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New: Inpatient Skilled Nursing Facility Care Benefit for FEP members

Horizon Blue Cross Blue Shield of New Jersey wants you to know about a benefit change for your patients who are enrolled in the Federal Employee Program® (FEP®). Effective January 1, 2018, FEP members who do not have Medicare Part A and have the Standard Option plan, will have benefits available for inpatient skilled nursing facility (SNF) care for a maximum of 30 days per benefit year, when the patient can be expected to benefit from short-term SNF services with a goal of returning home.

The following criteria must be met to receive these benefits:

  • The member is enrolled in Horizon BCBSNJ’s Case Management program prior to admission to the SNF (signed consent to participate in Case Management is required), and actively participates in Case Management both prior to and during admission to the SNF.
  • Precertification/prior authorization is obtained prior to admission (including overseas care).
  • Horizon BCBSNJ approves the preliminary treatment plan prior to admission (treatment plan must include proposed therapies and document the need for inpatient care).
  • The member participates in all treatment and care planning activities, including discharge planning/transition to home.

Our nurse care manager will work with you/your facility to ensure we have the member’s signed consent for Case Management prior to Horizon BCBSNJ rendering a benefit determination on the proposed SNF admission. A consent form is enclosed. Our care managers will also have regular conversations with the member and/or the member’s authorized representative during the member’s stay in the SNF.

Benefits are not available when inpatient SNF care is for any of the following:

  • Solely for management of tube feedings
  • For home level dialysis treatment
  • An interim transition to long-term care placement
  • For any other non-covered services

For new request(s) for transfers to SNF care on weekends and holidays, all criteria must be met and signed consent received by the Friday afternoon or the last business day before a holiday. Otherwise, the request will be handled on the next business day. For prior authorization for this SNF benefit, please fax your request with clinical information to 1-973-274-4120. To speak with a care manager, please call 1-866-697-9696 and select option 6, Monday through Friday, between 8 a.m. and 5 p.m. Eastern Time.

Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols, Federal Employee Program® and FEP® are registered marks of the Blue Cross Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.

Published on: March 22, 2018, 02:16 a.m. ET
Last updated on: May 6, 2021, 01:06 a.m. ET