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    v1.0.28
    OpenPayerPolicy UpdatesPost-Acute & Facility CareSecurity Health LTAC Coverage Update | OpenPayer
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    CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

    Long Term Acute Care (LTAC) Facility

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    This policy governs medical-necessity review, precertification, and coverage of long-term acute care facility admissions and continued stays for applicable Health Plan products, including Commercial, Medicaid, Medicare Advantage, Family Health Center, and TPA products.

    Policy Summary
    PayerSecurity Health Plan of Wisconsin, Inc.
    PolicyLong Term Acute Care (LTAC) Facility
    Policy CodePolicy N/A
    Change TypeAnnual reviewno material clinical or coverage changes
    Effective DateApril 1, 2026
    Last ReviewMar 2, 2026
    Next Review DateNot specified
    Key ActionSubmit LTAC admission and continued-stay precertification requests through the Health Plan provider portal.
    SourceLink
    POLICY UPDATE CHANGES

    Beginning January 1, 2025, LTAC medical-necessity reviews use InterQual criteria and are completed by the Health Plan rather than NaviHealth.

    Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy effective January 1, 2026.

    The March 2026 annual review reported no policy or criteria changes.

    RequiredPrecertification for LTAC services
    InterQualMedical-necessity criteria used from January 1, 2025
    No coverageLTAC admission or continued stay when criteria are not met

    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.

    Inpatient onlyFamily Health Center coverage limitation
    6Product or program sections addressed

    LTAC Coverage Criteria

    LTAC admission and continued stay

    LTAC coverage requires medical necessity under the applicable InterQual criteria.

    LTAC medical necessity: The member must meet the applicable InterQual criteria for LTAC admission or continued stay.

    Detailed InterQual criteria are not reproduced in this policy; LTAC reviews are completed by the Health Plan.

    Medicaid criteria

    BadgerCare Plus and Medicaid SSI coverage follows the Health Plan's Commercial LTAC criteria approach.

    BadgerCare Plus and Medicaid SSI: The service must meet the Health Plan's applicable Commercial LTAC medical-necessity criteria, while remaining no more restrictive than fee-for-service Medicaid under the BadgerCare Plus HMO contract.

    ForwardHealth has no available prior-authorization guidelines for this service.

    Medicare Advantage criteria

    Medicare Advantage coverage follows the Commercial LTAC criteria approach.

    Medicare Advantage: The service must meet the Health Plan's applicable Commercial LTAC medical-necessity criteria.

    Medicare covers Part A inpatient long-term acute care; no Medicare national coverage decision or Wisconsin local carrier coverage decision is identified in the policy.

    LTAC admission or continued stay is not covered when the applicable medical-necessity criteria are not met. The Health Plan uses InterQual criteria to determine medical necessity.

    Family Health Center offers no coverage for services provided as an inpatient, because the services are available only in an inpatient setting under the stated limitation.

    Precertification and Provider Requirements

    Prior Authorization

    Commercial Precertification Required

    Commercial LTAC admission and continued-stay requests require precertification. Submit the request through the Health Plan provider portal using the Prior Authorization Request form.

    • Precertification is required for LTAC admission and continued-stay requests.
    Prior Authorization

    Medicaid Precertification Required

    BadgerCare Plus and Medicaid SSI LTAC services require precertification. Submit the request through the Health Plan provider portal using the Prior Authorization Request form.

    • The Health Plan applies the policy to BadgerCare Plus members consistent with its Commercial application when ForwardHealth does not provide specific prior authorization guidelines.
    Prior Authorization

    Medicare Advantage Precertification Required

    LTAC Service Background

    Long-term acute care (LTAC) is intended for critically ill or clinically complex members whose primary or comorbid diagnoses result in multisystem complications or failure and who require acute inpatient hospitalization for an extended period.

    Long-Term Acute Care Definition

    Long Term Acute Care (LTAC)
    Care settingAcute inpatient hospitalization for extended periods
    Member populationCritically ill or clinically complex members
    Clinical characteristicsA primary and/or co-morbid diagnosis resulting in multi-system complications or failure

    LTACH Admission Criteria

    LTACH admission criteria

    LTACH admission is medically necessary when all of the following are met:

    LTAC admission: The member is critically ill or clinically complex, has a primary and/or comorbid diagnosis resulting in multisystem complications or failure, requires extended acute inpatient hospitalization, and meets applicable InterQual medical-necessity criteria.

    The policy does not reproduce the detailed InterQual admission criteria.

    LTACH Continued Stay Criteria

    LTACH continued stay criteria

    Continued LTACH stay is medically necessary when the following criterion is met:

    Continued LTAC stay: The member must continue to meet applicable InterQual medical-necessity criteria for LTAC care.

    Failure to meet the applicable criteria results in no coverage for continued stay; detailed continued-stay criteria are not reproduced.

    Policy Summary
    PayerSecurity Health Plan of Wisconsin, Inc.
    PolicyLong Term Acute Care (LTAC) Facility
    Policy CodePolicy N/A
    Change TypeAnnual reviewno material clinical or coverage changes
    Effective DateApril 1, 2026
    Last ReviewMar 2, 2026
    Next Review DateNot specified
    Key ActionSubmit LTAC admission and continued-stay precertification requests through the Health Plan provider portal.
    SourceLink
    On This Page
    LTAC Coverage CriteriaPrecertification and Provider RequirementsLTAC Service BackgroundLong-Term Acute Care DefinitionLTACH Admission CriteriaLTACH Continued Stay Criteria

    Medicare Advantage LTAC services require precertification through the Health Plan provider portal. Submit the Prior Authorization Request form for Align, Align DSNP, and Great Plains plans.

    • Medicare covers Part A inpatient long-term acute care.
    • The Health Plan applies the policy to Medicare Advantage members consistent with its Commercial application.
    Prior Authorization

    TPA Precertification Required

    TPA LTAC services require precertification. Submit the request through the Health Plan provider portal using the Prior Authorization Request form.

    • TPA groups that utilize the Health Plan to process services follow Commercial criteria when the member's Summary Plan Description does not contain specific guidelines or criteria.
    Documentation Required

    Submit Precertification Requests

    Use the Health Plan provider portal to submit LTAC precertification requests and include the Prior Authorization Request form. This submission process applies to Commercial, Medicaid, Medicare Advantage, and TPA requests.

    • Confirm the applicable product and request type before submission.
    • LTAC reviews are completed by the Health Plan using InterQual criteria effective 1/1/2025.
    Note

    Commercial Contact Information

    For Commercial LTAC precertification questions or submissions, providers may contact the Health Plan by telephone or fax.

    • Telephone: 715-221-9212
    • Fax: 715-221-9215
    Note

    Medicaid, Medicare Advantage, and TPA Contacts

    For Medicaid, Medicare Advantage, and TPA LTAC requests, providers may contact the Health Plan by telephone or fax.

    • Telephone: 1-800-991-8109
    • Fax: 715-221-6616

    Unsupported block type: documentation

    Denial Risk

    Criteria Not Met: No Coverage

    If the applicable medical-necessity criteria are not met, there is no coverage for the LTAC admission or continued stay.

    • Ensure the request supports the applicable InterQual medical-necessity criteria.
    Denial Risk

    Family Health Center Inpatient Limitation

    Family Health Center offers no coverage for LTAC services provided as an inpatient.

    • Services are only available in an inpatient setting; inpatient services are not covered under this limitation.