Posted in BCBS (Various States), Training, Updates

BCBS Kentucky: prior authorization requirements for admissions to in-network skilled nursing facilities

The following information applies to Kentucky Anthem BCBS local Commercial health plans.


Updated guidance for prior authorization requirements for admissions to in-network skilled nursing facilities (SNFs).


The Updated process applies to hospital inpatient transfers to SNFs only.

NOT TO  transfers from Acute inpatient Rehab, LTAC to SNF, or SNF to SNF.


Note: This updated process does not apply to admissions to out-of-network SNF facilities.


According to Anthem BCBS of Kentucky-effective August 1, 2021, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network SNF facility for Kentucky local Commercial members.

  • Facility and physician must be in-network for the member.
  • Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channel.
  • Anthem will approve an initial 5-day length of stay without the need to provide clinical information.
  • SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within 2-days after the admission.
  • Concurrent review will be required starting on day 5 of the SNF stay.
  • Anthem may apply monetary penalties such as a reduction in payment, for failure to provide timely notice of admission.

Anthem BCBS of Kentucky also stated that they will monitor this process through December 31, 2021 and conduct random audits and monitor trends to evaluate its effectiveness.


Looking for more information? The following FAQs will help you answer some of the questions:

1. As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?

Yes, notification is still required. However, you can notify Anthem of the admission and move the member without having to send in clinical information or wait for an approval. It will be important to verify member benefits.

2. When do I need to submit clinical information?

For the initial SNF admission, no later than two business days after the admission and for continued stay, prior to the last covered day.

3. Does this apply to SNF, IP Rehab and LTAC admissions and related transportation (air or ground ambulance)?

This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP Rehab, LTAC and any related transportation.

4. For the SNF initial authorization of 5 days, will Anthem assign a level of care?

Anthem UM will assign Level of care once the clinical information is received from the SNF.

5. What if a member needs to be admitted for wound care and IV antibiotics?

If a SNF has any concerns about the criteria for admission, they may still do the full prior authorization process.

6. If the physician and/or facility are out-of-network for the member, does this process apply?

No, the facility AND physician both need to be in network. All out-of-network facilities and providers must follow the full prior authorization process.

7. What if I am uncertain if the member is a local commercial member?

This process is applicable to local commercial accounts only.  It does not apply to FEP, National, Medicaid, Medicare, or IHM. If you are uncertain, reach out to the Anthem dedicated nurse for your facility.


Find this type of content useful? Follow my blog for more Insurance payer updates, medical billing and coding updates, and reimbursement/medical policy changes and updates.


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Author:

My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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