What to know if Medicare denies coverage

Size: px
Start display at page:

Download "What to know if Medicare denies coverage"

Transcription

1 What to know if Medicare denies coverage What Medicare covers Necessary post-hospital extended care for up to 100 days Extended care: nursing care and rehab provided to a Medicare beneficiary who is an inpatient in a SNF Nursing care and rehab must be provided daily Condition treated must be a condition for which the patient received hospital services or a condition that arose at the SNF while being treated for the initial condition What Medicare covers Coverage under Part A for first 20 days is in full Copayment for next 80 days 2012 copay: $144.50/day copay amount may be covered by Medicare Supplement Note: if client does not meet Medicare SNF coverage criteria, a WI issued supplement must cover 30 days of skilled nursing care in a SNF. The facility does not need to be certified by Medicare The stay does not have to meet Medicare s definition of skilled care No prior hospitalization may be required The facility must be a licensed skilled care nursing facility. The care must be medically necessary according to the insurer.

2 - Not less than three consecutive days Day of discharge not counted as one of the three qualifying days Check that date the patient brought to hospital is actual admission date If admission logged in by staff after midnight, admission set as next day Must be inpatient, not observation Medicare advantage plans may cover SNF stay without prior threeday hospital stay but are not required to do so - Patient must go to Medicare participating SNF within 30 days of discharge from hospital Limited exceptions: if not medically appropriate to begin the post hospital SNF care within 30 days, and if it is medically predictable at the time of hospital discharge that the patient will need covered care in a pre-determinable time period 30 day transfer requirement also met if beneficiary receiving covered SNF care leaves a SNF and is readmitted to same or any other participating SNF within 30 days of the last covered skilled day Does not require re-hospitalization 1. Skilled nursing services or skilled rehab services are needed 2. Must be performed by or under supervision of professional or technical personnel and ordered by a physician 3. Patient must require services on a daily basis 4. Services can be provided as a practical matter only on an inpatient basis in a SNF; and 5. Services must be reasonable and necessary

3 - vs. custodial: may have custodial services in addition but need daily skilled services included -evaluate inherent complexity of a service provided to patient; may be skilled services when: - conditions are complicated - skilled management of unskilled conditions - Note: when looking at primarily rehab services, key is whether skills of a therapist are needed, NOT whether patient has potential for recovery Skilled NURSING services may include the following when skills of a technical or professional worker are needed: Overall management and evaluation of care plan Observation and assessment of patient s changing condition Patient education services to train and teach self maintenance and management Certain services are per se skilled need to be done once daily: IV injections, IV feeding Treatment of widespread skin disorders Care of colostomy during early post-op period due to associated complications Questionable skilled nursing situations: When patient s primary need is oral medication or who are capable of independent ambulation, dressing or feeding

4 Examples of skilled rehabilitation services Again, need a skilled PT/OT/ST supervising the services but these are usually covered: Ongoing assessment of rehab needs/ potential Therapeutic exercises or activities needing skilled personnel Gait eval and training needed to restore function (no assistant allowed) R.o.M. exercises that are part of active treatment Maintenance therapy when designed and established by qualified therapist Ultrasound treatments Hot packs/ whirlpool baths/ infrared treatment if patient s condition complicated by circulatory or other problems Some examples of non covered therapy: Personal care services Admin of routine oral medication, eye drops, ointments General maintenance of colostomy Changes of dressings for non-infective post-op or chronic conditions Routine incontinence care Palliative skin care (treatment of minor skin problems) Assistance in dressing/eating/going to bathroom General supervision of exercises

5 Remember, restoration potential of the patient is NOT the controlling factor in determining whether skilled care is necessary Skilled care can be necessary for preserving current status or preventing deterioration Skilled nursing care or a combination of skilled nursing services and rehab services must be provided seven days per week Skilled rehab services provided five days per week satisfy the daily requirement Do not apply daily requirement too strictly the requirement may be met even when therapy is suspended in isolated break for a day or two due to fatigue of the patient SNF s can t bill Medicare or the beneficiary for care if beneficiary takes brief leave of absence but is not discharged from SNF (for reasons other than admission to hospital or other SNF) Even if daily skilled services are medically necessary, need to prove that services, as a practical matter, can only be provided in a SNF on an inpatient basis Depends on alternative services available in the patient s area and the feasibility and practicality of services Note: the important issue is feasibility of the alternative care, not whether Medicare will pay for it Important factor is the patient s medical condition if an alternative care setting would adversely affect a patient s medical condition, SNF care is appropriate Home care not an alternative to SNF care if patient does not have sufficient assistance from capable and willing family members

6 Medicare covers maximum 100 days of SNF care during benefit period ( Spell of Illness ) Benefit period begins first day Medicare beneficiary enters SNF and ends when he/she has been 1) receiving less than a skilled level of care or 2) outside a hospital or SNF for 60 consecutive days After either (1) or (2) occurs, need a new three day inpatient hospital stay for a new 100 day SNF coverage period to start Must be some connection between the patient s condition during the hospital stay and subsequent SNF admission Need to ascertain interrelationship between claimant s various illnesses to determine This rule should be construed liberally Refer to all of the conditions treated at the hospital good chance you will find SNF treating same condition Skilled vs. Custodial Care Central evaluation of every SNF coverage determination Focus on inherent complexity of the services Have a checklist, including: Is this a rehabilitation or nursing patient or both? What rehabilitation services have been provided (OT/PT/ST)? Check the list of per se skilled therapy and skilled nursing services Is skilled development, management and evaluation of the patient s care plan required? Is skilled observation and assessment of the patient s changing or unstable condition required? What specific nursing services have been provided? Any special medical complications that require services of skilled personnel?

