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.