Skilled Nursing Facility

Overview

Skilled nursing facilities (SNFs) must adhere to unique guidelines and claim filing requirements. This section addresses the most common billing problems for SNFs, based on provider inquiries and claim information gathered by HMSA.

Payment policy

Payment for SNF care is based on HMSA's per diem eligible charge less any member copayment and/or deductible.

The per diem eligible charge represents payment in full for all covered SNF services and ancillary services as defined in the member's Plan Certification, including:

• Semi-private room
• Regular nursing services
• All meals (including special diets)
• Physical, occupational and speech therapy
• Necessary medical supplies
• Use of appliances (e.g., wheelchair)

Note: When patients are wait-listed for SNF but have not been transferred to an SNF bed, SNF per diems do not apply. The DRG for the inpatient stay covers the wait-listed days.

The SNF per diem eligible charge does not include the following services. The following services may be billed on the same claim as the SNF services. Please bill the CPT code and the revenue code for the service.

• Laboratory and radiology services
• IV medication
• Chemotherapy drugs
• Respiratory therapy
• Prescription drugs
• Specialized or customized durable medical equipment (DME)
• Hemodialysis
• Patient personal supplies and services

Note: ICF beds (e.g. room & board etc.) are NOT covered by HMSA plans, but the ancillary services for ICF level of care can be billed separately. 

Medical appropriateness

If there is more than one medically appropriate method of treating an SNF patient, HMSA's benefit will be based on the least expensive method, even if the participating provider or the member elects a more expensive method. Similarly, if the services could be provided in more than one type of facility or setting, HMSA's benefits will be based on the least expensive facility or setting.

Treatment plan

For newly admitted patients, submit the face sheet of the treatment plan along with the claim. This helps HMSA verify that the SNF level of care is appropriate for the member. Treatment plans must be submitted to HMSA every 30 days for the duration of the patient's stay.

Revision History