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.

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Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

UHC: Payment for COVID-19 testing coverage, outpatient SNF

Previously, UHC would not reimburse for COVID-19 testing when done outside of a skilled inpatient stay at a SNF.

However, during the PHE, starting Jan 27,2020 and then renewed on April 21,2021, subject to further extension, UHC is going to pay for the COVID-19 testing that is done outside of the skilled inpatient stay at a SNF.

This change applies to the following Medicare Advantage Plans:

  • Medicare Advantage Plans
  • Dual Eligible Special Needs Plans (DSNP)
  • Chronic Special Needs Plans (CSNP)
  • UnitedHealthcare Assisted Living Plans (IE-SNP)
  • FIDE/MMP Plans

Plans that this change DOES NOT APPLY TO:

  • UnitedHealthcare Nursing Home Plans (ISNP)
  • UnitedHealthcare commercial plans
  • UnitedHealthcare Community Plans (Medicaid Only Plans)

UHC will re-process the claims, there is no further action needed.

UHC will reprocess claims previously paid at $0 to be reimbursed at 100% of the Medicare fee schedule. No action is required from affected SNFs for these adjustments.

The following codes are going be reimbursed at 100% of Medicare Fee Schedule:


COVID-19 testing performed during an approved skilled stay are subject to Centers for Medicare and Medicaid Services (CMS) consolidated billing rules and are not separately reimbursable, except for the UnitedHealthcare Nursing Home Plan (ISNP). New applicable CMS covered COVID-19 testing codes may be added periodically. We may add or remove codes from the following list, in accordance with CMS coverage guidelines.

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In a meantime, check out my latest posts below: