Reminder: Effective Oct. 1, 2019, the Centers for Medicare & Medicaid Services (CMS) changed the Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS) reimbursement methodology from Resource Utilization Groupings (RUGs) to the new Patient Driven Payment Model (PDPM).

Providers should update their billing, in accordance with CMS guidelines, when submitting claims to Humana.

Humana will apply the new payment methodology where applicable, per CMS guidelines, when paying the Medicare allowed amount.

Humana accepted the new PDPM codes beginning with Oct. 1, 2019, dates of service.

A new authorization will be required for members who are discharged from the facility past midnight. However, consistent with the CMS interrupted stay policy, the new authorization will not reset the variable per diem adjustment schedule. Humana still will determine pricing for these claims based on the interrupted stay rules outlined by CMS.

Providers who receive authorization from naviHealth should continue to follow the required Omnibus Budget Reconciliation Act (OBRA) Assessment Schedule, as directed by naviHealth, and use the PDPM code they received from naviHealth when submitting their claims. All other providers should follow the CMS expectations and schedule of assessments – as outlined by the CMS RAI-MDS 3.0 Manual and Medicare billing manuals – effective Oct. 1, 2019.

If you have questions, please contact your Humana market contractor representative as soon as possible.

Please refer to the CMS website for additional information about SNF PDPM:, opens new window