Anthem clarifies guidance on prior authorization requirements for admissions to in-network skilled nursing facilities (SNFs)*

Note that the following information applies to Anthem Blue Cross and Blue Shield (Anthem) local Commercial health plans in Indiana and Ohio only.

 

In the January 2021 newsletter, you were previously notified that effective November 1, 2020, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network skilled nursing facility (SNF) facility for Indiana and Ohio members.

 

To clarify, this process only applies to hospital inpatient transfers to a skilled nursing facility (SNF).

It does not apply to transfers from acute inpatient rehab to SNF, LTAC to SNF, or SNF to SNF.

 

• 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 channels to aid in our members’ care coordination and management.
• 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 and prior to the last covered day for concurrent review.
• 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.

• Indiana and Ohio will pilot this process through June 1, 2021 and will conduct random audits and monitor trends to evaluate the effectiveness of the pilot

 

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

 

998-0321-PN-IN.OH