CurrentHighmark Blueshield NenyPolicy N/A

Medicare Inpatient Rehabilitation Facility Services

Template and instructions for completing the inpatient rehabilitation facility (IRF) admission/continued stay clinical review form based on Medicare Benefit Policy Manual Chapter 1. Specifies required form sections, timing of clinical reviews, and minimum therapy tolerance for acute inpatient rehab requests.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedicare Inpatient Rehabilitation Facility Services

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProviders must complete Sections 1-8 of the IRF clinical review form and include required clinical details (diagnoses with ICD code, vitals, mental status, therapies, wounds, devices, discharge plan).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified.

8Required Form Sections

48hInitial clinical review recency

24hContinued stay review recency

3 hrs/dayMinimum acute IRF therapy tolerance

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This administrative guideline and intake form template operationalizes Medicare Benefit Policy Manual Chapter 1 requirements for inpatient hospital/IRF services by specifying the clinical data elements, form sections, and timing needed to support IRF admission and continued stay reviews. It is a Highmark BlueShield NENY administrative document used to guide completion and submission of the IRF clinical review form.

Scope: Template and instructions for completing the inpatient rehabilitation facility (IRF) admission/continued stay clinical review form based on Medicare Benefit Policy Manual Chapter 1, specifying required form sections, timing of clinical reviews, and minimum therapy tolerance for acute inpatient rehab requests.

Key scope & metadata

PolicyMedicare Inpatient Rehabilitation Facility Services

PayerHighmark BlueShield NENY

StatusCURRENT

Effective DateN/A

Policy NumberN/A

Required Form Sections8 sections (Demographics; PLOF; Clinical Review; PT; OT; ST; Discharge Plan; PHI)

Initial clinical review recency48 hours (clinical must be no older than 48 hours from requested admit date)

Continued stay review recency24 hours (clinical documentation must be no older than 24 hours from the last covered stay day)

Minimum acute IRF therapy toleranceMember must tolerate at least 3 hrs/day, 5 days/week for acute inpatient rehab requests

Coverage Stance & Purpose

Coverage stance: informational. Purpose: this form/template supports admission and continued stay reviews and documents the specific requirements used to determine IRF appropriateness per Medicare guidance — including completion of required sections (demographics, PLOF, clinical review, PT, OT, ST, discharge plan, PHI), documentation of diagnoses (with ICD code), clinical status, and therapy tolerance.

Scope summary: Template and instructions for completing the inpatient rehabilitation facility (IRF) admission/continued stay clinical review form based on Medicare Benefit Policy Manual Chapter 1; specifies required form sections, timing of clinical reviews, and minimum therapy tolerance for acute inpatient rehab requests.

Admission, Continued Stay & Form Completion Requirements

Admission / Clinical Review Timing & Therapy Tolerance Requirements

Requirements to support IRF admission or continued stay requests:

Initial clinical review recency: Clinical review/documentation must be no older than 48 hours from the requested admit date for initial requests<= 48 hours from requested admit date
Continued stay clinical recency: Continued stay requests clinical documentation must be no older than 24 hours from the last covered stay day<= 24 hours from last covered stay day
Therapy tolerance - standard: Member must be able to tolerate therapy sessions at least 3 hours a day, 5 days per week for acute inpatient rehab requests; if unable, consider a lower level of care>= 3 hours per day, 5 days per week
Admission to IRF may not be appropriate if tolerance not met
Therapy tolerance - alternate question: Intake asks whether the member can tolerate one hour of therapy 5 days a week with full participation (Yes/No)1 hour x 5 days question

Admission / Clinical Review Timing & Therapy Tolerance Requirements - summary: Ensure clinical reviews for initial admission and continued stay meet recency requirements and document therapy tolerance per form guidance

Form Completion Requirements

All sections must be completed as appropriate:

Section 1: Demographic Information
Section 2: Prior Level of Function (PLOF)
Section 3: Clinical Review
Section 4: Physical Therapy
Section 5: Occupational Therapy
Section 6: Speech Therapy

