CurrentWellCarePolicy CC.PP.206

Payment Policy: Skilled Nursing Facility Leveling

Defines reimbursement requirements for Skilled Nursing Facility (SNF) levels of care for providers contracted with Centene-affiliated health plans; affects SNFs and billing providers submitting claims to WellCare/Centene-affiliated plans.

Policy Summary

PayerWellCare

PolicyPayment Policy: Skilled Nursing Facility Leveling

Policy CodePolicy CC.PP.206

Change TypeAdministrative updates; references reviewed

Effective Date

Next Review Date

Key ActionProviders must follow plan-level administrative policies and state/federal requirements; payment policy is a guide and not a guarantee of payment.

SourceLink

POLICY UPDATE CHANGES

Updated header to reflect that policy is a payment policy and noted annual review with minor rewording in Background; references reviewed and updated.

Levels 1–4SNF levels of care described

~150+High-cost drug examples

08/2024Recent document activity

99304–99310Coding examples included

SNF Leveling Coverage Criteria

Reimbursement for SNF levels requires meeting specified skilled nursing and/or skilled therapy hour thresholds and, for the highest levels, the presence of high‑acuity conditions or administration of listed high‑cost drugs.

ALL of the following

Skilled nursing up to 4 hours per 7 days
Skilled therapy 1–2 hours per day for at least 5 days per week

ALL of the following

Skilled nursing at least 4 hours per 7 days
Skilled therapy at least 2 hours per day for at least 5 days per week

Policy Summary

PayerWellCare

PolicyPayment Policy: Skilled Nursing Facility Leveling

Policy CodePolicy CC.PP.206

Change TypeAdministrative updates; references reviewed

Effective Date

Next Review Date

Key ActionProviders must follow plan-level administrative policies and state/federal requirements; payment policy is a guide and not a guarantee of payment.

SourceLink

On This Page

Applicable Codes and Thresholds

CPT Codes — Nursing Facility E/MCPTCovered

99304	Initial nursing facility care; straightforward or low complexity — total time threshold: 25 minutes (when using total time for code selection).
99305	Initial nursing facility care; moderate complexity — total time threshold: 35 minutes (when using total time for code selection).
99306	Initial nursing facility care; high complexity — total time threshold: (per coding guidance)
99307	Subsequent nursing facility care; straightforward medical decision making — total time threshold: 10 minutes (when using total time for code selection).
99308	Subsequent nursing facility care; low complexity — total time threshold: 20 minutes (when using total time for code selection).
99309	Subsequent nursing facility care; moderate complexity — total time threshold: 30 minutes (when using total time for code selection).
99310	Subsequent nursing facility care; high complexity — total time threshold: 45 minutes (when using total time for code selection).
99315	Nursing facility discharge management; 30 minutes or less total time on the date of the encounter.
99316	Nursing facility discharge management; more than 30 minutes total time on the date of the encounter.
99318	Annual nursing facility assessment; detailed interval history, comprehensive exam, and medical decision making of low to moderate complexity.

Time thresholds for E/M code selection — examples of total time thresholds mapped to E/M codes

99304Total time >= 25 minutes

99305Total time >= 35 minutes

99306Total time threshold per coding guidance (high complexity) — typically > 45 minutes when using total time; verify current CPT time rules

99307Total time >= 10 minutes

99308Total time >= 20 minutes

99309Total time >= 30 minutes

99310Total time >= 45 minutes

99315Total time <= 30 minutes (discharge management)

99316Total time > 30 minutes (discharge management)

99318Annual nursing facility assessment — use descriptors, not time-based selection

Skilled nursing/therapy hourly thresholds by level — per-level hour thresholds and brief level definitions

Skilled nursing/therapy Level 1Skilled nursing up to 4 hours per 7 days per week OR skilled therapy 1–2 hours per day on at least 5 days per week

Skilled nursing/therapy Level 2Skilled nursing at least 4 hours per 7 days per week OR skilled therapy at least 2 hours per day on at least 5 days per week

Skilled nursing/therapy Level 3Skilled nursing > 4 hours per 7 days per week AND skilled therapy at least 3 hours per day on at least 5 days per week

Skilled nursing/therapy Level 4Skilled nursing > 4 hours per 7 days per week; high-acuity needs (eg, catastrophic trauma, stabilized spinal cord injury, severe head injury/CVA, ventilator-dependent) — both nursing and therapy requirements as specified

Skilled nursing/therapy Level 5Skilled nursing > 4 hours per 7 days per week OR administration of specified high-cost drugs; intensive care level requirements

Therapy CPT/HCPCS codes referencedPhysical & occupational eval/re-eval: 97161-97168; Therapeutic procedures & group/ADL training: 97532-97537, 97542; Orthotic/prosthetic management: 97760-97762; Speech-language/audiology: 92507-92526, 92597, 92609

Key Definitions

Skilled nursing / skilled rehabilitation services

DefinitionServices furnished in accordance with physician orders that must be provided directly by or under the general supervision of skilled nursing or skilled rehabilitation personnel to assure patient safety and achieve the medically desired result.

Required skillsRequire the skills of qualified technical or professional personnel (e.g., RNs, LPNs/LVNs, PTs, OTs, speech-language pathologists, audiologists).

Complexity criterionA nursing service is skilled only when the needed services are of such complexity that the skills of a registered nurse (or when permitted, a licensed practical nurse) are required to safely and effectively provide the service.

SupervisionMay be provided directly or under general supervision as appropriate to ensure safety and achieve the medically desired result.

Skilled nursing facility (SNF)

DefinitionAn institution (or part of an institution) licensed under state law whose primary focus is to provide skilled nursing care and related services for residents requiring medical or nursing care.

ScopeA SNF may also provide rehabilitation services for injured, disabled, or sick members/enrollees.

LicensingOperates under state licensure requirements as the basis for classification as a Skilled Nursing Facility.

Provider Obligations and Applicability

Documentation Required

Follow plan policies and recognize payment guidance limits

Providers must follow applicable plan-level administrative policies and state and federal requirements; this payment policy is a guide and does not guarantee payment. Coverage and payment determinations remain subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable law. The policy effective/posting date may differ and Health Plan may change, amend or withdraw the policy at any time.

Adhere to plan-level administrative policies and procedures and applicable state/federal requirements.
Recognize this payment policy is guidance only and not a contract or guarantee of payment.
Ensure claims and coverage decisions conform to the member's evidence of coverage, certificate, policy, or contract.