CurrentBlue Cross Complete of MichiganPolicy N/A

2026 Blue Cross and BCN Local Rules for Post-Acute Care

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Establishes Local Rules modifying InterQual criteria for skilled nursing facility, rehabilitation, and long-term acute care requests for commercial members in Michigan.

Policy Summary

PayerBlue Cross Complete of Michigan

Policy2026 Blue Cross and BCN Local Rules for Post-Acute Care

Policy CodePolicy N/A

Change TypeRevised

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionDocument discharge planning at admission, including goals, an estimated timeframe, the proposed next-level setting, and required services or support.

SourceLink

POLICY UPDATE CHANGES

Effective June 1, 2026, the listed Blue Cross and BCN Local Rules replace all previous modifications and InterQual criteria for these post-acute care settings.

06/01/26Effective date

3Contracted SNFs assessed before certain LTACH admissions

75 miMaximum SNF assessment distance

POD 3Earliest specified post-arthroplasty admission

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CurrentBlue Cross Complete of MichiganPolicy N/A

2026 Blue Cross and BCN Local Rules for Post-Acute Care

Customize your policy alerts

Sign up for all blue_cross_complete_of_michigan policy alerts

Know when blue_cross_complete_of_michigan releases new policies or updates existing guidance.

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Establishes Local Rules modifying InterQual criteria for skilled nursing facility, rehabilitation, and long-term acute care requests for commercial members in Michigan.

Policy Summary

PayerBlue Cross Complete of Michigan

Policy2026 Blue Cross and BCN Local Rules for Post-Acute Care

Policy CodePolicy N/A

Change TypeRevised

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionDocument discharge planning at admission, including goals, an estimated timeframe, the proposed next-level setting, and required services or support.

SourceLink

POLICY UPDATE CHANGES

Effective June 1, 2026, the listed Blue Cross and BCN Local Rules replace all previous modifications and InterQual criteria for these post-acute care settings.

06/01/26Effective date

3Contracted SNFs assessed before certain LTACH admissions

75 miMaximum SNF assessment distance

POD 3Earliest specified post-arthroplasty admission

4x/24hMinimum suctioning or new nebulizer frequency

2x/24hMinimum oxygen assessment frequency

Facility Coverage Criteria

Skilled Nursing Facility

SNF therapy and skilled nursing requests are subject to the following requirements and medical director review triggers.

SNF mobility and service requirements: SNF therapy must address a required mobility impairment involving transfers, walking, or wheelchair mobility, and must not be limited to eating, toileting hygiene, stair negotiation without stairs at home, stand-alone OT, RT, ST, swallowing, language, or cognitive therapy, or lower-level PT services such as balance, endurance, range-of-motion, self-care, or strengthening.

Lower-level care may include home health with family support or outpatient care.

Complex skilled nursing: When complex skilled nursing alone is requested, documentation must establish that care cannot safely be provided at home, in an outpatient setting, or in a long-term care facility, including applicable caregiver or home-health limitations and selected service-frequency or new-service requirements.IV or IM medication management at least twice daily or at least two IV or IM medications daily; suprapubic catheter management must be new; nasopharyngeal or tracheostomy suctioning at least 4 times per 24 hours; new nebulizer treatment at least 4 times per 24 hours; oxygen therapy requiring assessment and adjustments at least twice per 24 hours.

Continued stay and transition: Continued-stay documentation must support ongoing need and include discharge planning initiated at admission with reasonable goals, an estimated timeframe, the proposed next-level setting, and required services or support.

Improvement to contact guard assistance, stand-by assistance, supervision, modified independent, or independent in most areas indicates that rehabilitation potential has been maximized for the setting and discharge is expected.

Acute Rehabilitation

Acute rehabilitation admission and continued-stay requests are subject to the following criteria.

Rehabilitation admission: Admission must be supported by mobility or motor impairment and applicable condition-specific impairment criteria. Brain injury admissions require a brain-injury severity classification tool score demonstrating rehabilitation potential.

ADL, cognitive, or respiratory impairment alone does not satisfy the mobility or motor impairment requirement.

Required therapy: Acute rehabilitation requires both physical and occupational therapy. Requests supported only by occupational therapy plus speech-language pathology or prosthetics/orthotics, or only by physical therapy plus speech-language pathology or prosthetics/orthotics, may be reviewed.

Subacute rehabilitation is evaluated under SNF criteria rather than acute rehabilitation criteria.

