4.2 For Admissions
when TRICARE is Primary Payer
4.2.1 TRICARE is the primary payer
for SNF care for Medicare-eligible beneficiaries who have no OHI
and who satisfy the TRICARE SNF qualifying coverage requirements
(as discussed in
paragraphs 4.2.4 and
4.2.5) after exhausting
their 100 day covered Medicare SNF benefit. TRICARE is also the primary
payer for non-Medicare-eligible TRICARE beneficiaries who have no
OHI and who meet the TRICARE SNF coverage requirements. In both
situations, TRICARE’s coordination of benefit rules will determine
TRICARE’s status as primary payer.
4.2.2 For TRICARE dual eligible
beneficiaries, the Medicare SNF benefit provides for 100 days of SNF
care per benefit period. The Medicare benefit period is a period
of time for measuring the use of hospital insurance benefits. It
is a period of consecutive dates during which covered services furnished to
a patient, up to certain specified maximum amounts, can be paid.
This benefit period begins with the first day (not included in a
previous benefit period) on which a patient is furnished SNF care.
The benefit period ends with the close of a period of 60 consecutive
days during which the patient did not receive hospital care or was
not in a SNF. (A new benefit period starts when a beneficiary has
not received hospital or SNF care for 60 days in a row). After the
100 days of Medicare-covered care, the TRICARE benefit becomes primary
if the beneficiary continues to satisfy the TRICARE coverage requirements
and has no OHI.
4.2.3 For DVA/VHA facilities, unless
required by their Memorandum of Understanding (MOU) or Provider
Agreement, DVA/VHA facilities may not be subject to SNF PPS. SNFs
in Puerto Rico and the U.S. Territories (Guam, U.S. Virgin Islands,
American Samoa, and Northern Mariana Islands), are required to be
Medicare certified and will be subject to SNF PPS.
4.2.4 For
a SNF admission to be covered under TRICARE, the beneficiary must
both have a qualifying hospital stay of 3 consecutive days or more,
not including the hospital discharge day, and the beneficiary must
enter the SNF within 30 days of discharge from the hospital. For
TRICARE dual eligible beneficiaries, this requirement is already
met before TRICARE becomes primary. TRICARE and Medicare do make
exceptions to this “within 30 days” rule for those cases that require
future therapy after 30 days (e.g., a hip fracture patient who can’t
do weight-bearing exercises until after 30 days). TRICARE will follow
Centers for Medicare and Medicaid Services (CMS) policy as provided
in the Medicare Benefit Policy Manual, Chapter 8. Any application
of the Medicare Benefit Policy Manual to TRICARE shall be subject
to TRICARE requirements in the law, 32 CFR Part 199, and TRICARE
manuals. The Medicare Benefit Policy Manual (Publication # 100-02)
is an Internet Only Manual (IOM) and can be accessed at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/manuals. When
TRICARE is the primary payer, it shall be the responsibility of
the contractor to determine whether the beneficiary has had a qualifying
three day inpatient stay and has met the 30 day discharge standard.
The contractor shall use the information in block 35 and 36 of CMS
1450 UB-04 to make this determination. If block 36 of CMS 1450 UB-04
is blank, the SNF claim will be denied unless the patient was involuntarily
disenrolled from Medicare+Choice plan (see
paragraph 4.2.5). The contractor
shall calculate the Length-Of-Stay (LOS) based on the SNF actual
admission date provided on the CMS 1450 UB-04 claim form. Any adverse
TRICARE determinations involving medical necessity issues will be appealable
to TRICARE whenever TRICARE is the primary payer. However, a denial
based on the factual dispute (not the medical necessity) of SNF
benefit for failure to meet the three day prior hospitalization of
“within 30 days” requirement is not appealable. Any factual disputes
surrounding the three day prior hospitalization or “within 30 days”
requirement can be submitted to the TRICARE contractor for an administrative
review.
