Reminder: Medicare Advantage SNF claims will be denied when PDPM levels don't match the levels naviHealth authorized

Starting with dates of service on Oct. 1, 2019, naviHealth has authorized patient-driven payment methodology levels for skilled nursing facility stays for Medicare Plus Blue^SM and BCN Advantage^SM members. At that time, we communicated that you must include on claims the PDPM levels that naviHealth authorized or risk claim recoveries due to post-service auditing.

Previously, Blue Cross and BCN reviewed paid SNF claims on a quarterly basis to ensure that PDPM levels on claims matched the PDPM levels naviHealth authorized. We pursued payment recoveries when we found overpayments.

Starting in December 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will deny SNF claims when PDPM levels don’t match the levels naviHealth authorized.

As a reminder, naviHealth:

• Authorizes PDPM levels during the patient's SNF stay (from preservice through discharge) for dates of service on or after Oct. 1, 2019.
• Authorizes PDPM levels based on medical necessity review and their proprietary naviHealth Predict functional assessment.
• Works with SNFs to ensure billers submit proper PDPM levels for reimbursement.

For more information, see Post-acute care services: Frequently asked questions for providers

Posted: December 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network