Produced by - Mead Johnson Nutrition

❏❏❏❏❏❏❏SNF coverage datesSNF coverage policies for enteral productsSNF reimbursement amounts for facilityservices and enteral therapyDeductibles, lifetime maximums, remainingcoverage availableAny policy restrictions including pre-existingdiagnoses, limits on SNF stays and participationrequirements or contracts for SNF providersBilling requirements including claim formcodes, documentation and billing submittaladdressAuthorization requirements includingauthorization number, authorization period,authorization processTIMELY FILINGManaged care organizations (MCOs) have differentpolicies on the timely filings of claims. Some MCOsattempt to shorten the timely filing requirements to 30 to60 days, but this may be unreasonable for yourorganization. A minimal timely filing of 90 days shouldbe requested, and a period of one year is ideal. Thereimbursement department should work closely with themanaged care contracting department to ensure contractsare written in a reasonable manner. Whatever the timelyfiling limits may be, bill as soon as possible afterservices are rendered and conduct timely claim statusfollow-up.MEDICAL DOCUMENTATIONEven when insurance verification takes place,insurance companies will only approve services “subjectto medical necessity.” Private insurance companies do notrequire, nor do they prefer, Medicare CMNs, so these arenot recommended.Medical documentation needed is a single page ofpatient information that is signed by the prescribingphysician. Sometimes these are called letters of medicalnecessity (LOMN). These can be completed in a letter orform and they typically need to include:❏ The patient’s name❏ The insured’s name❏ Patient diagnosis❏❏❏❏Type(s) of enteral products and servicesrenderedMethod of administrationEstimated durationThe provider name, address, telephone numberand federal tax identification number❏ The prescribing physician’s name, address,telephone number, signature and dateManaged care payers often require a precertification(precert) or prior authorization before services aredelivered and/or to continue services. Sometimes these areverbal and other times there is a paper certificationgenerated that needs to be submitted with the claim form.Other times there is a certification number that needs to beput on the claim form. Providers should review precertificationrequirements with the payer and with intakeand billing staff to ensure compliance with applicablerules.May, 2002 41