What is the prior authorization process for Skilled Nursing Facility Admission?

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1 MyCare Long Term Care (LTC) Nursing Facility FAQs The nursing facility network is an essential part of the health care delivery system and we value your partnership. We appreciate the compassion you offer in delivering quality care to our members enrolled in My Care Ohio (Medicare Medicaid Plan). We want to provide you with answers to frequently asked questions about the nursing facility benefit. Covered services for the nursing facility benefit are outlined in the grid at the end of this document. How to request services: Nursing facility benefits are requested through the Prior Authorization (PA) process which may be initiated by a physician, a nursing facility, or a Care Manager. will facilitate the review process for skilled (medical) and non-skilled (room & board) services, including admissions considerations, continued stay reviews, notification of change in a member s level of care, room and board, bed hold days, hospice, and Part B therapies. What is the prior authorization process for Skilled Nursing Facility Admission? Normally the prior authorization will take place through the discharge planning process when post-acute care needs are identified. The MyCare Ohio Medical Management (MM) department will work in conjunction with the Care Manager to meet the member s on going needs. The Medical Management Department will be in direct contact with the acute inpatient facilities, assisting with the discharge process to P.O. Box 8738, Dayton, OH com/MyCare

2 ensure that medically necessary nursing facility admissions occur in a timely manner. In the event an admission to a nursing facility occurs after normal business hours, will accept the notification from the nursing facility and review the admission on the next business day. Who is responsible for requesting prior authorization of Nursing Facility admission? The nursing facility is responsible for the prior authorization for skilled services. Hospital discharge planners will work with to help select a facility that is in network and can care for the member s skilled needs. What is the process for skilled Nursing Facility Stay Authorizations? The MM department will work with the nursing facilities for skilled nursing facility admission and review of the member s level of care (LOC). Skilled LOC: Authorization will be provided with notification when updates are required to be submitted to the MM department. Hospice room and board: All hospice room and board services require prior authorization under the Medicaid benefits. The hospice provider is responsible for obtaining this prior authorization. Please ensure that the hospice provider notifies MM which facility the member is residing in for the hospice room and board services. Hospice services under the Medicare benefit must be billed to Medicare directly. What is the process for Custodial Nursing Facility Stay Authorizations? Custodial Nursing for long term care (LTC): Authorization is provided for a one year period and will be updated as yearly assessments are completed by the assigned Care Manager. Upon request, the Facility will provide information to the Care Manager to ensure proper authorizations are in place. NOTE: Part B therapies from the

3 approved custodial nursing facility do not require additional authorizations during the approved LTC stay. Please validate if the member has for their Medicare carrier. What is the preferred way to submit information to? MyCare Ohio will accept clinical information submissions via telephone, fax or . What is the policy for Bed Hold days? Medicare does not reimburse for any leaves of absence from the facility. Medicaid will reimburse up to 30 Bed Hold days per calendar year. Please work with your Care Manager regarding any needs over 30 days per year. What happens when the member exhausts their 100 day Medicare Skilled nursing benefit? For a member that does not have for their Medicare coverage, the member s Medicare plan will issue the Notice of Medicare Non-Coverage (NOMNC). will issue the NOMNC for members enrolled in MyCare Ohio for both Medicaid and Medicare. After 100 days of Medicare coverage, will evaluate the continued need for continued services, both skilled and non-skilled, under Medicaid. How are changes in Level of Care (LOC) addressed? Emergent admission to hospital from the Nursing Facility: The acute care facility/hospital will be responsible for contacting MM to provide clinical information. The Nursing Facility will be responsible for tracking the Bed Hold days and communicating this information to the Care Manager. Planned Admissions to acute Hospital: The acute facility and/or the member s treating physician are responsible for obtaining the prior authorization for the planned acute admission.

4 Transfers to Hospice: will cover the Room and Board under the Medicaid benefit, once the member has elected to utilize their Medicare Hospice benefit. How will Care Management interventions be addressed? The Care Manager will provide care coordination and development of a care plan that includes a transdisciplinary team approach. Members of the team could include the nursing facility staff, family members, caregivers, physicians and other providers that the member would like involved. The care plan contains goals and interventions that are designed to maximize the member s level of support and wellness. Collaboration with all the team members and the member to assess level of care, which will include face to face assessment, will be coordinated with the nursing facility s care management designee. The member s Care Manager will work with your nursing facility to develop trans-disciplinary team meetings, coordinate ongoing visits with the member, and establish any additional supports for the member needs.

5 Services Bed Hold Days Hospice Readmission from acute hospital to skilled facility Medicare-Medicaid 30 days per calendar year under Medicaid benefit; No Prior Authorization; Notification to CM > 30 days Room & Board covered under Medicaid benefit; PA required; Hospice must notify Medical Management of facility PA required; 3 -day hospital stay requirement waived Medicaid only Contact Information 30 days per calendar year under Medicaid benefit; No Prior Authorization; Notification to CM > 30 days CM contact number Room & Board covered under Medicaid benefit; PA required; Hospice must notify Medical Management of facility Seek authorization from the member's Medicare provider. After 100 days of Medicare skilled benefit, will review for Medicaid benefit Readmission from acute hospital to nonskilled facility (room & board) authorization for a 1 year period from the member's eligibility; Notify CM of the room & board readmission authorization for a 1 year period from the member's eligibility; Notify CM of the room & board readmission CM contact number New admission - skilled facility PA required; 3 -day hospital stay requirement waived Seek authorization from the member's Medicare provider. After 100 days of Medicare skilled benefit, will review for Medicaid benefit.

6 Services Medicare-Medicaid Medicaid only Contact Information New admission nonskilled facility (room & board) authorization for a 1 year period from the member's eligibility; Notify CM of the room & board readmission authorization for a 1 year period from the member's eligibility; Notify CM of the room & board readmission Change from skilled to non-skilled Notify the CM; if member was not previously approved for room & board the CM will complete an assessment to determine the LOC Notify the CM; if member was not previously approved for room & board the CM will complete an assessment to determine the LOC Admission from nonskilled to skilled admission Ancillary Services Part B therapies PA required; 3 -day hospital stay requirement waived PA required Seek authorization from the member's Medicare provider. After 100 days of Medicare skilled benefit, will review for Medicaid benefit. Verify eligibility with the member's Medicare plan. Medicaid primary services may require PA. Refer to the PA list in the MyCare Provider Manual No PA required as long as an authorization is in place for room & board or skilled services Follow the Medicaid benefits PA = Prior Authorization MM = Medical Management CM = Care Manager LOC = Level of Care H8452_OHPMC All Rights Reserved

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