Commercial Authorization Changes for Participating Skilled Nursing Facilities

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) recognizes the important role that Skilled Nursing Facilities (SNFs) provide to our members as they transition from the inpatient hospital setting back to their homes.

As a valued provider who is also committed to making sure our members receive quality care, we ask for your partnership as we take a more proactive approach to Transition of Care planning.   

For Commercial Plans, Blue Cross NC will begin to perform concurrent reviews on an earlier and more frequent basis to support SNFs and our members with their transitions of care beginning August 1, 2023. Our goal is to collaborate with providers to identify members in need of additional discharge planning support and be ready to assist with transitioning the member to the next appropriate level of care as soon as medically appropriate. 

• This enhancement will help with: 
  • More effectively managing members' transition-of-care phases. 
  • Developing strategies to reduce members’ length-of-stay. 
• Anticipated Changes: 
  • More frequent requests for clinical updates so that we can be prepared to assist with transition of care to home with medically necessary supporting services (i.e., home health, durable medical equipment) as soon as possible.  
  • Reassessment of SNF Acuity Level to be performed upon concurrent review.
  • Any resulting changes to the SNF Acuity Level will result in a change to your reimbursement, which corresponds with the global rate for that specific acuity level as outlined in your provider agreement. 

Please refer to the Blue Cross NC Corporate Medical Policy for Skilled Nursing Facility Care for medical necessity criteria for initial and continued care.