CurrentPriority HealthPolicy N/A

Post‑acute facility level-of-care definitions (Levels V–VII)

Defines admission, staffing, and service criteria for high-acuity post-acute facility levels (Long-Term Acute Care / Intensive Post-Acute Nursing/Rehab, Complex Post-Acute or Dialysis Care, and Direct Admits from ICU on Vent and Dialysis) affecting Priority Health members and provider placement decisions.

Policy Summary

PayerPriority Health

PolicyPost‑acute facility level-of-care definitions (Levels V–VII)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPlacement and level must be mutually agreed by Priority Health and the facility/case manager at time of placement; obtain case manager approval for higher-acuity services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6.5hMin skilled nursing/24h

6hVentilator threshold/24h

24/7Clinical coverage hours

V–VIIDefined levels

Coverage Criteria — Facility Levels V–VII

Level V (LTAC / Intensive Post-Acute Nursing/Rehab)

Covered when ALL of the following are met

Level V admission criteria: Member is medically stable; requires intensive monitoring with daily medical practitioner assessment or intervention; requires intensive nursing care; at least 6.5 hours of skilled nursing in a 24-hour period and/or frequent rehabilitation therapy to improve functional outcomes; services delivered by licensed personnel and available 24/7 and provided or supervised by professional nursing personnel and/or the attending physician.6.5 hours skilled nursing/24h

Ventilator-specific criteria below

Ventilator admission conditions for Level V: For ventilator patients: ventilator use at least 6 hours in 24 hours AND either ventilator dependent ≥1 week with failed weaning in acute care OR no prior attempt at weaning before admission.6 hours ventilator use/24h

Policy Summary

PayerPriority Health

PolicyPost‑acute facility level-of-care definitions (Levels V–VII)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPlacement and level must be mutually agreed by Priority Health and the facility/case manager at time of placement; obtain case manager approval for higher-acuity services.

SourceLink

On This Page

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This policy defines coverage for high-acuity post-acute facility levels (Levels V–VII). Coverage for each level is conditional on meeting all specified clinical and service criteria for that level. Key elements across levels include medical stability, availability of licensed personnel and 24/7 supervision by professional nursing personnel and/or the attending physician, daily medical practitioner assessment or intervention, and documented skilled services required to achieve the medically desired outcome. Level definitions escalate by clinical need: Level V is the baseline intensive post-acute/LTAC standard, Level VI adds complex or dialysis-specific services, and Level VII applies to direct ICU transfers requiring concurrent ventilator and dialysis support.

Key Quantifiers & Coding Thresholds

inv-06: Minimum skilled nursing per 24 hours

Minimum skilled nursing per 24 hoursAt least six and a half (6.5) hours of skilled nursing services in a 24-hour period.

Associated requirementPhysician assessment/intervention daily is required in conjunction with the minimum skilled nursing hours.

AvailabilityServices must be provided or supervised by professional nursing personnel and/or the attending physician and be available 24/7.

inv-07: Ventilator use threshold — 6 hours in 24-hour period

Ventilator use thresholdVentilator use for at least six (6) hours in a twenty-four (24) hour period is required for ventilator admission consideration.

Additional ventilator criteriaPlus either ventilator dependent ≥1 week with failed weaning in acute care, or no prior attempt at weaning before admission.

ContextApplies to Level V ventilator admission conditions as part of intensive post-acute care criteria.

Provider Responsibilities and Operational Requirements

Prior Authorization

Placement approval required

Placement and level must be mutually agreed upon by Priority Health and the facility/case manager at time of placement. Higher-acuity services (e.g., ventilator care, dialysis, or services requiring intensive monitoring) require coordination with Priority Health prior to placement.

Priority Health and Facility will mutually agree on appropriate level upon placement of the member.

Step Therapy

Step therapy / escalation — not applicable

Step therapy/escalation protocols do not apply within these level definitions. However, services that exceed the member’s current level of care or require a higher-acuity setting still require case manager coordination and prior agreement with Priority Health.

Not applicable within level definitions; services requiring approval require case manager coordination.

