routine services to maintain satisfactory functioning of indwelling bladder catheters; general maintenance care in connection with a plaster cast; general supervision of previously taught exercises and performance of maintenance programs; periodic turning and repositioning; prophylactic and palliative skin care (bathing, creams, minor skin problems); routine care of incontinent patients; routine care in connection with braces and similar devices; use of heat as a palliative/comfort measure; and routine administration of medical gases after a regimen is established.

These are non-covered examples per policy.

Custodial care when recovery not expected: When recovery or further meaningful improvement is not possible and skilled care is only needed to prevent deterioration (custodial care), skilled nursing services are not covered.

Policy distinguishes custodial care from covered skilled rehabilitative care.

This policy does not apply to substance abuse or alcoholism rehabilitation services or treatment facilities. Facilities and programs whose primary purpose is treatment of substance use disorders or alcoholism are excluded from the scope of this Skilled Nursing Facility / post-acute care policy.

Custodial care is not covered under this policy. When recovery or further meaningful improvement is not possible and skilled services are only required to prevent deterioration (i.e., the care is custodial rather than restorative), those skilled services are considered not medically necessary. Coverage requires that services be primarily restorative, ordered by a physician, require technical or professional personnel, and be reasonably expected to produce meaningful improvement within 60 days; if those conditions are not met and the needed care is custodial in nature, coverage is not provided.

Billing Codes and Coding Rules

Revenue codes for subacute/level of careRevenue

0191	Subacute care -Level I Note: Priority health doesn ' t reimburse this level of care. Level I (skilled care) reflect minimal nursing intervention. Comorbidities do not complicate the treatment plan. An assessment of vitals and body systems is required one to two times per day.
0192	Subacute care -Level II Level II (comprehensive care) reflects moderate nursing intervention. Active treatment of comorbidities is required. An assessment of vitals and body systems is required two to three times per day.
0193	Subacute care -Level III Level III (complex care) reflects moderate to extensive nursing intervention. Active medical care and treatment of comorbidities is required. There is potential for the comorbidities to affect the treatment plan. An assessment of vitals and body systems is required three to four times per day.
0194	Subacute care -Level IV This level IV (intensive care) reflects extensive nursing and technical intervention. Active medical care and treatment of comorbidities is required. There is potential for the comorbidities to affect the treatment plan. An assessment of vitals and body systems is required four to six times per day.

Related denial languagemixed

Occurrence Code 50

Required on SNF claims with Revenue Code 0022

inv-07: Expected functional improvement window

Expected improvement timeframeMeaningful improvement expected within 60 days of initiation of therapy

ApplicabilityApplies to skilled nursing and rehabilitative services provided in SNF, Subacute, or Rehabilitation Facilities

Implication for continued stayOngoing skilled services must be reasonably expected to result in meaningful improvement within 60 days to remain covered

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization / PSOD Required

All skilled services in a Skilled Nursing, Subacute, or Rehabilitation Facility must be authorized. For Medicare indications that do not meet NCD, LCD, or specific medical policy criteria, a Pre-Service Organization Determination (PSOD) is required. See the Priority Health Provider Manual for PSOD and prior authorization procedures.

All SNF/Subacute/Rehab admissions and skilled services require authorization/PSOD when applicable.
Prior authorization/PSOD required when services do not meet NCD/LCD or medical policy criteria.

Billing Rule

Occurrence Code Requirement

Providers must ensure required occurrence coding on SNF claims. Occurrence Code 50 is required on SNF claims with Revenue Code 0022. Failure to include the required occurrence code may result in claim denial or payment recoupment.

Add Occurrence Code 50 on claims with Rev Code 0022.

Documentation Required

Required SNF Documentation

Maintain complete, authenticated SNF medical records. Documentation must include admission orders, physician certification that daily skilled care was required and could only be provided in an inpatient SNF setting, an authenticated plan of care, and the time (in minutes) for therapy services provided. Records must also include a comprehensive nursing assessment performed within 14 days of admission (unless a readmission) covering demographics, cognition, communication, mood/behavior, physical function, continence, diagnoses, medications, skin and nutritional status, special treatments/procedures, discharge planning, and MDS-triggered assessment summaries. Document direct observation and staff communication on all shifts, regular assessment of treatment goals, the patient’s response to skilled services, a plan for future care, detailed rationale for skilled needs, complexity of service, and other pertinent patient characteristics.

