Skilled Nursing Facility (SNF) Demands - Service Specific Targeted Review Interim Findings

The Social Security Act requires CMS to ensure payment is made only for those medical services that are medically reasonable and necessary. CMS mandates the review of Skilled Nursing Facility (SNF) Demand claims. The purpose of this article is to inform providers of recent findings with the review of SNF Demand claims.

Summary of Findings

Findings of the 20 claims reviewed from October 1, 2024 through December 31, 2024 are as follows:

  • 19 claims were denied in full with beneficiary liability for the following reasons:
    • Documentation did not support medically necessary daily skilled services were provided and a valid SNF Advanced Beneficiary Notice of Non-coverage (SNF ABN) was issued timely.
  • 1 claim was denied in full with provider liability for the following reasons:
    • A SNF ABN was not issued timely.
    • A SNF ABN was invalid

The overall quarterly error rate for this service specific targeted review is 10.4%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.

Education

Topic Details
General Advance Beneficiary Notice of Noncoverage (ABN) An (ABN) is a written notice of Medicare denial of payment and must contain sufficient information to enable the beneficiary or authorized representative to understand the basis for the denial. Such notice must be given to the beneficiary timely, before he or she receives specified items or services that otherwise might be paid for so that the beneficiary has time to make other arrangements.

The ABN allows the beneficiary to make an informed decision whether or not to receive the items or services for which he or she may have to pay out of pocket or through other insurance. If documentation does not support that the ABN was given to the beneficiary or their representative, prior to their daily skilled care ending, the provider is liable up to the date the documentation supports the ABN was given.

For additional SNF ABN information, refer to the Medicare Claims Processing Manual (MCPM) Chapter 30 section 70.
Completing the SNFABN Please refer to the SNFABN and instructions which are located on the CMS FFS SNF ABN webpage. The SNFABN has the following 5 sections for completion: Header, Body, Option Boxes, Additional Information, Signature and Date. Failure to use this notice or significant alterations of the SNFABN could result in the notice being invalidated and/or the SNF being held liable for the care in question.

The Header must include SNF information including SNF name, address, and phone number, at a minimum. The header must also include the patient's name. Patient identification number is optional.

The Body must include the "beginning on…," date which the beneficiary may be responsible for payment. The Care, Reason Medicare May Not Pay, and Estimated Cost sections must also be completed in the Body.

In the Option Boxes section, there are three options with corresponding checkboxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary. Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice.

SNFs may use the Additional Information section to clarify and/or provide additional information they think might be helpful to the beneficiary.

The Signature and Date section must be signed by the beneficiary or their authorized representative to acknowledge s/he understood the notice. The SNF may fill in the date if the beneficiary requires assistance. This date should reflect the date that the SNF gave the notice to the beneficiary in-person, or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for the beneficiary, write "(rep)" or "(representative)" next to the signature. If the beneficiary refuses to choose an option and/or refuses to sign the SNFABN when required, the SNF should annotate the original copy of the SNFABN indicating the refusal to sign and may list a witness to the refusal.
Coverage Criteria In order for a Beneficiary to receive coverage in a skilled nursing facility (SNF), the following criteria must be met:
  • The beneficiary must be entitled to receive Medicare Part A
  • There must be a medically necessary 3-day qualifying hospital stay
  • Transfer or admission to the SNF must occur within 30 days at a skilled level of care
  • Benefit days must be available to the beneficiary
  • The patient requires skilled nursing services or skilled rehabilitation services, i.e.:
    • Services must be performed by or under the supervision of professional or technical personnel (see section 30.2 - 30.4)
    • Services must be ordered by a physician and 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.
  • The patient requires these skilled services on a daily basis (see section 30.6) and as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (see section 30.7.)
  • The services must be reasonable and necessary for the treatment of a patient's illness or injury, i.e.:
    • Being consistent with the nature and severity of the individual's illness or injury, the individual's particular medical needs, and accepted standards of medical practice.
    • The services must also be reasonable in terms of duration and quantity.
  • The patient must be admitted to a SNF within 30-days of discharge from a hospital and require skilled care. (See exception to this criteria)
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. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.
SNF Skilled Care Factors Skilled care in a SNF is covered if all of the following factors are met:
  • An inpatient stay is required.
  • A physician's order is in place and the patient requires skilled nursing services or skilled rehabilitation services on a daily basis.
  • Services must be performed by or under the supervision of skilled nursing or rehabilitation professionals.
  • Services need to be reasonable and necessary for the treatment of the patient's illness or injury.
Skilled nursing services or skilled rehabilitation (or a combination) must be needed and provided on a "daily basis," seven days a week. If skilled rehabilitation were not available seven days a week, a patient, whose inpatient stay is based solely on the need for the skilled rehabilitation would meet the "daily basis" requirement if they are provided at least five days a week. Please keep in mind that while the MDS RUG rate may be in the upper 26 categories prior to January 1, 2006 or upper 35 categories after that date does not necessarily mean that services were required at a skilled level.

