CurrentHighmark Blueshield NenyPolicy N/A

Medicare Inpatient Rehabilitation Facility (IRF) admission and documentation requirements

Governs clinical and documentation requirements for Medicare-covered inpatient rehabilitation facility (IRF) admissions and continued-stay/ discharge planning for Highmark BlueShield NENY members. Affects providers completing IRF admission requests and clinical review forms.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedicare Inpatient Rehabilitation Facility (IRF) admission and documentation requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete all sections of the IRF request form and fax the completed form to 1-800-416-9195.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=3 hrs/day, 5 days/weekMinimum therapy tolerance for acute inpatient rehab requests

48 hoursInitial clinical review recency

24 hoursContinued-stay clinical review recency

1-800-416-9195Form submission fax number

Admission and Coverage Criteria

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Admission (initial) criteria

Covered when ALL of the following are met

IRF admission basic criteria: Member has medical need for frequent medical assessment or intense monitoring, or medical complexity that makes care at home unsafe (e.g., frequent medical assessment, intense monitoring with potential for rapid deterioration, or home unsafe).see node text

Document diagnosis with ICD code, reason for skilled stay, and complete required form sections (Sections 1–7).

Therapy tolerance and participation: Member can tolerate the required therapy intensity for acute inpatient rehabilitation (ideally ≥ 3 hours per day, 5 days per week). If unable to tolerate this intensity, consider a lower level of care (e.g., SNF or home-based services). The IRF form asks whether the member can tolerate one hour of therapy 5 days/week to help determine appropriate level of care.>= 3 hrs/day, 5 days/week (preferred)

Prior authorization/authorization requests must document therapy tolerance; requests may be denied if member cannot tolerate required therapy intensity.

Current clinical review: Clinical assessment/documentation supporting the requested admit is current: initial clinical review must be no older than 48 hours from the requested admit date.<= 48 hours

Complete clinical review (Section 3) including vitals, mental status, labs, IV meds, respiratory status, nutrition, wounds as applicable.

Prior level of function and documentation: Prior level of function (PLOF) must be documented (mobility, transfers, ADLs, cognitive status), and demographic/transfer information and ICD diagnosis must be completed on the form.see node text

Form sections 1–4 and PLOF must be completed and faxed to 1-800-416-9195.

Continued-stay criteria

Continued stay covered when ALL of the following are met

Continued-stay clinical recency and participation: Clinical reviews for continued-stay must be current within 24 hours of the last covered day and clinical review documentation must be submitted within 24 hours of the requested admit date. Member must be participating in therapy as documented on the form and ongoing PT/OT/ST goals must be recorded.<= 24 hours

Document participation, updated vitals, abnormal labs if monitored, IV meds, respiratory needs, nutrition support, wound care, and updated PT/OT/ST functional measures and goals.

If a member cannot tolerate the required therapy intensity for acute inpatient rehabilitation — defined in this policy as at least 3 hours per day, 5 days per week — the IRF level of care is not appropriate and a lower level of care should be considered (for example, SNF or home-based services). The IRF request form explicitly asks whether the member can tolerate one hour of therapy 5 days per week with full participation to help determine the most appropriate level of care. Providers must document therapy tolerance on the IRF form and include clinical rationale when tolerance is limited.

Inpatient Rehabilitation Facility (IRF) Admission

IRF

IRF admission requirements: Complete demographic and transfer information; document diagnosis with ICD code and reason for skilled stay (frequent medical assessment, intense monitoring with potential for rapid deterioration, or home unsafe); document prior level of function (mobility, transfers, ADLs, cognitive status); clinical review current within 48 hours of requested admit date; document ability to tolerate required therapy intensity (≥3 hrs/day, 5 days/week) or provide rationale if not tolerable.see text

Form sections 1–4 and PLOF must be completed. Question on form: 'Can the member tolerate one hour of therapy 5 days a week with full participation?'

