Question |
Rationale |
|---|---|
Is the patient enrolled in Medicare Part A? |
• Beneficiaries must have: • Medicare Part A to cover inpatient claims • Medicare Part B to cover outpatient claims • Registration/admission staff should verify entitlement and benefit days prior to claim submission: • Verify eligibility using self-service tools: • Secure Provider Online Tool (SPOT) • Limited number of days per benefit period: • Begins when admitted to qualified hospital or SNF as inpatient after Medicare entitlement date • Ends 60 days from date of discharge from qualified hospital or SNF when patient either: • Facility free for 60 days • No skilled care for 60 consecutive days • Not bound by calendar year • Benefits days cannot be carried from one benefit period to the next if unused |
Does the patient have a three-day qualifying hospital inpatient stay? |
• Three consecutive days in one or more hospitals: • Only admission day, not the discharge day, counts as a hospital inpatient day • Time spent in observation or in the emergency room before admission does not count • Waiver applies in certain situations: • Official Public Health Emergency • Medicare advantage plan enrollment • Transfer to Medicare-certified SNF within 30 days after QHS discharge • Readmission to SNF within 30 days of discharge from SNF • If beyond 30-day window a new QHS needed to access same spell of illness • If nonskilled for 60 consecutive days a new QHS needed to access new benefit period: • Will receive new set of 100 days |
Does the patient have a 30-day transfer from qualifying hospital stay after discharge? |
• Transfer to Medicare-certified SNF within 30 days after QHS discharge • Readmission to SNF within 30 days of discharge from SNF • If beyond 30-day window a new QHS needed to access same spell of illness • Exception if both are true: • Patient’s condition makes it medically inappropriate to start active treatment in a SNF immediately after discharge • It’s medically predictable at patient’s hospital discharge that they’ll need covered SNF care within a predetermined period (generally no more than 30 days), and they meet that prediction |
Does the patient have SNF benefit days available? |
• 100 SNF inpatient days per benefit period: • Days 1-20: Full days: • Medicare pays for medically necessary services • Days 21-100: Coinsurance days: • Beneficiary/Supplemental insurance pays per diem rate • Medicare pays remainder • Days 101 and beyond: Benefits exhausted: • No Medicare Payment made |
Is the patient being transferred to a Medicare certified SNF? |
• Skilled nursing facility means an institution (or a distinct part of an institution) which is primarily engaged in providing to residents: • Skilled nursing care and related services for residents who require medical or nursing care • Rehabilitation services for the rehabilitation of injured, disabled, or sick persons • Not primarily for the care and treatment of mental diseases |
Will the patient require skilled nursing care seven days per week or skilled therapy services at least five days per week for a qualifying condition? |
Care in a SNF is covered if all the following factors are met: • Patient requires skilled nursing services or skilled rehabilitation services: • Services must be performed by or under the supervision of professional or technical personnel • Are ordered by a physician • 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 • Patient requires skilled services on a daily basis: • Daily skilled services can be provided only on an inpatient basis • Services delivered are reasonable and necessary for the treatment of a patient’s illness or injury • Services must be reasonable in terms of duration and quantity If any one of these factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. |
Is there an order from a physician or non-physician practitioner? |
• Physician’s admission assessment with orders specifying need for daily SNF care • Must include signature and date |
