Guidelines for submitting Skilled Nursing, Long-Term Acute Care and Inpatient Rehabilitation Facilities

Facilities must notify Blue Cross and Blue Shield of Nebraska (BCBSNE) of all post-acute admissions and provide clinical information prior to the admission for initial requests and prior to the expiration of approved days for continued stay review requests. Timely notification helps ensure that Medicare Advantage members receive care in the most appropriate setting, that BCBSNE Care Management is involved in the evaluation and coordination of discharge planning and that there are appropriate referrals to case management for members who need those services, including those managing active disease processes, those demonstrating high use of health resources or those who are at high risk for health complications.  

BCBSNE Care Management nurses conduct admission and concurrent reviews via telephone or fax by obtaining information from the hospital’s utilization review staff. Care Management nurses also speak to attending physicians when necessary to obtain information.  

Clinical information includes relevant information about the member regarding the following:  

• Health history  
• Prior level of functioning  
• Clinical assessment  
• Therapy evaluations  
• Admitting orders 
• Discharge plans  

A copy of the form used to submit clinical information for post-acute admissions can be found: Medicare Advantage Forms. 

For post-acute admissions, if authorization is obtained, it will be valid for a defined length of time. If additional days are needed, a continued stay review will be required prior to the expiration of the initial approved days.  

Decision Criteria and Guidelines  
BCBSNE criteria for certifying services are based on input from appropriate providers, nationally recognized criteria adopted by the plan or a combination of both. Individual circumstances of a member are taken into consideration when applying the criteria, as are characteristics of the local delivery system such as:  

• Availability of skilled nursing facilities, subacute care facilities or home care in the network to support the member after discharge  
• Member’s coverage of benefits for skilled nursing facilities, subacute care facilities or home care, where needed  
• Ability of network hospital(s) to provide all recommended services within the established length of stay