Reimbursement

  • Either a case rate or a per diem rate will be assigned if skilled criteria is met and depending on services being rendered
    • Per diem rates will be assigned if there are qualifying carve outs and the only carve outs that will be considered are those listed in the facility contract. Otherwise an estimated resource utilization group (RUG) will be assigned based on the supporting clinical documentation. Final reimbursement is based on the five-day minimum data set (MDS). The final MDS and invoices for any carve outs must be submitted to MediGold within five business days of discharge.
  • If the member does not meet skilled criteria, then an unskilled rate will be paid for those days incurred before the two business day notification.
  • Ambulance trips to hemodialysis, chemotherapy, radiation therapy, CT or MRI, outpatient surgery or other high end outpatient hospital services should be billed directly by the ambulance company under Medicare Part B. Facilities should use an in-network provider.
  • Requests for transfer to a different skilled nursing facility (SNF) will be reviewed by MediGold on a case-by-case basis.
    • Ambulance transport from one SNF to another SNF is not covered (unless MediGold determines that there was a quality issue at the first facility).

 SNF Claims Submission Guidelines

Updated 03/2018