CurrentPriority HealthPolicy N/A

Post-Acute Skilled Nursing Facility (SNF) Level-of-Care Definitions

Defines Priority Health's levels of post-acute non-acute inpatient care (Level I–IV) with examples of services that qualify members for each SNF level; applies to admission and benefit determination for Priority Health members in North Carolina.

Policy Summary

PayerPriority Health

PolicyPost-Acute Skilled Nursing Facility (SNF) Level-of-Care Definitions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument admission and continued-stay records showing combined skilled nursing and/or therapy of 1–1.5 hours per day (≥5 days/week) and an established care plan, or obtain PH case manager approval for other/complex skilled services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Defined levels of care (I–IV)

1-1.5 hrs/dayMin skilled time

5 days/weekFrequency

26%Enteral feeding threshold

SNF Level Definitions & Coverage

Non-skilled custodial care

Level I

Level I non-covered: Care that is custodial/non-skilled (Rev Code 191)

Reference the Priority Health Non-Acute Inpatient Services policy (91332) for more information

Routine SNF Care (Level II) — Covered when ALL of the following are met

Level II — Covered when ALL of the following are met

Level II admission criteria: Combined skilled nursing and/or skilled therapy totaling 1–1.5 hours per day at least 5 days/week after admission day AND care plan/goals established (except extenuating circumstances)1-1.5 hrs/day; >=5 days/week

Member may qualify due to skilled nursing, therapy, or both

Policy Summary

PayerPriority Health

PolicyPost-Acute Skilled Nursing Facility (SNF) Level-of-Care Definitions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Examples of qualifying skilled nursing: Daily IV antibiotic or infusion; daily skilled wound care requiring nursing skill (wound packing, medication application, specialized dressings); new enteral feeding comprising at least 26% of daily calories with assessments and rate adjustments; other skilled services upon PH case manager approval (examples include psychiatric/social work interventions, initiation/supervision of bladder and bowel regimen, suprapubic catheter, stable mechanical ventilation management, and other nursing interventions requiring assessment, observation, monitoring, and/or education)

Treatment must not be available at a lower level of care

Moderate SNF Care (Level III) — Covered when ALL of the following are met

Level III — Covered when ALL of the following are met

Level III admission criteria: Combined skilled nursing and/or therapy totaling 1–1.5 hours per day at least 5 days/week after admission day AND care plan/goals established (except extenuating circumstances)1-1.5 hrs/day; >=5 days/week

May qualify due to skilled nursing, therapy, or both

Examples of moderate skilled services: Multiple IV antibiotics or infusions given throughout a 24-hour period; 1:1 sitter

Complex SNF Care (Level IV) — Covered when ALL of the following are met

Level IV — Covered when ALL of the following are met

Level IV admission criteria: Combined skilled nursing and/or therapy totaling 1–1.5 hours per day at least 5 days/week after admission day AND care plan/goals established (except extenuating circumstances); or increased therapy intensity as specified1-1.5 hrs/day; or 2-3 hrs/day therapy for specific cases

Members may qualify due to skilled nursing, therapy, or both

Examples of complex skilled services: TPN/Lipids; bariatric patients requiring specialty equipment; specialty beds; IV therapy/PICC with history of IV drug use; methadone/Suboxone patients; high-cost IV medications (chemotherapy, specialty antibiotics/antifungals); increased therapy to a combined total of 2–3 hours per day across at least two disciplines delivered >=5 days/week (no skilled nursing needed); other complex skilled services upon PH case manager approval

Level I care is custodial (non-skilled) care and is a non-covered benefit. Claims billed as Rev Code 191 may be denied as non-covered. See the Priority Health Non-Acute Inpatient Services policy (91332) for additional details.

Codes, Time Thresholds, and Therapy Intensity

Non-covered Revenue CodesRevenueNot Covered

Rev Code 191

Level I: Non-Skilled Care

Covered with criteria (Level II) - Revenue CodesRevenueCovered

Rev Code 192

Level II: Routine SNF Care

Covered with criteria (Level III) - Revenue CodesRevenueCovered

Rev Code 193

Level III: Moderate SNF Care

Covered with criteria (Level IV) - Revenue CodesRevenueCovered

Rev Code 194

Level IV: Complex SNF Care

Minimum skilled service time — Levels II–IV

Minimum combined skilled time1–1.5 hours per day of combined skilled nursing and/or skilled therapy

Frequency requirementAt least 5 days per week (after admission day)

Care plan requirementCare plan and goals must be established after admission day (except extenuating circumstances)

Enteral feeding nutrition threshold

Enteral feeding thresholdNew enteral feeding comprising at least 26% of daily calories

Required clinical actionsAssessments and adjustments to feeding rates must be provided

Approval pathwayMay qualify as a skilled nursing example supporting Level II admission

Increased therapy intensity for Level IV

Therapy intensity for Level IVCombined total of 2–3 hours per day of physical, occupational, and/or speech therapy

Frequency and disciplinesDelivered at least 5 days per week with at least two disciplines

Nursing requirementNo skilled nursing needed when increased therapy intensity criteria are met

Documentation, Review, and Billing Guidance

Prior Authorization

SNF level determination and case manager review

SNF level determination is based on Revenue Codes 192–194 (Levels II–IV). Levels II–IV require demonstration of skilled nursing and/or skilled therapy needs and must meet frequency/duration expectations. Priority Health case managers review level assignment and may require collaboration with the provider to approve services that meet clinical criteria.

