CurrentBlue Cross Blue Shield - MinnesotaPolicy N/A

Long Term Acute Care (LTAC) Pre-Admission Evaluation — Coverage Criteria

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.

Policy Summary

PayerBlue Cross Blue Shield - Minnesota

PolicyLong Term Acute Care (LTAC) Pre-Admission Evaluation — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed LTAC pre-admission evaluation and required H&P to Blue Cross Blue Shield or call the listed precertification number to obtain precertification.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax or callprecertification contact methods provided

6InterQual admission criteria subsets listed

10+clinical data fields requested

Coverage and Medical Necessity Criteria

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Core documentation: Completed pre-admission evaluation form faxed to Blue Cross with H&P, primary and secondary diagnoses, anticipated LOS, planned treatment interventions, and discharge plan details.

References chunks 0,1,4

InterQual clinical match: Patient meets one or more InterQual Admission Criteria subsets relevant to LTAC (CVPV, Infectious Disease, Medically Complex, Respiratory Complex, Vent Weaning, Wound/Skin).

Chunk 3

Respiratory support need: Patient requires complex respiratory support such as ventilator dependence or ventilator weaning, BiPAP with documented settings, or high oxygen/FiO2 needs with ABG data and radiology support.

Chunk 5

Other complex needs: Patient requires IV therapy, wound care, specialized nutrition, dialysis catheter/CVPV, telemetry, or other specialty needs requiring LTAC-level care.

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.

LTACH Admission Criteria

LTACH

LTACH admission requires both administrative/identifying documentation and demonstrated clinical need for LTAC-level services:

Admission packet: Completed facility and patient identifiers, payer/contract info, referring physician and hospital contact, anticipated LOS, and documentation that LTAC referral was discussed with patient/caregiver.

Chunks 1,0

Clinical need: Demonstrated need for LTAC-level services: ventilator/respiratory complexity, IV therapy, wound care, nutrition support, rehab or other specialty needs; supported by H&P, current respiratory data (ABGs, ventilator settings), lines/devices and InterQual subset selection.

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:

Ongoing need for LTAC-level care: Continued ventilator weaning attempts documented with tolerance and number of attempts, ongoing need for IV therapies/wound care/complex medical monitoring, and reassessment against InterQual criteria for continued stay.

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

Prior Authorization

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

Documentation Required

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

Note

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

Documentation Required

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)

Documentation Required

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

InterQual® Admission Criteria subsets — definition of the InterQual subsets referenced for admission decisions

DefinitionInterQual® Admission Criteria subsets are structured clinical criteria used to determine appropriateness of admission for categories relevant to LTAC level of care.

Listed subsetsCVPV; Infectious Disease; Medically Complex; Respiratory Complex; Vent Weaning; Wound/Skin.

PurposeUsed to identify which clinical pathway(s) the patient meets to support medical necessity for LTAC admission.

How referenced on formProviders are instructed to 'Check applicable subset' on the pre-admission evaluation to indicate the InterQual pathway(s) that apply.

Use in decisionsSelection of one or more InterQual subsets, combined with required clinical documentation, supports the admission medical necessity determination.

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.

Policy Summary

PayerBlue Cross Blue Shield - Minnesota

PolicyLong Term Acute Care (LTAC) Pre-Admission Evaluation — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed LTAC pre-admission evaluation and required H&P to Blue Cross Blue Shield or call the listed precertification number to obtain precertification.

SourceLink

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