CurrentFidelis CarePolicy N/A

Concurrent Inpatient Rehabilitation Therapy Progress Review

This document governs the required form and submission process for requests for continued concurrent inpatient rehabilitation therapy for Fidelis Care members across specified product lines; it affects providers submitting authorization requests and accepting rehabilitation facilities.

Policy Summary

PayerFidelis Care

PolicyConcurrent Inpatient Rehabilitation Therapy Progress Review

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed form to Fidelis Care at 833-663-1611 and include the authorization number and requested rehabilitation level for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

833-663-1611fax number to submit form

1-888-FIDELISphone for questions

Metal/Medicaid/CHP/MAproduct lines required

Requiredauthorization

Coverage and Authorization Criteria

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.

Authorization and documentation criteria

Covered when ALL of the following administrative and documentation requirements are met

Administrative and documentation requirements

Submission: Form filled completely and faxed to Fidelis Care at 833-663-1611.
Product coverage: Member is enrolled in Metal-Level Products, Managed Medicaid, CHP, or Medicare Advantage.
Required form fields: Form includes authorization number, rehabilitation level requested, projected discharge date, discharge needs, and barriers to discharge.
Clinical documentation: Attach most current PT/OT/ST weekly progress notes with levels of assistance and ADL testing results; recent social work progress with discharge planning and/or barriers to discharge; current week nursing notes; IV antibiotic details if applicable (medication name, dosage, IV stop date); weekly wound care measurements and treatment plan if applicable; and any additional supporting information for continued concurrent rehabilitation services.

Administrative summary: Accepting rehabilitation facility information must be provided (facility name, telephone, contact person, tax ID or NPI, address, fax, and in‑network status). Providers will be notified of the determination within the appropriate regulatory timeframe; authorization does not guarantee payment and is subject to member eligibility and correct coding.

Submission, Documentation, and Provider Responsibilities

Prior Authorization

Submission and Authorization

Fill this form completely and fax it to Fidelis Care at 833-663-1611. Include the authorization number and the requested rehabilitation level for review. Questions? Call 1-888-FIDELIS (1-888-343-3547), ext: 16082 or 16871.

Fax number: 833-663-1611
Phone for questions: 1-888-FIDELIS (1-888-343-3547), ext: 16082 or 16871

Note

Provider Notification

Providers will be notified of the determination within the appropriate regulatory timeframe.

Documentation Required

Form Fields to Complete

Complete all required form fields when requesting Short-Term Rehabilitation authorization. Provide the authorization number, the rehabilitation level requested, projected discharge date, discharge needs, and any barriers to discharge.

Authorization number
Rehabilitation level requested
Projected discharge date
Discharge needs
Barriers to discharge

Documentation Required

Required Clinical Documentation

Include current clinical documentation to support the request. Submit the most recent therapy progress notes and relevant clinical records as detailed below.

Most current physical, occupational, and/or speech therapy weekly progress notes with levels of assistance noted for each functional mobility and testing results for activities of daily living
Recent social work progress notes documenting discharge planning and/or barriers to discharge
Nursing notes and medical management for the current week of review
If on IV antibiotics: medication name, dosage, and IV stop date
If receiving wound care: weekly wound measurements, specific treatments provided, and treatment frequency and plan
Any additional information to support the request for continued or concurrent rehabilitation services
Accepting facility information: facility name, telephone, contact person (and ext.), tax ID or NPI, address, fax, in-network status, and IPA affiliation (if applicable)

Denial Risk

Payment Risk Note

Authorization does not guarantee payment: payment is subject to member eligibility and correct coding.

Purpose and Scope

This form is used to request continued concurrent inpatient rehabilitation therapy and to document progress, discharge planning, and clinical needs that justify ongoing inpatient rehabilitation services. It collects multidisciplinary documentation including the most current physical, occupational, and/or speech therapy weekly progress notes with levels of assistance for each functional mobility and ADL testing results; recent social work progress with discharge planning and barriers to discharge; current week nursing notes and medical management; IV antibiotic details when applicable (medication name, dosage, and IV stop date); and weekly wound care measurements, specific treatments, and treatment frequency and plan when applicable.

Key Definitions

Concurrent Inpatient Rehabilitation Therapy Progress Review

Form nameConcurrent Inpatient Rehabilitation Therapy Progress Review

PurposeRequired review form to request continued inpatient rehabilitation therapy and document progress, discharge planning, and clinical needs

Required for product linesMetal-Level Products; Managed Medicaid; CHP; Medicare Advantage

Submission methodComplete the form and fax to Fidelis Care (see submission instructions in policy)

Key data captured on formAccepting facility info, authorization number, rehabilitation level requested, projected discharge date, discharge needs, barriers to discharge, multidisciplinary progress notes