Skilled nursing facility frequently asked questions

This guidance applies to Ohio Medicaid only.

For additional information please visit:

• The Ohio Department of Medicaid (ODM) website at Nursing Facilities | Medicaid
• Anthem website Home | Anthem Blue Cross and Blue Shield

You can also email us at OHMedicaidENCPESupport@anthem.com.

Q: Is preapproval required for a member's admittance into an SNF?

A: Yes. Effective June 1, 2023, Anthem allows a seven-day initial length of stay upon notification of an admission to an in-network skilled nursing facility (SNF) for members. Facility and physician must be in-network for the member.

We require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channel. Anthem will approve an initial seven-day length of stay without the need to provide clinical information. More information can be found here.

For the initial SNF admission, submit the clinical information no later than three business days after the admission. Then, by no later than by day eight of the admission, additional clinical documentation should be submitted for review.

Q: Does the floor to SNF process apply to out of-network care providers?

A: No, the facility and physician both need to be in network. All out-of-network facilities and care providers must follow the standard PA process.

Q: For the SNF initial authorization of seven days, will Anthem assign a level of care?

A: Anthem utilization management (UM) will assign a level of care once the PASRR | Department of Developmental Disabilities Form, the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form, and clinical information is received from the SNF.

Q: How can I check the status of my preapproval request?

A: Care providers can check the status of a preapproval by using the Interactive Care Reviewer (ICR) located within Availity Essentials.

Q: Does Anthem pay for transportation while in an SNF?

A: Charges for inpatient services for facility personnel are not separately reimbursable, and the reimbursement for such is included in the room and board rate. Examples include but are not limited to lactation consultants, dietary consultants, overtime charges, transport fees, nursing functions (including IV or PICC line insertion at bedside), professional therapy functions, including physical, occupational, and speech call back charges, nursing increments, therapy increments, and bedside respiratory and pulmonary function services. Charges for outpatient services for facility personnel are also not separately reimbursable. The reimbursement is included in the payment for the procedure or observation charge.

Q: Does Anthem pay a higher rate for skilled nursing care?

A: We follow the ODM fee schedule.

Q: Does Anthem pay for bed holds?

A: Yes, we follow OAC guidelines Rule 5160‑3-16.4 ‑ Ohio Administrative Code | Ohio Laws.

Q: How are bed holds requested?

A: To request a bed hold, please submit a preapproval request via Availity Essentials through the ICR or fax to 877‑643-0671.

Q: What is required when the member’s level of care changes?

A: When the level of care changes, the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form should be faxed to 877‑643-0671.

Q: What is required from the SNF when a member is admitted into the hospital from an SNF?

A: Notification from the SNF that a member has been admitted to a hospital can be faxed to 877‑643-0671 or submitted through the ICR on Availity Essentials. If a bed hold is needed, the SNF should submit a preapproval request.

Q: What is required from the SNF when a member readmits to the SNF from a hospital?

A: If a member returns to the SNF the same day, and there is no level of care change, no new authorization is needed. However, a notification is needed when the member returns before midnight the same day.

If a member returns to the SNF more than 24 hours after the hospital admission, past midnight, and no bed hold request, then a new authorization is required.

If the SNF knows how long a member will be admitted, they should submit a notification and bed hold request for the specific number of days. If the number of days is unknown a bed hold request can be submitted with no end date. We follow Rule 5160‑3-16.4 ‑ Ohio Administrative Code | Ohio Laws pertaining to bed holds.

The hospital admission and discharge summary for a member returning to an SNF is required regardless of length of time away from the SNF.

Q: What is needed when a member transitions to long-term care (LTC)/custodial?

A: The SNF should submit the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form, face sheet with admit date, and letter of intent to remain in LTC from facility via fax 877‑643-0671 or Availity Essentials.

If LTC transition occurs prior to the end of SNF approval, notification is required. We will cover 90 days of LTC, and our UM department assists the facility in transitioning the member to traditional Medicaid.

Q: What is needed when a member discharges home from an SNF?

A: Discharge summary, including discharge date and time, disposition, primary care provider (PCP) information, and follow-up instructions.

Q: Will we pay for private rooms?

A: Yes. The ODM will begin reimbursing private rooms at qualifying nursing facilities (NFs). Reimbursement for approved private rooms began in January 2025 for claims with dates of service (DOS) that include the effective date of December 18, 2024, and will apply to individuals covered by fee for-service (FFS) Medicaid, Medicaid managed care, and MyCare.

Please note: Per ODM guidance, private room reimbursement is capped at $160 million for each state fiscal year (SFY) beginning with SYF 2025: NF_Fact_Sheet_Private_Rooms.pdf

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.