This Acute Inpatient Rehab Request form operationalizes the clinical and functional information Highmark Blue Shield and its affiliates require to evaluate medical necessity and manage authorization for post-acute inpatient rehabilitation. It is a multi-part tool completed by providers/facilities requesting admission or continued stay review and must be fully completed to support timely review.
The form captures pre-admission baseline and transfer details (including date of acute admission, whether the date of injury/illness is within the last 30 days, and the stated reason for a skilled stay) and documents whether the member can tolerate one hour of therapy 5 days per week with full participation — a key threshold for appropriateness of inpatient rehab.
Clinical data elements required to support medical necessity include current vitals and mental status/ability to follow commands, any abnormal labs being monitored, IV medication details (name, frequency, stop date), respiratory support and goals (oxygen flow, sats, nebulizer/trach details, goals such as decannulation or weaning), feeding support and TPN status, and wound characteristics and treatment details.
The form requires standardized, discipline-specific functional and therapy items for Physical Therapy, Occupational Therapy, and Speech Therapy. PT sections capture bed mobility, transfers, sitting/standing balance, gait and wheelchair assistance, steps, endurance, strength, and PT goals. OT sections capture feeding, grooming, bathing, dressing, toileting/functional transfers, household management and OT goals. Speech sections capture cognition, command following, language and memory deficits, safety/judgement concerns, swallowing deficits and diet, and speech goals.
Discharge planning information is captured to ensure safe transition and continuity of care, including caregiver training status and barriers, anticipated disposition (home alone, home with caregiver, personal care home, assisted living, etc.), caregiver availability and hours, DME needs, planned home evaluation, community resources, need for home health or outpatient therapy, and next MD appointment.
Operational and timing requirements are emphasized: initial clinical reviews must be submitted within 48 hours of the requested admission date, and continued stay requests must be submitted within 24 hours from the last covered day. Failure to meet these timeframes may jeopardize timely review or coverage determinations.
Providers must complete all applicable parts of the form (Patient Information through PHI) and provide the detailed clinical, functional, therapy, and discharge data specified to support admission and continued stay reviews.
The form includes instructions on handling Protected Health Information: federal and state laws prohibit inappropriate use of PHI, and unintended recipients must return, destroy, or otherwise safeguard PHI they receive that pertains to a patient they are not treating.