CurrentHighmark Blueshield NenyPolicy N/A

SNF Initial Review — Coverage Criteria for Skilled Nursing Facility Admissions

Covers the required initial review documentation and clinical information submission for Skilled Nursing Facility (SNF) admissions and initial utilization review affecting Highmark Blue Shield members in North Carolina.

Policy Summary

PayerHighmark Blueshield Neny

PolicySNF Initial Review — Coverage Criteria for Skilled Nursing Facility Admissions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit clinical review documentation within 48 hours of the requested admission date to support the SNF admission request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8form parts to complete

48hclinical review timeframe

1hr x5dtherapy tolerance

PHIprivacy guidance

Coverage and Admission Requirements

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inv-01: Admission documentation and clinical need

Admission is supported when required documentation is submitted and clinical needs indicate skilled care:

Required documentation and timeframe: Completed SNF Initial Review form submitted within 48 hours of requested admission date48 hours

Form includes demographics, diagnosis with ICD code, reason for skilled stay, and therapy tolerance question

Clinical need for skilled care: Medical complexity requiring frequent medical assessment, intense monitoring due to potential for rapid deterioration, or debility making care at home unsafe

Captured in the 'Reason for skilled stay' field on the form

Therapy capacity (when therapy is the reason for SNF stay): Member able to tolerate one hour of therapy 5 days per week with full participation1 hour/day, 5 days/week

Document response on Part One of the form

What Providers Must Submit and When

Documentation Required

Required form completion and documentation

Complete all parts of the SNF Initial Review form. Ensure patient demographics and transfer information (member name, DOB, member ID, reference/case number, SNF facility name/NPI/address, contact name/phone/fax, accepting MD name/NPI/phone/address) are filled. Provide prior level of function (ambulation, gait limitations, wheelchair use, transfer and ADL assistance levels, DME at home, community resources, baseline mental status, cognitive issues) and answer whether the member can tolerate one hour of therapy five days per week with full participation. Document detailed clinical review information (date, vitals, mental status/ability to follow commands, abnormal labs if monitored, IV medications with name/frequency/stop date, respiratory needs including O2 flow/teaching/O2 sats/nebulizers/trach details and goals, oral diet status, NG/PEG details with date placed/feeds/rate/goal/tolerance, TPN status with stop date/rate/whether on TPN at home, wounds/treatment including stage, treatment, measurements, dressing frequency, wound specialist appointments). Include transfer details (transfer from, acute care admission date, date of injury/illness within 30 days, contact at transferring facility, diagnosis with ICD code, reason for skilled stay). Note home environment or physical limitations affecting care (unreachable wound locations, contractures, obesity, motor strength, blindness/paralysis, lack of utilities or access to services, abuse), and whether home oxygen is needed (yes/no and specify).

Fill Part One: patient demographics and transfer information
Fill Part Two: prior level of function and baseline status
Confirm: Can the member tolerate 1 hour of therapy, 5 days/week (Yes/No)
Complete Part Three: clinical review details (see required fields)
Document any home environment barriers or physical limitations
Specify home oxygen requirement if applicable

Prior Authorization

Timely clinical review submission

Submit clinical review documentation to the payer within 48 hours of the requested SNF admission date to support the admission request. This includes the completed SNF Initial Review form with the clinical review section populated.

Clinical review submitted <= 48 hours of requested admission date
Include completed SNF Initial Review form and supporting clinical details

Documentation Required

Therapy tolerance documentation

Document whether the member can tolerate one hour of therapy five days per week with full participation. This is required on the Initial Review form and is used to determine appropriateness for skilled therapy services.

Therapy tolerance: Yes or No (1 hour/day, 5 days/week, full participation)
If No, document reasons (physical limitations, cognitive status, medical instability)

Form Purpose and Clinical Context

The form collects baseline functional status, therapy needs, and medical complexity to determine the need for skilled SNF care. Required fields include demographics, diagnosis (with ICD code), the reason for skilled stay (e.g., need for frequent assessment, intense monitoring, or debility making home care unsafe), and the therapy tolerance question asking whether the member can tolerate one hour of therapy 5 days per week. These items, together with sections capturing prior level of function and clinical review, inform whether skilled services are clinically indicated.

Key Functional Level Definitions

Transfer level of assistance — definitions

IndependentPatient performs transfers without assistance or devices.

Modified IndependencePatient requires an assistive device or extra time but no physical assistance for transfers.

SupervisionPatient requires stand-by supervision for safety during transfers (no hands-on assistance).

Contact Guard AssistCaregiver provides light hands-on contact to maintain balance or stability during transfers.

Minimal/Moderate/Maximum AssistanceRanges of physical assistance required: Minimal = caregiver assists with <25% of effort; Moderate = assists with ~25–75%; Maximum = assists with >75% of effort.

Total Assistance/DependentPatient is fully dependent and requires total hands-on assistance for transfers.

SNF Admission Criteria

inv-10: SNF — Admission criteria

Admission to a SNF is supported when BOTH administrative submission requirements are met and there is an identified skilled care rationale:

Admission review submission: Clinical review and completed SNF Initial Review form must be submitted within 48 hours of the requested admission date48 hours

Supports the initial admission decision and must include diagnosis (with ICD code) and reason for skilled stay

Skilled care rationale: Member requires frequent medical assessment, intense monitoring due to potential for rapid deterioration, or has debility that makes care at home unsafe

Documented under 'Reason for skilled stay' on the form

Criteria for Continued SNF Stay

inv-11: SNF — Continued stay criteria

Continued SNF stay is supported when ongoing skilled needs are documented with functional measures and therapy goals:

Ongoing skilled needs documented: Regular documentation of functional measures (bed mobility, transfers, gait/balance, wheelchair assistance and distance, endurance, strength) and PT/OT/ST short‑ and long‑term goalsas of date entries for each domain

Use the clinical review sections to show progress or ongoing skilled needs to justify continued SNF services

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