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If you have any questions regarding the information in CCA’s provider manual, please email Provider Relations at [email protected].

Section 10: Information For Ancillary Providers

Extended Care Facilities

Commonwealth Care Alliance provides benefit coverage to its members at extended care facilities or nursing facilities. The protocols for benefit coverage take into account covered services, exclusions, clinical conditions and criteria, authorizations and operational expectations. 

Prior Authorization 

Prior authorization is required and shall be granted from Commonwealth Care Alliance’s designated care team authorizing the Extended Care Facility to render specified covered services to a Commonwealth Care Alliance member. Payment to a facility for covered services requires prior authorization. For more information, please see Section 8 of this manual.

Covered Services include:

  • Sub-acute level of care—short term, goal oriented treatment plan requiring nursing care or rehabilitation at a high intensity level; lower intensity than acute care
  • Skilled nursing level of care—short term, goal oriented treatment plan whereas the member cannot be treated in a community-based setting; lower intensity than sub-acute
  • Custodial level of care—absent of a defined treatment goal, yet the member’s functional or cognitive status requires the support of a facility setting
  • Medical leave of absence (MLOA) days – a bed is guaranteed for the member if he or she returns to the facility during the 1st day through the 20th day after transferring out of the facility. If the member returns after this period, his/her admission shall be accommodated upon the availability of a bed, unless otherwise arranged.
  • Non-medical leave of absence (NMLOA) – a bed is guaranteed for the member if he or she return to the facility during the 1st day through the 10th day after transferring out of the facility. If the member returns after this period, his/her admission shall be accommodated upon the availability of a bed, unless otherwise arranged.

Level of Care Determinations

All level of care determinations prior to, and during a member’s admission to an Extended Care Facility are made at the discretion of Commonwealth Care Alliance clinical staff and/or those designated and authorized by Commonwealth Care Alliance to direct member care.  The following Conditions and Criteria for Levels of Care Determination are as follows:

Sub Acute Care

Conditions & Criteria for the Assignment of Sub Acute Level of Care

Conditions:
There has been a determination by the CCA care team that a short term, goal oriented treatment plan is necessary; patient care needs requiring sub-acute nursing care and/or skilled rehabilitation; the patient requires a greater number of MD/NP visits, skilled nursing care hours, or rehabilitation services than are normally provided at a basic skilled level of care; there is active management of the treatment plan by the care team to stabilize the patient.

Criteria:
Care is at a Sub-Acute reimbursement level when the following criteria are met:

1. Presence of serious injury or illness that requires inpatient treatment but not acute
 hospital care

2. Active management of the treatment plan by the care team to stabilize the patient

3. Sub-Acute nursing care to manage complex medical issues:

  •  Frequent assessment
  •  Complex IV regimens
  •  Respiratory Care
  •  Complex pain management

4. Rehabilitation Therapy services (PT, OT, Speech Therapy) 2 or more hours of direct care daily 6 or 7 times per week, as part of a treatment plan that is goal oriented, measurable, and designed to promote recovery (dependent upon Patient’s individual condition, Rehabilitation Therapy services may or may not be present as part of the Sub Acute level plan of care, but if present, the patient must have the ability to participate in this level of therapy intensity, or level of care will be subject to change).

5. Sub-Acute / Skilled days shall be limited to 100 days per benefit period.

Skilled Care

Conditions & Criteria for the Assignment of Skilled Nursing Level of Care

Conditions:
There has been a determination by the CCA care team that a goal-oriented treatment plan is necessary, and that the patient cannot, as a practical matter, be treated in a community-based setting; patient care needs requiring skilled nursing care and/or skilled rehabilitation; such care is needed on a daily basis, at least 5 days per week;

Criteria:
Care is at a Skilled Nursing reimbursement level when the following criteria are met:

1. Less medically complex illnesses or injuries

2. Availability of skilled nursing care 24 hours a day

3. Daily skilled nursing care:

  •  Assessment
  • Skilled observation
  • Simple IV therapies, or injection needs
  • Dressing changes

4. Rehabilitation Therapy services (PT, OT, Speech Therapy) up to 2 hours a day, 5 times a week, as part of a treatment plan that is goal oriented, measurable, and designed to promote recovery (dependent upon Patient’s individual condition, Rehabilitation Therapy services may or may not be present as part of the Skilled Nursing level plan of care, but if present, the patient must have the ability to participate in this level of therapy intensity, or level of care will be subject to change).

5. Sub Acute/Skilled days shall be limited to 100 days per benefit period.

Custodial Care

Conditions & Criteria for the Assignment of Custodial Care Level of Care

Conditions:
There has been a determination by the CCA care team that there is an absence of a defined skilled need or treatment goal that the patient is expected to achieve; the patient’s functional or cognitive status is such that the support of a facility setting is necessary, as patient cannot be safely managed in the community with long term care supports.

Criteria:
Care is at a Custodial Care reimbursement level when the following criteria are met:

1. Less than daily skilled needs

2. Stable medical status

3. Care is not goal directed, focus is to maintain status

  •  Assist with ADLs
  •  Administration of routine medications

Rehabilitative Services in a Skilled Nursing Facility

Rehabilitation services provided intermittently while at the custodial level of care.  Intermittent therapy cannot exceed four calendar days per week as approved by CCA staff.  Prior authorizations are required for all evaluations and treatment.

Notice of Medicare Non-Coverage (NOMNC)

The Extended Care Facility shall deliver the Notice of Medicare Non-Coverage (NOMNC) on behalf of CCA no later than 2 days before an Enrollee’s covered services end in accordance with Medicare requirements. The Extended Care Facility shall provide CCA with a copy of the Notice within the same timeframe as the Member for monitoring and documentation purposes.

Status Change Form (SC-1) For SCO Members

In the instance when a CCA member is admitted to an extended care facility, the facility must submit a Status Change Form (SC-1) to Commonwealth Care Alliance and the appropriate member enrollment center with “Commonwealth Care Alliance Member” clearly indicated on the form. Please see the chart below for additional requirements: