CurrentWellCarePolicy CC.PP.206

Skilled Nursing Facility Leveling (payment criteria)

Defines reimbursement requirements for skilled nursing facility (SNF) levels of care (levels 1–5 depending on facility contract) based on skilled nursing and skilled therapy hours and other high-acuity criteria; applies to health plans affiliated with Centene Corporation/WellCare.

Policy Summary

PayerWellCare

PolicySkilled Nursing Facility Leveling (payment criteria)

Policy CodePolicy CC.PP.206

Change TypeRevisions and clarifications (annual reviewsadministrative header updateCPT table removed)

Effective Date

Next Review Date

Key ActionReport the appropriate SNF level using the corresponding revenue code and document skilled nursing/therapy time and clinical justification to support the billed level.

SourceLink

POLICY UPDATE CHANGES

CPT code table removed as of 03/2025 annual review.

Updated header to reflect that policy is a payment policy (08/2024).

Changed I.D.2. to note that the clinical circumstances noted are examples of intensive care (09/08/2023 migration from retired policy).

Levels 1-5SNF levels defined (dependent on facility contract)

191,192,193,194,199Revenue codes associated with levels 1-5

High-cost listHigh-cost drug administration may qualify for intensive level

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SNF Level of Care Criteria

SNF Level of Care criteria (facilities contracted for Levels 1–4)

Requirements that must be met to be reimbursed for each SNF level of care for facilities contracted for levels 1 through 4.

ANY of the following

Level 1 (Rev Code 191): Skilled nursing up to 4 hours/day, 7 days/week OR skilled therapy 1–2 hours/day, at least 5 days/week.

ANY of the following

Level 2 (Rev Code 192): Skilled nursing at least 4 hours/day, 7 days/week OR skilled therapy at least 2 hours/day, at least 5 days/week.

ALL of the following

Level 3 (Rev Code 193): Skilled nursing >4 hours/day, 7 days/week
AND skilled therapy at least 3 hours/day, at least 5 days/week.

ALL of the following

Level 4 (Rev Code 194): Skilled nursing >4 hours/day, 7 days/week
AND patient requires Level 4 due to high acuity such as catastrophic multiple traumas, severe head injury or CVA, stabilized spinal cord injury, ventilator dependence (weanable or non-weanable), or administration of a listed high-cost drug (examples provided).
High-cost drug examples are listed in the policy (see High-Cost Drug List).

SNF Level of Care criteria (facilities contracted for Levels 1–5)

Requirements that must be met to be paid for each SNF level of care for facilities contracted for levels 1 through 5.

ANY of the following

Level 1 (Rev Code 191): Skilled nursing up to 4 hours/day, 7 days/week OR skilled therapy 1–2 hours/day, at least 5 days/week.

ANY of the following

Level 2 (Rev Code 192): Skilled nursing at least 4 hours/day, 7 days/week OR skilled therapy at least 2 hours/day, at least 5 days/week.

ALL of the following

Level 3 (Rev Code 193): Skilled nursing >4 hours/day, 7 days/week
AND skilled therapy at least 3 hours/day, at least 5 days/week.

Revenue and Drug Codes

Revenue codes referenced by levelRevenue

191	Rev Code 191 — Level of Care 1 (SN services)
192	Rev Code 192 — Level of Care 2 (Comprehensive Care)
193	Rev Code 193 — Level of Care 3 (Medical/Surgical/Sub-Acute)
194	Rev Code 194 — Level of Care 4 (Intensive/Medically Complex)
199	Rev Code 199 — Level of Care 5 (Intensive)

High-cost drugs (administration may qualify for intensive level)NDC|mixed

Extensive list of drug names included in policy (e.g., Adempas, Avastin, Herceptin, Humira Pen, Ibrance, Neulasta, Rituxan, Soliris, etc.).

Billing, Documentation, and Drug Administration Requirements

Billing Rule

Report appropriate revenue code for SNF level

Report the SNF level using the corresponding revenue code that reflects the services performed and hours of skilled nursing and/or therapy delivered.

Rev Code 191
Rev Code 192
Rev Code 193
Rev Code 194
Rev Code 199

Documentation Required

Document skilled nursing and therapy services

Document the skilled nursing and therapy time and include clinical justification and physician orders to demonstrate that services meet the required skill level (e.g., skilled interventions, complexity, or high-acuity needs).

Billing Rule

High-cost drug administration

When billing for Level 4 or Level 5 intensive care based on drug administration, document the administration and the specific drug identity from the policy's high-cost drug list to support intensive-level billing.

Administration of listed high-cost drugs (examples include Avastin, Herceptin, Humira Pen, Ibrance, Neulasta, Rituxan, Soliris, etc.) may qualify for Level 4 or Level 5 intensive care.

Policy Context and Scope

Background: This payment policy references federal guidance, including the Medicare Benefit Policy Manual chapter on extended care (SNF) services and applicable federal regulations, to define how skilled nursing and skilled rehabilitation services are characterized and when those services require the skills of licensed professionals. The policy reiterates that skilled services must be furnished in accordance with physician orders and only when the complexity or the patient’s medical complications require the skills of qualified personnel such as registered nurses, licensed practical nurses, physical, occupational, or speech therapists. Medicare manuals and federal regulations take precedence where applicable (see referenced CMS manuals and CFR provisions).

Scope summary: This document is a payment policy that defines reimbursement requirements for Skilled Nursing Facility (SNF) levels of care — Levels 1–5 (as applicable by facility contract) — based on the hours of skilled nursing and skilled therapy provided and other high-acuity criteria (including administration of listed high-cost drugs). It applies to health plans affiliated with Centene Corporation/WellCare and is intended to guide payment determination; it is not a guarantee of coverage or payment and does not replace plan contract terms or legal/regulatory requirements.

Numeric and Clinical Thresholds

Skilled nursing hours threshold (level 1)up to 4 hours per day

Skilled nursing hours threshold (level 2)at least 4 hours per day

Skilled nursing hours threshold (levels 3-5)more than 4 hours per day

Skilled therapy threshold (level 1)1–2 hours per day, at least 5 days per week

Skilled therapy threshold (level 2)at least 2 hours per day, at least 5 days per week

Skilled therapy threshold (levels 3-4)at least 3 hours per day, at least 5 days per week

Policy Updates

2025-03revisedLatest

CPT code table removed as part of the 03/2025 annual review; minor background wording changes noted with no impact to criteria.

2024-08revised

Header updated to reflect that the document is a payment policy.

2023-09-08clarified

I.D.2. changed to clarify that the listed clinical circumstances are examples of intensive care (migration from retired policy CP.MP.206).

Policy Summary

PayerWellCare

PolicySkilled Nursing Facility Leveling (payment criteria)

Policy CodePolicy CC.PP.206

Change TypeRevisions and clarifications (annual reviewsadministrative header updateCPT table removed)

Effective Date

Next Review Date

Key ActionReport the appropriate SNF level using the corresponding revenue code and document skilled nursing/therapy time and clinical justification to support the billed level.

SourceLink

On This Page

OpenPayer

Skilled Nursing Facility Leveling (payment criteria)

SNF Level of Care Criteria

Revenue and Drug Codes

Billing, Documentation, and Drug Administration Requirements

Policy Context and Scope

Key Definitions

Numeric and Clinical Thresholds

Policy Updates

Skilled Nursing Facility Leveling (payment criteria)

SNF Level of Care Criteria

Revenue and Drug Codes

Billing, Documentation, and Drug Administration Requirements

Policy Context and Scope

Key Definitions

Numeric and Clinical Thresholds

Other Policies You May Need

Policy Updates