Admission orders and physician certification that daily skilled SNF care was necessary.
Authenticated plan of care and therapy time (minutes) for each service.
Comprehensive nursing assessment within 14 days of admission (unless readmission) including all listed domains.
Documentation of assessment participation (direct observation and staff communication on all shifts).
Regular assessment of treatment goals, response to skilled services, and plan for future care with rationale and service complexity.

Denial Risk

Denial and Recoupment Risk

Failure to follow Priority Health billing and documentation requirements, or to properly document services/items supplied, may result in claim rejection, denial, or recovery/recoupment of payments. An authorization does not guarantee payment if billing, coding, or documentation requirements are not met. Priority Health may perform pre- or post-claim payment integrity reviews.

Noncompliance may result in claim rejection/denial and payment recoupment.
Authorizations do not override coding, billing, or documentation requirements.
Payment integrity reviews may be performed pre- or post-claim.

Background and Context

A Skilled Nursing Facility (SNF) provides 24-hour nursing care, rehabilitative therapies, and medical treatment for patients who require temporary inpatient care following hospitalization. SNF services covered by this policy are those that are primarily restorative, require the skills of technical or professional personnel, are furnished pursuant to a physician's order, and are expected to result in meaningful functional improvement within 60 days of therapy initiation. Admission and continued SNF-level care rely on documentation showing the need for daily skilled services that cannot safely be delivered at home.

Key Definitions

inv-14: Skilled Nursing Facility (SNF)

DefinitionPlaces for people to live temporarily while they receive 24-hour nursing care, rehabilitation and medical treatments after hospitalization for an illness or injury.

Typical services24-hour nursing care, rehabilitation therapies, medical treatments and diagnostic/therapeutic services provided during confinement

Coverage contextAdmission and services not covered if necessary care can be provided safely in the home

inv-15: Skilled rehabilitative services

Primary natureServices must be primarily restorative and rehabilitative in nature

Frequency requirementNeeded on a daily (5-7 days/week) basis

Other requirementsFurnished pursuant to a physician's order and require the skills of technical or professional personnel

Expected outcomeReasonably expected to result in meaningful improvement in functional day-to-day activities within 60 days of therapy initiation

Admission Criteria for SNF/Subacute/Rehab

SNF — Admission criteria

Admission criteria: Patient requires 24-hour nursing care or skilled rehabilitative services that are primarily restorative, are ordered by a physician, require professional or technical personnel, must be provided on a daily basis in a Skilled Nursing Facility or inpatient facility as a practical matter, and documentation supports that the necessary care cannot be provided safely in the home.daily skilled need

Admission must be documented with admission orders, certification that daily skilled care was needed and only provided in a SNF, and an authenticated plan of care per documentation requirements.

Criteria for Continued Stay

SNF — Continued stay criteria

Continued stay criteria: Ongoing skilled services are reasonably expected to result in meaningful improvement within 60 days of therapy initiation; continued need for skilled services is documented including the member's response to skilled services, therapy minutes, regular reassessment of treatment goals, and a detailed rationale demonstrating complexity of service and other patient characteristics that justify ongoing SNF‑level care.meaningful improvement within 60 days

Therapy that does not meet goals is not covered; documentation of progress and reassessment required per SNF documentation standards.

Discharge Criteria

Discharge from SNF-level care is appropriate when the member no longer requires services that must be provided in an inpatient skilled setting. Typical discharge triggers include: the member has achieved recovery or sufficient meaningful improvement, the required services can be provided safely in the home, or the care being provided becomes custodial in nature with no reasonable expectation of further improvement. Documentation supporting discharge should reflect clinical progress, reassessment of goals, and the ability to transition care safely to a lower level of service or home setting.

Frequency and Day Limits

inv-19: SNF — daily frequency requirement

Practical daily expectationDaily, 5-7 days per week as the expected frequency for skilled services in SNF

Admission implicationCare must be needed on a daily basis and, as a practical matter, only provided in a skilled nursing or hospital facility

Documentation tie-inMedical record must certify that the patient needed daily skilled care that could only be provided in the SNF