Tuesday, April 23, 2019

Quality to the Next Level

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Skilled Nursing Facility Services

1-932734068 - Thursday, May 16, 2013
Rationale for the Referral: Physician certification is a condition of payment for skilled nursing facility (SNF) services under section 1814 of the Social Security Act and 42 C.F.R. Part 424, not an element of coverage. ALJ erred in ordering Medicare reimbursement for SNF services without considering the certification requirements articulated in 42 C.F.R. § 424.20.

Referral Document

Appeals Council Decision

1-874930013 - Friday, February 22, 2013

Rationale for the Referral: Medicare law and implementing regulations require as a qualifying condition for the coverage of SNF services a three-day inpatient hospitalization preceding admission to the SNF. 

When considering whether a beneficiary’s SNF stay was preceded by a qualifying three-day inpatient hospitalization, Medicare coverage for the hospital services themselves, as well as the characterization of the hospital stay, is not an issue before the ALJ.

A denial based on the lack of a qualifying three-day hospitalization is a technical denial pursuant to section 1861(i) of the Social Security Act; therefore, the beneficiary may be held responsible for the noncovered SNF services.

An ALJ cannot address services or dates of service beyond those which are properly before the ALJ on appeal.

Referral Document

Appeals Council Decision

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