Continued stay requires measurable progress toward pre-established goals and sustained gains. New-onset medical instability that prevents participation or progress in therapy requires medical director evaluation.

Progress to contact guard assistance, stand-by assistance, supervision, modified independent, or independent in most areas indicates that rehabilitation potential has been maximized for the setting and discharge is expected.

Long-Term Acute Care

LTACH admission and continued-stay requests are subject to the following criteria.

LTACH placement: For admissions other than ventilator weaning, contracted SNF availability must be assessed before LTACH placement. Three contracted SNFs within 75 miles of the current hospital must be assessed and determined unable to provide the required care, including two facilities accepting members requiring high levels of care such as ventilators.

Pain management: When pain management or IV analgesic titration every 3–4 hours is used as a stand-alone criterion, an alternative pain-medication treatment plan is required.IV analgesic titration every 3–4 hours

Ventilator weaning: Ventilator-weaning requests must address sedation, prior acute-care weaning attempts, airway status, expected weaning potential, and whether care can safely be provided at home or at a lower level of care.

Review may be triggered by a continuous sedative infusion within 24 hours of admission, no acute-care weaning attempts when tracheostomy and airway stability are selected, or an endotracheal tube with failed weaning and ventilator dependence.

The Subacute Rehabilitation criteria subset is not used to evaluate acute rehabilitation requests. Subacute rehabilitation is evaluated under the Skilled Nursing Facility (SNF) level-of-care criteria instead.

Requests for cognitive rehabilitation, cognitive therapy, or disorders-of-consciousness programs for central nervous system disorders or traumatic brain injuries are restricted under the rehabilitation modifications and may be subject to medical director review.

Operational Thresholds and Timing Rules

IV or IM Medication Management

Minimum frequencyAt least twice daily

Alternative thresholdAt least two IV or IM medications daily

ServiceIV or IM medication management

Nasopharyngeal or Tracheostomy Suctioning

Minimum frequencyAt least 4 times per 24 hours

ServiceNasopharyngeal or tracheostomy suctioning

Applies toSelected complex skilled nursing criteria

Provider Review and Documentation Requirements

Prior Authorization

Medical Director Review Required

A Blue Cross or BCN medical director reviews requests for SNF therapy, rehabilitation, and LTACH services identified in these criteria, including admissions and continued stays where specified.

Apply medical-director review requirements to the affected SNF, acute rehabilitation, subacute rehabilitation, and LTACH requests.

Documentation Required

SNF Admission and Skilled-Care Documentation

For SNF admission and continued-stay requests, document the required mobility impairment, why a lower level of care is unsafe or insufficient when applicable, and the skilled-care services supporting the request.

Required mobility impairments include transfers, walking, or wheelchair mobility.
Document why care cannot be safely provided at home, in an outpatient setting, or in a long-term care facility when complex skilled nursing is requested.

Policy Background

The Local Rules modify InterQual criteria for skilled nursing, acute rehabilitation, and long-term acute care. Facility-level care must be supported by the applicable clinical need, such as mobility or motor impairment, skilled-service intensity, active rehabilitation potential, clinical instability, ventilator-weaning potential, or inability to provide care safely at a lower level. Discharge planning and transition to the next appropriate setting are required throughout post-acute care.

Admission Criteria by Facility Type

SNF Admission Criteria

Covered for SNF admission when all of the following are met:

SNF therapy admission: A required mobility impairment involving transfers, walking, or wheelchair mobility is present; requested therapy is not limited to lower-level or stand-alone services; and, when complex nursing is the only basis for admission, the requested skilled care cannot safely be provided at home, in an outpatient setting, or in a long-term care facility.

Applicable caregiver, home-health, and service-frequency limitations must be documented.

IRF Admission Criteria

Covered for acute rehabilitation admission when all of the following are met:

Acute rehabilitation admission: Mobility or motor impairment is present with applicable condition-specific criteria and rehabilitation potential. Brain injury requires a severity classification tool score demonstrating rehabilitation potential, and both physical and occupational therapy are required therapy disciplines.

ADL, cognitive, or respiratory impairment alone does not satisfy the mobility or motor impairment requirement. Subacute rehabilitation is evaluated under SNF criteria.

Continued-Stay Criteria by Facility Type

SNF Continued Stay Criteria

Continued SNF stay is supported when all of the following are met:

SNF continued stay: The required mobility or complex skilled-care need remains supported, lower-level care cannot safely meet the need when applicable, and discharge planning is complete and active.

