Long Term Acute Care (LTAC) Pre-Admission Evaluation — Coverage Criteria
Customize your policy alerts
Sign up for all blue cross blue shield - minnesota policy alerts
Know when blue cross blue shield - minnesota releases new policies or updates existing guidance.
Monitor payer policy activity
Governs the information and documentation required to request precertification and admission evaluation to a Long Term Acute Care (LTAC) facility for Blue Cross Blue Shield - Minnesota members. Affects referring hospitals, physicians, LTAC facilities, and care coordinators completing pre-admission paperwork.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Admission medical necessity criteria
Admission supported when documentation demonstrates need for LTAC-level services and matches an InterQual subset:
References chunks 0,1,4
Chunk 3
Chunk 5
Chunks 2,5
The pre-admission form contains standard facility, patient, referral, and clinical fields but does not list any explicit clinical exclusions that would automatically disqualify a patient from LTAC consideration. The form focuses on gathering identifying, payer, and clinical details needed for evaluation rather than enumerating exclusionary diagnoses or conditions.
The document does not specify conditions labeled as ‘not medically necessary’. It is structured to collect clinical information to support medical necessity determinations (diagnoses, anticipated LOS, treatment needs) but contains no section that lists or defines services or diagnoses as not medically necessary.
LTACH Admission Criteria
LTACH
LTACH admission requires both administrative/identifying documentation and demonstrated clinical need for LTAC-level services:
Chunks 1,0
Chunks 4,5,2,3
Criteria for Continued Stay
LTACH continued stay criteria
Continued LTACH stay is supported when documentation shows ongoing need for LTAC-level care and reassessment against InterQual criteria:
Chunks 5,3
Discharge Criteria
Discharge criteria on the form require documentation of the intended discharge destination and completion of discharge planning. The form requests selection of a discharge destination (e.g., Home, Home Health, Inpatient Rehab, SNF, LTC, Hospice), prior living arrangements, and home DME needs, indicating discharge planning must be documented prior to LTACH discharge.
Precertification and Provider Documentation Requirements
Precertification submission
Please fax the LTAC Pre-Admission Evaluation form to the patient's Care Coordinator at Blue Cross and Blue Shield for precertification. Fax: 1-833-719-1602. Phone (precertification): 1-833-749-1967. Failure to submit the completed form to the Care Coordinator or to the listed precertification contact may result in denial or delay of authorization.
- Fax: 1-833-719-1602
- Phone: 1-833-749-1967
Treatment and criteria documentation
Document the planned treatment interventions and check all applicable InterQual admission subsets. Include specific physician orders and the expected plan of care to support medical necessity.
- Planned Treatment Intervention (document specific physician's orders): Ventilator weaning; Oxygen; IV therapy; Medications; Wound care; Nutrition; Rehab therapy; Specialty needs (DME, Hemodialysis, Telemetry, etc.)
- InterQual® Admission Criteria: Check applicable subset(s): CVPV; Infectious Disease; Medically Complex; Respiratory Complex; Vent Weaning; Wound/Skin
Discharge planning and supports
Include the LTAC discharge plan and prior living arrangements to support level-of-care decisions. Provide details for discharge destination, home DME needs, and number of steps/ramps if returning home.
- Discharge Destination (select): Home; Home Health; Assisted Living Facility; Inpatient Rehab; SNF; LTC; Hospice
- Prior living arrangements and Home DME (e.g., wheelchair, hospital bed, assistive devices)
- House/Apartment levels and entrance/inside steps and ramps — document counts
Required clinical documentation
Ensure required clinical documentation is attached to the faxed request: History & Physical (H&P), current diagnoses, surgeries during this admission, prior and current functional status, and any pertinent lab or imaging results.
- History & Physical (H&P) — please fax with request
- Primary acute diagnosis and surgeries this admission
- Prior level of function and current level of function
- Relevant labs and imaging (e.g., current ABGs, CXR)
Respiratory documentation
Provide complete respiratory documentation when respiratory support or evaluation is part of the request. Include current device use, ventilator/BiPAP settings, weaning attempts and tolerance, arterial blood gas results, chest x-ray information, and airway status (intubated, ET tube, tracheostomy).
- Respiratory device status: Oxygen (home O2), nasal cannula (L/min), mask (%), Ventilator, BiPAP
- Ventilator settings: Mode; Rate; Tidal volume (TV); PEEP; FiO2; Pressure support (PS)
- Weaning: Tolerating weaning attempts? Yes/No and number of attempts
- Current ABGs: pH; PCO2; HCO3; PO2; SaO2
- Current CXR: Date and results
- Airway/lines: Intubated; ET tube; Tracheostomy (include date); Chest tube; Drainage devices; Dialysis catheter; CVPV; Telemetry
Key Definitions
Background
LTAC admission evaluations collect information intended to demonstrate the need for prolonged acute-level care. The form emphasizes gathering the current hospitalization history (H&P, primary diagnosis, surgeries), respiratory parameters and device status, planned treatment interventions (ventilator weaning, IV therapy, wound care, nutrition, rehabilitation), and selection of an applicable InterQual® Admission Criteria subset to support appropriateness for LTAC-level services.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.