Provider Actions and Documentation Requirements

Denial Risk

Therapy tolerance requirement

PLEASE NOTE: Member must be able to tolerate therapy sessions at least 3 hours per day, 5 days per week for acute inpatient rehabilitation requests. Requests may be denied if the member cannot tolerate the required therapy intensity. If the member is unable to tolerate this intensity, consider and document a lower level of care.

Therapy intensity: ≥ 3 hours/day, 5 days/week for acute IRF requests
Denial risk if unable to meet therapy tolerance
If unable to tolerate, consider lower-level care (e.g., skilled nursing, outpatient, or home-based therapy)

Documentation Required

Complete and submit IRF request form

Complete and submit the IRF request form in full. All relevant sections must be filled out and current clinical information included: Section 1 Demographic Information; Section 2 Prior Level of Function; Section 3 Clinical Review; Section 4 Physical Therapy; Section 5 Occupational Therapy; Section 6 Speech Therapy; Section 7 Discharge Plan; Section 8 Protected Health Information. Fax completed form to 1-800-416-9195. Ensure clinical review dates meet recency requirements.

Include admit date, anticipated discharge date, and discharge plan
Provide facility NPI, accepting MD name and NPI, and contact information
Attach current clinical review and therapy sections (PT, OT, ST)

Prior Authorization

Lower-level care consideration

The transfer/request form asks whether the member can tolerate one hour of therapy 5 days a week with full participation to help determine appropriate level of care. If the member cannot meet the IRF intensity requirement (3 hrs/day, 5 days/week), document responses to this lower-level care consideration to support placement decisions.

Form question: "Can the member tolerate one hour of therapy 5 days a week with full participation?" (Yes/No)
Use this response to assess suitability for lower-intensity settings

Key Definitions

inv-10: Therapy tolerance — Definition and requirements

DefinitionAbility of the member to tolerate at least 3 hours per day of therapy, 5 days per week for acute inpatient rehabilitation requests.

ImplicationIf member cannot tolerate this intensity, consider a lower level of care (e.g., SNF or home-based services).

Documentation requiredPrior authorization/authorization requests must include documentation that the member can tolerate the required therapy intensity.

Form locationTherapy tolerance is assessed on the IRF request form (sections PT/OT/ST and clinical review).

inv-11: Current clinical review — Recency and content

DefinitionClinical assessment or documentation dated within 48 hours of the requested admit date for initial IRF requests; for continued-stay requests, clinical reviews must be no older than 24 hours from the last covered day.

Required elementsClinical review should include date, vitals, mental status, abnormal labs (if monitored), IV medication details, respiratory status/needs, oral/enteral/TPN nutrition status, wound treatment, and other relevant monitoring needs.

Timing for submissionClinical reviews for continued-stay must be submitted within 24 hours of the requested admit date.

Form sectionThese items are captured in SECTION 3 CLINICAL REVIEW of the IRF request form.

Background and Scope

This policy operationalizes Medicare Benefit Policy Manual guidance for Inpatient Rehabilitation Facility services by specifying the clinical and documentation items required to establish IRF medical necessity. It emphasizes three core elements: recent clinical review (initial clinical review within 48 hours of the requested admit date and continued-stay reviews within 24 hours), documentation of the member’s prior level of function, and evidence of the member’s ability to tolerate the required therapy intensity (ideally >=3 hours/day, 5 days/week). The standardized IRF form collects demographics, diagnosis with ICD code, reason for skilled stay, PT/OT/ST measures and goals, medical monitoring needs, and discharge planning to support admission, continued-stay, and discharge decisions.

OpenPayer

Medicare Inpatient Rehabilitation Facility (IRF) admission and documentation requirements

Admission and Coverage Criteria

Inpatient Rehabilitation Facility (IRF) Admission

Continued Stay (IRF)

Provider Actions and Documentation Requirements

Key Definitions

Discharge Criteria

Service Day Limits

Background and Scope