CurrentFallon HealthPolicy N/A

Short-Term Custodial and Long-Term Care Clinical Coverage Criteria

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Governs medical necessity, authorization, documentation, facility level of care, and billing requirements for Short-Term Custodial and Long-Term Care nursing facility services for eligible NaviCare members; Medicare-covered skilled nursing and skilled rehabilitation services are outside scope.

Policy Summary

PayerFallon Health

PolicyShort-Term Custodial and Long-Term Care Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 202622d

Next Review DateN/A

Key ActionObtain prior authorization before the first date of service for which Short-Term Custodial payment is sought.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered product

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CurrentFallon HealthPolicy N/A

Short-Term Custodial and Long-Term Care Clinical Coverage Criteria

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Know when Fallon Health releases new policies or updates existing guidance.

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Policy Summary

PayerFallon Health

PolicyShort-Term Custodial and Long-Term Care Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 202622d

Next Review DateN/A

Key ActionObtain prior authorization before the first date of service for which Short-Term Custodial payment is sought.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered product

2Authorization levels

Before serviceSTC authorization timing

AnnualLTC authorization cycle

6Medical necessity requirements

Medical Necessity and Coverage Criteria

General Medical Necessity Requirements

STC or LTC is medically necessary when all applicable benefit requirements are met and the clinical record supports all of the following:

General medical necessity requirements: The member meets applicable MassHealth nursing facility level-of-care requirements; has medical, functional, cognitive, behavioral health, environmental, or support needs that cannot be safely and adequately met in a less restrictive setting at the time of review; the requested nursing facility service is appropriate to the member’s individualized needs and is not duplicative of another covered service; available community-based services, informal supports, caregiver resources, housing, equipment, and environmental modifications have been considered, and any proposed alternative is available, appropriate, sufficient, consistent with the member’s preferences and person-centered care plan, and capable of safely meeting the assessed need; current clinical and functional information supports the requested level and duration of care; and applicable PASRR requirements, including Level II review when required, are satisfied.All 6 requirements

A request may not be denied, reduced, suspended, or terminated solely because a less costly alternative exists. Any adverse determination must be based on individualized review.

Short-Term Custodial Criteria

STC is medically necessary when the General Medical Necessity Requirements are met and all of the following apply:

Short-Term Custodial criteria: The member requires nursing facility level of care but does not require Medicare-covered or other skilled nursing or skilled rehabilitation care; cannot be safely supported in the community at that time; has a time-limited custodial need with return to the community or transition to another appropriate setting or level of care reasonably anticipated; has a documented discharge or transition plan identifying the anticipated destination, barriers to discharge, services or supports needed for community return, responsible parties, and a reassessment date; and active discharge or transition planning continues throughout the STC stay.All 5 requirements

STC is not a required step before LTC, is not automatically authorized for a fixed maximum period, and must not be used solely to delay an appropriate LTC determination.

Continued Short-Term Custodial Care

Continued STC requires updated documentation demonstrating that all continued-stay requirements remain met.

Continued STC: Nursing facility level of care continues to be met; the need remains temporary; the member still cannot be safely supported in the community; and active discharge or transition planning is continuing.All 4 requirements

A change from STC to LTC requires notification to and authorization by Fallon Health before LTC services are billed.

Long-Term Care Criteria

LTC is medically necessary when the General Medical Necessity Requirements are met and all of the following apply:

Long-Term Care criteria: The member requires ongoing nursing facility level of care; the need for custodial nursing facility care is expected to be ongoing rather than temporary; community-based services, informal supports, caregiver resources, housing, equipment, environmental modifications, and other available alternatives cannot safely and adequately meet the member’s assessed needs; and nursing facility placement is the least restrictive available setting capable of safely meeting the member’s current needs.All 4 requirements

A member may be admitted directly to LTC when these requirements are met. Prior STC placement is not required.

Short-Term Custodial Versus Long-Term Care Authorization

Authorization is based on individualized nursing facility level-of-care review.

Authorized level of care

Short-Term Custodial: The member requires a temporary custodial nursing facility stay, with a discharge or transition plan and active discharge planning.
Long-Term Care: The member requires ongoing nursing facility residency meeting nursing facility level of care.
Direct admission to LTC may be appropriate when supported by individualized review.

