10A NCAC 25M .0401. SKILLED NURSING FACILITY

(a)  Prior approval for services in skilled nursing facilities shall be required for all admissions.  Where cases warrant expeditious action, telephonic approval can be obtained.

(b)  Utilization review in each skilled nursing facility shall be provided by personnel under contract.

(c)  Participation (enrollment) as a Medicare provider is a prerequisite to participation (enrollment) in the North Carolina Medicaid Program.  North Carolina Medicaid is payor of last resort; facilities participating in North Carolina Medicaid must bill Medicare for all eligible clients prior to billing Medicaid.  All Medicare coverage, for services provided, must be exhausted prior to billing Medicaid.

(d)  Private accommodations shall not be covered, except when directed by a physician on the basis of medical necessity or when a patient census precludes semi‑private assignment.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.20; C.F.R. 440.40; 42 C.F.R. 440.230(d)

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1977; September 1, 1981;

Paragraphs (a)-(c) transferred from 10A NCAC 22O .0116 Eff. May 1, 2012 (Previously recodified from 10 NCAC 26B .0114 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0115 Eff. January 1, 1998;

Paragraph (d) transferred from 10A NCAC 22O .0403 Eff. May 1, 2012.