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Skilled Nursing Facility Coverage Provisions


Provider Administrative Policy

Section
Ancillary Provider
Policy Date
July 2013
Status/Date
New/July 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Skilled Nursing Facility Coverage Provisions

Custodial Care (Level 1) - Patients are basically stable and may require any or all of the following: Short term monitoring including assessment of lab values, vital signs, assistance with activities of daily living, terminal care, restorative programming, routine nursing care, pain management, oral medications or medications that usually can be self-administered, preparation of special diets, and physical therapy, occupational therapy, and speech therapy. Custodial Care or Level 1 services are not a covered member benefit.

Medium Level Skilled Nursing Care (Level 2) - Patients requiring daily Skilled Nursing Care including, without limitation, any or all of the following: intravenous (IV) medication administration, tube feedings, simple wound care with sterile dressing changes, ostomy care, intramuscular (IM) medication administration, catheter care, incision care, and/or require at least six (6) hours combined of one or more rehabilitation therapy services (physical therapy, occupational therapy, and speech pathology) a week.

High Level Skilled Nursing Care (Level 3) - Patients requiring daily Skilled Nursing Care including, without limitation, conditions in Level II with additional therapy needs in the amount of at least ten (10) hours of two or more rehabilitation therapy services (physical therapy, occupational therapy, and speech pathology) a week.

Complex Level Care (Level 4) - Skilled nursing of at least four (4) hours per day for patients with multiple complications. Care needs may include, without limitation, up to two of the following: dressings for stage III-IV wounds, parenteral nutrition with lab monitoring, respiratory treatments and suctioning every 4 hours (q4 hours), multiple intravenous (IV) antibiotics, negative pressure wound therapy (NPWT), tracheostomy care, respirator care, trauma patients requiring subacute care with total assistance with ADL's and a minimum for for (4) hours of one-to-one nursing care per day, and/or require at least twelve (12) hours combined of two or more rehabilitation therapy services (physical therapy, occupational therapy, and speech pathology) a week.

Extraordinarily High Cost Care - Skilled nursing of at least four (4) hours per day for patients with multiple complications. Care needs may include, without limitation, at least three of the complications as noted in Level IV, and/or requires at least twelve (12) hours combined of two or more rehabilitation therapy services (physical therapy, occupational therapy, and speedh pathology) a week.

Covered Skilled Nursing Facility Services

Care in a Skilled Nursing Facility may be covered if all of the following factors are met:

  • By or under the direct supervision of an interdisciplinary treatment team including a licensed registered nurse and a licensed social worker;
  • Medical services provided by a Physician are directly related to the care and treatment of the patient's condition;
  • Physical therapy, speedh therapy, occupational therapy, and/or respiratory therapy is provided by licensed physical therapists, certified speech pathologists, licensed occupational therapists, and/or licensed respiratory thereapists;
  • The patient requires skilled nursing services and/or skilled rehabilitation services, i.e., services that must be performed by an interdisciplinary treatment team including a licensed registered nurse and a licensed social worker;
  • The patient requires these skilled services on a daily basis;
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a Skilled Nursing Facility; and
  • The services are furnished pursuant to a Physician's orders, indicated in the individualized Plan of Care and follow-up reviews, as defined in the Plan of Care Section, and be reasonable and necessary for the treatment of a patient's illness or injury

Members Eligible for Skilled Nursing Facility Services

The delivery of covered skilled nursing services or skilled nursing with skilled rehabilitation services is provided by Facility as follows:

  • Professional nursing services are provided
  • Medical social services (psychological/social assessment and counseling of patients) and family counseling related to the patient's condition provided by a licensed social worker or a licensed professional counselor;
  • Dietary counseling provided by a licensed dietician

Evaluation and Plan of Care

Prior authorization is required by Blue Cross of Idaho based on medical necessity prior to all admissions and stays, as well as all changes to the Individualized Plan of Care.

Prior to admission to and commencement of SNF Care, a Skilled Nursing Facility provider must contact Blue Cross of Idaho for prior authorization and with a preliminary Individualized Plan of Care.  Preliminary Individualized Plan of Care may be transferred verbally. Provider must provide a written Individualized Plan of Care within 24-48 hours after admission, submitted to the supervising Physician, for certification by Blue Cross of Idaho in order to determine the appropriate level of care. Final leveling based on the number of rehabilitation therapy service hours is subject to the provision of evidence that therapy hours were actually provided.

Skilled Nursing Facility providers must document skilled interventions daily in the medical record including the patient's response to treatment. Provider must document rehabilitation therapy service outcomes using the Functional Independence Measure (FIM). A written review and/or update of the Individualized Plan of Care, signed by the interdisciplinary treatment team, must be submitted to Blue Cross of Idaho for authorization when the patient's condition changes or seven days later, whichever comes first. Provider must provide a follow-up written review and/or update of the Individualized Plan of Care, signed by the interdisciplinary treatment team, to Blue Cross of Idaho requests.

The intent of the Individualized Plan of Care should be to maximize the patient's ability to discharge to the most appropriate level of care as soon as possible. Provider must provide documentation of discharge planning within 72 hours after admission and as the patient's condition changes but no longer than every seven (7) days or as Blue Cross of Idaho requests. Individualized Plan of Care assessments will be conducted at no charge to Blue Cross of Idaho or the Member.


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