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Skilled Nursing Facility Patient Driven Payment Model Update

Friday, January 31, 2020

On Oct. 1, 2019, the Centers for Medicare and Medicaid Services (CMS) replaced its skilled nursing facility (SNF) Resource Utilization Groups (RUG)-IV classification system with a new case-mix classification model called the Patient-Driven Payment Model (PDPM). Under PDPM pricing, the focus shifts from the volume of services provided to the diagnosis, severity of illness and other variables associated with the specific patient. 

Release of held claims
We have been holding SNF claims with dates of service on or after Oct. 1, 2019, while we implement the claim system updates mandated by the Defense Health Agency. We anticipate these updates to complete in April 2020. At that time, we will begin releasing held claims. 

As a reminder, please continue to split any claims for SNF services that span before and after Oct. 1, 2019, and use PDPM codes for dates of service on or after Oct. 1. Any claims received with RUG-IV codes for dates on or after Oct. 1 will be rejected. 

Visit our Skilled Nursing Facility Care benefit page for additional details on PDPM pricing and www.cms.gov > Medicare > Skilled Nursing Facility PPS > Patient Driven Payment Model for fact sheets, FAQs, training presentations, and additional PDPM resources. 

Authorization requirements
With PDPM pricing came a change to authorization requirements. Previously, only beneficiaries enrolled in TRICARE Prime required approval from Health Net Federal Services, LLC (HNFS). As of Oct. 1, 2019, all TRICARE beneficiaries, except those dual eligible for TRICARE and Medicare where Medicare is primary, require HNFS approval for skilled nursing facility admissions. 

  • Please include all applicable clinical information when submitting your request. 
  • Learn more about submitting authorization requests to HNFS by visiting our Authorizations page. 

TRICARE patients who are dual eligible for TRICARE and Medicare require an approval on day 101 when TRICARE becomes the primary payer. Submit these requests directly to Wisconsin Physicians Services (WPS) – Military and Veterans Health, not HNFS, for review and approval. Learn more at www.tricare4u.com