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Medical necessity requirements for skilled nursing facility (SNF) admissions

Answering yes to the following questions can help ensure the SNF admission meets medical necessity requirements.  This criteria is required to meet Medicare guidelines for a SNF covered stay and medical necessity. Answering no to any of the questions would not meet these guidelines and would cause a claim denial. 

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)
      • HIPAA Eligibility Transaction System (HETS):
  • 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:
  • 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
  • Skilled nursing facility must meet requirements described within the Social Security Act 1819 
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

 

References