7 Management and Evaluation of the Patient Care Plan SNF patients are entitled to Medicare coverage if they need and receive skilled observation, assessment, management of care plan or patient education services even if they do not require or receive specific nursing services (ie. injections) Look for the following specific services in SNF medical records: Skilled nursing personnel that develop, manage, evaluate a doctor s plan of care Skilled nursing personnel involved to meet patient s needs, promote recovery, ensure medical safety Management by skilled personnel of personal care services requiring technical intervention Management and evaluation of Patient Care Plan, cont d. Review the following: Written care plan and how their elements are reflected in ongoing medical assessment data Did the patient show psychological or mental impairments in addition to physical impairments? Was nursing intervention needed to ensure patient safety and promote recovery? Assess all services in light of patient s total condition Some non skilled services might require skilled management even if each service is non skilled Multiple medical diagnoses requiring extensive nursing services may support need for skilled management Observation and assessment of patient s changing or unstable condition Look at the records for the following skilled services: Medical necessity was documented by doctor s orders and nursing or therapy notes Skilled personnel were used to identify and evaluate the patient s needs Modification of treatment was needed for additional medical procedures Care was necessary until the patient s condition stabilized or to make sure the patient remained stable Reasonable probability existed of potential complication or acute episode which required monitoring by skilled personnel (even if no complication occurred) Acute psychological symptoms present in addition to physical problems

8 Patient education may be skilled service if technical or professional personnel needed to teach a patient self maintenance and management of treatment regimen Examples include: Teaching self-administration of injectible medications or complex range of medications Teaching a newly diagnosed diabetic to administer insulin injections, prepare/follow diabetic diet, and foot care precautions Gait training and teaching of prosthesis care for a recent leg amputee Teaching colostomy care Teaching patients the use and care of braces/splints/orthotics, etc Opinion of the attending physician Critical: opinion of attending or treating physician to be given special consideration One administrative ruling sets out four specific points: No presumptive weight may be given to opinion of treating physician in determining medical necessity of inpatient hospital or SNF services The treating doctor s opinion must be evaluated in context of all evidence in the record Treating physician certification is required for Medicare payment but coverage decisions are not based only on physician certification Coverage decisions are based on objective medical information available from claims forms and the medical record NOTE: if at ALJ stage, cross examine medical adviser (ie. Maximus doctor) to establish that doctor has not treated or examined the beneficiary, but has only reviewed the documentation. Restoration potential of the rehabilitation patient Key: rehabilitation services are skilled services, even if the services are in the form of maintenance therapy, if provided by skilled therapists many Maximus doctors get this wrong and say improvement and rehabilitation potential are the correct standards - From Medicare manual: the restoration potential of a patient is not the deciding factor in determining whether skilled services are needed; even if full recovery is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities - Despite this rule, Medicare coverage usually denied for those who reach plateau

9 Non-certified bed Must determine the SNF is a Medicare provider and the patient is in a Medicare certified bed If the patient is placed in a non-certified bed erroneously / inadvertently, payment by Medicare should be made

Medicare Coverage of Skilled Nursing Facility Care

Medicare Coverage of Skilled Nursing Facility Care Helping Older Persons With Legal & Long-Term Care Problems Medicare Coverage of Skilled Nursing Facility Care 1. When does Medicare cover nursing facility care? Skilled nursing facility (SNF) care is covered

More information

MEDICAL POLICY No. 91332-R3 NON-ACUTE INPATIENT SERVICES

MEDICAL POLICY No. 91332-R3 NON-ACUTE INPATIENT SERVICES NON-ACUTE INPATIENT SERVICES Effective Date: November 16, 2007 Review Dates: 1/93, 12/99, 12/01, 12/02, 11/03, 11/04, 10/05, 10/06, 10/07, 10/08, 10/09, 10/10, 10/11, 10/12, 10/13, 11/14 Date of Origin:

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: skilled_nursing_facility_care 02/2008 2/2015 2/2016 2/2015 Description of Procedure or Service A skilled

More information

Coverage Basics. Your Guide to Understanding Medicare and Medicaid

Coverage Basics. Your Guide to Understanding Medicare and Medicaid Coverage Basics Your Guide to Understanding Medicare and Medicaid Understanding your Medicare or Medicaid coverage can be one of the most challenging and sometimes confusing aspects of planning your stay

More information

Admission to Inpatient Rehabilitation (Rehab) Services

Admission to Inpatient Rehabilitation (Rehab) Services Family Caregiver Guide Admission to Inpatient Rehabilitation (Rehab) Services What Is Rehab? Your family member may have been referred to rehab after being in a hospital due to acute (current) illness,

More information

Chapter 7: Inpatient & Outpatient Hospital Care

Chapter 7: Inpatient & Outpatient Hospital Care 7 Inpatient & Outpatient Hospital Care ACUTE INPATIENT ADMISSIONS All elective and emergent admissions require prior authorization and/or notification for all Health Choice Generations Members admissions.

