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Skilled Nursing Facility Billing Update

Beginning October 1, 2019, Horizon BCBSNJ aligned our approach to the processing of Skilled Nursing Facility (SNF) claims with that of the Centers for Medicare & Medicaid Services (CMS) services rendered to patients enrolled in any Horizon BCBSNJ Medicare Advantage (MA) plans.

On October 1, 2019, CMS replaced the Resource Utilization Group, Version IV (RUG-IV), with the Patient Driven Payment Model (PDPM), a new case-mix classification system for classifying SNF patients in a Medicare Part A plan covered stay into payment groups under the SNF Prospective Payment System (PPS).

CMS requires SNFs to bill for services under PDPM using the Health Insurance Prospective Payment System (HIPPS) code that is generated from a five-day PPS assessment and Interim Payment Assessment (IPA) with an assessment reference date on or after October 1, 2019.

For more information, please visit CMS’s Patient Driven Payment Model webpage.

If you have questions, please contact your Horizon BCBSNJ Ancillary Contracting Specialist.

Published on: January 13, 2020, 02:26 a.m. ET
Last updated on: April 27, 2021, 02:44 a.m. ET