STC or LTC is excluded when the member requires skilled nursing or skilled rehabilitation care, does not meet applicable nursing facility level-of-care requirements, can be safely and adequately supported in a less restrictive setting, or the requested service is solely for convenience, housing, or unrelated supervision.

STC is excluded when the custodial need is not temporary or when there is no documented and active discharge or transition plan. The plan must address the anticipated destination, barriers, needed services or supports, responsible parties, and reassessment date, with planning continuing throughout the stay.

Services are excluded when they duplicate another covered service or are not included in the member’s benefit.

Medicare-covered skilled nursing and skilled rehabilitation services are outside the scope of these criteria and must be reviewed under applicable Medicare requirements and Fallon Health Skilled Nursing Facility Clinical Coverage Criteria.

This policy addresses custodial nursing facility level of care, not Medicare-covered skilled services. STC applies when nursing facility level of care is required but Medicare-covered or other skilled nursing or skilled rehabilitation care is not required; LTC addresses ongoing custodial nursing facility residency meeting nursing facility level of care. Authorization identifies the approved custodial level of care, while Medicare-covered skilled services are reviewed separately.

Nursing facility services are not medically necessary when the member can be safely and adequately supported in a less restrictive setting using available and appropriate services and supports. The determination must reflect the member’s individualized current needs; the existence of a less costly alternative alone is not sufficient for denial or reduction.

STC is not medically necessary when the custodial need is not temporary or when active discharge or transition planning is absent. Continued STC requires ongoing nursing facility level of care, a temporary need, inability to safely support the member in the community, and continued active planning supported by updated documentation.

Billing and Coding

Revenue CodesRevenue

0022	HIPPS (Health Insurance Prospective Payment System) code
0100	Room and Board
0183	Non-Medical Leave of Absence Days
0185	Medical Leave of Absence Days

NaviCare Nursing Facility Add-On HCPCS CodesHCPCSCovered

S0310	Bariatric Add-on
S0311	Homelessness Add-on
S0315	Enhanced Temporary Resident Add-on
S0316	Temporary Resident Add-on
S0317	Medicaid Transitional Add-on
S0320	Substance Use Disorder Induction Add-on
S0340	Behavioral Indicator Add-on
S0341	Substance Use Disorder Add-on
S0342	Tracheostomy Add-on
S0353	Home Dialysis in a Nursing Facility Setting (Medicaid Secondary Payer)

1–10 of 13

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Authorization, Documentation, and Payment Requirements

Prior Authorization

STC Prior Authorization Required Before Service

Obtain Fallon Health prior authorization for Short-Term Custodial (STC) services before the first date of service for which payment is sought.

Prior Authorization

Initial, Annual, and Event-Based LTC Authorization

For Long-Term Care (LTC), obtain initial and annual prior authorization. Submit a new authorization request when the member changes level of care, transfers to another nursing facility, or when otherwise required by Fallon Health or applicable MassHealth requirements.

Effective December 1, 2026, initial and annual LTC authorization are required unless otherwise directed by Fallon Health or applicable law.

Prior Authorization

Authorize STC-to-LTC Conversion Before Billing

Policy Context

Short-Term Custodial (STC) and Long-Term Care (LTC) are non-skilled nursing facility services for members who meet nursing facility level-of-care requirements and cannot be safely and adequately supported in a less restrictive setting. STC is temporary custodial care with an anticipated discharge or transition, while LTC is ongoing custodial nursing facility care. Medicare-covered skilled nursing and skilled rehabilitation services are reviewed separately.

Key Definitions

Short-Term Custodial (STC)

Service typeTemporary custodial nursing facility care

DurationTemporary care

Planning requirementDocumented reassessment and discharge or transition plan

Long-Term Care (LTC)

Service typeOngoing custodial nursing facility care

Expected needThe need for institutional care is expected to continue

Care classificationLong-term care

Admission Criteria

SNF Admission Criteria: Short-Term Custodial Care

For SNF admission associated with STC, all of the following must be met:

STC admission: Nursing facility level of care is required; skilled nursing or skilled rehabilitation is not required; the member cannot be safely supported in the community; the custodial need is time-limited; a documented discharge or transition plan is in place; and active transition planning will continue.All criteria

STC is not required before LTC.