More information

Medical Policy Definition of Skilled Care

Medical Policy Definition of Skilled Care Medical Policy Definition of Skilled Care Document Number: 015 Authorization required Home skilled care and short term rehab Notification within 24 hours or next business day No notification or authorization

More information

This information is provided by SRC for Medicare Information. (The costs that are used in these examples are from 2006.)

This information is provided by SRC for Medicare Information. (The costs that are used in these examples are from 2006.) Medicare Information Source This information is provided by SRC for Medicare Information. (The costs that are used in these examples are from 2006.) The Senior Resource Center for Medicare Information

More information

Planning for Inpatient Rehabilitation (Rehab) Services

Planning for Inpatient Rehabilitation (Rehab) Services Family Caregiver Guide Planning for Inpatient Rehabilitation (Rehab) Services What Is Rehab? Many patients say that the transition (move) from a hospital or other care setting to rehab can be very confusing.

More information

Basic Training: Home Health Edition. Defining and Documenting, Medical Necessity. March 28, 2013

Basic Training: Home Health Edition. Defining and Documenting, Medical Necessity. March 28, 2013 Basic Training: Home Health Edition Defining and Documenting, Medical Necessity March 28, 2013 Presented by: Nancy Buseth, RN, PT, BS, Senior Consultant Fazzi Associates, Inc. 243 King Street, Suite 246

More information

Clinical Coverage Criteria Extended Care Facility

Clinical Coverage Criteria Extended Care Facility Clinical Coverage Criteria Extended Care Facility Document Number: 018 Commercial MassHealth* Commonwealth Care Authorization required X X X Notification within 24 hours of service or next business day

More information

Update: Medical Necessity Documentation. Kerry Dunning, MHA, MSH, CPAR, RAC-CT GPS HEALTHCARE CONSULTANTS November 2013

Update: Medical Necessity Documentation. Kerry Dunning, MHA, MSH, CPAR, RAC-CT GPS HEALTHCARE CONSULTANTS November 2013 Update: Medical Necessity Documentation Kerry Dunning, MHA, MSH, CPAR, RAC-CT GPS HEALTHCARE CONSULTANTS November 2013 REMINDER Many claim denials occur because the providers or suppliers do not submit

More information

SECTION 2 PHYSICAL THERAPY SERVICES. BY INDEPENDENT PHYSICAL THERAPISTS (including Group Practices) Not in Rehabilitation Centers

SECTION 2 PHYSICAL THERAPY SERVICES. BY INDEPENDENT PHYSICAL THERAPISTS (including Group Practices) Not in Rehabilitation Centers Division of Health Care Financing Updated July 2009 SECTION 2 PHYSICAL THERAPY SERVICES BY INDEPENDENT PHYSICAL THERAPISTS (including Group Practices) Not in Rehabilitation Centers Table of Contents 1

More information

Frequently Asked Questions about Fee-for-Service Medicare For People with Alzheimer s Disease

Frequently Asked Questions about Fee-for-Service Medicare For People with Alzheimer s Disease Frequently Asked Questions about Fee-for-Service Medicare For People with Alzheimer s Disease This brochure answers questions Medicare beneficiaries with Alzheimer s disease, and their families, may have

More information

Critical Access Hospital Swing Bed Manual Table of Contents

Critical Access Hospital Swing Bed Manual Table of Contents Montana Critical Access Hospital Swing Bed Manual June 2007 Table of Contents I. Introduction page 2 Critical Access Hospital Program Description. 2 Montana Criteria... 2 II. Swing Beds in Critical Access

More information

chapter 8, in the guidelines for SNF coverage under Part A.

chapter 8, in the guidelines for SNF coverage under Part A. CMS Manual System Pub 100-02 Medicare Benefit Policy Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 179 Date: January 14, 2014 Change Request 8458

More information

THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM. Wednesday, June 02, 2010

THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM. Wednesday, June 02, 2010 THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM Wednesday, June 02, 2010 As A Provider Of Continuing Nursing Education, Triumph Healthcare Is Required By Texas Nurses Association

More information

Subacute Inpatient MH - Adult

Subacute Inpatient MH - Adult Subacute Inpatient MH - Adult Definition Subacute Inpatient hospital psychiatric services are medically necessary short-term psychiatric services provided to a client with a primary psychiatric diagnosis

More information

RESTORATIVE. Yvonne Russell RN Long Term Care Nursing Coalition of Mississippi-1 st Teleconference Restorative Nursing

RESTORATIVE. Yvonne Russell RN Long Term Care Nursing Coalition of Mississippi-1 st Teleconference Restorative Nursing RESTORATIVE Yvonne Russell RN Long Term Care Nursing Coalition of Mississippi-1 st Teleconference Restorative Nursing OVERVIEW Restorative Nursing is not a new concept Techniques have been taught in nursing

More information

A Guide to Understanding Your Discharge Options After Hospitalization

A Guide to Understanding Your Discharge Options After Hospitalization A Guide to Understanding Your Discharge Options After Hospitalization DHMC Care Management: (603) 650-5789 Table of Contents Hospital to Home with Home Care... 3 Hospice Care... 5 Skilled Nursing Facility*...

More information

Extended Care Facility

Extended Care Facility Definitions... 2 Custodial Care Services... 3 Patient Eligibility... 4 Precertification Requirements... 4 Billing Example 1: Blue Cross Primary... 6 Billing Example 2: Medicare Primary, Blue Cross Supplemental...