Contact guard assistance, stand-by assistance, supervision, modified independent, or independent function in most areas indicates that rehabilitation potential has been maximized for the setting and discharge is expected.

IRF Continued Stay Criteria

Continued acute rehabilitation stay is supported when all of the following are met:

Rehabilitation continued stay: Measurable progress toward pre-established goals with sustained gains is documented. New-onset medical instability that prevents participation or progress in therapy requires medical director evaluation, and discharge planning includes an estimated timeframe, proposed next-level setting, and evaluation of necessary services or support.

Discharge planning must begin upon admission with reasonable goals for transition to the next level of care.

Discharge Planning and Discharge Criteria

For SNF, inpatient rehabilitation, and LTACH stays, discharge planning must begin at admission and include reasonable goals, an estimated discharge timeframe, the proposed next-level setting, and an evaluation of the services and support system needed after discharge. Continued-stay requests may be reviewed when these elements are incomplete or do not support a safe transition.

For SNF and inpatient rehabilitation, documented functional improvement to contact guard assistance, stand-by assistance, supervision, modified independent, or independent in most areas indicates a response to therapy and that rehabilitation potential may be maximized for the setting. When this level of function is reached, discharge is expected and the continued need for facility-based care should be reassessed.

Policy Summary

PayerBlue Cross Complete of Michigan

Policy2026 Blue Cross and BCN Local Rules for Post-Acute Care

Policy CodePolicy N/A

Change TypeRevised

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionDocument discharge planning at admission, including goals, an estimated timeframe, the proposed next-level setting, and required services or support.

SourceLink

On This Page

Comorbid-condition rehabilitation: Rehabilitation therapy for a comorbid condition requires physical therapy, a documented PT plan of care, and progress notes confirming functional improvement.

Occupational or speech therapy without physical therapy is insufficient.

Nebulizer Treatment

Treatment statusMust be new

Minimum frequencyAt least 4 times per 24 hours

ServiceNebulizer treatment

Oxygen Therapy Requiring Assessment and Adjustments

Minimum frequencyAt least twice per 24 hours

ServiceOxygen therapy requiring assessment and adjustments

Applies toSelected complex skilled nursing criteria

Post-Major-Joint-Arthroplasty Admission

Earliest admissionNo sooner than the third postoperative day

Excluded notesTherapy notes from the operative day and postoperative day 1 will not be accepted

ProcedureInpatient major joint arthroplasty

LTACH SNF Search

Required assessmentThree Blue Cross- or BCN-contracted SNFs

Maximum distanceWithin 75 miles of the member’s current hospital location

High-acuity requirementTwo of the three facilities must accept members requiring high levels of care, such as ventilators

Include the applicable skilled-care type, frequency, and supporting clinical documentation.

Documentation Required

Discharge Plan Documentation

Begin discharge planning at admission and establish reasonable goals for a successful transition. Continued-stay documentation must include the estimated timeframe, proposed next-level setting, and evaluation of necessary services or support after discharge.

Include an estimated discharge timeframe.
Identify the proposed setting for the next level of care.
Evaluate required services and caregiver or other support systems.

Documentation Required

Rehabilitation Progress and Therapy Documentation

Rehabilitation documentation must show measurable progress toward pre-established goals and sustained gains. Continued stays may require review when mobility is contact-guard assistance, stand-by assistance, supervision, modified independent, or independent in most areas.

Document measurable functional progress and sustained gains.
Explain ongoing rehabilitation potential and why continued treatment remains appropriate.
Improved mobility or function may indicate that discharge is expected.

Unsupported block type: documentation

Denial Risk

SNF Therapy Must Address Mobility

SNF therapy must address a required mobility impairment. A request identifying only eating, toileting hygiene, or stair negotiation as a change or decline is subject to medical-director review when there are no stairs at the home entry or within the home.

Required mobility impairments include transfers, walking, or wheelchair mobility.
Therapy limited to eating, toileting hygiene, or stair negotiation may be provided at home with home health and family support or in an outpatient setting.

Denial Risk

Stand-Alone Non-PT Therapy Is Insufficient

Physical therapy for the required mobility impairment is essential for SNF therapy services. Requests limited to OT, RT, ST, swallowing, language, cognitive training, or similar non-PT therapy are subject to review because the service may be provided at a lower level of care.

Stand-alone OT, RT, speech-language, swallowing, language, or cognitive therapy is insufficient for the SNF therapy criterion.
Consider home health with family support or outpatient care when the required mobility-focused PT is not present.

