2.0 Revisions
For Fiscal Year 2020
Under 10 United States
Code (USC) 1079(i)(2), the amount to be paid to hospitals, SNFs,
and other institutional providers under TRICARE shall, by regulation,
be established “to the extent practicable in accordance with the
same reimbursement rules as apply to payments to providers of services
of the same type under Medicare.
On
August 8, 2018, the Centers for Medicare and Medicaid Services (CMS)
published the Prospective Payment System (PPS) and Consolidated
Billing for Skilled Nursing Facilities (SNF) Final Rule for Fiscal
Year (FY) 2019. In the rule, CMS documented its plan to replace
the SNF PPS RUG-IV classification system with a new case-mix classification
model called the Patient-Driven Payment Model (PDPM) beginning on
October 1, 2019.
5.0 Policy
5.1 Statutory Background
In accordance with
32 CFR 199.4(b)(3)(xiv), covered services
in SNFs are the same as provided under Medicare under section 1861(h)
and (i) of the Social Security Act (42 USC 1395x(h) and (i)) and
42 CFR 409, Subparts C and D, except that the Medicare limitation
on the number of days of coverage under section 1812(a) and (b)
of the Social Security Act (42 USC 1395d(a) and (b)) and 42 CFR
409.61(b) shall not be applicable under TRICARE.
5.2 Applicability And Scope
All TRICARE authorized SNFs must be authorized
SNF providers under the Medicare program, and meet the requirements
of Title 18 of the Social Security Act, sections 1819 (a), (b),
(c), and (d) (42 United States Code (USC) 1395 i-3(a) - (d)), or
subsequent regulations.
5.2.1 If a pediatric SNF is certified by Medicaid,
it will be considered to meet the Medicare certification requirement
to become an authorized provider under TRICARE. The contractor shall
send a cover letter and Participation agreement, which is provided
at
Addendum A, to any SNFs that are not authorized
by Medicare, but would qualify as a TRICARE-approved pediatric SNF.
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.
5.2.2 VA facilities are required
to be Medicare approved or they are required to be Joint Commission
accredited to have deemed status under Medicare or TRICARE. Unless
required in their Memorandum of Understanding (MOU) or Participation
Agreement, Department of Veterans Affairs (VA) facilities may not
be subject to SNF PPS (see
paragraph 6.2).
5.3 SNF Admission Criteria
5.3.1 TRICARE follows Medicare requirements
for admission to a SNF and any exception policy per Medicare Benefit
Policy Manual, Chapter 8. For a SNF admission to be covered under
TRICARE, the beneficiary must both have a qualifying hospital stay
of three 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.
5.3.2 TRICARE is adopting Medicare’s
Interrupted Stay Policy.
• TRICARE
will adopt the Medicare definition of an interrupted stay as one
in where a patient is discharged from a SNF and subsequently readmitted
to the same SNF during the interruption window. The interruption
window is a three-day period that begins on the first non-covered
day following a SNF stay and ends at 11:59pm on the third consecutive
non-covered day. If both conditions are met, the subsequent stay
is considered a continuation of the previous “interrupted” stay
for the purposes of both the variable per diem schedule and the
assessment schedule.
• If
the patient is readmitted to the same SNF outside the interruption
window, or any instance when the patient is admitted to a different
SNF (regardless of the length of time between stays), then the Interrupted
Stay Policy does not apply, and the subsequent stay is considered
a new stay. In such cases, the variable per diem schedule resets
to Day 1 payment rates, and the assessment schedule also resets
to Day 1, necessitating a new five-day assessment required.
5.3.3 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.
5.3.4 When TRICARE is the primary payer, the contractor
shall determine whether the beneficiary meets the criteria for coverage.
The contractor shall use the information in block 35 and 36 of CMS
1450 UB-04 to make the admission determination. If block 36 of CMS
1450 UB-04 is blank, the SNF claim will be denied unless the patient
was involuntarily disenrolled from a Medicare + Choice plan. 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
or “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.
5.4 SNF
MDS Assessments
5.4.1 The Medicare-certified SNF must assess the
beneficiary using the Minimum Data Set (MDS) assessment form for
the SNF PPS rate to be applied.
