Utilization Review
Determines inpatient admission based on expected stay
What is the 2-Midnight Rule?
Patient must meet this status to qualify for home health services
What is homebound status?
Minimum inpatient hospital stay required before SNF coverage
What is a 3-midnight qualifying stay?
Typical initial review timeframe
What is within 1 working day?
To qualify for IPR, the patient must tolerate this amount of therapy per day
What is 3 hours of therapy per day?
Procedures automatically inpatient
What is the Inpatient-Only List?
This form documents that the patient or representative was given a list of Medicare‑certified providers and made their own selection without hospital steering
What is the Patient Choice Form?
Type of care that must be required daily for SNF coverage
What is skilled nursing and/or skilled therapy?
OBS review frequency
What is twice daily?
Patient must require at least this number of therapy disciplines
What are two therapy disciplines?
Time in this setting counts toward inpatient admission decision
What is time in the Emergency Department?
This Medicare requirement ensures the physician or allowed practitioner has had a qualifying encounter related to the primary reason the patient needs home health services.
What is the Home Health Face‑to‑Face Encounter?
Observation days do NOT count toward this requirement
What is the 3-midnight inpatient rule?
Medical necessity tools
What are MCG/InterQual?
Patients appropriate for LTACH usually require ongoing services such as these.
What are prolonged ventilator support, complex wound care, or intensive IV therapies?
Physician must document this clearly to support inpatient admission
What is the expectation of length of stay and medical necessity?
Patient must require this type of care intermittently
What is skilled nursing or therapy?
Nursing requirement for SNF
What is 7 days/week therapy?
Used to change IP to OP
What is Condition Code 44?
This percentage of IRF admissions must meet certain qualifying diagnoses under CMS rules.
What is the 60% Rule?
Patients can still be appropriate inpatient even if discharged early due to this
What are unforeseen circumstances?
Care must be ordered and overseen by this provider
What is a physician or allowed practitioner?
Therapy requirement for SNF
What is 5 days/week therapy?
Key difference between IP and OBS
What is expected LOS ≥2 midnights?
CMS defines this average length of stay threshold for LTACH classification.
What is greater than 25 days?