Update: Skilled nursing facility frequently asked questions

For additional information, please visit:

• The State Agency website at: Nursing Facilities | Medicaid
• Our website: https://providers.anthem.com/oh

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

Q: Is prior authorization required for a member's admittance into a skilled nursing facility (SNF) under the Floor to SNF process?

A: No, we allow a seven-day initial length of stay upon notification of members’ admission to an in-network SNF. The facility and physician must be in-network according to the member’s health plan.

We require notification of the Floor to SNF admission, which includes sending demographics and verifying benefits via the usual channel. We will approve an initial seven‑day length of stay without providing clinical information. For more information, access the Floor to SNF process document (PDF).

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

If the member does not qualify for the Floor to SNF process, the care provider should follow the normal prior authorization process to determine if the member can be approved for nursing facility level of care.

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 prior authorization process.

Q: Does Anthem assign a level of care for the initial seven‑day Floor to SNF authorization?

A: We engage utilization management (UM) to 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 are received from the SNF.

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

A: Care providers can check the status of a prior authorization by using the Interactive Care Reviewer (ICR) in Availity Essentials at https://Availity.com.

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

A: Charges for inpatient services for facility personnel are not separately reimbursable; 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.

Refer to Rule 5160-3-19 - Ohio Administrative Code | Ohio Laws for further information on covered services generally available to Medicaid recipients and their relationship to the services provided by a nursing facility.

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

A: Anthem follows the Ohio Department of Medicaid (ODM) fee schedule.

Q: Does Anthem pay for bed holds?

A: Yes, Anthem follows Ohio Administrative Code guidelines, which are located at Rule 5160-3-16.4 - Ohio Administrative Code | Ohio Laws.

Q: How are bed holds requested?

A: To request a bed hold, submit a notification with a requested start date 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, fax the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form (PDF) and an updated PASRR 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 notification with a requested start date for a bed hold.

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 or bed hold days are 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 days are utilized, a new authorization is required.

Q: What is required from the SNF when a member readmits to the SNF from a hospital while utilizing bed hold days?

A: If the member readmits within a 30‑day bed hold, we ask for a notice of readmission (including a readmit date) and the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form (PDF) with updated hospital clinical. We will adjust the bed hold days to the correct number of days used and continue with the level of care used prior to the bed hold days.

If the member uses 30 bed hold days and does not readmit to the SNF, this would be considered a discharge, and the case would be closed. If the member needs to readmit after using 30‑day bed hold days, a new prior authorization needs to be completed.

The member needs to be at the same Level of Care as they were prior to discharge to the hospital. If the level of care has changed, a new prior authorization request and PASRR would be needed.

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

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

If LTC becomes the discharge plan during a skilled/intermediate nursing stay, notification is required. We will cover 90 days of a nursing facility stay, and our UM department will assist the facility in transitioning the member to traditional Medicaid (FFS) starting as early as day 60 of the nursing facility stay.

If the member has been in the nursing facility for over 90 days and the discharge plan is not LTC, we will continue to follow this member.

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

A: A discharge summary, including discharge date and time, disposition, PCP information, and follow‑up instructions are required.

Q: Will Anthem pay for private rooms?

A: Yes, the ODM will begin reimbursing private rooms at qualifying nursing facilities. 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 people covered by fee‑for‑service (FFS) Medicaid, Medicaid managed care, and MyCare.

Note: Per ODM guidance, private room reimbursement is capped at $160 million for each state fiscal year (SFY) beginning with SYF 2025. See this fact sheet for more information: Nursing Facility_Fact_Sheet_Private_Rooms.pdf.

For additional support, visit the Contact Us section at https://providers.anthem.com/oh.