Denial Risk

Limited PT May Be Lower-Level Care

PT services limited to balance, endurance, range-of-motion, self-care, or strengthening exercises may be considered lower-level care rather than SNF-level therapy.

Balance training only
Endurance training only
Range-of-motion exercises only
Self-care training such as bathing, dressing, or personal hygiene only
Strengthening exercises only

Denial Risk

Functional Improvement May Require Discharge

For SNF continued stays, documented improvement and reduced limitations may show that the member has responded to therapy and that rehabilitation potential has been maximized for the setting. Discharge is expected when function is contact-guard assistance, stand-by assistance, supervision, modified independent, or independent in most areas.

Describe the remaining skilled need if these functional levels are documented.
Prepare discharge when improvement indicates the SNF level of care is no longer necessary.

Prior Authorization

Post-Arthroplasty Timing Restriction

Following an inpatient major joint arthroplasty, the SNF or rehabilitation admission date must be no sooner than the third postoperative day. Therapy notes from the operative day and postoperative day 1 will not be accepted.

Do not submit an admission earlier than postoperative day 3.
Do not rely on operative-day or postoperative-day-1 therapy notes for coverage support.

Documentation Required

Complex Skilled Nursing Requires Lower-Level-Care Exclusion

When complex skilled nursing is the only SNF criterion, document that the care cannot be safely provided at a lower level because of factors such as insufficient caregiver resources or an inability of home health to provide the required frequency.

Address home care, outpatient care, and long-term care alternatives.
Explain the specific safety, caregiver, or service-frequency limitation preventing lower-level care.

Documentation Required

SNF Skilled-Care Frequency Thresholds

For specified SNF skilled-care criteria, document the required frequency and whether the service is new when applicable.

IV or IM medication management: at least twice daily or at least two IV or IM medications daily.
Suprapubic catheter management: must be new.
Nasopharyngeal or tracheostomy suctioning: at least 4 times per 24 hours.
Nebulizer treatment: must be new and at least 4 times per 24 hours.
Oxygen therapy requiring assessment and adjustments: at least 2 times per 24 hours.

Denial Risk

Incomplete Discharge Planning Triggers Review

SNF continued-stay review may be triggered when discharge planning omits required elements. Planning must begin on admission and include reasonable goals to support transition to the next level of care.

Missing estimated timeframe
Missing proposed next-level setting
Missing evaluation of necessary services or support system
Missing admission-time goals or transition planning

Denial Risk

Rehabilitation Progress May Support Discharge

Rehabilitation progress can support discharge when measurable gains toward pre-established goals are sustained and mobility or function has improved. Continued stay must still explain why the member requires the current rehabilitation setting.

Review continued stay when the member is contact guard, stand-by assistance, supervised, modified independent, or independent in most areas.
Document ongoing deficits and rehabilitation potential when discharge is not yet appropriate.

Denial Risk

Required Rehabilitation Condition Criteria

Certain rehabilitation requests require additional condition-specific support and may be reviewed by a medical director when the selected condition does not meet the applicable criteria.

Myopathy selected under the Neuromuscular Disorder condition using the Medically Intensive subset requires review.
Brain Injury selected in the CNS/TBI subset requires brain-injury impairment criteria, including a severity-classification score demonstrating rehabilitation potential.

Denial Risk

Mobility or Motor Impairment Required

Mobility or motor impairment is required for rehabilitation admission. Selecting ADL, cognitive, or respiratory impairment without meeting mobility or motor impairment criteria is subject to medical-director review.

Do not rely solely on ADL impairment.
Do not rely solely on cognitive impairment.
Do not rely solely on respiratory impairment.

Prior Authorization

Medical Instability Requires Medical Director Evaluation

When new-onset medical instability prevents participation or progress in therapy, a medical director must evaluate whether the rehabilitation setting remains appropriate.

Document the new instability, its effect on therapy participation or progress, and the clinical rationale for the current setting.

Denial Risk

Acute Rehabilitation Requires PT and OT

Acute rehabilitation requires both physical therapy and occupational therapy. Requests indicating only OT plus speech-language pathology or prosthetics/orthotics, or only PT plus speech-language pathology or prosthetics/orthotics, are subject to review.

Include a PT plan and an OT plan for acute rehabilitation.
OT-only combinations do not satisfy the requirement for both PT and OT.
PT-only combinations do not satisfy the requirement for both PT and OT.

Note

Subacute Rehabilitation Uses SNF Criteria

The Subacute Rehabilitation level-of-care subset is excluded when evaluating acute rehabilitation. Subacute rehabilitation is captured through the Skilled Nursing level-of-care criteria.

