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 calendar 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 an SNF. (A new benefit period starts when a beneficiary has
not received hospital or SNF care for 60 calendar days in a row).
After the 100 calendar 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 United States (US) Territories (Guam, US 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
an 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 calendar 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 calendar days” rule for those
cases that require future therapy after 30 calendar days (e.g.,
a hip fracture patient who can’t do weight-bearing exercises until
after 30 calendar 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.
4.2.4.1 The contractor shall determine
(when TRICARE is the primary payer), 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).
4.2.4.2 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
calendar days” requirement is not appealable. Any factual disputes
surrounding the three day prior hospitalization or “within 30 calendar
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 an 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.
4.2.6 The contractor shall deny the
SNF claim when 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.
4.2.7 TRICARE
reimbursement will follow Medicare’s SNF PPS methodology and assessment
schedule.
4.2.8 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.
4.2.9 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).
4.2.10 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 calendar 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 an 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.
4.2.11 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:
4.2.11.1 Is not self-limiting (i.e.,
the condition will not normally resolve itself without further clinical intervention);
4.2.11.2 Impacts on more than one area
of the resident’s health status; and
4.2.11.3 Requires interdisciplinary
review or revision of the care plan.
Note: If an 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 calendar days of admission.
4.2.12 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.
MDS forms and relevant background information may be found on the
following websites:
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 calendar
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.
4.2.13 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
|
4.2.14 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.
4.2.15 Consistent with Medicare’s
SNF PPS methodology, under the TRICARE SNF PPS:
4.2.15.1 The PPS payment rates will
cover all costs of furnishing covered SNF services (routine, ancillary,
and capital-related costs).
4.2.15.2 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).
4.2.15.3 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
are not required to do these calculations as all of these calculations
are automated in using the RUG-III/IV Pricer software.
4.2.15.4 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 4.2.15.6.
4.2.15.5 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)
will be paid at the TRICARE rates.
4.2.15.6 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 website 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 website. 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 website. 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 website
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 website. 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.
4.2.15.6.1 The contractor shall implement
these updates within 30 calendar days of release on the above website
(unless the implementation date provided in the update allows for
greater time for implementation) at no additional cost to the Government.
4.2.15.6.2 The contractor shall check
the above website for annual SNF CB updates no later than the fifth business
day in December for implementation in the following January each
year.
4.2.15.6.3 The contractor shall check
the above CMS website for annual CB updates by no later than the annual
CHAMPUS Maximum Allowable Charge (CMAC) update for implementation
within 30 calendar days of the annual CMAC update if the annual
CB update is delayed by CMS (due to delay in the Medicare Physician
Fee Schedule).
4.2.15.6.4 The contractor shall check
the above CMS website for quarterly SNF CB updated 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.
4.2.15.6.5 The contractor shall closely
monitor billings and claims to prevent any duplicate billings. Following is
a list of services excluded from the SNF PPS and CB:
4.2.15.6.5.1 Services provided to individual
SNF residents by authorized practitioners, such as, physicians, certified
nurse-midwives, clinical psychologists, certified clinical social
workers (CSWs), nurse anesthetists;
4.2.15.6.5.2 Home dialysis supplies and
equipment;
4.2.15.6.5.3 Erythropoietin (EPO) for dialysis
patients as under Medicare;
4.2.15.6.5.4 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.
4.2.15.6.5.5 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 an 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 an SNF resident, then ambulance
transportation for “medically necessary” services are covered under
CB and are included in the bundled SNF PPS rate. However, when an
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), then that beneficiary is no longer
considered to be an 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 an SNF
“resident”. See Medicare fact sheet regarding CB and ambulance services
at
Addendum E.
4.2.15.6.5.6 Chemotherapy items and administration
services;
4.2.15.6.5.7 Radioisotope services;
4.2.15.6.5.8 Customized prosthetic devices;
4.2.15.6.5.9 Ambulance transportation for
dialysis;
4.2.15.6.5.10 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
an SNF resident, and the service, and payment for it, is included
in the SNF PPS rate.
4.2.15.7 If
the SNF submits a PPS claim that also includes an excluded service
(see
paragraph 4.2.15.7), 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.
4.2.16 SNF
Pricer
4.2.16.1 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.
4.2.16.2 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
4.2.16.3 The contractor 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. The Pricer
will automatically give the contractor the calculated rate for a
one day stay for the claim’s dates of service.
4.2.16.4 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.
4.2.16.5 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.
4.2.16.6 The contractor 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.
4.2.17 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.
4.2.18 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.
4.2.19 The contractor shall use generally
acceptable criteria such as InterQual in determining “medical necessity.”
4.2.19.1 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.
4.2.19.2 The TRICARE Medicare Eligible
Program (TMEP) contractor shall preauthorize care beginning on calendar
day 101, when TRICARE becomes the primary payer. 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 US and US territories will require preauthorization.
4.2.20 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.
4.2.20.1 The contractor shall send a
cover letter to the SNFs and the Participation Agreement (provided
at
Addendums A and
B).
4.2.20.2 The contractor shall first
get approval from the Government, if the contractor would like to
send a revised cover letter or if the contractor would like to revise
the Participation Agreement.
4.2.20.3 The contractor shall verify
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.
4.2.20.4 The contractor shall deny the
claim and send a Participation Agreement to the SNF for signature,
if a PPS claim is received from an SNF that has not signed a TRICARE
Participation Agreement. Once the SNF has signed the Participation
Agreement, the claim shall 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.
4.2.21 At their own discretion, the
contractor may conduct any data analysis to identify aberrant PPS
providers or those providers who might inappropriately place TRICARE
beneficiaries in a high RUG.
4.2.22 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 an 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.