5.4.2 Under the PDPM, SNF residents
will be assessed using MDS by SNFs at day 5 and at discharge (see
PDPM FAQ on Medicare Website at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html).
The interim payment assessment (IPA) is optional and will be completed
when providers determine that the patient has undergone a clinical
change that would require a new PPS assessment. SNFs are not required
to assess a resident upon readmission, unless there has been a significant
change in the resident’s condition. If a significant change is found,
the facility will follow Medicare policy for additional reviews.
5.4.3 SNFs are not required to automatically
transmit MDS assessment data to the TRICARE contractors. However,
the TRICARE contractor, at its discretion, may 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.
5.4.4 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 the SNF PPS
in which case there is no need for TRICARE to collect the MDS assessment
data. At any time when TRICARE is primary payer, the MDS assessment
data shall be collected by TRICARE for audit and tracking purposes.
5.4.5 SNF staff will follow Medicare
policy and use the MDS grouper which uses MDS data to classify patients
into PDPM groups. The grouper will then generate an appropriate
four-digit PDPM code. To supplement the four-digit codes, the SNF
will add a one-digit assessment indicator using codes determined
by Medicare to indicate the reason for the MDS assessment before
submitting the claim for payment. The five digits make up the Health
Insurance Prospective Payment System (HIPPS) code. 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. The components of this code are used
within the pricer (see
paragraph 5.5.2) to determine payment. SNFs will
code the fifth digit using Medicare MDS assessment codes to indicate
either initial, PPS discharge, or Interim Payment Assessments (IPA).
5.4.6 For untimely assessments,
if the SNF does an off-schedule assessment, or in some cases no patient
assessment at all, the SNF will submit the claim with a default
rate code ZZZZZ and the SNF will be reimbursed at the lowest PDPM
pricing.
5.5 SNF
PPS Payment Method
5.5.1 TRICARE reimbursement will follow Medicare’s
SNF PPS methodology and assessment schedule for all TRICARE patients
(including those Active Duty Service Members (ADSMs) using Supplemental
Care benefits, Transitional Assistance Management Program (TAMP)
beneficiaries, and Continued Health Care Benefit Program (CHCBP)
beneficiaries) admitted at Medicare-certified SNFs (or Medicaid-certified
pediatric SNFs), with specific exceptions as noted later in this
section. SNF PPS will apply to TRICARE beneficiaries who satisfy
the qualifying coverage requirements of the TRICARE SNF benefit.
5.5.2 The PPS
payment rates will cover all costs of furnishing covered SNF services
(routine, ancillary, and capital-related costs). For items that
Medicare pays outside the SNF PPS consolidated billing rules (e.g.,
professional services of physicians, chemotherapy), TRICARE will
also pay outside the SNF PPS rate utilizing the appropriate TRICARE
reimbursement system. The CB provisions of the SNF PPS are provided
at
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html.
5.5.3 Claims will be paid at 100%
of the PPS rate.
5.5.4 Claims processors shall regularly monitor and
download the latest Medicare SNF PPS Pricer software from the Medicare
website:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/SNF.html and
replace the existing pricer with the updated pricer within 10 calendar days
of download. 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.
5.5.5 The pricer will provide the
contractor the calculated rate for a one day stay for the claim’s dates
of service. Contractors shall multiply the PPS amount calculated
by the pricer by the number of revenue 022-line units on the claim
to come up with the complete amount for that HIPPS claim line.
5.5.6 Claims processors will not
need to split claims when a SNF admission crosses 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.
5.6 Additional
SNF Data
5.6.2 The SNF-PPS base rates will
be posted for each PDPM category annually. Contractors shall not
wait for issuance of these routine changes for implementation, because
the SNF rate, wage index, and these updates are built into the SNF
PPS pricer.
5.7 Miscellaneous
Policy
5.7.1 Medicare
is the primary payer for all dual eligibles during the first 100
days of SNF care per benefit period. For all care after 100 days,
TRICARE becomes the primary payer for Medicare-eligible beneficiaries
who have no other health insurance. TRICARE is also the primary
payer for non-Medicare-eligible TRICARE beneficiaries who do not
have other health insurance 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.