Evaluate subacute rehabilitation requests under SNF criteria rather than acute rehabilitation criteria.

Denial Risk

Specified Cognitive Programs Are Restricted

Requests for cognitive rehabilitation, cognitive therapy, or disorders-of-consciousness programs for central nervous system disorders or traumatic brain injuries are subject to medical-director review.

Identify the specific program and clinical indication.
Do not assume these programs meet acute rehabilitation criteria without the applicable review.

Prior Authorization

LTACH Requires Contracted-SNF Assessment

LTACH admissions that are not for ventilator weaning require an assessment by three Blue Cross- or BCN-contracted SNFs within 75 miles of the current hospital. Placement may proceed for review when the facilities cannot provide the required level of care.

Two of the three contacted facilities must be identified as accepting members requiring high levels of care, such as ventilators.
The contracted-SNF assessment requirement excludes ventilator-weaning admissions.

Documentation Required

Alternative Pain Plan Required

For LTACH admissions or continued stays using stand-alone pain management or IV analgesic titration every 3–4 hours, documentation must include an alternative pain medication treatment plan.

Apply when pain management is a stand-alone criterion.
Apply when IV analgesic titration every 3–4 hours is a stand-alone criterion.

Prior Authorization

Ventilator-Weaning Readiness Requirements

LTACH ventilator-weaning admissions require documentation supporting readiness and appropriate prior attempts. A continuous sedative infusion within 24 hours of admission, no acute-setting weaning attempts when the airway is stable after tracheostomy, or an endotracheal tube with failed-weaning and ventilator-dependence criteria may trigger review.

A weaning trial may not be appropriate while continuous sedation is being administered.
When a tracheostomy is placed and the airway is stable, document acute-setting weaning attempts; weaning may not be necessary at LTACH if none were attempted.
When the member has an endotracheal tube and failed ventilator-weaning criteria, tracheostomy placement is preferred to facilitate ventilator removal and reduce respiratory complications.

Documentation Required

LTACH Comorbidity Rehabilitation Requires PT

When LTACH rehabilitation is used to treat a comorbid condition, physical therapy is required and the record must demonstrate an active, improving therapy plan.

A plan consisting only of OT or speech therapy without PT does not meet the rehabilitation requirement.
Include a documented PT plan of care.
For continued stays, include PT progress notes confirming functional improvement.

Documentation Required

LTACH Discharge Planning Documentation

LTACH continued-stay requests must include an estimated timeframe, proposed next-level setting, and evaluation of necessary services or support. Begin discharge planning on admission and establish reasonable transition goals.

Missing timeframe, next setting, services, support-system evaluation, or admission-time goals may trigger review.

Denial Risk

Ventilator-Weaning Continued Stay Requires Potential

For ventilator-weaning continued stays, document a reasonable expectation and timeframe for weaning potential and explain why care cannot safely be provided at home or at a lower level such as SNF or long-term care.

No changes in ventilator or NIPPV settings may indicate permanent dependence and clinical stability for transfer or discharge to a lower level of care.
Unable to liberate from mechanical ventilation or NIPPV may indicate appropriateness for an alternative level of care or palliative care.
Address caregiver resources and the ability of lower-level facilities to safely provide care.

LTACH Admission Criteria

Covered for LTACH admission when all of the following are met:

LTACH admission: For non-ventilator-weaning admissions, three contracted SNFs within 75 miles of the current hospital are assessed and determined unable to provide the required care, including two facilities accepting members requiring high levels of care. When pain management or IV analgesic titration every 3–4 hours is used as a stand-alone criterion, an alternative pain treatment plan is documented.Three contracted SNFs within 75 miles; two high-acuity facilities

Ventilator-weaning admissions have additional sedation, airway, and prior-weaning requirements.

LTACH Continued Stay Criteria

Continued LTACH stay is supported when all of the following are met:

LTACH continued stay: An active medical or rehabilitation need remains supported, required physical therapy and functional progress are documented when rehabilitation is used for a comorbidity, and discharge planning includes an estimated timeframe, proposed next-level setting, and evaluation of necessary services or support. When ventilator weaning is requested, documentation includes a reasonable expectation and timeframe for weaning and explains why care cannot safely be provided at home or at a lower level such as SNF or long-term care.

No ventilator or NIPPV setting changes, or inability to liberate from mechanical ventilation or NIPPV, may indicate stability for transfer, discharge to an alternative level of care, or palliative care.