Prior authorization, billing reminders for SNF interrupted stays for Medicare Advantage members

Per Centers for Medicare & Medicaid Services guidance, a skilled nursing facility interrupted stay occurs when a patient is discharged from a SNF and is readmitted to the same SNF within three consecutive days. When this occurs:

• The readmission or subsequent stay is considered a continuation of the previous stay.
• One claim must be submitted for both stays.
• The completion of new patient assessments is optional.
• The variable per diem isn’t reset.

For more information, see the “Interrupted Stay Policy” section of the Medicare Learning Network^® document titled SNF PPS: Patient Driven Payment Model.**

How naviHealth issues authorizations for SNF interrupted stays

naviHealth’s authorization process is based on its medical necessity review process.

If a patient who’s receiving skilled services leaves a SNF for the emergency department, for an observation stay or for an acute-care hospital inpatient stay and:

• Returns to the same SNF before two midnights have passed, naviHealth will use the original prior authorization number.
• Returns to the same SNF after two or more midnights have passed, naviHealth will create a new authorization number.

How to submit claims for SNF interrupted stays

Here’s what you need to know about billing for SNF interrupted stays:

• You must submit only one claim for both stays.
• Submitting authorization numbers on Medicare Plus Blue℠ and BCN Advantage℠ claims for post-acute care stays is optional. If you choose to include an authorization number on the claim, include the prior authorization number for the initial SNF stay.
• If naviHealth assigns a different patient-driven payment model, or PDPM, code for the subsequent stay:
1. Include a claim line for the original dates of service and PDPM code.
2. Include a separate or new claim line for the subsequent dates of service and the second PDPM code.

Reminders

• naviHealth authorizes the first four digits of the PDPM code based on the associated case mix groups, or CMGs. The health care provider is responsible for assigning the appropriate fifth digit.
• Providers are responsible for billing appropriately.  
• Claims for unauthorized services and procedures are subject to denial.

Resources for CMS billing guidance

• Medicare Claims Processing Manual Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing** — Section 120.2 - Interrupted Stay Policy
• Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance** — Section 30.1 - Administrative Level of Care Presumption

Additional information

For more information, see the document titled Post-acute care services: Frequently asked questions for providers.

naviHealth Inc. is an independent company that manages authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.