Note 1: If the qualifying hospital stay is denied as
not being medically necessary and appropriate care, the SNF admission
will be denied.
Note 2: If a beneficiary receives
custodial, non-covered services, or care at an inappropriate level
in a SNF for greater than 30 consecutive days, a new qualifying
hospital stay requirement is to be met for a medically necessary
SNF stay in order to be covered under TRICARE with the exception
for medical appropriateness reasons as provided in the Medicare
Benefit Policy Manual, Chapter 8.
4.2.5 Covered
SNF services must meet the requirements in
32 CFR 199.4(b)(3)(xiv) and are to be skilled
services as provided in the Medicare Benefit Policy Manual, Chapter
8. Such skilled services must be for a medical condition that was
either treated during the qualifying three day hospital stay, or started
while the beneficiary was already receiving covered SNF care. These
coverage requirements are the same as applied under Medicare. TRICARE
will follow CMS policy and waive the three day prior hospitalization
requirement for those TRICARE dual eligible beneficiaries involuntarily
disenrolled from Medicare+Choice plans. Code 58 in the Condition
Codes block in CMS 1450 UB-04 will be the indication that patient
is a terminated enrollee in a Medicare+Choice Organization plan
whose three day inpatient hospital stay was waived. With regard
to the requirement that the skilled services must be for a medical condition
that was treated during the qualifying three day hospital stay,
it will generally be presumed that this requirement is met if the
qualifying three day hospital requirement is met. When the facts which
come to the attention of the contractor/claims processor in their
normal review process indicate that the skilled services are not
related to any of the diagnoses treated during the qualifying hospital stay,
the SNF claim shall be denied.
4.2.6 TRICARE reimbursement will
follow Medicare’s SNF PPS methodology and assessment schedule.
4.2.7 Under the
SNF PPS methodology and assessment schedule system, the patient
will be assessed upon admission to the SNF using the MDS assessment
tool. The Nursing Home Reform Act of the Omnibus Budget Reconciliation
Act (OBRA 1987) mandates that all certified Long-Term Care (LTC) facilities
must use the MDS as a condition of participating in Medicare or
Medicaid which TRICARE is also adopting.
4.2.8 The MDS is a set of clinical
and functional status measures that provides the basis for the Resource
Utilization Group (RUG) classification system and the PPS. Nursing
facilities must collect these data on each of their residents at
prescribed intervals and upon any significant change in physical
or mental condition. The MDS data are then used to classify residents
into one of the SNF case-mix RUGs based on their clinical characteristics,
functional status and expected resource needs (see
Addendum A).
4.2.9 SNF residents
will be assessed by SNFs on days 5, 14, 30, 60, and 90. Thereafter,
under TRICARE, the residents will be assessed every 30 days using
the same MDS assessment form. For untimely assessments, there will
be penalties similar to those used by CMS. In a case of untimely assessment,
the SNF will submit the claim with a default rate code and the SNF
will be reimbursed at the lowest RUG pricing. If a SNF resident
returns to the SNF following a temporary absence for hospitalization
or therapeutic leave, it will be considered a readmission. A leave
of absence will be counted as an inpatient day (i.e., not treated
as a discharge and readmission) if the patient returns to the SNF
by midnight of the same day.
4.2.10 SNFs are
not required to assess a resident upon readmission, unless there
has been a significant change in the resident’s condition. If the
resident experiences a significant change in condition (i.e., either
an improvement or decline in the physical, mental or psychosocial
level of well-being), the facility must complete a full comprehensive
assessment by the end of the 14th calendar day following determination
that a significant change has occurred. A “significant change” is
defined as a major change in the resident’s status that:
4.2.10.1 Is not
self-limiting (i.e., the condition will not normally resolve itself
without further clinical intervention);
4.2.10.2 Impacts
on more than one area of the resident’s health status; and
4.2.10.3 Requires
interdisciplinary review or revision of the care plan.