5.7.3 With regard to payment for
the lower PDPM classification groups, TRICARE will follow the SNF
level of care criteria as provided in the Medicare Benefit Policy
Manual, Chapter 8. If individual reviews are required by Medicare,
the contractor will be responsible to conduct the review for TRICARE primary-payer
patients to ensure that 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.
5.7.4 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 PDPM category.
5.7.5 Refer to the TRICARE Systems
Manual (TSM),
Chapter 2 for
the SNF PPS related revenue and edit codes.
5.7.6 The Waiver of Liability provisions
in the TRICARE Policy Manual (TPM),
Chapter 1, Section 4.1 apply to SNF cases.
5.7.7 TRICARE will allow those hospital-based
SNFs with medical education costs to request reimbursement for those
expenses. Only medical education costs that are allowed under the
Medicare SNF PPS will be considered for reimbursement. These education
costs will be separately invoiced by hospital-based SNFs on an annual
basis as part of the reimbursement process for hospitals (see
Chapter 6, Section 8). Hospitals with SNF
medical education costs will include appropriate lines from the
cost report and the ratio of TRICARE days/total facility days as
described in
Chapter 6, Section 8. The product will equal
the portion that TRICARE will pay. TRICARE days do not include any
days determined to be not medically necessary, and days included
on claims for which TRICARE made no payment because Other Health
Insurance (OHI) or Medicare paid the full TRICARE allowable amount.
The hospital’s reimbursement requests will be sent on a voucher
to the DHA Finance Office for reimbursement as a pass-through cost.
5.7.8 The need for enteral feedings
may not, alone, provide a sufficient basis for obtaining TRICARE
coverage of care provided in a SNF. Enteral feedings are not services
that can be provided only at a SNF level of care. The SNF extended
care benefit covers relatively short-term care as a continuation of
treatment begun in the hospital. The initiation of enteral feedings
or provision of skilled care needed to manage documented difficulties
or complications with the feedings may be considered skilled services
that qualify for SNF care. However, once a beneficiary is stabilized
for routine enteral feedings, a lower level of care may be more
appropriate, such as a home care setting or assisted living facility, with
non-licensed family members or facility staff trained to provide
feedings and only intermittent involvement of nursing personnel
needed to provide oversight. The appropriate level of care is subject to
medical necessity review.
5.8 Preauthorization
SNF care received in the United States (U.S.)
and U.S. territories will require preauthorization if TRICARE is
the primary payer. The TDEFIC contractor shall preauthorize care
beginning on day 101, when TRICARE becomes primary payer for dual
eligible beneficiaries without other health insurance. TRICARE contractors,
at their discretion, shall conduct concurrent or retrospective review
for TRICARE Select or TRICARE For Life (TFL) patients when TRICARE
is the primary payer. There will be no review when TRICARE is the
secondary payer. The existing referral and authorization procedures
for Prime beneficiaries will remain unaffected.
6.0 Exclusions
6.1 CAH swing beds are excluded
from the SNF PPS methodology.
6.2 VA facilities are excluded
from the SNF PPS methodology unless there is a SNF Participation Agreement
or MOU in place establishing that they will be reimbursed with the
SNF PPS methodology.
6.3 Children under age 10 at the time of admission
to a SNF that are not assessed using the MDS are exempt from the
SNF PPS methodology. The TRICARE contractor shall negotiate these reimbursement
rates utilizing their best business practices.
6.4 When no TRICARE inpatient
SNF PPS program payment is possible, otherwise covered medically
necessary services and supplies may be allowed under TRICARE’s outpatient
benefit. However, nursing care provided in a SNF setting is not
billable under the TRICARE outpatient benefit. For TRICARE dual
eligible beneficiaries, Medicare is primary payer for all Medicare
Part B services; therefore, the SNF will need to bill CMS for these
outpatient SNF services, rather than first submitting a claim to
TRICARE. (See
Chapter 4, Section 4.)