More information

Physical, Occupational, and Speech Therapy Services. September 5, 2012

Physical, Occupational, and Speech Therapy Services. September 5, 2012 Physical, Occupational, and Speech Therapy Services September 5, 2012 CMS Therapy Cap Team Members Daniel Schwartz Deputy Director, DMRE Division of Medical Review and Education Latesha Walker Division

More information

Reducing Hospital Readmissions & The Affordable Care Act

Reducing Hospital Readmissions & The Affordable Care Act Reducing Hospital Readmissions & The Affordable Care Act The Game Has Changed Drastically Reducing MSPB Measures Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE

More information

How Are We Doing? A Nursing Home Self Assessment Survey on Patient Transitions and Family Caregivers

How Are We Doing? A Nursing Home Self Assessment Survey on Patient Transitions and Family Caregivers How Are We Doing? A Nursing Home Self Assessment Survey on Patient Transitions and Family Caregivers Well-planned and managed transitions are essential for high quality care and patient safety. Transitions

More information

Physician Guide to Home Health Care Certification for Medicare Enrollees Steve Landers MD, MPH (landers@ccf.org) Director, Cleveland Clinic at Home

Physician Guide to Home Health Care Certification for Medicare Enrollees Steve Landers MD, MPH (landers@ccf.org) Director, Cleveland Clinic at Home Physician Guide to Home Health Care Certification for Medicare Enrollees Steve Landers MD, MPH (landers@ccf.org) Director, Cleveland Clinic at Home January 2011 Background Helping patients succeed at home

More information

Pathology and Audiology Services and Occupational and Physical Therapies

Pathology and Audiology Services and Occupational and Physical Therapies 3 O0100 O-1 Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre-

More information

Danbury Public Schools 63 Beaver Brook Rd. Danbury, CT 06810. 2. Family Member s Name (if different from employee):

Danbury Public Schools 63 Beaver Brook Rd. Danbury, CT 06810. 2. Family Member s Name (if different from employee): 1. Employee s Name: 2. Family Member s Name (if different from employee): 3. The attached sheet describes what is meant by a serious health condition under the Family and Medical Leave Act. Does the patient

More information

Level of Care Tip Sheet MANAGING CONTINUOUS HOME CARE FOR SYMPTOM MANAGEMENT TIPS FOR PROVIDERS WHAT IS CONTINUOUS HOME CARE?

Level of Care Tip Sheet MANAGING CONTINUOUS HOME CARE FOR SYMPTOM MANAGEMENT TIPS FOR PROVIDERS WHAT IS CONTINUOUS HOME CARE? Level of Care Tip Sheet National Hospice and Palliative Care Organization www.nhpco.org/regulatory MANAGING CONTINUOUS HOME CARE FOR SYMPTOM MANAGEMENT WHAT IS CONTINUOUS HOME CARE? TIPS FOR PROVIDERS

More information

REV. OCTOBER 15, 2003 NEBRASKA HHS FINANCE NMAP SERVICES MANUAL LETTER # 59-2003 AND SUPPORT MANUAL 471 NAC 13-000

REV. OCTOBER 15, 2003 NEBRASKA HHS FINANCE NMAP SERVICES MANUAL LETTER # 59-2003 AND SUPPORT MANUAL 471 NAC 13-000 REV. OCTOBER 15, 2003 NEBRASKA HHS FINANCE NMAP SERVICES MANUAL LETTER # 59-2003 AND SUPPORT MANUAL 471 NAC 13-000 CHAPTER 13-000 NURSING SERVICES 13-001 Standards for Participation: Providers of private-duty

More information

IN HOME CARE. What s available? Who pays for it?

IN HOME CARE. What s available? Who pays for it? IN HOME CARE What s available? Who pays for it? 1602 E. Ft. Lowell Road Tucson, AZ 85719 520.327.6351 email: care@catalinainhome.com www.catalina-in-home.com 1 MEDICARE HOME HEALTH Individuals are eligible

More information

September 4, 2012. Submitted Electronically

September 4, 2012. Submitted Electronically September 4, 2012 Ms. Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1589-P P.O. Box 8016 Baltimore, MD 21244-8016

More information

Medicaid Home Health Issues and Resolutions November 2009

Medicaid Home Health Issues and Resolutions November 2009 Medicaid Home Health Issues and Resolutions November 2009 Handwritten signed physician s note A handwritten note signed by a physician is not a requirement for prior authorization of Medicaid home health

More information

A Patient s Guide to Observation Care

A Patient s Guide to Observation Care Medicare observation services cannot exceed 48 hours. Typically a decision to discharge or admit is made within 24 hours. Medicaid allows up to 48 hours. Private Insurances may vary but most permit only

More information

Medicare Program. Introduction. Terry Lynch, Independent Living Consultant

Medicare Program. Introduction. Terry Lynch, Independent Living Consultant RIGHTS & REALITY II Medicare Program Terry Lynch, Independent Living Consultant Introduction It is commonly assumed that reductions in the rates of reimbursement to the providers of Medicare services affect

More information

Improving Transitions Between Emergency Departments and Long Term Care

Improving Transitions Between Emergency Departments and Long Term Care Improving Transitions Between Emergency Departments and Long Term Care Mary T. Knapp RN, MSN/GNP, NHA, FAAN The Health Care Improvement Foundation January 21, 2014 Purpose of Presentation Provide and overview

