UM Guidelines

	Added:
	Skilled Nursing Facility/Inpatient Rehabilitation Fax Form Exceptions may be required to comply with EPSDT, Medicare, and & BlueCare® regulations. Attachment #A for Commercial Lines of Business - details the 3 levels of SNF care listed below. Attachment #B for BlueCare/TCS - details the 3 levels of SNF care listed below. ATTACHMENT A SKILLED NURSING FACILITY LEVELS OF CARE DESCRIPTIONS For Commercial Lines of Business Level I (Skilled Care) Patients receiving the following types of care will meet the clinical criteria to qualify as Level I. Examples of the types of care include, but are not limited to: Semi-Private Room Meals (Including specialized dietary and administration of feeding) 24-Hour Skilled Nursing Care 24-Hour Physician Coverage Colostomy Care Wound Care (Stage 1 & 2) Tube Feeding & Medication Administration Routine Respiratory Care (Oxygen, Aerosol Treatments, Oxygen Saturations) Routine DME & Routine Medical Supplies Routine Oral & Inhaled Medications and Pharmacy Supplies SQ Insulin Case Management Services Social Services Laboratory Services Routine Diabetic Supplies (Lancets, Test Strips) Routine X-Rays Continuous IV Fluid Therapy (Peripheral Lines) 1.5 hrs or less of Rehabilitation Therapy per day Speech Therapy (at any level) must be provided in conjunction with another skilled service Level II (Comprehensive Care) Patients receiving Level I types of care - plus the following types of care - will meet the clinical criteria to qualify as Level II. Examples of the types of care include, but are not limited to: Wound Care (Stage 3) IV Site Care (Central Lines) Tracheotomy Care Respiratory Care (Frequent Suctioning) Routine Medications (Examples: IV, IM & SQ: 1st, 2nd & 3rd Generation Cephalosporins, Natural & Amino Penicillins, Extended Spectrum Penicillins, Tetracyclines, Sulfonamides, Fluoroquinolones, Aminoglycosides, Heparin, Coumadin) 1.75 - 3 hrs of Rehabilitation Therapy per day Level III (Complex Care) Patients receiving Level I & II types of care - plus the following types of care - will meet the clinical criteria to qualify as Level III. Examples of the types of care include, but are not limited to: Stage IV wound care Respiratory Care (Ventilator) Specialty Beds (Hill-Rom, KCI) High Cost IV, IM & SQ Medications: (Examples: 4th Generation Cephalosporins, Penicillinase-Resistant Penicillins, Desferal, Desmopressin, Epoetin Alfa, IVIG, Panretin, Remicade, Thrombolytic Enzymes, Chemo-Therapy Agents). Requests from providers for Level III based on cost of drugs other than above, should be verified with BCBST Pharmacy Benefit Management representative as needed, prior to approving this level of care. Negative pressure wound therapy pump for the treatment of acute and chronic wounds Peritoneal dialysis IV TPN, Lipids Authorization is given for a specific level and period of care. The provider must call BCBST if a change in the level of care occurs, or to obtain approval for additional days—prior to the expiration of the authorization. Physicians must bill for their services separately Specialty / custom wheelchairs are excluded—billed by a DME provider (see Exhibit B for definition). Transportation Request (Commercial ONLY), examples: home, facility to facility. Please review benefits/contract and refer to Case Management. ATTACHMENT B SKILLED NURSING LEVELS OF CARE REIMBURSEMENT For BlueCare/TCS ***Name of Skilled Nursing Facility*** BCBST Provider No.:_________ Level I - Skilled Nursing Care Including 1 Therapy Per Diem Examples: 1.5 hours or less of Rehabilitation Therapy per day, Simple wound care, or Continuous IV Therapy Semi-Private Room Meals (Including Specialized Dietary and Administration of Feeding) 24-hour Skilled Nursing Care Traction and Positioning Colostomy Care Wound Care (Stage 1 and 2) Tube Feeding and Medication Administration Routine Respiratory Care (Oxygen, Inhaler Treatments, Oxygen Saturations) Routine Durable Medical Equipment and Routine Medical Supplies Routine Medications and Pharmacy Supplies Case Management Services Social Services Laboratory Services (Examples: CBC, Bloodglucose, Urine Analysis, etc.) Routine X-Rays Routine Diabetic Supplies Hospice Rehabilitation Therapies (Physical, Occupational, Speech) 1.5 hours or less per day Speech therapy must be provided in conjunction with another skilled service. Excludes: Specialized/Customized DME (Examples: Beds, Wheelchairs, etc.) TPN, IV Medications (Pain, Antibiotics) Physician Services Level II - Subacute Per Diem Examples: 1.75 hours to 3 hours of Rehabilitation Therapies per day, Complex wound care, or IV medications (2 or more per day). Services included in addition to Level I care: 24-hour Skilled Nursing Care Wound Care (Stage 3) IV Care (Peripheral, Subclavian) Tracheostomy Care Respiratory Care (Frequent Suctioning) Medications and Pharmacy Supplies (IV Fluids, IV Medications [Excluding Third Generation Antibiotics]) Rehabilitation Therapies (Physical, Occupational, Speech) 1.75 hours to 3 hours per day Excludes: Specialized/Customized DME (Examples: Beds, Wheelchairs, etc.) Specialized Radiology (CT Scan, MRI) TPN, Lipids, Third Generation Antibiotics Physician Services Level III - Specialty Skilled Care Per Diem Examples: Ventilator dependent, Spinal Cord injury, or Brain injury. Services included in addition to Level II care: Respiratory Care (Ventilator) Multiple Wound Care (Greater than three stage three or four wounds with wound vac or requires dressing changes BID to two or more stage three or four wounds) Bariatric Care Patient (> 400 lbs) Excludes: Specialized/Customized DME (Beds, Wheelchairs, etc.) Specialized Radiology (CT Scan, MRI) TPN, Lipids, Third Generation Antibiotics Physician Services References BlueCross BlueShield of Tennessee network physicians. July - September 2024.