Rev Codes 192 (Level II), 193 (Level III), 194 (Level IV)
Levels II–IV: Skilled nursing and/or skilled therapy totaling ~1–1.5 hours per day, at least 5 days/week after admission day, with established care plan/goals (unless extenuating circumstances)
Level II examples: daily IV antibiotics/infusions, daily skilled wound care, new enteral feeding ≥26% of calories, other skilled services per PH case manager
Level III examples: multiple IV antibiotics/infusions across 24 hours, 1:1 sitter
Level IV examples: TPN/lipids, specialty beds/equipment, PICC/IV therapy with complex history, methadone/Suboxone management, increased therapy 2–3 hours/day with ≥2 disciplines, high-cost IV medications

Denial Risk

Non-covered custodial care

Level I (Revenue Code 191) is custodial, non-skilled care and is a non-covered benefit. Claims billed with Rev Code 191 may be denied as non-covered per Priority Health Non-Acute Inpatient Services (medical policy 91332). Providers should place members needing only custodial care in appropriate non-covered settings and document rationale when applicable.

Rev Code 191 = Level I (Non-Skilled/Custodial) — not covered
Reference: Priority Health Non-Acute Inpatient Services medical policy (91332)
Claims submitted with Rev Code 191 may be denied as non-covered custodial care

Documentation Required

Required admission documentation

Required admission documentation must demonstrate the member’s need for skilled nursing and/or skilled therapy, including the specific skilled services, frequency, and duration. Documentation must support the chosen SNF level and include an established care plan and goals (except in documented extenuating circumstances).

Admission note with clinical justification for skilled services
Care plan and goals established after admission day (or documented reason if delayed)
Skilled therapy disciplines, frequency, and expected duration (e.g., minutes/hours per day, days per week)
Nursing documentation describing procedures/complexity (e.g., wound care details, IV/TPN management, enteral feeding percent of calories)
Any approvals/communications with Priority Health case manager

Billing Rule

Providers must bill using the appropriate Revenue Code consistent with the member’s level of need and supported documentation. Billing Level I (Rev Code 191) when only custodial care is provided risks denial. For Levels II–IV, ensure claims reflect the skilled services provided and coordinate with the PH case manager for any services requiring prior approval.

Use Rev Codes 192–194 for Levels II–IV; Rev Code 191 for Level I (non-covered custodial)
Ensure billed services align with documented skilled nursing/therapy frequency and duration
Coordinate with Priority Health case manager for approvals and complex skilled services

Level Definitions

Level I — Custodial (non-skilled) care

DefinitionCustodial (non-skilled) care

Coverage stanceNon-covered benefit (Rev Code 191)

ReferenceSee Priority Health Non-Acute Inpatient Services policy (91332) for more information

Level II — Routine skilled nursing and/or therapy

Level labelLevel II — Routine SNF Care (Rev Code 192)

Skilled time requirementCombined skilled nursing and/or therapy totaling 1–1.5 hours per day

FrequencyAt least 5 days per week after admission day

Examples of qualifying skilled nursingDaily IV antibiotic/infusion; daily skilled wound care requiring nursing skill; new enteral feeding ≥26% of daily calories; other skilled services with PH case manager approval

Level III — Moderate skilled nursing care

Level labelLevel III — Moderate SNF Care (Rev Code 193)

Skilled time requirementCombined skilled nursing and/or therapy totaling 1–1.5 hours per day

FrequencyAt least 5 days per week after admission day

Examples of moderate skilled servicesMultiple IV antibiotics/infusions throughout a 24-hour period; 1:1 sitter

Level IV — Complex skilled care

Level labelLevel IV — Complex SNF Care (Rev Code 194)

Skilled time requirementCombined skilled nursing and/or therapy totaling 1–1.5 hours per day (or qualifying increased therapy intensity)

Examples of complex skilled servicesTPN/lipids; bariatric patients with specialty equipment; specialty beds; IV therapy/PICC with history of IV drug use; methadone/Suboxone patients; high-cost IV medications; other complex services with PH case manager approval

Increased therapy optionIncreased therapy of 2–3 hours/day across ≥2 disciplines delivered ≥5 days/week qualifies without skilled nursing

Initial Admission Requirements

SNF — admission criteria

General admission requirement for Levels II–IV: Combined skilled nursing and/or therapy totaling 1–1.5 hours per day at least 5 days/week after admission day AND an established care plan/goals, unless extenuating circumstances prevent participation1-1.5 hrs/day; >=5 days/week

Member may qualify due to skilled nursing, therapy, or both

Ongoing Medical Necessity for Continued SNF Stay

SNF — continued stay criteria

Continued stay requirement: Ongoing documentation of skilled nursing and/or therapy needs at the required frequency and duration and continued progress toward established care plan/goals; case manager review for other or complex skilled services

Extenuating circumstances should be documented if participation is limited

Discharge Considerations

Admission to a skilled nursing facility (SNF) for Levels II–IV requires documentation that the member needs combined skilled nursing and/or skilled therapy totaling 1–1.5 hours per day, at least 5 days per week after the admission day, and that a care plan with measurable goals is established (or that extenuating circumstances limiting participation are documented). This single top-level requirement applies across SNF admission determinations whether the member qualifies primarily for skilled nursing, therapy, or both.

Context and Scope

Post-acute SNF care is categorized by the intensity and complexity of skilled nursing and therapy services required. Levels II–IV specify minimum skilled service time of 1–1.5 hours per day, at least 5 days per week after the admission day and include examples of services that justify a higher level of care (for example, daily IV antibiotics or wound care for Level II; multiple IV infusions or 1:1 sitter for Level III; and TPN, complex IV therapy, specialty equipment, or increased therapy intensity for Level IV). Level I denotes custodial, non-skilled care and is a non-covered benefit.