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    v1.0.28
    OpenPayerPolicy UpdatesPost-Acute & Facility CareIndependent Health LTAC Prior Auth Policy Update |…
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    CurrentIndependent HealthPolicy M20210312011

    Long Term Acute Care (LTAC)

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    Defines Independent Health's medical necessity criteria and pre-authorization requirements for inpatient services provided in Long Term Acute Care facilities; applies to specified lines of business and plans.

    Policy Summary
    PayerIndependent Health
    PolicyLong Term Acute Care (LTAC)
    Policy CodePolicy M20210312011
    Change TypeNo material change
    Effective DateMay 1, 2021
    Next Review Date
    Key ActionObtain pre-authorization and submit documentation for Independent Health Medical Director review demonstrating the member requires LTAC-level care and cannot be treated in a less intensive setting.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Pre-authAdministrative requirement
    >25dAverage LTAC length of stay
    Required

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medical Director review
    Multiple linesApplies to

    Coverage Criteria for LTAC Admission

    Medical Necessity Criteria for LTAC Admission

    Services provided in a long-term acute care (LTAC) facility are covered upon Independent Health Medical Director review when the individual's condition cannot be adequately treated in a less intensive setting. All of the following must be met:

    LTAC coverage criteria: 1) The individual requires acute or subacute ongoing medically necessary inpatient hospital care services; 2) The individual is medically complex with one or more medical comorbidities (which are currently stable); 3) The individual's condition cannot be adequately treated in a less intensive setting

    All criteria must be met and case requires Medical Director review and prior authorization.

    Services provided in a long-term acute care (LTAC) facility are covered only after Independent Health Medical Director review and prior authorization. Coverage is limited to individuals whose condition cannot be adequately treated in a less intensive setting and who meet all medical necessity requirements: the individual requires acute or subacute ongoing medically necessary inpatient hospital care services; is medically complex with one or more comorbidities that are currently stable; and cannot be managed in a lower-intensity setting. All criteria must be met for LTAC placement and cases are subject to Medical Director determination of appropriateness.

    Care that is not acute or subacute, or care that can be adequately provided in a less intensive setting (for example, skilled nursing facility or home health when appropriate), is not appropriate for LTAC placement and should be evaluated under other benefits per the member’s underlying benefit plan.

    Coding and Key Definitions

    Average LTAC length of stay
    Average LTAC length of stay> 25 days
    Typical facility characteristicAverage inpatient length of stay greater than 25 days
    Comparative intensityServices are more individualized and resource‑intensive than skilled nursing or acute rehab
    LTACH / LTAC day limits
    Day limit thresholdAverage inpatient length of stay greater than 25 days
    SettingLTACH / LTAC
    ImplicationIndicates LTAC level of care differs from skilled nursing or acute rehab due to prolonged LOS

    Definitions

    Long term acute care (LTAC)
    DefinitionLong term acute care (LTAC) is a 24-hour inpatient comprehensive program of integrated medical and rehabilitative services provided in an approved LTAC facility during the acute phase of a member's care.
    Level of careProvides medical and rehabilitative care for clinically complex individuals with multiple acute or chronic conditions.
    Typical LOSGenerally has an average inpatient length of stay greater than 25 days.
    Services includedMay include comprehensive rehabilitation, respiratory therapy, complex wound therapy, cancer treatment, head trauma treatment, and pain management.

    Provider Actions and Authorization Requirements

    Prior Authorization

    Prior Authorization Required

    Pre-Authorization Required. All LTAC cases are reviewed by an Independent Health Medical Director for medical appropriateness. Pre-authorization is required; lack of pre-authorization may result in claim denial.

    • Pre-authorization required for LTAC services; all cases reviewed by IH Medical Director.
    • Services covered when the individual cannot be adequately treated in a less intensive setting and ALL of the following are met: requires acute or subacute ongoing medically necessary inpatient hospital care services; medically complex with one or more medical comorbidities (currently stable).
    Note

    Provider Action — Determine Acuity

    Determine acuity and benefits applicability. The provider must assess whether the member's needs are acute or subacute since services may fall under different benefits depending on the underlying plan.

    • Assess and document whether care needs are acute or subacute; benefit coverage may vary by plan (Commercial, Self-Funded, Medicare Advantage).

    Admission Criteria for LTACH / LTAC

    LTACH / LTAC — Admission Criteria

    Admission to an LTACH/LTAC requires that the following condition is met:

    Admission to LTAC: Patient requires 24-hour inpatient comprehensive integrated medical and rehabilitative services; requires acute or subacute ongoing medically necessary inpatient hospital care services; is medically complex with one or more currently stable comorbidities; and cannot be adequately treated in a less intensive setting.Average inpatient length of stay > 25 days

    Admission requires Medical Director review and prior authorization.

    Continued Stay Criteria for LTACH / LTAC

    LTACH / LTAC — Continued Stay Criteria

    Continued stay is covered only when ALL of the following are present and appropriateness is confirmed by an Independent Health Medical Director:

    Continued stay: Ongoing need for acute or subacute medically necessary inpatient services and continued medical complexity with care needs that cannot be managed in a less intensive setting; continued appropriateness subject to Independent Health Medical Director review.

    Continued authorization requires documentation demonstrating that the individual's condition cannot be managed in a less intensive setting and that comorbidities remain stable/require LTAC-level resources.

    Discharge Criteria

    Discharge from an LTAC is appropriate when the individual’s acute issues have been resolved, the individual’s condition can be managed in a less intensive setting, comorbidities no longer require LTAC-level resources, or per the Independent Health Medical Director’s determination.

    Background

    Long-term acute care (LTAC) facilities provide 24-hour inpatient medical and rehabilitative services for clinically complex individuals who require prolonged, resource-intensive management. LTACs serve patients with protracted acute medical issues and multiple comorbidities that necessitate integrated medical and rehabilitative care; these facilities typically have an average inpatient length of stay >25 days. Services may include comprehensive rehabilitation, respiratory therapy, complex wound management, and other interventions exceeding typical skilled nursing or acute rehab capabilities.

    Policy Summary
    PayerIndependent Health
    PolicyLong Term Acute Care (LTAC)
    Policy CodePolicy M20210312011
    Change TypeNo material change
    Effective DateMay 1, 2021
    Next Review Date
    Key ActionObtain pre-authorization and submit documentation for Independent Health Medical Director review demonstrating the member requires LTAC-level care and cannot be treated in a less intensive setting.
    SourceLink
    On This Page
    Coverage Criteria for LTAC AdmissionCoding and Key DefinitionsDefinitionsProvider Actions and Authorization RequirementsAdmission Criteria for LTACH / LTACContinued Stay Criteria for LTACH / LTACDischarge CriteriaBackground
  1. If needs are subacute, alternative benefit categories or settings may apply per the member's plan.
    2. Documentation Required

    Provider Action — Documentation Required

    Submit supporting documentation. Providers must submit documentation demonstrating the individual cannot be adequately treated in a less intensive setting and that medical complexity and need for ongoing acute/subacute inpatient care exist.

    • Clinical rationale showing inability to treat in a less intensive setting.
    • Documentation of medical complexity and current stability of comorbidities.
    • Records supporting requirement for ongoing acute or subacute inpatient hospital care services.
    Denial Risk

    Medical Director Review & Authorization

    IH Medical Director review required. Services require Independent Health Medical Director review and pre-authorization; failure to obtain pre-authorization may lead to denial of coverage.

    • All LTAC requests submitted for prior authorization will be reviewed by the Independent Health Medical Director.
    • Ensure prior authorization is obtained before admission when possible to avoid denial.