Skilled care coverage needs to include sufficient documentation to enable a reviewer to determine whether:
- Skilled involvement is required in order for the services in question to be furnished safely and effectively; and
- The services themselves are, in fact, reasonable and necessary for the treatment of a member’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs and accepted standards of medical practice. The documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals.
Initial documentation should be supplied within two business days of admission and, as requested, by your utilization review nurse thereafter. All documentation, including notification, must be supplied to MediGold within two business days of admission. Our notification form is available in the Skilled Nursing Facilities section at: MediGold.com/For-Providers/Tools-and-Resources/Forms. Any delay in notification may result in nonpayment of days.
Concurrent reviews are due on scheduled dates provided by your utilization review nurse. Failure to provide timely updates may result in denied reimbursement for days when skilled criteria is not met. The facility is to notify MediGold of any change in member status or treatment.
Do not include more than one member on one fax.