More information

Follow-up information from the November 12 provider training call

Follow-up information from the November 12 provider training call Follow-up information from the November 12 provider training call Criteria I. Multiple Therapy Disciplines 1. Clarification regarding the use of group therapies in IRFs. Answer: CMS has not yet established

More information

Medical Policy Extended Care Facility

Medical Policy Extended Care Facility Medical Policy Extended Care Facility Document Number: 018 Commercial and MassHealth* Connector/Qualified Health Plans Authorization required X X Notification within 24 hours of service or next business

More information

MEDICAID GUIDELINES FOR HOME HEALTH THERAPY SERVICES (PHYSICAL, OCCUPATIONAL & SPEECH THERAPY)

MEDICAID GUIDELINES FOR HOME HEALTH THERAPY SERVICES (PHYSICAL, OCCUPATIONAL & SPEECH THERAPY) MEDICAID GUIDELINES FOR HOME HEALTH THERAPY SERVICES (PHYSICAL, OCCUPATIONAL & SPEECH THERAPY) I. General Principles Governing Reasonable and Necessary Physical Therapy, Speech Therapy and Occupational

More information

Recovery After Stroke: Health Insurance

Recovery After Stroke: Health Insurance Recovery After Stroke: Health Insurance Stroke recovery can require lots of time and medical attention. Ideally, some of that medical care is covered by health insurance. Dealing with health insurance

More information

Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance

Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance Table of Contents (Rev. 204, 03-13-15) Transmittals Issued for this Chapter 10 - Requirements

More information

Moving Through Care Settings (Don t Send Me to a Nursing Home)

Moving Through Care Settings (Don t Send Me to a Nursing Home) Moving Through Care Settings (Don t Send Me to a Nursing Home) NCCNHR Annual Meeting October 23, 2009 Eric Carlson Alfred J. Chiplin, Jr. Gene Coffey 1 At-Home Care Getting More Attention Many federal

More information

Medical Necessity Criteria

Medical Necessity Criteria Medical Necessity Criteria 2015 Updated 03/04/2015 Appendix B Medical Necessity Criteria Purpose: In order to promote consistent utilization management decisions, all utilization and care management staff

More information

Medical Rehabilitation. Rehabilitation Unit

Medical Rehabilitation. Rehabilitation Unit Medical Rehabilitation Rehabilitation Unit Medical Rehabilitation The purpose of this handout is to give you information about University Hospital s Rehabilitation Unit (2 North or 2N). It will explain:

More information

Willamette University Long-Term Care Insurance Outline of Coverage

Willamette University Long-Term Care Insurance Outline of Coverage JOHN HANCOCK LIFE INSURANCE COMPANY Group Long-Term Care PO Box 111, Boston, MA 02117 Tel. No. 1-800-711-9407 (from within the United States) TTY 1-800-255-1808 for hearing impaired 1-617-572-0048 (from

More information

DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING

DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING STATE OF CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING FAIR EMPLOYMENT & HOUSING COUNCIL CERTIFICATION OF HEALTH CARE PROVIDER (California Family Rights Act (CFRA)) IMPORTANT NOTE: The California

More information

10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER II SECTION 68 OCCUPATIONAL THERAPY SERVICES ESTABLISHED 9/1/87 LAST UPDATED 1/1/14

10-144 Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER II SECTION 68 OCCUPATIONAL THERAPY SERVICES ESTABLISHED 9/1/87 LAST UPDATED 1/1/14 MAINECARE BENEFITS MANUAL TABLE OF CONTENTS 68.01 PURPOSE... 1 PAGE 68.02 DEFINITIONS... 1 68.02-1 Functionally Significant Improvement... 1 68.02-2 Long-Term Chronic Pain... 1 68.02-3 Maintenance Care...

More information

Brain Injury Alliance of New Jersey

Brain Injury Alliance of New Jersey Understanding the Rehabilitation Process after No one can prepare a family for the trauma of experiencing brain injury. Following the injury the subsequent move from the hospital to various rehabilitation

More information

State of Hawaii. Licensed Practical Nurse - Mental Health

State of Hawaii. Licensed Practical Nurse - Mental Health Entry Level Work HE-6 6.734 Full Performance Work HE-8 6.735 Function and Location This position works in a hospital or clinic which provides care and treatment to patients who are mentally ill. The primary

More information

GENERAL ADMISSION CRITERIA INPATIENT REHABILITATION PROGRAMS

GENERAL ADMISSION CRITERIA INPATIENT REHABILITATION PROGRAMS Originator: Case Management Original Date: 9/94 Review/Revision: 6/96, 2/98, 1/01, 4/02, 8/04, 3/06, 03/10, 3/11, 3/13 Stakeholders: Case Management, Medical Staff, Nursing, Inpatient Therapy GENERAL ADMISSION

More information

OVERVIEW This policy is to document the criteria for coverage of services at the acute inpatient rehabilitation level of care.

OVERVIEW This policy is to document the criteria for coverage of services at the acute inpatient rehabilitation level of care. Medical Coverage Policy Acute Inpatient Rehabilitation Level of Care EFFECTIVE DATE: 07 06 2010 POLICY LAST UPDATED: 06 04 2013 sad OVERVIEW This policy is to document the criteria for coverage of services

More information

Discharge or Episode of Care? CMS Redefines the Interrupted Stay Rule for LTACHS. Cherilyn G. Murer, J.D., C.R.A.

