Skilled Nursing Facility

Overview  
A skilled nursing facility provides skilled care such as nursing or rehabilitation services to individuals who can no longer care for themselves following an injury or illness. It can be a separate facility, or part of a hospital or other health care facility. 

Original Medicare  
Original Medicare benefits cover extended care services that are provided in a Medicare certified skilled nursing facility. There is a limit of 100 days for each benefit period. The benefit period is renewed when the beneficiary has not been in a skilled nursing facility for 60 days. There is no limit to the number of benefit periods a beneficiary can have.  

The beneficiary must meet the following requirements to be eligible for coverage:  

• The beneficiary must be an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days prior to discharge. 
• The beneficiary must be transferred to the skilled nursing facility within 30 days after discharge from the hospital.  
• In certain circumstances, the 30-day period may be extended if, at the time of hospital discharge, it is predictable that extended care services will be required subsequent to hospital care.

Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage Enhanced Benefit  
BCBSNE Medicare Advantage plans provide at least the same level of benefit coverage as Original Medicare (Part A and Part B) and may provide enhanced benefits beyond the scope of Original Medicare within a single health care plan. This flexibility allows BCBSNE to offer enriched plans by using Original Medicare as the base program and adding desired benefit options. 

Coverage for services provided in a Medicare certified skilled nursing facility is provided to members under BCBSNE Medicare Advantage. The three-day hospital stay requirement under Original Medicare is waived for all BCBSNE Medicare Advantage members. The member’s cost-sharing is determined by BCBSNE. 

Conditions for Payment  
The following table specifies payment conditions for skilled nursing facility coverage. 

Reimbursement  
The provider will be paid the lesser of the allowed amount or the provider’s charge, minus the member’s cost share. This represents payment in full and providers are not allowed to balance bill the member for the difference between the allowed amount and the charge. 

Member Cost-sharing  

• BCBSNE Medicare Advantage providers should collect the applicable cost-sharing from the member at the time of the service when possible. Cost-sharing refers to a flat-dollar copayment a percentage coinsurance or a deductible. Providers can only collect the appropriate BCBSNE Medicare Advantage cost-sharing amounts from the member.  
• If the member elects to receive a non-covered service, he or she is responsible for the entire charge associated with the non-covered service.  

To verify benefits and cost share, providers may call 888-505-2022.  

Billing Instructions for Providers  

1. Bill services on the CMS 1500 (02/12) or UB-04 claim form. 
2. Use the BCBSNE Medicare Advantage unique billing requirements.  
3. Report CPT/HCPCS codes and diagnosis codes to the highest level of specificity.  
4. Include your National Provider Identifier number on all claims.  
5. Send your claims to your local BCBS plan. 

Revision History:  
Policy Number: NEHMO 1007  
Policy Created: 07/18/2016  
Policy Revised: 01/20/2020  
Policy Effective: 01/01/2017