Cigna has moved their provider portal to
Cigna for Health Care Professionals
as of July 31, 2020. As of July 31, 2020, you will not longer be able to access Cigna on Availity.
Kepro Technical Denials
Kepro, the QIO (Quality Improvement Organization), is required to submit an annual report to their stakeholders; the report for each region can be found at
Florida is located in Region 4. The report provides summary information regarding the work they do, which includes discharge reviews from all levels of Part A services, quality of care concerns, denials of hospital admission and immediate advocacy cases. Of particular interest is how Florida is doing in regards to SNF appeals that were deemed ‘technical denials’, which are wins for the patient but cause the facility to have financial responsibility liability for care and services till the next last covered day is established through the issuing of a NEW NOMNC. Kepro labels these as ‘No Review Required’ and closes the case. This information was not in the report, so we reached to their team for assistance.
The total number of reviews in Florida, June 8 to December 31, 2019 was 7,559. There was a total of 4,020 ‘No Review Required’ June 8, 2019 to January 31, 2020. Per the report for the region, 57% of the ‘No Review Required’ were due to late or incomplete records. 13% were due to invalid notices (including NOMNCs and Important Messages from Medicare (Hospital)). This highlights the issues that SNFs are experiencing in Florida and why it is financially important for your team to know how to properly issue a NOMNC and respond to a QIO request. If you are in need of assistance in this area, please reach out to your Managed Care Liaison for assistance and training. We are happy to help.
MANAGED CARE AND 3-MIDNIGHT RULE
Did you know that CMS allows Medicare Advantage plans a waiver for the 3-overnight rule for SNF placement? Most Medicare Advantage plans utilize this waiver and will allow patients with a skilled need to be authorized for SNF admission and gain access to their Medicare A benefits.
What does this mean for you? As a SNF service provider you must verify benefits for Medicare Advantage members prior to admission. When you are completing verification be sure to ask if a 3-overnight stay is required. If you are told no then you can proceed to requesting authorization.
Working with hospital emergency rooms or physician’s offices can be easier if you know the waiver rule as well. Being the SNF that educates the ER and works with them to admit from the ER or the physician’s office to the facility is a big win! When working with these types of admissions you would need documentation similar to what an admission from home would need- most current H&P, physician order, med lists and documentation supporting the skilled need – the reason this patient cannot be serviced at a lower level of care. This is what you submit with your skilled request.
This also means that if you have a long -term care resident who has a Medicare Advantage plan acquires a new skilled need (i.e.; IV antibiotics q8 for pneumonia) you can request a skilled authorization for that patients’ care in house with no need for hospitalization. Please note that the 60-day wellness break still applies and the patient must have Medicare A days available.
Remember, MCCFL is here to help support you in a situation such as this.
Sunshine Health and WellCare have announced the integration of their Provider Relations teams. This means you will have one Provider Relations Representative to assist in serving both Sunshine Health and WellCare of Florida members. This change will become effective for August 3rd, 2020.