Discharge or Episode of Care? CMS Redefines the Interrupted Stay Rule for LTACHS. Cherilyn G. Murer, J.D., C.R.A. Introduction Discharge or Episode of Care? CMS Redefines the Interrupted Stay Rule for LTACHS By Cherilyn G. Murer, J.D., C.R.A. When CMS first implemented the prospective payment system for long term

More information

PRESENTATION. The Myth of Improvement

PRESENTATION. The Myth of Improvement CENTER FOR MEDICARE ADVOCACY, INC. THE MEDICARE IMPROVEMENT STANDARD IMPLEMENTING THE JIMMO SETTLEMENT American Health Lawyers Association Institute on Medicare & Medicaid Payment Issues Baltimore, MD

More information

Critical Access Hospital (CAH) and CAH Swingbed Questions and Answers

Critical Access Hospital (CAH) and CAH Swingbed Questions and Answers Critical Access Hospital (CAH) and CAH Swingbed Questions and Answers The following questions and answers are from the April 2012 CAH and CAH Swingbed web-based trainings: Q1. Is a non-covered/no pay bill

More information

Restorative Nursing Teleconference Script

Restorative Nursing Teleconference Script Slide 1 Slide 2 Slide 3 Maintaining independence in ADLs and mobility is very important to most of us. In fact, functional decline can lead to depression, withdrawal, social isolation, and complications

More information

1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated.

1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated. Follow-up information from the November 12 provider training call I. Admission Orders 1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated.

More information

STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION

STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION TITLE GRADE EEO-4 CODE LICENSED PRACTICAL NURSE III 33* C 10.364 LICENSED PRACTICAL NURSE II 31* C

More information

Physical Therapy Protocol Checklist

Physical Therapy Protocol Checklist Physical Therapy Protocol Checklist Service Recipient s Name Date of Birth (Last, First) Reviewer s Name (Last, First) Date Request Submitted Technical Review YES NO Is the correct funding source, site

More information

Florida Data as of July 2003. Mental Health and Substance Abuse Services in Medicaid and SCHIP in Florida

Florida Data as of July 2003. Mental Health and Substance Abuse Services in Medicaid and SCHIP in Florida Mental Health and Substance Abuse Services in Medicaid and SCHIP in Florida As of July 2003 2,441,266 people were covered under Florida's Medicaid and SCHIP programs. There were 2,113,820 enrolled in the

More information

Long-Term Acute Care Hospitals

Long-Term Acute Care Hospitals Long-Term Acute Care Hospitals What are they? What services do they offer? Presented by: Maxi Adams MBA, BSN, RN LTACH STACH LTACH = Long-Term Acute Care Hospital STACH = Short-Term Acute Care Hospital

More information

National Stroke Association s Guide to Choosing Stroke Rehabilitation Services

National Stroke Association s Guide to Choosing Stroke Rehabilitation Services National Stroke Association s Guide to Choosing Stroke Rehabilitation Services Rehabilitation, often referred to as rehab, is an important part of stroke recovery. Through rehab, you: Re-learn basic skills

More information

Medicare Benefit Review

Medicare Benefit Review Medicare Benefit Review What is Medicare? Medicare is Health Insurance For people 65 or older For people under 65 with certain disabilities For people at any age with End-Stage Renal Disease (permanent

More information

Career Options for Direct Service Workers in Maine

Career Options for Direct Service Workers in Maine Career Options for Direct Service Workers in Maine Maine s Career Options in the field of Direct Service Work (Specialized Content) Homemaker Homemakers assist individuals with household or personal care

More information

DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD. DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-11-1343

DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD. DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-11-1343 DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-11-1343 In the case of Claim for Hospital Insurance Benefits Restore Management

More information

HOSPICE SERVICES. This document is subject to change. Please check our web site for updates.

HOSPICE SERVICES. This document is subject to change. Please check our web site for updates. HOSPICE SERVICES This document is subject to change. Please check our web site for updates. This provider manual outlines policy and claims submission guidelines for claims submitted to the North Dakota

More information

Acute Inpatient Rehabilitation Level of Care

Acute Inpatient Rehabilitation Level of Care Printer-Friendly Page Acute Inpatient Rehabilitation Level of Care EFFECTIVE DATE 07/06/2010 LAST UPDATED 07/06/2010 Prospective review is recommended/required. Please check the member agreement for preauthorization

More information

Nurse Practitioners (NPs) and Physician Assistants (PAs): What s the Difference?

Nurse Practitioners (NPs) and Physician Assistants (PAs): What s the Difference? Nurse Practitioners (NPs) and Physician Assistants (PAs): What s the Difference? More than ever before, patients receive medical care from a variety of practitioners, including physicians, physician assistants

More information

Complex Continuing Care Restorative Care (Combined Functional Enhancement and Restorative Care Programs)

Complex Continuing Care Restorative Care (Combined Functional Enhancement and Restorative Care Programs) Complex Continuing Care Restorative Care (Combined Functional Enhancement and Restorative Care Programs) Description: The Restorative Care program provides a moderate to low intensity goal-oriented rehabilitation

More information

CERTIFICATION OF HEALTH CARE PROVIDER FAMILY AND MEDICAL LEAVE ACT

CERTIFICATION OF HEALTH CARE PROVIDER FAMILY AND MEDICAL LEAVE ACT OF HEALTH CARE PROVIDER FAMILY AND MEDICAL LEAVE ACT PART A: For Completion by the EMPLOYEE: Please complete all applicable sections of Part A before giving this form to your family member or your/their