Skilled Rehabilitation Services
The criteria for Skilled Rehabilitation include:
  • A physician's order for the type of skilled rehabilitation service (s) the patient is in need of.
  • The services ordered by the physician need to require the skills of a qualified therapist and must be reasonable and necessary for the patient's needs.
  • An evaluation that is performed by a physician or licensed professional therapist. The evaluation must also be completed during the Part A stay and reporting of these minutes cannot be included on the MDS.
  • The therapist then develops a plan of care addressing the patient's needs and has the physician certify the plan of care.
  • Re-evaluations are only indicated with a change in the beneficiary condition or new illness or injury.
  • Group Therapy may be used to provide therapy services to beneficiaries if the group consists of four or fewer beneficiaries. The therapist may not oversee or supervise any other therapy services while providing group therapy. It is also important to note, only 25% of the weekly therapy per discipline may consist of group therapy.
  • The services should be coordinated with nursing services.
Documentation of Skilled Rehabilitation Services:
Documentation of the skilled rehabilitation services should include:
  • A time frame that outlines an estimate of how long the patient will require therapy services in relation to the plan-of-care written for the patient.
  • Use objective and measurable terms to describe progress.
  • The documentation of functional accomplishments, which should support the skilled nature of the therapy provided and support the need for the establishment of a maintenance program.
  • Documentation to support the level of beneficiary participation, amount of cues provided, any modifications or accommodations and teaching completed.
  • Documentation of modalities provided for the patient indicating the type of modality, the intensity, volume or amount setting of the machine, time and duration spent, the anatomical site that is receiving the therapy, and the response of the beneficiary to treatment.
  • Indicators of progress such as:
    • A change in the level of assistance required.
    • A change in response to treatment provided.
    • A new functional activity learned and/or a new compensatory activity learned.
Other Types of Care that are Considered Skilled:
Skilled Care can be provided in a number of different ways:
  • Teaching and training activities:
    • These activities are defined as activities, which require skilled nursing or skilled rehabilitation personnel, to teach a patient how to manage their treatment regimen. An example of this skilled service is through daily education to teach a self-maintenance program or by teaching self-administration of an injectable medication.
    • Of note, the beneficiary must be present for the training although the caregiver may be the main person trained. Documentation of training must support daily training was completed.
  • Management and evaluation:
    • The development, management and evaluation of a patient's care plan, based on the physician's orders, constitute skilled nursing services when, in terms of the patient's physical or mental condition, these services require the involvement of skilled nursing personnel to meet the patient's medical needs, promote recovery, and ensure medical safety.
    • Skilled nursing management and evaluation is required to manage personal care services related to the beneficiary's condition and to safely plan, monitor, and manage the care of the beneficiary.
  • Observation and Assessment:
    • The beneficiary who is medically unstable may qualify under these guidelines. Observation and assessment are skilled services when the likelihood of change in a patient's condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient's need for intervention, until the patient's treatment regimen is essentially stabilized.
Documentation should reflect a medically unstable condition, requiring monitoring for and modification of the treatment plan, as well as initiation of additional medical procedures.
Timely Submission of Documentation and 56900s It is the responsibility of Medicare providers to submit all documentation requested on the additional documentation requests (ADR) within the allotted time frame. Noridian allows 45 calendar days for the medical records to be received per the ADR request for prepayment reviews. On day 46, if the medical records have not been received, the claim will be denied provider liable with reason code 56900. If there is no documentation to complete the medical review (MR), services billed on the claim cannot be supported.

A redetermination request should be submitted to Noridian within 120 days from the date of the 56900 denial. Contractors shall reopen the claim for review as long as all conditions are met. The determination made on the reopening claim has the potential to reverse non-covered dollars.

For additional information, refer to Internet-only Manual Pub 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6), and Social Security Act sections 1815(a), 1833(e) and 1862(a)(1)(A).

References

View SNF references used in review. Further educational opportunities may be found under Education & Outreach.

Provider Action Required

Providers should review individual claim determinations by checking page 4 of the claim in DDE to view medical review comments and determinations. Instructions on locating medical review comments are detailed in the article Access Medically Reviewed Claim Determinations in DDE.

Summary

Medical Review of SNF Demand claim are mandated by CMS; therefore, Noridian will continue this review.

If you would like to receive information regarding findings specific to your facility, send an email to myresults@noridian.com. To facilitate the response, follow these instructions:

  • Complete the Subject line with the following information: Results request for file number S1202-100.
  • In the body of the email, include the following elements:
    • Your name, title, and telephone number
    • The facility name
    • Provider number (Include provider's six-digit Provider Transaction Access Number (PTAN), do not include National Provider Identified (NPI)
    • Method of how you would like to receive results: Phone call, fax or U.S. mail. Include fax number or mailing address, if applicable. "My Results" contain beneficiary and claim specific information and will not be sent via email.

Upon request receipt, Noridian Medical Review will respond as timely as possible. A letter will be sent to your facility detailed specific facility claims findings. Requests may take up to two weeks to be completed.

If you have any other questions, contact the Provider Contact Center.

 

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