2018 Federal Employee Program Utilization Management Clinical Guideline 002: Inpatient Skilled Nursing Facility Care

December 1, 2017

Effective January 1, 2018, benefits will be available for Federal Employee Program (FEP) members for up to 30 days of inpatient skilled nursing facility (SNF) care per benefit year year for Standard Option Members who are not enrolled in Medicare Part A. The provider and Blue Cross and Blue Shield of New Mexico (BCBSNM) staff must be proactive in identifying members for whom a SNF stay is an appropriate level of care in the continuum toward transition home. It may also be necessary to obtain the member's written consent for Case Management (CM). This may include identifying of the member's surrogate decision maker/proxy, assisting BCBSNM in delivering the case management consent to the member/proxy and/or having the signed consent returned to BCBSNM's case manager prior to BCBSNM rendering a benefit determination on the proposed SNF admission.

To utilize this benefit:

  • The member must be enrolled in case management (CM) and the signed consent for CM must be received by the case manager prior to precertification approval of the SNF admission. This will require that the discharge planning staff collaborate with BCBSNM case manager, and in some cases, will necessitate the case manager/discharge planner's assistance in delivering the consent to the member and having it returned to BCBSNM after the member/proxy signs the document.
  • The transferring facility must submit a detailed description of the patient's clinical status and the proposed treatment plan for BCBSNM’s review of the proposed admission.

Once the member is admitted:

  • The SNF representative must provide specific information regarding the patient's status, progress towards goals, changes to the treatment plan and/or discharge plan (if applicable) and documentation of any obstacles preventing the member from achieving the goals.
  • The attending physician in the SNF must write admission orders and review the preliminary treatment plan within 24 hours of the patient’s admission. Patients admitting on a ventilator must be seen by a pulmonologist within 12 hours of admission and respiratory therapy be available in the facility 24 hours/day.
  • Members admitted for rehabilitation must receive an evaluation by a physical therapist and a physical therapy treatment plan must be in place within 16 hours of admission. Members admitted primarily for rehabilitation must receive at least 2 hours of physical therapy and occupational therapy combined at least 5 days per week (logs must be provided to BCBSNM to document therapy time).

The new FEP UM Guideline 002 Inpatient Skilled Nursing Facility Services will be added to the FEP Medical Policy Manual available at effective January 1, 2018.