Avoid SNF claim denials for Medicare Advantage by matching PDPM levels on claims to the PDPM levels naviHealth authorized

In the fourth quarter of 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will begin denying skilled nursing facility claims when patient-driven payment model levels don't match the levels naviHealth authorized. Facilities can resubmit denied claims with the approved PDPM levels.

This applies to SNF claims for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

In a future web-DENIS message, we’ll let you know the exact date on which we'll begin denying claims.

As a reminder, naviHealth:

• Authorizes PDPM levels during the patient's skilled nursing facility stay (from preservice through discharge) for dates of service on or after Oct. 1, 2019
• Works with skilled nursing facilities to ensure billers submit proper PDPM levels for reimbursement

For more information, see Post-acute care services: Frequently asked questions by providers (PDF).

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network