Revised July 2013

Martin’s Point Health Care Skilled Nursing Rehabilitation Guide

Martin’s Point Health Care administers two government-sponsored health plans. Our US Family Health Plan is a TRICARE Prime option. And our Generations Advantage plan is a Medicare Advantage plan offered to Medicare-eligible seniors in Maine and parts of New Hampshire. Please take a moment to familiarize yourself with theses two plans and the requirements for covered skilled nursing services.

Martin’s Point Generations Advantage

Coverage: Coverage includes up to 100 days per benefit period, with no prior hospital stay required. A benefit period begins on the first day of a member’s stay in a Medicare-covered skilled nursing facility. The benefit period ends when the member has not been an inpatient at any Skilled Nursing Facility (SNF) for 60 days in a row. Coverage for skilled nursing admission and continued stay is based on Medicare policy and Milliman criteria.

• Semi-private room (or a private room if medically necessary) • Meals including special diets • Skilled nursing services • All drugs administered to the member as part of the plan of care (includes

substances that are not naturally present in the body, such as blood clotting factors)*

• Blood – including storage and administration; covered from the first pint • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X-rays and other radiology services ordinarily provided by SNFs • Use of appliances (such as wheelchairs) ordinarily provided by SNFs • Physical therapy, occupational therapy and speech therapy services • Physician/Practitioner services

Reimbursement: 100% of Medicare Resource Utilization Group (RUG) payments less member cost-share

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Authorization: Before patient admission, a pre-authorization request must be submitted to the Martin’s Point Health Management Department.

*Important note about patient medications: Per the standard Medicare reimbursement methodology, medications are part of the RUG payment. Please do not bill the member’s Martin’s Point Generations Advantage drug card for medications provided during an approved stay.

Martin’s Point US Family Health Plan

Coverage: Coverage for skilled nursing admissions and continued stay is based on TRICARE policy and Milliman criteria. TRICARE policy states that covered SNF stays must be rehabilitative and not maintenance or custodial.

Reimbursement: Reimbursement and admission are paid using a per diem methodology which is not linked to Medicare RUGs or policies.* Please review all sections of this document.

Authorizations: Before patient admission, a pre-authorization request must be submitted to the Martin’s Point Health Management Department. Admissions are managed by a Martin’s Point case manager who determines the rehabilitation level and length of stay. You may be asked to complete a Rehab Review Form to convey any need for additional rehabilitation services.

*Per Diem Description

Services include:

• Consultation and weekly review by Medical Director • Semi-private room • Meals (including special dietary needs and enterals) • 24-hour nursing • Routine respiratory supplies (including oxygen) • Non-legend pharmaceuticals • Routine medical and nursing supplies (e.g. support hose and dressings) • Infusion pumps and related medical supplies

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• Case management and discharge planning • Therapies (PT, OT, SLP, RT) as requested (evaluations to be done within one

business day and therapy to be provided per contractual agreement). Providers should work with the assigned Case Manger when daily therapy is unavailable.

Standard exclusions to the above per diem include:

• Diagnostic procedures and lab work provided by outside laboratories or providers (e.g. mobile X-ray services)

• Ambulance transfers • Physician services and consultations (pre-authorization required for non-

participating physicians) • Specialized DME, prosthetics and orthotics (pre-authorization may be required,

please use participating DME vendors) • Legend pharmaceuticals including TPN and IV infusion (pre-authorization may be

required) • All injectables such as SQ, IM, IV (pre-authorization may be required) • Most drugs may be billed through Caremark (contact information below)

Legend Pharmaceuticals

Members should be sent home with any remaining amounts of pharmaceuticals. Ideally, SNFs should bill legend pharmaceuticals (oral, injectable or IV) for covered skilled stays via the US Family Health Plan Pharmacy Benefit Manager’s (PBM) online system through the Long Term Care (LTC) pharmacy. Facilities that use an LTC pharmacy (e.g. NCS, Omnicare, PharMerica or NeighborCare) should ask the LTC pharmacy to submit claims via the PBM on-line system.

• Facilities need to supply the LTC Pharmacy with the member’s identification number, see the example ID card.

• There will be no member co-payment for these services. • The facility should not include pharmacy charges on claims for medical charges

submitted to Martin’s Point. If a facility that uses an LTC pharmacy submits pharmacy charges to Martin’s Point, the charge will be denied.

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US Family Health Plan PBM

CVS Caremark Pharmacy Help Desk: 1 (800) 364-6331 Bin#: 004336 Process Control Number (PCN): ADV Group: USFHP Member ID # (11 digits) Local Retail Pharmacies

Facilities that cannot use LTC pharmacies but use local retail pharmacies which are participating with US Family Health Plan PBM for services:

• The pharmacy may not be both an LTC and a retail pharmacy with the PBM. • Provide your PBM participating retail pharmacy with the member’s identification

number and pharmacy information per above. • Facilities that use local retail pharmacies should include pharmacy charges on

claims to Martin’s Point. An itemization of charges and a detailed description of the pharmaceuticals is required for pharmacy claim adjudication. Revenue code 250 should be used to report these charges. Martin’s Point will reimburse all applicable co-payments.

PBM Online Denials and Workflows

The online claims system will occasionally deny claims for members. Please contact the PBM directly for any issues related to pharmacy claims transmission. Martin’s Point will need to authorize most common pharmacy benefit denial situations. LTC pharmacies and/or SNFs should contact our Provider Inquiry Department at 1-888-732-7364. Our representatives will assist you in resolving the issue. Denied PBM claims should be resolved and resubmitted to the PBM within ninety (90) days of denial.

