Medicare and Manage care Certs

Medicare 

• The Medicare program conditions of payment require a physician certification and (when specified) recertification for SNF services
  • To meet requirements the certification or recertification statement must clearly indicate posthospital extended care services were required because of the individual's need for skilled care on a continuing basis for which he/she was receiving inpatient hospital services.
  • If ambulance service is furnished by a skilled nursing facility, an additional certification is required. It may be furnished by any physician who has sufficient knowledge of the patient's case, including the physician who requested the ambulance or the physician who examined the patient upon his arrival at the facility. The physician must certify that the ambulance service was medically required
• The statement must be signed:
  • By an attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or
  • A nurse practitioner (NP), clinical nurse specialist (CNS) or a physician assistant (PA) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.
• Timing of Certification/Recertifications
  • The initial Certification is due at the time of admission, or as soon thereafter as is reasonable and practicable.
  • The first recertification must be made no later than the l4th day of inpatient extended care services.
    • A skilled nursing facility can, at its option, provide for the first recertification to be made earlier, or it can vary the timing of the first recertification within the l4-day period by diagnostic or clinical categories
    • Subsequent recertifications are required at intervals not to exceed 30 days
• The recertification statement must contain an adequate written record of the reasons for the continued need for extended care services, the estimated period of time required for the patient to remain in the facility, and any plans, where appropriate, for home care
  • The first recertification and any subsequent recertifications must state that the continued need for extended care services is for a condition requiring such services which arose after the transfer from the hospital and while the patient was still in the facility for treatment of the condition(s) for which he/she had received inpatient hospital services.
• Delayed Certification/Recertifications
• • Skilled nursing facilities are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where
    • Delayed certifications and recertifications are allowed for an isolated oversight or lapse.
    • The delayed certification or recertification must include an explanation of the delay along with any other information the SNF considers relevant to explain the delay.
• The facility will determine the format of delayed certification and recertification statements, and the method by which they are obtained

Manage care Certs

Treat them as Medicare certs