Tip for Insurer-specific

Document measurable, objective progress — payers deny continuation when notes show a plateau

Tip for Insurer-specific

Use standardized outcome measures (e.g., DASH, Oswestry, PHQ-9) to demonstrate improvement

Tip for Insurer-specific

Submit the continuation request BEFORE the current authorization expires — gaps in authorization can mean gaps in coverage

RehabilitationmoderateDoctor signature required

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.

Form Details

Total fields: 35
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Filled by: doctor
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Where to Submit This Form

📠

Fax to the insurer's utilization management department

Submit before the current authorization expires.

🌐

Submit through the insurer's provider portal

Electronic submissions are processed faster.

🌐

Call the insurer's prior authorization line for urgent situations

Filing Deadline

Submit at least 5-10 business days before the current authorization expires or the approved visits are exhausted.

Required Attachments

📎 Updated progress notes with objective outcome measures
📎 Updated treatment plan with revised goals
📎 Documentation of functional progress since the initial evaluation
📎 Justification for continued treatment (why goals have not yet been met)
📎 Re-evaluation findings (if a formal re-evaluation was conducted)

Processing Time

Standard: 5-10 business days. Expedited: 72 hours for urgent medical need.

What Happens Next

If approved, additional visits or treatment days are authorized. If denied or partially approved, you may request a peer-to-peer review or file a formal appeal.

Tips for This Form

✓ Document measurable, objective progress — payers deny continuation when notes show a plateau
✓ Use standardized outcome measures (e.g., DASH, Oswestry, PHQ-9) to demonstrate improvement
✓ Submit the continuation request BEFORE the current authorization expires — gaps in authorization can mean gaps in coverage
✓ If denied, a peer-to-peer review between the treating therapist and the insurer's reviewer can be very effective

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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.

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).

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.

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 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.