Requirements for assessments of Medicare Advantage members in skilled nursing facilities

Here's some important information about the assessments required for Blue Cross and Blue Care Network Medicare Advantage members admitted to skilled nursing facilities:

• You must complete an Omnibus Reconciliation Act, or OBRA, assessment for each member.
• You may opt to complete an additional Prospective Payment System assessment, but you are not required to complete one.

If you complete a PPS assessment:

• No Resource Utilization Group level is required, because naviHealth will determine the RUG level.
• A RUG level included in a PPS assessment may not match the level naviHealth assigns. If the levels don't match and you enter the RUG level from a PPS assessment rather than the naviHealth-assigned RUG level, this may cause a claim payment error.
• You must bill using the RUG level naviHealth assigns, which you'll find in the authorization on nH Access^™ at access.navihealth.com.

If you choose not to complete a PPS assessment, there will be no penalties, even if you're following CMS protocols.

This applies to BCN Advantage^SM and Medicare Plus Blue^SM PPO members admitted for skilled nursing care on or after June 1, 2019.

For more information, see the following documents on the Blue Cross Blue Shield of Michigan and Blue Care Network resources page of the naviHealth website*:

• naviHealth-assigned RUG level for Medicare Advantage Members
• Frequently Asked Questions: Claims Processing

If you have questions, contact your naviHealth network manager.

We'll incorporate this information into the Post-acute care services: Frequently asked questions by providers document.

Additional information:

• Starting Oct. 1, 2019, naviHealth will authorize Patient-Driven Payment Model levels during the patient's stay, which aligns with CMS payment methodology. Before this change takes place, we'll let you know how it will affect the assessments you must complete.
• As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019.
• As part of their partnership with Blue Cross Blue Shield of Michigan, naviHealth assigns and authorizes RUG levels for Medicare Advantage members' stays in skilled nursing facilities.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.