TRICARE SKILLED NURSING FACILITY SNF BENEFIT PROSPECTIVE PAY

1. 1 TRICARE SKILLED NURSING FACILITY (SNF)BENEFIT & PROSPECTIVE PAYMENT SYSTEM (PPS) Tariq Shahid Medical Benefits and Reimbursement Systems TRICARE Management Activity Shahid-022

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3. 3 SNF BENEFIT Medically necessary and appropriate SNF care covered with no day limit (TRM, Ch 8, Sec 2) Minimum 3-day prior hospitalization required Must enter SNF within 30 days of hospital discharge unless medically inappropriate Skilled services must be for a medical condition that was treated during the qualifying hospital stay or started while the patient was receiving covered SNF care SNF must be Medicare certified and enter into a participation agreement with TRICARE These new requirements implemented on Aug 1, 2003

4. 4 SNF PPS TRICARE adopted Medicare SNF PPS effective for admissions on or after Aug 1, 2003 (TRM, Chapter 8, Section 2) SNF PPS is a per diem PPS that covers all (routine, ancillary, and capital) costs of covered SNF services SNF PPS rates are based upon resident assessments. SNFs use a standardized assessment tool, called the Minimum Data Set (MDS) SNFs use RUG-III grouper which is a computer program that converts resident-specific assessment data into a case-mix classification

5. 5 SNF PPS SNF PPS (Continued) Based upon their clinical and functional characteristics, the grouper classifies residents into one of the 44 specific RUGs (Resource Utilization Groups) For each RUG, the SNF PPS per diem rate is calculated as the sum of three parts � the nursing component, the therapy component and the non-case-mix component TMA provides the Medicare SNF Pricer to TRICARE contractors which automatically calculates the SNF PPS rates. TRICARE rates are the same as Medicare SNF PPS rates and these are updated annually

6. 6 Medical Review Requirements The upper 26 RUGs represent the required SNF level of care. A SNF resident who is correctly assigned to one of the upper 26 RUGs is automatically classified as meeting the SNF level of care definition and does not require a review for medical necessity. The lower 18 RUGs are not automatically classified as meeting the SNF level of care definition and require a review for medical necessity.