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Skilled nursing, subacute, and inpatient rehabilitation facility admission guidelines

August 23, 2019

Independence closely reviews skilled nursing, subacute, and inpatient rehabilitation admissions for medical necessity and to ensure our members are receiving the right level of care and in the most appropriate setting.

As outlined in the Provider Manual for Participating Professional Providers and/or Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, we would like to remind you that Independence follows therapy guidelines set by the Centers for Medicare & Medicaid Services (CMS), and InterQual®, a product of Change Healthcare, an independent company.

According to CMS and InterQual therapy guidelines, the minimum required hours for the following services are:

  • Skilled Nursing Facility. At least 1 – 2 hours of direct physical, occupational, or speech therapy per day, at least 5 days/week.
  • Subacute facility. At least 2 hours of direct therapy (physical, occupational, or speech therapy) per day, at least 6 days/week (i.e., at least 12 hours of direct therapy per week). Member must be physically and cognitively willing and able to participate in, and benefit from, the rehabilitation program.
  • Inpatient rehabilitation. At least 3 hours per day direct physical, occupational, or speech therapy per day, at least 5 days/week. Physician intervention at least 3 times/week.

To protect against delays in advancing medical care and service, we will be evaluating the following with each concurrent review:

  • follow-up appointments are timely;
  • members are receiving appropriate skilled therapy hours and number of days;
  • members are discharged timely and discharge plans are continually reviewed and updated to reflect the members functional status and expectations;
  • Notice of Medicare Non-Coverage (NOMNC) is delivered timely.

If you have any questions regarding these guidelines, please contact Sheila Van Daly, Manager, Clinical Services, at Sheila.VanDaly@ibx.com.


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