CurrentMass General Brigham Health PlanPolicy N/A

Inpatient Rehabilitation and Long-Term Acute Care Reimbursement

Defines Mass General Brigham Health Plan reimbursement policy and payment guidelines for Inpatient Rehabilitation Facilities (IRFs) and Long-Term Acute Care Hospitals (LTACs), including covered services, level-of-care criteria, billing expectations, and provider responsibilities for network providers and contracted rates.

Policy Summary

PayerMass General Brigham Health Plan

PolicyInpatient Rehabilitation and Long-Term Acute Care Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for inpatient stays and note that a new inpatient authorization number is assigned each time the member's level of care changes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 hrs/daytherapy tolerance (IRF)

25+ daysavg LTAC LOS

24‑hour physician & RNstaffing requirement

Distinct authdistinct auth per LOC

Listedrevenue codes included

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Level-of-Care and Service Coverage

Level of Care Criteria

Covered when ALL of the following are met:

ALL of the following

Admission preceded by a new acute condition or an acute exacerbation of a chronic condition resulting in significant decrease in functional status compared to baseline
Member requires a medical need for an intensive multidisciplinary rehabilitation program (not therapy solely to maintain function)
Member able to actively participate in, and expected to benefit from, at least 3 hours per day (minimally 5 days/week) of therapy across at least two disciplines (physical therapy, occupational therapy, or speech therapy)
Member demonstrates capability for active participation (purposeful responsiveness to stimuli and ability to follow simple commands)
Expectation of significant practical improvement toward functional goals within a reasonable time period (short-term goal progress expected weekly)
Staffing and medical oversight requirements (ONE of the following must be met)
- 24-hour availability of a physician with special training or experience in rehabilitation and frequent (every 2–3 days) medically necessary physician involvement
- 24-hour availability of a registered nurse with specialized training or experience in rehabilitation
LTAC-specific requirement (ONE of the following applies)
- Daily physician intervention or 24-hour availability of hospital-level medical services and equipment
- Complex medical condition requiring hospital-level services with expected longer stay (LTAC candidates typically have average stays > 25 days)
No effective, less-costly alternative placement (e.g., subacute unit or SNF) is available

Therapy intensity threshold: patient must tolerate at least 3 hours/day of therapy, minimally 5 days/week

Covered Services and Exclusions

The plan reimburses the following services when provided as part of the covered level of care; the plan does not reimburse the listed exclusions.

ALL of the following

Covered services: Rehabilitation nursing
Covered services: Physical therapy
Covered services: Occupational therapy
Covered services: Speech-language pathology
Covered services: Social services

Revenue Codes, Therapy Intensity, and Length-of-Stay Indicators

Revenue Codes for Level of CareRevenue

0120	Long Term Acute Care (LTAC) revenue code
0128	Rehabilitation revenue code
0129	Acute Complex Rehabilitation revenue code

Therapy intensity threshold — IRF/Acute Rehab

Therapy intensity requirementPatient must tolerate at least 3 hours per day of intense rehabilitation therapy, minimally 5 days per week, including at least two disciplines (PT, OT, or SLP)

Participation capabilityAble to actively participate as demonstrated by responsiveness to stimuli and ability to follow simple commands

Expected functional gainSignificant practical improvement toward functional goals expected within a reasonable time period (weekly short-term goal progress benchmark)

LTAC average stay threshold

Typical LTAC length of stayPatients in LTACs typically stay more than 25 days

Patient complexity

Authorization, Claims, and Documentation Requirements

Billing Rule

Claims Audit and Payment Edits

All claims submitted to Mass General Brigham Health Plan are auditable and are subject to payment edits. Providers should expect routine claims review and corrective edits that may affect reimbursement.

All claims are subject to audit and medical record requests.
Payment edits are updated at regular intervals and may change reimbursable amounts or result in denials.
Follow CPT, HCPCS, Revenue, and ICD-10-CM coding guidelines and CMS/CPT modifier instructions to reduce risk of payment edits.

Prior Authorization

Prior Authorization and Authorization Number Assignment

Certain services and procedures require referral and/or prior authorization. A new authorization number is assigned whenever the member's level of care (LOC) changes; each LOC will therefore have a distinct inpatient authorization number.

Key Terms

Inpatient Rehabilitation Facility (IRF) — definition & scope

DefinitionFreestanding rehabilitation hospitals and rehabilitation units in acute care hospitals that provide intensive rehabilitation programs

Admission prerequisiteHospitalization is preceded by a new acute condition or acute exacerbation causing significant decrease in functional status

Therapy expectationPatients must be able to tolerate three hours of intense rehabilitation services per day

Medical oversightRequires 24-hour availability of a physician with rehab experience and frequent (every 2-3 days) medically necessary physician involvement

Long-Term Acute Care (LTAC) — definition & scope

DefinitionLong-Term Acute Care (LTAC) are certified acute care hospitals focusing on patients who on average stay more than 25 days

Policy Summary

PayerMass General Brigham Health Plan

PolicyInpatient Rehabilitation and Long-Term Acute Care Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for inpatient stays and note that a new inpatient authorization number is assigned each time the member's level of care changes.

SourceLink

On This Page

Covered services: Prosthetic and orthotic services

Exclusions: Private duty nursing is not reimbursed

Exclusions: Custodial care services are not reimbursed

Providers should bill the appropriate level-of-care revenue code as outlined in provider agreements and applicable policy

Often transferred from ICU; patients commonly have multiple complex medical conditions requiring daily physician evaluations

Services providedComprehensive rehabilitation, respiratory therapy, head trauma treatment, pain management, and hospital-level skilled nursing and equipment

Verify referral and prior authorization requirements before providing services.
When LOC changes, treat the event as a new admission for authorization purposes and obtain the newly assigned inpatient authorization number.
Failure to obtain required prior authorization may result in claim denial or reduced reimbursement.

Typical patient flowMany patients are transferred from an intensive or critical care unit

Care needsPatients require daily physician evaluations and hospital-level skilled nursing and equipment

Acute Rehabilitation Hospital/Unit — definition & expectations

DefinitionState-licensed facility or unit providing comprehensive services for patients whose disabilities are primarily physical

Therapy participationPatients have the ability to participate in 3 hours of rehabilitation at least 5 days per week

Medical oversightRequires oversight by a medical practitioner multiple times per week

Course of treatmentTreatment is limited to the period in which the patient continues to make progress toward treatment goals