Direct Admission to a Postacute Setting

Before submitting a prior authorization request

In some situations, members may be directly admitted to a skilled nursing or subacute rehabilitation facility from the community – such as from the member’s home, physician office, urgent care or other outpatient setting. When this occurs, the referring provider or ordering physician must complete the following before submitting a prior authorization request to HealthSpring:

To submit a prior authorization request

Once the facility is confirmed and the requirements above are met, submit a prior authorization request by:

When submitting a prior authorization request, you must include the following documentation:

• Ordering physician information and contact
• Accepting facility information and contact
• Patient information
• Planned admission date
• Diagnosis and clinical rationale for postacute admission from the community or an outpatient setting. Also include whether alternate level of care was considered or is contraindicated.
• Direct contact information for peer-to-peer review

• Supporting medical necessity documentation:

  • Physician’s order
  • Clinical assessment
  • History and physical
  • Medication list
  • Current mobility and functional status
  • Physical and occupational therapy evaluations, if applicable

We can’t accept prior authorization requests until the accepting facility is confirmed.

Next steps

Once we make a determination:

• We communicate the decision to the requesting provider.
• We fax approval/denial to the accepting facility.
• The referring provider is responsible for coordinating transportation for the member’s admission.
• We conduct continued-stay reviews for ongoing medical necessity on a weekly basis.