Tip for Insurer-specific

Medicare does not require prior authorization for IRF admission, but many Medicare Advantage and commercial plans do

Tip for Insurer-specific

The patient must require and be able to tolerate at least 3 hours of therapy per day, 5 days per week

Tip for Insurer-specific

If denied, request a peer-to-peer review between the rehabilitation physician and the insurer's medical director

RehabilitationmoderateDoctor signature required

Inpatient Rehab Pre-Authorization

Insurer-specific · Health insurance plans / UM organizations

Pre-certification for inpatient rehab admission. Must document patient can participate in 3 hours of therapy, 5 days per week (15 hours per week).

Form Details

Total fields: 40
Auto-fillable: 25 (63%)
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Filled by: doctor
Frequency: per incident

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Where to Submit This Form

🌐

Call the insurer's utilization management or pre-certification department

Obtain the phone number from the patient's insurance card or the insurer's provider portal.

📠

Fax the pre-authorization request to the insurer

Include comprehensive clinical documentation supporting the need for inpatient rehabilitation.

🌐

Submit through the insurer's provider portal

Many insurers now accept electronic pre-authorization requests.

Filing Deadline

Must be obtained before admission to an inpatient rehabilitation facility (except for direct transfers from acute care, which typically have 24-72 hour notification requirements).

Required Attachments

📎 Pre-authorization request form (insurer-specific)
📎 Physician order for inpatient rehabilitation
📎 Medical records documenting the qualifying condition
📎 Functional assessment demonstrating the need for intensive rehabilitation (3 hours/day minimum)
📎 Documentation that the patient requires physician supervision and 24-hour rehabilitation nursing
📎 Rehabilitation goals and estimated length of stay

Processing Time

Standard: 3-5 business days. Urgent: 24-72 hours for transfers from acute care.

What Happens Next

If approved, you will receive an authorization number and approved length of stay. Continued stay reviews are conducted during the admission — the facility submits ongoing clinical updates to the insurer.

Tips for This Form

✓ Medicare does not require prior authorization for IRF admission, but many Medicare Advantage and commercial plans do
✓ The patient must require and be able to tolerate at least 3 hours of therapy per day, 5 days per week
✓ If denied, request a peer-to-peer review between the rehabilitation physician and the insurer's medical director
✓ Continued stay authorization is separate from initial authorization — the facility must submit ongoing updates

More Rehabilitation Forms

IRF-PAI (Inpatient Rehabilitation Facility Patient Assessment)

IRF-PAI · CMS

Assessment instrument determining Medicare Part A FFS payment for IRF stays. Must be in the patient's medical record, dated, timed, and authenticated.

Rehabilitation Unit Compliance Form

CMS-437A · CMS

Documents that a rehabilitation unit is fully equipped and staffed for hospital inpatient rehabilitation care.

Rehabilitation Hospital Criteria Worksheet

CMS-437B · CMS

Submitted to maintain IPPS-excluded status for inpatient rehabilitation facilities.

Outpatient PT/OT/ST Prior Authorization

Insurer/state-specific · Health insurance plans / State Medicaid

Prior authorization for outpatient physical therapy, occupational therapy, or speech therapy. Must specify frequency, duration, and medical necessity.

Concurrent Therapy Treatment Request / Recertification

Insurer-specific · Health insurance plans

Request for continued therapy beyond initial authorization period. Must document progress toward goals and continued medical necessity.

Vocational Rehabilitation Application

State-specific (e.g., WA DSHS 11-022) · State Divisions of Vocational Rehabilitation

Application for VR services to help people with disabilities prepare for, find, and keep jobs. Eligibility based on disability that creates a barrier to employment.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Health insurance plans / UM organizations or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.