CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

SNF / Acute Rehab / LTAC Initial Authorization Request Form

This document is an administrative authorization request form used by Neighborhood Health Plan of Rhode Island for initial admission requests to Skilled Nursing Facility (SNF), Acute Rehabilitation, Long-Term Acute Care (LTAC), and custodial SNF levels of care; it governs submission of member, provider, and clinical information to Utilization Management for authorization determinations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySNF / Acute Rehab / LTAC Initial Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed initial authorization request form to Utilization Management via fax (401-459-6023).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pageform length

401-459-6023UM submission fax number

4 clinical areassections

SNF/Acute Rehab/LTAClevels selectable

Authorization Requirements

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Initial Authorization Requirements

Initial admission authorization requests require completion of member, provider, and clinical sections and submission of supporting clinical documentation.

Completed form includes member identification (name, ID, DOB), requesting facility/provider contact information, and ordering physician details.

Level of care selected (SNF skilled or custodial, Acute Rehabilitation, or LTAC) and date of admission if known.

Diagnosis information provided with ICD-10 code(s).

Purpose of referral indicated (e.g., rehab therapy, skilled nursing, respiratory support, custodial services).

Supporting clinical documentation attached to demonstrate medical necessity (examples: rehab evaluation, progress notes, skilled needs documentation, discharge planning notes).

Submission of the completed form to Utilization Management via fax to (401) 459-6023.

Authorization outcome: member/provider will be returned an authorization number, dates of service, and services approved; authorization is not a guarantee of payment. If not approved, a letter will follow notifying the provider.

Submission, Documentation, and Notifications

Prior Authorization

Submission and Authorization Outcome

Submit the completed SNF/Acute Rehab/LTAC Authorization Request Form to Neighborhood Health Plan of Rhode Island Utilization Management by fax at (401) 459-6023. Refer to www.nhpri.org for detailed benefit information, authorization requirements, and coverage criteria.

Fax: (401) 459-6023
Only initial requests: use the SNF / Acute Rehab / LTAC Initial Request form (1 page)

Denial Risk

Denial Notification and Authorization Details

If the request is not approved, the provider will receive a written denial notification. Authorization is not a guarantee of payment; the denial or approval letter will include the Authorization #, Dates of Service, Services Approved (if any), UM initials, and Notification Date.

Not Approved: Letter to follow
Authorization details provided on approval: Authorization #, Dates of Service, Services Approved, UM Initials, Notification Date

Documentation Required

Required Clinical Documentation

Include all required clinical documentation to support medical necessity for the requested level of care.

Rehab evaluation and therapy records (PT/OT/ST) when applicable
Progress notes documenting skilled needs (e.g., IV medications, complex wound care)
Respiratory documentation for ventilator/tracheostomy care
Discharge planning notes
Any other relevant clinical notes or supporting documentation
Check the form box if clinical notes are attached

Level of Care and Diagnosis Fields

inv-06: Level of Care

Selectable levels of care on the formSNF Skilled; SNF Custodial; Acute Rehab; LTAC (select one option)

Where to indicate level of care'Level of Care (select one option)' field in Provider Information section of the form

Related submission instructionReturn completed form to Utilization Management via fax (401) 459-6023

inv-07: Diagnosis / ICD-10

Required diagnosis codingICD-10 diagnosis code(s) — primary and additional codes as provided on the form

Location on form'CLINICAL INFORMATION' section under 'Diagnosis Description' and 'ICD-10 Diagnosis Code' fields

Supporting documentationInclude supporting clinical documentation (e.g., rehab evaluation, progress notes) to demonstrate medical necessity