2.17.3

Prior Authorization and Documentation Requirements

All inpatient rehabilitation services provided to clients who are birth through 20 years of age in a freestanding inpatient rehabilitation facility require prior authorization.

Prior authorization will be considered when the client has met all of the following criteria:

•	The client has an acute problem or an acute exacerbation of a chronic problem resulting in a significant decrease in functional ability that will benefit from inpatient rehabilitation services.

•	The intensity of necessary rehabilitative service cannot be provided in the outpatient setting.

•	The client requires and will receive multidisciplinary team care defined as at least two therapies (OT, PT, or ST).

•	This therapy will be provided for a minimum of three hours per day, five days per week.

The physician and the provider must maintain all documentation in the client’s medical record.

Inpatient rehabilitation may be prior authorized for up to two months when the attending physician submits documentation of medical necessity. The treatment plan must indicate that the client is expected to improve within a 60-day period and be restored to a more functional lifestyle for an acute condition or the previous level of function for an acute exacerbation of a chronic condition.

Requests for subsequent services for increments up to 60 days may be prior authorized based on medical necessity. Requests for prior authorization of subsequent services must be received before the end-date of the preceding prior authorization.

A prior authorization request for an additional 60 days of therapy will be considered with documentation supporting medical necessity.

Supporting documentation for an initial request must include the following:

•	The request for inpatient rehabilitation and the treatment plan must be signed and dated by the physician. The physician’s signature is valid for no more than 60 days prior to the requested start of care date.

•	A CCP Prior Authorization Form signed and dated by the physician.

•	A current therapy evaluation with the documented age of the client at the time of evaluation.

•	Therapy goals related to the client’s individual needs; goals may include improving or maintaining function, or slowing of deterioration of function.

•	An updated written comprehensive treatment plan established by the attending physician or by the therapist to be followed during the inpatient rehabilitation admission that:

•	Is under the leadership of a physician and includes a description of the specific therapy being prescribed, diagnosis, treatment goals related to the client’s individual needs, and duration and frequency of therapy.

•	Includes the date of onset of the illness or injury requiring the freestanding inpatient rehabilitation facility admission.

•	Includes the requested dates of service.

•	Incorporates an active interdisciplinary team.

•	Consists of at least two appropriate physical modalities (OT, PT, and ST) designed to resolve or improve the client’s condition.

•	Includes a minimum of three hours of team interaction with the client every day, five days per week.

•	In addition to the documentation for an initial request, supporting documentation for a request for subsequent services must include the following:

•	A brief synopsis of the outcomes of the previous treatment relative to the debilitating condition.

•	The expected results to be achieved by an extension of the active treatment plan, and the time interval at which this extension outcome should be achieved.

•	Discussion why the initial two months of inpatient rehabilitation has not met the client’s needs and why the client cannot be treated in an outpatient setting.

After receiving the documentation establishing the medical necessity and plan of medical care by the treating physician, prior authorization is considered by CCP for the initial service and an extension of service as applicable. A request for prior authorization must include documentation from the provider to support the medical necessity of the service.