Because TRICARE For Life beneficiaries may need to use a skilled nursing facility (SNF), coverage for those services is available.
Care from a skilled nursing facility is not the same as custodial care, long-term care, or nursing homes. TFL does not cover custodial care, long-term care, or nursing homes.
Coverage
Participation Agreement
For a beneficiary who is eligible for both Medicare and TRICARE For Life (TFL), TFL can be the secondary payer for:
When Medicare benefits run out, TFL may be the primary payer to SNFs that meet those conditions. An SNF provider must sign an SNF Prospective Payment System (PPS) agreement with TFL in order to be an authorized TFL provider. If you do not have this agreement on file, we will deny claims for SNFs.
SNF PPS Consolidated Billing
TFL uses Medicare's per diem prospective payment system (PPS) for skilled nursing facilities.
Under the PPS system, Medicare makes payments based on fixed amounts. The amounts are based on the type of service. The PPS applies to:
The PPS system applies to all SNF admissions that began on or after August 1, 2003.
Bill Types and HIPPS Codes
You must submit bill type 21X on the claim form. You also must include Revenue Code 0022 and the Health Insurance Prospective Payment System (HIPPS) codes for charges you are billing.
Use the Medicare-based Patient-Driven Payment Model (PDPM) for the HIPPS code claims. During Medicare's 100-day benefit period, please use the same HIPPS codes for TFL patients as you use for those under Medicare.
For TFL patients, after the 100th day in a benefit period, use the appropriate PDPM that makes up the HIPPS code. Be sure to use all five digits to help prevent processing delays and returned claims.
For dates of service up to December 31, 2019, TRICARE will use the RUG-III codes. Effective January 1, 2020, TRICARE will follow Medicare use of PDPM codes.
Prior Authorization and Concurrent Authorization
Billing Charges
All SNF claims must include:
This line-item listing should include a room rate charge (Revenue Code 10x, 11x, 12x, etc.) for the number of bed days equal to the date span of services billed.
Leave of absence or transfer to acute care
MDS Assessments
SNFs have to perform a patient assessment. Please use the Medicare MDS assessment form and guidelines to judge the medical need of services.
Use the default HIPPS rate code of ZZZZZ on the claim when there is:
Other Health Insurance (OHI)
Signature Requirements
When you submit a UB-04 claim form with a Medicare EOB, you do not need a representative from the facility to sign. Once benefits are exhausted, that changes. If you do not attach a Medicare EOB to your claim form, an authorized representative must sign the form in or around FL 80.
Acceptable options include:
Documenting Medicare exhaustion of benefits
You must use the electronic crossover claim from Medicare to use occurrence code A3 and show the date of exhaust.
Other ways to prove benefits from Medicare or other insurance have run out include:
Common Claim Return or Denial Reasons
Some of the most common reasons you may have a claim returned or denied include:
Questions?
