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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUniversity Health Alliance SNF Coverage & Limits |…
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    CurrentUniversity Health Alliance (HSA)Policy MPP-0127-180817

    Inpatient Skilled Nursing Facility (SNF) reimbursement

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    Defines medical necessity, coverage criteria, limitations, and payment-related administrative rules for inpatient SNF services offered to University Health Alliance members.

    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyInpatient Skilled Nursing Facility (SNF) reimbursement
    Policy CodePolicy MPP-0127-180817
    Change TypeNo material change
    Effective DateJun 2, 2021
    Last ReviewJun 2, 2021
    Next Review Date
    Key ActionNotify UHA's Health Care Services Department of member admissions to SNF as soon as possible.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    120 daysmaximum SNF coverage per calendar year
    5 days/weekminimum skilled services frequency
    30 daysphysician report interval if >30 days
    not requiredauthorization requirement

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medical Necessity and Coverage Criteria

    Medical necessity and LOC criteria

    UHA considers inpatient SNF services medically necessary when ALL of the following general and service‑specific criteria are met:

    ALL of the following

    • Skilled nursing care is required and skilled nursing criteria are met.
    • Admission is medically necessary, admission criteria are met, and admission has been approved by UHA.
    • Skilled nursing services are provided under the care of a physician during the admission.
    • The admission is not primarily for comfort, convenience, a rest cure, domiciliary, or custodial care.
    • If the stay exceeds 30 days, the attending physician submits a report showing the need for skilled nursing care at the end of each 30‑day period.

    • Service‑specific Level of Care (one or more required)

      • Nursing management of indwelling bladder catheter, nephrostomy tube, or suprapubic tube during the early post‑insertion period or in the presence of catheter complications; OR insertion, sterile irrigation, and/or replacement of suprapubic catheters.
      • Daily monitoring of unstable blood sugars and administration of varied doses of insulin (sliding scale) for unstable diabetic management.
      • (Examples) Newly inserted enteral tube management, complex medication monitoring or parenteral medications/fluids, complex wound care, respiratory care requiring frequent treatments, and rehabilitative programs meeting intensity thresholds.
    Pre‑admission evaluation documents baseline function, summary of medical history, medical treatment needs with expected frequency and duration, prognosis (expected improvement and anticipated length of stay), and family/caregiver willingness and ability to assist after discharge.
    An inpatient plan of care is developed and updated by facility staff and includes measurable nursing/rehabilitation goals, planned interventions, evidence of active skilled nursing involvement necessary to meet medical needs and ensure safety, and discharge planning.

    SNF Admission Criteria

    SNF — admission criteria

    Admission to an inpatient SNF is covered when ONE of the following sets of criteria is met:

    ALL of the following

    • Patient requires skilled services (RN/LPN/PT/OT/SLP) that are of inherent complexity such that they can be performed safely and effectively only by, or under the general supervision of, licensed professionals (cannot be provided by non‑skilled personnel).
    • Patient requires skilled services at least 5 days per week or on a daily basis as specified in the Service‑Specific LOC criteria.
    • The required services cannot be safely provided in a less restrictive setting (e.g., at home with skilled home health or outpatient services).
    • A preadmission evaluation documents baseline function, medical history, treatment needs including expected frequency and duration, prognosis, and caregiver ability/willingness to assist after discharge.
    Admission must be approved by UHA (notification requested) and the admission is not for custodial care, comfort, convenience, or domiciliary reasons.

    Continued Stay Criteria

    SNF — continued stay criteria

    Continued inpatient SNF care is covered when ALL of the following are documented:

    ALL of the following

    • Continued need for the inpatient SNF setting with documented significant medical and/or functional progress toward established goals.
    • Required services cannot be safely provided in a less restrictive setting.
    • Service‑Specific Level of Care (LOC) criteria that supported admission continue to be met.
    • Daily documentation of the patient’s progress and/or complications is maintained and ongoing medical necessity/clinical appropriateness is evaluated through concurrent review (daily documentation and concurrent review).

    Discharge Criteria

    Discharge from SNF level of care is appropriate when the individualized plan of care goals have been met or when the member no longer requires skilled nursing or skilled therapy services. The SNF plan of care must document realistic, measurable functional goals and planned interventions; when those goals are achieved such that continued skilled services are not needed, SNF care should be discontinued. (See required elements of the inpatient plan of care including nursing/rehabilitation goals, planned interventions, and discharge plans.)

    Members should be discharged from SNF when their needs become primarily custodial or routine/unskilled care (for example, if ongoing care consists of repetitious exercises, minimal or light physical assist for basic ADLs, or services that can be safely provided by supportive personnel), since these do not meet skilled rehabilitation criteria. Speech/language therapy provided only for language therapy does not alone meet SNF LOC and would not by itself justify continued SNF stay.

    Admission Notification and Review Requirements

    Prior Authorization

    Admission notification and review

    Notify University Health Alliance's Health Care Services Department of a member's admission to a skilled nursing facility as soon as possible; prior authorization is not required but UHA may perform retrospective or concurrent review of the admission and ongoing medical necessity.

    • Notification required whether recommendation comes from a participating or non‑participating physician.
    • UHA may perform retrospective review to validate services and evaluates ongoing medical necessity via concurrent review; daily documentation of progress/complications is required.

    SNF Day Limits

    inv-09: SNF — Up to 120 days.
    Coverage limitUp to 120 days per calendar year
    ScopeApplies to general Skilled Nursing Facility (SNF) services
    Benefit countingHospital Swingbed units utilize SNF benefit days
    inv-02: Annual SNF day limit — 120 days per calendar year.
    Annual day limit120 days per calendar year
    Counting periodPer calendar year
    Applies toCovered general SNF services within policy guidelines

    Key Definitions

    inv-04: SNF definition — Skilled Nursing Facility description.
    DefinitionSkilled Nursing Facility (SNF): an inpatient facility providing skilled nursing and/or therapy services; excludes institutions primarily for care and treatment of mental diseases.
    Swingbed unitsHospital Swingbed units are subject to the same coverage criteria as SNFs and utilize SNF benefit days.
    PurposeUsed when patient care needs and clinical condition require services not safely deliverable in a less restrictive setting.
    inv-05: Skilled services — definition of skilled services and provider qualifications.
    Definition of skilled servicesServices that must be performed by, or under the supervision of, licensed nurses and/or physical or occupational therapists.
    Minimum frequency for admissionTypically required at least 5 days per week for SNF admission.
    Provider qualificationsPerformed by or under general supervision of licensed professionals (RN, LPN, PT, OT, SLP) due to inherent service complexity.

    Coding and Utilization Limits

    inv-02: Annual SNF day limit referenced for coding/utilization guidance.
    Reference limitAnnual SNF day limit: 120 days per calendar year (used for coding and utilization monitoring)
    Admission documentationSNF admissions must document need for skilled services and service-specific LOC criteria to justify use of SNF days.
    Counting ruleSNF benefit days include hospital Swingbed utilization and fall within the annual 120-day limit.
    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyInpatient Skilled Nursing Facility (SNF) reimbursement
    Policy CodePolicy MPP-0127-180817
    Change TypeNo material change
    Effective DateJun 2, 2021
    Last ReviewJun 2, 2021
    Next Review Date
    Key ActionNotify UHA's Health Care Services Department of member admissions to SNF as soon as possible.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaSNF Admission CriteriaContinued Stay CriteriaDischarge CriteriaAdmission Notification and Review RequirementsSNF Day LimitsKey DefinitionsCoding and Utilization Limits