CurrentHighmark Blueshield NenyPolicy N/A

Medicare Skilled Nursing Facility Inpatient Continued Stay Review - Coverage Criteria

Administrative and clinical guidance for reviewing and documenting continued inpatient skilled nursing facility (SNF) stays for Medicare members; intended for providers submitting continued stay reviews to Highmark BlueShield NENY for SNF admissions and ongoing authorization.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedicare Skilled Nursing Facility Inpatient Continued Stay Review - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete all sections of the continued-stay form and fax clinical review materials within 24 hours of the requested admit date to 1-800-416-9195.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursclinical reviews must be submitted within

Sections 1-8form sections required to be completed

1-800-416-9195submission fax number

Medicare Ch.8governing guidance source

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Continued Stay Medical Necessity Criteria

Continued SNF inpatient stay should be supported when ALL of the following are documented:

Clinical submission timing: Clinical reviews and required form sections submitted within 24 hours of requested admit date24 hours

Requirement to submit clinical reviews within 24 hours is stated on the form

Completed form sections: Sections 1–8 of the continued-stay form completed, including demographic information, prior level of function (PLOF), clinical review, PT/OT/ST, discharge plan, and PHI acknowledgmentsSections 1-8

Form instructions list Sections 1–8 to be completed

Medical necessity for skilled care: Documentation demonstrates medical complexity requiring frequent medical assessment or intense monitoring with potential for rapid deterioration, or that the home setting is unsafemedical complexity present

Reason for skilled stay field queries frequent assessment, intense monitoring, or home unsafe

Therapy tolerance and participation: Member can tolerate and is participating in therapy when therapy is the basis for skilled care (e.g., able to tolerate one hour of therapy 5 days per week) and participation status for PT/OT/ST is documentedtherapy tolerance documented

Form asks specifically about ability to tolerate one hour of therapy 5 days/week and participation

Functional status and goals documented: Prior Level of Function (PLOF) and current mobility (bed mobility, transfers, sitting/standing balance, gait), ADLs, cognition, and therapy goals are documented to support need for skilled servicesPLOF and therapy goals included

PLOF section and detailed mobility/function fields present in form

Specific skilled treatments documented when applicable: When present, provide details of skilled treatments: IV medication name/frequency/stop date; respiratory support (oxygen flow, trach details, suction frequency, nebulizer use and goals); enteral/TPN specifics; wound stage/treatment/measurement and dressing frequencytreatment specifics documented

Clinical review section requests specifics for IV meds, respiratory, nutrition, TPN, and wound care

The continued-stay form does not list any explicit blanket exclusions. However, continued SNF-level coverage is contingent on documentation demonstrating the need for skilled services. In practice, stays will not be appropriate when the record fails to show a reason for skilled care (for example, no medical complexity requiring frequent assessment or intense monitoring) or when the member cannot tolerate or participate in skilled therapy if therapy is the basis for the stay. Absent those documented needs, the request for continued SNF inpatient care may not meet coverage criteria.

A continued SNF stay will be considered not medically necessary when the submitted documentation does not demonstrate the reasons for skilled care. Examples include failure to show medical complexity that requires frequent medical assessment or intense monitoring (i.e., risks of rapid deterioration or debility), lack of documentation that the home setting is unsafe, or absence of specific skilled treatment needs (IV meds, respiratory support, enteral/TPN, wound care) when applicable. Additionally, if therapy is the primary skilled service and the record does not document that the member can tolerate and participate in therapy (e.g., ability to tolerate one hour of therapy 5 days/week), continued stay would be considered not medically necessary.

Form Submission, Documentation & Provider Responsibilities

Documentation Required

Form completion and submission timing — clinical reviews and required form sections must be completed and faxed to the specified number within timeframe.

Please complete all areas of this survey and fax to 1-800-416-9195. Ensure you complete all sections of this form as appropriate: Section 1 Demographic Information; Section 2 - Prior Level of Function; Section 3 - Clinical Review; Section 4 - Physical Therapy; Section 6 - Speech Therapy; Section 5 - Occupational Therapy; Section 7 Discharge Plan; Section 8 Protected Health Information. Date Form Completed: 1 = Admit Date to Post Acute Facility; 2 = Anticipated Discharge Date. Complete and fax within required timeframe (see callouts).

Fax number: 1-800-416-9195
Complete Sections 1–8 as appropriate
Date Form Completed: 1 = Admit Date, 2 = Anticipated Discharge Date

Documentation Required

Required documentation and timing — complete Sections 1–8, include demographics, transfer/admission details, diagnoses, and submit supporting clinical materials.

Transfer information must document: transfer setting, acute care admission date, whether injury/illness date is within 30 days, reason for hospital admission, contact at transferring facility, diagnosis for post-acute admission (include ICD code), and the reason for skilled stay. Specifically document whether the medical complexity requires frequent medical assessment or intense monitoring with potential for rapid deterioration or debility that makes care at home unsafe.

