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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that all skilled nursing facility (SNF) Part A inpatient services are paid under a prospective 
payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System 
(HIPPS) rate code. Under the new Patient-Driven Payment Model (PDPM), which is effective for services 
provided on or after 10/1/2019, the HIPPS code is structured differently, as a result of there being five case-mix 
adjusted rate components under the revised model. The first position represents the Physical and Occupational 
Therapy case-mix group. The second position represents the Speech-Language Pathology (SLP) case-mix 
group. The third character represents the nursing case-mix group. The fourth character represents the Non-
Therapy Ancillary (NTA) case- mix group. The fifth character represents the assessment indicator code. You 
can find this information in the Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Sections 10, 30, and 120. 
 
The rules say the Resident Assessment Instrument (RAI) consists of three basic components: The Minimum 
Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process and the RAI Utilization Guidelines. 
The utilization of the three components of the RAI yields information about a residents functional status, 
strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have 
been identified. 
 
Federal regulations require the Registered Nurse (RN) assessment  coordinator to sign and thereby certify that 
the assessment is complete. 
 
Steps for Assessment: 
1. Verify that all items on this assessment are complete. 
2. Verify that Item Z0400 (Signature of Persons Completing the Assessment) contains attestation for all MDS 
sections. 
 
Coding Instructions: 
1. For Z0500B, use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator. This date must be equal to the latest date at Z0400 or later than the date(s) at Z0400, 
which documents when portions of the assessment information were completed by assessment team members. 
2. If for some reason the MDS cannot be signed by the RN assessment coordinator on the date it is completed, 
the RN assessment coordinator should use the actual date that it is signed. 
 
As the last day of the look-back period, the Assessment Reference Date (ARD) serves as the reference point for 
determining the care and services captured on the MDS assessment. Anything that happens after the ARD will 
not be captured on that MDS. For example, for a MDS item with a 7-day look-back period, assessment 
information is collected for a 7-day period 
ending on and including the ARD which is the 7th day of this look-back period. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Chapters 1 and 3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.