Print

Skilled Nursing Facility (SNF) Benefit Change for Federal Employee Program® (FEP) Members

Posted December 13, 2017

Starting Jan. 1, 2018, senior patients with an FEP Standard Option health plan who are not enrolled in Medicare Part A and need rehabilitation that a nursing home does not offer may be covered for up to 30 days per benefit year of inpatient SNF care.

To help ensure appropriate benefits are applied here are some requirements that you need to know:

  • The patient must be enrolled in Blue Cross and Blue Shield of Illinois’ (BCBSIL’s) case management program before being admitted to an SNF.
  • Per the Federal Employee Health Benefit Plan, before pre-certifying the SNF admission, a patient’s signed consent to be enrolled in the case management program must filed with BCBSIL. When the patient transfers from an acute care facility, discharge staff will collaborate with the BCBSIL case manager to help ensure this consent paperwork is completed by the patient or the patient’s guardian. 
  • When applying for pre-certification, the requesting provider and discharging acute care facility must submit a detailed description of the patient’s clinical status and proposed treatment plan to BCBSIL for review. The treatment plan includes: Rationale for inpatient care; Estimated length of stay; Medical and rehabilitation therapies to be provided during the stay, including frequency; Preliminary short- and long-term goals; and Plan for discharge, including discharge location and ongoing care.
  • A SNF representative must provide BCBSIL with updates on the patient’s status at least every seven days. Updates convey progress towards goals as well as changes to the treatment and the discharge plan.
  • The SNF’s attending physician must write the admission orders within 24 hours of a patient’s admission.
  • Within 12 hours of admission, patients on a ventilator must be seen by a pulmonologist. Respiratory therapy must always be available.
  • Within 16 hours of admission, patients who are admitted primarily for rehabilitation must be seen by a physical therapist and have a treatment plan in place. These patients must receive at least two hours of physical and occupational therapy, a minimum of five days per week. Documentation must be provided to BCBSIL.

For benefit approval, a patient’s information can be faxed to BCBSIL at 877-404-6455.

The new utilization management guidelines for SNF services have been added to the FEP Medical Policy Manual. This manual will be available to members at fepblue.org  after Jan. 1, 2018. 

If you have any questions regarding this update or to verify a patient’s eligibility, please call FEP Customer Service at 800-972-8382.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment.

Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.