CurrentHighmark DelawarePolicy N/A

SNF Initial Review / Post-acute facility admission form - Coverage Criteria

Template and requirements for Skilled Nursing Facility (SNF) initial review submission to Highmark (Delaware among served areas) — collects patient demographics, prior level of function, clinical review, therapy assessments, discharge planning, and PHI guidance. Applies to providers requesting admission to post-acute facility levels of care.

Policy Summary

PayerHighmark Delaware

PolicySNF Initial Review / Post-acute facility admission form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the clinical review within 48 hours of the requested admission date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8form parts to complete

48hclinical review timeframe

1admission date mapping

9/17/2021document last reviewed

Provider Submission & Documentation Requirements

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Documentation Required

Admission documentation required

Complete Part One patient demographic and transfer information. Include member name, DOB, member ID, reference/case number, SNF facility name and NPI, facility contact name/department and phone/fax, accepting MD name and NPI, MD phone/address. For transfer information provide transfer source, acute care admission date, date of injury/illness (indicate if within 30 days), contact at transferring facility, diagnosis for post-acute admission with ICD code, reason for skilled stay, and whether the member can tolerate one hour of therapy 5 days per week with full participation. Also list chronic conditions.

Include ICD-10 diagnosis code(s) for the post-acute admission.
Document explicit reason for skilled stay tied to medical complexity, monitoring needs, or safety concerns at home.
Answer whether the member can tolerate 1 hour of therapy × 5 days/week (yes/no).

Documentation Required

Therapy documentation

Complete Part Four / Part Five occupational therapy and Part Six speech therapy sections to document current participation and function. Record participation (yes/no), and detailed activity-level measures: feeding, grooming, bathing (UE/LE), dressing (UE/LE), hygiene/toilet transfers, household management, transfers (bed mobility, supine-to-sit, sit-to-stand, bed-to-chair), sitting balance (static/dynamic), wheelchair assistance and distance, endurance, strength, and PT/OT short- and long-term goals. Provide assistance level for each task using standard categories (Independent, Modified Independence, Supervision, Contact Guard, Minimal/Moderate/Maximum Assistance, Dependent) and include dates for the assessments.

For OT: document ADLs/IADLs with assistance levels and dates.
For PT: document bed mobility, transfers, gait/wheelchair distance, endurance, strength, and PT goals (short- and long-term).
For Speech: document participation, swallowing/feeding status (oral diet vs NG/PEG; dates placed, feeds, rates, tolerance), communication/cognitive issues, and any required therapy goals.

Criteria for SNF / Post-Acute Admission

SNF Admission Criteria

Covered when ALL of the following are met:

Complete Part One (demographics, diagnosis with ICD code, reason for skilled stay, and documentation that the member can tolerate one hour of therapy 5 days/week) and submit the clinical review within 48 hours of the requested admission date.

Use the SNF Initial Review form; DATE FORM COMPLETED field maps to admission date (1 = admission date).

Background and Purpose

This form captures the clinical and functional information required to assess medical necessity for Skilled Nursing Facility (SNF) or other post-acute facility admission. It documents current acuity (for example, IV medications, TPN, oxygen therapy, tracheostomy/airway management), the patient’s ability to participate in therapy (ability to tolerate 1 hour of therapy 5 days/week), and other ongoing skilled nursing needs. The form is used to communicate baseline function and skilled needs from the transferring facility and to support the admission decision-making process.

Providers must complete the clinical review portion and submit it in a timely manner: Clinical Reviews must be submitted within 48 hours of the requested Admission Date. Failure to submit the clinical review within this timeframe may result in delay or denial of authorization.

Key Definitions

Reason for skilled stay

DefinitionReason for skilled stay: Does the medical complexity require frequent medical assessment, intense monitoring with potential for rapid deterioration or debility that makes care at home unsafe?

ContextCaptured in Part One - Patient Information under Transfer Information to justify SNF/post-acute admission

Related required dataDocument diagnosis with ICD code and whether the member can tolerate one hour of therapy 5 days/week (full participation)

Use for medical necessitySupports assessment of need for frequent skilled nursing or monitoring (e.g., IV meds, wound care, respiratory support) documented elsewhere on the form

Form locationAsked in Transfer Information (Part One) alongside admission date and chronic conditions

Discharge Planning & Criteria

Part Seven documents discharge planning elements that must be completed before or during the SNF stay. The form collects whether caregiver training has been completed and any barriers to training, the anticipated disposition (examples: home alone, home with caregiver, personal care home, assisted living, long-term residential care), and whether a caregiver is available (including hours available).

It also records social determinants of health impacting discharge (for example, transportation, housing stability, food insecurity, financial strain, health literacy), durable medical equipment (DME) needs, whether a home evaluation is planned, and if home health care or outpatient therapy will be required after discharge. The form requests next MD appointment information, community resources needed, and any additional pertinent discharge barriers or notes.