Transfer from (current setting) and date of acute admission
Is date of injury/illness within last 30 days? (Yes/No)
Diagnosis for post-acute admission (include ICD-10 code)
Reason for skilled stay: indicate Frequent Medical Assessment and/or Intense Monitoring with potential for rapid deterioration or debility; state if home is unsafe

Documentation Required

Therapy participation requirement — document member's ability to tolerate therapy, participation status for PT/OT/SLP, expected frequency/duration.

Therapy participation must be documented. Record whether the member can tolerate one hour of therapy 5 days per week with full participation and specify participation status for Physical Therapy, Occupational Therapy and Speech-Language Pathology. Include expected frequency and duration of therapy services and relevant prior level of function.

Can the member tolerate one hour of therapy 5 days/week with full participation? (Yes/No)
Document participation status for PT/OT/SLP (Member is participating: Yes/No)
Provide expected frequency and duration of therapy services and relevant prior level of function

Denial Risk

Failure to document need for skilled stay — highlights denial risk if documentation does not show need for frequent assessment or intense monitoring.

Failure to document the need for a skilled stay — if the clinical record does not clearly show the need for frequent assessments or intense monitoring (with potential for rapid deterioration or debility), the request is at risk for denial. Ensure the clinical review documents monitoring needs, unstable conditions, IV or TPN/enteral dependencies, wound care complexity, respiratory support needs, abnormal labs requiring oversight, and other indicators of skill-level nursing or therapy.

Denial risk if 'Reason for skilled stay' is blank or lacks evidence of frequent medical assessment or intense monitoring needs
Include documentation of unstable vitals, abnormal labs being monitored/treated, IV/TPN/feeding tube needs, wound treatments with measurements and frequency, respiratory support (oxygen flow, trach, suctioning), or other skilled needs

Key Definitions & Clinical Concepts

Reason for skilled stay / Frequent medical assessment

DefinitionMedical complexity requiring frequent medical assessment, intense monitoring with potential for rapid deterioration or debility (e.g., unstable vitals, abnormal labs under active monitoring, IV medications, respiratory support, enteral/TPN, or complex wound care)

Examples of monitoring needsFrequent vital sign checks, ongoing abnormal lab monitoring, IV medication management (name/frequency/stop date documented)

Respiratory criteriaRespiratory support documented (O2 flow/goal, sats, nebulizer use, trach details and suctioning frequency) with plan (wean, decannulation, home trach/oxygen)

Nutrition and linesEnteral feeding or TPN documented with dates, rates, tolerance, and goals when present

Wound careWound stage, measurements, treatment plan, dressing frequency and specialist follow-up documented when wound care is the skilled need

Therapy tolerance relationIf therapy is the basis for skilled stay, documentation that member can tolerate 1 hour/day, 5 days/week with participation supports need for continued skilled services

Prior Level of Function (PLOF)

DefinitionPrior Level of Function (PLOF): baseline mobility and ADL status prior to current illness/injury, including ambulation, transfer assistance level, wheelchair use, and home setup

Mobility specificsAmbulation status (yes/no), gait limitations with description and assistance required, wheelchair use, and transfer level (Independent, Modified Independence, Supervision, Contact Guard, Minimal/Moderate/Maximum Assistance, Dependent)

ADL assistanceAssistance level for activities of daily living using the same assistance categories up to Total Assistance/Dependent

Home environment and supportsDME at home, number of steps, stair rails, bed/bath floor location, availability of first-floor setup, and existing community resources (meals, HHC, caregivers)

Cognition and safetyBaseline mental status and cognitive/perceptual deficits (communication, memory, processing) and whether home environment is conducive to care

SNF Continued-Stay Criteria

SNF — Continued stay criteria

Submit clinical review within 24 hours: Clinical review documentation must be submitted within 24 hours of the requested admit date24 hours

Form repeats the 24-hour submission requirement in multiple clinical review sections

Ongoing skilled need: Continued stay must be supported by documented ongoing skilled need demonstrated by medical complexity or monitoring needs, documented functional deficits and therapy participation, or ongoing skilled treatments such as IV meds, respiratory care, enteral/TPN, or wound caredocumented ongoing skilled need

Continued-stay justification draws on clinical review, PLOF, and therapy/clinical treatment fields

OpenPayer

Medicare Skilled Nursing Facility Inpatient Continued Stay Review - Coverage Criteria

Medical Necessity & Coverage Criteria

Form Submission, Documentation & Provider Responsibilities

Key Definitions & Clinical Concepts

SNF Admission Criteria

SNF Continued-Stay Criteria

Discharge Criteria

Policy Background & Governing Guidance