CMS Pub. 100-08, ch. 6, § 6.1.1

Under the SNF PPS, beneficiaries who are admitted (or readmitted) directly to a SNF

after a qualifying hospital stay are presumed to meet the level of care requirements of

42 CFR 409.31 up to and including the assessment reference date (ARD) for the initial

Medicare assessment (commonly referred to as the “5-day” assessment) prescribed in

42 CFR 413.343(b), when correctly assigned to one of the more intensive case-mix

classifiers that is designated (in the annual publication of Federal prospective payment

rates described in 42 CFR 413.345) as representing the required level of care. If the

beneficiary is not admitted (or readmitted) directly to a SNF after a qualifying hospital

stay, the administrative level of care presumption does not apply. For a further

explanation of the administrative presumption of coverage, please refer to §6.1.4 of

this chapter, and to Pub. 100-02, Medicare Benefit Policy Manual, chapter 8, §30.1

(including item 3 of that section for a discussion of a rehospitalization that exceeds the

3-day interruption window specified under the SNF PPS’s interrupted stay policy).

Medicare contractors shall:

• Use the Common Working File (CWF) to validate the presence of an inpatient

hospital claim that was paid by Medicare. Because the entire medical record

from the inpatient hospital stay is not received for a SNF claim, it is difficult to

determine if the medical record and the CWF conflict. Therefore, it is assumed

that the dates of service for the inpatient hospital claim in CWF are correct for

purposes of establishing the 3-day prior inpatient hospital claim dates. If the

CWF is silent as to an associated 3-day inpatient hospital claim, confirm that

the beneficiary had a 3-day inpatient hospitalization outside the Medicare

system (for example, the Veteran’s Administration hospital system). If such is

the case, the medical record from the inpatient hospitalization can be used to establish

inpatient hospitalization dates. This documentation need not be signed for this

purpose.

• Presume medical necessity of the qualifying inpatient hospitalization. If,

during the normal claims review process, evidence that the hospitalization

may not have been medically necessary emerges, the Medicare contractors

shall fully develop the case in accordance with the directions contained in

Pub. 100-02, chapter 8, § 20 and 20.1.

• Verify that the extended care services were for an ongoing condition that was

also present during the prior hospital stay (even if not the main reason for that

stay), or for a new condition that arose while the beneficiary was receiving

treatment in the SNF for the ongoing condition. In this context, the ongoing

condition need not have been the principal diagnosis that actually precipitated

the beneficiary’s admission to the hospital, but could be any one of the

conditions present during the qualifying hospital stay. The Medicare

contractors may use a hospital discharge summary or any additional

documentation from the inpatient hospital to make this verification. This

documentation need not be signed for this purpose.