CurrentHighmark Blueshield NenyPolicy N/A

Acute Inpatient Rehabilitation Admission Request Form — Coverage Criteria

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This document is the Highmark Blue Shield acute inpatient rehabilitation admission request form and instructions for providers to submit required clinical, functional, and discharge information to request initial or continued inpatient rehab coverage for members.

Policy Summary

PayerHighmark Blueshield Neny

PolicyAcute Inpatient Rehabilitation Admission Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed admission and continued-stay clinical review forms via fax within required timeframes (48 hours for admission; 24 hours for continued stay).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8form parts to complete

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CurrentHighmark Blueshield NenyPolicy N/A

Acute Inpatient Rehabilitation Admission Request Form — Coverage Criteria

Customize your policy alerts

Sign up for all Highmark Blueshield Neny policy alerts

Know when Highmark Blueshield Neny releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerHighmark Blueshield Neny

PolicyAcute Inpatient Rehabilitation Admission Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed admission and continued-stay clinical review forms via fax within required timeframes (48 hours for admission; 24 hours for continued stay).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8form parts to complete

Admission and Continued Stay Criteria

Admission and Continued Stay Documentation Criteria

Covered when documentation demonstrates medical complexity requiring inpatient rehabilitation and the member can participate in and benefit from therapy.

Admission documentation requirements: All of the following must be provided: Part One patient demographics and transfer information (including date of acute care admission, diagnosis and ICD code, date of injury/illness), Part Two prior level of function, Part Three clinical review (vitals, mental status, abnormal labs if being monitored, IV medications, respiratory status including O2 flow/trach/suctioning, enteral/parenteral nutrition, wounds), Part Four physical therapy functional status and goals, Part Five occupational therapy functional status and goals, Part Six speech therapy status/goals when applicable, and Part Seven discharge plan.

Form sections 1-7 as specified on the ACUTE INPATIENT REHAB REQUEST form.

Timeliness: Clinical review for admission must be submitted within 48 hours of the requested admission date; continued stay requests must be submitted within 24 hours from the last covered day.48 hours for admission; 24 hours for continued stay

See PART THREE and repeated statements in PART FIVE and PART SIX.

Therapy tolerance and recency: Documentation must indicate whether the member can tolerate one hour of therapy five days per week with full participation and whether the date of injury or illness is within the prior 30 days, as these items inform appropriateness for acute inpatient rehabilitation.1 hour x 5 days/week; injury within 30 days

Question appears in Transfer Information (Part One).

Medical complexity indicators: Provide any applicable indicators: need for frequent medical assessment or intensive monitoring due to potential for rapid deterioration, current IV medications (name, frequency, stop date), respiratory support details (O2 flow, sats, nebulizers, trach date/size, suctioning frequency, decannulation goals), enteral/parenteral nutrition details (NG/PEG/TPN dates, rates, tolerability), and wound treatment details (stage, treatment, measurements, dressing frequency, wound specialist appointments).

Clinical elements captured in Part Three clinical review.

The form does not list any explicit clinical exclusions. There is no section or checkbox that names specific diagnoses or conditions that are automatically excluded from consideration for acute inpatient rehabilitation on this request form.

The form does not present a list of not medically necessary conditions. Instead, it collects clinical information (for example, whether the date of injury/illness is within the last 30 days, the reason for skilled stay, and whether the member can tolerate one hour of therapy 5 days per week) that the payer uses to determine whether inpatient rehabilitation is appropriate or not.

Provider Submission Requirements & Timelines

Prior Authorization

Submit clinical review within required timeframes

Admission and continued-stay clinical reviews must be submitted on this form to the payer via fax within the required timeframes: admission reviews within 48 hours of the requested Admission Date; continued-stay requests within 24 hours from the last covered day.

Submit completed form via fax to the number on the form.

Step Therapy

Record injury recency and therapy tolerance

Document whether the date of injury/illness is within the last 30 days of the request and whether the member can tolerate one hour of therapy five days per week with full participation; these items are required on the form to support appropriateness for acute inpatient rehabilitation.

Question on form: “Is the date of injury or illness within the last 30 days of this request: (yes/no)?”
Question on form: “Can the member tolerate one hour of therapy 5 days a week with full participation: (yes/no)?”

Functional Assistance Levels

Functional assistance levels (definitions and use)

Assistance level categoriesThe form uses standardized assistance levels for transfers and ADLs: Independent; Modified Independence; Supervision; Contact Guard Assist; Minimal, Moderate, Maximum Assistance; Dependent/Total Assist.

Where appliedThese levels are used across PT sections (bed mobility, rolling, sit to stand, bed-to-chair, sitting balance) and OT sections (feeding, grooming, bathing UE/LE, dressing UE/LE).

PurposeProviders must document baseline and current functional status using these categories to support medical necessity for acute inpatient rehabilitation.

Most actionable itemWhen completing the form, indicate the specific assistance level for each task (e.g., Bed to chair: Contact Guard Assist; Feeding: Modified Independence) for both 'As of date' and baseline to demonstrate change and therapy need.

Related cognitive/communication itemsCognition, ability to follow commands, language deficits, memory deficits and safety/judgement are also documented to contextualize functional assistance needs.

Purpose of the Form

This request form gathers the necessary clinical, functional, and discharge-planning data to assess medical necessity for acute inpatient rehabilitation. It requests patient demographics and transfer information (including date of acute care admission and diagnosis/ICD code), indicators of medical complexity (need for frequent assessment or intensive monitoring), therapy tolerance and recency of injury (whether injury/illness occurred within the prior 30 days and whether the member can tolerate 1 hour of therapy 5 days/week), and other elements used to judge appropriateness for inpatient rehab.