Note: If a SNF has discharged a resident without the
expectation that the resident would return, then the returning resident
is considered a new admission (return stay) and would require an
initial admission comprehensive assessment including Sections AB
(Demographic Information) and AC (Customary Routine) of the assessment
form within 14 days of admission.
4.2.11 SNFs are
not required to automatically transmit MDS assessment data to the
TRICARE contractors. However, the TRICARE contractor, at its discretion,
shall collect the MDS assessment data and documentation for claim
adjudication or audit and tracking purposes at any time from SNFs
when TRICARE is the primary payer. MDS forms and relevant background
information may be found on the following web sites:
http://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp#TopOfPage and
http://www.cms.hhs.gov/MinimumDataSets20/.
For TRICARE dual eligible beneficiaries, during the first 100 days
of an inpatient SNF stay, TRICARE will function as a secondary payer
to Medicare under SNF PPS in which case there is no need to collect
the MDS assessment data. At any time TRICARE is primary payer, the
MDS assessment data shall be collected for audit and tracking purposes.
4.2.12 SNF staff
will input the MDS assessment data into the MDS RUG-III/IV grouper,
depending on the date of service. The Grouper will then generate
an appropriate three digit RUG-III/IV code. A complete listing of
three digit RUG-III/IV codes with corresponding definitions is included
in
Addendum A. To supplement the three digit
RUG-III/IV codes, the SNF will add the appropriate two digit modifier
to indicate the reason for the MDS assessment before submitting
the claim for payment. The three digit RUG-III/IV code and the two
digit modifier make up the five digit Health Insurance Prospective
Payment System (HIPPS) code. The assessment indicators and the HIPPS
code information related to SNF are available at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html.
The SNF will enter the HIPPS code on the CMS 1450 UB-04 claim form
in the Healthcare Common Procedure Coding System (HCPCS) code field
that corresponds with the Revenue Code
022. After the
100th day, for TRICARE patients, SNFs will use an appropriate three
digit RUG-III/IV code with a TRICARE-specific two digit modifier
that makes up the HIPPS code. The TRICARE-specific two digit modifiers
will be as follows:
|
|
120-day assessment
|
8A
|
|
|
150-day assessment
|
8B
|
|
|
180-day assessment
|
8C
|
|
|
210-day assessment
|
8D
|
|
|
240-day assessment
|
8E
|
|
|
270-day assessment
|
8F
|
|
|
300-day assessment
|
8G
|
|
|
330-day assessment
|
8H
|
|
|
360-day assessment
|
8I
|
|
|
Post 360-day assessments
with 30-day interval
|
8X
|
4.2.13 Upon completion
of the requisite HIPPS coding, when TRICARE is the primary payer,
the SNF will submit the claim to the TRICARE claims processor for
payment only after the beneficiary has been admitted, has satisfactorily
met the qualifying coverage criteria and has had an appropriate
MDS assessment completed. When TRICARE is the secondary payer, the
claim will be submitted in accordance with standard billing procedures.
4.2.14 Consistent
with Medicare’s SNF PPS methodology, under the TRICARE SNF PPS:
4.2.14.1 The PPS
payment rates will cover all costs of furnishing covered SNF services
(routine, ancillary, and capital-related costs).
4.2.14.2 The PPS
per diem payment rate is the sum of three parts: the nursing component,
the therapy component, and the non-case-mix component. The nursing
component includes nursing, social service and non-therapy ancillary
costs (such as medications, laboratory tests, radiology procedures,
respiratory therapy, medical supplies, and intravenous therapy).
The therapy component includes physical, occupational and speech-language
therapy costs. The non-case-mix component includes administrative,
overhead and other generally fixed patient care costs (such as dietary
services).
4.2.14.3 The MDS
data are used to classify residents into one of the case-mix RUGs.
Each of these RUG subgroups is assigned a relative weight factor
(when applicable) to determine the nursing component and the therapy
component of the total PPS rate. The relative weight factor reflects
the costliness of providing services to residents in that group
relative to the average costliness of residents across all groups.
