CurrentHighmark Blueshield NenyPolicy N/A

Long-Term Acute Care (LTAC) admission and continued-stay requirements

Defines clinical and documentation requirements for admission to and continued stay in LTAC facilities for Highmark BlueShield members, including specific respiratory, nursing, and review timeframes. Affects providers seeking authorization for LTAC care in Highmark's service area.

Policy Summary

PayerHighmark Blueshield Neny

PolicyLong-Term Acute Care (LTAC) admission and continued-stay requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit admission clinical reviews within 48 hours of the requested admission date and continued-stay requests within 24 hours from the last covered day.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48admission review timeframe (hrs)

24continued-stay timeframe (hrs)

dailymedical practitioner assessments

3x/24hrsrespiratory therapy frequency

6.5 hrsnursing hours (vent/complex)

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Admission and Continued-Stay Coverage Criteria

Covered when ALL of the following are met:

LTAC minimum clinical service levels: Patient receives at least daily medical practitioner assessment/intervention; ventilator (vent) patients receive respiratory therapy at least 3 times per 24 hours and receive at least 6.5 hours of nursing services daily; medically complex patients receive at least 6.5 hours of nursing services daily.see node text

If requirements are not met consider alternative level of care

Timely clinical review submission: Admission clinical reviews must be submitted within 48 hours of the requested admission date; continued-stay requests must be submitted within 24 hours from the last covered day.48 hours for admission; 24 hours for continued stay

Complete required LTAC form sections and clinical details: Provider must complete Parts One through Six of the LTAC form including: Part One — reason for stay (e.g., Medically Complex, Vent Management/Weaning, Wound/Skin); Part Two — prior level of function; Part Three — clinical review details (vitals, recent imaging, labs, IV medications, dialysis, nutrition); Part Four — respiratory therapy details (vent settings, weaning status, chest PT, breathing treatments/nebs); Part Five — rehabilitation therapy (PT/OT/Speech and frequencies); Part Six — discharge planning (anticipated LOS, tentative discharge plans, discharge barriers).see node text

Form sections listed in source document

If required minimum staffing or service levels for LTAC care are not met, consider an alternative level of care. The policy requires daily medical practitioner assessment/intervention for all LTAC patients. For patients who are ventilator-dependent, the facility must provide respiratory therapy at least 3 times per 24 hours and ensure at least 6.5 hours of nursing services daily. For medically complex patients (those with multiple active comorbidities or new functional impairment), the facility must ensure at least 6.5 hours of nursing services daily.

LTAC Admission Criteria

Admission staffing and service needs: Daily medical practitioner assessment/intervention is required. Ventilator patients require respiratory therapy ≥3× per 24 hours and at least 6.5 hours of nursing services daily. Medically complex patients require at least 6.5 hours of nursing services daily.

Reason for LTAC stay (document on Part One): Reason for stay documented as one or more of: Medically Complex; Vent Management/Weaning; Wound/Skin; or other specified reason listed on Part One of the LTAC form.

LTAC Continued-Stay Criteria

Continued stay submission timing: Continued-stay requests must be submitted within 24 hours from the last covered day.

Ongoing clinical documentation for continued stay: Provide updated clinical review information including ventilator/weaning status (vent settings, spontaneous breathing trial dates and tolerance), therapy tolerance and frequencies (PT/OT/Speech), vitals and recent imaging stability, relevant labs, IV medications and dialysis needs, nutrition status, wound status, and discharge planning updates.

Provider Submission and Documentation Requirements

Prior Authorization

Timing for Admission and Continued‑Stay Reviews

Clinical reviews for LTAC admissions and continued stays must be submitted within the timeframes below to avoid delays in authorization.

Admission clinical review: submit within 48 hours of the requested admission date.
Continued-stay clinical review: submit within 24 hours from the last covered day.

Denial Risk

Denial Risk for Unmet LTAC Requirements

Failure to meet minimum LTAC clinical and staffing requirements may result in denial of the LTAC level of care authorization. Confirm required daily practitioner assessments, nursing and respiratory service levels, and complete documentation before submission.

All LTAC patients require at least daily medical practitioner assessment/intervention.
Ventilator patients require respiratory therapy at least 3 times per 24 hours and at least 6.5 hours of nursing services daily.

Key Terms and Definitions

inv-08: Vent Management/Weaning

DefinitionVent Management/Weaning: care focused on patients requiring mechanical ventilatory support with active plans and interventions to reduce ventilator dependence and progress toward extubation or lower ventilator settings.

LTAC form referenceListed as a reason for LTAC stay on Part One: 'Vent Management/Weaning'.

Minimum service expectationsVentilator patients require respiratory therapy at least 3 times per 24 hours and at least 6.5 hours of nursing services daily.

inv-09: Medically Complex

DefinitionMedically Complex: patients with multiple active comorbid conditions or new functional impairment requiring prolonged acute services and enhanced clinical support.

LTAC form reference

Background

Long-term acute care (LTAC) facilities provide prolonged acute-level services for patients who require extended management such as ventilator dependence, complex wound care, or multiple comorbid conditions. These settings must maintain adequate daily medical, nursing, and respiratory resources to support safe care and potential ventilator weaning.

Discharge Criteria

Discharge planning must document the anticipated length of stay, a tentative discharge plan, and any additional information or identified discharge barriers that could affect transition from the LTAC setting.

Day Limits

inv-13: LTAC day limits

Day limits present in sourceNo explicit numeric day-limit for LTAC length of stay is specified in the LTAC day-limits section of the source.

Discharge planning expectationPart Six requires anticipated length of stay and discharge plan including tentative discharge and barriers to discharge.

Action when unspecifiedWhen no numeric day limit is provided, document anticipated length of stay on the LTAC form and follow clinical review timelines for continued stay requests.

Documentation Required

Required Documentation for LTAC Authorization

Complete and submit the LTAC authorization form with all applicable parts fully completed. Incomplete forms or missing clinical details will delay review and may risk denial.

Part One: Reason for LTAC Stay — specify primary reason (e.g., medically complex, ventilator management/weaning, wound/skin).
Part Two: Prior Level of Function — document baseline functional status prior to acute decline.
Part Three: Clinical Review — include recent clinical course, imaging/lab trends, active comorbidities, and submit within 48 hours of requested admission date.
Part Four: Respiratory Therapy — for ventilator patients provide vent settings, trach size and placement date (if applicable), weaning plan and SBT dates/tolerance.
Part Five: Rehabilitation Therapy — document PT/OT/SLP needs and frequency.
Part Six: Discharge Planning — include anticipated length of stay, tentative discharge destination, and discharge barriers.
Nursing section: include vitals, mental status/ability to follow commands, abnormal labs being monitored, continued IV meds (frequency and tentative stop dates), hemodialysis frequency (if applicable), nutrition support (NG/PEG/TPN details), and wound treatment details.
For vent-dependent patients: document at least 6 hours of ventilator dependence daily and active weaning plan; provide vent settings and any chest PT, breathing treatments, and therapy frequencies as applicable.