Skilled Nursing Facilities (SNF): Admission and Concurrent Review Form

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 10|01|2025 POLICY LAST REVIEWED: 08|20|2025 OVERVIEW This policy documents the utilization review process for admission and continued care in a skilled nursing facility (SNF). MEDICAL CRITERIA Medicare Advantage Plans and Commercial Products Care in a SNF is covered if all the following four factors are met: • The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel; are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services; • The patient requires these skilled services on a daily basis; and • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity. PRIOR AUTHORIZATION Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. Effective 10/1/2025, for Fully-Funded Commercial Products only, prior authorization requests may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider. See below for a list of specialties. Prior authorization continues to be needed for all other Commercial Products, including Self- Funded and Medicare Advantage Plans.
The following specialties, that are credentialed as a primary care provider, are included in this exemption: • Internal Medicine • Pediatric Medicine • Family Practice • Obstetrics and Gynecology • Doctor of Osteopathic Medicine • NP (Nurse Practitioner)/PCP (Primary Care Physician or Provider) • PA (Physician Assistant) Medicare Advantage Plans Effective March 15, 2025, a post-acute care vendor has been delegated to perform utilization management services for admission, concurrent, and retrospective requests according to this policy, except for members who are attributed to a Prospect Primary Care Provider. Medical Coverage Policy | Skilled Nursing Facilities (SNF): Admission and Concurrent Review d

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

POLICY STATEMENT Medicare Advantage Plans and Commercial Products

SNF is covered for all Blue Cross & Blue Shield of Rhode Island (BCBSRI) products when the medical criteria are met.

Medicare may change coverage or criteria. All changes are effective when Medicare determines them to be so and are applicable to Medicare Advantage Plan members and will supersede this policy.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for the applicable skilled nursing benefits/coverage.

BACKGROUND Not applicable

CODING Not applicable

RELATED POLICIES Not applicable

PUBLISHED Provider Update: January/September 2025 Provider Update, March 2024 Provider Update, April 2023 Provider Update, May 2022 Provider Update, May 2021

REFERENCES

1. Centers for Medicare and Medicaid Services, Medicare Benefit policy manual, Chapter 8-Coverage of Extended Care (SNF) Services Under Hospital Insurance. https://www.cms.gov/regulations-and- guidance/guidance/manuals/downloads/bp102c08pdf.pdf
2. Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual: Chapter 8-Coverage of Extended Care (SNF) Services Under Hospital Insurance. Section 30- Skilled Nursing Facility Level of Care - General

3. InterQual Criteria for Skilled Nursing Facility i

   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber a greement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS