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 USC 1395 i-3(a) -
(d)), or subsequent regulations.
5.2.1 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.
5.2.2 The contractor
shall verify that the SNF is Medicare-certified (or Medicaid-certified)
and has entered into a Participation Agreement with TRICARE. 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.
5.2.3 Department of Veterans Affairs/Veteran
Health Administration (DVA/VHA) 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,
DVA/VHA 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 calendar 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 The contractor shall determine
whether the beneficiary meets the criteria for coverage, when TRICARE is
the primary payer.
5.3.3.1 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.
5.3.3.2 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 or “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.
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 calendar 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 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 contractor
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. The Pricer will provide
the contractor the calculated rate for a one day stay for the claim’s
dates of service.
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 contractor
shall not wait for issuance of routine changes for implementation,
because the SNF rate, wage index, and these updates are built into
the SNF PPS Pricer. The SNF PPS base rates will be posted for each PDPM
category annually.
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 calendar
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.
5.7.3.1 The contractor shall, if individual
reviews are required by Medicare, 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.
5.7.3.2 The contractor shall use generally
acceptable criteria such as InterQual in determining “medical necessity.”
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 Contract Resource Management (CRM) 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
The TRICARE Medicare Eligible
Program (TMEP) contractor shall preauthorize care beginning on calendar
day 101, when TRICARE becomes primary payer for dual eligible beneficiaries
without OHI. SNF care received in the United States (US) and US
territories will require preauthorization if TRICARE is the primary
payer. 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 DVA/VHA facilities are excluded
from the SNF PPS methodology unless there is an 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.
Note: The 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.)