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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 skilled nursing facilities (SNFs) and hospital swing bed providers are required to report 
inpatient Part A prospective payment system (PPS) billing data as follows. 
- In addition to the required fields identified in Medicare Claims Processing Manual Chapter 25, SNFs 
must also report occurrence span code 70 to indicate the dates of a qualifying hospital stay of at least 
three consecutive days which qualifies the beneficiary for SNF services. 
- Separate bills are required for each Federal fiscal year for admissions that span the annual update 
effective date (October 1). 
- Use Type of Bill 21X for SNF inpatient services or 18X for hospital swing bed services. 
- Revenue Code 0022. This code indicates that this claim is being paid under the SNF PPS. This revenue 
code can appear on a claim as often as necessary to indicate different health insurance prospective 
payment system (HIPPS) Rate Code(s) and assessment periods. 
- Effective for claims with dates of service on or after January, 1 2011, there must be an occurrence code 
50 (assessment date) for each assessment period represented on the claim with revenue code 0022. The 
date of service reported with occurrence code 50 must contain the ARD. An occurrence code 50 is not 
required with default HIPPS code AAAxx (where xx equals varying digits) or ZZZZZ October 1, 
2019 and after. In addition, for OMRA related AIs 05, 06, 0A, 0B, 0C, 12, 13, 14, 15, 16, 17, 1A, 1B, 
1C, 24, 25, 26, 2A, 2B, 2C, 34, 35, 36, 3A, 3B, 3C, 44, 45, 46, 4A, 4B, 4C, 54, 55, 56, 5A, 5B, 5C 
where 2 HIPPS may be produced by one assessment, providers need only report one occurrence code 50 
to cover both HIPPS codes. As of October 1, 2019, SNF PDPM changes are effective. 
- HCPCS/Rates field must contain a 5-digit HIPPS Code. The first three positions of the code contain 
the RUG group and the last two positions of the code contain a 2-digit assessment indicator (AI) code. 
- SNF and SB PPS providers must bill the HIPPS codes on the claim form in the order in which the 
beneficiary received that level of care. 
- Service Units must contain the number of covered days for each HIPPS rate code. - Total Charges should be zero for revenue code 0022. 
- When a HIPPS rate code of RUAxx, RUBxx, RUCxx, RULxx and/or RUXxx is present, a minimum of 
two rehabilitation therapy ancillary codes are required (revenue code 042x and/or, 043x and/or, 044x). 
When a HIPPS rate code of RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, 
RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RVBxx, RVCxx, RVLxx, and/or RVXxx is 
present, a minimum of one rehabilitation therapy ancillary revenue code is required (revenue code 
042x, 043x, or 044x. Bills that are missing required rehabilitation therapy ancillary revenue codes are to 
be returned to the SNF for resubmission. As of October 1, 2019, SNF PDPM changes are effective. 
- The accommodation revenue code 018x, leave of absence is reported when the beneficiary is on a leave 
of absence and is not present at the midnight census taking time. 
- Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal diagnosis in the appropriate 
form locator. The code must be reported according to Official ICD-CM Guidelines for Coding and 
Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including 
any applicable guidelines regarding the use of V codes for ICD-9. The code must be the full ICD-CM 
diagnosis code, including all five digits (for ICD-9) or all seven digits (for ICD-10) where applicable. 
- Other Diagnosis Codes Required - The SNF enters the full ICD-CM codes for up to eight additional 
conditions in the appropriate form locator. Medicare does not have any additional requirements 
regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines. 
 
You can find these rules in Medicare Claims Processing Manual Chapter 6, Section 30. 
 
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.