CommercialCoverageMedium impact
Skilled Nursing Facility Care / Level of Care Criteria 11.01.21
Excellus BlueCross BlueShield·Miscellaneous
Effective date
Jul 17, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their skilled nursing facility (SNF) care policy effective July 17, 2025, establishing detailed medical necessity criteria for three levels of care (Level I SNF, Level II Subacute, Level III Medically Complex) with specific revenue codes 191-194. The policy requires skilled services at least 5 days per week and includes special provisions for Medicaid Managed Care/HARP members allowing custodial benefits when safe discharge plans are under development.
Action Required
By July 17, 2025: Billing team must update authorization processes to align with new three-tiered SNF criteria using revenue codes 191 (Level I), 192 (Level II Subacute), 193 (Level III Medically Complex), and 194 (Ventilator/TBI). Ensure prior authorizations document required daily skilled service hours, medical conditions meeting criteria, and justification why lower level care is inappropriate. For Medicaid Managed Care/HARP members, note custodial benefit availability when safe discharge planning is in progress.