More information

About to Retire: Preparing for Medicare Patient Financial Services Agenda Medicare Enrollment Covered Services Medicare-covered covered Preventive Services Agenda, continued Advance Beneficiary Notice

More information

LONG TERM CARE INSURANCE OUTLINE OF COVERAGE POLICY P148 NOTICE TO BUYER:

LONG TERM CARE INSURANCE OUTLINE OF COVERAGE POLICY P148 NOTICE TO BUYER: Physicians Mutual Insurance Company 2600 Dodge Street Omaha, Nebraska 68131 800-645-4300 LONG TERM CARE INSURANCE OUTLINE OF COVERAGE POLICY P148 NOTICE TO BUYER: This policy may not cover all of the costs

More information

Acute Rehabilitation Center

Acute Rehabilitation Center Acute Rehabilitation Center Acute Rehabilitation Courtyard Our Center Community Westview Hospital's Acute Rehabilitation Center and programs are specially designed to meet the needs of our patients and

More information

Your Long-Term Care Insurance Benefits

Your Long-Term Care Insurance Benefits Long-Term Care Long-Term Care Insurance can help you or an eligible family member pay for costly Long-Term Care assistance when you can no longer function independently. For more information on See Page

More information

A Guide for Transitioning to Home After a Rehab Stay

A Guide for Transitioning to Home After a Rehab Stay A Guide for Transitioning to Home After a Rehab Stay Transitioning home after a rehab stay can present unique challenges for patients and/or their caregivers. Patients who have had a debilitating illness

More information

Introduction to Hospice

Introduction to Hospice Introduction to Hospice Objectives The learner will be able to: Understand general hospice services Discuss ways that hospice services can be accessed Discuss Medicare regulations for hospice services

More information

Good Samaritan Inpatient Rehabilitation Program

Good Samaritan Inpatient Rehabilitation Program Good Samaritan Inpatient Rehabilitation Program Living at your full potential. Welcome When people are sick or injured, our goal is their maximum recovery. We help people live to their full potential.

More information

TRANSFERRING TO A NURSING FACILITY FOR KAISER MEMBERS

TRANSFERRING TO A NURSING FACILITY FOR KAISER MEMBERS SAN DIEGO CONTINUING CARE SERVICES DEPARTMENT TRANSFERRING TO A NURSING FACILITY FOR KAISER MEMBERS You are going to a skilled nursing facility for further care. This booklet gives you information about

More information

TEXAS. Downloaded January 2011

TEXAS. Downloaded January 2011 TEXAS Downloaded January 2011 Sec. 242.402. QUALITY OF CARE. An institution shall provide to each resident the necessary care or service needed to enable the resident to attain and maintain the highest

More information

What Your Organization can do to Avoid the Risks. Jane Snecinski Post Acute Advisors, LLC P.O. Box 12078 Atlanta, GA 30355 www.postacuteadvisors.

What Your Organization can do to Avoid the Risks. Jane Snecinski Post Acute Advisors, LLC P.O. Box 12078 Atlanta, GA 30355 www.postacuteadvisors. What Your Organization can do to Avoid the Risks Jane Snecinski P.O. Box 12078 Atlanta, GA 30355 www.postacuteadvisors.com Any level of care that occurs after an acute care stay LTAC (Long Term Acute Care

More information

TRUSTMARK INSURANCE COMPANY 400 Field Drive, Lake Forest, IL 60045 HOME HEALTH AND LONG TERM CARE BENEFIT RIDER

TRUSTMARK INSURANCE COMPANY 400 Field Drive, Lake Forest, IL 60045 HOME HEALTH AND LONG TERM CARE BENEFIT RIDER NOTICE: Benefits paid under this rider may or may not be taxable. Whether or not You or Your beneficiary incur a tax liability when benefits are paid depends on how the IRS interprets applicable portions

More information

UnitedHealthcare Medicare Solutions Readmission Review Program for Medicare Advantage Plans

UnitedHealthcare Medicare Solutions Readmission Review Program for Medicare Advantage Plans UnitedHealthcare Medicare Solutions Readmission Review Program for Medicare Advantage Plans General Clinical Guidelines for Payment Review Updated May 2015 Introduction The UnitedHealthcare Medicare Solutions

More information

OCCUPATIONAL THERAPY

OCCUPATIONAL THERAPY OCCUPATIONAL THERAPY This document is subject to change. Please check our web site for updates. This provider manual outlines policy and claims submission guidelines for claims submitted to the North Dakota

More information

Untimed Billing Procedure CPT Codes Effective February 1, 2010

Untimed Billing Procedure CPT Codes Effective February 1, 2010 20552 Therapeutic injections: Tendons, trigger points single or multiple trigger points; 1 or 2 muscles 20553 Therapeutic injections: Tendons, trigger points single or multiple trigger points; 3 or more

More information

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE:

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE: PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/PROCEDURE Policy Number: MCUP3003 (previously UP100303) Reviewing Entities: Credentialing IQI P & T QUAC Approving Entities: BOARD CEO COMPLIANCE FINANCE PAC

More information

Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment. BHM Healthcare Solutions 2013 1

Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment. BHM Healthcare Solutions 2013 1 Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment 1 Presentation Objectives Attendees will have a thorough understanding of Psychiatric Residential

More information

Rehabilitation. Care

Rehabilitation. Care Rehabilitation Care Bruyère Continuing Care is the champion of well-being for aging Canadians and those requiring Continuing Care, helping them to become and remain as healthy and independent as possible

More information

TREATMENT MODALITIES. May, 2013

TREATMENT MODALITIES. May, 2013 TREATMENT MODALITIES May, 2013 Treatment Modalities New York State Office of Alcoholism and Substance Abuse Services (NYS OASAS) regulates the addiction treatment modalities offered in New York State.

