Reminder: Here’s information skilled nursing facilities must submit to naviHealth for services provided to Medicare Advantage members

For Medicare Plus Blue℠ and BCN Advantage℠ members, skilled nursing facilities must submit certain items to naviHealth within specific time frames.

Therapy and nursing assessments

Skilled nursing facilities must submit physical therapy, occupational therapy, speech therapy and nursing assessments to naviHealth within 48 hours of a member’s admission to a skilled nursing facility.

naviHealth uses these assessments to:

• Complete the nH Predict functional assessment.
• Create and deliver the nH Predict outcome report to the member and the skilled nursing facility in a timely manner.

Clinical documentation and assessments for calculating CMG levels

By Day 7 of a member’s stay, skilled nursing facilities must submit the following items to naviHealth, so it can calculate the case mix group, or CMG, level:

• The PHQ-9 assessment
• The Medication Administration Record, also known as MAR, or the Treatment Administration Record, also known as TAR
• The discharge planning assessment
• Physician and nursing notes
• Physical, occupational and speech therapy notes

naviHealth will calculate the CMG level within two days of receiving clinical documentation and assessments. It will use the CMG level to generate patient-driven payment model, or PDPM, codes. Those codes are used for billing.

Requirements for reassessments of CMG levels

After naviHealth has calculated the CMG level, skilled nursing facilities can submit requests to reassess CMG levels. Be sure to request the reassessment prior to discharging the member from skilled services. Send the clinical documentation required for the reassessment to naviHealth as soon as possible.

Clinical documentation for the reassessment of CMG levels includes — but isn’t limited to — information from the most recent history and physical, transfer documents, physician progress notes, discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor’s orders, consults and diagnostic reports.

naviHealth will use the clinical documentation to determine whether to change the CMG level. The health care provider must identify where the supporting documentation appears within the clinical documentation. If naviHealth determines that the CMG level should change, it will change the level retroactive to the day of admission.

You can use the Request for a Reassessment of the CMG Level worksheet to ensure that you submit comprehensive clinical documentation to support the request. You can find this worksheet two ways:

• By requesting it from your assigned naviHealth care coordinator.
• Through the naviHealth resource website for Blue Cross Blue Shield of Michigan and Blue Care Network at partners.navihealth.com/partner/bcbsm.** (If you haven’t already registered for this website, see the “How do I access naviHealth documents related to this program?” section of Post-acute care services: Frequently asked questions for providers to learn how.)

Note: The decision to change a CMG level may require review of the request by a naviHealth medical director.

Additional information

If you have questions about the information in this article, contact your naviHealth care coordinator or your naviHealth provider relations manager.

You can also find more information in 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.