CSHCN 2009 > Hospital > Inpatient Services

22.3.1.2 Inpatient Rehabilitation Services

The inpatient rehabilitation program must include medical management, two or more therapies (e.g., respiratory therapy, speech-language pathology [SLP] services, physical therapy [PT], occupational therapy [OT]), and rehabilitation nursing. The CSHCN Services Program may reimburse inpatient rehabilitation services when the client meets one of the following criteria:

•The client is older than 4 years of age, sufficiently alert to respond to interventions and to participate with the rehabilitation team in setting treatment goals, and is an active participant in therapeutic activities.

•The client is 4 years of age or younger, sufficiently alert to respond to interventions and to participate with the rehabilitation team, and the parent or caregiver can actively participate in setting treatment goals and learning therapeutic management.

In addition, at least one of the following criteria must be met to be eligible for reimbursement of inpatient rehabilitation services:

•The client developed a recent onset of illness or trauma (within the last 12 months) without previous comprehensive rehabilitation efforts.

•There is no documentation of previous inpatient comprehensive rehabilitation effort.

•The client experienced a loss of previous level of functional independence through complications or recurrent illness, and the recovery of functional independence is feasible.

The following are examples of conditions that may be considered for coverage of inpatient rehabilitation:

•Spinal cord injuries

•Traumatic amputation of upper or lower extremities

•Rheumatoid arthritis and other inflammatory polyarthropathies

•Burns

•Postpolio syndrome

•Neoplasms

•Head or brain injuries

•Late effects of infections (e.g., Guillain-Barré syndrome)

•Cerebrovascular diseases

•Congenital conditions (for example, spina bifida and cerebral palsy) may be considered when there is a recent change in medical and functional status, such as postspinal surgery

The inpatient rehabilitation program must include medical management, two or more therapies
(e.g., respiratory therapy, SLP services, PT, OT, and rehabilitation nursing).

Inpatient Rehabilitation Prior Authorization Requirements

Prior authorization is required for inpatient rehabilitation services. An inpatient rehabilitation provider must be approved by the CSHCN Services Program as an inpatient rehabilitation facility or unit before a prior authorization may be approved.

Prior authorization may be approved in 14-day increments, not to exceed a maximum of 90 days of inpatient rehabilitation, and may be prior authorized per calendar year. Requests must be submitted in writing with documentation of medical necessity, including the diagnosis or condition of the client and progress toward goals (request for additional days) along with a copy of the treatment plan. The CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission must be submitted for the initial request and each extension. Providers must include all supporting documentation showing medical necessity for the extended inpatient stay.

A statement explaining the medical necessity of inpatient versus outpatient rehabilitation services must be included with the documentation submitted for prior authorization. The justification must state the client's current condition and why inpatient rehabilitation, as opposed to outpatient therapy, is required for optimal care. The client's need for daily, intense, focused, team-directed therapy must be substantiated by the circumstances of the case.

If the prior authorization request for additional days documents that the client has made progress toward treatment goals, an additional 14 days may be approved up to a maximum of 90 days per calendar year.

Requests for additional days must be received for prior authorization before the last inpatient rehabilitation day previously prior authorized.

Requests for extensions are not approved if one of the following conditions applies:

•The client has met treatment goals, as determined by the rehabilitation team or the CSHCN Services Program medical director or designee.

•The client has failed to make progress toward remaining treatment goals during the currently authorized period.

•The client no longer requires inpatient rehabilitation, and therapeutic goals can be met on an outpatient basis.

•The request was received after the last prior authorized inpatient day.

•The 90-day calendar maximum is exhausted.

Treatment for Acute Medical Episodes

If a client develops an acute medical condition during an inpatient rehabilitation admission that prevents participation in rehabilitation program activities, the CSHCN Services Program must not be billed for inpatient rehabilitation services. Acute care services (whether inpatient or outpatient) that are a benefit of the CSHCN Services Program may require authorization or prior authorization and must be billed as acute care services.

Refer to: "Inpatient Behavioral Health Prior Authorization Requirements" for additional information.

Section 4.3, "Prior Authorizations" for detailed information on prior authorization requirements.

Appendix B, "CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission,".