The relative weight factor is multiplied by the applicable nursing
or therapy base rate (urban or rural) which results in the nursing
component and the therapy component of the total rate. Patients
who are expected to be more resource-intensive (based on the MDS
assessment), are assigned to a RUG-III/IV category that carries
a higher relative weight factor. The non-case-mix component is not adjusted.
The total PPS payment rate is the sum of the nursing component,
the therapy component and the non-case-mix component. The labor
portion of the total PPS payment rate is then adjusted for geographic
variation in wages using the wage index. Contractors shall not be
required to do these calculations as all of these calculations are
automated in using the RUG-III/IV Pricer software.
4.2.14.4 Section
4432(b) of the Balance Budget Act of 1997 (BBA 1997) sets forth
a Consolidated Billing (CB) requirement applicable to all SNFs providing
Medicare services. Under this requirement, SNFs must submit to Medicare
all bills for Medicare-covered services furnished to their residents, regardless
of who provides the services. This requirement is similar to the
requirement that has been in effect for inpatient hospital services.
TRICARE adopted the Medicare’s CB requirements applicable to SNFs.
Services excluded from CB have been mandated by the provisions of
two separate pieces of legislation. First, there are several services
that are beyond the general scope of SNF comprehensive care plans
(excluded under 42 CFR 411.15 (p)(3)(iii)). Second, there are several
other services excluded from CB per the provisions of Section 1882(c)(2)(A)(iii)
of the Social Security Act, as amended by Section 103 of the Balanced
Budget Refinement Act of 1999 (BBRA 1999). A comprehensive listing
of these services excluded from CB is provided in
paragraph 4.2.14.5. The contractor
shall not issue benefit modifications for non-Medicare covered,
medically necessary services for TRICARE beneficiaries receiving
SNF care. There will be no benefit exceptions permitted. Services
excluded from the CB provisions of the SNF PPS (e.g., cardiac catheterizations
and emergency services, etc.) will be paid at the TRICARE rates.
4.2.14.5 The
cost of the services listed below will be excluded from the SNF
PPS rate. These services shall be billed directly and paid separately
using TRICARE rates. The “technical” component of a covered SNF
service is included in the PPS rate but the “professional” component
shall be billed separately. The identifying codes for contractor
implementation of the CB provisions of the SNF PPS are provided at
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html.
This web site provides the SNF CB annual updates in Excel and PDF
formats. Annual update files, as well as subsequent quarterly updates
(if any), for SNF CB can be found at the above web site. This file
lists services by HCPCS Code, Short Descriptors, and the Major Category
under which the HCPCS falls. HCPCS added or removed by subsequent
quarterly updates will be listed under the respective year’s annual
update section at the above web site. The respective year’s annual
update file will be updated to add or remove the HCPCS listed in
the quarterly updates. A separate file containing the explanation
of the five Major Categories for SNF CB can also be found at the
above web site and it includes additional exclusions that are not
driven by HCPCS codes (as some Major Categories exclude services
by revenue code as well as bill types). These additional exclusions
shall be included in SNF CB implementation. The effective dates
for CB updates for TRICARE shall be the same as under Medicare and
those will be provided with the CB updates at the above web site.
