Skilled Nursing Facility

Three-Day Qualifying Hospital Stay Required for Medicare-Covered SNF Stay

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Three-Day Qualifying Hospital Stay Required for Medicare-Covered SNF Stay

Medicare coverage of inpatient SNF services requires a qualifying, medically necessary inpatient hospital stay of at least three consecutive calendar days (not including the discharge day) within 30 calendar days prior to admission to a SNF for continued treatment of a condition for which the beneficiary was receiving inpatient hospital services.

Before Medicare can pay for post-hospital extended care services, including SNF services, it must determine whether the beneficiary had a prior qualifying inpatient hospital stay of at least three consecutive calendar days. Note that the beneficiary must be eligible for Part A coverage, including age requirements, which means that the hospital discharge must have occurred on or after the first day of the month in which the individual attained age 65 or became entitled to health insurance benefits under the disability or chronic renal disease provisions of the law.

When a beneficiary’s liability for an inpatient hospital stay is waived, such as when the services rendered during the days in question were found noncovered because they were not considered reasonable and necessary or because they constituted custodial care, the hospital days to which the limitation on liability applies cannot be used to satisfy the three-day prior hospitalization requirement. If a beneficiary’s inpatient hospital stay was partially covered, NGS considers the covered portion of the stay in determining whether the SNF three-day prior hospitalization requirement is met.

Hospice care related to a beneficiary’s terminal condition is excluded from coverage under the SNF PPS. However, when a hospice patient receives general inpatient hospital care for three days or more in a hospital, and chooses to revoke hospice, then the three-day stay (although not equivalent to a hospital level of care) would still qualify the beneficiary for covered SNF services provided all other coverage requirements are met.

  • Note: A Medicare beneficiary in a covered hospice benefit period may be eligible to receive SNF care for a condition that is not related to the terminal condition.

What is Not Included in Calculation of Three-Day Qualifying Inpatient Stay

When determining whether the three consecutive day inpatient hospital stay requirement has been met, it is important to understand:

  • The required three consecutive day inpatient hospital stay begins on the day the patient is formally admitted as an inpatient to the hospital.
    • Note that Medicare requires a physician’s order specifying an inpatient admission.
  • The date of discharge is not included in the three-day qualifying stay count.
  • All emergency department or other outpatient care, including observation care, is not included in the three consecutive day qualifying inpatient stay calculation.
    • No outpatient services are included in the three-day qualifying inpatient stay calculation regardless of whether the patient remains overnight, and regardless of the length of the outpatient and/or observation length of the stay.

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Additional Information

Circumstances in which Medicare is expected to deny payment for an item or service which may be a Medicare benefit but for which the coverage requirements are not met, includes, but is not limited to, SNF stays not preceded by the required three-day hospital stay.

It is inappropriate to issue a SNF ABN form (CMS 10055) for a technical denial. Lack of a three-day qualifying inpatient hospital stay is an exclusion (technical denial) from Medicare coverage of an inpatient SNF stay.

CMS and NGS strongly encourage SNFs to issue an FFS "Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility" (CMS 20014) to Medicare beneficiaries who do not have a three-day qualifying inpatient hospital stay prior to admission to the SNF. The SNF NEMB is available to assist the SNF in discussing their determination that Medicare will not cover the SNF stay. The SNF NEMB provides written notice to the Medicare beneficiary about the reason the SNF stay would not be covered by the Medicare Program thus assisting the beneficiary in making an informed decision concerning their care and it offers the opportunity to have a claim submitted to receive an official Medicare decision. The SNF NEMB should be issued prior to or during the admission process to alert Medicare beneficiaries in advance that Medicare does not cover certain extended care item(s) and/or service(s) because the item or service does not meet the definition of a Medicare benefit or because the item or service has been specifically excluded by law. The NEMB form itself lists some of the common technical denials. as well as the CMS IOM Publication 100-02, Chapter 8.

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Billing Reminders

When the beneficiary does not meet the technical requirements for SNF coverage, they may choose to remain in the SNF.

  • If no skilled services are provided:
    • The SNF is not required to bill Medicare. However, the SNF provider must submit a demand bill upon the request of a beneficiary.
  • When skilled services are provided:
    • The SNF is required to submit claims to Medicare. This requirement includes the submission of claims for beneficiaries that do not meet the qualifying stay or transfer criteria. Such claims are not covered by Medicare; however, the claim is submitted as covered in order to extend existing beneficiary spells of illness in CWF but does not include occurrence span code 70 (prior qualifying hospital stay).

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