More information

CAREGIVER GUIDE. A doctor. He or she authorizes (approves) the rehab discharge.

CAREGIVER GUIDE. A doctor. He or she authorizes (approves) the rehab discharge. Guide for Discharge to Home From Inpatient Rehab Who Is on the Discharge Team? Many people help plan a rehab discharge, and they are often referred to as a team. The team members include: A doctor. He

More information

HOSPICE CARE. and the Medicare Hospice Benefit

HOSPICE CARE. and the Medicare Hospice Benefit For more information, or to locate a hospice in your area, contact Caring Connections: www.caringinfo.org caringinfo@nhpco.org HelpLine 800.658.8898 Multilingual Line 877.658.8896 Item #: 810002 Hospice

More information

Easing the Transition: Moving Your Relative to a Nursing Home

Easing the Transition: Moving Your Relative to a Nursing Home Easing the Transition: Moving Your Relative to a Nursing Home Alzheimer s Association, New York City Chapter 360 Lexington Avenue, 4th Floor New York, NY 10017 24-hour Helpline 1-800-272-3900 www.alz.org/nyc

More information

BANKERS LIFE AND CASUALTY COMPANY 111 East Wacker Drive, Suite 2100, Chicago, Illinois 60601-4508 Telephone 1-312-396-6000

BANKERS LIFE AND CASUALTY COMPANY 111 East Wacker Drive, Suite 2100, Chicago, Illinois 60601-4508 Telephone 1-312-396-6000 BANKERS LIFE AND CASUALTY COMPANY 111 East Wacker Drive, Suite 2100, Chicago, Illinois 60601-4508 Telephone 1-312-396-6000 COMPREHENSIVE LONG-TERM CARE INSURANCE POLICY OUTLINE OF COVERAGE Policy Form

More information

Your Long-Term Care Insurance Benefits

Your Long-Term Care Insurance Benefits Long-Term Care Long-Term Care Insurance can help you or an eligible family member pay for costly Long-Term Care assistance when you can no longer function independently. For more information on See Page

More information

Guidelines for Medical Necessity Determination for Occupational Therapy

Guidelines for Medical Necessity Determination for Occupational Therapy Guidelines for Medical Necessity Determination for Occupational Therapy These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine

More information

Mode & Service Function Information

Mode & Service Function Information Mode & Service Function Information 20 S/D Mode 05 = 24-Hour Services SD/MC Mode 05 = Residential/PHF SD/MC Mode 07 = General Hospital SD/MC Mode 08 = Psych Hospital: Age < 21 SD/MC Mode 09 = Psych Hospital:

More information

MAPLES /PHOENIX REHABILITATION REFERRAL REFERRAL DETAILS:

MAPLES /PHOENIX REHABILITATION REFERRAL REFERRAL DETAILS: MAPLES /PHOENIX REHABILITATION REFERRAL Each section must be completed by the treating health professional and goals for rehabilitation must be indicated. Once completed, please post the referral form

More information

Clinical Medical Policy Outpatient Rehab Therapies (PT & OT) for Members With Special Needs

Clinical Medical Policy Outpatient Rehab Therapies (PT & OT) for Members With Special Needs Benefit Coverage Rehabilitative services, (PT, OT,) are covered for members with neurodevelopmental disorders when recommended by a medical provider to address a specific condition, deficit, or dysfunction,

More information

Health Professionals who Support People Living with Dementia

Health Professionals who Support People Living with Dementia Clinical Access and Redesign Unit Health Professionals who Support People Living with Dementia (in alphabetical order) Health Professional Description Role in care of people with dementia Dieticians and

More information

Family Caregiver s Guide to Hospice and Palliative Care

Family Caregiver s Guide to Hospice and Palliative Care Family Caregiver Guide Family Caregiver s Guide to Hospice and Palliative Care Even though you have been through transitions before, this one may be harder. If you have been a family caregiver for a while,

More information

Family & Medical Leave Request and Medical Certification Form. Part 1: EMPLOYEE INFORMATION (to be completed by employee)

Family & Medical Leave Request and Medical Certification Form. Part 1: EMPLOYEE INFORMATION (to be completed by employee) New Jersey's Science & Technology University Part 1: EMPLOYEE INFORMATION (to be completed by employee) Name (Please print) Address: City: State _ Zip Telephone: Home E-Mail: If Family & Medical leave

More information

Administrative Code. Title 23: Medicaid Part 205 Hospice Services

Administrative Code. Title 23: Medicaid Part 205 Hospice Services Title 23: Medicaid Administrative Code Title 23: Medicaid Part 205 Hospice Services Table of Contents Table of Contents Title 23: Division of Medicaid... 1 Part 205: Hospice Services... 1 Part 205 Chapter

More information