SNF Admission Criteria: Long-Term Care

For SNF admission associated with LTC, all of the following must be met:

LTC admission: Ongoing nursing facility level of care is required; custodial need is expected to continue; available community alternatives cannot safely and adequately meet the member’s assessed needs; and nursing facility placement is the least restrictive available setting.All criteria

Continued Stay Criteria

SNF Continued-Stay Criteria: Continued Short-Term Custodial Care

Continued STC requires updated documentation demonstrating that all of the following remain met:

Continued STC stay: Nursing facility level of care continues; the need remains temporary; the member cannot be safely supported in the community; and active discharge or transition planning continues.All criteria

A change from STC to LTC requires Fallon notification and authorization before LTC billing.

SNF Continued-Stay Criteria: Long-Term Care Documentation and Authorization

Continued LTC eligibility requires all of the following:

Continued LTC eligibility: The member continues to require ongoing nursing facility level of care, and available alternatives cannot safely and adequately meet current needs. Current MDS information and other requested documentation must support continued eligibility.

Discharge and Transition Criteria

For STC discharge or transition, the plan must identify the anticipated destination, barriers to discharge, services or supports needed for community return, responsible parties, and a reassessment date. Active planning must continue throughout the stay, and continued requests must document progress toward goals, remaining barriers, actions being taken, required supports, and the updated reassessment date. A fixed maximum STC period is not specified.

LTC represents ongoing nursing facility residency when the need for custodial care is expected to continue. Facilities must provide required admission, discharge, assessment, and status-change documentation to EOHHS and Fallon Health within the required form and timeframe, including current MDS information and other requested records to support continued eligibility and payment review.

Policy Summary

PayerFallon Health

PolicyShort-Term Custodial and Long-Term Care Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 202622d

Next Review DateN/A

Key ActionObtain prior authorization before the first date of service for which Short-Term Custodial payment is sought.

SourceLink

On This Page

Notify Fallon Health and obtain authorization before changing the member from STC to LTC or billing LTC services.

Prior Authorization

Authorize the Applicable Level of Care

Obtain authorization for the applicable level of care—STC or LTC. Authorization establishes the approved level of care but does not guarantee payment.

STC is a temporary custodial nursing facility stay with a discharge or transition plan.
LTC is an ongoing nursing facility residency meeting nursing facility level-of-care requirements.

Documentation Required

Initial STC Request Documentation

Submit documentation sufficient to establish clinical eligibility and the planned duration of the initial STC stay.

Physician or referring provider order or request and clinical documentation supporting nursing facility level of care.
Current facility care plan, relevant hospital or provider records, and recent clinical notes.
PASRR documentation, including Level II information when required.
Available alternatives to institutionalization and why they are inadequate.
Anticipated discharge destination, discharge barriers, needed community services or supports, responsible parties, and reassessment date.
SC-1 and other applicable MassHealth forms or eligibility documentation.

Documentation Required

Continued STC Request Documentation

For continued STC authorization, provide current evidence that nursing facility level of care remains necessary, the need remains temporary, community support remains unsafe or inadequate, and transition planning is active.

Current clinical and functional documentation supporting continued level of care.
Updated facility care plan and progress toward established goals.
Community alternatives considered and why they remain insufficient.
Updated discharge or transition plan identifying disposition, barriers, actions, required services and supports, responsible parties, and reassessment date.
Continued STC will not be authorized solely because the member remains in the facility or to delay an appropriate transition to LTC.

Documentation Required

LTC Facility Documentation

Complete and submit required LTC admission, discharge, assessment, and status-change documentation to EOHHS and Fallon Health in the required form and timeframe.

Provide current MDS information and other requested records supporting continued eligibility, care management, payment integrity, audit, or institutional rating-category reconciliation.
Routine contracted-provider LTC authorization requests do not require submission of a HIPPS code.

Billing Rule

Support Authorization and Claims

Maintain documentation supporting the authorized level of care and ensure claims satisfy all applicable payment requirements.

