BCN AdvantageSM to audit SNF claims for RUG codes starting June 1

Starting June 1, 2019, BCN Advantage will audit claims for members admitted to skilled nursing facilities. In the audit, we'll review the RUG codes to ensure that the codes submitted on the claim and the associated reimbursement amounts are appropriate and reflect the approved RUG levels provided when authorization determination was made for the member's stay.

RUG codes represent the Resource Utilization Groups that the Centers for Medicare & Medicaid Services uses to determine reimbursement for SNF stays.

RUG codes for Medicare Plus BlueSM PPO members in SNFs have been audited for some time. The change is that the auditing process will also be applied to claims for BCN Advantage members in SNFs.

For SNF admissions, naviHealth will authorize RUG levels during the course of the patient's stay, from preservice through discharge. naviHealth will work with SNFs to ensure the provider submits the appropriate RUG level for reimbursement. When you submit claims for Blue Cross Medicare Advantage members admitted to a SNF, make sure the RUG code you use is appropriate for the authorization connected to the stay.

As a reminder, naviHealth will manage authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019.

Posted: April 2019
Line of business: Blue Care Network