This is a reminder of the
billing guidelines and referral requirements for professional providers when
rendering services to members in long-term care (LTC) facilities. Please review
the information below and be sure to adhere to these requirements when
providing such services.
Place-of-service codes
Primary care physicians (PCP)
often visit their patients while they are in an LTC facility. On a professional
claim, participating PCPs are required to use the most accurate
place-of-service code to specify where a service is rendered. Therefore, it is
important to distinguish between skilled nursing care visits and custodial care
visits and use the appropriate place-of-service code on professional claims.
- Skilled nursing care: Place-of-service code = "31"
Skilled nursing visits are intended for HMO, POS, and PPO members who need
skilled or sub-acute care. Skilled nursing visits are subject to the
precertification requirements and benefits limitations of the member's plan.
Admissions to a skilled nursing facility (SNF) are arranged by care
coordinators and must be preapproved through the precertification process.
These admissions are reviewed weekly, or more often if applicable, to ensure
the appropriate use of benefits and promote optimal benefits coverage. SNF
reviews may be on-site or by telephone or fax, depending on the arrangement
with the individual facility.
- Custodial care: Place-of-service code = "32"
Many of the services provided by PCPs to members who have been admitted to an
LTC facility are considered custodial care services. These services do not
require precertification like skilled nursing care.
Referral requirements
We have established LTC
panels for our PCPs who provide care in participating LTC facilities. PCPs with
an LTC panel must issue referrals for any professional service or consultation
that an LTC-panel member in long-term care receives, including:
- podiatry, physical therapy,
and radiology services;
- consultation or follow-up
with a specialist;
- ancillary services
(note that LTC-panel members do not have capitation requirements for
laboratory, physical therapy, radiology, or podiatry services).
PCPs should submit referrals for
LTC-panel members in advance of the service being provided. Referrals can be
submitted either by using the NaviNet? web
portal or by calling the Provider Automated System at 1-800-ASK-BLUE, and they should be submitted in a
timely manner to allow for appropriate claims processing. Claims will not be authorized for payment without a referral on
file. In addition, consultants and ancillary providers are encouraged to
provide the referral information with the claim to assist in processing.
Note:
LTC-panel members do not need precertification for the services listed above.
Precertification is required only for inpatient admissions for hospital care,
skilled nursing care, short procedure unit cases, and outpatient ambulatory
surgical center procedures. During an approved skilled nursing care admission,
it is not necessary for the attending physician to issue a referral. However,
all providers rendering care to the member should use the inpatient skilled
nursing care authorization number on any claims during the dates of service
within the skilled nursing inpatient stay.
NaviNet® is
a registered trademark of NaviNet, Inc., an independent company.