1.0 APPLICABILITY
This policy is mandatory for
reimbursement of services provided by either network or non-network
providers. However, alternative network reimbursement methodologies
are permitted when approved by the Defense Health Agency (DHA) and
specifically included in the network provider agreement.
3.0 POLICY
Payment Rate.
3.1 When it is determined that
a hospital may be paid for care provided to a beneficiary who requires
only SNF care, payment is to be at the SNF Prospective Payment System
(PPS) rate.
3.2 In order to determine the payment
for a beneficiary who is exempt from the SNF PPS, the contractor
is to use either the rate for the SNF which most likely would be
used by the beneficiary, or it may use an average of the rates of
comparable, equally accessible SNF.