Documentation Required

Required clinical documentation

Documentation must clearly demonstrate the member’s medical stability and the need for the requested level of skilled services. Required clinical documentation should support daily physician assessment or intervention, the frequency and total skilled nursing hours (including evidence of at least 6.5 skilled nursing hours per 24-hour period when applicable), and details of skilled therapy or other skilled interventions (e.g., ventilator management, dialysis, IV therapies, wound care).

Physician assessment/intervention documented daily.
Evidence of skilled nursing services totaling at least 6.5 hours per 24‑hour period when applicable.
For ventilator patients, document ventilator use ≥6 hours per 24‑hour period and either: ventilator dependence ≥1 week with failed weaning in acute care, or no prior attempt at weaning before admission.
Document specific skilled services provided (e.g., ventilator care, tracheostomy care/weaning, oxygen >40%, IV medications/TPN, IV anticoagulant, respiratory therapist interventions, renal dialysis, complex wound care).
Any other high‑acuity or high‑cost services require prior approval and documentation for case manager review.

Denial Risk

Admission level mismatch — denial risk

Admission may be denied if the member does not meet the minimum skilled nursing threshold or other level-specific criteria. Specifically, admissions can be denied when the member does not require at least six and a half (6.5) hours per 24‑hour period of skilled nursing, does not have documented daily physician assessment/intervention when required for the level, or does not meet specified level criteria (for example, ventilator or dialysis criteria where applicable).

Admission level mismatch risk: deny when member does not require ≥6.5 skilled nursing hours per 24-hour period.
Ventilator admissions require documentation of ventilator use ≥6 hours/24 hours and meeting the stated vent criteria.
Level-specific additions (e.g., dialysis, active ventilator weaning) must be documented to justify Level VI/VII admission.

Background and Scope

These sections describe clinical-intensity levels for post-acute care where members are medically stable but require intensive monitoring and frequent skilled services. Level V is intended for members needing intensive nursing care and/or frequent rehabilitation with services delivered or supervised by licensed personnel and available 24/7. Level VI describes escalated needs such as active ventilator weaning, tracheostomy management, or renal dialysis. Level VII applies to direct admits from the ICU who require concurrent ventilator support and dialysis with frequent respiratory interventions and are expected to transfer to a lower level once stable.

Key Definitions

inv-13: medically stable — definition note

DefinitionMedically stable: Member no longer requires acute inpatient care but requires intensive monitoring, daily medical practitioner assessment or intervention, and intensive nursing care in a post-acute setting.

Implication for placementMember must still require skilled services (e.g., ventilator care, dialysis, IV medications, wound management) provided or supervised by licensed personnel.

Transfer considerationWhen the patient is determined to be stable at Level VII, transfer to a lower level of care is indicated.

inv-14: minimum skilled nursing — Skilled nursing services at least six and a half (6.5) hours in a twenty-four (24) hour period

Minimum skilled nursingSkilled nursing services of at least six and a half (6.5) hours in a twenty-four (24) hour period.

Required oversightServices must be provided or supervised by professional nursing personnel and/or the attending physician.

Associated documentationDocumentation must support the number of skilled nursing hours and the skilled services provided for admission and continued stay determinations.

Admission Criteria by Setting

SNF | LTACH | IRF — admission criteria (top-level node)

Admission to SNF, LTACH, or IRF requires ALL of the following

SNF | LTACH | IRF admission: Physician assessment or intervention daily; skilled nursing services at least 6.5 hours in a 24-hour period; for ventilator admits, ventilator use ≥6 hours in 24 hours plus either ventilator dependence ≥1 week with failed wean in acute care OR no prior attempt at weaning before admission.

SNF | LTACH | IRF — admission criteria (top-level node)

Admission to SNF, LTACH, or IRF at Level VI requires ALL Level V admission criteria plus one or more of the following

Level VI admission: Meets Level V criteria plus one or more: active ventilator weaning (weanable ventilator patients actively weaning); tracheostomy care, tracheostomy weaning, or decannulation; renal dialysis; or other Priority Health–approved high-cost skilled services.

LTACH | IRF — admission criteria (top-level node)

Admission to LTACH or IRF at Level VII requires ALL Level V admission criteria plus the following

Level VII admission: Meets Level V criteria plus: renal dialysis while on ventilator with frequent respiratory interventions; direct admits from ICU. Patient will be transferred to a lower level of care when determined stable.

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