Non-PBM Legend Pharmaceuticals

Facilities that contract with an LTC or retail pharmacy that does not participate with the US Family Health Plan PBM, may continue to include pharmacy charges on claims to Martin’s Point. An itemization of charge (with NDC numbers) is required for

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pharmacy claim adjudication. These charges will be processed on a discounted Average Wholesale Price (AWP) basis.

IV/IM Medications

The majority of IV/IM medications will be processed by our PBM. Please contact the Martin’s Point Provider Inquiry Department at 1-888-732-7364 for assistance with any PBM denials or workflow questions.

Non-legend, over-the-counter pharmaceuticals

Whether from an LTC Pharmacy or facility stock, non-legend, over-the-counter pharmaceuticals are covered as part of the per diem and are not billable to the PBM or member.

Total Parenteral Nutrition (TPN)

The majority of TPN services will not go through the PBM for processing. Martin’s Point Case Managers will work with facilities to provide a list of participating vendors. The infusion vendor will contact Martin’s Point for authorization. The facility will arrange for delivery of medications for patient needs.

Transportation

• Ambulance transfers from the hospital to a SNF are covered and should be billed by the rendering vendor.

• Emergency transfers from a SNF to the nearest hospital are a covered benefit. • Wheelchair vans are a covered benefit for patients requiring transportation to

necessary visits (e.g. physician office or outpatient therapy such as renal dialysis which is not available at the SNF).

• No benefit coverage exists for ambulance or van services that are not medically necessary or provided for the convenience of the member, physician or SNF.

• No pre-authorization is required for ambulance services provided by participating or non-participating ambulance vendors.

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Claim Submission Guidelines

Claims should be submitted on the UB-04 claim form. Facilities should report 211 for the type of bill.

Revenue Code Description

120 Room and Board

420 Physical Therapy

430 Occupational Therapy

440 Speech Therapy

250 General Pharmacy (co-payments when applicable)

636 Drugs Requiring Detailed Coding

Claim Adjudication

Claims are processed against the “Room and Board” charge on the claim detail line; all services included in the per diem are denied inclusive to the room and board with the exception of standard exclusions listed above. Providers may bill either the agreed-upon per diem rate for room and board or the full charge for room and board. In either instance, claim processing is based upon the contractually-agreed level/rate for the number of days on the claim.

It is required to bill the room and board and therapy modalities even though the therapy is included in the per diem. All other services that are part of the per-diem may be reported at the provider’s option.

Approved admissions begin with the day of admission regardless of the length of that day’s service and/or if therapy is provided. Claims processing is based upon the authorized length of stay less the discharge day.

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Medicare and US Family Health Plan Members

US Family Health Plan members who are eligible for Medicare typically have Medicare Part A and are encouraged to enroll and maintain Medicare Part B in addition to their US Family Health Plan coverage. Members with Medicare A and B do not pay an enrollment fee and their co-payments for SNF stays are waived.

Members with Medicare A and B have waived their right to access benefits under Medicare with the exception of TRICARE non-covered benefits. Medicare is not considered secondary to the US Family Health Plan for coordination of benefits purposes. In a US Family Health Plan member is also receiving maintenance dialysis, please contact our Provider Inquiry Department at 1-888-732-7364. A representative will advise you of any exception to this rule.

Members Converting to Long Term Care

• The US Family Health Plan is a TRICARE Prime program which is the managed care plan. Members are required to select and see a Primary Care Physician (PCP) who is responsible for providing and coordinating the member’s medical care.

• The TRICARE benefit is for skilled rehabilitation only. There may be other options for member situations that no longer meet this criteria.

• To maintain membership in the US Family Health Plan, the member must be able to maintain a PCP relationship, to use participating providers for care and to receive medications from the Martin’s Point mail-order pharmacy.

• Members unable to maintain US Family Health Plan eligibility may convert to Medicare and/or other TRICARE options (e.g. TRICARE for Life). These members should call our Member Services team at 1-888-674-8734 and ask for a Health Benefit Advisor to review their TRICARE options.

Appeals and Patient Financial Responsibility Form

In the event that the member’s stay no longer meets TRICARE and Milliman guidelines, the Case Manager will communicate the change in status to the facility. Appeal rights are provided to the member and physician at the time of denial.

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Approved appeals are retroactive to the date of denial. US Family Health Plan members may only be held liable for non-covered services if they are notified in advance of the non-coverage or potential non-coverage and have signed a waiver specifically acknowledging their liability. Most standard waivers signed upon admission are generally not sufficient to meet TRICARE policy. Please visit https://martinspoint.org/for-providers/claims to download our US Family Health Plan Patient Financial Responsibility waiver.

Key Contacts

Department Phone / Fax

Health Management Department

(pre-authorizations, continued stays)

Phone: 1 -888-339-7982

Fax: 1-207-828-7859

Provider Inquiry Department

(general questions, eligibility and claims)

Phone: 1-888-732-7364

Network Management and Provider Operations – (contract questions)

Phone: 1-800-348-9804

US Family Health Plan PBM Caremark

(pharmacies only)

Phone: 1-800-364-6331

Martin’s Point operates Monday– Friday 8:00 am to 5:00 pm EST.

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Sample Identification Cards

Martin’s Point US Family Health Plan

Martin’s Point Generations Advantage