CurrentAnthemPolicy N/A

Medicare Advantage SNF/Rehabilitation Pre-Certification Worksheet

A form and instructions for submitting pre-certification and continued stay review requests to Anthem Blue Cross and Blue Shield for Medicare Advantage members being admitted to or continuing in skilled nursing facility (SNF) or acute rehabilitation services in specified states (Colorado and Nevada). It identifies required clinical, demographic, transfer, therapy, and discharge information needed to process requests.

Policy Summary

PayerAnthem

PolicyMedicare Advantage SNF/Rehabilitation Pre-Certification Worksheet

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed pre-certification or continued stay review form via secure email or fax and include the case reference number, admit date, and request type.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 pagesdocument length

CO, NVexplicit email/fax routing states

1 formpre-certification worksheet

Demographics, Transfer, Clinical, Therapy, Dischargerequired information sections

Coverage Information & Documentation Requirements

Policy Summary

PayerAnthem

PolicyMedicare Advantage SNF/Rehabilitation Pre-Certification Worksheet

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed pre-certification or continued stay review form via secure email or fax and include the case reference number, admit date, and request type.

SourceLink

On This Page

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Coverage information and documentation requirements

Information required to support coverage decisions for SNF/rehabilitation admissions and continued stay reviews includes:

ALL of the following

Request type
- Select which service is being requested: SNF initial request, SNF CSR request, Acute rehabilitation initial request, or Acute rehabilitation CSR request.
Provide admit date to post-acute facility and the date the form was completed and sent to Anthem; include a case reference number for continued stay review (CSR) when applicable.
Member identifiers: member name, date of birth, Member ID#, and reference number.
Facility and provider information: SNF/Rehab facility name, facility NPI, facility address, and fax number or contact at transferring facility.
Diagnosis and clinical justification: diagnosis for post-acute admission including ICD code and reason for skilled stay; past medical history and relevant clinical details (e.g., PEG placement).
Therapy evaluation and functional status: date of therapy evaluation, date of current therapy status, weight bearing status, ambulation (evaluation and current status), wheelchair mobility, bed mobility, transfers, stairs, balance, and activities of daily living evaluations (feeding, grooming/hygiene, bathing, dressing, toileting).
Nursing/medical needs and vitals/labs/medications as relevant to the skilled need (documented on the form).
Discharge planning: teaching/training completed or needed, anticipated disposition, barriers to discharge, discharge plan and estimated discharge date, care conference date/discussion, referrals to home health (company name if yes), DME needed (and what), community resources needed, and next MD appointment.
Operational note: If you are not set up on secure email, send contact information to have secure email set up; email and fax addresses are provided for Colorado and Nevada (WestRegionMA_PostAcute@anthem.com).
Compliance note: Do not use or disclose Protected Health Information about individuals you are not treating or who are not enrolled in your practice.

Diagnosis coding: include the ICD-10 diagnosis code(s) for the post-acute admission as requested on the form.

Therapy evaluation dates: record the date of therapy evaluation and the date of current therapy status on the form.

Diagnosis Coding and Therapy Dates

Diagnosis codingICD-10

ICD-10

Diagnosis for post-acute admission should include ICD code as requested on form

Therapy evaluation dates

Required therapy datesDate of therapy evaluation and date of current therapy status are required on the form

Therapy domains documentedPT/OT/ST evaluations and current status for ambulation, transfers, bed mobility, stairs, balance, feeding, grooming, bathing, dressing, toileting

Mobility specificsWheelchair mobility, weight bearing status, and ambulation details (distance, level of assistance) must be recorded

Submission Instructions and Important Provider Notices

Prior Authorization

Submission instructions for pre-certification/CSR

Submit the completed pre-certification or continued stay review (CSR) worksheet to Anthem via secure email or fax. For Colorado and Nevada, email the form to WestRegionMA_PostAcute@anthem.com or fax to 855-443-7823. For CSR submissions, include the case reference number, the date the form was completed, the date form was sent, the admit date to the post-acute facility, and the selected request type (SNF initial, SNF CSR, acute rehabilitation initial, or acute rehabilitation CSR).

Include case reference number for continued stay review (CSR).
Provide date form completed and date form sent to Anthem.
Indicate admit date and select the appropriate request type (SNF initial, SNF CSR, acute rehabilitation initial, or acute rehabilitation CSR).

Denial Risk

Incomplete submission risk — provide all requested information

Requests may be delayed if all requested information on the form is not provided. Ensure all required demographic, clinical, therapy, transfer, and discharge fields are completed before submission to avoid processing delays.

Complete all requested sections on the worksheet (including member identifiers, facility information, clinical justification, and therapy status).

Key Definitions

CSR — Continued Stay Review

CSR (Continued Stay Review)Provide a case reference number for continued stay review (CSR) when submitting the form to Anthem

Definition — CSR term on formThe form includes an option to select SNF CSR request or acute rehabilitation CSR request to indicate a continued stay review

PLOF linkagePrior Level of Function (PLOF) is captured on the form as the member's measurable functional status prior to the current admission (ambulation, transfers, ADLs, wheelchair mobility)

Prior Level of Function (PLOF)

PLOF definitionPrior Level of Function (PLOF) — the member's measurable functional status before the current admission

Ambulation detailsIndicate whether member ambulates; if yes, report distance and level of assistance

Transfers and ADLsDocument transfer ability and activities of daily living (ADLs) status

Wheelchair mobilityReport wheelchair mobility and whether self-propel is possible