01-056 SNF 3 Day Stay Waiver PHE Notification of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of Medicare Part A Skilled Nursing Facility (SNF) claims on dates of service from March 1, 2020, through December 31, 2021. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Prior to the COVID-19 pandemic and subsequent Public Health Emergency (PHE), qualification for post-hospital extended care services, including SNF care, required the beneficiary to have a medically necessary hospital stay of at least three consecutive calendar days prior to SNF admission per the Medicare Benefit Policy Manual, Publication 100-02, Chapter 8, Section 20. In response to the PHE, the Centers for Medicare and Medicaid Services (CMS), using authority under Section 1812(f) of the SSA, waived the requirement for a 3-day prior hospitalization for coverage of a SNF stay. This waiver provides for coverage of a SNF stay, without a three day qualifying hospital stay (QHS) during the PHE.

Data analysis done by CMS and the SMRC identified a potential area of vulnerability. The SMRC is tasked to performed medical review on SNF claims that had zero hospital days prior to admission.

Reason for Review

The SMRC is tasked with performing claim review on a sample of SNF claims from March 1, 2020, through December 31, 2021. The SMRC will conduct medical record reviews following applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Type of Bill (TOB)
SNF Inpatient 21X
Revenue Code (REV)
SNF Prospective Payment System (PPS) 0022

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

  1. Physician/Non-Physician Practitioner (NPP) Admission Orders
  2. All records to justify and support the level of care received
  3. Documentation to support the medical necessity of service
  4. PT/OT/SLP Initial evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
  5. Documentation to support each of the Health Insurance Prospective Payment System (HIPPS) code(s) billed
  6. Documentation to support the Minimum Data Set (MDS) Assessments (i.e., hardcopy version of each MDS related to claim period under review (e.g., 5-day, interim, discharge and any off-schedule assessments)
  7. Documentation to support the look back period under review based on the Assessment Reference Date (ARD) (The look back period may fall outside of the dates of service under review. The documentation requested may include documentation 30-45 days prior to the dates of service (DOS) under review.)
  8. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  9. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  10. Advance Beneficiary Notice of Liability (ABN); if applicable
  11. Any other supporting documentation
  12. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  13. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/Resources

Title XVII of the Social Security Act (SSA)

  • SSA, § 1812(a)(2)(A). Scope of Benefits
  • SSA, § 1813(3). Deductibles and Coinsurance
  • SSA, § 1814(2)(B). Conditions of Payment and Limitations on Payment for Services
  • SSA, § 1815. Payment to Provider of Services
  • SSA, § 1819(a)-(d) and (f). Requirements for, and Assuring Quality of Care In, Skilled Nursing Facilities
  • SSA, § 1833(e). Payment of Benefits
  • SSA, § 1861(a), (h)-(j). Definitions of Services, Institutions, Etc.
  • SSA, § 1862(a)(1)(A). Reasonable and Necessary
  • SSA, § 1862(a)(20). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, § 1879(a). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • SSA, § 1888(e). Prospective Payment
  • SSA, § 1888(g). Skilled Nursing Facility Readmission Measure
  • SSA, § 1888(h). Skilled Nursing Facility Value-Based Purchasing Program
  • SSA, § 1893(b). Medicare Integrity Program
  • SSA, § 1899(f). Waiver Authority

Balanced Budget Act of 1997 (BBA), Public Law 105-33

  • BBA, § 4432(b). Prospective Payment for Skilled Nursing Facility Services

Title 42 of the Code of Federal Regulations (CFR)

  • 409.30-409.36. Requirements for Coverage of Posthospital SNF Care
  • 410.12. Medical and other health services: Basic conditions and limitations
  • 411.15(k)(1). Particular Services Excluded from coverage
  • 411.15(p). Services Furnished to SNF Residents
  • § 411.4. Payment for custodial care and services not reasonable and necessary
  • Subpart A, § 413.1. Introduction and General Rules
  • Subpart J, § 413.330. Basis and Scope
  • Subpart J, § 413.333. Definitions
  • Subpart J, § 413.335. Basis of Payment
  • §413.343. Resident Assessment Data
  • §413.360. Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
  • §424.20. Requirements for Posthospital SNF Care
  • §424.5(a)(6). Sufficient Information
  • §425.612. Waivers of payment rules or other Medicare requirements
  • §483.315. Specification of Resident Assessment Instrument

Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication 100-02

  • MBPM, Chapter (Ch.) 8. § 10. Requirements General
  • MBPM, Ch. 8. § 20. Prior Hospitalization and Transfer Requirements
  • MBPM, Ch. 8. Coverage of Extended Care (SNF) Services Under Hospital Insurance
  • MBPM, Ch. 8. § 30. Skilled Nursing Facility Level of Care General
  • MBPM, Ch. 8. § 40. Physician Certification and Recertification of Extended Care Services
  • MBPM, Ch. 8. § 70. Medical and Other Health Services Furnished to SNF Patients
  • MBPM, Ch. 15, § 250. Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities
  • Chapter 16, § 20. Services Not Reasonable and Necessary
  • Chapter 16, § 110. Custodial Care

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

  • MCPM, 1. General Billing Requirements
  • MCPM, Ch. 6. SNF Inpatient Part A Billing and SNF Consolidated Billing
  • MCPM, Ch. 6. § 30. Billing SNF PPS Services
  • MCPM, Ch. 6. § 100. Part A SNF PPS for Hospital Swing Bed Facilities
  • MCPM, Ch. 6. § 120. Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
  • MCPM, Ch. 30. Financial Liability Protections.
  • MCPM, Ch. 30 § 40 and 50. Advance Beneficiary Notice of Non-coverage (ABN)
  • MCPM, Ch. 30. § 130.2. A Three-Day Prior Hospitalization

IOM, Medicare Program Integrity Manual Publication (MPIM), Pub. 100-08

  • MPIM, Ch. 3, § 3. Verifying Potential Errors and Taking Corrective Actions
  • MPIM, Ch. 3 § 3.2.3.2. Time Frames for Submission
  • MPIM, Ch. 3 § 3.2.3.4. Additional Documentation Request Required and Optional Elements
  • MPIM, Ch. 3 § 3.2.3.8. No Response or Insufficient Response to Additional Documentation
  • MPIM, Ch. 3 § 3.3.2.1. Documents on Which to Base a Determination
  • MPIM, Ch. 3 § 3.3.2.4. Signature Requirements
  • MPIM, Ch. 3 § 3.3.3. Reviewing Claims in the Absence of Polices and Guidelines
  • MPIM, Ch. 3. § 3.6.2.2. Reasonable & Necessary Criteria
  • Chapter 6, Section 6. Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
  • Chapter 6, § 6.3. Medical Review of Certification and Recertification of Residents in SNFs

Local Coverage Determination (LCD)

  • LCD L35008 Non-Covered Services. Effective October 1, 2015 (Retired June 30, 2020)
  • LCD L36219 Non-Covered Services. Effective October 1, 2015 (Retired June 30, 2020)

Local Coverage Article (LCA)

  • LCA A55503 Skilled Therapy Services in the SNF PPS Setting. Effective October 23, 2015.
  • LCA A55505 Skilled Therapy Services in the SNF PPS Setting. Effective October 23, 2015.

Other:

  • Minimum Data Set Manual, CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.17.1, Effective October 2019
  • Medicare Learning Network (MLN) SE18026 November 2018. New Medicare Webpage on Patient Driven Payment Model
  • Medicare Learning Network (MLN) ICN MLN006846 December 2018. SNF Billing Reference
  • Medicare Learning Network (MLN) ICN 9730256 April 2021. Skilled Nursing Facility 3-Day Rule Billing
  • Medicare Learning Network (MLN) SE20011 September 2021. Medicare FFS Response to the PHE on COVID-19

Last Updated Jun 7, 2022