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  • Care Management > Skilled Nursing Home or Rehabilitation Facility Procedures

    Prior to Admission

    The skilled nursing facility (SNF) staff is required to notify the managing entity of a member's admission. For EmblemHealth-managed members, contact the EmblemHealth SNF/rehabilitation nurse assigned to the facility. The call must be made prior to the member's admission. Notification of admission is not prior approval for the admission.

    For all admissions, the SNF should check member eligibility, benefits and prior approval by signing in to www.emblemhealth.com or by otherwise contacting the member's plan/managing entity as provided in the Your Plan Members chapter.

    Facilities that do not know the number of their SNF/rehabilitation nurse should call the plan/managing entity.

    At the Time of Admission

    SNFs receiving patients who have not been given prior approval should contact the managing entity on the member's ID card to obtain or verify the approval prior to admitting the member to the SNF. For EmblemHealth-managed members, the SNF should contact the EmblemHealth/SNF rehabilitation nurse assigned to the facility. (See the Dispute Resolution chapters of the manual - Commercial/CHPMedicaid or Medicare for guidelines regarding claims submitted without prior approval.) The SNF representative must have the following information available when contacting the plan:

    • Member ID number
    • Member name
    • Admission date
    • Clinical documentation supporting the appropriateness of the admission
    • Copy of the hospital discharge summary and PRI

    The physician (PCP or consultant) attending to the patient while in the acute-care setting must attest by a certificate of medical necessity (CMN) to the patient's requirement for post-acute inpatient placement.

    Failure to get prior approval will result in claim denial. Please see the Dispute Resolution chapters - CommercialMedicaid and Medicare.

    Concurrent Review

    Authorization for admission and continued stay is based on medical appropriateness and necessity of services. We evaluate every request for prior approval and make coverage decisions by applying generally accepted medical standards as well as applicable Medicare and InterQual guidelines. The managing entity (e.g., the EmblemHealth concurrent review nurse assigned to the case) will evaluate the patient's ability to function prior to admission to the skilled care setting, the event that necessitated the skilled care admission, the patient's progress to date, and long- and short-term goals and objectives.

    The managing entity will not issue a prior approval and/or case number until the admission or procedure has been reviewed and either approved or denied. Notification of the determination is provided to the SNF at the time of the determination.

    Once an initial authorization has been issued, it is the responsibility of the SNF to provide the managing entity (e.g., the EmblemHealth concurrent review nurse) with the necessary clinical updates, no less than every seven days, to authorize additional days. The benefit for SNF care varies according to line of business. Plan members' benefits may be verified after signing in to www.emblemhealth.com.

    Concurrent Review Status Report

    The Concurrent Review Status Report (an example of which is provided at the end of the chapter) will be posted to www.emblemhealth.com, Monday through Friday (excluding holidays), twice a day around 10 am and 5 pm. This report lists each admitted member and whether the current day is approved, denied or pending further information. Pending information means that we require additional information to make a determination. If the requested information is not provided, the day will be denied with a provider/facility denial. The member may not be billed for this day.

    Treatment Course Extension

    The facility should request a treatment course extension at least 24 hours in advance. The managing entity should render a decision within 24 hours of receipt of the request.

    Benefit Extensions

    You may submit a benefit extension request by signing in to our website at www.emblemhealth.com for GHI HMO, GHI EPO/PPO or EmblemHealth EPO/PPO members who have GHI or EmblemHealth listed as their primary insurer on our Member Eligibility look-up screens. Once signed in, click on Benefits/Eligibility.

    You may also request a Benefit Extension Treatment Plan Form for an EPO/PPO member by calling:

    EmblemHealth: 1-877-482-3625
    GHI: 1-800-223-9870

    Skilled nursing facilities that fail to provide clinical updates and/or progress notes to the managing entity (concurrent review nurse) will not be reimbursed for unauthorized days.

    Specialist Referrals

    We continue to provide routine services for members in a SNF, either for short-term care until the member returns home, or for long-term custodial care, should the member choose to reside permanently in the SNF (not covered under the member's benefit plan). If at any point during an HMO member's stay, the SNF physician requires consultant services, these services must be referred by the member's PCP. Other services, such as dialysis, must be delivered at a network facility. If dialysis is provided to an inpatient member at the SNF, payment for dialysis is included in the rate for the inpatient stay and the SNF is responsible for reimbursing the dialysis vendor.

    The care manager responsible for authorizing continued stay can also coordinate specialty and transportation services needed by the member. The HMO member's PCP is responsible for coordinating all medical care provided to the member at the SNF. SNF staff should keep the PCP informed of the patient's health status. To obtain the PCP's contact information, use the Member Eligibility Details after signing in to www.emblemhealth.com or call the member's managing entity.

    Hospital Transfers

    If an emergency occurs, the facility should take all medically appropriate actions to safely transport the member to the nearest hospital, including the use of an ambulance, if necessary.

    The managing entity must be notified when a member temporarily leaves and returns to a SNF, such as when the member is readmitted to the hospital.

    Discharge Planning

    The discharge planning process should begin as soon as possible to allow time for the arrangement of appropriate resources for the member's care.

    For post-acute care based services, which may include acute rehabilitation, skilled nursing facility stay, home care, durable medical equipment (DME), hospice care and transportation, the concurrent review nurse will facilitate prior approvals of medically necessary treatments if the member's benefit plan includes these services.

    For Medicare members, SNFs are responsible for notifying the member's plan of the planned discharge date so that the plan can issue a Medicare notice of non-coverage (MNONC) in accordance with CMS guidelines at least two days prior to discharge. The SNF is responsible for delivering the MNONC to the member on the day the letter is issued, having it signed by the member and faxing the signed copy back to EmblemHealth on the same day. If the member is cognitively impaired, the SNF is responsible for informing the health care proxy of the end-of-service dates and the appeal rights. If the proxy is unable to sign and date it, the SNF staff member who informed the proxy of the end date and appeal rights is to sign and date the form and fax it back to EmblemHealth.

    If a member appeals the end-of-stay decision through IPRO, the SNF is responsible for sending the medical records to IPRO by the end of the day on which they were requested. IPRO is open seven days a week to take appeal information.

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    Formal acceptance as an inpatient by an institution, hospital or health care facility.

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The government agency responsible for administering the Medicare and Medicaid programs.

    Maintenance care of a patient that is designed to assist the patient in daily living and not primarily provided for the treatment of an illness, disease or condition. Custodial care includes but is not limited to help in walking, bathing and feeding.

    Date the patient left the hospital.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    A facility or service that provides care for the terminally ill patient and support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

    A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

    Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

    • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
    • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
    • It is in accordance with accepted standards of good medical practice in the community.
    • It is furnished in a setting commensurate with the member's medical needs and condition.
    • It cannot be omitted under the standards referenced above.
    • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
    • It is not furnished primarily for the convenience of the member, the member's family or the provider.
    • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

    The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

    Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as ID Number.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A facility that is part of EmblemHealth's provider network and has signed an agreement to provide covered services to its members. Sometimes, network facilities are referred to as participating facilities.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a SNF.

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a skilled nursing facility.

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