Retain records supporting the level of care, authorized dates, and authorized level.
Use accurate coding and provide accepted MDS/HIPPS support when applicable.
Apply member eligibility, MassHealth requirements, and provider-agreement requirements to every claim.

Documentation Required

Document Discharge Planning for STC

Maintain an active discharge or transition plan for every STC stay and document progress toward an appropriate community disposition or other transition.

Identify anticipated disposition, barriers, actions being taken, required services and supports, responsible parties, and reassessment date.

Denial Risk

Ineligible Level of Care or Alternative Setting Available

STC or LTC may be denied when the member requires skilled nursing or skilled rehabilitation care, does not meet nursing facility level-of-care requirements, or can be safely and adequately supported in a less restrictive setting with available and appropriate services and supports.

Community alternatives, informal supports, housing, equipment, and environmental modifications must be considered and be appropriate, sufficient, available, consistent with the member’s preferences and person-centered care plan, and capable of safely meeting the assessed need.

Denial Risk

STC Must Be Temporary and Transition-Focused

STC is not medically necessary when the need is not temporary or there is no active discharge or transition plan. Continued STC cannot be used solely because the member remains in the facility or to delay an appropriate transition to LTC.

Denial Risk

Duplicative or Noncovered Service

Coverage may be denied when the requested service is solely for convenience, housing, or unrelated supervision, duplicates another covered service, or is not included in the member’s benefit.

Note

Individualized Review Required

Any adverse determination must be based on an individualized review of the member’s current needs and applicable benefit and MassHealth requirements; it may not rely solely on the existence of a less costly alternative.

Consider the member’s clinical, functional, cognitive, behavioral health, environmental, and support needs.
The determination must be consistent with applicable law and the member’s person-centered care plan and preferences.

Billing Rule

Authorization Does Not Guarantee Payment

Authorization of STC or LTC establishes the approved level of care but does not guarantee payment. Claims remain subject to eligibility, authorized dates and level of care, coding, MDS/HIPPS support when applicable, MassHealth requirements, and the provider agreement.

Authorization level of care

MeaningThe approved level of care established by Fallon authorization

Payment statusAuthorization does not guarantee payment

Claims conditionsClaims remain subject to member eligibility, authorized dates and level of care, accurate coding, accepted MDS/HIPPS support when applicable, MassHealth requirements, and the provider agreement

Non-medical leave of absence

Type of absenceTemporary absence for non-medical reasons

Qualifying leave dayA continuous 24-hour period

Less-than-24-hour absenceAn absence of less than 24 hours is not a leave day

Medical leave of absence

Type of stayInpatient hospital or observation stay

Affected individualA nursing facility resident

Leave classificationMedical leave of absence

Short-Term Custodial (STC)

Stay typeTemporary custodial nursing facility stay

Care classificationShort-Term Custodial (STC)

Planning requirementDischarge or transition plan

Long-Term Care (LTC)

Residency typeOngoing nursing facility residency

Care classificationLong-Term Care (LTC)

Level-of-care requirementMeeting nursing facility level of care

Direct LTC admission is permitted without prior STC.

SNF Admission Criteria: Authorized Level of Care and Transition Planning

SNF authorization is based on individualized review of the applicable nursing facility level of care:

Nursing facility level of care

Short-Term Custodial admission: The member requires a temporary custodial nursing facility stay with a discharge or transition plan.
Long-Term Care admission: The member requires ongoing nursing facility residency meeting nursing facility level of care.
Direct admission to Long-Term Care may be appropriate when supported by individualized review.

Annual renewal is required before the current authorization expires. Required admission, discharge, assessment, and status-change documentation must be submitted to EOHHS and Fallon Health in the required form and timeframe.

SNF Continued-Stay Criteria: Authorized Level of Care and Payment Requirements

A continued SNF stay must meet all of the following authorized level-of-care and payment-related requirements:

Continued authorized stay: The stay remains within the authorized dates and authorized level of care and continues to meet the applicable nursing facility level-of-care requirements.All criteria

Authorization does not guarantee payment. Claims remain subject to member eligibility, accurate coding, accepted MDS/HIPPS support when applicable, MassHealth requirements, and the provider agreement.