CurrentHighmark DelawarePolicy N/A

Rehab Precert Worksheet

A multi-part precertification/authorization worksheet to collect clinical, functional, therapy, discharge planning, and PHI information for requests for acute inpatient rehabilitation admissions and continued stays for Highmark Blue Shield members. Specifies submission timeframes for admission and continued stay requests and outlines required patient, clinical, therapy, and discharge data to support authorization.

Policy Summary

PayerHighmark Delaware

PolicyRehab Precert Worksheet

Policy CodePolicy N/A

Change TypeInformational (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete all applicable sections (Parts One through Eight) of the Acute Inpatient Rehab Request form and fax to 1-800-416-9195 to support admission/continued stay review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this document is an administrative worksheet with no changes to policy or coverage.

8Form Parts

48hAdmission Review Deadline

24hContinued Stay Deadline

Policy purpose and scope

This worksheet is issued on behalf of Highmark Blue Shield and affiliated Blue companies to collect necessary information for acute inpatient rehabilitation admissions and continued stay reviews. It is a standardized multi-part form used to gather clinical, functional, therapy, discharge planning, and protected health information to support utilization review and authorization decisions.

The form is organized into multiple parts (Parts One through Eight) to capture patient demographics and transfer details; prior level of function; clinical review (including vitals, labs, IV/TPN, respiratory, nutrition, and wound details); physical, occupational, and speech therapy functional status and goals; discharge planning; and PHI handling instructions to support admission and continued stay requests.

Key Policy Fields

PayerHighmark Delaware

PolicyRehab Precert Worksheet

Policy CodeN/A

Effective Date

Last Review2021-09-17

Next Review

StatusCURRENT

Scope SummaryA multi-part precertification/authorization worksheet to collect clinical, functional, therapy, discharge planning, and PHI information for requests for acute inpatient rehabilitation admissions and continued stays for Highmark Blue Shield members. Specifies submission timeframes for admission and continued stay requests and outlines required patient, clinical, therapy, and discharge data to support authorization.

Coverage stance and timing requirements

Coverage stance: informational — This document is an informational precertification/authorization worksheet intended to collect clinical, functional, therapy, discharge planning, and PHI details to support review and authorization processes and does not itself constitute a coverage determination.

Submission Timing Requirements

Clinical Reviews and Continued Stay Requests must meet the following timing requirements:

ALL of the following

Clinical Reviews must be submitted within 48 hours of requested Admission Date.
Continued Stay Requests must be requested within 24 hours from the last covered day.

Timing & Form Stats

Admission Clinical Review Deadline48 hours

Continued Stay Request Deadline24 hours

Form Parts8

Required provider documentation and submission steps

Documentation Required

Complete full precertification worksheet

Providers must complete Parts One through Eight and fax the completed Acute Inpatient Rehab Request form to 1-800-416-9195 to support admission and continued stay review.

Documentation Required

Include diagnoses with ICD code

Include the diagnosis for the post-acute admission and specify the ICD code(s) on the form.

Documentation Required

Provide clinical and therapy details

Provide clinical review details (vitals, mental status/ability to follow commands, abnormal labs, IV medications with name/frequency/stop date, respiratory and O2 needs including flows and goals, NG/PEG/TPN details, wound stage/treatment/measurements/frequency) and comprehensive PT/OT/ST functional status and short‑ and long‑term goals as requested on the form.

Documentation Required

Return PHI handling requirement

If you receive PHI that is not intended for you, you must return, destroy, or otherwise protect that PHI immediately as required by federal and state law; contact the facility phone number listed in the demographic section for instructions if needed.

Form details and submission instructions

The document is a multi-part precertification/authorization worksheet (Parts One through Eight) used to collect clinical, functional, therapy, discharge planning, and PHI information to support requests for acute inpatient rehabilitation admissions and continued stays for Highmark members. It specifies submission timeframes for Clinical Reviews (within 48 hours of requested admission date) and Continued Stay Requests (within 24 hours from the last covered day) and outlines required patient, clinical, therapy, and discharge data to support authorization.

Operational Details

Fax Number1-800-416-9195

Number of Form Parts8

Admission Deadline (reiterated)Submit clinical reviews within 48 hours of requested admission date

Continued Stay Deadline (reiterated)Request continued stay within 24 hours from the last covered day

Policy Summary

PayerHighmark Delaware

PolicyRehab Precert Worksheet

Policy CodePolicy N/A

Change TypeInformational (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete all applicable sections (Parts One through Eight) of the Acute Inpatient Rehab Request form and fax to 1-800-416-9195 to support admission/continued stay review.

SourceLink

On This Page

OpenPayer

Rehab Precert Worksheet

Policy purpose and scope

Coverage stance and timing requirements

Required provider documentation and submission steps

Form details and submission instructions

Document reviews