No additional services will be added by the annual or quarterly
updates related to CB; that is, new updates are required by changes
to the coding system, not because the services subject to SNF CB
are being redefined. Contractors shall implement these updates within
30 days of release on the above web site (unless the implementation
date provided in the update allows for greater time for implementation)
at no additional cost to the Government. To implement this requirement,
contractors shall check the above web site for annual SNF CB updates
no later than the fifth business day in December for implementation
in the following January each year. If the annual CB update is delayed
by CMS (due to delay in the Medicare Physician Fee Schedule), contractors
shall check the above CMS web site for annual CB updates by no later
than the annual CHAMPUS Maximum Allowable Charge (CMAC) update for
implementation within 30 days of the annual CMAC update. For quarterly
SNF CB updates, contractors shall check the above CMS web site no later
than the fifth business day in March, June, and September of each
year for implementation of any updates in April, July, and October
of each year respectively. Contractors shall closely monitor billings and
claims to prevent any duplicate billings. Following is a list of
services excluded from the SNF PPS and CB:
4.2.14.5.1 Services
provided to individual SNF residents by authorized practitioners,
such as, physicians, certified nurse-midwives, clinical psychologists,
certified clinical social workers (CSWs), nurse anesthetists;
4.2.14.5.2 Home dialysis
supplies and equipment;
4.2.14.5.3 Erythropoietin
(EPO) for dialysis patients as under Medicare;
4.2.14.5.4 Hospice
care related to a beneficiary’s terminal condition. Such hospice
care will be excluded from the CB provisions of the SNF PPS and
will be reimbursed in accordance with the TRICARE hospice benefit.
4.2.14.5.5 An ambulance
trip that transports a beneficiary to the SNF for the initial admission
or from the SNF following a final discharge. If the beneficiary
is a resident of the SNF, then ambulance services are covered under
CB and are included in the bundled rate. The initial admission ambulance ride
and the final discharge ambulance ride are not covered under CB
because the patient is not considered a SNF resident. (42 CFR 411.15
(p)(3)(I)-(iv). TRICARE will follow CMS policy for medical necessity
for ambulance transportation (42 CFR 410.40(d)(l)) which is consistent
with the DHA policy.
Note: If the beneficiary
meets the criteria of a SNF resident, then ambulance transportation
for “medically necessary” services are covered under CB and are
included in the bundled SNF PPS rate. However, when a SNF resident
leaves the SNF to receive any outpatient hospital services that
are specifically excluded from CB (e.g., cardiac catheterization,
Computerized Tomography (CT) scans, Magnetic Resonance Imagings
(MRIs), emergency room services, etc.), then that beneficiary is
no longer considered to be a SNF resident for CB purposes. As such,
any associated ambulance trips themselves would be excluded from
CB. Such ambulance trips associated with the receipt of excluded services
are not included in the bundled SNF PPS rate and may be billed separately
to Part B (Medicare) and TRICARE. If the beneficiary leaves the
SNF to receive outpatient hospital services that are excluded from
CB, then by definition that beneficiary no longer retains the status
of a SNF “resident”. See Medicare fact sheet regarding CB and ambulance
services at
Addendum E.
4.2.14.5.6 Chemotherapy
items and administration services;
4.2.14.5.7 Radioisotope
services;
4.2.14.5.8 Customized
prosthetic devices;
4.2.14.5.9 Ambulance
transportation for dialysis;
4.2.14.5.10 Certain
outpatient services when provided in a hospital (including associated
medically indicated ambulance transport) as these services are considered
beyond the scope of the SNF care. These services include:
• Cardiac
catheterization
• CT
scans
• MRIs
• Ambulatory surgery
performed in operating rooms
• Emergency services
• Radiation therapy
• Angiography
• Venous and lymphatic
procedures.
Note: If the listed
service is delivered in another setting (such as an ambulatory surgery
center or imaging center) or if another (not excluded) service is
provided in a hospital outpatient department (such as an x-ray),
the beneficiary is still considered a SNF resident, and the service,
and payment for it, is included in the SNF PPS rate.
4.2.14.6 If
the SNF submits a PPS claim that also includes an excluded service
(see
paragraph 4.2.14.6), the service that is excluded
will be ignored and the claim will process and pay as it would without
the excluded service. The SNF PPS claims are priced strictly on
the RUG groups, and none of the ancillaries are themselves paid.
If the SNF claim is just for the excluded service that SNFs may
not bill, the claim will be rejected, and an explanation should
appear on the Explanation Of Benefits (EOB). This is similar to
a denial, but does not carry appeal rights.
