Skilled nursing facility care

Kaiser Permanente Nursing Home Services coordinates skilled nursing facility (SNF) services.

Kaiser Permanente members may receive inpatient care in one of our in-network SNFs when that care is preauthorized by a Kaiser Permanente Care Management representative. We must review all SNF admissions to determine whether the member meets SNF criteria to issue an authorization or a notice of non-coverage. In order to meet Medicare Criteria, patients must have a daily nursing or therapy need.

Arranging for services

All SNF placements require prior authorization. If the member is in the hospital, discharge planners will arrange for SNF placement. If a member is in your office, request prior authorization online or contact Nursing Home Services toll-free at 1-800-887-3873.

In order to determine whether the member meets clinical criteria, has a SNF benefit, and which facility can meet their care needs, we will need the following information:

• Member name and Kaiser Permanente ID number
• Reason for referral
• Physician admission orders
• Specific diagnoses for all medications
• Current history and physical or emergency department evaluation
• Therapy evaluations and recent progress notes, if applicable
• Pre-admission screening resident review (PASRR)

Authorization for items or services not included in the per diem

• Authorization for items or services not included in the per diem must be obtained in advance from Nursing Home Services SNF Placement Office prior to admission.
• Prior authorization for items or services not included in the per diem that are ordered after admission to skilled care must be obtained from the SNF CMLN assigned to the Contractor’s facility.
• Contractor shall submit invoices for these items or services in accordance with this Agreement.

Payment rates for medicare primary enrollees

Skilled Nursing Facilities and Acute Rehabilitation Facilities shall bill Medicare as the primary payer for Medicare Part A and B Covered Services in accord with Medicare coverage and billing requirements. Kaiser Permanente is responsible only for Coinsurance and Deductibles not covered by Medicare. Skilled Nursing Facilities and Acute Rehabilitation Facilities must submit a Medicare “Explanation of Benefits” when submitting a billing to Kaiser Permanente for Coinsurance and Deductibles not covered by Medicare.

Authorizations for items or services not covered by Medicare (excluding Coinsurance and Deductibles) must be obtained in advance from Nursing Home Services. If the need for such items or services is known prior to admission, Kaiser Permanente staff shall make the necessary arrangements. If the need is established following admission, Contractor shall contact the CMLN. Such items or services must be ordered directly by the CMLN.

Contractor shall submit invoices for these items or services in accord with this Agreement. Payment by Health Carrier for these excluded items or services will be at Contractor’s cost, which cost must be supported by original invoices.

Admission and continued-stay review

Skilled Nursing Facilities and Acute Rehabilitation Facilities are responsible for Admission Notification for inpatient services. Notification of each admission must be received within 24 hours after actual weekday admissions (or by 5 p.m. local time on the next business day if 24-hour notification would require notification on a weekend or Federal holiday). For weekend and Federal holiday admissions, notification must be received by 5 p.m. local time on the next business day. Skilled Nursing Facilities and Acute Rehabilitation Facilities must respond to calls from KFHPWA SNF CMLN within two (2) working hours.

We review admissions from hospitals, nursing homes, and home health for clinical need and appropriateness and to identify coordination of care needs. Continued stay reviews focus on high-risk diagnoses, variance from length of stay guidelines, and coordination of care needs.

Skilled Nursing Facility continued-stay reviews focus on medical necessity, variance from length of stay guidelines, and coordination of care needs.

When requested, the Skilled Nursing Facilities and Acute Rehabilitation Facility shall provide periodic clinical progress reports within same day when requested by KFHPWA SNF CMLN by noon. Clinical progress reports to address medical necessity of continued SNF level of care and include current updates re: patient’s clinical status, rehab progress, plan of care, discharge planning and provide pertinent medical record documentation as requested.

Our care management nurses work closely with a facility's staff to conduct reviews and coordinate care. If the admission or continued stay appears to be inappropriate, our nurses, in conjunction with the patient and the multidisciplinary team, will develop an alternative plan.

If it is determined that the stay is not covered, the Skilled Nursing Facilities and Acute Rehabilitation Facility shall deliver a Notice of Medicare Non-Coverage (NOMNC) letter or Notice of Non-Coverage (NONC) letter to the patient or the patient’s legal representative on the day determined by KFHPWA SNF CMLN to issue Notice. If the NOMNC or NONC is delivered by telephone a copy of the NOMNC or NONC will be mailed to the patient’s legal representative on the same day. The Skilled Nursing Facilities and Acute Rehabilitation Facility shall return the signed NOMNC or NONC letter to KFHPWA NOMNC Specialist by fax to 855-277-3607 within two (2) hours and file copy of the signed letter in the patient’s chart.