Clinical Content Elements to Document

Key clinical and social information required on the form:

Transfer/acute admission date and whether date of injury/illness is within 30 daysdate within 30 days flag
Diagnosis with ICD: Diagnosis for post-acute admission (include ICD code)
Reason for skilled stay/monitoring needs: Reason for skilled stay and whether frequent medical assessment or intense monitoring is required
Prior Level of Function details: Prior Level of Function: ambulation, wheelchair use, transfers, ADL assistance levels, home DME, community resources

What Providers Must Do

Documentation Required

Complete all form sections

Complete Sections 1–8 of the IRF clinical review form and include required clinical details: diagnoses with ICD code, vitals and mental status, therapies (PT/OT/ST), wounds and treatments, devices (IV/respiratory/feeding/TPN), and the discharge plan.

Documentation Required

Timely clinical reviews

Ensure clinical documentation for initial admission requests is dated within 48 hours of the requested admit date and documentation for continued stay requests is dated within 24 hours of the last covered stay day.

Prior Authorization

Fax completed form for review

Fax the completed survey to 1-800-416-9195 for IRF authorization and clinical review.

Denial Risk

Risk if therapy tolerance not met

If the member cannot tolerate at least 3 hours of therapy per day, 5 days per week, consider a lower level of care; IRF admission may not be appropriate.

Documentation Required

PHI handling

These documents contain PHI. Providers must return, destroy, or further protect any PHI they received for patients they are not treating and must immediately destroy or safeguard inappropriate PHI in accordance with federal and state laws.

Required Form Sections & Clinical Data Elements

The following lists the specific sections and the detailed clinical and social data elements required on the IRF intake/clinical review form, including: Section 1 Demographic Information; Section 2 Prior Level of Function (PLOF); Section 3 Clinical Review (vitals, mental status, labs, IV meds, respiratory support, nutrition, wounds); Section 4 Physical Therapy (bed mobility, transfers, gait, endurance, assistive devices, PT goals); Section 5 Occupational Therapy (ADLs, household management, OT goals); Section 6 Speech Therapy (cognition, language, swallowing, ST goals); Section 7 Discharge Plan (caregiver training, disposition, home resources, DME, home eval, post-discharge services); and Section 8 Protected Health Information handling instructions.

Section 1Demographic Information

Section 2Prior Level of Function (PLOF)

Section 3Clinical Review

Section 4Physical Therapy

Section 5Occupational Therapy

Section 6Speech Therapy

Section 7Discharge Plan

Section 8Protected Health Information

Key Thresholds and Timing Requirements

Thresholds & timing

Therapy tolerance (required)>= 3 hours/day, 5 days/week

Alternate therapy tolerance questionCan the member tolerate 1 hour of therapy x 5 days/week (Yes/No)

Clinical review recency — initial admit (required)<= 48 hours from requested admit date

Clinical review recency — continued stay (required)<= 24 hours from last covered stay day

Action if therapy tolerance not metConsider lower level of care; IRF admission may not be appropriate

Note: these thresholds and timing requirements determine IRF appropriateness and, if not met (for example, inability to tolerate the required therapy or lack of timely clinical documentation), may prompt consideration of a lower level of care.

Definitions

Key definitions

PLOFPrior Level of Function — baseline functional status before current illness/injury.

This form operationalizes Medicare Benefit Policy Manual Chapter 1 for inpatient hospital/IRF services by translating Medicare requirements into the IRF clinical review intake fields, required documentation timing, therapy tolerance thresholds, and PHI handling instructions to support admission and continued stay determinations.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedicare Inpatient Rehabilitation Facility Services

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Medicare Inpatient Rehabilitation Facility Services

Summary

Coverage Stance & Purpose

Admission, Continued Stay & Form Completion Requirements

What Providers Must Do

Required Form Sections & Clinical Data Elements

Key Thresholds and Timing Requirements

Definitions

Document Changes