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UM Guidelines
Skilled Nursing Facility (SNF) Levels of Care

Recovery Facility Care (RFC)

BCBST last reviewed September 20, 2017*

Added:
 

 

Skilled Nursing Facility/Inpatient Rehabilitation Fax Form

Exceptions may be required to comply with EPSDT, Medicare, and & BlueCare® regulations.

Attachment #A for Commercial Lines of Business - details the 3 levels of SNF care listed below.

Attachment #B for BlueCare/TCS - details the 3 levels of SNF care listed below.


ATTACHMENT A
SKILLED NURSING FACILITY
LEVELS OF CARE DESCRIPTIONS

For Commercial Lines of Business

Level I (Skilled Care)

  • Patients receiving the following types of care will meet the clinical criteria to qualify as Level I. Examples of the types of care include, but are not limited to:
    • Semi-Private Room
    • Meals (Including specialized dietary and administration of feeding)
    • 24-Hour Skilled Nursing Care
    • 24-Hour Physician Coverage
    • Colostomy Care
    • Wound Care (Stage 1 & 2)
    • Tube Feeding & Medication Administration
    • Routine Respiratory Care (Oxygen, Aerosol Treatments, Oxygen Saturations)
    • Routine DME & Routine Medical Supplies
    • Routine Oral & Inhaled Medications and Pharmacy Supplies
    • SQ Insulin
    • Case Management Services
    • Social Services
    • Laboratory Services
    • Routine Diabetic Supplies (Lancets, Test Strips)
    • Routine X-Rays
    • Continuous IV Fluid Therapy (Peripheral Lines)
    • 1.5 hrs or less of Rehabilitation Therapy per day
    • Speech Therapy (at any level) must be provided in conjunction with another skilled service

Level II (Comprehensive Care)

  • Patients receiving Level I types of care - plus the following types of care - will meet the clinical criteria to qualify as Level II. Examples of the types of care include, but are not limited to:
    • Wound Care (Stage 3)
    • IV Site Care (Central Lines)
    • Tracheotomy Care
    • Respiratory Care (Frequent Suctioning)
    • Routine Medications (Examples: IV, IM & SQ: 1st, 2nd & 3rd Generation Cephalosporins, Natural & Amino Penicillins, Extended Spectrum Penicillins, Tetracyclines, Sulfonamides, Fluoroquinolones, Aminoglycosides, Heparin, Coumadin)
    • 1.75 - 3 hrs of Rehabilitation Therapy per day

Level III (Complex Care)

  • Patients receiving Level I & II types of care - plus the following types of care - will meet the clinical criteria to qualify as Level III. Examples of the types of care include, but are not limited to:
    • Respiratory Care (Ventilator)
    • Specialty Beds (Hill-Rom, KCI)
    • High Cost IV, IM & SQ Medications: (Examples: 4th Generation Cephalosporins, Penicillinase-Resistant Penicillins, Desferal, Desmopressin, Epoetin Alfa, IVIG, Panretin, Remicade, Thrombolytic Enzymes, Chemo-Therapy Agents). Requests from providers for Level III based on cost of drugs other than above, should be verified with BCBST Pharmacy Benefit Management representative as needed, prior to approving this level of care.
    • Negative pressure wound therapy pump for the treatment of acute and chronic wounds
    • Peritoneal dialysis
    • IV TPN, Lipids
      • Authorization is given for a specific level and period of care. The provider must call BCBST if a change in the level of care occurs, or to obtain approval for additional days—prior to the expiration of the authorization.
      • Physicians must bill for their services separately
      • Specialty / custom wheelchairs are excluded—billed by a DME provider (see Exhibit B for definition).

Transportation Request (Commercial ONLY), examples: home, facility to facility. Please review benefits/contract and refer to Case Management.

ATTACHMENT B
SKILLED NURSING
LEVELS OF CARE REIMBURSEMENT

For BlueCare/TCS

***Name of Skilled Nursing Facility***
BCBST Provider No.:_________

Level I - Skilled Nursing Care Including 1 Therapy

Per Diem

  • Examples: 1.5 hours or less of Rehabilitation Therapy per day, Simple wound care, or Continuous IV Therapy
    • Semi-Private Room
    • Meals (Including Specialized Dietary and Administration of Feeding)
    • 24-hour Skilled Nursing Care
      • Traction and Positioning
      • Colostomy Care
      • Wound Care (Stage 1 and 2)
      • Tube Feeding and Medication Administration
    • Routine Respiratory Care (Oxygen, Inhaler Treatments, Oxygen Saturations)
    • Routine Durable Medical Equipment and Routine Medical Supplies
    • Routine Medications and Pharmacy Supplies
    • Case Management Services
    • Social Services
    • Laboratory Services (Examples: CBC, Bloodglucose, Urine Analysis, etc.)
    • Routine X-Rays
    • Routine Diabetic Supplies
    • Hospice
    • Rehabilitation Therapies (Physical, Occupational, Speech) 1.5 hours or less per day
      • Speech therapy must be provided in conjunction with another skilled service.
  • Excludes:
    • Specialized/Customized DME (Examples: Beds, Wheelchairs, etc.)
    • TPN, IV Medications (Pain, Antibiotics)
    • Physician Services

Level II - Subacute

Per Diem

  • Examples: 1.75 hours to 3 hours of Rehabilitation Therapies per day, Complex wound care, or IV medications (2 or more per day). Services included in addition to Level I care:
    • 24-hour Skilled Nursing Care
      • Wound Care (Stage 3)
      • IV Care (Peripheral, Subclavian)
      • Tracheostomy Care
    • Respiratory Care (Frequent Suctioning)
    • Medications and Pharmacy Supplies (IV Fluids, IV Medications [Excluding Third Generation Antibiotics])
    • Rehabilitation Therapies (Physical, Occupational, Speech) 1.75 hours to 3 hours per day
  • Excludes:
    • Specialized/Customized DME (Examples: Beds, Wheelchairs, etc.)
    • Specialized Radiology (CT Scan, MRI)
    • TPN, Lipids, Third Generation Antibiotics
    • Physician Services

Level III - Specialty Skilled Care

Per Diem

  • Examples: Ventilator dependent, Spinal Cord injury, or Brain injury. Services included in addition to Level II care:
    • Respiratory Care (Ventilator)
    • Multiple Wound Care (Greater than three stage three or four wounds with wound vac or requires dressing changes BID to two or more stage three or four wounds)
    • Bariatric Care Patient (> 400 lbs)
  • Excludes:
    • Specialized/Customized DME (Beds, Wheelchairs, etc.)
    • Specialized Radiology (CT Scan, MRI)
    • TPN, Lipids, Third Generation Antibiotics
    • Physician Services

References

BlueCross BlueShield of Tennessee network physicians. September - December 2014.

 

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