4.2.15 SNF Pricer
4.2.15.1 DHA
will provide the annual SNF PPS pricer (via link) once it is posted
by CMS, to the claims processors upon contract award. Once posted
or upon notification of the link availability, claims processors
are required to replace the existing pricer with the updated pricer
within 10 calendar days. As the annual or quarterly pricer file
totally replaces the previous pricer, claims processors are not required
to maintain quarterly iterations. Claims processors must maintain
the last version of the pricer software for each prior fiscal year
and the most recent quarterly release of the current fiscal year.
4.2.15.2 Claims
processors will use the 100% of the PPS rate and override any rate
that is less than 100% of the PPS rate. For the call to the SNF
pricer the claims processors should use the following:
• HIPPS
= HIPPS code from claim
• EFFECTIVE DATE
= end date of service or through date from claim
• FEDERAL BLEND =
4
• FACILITY
RATE = 0
4.2.15.3 The pricer
will automatically give the contractor the calculated rate for a
one day stay for the claim’s dates of service. Contractors shall
multiply the PPS rate given to the revenue 022 line units on the
claim to come up with the complete rate for that HIPPS claim line.
4.2.15.4 Claims
processors will not need to split claims when an SNF admission cross
fiscal year dates. Providers are to prepare separate bills for services
prior to and on or after October 1 as the SNF PPS rate is updated
for each fiscal year. This split billing by providers ensures that
the claim is paid using the correct rate.
4.2.15.5 For information
purposes, current Wage Index file, the SNF PPS rates, and other
related updates annually to DHA will be issued as routine changes
to
Addendums A, B, D, E, and F, as applicable.
Contractors shall not wait for issuance of these routine changes
for implementation, as the SNF rate, wage index, and these updates
are built into the SNF Pricer.
4.2.16 If the
SNF does an off-schedule assessment, a late patient assessment or,
in some cases, no patient assessment at all, the SNF will submit
the claim using the default HIPPS rate code of AAA and the two digit
default assessment indicator modifier code of 00 which will result
in payment of the default rate.
4.2.17 With
regard to payment for the lower 18 RUGs (i.e., IB2, IB1, IA2, IA1,
BB2, BB1, BA2, BA1, PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2,
PA1), for services prior to October 1, 2010, and the lower 14 RUGs
(i.e., BB2, BA2, BB1, BA1, PE2, PD2, PC2, PB2, PA2, PE1, PD1, PC1,
PB1, PA1) for services on/after October 1, 2010, TRICARE will follow
the SNF level of care criteria as provided in the Medicare Benefit Policy
Manual, Chapter 8 (Publication # 100-02), which can be accessed at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html.
Beneficiaries in the lower 14 RUGs do not automatically qualify
for SNF coverage. Instead, these beneficiaries will be individually
reviewed to determine whether they meet criteria for skilled services
and the need for skilled services as defined in 42 CFR 409.32, Subpart D.
In determining “medical necessity”, the contractor shall use generally acceptable
criteria such as InterQual.
Note: A beneficiary
who is correctly assigned to one of the upper RUGs under the initial
five day assessment is automatically classified as meeting the SNF
level of care definition and does not require a medical review unless
there is a reason to do so (e.g., data analysis suggests an unusual
pattern of claims submission). When a beneficiary is correctly assigned
to one of the upper RUG-III/IV groups, depending on the date of
service, under the initial five day assessment, the SNF level of
care requirement is met for the period from SNF admission up to
and including the assessment reference date for that assessment.
This presumption of coverage only applies if the beneficiary is
admitted to the SNF immediately following a three day qualifying
hospital stay, and lasts through the assessment reference date of
the five day assessment, which must occur no later than the eighth
day of the stay due to the three day grace period for SNF assessments.
Note: For TRICARE dual eligible beneficiaries: Medicare
is primary payer during the presumption of coverage period; therefore,
TRICARE will follow Medicare’s determination. If the services are determined
not to be medically necessary under Medicare, they will not be covered
under TRICARE. SNF care received in the U.S. and U.S. territories
will require preauthorization. The TDEFIC contractor shall preauthorize
care beginning on day 101, when TRICARE becomes primary payer.
