Updated guidance on prior authorization requirements for admissions to in-network skilled nursing facilities

Please note that the following information applies to Anthem Blue Cross and Blue Shield (Anthem) in Kentucky local Commercial health plans.

 

Anthem is updating guidance on prior authorization requirements for admissions to in-network skilled nursing facilities (SNFs).

 

This process applies to hospital inpatient transfers to SNFs only.

It does not apply to transfers from Acute inpatient Rehab, LTAC to SNF, or SNF to SNF.

 

The goal of this updated guidance is to minimize any delays in the transfer of members to an in-network SNF facility.

 

Effective August 1, 2021, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network SNF facility for Kentucky local Commercial members.

• Facility and physician must be in-network for the member.
• Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channel.
• Anthem will approve an initial 5-day length of stay without the need to provide clinical information.
• SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within 2-days after the admission.
• Concurrent review will be required starting on day 5 of the SNF stay.
• Anthem may apply monetary penalties such as a reduction in payment, for failure to provide timely notice of admission.

 

We will monitor this process through December 31, 2021 and conduct random audits and monitor trends to evaluate its effectiveness

 

*Note: This process does not apply to admissions to out-of-network SNF facilities.

 

Frequently Asked Questions (FAQs)

 

As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?

Yes, notification is still required. However, you can notify Anthem of the admission and move the member without having to send in clinical information or wait for an approval. It will be important to verify member benefits.

 

When do I need to submit clinical information?

For the initial SNF admission, no later than two business days after the admission and for continued stay, prior to the last covered day.

 

Does this apply to SNF, IP Rehab and LTAC admissions and related transportation (air or ground ambulance)?

This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP Rehab, LTAC and any related transportation.

 

For the SNF initial authorization of 5 days, will Anthem assign a level of care?

Anthem UM will assign Level of care once the clinical information is received from the SNF.

 

What if a member needs to be admitted for wound care and IV antibiotics?

If a SNF has any concerns about the criteria for admission, they may still do the full prior authorization process.

 

If the physician and/or facility are out-of-network for the member, does this process apply?

No, the facility AND physician both need to be in network. All out-of-network facilities and providers must follow the full prior authorization process.

 

What if I am uncertain if the member is a local commercial member?

This process is applicable to local commercial accounts only.  It does not apply to FEP, National, Medicaid, Medicare, or IHM. If you are uncertain, reach out to the Anthem dedicated nurse for your facility.

 

1317-0921-PN-KY