This is a reminder of the billing guidelines and referral requirements for professional providers when rendering services to members in long-term care (LTC) facilities. Please review the information below and be sure to adhere to these requirements when providing such services.

Place-of-service codes

Primary care physicians (PCP) often visit their patients while they are in an LTC facility. On a professional claim, participating PCPs are required to use the most accurate place-of-service code to specify where a service is rendered. Therefore, it is important to distinguish between skilled nursing care visits and custodial care visits and use the appropriate place-of-service code on professional claims.

• Skilled nursing care: Place-of-service code = ?31?
  Skilled nursing visits are intended for HMO, POS, and PPO members who need skilled or sub-acute care. Skilled nursing visits are subject to the precertification requirements and benefits limitations of the member?s plan. Admissions to a skilled nursing facility (SNF) are arranged by care coordinators and must be preapproved through the precertification process. These admissions are reviewed weekly, or more often if applicable, to ensure the appropriate use of benefits and promote optimal benefits coverage. SNF reviews may be on-site or by telephone or fax, depending on the arrangement with the individual facility.
• Custodial care: Place-of-service code = ?32?
  Many of the services provided by PCPs to members who have been admitted to an LTC facility are considered custodial care services. These services do not require precertification like skilled nursing care.

Referral requirements

We have established LTC panels for our PCPs who provide care in participating LTC facilities. PCPs with an LTC panel must issue referrals for any professional service or consultation that an LTC-panel member in long-term care receives, including:

• podiatry, physical therapy, and radiology services;
• consultation or follow-up with a specialist;
• ancillary services (note that LTC-panel members do not have capitation requirements for laboratory, physical therapy, radiology, or podiatry services).

PCPs should submit referrals for LTC-panel members in advance of the service being provided. Referrals can be submitted either by using the NaviNet? web portal or by calling the Provider Automated System at 1-800-275-2583, and they should be submitted in a timely manner to allow for appropriate claims processing. Claims will not be authorized for payment without a referral on file. In addition, consultants and ancillary providers are encouraged to provide the referral information with the claim to assist in processing.

Note: LTC-panel members do not need precertification for the services listed above. Precertification is required only for inpatient admissions for hospital care, skilled nursing care, short procedure unit cases, and outpatient ambulatory surgical center procedures. During an approved skilled nursing care admission, it is not necessary for the attending physician to issue a referral. However, all providers rendering care to the member should use the inpatient skilled nursing care authorization number on any claims during the dates of service within the skilled nursing inpatient stay.

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