4.2.18 If a pediatric
SNF is certified by Medicaid, it will be considered to meet the
Medicare certification requirement in order to be an authorized
provider under TRICARE. The cover letter to SNFs and the Participation
Agreement are provided at
Addendums A and B which
the contractor shall send to SNFs. If the contractor would like
to send a revised cover letter or if the contractor would like to revise
the Participation Agreement, the contractor shall first get approval
from the Government. SNFs must provide evidence that they are certified
by Medicare (or Medicaid). The contractor shall be responsible for
verification that the SNF is Medicare-certified (or Medicaid-certified),
and has entered into a Participation Agreement with TRICARE. TRICARE
will not permit a waiver to allow non-Medicare (or non-Medicaid)
certified SNFs to be authorized SNFs under TRICARE. Non-participating
SNFs will not be eligible for reimbursement under TRICARE. If a
PPS claim is received from a SNF that has not signed a TRICARE Participation
Agreement, the contractor shall deny the claim and send a Participation Agreement
to the SNF for signature. Once the SNF has signed the Participation
Agreement, the claim will be processed provided the SNF was Medicare
(or Medicaid) certified and met all other TRICARE SNF criteria at
the time when the services were furnished to the TRICARE beneficiary.
Note: DVA/VHA facilities are required to be Medicare
approved or they are required to be Joint Commission accredited
in order to have deemed status under Medicare or TRICARE. DVA/VHA
facilities that enter into an MOU with Department of Defense (DoD)
are not required to enter into the Participation Agreement provided
at
Addendums A and B.
4.2.19 At their
own discretion, the contractors shall conduct any data analysis
to identify aberrant PPS providers or those providers who might
inappropriately place TRICARE beneficiaries in a high RUG.
4.2.20 Refer to
the TRICARE Systems Manual (TSM),
Chapter 2 for
the SNF PPS related revenue and edit codes.
4.3 For Admissions
when TRICARE is Secondary Payer to Medicare
4.3.1 TRICARE is the secondary payer
to Medicare for SNF care for beneficiaries under age 65 who are
eligible for Medicare, with no OHI and for beneficiaries age 65
and over who are eligible for Medicare with less than a 100-day
covered Medicare SNF stay with no OHI.
4.3.2 The beneficiary has no liability
under Medicare for days 1 through 20; therefore, there will not
be any unpaid amount for TRICARE to reimburse until day 21. For
days 21 to 100, the beneficiary does have a cost-share for which
TRICARE will pay the remaining liability as secondary payer.
4.3.3 The Medicare-eligible
patient will be assessed by the SNF using the MDS.
4.3.4 The
MDS data will be run through the MDS RUG-III/IV grouper to generate
a three digit RUG-III/IV code. The RUG grouper software assigns
a RUG code for billing and payment purposes. Each Medicare-certified
SNF must process the MDS assessment data by using the appropriate
RUG grouper, depending on the date of service. A two digit modifier
will be added to this to get the five digit HIPPS code which the
SNF will put on the claim and send that to the Medicare claims processor
for payment.
4.3.5 For TRICARE dual eligible beneficiaries, the
Medicare claims processor will pay the SNF claim as the primary
payer and then electronically submit the claim to the TRICARE contractor
for secondary payer purposes.
4.3.6 For a beneficiary who is both
Medicare and TRICARE eligible, TRICARE can pay secondary for a SNF
that participates in Medicare and has entered into a Participation
Agreement with TRICARE. Upon exhaustion of Medicare benefits, TRICARE
shall pay primary to such SNFs.
4.3.7 As secondary payer, TRICARE
will use Medicare’s determination of coverage rather than performing
an additional review. If Medicare denies the services as not medically
necessary, TRICARE will also deny the care and the beneficiary will
have appeal rights through Medicare.